-A social system perspective
BRANDT (Brandt, 1985) makes the point that negative social meanings and inadequate public funding related to venereal disease (VD) can impede medical efforts. Even with the discovery of penicillin, VD researchers expressed indifference as they believed a cure for syphilis would promote sexual promiscuity. Thus, the cost factor in the treatment of AIDS is not only dependent upon its potential results, but also upon the negative social images associated with the disease.
Another argument against partner notification is its negligible value (Potterat, Spencer, Woodhouse, 1989), as currently there is no cure for AIDS. Despite this fact, there is treatment. Early administration of zidovudine (AZT) extends the symptomless period of infection (Volbering, Lagakos, Koch, 1990).
Mortality among patients with advanced HIV infection declined from 29.7 per 100 person-years in 1995 to 8.8 per 100 person- years in the second quarter of 1997 (Palella, 1998), a change attributable to the availability of HAART. Prophylaxis against P. carinii pneumonia and other opportunistic infections reduces their frequency and severity (Leoung, Feigal, Montgomery, 1990). The incurability of AIDS at this time requires a new thrust toward developing a better quality of life for persons infected with HIV/AIDS and creating a priority for the development of effective partner notification programmes, with the intent to eliminate the further spread of HIV.
Stigmatisation and discrimination continue to negatively affect the victims of AIDS. Stigma is a mark of social disgrace that places the infected person apart from those who see themselves as ‘normal’. Goffman (1963) perceives the stigmatised individual as having a ‘spoiled identity’ due to negative evaluations by others.
Persons consumed by AIDS are seen as having a spoiled identity by some sections of the population considered to be normal. Legislation on its own will not reduce the stigma experienced by people with AIDS.
The AIDS-stigmatised image is reinforced by incorrect information. This misrepresentation and mythology of the disease need disclosure, discussion and clarification; they should not be incorporated as the basis for social policies. Stigma can be reduced by ‘normalizing’ the illness. Attempts can also be made to show that not only ‘deviants’ contract HIV.
Conrad (1990), points out that “we need to develop policies that focus on changing the image of AIDS and confront directly the stigma, resistance to information, and the unnecessary fears of the disease. Given the social meaning of AIDS, this will not be easy.” One needs to believe; however, it can be done. Partner notification programmes will be much more successful if the stigmatised images of AIDS are reduced or eliminated.

PROVIDER REFERRAL VERSUS PATIENT REFERRAL

Partner notification programmes, rooted in voluntaristic choice, have become integral to HIV prevention strategies in most states. These programmes are manifested in terms of either provider referral (third-party referral) and/or patient (client) referral.
Provider referral refers to a situation in which the patient requests assistance from the public health department to help locate his/her sexual/needle-sharing contacts/partners. Patient referral has to do with a situation in which the patient notifies his/her own sexual/needle-sharing contacts/partners.
Partner notification facilitates primary and secondary prevention of HIV infection, as shown by the following data from a study by the New York City Department of Health (Annual Report 1996).
In 1996, 572 HIV-positive patients were interviewed in the partner notification programme. The interview yielded 485 contacts, with a contact index of 0.9. Of these 485 contacts, 82 had previously tested positive; approximately 218 contacts were given pre-test counselling and tested for the HIV infection; 185 partners were not tested; 12.2% of the partners tested positive.
The contact index in 1995 was 0.8, and 12.5% of the partners contacted were tested and found to be HIV-positive. These data are elicited from third-party referrals, which seem to have a fair measure of success.

SWEDISH APPROACH TO PARTNER NOTIFICATION

Strategies for implementing partner notification were applied at a Gothenberg Clinic in Sweden. General characteristics of the Swedish approach included the following (Gieseck, Ramstedt, Granath, 1991):

•    Partner notification effected shortly after diagnosis
•    Sexual history traced to 3-4 years or more
•    Concern for civil rights manifested by truly enabling patients to participate
•    Patients encouraged to reveal information on contacts, any medical examination done, sex techniques utilised, and condom usage
•    Method of referral made via letter to the partner, without disclosing reason for the meeting

This partner notification scheme was successful, and was based on a system of third party referral.
In a follow-up evaluative study of the Gothenberg Clinic (Gieseck, Ramstedt, Granath, 1991), it became clear that a partner notification programme  is supportable if the following criteria are met:

•     Guarantee of good medical care
•    Guarantee of good psychosocial care
•    Support of diagnosed patients.

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