Product Details

Author Information

Corresponding Author
E. Jennifer Edelman
Yale University School of Medicine
367 Cedar Street
New Haven, CT
United States
p: 203-737-7115
ejennifer.edelman@yale.edu

Authors (listed in order of authorship):
Christopher Cole
AIDS Project New Haven

Nicholas Boshnack
AIDS Project New Haven

Heidi Jenkins
Connecticut State Department of Public Health

Wanda Richardson
Connecticut State Department of Public Health

Marjorie S. Rosenthal
Yale University School of Medicine

Product Description and Application Narrative Submitted by Corresponding Author

What general topics does your product address?

Public Health

What specific topics does your product address?

HIV/AIDS, Prevention, Community-based participatory research

Does your product focus on a specific population(s)?

LGBTQ

What methodological approaches were used in the development of your product, or are discussed in your product?

Community-based participatory research , Qualitative research

What resource type(s) best describe(s) your product?

Manual/how to guide

Application Narrative

1. Please provide a 1600 character abstract describing your product, its intended use and the audiences for which it would be appropriate.*

Partner notification (PN) represents an increasingly promoted public health strategy for detecting undiagnosed HIV. PN is the process of confidentially informing the sex or needle-sharing partners of a person diagnosed with a sexually transmitted infection of their potential exposure. It is most effective when public health officials, known as Disease Intervention Specialists (DIS), are involved in collaboration with health care teams as occurs through the Department of Public Health’s Partner Services programs. There is a paucity of data examining the perspectives of medical case managers (MCM), DIS, and men who have sex with men (MSM) on the process of partner notification. To address this gap, we conducted a qualitative study, guided by community-based participatory research principles with MCM, all Connecticut DIS, and MSM seeking community-based services, to inform the implementation of partner notification for HIV in Connecticut. Through this project, we heard that there were varying comfort levels in how to approach questions about relationships and sexual practices. Further, we learned that there was a general lack of knowledge among MCM about how to initiate a PN referral. Therefore, through an iterative process with input from multiple stakeholders, we developed a double-sided information card, entitled "Promoting HIV Testing Among Partners of HIV-Positive Clients." This card is intended for MCM, health care providers, and HIV counselors and testers. One side gives specific information about the Partner Services program and provides suggestions for how to initiate conversations about relationships and sexual practices in a culturally-competent, nonjudgmental manner. The alternate side gives pertinent statistics and a quote from a letter written from a MSM to a DIS after a recent interview for partner notification.

2. What are the goals of the product?

The goals of this product are to assist staff with interview skills useful for fostering conversations with their clients about their relationships and sexual practices, raise awareness about the partner services program and outline the process of referring a client to the Partner Services program. Our research showed that connecting with clients about their relationships was often difficult due to perceived personal judgment, lack of time in building trusted relationships, and lack of knowledge about Connecticut’s Partner Services program. It is our belief that having a tool available will serve as a reminder to staff to connect with clients about their relationships on a regular basis, when this is often not the highest priority or intended reason for interaction with clients. This product is intended to illustrate simple and straightforward questions to prompt conversation about relationships and sexual behaviors often tied to stigma and judgment. By outlining the referral process and methods for linking to the Partner Services program, this tool is intended to promote the dissemination of consistent information across agencies with the goal of increasing appropriate referrals to the program and helping link individuals at high-risk for HIV with necessary counseling, testing and linkage to treatment as indicated.

3. Who are the intended audiences or expected users of the product?

The expected users of this product are MCM, HIV counselors and testers, health care providers and other medical or client services staff in clinics, health departments and community-based organizations.

4. Please provide any special instructions for successful use of the product, if necessary. If your product has been previously published, please provide the appropriate citation below.

The successful use of this product depends on broad distribution to client service providers. Individuals should be instructed to keep the product in a readily available and visible location, where providers regularly interact with clients so that it may serve as a regular prompt and resource to increase appropriate referrals to partner services. It is intended to complement and reinforce educations and trainings about taking a sexual history and facilitating partner notification, and not to replace them. As the legal implications of non-disclosure of HIV status and the referral processes vary state by state, MCM, counselors and testers, physicians and other staff should be aware of their state-specific laws surrounding these complex issues.

5. Please describe how your product or the project that resulted in the product builds on a relevant field, discipline or prior work. You may cite the literature and provide a bibliography in the next question if appropriate.

