-A social system perspective

ABSTRACT

Provider referral and contact referral are two established means to provide notification of contagious, but treatable diseases, as has been done for tuberculosis and sexually transmitted diseases (e.g., syphilis). Because AIDS is at this time an incurable disease, programmes of notification have proved highly controversial. The author examines recent adjustments to the New York State public health law regarding HIV/AIDS notification mechanisms. A literature re- view supports further discussions of ethical and partner notification issues as they bear on the perception and objections of various constituencies, stigmatization, and principles of confidentiality. Both U.S. and Swedish strategies to partner notification are outlined as well as why these schemes may not be interchangeable based on cultural differences; points for general improvement are drawn from this comparison. A social system perspective based on the social functions of adaptation, goal attainment, integration, and latency (pattern maintenance) is introduced as a means to address the barriers inherent in HIVIAIDS notification programmes and to enhance counselling programmes-the objective being that knowledge and understanding of the patient’s culture and social context can give providers additional tools with which to stop the spread of HIV/AIDS and bring people to treatment earlier.

INTRODUCTION
“Despite the well-established role of public health a disease is carried out through patient referral departments in identifying and notifying the sexual where the patient informs his/her partners, by contacts of those reported to have venereal diseases,   provider referral (also called ‘contact tracing’), this strategy of intervention-designed to break the   where the public health department notifies the chain of disease transmission-played no role to the sexual partners, and by contract referral, where early response to AIDS (Bayer, 1991).                                

IDENTIFYING AND NOTIFYING sexual contacts of those stricken with HIV have  proven to be controversial, largely as a result of its incurable status and the stigma attached to it. Notification of   a disease is carried out through patient referral, where the patient informs his/her partners, by provider referral (also called “contact tracing”), where the public health department notifies the sexual partners, and by contract referral, where the client is encouraged to notify his her partners, on condition that the health-care worker will trace any partner who does not contact the clinic within a contracted time period.
Partner notification has been utilized as a standard health practice for combating the transmission of treatable sexually transmitted diseases (STDS) since 1937 and has worked well. At that time, partner notification was used to halt the spread of syphilis ( (Brandt, 1985). Today, the scourge of HIV demands a more comprehensive, effective, and rapid implementation of partner notification as public health policy.
The term “partners” refers to sex partners and injecting drug users (IDUs) who engage in needle-sharing. Research data demonstrates a growing interest in partner notification with many states and constituencies acknowledging its efficacy in contributing to constraining the spread of HIV. The Centers for Disease Control and Prevention (CDC) recommendations suggest that public health department staff should inform known partners in cases where an HIV- infected patient refuses to comply.
New York State recently reinforced its partner notification mechanisms through the passage of an act to amend the public health law, pertaining to HIV infection and reporting cases of this infection to spouses and known sexual partners (New York State Public Health Law, 1998). This law was enacted on July 7,1998 and covers the following provisions on the duty to report and the procedure of contact tracing:

•    Every physician or other personnel authorized by law to arrange for diagnostic tests, or provide a medical diagnosis, or any laboratory administering this test, shall immediately upon first diagnosis that the person is HIV-infected, or upon first diagnosis that a person is assailed with AIDS, or upon first diagnosis that a person is beset with HIV-related illness, report such case to the Health Commissioner.
•    Every Health Commissioner, upon establishing that such reported case, or other identified known case of HIV infection, justifies contact tracing, shall personally inform the known contacts of the protected person.
•    The contact shall be notified of the characteristics of HIV, the known viral transmission routes, risks of prenatal and perinatal transmission, actions the person can effect to further reduce viral transmission, and community-based organizations (CBOs) accessible to the person that dispense counselling, medical care and treatment, and additional information of other appropriate services for HIV-infected persons.
•    Any physician or other public health personnel effecting this notification must make the notification in person.

The New York State law provides mechanisms for the use of provider referral, and no opportunity is given to the patient to inform contacts about the infection status. Greater utilization is made of public health personnel outside of clinic settings to achieve provider referral. However, at the core of partner notification are the issues of ethics and law. To be continued…

(This paper was published in AIDS PATIENT CARE AND STDs, Vol. 13, No. 6, June 1999)