Program Operations Guidelines for STD Prevention

Partner Services Table of Contents

FOREWARD iii

INTRODUCTION iv Program Operations Guidelines Workgroup Members vi Partner Services Subgroup Members vii Partner Services Internal/External Reviewers vii

INTRODUCTION PS-1 Shared Principles PS-1 Overview PS-2 Legal Authority PS-3 Case Management PS-3 Resource Requirements PS-3 Safety PS-4 Confidentiality PS-4

PARTNER SERVICES PS-5 Patient Types PS-5 Volunteers and Index Patients PS-5 Partners to the Index Patient PS-6 Index Patients Referred by Other Providers PS-7 Presumptive Interviews PS-7 Pre-interview Activities PS-7 Setting Priorities PS-7 Interview Periods PS-8 The Interview Setting PS-8 Pre-interview Analysis (patient assessment) PS-9 Types of Interviews and Their Objectives PS-9 Original Interview PS-10 Reinterview PS-10 The Cluster Interview PS-11 Other Important Interview Concepts PS-11 Motivational Techniques to Encourage Voluntary Disclosure PS-11 Client-centered Approach to Risk Reduction PS-12 Referrals PS-12 Post-interview Activities PS-13 Documentation PS-13

Partner Services i Analysis of Case Information and Problem Solving PS-14 Prioritization of Partners, Suspects, and Associates PS-14 Obtaining Further Information PS-14 Using Information Obtained From the Interview to Identify Possible Outbreak Situations PS-15 Lot System: A Case Management Tool PS-15 Lot System Forms PS-15 Partner Notification Strategies PS-16 Provider Referral PS-16 Self (Patient) Referral PS-16 Contract Referral PS-17 Evidence Supporting Partner Notification PS-18 Other Important Concepts About Partner Notification PS-18 Encouraging the Partner to Seek Medical Treatment PS-18 Follow-up to Ensure Notification Is Received and Understood PS-18 Ensuring That the Partner Has Access to Health Care PS-18 Diagnostic Assessment of Partners in the Field PS-19 Case Closure PS-20

SPECIAL CONSIDERATIONS PS-20 Collaborating With Other Service Providers PS-20 Interstate Transmission of STD Intervention Information PS-20 Suggested Strategies for Patients With Repeat Infections PS-20

EVALUATION AND QUALITY ASSURANCE PS-20 Case Management PS-20 Components of Case Management Quality Assurance PS-21 Using Information Gathered to Describe and ReachTarget Populations PS-21 Measures for Evaluating Program Effectiveness PS-22

COMMUNITY-BASED OUTREACH PS-23 Overview of Interventions PS-24 Social Network Analysis PS-24 Targeted Screening and Field Testing PS-26 Community Outreach PS-27 STD Clinic Outreach PS-28

Appendix PS-A Interview Periods by Disease PS-29 Appendix PS-B Original Interview Format PS-30 Appendix PS-C Reinterview Format PS-32 Appendix PS-D Cluster Interview Format PS-33 Appendix PS-E Lot System Forms PS-35 Appendix PS-F Field Investigations PS-46 Appendix PS-G Interstate Transmission of STD Intervention Information PS-49 Appendix PS-H Skills Inventory PS-53 Appendix PS-I “Evaluation Tables” PS-62 Appendix PS-J Glossary of Terms Associated With Partner Services PS-63 Appendix PS-K Tools for Network Analysis PS-66 References PS-68

ii Program Operations Guidelines for STD Prevention Foreword

The development of the Comprehensive STD Prevention Systems (CSPS) program

announcement marked a major milestone in the efforts of CDC to implement the recommendations of the Institute of Medicine report, The Hidden Epidemic, Con­ fronting Sexually Transmitted Diseases, 1997. With the publication of these STD

Program Operations Guidelines, CDC is providing STD programs with the guid­ ance to further develop the essential functions of the CSPS. Each chapter of the guidelines corresponds to an essential function of the CSPS announcement. This

chapter on partner services is one of nine. With many STDs, such as syphilis, on a downward trend, now is the time to employ new strategies and new ways of looking at STD control. Included in these

guidelines are chapters that cover areas new to many STD programs, such as com­ munity and individual behavior change, and new initiatives, such as syphilis elimi­ nation. Each STD program should use these Program Operations Guidelines when

deciding where to place priorities and resources. It is our hope that these guidelines will be widely distributed and used by STD programs across the country in the future planning and management of their prevention efforts.

Judith N. Wasserheit Director Division of STD Prevention

Partner Services iii Introduction

hese guidelines for STD prevention program topics. The chapter containing the most evidence-based operations are based on the essential functions guidance is on partner services. In future versions of Tcontained in the Comprehensive STD Preven­ this guidance, evidence-based information will be ex­ tion Systems (CSPS) program announcement. The panded. Recommendations are included in each chap­ guidelines are divided into chapters that follow the ter. Because programs are unique, diverse, and locally eight major CSPS sections: Leadership and Program driven, recommendations are guidelines for opera­ Management, Evaluation, Training and Professional tion rather than standards or options. Development, Surveillance and Data Management, In developing these guidelines the workgroup fol­ Partner Services, Medical and Laboratory Services, lowed the CDC publication “CDC Guidelines—Im­ Community and Individual Behavior Change, Out­ proving the Quality”, published in September, 1996. break Response, and Areas of Special Emphasis. Ar­ The intent in writing the guidelines was to address eas of special emphasis include corrections, adoles­ appropriate issues such as the relevance of the health cents, managed care, STD/HIV interaction, syphilis problem, the magnitude of the problem, the nature of elimination, and other high-risk populations. the intervention, the guideline development methods, The target audience for these guidelines is public the strength of the evidence, the cost effectiveness, health personnel and other persons involved in man­ implementation issues, evaluation issues, and recom­ aging STD prevention programs. The purpose of these mendations. guidelines is to further STD prevention by providing a STD prevention programs exist in highly diverse, resource to assist in the design, implementation, and complex, and dynamic social and health service set­ evaluation of STD prevention and control programs. tings. There are significant differences in availability The guidelines were developed by a workgroup of of resources and range and extent of services among 18 members from program operations, research, sur­ different project areas. These differences include the veillance and data management, training, and evalua­ level of various STDs and health conditions in com­ tion. Members included CDC headquarters and field munities, the level of preventive health services avail­ staff, as well as non-CDC employees in State STD Pro­ able, and the amount of financial resources available grams and university settings. to provide STD services. Therefore, these guidelines For each chapter, subgroups were formed and as­ should be adapted to local area needs. We have given signed the task of developing a chapter, using evidence- broad, general recommendations that can be used by based information, when available. Each subgroup was all program areas. However, each must be used in con­ comprised of members of the workgroup plus subject junction with local area needs and expectations. All matter experts in a particular field. All subgroups used STD programs should establish priorities, examine causal pathways to help determine key questions for options, calculate resources, evaluate the demographic literature searches. Literature searches were conducted distribution of the diseases to be prevented and con­ on key questions for each chapter. Many of the searches trolled, and adopt appropriate strategies. The success found little evidence-based information on particular of the program will depend directly upon how well

iv Program Operations Guidelines for STD Prevention program personnel carry out specific day to day re­ These guidelines, based on the CSPS program an­ sponsibilities in implementing these strategies to in­ nouncement, cover many topics new to program op­ terrupt disease transmission and minimize long term erations. Please note, however, that these guidelines adverse health effects of STDs. replace all or parts of the following documents: In this document we use a variety of terms familiar • Guidelines for STD Control Program Operations, to STD readers. For purposes of simplification, we will 1985. use the word patient when referring to either patients • Quality Assurance Guidelines for Managing the or clients. Because some STD programs are combined Performance of DIS in STD Control, 1985. with HIV programs and others are separate, we will use • Guidelines for STD Education, 1985. the term STD prevention program when referring to ei­ • STD Clinical Practice Guidelines, Part 1, 1991. ther STD programs or combined STD/HIV programs.

The following websites may be useful: • CDC www.cdc.gov • NCHSTP www.cdc.gov/nchstp/od/nchstp.html • DSTD www.cdc.gov/nchstp/dstd/dstdp.html • OSHA www.osha.gov • Surveillance in a Suitcase www.cdc.gov/epo/surveillancein/ • Test Complexity Database www.phppo.cdc.gov/dls/clia/testcat.asp • Sample Purchasing Specifications www.gwu.edu/~chsrp/ • STD Memoranda of Understanding www.gwumc.edu/chpr/mcph/moustd.pdf • National Plan to Eliminate Syphilis www.cdc.gov/Stopsyphilis/ • Network Mapping www.heinz.cmu.edu/project/INSNA/soft_inf.html • Domestic Violence www.ojp.usdoj.gov/vawo/ • Prevention Training Centers www.stdhivpreventiontraining.org • Regional Title X Training Centers www.famplan.org www.cicatelli.org www.jba-cht.com • HEDIS www.cdc.gov/nchstp/dstd/hedis.htm • Put Prevention Into Practice www.ahrq.gov/clinic/ppipix.htm

Partner Services v Program Operations Guidelines Workgroup Members

David Byrum Program Development and Support Branch, DSTD

Janelle Dixon Health Services Research and Evaluation Branch, DSTD

Bob Emerson Training and Health Communications Branch, DSTD

Nick Farrell Program Support Office, NCHSTP

Melinda Flock Surveillance and Data Management Branch, DSTD

John Glover Program Development and Support Branch, DSTD

Beth Macke Behavioral Interventions and Research Branch, DSTD

Charlie Rabins Illinois Department of Public Health

Anne Rompalo Johns Hopkins School of Medicine

Steve Rubin Program Development and Support Branch, DSTD, New York City

Lawrence Sanders Southwest Hospital and Medical Center, Atlanta

Don Schwarz Program Development and Support Branch, DSTD

Jane Schwebke University of Alabama Birmingham

Kim Seechuk Program Development and Support Branch, DSTD

Jerry Shirah Training and Health Communications Branch, DSTD

Nancy Spencer Colorado Department of Public Health

Kay Stone Epidemiology and Surveillance Branch, DSTD

Roger Tulloch Program Development and Support Branch, DSTD, Sacramento, California

vi Program Operations Guidelines for STD Prevention Partner Services Subgroup Members

John Glover Program Development and Support Branch, DSTD

Jim Lee Program Development and Support Branch, DSTD, Austin, Texas

Lori Leonard University of Texas

Beth Macke Behavioral Interventions and Research Branch, DSTD

Nancy Spencer Colorado Department of Public Health

Roger Tulloch Program Development and Support Branch, DSTD, Sacramento, California

Partner Services Internal/External Reviewers

Mark Aubin Washington Department of Health

Dennis Dorst Program Development and Support Branch, DSTD, New Orleans, Louisiana

Dan George Program Development and Support Branch, DSTD, Tallahassee, Florida

Matt Hogben Behavioral Interventions and Research Branch, DSTD

Beverly Nolt Texas Department of Health

Richard Rothenberg Emory University School of Medicine

Partner Services vii Partner Services

INTRODUCTION provider referral, whereby the provider locates and informs partners of their exposure; and client Shared Principles referral, whereby the infected person takes respon­ sibility for informing his or her partners. Some­ Both STD prevention programs and HIV programs times a combination of these approaches is used. provide guidance on services to partners. Although STD prevention programs call these services “Partner Ser­ vii. Support Services and Referral—Partner services are vices,” and HIV programs call these services “Partner delivered in a continuum of care context that Counseling and Referral Services,” the services offered includes the capacity to refer partners to HIV coun­ share many principles. Those principles are listed be­ seling, testing, and treatment, as well as other ser­ low. vices (e.g., family planning, violence prevention, i. Voluntary—Partner services are voluntary on the drug treatment, social support, housing). part of the infected person and his or her part­ viii. Analysis and Use of Partner Service Data—Pro­ ners. grams should collect confidential data on the coun­ seling and referral services provided and use the ii. Confidential—Every part of the partner service data for evaluating and improving program effi­ process is confidential. ciency, effectiveness, and quality. iii. Science-Based—Partner service activities are sci­ ix. Counseling and Support—Counseling and support ence-based and require knowledge, skill, and train­ for those who choose to notify their own partners ing. is essential. Assistance to patients in deciding if, iv. Culturally Appropriate—Partner services are to be how, to whom, where, and when to disclose their delivered in a nonjudgmental, culturally appropri­ infection can help them avoid stigmatization, dis­ ate, and sensitive manner. crimination, and other potential negative effects. v. A Component of a Comprehensive Prevention Sys­ x. Client-Centered Counseling—Providing client-cen­ tem—Partner services is one of a number of pub­ tered counseling for STD-infected individuals and lic health strategies to control and prevent the their partners can reduce behavioral risks for ac­ spread of STD and HIV. Other strategies include quiring or transmitting STDs. accessible clinics, outreach to, and targeted screen­ ing of at-risk populations, behavioral interventions, xi. Increased Importance as New Technologies Emerge—As new technologies emerge, such as and educational programs. more sophisticated testing procedures and behav­ vi. Diverse Referral Approaches—Partner services ioral interventions, partner services will become may be delivered through two basic approaches: an increasingly important prevention tool.

Partner Services PS – 1 Overview vidual privacy, confidentiality of medical records, dis­ ease histories, and related information. Programs must Partner services have evolved from an exclusive focus be perceived by at-risk populations in particular and on finding the sexual contacts of infected persons to a by the community in general as being fully committed broad view of the clinical and epidemiologic activities to this principle. STD program staff must understand needed to help persons infected with STDs. The basic and adhere to their responsibilities with regard to con­ process - interviewing infected persons and others po­ fidentiality and to the overall quality of partner ser­ tentially involved in transmission, identifying persons vices and must be held accountable by performance still at risk (whether through direct exposure or indi­ guidelines and by supervisor observation. For the pur­ rect involvement), and bringing the latter to diagnosis pose of these guidelines, the term Disease Intervention and treatment - has changed little, but the context for Specialist (DIS) will be used to describe those person­ such activity has greatly changed. Partner services play nel who are charged with providing partner services several roles in this context. First, they are a clinical once a person has been diagnosed with a STD. tool for identifying a patient’s needs and requirements Effective prevention of disease transmission begins and connecting the patient to appropriate care. Sec­ with infections that are properly diagnosed, appropri­ ond, partner services provide the basis for assessing ately treated, and fully reported in accordance with local epidemiologic conditions, targeting resources, and established laws and regulations. Cases reported from evaluating program performance. Third, follow-up of non-STD clinic settings must be carefully reviewed and partners who are at risk is a powerful tool for under­ record searched before contact with the reporting pro­ standing the dynamics of disease transmission. vider is initiated to confirm diagnoses and treatment Partner services are offered to individuals who are status and to obtain, if necessary, permission to con­ infected with STD, to their partners, and to other per­ tact patients regarding partner services. Oftentimes, sons who are at increased risk for infection in an ef­ prior agreement or a memorandum of understanding fort to prevent transmission of these diseases and to with a provider allows routine permission to follow up. reduce suffering from their complications. Services Each program must individually determine those include: STDs for which partner services will be made avail­ able and to what extent these services will be provided. • providing information regarding current infection(s) Factors to be considered include staffing, specific mor­ and other STDs; bidity, infectiousness of disease (and stage of infection • ensuring confidential notification, appropriate for syphilis), public health costs of infections and their medical attention, and appropriate social referrals sequellae, cost benefit of services, and amenability of for partners and other high-risk individuals; the disease to the intervention planned. The availabil­ • using client-centered counseling to develop risk re­ ity of resources and the ability to enlist the support duction plans to reduce the likelihood of acquiring and cooperation of the medical community—particu­ future STDs; larly those located in or serving high risk communi- • providing needed referrals to additional medical or ties–also play a role in the decision-making process social services; and with respect to partner services. Measures should be • defining and better targeting the at-risk community implemented to identify such providers and to develop while assuring complete cnfidentiality for the pa­ a wide range of strategies, including informing pro­ tient. viders about the components and importance of part­ Provision of partner services involves discussion and ner services, to gain their support and cooperation. documentation of highly sensitive personal informa­ One example might be collaboration with high-vol­ tion about patients and their partners. Therefore, pro­ ume providers such as family planning clinics, juve­ grams must demonstrate the highest regard for indi­ nile detention facilities, selected jails and correctional

PS – 2 Program Operations Guidelines for STD Prevention facilities, delivery hospitals, drug rehab groups, or needs and activities resulting from personal analysis, other high-volume providers to ensure more compre­ supervisory input, or the contributions by other staff hensive testing, appropriate treatment, early report­ members—both within and outside of the immediate ing, and the availability of partner services. program area.