Since 2008, partner notification with active health department involvement has been recommended for those newly diagnosed with HIV and those previously diagnosed with HIV but engaging in ongoing high risk behaviors for HIV transmission.1 Previous data have found that partner notification is most effective at ensuring appropriate counseling and testing of partners when DIS are involved.2 The HIV epidemic is disproportionately impacting MSM, with greatest incidence among this group3 and delayed diagnoses.4 Implementing partner notification for MSM, however, has been challenging.5-6 Though previous work has explored barriers to partner notification in a clinic-based MSM population,7 there was a dearth of research examining experiences among a sample of MSM engaged with community-based services. Further, there was a lack of research examining the experiences of MCM or DIS, as it related to partner notification for MSM. We, therefore, designed Project COACH (Counseling Others about Contacts and exposures with HIV) to understand the perspectives and opinions of MSM engaged with community-based services, DIS and MCM within a single geographic region. This qualitative,8 community-based participatory research guided project,9 represents a collaboration among the leadership from an AIDS service organization, the Connecticut State Department of Public Health, and academics to improve the process of partner notification for HIV among MSM living in Connecticut. As part of the dissemination of our project, we developed this tool.

6. Please provide a bibliography for work cited above or in other parts of this application. Provide full references, in the order sited in the text (i.e. according to number order). .

1. Centers for Disease Control and Prevention. Recommendations for partner services programs for HIV infection, syphilis, gonorrhea, and chlamydial infection. MMWR Recomm Rep. Nov 7 2008;57(RR-9):1-83; quiz CE81-84.
2. Hogben M, McNally T, McPheeters M, Hutchinson AB. The effectiveness of HIV partner counseling and referral services in increasing identification of HIV-positive individuals a systematic review. Am J Prev Med. Aug 2007;33(2 Suppl):S89-100.
3. Prejean J, Song R, Hernandez A, et al. Estimated HIV incidence in the United States, 2006-2009. PLoS One. 2011;6(8):e17502.
4. Nelson KM, Thiede H, Hawes SE, et al. Why the wait? Delayed HIV diagnosis among men who have sex with men. J Urban Health. Jul 2010;87(4):642-655.
5. Hogben M, Paffel J, Broussard D, et al. Syphilis partner notification with men who have sex with men: a review and commentary. Sex Transm Dis. Oct 2005;32(10 Suppl):S43-47.
6. Richardson W, Jenkins H, A. R. HIV Sex Partner Notification Services Available. Connecticut Epidemiologist. March 2009;29(3):9-10.
7. Mimiaga MJ, Reisner SL, Tetu AM, et al. Partner notification after STD and HIV exposures and infections: knowledge, attitudes, and experiences of Massachusetts men who have sex with men. Public Health Rep. Jan-Feb 2009;124(1):111-119.
8. Curry LA, Nembhard IM, Bradley EH. Qualitative and mixed methods provide unique contributions to outcomes research. Circulation. Mar 17 2009;119(10):1442-1452.
9. Israel BA, Schulz AJ, Parker EA, Becker AB. Review of community-based research: assessing partnership approaches to improve public health. Annu Rev Public Health. 1998;19:173-202.
10. Cashman SB, Adeky S, Allen AJ, 3rd, et al. The power and the promise: working with communities to analyze data, interpret findings, and get to outcomes. Am J Public Health. Aug 2008;98(8):1407-1417.
11. Plumb M, Collins N, Cordeiro JN, Kavanaugh-Lynch M. Assessing process and outcomes: evaluating community-based participatory research. Prog Community Health Partnersh. Summer 2008;2(2):85-86, 87-97.
12. Morgan DL. Focus Groups. Annu. Rev. Sociol. . 1996;22:129-152.
13. Makadon HJ, Mayer KH, Potter J, Goldhammer H. Fenway Guide to Lesbian, Gay, Bisexual and Transgender Health. Philadelphia, PA: American College of Physicians; 2008.
14. Corbie-Smith G, Thomas SB, Williams MV, Moody-Ayers S. Attitudes and beliefs of African Americans toward participation in medical research. J Gen Intern Med. Sep 1999;14(9):537-546.
15. Campsmith ML, Rhodes PH, Hall HI, Green TA. Undiagnosed HIV prevalence among adults and adolescents in the United States at the end of 2006. J Acquir Immune Defic Syndr. Apr 2010;53(5):619-624.

