HIV Partner notification: a neglected intervention

1
HIV Partner notification a neglected
intervention?

• Melanie Ottewill.
• Senior health advisor, Claude Nicol Centre,
  Brighton.

2
Background

• Lack of research into HIV PN effectiveness
  studies outdated and inconclusive. (8 out of 9
  USA published studies conducted before HAART)
• Most studies that exist set in USA ?comparable
  populations.
• Conflicting evidence regarding willingness of
  patients to engage and which methods most
  effective
• Useful UK study (1998) by Fenton et al evaluating
  HIV PN in 19 STD clinics in UK .

3
Context

• DoH (1992) guidance on HIV PN encouraged
  notification and local policies.
• SSHA does not set a standard for HIV PN outcome
  (lack of evidence)
• BASHH guidelines on HIV testing in general
  medical settings does not mention PN.
• Criminalisation of HIV scrutiny of PN practice
  accountability.
• HAART proven impact on mortality, morbidity
  possibly transmission create strong impetus for
  proactive PN.

4
Baseline audit - objectives

• To evaluate the effectiveness of PN in HIV new
  diagnoses.
• To identify differences, if any, between
  different groups of patients.
• To identify opportunities for improvement.
• To discuss setting a standard for HIV PN.

5
Population

• New HIV diagnoses in 2003 108.
• Sample approximately 50 of
• MSM (31)
• Black African men (5)
• Black African women (8)
• White heterosexual (3)
• N 47.

6
Diagnosis Details

• 13 had primary HIV infection 9 of whom had
  primary resistance.
• 7 had an AIDS diagnosis 6 of whom were
  in-patients.
• 23 were asymptomatic (E1).
• 4 were symptomatic (E2).

7
Partner Notification

• 43/47 (91) patients were seen by a HA.
• 15 seen once.
• 20 seen twice.
• 6 seen 3 times.
• 2 seen 4 times or more.
• PN was discussed with 36/43 (84).
• Completed PN was documented in 26/43 (60).

8
Partner Notification

• In those where PN not completed (21) PN was
  raised by other HCPs in 6 (29) but was not
  completed in any.

9
Regular Partners

• 36/47 (77) had regular partners.
• Range 1 to 4, total no. of partners 44.
• 11 known to be HIV
• 19/33 (58) RPs were reported to have tested
• Result known for 15/19 (79)
• 5/15 (33) tested HIV.

10
Casual Partners

• 29/47 (62) had CPs.
• Range 1 to 12, total of 60.
• 13/60 (22) were contactable.
• 8/13 (61) were contacted.
• 3 by provider referral.
• 6/8 (75) were documented to have tested.
• None were HIV.

11
Contacts per case tested

• Denominator 104 (total number of casual and
  regular partners, including uncontactable).
• Number tested 36 (casual and regular partners).
• Contacts screened per case 0.35
• (BASSH standard for GC or CT is 0.6).

12
Partner Notification(by stage of diagnosis)
13
Partner Notification(by risk factor)
14
PN Completed
15
Conclusions from baseline audit

• Most pts (91) seen by HA following diagnosis.
• PN discussed with 84 pts (more than 1 appt
  needed).
• PN outcomes documented in 60 cases (0.3 contacts
  per case).
• PN rarely raised by other professional groups.
• 1/3 untested RPs tested HIV (5/15). Reflects
  prevalence of HIV in community.

16
Recommendations from baseline audit

• Health Advisers to keep pts on recall system
  until PN completed (chlamydia/Gc).
• Health Advisers to aim to see all newly diagnosed
  pts at least twice.
• Health Adviser to review all pt notes attending
  New pt clinic to follow-up PN.
• Health Adviser HIV PN guidelines to be written.
• Review 10 sets of notes every 3 mths to evaluate
  progress (using a defined audit tool) .
• ?Standard for HIV PN yes, after further
  evaluation.

17
Mini PN Audit

• Case note review from 1/09/2004 to 31/12/2004
  (recommendations implemented from August 2004).
• Audit against new HA guidelines /audit tool
• Random sample of 36

18
Partner Notification2004
19
Regular Partners

• 83 (30/36) had regular partners (77)
• Total no. of partners 33 (44)
• 5(15) known to be HIV (25)
• 19/28 (68) RPs were reported to have tested
  (58)
• 9/19 (47) tested HIV (33)

20
Casual Partners

• 21/36 (58)had CPs (62)
• Total of 74 (60)
• Majority uncontactable as with last audit
• 5/74 (7) were documented to have tested (10)
• 3 were HIV positive 2 known HIVve (none )

21
In summary

• HIV PN guideline clarifies approach and
  importance of this activity
• Audit tool (evolving) useful in measuring
  performance facilitating change
• Reviewing 10 case notes every 3 months is not
  labour intensive and facilitates ongoing change
• Improvement in discussion of, completed, PN
  (88 vs 55 )

22
Summary - cont

• Reduction in number of patients only seeing HA
  once (16 vs 32)
• High rate of RMP who tested diagnosed HIV (47
  vs 33)
• Contacts tested per case remains low 0.27 (0.35
  previously)
• Proposed outcome standard for HIV 0.3 locally
• Evidence from other clinics?