Recommendations Resource Requirements

• Programs should establish the mix of partner Programs should provide DIS and managers with the services that is appropriate to local epidemi­ tools, training, and resources necessary to conduct ology. partner services successfully. Interview rooms that are quiet and contain at least a desk or table, three chairs, • Programs should prioritize patients for part­ a telephone, and appropriate support materials should ner services in terms of specific diseases, local be readily accessible to the DIS. Also, DIS should have area data, the potential for productive inter­ access to appropriate STD clinic patient records, pro­ vention, case load, and available resources. gram interview and investigative files, relevant maps, telephone books, and cross directories. Investigative Legal authority resources should be carefully developed and main­ tained. At a minimum, efforts should be made to de­ Legal authority for the notification and referral of velop access to department of motor vehicles (DMV), partners to persons with known STD infections re­ welfare, utilities, post office, local schools, and health sides with the states. Program policies and procedures department records. should be consistent with applicable state laws, stat­ DIS should be encouraged to identify, develop, and utes, and regulations. share information with each other on agencies that serve or that have information on at-risk populations. Case Management Such efforts would include identifying specific mem­ bers of the at-risk community willing to advocate com­ Case management is the systematic pursuit, documen­ munity support for program activities. Programs are tation, and analysis of medical and epidemiologic case further encouraged to develop and implement inter­ information that focuses on opportunities to develop view records and data collection instruments that re­ and implement timely disease intervention plans. Ef­ flect information needed by the program, that are easy fective case management normally progresses through to complete, that can be stored and retrieved electroni­ a very specific process: pre-interview analysis, inter­ cally, and that will assist program efforts to better de­ view (original, reinterviews, and cluster interviews), fine and serve at-risk populations. Programs should post-interview analyses, referral of sex partners, and make maximum possible use of current technology to case closure. Although the concepts and techniques of facilitate DIS record keeping and case management, case management are usually consistent in various pro­ including computer storage and case analysis software gram areas, specific policies may differ. when available. Case management tools can be stored Effective case management is sustained by 1) iden­ and retrieved electronically, provided the security and tifying the information needs of individual and re­ confidentiality of those tools are maintained. lated cases; 2) developing agendas for prospective in­ terviews; 3) assuming responsibility for critical communications with other members of the staff; and 4) remaining current on progress of case elements as­ signed to others. The DIS must promptly pursue case

Partner Services PS – 3 Recommendations daily route sheet of intended stops to the supervisor so that a DIS route can be followed if an emergency • Programs must ensure that DIS and manag­ arises. Although route sheets change as a DIS devel­ ers possess the tools, training, and resources ops investigational leads, such sheets offer a place to necessary to conduct program business suc­ start. cessfully. Before allowing new DIS to conduct field work • Programs must have some form of case man­ alone, immediate supervisors or other, more experi­ agement process in place. Case management enced workers should be assigned to accompany them “tools” should reflect established information for purposes of identifying locations within the com­ needs, should be easy to complete, and should munity where high-risk activities take place—drug provide information that can be used to de­ houses, parks, bars, prostitution stroll areas, or those fine at-risk populations and to target them for controlled by gangs—and to model desired behavior. intervention. When working in such areas, DIS must learn to be particularly alert. Safety issues and emerging problem • Programs should provide interview space that areas should be routinely discussed in staff meetings is quiet and confidential, and contains at least and daily debriefings. a desk or table, three chairs, a telephone, and The primary protection from unsafe situations is educational materials needed by the DIS. the DIS’s knowledge of the community and visibility in important locations. Programs should understand Safety the need for DIS to spend time in areas to establish critical personal rapport with members of the com­ Many field activities may pose potential unsafe situa­ munity. This can be accomplished while performing tions for public health workers. Program managers outreach activities, organizing field screenings, and par­ should develop and maintain detailed guidelines for ticipating with CBOs in outreach activities. ensuring DIS safety in the performance of their respon­ Other safety issues involve “occupational infections sibilities. Training should include a common-sense in the workplace.” At a minimum, local policies and approach to field work (appropriate dress; expensive procedures should encompass those in the Occupa­ looking jewelry, purses, and other valuables kept out tional Safety and Health Administration policy (more of sight; car doors locked and windows rolled up; con­ current information may be obtained from the OSHA stant awareness of surroundings; and the importance website at www.osha.gov). Each program area must of relying on instincts). DIS should be provided pic­ have a local policy for avoiding occupational expo­ ture identification (ID) and the ID should be required sure and for dealing with such exposures, should they to be in an employee’s possession when in the field. occur. Each DIS should be required to practice local An employee file should be kept on each field worker policies and procedures for avoiding infection(s) that which can be shared with authorities in case of emer­ could be acquired in the performance of their program gency. This file should include name, address, physi­ responsibilities. These policies and procedures should cal description, emergency locating information, a re­ be regularly updated and formally reviewed with staff cent picture of the employee, a description of the members at least yearly. The section titled “Diagnos­ employee’s vehicle, and the vehicle license number. tic assessment of partners in the field” also addresses Other steps that programs might take to promote safety this issue. include allowing DIS to work in pairs as situations warrant, making cellular phones and pagers available and requiring DIS to call in when changing plans or Confidentiality when an investigation becomes problematic. Some Confidentiality policies of public health agencies are programs require DIS to have all field notes prepared designed to prevent unauthorized persons from learn­ ahead of time to ensure the DIS is efficient and alert to ing information shared in confidence. Confidential the surroundings. Others require that DIS submit a

PS – 4 Program Operations Guidelines for STD Prevention information includes any material, whether oral or Patients who are being treated for STDs are the best recorded in any form or medium, that identifies or source of information regarding their infections. Ev­ can readily be associated with the identity of a person ery interview must be planned and approached as if it and is directly related to their health care. will be the only opportunity to provide and to secure Minimum professional standards for any agency information from the patient. Every effort must be handling confidential information should include pro­ made to interact face-to-face. Interviews should include viding employees with appropriate information regard­ an effort to identify others at risk within the commu­ ing confidential guidelines and legal regulations. All nity who would benefit from an examination. Neces­ public health staff involved in partner notification ac­ sary identifying, descriptive, locating, and exposure tivities with access to such information should sign a information for each partner within the interview pe­ confidentiality statement acknowledging the legal re­ riod must be exhaustively pursued. Finally, interviews quirements not to disclose STD/HIV information. afford an opportunity to identify areas or specific lo­ Efforts to contact and communicate with infected cations within a community where at-risk populations patients, partners, and spouses must be carried out in reside or congregate. This information can be used to a manner that preserves the confidentiality and pri­ conduct carefully planned screening efforts for at-risk vacy of all involved. This includes counseling partners populations. Such an approach to targeted screening in a private setting; trying to notify exposed partners can be particularly effective and is critically impor­ face-to-face; never revealing the name of the original tant to the efficient use of limited resources. patient to the partner; not leaving verbal messages that While interviewing the patient, the DIS should make include STD/HIV on answering machines; not leaving every attempt to enlist the patient as a resource, mak­ written messages that include any mention of STD/ ing it clear that the information the patient provides HIV; not giving confidential information to third par­ will be confidential and very helpful to the DIS, the ties (roommates, neighbors, parents, spouses, children). patient, and the patient’s partners. The DIS can incor­ porate elements of client-centered counseling by ac­ knowledging treating the patient as a partner in re­ Recommendations ducing additional STD in their community. The • Programs must have written safety guidelines partnership should be clear to the patient. and procedures in place and follow these poli­ cies. Recommendation • Programs must ensure that DIS are aware of • Interviews with patients about partner services and comply with safety guidelines. should be planned, client-centered, culturally appropriate, and voluntary. PARTNER SERVICES Patient types Partner services are offered to all patients with STDs Volunteers and Index patients whether reported by public or private agencies. Some The person who comes into a clinic for STD services patients voluntarily seek medical attention, while oth­ without being referred is known as a volunteer. Gen­ ers are examined as a direct result of outside interven­ erally, people who voluntarily come into the clinic for tion, such as insurance or job requirements, legal rea­ a STD exam have noticed symptoms of disease on sons (e.g., premarital, jail sentence), local health themselves or their partners, have been told that they departments efforts, or partner request. Ideally, every need an exam, or have been motivated by something patient would be offered partner services, but the spe­ they have read, seen, or heard. This reason may be cific population for partner services may vary by pro­ an important clue which can be used later to elicit gram, as determined by locally established priorities partners. and by available resources.

Partner Services PS – 5 Index patient is a term often inter-changed with the preceding 90 days may test negative, yet still be “original” patient and refers to patients newly diag­ infected since the incubation period for syphilis can nosed with a STD who are candidates for interview be up to 90 days. Even though a partner tests nega­ by trained DIS. Included among the services offered tive, he or she should be treated. If test results are not during the course of such interviews is assistance with available on a stat basis, the partner should still be the notification and timely referral of those partners treated during the initial visit and the infection status determined to be at risk for infection. Effort also is (infected-brought to treat or preventively treated) can expended to identify others within the patient’s “com­ be determined when test results return. munity or social network” of friends or acquaintan­ If the partner is not infected, he or she may be in­ ces (but not sexual partners) who might benefit from terviewed about recent partners and other persons an examination. This is called “clustering”. within the community who might benefit from an ex­ In addition to partners, individuals who are identi­ amination. Interviews of this type are called cluster fied as the result of an interview with an infected per­ interviews and often provide important information. son but who are not partners of that person are called For example, if the individual being cluster interviewed suspects and are divided into three (3) categories based is a partner who provides more recent date(s) of expo­ on likelihood of infection: sure than the date stated by the index patient, the re­ sult could be the prophylactic treatment that might S-1—People with symptoms suggestive of disease otherwise not have been offered. These same individu­ S-2—Partners of other persons known to be infected als may be able to provide target locations for screen­ S-3—Others who might benefit from a STD examina­ ing and outreach, additional information about part­ tion (e.g., pregnant females, roommates) ners, or locating information for other partners or All partners and suspects who are referred for exami­ cluster suspects already named but for whom there nation as the result of an interview should, at a mini­ was insufficient information to initiate field investiga­ mum, be informed as to the reason for the referral; tion. To maintain confidentiality it is important to should be provided information about the disease; pursue such cluster information equally among all at- should be informed of the reasons why they should risk persons named by the partner during the inter­ have a sense of urgency in seeking a timely and appro­ view. This approach provides valuable social network priate medical evaluation; should be given the oppor­ information. This type of interview requires special tunity to be examined, should be given the opportu­ training, as the DIS employs specific motivational ap­ nity to ask questions; and should receive client-centered proaches and because special measures must be taken counseling to develop a personalized risk reduction to preserve the confidentiality of the index patient. plan. In certain situations it may be appropriate also Individuals initiated for field investigation from non­ to interview partners and suspects. infected persons during cluster interviews are called “associates” and also fall into three categories: Partners to the index patient A-1—People with symptoms suggestive of disease Another reason people come to the clinic is that they A-2—Partners of other persons known to be infected have been told by a partner or by a DIS that they may A-3—Others who might benefit from a STD exami­ have been exposed to a disease. In such cases, the per­ nation son may not have any signs or symptoms of the dis­ ease but still needs to be examined and treated. Any­ Information obtained from interviewing partners, sus­ one reasonably believed to have been exposed to a pects, and associates should be carefully reviewed in disease should be prophylatically treated at the time light of information provided by the index patient and of exam based on CDC treatment guidelines. As an through other investigative efforts and used as the basis example, any partner thought to have been exposed for any subsequent reinterview of the index patient. to primary, secondary, or early latent syphilis within

PS – 6 Program Operations Guidelines for STD Prevention Index patients referred by other providers Recommendation New STD infections diagnosed by non-health depart­ ment providers come to the attention of program sur­ • Anyone reasonably believed to have been veillance units in a variety of ways. A health care pro­ exposed to a STD should be treated prophyla­ vider may directly notify the program office of a newly tically at the time of exam based on CDC treat­ diagnosed case; a provider may send a patient to the ment guidelines. health department clinic for clinical management; or positive laboratory results may be reported which Pre-interview activities prompt follow-up by the surveillance unit. Providers reporting cases of STD to the health department should Case management efforts entail seven steps: pre- in­ be contacted for permission before the DIS approaches terview analysis, original interview, post-interview the patient for partner services. Many providers pre­ analysis, referral of at-risk individuals (sex or needle- fer to treat their patients for STD and leave the re­ sharing partners and clusters), cluster interview(s), sponsibility of counseling them to the health depart­ reinterview(s), and case closure. Please refer to the STD ment. In many instances, prior agreements or Employee Development Guide (Centers for Disease memoranda of agreement are in place, providing rou­ Control and Prevention) for additional information. tine permission for follow up. In this case, the DIS Because the interview process is complex, a recom­ would contact the patient and perform an original in­ mended “interview format” has been developed and terview. is discussed in the section on types of interviews. For­ Another type of index patient is the patient who is mal training in the application of this format is avail­ identified via syphilis screening. In this case, the posi­ able and programs are strongly encouraged to require tive test result is reported to the health department by formal training for all new staff performing DIS part­ the laboratory while the result may not be known to ner services before they interview patients. the individual who was screened. The DIS in this situ­ ation must first perform a record search to determine Setting priorities whether the positive test is related to a previously Ideally, every patient with a STD should be interviewed known infection. If it is a new (and not previously and counseled. However, the extent to which all such adequately treated) infection, the DIS should notify patients can be interviewed and counseled will be de­ the index patient of his or her infection and then refer termined by the availability of qualified staff, by fund­ the index patient for the full range of partner services. ing, and by morbidity levels. If it is not feasible to pro­ vide these services to every patient, programs should Presumptive interviews establish a priority basis for determining which pa­ Patients are sometimes presumptively interviewed on tients with STD will be interviewed and counseled. the basis of presenting symptoms or laboratory find­ The extent to which DIS assist patients in notifying ings that are suspicious or not yet available or con­ their partners should also be determined by local pro­ firmed. This also may be the only opportunity to speak gram areas. The following factors should be consid­ to the patient. The purpose of this type of interview is ered for setting interview priorities: STD specific mor­ to afford the staff additional information by assuring bidity, infectiousness of disease (and stage of disease the rapid examination and medical evaluation of re­ for syphilis), public health cost or burden of infections cent sex partners. This information can help medical and their sequellae, amenability of the disease to the practitioners make appropriate diagnostic and treat­ intervention, profile of partners (e.g., adolescent or ment decisions. These efforts have the secondary ben­ female with a known or suspected pregnancy), and efit of expediting the disease intervention process for available program resources. Programs should re­ those patients later determined to be infected. evaluate priorities for partner notification in light of these factors at regular intervals.

Partner Services PS – 7 and 90 to 180 days for early latent syphilis (Gunn, Using these principles, some program areas have 1998; unpublished data, 1997). developed priorities similar to the following: The interview setting • Pregnant females testing positive for HIV, Most often, the public health clinic provides a safe syphilis, gonorrhea, or chlamydia and convenient setting in which to interview and coun­ • Persons testing positive for HIV sel patients compared to the field setting. The clinic • Persons with early syphilis allows for greater control over the interview process • Persons with positive tests from a high risk and permits access to additional personnel and mate­ geographic area rials, including medical records. However, interviews conducted outside the clinic setting afford the oppor­ tunity to observe patients in surroundings in which they are more comfortable and more in control. Inter­ Interview periods views conducted in the home, for example, will afford The interview period covers the time from the earliest the patient ready access to personal address books, date a patient could have been infected to the date of pictures, etc., that can be helpful in locating partners, treatment. It is divided into two sections; the source suspects, and associates. Interviews undertaken in other period (which always includes the maximum incuba­ settings (e.g., crack houses, bars, housing projects, cars) tion period) and the spread period. The incubation also introduce the issue of personal safety for staff. period begins with the date of infection and ends with Whatever the setting, DIS must foster a patient’s trust the first appearance of signs or symptoms. The source and must assure confidentiality if an interview is to be period is the interval during which a patient most likely successful, that is, create an opportunity for disease contracted the disease. The spread period is the time intervention. during which a patient is potentially infectious and Interviews should be conducted in person and con­ could have passed the disease on to others. With syphi­ fidentially. However, in certain situations, it may be lis, the source period and the incubation period never necessary to interview and counsel the patient by tele­ overlap with the spread period, since the exposure phone. When efforts to meet with a patient in person (source) and the development of disease (incubation) have been unsuccessful or when the patient is not in precede active infection (spread). It is important that the same city as the DIS, a telephone interview may be the components of the interview period be thoroughly considered, if consistent with local policy. Telephone understood. See Appendix PS-A for disease specific interviews do not allow patient observation and should information. be used with discretion and in accordance with local Although there are standard interview periods program policy. When interviewing by phone, certain recommended in this guideline (Appendix PS-A), it is privacy issues must be taken into account (such as suggested that individual programs regularly review making sure that one is speaking to the patient, cellu­ local data and social network analysis to determine lar phones are not being used, no one else is on the appropriate interview periods for optimal resource al­ line, etc). Telephone interviews may be followed by a location and case-finding. For example, recommenda­ face-to-face reinterview. No studies have been pub­ tions based on localized data collection have ranged lished comparing the effectiveness of telephone inter­ from 15 to 30 days for gonorrhea patients (Starcher, viewing vs. face-to-face interviewing, nor have any 1983; unpublished data, 1997), from 30 days to as studies been published that discuss the ethical impli­ long as six months for female chlamydia patients cations of telephone interviewing vs. face-to-face in­ (Zimmerman-Rogers, 1997; unpublished data, 1997), terviewing.

PS – 8 Program Operations Guidelines for STD Prevention Pre-interview analysis (patient assessment) speak with a DIS does not mean that the individual is DIS should thoroughly review all available materials willing to fully disclose everything that is needed to related to a patient’s case before each interview and best manage the case, especially partner information. counseling session. Such a review should include as When the patient is resistant to the interview process, many of the following as possible: the DIS should attempt to determine the reason(s) be­ hind this unwillingness to cooperate and then address • reviewing available medical and case information, each issue, using motivational techniques such as: mode supervisor’s notes/comments, and closed field of transmission, confidentiality, asymptomatic nature records to: of disease, reinfection, complications, consequences, - establish the reason for the initial examination; social responsibility, and risk of HIV. Sometimes, a - establish possible history of STDs; change in interviewer will facilitate a more open dis­ - establish a critical period and interview period; cussion. An interview should not be conducted with a - establish pregnancy status for females; third party present, even at the patient’s request, un­ - establish information objectives (e.g. relationship less it is for reasons of auditing DIS performance or to other cases); and translation. - identify any unique problems and circumstances For those patients that still refuse to go forward concerning the patient (confidentiality, embar­ with the interview, the DIS must carefully weigh any rassment, sexual orientation, cooperativeness, benefits to be gained by continuing to pursue the is­ apathy about infections, domestic violence his­ sue. Any decision not to interview a patient should be tory, etc.); reviewed with the immediate supervisor. Whenever possible, this review should take place before the pa­ • reviewing available socio-sexual information and tient leaves the clinic. Programs are encouraged to re­ attempting to verify: quire supervisory personnel to follow up with patients - demographics (age, DOB, race and ethnicity, sex, refusing an interview to assess whether there are DIS marital status); skill deficiencies that need to be addressed, patient - address and phone; dissatisfaction issues or a poor match of patient and - living situation; interviewer. - employment; and - emergency locating information; Types of interviews and their objectives • assembling necessary materials and supplies, includ­ The following section describes three types of inter­ ing: views: the original interview, the reinterview, and the - visual aids; cluster interview. All interviews should employ the - writing materials (no official documents); techniques in the section that follows, titled “Other - business cards; important interviewing concepts.” In any interview - disease-specific pamphlets; situation the interviewer should always pursue infor­ - referral forms and envelopes; mation on pregnant females who would benefit from - local map(s); and, STD screening and should ultimately ensure prenatal - phone book and cross directory. care. For example, the interviewer should always ask the interviewee (male or female) if they know anyone Verification is particularly important for those patients who is pregnant. If yes, the interviewer should then who “volunteer” at the STD clinic because any dis­ ask if they know if the pregnant person is receiving crepancy provides cause for concern that must be ad­ prenatal care. If the answer is no, the person should dressed in the interview as this may be the only oppor­ be initiated for follow-up and the interviewer should tunity to speak with the patient. offer screening and have a specific prenatal service pro­ Once pre-interview analysis is completed, the DIS vider for referral. should initiate the session. However, a willingness to

