Q J Med 2001; 94: 379-390
© 2001 Association of Physicians
Recently diagnosed sexually HIV-infected patients: seroconversion interval, partner notification period and a high yield of HIV diagnoses among partners
European Partner Notification Study Group,*Received 7 March 2001 and in revised form 10 May 2001
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Summary |
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We collected data on the outcome of partner notification (PN) for 356 index patients (iPs) newly diagnosed with HIV, all sexually infected, in six European countries, 1995–96. The PN period (the period during which exposed partners should be notified about their risk of being HIV infected) could be defined on the basis of last negative HIV test in 170/356 (48%), from other key dates for 12, and for 14 more on the sole basis of known HIV exposure (total 196/356, 55%). However, of the 170 iPs with a last negative HIV test date, PN period was not defined in 52 (31%), even though 28/52 were recent seroconverters (negative HIV test within 24 months of HIV diagnosis). Discrepancies in PN period evaluation were common: of the 85 iPs for whom PN period was reportedly defined as ‘3 months before last HIV-negative date’, the period actually used was equal to this in only 12. A user-friendly worksheet would simplify the task of eliciting and using key dates to define the PN period. Forms on PN outcome were received for 166/200 (83%) reported current partners, but only 124/508 (24%) ex-partners. Fifty-two of 290 (18%) notified partners already knew they were HIV-positive, and 38/130 (29%) notified partners for whom pre-PN status was negative or unknown were HIV-positive on post-PN testing. Results of HIV tests (if any) after PN were unknown for 37/133 (28%) current partners not already known to be HIV-positive, and for 71/105 (68%) ex-partners—a doubling of the information loss rate. Notification of 133 current and 105 ex-partners not previously identified as HIV-positive thus produced 28 (21%) and 10 (10%) new HIV diagnoses, respectively. The total yield of HIV diagnoses was 38/100 (38%) partners of recent seroconverters (22 already known plus 16 PN-diagnosed), compared with 52/190 (27%) partners of other iPs (30 already known plus 22 PN-diagnosed). We propose prioritization for PN of partners of recent seroconverters, augmented surveillance for HIV diagnoses and recurrence in PN networks of at-risk, non-notified partners, and new measures that preserve anonymity to alert potential and past sexual contacts of HIV-diagnosed individuals who are unable or unwilling to assist in PN.
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Introduction |
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Partner notification (PN) for HIV and the difficulties, time and costs encountered have been severally described.1–10 Table 1
briefly summarizes the results of published PN studies in Europe and USA,11–20 in terms of new HIV diagnoses per 100 index patients (iPs), PN testees not previously known to be HIV-infected per 100 iPs, and HIV seroprevalence in PN testees not previously known to be HIV-infected. There was heterogeneity between studies in respect of new HIV diagnoses and PN testees not previously known to be HIV-infected per 100 iPs. However, consistently across studies, HIV seroprevalence in PN testees not previously known to be HIV-infected was around 25% (95%CI 22–28%).
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In the mid-1990s, a Concerted Action on HIV Partner Notification (PL 93 11 44) was initiated to document the routine of partner notification in Europe, with particular emphasis on current partners and recent seroconverters. Its design and analysis of preliminary reports on 694 consecutive, newly diagnosed index patients (iPs) from eight countries have been summarized previously.21 Briefly, index patients were from geographically- or clinic-restricted settings in Belgium, Denmark, England, Finland, Greece, Norway, Scotland20 and Sweden. Preliminary reports gave baseline demographic and behavioural information about iPs. The index healthcare worker (iHCW), defined as the HCW who informed the iP of his/her HIV-positive test result and/or the person responsible for initiating the PN process, was key thereafter, as further information about the iP depended also upon the iHCW's willingness to assist in data collection. The Concerted Action aimed to document the PN process as it was routinely practised in different European countries, using a common questionnaire (the A questionnaire).
These questionnaires were completed in Belgium, Denmark, Finland, Greece, Norway and Scotland, and were available for 397 (67%) of their 592 iPs. Anonymous A-questionnaire data focused on critical HIV-related dates, known HIV exposure, and number of current and non-current sexual partners: in particular, those who were potential infectors or infectees because of unsafe sexual exposure during the iP's PN period. In this paper, we highlight the key data items which were important in characterizing recent seroconverters and in defining the PN period (the period within which exposed partners should be notified about their risk of being HIV-infected).
