PUBLIC HEALTH DEPARTMENTS HAVE OBLIGATION TO REACH OUT AND ASSIST PERSONS WITH NEWLY REPORTED HIV

INTRODUCTION: 

The Beyond AIDS Foundation recommends that the following services be routinely and consistently provided by public health departments upon receipt of a new HIV diagnosis (a positive laboratory test report or a report by a provider). These recommendations are consistent with CDC surveillance and prevention grant expectations, but currently adherence is not monitored as a condition for continued CDC funding. They both serve the interests of the patient and help to fulfill the public health goal of preventing further infections. 

A published survey of state and territorial HIV/AIDS directors conducted by our Foundation (https://guilfordjournals.com/doi/abs/10.1521/aeap.2019.31.1.82) demonstrated wide discrepancies in actual practices among U.S. states and territories and gaps in services in many locations. Such discrepancies and gaps, and the lack of monitoring for adherence to national guidelines by CDC, highlight the need for this policy.

We encourage concurrence with this policy by state and territorial HIV/AIDS directors and epidemiologists, city and county public health officials, federal, state, and local communicable disease-related agencies, local HIV/AIDS projects, state conferences of local health officers and of communicable disease controllers, and others. 

On another page of our Website, below this policy statement, we have provided more detailed guidelines as a reference to public health departments for developing their HIV outreach services after new HIV diagnoses are reported (https://www.beyondaids.org/articles/ApprovedPolicies032023.pdf).

POLICY: 

When a new HIV diagnosis is reported by a laboratory or a provider, surveillance by public health departments should either include or be seamlessly integrated with outreach and “case management” services to prevent further transmission: 

• Initiation and facilitation of the HIV Care Continuum (linkage to care, and encouragement of maintenance of treatment to reach undetectable viral loads). The achievement of undetectable viral loads both eliminates sexual transmission and achieves the best clinical outcomes, and is therefore a major public health objective. 
• Partner services (contact tracing and partner notification) with referrals of contacts for testing and counseling; best conducted by public health personnel 2 with or without the presence of the patient. Trusting the patient to notify partners is not consistently reliable, and should only be used as a last resort and when adherence can be verified 
• Referrals to other needed services (substance abuse or mental health treatment, housing, etc.) 
• Counseling/education on HIV infection and its prevention and treatment. This should include information that the patient does not yet have and is interested in receiving. Safe behaviors, protection of partners (e.g., condoms and PrEP), and the benefits of rapid treatment initiation are priority topics. 
• Obtaining information to accurately complete the morbidity reporting form. This is important to the local jurisdiction, state, and CDC for monitoring the epidemic, but does not in itself interrupt transmission or result in treatment, and therefore should not be the sole objective when following up on new reported diagnoses. 

These services can be provided by communicable disease investigators if they receive adequate training. Some jurisdictions may assign other staff, such as public health nurses or health educators. These staff may be assigned as case managers, so that there is consistent follow-up by a worker who has already established rapport and knows the patient. 

When a public health department receives a new positive HIV test result, there should be immediate outreach. If the test was ordered by a medical provider, there are advantages to contacting the provider first. The provider’s office can frequently provide information regarding reaching the patient, completing the morbidity reporting form, known partners, acute transmission risks such as history of needle sharing, comorbidities including mental illness and substance abuse, homelessness, and whether the provider can offer immediate initiation of therapy, has already made arrangements for referral or consultation regarding HIV care, or is willing to delegate referral for treatment initiation to the public health department or designee. 

Following the communication with the provider, or if there is no provider associated with the test, the public health department should make every possible effort to contact the patient directly. In-person meetings have the advantage of establishing trust and rapport. Virtual meetings may be next best, and in some cases, the only opportunity to see each other. 

The same four bulleted priorities listed above should be discussed with the patient, emphasizing rapid linkage to care and partner services. A follow-up contact a few weeks later, should help verify that linkage actually occurred. Subsequently, monitoring of periodic lab reports, particularly of viral load, should be done to determine whether the patient is maintaining treatment and that the viral load is approaching undetectable levels. The patient, medical provider, and in some cases the laboratory should be contacted if these test results are not being regularly reported. 

If a patient is found to live outside of the jurisdiction of the public health department, the appropriate department in the jurisdiction of residence should be informed of the case, so that services can be initiated.

BENEFITS OF HIV PARTNER SERVICES EXPLAINED, DEFICIENCIES IDENTIFIED, IN PUBLISHED LETTER FROM BEYOND AIDS FOUNDATION

 

A letter from our organization to the journal Sexually Transmitted Diseases on the topic of HIV partner services (contact tracing, partner notification and testing, result-specific follow-up, and other appropriate services), has been published in the August2023 issue. The letter, authored by Ronald Hattis, Gary Richwald, Jeffrey Klausner, and Deanna Stover, had been unanimously approved by our Board, with favorable input from responding members of our Scientific Committee.