Partner Services PS – 9 Original Interview • elicit (or confirm) all information necessary and The objective of the original interview (Appendix PS­ provide appropriate case management to complete B) is to prevent further transmission of disease through the interview record. the prompt identification and examination of all elic­ In accordance with local practice, the DIS should con­ ited partners and suspects. The original interview is fer with the supervisor (or designated co-worker) be­ designed to ensure the patient understands the seri­ fore completion of a patient interview if: ousness of the infection and the importance of their cooperation in STD/HIV prevention and control ef­ • an unexplained exposure gap exists; forts. It is also designed to provide client-centered coun­ • no source candidate has been elicited; seling to develop a personalized risk reduction plan • inconsistencies in information persist; or and to increase the likelihood that all partners and • the DIS feels dissatisfaction or uncertainty regard­ suspects are disclosed so that they can receive an ex­ ing the outcome. amination and treatment. The DIS should elicit a commitment from the patient A fundamental part of the original interview (as well to pursue identified information needs, establish an as reinterviews and cluster interviews) is partner elici­ appointment for reinterview, and determine best time(s) tation. Elicitation is the process by which the inter­ and alternate methods for reaching the patient. When viewer assists the patient in identifying partners and appropriate, the DIS arranges for a field tour with the other high-risk individuals (suspects) who might ben­ patient to identify home addresses, to point out loca­ efit from a medical examination. The goal of partner tions where partners hang out, where the patient met elicitation is to obtain sufficient information to confi­ a partner, etc. The DIS concludes by addressing any dentially locate, notify, and refer the partners or sus­ questions, providing reassurance on any problem ar­ pects for necessary examination, treatment (if appro­ eas, restating commitments, providing handouts, and priate), and risk reduction counseling. planing for the reinterview. Referrals to other medical and social services (such as HIV early intervention, prenatal care, or substance- Reinterview abuse treatment) are an important aspect of original While the original interview is intended to elicit all interviews. The interviewer should make every effort interview period partners and suspects, the reinterview to create an accessible and appropriate referral and of persons with high-priority infections (HIV, early should also follow up to ensure that any referral ap­ syphilis, or other high-priority infections, based on pointment is kept. All information obtained in an origi­ local criteria) is usually warranted. A reinterview may nal interview should be documented on a standard­ be required, for example, when a patient has clearly ized form, an example of which is located in Appendix evaded discussing or referring all partners or suspects PS-E. during the original interview. When a patient is diagnosed and treated in a non- A reinterview (Appendix PS-C) is any interviewing public health clinic setting, or when a patient exits the session following the initial interview with a STD pa­ clinic prior to the DIS conducting an interview, the tient. DIS conduct reinterviews when indicated, or original interview must be assigned for field follow- when requested by the supervisor, and always with a up at the earliest opportunity and with the expecta­ plan to accomplish specific objectives that are the prod­ tion that the interview will: uct of careful review and analysis. Reinterviews are • occur within 72 hours of assignment, or within es­ conducted to: tablished program time frames; • gather additional information that may help prove • be conducted face-to-face in the clinic, at the or disprove a hypothesis about case relationships; patient's place of residence, or in some other suit­ • address points not covered during the original in­ ably private place; and terview;

PS – 10 Program Operations Guidelines for STD Prevention • identify additional partners or suspects (“cluster­ This information in turn may be used by the pro­ ing”) to the original patient; gram to determine the appropriateness of screening • support patient risk-reduction attempts; activities, including risk or demographic profiles and • support and reinforce a patient’s successful use of the geographic location of target groups for screen­ referred services; ing. Cluster interviews should be planned, time per­ • confront points that are illogical or that are dis­ mitting, and are particularly helpful in outbreak situ­ puted by other information; and ations. They require skill and time commitment by • solicit assistance in locating previously named per­ the interviewer in exchange for returns that are often sons who have not been located or are being unco­ difficult to estimate in advance. operative. The DIS conducts cluster interviews, as indicated by case analysis or when requested by the supervisor, In most program areas, reinterviews are conducted with a plan to accomplish specific objectives such as: with a plan to obtain information necessary to advance disease intervention. The benefits to be derived from • identify high-risk associates such as individuals with reinterviews are further enhanced when conducted symptoms of STD (A-1); individuals exposed to within reasonable time frames—normally within 72 known cases of STD (A-2); and, others at increased hours of the last interview. The time and place of the risk for acquiring STD (A-3). reinterview should be set during the original interview • meet informational needs revealed by case analy­ process. sis; and, DIS should document the results of reinterviews on • gain information about known cases of STD which a STD Reinterview Record within time frames estab­ can be used to better plan re-interviews through case lished by the local program. At a minimum, the docu­ management. mentation must address information needs previously In conducting STD cluster interviews, care must be established for the reinterview and must provide an taken never to indicate that any specific person is in­ updated analysis. The updated case is made available fected with any disease, has been exposed to disease, for supervisory review or is given to the appropriate or has been examined for disease. In the interview, the case manager at the earliest reasonable time after the patient should be provided with: DIS completes the documentation. • logical reasons as to why it is in his or her personal The Cluster Interview interest to discuss partners and other high-risk per­ When interviewing patients regarding partners, ad­ sons and the behavior of others to reduce the risk equate information for disease intervention is not al­ of disease in his or her social network; and ways known or able to be obtained. Therefore, other • easily understood information about the disease to intervention strategies, such as cluster interviewing, which he or she has been exposed, and ways to avoid are initiated to expedite the intervention process. The similar risk in the future. cluster procedure has progressed through many stages since at least 1950 (Spencer, 2000) and currently con­ Other important interview concepts sists of selective interviewing of partners, suspects, and associates who are not known to be infected at the Motivational techniques to encourage time of the interview. voluntary disclosure The purpose of the cluster interview (Appendix PS­ The ability to motivate patients to voluntarily disclose D) is to gather information about previously unnamed information about their partners and others is central or uninitiated partners, suspects, or associates of to the success of disease control and prevention. An known cases. The cluster interview is designed to fur­ interviewer can use a number of techniques to moti­ ther expedite the disease intervention process by ex­ vate disclosure. Several approaches are described in panding the base of information about any high-risk the Employee Development Guide and the two week groups associated with the infected person. Introduction to STD Intervention course. One example,

Partner Services PS – 11 the LOVER approach, is a very effective method of natal care, etc.), and related concerns (intimate vio­ addressing patients’ questions and encouraging disclo­ lence, gangs); sure of information. Using this approach, the inter­ • discussing partner location information and recent viewer will Listen, Observe, Verify, Evaluate, and Re­ patient-partner or patient-network contacts in de­ spond to the patient’s issues. The interviewer must tail; and listen to what the patient is saying and observe any • seeking assistance and advice about unknown in­ non-verbal cues that the patient is giving. The infor­ formation on clusters, screening sites, patient hang­ mation must be verified and evaluated against other outs, and partner homes (e.g., field tours through known information and the DIS must respond to the area, etc.). information given. Another example is providing information about a Client-centered approach to risk reduction potential issue such as same-sex transmission, com­ Counseling patients who are sexually active is likely plications, etc., followed by an open ended question. to be more effective when counseling strategies are In addition, the interviewer can appeal to patient’s shaped to fit the individual patient’s needs. To ensure sense of responsibility to other members of their com­ patient-centered STD and HIV prevention counseling, munity and to their responsibility to themselves with interviews should be based on CDC’s standards for regard to re-infection. To increase the likelihood for prevention counseling, including a discussion of risk- success, motivational techniques should be tailored reduction strategies the patient will be able to realisti­ to the specific needs of the patient. Visual aids are also cally attempt, as well as specific strategies to assist the very helpful and can be used to depict the potential patient with making these changes. consequences of untreated infection. Suggestions for successful motivation of disclosure include: Referrals Referrals to other medical and social services are an • establishing and making the most of rapport with important aspect of all interviews. Although the focus the patient; of interactions is disease intervention, the interviewer • reassuring patient confidentiality by redefining con­ should remain sensitive to other health or social needs fidentiality, role playing, or demonstrating confi­ of individuals served in the STD clinic or through the dentiality; disease intervention process. Training will help DIS • remaining non-judgmental—exhibiting a strong recognize and address problems that interfere with sense of comfort in dealing with diverse sexual or sexual health, such as intimate (or domestic) violence, social histories and being familiar with and using substance abuse, and homelessness. When such needs sexual vernacular; are expressed by a patient or are otherwise perceived, • being direct and client-centered—asking the patient the DIS should facilitate appropriate referrals to other about his or her concerns; available services in a tactful manner that does not • focusing on changing negative perceptions of dis­ interfere with disease intervention priorities. Local pro­ closure; grams should develop a community referral guide or • confronting and minimizing specific biases that may directory, including such services as: be apparent or relative to the case; • addressing possibilities of and potential risks for • HIV intervention; reoccurrence of symptoms, re-infection, multiple in­ • Prenatal care; fections, and complications for both the patient and • Family planning; others, including the possibility of fetal damage or • Drug and alcohol counseling; death, when appropriate; • Tuberculosis; • using social or sexual network diagrams to illus­ • Maternal and Child Health; trate the infection or re-infection picture; • Mental health; • addressing and assisting with socio-economic issues • Immunization; (e.g., homelessness, unemployment, need for pre­ • Intimate or domestic violence;

PS – 12 Program Operations Guidelines for STD Prevention • Sex addiction groups; review related cases and discuss the current interview • Crisis intervention; with a supervisor or co-worker before completing the • Rape crisis; case write-up. Once all the paperwork necessary to • Language assistance; fully document the initial interview has been com­ • Temporary housing; pleted, the entire case—including all field records and, • Family counseling; where appropriate, a completed confidential morbid­ • Legal services; ity report card—should immediately be directed to the • Child Protective Services; attention of the supervisor for necessary review and • and other social or medical services. comment. Proper documentation promotes effective disease intervention efforts through the efficient shar­ When local policies allow, DIS should facilitate the ing of information with others—allowing co-workers referral by making a telephone call in the patient's to build on what has already occurred without having presence and attempt to secure the first available ap­ to needlessly repeat steps or actions already taken. pointment. All referrals should be documented in case Interview and field records, whether on paper or in management notes. The DIS should further assist pa­ an electronic format, must be viewed as legal and con­ tients by guiding them to a contiguous service area, fidential documents. As such, every effort must be providing directions to other locations, and offering made to ensure that each record is complete, accurate, transportation. Referrals should be documented and fully legible, and able to stand the test of careful scru­ confirmed. Referrals made for the reasons listed be­ tiny. Interview records should be maintained in a se­ low need to be followed up to ensure that they were cure location, accessible to the DIS and supervisors. successfully completed: DIS should review open cases at least twice weekly to • HIV positive individuals referred for early interven­ determine status and evaluate needs. Such reviews en­ tion and case management; able reinterviews and cluster interviews to be easily • patients referred for penicillin desensitization; and effectively planned. Supervisors should also regu­ • congenital syphilis treatment; larly review cases and should clearly date, record, and • pregnant females referred for prenatal care; initial all comments and directions. Whenever possible, • and other locally defined priority referrals. supervisors should be encouraged to review cases in the presence of the responsible interviewers. Unsuccessful referrals for these priority services require Information obtained from well documented inter­ documentation and immediate action, including addi­ view and field records enables programs to make the tional contact with the patient. most efficient use of resources by identifying and then targeting locations or specific populations within the Post-interview activities community for screening activities. It also affords pro­ grams the opportunity to identify and draw upon ad­ Documentation ditional resources and support by developing collabo­ Documentation is the careful and complete recording rations with carefully selected community-based and of facts surrounding a particular case or investigation related organizations serving particular communities and includes the essential events leading to its closure. or at-risk populations. DIS should concisely and legibly document the results of interviews, including case analysis, on the interview record and related program forms at the first reason­ Recommendation able opportunity (not to exceed one workday) consis­ • Documentation of partner services must be tent with established policy. Information to document systematic, confidential, and regularly re­ includes unexplained exposure gaps, clustering needs or opportunities, and other information needs. The viewed by the next level of supervision. interview record and related forms are never completed in the presence of the patient. It may be helpful to

Partner Services PS – 13 Analysis of case information and Prioritization of partners, suspects, and problem solving associates Information obtained from medical records, interviews, Once field records have been completed for notifica­ reinterviews, and cluster interviews must be carefully tion of partners, suspects, and associates, they should analyzed for consistency. Visual case analysis (VCA) be carefully prioritized to ensure that those at highest is an essential tool in syphilis case management for risk—those who are pregnant, those exposed to le­ analyzing data from multiple sources. VCA allows the sions, or those indicated to have suspicious symp­ DIS to systematically document medical and epidemio­ toms—are contacted or interviewed first. The logic facts related to early syphilis cases, analyze those prioritization of partners should be based on local pro­ facts, determine the most likely hypothesis of disease gram area policy and DIS workload using the same spread, identify where disease intervention could oc­ principles for priority setting discussed earlier. cur, and develop a plan for action. Information that is Some program areas assign all field records (FRs) conflicting, unclear, or absent, but pertinent (for ex­ resulting from patient or cluster interviews to the in­ ample, patient address(es), number of partners, descrip­ terviewing DIS. However, if the number of priority tions of a partner, locating or exposure information) partners or suspects is more than can reasonably be should be analyzed. In many instances, these issues followed up in a 24-hour period, the immediate su­ can be quickly and easily clarified by speaking with pervisor should assign some of the investigations to the patient. There may be occasions, however, where others. Priority suspects are individuals not named as the DIS chooses to explore other avenues before re­ sex partners, but who are identified as having suspi­ turning to the patient. Strategies for resolving incon­ cious symptoms (S-1) or as being an unnamed sex part­ sistencies in case management information include the ner of another known case (S-2). following. Quality analysis can only take place when interview records and supporting forms are properly completed • Reinterviewing individuals who give sketchy infor­ and fully documented. A complete visual case analysis mation or whose partners give discrepant informa­ can be invaluable in documenting risk patterns in com­ tion. plex clusters of sex and STD transmission. Programs • Offering field tours to patients in an effort to gain are encouraged to collect risk-behavior information more complete locating information and to iden­ on the interview record (i.e., with respect to drug use, tify locations where the at-risk population gathers. the type of substances used and date of last use; These locations may become possible sites for tar­ whether the patient exchanged sex for drugs or money, geted outreach activities. or has had sex with someone or a partner of someone who exchanges sex for drugs or money). Important • Performing an unannounced home visit for purposes patient information should also identify the patient’s of reinterview and to confirm the patients address usual health care provider and should provide suffi­ and living situation. cient space to fully document marginal partners. Col­ • Clustering partners, suspects, and other individu­ lecting that information will assist program efforts to als not named by the original patient (roommates, better understand the risk factors associated with vari­ family members, neighbors, etc.) in an attempt to ous STDs. gain additional information about the original pa­ tient and the at-risk community. This is done with Obtaining further information the understanding that some individuals can be ex­ DIS should tell all patients that it may become neces­ pected to provide greater insights and information sary to speak with them again and should attempt to than others. For example, spouses and roommates determine the best way for doing so. Patients should should be considered for initiation and clustering be contacted the day following treatment to inquire even when exposure is denied by the index patient. about any reaction to medications, to answer any ques­ tions that may have come to mind, and to seek clarifi­ cation concerning partner locating information as

PS – 14 Program Operations Guidelines for STD Prevention needed. Follow-up after diagnosis underscores pro­ morbidity. While it is most often used for syphilis, the gram concern for the patient as an individual. Rapid lot system may be used for other diseases as well. Lot follow-up about partner locating information rein­ systems can facilitate identification of populations for forces the urgent nature of partner notification. It pro­ which targeted screening is a suitable intervention. vides an opportunity to follow up on how patients are The decision to file cases together can be for any doing with any commitments made; and affords an “logical” reason, for example: 1) patients are related, opportunity to review locating information already i.e., they name one another as sex partners or are linked provided and to ask about additional partners that through clustering or 2) cases share something in com­ may have come to mind. If the original patient inquires mon, such as working for the same company or living about the status of partners that have been identified, in the same apartment building. the only information that may be relayed is whether The individual folders that constitute the lot sys­ the partners have or have not been notified. tem should be filed sequentially, by date reported. A “lot book”, card file, or computerized system should Using Information Obtained From be established, with information such as lot number, the Interview to Identify Possible patient name, date of interview, diagnosis, etc. This Outbreak Situations system can be referred to when attempting to locate a Programs should pursue information that will delin­ particular interview record. When information allows eate at-risk populations so they might be more easily cases in two or more lots to be “collapsed” into a single and effectively targeted for a wide range of interven­ lot, the lot folder containing the most recently initi­ tions. This information can be obtained through com­ ated case should normally be selected. The folders for munity outreach activities, clustering, and increased those cases being moved should be retained in the file, testing by providers beyond the public STD clinic. with the lot number to which the case was moved Patients, their partners, and cluster suspects and asso­ written on the front. ciates can be particularly helpful in program efforts to With the increasing use of computers to store pa­ identify specific at-risk populations in need of special tient records, the use of an electronic lot system sim­ initiatives. For example, a program may consider de­ plifies tasks. This may be accomplished by assigning a signing, evaluating, and implementing specific forms lot number in a local use field and then assigning the to identify and to assure the routine and continuing same number to all of the related records. When the examination of sex workers within a particular com­ records are sorted by the lot number, all of the records munity or program area. in that lot should be listed. A system should exist, ei­ ther electronic or as hard copy, to cross-reference pa­ Lot system: a case management tool tient names, lot numbers, and case numbers. A lot system requires that case management records be maintained in a single folder. The goal of a lot sys­ Lot system forms tem is to assure that all obtainable information regard­ A major analytical points (MAP) sheet is used for gath­ ing the continuing management of cases contained in ering information about members of a lot as well as a lot is readily available to all responsible workers. for analysis and communication. The MAP sheet is a Workers should have access to information regarding preprinted list of items that are frequently needed in other infections so that they have a comprehensive case management. Spaces are provided for other items picture of the situation before conducting a reinterview unique to the lot. In addition, cluster and reinterview or cluster interview. To further assure this process, in­ records may contain information that may generate formation contained within each lot must be carefully agenda items during an interview of another patient maintained for each individual patient, and lots must in the same lot. These forms also may be used to docu­ be returned to a secure central location (file) when not ment what occurred during the same interview. The being reviewed or updated. The lot system is a very original patient information sheet, along with the origi­ useful tool in the management of syphilis, particularly nal interview record provides important disease inter­ in larger program areas or in areas with high syphilis vention information. The lot folder status sheet is both

