A social network approach to HIV investigation and partner notification

What is the Program?

HIV investigation and partner notification is a public health practice in which recent sexual and drug-using partners of people newly diagnosed with HIV are contacted and offered the opportunity to be tested. An HIV investigation has several components, including follow-up services for the person newly diagnosed, partner notification, HIV testing, risk reduction counselling, and prevention education.

The social network approach to HIV investigation and partner notification is a recruitment strategy that facilitates rapid dissemination of HIV testing, HIV risk reduction counselling and HIV prevention education through social networks. This offers people recently diagnosed with HIV the opportunity to refer people they know but who are not direct contacts to public health staff for HIV testing, counselling and education.

The goal of this intervention is to increase access to HIV testing and early diagnosis, counselling and prevention education during an outbreak of HIV among people who may be at ongoing high risk for HIV infection and who may not know their HIV status. This method is easily applied in any HIV investigation conducted by public health personnel because it builds on traditional HIV investigation and partner notification practices.

Since 2005, Saskatoon Health Region has included a social network component in its traditional HIV investigation and partner notification work, when appropriate. In addition to their sexual and drug-using partners, people newly diagnosed with HIV are asked about others in their social network they are concerned may be at high risk for HIV. Individuals identified through the social network approach are contacted by a public health nurse and offered testing. They are told that there is no reason to believe they have been exposed to HIV but that Saskatoon Health Region is encouraging everyone to test so they can know their status.

A social network approach focuses on the context in which high-risk behaviours occur. In implementing the social network approach, Saskatoon Health Region learned that stigma associated with drug use (especially with some specific partners^*) and sex prevents some people from identifying all their direct contacts. This stigma has been reduced through the social network approach because individuals are asked about people in their social circle who they think may benefit from HIV counselling and testing.

Although this case study focuses on the use of a social network approach to HIV investigation and partner notification, a similar approach can also be used during investigations for other sexually transmitted infections and other relationally driven communicable diseases such as tuberculosis.

*When individuals are asked as part of the social network approach about people they worry about, the social contacts they identify include close family members such as parents, uncles, aunts, siblings and friends.

Why Was the Program Developed?

The social network approach was first used in Saskatoon Health Region in 2005. At the time, Saskatoon Health Region was experiencing an unexpected increase in HIV diagnoses, and the medical health officer believed the increase in infections may have been the result of an outbreak among a network of people who injected drugs. Traditional HIV investigation and partner notification did not lead public health to the source of active HIV transmission. The public health team decided to innovate by testing known associates of people newly diagnosed with HIV as part of its investigation approach.

From July 2005, traditional HIV investigation and partner notification services added questions about social contacts to standard follow-up procedures in Saskatoon Health Region. This approach revealed a close-knit group of injection drug using and sexual and social contacts who had not initially been identified as direct sexual partners and/or needle-sharing partners of people newly diagnosed with HIV; many of these contacts subsequently tested positive for HIV. Subsequent analysis showed that the social network approach to HIV testing yielded a higher HIV positivity rate than the traditional HIV investigation and partner notification process.

How Does the Program Work?

When information associated with a new HIV-positive test is received by Saskatoon Health Region, health region staff are mandated to locate that person and provide services. Support services are provided by a public health nurse under the direction of the local medical health officer and may be offered over the phone or in person. Follow-up services for people recently diagnosed with HIV include education on HIV transmission, prevention and treatment, information on the legal duty to disclose, partner notification, post-test counselling and linkage to care.

In a traditional HIV investigation and partner notification process, a public health nurse works with the person newly diagnosed with HIV to identify and contact their direct drug-using and sexual partners. Newly diagnosed individuals are encouraged to inform their partners themselves and Saskatoon Health Region nurses follow up with direct partners to provide them with additional information and to remind them that it is important to be tested for HIV as soon as possible, through either public health or their primary care provider.

Once HIV testing has occurred, any partners who test negative for HIV are counselled on how to remain negative and assessed to determine if they need any referrals to additional services. Partners who test positive for HIV are subsequently linked to care.

Adding a social network approach

The social network approach builds on the existing methodology of HIV investigation and partner notification and therefore is easy to implement. The approach focuses on the social environment where risk behaviours occur and involves peers, families and the community. A main goal of the social network approach is to disseminate accurate knowledge and raise awareness in the community to prevent HIV transmission. This is done through education of people recently diagnosed with HIV and the partners, friends and family they identify as part of their social network. As a result, the approach builds a level of knowledge and awareness in the community that may reduce ongoing transmissions.

