Report on HIV Partner Notification Activities 2002-2003

New York State Department of Health

On June 1, 2000, the New York State Department of Health (NYSDOH) implemented the HIV Reporting and Partner Notification Law passed in 1998. The law enhanced the existing AIDS case reporting system by adding reporting of newly diagnosed cases of human immunodeficiency virus (HIV) infection, HIV-related illness and AIDS by health care providers and laboratories to the State Commissioner of Health. The law also mandated reporting of known contacts of persons with newly diagnosed HIV and AIDS to allow for the provision of partner notification assistance, and the conducting of a domestic violence screen to determine if such risk exists before proceeding with partner notification. The implementing regulations indicate that all newly diagnosed cases of HIV infection and any known contacts reported by physicians merit priority consideration for partner notification. This report covers information on the partner notification assistance provided during 2002 and 2003, and includes three-year comparison charts (2001 – 2003) for notification outcomes.

Program Activities/Methods:

Operationally, partner notification activities outside New York City are conducted by a combination of NYSDOH and county health department staff, with staff of the New York City Department of Health and Mental Hygiene (NYCDOHMH) conducting follow-up on New York City cases. In New York City, the NYCDOHMH Contact Notification Assistance Program (CNAP) conducts partner notification activities.

New York State cases residing outside of New York City (NYC) are referred for partner notification evaluation to the 13 participating county health commissioners and NYSDOH regional PartNer Assistance Program (PNAP) staff. In New York State outside NYC, provider reports and laboratory reports needing possible partner follow-up are distributed electronically from the NYSDOH central office using a confidential and secure tracking system. Reports are assigned to the county health department or NYSDOH regional office responsible for conducting partner notification.

PNAP staff, who are a mix of state and participating county staff, routinely contact the health care provider regarding reports of newly diagnosed HIV infection for the purpose of offering voluntary partner notification assistance even if the provider did not specifically request PNAP assistance. PNAP staff also contact the providers regarding reported cases of HIV illness and AIDS where the provider has listed known contacts or requests assistance. This is a consultation that enables the public health worker to confirm the diagnosis, update information about the index case (and partners' status), and to discuss information the physician has that may facilitate contacting the index case to discuss partners.

In addition to partner notification activities initiated through HIV reporting, there are a limited number of partner notification referrals which fall outside the reporting law. Examples include referrals from other states where a New York State partner has been identified, index cases who tested anonymously who later seek voluntary partner notification assistance from a local health department, or continuing partner notification requests for AIDS cases diagnosed before the law (and therefore not newly reportable).

Program Outcomes / Results:

Table 1 presents the cumulative three year trend data (2001-2003) for cases with any vs. no partner, to allow easy comparison across years. Statewide during both 2002 and 2003, about one in four (25% in 2002 and 27% in 2003) of the HIV/AIDS cases reported included at least one identified partner by the time partner services follow-up was completed. The trend was slightly better for New York State outside New York City cases –where for 2002 and 2003 close to one-third of cases had at least one identified partner. The three-year statewide trend shows one-third of cases having identified at least one partner. The difference seen for New York State Outside NYC between 2001 and subsequent years is partially explained by the 2001 data being limited to cases reported on provider reports (the report type most likely to identify partners). Partner assistance follow-up with the reporting provider on laboratory reports (even where no provider report was received) was not routinely initiated until 2002.

Table 2 presents the number, source and initiation status of partners identified during 2002 and 2003. The 8% reduction in number of total partners identified in 2003 is a reflection of 14% fewer HIV/AIDS cases assigned for partner follow-up than in the previous year (2002). For both years, approximately two-thirds of these partners lived in New York City and one-third lived in New York State outside NYC. Statewide, the majority of partners (88% in 2002, 86% in 2003) were identified on provider report forms. This distribution is very different for New York City and for New York State outside New York City however, with the state/county PNAP program eliciting a higher proportion of additional partners—where close to one-third of the total partners were identified by PNAP staff interviews. Some partners have insufficient information to initiate for PNAP/CNAP follow-up because there was not enough valid identification information to make notification possible. A separate analysis of partners with insufficient information to initiate for PNAP for New York State outside New York City (data not shown in table) found that 88% of these were initially elicited by non-PNAP providers. Examples of insufficient information provided include just the first name and city of residence of a partner with no last name or locating information provided, or partners reported only with "anonymous" listed in the name field.

Tables 3a and 3b summarize the status of partner notification for partners identified on the provider report form at the time the provider report was submitted, i.e. for those cases whose partners were identified by providers. Statewide, close to half (55% in 2002 and 41% in 2003) of these partners were reported with a status indicating the notification had already been completed. This included confirmed notifications (provider performed the notification, confirmed that the patient completed the notification, or confirmed that the partner already knew his/her own HIV+ status) and unconfirmed notifications (patient states he/she has notified partner, patient states partner already aware of own HIV+ status). Trends were different for New York State outside NYC. New York City provider reports listed 65% of all partners as already notified in 2002 (47% in 2003), compared to provider reports for New York State outside NYC where only 28% of partners were listed as already notified in 2002 (26% in 2003) at the time of report.

