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by Richard Steen
Discussing a sexually transmitted disease (STD) with a partner is difficult because it raises questions about fidelity, trust and blame.
Such communication is essential, however, because sexual partners of STD patients are at high risk of being infected themselves. Because many of them do not have symptoms, they do not seek medical care on their own.
As one of the few available means of reaching individuals with symptomless STDs, partner notification and treatment are important parts of an STD control strategy. In two studies sponsored by the AIDS Control and Prevention (AIDSCAP) Project, partner referral increased by 25 to 35 percent the number of individuals with a high likelihood of having an STD who actually received treatment.
Partner Referral in Haiti
In Haiti, partner referral was included in a pilot STD screening and treatment project for women attending antenatal clinics in Citoleil, Port-au-Prince. As part of a baseline study, information about attitudes toward partner notification was gathered in focus group discussions conducted by researchers from the Centres pour le Dloppement et la SantCDS) - the largest local nonprofit health care provider in Haiti-the Department of Medicine of the University of North Carolina at Chapel Hill, and AIDSCAP.
The discussions revealed that common STD syndromes were well known, but people had misconceptions about STD transmission. Participants agreed that STDs can be contracted through sexual intercourse, but felt that they could also be brought on by abrupt changes in temperature, supernatural forces or poor hygienic conditions in the slums, said Frieda Behets, one of the investigators.
Rwandan women chat in the fields, A study in Rwanda found that women were more likely than men to refer their partners for STD treatment.
Both men and women understood the need to treat sexual partners and the risk of transmitting STDs from mother to child during pregnancy or at birth. One woman described how she could unknowingly transmit an infection to her infant that would be discovered only after delivery.
But members of the group did not recognize the possibility that some people infected with STDs are asymptomatic. Some discussion participants believed that people infected with STDs would always have symptoms. Others thought that asymptomatic STDs simply did not exist.
The community as a whole was receptive to a partner referral program, but policy makers and health care workers seemed to think it was a particularly delicate issue. Several women in the focus group wanted to enroll in the program immediately.
Using the findings of the focus group discussions, CDS began a partner referral program in its antenatal clinics. Pregnant women found to have an STD were educated about STDs, treated and encouraged to refer their partners to the clinic for treatment. They were also asked to volunteer the names and addresses of partners to allow community health workers to contact those who did not come to the clinic on their own.
Of 1,001 women who enrolled in the program from April to September 1993, 418 tested positive for an STD. More than 90 percent of them agreed to inform their partners; 73 percent agreed to partner referral by a health worker and supplied the names and addresses of their partners.
The 384 women who were treated for an STD named 331 partners. Only 30 percent (101 men) of partners of women infected with STDs went to the clinic for treatment after referral by the women. An additional 11 percent (38 men) sought treatment as a result of referrals by health workers.
Convincing male STD patients to refer partners is one of the few ways of reaching women at risk.
As part of an effort to determine the effect of referring the male partners of the women to another clinic, half the men who presented to the antenatal clinic were treated there and half were referred elsewhere. More than half the 59 male partners who were sent to another center for treatment failed to receive care. Lack of money and time were among the reasons the men gave for not going to the second center for treatment. The researchers recommended treating partners at the same facility as the initial (index) patient and removing barriers to partner treatment, such as clinic fees.
The researchers also emphasized the importance of communication. They concluded that more STD patients could be encouraged to refer their partners for treatment through community-based educational campaigns stressing the asymptomatic nature of many STDs and the fact that many STDs are curable. They also speculated that training to improve the communication skills of community health workers who referred partners would increase referral rates.
Results in Rwanda
In Rwanda, partner referral was introduced in two primary health care facilities to assess the feasibility of making partner notification a part of upgraded national STD services. The study, conducted by researchers from the Rwandan national AIDS control program, the U.S. Centers for Disease Control and Prevention, the U.S. Agency for International Development and the AIDSCAP Project, provided all patients found to have an STD with treatment and counseling about STD transmission and condom use. Patients with STDs also were urged to use a referral coupon to encourage sexual partners to come to the clinic.
