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PARTNER
NOTIFICATION
What is contact
tracing?
Contact
tracing is the process of identifying relevant contacts of a person
who has an infectious disease and ensuring those contacts are aware
of their exposure.
Contacts
may be
- Sexual partners
- People who shared needles
or IV equipment
- Domestic or social contacts
- Recipients of blood or
blood products
The
period of infectivity determines who is a "relevant" contact.
What
are the objectives of contact tracing?
- To interrupt transmission
of infection
- To offer treatment to all
infected persons
- To counsel regarding behaviour
change (to reduce/prevent further transmission)
- To identify and reach populations
at particular risk
The principles
of contact tracing
- Respect the rights and
dignity of the index case and contacts
- Be non-judgmental and supportive
- Ensure confidentiality
- Contact tracing should
be part of an integrated service providing preventive services,
care and support
- Ensure that support services
and follow-up can be provided
- Contact tracing is voluntary.
It relies on the good will of the index case. If there is refusal
to notify or permit notification of a contact, seek expert assistance.
Help may be available through your local Public Health Unit or
your local Sexual Health Service
How can contact
tracing occur?
The
index case advises and informs contacts. "Contact letters" from
the GP or health service may help during follow-up consultations,
confirm the process that has occurred, the health care provider
or agency advises and informs contacts.
- Obtain explicit approval
from the index case
- Ensure confidentiality
of the index case
- Discussing contact tracing
with an index case
- Discuss the principles
of contact tracing during pre-test counseling
- Address concerns about
confidentiality
- Identify how confidentiality
will be ensured after diagnosis, reassess risk history
- Make no assumptions about
risk activities
- Be explicit. Ask about
sexual practices, IV drug use, excessive alcohol use, blood donation
and receipt.
The timing of
contact tracing may vary according to circumstances:
- If a condition is being
diagnosed and treated in the one consultation, that is the time
to discuss contact tracing
- If others are at immediate
risk, contact tracing is a priority
- If a patient understands
the risk to others but it having difficulty adjusting to a diagnosis
(e.g. HIV), contact tracing may be deferred
- There will be barriers
to notifying contacts. Identify these and create strategies to
overcome them.
- Discuss and agree on the
method for notifying contacts. If the index case agrees to inform
contacts, provide support. Letters, instructions and role-play
may help.
- The actual mode of contact
tracing will depend on circumstances. Telephone, letters and personal
visits have advantages and disadvantages.
Managing reluctance
- Ensure concerns about confidentiality
have been addressed
- If there is little demonstrated
concern regarding consequences for contacts, explain the requirements
and risks of re-infection if relevant
- If there are practical
difficulties, discuss strategies to overcome them
- If there is difficulty-accepting
diagnosis, time and support may resolve contact tracing issues
- Seek advice from or refer
to other agency (e.g. Sexual Health Service)
PARTNER COUNSELING
AND REFERRAL SERVICES (PCRS)
Setting Priorities
for Reaching Partners
The PCRS
plan must include prioritizing which sex or needle-sharing partners
need to be reached first, based on each client' s and partner' s
circumstances. Ideally, all partners should be reached, but limited
program resources usually dictate that priorities have to be set.
Priorities are determined by deciding (1) which of the partners
are most likely to be already infected and to transmit infection
to others; (2) which of those partners are most likely to become
infected; and (3) which of these partners can be located.
A
number of factors influence how the PCRS provider and client decide
which partners need to be reached first. Obviously, if the client
has had only one partner during his or her lifetime, that partner
is likely to be infected. When the client has had more than one
partner, other factors then have to be considered, such as the following:
Possible Transmission
of HIV to Others
The
partner who is most likely to transmit HIV to others must receive
highest priority. A partner who is a pregnant woman should be reached
as soon as possible for counseling, testing, and referral to medical
treatment if infected, to avoid perinatal transmission. Likewise,
the partner who the client knows has multiple other sex or needle-sharing
partners needs to be reached as soon as possible to reduce the potential
for transmission of HIV to others.