To document the routine PN process during a 9-month period beginning at the date of iP's HIV diagnosis, there was one B questionnaire for completion per current or ex-partner to be notified. We report the outcome of PN according to whether the sexual partner was a current or ex-partner; and whether the iP was a recent seroconverter (last negative HIV test <2 years ago) or not.
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Methods |
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Inclusion of consecutive iPs began during 1995 and ended before April 1996. Follow-up period for the outcome of PN was 9 months. The study setting was defined as national in Denmark and Scotland,20 capital city areas in Finland, Greece and Norway, and a major department of infectious diseases in Belgium. For these six countries where A questionnaires were in use, two-thirds (67%, 397/592) were returned for iPs for whom there were preliminary reports. We restrict attention to the major subset of 356/397 iPs whose most likely mode of HIV infection was sexual.
We define as ‘recent seroconverters’ iPs for whom the interval between HIV diagnosis and last negative HIV test was at most 24 months.
Data from two other PN special-emphasis countries in the Concerted Action—England, where there was an ongoing PN research study,19 and Sweden, which has a well established practice of PN12—provided a comparative backdrop for the six countries where the routine of PN was being documented without research or statutory intervention.
Standard statistical methods have been used for comparison of outcome data between subgroups of major interest: heterosexual vs. homosexual HIV transmission, recent seroconverters vs. other iPs, current vs. non-current partners.
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Results |
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Descriptive data
Demographic and A-questionnaire characteristics of the 356 sexually-infected iPs (262 men [74%] and 94 women) for whom we have information about partner notification are summarized in Table 2
. Table 2 also shows the frequency distributions for four major subsets of interest: 176 iPs who were men who had sex with men (MSM); 172 iPs who had previously tested HIV-negative; 102 recent seroconverters; and 80 iPs for whom notification of ex-partners was initiated. Excluded from the analysis are 41 other iPs for whom most likely mode of HIV transmission was: injecting drug use (19), blood transfusion (4), other (2), or unknown (16).
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Median age of all iPs was 33 years, 95/356 (26%) iPs were female, 78/356 (22%) were non-White, and heterosexual HIV transmission accounted about half the cases. A sexually transmitted diseases (STD) clinic was the test site for a fifth of patients and general practice for about 30%. A previous negative HIV test was recorded for 172/356 (48%) of the sexually infected iPs, compared to 283/694 (41%) iPs for whom there were preliminary reports from all eight countries; and 102 iPs were recent seroconverters (29%, 102/356), compared to 24% in preliminary reports.
Additional characteristics of iPs, gleaned from A questionnaires, included the following: a quarter of recently HIV-diagnosed sexually-infected iPs had had two or more sexual partners in the last 12 months; around half had never been treated for a sexually transmitted disease (164/356, 46%) but information was not available for 117/356 (33%); 106/356 (30%) of sexually infected iPs had symptoms at HIV diagnosis, only 15% of whom were diagnosed due to PN referral; and 196/356 (55%) acknowledged at least one current partner with whom they had had unsafe sex. A quarter (85/356: 24%) of iPs reported a current partner who was known to be HIV-infected; a sixth (56/356: 16%) had an ex-partner who was known to be HIV-infected.
Table 2
shows that 94/180 (52%) heterosexually infected iPs were female, and 70/180 (39%) were non-White compared to only 5% (8/176) non-White among male iPs who had sex with men (MSM). Heterosexually infected iPs had a different distribution of sexual partners in the last 12 months from MSM (
2=16.2 on 3 df), the former being more likely to report only one sexual partner in the last 12 months: 73/180 (41%) vs. 45/176 (26%). Reported STD treatment also differed markedly by sexual orientation (2=18.7 on 2 df) with information being missing for 71/180 (39%) heterosexually infected iPs vs. 46/176 (26%) MSM and, whereas only 22/109 (20%) heterosexual iPs for whom there was information about STD treatment reported having been treated, the treatment rate was twice as high at 53/130 (41%) for MSM respondents. Also different between heterosexual and MSM iPs were the distributions of reported number of unsafe current and non-current partners in the defined PN period (respective 2 of 13.6 on 2 df and 11.7 on 3 df).
