Patient-led partner referral in a district hospital based STD clinic.VV Sahasrabuddhe, TA Gholap, YS Jethava, NS Joglekar, RG Brahme, BA Gaikwad, AK Wankhede, SM Mehendale
District Hospital, Nashik and National AIDS Research Institute, Pune - 411 026, India. , India
CONTEXT: Sexual communication and appropriate treatment of sexual partners is critical to the success of STD and HIV/AIDS prevention and control. AIMS: To understand factors influencing intention of STD patients to inform their regular sexual partners and identify predictors influencing actual return of the partners. SETTINGS AND DESIGN: A non-randomised survey of patients attending STD clinic in a district hospital between May and November 2000. METHODS AND MATERIAL: 182 patients were administered structured questionnaires to understand their intention to notify their regular sexual partners and encouraged to refer their regular sexual partners to the clinic for management. Factors related to intent to notify partners and actual partner referral were analysed. Statistical analysis used: Chi square test and forward stepwise logistic regression. RESULTS: Of the 182 STD patients 77.47% expressed their positive intention to notify their regular sexual partners. However, overall partner return rate was 40.65%. Patients from a better economic class (p=0.014), those who had sex since having the disease (p=0.001), those who felt it was easy to tell their partners (p=0.047) and perceived the necessity of investigating their partners (p<0.001) were more likely to have an intention to notify their partners. Independent predictors of actual return of sexual partners were patients' perception of partners' susceptibility (p=0.044), positive intention to notify partners (p=0.001), partners already informed before clinic visit (p=0.030) and presence of genital ulcerative diseases (p=0.033). CONCLUSIONS: STD clinic counselling and education should focus on risk reduction, partner susceptibility, role of STDs in HIV transmission and improving spousal communication.
Keywords: Adolescent, Adult, Aged, Analysis of Variance, Chi-Square Distribution, Cohort Studies, Female, Hospitals, District, utilization,Human, India, Interpersonal Relations, Logistic Models, Male, Middle Age, Multivariate Analysis, Outpatient Clinics, Hospital, utilization,Patient Acceptance of Health Care, statistics &numerical data,Primary Prevention, methods,Questionnaires, Risk Assessment, Sexual Partners, Sexually Transmitted Diseases, prevention &control,therapy,Support, Non-U.S. Gov′t, Ur
Notification and referral of sexual partners of patients presenting with a Sexually Transmitted Disease (STD) involves tracing the partner/s and advising them about their exposure, assessing risk and helping them to access appropriate treatment and counselling services. Partner notification (contact tracing) has traditionally remained an important tool in the management of STDs because it provides an opportunity for diagnosing asymptomatic cases and checking the spread of infection. Partner notification can be done by the patient himself or herself (patient-led referral), by health-care providers (provider-referral) or through combined efforts of both.
However, a vast majority of patients with STDs in developing countries receive treatment without getting adequate advice on partner notification. Availability of ‘over the counter’ drugs and reasons like inadequacy, undue delays and lack of faith in maintaining confidentiality in government clinics may result in drift of STD patients to private sector and unqualified or unskilled medical practitioners, who may not offer efficient counselling and health educational services along with STD management. This may limit subsequent partner investigation and pose difficulties in effective STD control.
A close association between STDs and prevalent and incident Human Immuno-deficiency Virus (HIV) infection has been reported., Need for appropriate investi-gation and treatment of sexual partners of male STD patients has been reported to be critical to curb the rapidly increasing incidence of HIV among married mono-gamous women., Patient-led partner referral could be considered as an important strategy because it addresses the issues of access to health care and communication on sexual matters in this vulnerable population. It is therefore important to identify the problems in patient-led partner notification and subsequent referral to health care facilities for investigation and management.
The study was aimed at identifying various socio-demographic and behavioural factors that could influence the intention of STD patients to inform their regular partners (spouses) about their disease and assessing the extent of spousal communication as seen by the proportion of partners of STD patients who returned to the clinic for further medical management.
The study was conducted at the STD outpatient clinic of the State Government-run District Hospital at Nashik between May and November 2000. The Ethical Committee of National AIDS Research Institute approved the study protocol. With a presumption that about 40 percent of STD patients would refer their partners (based on evidence in similar studies elsewhere9, 10, 11) and allowing for a variability of 15%, a sample size of a minimum of 150 was considered to yield 80% power to the study at 5% significance level.
Of the 240 new patients visiting the clinic, we interviewed 182 in the study who had regular sexual partners (defined as “persons who were in steady sexual relationships”) residing in the same city. Since this study was designed to identify factors influencing patient-led regular sexual partner notification and referral, we excluded patients with casual or one-time sexual partners. Informed consent was obtained from all the participants.
