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Abstract
Objectives Partner notification (PN) is a useful public health approach to enhance targeted testing of people at high risk of HIV and other STIs, and subsequent linkage to care for those diagnosed. In France, no specific PN guidelines exist and information about current practices is scarce. We used the ANRS-IPERGAY PrEP trial to investigate PN in HIV-negative men who have sex with men (MSM) reporting a bacterial STI.
Methods This substudy included 275 participants who completed a specific online PN questionnaire during the open-label extension study of the ANRS-Intervention Préventive de l’Exposition aux Risques avec et pour les Gays (IPERGAY) trial. Variables used as proxies of at-risk practices were defined using data collected at the previous follow-up visit about participants’ most recent sexual encounter and preventive behaviours. χ2 or Fisher’s exact test helped select variables eligible for multiple logistic models.
Results Of the 275 participants, 250 reported at least one previous STI. Among the latter, 172 (68.8%) had informed their partner(s) of their most recent STI. Of these, 138 (80.2%) and 83 (48.3%) had notified their casual and main partners, respectively. Participants were less likely to notify their main partner when their most recent sexual encounter involved unsafe anal sex with a casual partner (adjusted OR (aOR) (95% CI) 0.18 (0.06 to 0.54), P=0.02). Older participants were less likely to inform casual partners (aOR (95% CI) 0.44 (0.21 to 0.94), P=0.03), while those practising chemsex during their most recent sexual encounter were more likely to inform their casual partners (aOR (95% CI) 2.56 (1.07 to 6.09), P=0.03).
Conclusion Unsafe sexual encounters with people other than main partners and street drugs use were two sociobehavioural factors identified, respectively, as a barrier to main PN and a motivator for casual PN, in a sample of high-risk MSM. These results provide an insight into current PN practices regarding STI in France and might inform future decisions about how to define feasible and acceptable PN programmes.
- behavioural science
- gay men
- infectious diseases
- partner notification
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Introduction
Partner notification (PN) is an important public health approach to control STI epidemics, including HIV and hepatitis, by (1) offering screening to sexual partners of infected people, and subsequent rapid counselling and treatments should they be diagnosed positive; (2) avoiding reinfection in the index patient; and (3) decreasing the STI burden in sexual networks. In 2012, the WHO estimated 357 million annual cases worldwide of four curable bacterial STIs.1 Currently 24 European countries have developed policies for STI/HIV PN,2 ranging from mandatory to voluntary processes depending on national health policies and legislations. Different PN methods exist, but there is no consensus about which is the most effective one.2 3 However, in 2016, the WHO recommended that countries develop strategies for PN as a measure towards ending STIs by 2030.1
In France, no specific guidelines for PN exist and information about current PN practices is scarce. The continued increase of STI in the country4 indicates that such guidelines are crucial. The ANRS Intervention Préventive de l’Exposition aux Risques avec et pour les Gays (IPERGAY) trial was conducted in 2012–2015 to evaluate the efficacy and safety of on-demand PrEP) in men who have sex with men (MSM) with high-risk sexual behaviour. During the double-blind randomised phase, 41% and 33% of the participants in the PrEP and placebo groups, respectively, acquired a new STI.5 This trial was continued with an open-label extension (OLE) in 2014–2016, during which 43% of the participants acquired at least one STI, representing a non-significant increase in STI incidence from 49.1/100 to 59.0/100 person-years between the two phases.6 We performed a cross-sectional substudy during the ANRS IPERGAY OLE to provide data on current STI PN practices and to characterise motivators for and barriers to PN that might be helpful when developing future health policy guidelines.
Methods
Study population
In November 2014, all 361 participants in the ANRS IPERGAY trial were invited to continue 2-monthly follow-up visits while receiving TDF/FTC (tenofovir disoproxil fumarate/emtricitabine) during the ANRS IPERGAY OLE.6 The inclusion criteria were as follows: (1) HIV-negative men or transgender women who had sex with men, (2) aged ≥18 years and (3) reporting unprotected anal sex with at least two different partners over the previous 6 months. Every 2 months, participants completed an online questionnaire covering sociodemographic characteristics, sexual behaviour and PrEP adherence during their most recent sexual encounter.5 All participants provided a written informed consent. The present substudy took place between 6 April and 30 June 2016 (see online supplementary file S1). Apart from the 2-monthly questionnaire, participants answered a once-off specific online questionnaire addressing the experience of previous STI and partner(s) notification, and how they would like PN to be in the future (see online supplementary file S2). Since participants’ follow-up included regular STI testing, data were collected on the kind of bacterial STI most recently diagnosed and the date of diagnosis.
Supplementary file 1
Supplementary file 2
Outcome
Participants indicating they had had at least one bacterial STI were asked whether or not they had notified their partners about the most recently diagnosed one. Two outcomes were considered, distinguishing main from casual partners.
