In 2010, there were over 74 000 newly diagnosed cases of chlamydia infection in Australia, a steady increase over previous years.1 In addition, other sexually transmissible infections (STIs) including HIV, gonorrhoea and syphilis remain a significant issue in certain communities, predominantly among men who have sex with men (MSM). Contact tracing (also called 'partner notification') is an essential component of the effective management of STIs.
The aim of contact tracing is to reduce re-infection and complications of disease and to reduce the population burden of STIs.2 Many STIs are asymptomatic so contact tracing can be an important means of identifying patients at risk. Contact tracing also helps identify males with an STI. This is important because males are less likely to present for chlamydia screening.3
Recent research has found that some general practitioners do not feel adequately skilled in the area of contact tracing and would like clearer guidance on best practice.4–6 Ensuring that GPs have appropriate skills and knowledge in this area has the potential to help facilitate effective management of STIs in the community.
A questionnaire study of 65 Queensland GPs suggested that some GPs may not be aware of their contact tracing responsibilities.7 Importantly, for all STIs the diagnosing practitioner is responsible for initiating a discussion about informing sexual contacts.8 Another potentially confusing area is the role of disease notification to a public health unit and whether or not this includes contact tracing. State differences in levels of intervention by public health units in this process may have contributed to this confusion. However, in most Australian states and territories, public health units now only proactively support the contact tracing of rarer STIs, not chlamydia.
This article aims to clarify the process of contact tracing and update the general practitioner on the evidence and available resources. Resources for both GPs and patients are outlined in Table 1.
Methods of contact tracing
Contact tracing begins with a conversation with the index patient about informing their partners.6 From here, the patient can decide to inform their own contacts (patient referral) or organise for someone else to inform them (provider referral). Patient referral is the most common type of contact tracing used in general practice. For this type of contact tracing to be successful, it is important that the GP informs the patient about who needs to be informed and what information needs to be given.5,9,10 The most common STI requiring contact tracing diagnosed by GPs is chlamydia and patient referral is usually adequate for patients with this diagnosis. If the patient elects for provider referral, the GP can collect the contact person's details and either notify the contacts themselves, or pass the details to a practice nurse or a sexual health clinic who can undertake this.
Both methods can be anonymous or not, and both can employ a range of techniques including in person, telephone, SMS, email or letter. With either method, a nonjudgemental approach and a trusting patient-doctor relationship is likely to give the patient reassurance of confidentiality and result in more effective outcomes.11,12 Importantly, different methods may be appropriate for different partners of a single index patient. Patients are usually willing to inform regular partners, however more assistance, including provider referral, may be appropriate for casual or ex-partners or particular index patients.13–17
Discussing contact tracing with patients
When discussing contact tracing with patients it is important to cover the reasons for tracing and provide an explanation about the fact that most chlamydia infections are asymptomatic, identify which patients need tracing, and provide referral support and follow up.
Outline the reasons for contact tracing: 'It's important your partner(s) get treated so you don't get infected again.' Well informed patients are more likely to tell partners than those not given an explanation of the reasons for contact tracing.8,18
Explain that most infections with chlamydia are asymptomatic: 'Most people with an STI don't know that they have it because they don't have any symptoms, but they could still have complications and pass it on to a partner.' Patients may be less likely to inform a perceived transmitter because they believe the perceived transmitter was aware of the infection,19 so reminding patients that most STIs are asymptomatic may help with contacting of past partners.
Help identify which partners need tracing. It is important that the GP guides the patient to help identify the appropriate people to contact as patients may misjudge or bias which partners they mention.20 Figure 1 outlines consensus guidelines on how far back to trace. Using interviewing cues such as asking about locations and events can improve identification of all partners that need tracing.21,22 Eliciting and recording names or tallies of number of contacts to be advised may also increase the number of contacts advised.23
Explain the methods and offer choice. Most studies suggest that while provider referral is more effective than patient referral, provider referral is much more resource intensive.24 It is important to outline both methods and recognise when each is more appropriate. Patients generally prefer patient referral for regular partners; provider referral may be more effective for casual, ex or incarcerated partners (Figure 2).14–16 Provider referral may also be appropriate for HIV, syphilis and gonorrhoea due to higher morbidity and need for greater involvement in after care.8,25,26 Repeat infections may indicate that the partner was not appropriately treated the first time and that the index patient requires support with contact tracing.27,28
Support patient referral. If patient referral is selected, it is important to support this by supplementing verbal information given to patients with specific information on STIs (written or web links).29 Specific treatment letters have been shown to improve contact tracing rates and enable contacts to be appropriately treated at their place of choice.30,31 While online notification tools are available, Hopkins et al32 showed that the majority of patients chose to inform partners, especially regular partners, via telephone or face-to-face. However, online notification, either self initiated or via a sexual health clinic, may be relevant for index patients with multiple partners, particularly MSM who have sourced partners online.33
Arrange follow up. Tactful follow up may be one of the most simple and effective interventions in contact tracing.8 A practice nurse could be employed to make a follow up telephone call 1–2 weeks after diagnosis, and there is evidence that simply scheduling the call is motivating.34–36 For many STIs a repeat test is recommended, and this may be the appropriate time to check on the progress of contact tracing.
Is patient delivered partner therapy an option?
Patient delivered partner therapy (PDPT) is providing a prescription or medication to a patient to give to their partner, without the partner having been seen for a medical consultation. In one Australian study almost half the GPs reported 'sometimes' or 'always' using PDPT for chlamydia.5 However GPs often express mixed feelings about this course of action given the lack of specific guidelines or legislation.4,5 The Sexual Health Chapter of the Royal Australasian College of Physicians has a working group developing guidelines and is planning negotiation with The Royal Australian College of General Practitioners and the Pharmacy Guild, but legislation change has some way to go. In the meantime, while PDPT may be an option for some, particularly patients with repeat chlamydial infection, it is not recommended for MSM index patients where offering the contacts testing for other STIs is a priority.37
General practitioners have raised concerns that it is difficult to fit contact tracing into a standard consultation.9 Certainly there are multiple issues to cover when seeing a patient with a new diagnosis of an STI, including those relating to the patient's own physical and emotional health. It can be useful to set the scene for contact tracing early in the discussion about the infection. Once the patient's treatment and concerns are addressed, return to discussing how sexual contacts will be notified. In many cases, a long consult or a subsequent appointment may be required. Practice nurses can assist in provider referral, or making follow up telephone calls.
Some GPs have raised concerns that asking a patient to inform contacts may affect the patient-doctor relationship.8,14 However, research suggests that almost all patients found the experience better or at least no worse than expected38 and that patients expressed the feeling that it's 'the right thing to do'.39 If a patient is concerned about potential violence when informing a contact, then provider referral is recommended.
Where confidentiality is difficult, such as in rural settings,5,9 GPs can refer to regional sexual health clinic staff for assistance (Table 1).
- Contact tracing is an integral part of the management of an STI.
- It is the responsibility of the diagnosing clinician to initiate contact tracing.
- Contact tracing begins with a conversation with the index patient about informing their partners. The patient can then decide to inform their own contacts (patient referral) or organise for someone else to inform them (provider referral).
- Initiating contact tracing in general practice can be particularly effective if resources and methods are tailored to the specific needs of the index patient.
Conflict of interest: The NSW STI Programs Unit provided funding to the Burnet Institute for travel expenses and payment for writing the manuscript. Siobhan Reddel is employed by the Burnet Institute.