Relative to other iPs with a previous negative HIV test, recent seroconverters (last negative HIV test <2 years: 102/356 iPs and 102/170 (60%) iPs with a previous negative HIV test) were younger, more likely to report a high number of sex partners, and to have had sex with a ex-partner known to be HIV-infected at the time of exposure (based on logistic regression: table of results not shown, but available from authors).
How accurate was the PN period recorded by index healthcare workers?
Table 3 shows that a last negative HIV test date was available for 170/356 (48%) iPs. For one additional iP, his/her (not very recent) last blood donation should have been recognized as a last HIV-negative test date. Surprisingly, the iHCW did not define the PN period for 52/170 (31%) iPs who had a known last negative HIV test date, 28 of whom even had a last negative test date within 24 months of their HIV diagnosis, and all but four of whom had had their last HIV test within the past 5 years.
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Of the 85 iPs with available last HIV-negative date for whom PN period was reportedly defined as ‘3 months before last HIV-negative date’, 13 in fact had their PN period delimited by a more recent date than their last negative test date, 23 by the last negative date itself, 20 by a date up to 3 months prior to last negative date, 12 by a date from 4 to 6 months prior to last negative date; and 17 ultra-cautiously by more than 6 months prior to the iP's last HIV negative test date.
After last negative HIV test date (available in 171 iPs), known HIV exposure, for 39 iPs, was the next most important PN-defining criterion according to iHCWs. Indeed, known HIV exposure took precedence over last HIV negative test date in 25 cases as far as the iHCW was concerned. The PN period defined by iHCW and by last negative HIV test were compared in these 25 instances: in 9/25, last negative date in fact gave a shorter PN interval but if the delimiter was, more appropriately, ‘3 months before last HIV negative test date’, then the PN period could be shortened in only 4/25 cases. In 16/25, last negative HIV test gave a longer PN interval which iHCWs and iPs rejected, in effect assuming that the known HIV exposure was the relevant exposure. Strictly, only seroconversion illness or molecular results22 could substantiate such a presumption.
Table 4 lists the 39 ‘known HIV exposures’ together with most likely mode of HIV transmission, demographics and information about numbers of unsafe current and ex- sex partners, known HIV-infected partners, whether the iP was aware of the partner's HIV status prior to own diagnosis, and whether PN was intended. The 39 iPs included seven heterosexual females, 10 heterosexual males, five bisexual males and 18 homosexual males. From the explanations provided by the iHCWs, there were 12 iPs with a known HIV-infected current partner but only two (one MSM, one heterosexual transmission) of the 12 knew the partner's HIV status at the time of exposure. There were 15 iPs with a known HIV-infected non-current partner, six of whom knew about the partner's HIV status at the time of exposure. Also of note is the fact that four iPs had known HIV exposures due to condom failure and five others (only) could date their exposure because of acute retroviral syndrome.
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Time in country was the third most useful criterion for defining PN period (used in eight cases), followed by sexual debut which, although cited in seven cases, was verified by consistent data in three cases only.
In summary, PN period was definable, or defined, on the basis of key dates in the A questionnaire for 182/356 iPs (51%), and for a further 14 on the sole basis of known HIV exposure (55%, 196/ 356). PN period was defined by other or undocumented means in 10 cases, see Table 3.
Reported partners per iP, and notified partners
Table 5 shows that 200 current and 508 non-current partners were reported by 356 sexually infected iPs in Belgium, Finland, Denmark, Greece, Norway and Scotland, a mean of 0.6 current and 1.4 non-current partners per iP. The report rate for current partners was consistent between countries, and in line with the 0.6 current partners per iP reported in England. The report rate for non-current partners, however, varied between 0.6 (Denmark and Greece) and 4.8 (Finland) with only one other country (Norway) reaching the report rate of 3.2 non-current partners per iP in England.
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B questionnaires on the outcome of partner notification were received for 166/200 (83%) reported current partners, but the B questionnaire return rate was low (124/508, 24%) for ex-partners. In PN-dedicated settings, such as England and Sweden, over three times as many ex-partner B questionnaires were achieved per sexually infected iP (129/102=1.3) as in the European study of routine PN practices (124/356=0.3).
Notification approach
Overall, 22% of partners (63/289) were informed by a healthcare worker of their exposure to risk of HIV infection (provider referral), more so for non-current partners than for current partners.