Explanatory variables
Since the present substudy was a cross-sectional survey nested in a longitudinal clinical trial using different questionnaires, other data than PN were collected at different time points. Sociodemographic and socioeconomic characteristics were collected at baseline (age, educational level, employment status). Whether the participant had a main partner or not was recorded at each annual visit. Sexual behaviour variables were collected at the most recently completed 2-monthly questionnaire before filling in the specific STI/PN questionnaire. These were the following: (1) number of sexual encounters in the previous 4 weeks; (2) number of sexual partners in the previous 2 months; for the most recent sexual encounter, (3) partner type (main partner, known or unknown casual partner, sex party partner); (4) type of sexual practice (oral sex only, oral sex and/or insertive anal sex, oral sex and/or insertive anal sex and/or receptive anal sex) and high-risk HIV exposure (condomless anal sex); and (5) HIV risk perception (10-point visual scale). We used proxies to measure (1) high-risk behaviour by combining the partner type and high exposure level variables; and (2) chemsex practice, defined as being under the influence of chemical drugs while having sex (excluding Viagra, cannabis, poppers, tobacco and alcohol).
Statistical analyses
Analyses were conducted separately according to whether the participants notified their main or casual partner of their most recent STI. Regarding notification to main partner, analyses were performed among participants who reported a main partner at least once during the time course of the OLE phase, while we assumed that all respondents had more than one casual partner during follow-up (eligibility criterion). Logistic regression models helped estimate the relationship between PN and potential correlates. Variables with a P value ≤0.25 in the univariate analysis were considered eligible for multivariate analysis. All analyses were based on two-sided P values, with P≤0.05 indicating statistical significance. Analyses were conducted using SAS V.9.4 software.
Results
Among the 275 participants enrolled in this substudy, 250 (90.9%) reported at least one previous STI. For the 206 participants with available data on the most recent STI diagnosis, the median (IQR) time between this diagnosis and the filling in of PN questionnaire was 12 (7–21) months. Among them, the most frequently diagnosed STIs were syphilis (n=55, 23.7%), anal chlamydia infection (n=44, 19%) and oropharyngeal gonococcal infection (n=30, 13%). Twenty-two of these 206 MSM had two STIs and two had three infections at their most recent STI diagnosis. There was no significant difference in PN to main and casual partner according to the type of bacterial STI (P=0.73 and P=0.75, respectively).
Among the 250 participants with at least one previous STI, 184 (73.6%) reported a main partner during the OLE follow-up, of whom 26.7% were HIV-positive; 235 (85%) declared at least one casual partner in the previous 2 months; and 172 (68.8%) had informed their partner(s) of their most recent STI, mostly by themselves (n=166, 96.5%). Among the 172 participants who had their partners informed, 67 (39%) did not have a main partner at the last annual visit, while 34 (19.8%) did not report any main partner during the OLE follow-up. MSM notified their casual partners (n=138/172, 80.2%) more frequently than their main partners (n=83/172, 48.3%). Among those 172 MSM, more than half reported that their notified partners saw a doctor afterwards (n=89, 51.7%). When questioned about a future potential new STI, majority of participants reported that they would like all, most or some of their partners to be notified (n=267/275, 97.4%), and that they could easily identify all or most of them (n=151/267, 56.6%). Respondents preferred PN by themselves (n=199/266, 74.8%) or by a healthcare provider or coach (n=42/266, 15.8%). They also reported that they would use phone calls (n=157/275, 57.1%), text messaging (n=147/275, 53.5%) and dating applications (n=93/275, 33.8%) to contact their partners. Multiple logistic regression (table 1) showed that MSM who reported a main partner during follow-up (n=184/250) were less likely to notify their main partner when their most recent sexual encounter involved condomless anal sex with a casual partner (adjusted OR (aOR) (95% CI) 0.18 (0.06 to 0.54), P=0.02). Information of the casual partners (n=250) was less likely for older MSM (aOR (95% CI) 0.44 (0.21 to 0.94), P=0.03), while MSM who used chemsex during their most recent sexual encounter were more likely to notify their casual partners (aOR (95% CI) 2.56 (1.07 to 6.09), P=0.03). PrEP uptake at the most recent sexual encounter was not significantly associated with notification to main or casual partners.
Factors associated with notification of the most recently diagnosed STI to main or casual partners (ANRS IPERGAY OLE substudy, n=250)
Discussion
Our results showed that, in this study sample of high-risk MSM, people were less likely to inform their main partner when they had unprotected sexual intercourses with casual partners, while those who practised chemsex were more likely to notify their casual partners. This finding highlighted that different types of sociobehavioural determinants are at play according to the type of partner, main or casual. One explanation for this contrast might be that participants accumulating sexual and chemsex risks were very concerned about their partners’ health and therefore chose PN. Another explanation might rely on differences between the sexual networks of people who engage in chemsex and those who do not. Chemsexers might have smaller networks of partners, with whom they might have sex more often, and therefore are more likely to inform them. However, those who did not inform their casual partners might experience barriers to notification that deserve further studies.