In Saskatoon, the social network approach has increased HIV testing and counselling opportunities for individuals who may be at high risk of HIV infection but who have not been named as direct contacts by someone recently diagnosed with HIV. The risk is high for these individuals because it is known that high-risk behaviours such as sharing injection drug use equipment often occur within the social circles, and it is also known that injection drug using networks often include people living with HIV.

Social network approach protocol

When contacted during an HIV investigation that uses a social network approach, an individual identified initially as a social contact of someone recently diagnosed with HIV is told that as far as public health is aware there is no reason to believe they have been directly exposed to HIV. A public health nurse explains they are currently investigating an HIV outbreak in the community and would like to offer the individual an opportunity for HIV testing. Most people contacted by Saskatoon Regional Health as part of the social network approach have accepted the offer of an HIV test.

Saskatoon Health Region has found that when this approach is used during HIV cluster outbreaks among people who inject drugs, people recently diagnosed with HIV give a much longer list of social contacts than they do when they are only asked for their direct drug-using and sexual partners.

Required Resources

1. Clear mandate from the province or territory’s  public health act , and the addition of a social network approach to communicable disease regulations. This will give jurisdictions justification for asking individuals for their social contacts.
2. Public health nurses. Experienced, non-judgemental nurses are needed to provide post-test counselling, partner notification, linkage to HIV care, referrals and support.
3. Medical health officer. The medical health officer provides guidance and medical direction to public health nurses and must be willing to apply the enforcement elements of the public health act in their jurisdiction.

Challenges

1. Resource allocation. Adding a social network approach to HIV investigation and partner notification may increase the number of staff hours devoted to the service. This can be challenging in a system that may not have the necessary additional resources.
2. Soliciting contacts. Public health nurses ask people newly diagnosed with HIV for personal information about their sex and drug-using habits and partners. Many of these clients may already be mistrustful of the healthcare system. Nurses must be approachable and skilled at having these discussions so that clients are comfortable sharing any direct or social contacts exposed to HIV in their networks.

Evaluation

The social network approach is evaluated on an annual basis when Saskatoon Health Region reviews its HIV statistics. The processes that have improved as a result of this approach include the following:

• HIV case finding has increased, as Saskatoon Health Region has continued to find a higher proportion of cases per tests performed (higher HIV positivity rate) than with its traditional HIV investigation and partner notification process.
• A contact tracing database has been developed, which is used to monitor partner follow-up and completion of testing and counselling and to generate a daily workload follow-up list for public health nurses.

In 2004, before the social network approach was added to HIV investigation and partner notification services in Saskatoon Health Region, the rate of new HIV diagnoses in the Saskatoon Health Region was 5.57 per 100,000 people. In 2005, after the social network approach was introduced, the number of new HIV diagnoses in the Saskatoon Health Region increased dramatically to 20 per 100,000 people. The same dramatic increase was not seen in any other health region in Saskatchewan; none of these had implemented the social network HIV investigation approach.

Lessons Learned

1. Take the time to provide clear prevention and testing messages. Social network approaches to partner notification may take significantly more time than the traditional approach. This is because one of the goals is to increase community knowledge and awareness of HIV and HIV prevention.
2. A social network approach may increase risk reduction counselling. A social network approach introduces accessible testing and counselling for HIV and other sexually transmitted infections  into an environment where it may be needed. Regardless of whether social contacts test positive or negative, the interaction with a public health nurse provides an opportunity for tailored prevention, testing and care services.
3. Be clear when talking to social contacts. Social contacts are always told that they have been identified as someone who may benefit from HIV testing and counselling but that there is no reason to believe they have come into direct contact with someone living with HIV. Using clear language may reduce the risk that social contacts will panic, allowing them to absorb and act on the prevention and testing information they are given.
4. A social network approach may yield earlier diagnoses. A social network approach targets an environment where there is known risk. Regular testing in a context of ongoing risk may increase the likelihood that new infections will be diagnosed earlier.

Program Materials

Information found on the CATIE website

• HIV testing and diagnosis

Contact Information

Dr. Johnmark Opondo, deputy medical health officer
Saskatoon Health Region
Johnmark.Opondo@saskatoonhealthregion.ca