The coupons, which invited the partners to the clinic for a free STD examination, were coded to tell health care providers what treatment to give the patient based on the STD treated in the initial patient. The coupons also enabled the program manager to monitor referral trends.
Three-quarters of the 427 patients presenting with STD symptoms from September 1993 to March 1994 were women. Although 248 index patients accepted referral coupons, only 110 partners were actually treated at the clinics.
Women were more likely than men to accept partner referral coupons and to successfully refer partners. Patients who were aware of STD symptoms in their partners were twice as likely to refer them for treatment. The results of the Rwandan study also suggest that better counseling and education of index patients would increase the number of partners successfully referred for treatment.
A training session at one of the health centers run by the Centres pour le Dloppement et la Santn Haiti. (Frieda Behets/UNC)
Nearly all partners referred by index patients were spouses or regular partners. Patient referral was not effective in identifying casual contacts, who are usually more important in the spread of STD in a community. Future partner referral programs should incorporate additional strategies for reaching casual partners.
Gender and Partner Referral
Most attempts to evaluate partner referral strategies have reported referral rates in the range of one partner treated for every two to five index patients seen with an STD. Much of this previous work took place in STD clinics, where the majority of index patients are men. The partner referral programs in Haiti and Rwanda achieved similar referral rates, though among different populations.
Targeting male STD patients for partner referral makes sense. STDs are easier to identify in men, and their female partners are more likely to be asymptomatic. Serious complications of untreated STDs in women, such as infertility, ectopic pregnancy or congenital infection, can develop months to years after infection, often long after a partner has forgotten his initial infection. Convincing male STD patients to refer partners is one of the few ways of reaching women at risk.
Treating the partners of women with STD is important too, for many of the same reasons. An untreated infection in a partner increases the likelihood of reinfection of the woman, contributes to the spread of STD in a community and is a potent cofactor facilitating HIV transmission.
Prenatal syphilis screening presents an opportunity to identify silent syphilis infection in mothers and prevent the severe consequences of congenital infection in newborns. Through partner referral, it is an opportunity to treat many fathers as well. Provided the quality of laboratory testing is good, there should be few false positives that would result in unnecessary partner notification and treatment.
When accurate laboratory testing is not available, however, some STDs are more difficult to diagnose in women. Current syndromic methods for identifying STDs in women with vaginal discharge, for example, are imprecise and sometimes lead to treatment of women who have non-sexually transmitted conditions. Treatment of these women, although justified by the serious consequences of untreated STD, raises concerns for care providers when they counsel partners. Without more diagnostic certainty, providers may decide not to inform a patient or her partner that the condition may be sexually transmitted, especially when such information could lead to accusations, divorce or abuse.
It might, however, be reasonable to advise partner treatment as a means of preserving fertility and promoting family health. Advising treatment of genital infections as part of responsible family planning or to help ensure a healthy pregnancy may lead to better cooperation and reduce the risk of discord between partners. This approach is a departure from traditional approaches used to counsel men but may be more appropriate than stressing the sexual transmissibility of an infection that may not, in fact, be an STD.
Health workers in Haiti found that men were more willing to come for treatment when the problem was framed in the context of preserving fertility or ensuring healthy offspring. When men who had come to the clinic were asked why it was important to them to receive treatment, one of the most common responses was to protect the child.
The Haiti and Rwanda studies show that it is important to refine strategies for reaching sexual partners, many of which were developed for STD programs targeting men, to meet the needs of women. More work is needed to develop counseling approaches that encourage partner treatment while avoiding stigmatization and partner accusation. Better methods also are needed to convince patients of the importance of notifying partners, even when the partner has no symptoms of STD, and to reach and treat casual sexual contacts in order to break the chain of STD infection in a community.
Richard Steen, PA, MPH, is the STD officer in AIDSCAP's Africa Regional Office in Nairobi, Kenya. He was AIDSCAP's resident advisor in Rwanda from 1993 to 1994.