Abstract
Partner notification and treatment are essential to sexually transmitted infection (STI) management. However, in low- and middle-income countries, half of partners do not receive treatment. A mixed methods study was conducted to explore experiences and preferences around partner notification and treatment in patients seeking STI care in Gaborone, Botswana. Thirty participants were administered a quantitative survey, followed by a semi-structured interview on partner notification, treatment, and expedited partner therapy (EPT). Among the 30 participants, 77% were female with a median age of 28 years (IQR = 24–36), 87% notified their partner, and 45% of partners requiring treatment received treatment. Partners who received a contact slip were more likely to have been treated than those who did not (75% vs. 25%). Contact slips were identified as facilitators of notification and treatment, while asymptomatic partners and limited clinic resources were identified as barriers to treatment. Few participants expressed a preference for EPT and concerns included preference for medical supervision, a belief their partner would refuse, and an inability to explain the treatment. Despite successful notification, partner treatment was modest within this population. Information for partners, provider counseling, and improved access to services may increase partner treatment. Education on STIs and treatment options may improve EPT acceptability.
Introduction
Partner notification and treatment are essential to the successful management of sexually transmitted infections (STI). 1 Identification and treatment of the sex partners of individuals diagnosed with an STI may prevent complications in partners, reduce the risk of reinfection to the index patient, and interrupt the chains of transmission in sexual networks, thereby reducing the prevalence of STIs.2–4
The World Health Organization Africa Region has the highest prevalence of gonorrhea and syphilis; chlamydia in men; trichomoniasis in women; and the highest global burden of HSV-related genital ulcer disease.5,6 Recent research in low- and middle-income countries suggests that low numbers of exposed partners receive treatment.7,8 In order to address the high burden of STIs, improved strategies for partner notification and treatment are needed.
The most common approaches to partner notification are patient-based tracing, provider-based tracing, and a mixed approach whereby a patient notifies partner(s) with the help of a provider.8,9 There are two main approaches to partner treatment: a traditional approach, in which the partner is seen by a healthcare provider to receive treatment, and expedited partner therapy (EPT), in which the partner receives treatment without needing to see a provider.8,9 No single approach has been identified as the gold standard and services may need to be tailored to the populations and systems within which they operate.
The standard of care in Gaborone, Botswana, our study location, is syndromic management, in which signs and symptoms are used to categorize STIs into syndromes that are treated with a standard antibiotic regimen. 10 Etiologic testing is not routinely performed. National STI guidelines instruct providers to encourage patient-based partner notification and to offer contact slips for index patients to pass on to all sex partners. 11 A contact slip includes the patient’s diagnosis, facts about STIs, and instructions to seek care. Partners may take the contact slip to local clinics for treatment. National guidelines recommend contact slips for all patients diagnosed with an STI, including those for which partner treatment is not recommended (e.g., genital warts). EPT is not routinely performed.
This mixed methods study seeks to explore patient experiences and preferences related to partner notification and treatment, as well as the perceived acceptability of alternative methods for notification and treatment, including EPT. We aim to inform future approaches to STI care and research by identifying possible facilitators and barriers to partner notification and treatment, and by establishing baseline knowledge to guide the potential future implementation of EPT in Botswana.
Methods
Participant selection
Between February and March 2018, study staff recruited a convenience sample of men and women for participation in a government STI clinic in Gaborone. Recruitment took place on Monday and Tuesday mornings. Eligibility criteria included (1) being at least 18 years of age and (2) seeking care for an STI or STI-related symptom (e.g., abnormal vaginal discharge, painful urination, genital ulcer, and genital wart). At the start of each day, all patients in the waiting room were informed of the study. Those interested in participation were directed to a private room where they were provided with more information about the study and, if interested and eligible, were asked to give written informed consent.
Data Collection
Prior to enrollment, an interview guide with both closed- and open-ended questions was developed. The question domains were chosen based on factors identified in previous research as being associated with partner notification and treatment outcomes in low- and middle-income countries. 7 Closed-ended quantitative questions collected information on sociodemographic characteristics, sexual partner status and history, HIV status, and utilization of STI services in the past year. When applicable, responses were verified by reviewing patient-held medical records. Open-ended qualitative questions collected information on relationship background, partner communication, partner notification, partner treatment, facilitators of and barriers to notification and treatment, future preferences for notification and treatment, and attitudes toward EPT. The interviews were conducted one-on-one in the participant’s language of choice (English or Setswana) by one of two female research assistants, both of whom had a university degree, training in qualitative methods, and extensive experience interviewing on sexual and reproductive health issues.
