Introductory Section

2.1 INTRODUCTION

Partner services, according to the 2008 CDC Recommendations for Partner Services Programs for HIV Infection, Syphilis, Gonorrhea, and Chlamydial Infection ², are defined as “a broad array of services that should be offered to persons with HIV infection, syphilis, gonorrhea, or chlamydial infection and their partners. A critical function of partner services is partner notification, a process through which infected persons are interviewed to elicit information about their partners, who can then be confidentially notified of their possible exposure or potential risk. Other functions of partner services include prevention counseling, testing for HIV and other types of STDs (not necessarily limited to syphilis, gonorrhea, and chlamydial infection), hepatitis screening and vaccination, treatment or linkage to medical care, linkage or referral to other prevention services, and linkage or referral to other services (e.g., reproductive health services, prenatal care, substance abuse treatment, social support, housing assistance, legal services, and mental health services).” Partner Services is supported by the CDC as an effective public health strategy to reduce STD and HIV transmission and associated morbidity.³  Partner notification is an important component of partner services and is intended to identify, locate and inform people of their potential exposure to infections, and to refer them into care, thereby breaking the chain of infection and reducing morbidity.  

For the purposes of this toolkit, Internet Partner Services (IPS) is the use of technology, including, but not limited to, the Internet, and venues accessed through the Internet, such as social networking sites, email, instant messaging (IM), and mobile devices, for partner services (Note: currently some programs are also using technology for technology-based outreach, recruitment, and health communications, which are not extensively addressed in this toolkit).  IPS is also supported by the CDC^4,5  It can be used to identify partners of STD positive patients, to collect locating information of partners, and notify them of a possible exposure or potential risk.  IPS can also assist patients who choose to notify partners on their own. Lastly, it can be used as a means to notify communities about local epidemics or outbreaks and provide information and access to relevant resources and services, such as testing and treatment for STD/HIV.  

National guidance exists, and applies to the provision of partner services, and these guidelines remain applicable to IPS as well.  These guidelines and relevant resources are listed in the National Partner Services Guidelines, Table 1.

Additionally, technical assistance (TA) for IPS is available from various sources on a variety of IPS topics.  Resources available to all STD/HIV programs for IPS-related TA are listed below and in Section 9, 9.2 Technical Assistance (TA) for IPS Table 2.

2.1.1 Technical Assistance for Technology-based Partner Services

Technical Assistance Provider	Contact information
CDC’s Division of STD Prevention, IPS Working Group.  Members of the IPS Working Group have extensive knowledge and experience working with health departments on developing, implementing and evaluating IPS programs. They can provide TA and trainings.  Additionally, they facilitate quarterly conference call discussions with DIS staff across the nation about IPS related topics.	Contact Frank Strona (fhs3@cdc.gov) or Rachel Kachur (rlk4@cdc.gov) for more information.
CDC’s Division of HIV Prevention, Capacity Building Branch. Organizations and health departments that receive direct funding from CDC may request TA through the web-based Capacity Building Assistance Request Information System (CRIS).     Organizations not funded directly by the CDC can ask the health departments in their jurisdictions to submit a TA request on their behalf.	Capacity Building Assistance Request Information System (CRIS) - https://wwwn.cdc.gov/Cris2009/pages/main/e1.aspx.       Health department listings - https://wwwn.cdc.gov/Cris2009/pages/main/hdexternalinfo.aspx
The National Network of STD/HIV Prevention Training Centers (NNPTC) offers courses related to IPS.	http://nnptc.org/partner-services-ptcs/

Technical assistance from experienced programs has also proven to be a valuable tool to those programs new to IPS.  CDC and NCSD staff can help refer programs to peers.

2.2 USING THIS TOOLKIT

This toolkit was developed to be a flexible resource for use by a variety of stakeholders, from seasoned programs with years of IPS experience to the individual DIS brand new to partner services.  This toolkit is not meant to be a one size fits all resources rather we hope programs can take what they need to adapt or improve their current IPS efforts.  

While developing the toolkit, we worked under the following assumptions; 

1. You have a solid understanding of the basics of traditional partner services.
2. Internet Partner Services is viewed as a part of a menu of activities and is intended to augment, not to replace, face to face services.
3. This is not a manual or a set of guidelines. Instead, we have curated and developed some of the shared best practices and experiences from those already doing this type of work.
4. Just like technology, the content, examples and web links currently found in the toolkit will change.

