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Abstract
Objectives Partner notification (PN) is a key component of sexually transmitted infection control. British Association for Sexual Health and HIV guidelines now recommend partner-centred PN outcomes using a five-category partner classification (established, new, occasional, one-off, sex worker). We evaluated the reporting of partner-centred PN outcomes in two contrasting UK sexual health services.
Methods Using the electronic patient records of 40 patients with a positive gonorrhoea test and 180 patients with a positive chlamydia test, we extracted PN outcomes for the five most recent sexual contacts within the appropriate lookback period.
Results 180 patients with chlamydia reported 262 partners: 220 were contactable (103 established, 9 new, 43 occasional, 52 one-off, 13 unknown/unrecorded). 40 patients with gonorrhoea reported 88 partners: 53 were contactable (7 established, 1 new, 14 occasional, 10 one-off and 21 unknown/not recorded). No sex worker partners were reported. Most established partners of people with chlamydia (96/103) or gonorrhoea (7/7) were notified but fewer (60/103 and 6/7, respectively) attended for testing. Of those, 39 had a positive chlamydia test and two had a positive gonorrhoea test. For both chlamydia and gonorrhoea, most occasional and new partners were reported to be notified but there was a sharper decline in those tested. For both infections, one-off partners had the lowest rates of accessing services and testing. For chlamydia, 81% were notified (42/52), 23% accessed services (12/52) and 21% tested (11/52). However, 91% of those tested were positive (10/11). The number of contactable one-off gonorrhoea contacts was small and few attended.
Conclusions Measuring partner-centred PN outcomes was feasible. There were differences in partner engagement with PN between the different infections and partner types. If these findings are replicated in larger samples, it suggests that interventions to target one-off partners who have low rates of PN engagement yet high levels of positivity could play a key role in reducing infection at population level.
- SEXUAL HEALTH
- Sexual Partners
- CONTACT TRACING
- Sexual Behavior
- PUBLIC HEALTH
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What is already known on this topic
An evidence based partner type (established, new, occasional, one-off, sex worker) classification has been adopted into UK national guidelines.
What this study adds
Different types of sex partner appear to have different rates of infection, variable engagement with partner notification (PN) strategies, and likely contribute differently to onward transmission of infection.
How might this study affect research, practice or policy
If these provisional findings are replicated with a larger data set, this could highlight partner types for whom targeted PN approaches would be most beneficial in reducing infection transmission. This small study could act as a template for a national audit.
Introduction
Partner notification (PN) is a key component of sexually transmitted infection (STI) control that aims to identify unrecognised infections among sexual partners of people with STIs (index patients) to prevent reinfection and onward transmission within the community.1 However, the traditional dichotomous classification of sexual partners as casual or regular fails to capture important features of sexual partnerships which impact on the likely success of PN and the probability of reinfection and onward transmission.
A more nuanced, evidence-informed partner-type classification and new PN outcomes were adopted into UK national guidelines for consultations requiring a sexual history in 2019.2 The five novel partner types are established, occasional, new, one-off and sex worker (for further details on each partner type see online supplemental material 1). They differ in terms of the associated biomedical, psychological and social factors which have implications for risk of reinfection, onward transmission, engagement with and success of PN.3 Different types of sexual partner are likely to benefit from different PN support, enabling tailored and targeted PN strategies, for example, accelerated partner therapy for established partners.4 The new classification enabled a shift from index patient-centred PN outcomes (ie, ratio of partners per index attending a service) towards partner-centred PN outcomes (ie, number of each partner type tested and treated) which could provide more meaningful measures of PN practice.3 5 We conducted a service evaluation to measure the reporting of the new partner-centred PN outcomes using routinely collected data in two UK sexual health services (SHS).
Supplemental material
Methods
Using the new partner-type classification and PN outcomes, we collected data on partner type and PN outcomes in people with a positive gonorrhoea or chlamydia test in two UK SHS (S1 and S2).
In S1, electronic patient records (EPR) for 40 consecutive patients (from 1 June 2022) aged ≥18 years with a positive gonorrhoea nucleic acid amplification test (NAAT) and/or culture from any site (throat, urine, vulvovaginal, endocervical or rectal) were reviewed, as well as 60 consecutive patients (from 1 June 2022) with a positive chlamydia NAAT (any site). In S2, EPRs for 120 consecutive patients (from 1 September 2021) with a positive chlamydia NAAT (any site) were reviewed. The data for index patients with positive chlamydia tests were combined across S1 and S2 to create a larger data set.
PN outcomes for the five most recent sexual contacts within the appropriate lookback period were extracted.1 This included:
Partner type, using ‘established’, ‘occasional’, ‘new’, ‘one-off’ and ‘sex worker’.
Whether each partner was contactable, defined as partners for whom a means of contact is available (eg, phone number/email address/home address), either provided by the index patient or through past attendances at the service.
Index-reported and healthcare-verified partner outcomes of whether contactable contacts were notified, subsequently accessed an SHS, were tested for chlamydia and gonorrhoea, and the results of those tests.
Results
For 180 index patients with chlamydia, 262 partners were identified (median 1 partner per index, range 1–30), 40% of which were established partners. Breakdown of index patients and partners is available in online supplemental material 2.
Supplemental material
Compared with the other partnership types, contactable established partners had high rates of notification (93%, 96/103), accessing services (69%, 71/103) and testing (58%, 60/103), with high rates of positive tests (65%, 39/60) (see figure 1). The majority of occasional partners were notified (95%, 41/43) but fewer accessed services (37%, 16/43), or were tested (30%, 13/43). Of the occasional partners tested for chlamydia, 46% (6/13) were positive. All nine new partners were notified, with 67% (6/9) accessing services and 56% being tested (5/9). 40% of those tested were positive for chlamydia (2/5).
