BASHH 2018 UK national audit of HIV partner notification

Abstract

HIV partner notification (PN) is a highly effective strategy to identify people living with undiagnosed HIV infection. This national audit of HIV PN is against the 2015 British Association of Sexual Health and HIV (BASHH)/British HIV Association (BHIVA)/Society of Sexual Health Advisers (SHAA)/National AIDS Trust (NAT) HIV PN standards, developed in response to the 2013 BASHH/BHIVA national HIV PN audit. We report significant improvements in the number of contacts tested per index case, likely due, in part, to clearer definitions as well as better ascertainment and reporting. There remains scope for improvement with informing and testing contactable contacts. Recommendations from this audit include further refinement of definitions and development of a national proforma for HIV PN.

Keywords

Partner notification HIV prevention audit

Background

Partner notification (PN) remains a key public health intervention for the control of sexually transmitted infections (STIs) and is an effective tool for accessing some of the estimated 7500 people who are living with HIV in the UK who are unaware of their status.¹ Those with undiagnosed HIV are at higher risk of late diagnosis² and associated increased morbidity and mortality³ and risk of onward transmission.⁴ The UK has committed to achieving zero HIV transmissions by 2030; as the number of HIV diagnoses continues to decline, with decreasing cost effectiveness of wide scale testing, HIV PN will become increasingly key to achieving this goal. Additionally, people living with HIV who maintain an undetectable viral load on antiretroviral therapy (ART) do not sexually transmit HIV infection,⁵ and so by ensuring patients are aware of their diagnosis and commenced on ARV in a timely fashion, PN can also contribute to preventing incident infections. In the UK, the National Institute for Health and Care Excellence (NICE) recommends that services have processes in place to ensure that people who may have been exposed to HIV by a person newly diagnosed with HIV are identified and offered an HIV test.⁶

Standards for HIV PN for adults⁷ were launched in 2015 having been developed following review of the results of the British Association of Sexual Health and HIV/British HIV Association (BHIVA) 2013 national HIV PN audit⁸ and a multi-stakeholder consultation. The audit demonstrated the effectiveness of PN for diagnosing HIV, with a prevalence of newly diagnosed HIV among the contacts who were tested of 20.9%. However, it also highlighted some inconsistencies in approach between centres, a lack of clarity around definitions and how to categorise some contacts in addition to large regional variations in performance.

We describe the 2018 national audit against the 2015 standards, some of which had never been assessed by a national audit previously.

Methods

All UK level 3 genito-urinary medicine (GUM) and integrated sexual health services were invited to participate, as were all HIV treatment services via the BHIVA Audit and Standards Committee (although it did not form part of the formal BHIVA audit work plan). Data were collected via an online tool (LimeSurvey GmbH, Hamburg, https://www.limesurvey.org) between 23 January and 12 March 2018. The audit consisted of two parts: a survey collecting information about the clinic’s role in partner notification, and a clinical audit consisting of a retrospective case-note review. Services were asked to review 40 cases, selected in reverse consecutive order on all adults (>16 years) newly diagnosed with HIV infection during 2016 or 2017 (index cases).

Data collected included demographic information and HIV testing history. Information was then collated regarding the PN processes and outcomes.

The definitions used in this audit were as described in the 2015 Standards.

The primary auditable outcomes were as follows:

The number of contacts tested per total number of index cases (i.e. the number of status-known contacts + number of status-unknown contacts tested/total number of index cases).

Comparison was made with the standard ratio of 0.6 for healthcare professional (HCP) verified tests and 0.8 for index case reported (ICR) or healthcare worker verified tests.

The proportion of contactable partners tested (i.e. the number of status-known contacts + contactable status-unknown contacts tested/total number of status-known contacts + contactable status-unknown contacts).

2. Comparison was made with the standard proportion of 65% healthcare professional verified (HCPV) or 85% HCP or index case verified as having tested.

3. The proportion (%) of index cases for whom there is a documented PN plan in the case notes within four weeks of the date of the index case diagnosis (standard: 97%).

4. The proportion (%) of index cases with documented evidence of PN discussion at the time of diagnosis to determine if any at risk contact had occurred within previous 72 h in order to identify and refer partners potentially eligible for post-exposure prophylaxis (PEP) (standard: 97%). Post hoc analysis including those who did not require PN and/or PN was already resolved was also performed.

Comparison was made overall and also for men who have sex with men (MSM), heterosexual males and heterosexual females.

Concerns were raised by some data suggesting influential outliers. Therefore, the analyses were re-run for outcomes 1 and 2 after removing these individuals; see the Discussion section.

Results

Survey responses were received from 149 sites including 11 non-GUM services; 131 (88%) undertake HIV PN with the majority of services (n = 123, 83%) also providing ongoing HIV treatment and care. A small proportion of services described shared care of HIV patients between genito-urinary services and HIV services (n = 9, 6%).

