Partner Notification for HIV and STD in the United States:
Low Coverage for Gonorrhea, Chlamydial Infection, and HIV
MATTHEW R. GOLDEN, MD, MPH,*† MATTHEW HOGBEN, PHD,‡ H. HUNTER HANDSFIELD, MD,*†
JANET S. ST. LAWRENCE, PHD,‡ JOHN J. POTTERAT, BA,§ AND KING K. HOLMES, MD, PHD*
From the *Division of Infectious Diseases and the Center for AIDS
& STD, University of Washington, and †Public Health–Seattle and
King County STD Program, Seattle, Washington; and ‡Division of
STD Prevention, Centers for Disease Control and Prevention, and
§
Independent consultant, Atlanta, Georgia
Background: Little is known about the scope of current public
health partner-notification (PN) activities in the United States.
Goal: The goal of the study was to define what PN services U.S. health
departments provide in areas with high STD/HIV-related morbidity.
Study Design: The study involved a survey of STD program staff
members in U.S. areas with the highest reported rates of infectious
syphilis, gonorrhea, chlamydia, and HIV in 1998.
Results: Staff members of 60 (77%) of 78 health departments provided data. PN interviews were conducted with 7583 (89%) of 8492
cases of syphilis, 23,097 (17%) of 139,287 cases of gonorrhea, and
26,487 (12%) of 228,210 cases of chlamydia. In areas with mandatory
HIV reporting, 4375 (52%) of 8328 persons infected with HIV were
interviewed for PN.
Conclusions: Except for patients with syphilis, public health PN
services affect only a minority of persons with STD or HIV infection in
high-morbidity areas of the United States.
and through the development of new, more cost-effective approaches to health department–mediated PN.9
Despite prevailing skepticism about the value of PN for preventing bacterial STD, the Centers for Disease Control and Prevention (CDC) has advocated increased emphasis on HIV PN as
part of the Serostatus Approach to Fighting the HIV Epidemic
(SAFE), a key component of which is decreasing the proportion of
persons infected with HIV who are unaware of their HIV status.10
American STD/HIV control efforts are decentralized, and there
are no current national data on PN activities. A 1995 survey of
local health departments found that 92% offered at least some PN
services to persons with syphilis, while 67% provided PN services
to persons diagnosed with gonorrhea and 52% offered such services to persons with chlamydial infection.11 However, no publication has reported what proportion of persons with HIV or other
STDs receive publicly supported PN services, how health departments target these services, or what type of PN assistance patients
routinely receive.
To better define the current PN system in the United States, we
surveyed health departments in U.S. cities and counties with high
rates of STD and HIV infection to determine how they target PN
services, what services they provide, and what proportion of persons with reportable STD and HIV infection in their jurisdictions
are interviewed for purposes of PN. In addition, we sought to
identify barriers to improved PN.
PARTNER NOTIFICATION (PN) has been a cornerstone of STD
control efforts in the United States since the 1940s, when Surgeon
General Thomas Parran promoted the practice as a syphilis casefinding tool.1 Over the course of the subsequent 6 decades, many
health departments expanded PN programs to include gonorrhea,2
chlamydial infection,3 and HIV infection.4 These public health
programs seek to ensure that the sex partners of persons with
diagnosed STD are evaluated and treated, typically by offering
patients voluntary assistance in notifying their sex partners. (HIV
PN programs also attempt to ensure that the needle-sharing partners of persons infected with HIV are notified and receive HIV
testing and counseling.)