Partner Services PS – 15 a reminder of cases in the lot and a summary of their be needed if the partner has been recently tested, relationships. Recent examples of these forms from treated, or counseled and is aware that he or she has the state of California, along with a field record form been exposed to an STD. If notification is needed, the and a syphilis case management sheet, can be found in DIS can use the information provided by the original Appendix PS-E. patient or by record search to locate and refer the part­ ner for prevention counseling, testing, and examina­ tion (see Appendix PS-F for details of provider notifi­ Partner Notification Strategies cation process). Once the partner has been located, Three primary strategies can be used to notify part­ the DIS informs him or her confidentially and privately ners of possible exposure to STD or HIV infection: of the possibility of his or her exposure to STD. Infor­ Provider, Self, or Contract referral. Often, more than mation leading to the identity of the original patient is one strategy may be used to notify different partners never revealed to the partner. of the same infected patient. The strategy will depend Research has shown that provider referral is the on the particular patient, the particular STD, and on most effective method to notify partners (Macke, partner circumstances. For example, a patient with a 1999). When discussing partners, the DIS should elicit STD may feel that he or she is in a better position to names and exposure information with the assumption notify a main partner, but would prefer that the pro­ the health department will perform the notification. vider (DIS) notify other partners. Advantages to this method are the ability to: Programs must make the decision as to when a par­ • verify that partners have been offered and have re­ ticular type of notification will work best in their area. ceived evaluation and risk reduction counseling; This decision should be based on program priorities, • ensure the patient’s confidentiality since no infor­ disease morbidity, and program staffing levels. For mation about the patient is disclosed to partners; example, a program may chose to utilize provider re­ • help defuse any partner anger or blame reactions, ferral for patients with infectious syphilis yet utilize and respond to the partner’s questions or concerns; patient referral or contract referral for patients with • offer field specimen collection (blood, saliva, urine); gonorrhea and chlamydia. Others may chose to con­ • provide on the spot counseling; duct provider referral for all patients, regardless of • identify opportunities to provide behavior change disease. In any case, DIS must work under the assump­ counseling; and tion they may have to locate a partner, even if the pa­ • provide immediate referrals and offer information. tient referral or contract referral option is used. DIS should obtain locating information on all partners and Disadvantages to this method are: suspects, regardless of the option chosen, so they are • the difficulty in readily locating and identifying part­ prepared to follow up on partner notification activi­ ners; ties. • less familiarity with the lifestyle and problems of the partner; and Provider Referral • it uses more staff members and financial resources Provider referral is a notification strategy where, with as compared with other methods. the consent of the infected patient, the provider takes responsibility for confidentially notifying partners of Self (Patient) Referral the possibility of their exposure to a STD. The DIS Self referral (sometimes called patient referral) is the will search health department open and closed records notification strategy whereby the patient with a STD to determine whether the partner has ever been tested accepts full responsibility for informing partners of or treated for STD or HIV and to seek additional lo­ their exposure to a STD and for referring them to ap­ cating information. If the partner has been previously propriate services. When self referral is chosen, the tested and/or treated, then the DIS determines whether interviewer should coach and/or role play the follow­ notification is still warranted. Notification may not ing:

PS – 16 Program Operations Guidelines for STD Prevention • WHEN to do the notification—encouraging the pa­ their exposure and to refer them to appropriate ser­ tient to notify partners promptly. vices. The DIS collects all locating information for all • WHERE to perform the notification—encouraging partners, suspects, or associates discussed during the a private setting. interview. If the patient is unable to inform partners • HOW to tell the partner—coaching the patient to within an agreed-upon time period, the DIS will no­ avoid blame by stating in simple terms someone has tify and refer the partners. As in provider and self re­ tested positive, and because this person cares about ferral, the interviewer needs to obtain identifying and the partner, he/she is encouraging the partner to seek locating information on partners at the time of the examination and treatment. interview. The DIS should also negotiate a confirma­ • REACTION—asking the patient how they think the tion of referral. Similar to provider referral, this op­ partner will react, or has reacted to difficult news tion affords the DIS the ability to verify that partners in the past. Help the patient anticipate potential have been notified and referred. problems, especially in regard to loss of anonymity. The advantages of this method are: If a patient has difficulty at this point, the benefits • it provides professionally trained support for the of provider referral should be discussed and pro­ patient who chooses to notify his or her partners; moted. • it ensures that referral to appropriate services is pro­ vided and that prompt follow-up for the partner is Advantages to this method are: available. • notification may result in a more prompt referral Disadvantages to this method are: to appropriate services because the patient is usu­ ally more familiar with the identity and location of • it may result in lost time and the potential for fur­ the partner; and ther transmission of disease if the patient does not • fewer staff members and financial resources may notify partners. be used. The following ideas and recommendations (West, The disadvantages of self referral include: 1997) may serve as guides for developing partner no­ tification approaches: • forfeiting of anonymity, resulting in possible dis­ closure of the infection to third parties, subsequent • Provider referral is more effective than self referral discrimination, or a partner’s reaction; in reaching partners, suspects, and associates. • the loss of confidentiality may increase the poten­ • Most individuals will cooperate in notifying at least tial for violence; some partners, suspects, and associates. • the patient may, intentionally or unintentionally, • Partners are generally receptive to being notified convey incorrect information, resulting in incom­ and will seek testing once they have been notified. plete or ineffective referrals; • Partners often are unaware of their or their part­ • the patient may not follow through on the notifica­ ners’ STD risks. tion of the partner, resulting in the increased prob­ • Partners frequently are found to have a STD. ability of transmission to others and in additional • It is important for patients to recognize and under­ time for the DIS, who will then have to contact the stand the importance of partner notification. partner; and • Reaching persons in early stages of their infection • increased difficulty in evaluating outcomes. can enhance disease intervention and prevent dis­ ease complications. Contract Referral • Many legal and ethical concepts pertain directly to Contract referral is the notification strategy in which partner notification and have important implica­ the provider negotiates a time frame (usually 24-48 tions (duty to warn, right to know, duty to protect hours) for the patient to inform his or her partners of public health, right of confidentiality and privacy,

Partner Services PS – 17 protection against discrimination, need to protect an appropriate medical evaluation (including treat­ family and personal relationships). ment, if needed). Published literature identifies that the following factors contribute to delays in seeking DIS should be prepared to discuss the pros and cons appropriate treatment for an STD: a lack of symp­ of each notification strategy, including the likelihood toms (Niemiec, 1978) or the classification of STD of verbal or physical abuse. Programs should have in symptoms as normal (Harrison, 1982; Fortenberry, place a means of assessing the likelihood of violence 1997); being female (Leenaars, 1993); adolescents’ as a result of partner notification and have a plan for sense of invulnerability and the stigma associated with addressing those situations. acquiring a STD (Fortenberry, 1997). It is worth not­ ing that persons with multiple partners and persons Recommendation with a single partner are equally likely to delay care (Leenaars, 1993). Finally, partners may need other • Partner services should be delivered in one of types of referrals as well (i.e., pregnancy, intimate vio­ three ways: provider referral, patient referral, lence) and DIS should be prepared to make these re­ or contract referral. ferrals and to support the patient in obtaining other services to the extent possible. Evidence supporting partner notification While there are unanswered questions about partner Follow-up to ensure notification is received notification, a review of the evidence supports several and understood recommendations (Macke, 1999). There is good evi­ When a partner who has been notified of his or her dence to show 1) partner notification can be an effec­ exposure does not seek medical evaluation, the DIS tive means of finding at-risk and infected persons, 2) should follow up with that partner to ensure they un­ provider referral generally ensures that more partners derstand the importance of timely and appropriate are notified and medically evaluated; and 3) the repu­ medical evaluation. Often, repeated conversations are tation of partner notification service providers influ­ needed. In these situations, DIS should be persistent ences the success of partner notification as an inter­ and employ appropriate motivational techniques in a vention. More research is needed on tailoring manner that conveys a sense of urgency and re-em­ elicitation and notification procedures to specific popu­ phasizes the benefits and value of medical evaluation. lations, the effect of new testing technologies on part­ Stalled investigations should be brought to the atten­ ner notification, and the consequences of partner no­ tion of a supervisor at the earliest opportunity for dis­ tification for infected persons and their partners. cussion and further action. Non-productive routine visits or dropping a referral letter is not an effective Other important concepts about partner use of program resources. notification Ensuring that the partner has access to Encouraging the partner to seek medical health care treatment If a partner is evaluated by a provider outside the health The actions that a person takes (or does not take) to department, the DIS should contact the provider to address health concerns include appraising the prob­ ensure that the partner receives appropriate and timely lem and the need for clinical care, reaching a decision test(s) and treatment(s). Following the appointment to seek care, and acting on that decision. For example, time, the DIS should contact the provider to verify a partner may have symptoms consistent with a STD appropriate management of the partner. Self-report­ but “appraise” the situation as a “normal” discharge ing is not sufficient. The health care provider treating and, as a result, not seek clinical care independently. a partner should be personally contacted, or the medi­ People also sometimes treat themselves or consult with cal record reviewed to verify that appropriate tests and alternative practitioners. Partners tested in the field treatments were administered. Conversely, if the part­ should be encouraged to obtain their test results and ner was referred from another health care provider

PS – 18 Program Operations Guidelines for STD Prevention and is treated in a health department clinic, the infor­ tent with DIS position descriptions; 2) DIS ability to mation regarding treatment of the partner should be legally provide the services outlined; and 3) DIS being communicated back to the referring health care pro­ afforded the necessary training to properly and safely vider. deliver those services.

Diagnostic assessment of partners in the field Case closure

Venipuncture is a skill required of public health nurses, For some cases of syphilis, diagnosis is not determined and of many federal, state, and local DIS and is an until case closure. This is particularly true for those especially valuable tool in the disease intervention pro­ persons with positive bloods, but without a symptom cess. Programs intending to use DIS in this manner or blood test history. Only through interview and fol­ need to review all relevant state health and safety codes low up of sex partners can it be determined if such a and local public health protocols to determine required person should be classified as early latent, late latent, training and certification procedures before perform­ or syphilis of unknown duration. ing this activity. DIS must exercise the utmost care and A case is closed when the DIS and next level super­ professional judgement when performing field veni­ visor agree that all reasonable steps to intervene in the puncture procedures and must be certain to have the disease process have been completed. Before such a appropriate equipment and supplies available before discussion, the DIS should carefully review the entire undertaking field activities that may include drawing case record and those of related infections to ensure blood. For more detailed information regarding veni­ that all program required data needs have been met; puncture, see the chapter titled “Medical and Labora­ that information is complete and consistent (e.g., test tory Services.” It is strongly recommended that part results documented, reinterview and cluster interview of the training afforded DIS include an orientation to forms present, contacts and clusters dispositioned, and the state or local “Occupational Infections in the Work­ any necessary source/spread determinations made); and place” policy and the supporting procedural manual. that all supervisory recommendations have been fully This will expose the DIS to precautions and proce­ addressed. The entire lot or record should be submit­ dural recommendations set forth by NIOSH, CDC, ted to the supervisor for final review. Interview records and state OSHA programs. Programs also must have indicating that contact was not made or that partners in place an “Occupational Infections in the Workplace” were not medically evaluated must be discussed and policy that is at least as restrictive as the Occupational signed off with the supervisor before closure. With the Safety and Health Administration policy (see references concurrence of the supervisor, the case is updated to for complete citation). More current information may reflect the closure date. Cases should be closed within be obtained from the OSHA website (www.osha.gov). locally established time frames. More and more disease control programs are ex­ ploring opportunities presented by emerging labora­ Recommendations tory technology and the resulting testing procedures to identify and control communicable diseases. For • Partner services should be one of a number of example, tests that rely on urine or saliva to detect public health strategies, including accessible chlamydia, gonorrhea, or HIV infection have created clinics, outreach, and targeted screening of at opportunities for conducting screening activities that risk populations. target specific high-risk populations at the community • Programs should have the capacity to deliver level. Some programs have expanded or are in the pro­ services such as counseling, testing, and treat­ cess of expanding the responsibilities of DIS to include ment, as well as referral for other services (e.g., administering these tests in the field and are using DIS family planning, drug treatment, social sup­ to read skin tests for tuberculosis. Any decision to ex­ port, and housing). pand the responsibilities of the DIS in this area must be predicated on 1) the additional duties being consis­

Partner Services PS – 19 SPECIAL CONSIDERATIONS Suggested Strategies for Patients With Repeat Infections Collaborating with other service providers Persons repeatedly infected and treated are often re­ Programs should implement protocols for the follow­ ferred to as recalcitrant patients or “repeaters.” Man­ ing circumstances: agement of such patients should include HIV preven­ tion counseling and testing (and possibly HIV • The diagnosis of the index patient is performed by prevention case management), since they are at high non-health department agencies and the patient is risk for acquiring HIV. Although such patients are a referred to the health department for partner ser­ challenge for any STD prevention program, they are vices; an important source of information regarding other • The elicitation of partners is performed by non- at-risk individuals and locations within the commu­ health department agencies and such information nity where they gather and interact. This information is provided to the health department for partner can be used to develop specific outreach screening ac­ notification. tivities targeting these areas that include carefully STD prevention programs should actively inform pro­ crafted and intensive behavioral interventions. viders about partner services (for example, through DIS distributing pamphlets to key providers) and ini­ Recommendations tiate collaborations with providers outside of the health department. • Programs should implement a protocol for collaboration with non-health department Interstate Transmission of STD Intervention care providers within their own area and with Information STD programs in other jurisdictions. • Programs should implement a protocol for The Interstate Transmission of STD Intervention In­ identifying and developing a case management formation is the system that oversees the transmission of STD intervention information between STD pre­ plan for patients with repeat infections. vention programs. Success depends upon the willing­ ness of program managers to take the steps necessary to assure its provisions are observed and to hold one EVALUATION AND QUALITY another accountable when deviations occur. STD pre­ ASSURANCE vention programs should review existing protocols and procedures to ensure they are specific on how to handle Case Management incoming and outgoing intervention requests. In re­ Supervisors and managers should regularly and care­ viewing or developing these protocols and procedures, fully review information obtained through patient and programs should consider the principles outlined in cluster interviews to assure that cases are being vigor­ Appendix PS-G to ensure consistency on a national ously pursued, properly documented, effectively ana­ level for interstate and intrastate transmission of in­ lyzed, and that the findings are appropriately applied formation. Disease prevention will be facilitated by to continuing intervention activities. Managers should inter-jurisdictional sharing of information on patients, also assure that case information involving other pro­ partners, suspects, and associates in a secure and con­ gram areas is being shared promptly and cooperatively. fidential manner. Performance expectations of the program and per­ sonnel for all aspects of disease control should be es­ tablished. Performance guidelines are relatively detailed instructions and standards about the process by which staff are expected to apply acquired knowledge and skills to critical elements of daily work in STD con-

PS – 20 Program Operations Guidelines for STD Prevention trol. For supervisors, guidelines are an aid to evaluat­ opportunities for program management to encourage ing the capabilities and deficiencies of workers. Be­ appropriate attitudes and philosophies. yond simply establishing program expectation, “guide­ Programs should establish the expectation that case lines” describe the process by which those expectations management—and the interview and investigative ac­ can be achieved. Programs should develop, dissemi­ tivities that support it—will be rigorously approached, nate, and maintain signed copies of local process per­ fully documented, and carefully analyzed. This will formance standards, indicating that an employee has place the STD prevention program in position to ob­ received, reviewed, understood, and agreed to these tain the information necessary to address STD mor­ standards. bidity within communities.

Components of case management quality Recommendations assurance • Supervisors should regularly observe and Involved program managers and firstline supervisors document individual DIS in the performance are critical to successful case management. Active in­ of their day-to-day activities and should be volvement of supervisors is necessary to maximize DIS willing and able to demonstrate appropriate intervention activities. There must be the expectation skills and behaviors. that DIS will obtain complete locating information on partners, negotiate a risk reduction plan, and cluster • Supervisors should conduct sessions that fa­ to determine who may benefit from examination or to cilitate DIS discussion of case management ef­ identify locations where high risk activities occur. forts and provide opportunity for input from Supervisors should regularly and directly observe others. individual DIS in the performance of their day-to-day • Programs should routinely monitor partner activities and should be willing and able to demon­ services to improve efficiency, effectiveness, strate appropriate skills and behaviors. Forms should and quality of services. be in place to fully document these audits and demon­ strations (pouch, interview, and field audits). Com­ pleted forms should be shared with the individual Using information gathered to describe and employee regularly and immediately following the reach target populations audit. Such forms can be used when writing individual Much of the information gathered in the partner ser­ evaluations to call attention to areas of strength and vices process may be used to describe and reach target to those requiring improvement. An example of tools populations in the program’s jurisdiction. Information that can be used to assess the quality of partner ser­ that may be used includes, but is not limited to, dis­ vice work is the skills inventory assessment, included ease outcomes, risk behaviors (i.e., drug use or com­ in Appendix PS-H. mercial sex work), location of home and “hang-outs”, Supervisors should conduct sessions (sometimes as well as information about partners, suspects, and called “Chalk Talks”) that facilitate DIS discussion associates. At the most basic level, trends in disease of case management efforts and provide opportunity found through evaluating partners should be used to for input from others. Such discussions can be used to monitor disease transmission and to increase program share information on marginal partners—those part­ awareness regarding potential outbreaks. Once this ners for whom insufficient information has been elic­ system is in place, more advanced analyses of data ited to initiate. Such meetings should also be used to should take place regularly. For example, tabulate discuss other case management issues, safety concerns, monthly the number (and type, where applicable) of social network analysis, and newly developed investi­ risk behaviors that the original patient discusses in the gative resources. Chalk talks provide the opportunity original interview (i.e., sex for drugs), partners testing for peer-to-peer sharing of interviewing and investiga­ positive, partners testing negative, and the number of tive techniques and approaches. They also provide partners tested.

Partner Services PS – 21 Recommendations • Time frames for locating and notifying partners (i.e., How many were notified within seven days of the • Trends in disease found through evaluating interview of the original patient); partners should be used to monitor disease • Number of partners notified of their exposure to transmission and to increase program aware­ an STD, including: ness regarding potential outbreaks. - Number of STD negative and no subsequent STD • At a minimum, programs should analyze part­ infection ners who are positive by residence (zip code, - Number of STD negative who have at least one address). If resources permit, programs should subsequent STD infection also analyze location, demographics, and risk - Number of STD positive who have at least one behaviors of partners and should compare subsequent STD infection positive (including previously treated partners) - Number of STD positive with no subsequent STD with negative partners to see what, if any, fac­ infection tors predict positive partners. Programs should also be able to evaluate partner ser­ vices by:

Measures for evaluating program effectiveness • Individual Program Area (e.g., county, district, re­ The list of measures that follow are aids to help evalu­ gion, etc.) ate the effectiveness of the partner services component • Provider Type (STD Clinic, Family Planning, Cor­ and to help reallocate resources if necessary. These rectional Facilities, PMD, HMO, etc.) measures are not an end in themselves but a means to • Sex of the patient analyze and improve program effectiveness. They • Referral strategy (patient, provider, or other) should be reviewed regularly (i.e., monthly or quar­ • Any selected time frame terly) and tailored to meet the program’s identified The ability to delineate partner services information needs. Many states have developed detailed monthly in a variety of ways enables a program to more easily reports of DIS productivity. In addition, programs may determine activities that appear to be effective from wish to use the tables in Appendix PS-I as analysis those that do not. Is one program area or type of ac­ tools. Tables may be completed for each disease for tivity more effective or worthwhile than another? which patients are interviewed; separate tables for sus­ What are the individual strengths and weaknesses of pects and associates may be done as well. These mea­ field staff? Individual employee reports may help a su­ sures can be calculated using STD*MIS. pervisor and the program identify interviewing defi­ Essential Measures (for each disease): ciencies that can be remedied by training. For example, managers can generate reports for a particular area • Number of original patients interviewed before a scheduled visit. They may identify possible • Total number of partners elicited areas of concern that can then be examined more • Number of partners initiated to field follow-up closely during the visit. • Number of partners out of jurisdiction Programs should also collect data on reinterviews • Number of partners identified but not located (number reinterviewed and results), on new partners, • Number of partners identified and located but not suspects, and associates initiated, and on the numbers notified (i.e., located in records as previously of partners, suspects, and associates afforded prophy­ treated) laxis. Programs should also develop reports that rou­ • Number of partners located and notified by pro­ tinely examine the speed and effectiveness by which vider; services are delivered to partners, suspects, and asso­ ciates. Finally, these reports should be available to and used by all levels of management.

