cost of carrying out provider referral is significantly higher than that for patient referral (Oxman et al., 1994).

Partner notification performed for patients seen outside of the STD clinic setting has never been well developed or documented. Although disease intervention specialists make intensive efforts to identify partners of syphilis patients seen in public STD clinics and in private practice and to follow up on positive tests reported by laboratories, little effort is generally made to support partner notification for patients treated for gonorrhea or chlamydial infection in private health care settings such as physician offices and hospital emergency rooms (Toomey, 1990). Little is known about the practices of private providers regarding partner follow-up, and no systematic national efforts have been made to educate private sector providers regarding the importance of partner treatment as an essential component of STD-related care.

When the provider referral model was applied to HIV prevention and AIDS, other concerns about partner notification emerged (Potterat et al., 1989; Toomey and Cates, 1989; Giesecke et al., 1991; Bayer and Toomey, 1992; Rothenberg and Potterat, in press). The long asymptomatic incubation period for HIV infection makes partner follow-up difficult (Rutherford et al., 1991), and curative therapies are not available. Exposed partners who are identified and not yet infected can benefit substantially from risk-reduction counseling to change behavior, thereby potentially preventing future HIV infection among at-risk partners. HIV-infected persons benefit from early intervention since retroviral therapy and prophylaxis against opportunistic infections are beneficial when utilized appropriately.

Although confidentiality has been ensured with provider referral for STDs, concern about the scope and limits of confidentiality—as well as doubt about the relevance and potential efficacy of partner notification in preventing any STD—have emerged. As the debate regarding partner notification intensified, some public health leaders questioned the value of any provider referral activities (Bayer and Toomey, 1992).

Effectiveness of Partner Notification. Temporal trends suggest that partner notification contributed to the reduction of syphilis and congenital syphilis after the program was widely implemented in the 1950s (Baumgartner et al., 1962). In addition, published reports have documented the effectiveness of partner notification strategies in controlling focal outbreaks of gonorrhea and chancroid (Handsfield et al., 1982, 1989; Blackmore et al., 1985; Zenilman et al., 1988) and in targeting intervention for specific high-risk populations (Yorke et al., 1978; Phillips et al., 1980). In some countries, such as Sweden, partner notification for gonorrhea, syphilis, and chlamydial infection has been highly effective (Ramstedt et al., 1991). The effectiveness of partner notification strategies for STD prevention, however, has not been rigorously evaluated in terms of STD incidence or prevalence in the population at large or rates of reinfection among index patients.



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