Partner notification and treatment Institute of Venereology-experience.

INTRODUCTION: There has been a significant increase in general awareness about Sexually transmitted diseases (STD's) among the general public. However, rates of partner notification and treatment which are an integral part of STD awareness is still questionable. METHODOLOGY AND
RESULTS: We analyzed the statistics for prevalence of partner notification (which is about 52%) as well as the possible reasons for non-compliance. An overview of various ways of partner notification has been given as patient delivered partner medication (PDPM) and patient based partner referral (PBPR) of which PDPM is the most acceptable and effective method worldwide.

INTRODUCTION

In the treatment of STD, partner management (PM) is an important activity designed to increase the number of infected persons brought for treatment and disrupt transmission networks.

An important component of PM is partner notification (PN) – the process by which the health care providers (HCP) learn about the infected patients’ sex partners and provide help for partner evaluation and treatment.[1]

Partner notification interventions have documented to be an important contribution to make case-finding in clinical and community contexts.[2]

Where partners are treated, index patients have a reduced risk of reinfection. Therefore, HCP should encourage persons with STD to notify their sex partners and urge them to seek medical evaluation and treatment. Time spent in counseling index patients regarding the importance of notifying partners, is associated with improved notification outcomes.[3]

Despite the conservative nature of our society, the country has-over the last few years, seen a tremendous growth in the number of polygamous relationships-rapid urbanization being one of its main causes. Urbanization, however, has also led to an increase in general awareness about STD. It has been observed that on the whole people are more aware and knowledgeable regarding unsafe sex and its resulting ailments.

Whilst the increase in general awareness regarding STD is significant, the rates of treatment and partner notification still remain a major issue.

Emphasizing on partner notification and management could be the next most effective tool in the battle against STD. The commonly used methods in this area are patient based partner referral (PBPR) and patient delivered partner medication (PDPM) of which PBPR is commonly practiced worldwide.[45]

Objectives

To assess the present percentage of STD patients who comply with partner notification and treatment

To find possible explanations for poor reporting by partners

To suggest ways to improve/enhance notification and treatment of partner in order to control the spread of STD's.

MATERIALS AND METHODS

A retrospective study was conducted in which all new patients who attended the STD Out Patient Department of Institute of Venereology from 01-05-2008 to 30-04-2009 were analyzed. Only the patients who were suffering with any of the sexually transmitted diseases and who were advised to bring their partners for evaluation are included in this study. Final evaluation was based on the percentage of patients who turned up with their sexual partner.

RESULTS

After analysis of the data we found that [Figure 1] the commonest (56%) age group presenting with STD was between 31-45 years followed by 16-30 years age group. Patients less than 15 years or more than 60 years were the smallest proportion with only 7%.

Figure 1

Age Group of STD Cases

In this study [Table 1] there were 3,024 male and 1,332 female patients examined adding to a total of 4,356 patients. Out of these only 348 were asked to come with their partners for evaluation but unfortunately only 180 brought their partners for evaluation, hence, the partner notification rate is 51.9%.

Table 1

Analysis of partner notification

Figure 2 shows that the most common (46%) reason for poor partner notification was due to sexual contact with a commercial sex worker or unknown person. About 28% patients had history of an extra-marital or pre-marital contact and the unwillingness of the partner/patient was a limiting factor. Another 19% stated that they hailed from a distant place and it would be difficult for them to follow-up. A very small proportion (3%) were non compliant either because they were sexually assaulted or denied having sexual exposure at all.

Figure 2

Reasons for non compliance

DISCUSSION

Partner notification and management is a treatment strategy wherein the patient, as well as their sexual contacts are evaluated and treated accordingly in order to avoid transmission and re-infection of the STDs.[6] Through this retrospective study of total 4,356 patients, we found that, out of 3,024 male cases, 156 of them had sexually transmitted diseases (5.1%) and needed partner notification. Out of 1,332 female cases, 192 of them had sexually transmitted diseases (14.4%) and needed partner notification. The remaining patients were referred to STD OP to rule out STDs as part of preoperative evaluation, cases of balanoposthitis (due to diabetes, trauma or chemicals) or as part of complete health screening program.

We all know that partner notification is an essential tool and yet partner notification rates remain dismally low. The possible reasons for poor reporting are firstly; the social taboo and stigma still remain. Many cases who attend the STD clinic prefer to maintain their anonymity and so they consult a doctor from a distant area or city. In such cases they do not find it convincing enough to bring their partner for treatment. This apart, there are a set of people who acquired their STD's from sex-workers or unknown persons wherein again the partner notification is difficult.

And lastly, the STD's born out of extra-marital affairs and sexual assaults are such a disgrace and embarrassment that makes partner notification difficult.

In our study the majority (56%) of cases of STD belonged to the 31-45 years age group. It would be much more challenging to treat this subset of mature, married and supposedly well informed individuals since it is associated with a lot of stigma and could have devastating consequences on an individual's marriage and family. Accordingly, most patients consider this fact alone and mostly abstain from partner notification.

Partner notification among the male and female is almost equal (53.8% and 50%) respectively. Partner notification rate in Pune as per the study by D. Sharma et al.,[7] was 20.7% in 2005 where as it was 27% in Chennai as per Mertens et al.,[8] published in 1998.

The results of partner notification in our Institute are very well comparable to other interventional studies conducted worldwide.

There are surveys conducted to find newer and better ways of partner management. As per Laurie Barclay-current methods of patient referral only reach 40-60% of named sexual partners.[4] Of all, the focus remains on PBPR and PDPM. The trials and meta-analyses revealed that PDPM has reduced reinfection of index case-patients compared with PBPR in heterosexual men and women with chlamydia or gonorrhea infections.[9101112]

The other methods have been handing out home sampling kits for partners, partner notification slips/contact slips and the health provider personally contacts the partner. But, the most acceptable approach has been PDPM.

The same authors also reported that patient delivered partner medication and home sampling kits were effective management strategies to reduce STD occurrence in partners of patients with an existing STD.

A similar study conducted in South Africa[5] which involved only female patients and cited in International journal of STD and AIDS May 2007 showed that nearly all (94%) partners took medication or went to a clinic for treatment and concluded that PDPM could be used as a strategy to improve STD treatment coverage.

SUMMARY

Partner notification is above 50% in our Institute and we followed the PBPR. Social taboo and stigma about STDs still remain high in our society. It is time to educate the patients about the need for partner management and bring about awareness in them.

CONCLUSION

Partner notification by PDPM may be used in our setup to increase the treatment rate and to control STDs since, the PBPR has low partner notification.