Patient referral appears to be the most commonly used PN method. Our result is in line with previous pilot studies on PN practices in the Netherlands6 and in Spain7, where 90% and 91.6% of MSM used this option for HIV notification, respectively. In the Spanish study, the overall patient referral rate was 70%, while 30% of the index cases needed assistance to notify their partner7 8
One of the main obstacles to PN is the anonymity of some partners, creating a gap between the numbers of partners at risk and those who can be notified. In the present substudy, more than half of the participants who declared they would like their partners to be notified of future STI reported that they could easily identify all or most of them, if necessary. A previous study reported that of the 41.5% of MSM index cases’ partners who could be identified, 87% were notified about an STI.9 A subsequent analysis showed that MSM had the lowest percentage of identifiable partners, but were more likely to notify them.10 Given these results, PN programmes should integrate new messaging technologies to reach the highest number of unidentifiable partners. The present study has several limitations. First, we used different questionnaires at different time points to collect the data, and no information was collected about the number of sexual partners—anonymous or not—at the time of the most recent STI diagnosis. Accordingly, we could not evaluate the difference between those identifiable (therefore notifiable) and those actually notified. Second, the time between completing the PN questionnaire and the most recent STI diagnosis was not similar for all participants. Third, there were no data available on how index cases selected the partners they notified, so we cannot exclude recall bias. Fourth, questions centred only on bacterial STI notification. Our sample study were HIV-negative, but it is well known that for HIV-positive index cases, disclosure of one’s status is very different from disclosing other STIs, and this might impact the decision to notify, as previously demonstrated.10 As a consequence, one might expect that without any official PN programme in place, spontaneously notifying one’s partners of a high HIV transmission risk would be less likely than for any other STIs. Finally, this study provided information about attitudes and practices of HIV-seronegative MSM enrolled in a clinical prevention trial, that is, a highly concerned and motivated subgroup of MSM. More studies are needed to address PN in other socioepidemiological groups, especially the very vulnerable migrant population.
Despite these limitations our study provides for the first time important information about current STI PN practices in France and might inform decisions about how to define feasible PN programmes acceptable for the different profiles of high-risk individuals, taking into account the current functioning of their sexual networks and the new messaging media. In addition, in the context of the development of PrEP consultations in France, PN implementation in these programmes would offer the possibility to take advantage of PrEP users to identify their high-risk sexual partners and in turn target them to PrEP and other prevention messages.
Abstract translation
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.Acknowledgments
We would like to thank the study participants and healthcare staff at the various study sites for their time and their dedication to this research. We would like to thank the reviewers for their helpful comments. We would also like to thank Jude Sweeney for revising and editing the manuscript.
Footnotes
Handling editor Jackie A Cassell
Contributors MS-M participated in the data analysis and interpretation of results and wrote the first draft of the manuscript. LF performed the statistical analyses. LC, EC, CC, LM, J-MM and BS participated in the interpretation of results and contributed to reviewing the manuscript. LC and EC were also involved in the design of the substudy. All authors approved the final version of the manuscript.
Funding The ANRS IPERGAY trial was sponsored by the ANRS (France Recherche Nord & Sud Sida-HIV Hepatites), and funded by ANRS, the Canadian HIV Trials Network, the Fonds de dotation Pierre Bergé pour la Prévention - SIDACTION, and the Bill & Melinda Gates Foundation.
Competing interests None declared.
Ethics approval The ANRS IPERGAY trial was approved by public health authorities and by ethics committees in France (Comité de Protection des Personnes Ile de France IV, n°2011/26) and Canada (Comité d’Ethique de la Recherche de Montréal, CTN268).
Provenance and peer review Not commissioned; externally peer reviewed.
Collaborators The ANRS IPERGAY Study Group: J-M Molina (coordinator), C Capitant, B Spire, G Pialoux, L Cotte, I Charreau, C Tremblay, J-M Le Gall, E Cua, A Pasquet, F Raffi, C Pintado, C Chidiac, J Chas, P Charbonneau, C Delaugerre, M Suzan-Monti, B Loze, J Fonsart, G Peytavin, A Cheret, J Timsit, G Girard, N Lorente, M Préau, JF Rooney, MA Wainberg, D Thompson, W Rozenbaum, V Doré, L Marchand, M-C Simon, N Etien, J-P Aboulker, L Meyer and J-F Delfraissy.