Tables 4 (Statewide Notification Status of Partners) and 5 (NYC vs. NYS Outside NYC Notification Outcomes) present the outcomes for PNAP and CNAP initiated partners, and provide an opportunity to compare trends across years. As shown, 1,602 or 69% of all initiated partners were reported as having been notified in 2002 (68% of NYC partners and 73% of partners in New York State outside NYC) by the time all follow-up was completed. In 2003, 61% of all initiated partners were reported as having been notified (57% of NYC partners, and 73% of partners in New York State outside NYC). The type of notification was most often by the patient, or a situation where the partner already knew their own HIV+ status. Additional partners were notified by the Health Department in follow-up to a provider or lab report, or directly notified by the provider. New York State outside NYC had a much higher percentage of the health department notifications, and New York City reported higher levels of both patient notifications and cases where the partner already knows their own HIV+ status. Reasons some partners were either not notified or not confirmed as notified are also presented. Approximately one-third of initiated partners were not known to be notified (31% in 2002 and 39% in 2003). Two percent (2%) of notifications statewide were deferred because of domestic violence (DV) concerns. The DV protocol requires immediate referral to needed services and delineates a follow-up process to determine if and when the notification can safely occur.

Summary and Discussion:

In New York State for the period of 2002-2003, there were 2,897 sex or needle-sharing partners of persons with newly diagnosed HIV infection, HIV illness or AIDS known to be notified of their exposure. It is clear that partner notification can play an important role in helping identify people who are unaware of their HIV infection, and in helping them link to needed services and care. A relatively high percentage of notified partners are subsequently found to themselves be infected. For example, in New York State outside New York City, 18% of notified partners during 2002 (21% in 2003) for whom subsequent HIV tests results were known were found to have a newly identified confirmed HIV positive test result (Source: NYSDOH HIV Prevention Cooperative Agreement Performance Indicators).

In 2003, the Centers for Disease Control and Prevention (CDC), Health Resources and Services Administration (HRSA), National Institutes of Health (NIH) and the HIV Medicine Association of the Infectious Diseases Society of America issued joint recommendations on “Incorporating HIV Prevention into the Medical Care of Persons Living with HIV”. These included the recommendation that “all patients should be referred to the appropriate health department to discuss sex and needle-sharing partners who have not been informed of their exposure and to arrange for their notification and referral for HIV testing1. PNAP/CNAP referral is a voluntary process, except for required physician reporting of partners known to them, and there will inevitably be some patients who decline health department assistance. What is important is that all patients be given the opportunity to understand that the assistance is available and that they be provided easy access to these services.

In the last several years, there has also been increased attention on research on effective partner notification strategies. In summarizing current knowledge in its 2004 guidance document CDC states: “Although some persons initially prefer to inform their partners themselves, many clients often find this more difficult than anticipated. Furthermore, notification by health department staff seems to be substantially more effective than notification by the infected person."2 It will be important to incorporate information about the relative effectiveness of different notification approaches into ongoing efforts to educate providers.

For New York State outside NYC, PNAP staff have begun to follow-up directly with providers upon receipt of the initial lab report, in order to offer their consultation early in the partner elicitation process. Within New York City, the health department has modified policies to allow referral of additional cases (those where the notification plan has not been finalized) to CNAP for follow up. All partners listed on the provider report form that list partner notification activities as being incomplete will now be referred to the NYCDOHMH CNAP Program for follow up, whether or not the provider requests assistance. Upon referral of these cases, personnel at CNAP will contact the provider and offer assistance with notification on those incomplete cases under their care. These expanded efforts are underway to ensure the intent of the 1998 legislation of offering needed partner notification assistance is fully realized.

Footnotes

1Incorporating HIV Prevention into the Medical Care of Persons Living with HIV. Recommendations of CDC, the Health Resources and Services Administration, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR. July 18, 2003 / 52 (RR12); 1-24.

2 Centers for Disease Control and Prevention. Advancing HIV Prevention: Interim Technical Guidance for Selected Interventions. 2004, p. 32. Full document is available at HIV Prevention, Strategies for a Changing Epidemic.


