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EDITORIALS: Sarah Hawkes, David Mabey, and Phillippe Mayaud Partner notification for the control of sexually transmitted infections BMJ 2003; 327: 633-634 [Full text]

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STI partner notification in resource poor settings: The value of our systematic review, and insights from the South African public health services

Catherine Mathews, Nicol Coetzee, Merrick Zwarenstein, and Andy Oxman   (20 November 2003)

STI partner notification in resource poor settings: The value of our systematic review, and insights from the South African public health services 20 November 2003
Catherine Mathews, Public health researcher South African Medical Research Council and University of Cape Town School of Public Health, Nicol Coetzee, Merrick Zwarenstein, and Andy Oxman Send response to journal: Re: STI partner notification in resource poor settings: The value of our systematic review, and insights from the South African public health services	As authors of the systematic review (Mathews 2001) on sexually transmitted infection (STI) partner notification on which a recent editorial (Hawkes 2003) was based, we would like to elaborate on the possibilities and constraints in transferring the findings of our systematic review to resource-poor settings, by referring to our experiences in the South African public health services. In most South African clinics provider and contract referral (shown to be effective in other settings) are not feasible, due to health workers’ workloads and the potential difficulties of locating partners. New strategies to improve patient referral need to be used. Health education and counseling are particularly important strategies for South Africa, where they are inadequate or absent in the overburdened public health services. Our systematic review included a South African trial which demonstrated that the combination of a short, verbal, nurse-given health education message together with intensive, one-on-one counseling by lay counsellors, resulted in small increases in the number of partner treated. The use of lay counselors is especially appropriate to the resource-poor public health setting. The introduction of such a strategy might result in other benefits not measured in the partner notification trial (such as increased condom use and drug compliance among patients). Although our public health services have not yet implemented lay counseling for patients with STIs other than HIV, lay counselors are being introduced as part of a national initiative to implement voluntary counseling and HIV testing in selected public health clinics. There is evidence that voluntary counseling and HIV testing leads to reductions in sexual risk behaviour (The Voluntary HIV-1 Counseling and Testing Efficacy Study Group 2000). Ways of broadening this intervention to include patients with STIs other than HIV now need to be considered. Aside from health education and counseling approaches to improving partner notification, other innovative strategies to improve partner treatment need investigation. Index-patient delivered partner medication is one such strategy. It has been suggested both in South Africa and Zambia, as a possible solution to the problem of treating partners (Harrison 1997, Nuwaha 2001). Developing valid methods of measuring the effects of partner notification interventions (both beneficial and harmful) are hampered, in developing countries, by the difficulties of tracing partners, and the potential biases in relying on index patients reports. Other potential strategies, which move away from the focus on individual partners, are to target prevention efforts at high transmission areas (Weir 2003), broader community treatment and community screening. In the absence of good evidence of the comparative benefits alternative strategies, we would recommend using low cost, low risk strategies for partner notification. The effects of such strategies are likely to be modest, but worthwhile. Large, well-designed, international collaborative trials of alternative partner notification interventions are needed to inform decisions about how best to use scarce resources to reduce the burden of STIs in resource-poor settings. References Harrison A, Wilkinson D, Lurie M. From partner notification to partner treatment. South African Medical Journal 1997 Aug;87(8 Suppl):1055. Hawkes S, Mabey D and Mayaud P. Partner notification for the control of sexually transmitted infections. British Medical Journal 2003;327:633- 634. Mathews C, Coetzee N, Zwarenstein M, Lombard C, Guttmacher S, Oxman A, et al. Strategies for partner notification for sexually transmitted diseases. Cochrane Database Syst Rev 2001;(4):CD002843[GenBank]. Nuwaha F, Kambugu F, Nsubuga PSJ, Hojer B, Faxelid E. Efficacy of patient-delivered partner medication in the treatment of sexual partners in Uganda. Sexually Transmitted Diseases 2001 Feb;28(2):105-10. The Voluntary HI-1 Counseling and Testing Efficacy Study Group. Efficacy of voluntary HIV-1 counselling and testing in individuals and couples in Kenya, Tanzania, and Trinidad: a randomised trial. Lancet 2000; 356: 103-112. Weir SS, Pailman C, Mahlalela X, Coetzee N, Meidany F, Boerma JT. From people to places: focusing AIDS prevention efforts where it matters most. AIDS. 2003 Apr 11;17(6):895-903. Competing interests: None declared