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• W2030272893 abstract "The real significance of Katz et al’s report1 in this issue of Sexually Transmitted Diseases is that it exposes a fundamental weakness of laissez-faire HIV partner notification (PN): outcomes can not be assessed with confidence because laissez-faire PN permits unverified partner information. Actually, Katz et al did not attempt to study HIV PN outcomes per se but, rather, an epiphenomenon: how health department disease intervention specialists (DIS) are likely to code outcomes, verified or not. Their study aims to assess the reliability of the HIV PN disposition codes recommended by the Centers for Disease Control and Prevention (CDC). That is, whenever an HIV patient’s at risk partner is identified during the DIS interview/counseling session, that partner is slated to be notified by the HIV patient, or by the DIS, or by a combination of the 2. At the time the notification is deemed complete (“dispositioned”), a specific CDC code is used to administratively close this activity. To get a sense for the reliability of such coding by DIS, the authors use a surrogate: they do not examine real data but rely on (nonsupervisor reviewed) DIS coding of theoretical PN scenarios, presented in 2 short vignettes. These vignettes are well constructed and unambiguous. They were presented to a sample of local health department DIS who are probably representative of DIS in jurisdictions that see the majority of HIV cases in the United States. Results were disappointing. In brief, coding of vignette scenarios by the DIS, which they enrolled was deemed reliable for “simple scenarios with verified outcomes, but less reliable when …”1 outcomes were unverified. This is the most important conclusion from the authors’ imaginative PN exercise and it requires reflection. While a small minority of DIS respondents made baffling, illogical, or just plain wrong, coding decisions, the fault for most of the erratic (mis)coding lies not so much with putative weaknesses in the CDC coding rubric as with the judgment (actually, guessing) game, which is at the heart of reliance on partner-reported (read: unverified) outcomes. Get rid of the latter and the former will be a trivial problem. And while the authors’ call to develop new disposition codes, to improve guidelines, and to ameliorate DIS training, is understandable, they stop short of suggesting a Gordian knot solution: routine verification of patient-reported outcomes. As previously indicated, verified partner outcomes are a basis to validly measure HIV PN′s yields and efficacy, not to mention delineation of community-wide epidemiologic patterns.2,3 (Such a modus may also provide critical empirical evidence to help elucidate the most pressing unsolved puzzle in HIV epidemiology in the United States: why blacks, especially noninjecting black women, are at such extraordinarily disproportionate risk of HIV infection).4 Notably, the authors’ hesitation to explicitly recommend verification of HIV PN outcomes—routinely done for the sexually transmitted bacterial infections, which are targeted for PN efforts in the United States—mirrors the hesitation on the part of the CDC, as articulated in the recently published national guidelines for conducting PN for HIV, syphilis, gonorrhea, and Chlamydia.5 A careful reading of this consensus document reveals adroitly crafted language that, as it were, yearns for, but just can not seem to clearly emphasize the “v” word, or to explicitly call for verification. Here is a sample from that CDC document: “All partner services programs should be able to demonstrate, through monitoring and evaluation, that their program is accomplishing this goal.” (notifying partners) (p 2),5 “… programs should develop methods of monitoring whether partners who are to be notified by the index patient … are actually notified …” (p 33)5; “DIS should follow up on partners not tested at the time of notification to verify that testing has occurred … If another health jurisdiction has been asked to contact the partner, follow-up should be conducted by the initiating health department to determine whether services have been received” (p 37)5; and “… ensure that the partner receives appropriate counseling and testing.” (p 68).5 Reread the above quoted sentences and substitute “verify or verifying” for “demonstrate,” “monitoring,” “determine,” and “ensure.” “Verify” is a rarely used word in this document. Perhaps it is the mandatory sounding connotation of “verification,” which accounts for the CDC’s apparent reticence. In any event, my admittedly biased interpretation of the statements excerpted above is that the CDC really would prefer that DIS not take the patient’s word for partner management outcomes. Implicit in their language, it seems to me, is: “Trust but Verify.” If this interpretation is correct, then supporters of partner outcome verification should be told that they may now be operating in an epidemiologic climate much more receptive to standard, time-honored communicable disease follow-ups than in the past. Indeed, recent systematic reviews6,7 of the acceptability of PN among diverse populations of patients confirms that when PN services are provided sensitively and appropriately,8–11 public health interventions are viewed “as a service rather than an imposition by those for whom they are intended” (p 7).5 While the authors should be thanked for evaluating and aiming to improve the reliability of CDC partner disposition codes, as previously recommended,11 this concern pales in view of the critical importance of validity in HIV follow-up epidemiology. Public health officials, DIS included, have often approached HIV PN as if it were a mine field, hence the legacy of timid approaches, laissez-faire notification and tracing, and low-validity data expectations. Unverified data yield untrustworthy answers. Continuing the legacy of laissez-faire PN fates us to measure our disease intervention losses." @default.
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• W2030272893 title "The End of Laissez-Faire HIV Partner Notification?" @default.
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