PS – 22 Program Operations Guidelines for STD Prevention Other types of analysis and measures: Recommendations The measures discussed above are the traditional “bot­ tom line” measures of success of partner services, but • Programs must have a means of regularly they are not the only ones. Using the number of origi­ evaluating the effectiveness of partner services nal patients interviewed as the denominator, one can by time period and disease. calculate various indices for each time period such as: • Programs should develop the capacity to • Number or percentage of patients being interviewed; evaluate the effectiveness of the partner ser­ percent in 24 hours. vices by other locally set criteria to improve • Number or percentage of patients coming from: services and target them better. clinic, corrections settings, substance-abuse pro­ grams. Knowing this can help target screening re­ sources more effectively. COMMUNITY-BASED OUTREACH • Number of partners elicited compared to the num­ ber initiated. Public health and STD prevention programs, in par­ • Number of out of jurisdiction partners initiated ticular, have a duty to warn individuals that they may and the timeframe on receiving disposition on these have been exposed to a sexually transmitted disease. out of jurisdiction partners. In response, most STD prevention programs provide • Number of incoming out-of-jurisdiction partners for the notification and evaluation of exposed part­ actively pursued. Number and timeframe of incom­ ners who have been identified by an infected index ing out-of-jurisdiction partners where disposition case or partner. Examples of such services include part­ was given to other jurisdictions. ner notification (PN), clinical evaluation and testing • Number of partners closed as unable to locate. of partners, the concurrent provision of prophylaxis, Additional locating resources or training in the use and risk-reduction counseling. Some have stated that of those resources may be needed (e.g., Internet di­ this duty to warn extends also to individuals who were rectories as well as updated cross-directories; closer exposed but who could not be located through PN relationship with the department of motor vehicles (Peterman, 1997). However, not all STD prevention or other agencies). programs directly provide for the evaluation of per­ • Number of partners refusing service. sons who have not been located through PN or who • Number of partners treated prior to being notified have not been identified by an infected index case or by the DIS. partner. Examples of strategies that address this ex­ • Percentage of original patients, partners, suspects, panded charge include clinical evaluation and testing and associates with more than one STD. of patients who come to the clinic as volunteers, clus­ • Number of partners, suspects, and associates that ter interviewing with resultant disease screening and were located, notified, examined, and treated. prophylaxis, review of epidemiologic data collected through ethnographic means, targeted outreach, These calculations may be done for each individual DIS screening, and public awareness campaigns. It is im­ as well as the entire program. Useful calculations include portant for STD prevention programs to evaluate their the percentage of partners located and tested in a timely local situations and to employ interventions which manner, for example, in less than a week. The ultimate complement PN. Such interventions include social net­ question that these data should answer is how the pro­ work analysis in conjunction with PN, targeted screen­ gram is doing in terms of controlling disease. ing and field testing, and other forms of outreach.

Partner Services PS – 23 Overview of Interventions viewing, to identify the populations and conditions within its jurisdiction that facilitate disease transmis­ Social Network Analysis sion, especially by high-frequency (core) transmitters. Network analysis is defined as the study of how people In addition, programs may be able to prevent outbreaks connect in social structures and of its implications by limiting disease occurrence in core transmitters. This (Potterat, 1998). A detailed discussion of social net­ should be done in partnership with communities that work analysis is available in Appendix PS-K. Several the program serves (Oxman, 1996a). different social networking methods are commonly Woodhouse et al. researched how a group’s social, used. One method is to collect information about core sexual, and injection drug-sharing relationships might environments in addition to partner names. Another help or hinder the spread of various STD, including is to make a programmatic commitment to investigate HIV (Woodhouse, 1994). What they found, surpris­ the networks where disease is located rather than in­ ingly, was that the majority of the infected individuals vestigating only individuals known to have a STD. were not part of the larger interconnected group en­ Clustering, the technique by which infected and gaging in high-risk activity, but in fact were connected uninfected patients are interviewed about their asso­ to much smaller groups with no links to the larger ciates (as well as their partners), may provide extra group. In other words, it is not just the presence of information about the identity and location of sought- infection that produces transmission, but other social after sex partners. Clustering also can be used to iden­ factors such as group dynamics and behaviors, group tify geographic areas or for narrowing criteria for tar­ size, and geographic area. Programs can take the geted screening. Additional methods of social information gathered from network analysis and networking are spot-mapping home addresses and review and can create and implement policy and op­ hangouts, studying partner mixing patterns, and per­ erations that take into consideration the dynamics of forming old-fashioned shoe-leather epidemiology. day-to-day transmission within their jurisdictions Research often centers around which behavioral and (Woodhouse, 1994). social features are necessary to continue disease trans­ Rothenberg and Narramore outlined how social net­ mission in epidemic numbers and around the explora­ working analysis was used by public health officials tion of which interventions could be implemented to to address an increase in early syphilis cases in certain halt transmission. Transmission dynamics are prima­ areas of Nashville, Tennessee (Rothenberg, 1996b). A rily dependent upon the effects of small populations map was created of all the addresses reported by indi­ with varying levels of sexual activity (i.e., frequency, viduals with early syphilis. As a result, staff were able number of different sex partners) (Oxman, 1996a). to identify that 89.7% of all persons with early syphi­ For example, in Oregon the number of syphilis infec­ lis lived within nine well-defined geographic areas. This tions was found to be affected by the number of clus­ pattern had actually been occurring for several years. ters of women who have a large number of casual or In addition, staff observed the use of crack cocaine in anonymous partners. Oxman found that when the this network. In response, the Nashville STD control actual number of women in the group or the number program implemented a network-informed approach of partners exchanged in any given time period, or to their syphilis prevention activities. Such efforts in­ both, was reduced, the rate of the group’s infection cluded the assignment of public health workers to decreased. When an epidemic begins, the number of specific geographic areas, staff having continuing con­ infected people rises quickly to a peak that appears to tact with persons at risk and other community lead­ be closely linked to the sexual behavior characteris­ ers, and mandatory reinterviewing of all infected per­ tics of the involved population. sons to gather additional information on personal There is support for the notion that syphilis out­ networks. breaks in heterosexuals, which are extremely difficult A recent report described the importance of social to control once underway, are a result of core trans­ network and ethnographic tools in the investigation mission (a small number of interactive and networked of a cluster of syphilis cases in Georgia (Rothenberg, individuals). STD control programs can incorporate 1998). Several complementary methods were used, social network methods, e.g., mapping, cluster inter­

PS – 24 Program Operations Guidelines for STD Prevention including the interviewing of as many people as pos­ has often resulted in a broad characterization of vari­ sible who were believed to be involved in transmis­ ous social groups, i.e., gay men and teenagers. Research sion (both infected and uninfected people); the detailed has shown that specific behaviors determine the risk ethnographic exploration and documentation of sexual for infection and that social networks determine the and social patterns; the collection of interview infor­ extent of the disease within that given population. Over mation on standard CDC interview forms; the con­ the years, partner notification has shown that social version of interview data into databases to which net­ networks do play an important role in the public health work analysis software could be applied (including approach to disease control. Initial work suggests that programs that allowed for graphic representations of social structures can influence STD transmission. So­ patterns); and follow-up interviews several months to cial structures also can increase the effect of risky be­ a year later to examine the social and sexual patterns haviors within each social setting. Epidemics do not that followed the outbreak. Ethnographic interviews result just from many risky acts, but are the result of revealed the existence of a complex sexual picture that complex interactions embedded in a social and geo­ predated the diagnosis of the first case by one year graphic context (Rothenberg, 1996a). It is crucial that and that people without infection were often as cen­ programs take into account both the risky behaviors tral in the network and as important in transmission of individuals and the risky behaviors ingrained within as infected people. In addition, uninfected people were the culture of the social network when critiquing, re­ as likely to identify partners with infection as people vising, or developing disease control interventions. without infection. This approach underscores that if History has shown that the act of segmenting so­ programs interview only people known to have infec­ cial networks, such as closing bathhouses and shoot­ tion, they will miss important people, including in­ ing galleries, or housing disruption in economically fected partners and individuals who do not have a STD, impoverished areas, may result in higher rates and but who, by their connectedness within a network, widespread disease for a period of time (Rothenberg, sustain transmission. With appropriate training in eth­ 1996a). Disease that was once self-contained in a small nographic and social network methods and the use of segregated community can expand beyond its previ­ databases such as STD*MIS, a network informed ap­ ous boundaries and, as a result, create new possibili­ proach can be incorporated into STD prevention pro­ ties for disease transmission. Instead of dividing so­ gram activities. cial networks, programs can use social networking An example of such incorporation has been at­ methods to identify those individuals who hold influ­ tempted in an inner city area of Atlanta, Ga. with high ence and who can potentially act in partnerships with syphilis rates. A DIS team, spending approximately health professionals in disease prevention. 80% of its time in the field (compared to interviewing A more formal approach to social network analy­ infected persons in the clinic and then seeking the part­ sis has been shown to be very effective in reducing the ners), used network and ethnographic methods to iden­ incidence of disease transmission by targeting specific tify an interconnected group of over 300 persons with areas (Rothenberg, 1996b). However, it can be a very a six month syphilis incidence of 12.6% (Rothenberg, labor-intensive process and is recommended only if in press). By identifying such groups at risk, the field program staff are familiar with the techniques of data team is in a position not only to interrupt disease trans­ collection and evaluation and have the resources to mission but to predict and respond to changing dis­ process the information gathered. First, programs can ease trends. These approaches provide direct observa­ expand the scope of partners to include close friends, tions of behavior change in a community (e.g., acquaintances, persons within the same social group, adoption of condom use, limiting numbers of anony­ roommates, former or occasional sex partners, and mous partners, decreasing the frequency of sex and anyone else deemed at risk. Local protocol should dic­ drug partner change) (Rothenberg, 1995), and pro­ tate the exact criteria. Second, people identified would vide a built-in mechanism for appropriate targeting. be (cluster) interviewed to determine the appropriate­ Traditionally, public health has focused on specific ness of prophylaxis, to pursue further partners and behaviors or on some overall assessment of risk, which associates, to identify what other social groups may

Partner Services PS – 25 be involved, to determine the behaviors associated with As an example, the prevalence of Chlamydia the groups, and to gauge the strength of associations trachomatis infection in inner-city youth was measured within the social network. Care must be taken to as­ by collecting 486 urine specimens during a 20 month sure that there is no violation of confidentiality nor period (Rietmeijer, 1997). Specimens were collected the perception of violation. Subsequently, programs both in the field and in clinic settings. The study found can document what they have learned about individual that positivity rates were higher in the field than in the communities, with a focus on the mixing patterns, fre­ clinic facilities (11.9% vs. 4.4%). Ninety-seven per­ quency of partner change, and social hierarchy. Once cent of all infected patients were treated within eight these elements are understood and discussed by pro­ days of testing. Thus, screening can be done in non­ gram staff, it will be easier to tailor and implement traditional settings and still yield similar, if not better, disease control methods toward the specific dynamics results than screening done in standard clinic settings. of disease transmission within the social network. Considering the substantial numbers of asymptomatic Social network analysis, in essence, means reduc­ chlamydia infections in field-recruited male youths, the ing the emphasis on individuals and looking at the com­ large number of recent sex partners, and a reluctance monalities among individuals with a STD and their to seek clinic-based STD screening, it is doubtful associates. Experts believe that increased focus on STD whether, even with optimal access to STD treatment transmission analysis or intervention should be placed services, traditional clinic-based approaches will ever on the social network rather than solely on the indi­ bring the chlamydia epidemic under control vidual. It is widely thought that disease control meth­ (Rietmeijer, 1997). In this context, the use of non-in­ ods targeted to the general population may be less vasive screening methods embedded in targeted, com­ valuable than approaches that focus resources on im­ munity-level prevention programs has the potential to portant group structures (Rothenberg, 1996a). Re­ make significant contributions to STD control. searchers add that since some social network analysis Disease control efforts also have used targeted in the infectious diseases context may fall short in the screening to find otherwise unseen or undiagnosed dis­ area of sampling strategies and data collection, results ease. It continues to be a very effective way to locate a should be used to stimulate further research in this high percentage of new cases (Gerber, 1989). When area (Potterat, 1998). As a result, social network analy­ traditional means of disease control fall short, cluster­ sis can be seen as complementary to other models of ing others within the same social network of the in­ infectious disease prevention. fected patient and offering them testing can be ex­ tremely effective. In this setting, screening close social associates of infected patients is almost as effective as Recommendations screening actual partners. • Programs should establish strategies for find­ During the first half of 1990, traditional approaches ing at-risk persons not identified by an infected to the control of syphilis were found to be ineffective index case or partner. in slowing a syphilis epidemic (Mellinger, 1991). Per­ sons who were involved in the exchange of drugs or • Programs should evaluate or assess the social money for sex often could not or would not provide networks that influence disease transmission sufficient information about their sex partners. That in their area. prevented public health personnel from locating ex­ posed partners. As a result, alternative case-finding Targeted Screening and Field Testing methods were needed. Disease transmission was re­ Targeted screening can be defined as an activity to iden­ duced by using cluster interviewing to identify friends tify people with infection in a select group who are and associates at risk for syphilis and by setting up engaged in a behavior that puts them at greater risk targeted serologic screening for those identified and for infection. Field testing is when public health work­ for others engaging in high-risk sexual activity. This ers offer testing at non-clinic locations associated with process documented a 27% reactivity rate, with 3% known cases and their partners.

PS – 26 Program Operations Guidelines for STD Prevention of those newly infected diagnosed with either primary ners. However, delays between diagnosis and treatment or secondary syphilis. are not uncommon and often result in recurrences of Similarly, staff involved in a different syphilis epi­ transmission and reinfection. To prevent the uninten­ demic began to focus on identifying places associated tional transmission of disease, suggestions have been with cases and partners, instead of just on partner made to expand targeted testing in non- clinic settings. names (Hutcheson, 1993). They discovered 21 places Communities that have traditionally avoided clinical where affected people were most likely to meet sex care will be more likely to seek care in non-traditional partners. Subsequently, staff members familiar with settings if given the opportunity. Field screening will the community visited the sites and took over 200 become more practical with the increasing availabil­ blood samples that were tested for syphilis. Thirty- ity of convenient techniques for the detection of STD, one percent tested positive, and 17% were preventively such as urine testing. treated. Of those testing positive, 78% received ex­ While no one in the field of disease control is de­ amination and treatment, and a majority were found bating the usefulness of screening to identify undiag­ to have additional STD. It is important to note that in nosed disease, the common thought is that screening this case a combination of innovative, conventional, needs to target the highest prevalence areas to inter­ and cluster interviewing and investigation methods rupt core transmission and, in turn, reduce disease were used to effectively identify previously undiag­ rates. In general, STD prevention programs need to nosed syphilis cases. balance screening and DIS activity so that testing and Increased use of crack cocaine and the exchange of field activity are complementary. sex for money or drugs have been major contributors There is a strong movement to combine both field to the increased occurrence of syphilis in many areas and clinic screening efforts. Each acts as a bridge to throughout the country, affecting disproportionate the other. Field screening results in patients accessing numbers of people of color (Greenberg, 1992). Tradi­ clinical care, and clinical care plays a very important tional syphilis control programs usually offer a com­ part in disease control. Without traditional clinic bination of interventions, including serologic screen­ screening, communities risk missing cases of other ing of asymptomatic individuals, diagnostic testing of STDs, and reducing opportunities for such related pre­ individuals self-motivated by symptoms or by perceived vention activities as pregnancy testing, Pap smear risk, and DIS case management (Oxman, 1996b). To screening, risk-reduction counseling, HIV testing, hepa­ increase the effects on disease transmission, many pro­ titis B vaccination, and the initiation of contraception. grams have instituted targeted syphilis screening in areas connected with cases and their associates. In re­ Recommendations cent years, these targeted screenings have been pro­ vided for sex workers and their customers, and for the • Programs should target screening based upon drug (crack cocaine) dealers and crack users. Since program morbidity data, including informa­ those groups tend not to use traditional health care, tion on core transmission groups. screening should be offered in non-clinic settings such • Programs should use information from social as crack houses, bars, shelters, parks, jails, detention network analysis, if available, to assist in tar­ centers, back alleys, and other locations frequented geting both field and clinic screening efforts. by at-risk populations. Traditional control of gonorrhea and chlamydia has often been clinic based and relied on the treatment of Community Outreach self-referred, mostly symptomatic patients in combi­ An effective strategy in reducing disease transmission nation with the notification and treatment of their part­ is for DIS or other health professionals to develop re­ lationships with the social and sexual leaders (core transmitters) within any given population. This re­ quires that DIS build partnerships with people affected

Partner Services PS – 27 by STD. However, first it is necessary to establish an patients (Dunn, 1991) Presumptive treatment of close effective line of communication between those who associates and cluster suspects can be more effective analyze data and the field staff, so that programs (and than partner notification in controlling transmission particularly DIS) can identify the core transmitters of syphilis, especially in crack users, and the cost of within their areas, i.e., develop a picture of the socio­ this treatment may be negated by the cost savings of sexual networks and transmission dynamics (Potterat, the cases prevented. Others have suggested that clin­ 1992). Once trust is established between the commu­ ics consider gang boundaries and their effects when nity and DIS, it may be much easier to locate partners planning and implementing services. and associates, set up effective targeted screening, pro­ vide risk-reduction counseling, and perform cluster in­ Recommendations terviews. • Programs should build partnerships with STD Clinic Outreach people affected by sexually transmitted dis­ Some practical approaches that STD prevention pro­ eases to increase trust and to facilitate part­ grams can use to help control STD, especially in popu­ ner services and other interventions. lations who trade sex for money or drugs include: lo­ • Programs should assess which diseases are cating clinics close to high-incidence areas, adding being transmitted within their jurisdiction and evening hours, reducing waiting time, encouraging how, including partner selection patterns and community participation in targeting behaviors to be other risk factors for infection. changed, and immediately following up with infected

PS – 28 Program Operations Guidelines for STD Prevention Appendix PS–A INTERVIEW PERIODS BY DISEASE

Disease Code Disease Type Interview Period

200/300 Chlamydia/Gonorrhea Symptomatic—60 days prior to onset of symptoms through the date of treatment Asymptomatic cases—60 days prior to treatment

490 Pelvic Inflammatory Disease 60 days prior to onset of symptoms through the date of treatment

710 Primary Syphilis 90 days prior to date of onset of primary lesion through the date of treatment 720 Secondary Syphilis 6.5 months prior to date of onset of secondary symptoms through the date of treatment 730 Early Latent Syphilis* 1 year prior to start of treatment

900/950 HIV/AIDS 1 year prior to the date of positive test through the date of posttest counseling (extended interview period may be warranted by individual circumstances) 10-year interview period for current or any previous spouses

Note: Interview periods may be modified if a history of symptoms, a negative test result, or incidental treatment are documented. If symptom history is questionable, a maximum interview period should be used. If the patient claims no partners during the interview period, then the most recent partner before the interview period should be elicited and notified. * Many syphilis cases cannot be staged until after the case is closed. When the stage of syphilis is undetermined at the time of interview, a one-year interview period should be used. That is, STD prevention programs should initially interview a patient as early latent syphilis (730) and then, if appropriate, reclassify at case closure as late latent syphilis (745), latent syphilis of unknown duration (740), or not syphilis (serofast). To reclassify an early latent case as late latent or unknown duration, the following criteria must be met: no history of exposure to a known case of syphilis (as determined by interviewing the case and following up on sex partners), no history of symptoms in the last year, no history of a negative blood test in the last year, and no rise in titer of two dilutions or more. A case should be reported even if treatment is not verified.

