Internet Partner Services: History & Effectiveness
The first documented instance of the Internet being used for the purposes of notifying partners that they may have been exposed to an STD and should get tested 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 STD 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 (IPS) held promise as a legitimate tool when partnered with other traditional methods for disease prevention.
The CDC supports using dating websites as a strategy to find partners. By September of 2005, CDC had responded to the promising outcomes shown in several areas with a “Dear Colleague Letter” to public health departments 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 partner notification (PN) communication.27
Ehlman et al. assessed the effectiveness of Internet partner services in Washington, D.C. 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 co-infected 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 Disease Investigation Specialists, or DIS (also known as Health Specialists), 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.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 to reach them by phone; 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
Additionally, BHOC assessed the levels of support for partner notification by users, website owners, and public health in 2009. Two-thirds of the website users welcomed internet partner services by the government. Currently, BHOC is also working with University of Washington researchers to assess interest in mobile-app based partner notification strategies. Initial analysis suggests that while users believe they themselves should notify their partners, they still welcomed assistance by public health agencies. 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.
Partner notification has lent itself much more to websites than apps. First, site users have unique identities, which make it easier for a user to find a partner. Second, unless a user has saved a partner’s profile, he may not be able to see him if he’s not in the same geographic area. This also makes it much harder for them to notify partners, as well as for health specialists to find them if they’re trying to help.