The layout of the toolkit is designed to be easily navigable by topic/action. Those of you accustomed to the formal “start to finish” instruction manuals may find this different. While you can read the entire contents from acknowledgement to references – you may find it more useful to start in the sections that are most relevant to your program. 

The toolkit is made up of seven (7) sections.

Section 2

Introduction

Using this Toolkit

Executive Summary            

Background          

A Brief Historical Context of IPS       

Section 3

Cultural Understanding & Awareness             

Communicating in digital venues     

Code of conduct in digital venues   

Engagement of Appropriate Stakeholders

Section 4: (IPS) Components           

Creating Profiles, Screen Names, and E-mail Addresses              

Interviewing and elicitation              

Language used for Technology-based Partner notification

Confidentiality during Partner Notification/Partner Services

Text Notification & Mobile Applications

Section 5 Documentation, Data Collection and Evaluation

Data Security and Confidentiality

Evaluation

Logic Models

Examples of possible evaluation questions and associated indictors

Supporting Resources for Program Evaluation

Section 6 IPS Staffing and Supervision

IPS staffing

IPS Supervision

Training

Section 7 Summary

Section 8 Glossary of Acronyms

Section 9 Tables

Section 10 Appendices

Section 11 References

Whenever possible we have created hyperlinks to reinforce the content, and have provided examples shared from existing programs.  Lastly, we welcome your feedback.  Hearing what worked for you and what didn’t and how your program is implementing IPS will be us improve future iterations of the toolkit.  

2.3 BACKGROUND

Mobile phone ownership and access to the Internet has become nearly universal for most Americans.  Eighty-four percent of all U.S. adults are online⁶ and 90% own a cell phone⁷, 58% of which are smart phones. ⁸  The wide use of the Internet and mobile devices for communication makes them ideal settings for meeting prospective sex partners.  Research has shown that these venues are, in fact, being used to find potential sex partners, by a variety of populations, and that this behavior can lead to STD acquisition and transmission.^9-20 Furthermore, mobile phones and mobile phone applications can increase the speed with which a sex partner can be found, further compounding STD risk. ¹⁹ As a result of the pseudo-anonymity of the Internet and mobile communications, individuals, who are newly diagnosed with STD/HIV, may know little more than a profile name or email address of their sex partners.  When partner-locating information is limited to such virtual identifiers, the Internet and other digital media often become the only means for notifying a partner of their exposure.  These venues can also provide access to valuable information that can then be used for partner notification (PN), such as locating information and physical and behavioral characteristics of sexual partners.^14,21,22   As such, STD and HIV prevention programs have been encouraged to incorporate the Internet and other digital technologies into their prevention efforts.^4,5

2.4 A BRIEF HISTORICAL CONTEXT OF IPS

The first documented instance of the Internet being used for the purposes of partner notification was in 1999 and was a response to a syphilis outbreak in San Francisco attributed to sexual encounters that were facilitated through a chat room.²³ In the same year, another study was conducted that focused on the Internet as a sex-seeking environment and was identified as a possible STD/HIV risk environment.⁹

As a result of a significant increase in the number of patients reporting sex partners met online through chat rooms, social networking, and “hook-up” sites, public health programs began incorporating the internet and email into their partner services programs.^24-26  These early efforts showed that Internet-based partner services held promise as a legitimate tool when partnered with other traditional methods for disease prevention.

By September of 2005, CDC had responded to the promising outcomes shown in several areas with a “Dear Colleague Letter”  ⁴  that encouraged program areas to explore the Internet as a disease intervention and prevention tool.  A second CDC “Dear Colleague Letter” supporting the use of the internet for partner services was released in 2010.⁵  

Since the release of the first Dear Colleague letter, several studies have been conducted to evaluate IPS outcomes by assessing rates of partner elicitation, notification, and testing and quantifying the number of partners who otherwise would not have been contacted without IPS. 