PN outcome for current versus non-current partners
The outcome of PN in current partners was similar whether the iP was MSM or heterosexually infected; and likewise for non-current partners (data not shown). Table 6 therefore differentiates only between current and ex-partners.
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Twenty percent of current partners (33/166) already knew that they were HIV-positive. Information on post-PN HIV status was not available for 37/133 (28%) remaining current partners; 28/96 (29%) current partners for whom pre-PN status was negative or unknown were found to be HIV-positive on post-PN testing.
The first and last of the above statistics were similar for ex-partners: 15% (19/124) already knew they were HIV-positive and 10/34 (29%) followed-up non-current partners for whom pre-PN HIV status was negative or unknown were positive on post-PN testing.
The major difference lay in the information loss for partners not already known to be HIV positive, which was double at 71/105 (68%) for non-current partners vs. 37/133 (28%) for current partners. Of the 43 partners who had previously had a negative HIV test, 13/43 (30%) partners were discovered by PN to be HIV-positive: 9/34 current and 4/9 non-current partners.
Prior hypothesis: higher PN yield of HIV diagnoses if iP was recent seroconverter
A prior hypothesis in the European Study was that the PN yield of HIV diagnoses (already known to be HIV-infected, or PN-diagnosed) would be higher if the iP was a recent seroconverter. Recent seroconversion means that the iP is likely to have been recently highly viraemic, and potentially infectious to others; and that he or she was infected recently by an HIV transmitter, who may (or may not) have known their infection status. PN yield of HIV diagnoses was 38/100 (38%) partners of recent seroconverters (22 already known to be HIV-infected plus 16 PN-diagnosed) compared with 52/190 (27%) partners of other iPs (30 already known to be HIV-infected plus 22 PN-diagnosed: 1-directional p value=0.035). The yield of PN-diagnosed HIV infections was 16/78 (21%) if the iP was a recent seroconverter and 22/160 (14%) otherwise (1-directional p value=0.11). This included, for recent seroconverters, 7/14 (50%) partners who had previously tested HIV-negative but were discovered to be HIV-positive, compared with 6/29 (21%) such partners of other iPs (0.05<1-directional p value <0.10).
In summary, PN in respect of 133 current partners who were not already known to be HIV-positive resulted in 28 (21%) new HIV diagnoses: 11/38 (29%) for recent seroconverters' current partners and 17/95 (18%) for other iPs' current partners. PN in respect of 105 ex-partners who were not already known to be HIV-positive resulted in 10 (10%) new HIV diagnoses.
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Discussion |
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Basic results on prior HIV testing and recency of seroconversion for the major subset of 356 sexually infected iPs were in line with preliminary reports from all eight countries for all 694 newly HIV-diagnosed iPs.21 This paper therefore deals only with the major subset of 356 sexually infected iPs from six countries who participated in documentation of routine PN practices without statutory or research intervention. Thirty-two percent of newly HIV-diagnosed MSM iPs were recent seroconverters (57/176), as were a quarter (45/180) of those with recently diagnosed heterosexually-acquired HIV infections.
Attention to a few key dates, last negative HIV test date being the most important, allowed PN period to be defined for half the newly diagnosed sexually-infected iPs. Documentation of known HIV exposure (including via condom breakage or recognized because of acute retroviral syndrome, Table 4) was the second most important factor in delimiting PN period. With early post-exposure prophylaxis being now recommended for healthcare workers,23 and discussion of its extension to rapid-referral cases of accidental sexual-exposure,24,25 the documentation and management roles of the iHCW come into ever-closer alliance.
Greater effort should be devoted by iHCWs to recognition of, and information about, recent seroconverters. There is a three-way benefit: to individual iPs for whom early combination therapy, including in randomized controlled trials, may offer state-of-the-art clinical management; to their recent sexual contacts who may be highly viraemic or who may have been exposed to HIV infection when the iP was highly viraemic because of having recently become infected; and for surveillance, because even lower bounds for the number of recent HIV seroconversions may assist in quantifying HIV incidence.26–28 Recognition relies firstly upon careful history taking from iPs by iHCWs who make new HIV diagnoses; and, secondly, on the appropriate marshalling of the event and date information so gathered.