Partner Services PS – 29 Appendix PS–B ORIGINAL INTERVIEW FORMAT

Introduction, Professional Role, and Purpose Medical History and Disease Comprehension The interviewer ensures that each patient is informed The interviewer initiates the interview so as to foster about the specific STD at issue (asymptomatic nature productive dialogue by: of disease, risk of re-infection, mode of transmission, • introducing himself or herself and anyone else course of disease, symptoms, sites of possible expo­ present, and explaining his or her professional role sure, seriousness of disease, and risk reduction), uses (avoiding titles such as DIS); visual aids to gather information on signs and symp­ • explaining the purpose of the session; and toms of the original patient and ask about other per­ • emphasizing the confidential nature of the interview, sons with symptoms (S-1), and gathers information defining confidentiality and its relevance to the about STD history and previous testing and treatment. patient's situation.

Disease Intervention Behaviors

Patient Assessment Assuring Examination of Partners and Suspects After eliciting the names of partners and other high- The interviewer maintains active, two-way client-cen­ risk persons (especially if pregnant), the interviewer tered communications throughout the interview by: pursues detailed identifying and descriptive informa­ • communicating at the patient's level of understand­ tion, making certain to get complete sexual exposure ing; data and nature of symptoms when appropriate. Note: • using open-ended questions; The same amount of locating and descriptive infor­ • using appropriate nonverbal communication; mation should be pursued on all partners and suspects, • using positive reinforcement; even if the DIS is aware of the named individual. • soliciting feedback; “Clustering” is the process of identifying people • listening effectively; and who may be indirectly associated with the infected • using plain paper to record interview notes (never patient and who may benefit from an examination, take official forms into the interview). even when they are not named as interview period partners. This is done by eliciting suspects during in­ Patient Concerns terviews with infected patients. While the number of The interviewer identifies and addresses the patient’s actual partners exposed during the critical period is concerns, determines reason for exam, and clarifies finite, the potential for clusters is almost limitless. patient’s concerns or misconceptions about the diag­ The following locating information should be pur­ nosis. sued when a partner or suspect is elicited:

• name, nicknames, and other aliases; Socio-sexual Information • dates and frequency of exposure; The interviewer uses open-ended questions to gather • address, phone and pager numbers; information about where the patient lives; telephone, • place and type of employment, trade, or school and cell phone, beeper number; alternative locating infor­ phone number; mation; who the patient is living with; employment; • personal appearance and description (including age recent travel; recreation; and social groups. Explain or date of birth); reasons for questions if patient shows signs of con­ • co-residents and others residing at residence; cern. • other person(s) who can provide locating informa­ tion or convey a message;

PS – 30 Program Operations Guidelines for STD Prevention ORIGINAL INTERVIEW FORMAT, continued

• hangouts, best places and times to encounter; Conclusion • previous place(s) of residence or employment; Before concluding the original interview, the inter­ • history of arrest or incarceration; viewer should: • other mailing address; and • map and directions, especially when no address is • clear up any remaining questions; known or there is patient uncertainty. • restate commitments (e.g., contract referral, risk reduction plan, referrals); The DIS recognizes and addresses problem indicators • plan for reinterview; and through a process of: • provide handouts (e.g., referrals, condoms, follow- • analysis; up appointments, pamphlets) • using the LOVER method (Listen, Observe, Verify, In accordance with local practices, the DIS should con­ Evaluate, and Respond); fer with the supervisor (or designated co-worker) be­ • assertive confrontation (without alienation); fore completing a clinic interview if: • tactful persistence; • timely uses of appropriate motivations, such as: • an unexplained exposure gap exists; - mode of transmission, • no source candidate has been elicited; - confidentiality, • information inconsistencies persist; or - asymptomatic nature of disease, • the DIS feels dissatisfaction or uncertainty regard­ - risk of re-infection, ing the results of the interview. - complications and consequences, - social responsibility, - higher chance of getting or giving HIV, and - pregnancy and children.

Negotiating a risk reduction plan STD prevention counseling should be incorporated into interviews. Prevention counseling with patients who are sexually active is likely to be more effective when the counseling skills and strategies are shaped to fit the individual’s needs. To ensure that STD prevention counseling is client-centered, the interview should be based on appropriate CDC standards for prevention counseling, a discussion of risk-reduction or harm- reduction strategies that the patient will be able to at­ tempt, and specific strategies to help the patient with making these changes.

Partner Services PS – 31 Appendix PS–C REINTERVIEW FORMAT

Introduction, Professional Role, and Purpose • Pursue a specific agenda based on the analysis of the original interview and the interim period. • Introduce (or reintroduce) yourself and anyone else • Analysis of the original interview: present. - Problem-solving analysis to motivate the patient • Explain your role if different from the original in­ effectively terviewer. - Identification of potential source candidates • Review confidentiality (if different DIS, emphasize - Identification of potential spread candidates that confidentiality is maintained). - Dispositions of previously identified partners or • Define the purpose of the session: suspects • to discuss problems with commitments made in the - Analysis of areas unexplored in the original inter­ original interview, view • to discuss new information learned about the patient’s infection. • Analysis of the interim period: - Locating problems - Partner and locating information validity. Patient Assessment - Results of cluster interview(s) Patient Concerns - Other incidental intelligence • Inquire about and resolve any of the patient’s con­ - Pursue S-2’s and S-3’s cerns during the interim period (possible reactions to the medication, compliance issues, etc.) Risk-Reduction Plan • Review the patient’s plan for preventing future STD/ Socio-sexual Information HIV exposures, as discussed in the original inter­ • Describe the importance of having accurate personal view. and medical information in resolving the patient’s • Engage the patient in a discussion on how their disease problems. behavior change plan has worked to date. • Address any conflicting locating or demographic • Support any positive changes that have occurred. information provided by the patient. • Discuss any barriers to behavior change that oc­ curred, and how to work around those barriers in Medical History and Disease Comprehension the future. • Review what the patient knows about the disease. • Review test results that have returned, and reinforce • Emphasize the infectiousness of the disease, the as­ the necessity to return for future test results. ymptomatic nature of the disease, and the severity of the disease. Conclusion • Confirm that the patient kept referrals made in the original interview. • Evaluate remaining patient needs or potential com­ • Pursue S-1’s based on the responsiveness of the pa­ pliance problems. tient. • Analyze case information for any inconsistencies, gaps, or missing information. • Confront any inconsistencies, and apply problem- Disease Intervention Behaviors solving approaches needed to resolve problems. Assure the Examination of All Partners • Reinforce any commitments made by the patient. • Stress the importance of all partners getting exam­ ined.

PS – 32 Program Operations Guidelines for STD Prevention Appendix PS–D CLUSTER INTERVIEW FORMAT

Introduction, Professional Role, and Purpose • Question the patient conversationally about where he or she lives; telephone number; alternative lo­ • Introduce yourself and anyone else present. cating information; living with whom: employment; • Explain your professional role (avoiding titles such travel; recreation; and social groups. Explain rea­ as DIS). sons for questions if patient shows signs of con­ • Explain confidentiality. cern. • Explain the purpose of the session: - to provide information about the disease to which exposed and the reason for treatment Medical History and Disease Comprehension - to provide information to help prevent future ex­ • Determine what the patient knows about the dis­ posures ease. - to help the patient know what to do if reexposed • Reinforce what the patient knows about the dis­ ease, and correct any misconceptions that arise. Patient Assessment • Present an individualized discussion, not a medical lecture. The interviewer maintains active, two-way client-cen­ • Discuss incubation and the natural course of the tered communications throughout the interview by: disease, mode of transmission, symptoms, possible • communicating at the patient’s level of understand­ sites of exposure, risk of re-infection, risk reduc­ ing; tion, and patient’s STD history. • using open-ended questions; • Pursue A-1’s based on the responsiveness of the • using appropriate nonverbal communication; patient. • using positive reinforcement; • soliciting feedback; Disease Intervention Behaviors • listening effectively; and • using plain paper to record interview notes (never Assuring Examination of Partners and take standard forms into the interview). Associates • Review confidentiality and the professional role of the DIS. Patient Concerns • Briefly review the patient’s comprehension of the • Identify and resolve any of the patient’s concerns disease and the modes of transmission. (why given treatment with a negative test; why talk • Define the significance of immediate partner refer­ with DIS if test is negative; confidentiality; time; ral, emphasizing that one or more may have an STD clinic experience; etc.). which would re-expose the patient. • Determine the content and emphasis of disease in­ • Establish that the referral will be done immediately tervention behaviors based on the patient’s attitudes and will be for everyone’s benefit. and needs. • Assess the patient’s response to the session thus far and determine the patient’s concerns regarding part­ ners. Socio-sexual Information • Determine the patient’s capability to participate in • Describe the importance of having accurate personal partner referral (if that option exists). and medical information in resolving the patient’s • Evaluate problems and select appropriate solutions. disease problems. Some specific motivational approaches to problem solving are:

Partner Services PS – 33 CLUSTER INTERVIEW FORMAT, continued

- prevention of reexposure to disease • Review the patient’s sexual and drug-related behav­ - potential of having asymptomatic partners iors and STD history from earlier in the interview, - risk of being asymptomatic if infected and engage the patient in a discussion regarding the - risk of complications if infected patient’s perceived risks for HIV and STDs. - inconvenience • Reinforce and support patient’s knowledge, actions, - concern about partners or social group intentions, and communications about current or - rapid examination reduces potential for spread future safer sex and other risk-reduction behavior - reduce the chance of complications by helping changes. now. • Negotiate a realistic and incremental plan for re­ ducing risks. • Gather the following information about each part­ • Help the patient identify possible barriers to behav­ ner: ior change, particularly condom use. - Name (including nicknames), address (including • Document what the patient feels is a reasonable, apartment number), telephone number, living ar­ attainable risk-reduction plan, and offer the patient rangements, work address and telephone num­ a copy. ber, age/race/sex/marital status, physical descrip­ • Offer the patient the opportunity to test for HIV. If tion, and other locating information the patient refuses the test, offer the facility’s HIV - Exposure information services in the future. • Pursue A-2’s and A-3’s (A-2’s will include the origi­ • Document the date and time for return appoint­ nal patient’s partners). ments for STD and HIV test results. • If tested, discuss the patient’s plan to cope while waiting for the test results. If the patient appears Risk-Reduction Plan not to have a support system, offer your office phone (This section shifts attention to the patient’s behaviors number and a hotline number as part of support that put him or her at risk for all sexually transmitted available during the waiting period. disease, and includes an HIV counseling session. These messages should be individualized and tailored to each Conclusion patient.) • Evaluate remaining patient needs or potential com­ • Point out that the patient can expose themselves to pliance problems. HIV or other STDs in exactly the same manner as • Reinforce any commitments made by the patient. this exposure occurred. • Redefine respective roles and referral procedures. • Determine what the patient knows about HIV and • Reinforce confidentiality. other STDs, and correct any misconceptions.

PS – 34 Program Operations Guidelines for STD Prevention Appendix PS–E LOT SYSTEM FORMS

The lot system includes the major analytical points (MAP) sheet, the lot folder status sheet, an original interview record (73.54), the original patient information sheet, the reinterview record, the cluster interview record, the syphilis case analysis sheet, and copies of any field records (73.2936) associated with the case.

Partner Services PS – 35 LOT SYSTEM FORMS, continued

PS – 36 Program Operations Guidelines for STD Prevention LOT SYSTEM FORMS, continued

Partner Services PS – 37 LOT SYSTEM FORMS, continued

PS – 38 Program Operations Guidelines for STD Prevention LOT SYSTEM FORMS, continued

Partner Services PS – 39 LOT SYSTEM FORMS, continued

PS – 40 Program Operations Guidelines for STD Prevention LOT SYSTEM FORMS, continued

Partner Services PS – 41 LOT SYSTEM FORMS, continued

PS – 42 Program Operations Guidelines for STD Prevention LOT SYSTEM FORMS, continued

Partner Services PS – 43 LOT SYSTEM FORMS, continued

PS – 44 Program Operations Guidelines for STD Prevention LOT SYSTEM FORMS, continued

Partner Services PS – 45 Appendix PS–F FIELD INVESTIGATIONS

It is the responsibility of the DIS to ensure that per­ • The DIS should prepare for field investigations by: sons who have or are at risk of acquiring a STD re­ a. arranging investigations by investigative or in­ ceive appropriate medical care at the earliest possible tervention priority; time. The use of the telephone for initial follow-up b. planning a route that addresses the greatest num­ activities can be an efficient use of DIS time, especially ber of investigative priorities in the most efficient when calls are made in the early morning or evening sequence; hours. Telephones, however, are not valuable for in- c. including lower priority field activities that are depth investigation and confronting highly sensitive near high-priority investigations; issues. Also be aware of caller ID and like technolo­ d. consulting the supervisor on the potential for gies, as they may compromise confidentiality. pooling work when distant locations are in­ While the field investigation may require a greater volved; initial investment of DIS time, it is the most effective e. arranging work in the planned sequence at the follow-up method and frequently the most efficient as front of the investigative pouch; and well. All field investigations should be conducted in f. preparing all referral notes before leaving for the unmarked vehicles. field to improve efficiency and alertness. It is incumbent upon the DIS to make the most effi­ • Before leaving for the field, the DIS should assemble cient use of field time and to conduct each field inves­ standard materials and supplies, including: tigation thoroughly to make the most of this activity. a. investigative pouch; • To avoid duplication of effort and to expand locat­ b. maps; ing information, the DIS should perform a record c. venipuncture kit; search immediately after initiating an investigation d. writing materials (with spare pen); by reviewing available resources, including: e. referral forms with envelopes; a. open field investigation and case interview files; f. business cards; b. closed field investigation and case interview files; g. change for parking meter and public telephone c. medical records; (and telephone credit card, if available); d. telephone white and yellow pages; h. identification card; and e. directory assistance; i. materials needed to perform field interviews, e.g., f. cross directory; and visual aids, consent forms. g. computer locator resources. • The DIS should record the beginning and ending The record(s) search and results should be completely odometer readings and the distances between stops, documented on the back of the field record. as needed for travel reimbursement.

• The DIS should begin investigative action on prior­ • Before leaving the car for a field visit, the DIS should: ity follow-ups within one workday of assignment a. review the field record and memorize all perti­ or of DIS initiation. nent data to establish the precise objective(s) of the visit; • When initial telephone attempts fail to reach the b. observe the environment and anticipate obstacles individual sought, or when the patient does not fol­ to the investigation; and low through with a commitment, the DIS should c. stow the pouch, confidential forms, and valu­ make a field visit within one working day or as di­ ables in a secure place. rected by supervisor.

