Partner notification outcomes must treble for effective gonorrhoea control

Dear Editor,

The highest number of gonorrhoea infections in recorded history were seen in England in 2022 with 82,592 diagnoses up from 26,909 in 2012, an increase of 300%. An audit of gonorrhoea management in 2020 highlighted that clinical services were having difficulty meeting national standards. ¹ The diagnosis rate was 146.1/100,000 in 2022 compared to 50.3/100,000 in 2012. In 2022 gonorrhoea diagnosis rate for men, women, and gay and bisexual and other men who have sex with men (GBMSM) was 206.6, 72.8 and 6349.4/100,000 respectively. Ten years earlier, the diagnosis rate in men and women was 72.9 and 28.4/100,000 respectively - there were no data for GBMSM specifically. ²

The three key interventions to address the rising sexually transmitted infection (STI) epidemics are using condoms, ³ reducing time to treatment ⁴ and partner notification (PN). ⁵ Condom usage has waned with the increasing adoption of HIV pre-exposure prophylaxis (PrEP). Access to testing and treatment have both improved over the last decade; however, this ‘test & treat’ approach has not led to epidemic control.

The number of partners tested per index patient is the measure used to determine the effectiveness of PN. The British Association of Sexual Health and HIV/Society for Sexual Health Advisors National Guidelines for Partner Notification (2012) proposed that 0.6 [0.4 in London] partners are seen and tested within 4 weeks. ⁶ In 2022 and 2012 the estimated number of index patients diagnosed with gonorrhoea in level 3 services were 52,744 and 22,377 respectively (for the calculation see). ⁷ The number of partners accessing care were 20,968 and 11,220 which equates to 0.4 and 0.5 partners seen per index patient in 2022 and 2012 respectively. ⁸

Over the last decade PN performance for patients diagnosed with gonorrhea has worsened by 20% and yet PN has the potential to change the direction of the STI epidemics. The diagnostic yield is 10x higher in partners, with 40% of partners testing positive for gonorrhoea ⁸ compared with 3.8% from overall STI testing. ² In addition, seeing partners offers an opportunity to provide additional prevention services (vaccinations, PrEP, ChemSex support).

There is a strong public health case to treble the current PN outcome to 1.2 partners per index case to match the worsening epidemic.

This new PN target is achievable. As seen in banking (ATM), airlines (self-check in), and with ride sharing services, more effective results are achieved through digitization and bringing control of an outcome into the hands of the user. Digital PN works in the same way by empowering diagnosed patients to use their mobile phone to alert potential partners anonymously and then provide partners with a personalized linkage to care.

Last quarter (July-September 2023), clinics using the digital PN services provided by the social enterprise SXT Health CIC (https://sxt.health) managed 2034 index patients diagnosed with gonorrhoea across 46 clinics and 1.24 partners were verified as seen and tested per index patient. In 2014, the National Institute for Health Research estimated that high intensity PN cost £27 per index patient. ⁹ A significant fraction (43%) of PN was done automatically by SXT saving over £23,000 in staff time.

Now is the time to focus efforts on effective PN delivery and outcomes.