References for Page 2 of Product:

1. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. Sep 22 2006;55(RR-14):1-17; quiz CE11-14.
2. Centers for Disease Control and Prevention. Cases of HIV infection and AIDS in the United States and dependent areas, by race/ethnicity, 2002-2006. HIV/AIDS Surveillance Supplemental Report. 2008;13(1).
3. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. Aug 11 2011;365(6):493-505.
4. Richardson W, Jenkins H, A. R. HIV Sex Partner Notification Services Available. Connecticut Epidemiologist. March 2009;29(3):9-10.

7. Please describe the project or body of work from which the submitted product developed. Describe the ways that community and academic/institutional expertise contributed to the project. Pay particular attention to demonstrating the quality or rigor of the work:

• For research-related work, describe (if relevant) study aims, design, sample, measurement instruments, and analysis and interpretation. Discuss how you verified the accuracy of your data.
• For education-related work, describe (if relevant) any needs assessment conducted, learning objectives, educational strategies incorporated, and evaluation of learning.
• For other types of work, discuss how the project was developed and reasons for the methodological choices made.

Project COACH (Counseling Others about Contacts and exposures with HIV) evolved based on a shared interest among the leadership of AIDS Project New Haven, DPH staff, and academics from a local university to improve the implementation of partner notification for HIV, specifically for MSM living in Connecticut. Our aims were to develop a comprehensive understanding of the perspectives and experiences of partner notification for HIV among MSM living in Connecticut to inform and improve the implementation of the existing program. This was a qualitative study, with each phase of the project being guided by community-based participatory research principles.9 The study team consisted of the Executive Director (CC) and Director of Client Services (NB) from AIDS Project New Haven (APNH), the oldest and largest AIDS service organization in New Haven; the Program Director of the STD/TB Program (HJ) and one of two DIS supervisors (WR) at the Connecticut State DPH; and two academic physicians, one with expertise in community-based participatory research and qualitative methods (MSR) and one with expertise in HIV medicine and health services research training (EJE). While the entire team was involved in the design, review of the findings and dissemination of the work, two team members (CC and EJE) conducted the data collection, and three team members performed the data analysis (CC, MSR and EJE). The role of the leadership from APNH was critical for the project as it allowed for the development of culturally-competent, appropriate and relevant discussion guides; data collection by someone who was matched on important characteristics, including gender, sexual orientation and HIV status; richer data analysis; and ultimate dissemination of findings with a relevant action plan.10 The strength of the team member’s partnership allowed for the project’s conduct and outcome.11

The study included a focus group12 with MCM (n=14) and in-depth in-person interviews8 with all Connecticut DIS (n=6) and MSM (n=24) seeking community-based services. Specifically, MSM were recruited through APNH; a non-profit serving the needs of the Lesbian, Gay, Bisexual, and Transgender communities; a substance abuse treatment center; and peer referral. Recruitment and data collection occurred until thematic saturation was achieved.8 We conducted semi-structured discussions, which were each audio-taped, professionally transcribed and reviewed. Data were analyzed with the constant comparative method, based on a code structure which was developed using grounded theory.8 The project was approved by the Human Investigations Committees at Yale University and DPH. All participants provided verbal informed consent and the study was Health Insurance Portability and Accountability Act (HIPAA) compliant.

During the initial design and through the conduct of our study, it was learned that there was a lack of comfort among MCM about discussing relationships and sexual practices and lack of basic knowledge about the partner notification program.

This product was, therefore, developed in direct response to a perceived need for tools for initiating conversations in a nonjudgmental manner about relationships and sexual practices and clear, consistent information about the partner notification program to be given across agencies. Drafted initially by the Project COACH team, it was developed in an iterative process with input from various stakeholders, including staff from the state and local health departments, providers at AIDS service organizations, HIV counselors and testers, medical case managers, HIV-infected and uninfected MSM, HIV providers and educators.

8. Please describe the process of developing the product, including the ways that community and academic/institutional expertise were integrated in the development of this product.

The product was developed based on feedback heard in the focus group with MCM about varying comfort with discussing relationships and sexual practices with clients in general, and MSM in particular, and their lack of knowledge about the Partner Services program and the associated referral process. These findings were confirmed through the interviews with the DIS and reinforced by lack of knowledge about the partner notification among MSM, including HIV-infected men receiving care through community-based organizations.

