Audit on the success of partner notification for sexually transmitted infections in the West Midlands

Introduction

Rising figures in the prevalence of most of the sexually transmitted infections (STI) in the UK in recent years have been of concern. This has resulted in investment in sexual health services focussing particularly on improvement of access. Improvement of access may facilitate more screening and treatment of STIs. Identification and screening of the sexual partners of patients with STI however, plays an important role in the reduction of further transmission of infection.

The national guidelines propose some criteria for assessment of success of partner notification (PN) for STI. The targets assist in auditing the success of STI PN. In view of the recent increases in the incidence and prevalence of STIs, the guidelines may be warranted.

The aim of the present study is to audit the success of PN among genitourinary (GU) medicine centres in the West Midlands against national standards.

Methods

This was a regional audit conducted by the West Midlands Audit Group between June and August 2007. All GU medicine centres in West Midlands were invited to participate.

Information on screening and management of patients with chlamydia, gonorrhoea, early syphilis and HIV were collected separately. Participating centres were asked to provide PN details retrospectively for 10 index patients with each of chlamydia, gonorrhoea, early syphilis and HIV infections. Three large centres (in Birmingham and Coventry) were asked to provide information on 20 index patients with chlamydial infection.

Participating centres were also asked to clarify their policies on PN, follow-up of partners and verification of partners’ screening elsewhere.

In order to ensure uniformity of data, all GU medicine centres received similar spreadsheets. Data collected included the local GU medicine identification number of index patients, the total number of sexual partners within the previous 90 days identified by each index patient, the type of their partnership with the index patients (casual or regular – one index patient may have had more than one partner traced and screened), and the GU medicine identification numbers of any partners screened.

PN of sexual partners in settings other than the local GU medicine centre was considered completed if (i) the contact(s) had GU medicine number(s) from other centre(s) or (ii) verification of the contact(s) attendance by other sexual health providers (including general practitioners [GPs]) was documented.

Success of PN for the purpose of this study was calculated as the number of partners verified as attended for each index case. According to targets set by the Society of Sexual Health Advisors (SSHA) for each index case of gonorrhoea or chlamydia, at least 0.5 sexual contacts within the previous 90 days should be screened. ¹ British Association of Sexual Health and HIV (BASHH) guidelines have stated the figure should be 0.6 sexual contacts per index case for gonorrhoea and 0.43 contacts per index case for chlamydia (for clinics in large cities) or 0.64 for other clinics.^2,3 The SSHA does not propose targets for early syphilis or HIV infection. A review article has proposed that 0.6 sexual contacts for each index patient with chlamydia or gonorrhoea should be screened. ⁴

The above targets ignore the fact that a substantial number of patients with STI have more than one sexual partner in need of screening. Achieving those targets therefore may not have a significant impact on the local transmission of STI and their epidemiology. In that respect the proportion of identified partners who have been screened for STI may project a more accurate figure for the impact of PN on the local epidemiology of STI.

Data were recorded in an MS-Excel spreadsheet. Success of PN was calculated according to the SSHA targets for all infections. The proportions of sexual partners screened for each infection were also calculated.

Results

A total of 13 GU medicine centres participated in the audit. All centres had policies for patient referral and provider referral of sexual partners. Ten centres had a policy for follow-up of the partners who had not been screened. Nine centres had a verification policy for partners who had attended other centres for STI screening.

Table 1 summarizes the success of PN for different STI. It shows that the region's performance on PN for genital chlamydia was 0.54 overall, which may reflect the urban/rural nature of the region. The rate for gonorrhoea was 0.44, in fact, lower than that set by the guidelines. Rates for HIV were difficult to compare as no BASHH standards were available for these.

OPEN IN VIEWER

Table 1

The results from partner notification for different sexually transmitted infections (STI) from 13 Genitourinary medicine clinics in West Midlands

Infection	Number of index patients	Number of partners identified	Number of screened partners	Number of traced patients who were regular partners (%)*	Success of partner notification
					Partners screened per index patient	Proportion of partners screened (%)
Chlamydia †	258	355	140	125 (89)	0.54	39
Gonorrhoea †	140	225	61	51 (84)	0.44	27
Syphilis ‡	122	220	54	52 (96)	0.44	24
HIV §	112	158	56	55 (98)	0.50	35
All infections	632	958	311	283 (91)	0.49	32

*

Proportion of all partners screened

†

Target: 0.5-0.6 partners for each index patient should be screened^1,2

‡

Target: 46-60% of contactable sexual partners should be screened ³

§

Target: 63% of contactable sexual partners should be screened ⁴

Among 311 screened partners, 283 (91%) were involved in regular sexual partnership with the index patients. Two-thirds (647/958) of identified partners were untraceable; the majority of whom were casual partners. These figures may suggest that screening and treatment of index patients may have had a limited impact on the transmission of STIs.

Discussion

The results of the present audit confirm that the GU medicine centres in the West Midlands met SSHA and possibly BASHH performance targets for PN for chlamydia but not for gonorrhoea. PN for gonorrhoea in the region was sub-optimal. Despite a 10% decline in its UK prevalence between 2003 and 2004, the West Midlands has one of the highest rates of gonorrhoea in the UK. ⁵ In this respect, the rate of PN for gonorrhoea is concerning.

UK national guidelines for treatment of early syphilis propose that 46–60% of contactable sexual partners should be screened and treated for early syphilis. ⁶ In the present audit, 24% of partners of patients with syphilis were screened for this infection. Unlike targets for PN for chlamydia or gonorrhoea, this proposal does not measure the number of partners screened for each index patient and instead focuses on the screening of all partners who are at risk of syphilis.

Surprisingly, small amount of data on targets for HIV PN are available. A recent review of nine studies reported that a mean of 67% of partners of HIV-infected patients had been notified of whom 63% were tested for HIV. ⁷ Compared with those data, the proportion of screened partners of patients with HIV in the present audit was unsatisfactory. This was surprising as HIV-infected patients tend to attend the departments regularly and can be followed-up for PN.

Targets based on the proportion of at risk or exposed partners may reduce future transmission of STI. Targets set on the ratio of partners screened for each index patient however do not reflect the complexity of STI transmission, especially among those with more than one partner.

The discrepancy between the two methods for measuring success of PN was most obvious for HIV infection. While 0.5 partners for each patient with HIV were screened, they accounted for only 35% of all partners identified by HIV-infected patients.

PN plays an important role in prevention of further transmission of STI including HIV. ⁷ Adoption of targets consistent with such an aim may lead to improvement of performance of PN in GU medicine departments.

Improvement in PN may require such measures as increase resources for health advising and better communication between clinics for verification of contact attendance. Data suggest that success must be more in PN through provider referral policies.^7–10 Such policies however may not be favoured by patients or by physicians.^11,12 GU medicine departments may need to favour such policies over patient referral policies as the preferred method of PN. Patient-delivered partner treatment has also been reported to be successful in certain settings. ¹³

One of the challenges in PN for STI is identification and screening of casual sexual partners of patients with STI.^14,15 Similarly, in the present audit, notification of casual partners was not successful. More research on successful methods for notification of casual sexual partners is urgently needed.

Consistent with other parts of the UK, there has been a marked improvement in access to GUM services in West Midlands over the past year. ¹⁶ Improvement in access, however, has not led to screening of more partners of patients with STI.

In conclusion, acquisition of more robust targets for PN, better recording and communication between GU medicine centres, provider referral notifications may improve the outcome of PN.