The case-note audit reported on 2753 individuals with new HIV diagnoses (Table 1). Of these, 2139 (77.6%) were male and 1474 (53.5%) were MSM (Table 2). Cases were predominantly white (65.3%) and over the age of 30 (71.2%). The median age was 37 (range 16–86). Overall, 576 (20.9%) of index cases were likely to have recently acquired their HIV infection (within the preceding 6 months) as demonstrated by the recent infection testing algorithm (RITA): 439 (29.6%) of MSM and 117 (10.8%) of heterosexuals (60 male, 56 female and 1 unknown).

Table 1.

Index case demographics.

	Number (%)
Current gender
Male (including 2 trans men)	2122 (77.1)
Female (including 10 trans women)	597 (21.7)
Non-binary or others	1 (0.0)
Not answered	33 (1.2)
Total	2753 (100)
Ethnicity
White	1798 (65.3)
Black African	401 (14.6)
Others	482 (17.5)
Not stated/not answered	72 (2.6)
Total	2753 (100)
Exposure
MSM	1485 (53.9)
Heterosexual	1084 (39.4)
PWID	30 (1.1)
Others	51 (1.9)
Not known/answered	103 (3.7)
Total	2753 (100)
Age (years)
16–19	41 (1.5)
20–29	705 (25.6)
30–39	783 (28.4)
40–49	622 (22.6)
50–59	388 (14.1)
>60	168 (6.1)
Not stated	46 (1.7)
Total	2753 (100)

MSM: men who have sex with men; PWID: people who inject drugs.

Table 2.

Outcomes of status-known contacts.

Status-known contacts per index case	All index cases, N = 2753	MSM, N = 1474	M heterosexual, N = 517	F heterosexual, N = 562
Number of status-known contacts (status-known contacts per index case)	1848 (0.67)	1067 (0.72)	299 (0.58)	350 (0.62)
Number of contacts who tested HIV positive before index case diagnosis (tested HIV positive before index case diagnosis per index case)	845 (0.31)	491 (0.33)	146 (0.28)	159 (0.28)
Number of contacts who tested HIV negative >4 w after last possible exposure but before index case diagnosis (tested HIV negative before index case per index case)	933 (0.34)	559 (0.38)	137 (0.26)	158 (0.28)
Number of contacts who were deceased (deceased contacts per index case)	70 (0.03)	17 (0.01)	16 (0.03)	33 (0.06)

MSM: men who have sex with men.

Nationally, the majority of cases reported a total of one or two contacts; however, 18% of MSM index cases reported six or more contacts (Figure 1). An average cannot be calculated because this would be swayed by a small minority of index cases with large but imprecise numbers of contacts (16 had an estimated 100 or more contacts).

Figure 1.

Number of contacts reported per index case. *>6 is used as a minority reported large but imprecise contact numbers. MSM = men who have sex with men.

Outcome 1: The number of contacts tested per total number of index cases 0.6 HCP and 0.8 HCP plus ICR

This standard was achieved overall and for all groups. Overall HCPV performance was 0.9 (2477 contacts/2753 index cases), and HCPV + ICR was 1.03 (2836 contacts/2753 index cases). Analysis of subgroups revealed that for HCPV and HCPV + ICR respectively, performance for MSM was 0.98 (1441/1474) and 1.15 (1691/1474); for heterosexual males, they were 0.89 (414/517) and 0.89 (462/517), and for heterosexual females, 0.8 (451/562) and 0.88 (496/562) (contacts/index cases, respectively).

After removing the outliers as discussed in the Methods section, the number of contacts tested per total number of index cases was 0.83 HCP and 0.96 HCP plus ICR.

Outcome 2: The proportion of contactable partners tested. Standards: 65% HCPV, 85% HCPV plus ICR.

This standard was not met overall; it was achieved for HCPV tests for heterosexuals. Overall HCPV was 63.6% (2477/3894), and HCPV+ICR was 72.8% (2836/3894). Analysis of subgroups revealed that for HCPV and HCPV + ICR respectively, performance for MSM was 59.0% (1441/2443) and 69.2% (1691/2443); for heterosexual males, they were 70.9% (414/584) and 79.1% (462/584), and for female heterosexuals 71.1% (451/634) and 78.2% (496/634).

After removing the outliers as discussed in the Methods section, the number of contacts tested per total number of index cases was 62.1% HCPV and 71.9% HCPV plus ICR.

Outcome 3: The proportion (%) of index cases for whom there is a documented PN plan in the case notes within four weeks of the date of the index case diagnosis (standard: 97%).