A pre-tested structured questionnaire was used to collect information on factors that could possibly influence patients’ willingness and unwillingness to inform their sexual partners about their disease. Participants were administered the questionnaire in their native language and on average the interview lasted for about 25 minutes. After the interview, counselling was given and advice regarding importance of partner communication and referral was provided. Patients were encouraged to bring their regular partners to the clinic for investigations in the next follow-up evaluation visit. From the second day after the study initiation, each STD patient reporting to the clinic was specifically asked whether he/ she referred his/ her partner to the clinic or his/her sexual partner referred him/her to the clinic. Thus linkages between patients and their partners were established. Partners were treated and counselled following procedures similar to the index cases.
Data was analysed using SPSS (version 10.0.5: SPSS. Inc., Chicago, IL) and EpiInfo 2000 (version 1.0, June 2000, CDC, Atlanta, GA). Univariate analysis was done to determine significant associations between socio-demographic, behavioural and psychosocial factors and the “intention” of STD patients to inform their regular partners as well as the “actual return” of regular sexual partners to the STD clinic. Chi square test was employed to assess the significance between associations and variables that were significant in univariate analysis were included in the multivariate model. Stepwise logistic regression method was used to build a multivariate model to assess independent associations between various factors and “intention to notify” as well as “actual partner return”.
Among 182 patients interviewed, a large majority were males (157, 86.3%). The distribution of the study participants according to the syndromic diagnosis is given in [Table - 1]. The outcome variables of interest were the percentage of patients having a positive intention to inform their regular partners, and the rate of actual partner return. The distribution of these outcomes of interest by gender is summarised in the same table. Of the 74 partners who returned, 46 (62.2%) were symptomatic and were treated appropriately.
Socio-demographic and behavioural variables that were observed to be independent predictors of intention to inform and the rates of actual partner referral are summarised in [Table - 2]. The outcome variables were analysed by age and gender, but we did not find any statistically significant difference in various categories.
Prevention and control of STDs is considered as an important strategy for prevention of HIV transmission. Effective STD control warrants emphasis on integration of prevention strategies and curative services. Since partner notification and referral and treatment of sexual contacts are crucial for STD control, research needs to address issues related to the barriers and facilitators of effective partner notification and spousal communication.
Ideally contact tracing in case of STD patients should include regular partners (spouses) as well as other partners like casual partners and sex workers. However, in resource-limited settings, individual patients (index cases) often are the only “outreach” mechanisms for contact tracing. It has been shown that individual counselling of STD patients has led to improved partner notification in developing countries. With this background, protection of the regular partners is often the operationally viable option and also an opportunity to restrict the secondary spread of HIV to unsus-pecting partners. Factors that might affect spousal communication and partner referral may vary in different regions and cultures and they must be recognized.
Our study on STD patients attending a district level government hospital-based clinic aimed at identifying factors that could influence and facilitate partner communication and partner return. Patient-led partner referral has been studied in other resource-limited settings including Uganda, Rwanda, the Central African Republic and Haiti, however no documentation of similar studies is found in the Indian scenario characterised by taboo on discussion on sex and sexuality, high rates of migration of adult population for work, multi-partner sex, illiteracy and lack of awareness and risk perception.
The rate of partner referral in our study was 40.65 % and this was found to be comparable to findings in other studies in developing countries.
Various theories of behavioural change in STD patients have been used to describe changes in behaviours in STD patients, including the Theory of Reasoned Action and the Health Belief Model. We have used broad constructs of these models (intention of performing desired action, desired behavioural change, sociodemographic determinants) to predict the factors influencing the decision of the index patients to inform their regular partners and refer them for evaluation and treatment.
Independent predictors or factors identified by us may provide clues to the physicians and counsellors about the prototype of patients who might have “intention to inform regular partner” and who might “actually refer their partners” and this might help them to direct counselling strategies in a focused direction. Overall it appeared that persons who displayed a positive intention to inform were also positively inclined to refer their partners. These patients also seemed to be more “health conscious” and “concerned” about the health of their partners. Furthermore, they recognized the risk they posed to their spouses and were ready to inform their spouses and get them investigated. Focusing efforts on such patients may result in definitive success in partner notification and referral.
Our study has some limitations that might affect the generalisation of our data. We restricted the scope of assessment of communication with sexual partners as reflected in patient-led partner notification and referral to spouse or other regular partner/s only. Further research needs to be done to identify differences and variations in factors affecting communication with non-regular partners. It is also essential to collect data on contacts or partners of STD patients and determine contact and epidemiological indices by doing more systematic studies in India.
It has been stated that behavioural prevention is today’s AIDS Vaccine. Appropriate person-specific messages on partner notification and partner referral based on experiences gained from such studies can be used during counselling and patient care. Efforts in prevention of secondary transmission of STDs would provide a significant contribution in prevention of HIV transmission in the long run. In absence of any legislation regarding provider-led partner referral, research on efficiency and cost-effectiveness of patient-led partner notification needs to be done to decide whether scaling up such activities would be useful, particularly in settings of limited resources and over-burdened health infrastructure.
Intramural funds from Indian Council of Medical Research.
[Table - 1], [Table - 2]