-A social system perspective
THESE criteria will not be met in the foreseeable future in the United States. Indeed, President Clinton recently admitted that because of a misjudgment relating to probable need, anti-retrovirals will not be covered for HIV-infected Medicaid patients until the onset of AIDS. The follow-up evaluative study (Gieseck J, Ramstedt K, Granath F. Efficacy of partner notification for HIV infection.  Lancet 1991;338:1096-1100) in Sweden recommends less as opposed to more involvement by the public health department in contact tracing. The results support the position that a system in which the client is dealt with by clinically active health care providers, where names of patients and partners never get out of the clinic, is better for the person with HIV infection than a system using the public health department resources. Partner notification tasks in this process are also better effected by a specially trained counsellor than by the physician.
The New York State law to amend public health relating to HIV infection, Chapter 163, makes no clear provisions for guaranteeing good medical care, psychosocial care, or support for HIV-infected patients. These criteria have been associated with supportable partner notification programmes. The legal situation in New York relies heavily on public health personnel to make provider referral happen outside of the clinic setting. Applying this strategy could not only make confidentiality of information violable, but could result in failure of partner notification programmes. The major objection to partner notification is HIV name reporting. The lack of anonymity may prevent many people from being tested. This is a very important issue to the HIV-infected community and should be addressed. Various coding systems have been suggested to retain anonymity in the face of name reporting, which should also be mentioned, but these code systems are apparently very costly to develop and implement and are imprecise as well. Further, index patients and partners were linked by internal code numbers at each clinic. The index patient’s name and their partner’s test results are not disclosed in medical communications. The HIV test results of notified partners are never revealed to the index patient. Between 1985 and 1991, there was an 18.4% increase in reported cases.

SWEDISH AND AMERICAN VIEWPOINTS
While these principles of partner notification may work well in Sweden, they can present serious problems within the U.S. health care setting. Value differences exist between the two countries: Americans are more likely to view poverty as an individual problem, whereas in Sweden, poverty is seen as the product of the economic system. In effect, in the United States, emphasis is on “equality of opportunity,” whereas in Sweden focus is on “equality of result.” In Sweden, considerable authority is vested in government, while “less government”, at least regarding this issue in the United States seems to be the case.
Klass (1985) indicated that U.S. individualism and social and ethnic heterogeneity have produced “fractionalized understandings of citizenship.” In Sweden, citizenship is rooted in solidarity and universal entitlement. This approach is evidenced by two-thirds of Sweden’s $190 billion budget being allocated for healthcare, with everyone being covered through the state. This is not so in the United States. Rodwin (1990), argues that the United States has a small public hospital policy, and with no national health insurance, a multipayer system exists. Those patients with more resources can afford the best health care.   Therefore, for the aforementioned reasons, the principles for an effective partner notification programme as described in the Swedish research, may not have direct applicability in the United States. This point becomes clear when one keeps in mind that many AIDS patients are either uninsured or underserved in the United States.
On a more specific note, the New York City Planning Prevention Group (PPG) has had discussions about partner notification. However, so far the PPG has not accorded a precise priority status to partner notification. The research literature (West & Stark, Partner notification for HIV prevention: a critical re-examination.  1997); Pattman & Gould, 1993); Pavia, Benyo, Niler, 1993) is quite clear about the significance of partner notification in secondary prevention. The Bureau of STD Control provides partner notification services via its Contact Notification Assistance Program (CNAP) and, as aforementioned, has had a fair measure of success. However, CNAP may find it useful to review the results at the Gothenberg Clinic. This Swedish Clinic was effective in partner notification processes where the counselors were clinically active providers and not Department of Health pseudo-counselors. In this way, the names of clients and partners do not leave the clinic.
The current literature on partner notification shows the efficacy of clinic-based partner notification programmes. Partner notification in slum-based, antenatal clinics in a poor Haitian community was a considerable success (Desormeaux, Behets, Adrien, 1996). Partner notification also has widespread acceptance in clinical practice, specifically in genitourinary medicine clinics (Fenton, Copas, Johnson, 1997). In Colorado and North Carolina, a high success rate was found at confidential test sites compared to anonymous sites (Hoffman, Spencer, Miller, 1995); Kassler et al, 1997). Recommendations from these latter studies suggested that local health departments should have responsibility for evaluating and improving partner notification services. The confidential clinic test sites seem to have greater efficacy than anonymous test sites (these are run by local health departments and are less clinic-based) for partner notification programmes.
From the literature and established partner notification programmes, one can draw positive suggestions to improve existing notification programmes or design new ones.  (See Table 1)
(This paper was published in AIDS PATIENT CARE AND STDs, Vol. 13, No. 6, June 1999 (USA)