Despite their long history, relatively little is known about these
basic public health activities. Systematic reviews of the literature
have generally emphasized the paucity of data supporting the
efficacy of PN,5– 8 and there is considerable dissatisfaction with
this basic tool to control bacterial STD. In 1997, the Institute of
Medicine report on STD advocated overhauling the PN system in
the United States by placing greater emphasis on the role of
clinicians in ensuring the treatment of their patients’ sex partners
Methods
We identified the 50 cities in the United States with the highest
rates of each of the three commonly reportable bacterial STDs (gonorrhea, chlamydial infection, and syphilis), using the 1998 STD surveillance report of the CDC.12 Because some cities had among the 50
highest rates of some STDs but not others, this process identified a
total of 58 locations. We then identified the 50 Metropolitan Statistical
Areas (MSAs) with the highest prevalence of AIDS, using the 1999
HIV/AIDS Surveillance Report from the CDC.13 This yielded 20
additional areas, for a final sample size of 78 jurisdictions.
Contact persons for each selected area were identified from a list
of local health departments published by the National Association
The authors thank the survey respondents who voluntarily provided
information for this study, Tim Tyree for help with data management, and
Tamara Battle for assistance contacting survey respondents.
Dr. Golden is supported by NIH K23 AI01846-02.
Reprint requests: Matthew R. Golden, MD, MPH, Harborview Medical
Center, Box 359777, 325 9th Avenue, Seattle, WA 98104. E-mail:
[email protected]
Received September 11, 2002, revised January 02, 2003, and accepted
January 6, 2003.
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PARTNER NOTIFICATION: LOW COVERAGE FOR GONORRHEA, CHLAMYDIA, AND HIV
of County and City Health Organizations (NACCHO). The survey
was mailed to officials at city health departments and to county
officials in locations where county departments act as the primary
source of public health services. If respondents reported serving
several adjacent counties, one of which was identified as having
high rates of STD, and the respondent had only aggregated data for
the entire jurisdiction, data from more than one county were used.
Each health department originally received a survey in July
2000. Respondents received duplicate copies to allow completion
of separate surveys by persons in STD and HIV/AIDS programs in
areas where separate programs existed. To encourage completion
of the survey, a minimum of two additional copies were subsequently sent to nonresponding health departments during the following year, and contact persons were telephoned. Respondents
were also telephoned to obtain missing data and to clarify inconsistent responses.
The survey collected data on three topics: (1) numbers of
full-time-equivalent (FTE) personnel assigned to work on STD
problems in general and on PN in particular; (2) numbers of cases
of each STD reported in 1999, number of cases reported from
public health settings, and number of case patients interviewed for
PN; and (3) type of PN provided to persons whose STDs were
diagnosed in public STD clinics, public health venues other than
STD clinics, criminal justice settings, and the private medical
sector. Respondents were asked open-ended questions to identify
barriers to improving PN and to solicit suggestions on what the
CDC could do to improve PN services. Data on syphilis-related
morbidity and PN were limited to primary, secondary, and early
latent cases.
To describe the type of PN their health departments provided in
1999, we asked respondents to characterize their PN programs by
choosing among four described approaches in PN, three of which
have been regarded as standard in the public health literature.5
These approaches included the following options: (1) attempted
contact of all or almost all patients and all partners (provider
referral); (2) attempted interview of all or almost all patients and
contact of only partners who are not examined within a specified
period of time (conditional referral); and (3) no routine public
health assistance with PN is provided and individual clinicians are
responsible for PN. Because clinicians probably infrequently do
more than advise patients to refer their partners for treatment,14
this was assumed to imply PN would be left up to patients
themselves (patient referral). In addition, we offered respondents a fourth option: attempted interview of all or almost all
patients and contact of only the partners who patients themselves cannot or will not contact (offer assistance). Respondents
were invited to clarify how PN is targeted in their jurisdictions
if the four choices given did not accurately describe their
practice. For gonorrhea and chlamydial infection, respondents
were asked to estimate how frequently clinicians in their health
department give medication to patients to give to their sex
partners (0%, 1–24%, 25– 49%, 50 –74%, or 75–100%).
To assess the scope of PN programs, we calculated the proportion of persons reported with each STD who were interviewed for
purposes of PN. Because PN generally focuses on newly diagnosed STD, whereas AIDS reporting includes newly diagnosed
cases and previously reported cases of HIV disease that have
progressed to AIDS, we chose to calculate only the proportion of
newly reported case patients with HIV infection receiving PN.