Table 1

Number of Cases With Any vs. No Partners*
Cumulative Trends 2001 to 2003
Location Number of partners per case 2001 2002 2003 Cumulative
2001 to 2003
N % N % N % N %
* Includes partners listed on provider reports and partners for cases identified with PNAP/ CNAP assistance in follow-up. PNAP assignments include some cases that may not be new HIV infection.
New York State Total No partner 3,723 53% 5,889 75% 4,935 73% 14,483 67%
1 or more partner/s 3,316 47% 1,993 25% 1,851 27% 7,167 33%
Total 7,039 7,882 6,786 21,650
New York City No partner 3,294 55% 4,730 76% 3,880 74% 11,904 68%
1 or more partner/s 2,714 45% 1,454 24% 1,333 26% 5,501 32%
Subtotal 6,008 6,184 5,213 17,405
Rest of New York State No partner 429 42% 1,121 67% 1,029 66% 2,579 61%
1 or more partner/s 602 58% 540 33% 524 34% 1,666 39%
Subtotal 1,031 1,661 1,553 4,245

Table 2

Number, Source, and Classification of Partners Identified 2002 and 2003
Location Partners 2002 2003
1 Includes additional unduplicated partners identified by health department staff in follow-up to provider or lab reports, and any partners referred by other jurisdictions (e.g., from other states, or between NYCDOHMH and NYSDOH) or through mechanisms outside HIV reporting.
2 Some reported partners lacked sufficient information to initiate for partner follow-up (e.g., no name or partial name, unable to complete Domestic Violence screen, no address/ locating information). Total partners initiated is the number of partners identified minus partners with insufficient information to initiate for follow-up.
New York State Total (NYC and NYS Outside NYC Combined) Partners listed on provider reports 2,324 2,083
Additional partners identified by health department1 306 346
Total partners initially listed/identified 2,630 2,429
Of identified partners, # initiated for PNAP/CNAP2 2,320 2,107
New York State Outside New York City Partners listed on provider reports 672 537
Additional partners identified by health department1 244 242
Subtotal partners initially listed/identified 916 779
Of identified partners, # initiated (PNAP)2 661 571
New York City Partners listed on provider reports 1,652 1,546
Additional partners identified by health department1 62 104
Subtotal partners initially listed/identified 1,714 1,650
Of identified partners, # initiated (CNAP)2 1,659 1,536

Table 3a

Status of Partner Notification at Time of Submission of Initial HIV/AIDS Provider Report Form (2002)
Notification Status of Partner As Indicated by Provider on
Provider Report:		 Region
New York State Outside NYC New York City Total New York State
Number Percent Number Percent Number Percent
1 The Contact Notification Assistance Program (CNAP) provides services in New York City; the PartNer Assistance Program (PNAP) provides services in New York State outside of New York City.
Notified by Provider 37 6% 144 9% 181 8%
Provider Confirmed Patient Has Notified Partner 37 6% 212 13% 249 11%
Provider Confirmed Partner Already Knows Own HIV+ Status 32 5% 134 8% 166 7%
Patient States S/he Has Notified Partner (Unconfirmed) 53 8% 340 21% 393 17%
Patient States Partner Already Knows Own HIV+ Status (Unconfirmed) 31 4% 241 15% 272 12%
Notification in Progress 42 6% 115 7% 157 7%
Notification Plan Undetermined 56 8% 156 9% 212 9%
Domestic Violence Risk 15 2% 19 1% 34 1%
Other Mitigating Circumstances 6 1% 188 11% 194 8%
Request CNAP/PNAP1 Assistance 144 21% 91 6% 235 10%
Already Referred to PNAP/CNAP1 4 - 2 - 6 -
Attempted, partner declined 1 - - - 1 -
Blank (No Status Noted) 214 32% 10 1% 224 10%
TOTAL PARTNERS LISTED ON PROVIDER REPORTS 672 100% 1,652 100% 2,324 100%

Table 3b

Status of Partner Notification at Time of Submission of Initial HIV/AIDS Provider Report Form (2003)
Notification Status of Partner As Indicated by Provider on
Provider Report:		 Region
New York State Outside NYC New York City Total New York State
Number Percent Number Percent Number Percent
1 The Contact Notification Assistance Program (CNAP) provides services in New York City; the PartNer Assistance Program (PNAP) provides services in New York State outside of New York City.
Notified by Provider 33 6% 40 3% 73 4%
Provider Confirmed Patient Has Notified Partner 34 6% 162 10% 196 9%
Provider Confirmed Partner Already Knows Own HIV+ Status 18 3% 137 9% 155 7%
Patient States S/he Has Notified Partner (Unconfirmed) 31 6% 203 13% 234 11%
Patient States Partner Already Knows Own HIV+ Status (Unconfirmed) 21 4% 179 12% 200 10%
Notification in Progress 26 5% 115 7% 141 7%
Notification Plan Undetermined 29 5% 191 12% 220 11%
Domestic Violence Risk 5 1% 12 1% 17 1%
Other Mitigating Circumstances 9 2% 214 14% 223 11%
Request CNAP/PNAP1 Assistance 115 21% 285 18% 400 19%
Already Referred to PNAP/CNAP1 1 - 1 - 2 -
Attempted, partner declined - - - - - -
Blank (No Status Noted) 215 40% 7 - 222 11%
TOTAL PARTNERS LISTED ON PROVIDER REPORTS 537 100% 1,546 100% 2,083 100%

