European countries have used partner notification as one of a range of measures to control sexually transmitted infections (STI) since the early 1900s. Besides clinical benefits, public health benefits are also recognised such as controlling the spread of STI, reducing STI-related morbidity and mortality, reaching people with asymptomatic STI and people who do not present for diagnosis, counselling and treatment. Considerable variation in the ways of implementation exists across countries. Differences in laws, policies, regulations and clinical guidelines contribute to this. Health system characteristics, such as governance structures, public-private mix, models of service provision, resource allocation, financing – including payment for care and reimbursement of clinicians, and access to care, also influence practice. Differences in the microbiological and clinical characteristics of STI moreover contribute to variations in partner notification practice. Cultural, social and economic contexts also influence the way in which partner notification is perceived and practised in countries in Europe.
There are different approaches to partner notification, which can be broadly defined as patient referral, provider referral, and contract or conditional referral. Lack of consensus about the most effective methods of partner notification is another reason for the diversity of practice across countries and also represents a challenge to improving partner notification efforts.
Purpose and scope
The overall aim of this project was to provide a better understanding of current policies and practice in Europe and to evaluate the public health benefits of partner notification, particularly its role in STI and HIV prevention. The specific objectives were to:
- review the legal, regulatory and policy context for partner notification, including laws concerning the criminalisation of STI transmission
- review the availability and content of clinical guidelines for partner notification
- describe the organisation of health services for delivery of partner notification
- review current practices and evidence on the effectiveness of different approaches to partner notification for selected STI
- identify factors that facilitate or limit implementation of partner notification.
The project focused on the 27 EU Member States, Iceland, Liechtenstein and Norway. Sexually transmitted infections covered were HIV, chlamydia (Chlamydia trachomatis), gonorrhoea (Neisseria gonorrhoeae), syphilis (Treponema pallidum), trichomonas (Trichomonas vaginalis), Mycoplasma genitalium, herpes simplex, genital warts, hepatitis B and hepatitis C.
Information was obtained through three online questionnaires designed to gather information about the:
- legal and policy framework for partner notification
- availability and content of clinical guidelines for partner notification
- organisation of healthcare services for delivering partner notification.
More in-depth information about issues influencing partner notification practice was collected through interviews with health professionals and policy-makers from Denmark, Estonia, France, Romania and Sweden. Information collected through the questionnaires and in-depth interviews, was triangulated through a review of documents relating to the legal, policy and regulatory context for partner notification in Europe.
Two literature reviews were performed; a systematic review of the literature on effectiveness of different methods of partner notification for syphilis, HIV, gonorrhoea, chlamydia, non-specific urethritis, trichomoniasis, hepatitis B and C; and, a literature review of qualitative studies on STI/HIV patients’ views and attitudes about partner notification, their preferred methods, factors limiting partner notification; and on health professionals’ attitudes and perceptions of barriers to partner notification.
- The legal context for partner notification varies within Europe.
- Some countries have wide-ranging legal obligations to enforce partner notification, others have laws that are not enforced, and some have no such laws.
- Eleven of the 24 countries that responded to the specific questionnaire reported the existence of laws or regulations that make partner notification compulsory for the healthcare provider, the patient or both.
- These laws most often apply to HIV, syphilis, gonorrhoea, chlamydia, hepatitis B and C.
- There is no clear correlation between the existence of laws that make partner notification compulsory and routine partner notification.
- In 22 of the 24 countries, partner notification was described as routine for at least one STI. Infections for which partner notification is considered routine are often those for which notification is also mandatory.
- Compulsory partner notification can have both positive and negative effects.
- International guidelines recommend voluntary partner notification as an intervention for STI control, with non-voluntary disclosure to partners only when all other avenues have been exhausted.
- Voluntary partner notification is still the rule in most countries in Europe.
The existence of laws, and attitudes towards compulsory partner notification, are influenced by a country’s social, political and historical context. Laws that criminalise transmission exist, and have been used in nine countries. However, comparison of survey responses with other sources suggested that this may have been underreported, in particular for HIV…