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Meta-Analysis
. 2013 Oct 3;2013(10):CD002843.
doi: 10.1002/14651858.CD002843.pub2.

Strategies for partner notification for sexually transmitted infections, including HIV

Adel Ferreira  1 , Taryn Young, Catherine Mathews, Moleen Zunza, Nicola Low
Affiliations
Meta-Analysis

Strategies for partner notification for sexually transmitted infections, including HIV

Adel Ferreira et al. Cochrane Database Syst Rev. .

Abstract

Background: Partner notification (PN) is the process whereby sexual partners of an index patient are informed of their exposure to a sexually transmitted infection (STI) and the need to obtain treatment. For the person (index patient) with a curable STI, PN aims to eradicate infection and prevent re-infection. For sexual partners, PN aims to identify and treat undiagnosed STIs. At the level of sexual networks and populations, the aim of PN is to interrupt chains of STI transmission. For people with viral STI, PN aims to identify undiagnosed infections, which can facilitate access for their sexual partners to treatment and help prevent transmission.

Objectives: To assess the effects of different PN strategies in people with STI, including human immunodeficiency virus (HIV) infection.

Search methods: We searched electronic databases (the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE) without language restrictions. We scanned reference lists of potential studies and previous reviews and contacted experts in the field. We searched three trial registries. We conducted the most recent search on 31 August 2012.

Selection criteria: Published or unpublished randomised controlled trials (RCTs) or quasi-RCTs comparing two or more PN strategies. Four main PN strategies were included: patient referral, expedited partner therapy, provider referral and contract referral. Patient referral means that the patient notifies their sexual partners, either with (enhanced patient referral) or without (simple patient referral) additional verbal or written support. In expedited partner therapy, the patient delivers medication or a prescription for medication to their partner(s) without the need for a medical examination of the partner. In provider referral, health service personnel notify the partners. In contract referral, the index patient is encouraged to notify partner, with the understanding that the partners will be contacted if they do not visit the health service by a certain date.

Data collection and analysis: We analysed data according to paired partner referral strategies. We organised the comparisons first according to four main PN strategies (1. enhanced patient referral, 2. expedited partner therapy, 3. contract referral, 4. provider referral). We compared each main strategy with simple patient referral and then with each other, if trials were available. For continuous outcome measures, we calculated the mean difference (MD) with 95% confidence intervals (CI). For dichotomous variables, we calculated the risk ratio (RR) with 95% CI. We performed meta-analyses where appropriate. We performed a sensitivity analysis for the primary outcome re-infection rate of the index patient by excluding studies with attrition of greater than 20%. Two review authors independently assessed the risk of bias and extracted data. We contacted study authors for additional information.

Main results: We included 26 trials (17,578 participants, 9015 women and 8563 men). Five trials were conducted in developing countries. Only two trials were conducted among HIV-positive patients. There was potential for selection bias, owing to the methods of allocation used and of performance bias, owing to the lack of blinding in most included studies. Seven trials had attrition of greater than 20%, increasing the risk of bias.The review found moderate-quality evidence that expedited partner therapy is better than simple patient referral for preventing re-infection of index patients when combining trials of STIs that caused urethritis or cervicitis (6 trials; RR 0.71, 95% CI 0.56 to 0.89, I(2) = 39%). When studies with attrition greater than 20% were excluded, the effect of expedited partner therapy was attenuated (2 trials; RR 0.8, 95% CI 0.62 to 1.04, I(2) = 0%). In trials restricted to index patients with chlamydia, the effect was attenuated (2 trials; RR 0.90, 95% CI 0.60 to 1.35, I(2) = 22%). Expedited partner therapy also increased the number of partners treated per index patient (three trials) when compared with simple patient referral in people with chlamydia or gonorrhoea (MD 0.43, 95% CI 0.28 to 0.58) or trichomonas (MD 0.51, 95% CI 0.35 to 0.67), and people with any STI syndrome (MD 0.5, 95% CI 0.34 to 0.67). Expedited partner therapy was not superior to enhanced patient referral in preventing re-infection (3 trials; RR 0.96, 95% CI 0.60 to 1.53, I(2) = 33%, low-quality evidence). Home sampling kits for partners (four trials) did not result in lower rates of re-infection in the index case (measured in one trial), or higher numbers of partners elicited (three trials), notified (two trials) or treated (one trial) when compared with simple patient referral. There was no consistent evidence for the relative effects of provider, contract or other patient referral methods. In one trial among men with non-gonococcal urethritis, more partners were treated with provider referral than with simple patient referral (MD 0.5, 95% CI 0.37 to 0.63). In one study among people with syphilis, contract referral elicited treatment of more partners than provider referral (MD 2.2, 95% CI 1.95 to 2.45), but the number of partners receiving treatment was the same in both groups. Where measured, there was no statistical evidence of differences in the incidence of adverse effects between PN strategies.