This standard was not achieved with an overall performance of 80.4% (2214/2753): 81.4% (1209) MSM, 79.9% (413) male heterosexuals and 79.5% (447) female heterosexuals. However, if this measure includes those who did not require PN and/or PN was already resolved in the numerator, the performance improves to 93.5% (2574) overall and 93.6% (1390) for MSM, 94.2% (487) for male heterosexuals and 93.6% (526) for female heterosexuals, all still below the standard.

Outcome 4: The proportion of index cases with documented evidence of PN discussion at the time of diagnosis to determine if any at risk contact had occurred within previous 72 h in order to identify and refer partners potentially eligible for PEP (standard: 97%).

The standard was not achieved overall, nor for any subgroup. Overall performance was 69.4% (1910) with 70.1% (1041) MSM, 72.1% (373) male heterosexuals and 67.4% (379) female heterosexuals.

The outcome numerators include contacts whose HIV status (both negative and positive) is already known before the index case was diagnosed (albeit not necessarily by the case). Table 2 demonstrates the break-down of status-known contacts.

After removing the outliers as discussed in the Methods section, the total status-known contacts per index case was 0.6, of which status-known positive was 0.29, status-known negative 0.28 and deceased 0.03.

A total of 2046 contacts with unknown HIV status were identified as being potentially contactable (see standards for definition⁷). Table 3 shows that among these 2046 contacts, nearly half (48.3%) were verified or reported as having tested as a result of PN, and 4 in 5 (79.9%) were made aware of the need to test (i.e. notified or reported as having tested). More contacts were reported as having tested for heterosexual index cases, whilst a higher proportion of MSM contacts were notified but with the testing outcome unknown.

Table 3.

Notification and testing rates of HIV-status-unknown contactable contacts.

	All index cases, n = 2046 (%)	MSM, n = 1376 (%)	Heterosexual
	All index cases, n = 2046 (%)	MSM, n = 1376 (%)	Male, n = 285 (%)	Female, n = 284 (%)
Tested
HCP verified	629 (30.7)	374 (27.2)	115 (40.4)	101 (35.6)
ICR	359 (17.5)	250 (18.2)	48 (16.8)	45 (15.7)
Total tested	988 (48.3)	624 (45.3)	163 (57.2)	146 (51.4)
Notified but not known to have been tested	647 (31.6)	474 (34.4)	69 (24.2)	79 (27.8)
Notified or tested	1635 (79.9)	1271 (79.8)	810 (81.4)	793 (79.2)

ICR: index case reported; HCP: healthcare professional; MSM: men who have sex with men.

Table 4 demonstrates the reported and verified testing outcomes of previously status-unknown contactable contacts where this is known. Out of 988 contacts, 180 (18.2%) of these tested positive. The number of new HIV-positive cases per index is quite low: 0.066 overall (0.063 for MSM, 0.071 for male heterosexuals and 0.076 for female heterosexuals). However, one or more positive or deceased contacts were already known or identified via PN for 799 (29.0%) for all index cases (429 (28.9%) of MSM, 149 (28.8%) of male heterosexuals and 189 (33.6%) of female heterosexuals).

Table 4.

Testing outcomes of status-unknown contactable contacts.

	All index cases	M MSM	M het	F het
Total status-unknown contactable contacts who were tested (verified or reported)	988 (100%)	629 (100%)	163 (100%)	146 (100%)
Tested positive	180 (18.2%)	94 (14.9%)	37 (22.7%)	42 (28.8%)
Tested negative	622 (63.0%)	400 (63.6%)	101 (62.0%)	84 (57.5%)
Tested, but result not reported	173 (18.8%)	124 (21.3%)	24 (15.3%)	19 (13.7%)
New positive tests per index case	0.066	0.063	0.071	0.076

Discussion

All participating sexual health and HIV services met the ‘gold standard’ PN outcome of contacts tested per index case (both verified and reported), demonstrating significant improvement compared to the 2013 audit (which was 0.64 reported and 0.45 verified).⁷ Importantly, this standard was achieved for all groups. This is likely to be due in part to the production of new standards with clearer definitions and infection-specific targets. These targets were based on performance in the 2013 audit⁷ and agreed by multi-stakeholder consultation in order to represent moderate stretch targets for the majority of services. Given current performance, these should be revisited in order to support ongoing improvement.

When focussing on those contacts who are potentially contactable, the HCPV standard was achieved for heterosexuals but not for MSM nor overall. The number of partners and level of contact detail are likely to differ between the two groups and may explain this difference in outcome. Other studies have also demonstrated individuals who may be less able or willing to identify partners,⁹ particularly with casual partners,¹⁰ and better recall of partner information among heterosexual women than among MSM or PWID.¹¹ More research is required into how these differences can be effectively addressed in order to improve outcomes in these groups.