Jurisdictions in which HIV infection was not reportable during the
study period could not supply data on the number of new cases of
HIV infection in their area in 1999; as a result, it was not possible
to calculate what proportion of persons with newly diagnosed HIV
infection in those areas were interviewed for purposes of HIV PN.
491
Consequently, all data presented on the proportion of HIV-infected
patients interviewed for PN include only areas in which HIV
infection was reportable.
Two health department respondents stated they were unable to
determine how many recipients of PN had been reported with HIV
infection as opposed to AIDS. In these instances, we used combined data. Four respondents indicated their health departments did
not compile data on how many patients with gonorrhea they
interviewed for PN, and five reported they did not collect such data
for chlamydial infection. One jurisdiction indicated that chlamydial infections were not reportable in their area in 1999. Thus, the
proportion of persons interviewed for PN could not be calculated
for chlamydial infection in six jurisdictions and for gonorrhea in
four jurisdictions.
Five health departments could not provide numbers of persons
interviewed for PN for one or more STDs but estimated the
proportion of patients in their area who received PN services.
These estimates are included in the present analysis. Although the
survey asked how many person with each STD were interviewed
for PN, six respondents reported interviewing more persons with
HIV infection than the total number of cases occurring in their area
in 1999, and 9 reported interviewing more persons with syphilis
than the total number of syphilis cases in their county. This likely
reflected respondents’ interpretation of the question to include
contact interviews as well as interviews in known cases. In these
instances, the number of case patients interviewed was calculated
as the total number of cases reported.
Bivariate analyses of association were performed with the chisquare test. The correlation between the proportion of STD case
patients interviewed for PN and the number of reported cases and
number of PN staff were calculated with the Pearson correlation
coefficient. All statistical procedures were performed with the SAS
system (SAS Institute, Cary, NC).
Results
Of the 78 surveys sent out, 61 were returned to us by the contact
person, of which 60 were sufficiently complete to be included in
the final analysis, a response rate of 77%. Table 1 presents the
regional distribution of participating health departments, the job
title of respondents, and the number and types of persons conducting PN in each health department.
Syphilis
Eighty-seven percent of all respondents reported that their
department attempts to interview all persons reported to have
infectious syphilis, regardless of where the original diagnosis
was made (Table 2), and 95% indicated that provider referral
was their standard approach. Forty-two respondents (70%) indicated that their department did not require the permission of
a patient’s clinical provider before contacting the person reported to have syphilis. The majority of health departments
(52%) indicated that they interviewed all persons reported to
have early syphilis during 1999, and of the total 8492 cases
occurring in areas served by participating health departments,
respondents reported that 7583 (89%) of the patients were
successfully contacted and interviewed.
HIV
Of the 60 health departments who returned a useable survey, 41
(68%) responded that HIV infection was reportable in their jurisdiction in 1999. Of these, 37 (90%) were in the Midwest or South.
In large measure this reflected the absence of HIV infection
492
GOLDEN ET AL
TABLE 1. Persons Completing Survey, Location, and Persons
Conducting Partner Notification (PN) in Health Department STD
Programs
Variable
Person completing survey
STD/HIV program director
Director or deputy director of dept. of health
DIS* or communicable diseases supervisor
Other†
Geographic region
Northeast
Midwest
South
West
Health department operates STD clinic
Person conducting PN‡
DIS*
Nurses
Physican assistant or nurse practitioner
Other
Median no. of people conducting PN (range)
No. (%) of
Persons
26 (43)
8 (13)
14 (23)
12 (20)
8 (13)
12 (20)
28 (47)
12 (20)
51 (86)
59 (98)
12 (20)
7 (12)
7 (12)
6 (1–87)
*Disease intervention specialist.