Authors' conclusions: The evidence assessed in this review does not identify a single optimal strategy for PN for any particular STI. When combining trials of STI causing urethritis or cervicitis, expedited partner therapy was more successful than simple patient referral for preventing re-infection of the index patient but was not superior to enhanced patient referral. Expedited partner therapy interventions should include all components that were part of the trial intervention package. There was insufficient evidence to determine the most effective components of an enhanced patient referral strategy. There are too few trials to allow consistent conclusions about the relative effects of provider, contract or other patient referral methods for different STIs. More high-quality RCTs of PN strategies for HIV and syphilis, using biological outcomes, are needed.

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Conflict of interest statement

Taryn Young and Catherine Mathews are co‐authors of studies cited in the Background section.

Nicola Low is a co‐author on one of the included RCTs and a systematic review that is cited in the Background and Discussion section.

Figures

1
1
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Flow diagram detailing the updated search and selection of studies.
4
4
Forest plot: 1 Enhanced patient referral versus simple patient referral, outcome: 1.1 Re‐infection in index patient, by STI.
5
5
Forest plot: 3 Expedited partner therapy versus simple patient referral, outcome 3.1 Re‐infection in index patients, by STI.
6
6
Forest plot: 3 Expedited partner therapy versus simple patient referral, outcome 3.2 Number of partners elicited.
7
7
Forest plot: 3 Expedited partner therapy versus simple patient referral, outcome 3.3 Number of partners notified.
8
8
Forest plot: 3. Expedited partner therapy versus simple patient referral, outcome 3.5 Number of partners treated.
9
9
Forest plot: 4 Expedited partner therapy versus enhanced patient referral, outcome: 4.1 Re‐infection in index patients.
10
10
Forest plot: 4 Expedited partner therapy versus enhanced patient referral: 4.2 Secondary outcomes.
11
11
Forest plot: 5 Contract referral versus simple patient referral, outcome: 5.1 Number of partners elicited.
1.1
1.1. Analysis
Comparison 1 Enhanced patient referral versus simple patient referral, Outcome 1 Re‐infection in index patient.
1.2
1.2. Analysis
Comparison 1 Enhanced patient referral versus simple patient referral, Outcome 2 Number of partners elicited.
1.3
1.3. Analysis
Comparison 1 Enhanced patient referral versus simple patient referral, Outcome 3 Number of partners notified.
1.4
1.4. Analysis
Comparison 1 Enhanced patient referral versus simple patient referral, Outcome 4 Number of partners presenting for care.
1.5
1.5. Analysis
Comparison 1 Enhanced patient referral versus simple patient referral, Outcome 5 Number of partners testing positive.
1.6
1.6. Analysis
Comparison 1 Enhanced patient referral versus simple patient referral, Outcome 6 Number of partners treated.
2.1
2.1. Analysis
Comparison 2 Enhanced patient referral versus other enhanced patient referral, Outcome 1 Partners elicited.
2.2
2.2. Analysis
Comparison 2 Enhanced patient referral versus other enhanced patient referral, Outcome 2 Number of partners presenting for care.
2.3
2.3. Analysis
Comparison 2 Enhanced patient referral versus other enhanced patient referral, Outcome 3 Number of partners treated.
3.1
3.1. Analysis
Comparison 3 Expedited partner therapy (EPT) versus simple patient referral, Outcome 1 Re‐infection in index patients.
3.2
3.2. Analysis
Comparison 3 Expedited partner therapy (EPT) versus simple patient referral, Outcome 2 Number of partners elicited.
3.3
3.3. Analysis
Comparison 3 Expedited partner therapy (EPT) versus simple patient referral, Outcome 3 Number of partners notified.
3.4
3.4. Analysis