Partners of
a Recently Infected Client
If,
for example, the client had a negative HIV test result 6 months
ago, but now the test result is positive, partners within that 6-month
time period or in the potential "window period" that preceded the
negative test would receive priority. These partners are more likely
to have acquired or been exposed to HIV than any of the client's
partners during the period before the client's HIV negative test.
Other evidence of a recently infected person might be indicated
by the exposure history of the client, e.g., client with a history
of negative test results or any other evidence of recent infection.
Likelihood of
the Partner Being Unaware of Exposure to HIV
Some
individuals are less likely than others to suspect a risk for HIV
infection or to understand what being "at risk" means. For example,
many heterosexual women might be less aware of their HIV risk and
therefore less likely to access counseling, testing, or other prevention
services without PCRS.
Partners at
Continued Risk
Reaching
the client's current, recurring, or recent partners is a high priority
because those partners might be at continued risk of becoming infected
with HIV, if not already infected.
History of Other
STDs
.
Services for
Those Persons Tested Anonymously
Opportunities
to access PCRS must be provided to HIV-infected clients who have
been tested anonymously and choose to remain anonymous. Program
experience has indicated that PCRS can be conducted in an anonymous
setting. unless prohibited by state law or regulation, grantees
must provide reasonable opportunities for anonymous testing. Clients
who test HIV-positive in anonymous settings must be counseled on
how to enter a confidential system and be strongly encouraged to
do so. This will assist them in receiving medical care and other
services, including PCRS.
PCRS for Needle-sharing
Partners
Sharing
of needles, syringes, and other paraphernalia used for injection
drug use (e.g., illicit drugs, steroids) carries high risk for transmission
of HIV. Throughout this document, the importance of providing partner
counseling and referral services to HIV-infected clients with needle-sharing
partners is emphasized. CDC recognizes that some HIV prevention
programs have relatively limited experience in working with needle-sharing
partners and that special issues exist relating to clients disclosing
information about such partners, reaching such partners, deciding
which prevention interventions should be provided, and referring
them for needed services.
Some
state and local HIV prevention programs have already gained considerable
experience in reaching and serving needle-sharing partners and report
that such services are feasible and likely to be effective. Information
provided by HIV-infected clients who are injection drug users may
help HIV prevention program managers gain insight into the extent
and types of prevention service needs of injection drug users and
how best to deliver and target such services.
Preparing
the PCRS Provider
In
large part, the manner in which PCRS is provided to and perceived
by the affected communities determines how successful HIV prevention
programs will be .Therefore, program managers and supervisors should
ensure that PCRS staff -
- Are skilled and competent
in providing PCRS;
- Are culturally competent
and demonstrate respect for the community to be served;
- Are knowledgeable about
HIV infection, transmission, and treatment;
- Are knowledgeable in local,
state, and federal laws regarding HIV and other relevant issues
of providing health care, especially the right to privacy and
confidentiality;
- Receive updated information
and periodic retraining as appropriate;
- Have standards, objectives,
and specific guidelines for performance;
- Are appropriately supervised
and given written and oral feedback about their performance on
a regular basis; and
- Have appropriate problem-solving
skills to deal with situations that might be encountered in a
field setting, e.g., personal safety, violence to others.
In
addition to receiving formal training, an inexperienced PCRS provider
should complete an internship by being teamed with a more experienced
provider for a period of time before conducting PCRS alone. Another
way to enhance a provider's performance is through routine peer
review of selected cases.
Providers
of successful PCRS programs regularly go outside the clinic or office
setting to reach partners. The inexperienced provider will need
training in deciding when to deliver PCRS outside the office or
clinic and when to postpone PCRS. Benefits of delivering PCRS in
a partner' s home might include providing the partner with a familiar
environment and helping the provider better understand the personal
circumstances of that partner. Whether or not to do PCRS outside
the clinic or office, or whether it is best postponed until an adverse
situation can be resolved, must be decided on a case-by-case basis.
In addition, training in avoiding confrontations, diffusing anger,
and mediating disputes will better prepare any provider for handling
potentially violent situations.
Helping Partners
Access Services
The
PCRS provider must be well prepared to handle the initial reactions
of the person who is being informed of possible exposure to HIV.