In Texas, Vest et al found that the use of email to reach partners for whom no other contact information was available resulted in 50% of those partners being notified of which 26% were found to be infected with an STD. Additionally, they found that sending emails did not require additional staff time, and allowed for rapid PN communication.²⁷

Ehlman et al. assessed the effectiveness of Internet partner services in Washington, D.C. using STD program disposition codes and found Internet partner notification (IPN) improved notification and treatment for early syphilis. Using IPN led to a 75% increase in the number of partners investigated and a 26% increase in number of partners examined and treated, when necessary. At least 285 partners who would not have otherwise been contacted were notified of exposure.²⁸

In addition to emails, social networking sites can also be a venue for PN.  The Milwaukee Health Department in Wisconsin reported on the use of the social networking site, Facebook, to augment partner notification efforts involving a syphilis cluster (n=55).  Within the cluster, 17 positive cases of syphilis were found, 10 of which were coinfected with HIV.  Among the cluster, two of the positive cases had been named as Facebook contacts, and as a result, were able to be located by DIS when traditional methods failed. Moreover, these two cases were found to be key connectors within the cluster. Facebook was also used to augment traditional partner notification for an additional five individuals.  Hunter et al (2014) found that the use of Facebook augmented traditional efforts by allowing DIS to reach partners more quickly, especially among those individuals who may frequently change phone numbers or addresses while also aiding in the identification of sought-after partners.²⁹ 

More recently, texting has also been shown to be a very effective way of reaching partners.  In a 2011 Letter to the Editor, Kachur et al. described a case in which text messaging was successfully used for partner notification.  In this case, DIS in the New York State Department of Health were able to reach and notify a partner of their syphilis exposure through text messages after traditional efforts had failed.¹⁵
In 2012, Mendez et al reported on Multnomah County’s texting PS program, which consisted of sending a text message for partner notification immediately following an attempt to reach cases by phone, but before mailing letters or conducting a field visit.   Text messages were sent to 149 clients immediately following an attempted phone call; 56% of those texted responded to DIS with a phone call, many within 10 to 15 minutes.  They also found texting reduced the need for mailing letters and making field visits.³⁰

Hightow-Weidman et al evaluated the use of text messaging for the partner notification of 29 contacts in North Carolina.  Text messaging was used only after traditional or IPN attempts did not elicit a response.  Of the 29 contacts, 48% (n=14) responded to the text, all within in a median time of 57.5 minutes.  Among the 14, two new cases of syphilis and one new case of HIV were identified.³¹

Udeagu et al. compared traditional, internet and text-based (txtPS) PS delivery methods on contact, notification, and HIV testing rates.  They found the contact rates for txtPS (77%) to be significantly higher than traditional PS (69%) or IPS (41%; p<0.0001).  IPS (odds ratio (OR), 2.1; 1.2-3.4) and txtPS (OR, 2.4, 1.7-3.2) resulted in a greater likelihood of notifying partners than traditional PS (p<0.0001), but traditional PS yielded the highest proportion of partners testing for HIV (69% versus 34% and 45%, respectively; p<0.0001).   They concluded that augmenting their PS program by incorporating the three modes of PS improved their overall PS outcomes, reached partners who were otherwise unreachable, and improved their operational efficiency.³²

Lastly, Pennise et al reported on the Monroe County Department of Public Health in New York, which has, since 2012, issued smart phones to the DIS for use during field investigations.  They reported on a cluster investigation conducted between February and May 2013 through which partner elicitation, notification, and testing was improved through the use of smart phones. Use of smart phones allowed DIS to search online sites and mobile applications with patients in order to elicit partner information in real time. These efforts resulted in seven new cases of disease being diagnosed, including two new cases of HIV.²²  

In addition to augmenting traditional partner services, partner notification through an online community is considered an acceptable tool by members of that community. In a national IPS study performed by The Fenway Institute, Fenway Community Health looked at the acceptability of IPS among men who have sex with men (MSM). A total of 1,848 MSM were recruited online via an Internet sex partner-seeking website between October and November 2005. The study concluded that IPS should be considered an acceptable tool for partner services, with more than 92% of participants reporting that they would use IPS in some capacity to inform their sexual partners of possible exposure, if they were to become infected with an STD in the future.³³

Since its inception in 1999, IPS has become a standard practice in many health departments.  IPS has been an effective tool for the elicitation, notification, and testing of partners and for reaching those partners, who otherwise would not have been notified of their exposure to an STD or HIV.