When examining for reasons for underperformance, it became apparent there was some lack of clarity in the questions for outcomes 3 and 4. Specifically, post hoc analysis revealed that those with fully resolved PN had been excluded. When re-examined with a modification to the definition, index cases with a documented PN plan within 4 weeks of diagnosis or PN fully resolved by this time point resulted in an improvement from 80.4% to 93.5% (as compared to 88% in the previous audit).⁷ Similarly, significant underperformance was also seen in relation to documentation of a discussion about recent contacts being eligible for PEP. This, along with the preceding measure, may be explained, in part, by poor documentation (no documented evidence of no need).

The impact of PN in identifying undiagnosed HIV cases remains high, albeit less than in 2013. In 2013, one contact was newly diagnosed with HIV per 10 index cases; in 2018, there was one new diagnosis per 15 index cases. This probably reflects improvements in testing and treatment resulting in lower prevalence of undiagnosed HIV. Overall, the HIV prevalence in contacts with unknown HIV status whose subsequent HIV test result is known was 18.2%; this is similar to previous reports (20–23%).^8,12-14

The policy questionnaire demonstrated comprehensive provision of HIV PN in sexual health and HIV services in the UK.

Limitations

As described above, a small number of index cases might be considered outliers on the basis of implausible reported contact numbers of known status, affecting results for outcomes 1 and 2. There were six individuals (five MSM and one female PWID) who might be considered outliers on the basis of reportedly having either ten or more status-known negative contacts or a very large, estimated round number of total contacts together with large, precise round numbers of both status-known positive and status-unknown contactable contacts. The former is implausible since in order to qualify as status-known negative, a contact must have tested negative for HIV at least four weeks after last exposure to the index case, but before the index case’s diagnosis. The latter is also dubious as it suggests the supposedly precise numbers were also estimated rather than derived from listing individual contacts and their status. Therefore, the analyses were re-run for outcomes 1 and 2 after removing these individuals. However, in addition, as shown in Table 2, there were 0.34 status-known negative contacts reported per index case (0.28 if outlier index cases are excluded). This seems questionable, given the difficulty in identifying individuals who have tested negative for HIV after last contact with the index case, but before the latter’s diagnosis. It suggests possible wider data quality issues in recording and reporting PN in accordance with definitions set out in the standards or possibly people’s perception of their partner’s status.

The current standards reflect both public health and service-level processes. Documentation of partners already diagnosed with HIV may have minimal public health impact but is essential for quality assurance in ensuring completeness of PN overall. Furthermore, it may involve considerable work, especially when the index case is unaware of the partner’s diagnosis. In any future revision of the standards, it may be worthwhile to develop additional measures for contacts of unknown status in order to capture the public health benefit of partner notification.

Conclusion and recommendations

This audit further highlights the importance of HIV PN as a highly effective strategy to identify individuals with undiagnosed HIV infection, thus improving individual and public health. However, there remains scope for improvement in the delivery of HIV PN.

We, therefore, recommend

The 2015 standards be revised with clearer definitions and exclusion criteria, to minimise interpretational discrepancies.

Development of a national pro forma or template to ensure consistent cross site recording.

We recommend all centres should examine their outcomes closely and work as a clinical team and with their local stakeholders and commissioners to maximise HIV PN outcomes.

Footnotes

BASHH National Audit Group

Dr Amelia Hughes Dr Ann Sullivan (vice-chair), Erna Buitendam, Dr Helen Wiggins, Dr Hugo McClean, Dr John Saunders, Dr Sarup Tayal, Dr Vanessa Apea (chair), Dr Nisha Pal, Dr Lisa Goodall, Dr Sophia Davies, Dr Lauren Bull, Merle Symonds, Dr Emma McCarty, Dr Harriet Wallace, Dr Chit Saing, Dr Naomi Fitzgerald, Dr Helen Iveson (honorary secretary), Dr Durba Raha, Dr Kati Perez, Dr Kirsten Michie, Dr Khine Phyu, Dr Malaki Ramogi, Dr Rebecca Metcalfe, Dr Ceri Slater, Dr Jennifer Murira, Dr Kajal Verma, Dr Helen Bradshaw, Dr Hardeep Kang. Members of the BASHH National Audit Group contributed to the design, conduct and analysis of the audit. This audit was funded by the National Audit Group of the British Association of Sexual Health and HIV.

Authors’ Contribution

All authors designed the audit, coordinated data collection and reviewed and analysed the data. Lauren Bull drafted the article and all authors reviewed it.

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.

Data sharing statement

All original and unpublished data are available on request. Please direct enquiries to Hilary Curtis at: hilary@regordane.net.

ORCID iDs

Lauren Bull

Hilary Curtis

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