Comparison 3 Expedited partner therapy (EPT) versus simple patient referral, Outcome 4 Number of partners presenting for care.
3.5
3.5. Analysis
Comparison 3 Expedited partner therapy (EPT) versus simple patient referral, Outcome 5 Number of partners treated.
3.6
3.6. Analysis
Comparison 3 Expedited partner therapy (EPT) versus simple patient referral, Outcome 6 Number of harmful events reported.
4.1
4.1. Analysis
Comparison 4 Expedited partner therapy (EPT) versus enhanced patient referral, Outcome 1 EPT vs. enhanced patient referral.
4.2
4.2. Analysis
Comparison 4 Expedited partner therapy (EPT) versus enhanced patient referral, Outcome 2 EPT vs. enhanced patient referral.
4.3
4.3. Analysis
Comparison 4 Expedited partner therapy (EPT) versus enhanced patient referral, Outcome 3 Enhanced patient referral plus EPT vs. simple patient referral.
5.1
5.1. Analysis
Comparison 5 Contract referral versus simple patient referral, Outcome 1 Number of partners elicited.
5.2
5.2. Analysis
Comparison 5 Contract referral versus simple patient referral, Outcome 2 Number of partners notified.
5.3
5.3. Analysis
Comparison 5 Contract referral versus simple patient referral, Outcome 3 Number of partners presenting for care.
5.4
5.4. Analysis
Comparison 5 Contract referral versus simple patient referral, Outcome 4 Number of partners testing positive.
5.5
5.5. Analysis
Comparison 5 Contract referral versus simple patient referral, Outcome 5 Number of partners treated.
5.6
5.6. Analysis
Comparison 5 Contract referral versus simple patient referral, Outcome 6 Number of harmful events reported.
6.1
6.1. Analysis
Comparison 6 Contract referral versus enhanced patient referral, Outcome 1 Number of partners elicited.
6.2
6.2. Analysis
Comparison 6 Contract referral versus enhanced patient referral, Outcome 2 Partners presenting for care.
6.3
6.3. Analysis
Comparison 6 Contract referral versus enhanced patient referral, Outcome 3 Partners testing positive.
7.1
7.1. Analysis
Comparison 7 Contract referral versus expedited partner therapy (EPT), Outcome 1 Re‐infection in index patient.
8.1
8.1. Analysis
Comparison 8 Provider referral versus simple patient referral, Outcome 1 Provider referral vs. simple patient referral.
8.2
8.2. Analysis
Comparison 8 Provider referral versus simple patient referral, Outcome 2 Choice between provider or simple patient referral vs. simple patient referral.
9.1
9.1. Analysis
Comparison 9 Provider referral versus enhanced patient referral (disease intervention specialist), Outcome 1 Number of partners elicited.
9.2
9.2. Analysis
Comparison 9 Provider referral versus enhanced patient referral (disease intervention specialist), Outcome 2 Number of partners testing positive.
9.3
9.3. Analysis
Comparison 9 Provider referral versus enhanced patient referral (disease intervention specialist), Outcome 3 Number of partners treated.
10.1
10.1. Analysis
Comparison 10 Provider referral versus contract referral, Outcome 1 Number of partners elicited.
10.2
10.2. Analysis
Comparison 10 Provider referral versus contract referral, Outcome 2 Number of partners presenting for care.
10.3
10.3. Analysis
Comparison 10 Provider referral versus contract referral, Outcome 3 Number of partners located.
10.4
10.4. Analysis
Comparison 10 Provider referral versus contract referral, Outcome 4 Number of partners tested.
10.5
10.5. Analysis
Comparison 10 Provider referral versus contract referral, Outcome 5 Partners testing positive.
10.6
10.6. Analysis
Comparison 10 Provider referral versus contract referral, Outcome 6 Number of partners treated.
10.7
10.7. Analysis
Comparison 10 Provider referral versus contract referral, Outcome 7 Number of harmful events reported.
See this image and copyright information in PMC

Update of

References

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Colvin 2006 {published data only}
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Cassell 2010 {published data only}
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