†
Includes 1 director of preventive medicine, 2 operations management consultants, 1 medical director of health services support, 1
community health services director, 1 public health supervisor, 1
epidemiologist, 1 clinical services supervisor, and 1 senior epidemiology health counselor.
‡
Percentages are based on all health departments that have different personnel conducting PN. Because some health departments
have more than one type of personnel participating in PN, percentages exceed 100.
reporting in New York and California, states containing 10 jurisdictions that returned surveys. Most health departments in jurisdictions with reportable HIV infection indicated that their policy
was to attempt to provide HIV PN services to all patients, regardless of where it was diagnosed, and as with syphilis, provider
referral was the dominant PN strategy.
Thirty-four respondents (83%) stated that their department did
not routinely seek the permission of the reporting clinical providers before contacting patients infected with HIV. Thirty-seven
health departments with reportable HIV (90%) provided data on
the number of persons reported with HIV infection and on the
number interviewed for PN in 1999. The median proportion of
cases interviewed for PN was 75% (Table 2). Of the total 8328
cases of HIV infection reported from all responding health departments in which HIV was reportable, 4375 (52%) of the case
patients were interviewed for PN.
The proportion of reported HIV case patients successfully
interviewed for PN in a jurisdiction was inversely proportional
to the total number of cases reported (r ⫽ ⫺0.55; P ⫽ 0.0004)
(Figure 1). Eight health departments (24%) with 250 or more
cases of HIV infection in 1999 received 59% of the HIV case
reports in jurisdictions with reportable HIV that responded to
the survey; a median of 27% of persons reported to have HIV
infection in these 8 jurisdictions were interviewed for PN. The
ratio of the number of PN staff to the number of HIV cases
reported varied 20-fold among health departments, from 0.01 to
0.2 (median, 0.05). The proportion of persons infected with
HIV who were interviewed was positively associated with the
number of staff members available for interviewing (r ⫽ 0.48;
P ⫽ 0.004).
Sexually Transmitted Diseases
●
June 2003
Gonorrhea and Chlamydial Infection
Most health departments reported concentrating PN services for
gonorrhea and chlamydial infection on patients seen in STD clinics
(Table 2). Although the overwhelming majority of all PN interviews for the four STDs (80%) involved gonorrhea or chlamydial
infection, PN was offered to only very small minorities of patients
with these infections. Twenty-two health departments (37%) provided no routine PN services for gonorrhea and 27 (45%) provided
no such services to patients with chlamydial infections. Among
those health departments providing PN services, a median of 43%
of patients with gonorrhea and 14% of patients with chlamydial
infection were interviewed. Among all persons reported to have
these STDs in jurisdictions served by responding health departments, only 17% of persons with gonorrhea and 12% of persons
with chlamydial infection were interviewed for PN.
The proportion of persons with gonorrhea interviewed was
associated with a higher ratio of PN staff members to cases (r ⫽
0.28; P ⫽ 0.03) and was inversely related to the total number of
reported cases in the area (r ⫽ ⫺0.29; P ⫽ 0.03). In addition, there
was marked regional variation in how frequently PN was provided
for gonorrhea. Compared to health departments in the East or the
West, health departments in the South and Midwest more frequently provided PN services in fewer than 20% of gonorrhea
cases (68% versus 35%; P ⫽ 0.02). No association was observed
between the provision of PN for chlamydial infection and (1) the
ratio of number of reported cases to PN staff members (r ⫽ ⫺0.04;
P ⫽ 0.77) or (2) the number of cases of infection (r ⫽ ⫺15; P ⫽
0.26).
When services were provided outside of STD clinics, health
departments generally reported adopting a more tentative and less
labor-intensive approach to PN. In contrast to cases of HIV infection and syphilis, 53% of health departments routinely sought the
permission of clinical providers before contacting patients with
gonorrhea or chlamydial infection. In settings other than public
STD clinics, PN most frequently consisted of offering patients
assistance with PN rather than conditional or provider referral. Six
health departments (10%) in six different states reported ever
giving patients medication to treat their sex partners, and of these,
only one reported doing so for greater than 25% of cases.
