Contacting sexual partners of the HIV-infected
By Prem Misir
July 5, 2004
GUYANA has become a human laboratory, attracting considerable international attention in its fight against Human Immunodeficiency Virus (HIV)/ Acquired Immune Deficiency Syndrome (AIDS), following closely on the devastation in Sub-Saharan Africa. Consider the number of international grants given to several NGOs that mainly use education as a tool for combating this dreaded infection. However, knowledge about Sexually Transmitted Infections (STIs) and HIV alone is not sufficient to employ change in sexual behavior, as demonstrated in a number of randomized-controlled studies.
We need factors other than didactic education to motivate change. In addition, targeting specific risk populations is an important first step to change behaviors. But these programs mostly focus on the non-HIV-infected with risky behaviors. We also need specific programs that target in an equal sense the HIV-infected, aimed at reducing the spread of this infection. But before this can happen, we would have to find the people at risk, and these would include both the infected and their sexual partners.
Contacting sexual partners stricken with the HIV is a difficult undertaking because HIV is still incurable and carries with it a deadly stigma.
In the U.S., reporting HIV/AIDS is carried out through each of the following or a combination of them: (1) patient referral where the patient informs his/her partner(s), (2) by provider referral, also called contact tracing in which the public health department notifies the sexual partner(s), and (3) by contract referral where the client is encouraged to notify his/her partners, on condition that the health care worker will trace any partner who does not contact the clinic within a mutually-agreed specified time period.
Research findings demonstrate a growing interest in partner notification with many constituencies acknowledging its usefulness in resisting the spread of HIV. The Centers for Disease Control and Prevention (CDC) recommendations suggest that public health department staff should inform known partners in cases where an HIV-infected patient refuses to comply.
Partner notification in New York
The New York State Public Health Law, 1998, reinforced partner notification programs with these provisions:
• Every physician or other personnel authorized by law to arrange for diagnostic tests, or provide a medical diagnosis, or any laboratory administering this test, shall immediately upon first diagnosis that the person is HIV-infected, or upon first diagnosis that a person is assailed with Acquired Immune Deficiency Syndrome (AIDS), or upon first diagnosis that a person is beset with HIV-related illness, report such case to the Health Commissioner.
• Every office of a Health Commissioner, upon establishing that such reported case, or other identified known case of HIV infection, justifies contact tracing, shall personally inform the known contacts of the protected person.
* • The contact shall be notified of the characteristics of HIV, the known viral transmission routes, risks of prenatal and perinatal transmission, actions the person can perform to further reduce viral transmission, and community-based organizations (CBOs) accessible to the person that dispense counseling, medical care and treatment, and additional information of other appropriate services for HIV-infected persons.
• Physician or other public health personnel effecting this notification must make the notification in person.
The New York State law provides mechanisms for the use of provider referral, and no opportunity is given to the patient to inform contacts about the infected status. Greater utilization is made of public health personnel outside of clinic settings to achieve provider referral. This is a strong line of almost mandatory reporting that New York State has adopted.
The latest New York City (NYC) Health Department HIV surveillance report from the first 3 months of 2003, shows that 85,000 adults were reported living with HIV/AIDS in NYC; about 20,000 more are projected to be living with HIV/AIDS and don't know it. I believe Guyana needs to review the New York State reporting system with a view to creating its own customized system.
However, at the core of partner notification are the issues of ethics and law. Some issues are:
* Should partner notification be voluntary or mandatory?
* Does partner notification not violate confidentiality?
* Is partner notification not an invasion of privacy?
* Does partner notification bestow upon us a duty to warn those at risk?
* Does partner notification not give those at risk the right to know?
* Is partner notification too expensive to implement?
In the case of confidentiality, there may be grounds for violating this principle. Firstly, this principle may be in conflict with the rights of the patient himself/herself, as when the patient may be a threat to himself/herself. Secondly, the principle may conflict with the right of an innocent third party, as in the case of a bride-to-be who may not know the bridegroom-to-be has a viral infection, but her physician knows. Should the physician provide full disclosure? In such a case, the physician can invoke a 'privilege to disclose' and effect the warning, although the HIV-infected individual may withhold consent. Thirdly, the principle may generate a conflict between confidentiality and societal interests, as when physicians report communicable diseases. Violation of confidentiality has to be assessed on an individual basis and carefully balanced against any adverse impact on society. This violation cannot be applied as a general rule in the physician-patient relationship, especially in the case of AIDS as a viral infection.
Stigma & discrimination
Partner notification programs will be much more successful if the stigmatized images of AIDS are reduced or eliminated. Stigma and discrimination continue to negatively affect the victims of AIDS. Stigma is a mark of social disgrace that separates the infected person from those who see themselves as "normal." Goffman perceives the stigmatized individual as having a 'spoiled identity', due to negative judgments by others. Persons consumed by HIV/AIDS are seen as having a spoiled identity by some sections of the population considered to be normal. Legislation on its own will not reduce the stigma experienced by people with AIDS.
The HIV/AIDS stigmatized image is reinforced by false information. This misrepresentation needs to be exposed, and not be included as the basis for social policies aimed at destroying the stigma. ‘Normalizing’ the illness also can reduce stigma. Conrad points out that "we need to develop policies that focus on changing the image of AIDS and confront directly the stigma, resistance to information, and the unnecessary fears of the disease. Given the social meaning of AIDS, this won't be easy." But it can be done.
Improving Partner Notification
Below are some suggestions from the literature on the key components of a partner notification program:
* Legislative protection of the ethical issues
* Targeting people who exchange sex for drugs or money
* Hiring staff from minority ethnic groups and those with inner city experiences
* Using outreach clinics for difficult-to-reach risk groups
* Flexible usage of patient referral and third party referral
* Tracing of contacts not to exceed a period of more than two years
* Evaluating partner notification by these criteria: numbers educated, counseled, and tested per staff person
* Risk-reduction education as a component in partner notification programs should incorporate a culture of restraint and responsibility, embracing the norms of each cultural group
* Persons living with HIV/AIDS to be recruited, and placed in appropriate partner notification programs
* Conditional contracting where health professionals present the patient with an option to have special sexual partners referred by health workers, or effect self-referral over a specific period.
Need for testing
People who are infected and do not know it, as among the 20,000 in NYC, exclude themselves from receiving early treatment and place a large number of people at risk of contracting the infection. People need to present themselves for testing and to disclose their HIV status to their partners. June 27 was National HIV Testing Day in the U.S. The health authorities should consider declaring a National HIV Testing Day in Guyana. Knowing one’s HIV status should become a significant part of the health policy here.