The interview guide was pilot tested for three participants and minor revisions were made to the qualitative section on multiple partners in order to ensure sufficient details were captured for each partner. While the sample size of 30 was chosen in advance based on budgetary and logistical constraints, thematic saturation was monitored as new ideas or themes were discussed weekly by the study team. By the end of enrollment, no new themes or ideas were identified.
Interviews lasting 20–30 min were digitally recorded, transcribed verbatim, and translated to English. An additional three interviews were randomly selected to be translated independently by another researcher to identify and resolve discrepancies, but only minor changes were made.
Data analysis
We assessed correlates of partner notification via bivariate comparisons using Fisher’s exact test for categorical variables and Wilcoxon–Mann–Whitney test for continuous variables. Interview transcripts were read by four researchers to develop a codebook based both on the interview guide domains and emerging themes from the data. 12 The independently developed lists of codes were compared and compiled into a master codebook with codes and definitions. All transcripts were read and coded by three research assistants using Dedoose. 13 The resulting codes were compared and minor edits were made to the codebook. This process was repeated to create a final set of coded transcripts. Codes were exported and analyzed in Excel for frequency and patterns of use and illustrative quotations were extracted.
Ethics
The institutional review boards at the University of Botswana (URB/IRB/1547), the Botswana Health Research Development Committee (PPME 13/18/1 IX(434)), and Princess Marina Hospital (PMH 5/79(223-3–2016)) approved the study protocol. The University of California, San Diego, provided an exemption for analysis of existing, de-identified data.
Results
Quantitative
Characteristics of participants and partner notification/treatment outcomes at an STI clinic in Gaborone, Botswana (N = 30).
aAmong those who required treatment (n = 20).
bAmong those with a partner.
cAmong primary partners.
dNot including current visit. Percentages may not add to 100 due to rounding.
Among the 30 participants, 26 (87%) reported notifying their partner(s) of their diagnosis. (Table 1). Higher percentages of partner notification were reported in participants who did not have multiple partners (92% vs. 50%), who lived with their partner (100% vs. 78%), had a tertiary level of education (100% vs. 78%), or who were employed (94% vs. 79%).
Among the 20 participants who had symptoms other than genital warts alone, nine reported that their partners were treated (45%), nine reported that their partners were not treated (45%), and two were not sure (10%). (Table 1). In this subset of participants with a diagnosis requiring partner treatment, higher percentages of partner treatment were reported in those who were male (67% vs. 41%), employed (67% vs. 27%), or had a current partner (54% vs. 29%).
Despite the Botswana standard of care recommendation for the use of contact slips for all patients diagnosed with an STI, including genital warts alone, only 14 participants (46.7%) received a contact slip from their provider. Ten of the fourteen (71.4%) reported giving their partner the contact slip. Among the 20 partners eligible for treatment, 6 of 8 partners (75%) that received a contact slip were treated compared to 3 of 12 partners (25%) that did not receive a contact slip.
Notification experiences
Among those who notified their partners of an STI, most told them in-person and one person notified over the phone. Two participants took their partners with them to the clinic. The most common reason for notifying partners was the presence of symptoms or to provide a reason for refusing sex: “…maybe he was going to want us to have sex, so I had to tell him.” (Participant 26, Female, 21yrs) “I knew she was obviously going to know [on why he told his partner about warts].” (Participant 6, Male, 24yrs)
Among the four participants who did not notify their partners, one reported no current partner, one was not sure if their discharge was due to an STI, one planned to tell her partner in the future, and one did not think her partner was infected. While two women reported that their partners had previously been violent in the relationship, no participants reported a violent or angry partner reaction to partner notification. Several people reported that persistent STI-related symptoms were a source of relationship turmoil. “Because at the end of the day, the person becomes suspicious that you are sick and I’m not.” (Participant 5, Female, 36yrs) “I’m asking myself why am I not getting cured… I told him you can see that I’m faithful so who’s coming with the illness, obviously it’s you right.” (Participant 15, Female, 27yrs)
Barriers and facilitators to notification
The majority of the facilitators to partner notification related to provider counseling of the index patient. Several participants cited information from their provider that underscored the importance of notification. “They told me it’s important he gets treatment… because if he doesn’t and I continue sleeping with him it will keep reoccurring in me.” (Participant 17, Female, 20yrs) “[The doctor] said this thing is not something that you can get home and fight about… you must just sit down and talk about it.” (Participant 10, Female, 27yrs)
Additionally, contact slips were a frequently identified facilitator of notification. Participants, particularly men, emphasized their role in lending legitimacy to the conversation and ensuring their partner believed them. “I believe it is important to be given something that you can show your partner what you are talking about so that they can believe you.” (Participant 29, Male, 29yrs)
A minority of participants identified barriers to notification. Barriers that were raised included blame and/or stigma. “I could not tell him because he would go around spreading rumors about me.” (Participant 7, Female, 31yrs) “He blames who? Me. Because I was open and told him, but he wasn’t open with me.” (Participant 15, Female, 27yrs)
Barriers and facilitators to treatment
Contact slips were additionally identified as the primary facilitator of partner treatment. Many participants who were not given a contact slip and whose partner was not treated believed treatment would have been more likely if they had received a contact slip.
