HIV Partner Notification examined
Dreaded call becomes words to live by
Notifying partners of HIV-positive people an important weapon in fight against AIDS
San Francisco Chronicle
- Sabin Russell, Chronicle Medical Writer
Monday, January 9, 2006
No. You do not want to get a telephone call from Luis Hernandez.
It is his job to tell people that they might have been exposed to HIV, the virus that causes AIDS.
When a client at the San Francisco Department of Public Health's sexually transmitted disease clinic tests positive for HIV, Hernandez is often the one who breaks the news in a face-to-face counseling session.
For the past year, he has had an added responsibility -- notifying sexual partners of newly diagnosed HIV-positives that they, too, should come in for a test.
He will call them on the telephone, send them a letter, shoot them an e-mail or even drive to their home to knock on their door.
The people he contacts are gay and straight, male and female.
If his message comes through the mail or by answering machine, it is always couched in careful terms, never mentioning sexual contacts, HIV or AIDS. "Please call the San Francisco Department of Public Health about an important medical matter," he will say.
Partner notification, a variant of the old "contact tracing" system used for the control of syphilis since the 1940s, is re-emerging as an important tool in AIDS prevention -- one that the federal government has adopted as a cornerstone of its efforts to control the spread of HIV in the United States.
One reason for the federal government's push for partner notification is that it is a more efficient and focused way to test for HIV.
Studies show that routine testing and counseling among the general population typically turns up new infections in less than 1 percent of those tested.
But among the sexual partners of HIV-positive people, infection rates hover around 20 percent. Partner notification concentrates on a group most likely to have previously undetected infections.
Hernandez shares an office with three others who do similar work at City Clinic, the South of Market center that offers free testing for sexually transmitted diseases, including syphilis, gonorrhea and HIV. The four work in a partner-notification program known as Disclosure Assistance and Partner Services, or DAPS.
"It takes a special kind of person to do this job," said Hernandez, who has worked eight years as a certified HIV counselor. "It is not easy giving people such a powerful piece of information."
Persuading a newly diagnosed HIV-positive client to offer a list of sexual partners is among the most sensitive tasks for team members. Such disclosures are always voluntary. Typically, a client will provide two or three names of sexual partners from the past year. "It's pretty rare to get a stack of names and phone numbers," Hernandez said.
Often, that person's sexual encounters were brief and anonymous. In those instances, partner notification is impossible.
Whether or not a name is disclosed, city health workers can offer counseling and role-playing to teach clients how to tell their partners the news.
"If they are in a relationship, they tend to tell their partners themselves,'' Hernandez said.
Soft-spoken and sympathetic, Hernandez operates within a tight bubble of confidentiality. The list of partner names is kept secure. The name of the newly diagnosed HIV-positive person is never disclosed to the partner.
"The first questions I am always asked is, 'How did you get my name?' or 'Who was it?' " Hernandez said. They are questions he can never answer, unless he accompanies clients to help them make the disclosures themselves.
When partners are contacted, they are advised of the free testing services offered by the city -- a finger-stick blood test that can provide a preliminary result in just 20 minutes. Positive test results are immediately retested with a more definitive assay whose results can take at least a week to come back.
Newly diagnosed HIV-positives have been advised to tell their partners about their test results since AIDS antibody testing first became available in 1985, but in practice, there has been little organized effort to promote partner notification until recently. A University of Washington survey found that only 30 percent of HIV-positive people received partner-notification counseling of any kind.
"It is a pretty anemic system," said study author Dr. Matthew Golden, director of sexually transmitted disease control for Seattle and King County.
Golden said that while San Francisco and Seattle had increased partner-notification services, virtually none existed in New York, Chicago or Los Angeles.
"Clearly, people are not receiving the service. That is why we are putting more emphasis on it,'' said Dr. Sam Dooley, an associate director in the Centers for Disease Control's Division of HIV/AIDS Prevention.
Alarmed by studies showing that at least a quarter of HIV-positive Americans do not know they are infected, the federal agency issued a revamped HIV-prevention strategy in April 2003 to expand testing, produce the results quickly, and increase emphasis on partner notification. The ultimate goal is to reduce the estimated 40,000 new HIV infections that occur in the United States each year.
Dooley acknowledged that partner-notification programs had been hampered in the past by the perception that they are intrusive and that the gay population had been wary of government efforts to collect names of men who have sex with men.
But since 1996, treatments with antiviral drug cocktails have made AIDS a more treatable disease, and hence much of the stigma surrounding an HIV-positive diagnosis has been lifted. "The bottom line is that it is really important for people who are infected to know they are infected, so they can access health care services," Dooley said.
One year after San Francisco stepped up its partner-notification efforts, a study showed that it had help uncover previously undiagnosed cases. In 2004, according to a report published in the New England Journal of Medicine, 112 partners of 136 clients newly diagnosed with HIV were interviewed through the program. Ten new HIV infections were detected.
"Even if they were negative, they were at least notified that they had been exposed,'' said Dr. Jeffrey Klausner, San Francisco's director of sexually transmitted disease prevention and control. The news can be a powerful reminder to practice safer sex in the future.
Kevin Farrell, chief of the education and prevention services branch of the California Department of Health Services Office of AIDS, said partner-notification programs were being expanded statewide. "The CDC has been more forceful in discussions with us, and other states, to use this,'' he said.
Although there is no new money budgeted for partner notification, Farrell said the state was shifting its training dollars toward such programs. "It is one tool in the tool kit,'' he said.
For clients who give their partners' names to the city health department, it can help relieve a burden of guilt. A City College student who learned in May that he was HIV-positive gave Hernandez a list of seven names.
"It might be difficult for them, but it's better to know, so they can take care," said the student, who agreed to discuss the program as long as he was not identified.
There have been awkward moments, such as when one of his friends told him he had received a call from City Clinic to come in for an HIV test. The student and his friend puzzled over who the HIV-positive person might have been.
Others on the list may have suspected that he was the person who tested positive because he stopped hearing from them. But the program has allowed him to be sure that his past partners know they might have been exposed, without his having to reveal his secret. "My life is already difficult because I am gay and a foreign student here," he said.
He keeps in contact with counselors at City Clinic and takes comfort that at least one of his partners responded to the news by telling Hernandez, "Say 'Thank you' to whoever gave you my phone number."
Giuliano Nieri, manager of Sexually Transmitted Disease and HIV Services at City Clinic, said the notified partners were often grateful for the service.
"We tell them that 'someone you've had sex with cares about you, is concerned about you, and wants to make sure you know you might have been exposed,' " he said.
How to tell your partner
HIV prevention efforts are placing new emphasis on partner notification -- telling those who may have been exposed to the virus that they, too, should get tested. Here is what City Clinic counselors tell newly diagnosed HIV-positives to take into consideration before they tell their partners the news:
-- Assess the risk, if any, of domestic violence from the person about to receive the information. Counselors can deliver the news for you, without identifying you as the person who tested positive.
-- Think about the best time and place to tell them. Your home? His or her home? Or a neutral space, such as a coffee shop or a park?
-- Be prepared for an unexpected response. Your partner might tell you he or she is HIV-positive, too.
-- Expect a lot of questions. Think about what your partner will want to know about AIDS and do your research ahead of time, so you have answers.
-- Have a list of referrals ready, so your partner knows where he or she can get tested and receive the same services available to you.
-- Unsure what to say? Counselors can run through role-playing exercises to help you anticipate your own emotions and those of your partner.