That person will undoubtedly need immediate counseling, followed
by referral to additional HIV prevention counseling. The provider
must be prepared to answer the questions and concerns of each partner
without revealing any identifying information about the original
HIV-infected client.
COLLECTING,
ANALYZING, AND USING PCRS DATA
Why Collect
Program Data?
PCRS
data must be collected and used
(1) to assess the behavioral risks for sex and needle-sharing partners
of HIV-infected persons.
(2) to evaluate the effectiveness of the PCRS program as part of
the overall HIV prevention effort.
(3) to improve how other HIV prevention activities, interventions,
and services are implemented.
Accurate
and consistent data collection is a critical component for evaluating
how effective the PCRS program is, as well as how well it enhances
the overall HIV prevention intervention Moreover, PCRS data enable
providers to better focus prevention efforts on those persons most
at risk. When the data reveal information about networks of people
who are having sex or injecting drugs, the dynamics of HIV transmission
can be better analyzed, and more intensive prevention and education
efforts can be applied for specific high-risk groups .To do all
this, however, the collected data must be relevant to behavioral
risks, HIV/AIDS prevalence, and the demographics of affected communities.
With accurate and consistent data, the staff of health departments
and community-based organizations and members of HIV prevention
community planning groups can establish an effective mix of prevention
strategies.
What Data Should
Be Collected?
Any
data collection tool used in a PCRS program should be designed so
that certain core information can be ascertained, including answers
to the following:
- What proportion of HIV-infected
clients is offered PCRS?
- What are the reasons those
clients either reject or accept PCRS?
- What is the range of PCRS
services (e.g., client referral, provider referral, combinations
of referral approaches) offered to and accepted by each client?
- How many sex or needle-sharing
partners are identified?
- What is the percentage
of partners actually reached through PCRS, and how many of those
partners are HIV-infected? Of those partners who are HIV-infected,
how many are being informed of their infection for the first time?
- What are the demographics
(e.g., marital status, age, sex, race/ethnicity) of the clients
and partners actually served?
- How many partners are offered
referral services? How many receive these services? In what time
frame do they receive referral services?
And,
perhaps most importantly, PCRS program managers should routinely
assess what all of this information means in regard to how well
PCRS is working for HIV-infected clients, their partners, and the
community at large. Are clients served well? Are partners gaining
access to services that might not be otherwise available? Are communities
becoming more supportive of public health efforts? Does evidence
exist that risks are being reduced? Are other prevention program
services better targeted to communities in need?
The
HIV prevention program managers in each health jurisdiction should
decide how best to collect, analyze, and use PCRS data. This should
be done in a manner that is consistent with the policies and procedures
that they have developed to safeguard the security of the data and
the confidentiality of the client or partner .Those managers should
keep in mind that misconceptions about the collection and use of
HIV data, in addition to a general mistrust of publicly funded agencies,
are two of the biggest barriers to HIV prevention efforts in affected
communities.
Quality Assurance
and Evaluation
Quality
assurance for PCRS programs entails ensuring that appropriate and
standardized methods are used for -
- Counseling HIV-infected
clients regarding the notification of their partners;
- Developing a PCRS plan
with HIV-infected clients;
- Prioritizing which partners
are to be reached;
- Locating and informing
those partners of their possible exposure to HIV;
- Providing immediate counseling
and testing services to informed partners and/or referring them
to other service providers; and
- Collecting, analyzing,
using, and storing PCRS data.
- Written job descriptions,
including minimum performance criteria, and comprehensive procedures
for delivering quality PCRS should be developed and copies made
available to all personnel. Also, supervisors should directly
observe a new PCRS provider until confident that the provider
is proficient in serving clients and their partners. Then, through
periodic supervisor observation, peer review of selected cases,
and "customer" satisfaction surveys, each PCRS provider should
be given constructive oral and written feedback.
PCRS
programs should include policies relevant to situations in which
an HIV-infected person knowingly exposes others to HIV. These policies
must comply with relevant state or local laws.
The
overall program should also be regularly evaluated to determine
the quality of effort and the success in reaching the PCRS goals.
Program evaluations should include a comprehensive assessment of
all confidentiality procedures that includes, at a minimum, record-keeping.
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