2008 HIV/STD Partner Services Recommendations:  Comparison with Previous Guidance Documents

• State and local health department HIV cooperative agreement grantees and HIV community planning groups (CPGs)

• Public health personnel and others involved in managing STD prevention programs

• Health department program managers responsible for overseeing HIV/STD partner services programs at the state and local levels

• Provides Standards, which must be followed by CDC grantees in any instance where CDC funds are used to support services
• Provides Guidance, which generally should be followed, but which can be tailored/amended to fit local contexts

• Provides broad, general recommendations that can be adapted to local needs and conditions
• Provides a series of appendices that give concrete “how to” examples and templates for programs to use in implementing these guidelines

• Recommends what programs should do and why, but not how (i.e. not operational guidelines)
• Provides recommendations, not program requirements or technical guidance for CDC grantees

• Addresses HIV, only

• Not explicitly stated –  implicitly, includes early syphilis, gonorrhea, chlamydial infection, and HIV, but recommendations do not distinguish among these
• Each program determines for which STDs it will make partner services available and to what extent those services will be provided

• Addresses HIV, early syphilis, gonorrhea, and chlamydial infection
• Emphasizes similarities in PS across diseases, but highlights differences where they arise

• All principles cited in the POG

PLUS

• Ongoing access to PCRS for HIV-infected persons and their partners
• Assistance accessing medical evaluation and treatment

• Voluntary
• Confidential
• Science-based
• Culturally appropriate
• A component of a comprehensive prevention system
• Diverse referral approaches
• Support services and referral
• Data analysis and use for program evaluation and quality improvement
• Counseling and support for those who wish to notify their own partners
•  Client-centered counseling
• Increased importance as a prevention tool as new technologies emerge

• Voluntary and non-coercive
• Confidential
• Evidence-based
• Culturally, linguistically, and developmentally appropriate
• Comprehensive and integrative
• Client-centered
• Free
• Accessible and available to all

• Minimal

• Supporting evidence and examples cited

• Substantial evidence and examples offered and evaluated

• Service Title: Partner Counseling and Referral Services (PCRS)
• Infected Person: Client
• Contacts of Infected Person:
  • Partners (sexual or drug-injecting)

• Service Title: Partner Services (PS)
• Infected Person: Index Patient
• Contacts of Infected Person:
  • Partners (sex or drug-injection)
  • Suspects – Individuals identified as the result of an interview with infected persons but who are not partners of that person
  • Associates – Persons named as being at risk or possibly infected by persons who are not themselves infected with the disease in question

• Service Title: Partner Services (PS)
• Infected Person: Index Patient
• Contacts of Infected Person:
  • Partners (sexual or drug-injection)
  • Social contacts – Persons named by index patients as part of their social network, but who are not sexual or drug injection partners (known as suspects in POG)
  • Associates – Persons named as being at risk or possibly infected by persons who are not themselves infected with the disease in question

• Emphasis on making PCRS accessible to all HIV-infected persons (passive process)

• Emphasis on health department staff offering PS to every person newly diagnosed with an STD (active process)

• Emphasis on health department staff offering PS to all persons newly diagnosed with HIV or early syphilis (active process)

• No section of the document specifically devoted to addressing legal and ethical issues
• Notes that under Public Health Law 104-146, Section 8a of the Ryan White CARE Reauthorization Act of 1996, partner services programs must make a “good faith effort” to notify current or former

• Small sections in Introduction address legal authority for partner services as well as confidentiality

• Specific section of document outlines important legal and ethical considerations and offers relevant recommendations
• Issues addressed in legal/ethical section include the following:
• Legal authority for partner services
• Spousal notification requirements
• Voluntary and informed participation in partner services on the part of patients and their partners
• Protection of confidentiality
• Criminal transmission laws
• Duty and Privilege to Warn
• Recommends that programs ensure that policies and protocols are in alignment with all relevant laws

NOT DIRECTLY ADDRESSED

• Assumes those administering HIV tests (e.g. counseling, testing, and referral (CTR) providers) either are also PCRS providers, or will refer HIV-infected client to PCRS providers

• Patients may voluntarily come to STD clinics for STD services
• May be reported to health department by private provider
• May be referred to health department by private provider
• May be reported by diagnostic laboratory