In response to open-ended questions about how PN services
were targeted, four health departments indicated that they specifically directed PN services to pregnant women, two stated they
target untreated cases, one concentrated efforts on adolescents, and
one focused efforts on a geographic area defined as a core. Six
respondents stated they routinely gave patients with gonorrhea or
chlamydial infection referral cards to give to partners.
Barriers and Suggestions to Improve PN
Among the 60 respondents, 53 (88%) identified at least one
barrier to improved PN or offered at least one suggestion to
improve PN in their jurisdiction. The most commonly reported
barrier to improved PN was insufficient funding or personnel, a
factor identified by 24 respondents (40%). Six (10%) reported the
inability to retain staff as a barrier to improved PN. Other factors
mentioned as barriers by three or more respondents included
noncooperation by private providers and community-based organizations in PN, particularly for HIV infection; political opposition
by men who have sex with men and by organizations opposed to
condom distribution; and the absence of mandatory HIV infection
reporting. Twenty-eight respondents (47%) suggested that increased funding or increased federal disease intervention specialist
(DIS) assignees would improve their PN services, and seven
suggested that improved wages and DIS career opportunities
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PARTNER NOTIFICATION: LOW COVERAGE FOR GONORRHEA, CHLAMYDIA, AND HIV
TABLE 2. Proportion of Persons with Reported STDs Interviewed for PN and What PN Services Health Departments Provide to Persons
Diagnosed in Different Clinical Settings in High-Morbidity Areas of the United States, 1999
Variable
Syphilis
HIV*
Gonorrhea
Total cases
Median no. of cases (range)
Median proportion of reported cases diagnosed in public
health clinics (range)
Median percentage of persons interviewed for PN (range)
Total no. of cases interviewed, among all health
departments (% of cases interviewed)
Type of PN, by diagnosing clinical setting‡
STD Clinic
Provider referral
Conditional referral
Offer assistance
Patient referral
Other PH clinic
Provider referral
Conditional referral
Offer assistance
Patient referral
Jail/Prison
Provider referral
Conditional referral
Offer assistance
Patient referral
Private practice
Provider referral
Conditional referral
Offer assistance
Patient referral
Patients ever given medication for partners
8492
69 (0–789)
8328
142 (13–3769)
139,287
1537 (90–12,207)
50 (19–100)
100 (28–100)
38 (10–100)†
75 (2–100)
46 (15–100)
13 (0–96)
Chlamydia
228,210
2263 (132–27,584)
23 (3–100)
5 (0–90)
7583 (89)
4476 (52)
23,097 (17)
26,487 (12)
57 (95)
2 (3)
0
1 (2)
38 (93)
1 (2)
1 (2)
1 (2)
21 (35)
2 (3)
15 (25)
22 (37)
15 (25)
3 (5)
15 (25)
27 (45)
53 (89)
3 (5)
1 (2)
2 (3)
33 (80)
3 (7)
2 (5)
3 (7)
9 (16)
4 (7)
13 (22)
33 (56)
6 (10)
4 (7)
13 (22)
36 (61)
54 (90)
3 (5)
1 (2)
2 (3)
33 (80)
3 (7)
2 (5)
7 (7)
8 (13)
5 (8)
8 (14)
39 (65)
6 (10)
4 (7)
7 (12)
43 (72)
52 (87)
3 (5)
3 (5)
2 (3)
NA
31 (76)
2 (5)
5 (12)
3 (7)
NA
7 (12)
2 (3)
10 (17)
41 (68)
5 (8)
3 (5)
2 (3)
9 (15)
46 (77)
6 (10)
NA ⫽ not applicable.
*Includes only 41 health departments in jurisdications in which HIV is a reportable disease.