Conversely, approximately half of participants identified barriers to treatment. Barriers could be classified as pertaining to (1) clinic resources, (2) asymptomatic partners, or (3) partner characteristics.
Half of the identified barriers to treatment related to clinic resources, such as operating hours and the availability of tests and medication. “I don’t know what to do because they don’t have even the resources for my partner to also come and get tested.” (Participant 5, Female, 36yrs) “I gave him my card and showed him where he should go… but the doctor was not there that day and he went back home.” (Participant 11, Female, 48yrs)
Many participants noted that their partners were asymptomatic and cited a common belief that an absence of symptoms signified that treatment was not necessary. “No [I did not give him the contact slip], because I was sure he is not sick.” (Participant 7, Female, 31yrs) “He hasn’t been treated because he doesn’t have the symptoms… It is difficult to tell someone ‘you are sick’ but you have no evidence this person is sick.” (Participant 5, Female, 36yrs)
As with partner notification, individual partner characteristics acted as a barrier to treatment for certain participants. “He is a difficult person, he wouldn’t want us to talk about health issues, he used to say that he won’t be infected with any diseases.” (Participant 19, Female, 23yrs)
Future preferences for partner notification
Participants were presented with four possible ways to notify partners in the future and asked to explain their preferences. These included (1) direct notification by the participant, (2) notification by a provider, (3) sharing a video of a doctor explaining the diagnosis, or (4) an anonymous SMS text message sent to the partner. For both their partners and themselves, participants preferred more direct methods and disliked SMS and video options.
There was a strong preference for direct partner notification by the participant, with 17 participants preferring this method (56.7%) and an additional 8 (26.7%) preferring a combination of direct notification and provider notification. “I take it that he would believe more of what is being said if he heard it from me.” (Participant 17, Female, 20yrs) “I would tell her myself because if she hears it from the doctors she will lose all trust in me.” (Participant 14, Male, 52yrs)
Additionally, there was a strong preference against notification via an anonymous SMS text message or a physician video, with 14 (46.7%) and 9 (30%) participants, respectively, citing this method as their least preferred of the four. Opposition related largely to the anonymity and clarity. Only one participant preferred each of these methods. “The anonymous one is not good… because you don’t have any information… he can ignore it.” (Participant 15, Female, 27yrs) “You understand someone talking to you better than a video.” (Participant 27, Female, 27yrs)
Participants were also asked about their preference for being notified if their partner was diagnosed with an STI. There was a decisive preference among participants for being notified directly by their partner, with 19 of the 23 participants asked expressing this view (82.6%).
Attitudes toward EPT
While a majority of participants did not outright reject the possibility of using EPT in the future, most expressed skepticism and would prefer for their partner to be treated in a clinic. Opposition to EPT was more common amongst female participants, while male participants were more evenly divided.