• Patients may be diagnosed with HIV/STDs in health department clinics
• May be reported to health department through a disease reporting system.  At a minimum, programs should use provider level and aggregate level surveillance data to identify facilities or geographic areas with high diagnosis rates. If appropriate security and confidentiality protections are in place, programs should consider using individual level information to identify candidates for PS
• Provides explicit principles and standards for record keeping and data security in an appendix
• Recommends active outreach to private providers, service providers, or diagnostic laboratories

NOT ADDRESSED

• Suggests some criteria (e.g., STD specific morbidity) for consideration in prioritizing index patients, but defers to local priorities

• Recommends that all persons with newly diagnosed or reported early syphilis or HIV infection should be offered partner services
• Describes specific criteria for prioritizing index patients across, within, and between infections, but defers to programs to determine how to apply criteria

NOT ADDRESSED

• Treatment for the index patient is not specifically addressed.  Presumes that index patients have already been treated

• For STDs other than HIV, recommends that programs ensure that patients are treated according to CDC’s STD Treatment Guidelines
• For HIV-infected persons, recommends that programs have systems for linking index patients to HIV care providers or case managers

• Recommends that all clients who are tested for HIV receive client-centered counseling.  Does not address additional counseling, post-diagnosis, delivered by a PCRS provider

• Recommends that all patients should receive client-centered counseling

• Recommends that all index patients receive a minimum amount of prevention information and messages
• Recommends that index patients with current or recent behavioral risk factors receive prevention counseling or other, more intensive, prevention interventions

• Mentions that some clients may have needs or issues that must be addressed before they are ready to participate in PCRS.  Notes that PCRS providers should recognize and accommodate those needs, but gives no indication that providers should offer clients referrals to services or help clients access them

• Recommends that patients who express a need, or are perceived as having such a need, for other services (e.g. prenatal care, drug counseling) should be given appropriate referrals
• Recommends that disease intervention specialists (DIS) follow up on referrals in some cases, such as HIV-infected persons referred to early intervention or case management

• Recommends that program staff should be able to make referrals to agencies providing a variety of other needed services (e.g. housing)

• Lists some factors that should influence prioritization decisions, such as potential for transmission of HIV to others (e.g. partner  is pregnant)

• Recommends that those at highest risk (i.e. pregnant women, individuals with symptoms) be contacted first
• Other criteria similar to those for prioritizing index patients
• Does not explicitly prioritize partners over suspects or associates

• Describes specific criteria for prioritizing across and within different infection exposures, but defers to programs to determine how to apply criteria
• Notification of partners is assigned a higher priority than that of social contacts or associates

• 4 notification methods:
  • Client referral
  • Provider referral
  • Contract referral
  • Dual referral
• If there is a concern about potential partner violence, providers must be prepared to make necessary referrals to clients and seek expert advice before proceeding with partner notification

• 3 notification methods:
  • Patient referral
  • Provider referral
  • Contract referral
• Programs determine which notification strategy (or strategy mix) to use in their jurisdictions, based on program priorities, disease morbidity, and program staffing level

• 5 notification methods:
  • Patient referral
  • Provider referral
  • Third party referral
  • Contract referral
  • Dual referral (index patient and a provider)
• Programs should accommodate various notification strategies that allow the DIS and the index patient to collaborate on the best approach for notifying each partner
• Program providers should screen for potential violence before each named partner is notified.  If a violent situation is possible, provider should seek expert advice before proceeding with notification

• Suggests that blood specimens can be drawn in field at time of notification, although this requires special provider training
• Recommends that new, rapid-test technologies that use oral fluid or urine samples be considered for on-the-spot specimen collection and testing

• Field testing is encouraged
• Recommends that, if partner is evaluated outside of the health department, DIS should verify that partner received appropriate tests and treatment

• Recommends that, when possible, testing should be done at the time of notification
• If testing does not take place at this time, DIS should verify that testing was done and results were received
• For syphilis, gonorrhea, and chlamydia, specimens should be collected in the field if conditions allow
• For HIV, rapid testing should be considered
• Explore ways to integrate screening for HIV and other STDs into all partner services, regardless of which infection is being investigated.