†
Missing 7.
‡
Provider referral involves a routine effort by public health officials to contact cases’ sex partner(s). Conditional referral is the process whereby
cases are given an opportunity to contact partners, and public health officials contact only partners who are not evaluated within a specified
period of time. “Offer assistance” refers to the practice of interviewing cases and offering to contact partners for them if they state they cannot
or will not do so themselves. “Patient referral” means that patients are responsible for notifying their partners, and health departments make
no routine effort to offer them assistance. Excludes data on PN practices in public health clinics for one jurisdiction that had no clinics other
than an STD clinic.
would help. Beyond increased funding, 23 respondents (40%)
suggested that the CDC improve ongoing training opportunities for
PN staff. Several articulated a belief that there had been a general
erosion in PN practices, such as in ongoing training in interviewing
techniques, quality assurance by the CDC, and epidemiologic and
data management support.
Discussion
PN was initiated as a means to control syphilis. Our findings
suggest that in much of the United States, it remains little more
than that. We found that in areas of the United States where
HIV/STD-related morbidity is high, PN services are universally
offered to persons with early syphilis, frequently provided to
persons with newly diagnosed HIV infection in areas where HIV
infection reporting is mandatory, and provided to only a very small
minority of persons reported to have gonorrhea and genital chlamydial infections.
In areas of the United States with the highest rates of HIV
infection, most HIV-infected persons do not receive public health
PN services. At the time of our survey, only 68% of responding
health departments in our sample were in states where HIV infection reporting is mandatory, and only 52% of persons reported to
have HIV infection in those states were interviewed by public
health workers for purposes of PN. Given that HIV infection
reporting is incomplete and that it is not required in some states,
including New York and California (which together reported 29%
of all AIDS cases in the United States in 1999),13 it seems likely
that fewer than one third of people with newly diagnosed HIV
infection in the United States received public health PN services in
1999. (New York instituted mandatory HIV infection reporting in
2000.)
The effectiveness of PN for HIV infection is uncertain, and the
practice remains controversial.8,15 Several states have described
successful HIV infection PN programs,16,17 and a small randomized trial showed that providing persons with newly diagnosed
HIV infection with voluntary public health PN services increased
the number of their sex partners who were notified and the number
who had HIV infection diagnosed, in comparison with relying on
patients to notify partners themselves.18 The CDC is currently
promoting greater emphasis on HIV infection PN.10 Our findings
demonstrate HIV infection PN was far from universal in 1999.
The fact that areas that reported higher numbers of HIV infection cases provided PN to a smaller proportion of patients suggests
that providing PN services to all persons with newly diagnosed
HIV infection may require increased funding. In addition, there
494
GOLDEN ET AL
Sexually Transmitted Diseases
●
June 2003
Fig. 1. The proportion of reported HIV (A) and gonorrhea (B) patients interviewed for purposes of partner-notification (PN) in a jurisdiction was
inversely proportional to the total number of cases reported (r ⫽ ⫺0.55; P ⫽ 0.0004).
was a common belief among respondents that DIS personnel
require additional training to effectively implement PN. The information we collected does not allow us to assess the effectiveness of HIV infection PN, and the effectiveness of HIV infection
PN remains to be established.15 However, if more widespread HIV
infection PN is to be promoted, improved funding for staff, training, and data collection will be needed and will likely require
federal leadership and resources.