Proportion of contacts of index cases with chlamydia (A) and gonorrhoea (B) who are contactable, notified, accessed services, tested and positive by partnership type (established, occasional, new, one-off and sex worker).
One-off partners had the lowest rates of notification (81%, 42/52), accessing services (23%, 12/52) and testing (21%, 11/52) of all partnership types but the highest rates of chlamydia positivity (91%, 10/11).
For 40 index patients with gonorrhoea, 88 partners were identified (median 2 partners per index, range 1–15) with a majority of unknown or not recorded partnership type (52/88). A lower rate of contacts tested positive: 48% compared with 64% for contacts of chlamydia.
Of seven contactable established partners, all were notified and 86% accessed services and were tested (6/7). The gonorrhoea positivity rate was 33% (2/6). Occasional partners had relatively high rates of accessing services and being tested (43%, 6/14 for both) and two-thirds of those testing were positive for gonorrhoea (67%, 4/6).
The numbers of one-off contactable contacts for gonorrhoea were small and a low proportion of these accessed services or tested (20%, 2/10 for each). One of the two contacts who tested was positive for gonorrhoea.
Discussion
In our service evaluation of partner-centred PN outcomes for chlamydia and gonorrhoea, we observed differences across the PN cascade between partner types. A greater proportion of established and new partners received testing as a result of PN compared with occasional and one-off partners. Among all partners who tested, almost two-thirds were positive for chlamydia or gonorrhoea, with variation in positivity between partner types, reinforcing the importance of PN in identifying people with undiagnosed infections.
Differences emerged among infections; more contacts per index patient with gonorrhoea were recorded than for chlamydia, but partner types were not assigned for the majority of partners. The majority of index patients with gonorrhoea identified as male and reported male sexual partners within the lookback period. For contacts of chlamydia, the majority were established partners, and index patients were more likely to report partners of the opposite gender only. This reflects the epidemiology of these infections in the UK6; gonorrhoea disproportionately affects men who have sex with men, whereas chlamydia is more focused among young heterosexuals. These two population groups will have different and distinct sexual networks, as well as differing partner numbers, partner types and distribution of partner types with implications for contactability and index patient willingness to contact.
There was a lower rate of test positivity in contacts of gonorrhoea. However, numbers were very small. Individuals with gonorrhoea are more likely to be symptomatic compared with those with chlamydia,7 8 which could suggest that that individuals with gonorrhoea are less likely to present solely as a result of PN.
Variations in engagement were observed across different partnership types. Established partners had the highest rates of notification, service utilisation and testing. This is expected, as index patients are likely to be emotionally invested in these partner types, more motivated to notify them and more likely to possess information about their PN outcomes when compared with other partner types.
There were low levels of service utilisation and testing among occasional partners and very few one-off partners were notified or verified to have attended services for testing for either infection. This implies that current PN strategies are insufficiently engaging one-off and occasional partners. This is important because among one-off partners who did test, 91% of contacts of chlamydia and half of the contacts of gonorrhoea tested positive (although only two contacts were tested). This confirms findings from an earlier theoretical study9 which concluded that PN targeting casual partners would likely prevent more secondary transmissions per partnership and provide greater public health benefit. If upheld in larger samples, the high positivity but low service engagement of one-off and occasional partners suggests that PN interventions tailored to these partner types could be useful in enhancing the effectiveness of PN strategies.
We have used a partner-centred approach to measure PN outcomes for two common bacterial STIs showing that it is a feasible and useful approach. However, despite combining data across two services, the number of patient records included is small, limiting the generalisability and interpretation of the findings. While this study initially aimed to include patients and partners of all genders, sexualities and partnership type, very few transgender patients and no sex worker patients were identified in the sample. It is also possible that some of the differences observed between partnership types may be accounted for by differences in the services themselves, which are contrasting in their geography, patient demographics and EPR systems.
Additionally, the majority of the data recorded in this service evaluation were reported by the index patient, with information on partner attendance, testing and positivity verified by a healthcare worker in 27% of cases. This is an expected limitation of a service evaluation focused on PN and reflects real-world practice. However, index patients may be less likely to be updated on the subsequent care of occasional and one-off partners, and outcomes from sex partners attending other services are unlikely to be available, which may lead to a skewing of the reported outcomes.
The continuing rise6 in diagnoses of bacterial STIs across the UK, and existing pressures on SHS require providers, commissioners and policymakers to re-evaluate the aims of PN and how to optimise its delivery. A more granular understanding of PN outcomes, using a partner-centred approach, could allow more targeted delivery and allocation of resources as it acknowledges the different effort, time, cost and return of PN for different infections, index patients and partner types. Consistent recording of the five partner types across clinics should be encouraged, in line with the British Association for Sexual Health and HIV guidelines.2 Although changes to practice will require training, UK sexual healthcare professionals have implemented the new partner types with ease.3 10 Standardising collection of partner types within EPR systems would help improve data quality, collection, monitoring and evaluation of PN outcomes.
Future work needs to develop new PN standards taking account of partner type and type of infection to recognise the different consequences of these infections and relevance of partner type with respect to individual and public health. A national audit, with established national standards and a larger data set, could enhance understanding of variations in engagement with services between partner types, informing clinical guidelines and development of tailored PN interventions.
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Supplementary materials
Supplementary Data
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Footnotes
Handling editor Ming Jie Lee
Contributors All authors contributed to the service evaluation design. Data collection was completed by BLM and MS. All authors interpreted the data and BLM and EB drafted the initial manuscript. Subsequent revisions to the manuscript were made by all authors. All authors have read and approved the final manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.