• Recommends that programs should facilitate referrals for medical services

• Recommends that DIS urge partners tested in the field to obtain the test results and medical evaluation (as needed); for those not tested in the field, DIS must urge them to seek medical evaluation

• Recommends that partners be treated according to CDC’s STD Treatment Guidelines as soon as possible following notification
• For some STDs (e.g. chlamydial infection, uncomplicated gonorrhea), programs should consider patient delivered partner therapy (PDPT) or field delivered therapy (FDT)
• Partners who test positive for HIV should be linked to medical care and case management, and DIS should conduct  follow-up to ensure partners have accessed medical care or case management at least once

• Recommends that providers must be prepared to offer partners immediate counseling and referrals to more intensive counseling

• Does not directly address counseling for partners, but assumes that client-centered counseling will be made available to partners, either in the field (if notified by a DIS) or when the partner comes in for testing/treatment

• Recommends that all partners of STD/HIV-infected persons should receive prevention counseling at the time of notification
• If needed, partners should also receive referrals to additional risk-reduction interventions

• Recommends that programs facilitate referrals for a range of social and medical services (e.g. STD treatment, domestic violence, etc.)
• Providers should follow-up with each partner to ensure that referral services have been received

• Recommends that DIS must be prepared to make other types of referrals (e.g. for prenatal care) for partners and to support (to the extent possible) those individuals in obtaining these additional services

• Recommends that program staff should make referrals as needed to agencies providing a variety of other needed services

• Needle-sharing partners

NOT ADDRESSED

• Youth
• Persons in correctional facilities
• Migrant and immigrant populations

• Mentions social network and clustering methods as ways to identify high-risk venues and sexual or drug networks

• Offers adjuncts to partner services to help programs identify cases not captured through partner services
• Social Network Analysis:
• Targeted Screening and Field Testing:
• Community Outreach

• Offers methods for enhancing the case-finding potential of partner services programs:
• Social Networks
• Core areas identification
• Internet Partner Services (IPS)

• Recommends that programs improve PCRS accessibility by developing agreements with private providers that specify  these providers will deliver PCRS
• Recommends that programs build relationships with communities served and increase community support by working with CPGs

• Recommends that programs establish collaborative mechanisms with providers outside the health department to ensure that patients diagnosed, and partner names elicited, by these providers are referred to the health department

• Recommends that programs ensure that services are integrated at the client level
• Recommends establishing collaborative relationships and coordinating services with CPGs, other jurisdictions, other agencies and organizations (e.g. community-based organizations, or CBOs), and medical providers

• Recommends that programs must be able to collect data to answer core questions such as the following:
• What proportion of HIV-infected individuals is offered PCRS?
• What is the range of PCRS services offered to and accepted by each client?
• What is the percentage of partners actually reached through PCRS, and how many of those partners are infected with HIV?
• How many partners are offered referral services, and how many actually receive these services?
• CDC-funded programs must have a quality assurance plan and must be able to evaluate the services they offer

• Recommends a number of measures deemed essential for evaluating program effectiveness, including the following:
  • Number of index patients interviewed
  • Total number of partners elicited
  • Number of partners located and notified by DIS
  • Time frames for locating and notifying partners
  • Number of partners notified of their exposure who are, and who are not, infected with the STD in question
• In addition, programs should be able to evaluate their programs with respect to provider type, sex of patient, referral type, and any other locally defined priorities

• Recommends that programs be able to answer four key questions:
  • How completely is the program identifying and interviewing newly reported cases with partner services?
  • How effectively is the program identifying partners, notifying them of their risk, and ensuring that they are examined or tested for infection?
  • How effectively is the program identifying and treating (or linking to care) new cases?
  • Any variance in performance measures with respect to age, race, sex, or risk category?
• All programs should develop and implement (at least quarterly) quality improvement (QI) measures, and QI activities

• Recommends that supervisors/program managers ensure that each PCRS provider has appropriate skills and training (e.g. knowledge of relevant federal, state, and local laws.)
• Staff should received period training, as appropriate

• Recommends that programs should establish safety guidelines/procedures and ensure that DIS are aware of and comply with these.
• Programs should implement performance guidelines for staff that detail process standards to which staff should adhere, and skills which staff should master and demonstrate

• Recommends that comprehensive training plans be developed for PS staff and supervisors; at minimum, these should include annual training updates
• A range of measures, both qualitative and quantitative, should be used to measure and improve staff performance
• Programs should develop policies and provide training to safeguard staff from occupational hazards, (e.g. occupational exposure to infectious agents)