One common reason for this opposition was a belief that their partner was responsible for seeking treatment themselves. “I’m talking about someone else’s feelings. You can’t make decisions for someone even if you think you know them.” (Participant 13, Female, 36yrs) “Why is he at home if we are both sick? We have to go together.” (Participant 20, Female, 23yrs)
Among female participants, there was a belief that their partner would refuse the treatment if it came from the participant. No male participants expressed a similar concern. “He would feel I am lying, that it is not his pills. He is just difficult.” (Participant 9, Female, 23yrs) “He is going to refuse. He would tell me why didn’t they say I should come with you. He believes that he should also be told, be counselled, be told to do one, two, three.” (Participant 3, Female, 37yrs)
Additionally, many participants expressed doubts in their ability to correctly deliver the treatment, and a desire for a healthcare provider’s supervision. “I will explain to him the way that I understood it. But it’s better for him to come and understand it the way he will understand it, to come and find out for himself.” (Participant 5, Female, 36yrs) “I would prefer her to go and see the doctor… Because the doctor would be able to monitor her, to see if the treatment they are giving her is useful.” (Participant 30, Male, 24yrs)
Participants held similar views when asked about receiving EPT if their partner were to bring it to them. Most patients were open to the possibility of EPT but would prefer to receive treatment directly from the clinic rather than through their partner. The reasons provided were consistent with opinions expressed regarding EPT for their partner. “I would want to be told and then go to the doctor, because the doctor would give me more information than my partner, maybe because he would think I will get angry and throw tantrums.” (Participant 12, Female, 24yrs)
Several participants (all female) were against bringing EPT to their partner, but were open to receiving EPT themselves. “With me [EPT] will be ok but to him maybe it will feel like an insult… because he’ll tell them “did you diagnose me, did you find out that I’m sick or not?” (Participant 5, Female, 36yrs)
Discussion
Our study evaluated the experiences and preferences regarding partner notification and treatment among patients seeking care at an STI clinic in Gaborone, Botswana. Most participants reported notifying their partners; however, less than half of partners requiring treatment received treatment. Healthcare provider counseling and contact slips were identified as facilitators to notification and treatment. Barriers to treatment included limited clinic resources and asymptomatic partners. While participants were open to EPT, the vast majority would not choose this method. Concerns regarding EPT included not wanting to make decisions for partners, anticipating partner refusal, and preferring the supervision of a healthcare provider.
Our finding that many partners did not receive treatment is consistent with previous studies in other LMICs. 7 A recent study among pregnant women in Botswana found that although 84% of women notified partners about an STI diagnosis, only 63% reported that their partners received treatment.14,15 This study was included in a review on partner notification and treatment in sub-Saharan Africa, which found that, among successfully notified partners, only 25% (range: 0–77%) sought treatment. 7 Thus, more efforts are needed to ensure that partners are appropriately notified and treated.
Information to take to partners, provider counseling, and access to clinic services facilitated both notification and treatment. Our data suggest contact slips in particular may be a low-cost, high-impact intervention in this setting, when used consistently. This is in line with prior research in Southern Africa, suggesting enhanced counseling, contact slips, extended clinic hours, and expedited clinic flow for sex partners increased partner notification and treatment.16,17 Additionally, a systematic review found that supplemented notification strategies, such as providing educational information for partners, were as effective in preventing reinfection as EPT. 9 Our study provides further evidence that such low-cost interventions may increase partner treatment.
Due to the COVID-19 pandemic, there is increased interest in automated notification strategies for reducing strain on the healthcare system. 18 While there is evidence for acceptability of digital notification in high-resource settings, 19 our participants did not prefer these options over in-person notification. Further, while EPT may overcome barriers to accessing care and reduce the strain on healthcare workers, participants in our study expressed hesitancy for this method, including concern that they would not have sufficient information for partners. Previous EPT research ranged from high acceptability and feasibility 20 to near unanimous rejection. 15 As this study took place in a setting where digital notification and EPT are not routine, increased education on STIs and treatment options may increase acceptability and feasibility of EPT.
This study had several limitations. First, our sample size was small and was not guided by thematic saturation. While we believe we achieved data saturation, 21 true saturation may not have been reached, thus limiting the generalizability of our findings outside our study sample. Additionally, not all conditions required partner treatment, reducing the sample size further. Second, our data are based on responses from index patients only and therefore cannot draw conclusions about partners’ perspectives on treatment. Third, the definition of “current sexual partner” was ambiguous in our survey and may have influenced the number of participants reporting partner notification and treatment. Finally, there is potential for response bias; however, given the extensive nature of the interviews and the corroborating details provided therein, this is less of a concern.
In conclusion, our study found that most participants notified their partners about an STI diagnosis; however, fewer reported that their partners received treatment. Participants expressed strong preferences for notifying partners in-person and identified provider counseling and contact slips as facilitators to both notification and treatment. While participants were open to the possibility of EPT, the vast majority would not choose this method. Future studies should examine the effectiveness of enhanced partner notification counseling and contact slips on partner treatment uptake. Finally, efforts to expand access to EPT and other novel treatment methods may need to be accompanied by increased patient and public education to counter identified barriers.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
