Main findings
Similar proportions of partners were reported to have been treated across the three arms of the trial, in each case fewer than half. Although overall outcomes for partner notification were similar between the three arms, only a minority of those in the APTHotline and APTPharmacy intervention arm actually used that modality and their availability did not appear to improve outcomes.
The online patient and data management tool was acceptable to clinical staff and feasible for the referral of patients for partner notification support, including in the intervention arms, and for outcome measurement. However, recruitment to the research study within the clinic setting was challenging. The need to seek individual informed consent from index patients at an often emotional time and often by telephone acted as a barrier to participation for both patients and HCPs, whereas rapid changes in health services created challenges to clinical services in terms of prioritising research. The numbers of sex partners reported by women were comparable to the numbers reported by women attending specialist sexual health services104 and the majority of sex partners were contactable. However, fewer than half of the sexual partners were confirmed to have been treated across the trial and the addition of the APT interventions did not appear to improve outcomes. Uptake of the interventions was poor and most of the successful partner notification was achieved using standard methods rather than by APT.
No sex partners were known to have attended for HIV and syphilis testing although a small number of sex partners who took up the interventions returned a postal test kit for chlamydia and gonorrhoea. Despite good levels of index patient follow-up, including reminders about retesting, return of postal test kits for reinfection testing at 4–6 weeks post treatment was low.
TABLE 21 Time to partner treatment
Days Standard (n=39), % (n) Hotline (n=23), % (n) Pharmacy (n=35), % (n) Total (n=97), % (n) 0 82.1 (32) 78.3 (18) 60.0 (21) 73.2 (71) 1 2.6 (1) 13.0 (3) 2.9 (1) 5.2 (5) 2 10.3 (4) 0.0 (0) 5.7 (2) 6.2 (6) 3 2.6 (1) 0.0 (0) 5.7 (2) 3.1 (3) 4 0.0 (0) 4.3 (1) 2.9 (1) 2.1 (2) 5 0.0 (0) 0.0 (0) 0.0 (0) 0.0 (0) 6 0.0 (0) 0.0 (0) 0.0 (0) 0.0 (0) 7 0.0 (0) 4.3 (1) 5.7 (2) 3.1 (3) 8+ 2.6 (1) 0.0 (0) 17.1 (6) 7.2 (7)
p-value for APT relative to
standard care
Findings in the context of published literature
Effective partner notification in primary care is recognised as difficult to achieve97,99but the importance of improving the effectiveness of partner notification as a strategy for improving population control of C. trachomatisis well recognised. It is increasingly recognised that partner notification outcomes should be measured per partner, rather than per index patient,105as this reflects the true potential for the prevention of further transmission. However, current guidelines for partner notification, and newly available
surveillance reports in England, continue to focus on outcomes per index patient.106Our choice to use partner-focused notification outcomes makes it hard to compare our data with audit data, which are typically reported as number of partners treated per index. Nevertheless, the suboptimal rates of partner notification described in this pilot trial are superior to those reported in similar settings.68,104,105
Beyond the availability of partner-focused outcome data, there are further conceptual and empirical challenges with regard to the comparison of our data with those from other settings. Primary care and other non-specialist settings have not historically had a routinely available partner notification infrastructure and partner notification outcomes have typically not been measured or recorded at all. The provision of a partner notification service is of itself likely to produce a substantial‘Hawthorne effect’by normalising the discussion of partner notification. This may on its own be sufficient to motivate and empower an index patient to attempt discussion of the need for testing and treatment with his/her partner(s). Ideally, we would compare our data, at least for general practice, with data from a completely undeveloped service, but this is not in fact possible. We can nevertheless compare our data with limited data from community services, including the NCSP.
Our previous study of APT in specialist sexual health/GUM settings did use partner-focused outcome measures and suggested that APT could provide an improvement in partner notification outcomes compared with standard patient referral.101However, there were important differences in the design, inclusion criteria and exact nature of the interventions, which make direct comparisons inappropriate. Our initial APT study allowed index patients to select the method of partner notification that they thought would best suit each sex partner, whereas this study randomised patients. In routine clinical practice, index patients choose from a range of partner notification options and we believe that removing the element of choice by randomising patients to one intervention may not be the optimal design for sensitive interventions such as partner notification.
Limitations
Implementation of a pilot trial of this size, which required a large number of recruitment sites, at a time of unanticipated and wide-ranging health service change was extremely difficult. We had to scale down our original sample size to provide more realistic recruitment requirements for each service and support recruitment centrally. Our primary outcome was largely index reported rather than sex partner verified, which introduces uncertainty around the robustness of outcome ascertainment. Although we included a biological outcome (index patient positivity 4–6 weeks post treatment), in practice it did not prove useful as postal retesting had a low uptake rate despite telephone reminders.
We do not know whether the partners of women who declined to take part, or who did not take part for other reasons, were more or less likely to be treated. Our sample could therefore be biased in either direction with respect to the target population of index patients and partners.
Although APT did not appear to reduce the time to partner treatment, some centres recruited sex partners who attended with the index patient (contrary to protocol), which would bias the measures of routine partner notification to make it appear much faster.
Implications for public health and clinical practice
The care pathways that we developed, all of which used a novel online patient and data management tool, provide a feasible and acceptable infrastructure for the onward referral of patients diagnosed with STIs in general practice and other community settings to receive support with partner notification.
Outside the research setting, where there are major barriers to recruitment and randomisation at an emotionally taxing time, our model interventions appear to be capable of providing acceptable approaches to partner notification support. These could usefully form part of the portfolio of partner notification choices aimed at improving outcomes for all kinds of partner. It is increasingly recognised that novel interventions should not be seen as standalone strategies, but rather in the context of a portfolio of partner notification modalities that collectively improve overall partner notification outcomes.
The low uptake of follow-up STI or HIV testing is notable and suggests that these modes of partner notification which do not require direct engagement with a clinical service that can provide comprehensive testing may be unsuitable for higher-risk populations. Although in the future this may be addressed through postal self-sampling as a means of delivering more comprehensive testing, they are not suitable either for individuals or for populations who have been identified as being of higher risk, such as men who have sex with men (MSM) and MSM partners of heterosexual women.107,108
Implications for research
Overall partner notification outcomes were superior to previously reported partner notification measures in similar settings and so further work is required to optimise the uptake of APT outside specialist services. An in-depth understanding of the reasons for poor uptake of the interventions, that is, whether it was the index patient failing to forward the text or partners not finding APT acceptable, will be important for future partner notification research, irrespective of setting. A cluster design in which whole services are randomised to the offer of an APT intervention is likely to facilitate uptake, improve staff familiarity, normalise the interventions and minimise the negative impact of health service changes on ongoing clinical staff-dependent research. However, this may be difficult to implement as large numbers of clinics may be required to accommodate the cluster design and this may prove excessively costly. In addition, given the difficulties in achieving individual consent, a non-consented trial could be considered, which, although controversial, has been undertaken in the field of chlamydia screening.99,109
Research should also be undertaken to explore how to identify and reach higher-risk partners who may benefit from a more comprehensive range of sexual health services.