The information card was initially drafted and revised by the Project COACH team based on recommended practices.1, 13 As a part of the participant confirmation process, during which time we provided a summary of our study findings, we shared the draft of the information card to MCM, DIS and MSM. Feedback was obtained and incorporated into an edited version. The product was then shared in an iterative process with client services supervisors, health care providers, including HIV specialists, state and local health department staff, and CDC-trained HIV counselors and testers for their input. Finally the product was presented at the Connecticut state-wide prevention task-force (Connecticut HIV/AIDS and Identification Referral Task Force) for feedback prior to finalization of the product. The product will be distributed through this task force as well as through the state-wide Connecticut HIV Planning Council.

9. Please discuss the significance and impact of your product. In your response, discuss ways your product has added to existing knowledge and benefited the community; ways others may have utilized your product; and any relevant evaluation data about impact, if available. If the impact of the product is not yet known, discuss its potential significance.

This product is intended to function as a readily accessible information card for broad distribution to individuals who may be providing services to HIV-infected clients. It became self-evident during this project that despite ongoing trainings on partner notification to various groups, including MCM and providers, it was consistently challenging to raise consistent awareness and prioritization of the program, and the associated appropriate referrals. While we found that this was related to several barriers, including complicated client needs, it was also due to a lack of comfort with discussing relationships and sexual practices, in addition to an absence of understanding of the importance of partner notification, criteria for referral and necessary logistical information. To address this gap, this information card is intended to provide language tools for discussing relationships and sexual practices and the referral criteria for partner notification. Further, it was believed that providing the necessary contact information, would help streamline the process for busy providers serving complicated client needs. We recognized that a critical part of this process is understanding among the providers of the importance of the partner notification program. The summary statistics are intended to raise awareness among providers, which may be used to educate clients about why partner services is important. In response to concerns that were raised during the interviews about sharing confidential information with the state, particularly due to historical experiences,14 we shared the message from a recently interviewed client sent to a DIS to help demystify the experience. It is our hope that by creating and disseminating this information card, we will help promote appropriate referrals to the partner notification program and increased collaboration with the health department and other agencies We believe this is an important step for increasing diagnoses of those unaware of their HIV status.15

10. Please describe why you chose the presentation format you did.

The presentation format for this product was chosen to be simple, easily accessible and easy to follow. We intend to have these information sheets laminated, as they are durable, easy to distribute and likely to be posted or kept on the desk of client service providers for easy reference.

11. Please reflect on the strengths and limitations of your product. In what ways did community and academic/institutional collaborators provide feedback and how was such feedback used? Include relevant evaluation data about strengths and limitations if available.

The product was developed in an iterative process with input from various stakeholders to ensure that it was accurate, culturally-competent and user-friendly. The process of developing the product, alone, served to increase awareness of the importance of partner notification and the DPH program. The product may be limited in its generalizability to other settings which have adopted the CDC recommendations differently.1 Further, the product is optimally used to complement ongoing trainings as an additional information source; it is not intended to replace these trainings. This product may serve as an example of an important step for raising awareness and promoting collaboration between community-based agencies and DPH for Partner Services. In addition, it may serve as a template of the components which may be included in an information card to facilitate referrals across agencies. As this product was recently distributed for general use, information about acceptability and usability is not currently available.

12. Please describe ways that the project resulting in the product involved collaboration that embodied principles of mutual respect, shared work and shared credit. If different, describe ways that the product itself involved collaboration that embodied principles of mutual respect, shared work and shared credit. Have all collaborators on the product been notified of and approved submission of the product to CES4Health.info? If not, why not? Please indicate whether the project resulting in the product was approved by an Institutional Review Board (IRB) and/or community-based review mechanism, if applicable, and provide the name(s) of the IRB/mechanism.

From the perspective of all of the team members, Project COACH represented an equitable partnership from the conceptualization through the dissemination of the study. Each team member contributed unique yet complementary skills and knowledge to the project, that were valued and necessary, at all stages of the project. This included the development of discussion guides and recruitment strategies and approaches to handling and presenting data. All team members contributed to presentations at the Robert Wood Johnson Foundation Clinical Scholars Program Steering Committee meetings, which served as the community advisory board. In addition, all team members contributed to dissemination of the findings, such as providing input on poster conferences and other presentations, and manuscript drafts. A notable strength of the team was the strong relationships which developed over time. While these were initially fostered by regular in-person meetings, this evolved into frequent ongoing communications for project-related activities and for client-related issues. These relationships have developed into other partnerships, such as APNH board membership to ensure ongoing collaborations.

The project was approved by the Human Investigations Committees at Yale University and DPH. All participants provided verbal informed consent and the study was Health Insurance Portability and Accountability Act (HIPAA) compliant.