In the letter, we commended an article in the journal by Williams et al.,¹ which documented that partner services detect undiagnosed HIV infections. However, we pointed out four additional public health benefits of HIV partner services that were not mentioned in that article:

1.      Many identified partners of a newly diagnosed person with HIV infection, who test positive, are themselves likely to have been recently infected. Initiating treatment for such individuals can both provide the earliest opportunity to prevent additional infections, and achieve the best clinical outcomes.²

2.   One of the contacts may be the source of infection, likely an undiagnosed and untreated person with a high viral load, and capable of causing further infections. Testing and treating such an individual is a high priority for prevention.

 3.   Partners who test negative for HIV infection have been exposed to the virus, and without intervention such exposure may continue. They, too, are a high priority for prevention. Increased attention to at-risk HIV-uninfected individuals, including safer sex counseling and referrals for PrEP, is consistent with CDC’s new “status neutral” initiative.³

4.   Partners can be referred for additional appropriate services, such as screening for syphilis and other STIs along with HIV testing, and linkage of any such infections detected to treatment. Those partners who test positive for HIV can also be provided with access to primary care, housing, Medicaid or Ryan White coverage, nutritional assistance, and other needs, and assisted in achieving viral suppression (and thus becoming non-infectious sexually).  

We included some findings from our survey of U.S. state and territorial HIV/AIDS directors or their designees, which found substantial discrepancies among jurisdictions in methods, content, and consistency of outreach for partner services and linkage to care.⁴  As the Williams article noted,¹ partner services activities are currently required for all CDC-funded health departments, applying the shared guidelines for HIV, syphilis, gonorrhea, and chlamydia.⁵  However, our survey suggested that CDC does not monitor jurisdictions for details on whether and how this is done.  We have recommended that uniform standards for public health outreach after newly reported diagnoses be established and written into CDC grant requirements, with appropriate compliance monitoring.⁴ CDC could require that a portion of grant funds be specifically designated for partner services.

State requirements can supplement federal grant stipulations. In New York State, for example, a law authored by one of our founding officers, the late Nettie Mayersohn, has required since 1998 that the names of any known sexual or needle-sharing partners be included as a part of reporting of new HIV diagnoses, and that local health departments perform contact tracing and partner notification along with HIV education, which may also be done by physicians.^6.7  Other states could consider similar legislation.

The letter also mentioned some heretofore unpublished findings of our earlier study  (1993) of partner services by local public health departments in California. That survey had found that 5% were not performing any partner services for HIV or other STIs, and 66% were performing them but not for all four sexually transmitted diseases for which they were recommended by CDC.⁵  Then-current CDC guidelines on how to conduct partner services were not being followed by 39%, and 27% were not receiving any specific funding for the performance of partner services.

We declared that state public health departments have a responsibility to assure that essential public health programs, including partner services, are available and adequately maintained in all cities and counties. Partner services are valuable components of HIV prevention with multiple benefits, and federal and state policy changes could improve their uniformity, quality, and impact.

 REFERENCES

1.      Williams WO, Song W, Huang T, et al. HIV diagnoses through partner services in the United States in 2019 and opportunities for improvement. Sex Trans Dis 2023; 50:74-78.

2.      National Institutes of Health. Early HIV diagnosis and treatment important for long-term outcomes. October 21, 2022. Available at: https://www.nih.gov/news-events/news-releases/early-hiv-diagnosis-treatment-important-better-long-term-health-outcomes. Accessed March 25, 2023.

3.      Centers for Disease Control and Prevention. Status neutral HIV prevention and care. Available at https://www.cdc.gov/hiv/effective-interventions/prevent/status-neutral-hiv-prevention-and-care/index.html. Accessed March 25, 2023.

4.      Hattis RP, Strydom RY, Gaio J, and Stover DC. HIV prevention practices and non-federal funding among U.S states and non-state regions: a survey of HIV/AIDS directors. AIDS Education and Prevention 2019; 31:82-94.

5.      Centers for Disease Control and Prevention. Recommendations for Partner Services Programs for HIV Infection, Syphilis, Gonorrhea, and Chlamydial Infection. MMWR 2008; 57:1-57. Available at: https://www.cdc.gov/mmwr/pdf/rr/rr57e1030.pdf. Accessed March 26, 2023.

6.      Neidl, BF. The lesser of two evils: New York's new HIV/AIDS partner notification law and why the right of privacy must yield to public health. St. John’s Law Review 1999 73;1191-1238. Available at: https://scholarship.law.stjohns.edu/cgi/viewcontent.cgi?article=1506&context=lawreview.

7.      New York State Senate, Legislation. Section 2133, PBH chapter 45, article 21, title 2: contact tracing of cases of AIDS, HIV, related illness, or HIV infection. Available at: https://law.justia.com/codes/new-york/2022/pbh/article-21/title-3/2133/. Accessed March 26, 2023.

8.      Centers for Disease Control and Prevention. Statistics overview, HIV surveillance report, 2020. Available at: https://www.cdc.gov/hiv/statistics/overview/index.html. Accessed March 26, 2023.