PS – 46 Program Operations Guidelines for STD Prevention FIELD INVESTIGATIONS, continued

• When there is no response at the door of the indi­ d. establishing rapport and demonstrating concern; vidual sought, the DIS should check for occupants e. informing the patient of the STD at issue and of at the side and back of the building when the way their risk status; is not barred and it appears safe to do so. f. clustering the patient for other high-risk persons; and • When the individual sought is not found, the DIS g. referring the patient for the most immediate ap­ should attempt to confirm the locating information propriate medical attention, which may include in the initial visit by exploring all reasonable sources obtaining consent and collecting a specimen for of information, such as: testing. a. other persons encountered at the address; b. names on mailbox; • When the individual wants care from a non-health c. neighbors, apartment managers, building super­ department provider, the DIS should arrange or con­ intendents; firm the appointment personally. The DIS should d. postal employees and other delivery personnel; tell both the health provider and the individual of e. local business people; and the need for recommended testing, counseling, and f. children in the area. treatment, and determine when the test results will be available. The DIS should try to get a signed re­ • The DIS should gather patient locating informa­ lease of information form from the patient, so that tion from sources in a manner which serves to test results and treatment can be confirmed. improve upon the original data provided, includ­ ing previously unknown information such as: • Even when the individual sought is not found, the a. full name and physical description; field visit offers many advantages that can enhance b. precise address, including apartment number; disease intervention, such as: c. identity of co-residents; a. information about the individual’s living situa­ d. telephone number; tion, lifestyle, habits, or about the identity of co­ e. type and place of employment; habitants or co-residents, etc., may be gained, f. hours and habits; along with additional locating information; g. hangouts and associates; b. the DIS can leave a sealed referral notice that h. description of individual’s car; and directs the individual to the first clinic session i. where the individual can be found now. available; c. other high-risk persons may be identified; and, • When locating information appears invalid, the DIS d. the validity of the provided locating information should transpose house and street numbers, etc., can be determined. and checks similar locations in the immediate vi­ cinity. • When the individual sought is not encountered at a confirmed place of residence, the DIS may leave a • When the individual sought is encountered in the referral notice in a sealed envelope marked “per­ field, the DIS should convey a sense of urgency and sonal” or “confidential.” The DIS may add a per­ motivate the patient to participate in the disease sonal note of urgency to the form. Referral notices intervention process by: may be left by the DIS with co-residents, building a. establishing the identity of the patient; managers, employers, or under the door or in any b. engaging the patient in a private conversation; area where the referral is protected and not acces­ c. identifying self and conveying the reason for visit; sible to children or casual visitors. Referral notices

Partner Services PS – 47 FIELD INVESTIGATIONS, continued

are not placed in or affixed to any mail box (U.S. of the information at the first reasonable opportu­ Postal Service Code 1702, 1705, 1708, and 1725). nity in order to correct or to expand locating data. Sources to contact include: • The DIS should not leave a third referral notice at a. the patient or others involved in a case; the same address except with supervisor’s consent. b. other case managers; • When in a safe location, the DIS should document c. health care providers; and the results of the field investigation. The following d. Interstate Transmission of STD Intervention In­ information should be legibly, accurately, and con­ formation desk (according to established local cisely documented on the back of the investigative procedures) form with the use of accepted abbreviations and • When there is no direct avenue to correct inadequate symbols: locating information, the DIS should discreetly ac­ a. date and time of day; cesses other agency resources, such as: b. type activity (e.g. FV=field visit); a. Department of Motor Vehicles; c. persons encountered; b. Postal Service; d. results of investigation, which may include next c. utilities; planned action (date and type); d. Public Assistance; e. referral specifics; and e. local schools; f. directions for difficult-to-find locations, when ap­ f. trade unions; propriate. g. law enforcement (jail rosters); • If practical, before returning to the office from dis­ h. voter registration; tant locations, the DIS should contact the supervi­ i. tax appraisal office; sor (or other designated team member) by telephone j. fire department (directory/department of streets); to inquire about emergent needs to which she or he k. other health department programs (e.g. family should attend before returning. planning, WIC, TB, etc.); and l. other community resources (e.g., hospitals, • The DIS should follow through on all commitments CBOs, etc.). and pursue new information elicited during the course of investigations, as follows: • When an investigation stalls, the DIS should notify a. confirms appointments made and kept (within the supervisor or appropriate case manager at the one working day); earliest reasonable opportunity (not to exceed 72 b. re-initiates action within one working day when hours). Supervisor’s approval is needed to close commitments fail; and, unsuccessful investigations. c. pursues new locating information within one • The DIS should complete and submit all assigned working day. work to his or her supervisor before taking planned • When the original information fails to locate the leave. individual, the DIS should seek to contact the source

PS – 48 Program Operations Guidelines for STD Prevention Appendix PS–G INTERSTATE TRANSMISSION OF STD INTERVENTION INFORMATION

Basic Policy low for flexibility, programs should assume that man­ agers in other areas are exercising appropriate pro­ The Interstate Transmission of STD Intervention In­ fessional judgment when requests for follow-up are formation is the system that oversees the transmission made. Therefore, the receiving area should accept of STD intervention information among project ar­ these follow-up requests and act upon them without eas. Success of the system depends on the willingness challenge. Questionable records should be brought of each program manager to take the steps necessary to the attention of a supervisor. If it appears that ar­ to assure that its provisions are observed and to hold eas are overloading the system with questionable re­ one another accountable when deviations occur. While quests, program managers are encouraged to discuss these guidelines are designed to support and, where the issue with their counterparts in other program necessary, refine or clarify the process and procedures, areas. project areas should review their protocols and pro­ The following categories of partners and individu­ cedures to ensure that they specify how to handle in­ als are considered high priority: coming and outgoing intervention requests. In review­ ing or developing these protocols and procedures, • Women who are known to be pregnant and ex­ programs are encouraged to consider these national posed to confirmed infectious syphilis, gonorrhea, guidelines in order to ensure consistency with respect chlamydia, or who have a reactive test for HIV. to transmission of STD information between jurisdic­ • Women or infants with reactive prenatal or post­ tions. Investigations should be conducted in accor­ partum serologies and unknown treatment status. dance with local protocol, with respect to contacting • Persons with positive tests for or symptoms of partners outside your jurisdiction. There are situations gonorrhea, chlamydia, syphilis, and with unknown where local protocol will specifically permit or pro­ treatment status. hibit cross-jurisdiction investigations. Disease preven­ • Persons with positive tests for HIV (Not all areas tion will be facilitated by the confidential sharing of will investigate HIV. If your area investigates HIV information on STD cases, partners, suspects, and as­ positives, then you should initiate an out-of-juris­ sociates between jurisdictions. diction HIV positive. The receiving area will de­ All requests received by an area for conducting an termine whether to investigate based on local poli­ interstate STD investigation, interview or counseling cies and priorities). session, reinterview, etc., should be accorded at least • All partners who could be incubating disease be­ the same priority as the same program activity initi­ cause of a recent exposure to an infectious indi­ ated within the receiving area. It is suggested that the vidual. receiving area process cases from other areas, even if Areas with staff, workload capability, and desire to the program area does not process these same type of follow persons exposed to diseases beyond the nor­ cases for patients in its own jurisdiction. To the extent mally prescribed periods should make this known in possible, information on sex partners that is transmit­ writing to other program areas. High-priority per­ ted should focus on disease intervention priorities. Pro­ sons are those about whom the program has suffi­ gram areas should review the information carefully cient information to indicate that they may have been before transmitting information about partners or in­ exposed to an infectious person, or those who the dividuals with a last exposure date that represents a program has reason to believe may be infected and minimal likelihood of disease intervention and, if such that locating them would prevent the further spread a request is made, should explain the reason for the of disease. request. While each case is unique and rules must al­

Partner Services PS – 49 INTERSTATE TRANSMISSION OF STD INTERVENTION INFORMATION, continued

Field Records Military Patients

Field records (FR) that are initiated by a program area Program managers are encouraged to work closely with that are to be transmitted for investigations out of ju­ military installations in their jurisdictions to ensure risdiction should be as accurate and complete as pos­ that the military understands these guidelines for trans­ sible, and should at a minimum include the following mitting information on persons initiated during the information: course of their STD investigation, providing that no other system has been established. Any domestic mili­ • For sex partners, suspects, or associates, a complete tary installation that initiates STD intervention infor­ identification and physical description (name, sex, mation on civilians for investigation outside of its ju­ age, weight, height, complexion, ethnicity, etc.) as risdiction should forward the information through the well as exposure dates, test results, and basis for appropriate state control point. The STD prevention the diagnosis of the original patient to whom the program should review the information for appropri­ partner, suspect, or associate is linked, if applicable. ateness and comprehensiveness then transmit appro­ • At least two items of locating information (home priately. Program managers should discourage mili­ address and telephone number are considered as one tary installations from sending investigative item). Other locating information could include information directly to the Centers for Disease Con­ place of work; work telephone number; beeper or trol and Prevention (CDC). cell phone numbers; friend or relative or other per­ son known by the person; hangouts; make, model, Corrections color of car, etc. Program managers are encouraged to work closely with • When a male partner is known to have the same prisons, local jails, and juvenile detention centers. See name as his father or son, care should be taken to the chapter on Special Emphasis for a detailed discus­ ensure that correct designations such as “Jr.” or sion of corrections issues. “Sr.” are communicated to help avoid the potential for confidentiality problems. Transmission and Disposition Procedures When field records that are transmitted out of juris­ diction do not include any of these provisions, the ini­ When possible, program areas should telephone state tiating area should include the reason for the omis­ control points in the receiving areas with all informa­ sion. An acceptable reason for omitting information tion on persons (see the following appendix for cur­ should not include failure on the part of the initiating rent list of interstate control points). When telephon­ area to pursue the information. If the reason provided ing or transmitting STD intervention information, by the initiating agency is acceptable, receiving areas strict rules of confidentiality must be followed. The should accept and proceed with the individual requests. person responsible for transmitting that information When an acceptable reason for omission of information between control points should observe confidentiality is not given, receiving areas may demand one or suspend by affirming that the control point called is the cor­ further action until an acceptable reason is given. Pro­ rect one, and by receiving assurance that the person gram areas should exercise sound judgment when mak­ receiving the information is authorized to accept STD ing a decision to reject or suspend an investigation on related intervention information. This assurance should technicalities since the primary concern for all areas come before the discussion of any STD intervention should be the health of the individual and the preven­ information. If either the initiating or receiving area is tion, or further spread, of disease in the community. concerned about the confidential nature of the call,

PS – 50 Program Operations Guidelines for STD Prevention INTERSTATE TRANSMISSION OF STD INTERVENTION INFORMATION, continued

communication should cease until such time as con­ position. In those instances when a “return disposi­ fidentiality can be assured by both parties. The initi­ tion” is desired, initiating areas should indicate “re­ ating area should keep a record of the date, time of turn disposition requested” on the field record. Re­ day, and name of the individual receiving the STD quests for “return dispositions” on low priority information. Confirmation of telephoned information reactors should be kept to a minimum. Sex partner can be mailed if requested by the receiving area. information on uncomplicated gonorrhea and chlamy­ Before telephoning or mailing STD investigation dia should be written on a field record and exchanged information, it would help the receiving area if the by mail or phone. As with low priority reactors, “re­ initiating area checked zip code directories and long turn dispositions” should not be routinely requested distance telephone information to verify the spelling unless there is a compelling reason. Areas requesting of the name and address and that the address and “return dispositions” should follow procedures previ­ telephone number exist. Initiating areas should let ously described in these guidelines. receiving areas know if these verification activities were conducted and the results of those activities. Maps Priority STD intervention information, and infor­ mation on individuals on which a “return disposi­ A map showing where an individual may be found tion” is requested should be recorded on the Field might prove critical to the success of an investigation. Record, CDC 73.2936S, or a similar local form by Since it could prove difficult to communicate the de­ the receiving area. Field record control numbers (pre­ tails of a map orally to the investigating area, the ini­ printed number on a field record) and disposition due tiating area should prepare the field record with the date should be exchanged between initiating and re­ map and mail it to the investigating area. If the re­ ceiving areas. This information will be used by both quest is a priority investigation, the investigating area areas to track the investigation request. The disposi­ should be telephoned and alerted to expect the mailed tion due date is generally established as 14 calendar field record. Program areas should also consider faxing days from the date of receipt. the information if it can be assured that the faxed in­ Low priority reactive serologic tests for syphilis formation would be secure and confidential. (STS) are those tests that would not receive high pri­ ority attention within an area. Low priority requests Record keeping should be written on Field Records and exchanged by mail. The information should be exchanged even All areas should develop a record keeping system that if these low priority reactors would be administra­ will enable them to efficiently conduct the disease in­ tively closed in the initiating area, or if they could be tervention outreach transmittal component of the in­ closed through a record search by the initiating area. terstate procedures. In most cases, the system will con­ A reason for exchanging the information is to give sist only of a file for field records or a log to record the receiving area test results that could be used for transmittal information. Simplicity is the key when updating records. If a record exists on the reactor in record keeping systems are established by areas. For the initiating area, and if local policy permits, that example, a system could be as simple as filing all in­ information should also be included on the field coming and outgoing forms together chronologically record when transmitted out of jurisdiction. by “disposition due date.” While the system should Initiating areas should not routinely expect or re­ be specific to an area, each should have a method for quest a “return disposition” on low priority reactors keeping up with overdue follow-up requests. Overdue unless there is a compelling reason to ask for the dis­ follow-up requests are those incoming and outgoing

Partner Services PS – 51 INTERSTATE TRANSMISSION OF STD INTERVENTION INFORMATION, continued

requests that have been open for more than 14 days, tion is currently under review and is expected to be or that are beyond the “disposition due date.” Inves­ revised. While this policy is being reviewed, program tigating areas have the responsibility to call initiating areas should continue to use current polices that have areas and inform them of the status of the investiga­ been established in their areas for handling interna­ tions if they are still open beyond the “disposition due tional and military transmission of non-HIV/STD in­ date.” Whenever an initiating area obtains new or clari­ formation. The CDC involvement in the transmission fying information on individuals being followed out of international STD information is minimal and will of jurisdiction, every effort should be made to inform be done only on a case-by-case basis. Since CDC has the area. limited involvement in the transmission of other inter­ national STD information, program areas are encour­ aged to counsel patients to self-refer or notify their International Transmission of STD Information partners who reside in foreign countries and who may The CDC policy and procedure for the international have been exposed to a disease. and military transmission of non-HIV/STD informa­

PS – 52 Program Operations Guidelines for STD Prevention Appendix PS–H SKILLS INVENTORY

Interviewing Skills Individual Feedback Record

Interview date______

How did the Disease Intervention Specialist perform in the following areas?

Write N/O (not observed) in the satisfactory column if the interview did not present an opportunity to observe the skill.

COMMUNICATION Needs Improvement Satisfactory Excellent

1. Demonstrates professionalism

2. Establishes rapport

3. Listens effectively

4. Uses open-ended questions

5. Communicates at the patient's level of understanding

6. Gives factual information

7. Solicits patient feedback

8. Uses reinforcement

9. Uses appropriate nonverbal communication

Observations ______

Recommendations ______

Partner Services PS – 53 SKILLS INVENTORY, continued

PROBLEM SOLVING Needs Improvement Satisfactory Excellent

10. Recognizes verbal problem indicators

11. Recognizes nonverbal problem indicators

12. Verifies the meaning of recognized problem indicators

13. Assertively confronts problems communicated by patients

14. Resolves patient problems

15. Uses STD motivations

16. Motivates clearly and convincingly

17. Emphasizes confidentiality

ANALYTICAL CAPABILITIES Needs Improvement Satisfactory Excellent

18. Computes and uses interview periods

19. Recognizes exposure gaps

20. Determines accurate source/spread relationships

21. Determines investigative priorities

22. Recognizes discrepancies in patient responses

Observations ______

Recommendations ______

PS – 54 Program Operations Guidelines for STD Prevention SKILLS INVENTORY, continued

DISEASE INTERVENTION BEHAVIORS Needs Improvement Satisfactory Excellent

23. Emphasizes sex partner referral

24. Tactfully persists to identify all at-risk sex partners

25. Pursues detailed locating/identifying information on sex partners

26. Emphasizes appropriate risk reduction behaviors

27. Conveys a sense of urgency

28. Establishes specific contracts and coaches patients

29. Pursues timely reinterviews with a plan

Observations ______

Recommendations ______

Partner Services PS – 55 SKILLS INVENTORY, continued

Field Activity One Day Skills Feedback Record

Field investigation date ______Number of persons investigated ______

How well did the Disease Intervention Specialist perform in the following areas?

Write N/O (not observed) in the satisfactory column if the investigation did not present an opportunity to observe the skill.

DISEASE INTERVENTION BEHAVIORS Needs Improvement Satisfactory Excellent

1. Assume the responsibility for the ultimate success of assigned investigations, regardless of co-worker participation in the referral process

2. Utilize resources effectively in plan­ ning and executing referrals

3. Recognize investigative priorities

4. Select appropriate referral methods

5. Take prompt initial action on priority investigations and promptly follow up when a person defaults on a referral

6. Demonstrate timely, persistent, and imaginative action required to move a stalled investigation

7. Demonstrate discretion and judge­ ment in the use of the telephone as an investigative tool

8. Confidentially and professionally manage circumstances that are obstacles in any investigation

9. Motivate people to come in promptly

10. Document the investigative activities completely and accurately

Observations ______

Recommendations ______

PS – 56 Program Operations Guidelines for STD Prevention SKILLS INVENTORY, continued

Definitions of Elements in Interviewing and Field Activities Skills Inventories

Needs Improvement 2. Establishes rapport Should be checked anytime the supervisor makes a Displayed respect, empathy, and sincerity to pa­ constructive recommendation that the DIS is to fol­ tients, e.g., introduced self, was polite, used plau­ low. sible and factual motivations and sought out and dealt with patient’s concerns. Excellent 3. Listens effectively Should be checked anytime the supervisor compliments Did not interrupt patients unnecessarily. Responded the DIS on a specific aspect that is clearly above the to patients’ questions appropriately and gave evi­ expectations for satisfactory performance. The super­ dence that important information was noted, such visor should be able to articulate exactly what led to as following up with additional questions or men­ this rating. tioning specifics in the post-counseling critiques. Check marks should be placed in the center of the appropriate box so that the DIS does not interpret per­ 4. Uses open-ended questions formance as almost satisfactory or excellent. If the su­ Phrased questions (beginning with who, what, pervisor is unable to observe a particular skill element when, where, why, how, tell me) to stimulate mean­ for any reason, N/O should be placed in the Satisfac­ ingful responses. Used open-ended questions, par­ tory box. An effort should be made to create an op­ ticularly where the patient might avoid giving can­ portunity for observation before the completion of the did answers by using negative or condescending next skills inventory. Supervisors may role-play to find responses. out whether the DIS makes appropriate responses but 5. Communicates at the patient’s level of should see how the DIS performs with an actual pa­ understanding tient before making a determination on the skills in­ Avoided technical terms, jargon, or words deemed ventory. beyond the comprehension of patients. Clearly ex­ plained necessary medical and technical terms and Interviewing concepts.

Satisfactory ratings indicate that the Disease Interven­ 6. Gives factual information tion Specialist consistently: Demonstrated an accurate knowledge of STDs. Cor­ rected patient’s misconceptions and provided com­ 1. Demonstrates professionalism prehensive disease information. Avoided extrane­ Displayed self-confidence, competence, dependabil­ ous information. ity, preparation, integrity, and appropriate serious­ ness. Convincingly conveys the capability (exper­ 7. Solicits patient feedback tise, training, knowledge, devotion) and commit­ After delivering messages, asked appropriate ques­ ment to maintaining a patient’s confidentiality. tions to determine whether patients understood and Smoothly preempts a patient’s likely concerns about how they intended to comply. Used content (rephras­ confidentiality and effectively reinforces it when dis­ ing what the patient said) and feelings (interpreting cussing sex partners and when resolving a patient’s how the patient felt) responses to verify patients’ special problems. Was nonjudgmental and objec­ meanings. tive about patient’s behavior and conveyed toler­ ance for patient’s lifestyle.

Partner Services PS – 57 SKILLS INVENTORY, continued

8. Uses reinforcement 15. Uses STD motivations Sincerely complimented or acknowledged pa­ Demonstrated an understanding of STD motiva­ tients after hearing intentions to use, or descrip­ tions including confidentiality, reinfection, spread tions of, healthful behaviors. Used smiles and and reinfection, responsibility to others, self-sur­ affirmative nods and words effectively. vival, potential hassles, and disease complications.

