What Is HIV Contact Tracing and Why Is It Important?
New Technologies in STI Contact Tracing
There are new approaches to contact tracing to reach people who may not be reached by more traditional approaches (in-person and telephone). Email, email postcards (e-cards) and text messaging can be used by both patients and providers to notify someone of a potential exposure to an STI, including HIV.
One program in North Carolina used email and text messaging for contact tracing for syphilis and HIV and increased notifications by 600%22 when compared to data collected on traditional contact tracing approaches. Out of 362 people notified using email, seven new cases of HIV and 11 new cases of syphilis were diagnosed.22
One such technology, inSPOT, has been introduced in British Columbia, Toronto and Ottawa. inSPOT is a website that allows people recently diagnosed with an STI to send e-cards (without using their personal email address) to their sexual partners to let them know they may have been exposed. The service also lets them maintain their anonymity if they wish. Although the approach is acceptable to both heterosexual people (65%) and gay men (73%),23 the evidence for its effectiveness in the long term is weak.24
Although email remains one of the most widely used new technologies in contact tracing, there is some evidence to suggest that using text messaging for contact tracing could improve notification outcomes. A study in North Carolina concluded that text messaging was effective with contacts who did not respond to traditional forms of follow-up and/or email notification.22 Before using this approach, however, service providers should be mindful that text messaging is not considered a secure form of communication.
Overall, the use of new technologies, although acceptable for contact tracing, are not always preferred where multiple options are available.25 According to one study among men and women diagnosed with chlamydia, the most appropriate option reported by participants was in-person disclosure.25 This same study found, however, that participants considered email or text was appropriate when the person being notified was a casual partner or if the relationship had ended badly.
Enhanced Approaches to Contact Tracing in Canada
In 2012, Saskatchewan had the highest rate of new HIV diagnoses in Canada at 17 diagnoses for every 100,000 people.26 This is almost triple the national rate of six diagnoses for every 100,000 people.26 Sixty-seven percent of new HIV diagnoses in Saskatchewan in 2012 were attributed to injection drug use,27 and 74% were among Aboriginal peoples.27
Since 2005, Saskatoon Health Region has enhanced a traditional approach to contact tracing using a social network strategy. In addition to index cases being asked for their immediate drug use and sexual contacts, they are also asked who among their social networks would benefit from the offer of testing and counselling but who did not come into immediate contact with them. This approach focuses on the social context in which risky behaviours occur and engages peers to identify those people in their networks who may be at higher risk for HIV.
In 2004, before the enhanced approach was implemented, the rate of new HIV diagnoses in the Saskatoon Health Region was 5.57 per 100,000 people. In 2005, after the implementation of the social networking strategy, the number of new HIV diagnoses in the Saskatoon Health Region increased dramatically to 20 per 100,000 people. These numbers were compared to another health region in Saskatchewan, which did not implement the social network strategy. The rate of new diagnoses did not change in the region that was not using the enhanced approach.28
Since 2011, Vancouver Coastal Health has taken a more robust approach to traditional HIV contact tracing services. The program engages public health nurses in HIV contact tracing as soon as someone is diagnosed with HIV. Since every new HIV infection in Vancouver is reported to the Vancouver Coastal Health Communicable Diseases Control, nurses follow up with healthcare providers and clients to determine how best to perform contact tracing. Clients are encouraged to allow public health staff to notify their contacts or to assist them in notifying them.
In addition, Vancouver Coastal Health has implemented a social networking approach. Clients who may not know the names and contact information of their sexual partners, can instead disclose where contacts were met. If, for example, a contact was met at a bathhouse, public health nurses would set up additional or extended HIV testing clinics at that venue.
Vancouver's enhanced contact tracing service has been critical to the increase in the percentage of people aware of their status. The HIV positivity rate for contacts tested through this program was 12%, significantly higher than the positivity rates for other testing strategies being used in Vancouver at the same time. Key to the success of increasing the number of people living with HIV who are aware of their status has been the measurement of outcomes, such as proportion of partners identified, reached, tested and diagnosed.
Contact tracing in some areas of Canada may not currently be occurring as outlined in the Canadian, provincial or territorial guidelines. Learning about how contact tracing is conducted in your area may be key to improving the experience of people newly diagnosed with HIV and reducing the number of people living with HIV who are unaware of their status.
The criminalization of HIV and the fear some clients may have of disclosing their status are real. Service providers may need to work with clients to help them make informed choices about how to tell their contacts in a way that feels safe for them. It may be important in your work to discuss with people recently diagnosed with HIV the value of telling their partners that they may have been exposed to HIV. Service providers can encourage newly diagnosed clients to inform their contacts personally, through public health staff, or through inSPOT, where it is available.
In some instances, service providers may be able to work with public health staff and healthcare providers to improve contact tracing so that clients concerned about disclosure feel safe sharing their contacts' information. Certain populations may also need a more appropriate approach to contact tracing. Positive Living B.C., for example, has worked with Vancouver Coastal Health Communicable Diseases Control to strengthen contact tracing for MSM.
There is a significant lack of research in the Canadian context on HIV contact tracing, particularly regarding current trends. Contact tracing has the potential to significantly reduce the number of people living with HIV who don't know their status. More needs to be done to understand the acceptability and effectiveness of all types of contact tracing services in Canada.
This article drew heavily upon the work of the National Collaborating Centres for Infectious Diseases and their evidence reviews: HIV Partner Notification: A review of the evidence with recommendations to move the field forward (Nicole Findlay) and New Technologies for Partner Notifications for Sexually Transmitted Infections (Colin Lee and Mayank Singal).
HIV disclosure: a legal guide for gay men in Canada -- HIV & AIDS Legal Clinic Ontario (HALCO), Ontario's Gay Men's Sexual Health Alliance GMSH), CATIE
Logan Broeckaert holds a master's degree in history and is currently a researcher/writer at CATIE. Before joining CATIE, Logan worked on provincial and national research and knowledge exchange projects for the Canadian AIDS Society and the Ontario Public Health Association. Margaret Haworth-Brockman is the program manager at the National Collaborating Centre for Infectious Diseases (NCCID), which provides evidence for action in public health. NCCID has numerous resources available (www.nccid.ca) on HIV, and also works to foster working partnerships and networks to improve information exchange. Margaret's past work includes developing new resources on gender and HIV and AIDS for communities in Canada, Belize, and southern African countries.
This article was provided by Canadian AIDS Treatment Information Exchange. It is a part of the publication Prevention in Focus: Spotlight on Programming and Research. Visit CATIE's Web site to find out more about their activities, publications and services.
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