Partner notification for the control of sexually transmitted infectionsBMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7416.633 (Published 18 September 2003) Cite this as: BMJ 2003;327:633
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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
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
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.
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-
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: No competing interests