Our survey findings lend support to the Institute of Medicine’s
conclusion that the current public health approach to gonorrhea
and chlamydia PN needs to be redesigned. Many (perhaps most)
persons with gonorrhea or chlamydial infection do not notify all of
their sex partners.14,19 –21 While no definitive study data have
demonstrated that PN decreases the incidence or prevalence of
gonorrhea or chlamydial infection, the institution of more aggres-
sive PN programs has been temporally associated with declines in
rates of these infections,19,22 and mathematical modeling studies
have consistently suggested that PN can have a significant prevention impact.23–26
However, even if PN can affect bacterial STD rates, it appears
that the PN programs that exist in most U.S. cities with high rates
of STD are much too modest to have a meaningful impact, and the
persistence of hyperendemic rates of gonorrhea and chlamydial
infection in these cities may in part be attributable to the failure to
scale up effective PN. We found that public health PN services for
gonorrhea and chlamydial infections affect very small minorities
of persons with these infections and that these services are focused
almost exclusively on STD clinic patients, accounting for a relatively small percentage of all patients with reportable STD.27
We recently reported that STD clinic patients were only slightly
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PARTNER NOTIFICATION: LOW COVERAGE FOR GONORRHEA, CHLAMYDIA, AND HIV
less likely to notify their partners then were patients treated in the
private sector,21 and the focus on STD clinic patients is more a
product of convenience and tradition than one of epidemiologic
rationale.
Providing traditional PN services to a majority of persons with
gonorrhea and chlamydial infection would require substantially
increased funding, substantially more efficient use of existing
resources, or both. Providing traditional PN services to all persons
with gonorrhea or chlamydial infection would involve hundreds of
thousands of additional DIS investigations annually and is probably not feasible from a cost perspective.
Clearly, significant reform of the U.S. PN system for gonorrhea
and chlamydial infection will need to involve new, more efficient
approaches to partner management. Two observational studies
have associated lower rates of recurrent chlamydial infection with
the practice of providing antibiotics to infected women to treat
their sex partners (i.e., patient-delivered therapy).28,29 Most private
sector clinicians report that they have given patients medication to
give to sex partners, although few report doing so for all of their
patients with gonorrhea or chlamydial infection.14,30
A recent report from King County, Washington, demonstrated
that a health department can implement such an approach to affect
a large segment of the population with gonorrhea and chlamydial
infection.21 Although patient-delivered therapy may prove to be a
feasible and relatively cost-effective approach to PN, our survey
indicates this practice remains extremely uncommon in U.S. health
departments.
Our study has several limitations. First, we surveyed only selected areas with high STD and HIV morbidity. Consequently, we
cannot comment on PN practices in areas with lower rates of
infection; PN may be more widely offered in such areas. However,
our findings apply to a substantial number and proportion of all
reported STD and HIV infection cases. The areas that responded to
our survey reported 8328 (39%) of the 21,419 cases of HIV
infection reported in the United States during 1999,13 139,287
(39%) of the 360,076 cases of gonorrhea reported in 1999, and
228,210 (35%) of the 659,441 cases of chlamydial infection reported in 1999.31
Second, our estimates of the proportion of persons interviewed
for PN may be imprecise. STDs are underreported, and some
respondents reported more interviews of patients with syphilis and
HIV infection than the total number of cases in their jurisdiction in
1999, a circumstance suggesting that they may have included in
their tabulations interviews conducted with contacts of case patients who never had an STD diagnosed. As a result, the true
proportion of persons receiving public health PN services for HIV
infection and STD in high-morbidity U.S. counties is probably
lower than we found.
In summary, health jurisdictions in the United States with high
rates of STD and HIV infection provide PN services to the majority of persons with infectious syphilis, fewer than half of persons with newly diagnosed HIV infection, and fewer than 20% of
persons reported to have gonorrhea and genital chlamydial infections. Although additional resources are probably needed to expand and improve HIV infection PN services, the number of cases
nationally and the breadth and funding of current prevention and
treatment programs suggest universal provision of HIV PN services is probably feasible if PN is prioritized.
Efforts to improve PN for gonorrhea and chlamydial infection
may also require additional funds but will need to incorporate new,
more efficient approaches to PN that target services to those in
greatest need of assistance and persons playing demonstrably key
roles in sustaining community transmission of these infections.
Developing low-cost mechanisms to assist providers in ensuring
495
that their patients’ sex partners are treated could substantially
increase the efficacy of PN efforts.
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