Table 4

Notification Status of Partners of HIV/AIDS Cases New York State Total
(NYC and NYS Outside NYC Combined)
Cumulative Trends 2001 to 2003
Partner Notification Status 20011 2002 2003 Cumulative
2001 to 2003
N % N % N % N %
1 For data comparability, 2001 data have been adjusted to drop those contacts included in the initial data report that do not meet the CDC definition of a contact (262 total partners in NYS: 57 in NYC, 205 in Rest of New York State) due to insufficient information to initiate for Partner Counseling and Referral Services (PCRS). Subsequent year reports (2002, 2003) reports did not include these partners.
Notified by provider 140 4% 189 8% 192 9% 521 6%
Notified by patient 984 26% 650 28% 449 21% 2,083 25%
Partner already knows own HIV+ status 744 20% 432 19% 374 18% 1,550 19%
Notified by DOH 493 13% 251 11% 184 9% 928 11%
Other confirmed notifications 129 3% 80 3% 96 5% 305 4%
Subtotal notified partners 2,490 66% 1,602 69% 1,295 61% 5,387 66%
Provider attests notification in progress 113 3% 271 12% 306 15% 690 8%
Health Dept. follow-up in progress 73 2% 26 1% 76 4% 175 2%
Deferred - DV risk 79 2% 42 2% 25 1% 146 2%
Lost to follow-up 113 3% 132 6% 137 6% 382 5%
Other 925 24% 247 11% 268 13% 1,440 18%
Subtotal partners not known to be notified 1,303 34% 718 31% 812 39% 2,833 34%
Total New York State initiated partners 3,793 100% 2,320 100% 2,107 100% 8,220 100%

Table 5

Notification Status of Partners of HIV/AIDS Cases
Comparing NYC to New York State Outside NYC Outcomes
Cumulative Trends 2001 to 2003
Partner Notification Status 20011 2002 2003 Cumulative
2001 to 2003
N % N % N % N %
1 For data comparability, 2001 data have been adjusted to drop those contacts included in the initial data report that do not meet the CDC definition of a contact (262 total partners in NYS: 57 in NYC, 205 in Rest of New York State) due to insufficient information to initiate for Partner Counseling and Referral Services (PCRS). Subsequent year reports (2002, 2003) reports did not include these partners.
New York City (CNAP)
Notified by provider 64 2% 144 9% 133 9% 341 6%
Notified by patient 816 27% 552 33% 365 24% 1,733 28%
Partner already knows own HIV+ status 658 22% 375 23% 316 21% 1,349 22%
Notified by DOH 299 10% 17 1% 24 2% 340 6%
Other confirmed notifications 54 2% 33 2% 40 3% 127 2%
Subtotal notified partners 1,891 63% 1,121 68% 878 57% 3,890 63%
Provider attests notification in progress 113 4% 271 16% 306 20% 690 11%
Health Dept. follow-up in progress 70 2% 24 2% 68 4% 162 3%
Deferred - DV risk 47 2% 19 1% 12 1% 78 1%
Lost to follow-up 43 1% 68 4% 75 5% 186 3%
Other 814 27% 156 9% 197 13% 1,167 13%
Subtotal partners not known to be notified 1,087 37% 538 32% 658 43% 2,283 37%
Total New York City Initiated Partners 2,978 100% 1,659 100% 1,536 100% 6,173 100%
Rest of New York State (PNAP)
Notified by provider 76 9% 45 7% 59 10% 180 9%
Notified by patient 168 21% 98 15% 84 15% 350 17%
Partner already knows own HIV+ status 86 11% 57 9% 58 10% 201 10%
Notified by DOH 194 24% 234 35% 160 28% 588 29%
Other confirmed notifications 75 9% 47 7% 56 10% 178 9%
Subtotal notified partners 599 73% 481 73% 417 73% 1,497 73%
Provider attests notification in progress - - - - - - - -
Health Dept. follow-up in progress 3 - 2 - 8 1% 13 1%
Deferred - DV risk 32 4% 23 3% 13 2% 68 3%
Lost to follow-up 70 9% 64 10% 62 11% 196 10%
Other 111 14% 91 14% 71 12% 273 13%
Subtotal partners not known to be notified 216 27% 180 27% 154 27% 550 27%
Total Rest of New York State Initiated Partners 815 100% 661 100% 571 100% 2,047 100%