9. Uses appropriate nonverbal communication 16. Motivates clearly and convincingly Conveyed sincere interest by maintaining eye con­ Created a sense of urgency. Used visual aids to tact, minimizing physical barriers, and leaning enhance motivations. Tailored motivations appro­ toward the patient. Avoided negative nonverbal priately to patient and problem. signals that communicate anger, surprise, distaste, 17. Emphasizes confidentiality or fear of contagion; avoided finger shaking, arm Gave examples of how the system works and em­ crossing, and expressions of disinterest. Nonver­ phasized the discreet approaches used by the pro­ bal communication complemented the verbal gram. Demonstrated what would be said to the communication. partner (suspect, associate) when confidentiality 10. Recognizes verbal problem indicators seems a particularly sensitive issue or when the Recognized verbal indicators by responding when partner seemed not to understand. patients asked direct questions, made direct con­ 18. Computes and uses interview periods tradictions, expressed or reiterated concerns, hesi­ Used correct periods according to program crite­ tated, or expressed misunderstandings. ria and communicated the time period to the pa­ 11. Recognizes nonverbal problem indicators tient, using an understandable beginning date. Recognized problem indicators either by respond­ 19. Recognizes exposure gaps ing to patient’s eye contact, body language, pos­ Identified gaps when they occurred during inter­ ture, or other nonverbal gestures and behaviors views and confronted patients about them appro­ or by discussing observations after the interviews. priately. 12. Verifies the meaning of problem indicators 20. Determines accurate source/spread relationships Asked patients directly about problem indicators, Used case management and analysis methods to using techniques such as soliciting feedback (de­ accurately determine source/spread relationships. scribed above). Accurately charted lesion histories, lesion loca­ 13. Assertively confronts problems tions, exposure data, and ghosted primary lesions In confronting problems, demonstrated self- on the infectious syphilis epidemiologic analysis confidence, appropriate body language and eye chart. contact, and communicated his or her position 21. Determines investigative priorities while still maintaining rapport. Given a set of field investigation forms, was able 14. Resolves patient problems to set priorities according to the criteria set by Solved typical STD patient problems such as those the program or the course. concerning marital situation, confidentiality, guilt, 22. Recognizes discrepancies in patient responses embarrassment, fatalism, homosexuality, special sex Detected and appropriately challenged discrepan­ partners, parents, employers, hostility toward sex cies such as history inconsistent with medical facts, partners or clinic personnel, and apathy about infections.

PS – 58 Program Operations Guidelines for STD Prevention SKILLS INVENTORY, continued

social and sexual history inconsistent with lifestyle 28. Establishes specific contracts and coaches patients described by patient, and contradictory exposure Made it clear to patients the time period during dates. which they could refer partners before the DIS would take on that responsibility. Pointed out the 23. Emphasizes sex partner referral pros and cons of patient referral when the patient Regardless of other issues, ensured that appropri­ selects that option. Helps patients know what to ate time, attention, and importance were given to say when confronting their partners and, when sex partner referral. necessary, made suggestions as to how to direct 24. Tactfully persists in identifying sex partners the conversation. Within reason, and in a manner that maintained 29. Pursues timely reinterviews with plan rapport, continued to probe for additional sex Scheduled and performed reinterviews on the ba­ partners (including same sex) after the patient in­ sis of the knowledge gained from the analysis of dicated that all had been discussed. interviews and investigations. Prepared written 25. Pursues locating and identifying information agendas specifying the points to be pursued in Gathered detailed locating information, including reinterviews. Performed reinterviews as quickly as at least two items (home address and telephone possible when major problems arose (e.g., number count as one item). Obtained basic iden­ unlocatable partners, no eligible source candidates, tifying information (i.e., age, race, sex, marital or new information indicating unidentified part­ status, height, weight, and complexion) and pur­ ners). sued distinguishing characteristics (i.e., hair color and style, facial hair, glasses, scars, physical im­ Field Activities pairments, and distinctive clothing).

26. Emphasizes risk reduction behaviors, as 1. Assumes responsibility for success of investigations appropriate Displayed a sense of obligation for the successful Time permitting, used an interactive approach to resolution of any investigation in which the DIS discuss (other than sex partner referral) additional played a role. Assumed responsibility for initiating individualized intervention behaviors with patient, the investigation (gathered identifying and locating including taking medication, returning for follow information and prepared the 73.2936 completely up tests, reducing risk, and responding to disease and legibly) and followed through with prompt, per­ suspicion. Discussed a risk reduction plan with sistent, imaginative, assertive, and sensitive appli­ each patient to encourage behavioral change when cation of techniques and the complete, legible docu­ applicable. mentation of all activities. Accorded the same importance and applied the same effort to investi­ 27. Conveys a sense of urgency gations initiated by others as to those initiated by Communicated to patients by word and deed that himself or herself. the spread of infection and the development of symptoms and complications can be averted only 2. Utilizes resources effectively by immediately notifying and referring others who Used standard locating resources before and dur­ are at risk. ing investigations (e.g., telephone book, cross di­ rectory, closed 73.2936s, clinic medical records, utility companies, public assistance files, driver’s

Partner Services PS – 59 SKILLS INVENTORY, continued

license bureau, telephone company security, neigh­ layed or resolved inappropriately because of pro­ bors, children in vicinity, neighborhood businesses, crastination, timidity, the premature concession of zip code directory, and long distance telephone in­ defeat, or the unimaginative use of resources or in­ formation for investigations sent out-of-area). vestigative techniques. Used alternative avenues for locating or notifying when primary approaches 3. Recognizes investigative priorities seemed unproductive or likely to violate confiden­ Observing program guidelines, routinely and ap­ tiality. The supervisor was involved only in legiti­ propriately determined high and low priority in­ mately difficult cases or when information was vestigations and organized field activity accordingly. needed. Explained logically to supervisor when lower pri­ ority work was done before higher priority work. 7. Demonstrates discretion in use of the telephone as an investigative tool 4. Selects appropriate referral methods When using the telephone to expedite an investiga­ Selected methods that ensured the earliest exami­ tion, initially tried to motivate subjects to come in nation while preserving confidentiality. Mailed let­ or to meet face-to-face in a confidential setting while ters only with supervisor’s approval in conjunction revealing as little sensitive information as possible, with field or telephone referrals or after such refer­ including exposure to an STD. Before discussing any rals had failed. Left referral cards only after a rea­ sensitive information, took all reasonable steps to sonably exhaustive investigation had failed to es­ verify that the person on the line was the subject of tablish contact. Unless with supervisor’s approval, the investigation. referral methods that failed once were not repeated (e.g., calling the same number at the same approxi­ 8. Confidentially and professionally manages obstacles mate time of day, leaving referral cards at the same Was able to think on his or her feet when confronted address). with obstacles to an investigation (i.e., parents, sib­ lings, spouses, roommates, school officials, bartend­ 5. Takes prompt action on initial and follow-up in­ ers, coworkers, or employers who have blocked no­ vestigations tification efforts or whose curiosity could threaten Verified the locating information for priority inves­ confidentiality unless handled effectively). Provided tigations within 24 hours after assignment. Con­ subjects of investigation with believable covers when sulted private physicians within 24 hours after re­ a third party had to be circumvented to reach the ceiving follow-ups from them. Intervals between intended person. Gave logical reasons for the need action on priority investigations did not exceed more for face-to-face meetings in confidential settings. than one working day except in circumstances Gave no clues to people who have no need to know deemed justifiable by the supervisor. Referrals were the identity of patients or the purpose of field in­ made for next working day. Followed up by the vestigations. next day on anyone who failed to keep an appoint­ ment. 9. Motivates people to come in promptly Created a sense of urgency about examinations 6. Demonstrates timely, persistent, and imaginative through factual information and persistence. Did action to move a stalled investigation not imply that persons who had been notified were With investigative workload and other professional infected. Verified whether people were likely to keep obligations considered, took all reasonable steps to appointments by exploring transportation plans and ensure that assigned investigations were resolved other conflicts such as job and child care. During promptly and that they were not unnecessarily de­ field visits, updated locating information such as

PS – 60 Program Operations Guidelines for STD Prevention SKILLS INVENTORY, continued

home and work telephone numbers and addresses, 10. Documents investigative activities and other methods of getting back in touch. In or­ Documented each investigative step immediately der to allay patient’s fears (about embarrassment, after the activity took place and reflected the date, parking, delays, etc.), explained how the appoint­ time, and nature of the activity according to pro­ ment is likely to go. tocols. Documentation was sufficiently legible, co­ herent, and accurate to permit the reconstruction of all activities so that a co-worker could com­ plete any investigation without duplicating steps.

Partner Services PS – 61 Appendix PS–I “EVALUATION TABLES”

Table 1. Comparison of risk factors among partners, by disease outcome.

Risk behavior # of partners # of partners # of partners total # of discussed in testing positive testing negative initiated not tested partners initiated original interview for STD of index for STD of index patient patient

Sex for drugs

Yes

No

Multiple Partners

Yes

No

Table 2. Partner Services Outcomes, by Disease and Time Period

For all original patients that are interviewed Disease (Fill in):

Time Period # of original Number of sex partners (and needle-sharing, if applicable) patients interviewed elicited initiated out of located located and located and not jurisdiction and not notified by notified by located notified provider provider; (Previously but refused accepted treated) services services

January

February

PS – 62 Program Operations Guidelines for STD Prevention Appendix PS–J GLOSSARY OF TERMS ASSOCIATED WITH PARTNER SERVICES

Associate—Individuals initiated for field follow-up Contract Referral—Notification strategy in which the from cluster interviews. Associates are named by per­ provider elicits locating information, negotiates a time sons not infected with the disease in question. Associ­ frame for the infected patient to notify his or her part­ ates can fall into one of three categories: A-1 People ners of the possibility of their exposure, and refer them with symptoms of the disease. A-2 Unnamed partners to appropriate services. If the patient is unable to do of an infected patient. A-3 Others who might benefit so within an agreed-upon time period, the provider from an examination. See Cluster Interview, Social has permission to notify and refer the partner(s). Network Analysis. Disease Intervention—The process of stopping the Case Closure—A case is closed when the responsible spread of a disease and the complications of disease. DIS and the next-level supervisor agree that all rea­ sonable steps to intervene in the disease process have Field Investigation—The process of informing infected been completed and documented. persons and their partners of their status by going into the community to find them and to motivate them to Case Management—The systematic pursuit, documen­ accept medical attention and risk reduction counsel­ tation, and analysis of medical and epidemiologic case ing. information that focuses on opportunities to develop and implement timely disease intervention plans. Incubation Period—The incubation period begins with the date of infection and ends with the appearance of Client—An individual who seeks HIV prevention coun­ signs or symptoms. seling and testing services. Index Patient—A patient newly diagnosed with a STD Client-Centered Counseling—Counseling conducted in and who is a candidate for interview by trained DIS. an interactive manner, responsive to the individual The term index patient is often interchanged with origi­ patient’s needs and requiring an understanding of the nal patient. Typically, the index patient is the first in­ unique circumstances of the patient including behav­ fected person identified in a lot involving multiple in­ iors, culture, knowledge, and social and economic sta­ fections. tus. Interview Period—The interview period covers the time Cluster Interview—An interview of an uninfected per­ from the earliest date a patient could have been in­ son conducted to gather information about previously fected to the date of treatment; it always includes the unnamed or uninitiated partners of known cases and maximum incubation period and the duration of symp­ about individuals who may be in need of an STD ex­ toms. Thus, it includes the time during which a pa­ amination. The cluster interview is conducted with tient could become infected or spread the disease to partners, suspects, or associates of known cases. others.

Confidentiality—The concept that information will be Lot System—A system of organizing cases so that re­ released only to persons who need the information to lated cases are filed in the same “lot” or folder. The help with the patient’s medical care and to protect the goal is to assure that all obtainable information re­ public health. garding the continuing management of related cases contained in a lot is readily available to all respon­ sible workers.

Partner Services PS – 63 GLOSSARY OF TERMS ASSOCIATED WITH PARTNER SERVICES, continued

MAP Sheet—The major analytical points (MAP) sheet forming partners of the possibility of exposure to an is used for gathering information about members of a STD and for referring them to appropriate services. lot as well as for analysis and communication. With patient referral, the provider coaches the infected patient on when, where, and how to notify and what Original Interview—The first interview conducted with to expect with reactions. an infected patient. The objective of the interview is to prevent further spread of disease through the prompt Post-Interview Analysis—An analysis of the informa­ identification and examination of all elicited partners tion obtained during the interview. The post- inter­ and suspects. The interview is designed to ensure that view analysis should be done immediately after the the patient understands the seriousness of the disease, interview when the information is still fresh on the and motivates them to cooperate with STD/HIV con­ mind of the DIS. trol efforts. It is also designed to increase the likeli­ hood that all at-risk partners and suspects are disclosed Pre-Interview Analysis—An analysis of the patient’s so they can be brought in for examination and treat­ situation done by the DIS before the original inter­ ment and to provide client-centered counseling to de­ view. The pre-interview analysis includes reviewing velop a personalized risk reduction plan. available medical information and case information, reviewing available socio-sexual information, and as­ Original Patient (OP)—See index patient. sembling necessary materials and supplies needed dur­ ing the interview. Partner—A person who engages in any type of sexual activity or needle-sharing activity with the infected Presumptive Interview—An interview conducted on the person. basis of a patient presenting with symptoms or labo­ ratory findings that are suspicious or not yet avail­ Partner Elicitation—The process of obtaining names, able. The purpose of this type of interview is to afford descriptions, and locating information of persons who the staff additional time and information by assuring are either partners, suspects, or associates to the origi­ the rapid examination and medical evaluation of re­ nal patient. cent sex partners.

Partner Notification—The process of locating and Provider Referral—A notification strategy where the notifying partners that they have been exposed to a provider takes responsibility for confidentially notify­ disease. ing partners of the possibilities of their exposure to a STD. Partner Services—The wide range of services provided to partners of infected patients. Partner notification is Re-Interview—Any interview following the original but one aspect of these services. Other services include interview with a STD patient. Reinterviews are con­ counseling, testing, and treatment, as well as referrals ducted to provide feedback, to gather additional in­ to appropriate services such as family planning, pre­ formation that may help prove or disprove a hypoth­ natal, drug treatment, social support, housing, etc. esis about case relationships, to address points not covered during the original interview, to identify ad­ Patient—An individual who is treated for a STD. ditional partners or suspects to the original patient, to confront points that are illogical or that are disputed Patient (Self) Referral—A notification strategy whereby by other information, to solicit assistance in locating the infected patient accepts full responsibility for in­

PS – 64 Program Operations Guidelines for STD Prevention GLOSSARY OF TERMS ASSOCIATED WITH PARTNER SERVICES, continued previously named persons who have not been located Suspect—Individuals identified as the result of an in­ or are being uncooperative, to support patient risk- terview with an infected person but who are not part­ reduction attempts, and to support and reinforce a ners of that person. Suspects are divided into three patient’s successful use of referred services. categories: S-1 People with symptoms of disease. S-2 An unnamed partner of an infected patient. S-3 Oth­ Social Network Analysis—The study of how people ers who might benefit from a STD examination. See connect in social structures and of its implications. See Cluster Interview, Social Network Analysis. Cluster Interview. Targeted Screening—An activity to identify infected Source Period—The interval during which a patient people in a select group who are engaged in behaviors most likely contracted the disease. that put them at greater risk for infection.

Spread Period—The time during which a patient is Volunteer—A person who comes into the clinic with­ potentially infectious and could have passed the dis­ out being referred. ease on to others.

Partner Services PS – 65 Appendix PS–K TOOLS FOR NETWORK ANALYSIS

The lot system, developed in the 1960s to assist in the The data set can be created directly from the analysis of syphilis transmission, places person who STD*MIS, if it is used, or by entering the data from are connected to each other in the same case folder the interview record into a data base manager, such as (for example, if A and C are both interviewed, and Epi Info, or a spreadsheet. Once entered, the data are both name B, they are thereby connected, and can be converted into an ASCII, or “flat” file. The total num­ placed in the same lot). Thus, the notion of examin­ ber of observations in the file will be equal to the total ing networks of persons involved in sexual transmis­ number of partners named by all of the persons inter­ sion is a traditional part of syphilis epidemiology. In viewed. The preservation of a unique ID for each indi­ the past few years, a number of software tools have vidual identified is crucial. For example, if a person is been developed to assist in network visualization and named as a partner, he or she will be assigned a unique analysis. These tools, once implemented as part of a ID. That unique ID should be carried with him if he is case management approach, can provide useful insights then interviewed. This procedure permits the network into the nature of the groups at risk for STD trans­ program to create the connections between people. If mission, and may provide a program manager with the STD*MIS currently in use in a program area uses guidance on how to proceed with the investigation of multiple identifiers for the same person, this proce­ both endemic transmission and STD outbreaks. dure will not work. Creating a unique ID for each in­ The traditional syphilis and gonorrhea interview­ dividual, whether identified as a patient or a partner, ing forms and the contact investigation form contain may be the major source of extra work that has to be all of the information necessary to perform a network performed. analysis. Program managers may choose as well to Once a flat file has been constructed, it is read by a gather information not included in these forms (or the program that converts it to a “DL” file that can be versions used in program areas) such as places of ag­ read by the network analysis program, UCINET V. gregation, household information, history of incarcera­ The DL file is then used by the network analysis pro­ tion, etc.; such additional information can be system­ gram to construct a file that can be used for network atically added to the record. Most managers will analysis. Program managers may or may not want to probably select a subset of the variables that are col­ calculate the properties of the network they are exam­ lected on the routine interview forms. For network ining. More likely, they will want to visualize the net­ analysis, the single critical variable is the unique iden­ work. UCINET V contains a module that will create tification number (ID). Together, the information on another file to be read by KRACKPLOT, a program a patient and on one of his/her partners is the basic that permits visualization of all the connections in the observational unit for network analysis. To create a network, and permits the manager to move the nodes file for network analysis, the manager will want a (patients and partners) on the screen to create a visu­ single observation for each patient-partner pair. Thus, ally informative display. The combination of these two if a man names four women, he will generate four programs permits attributes to be assigned to nodes observations in the data set. Each of the observations (such as infected or not infected, male or female, sex will contain all of his information and all the infor­ partner or nonsex partner, etc.). Specific attributes of mation on a contact. (The repetition of his informa­ nodes are represented by the types of boxes in which tion four times is simply a convenience; he will not be the node identifiers are placed, and specific types of counted four times.) connections can be identified by the color of connect­ ing lines.

PS – 66 Program Operations Guidelines for STD Prevention TOOLS FOR NETWORK ANALYSIS, continued

As an investigation unfolds, and cases with part­ tant to revisit. Such visualization can also provide a ners are added, the diagrams can be frequently redrawn graphic sense of the boundaries of the epidemic. to visualize the direction and intensity of the outbreak For additional information on programs for net­ or of endemic spread. By manipulating the visualiza­ work mapping, consult: http://www.heinz.cmu.edu/ tion, managers can develop a sense of the “loose ends” project/INSNA/soft_inf.html and the persons or groups that might be most impor­

Partner Services PS – 67 References

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PS – 68 Program Operations Guidelines for STD Prevention