Discordance between how iHCWs reported that they had determined the PN period for individual iPs and the period as defined by available dates, reflects on the complexity of the logical task that iHCWs undertake in the marshalling of diverse data sources: not only key dates but also personal information on sexual relationships. IHCWs have to grapple with these logical complexities while also having the welfare of the iP as their primary concern. Mismatch between calmly computed PN period and that adopted by iHCWs suggests that a simple worksheet should be devised to ensure the date information which has been ascertained is then used correctly—without arithmetical or logical errors—in determining the PN period.
We have shown that priority should be given to establishing the date of last negative HIV test (including date of last blood donation, if any). Other key dates by which to define PN period, in order of importance, were: date of known HIV exposure, date of entering the country for foreign nationals and, lastly, date of sexual debut.
We recommend the development of a simple data-collection worksheet for use by iHCWs, which would simplify their computation of the PN period, and allow them easily to check that the PN period, as defined, conforms to their intended method for its definition.
Several studies have provided evidence that PN, at modest cost,7,12,16 can lead to the disclosure of HIV infection in persons unaware of their infection. Previously published results, as summarized in Table 1, show heterogeneity in new HIV diagnoses per 100 iPs (11 in European study), partly because of heterogeneity in the number of PN testees not known to be infected per 100 iPs (37 in European study). The European results are consistent with previous studies, in showing that one in four PN testees not previously known to be infected is thereby diagnosed as HIV-antibody-positive (29%: 38/130 post-PN testees). Ideally, all HIV-exposed partners should be alerted to their risk of infection and offered counselling and referral services to lower their risk of exposure to future HIV infection or, if infected, to prevent onward transmission and to have earlier access to clinical care, including highly active antiretroviral therapy.
Against that ideal, the outcome of our European study on routine PN practices may seem unsatisfactory, because further information about partners was obtained, via iHCWs, from only two-thirds of iPs. B questionnaire information on the outcome of PN was received, as expected, for a high proportion of reported current partners (166/200: 83%), but for only 124/508 (24%) reported ex-partners. Similar difficulties have previously been identified in PN-dedicated research studies.19 The partner report rate in the European study was 2.0 (708/356) per iP, similar to that found in other studies; post-PN HIV seroprevalence was also similar in PN testees who were not previously known to be HIV-infected, but the test rate was low compared to PN-dedicated locations such as Newcastle,16 Sweden,12 and rural South Carolina,14 see Table 1.
The aim of the European Concerted Action on PN was to document routine PN practices and outcomes in the participating countries, and so have data that might be helpful for planning new HIV prevention strategies. Half the newly HIV-diagnosed iPs had had a previous negative HIV test, and 60% of these previous testees had seroconverted in the last 2 years. Because of partners’ higher risk of infection if exposed during the iP's initial viraemic phase, the partners of recent seroconverters should therefore (if any) have priority for being notified; alternatively, the partner-network includes an infector who has recently transmitted HIV. CDC Guidance about HIV partner counselling and referral services8 has taken a similar line, which has empirical support from our study's higher PN yield of HIV diagnoses for partners of recent seroconverters (38/100 or 38%: 22 already known to be HIV infected plus 16 PN-diagnosed) compared with partners of other iPs (52/190 or 27%: 30 already known to be HIV infected plus 22 PN-diagnosed).
A marked difference in PN outcome for notified current vs. ex-partners was the loss of information to iHCW about post-notification HIV test results in previously HIV-negative/HIV status unknown partners, which were lacking twice as often for ex- (71/105: 68%) as for current partners (37/133: 28%). In previously HIV-negative/status unknown current as well as ex-partners for whom there was information, post-PN testing disclosed HIV infection in 38/130 (29%: 95%CI 21–37%). Whether this diagnosis rate applies equally to those who may have chosen not to be tested is unclear, but similarity of diagnosis rate across PN studies which differ markedly in number of PN testees not known to be infected per 100 iPs suggests that it may do.
It is therefore time for public, medical, legal and ethical debate about whether a partial identifier (such as master index: initial of first name, soundex of surname,29 gender, date of birth) of at-risk individuals, together with their exposure category, should be notified to surveillance centres. Two purposes would be served: (a) to track if these at-risk individuals are HIV diagnosed in the future; and (b) to discover if their master index recurs in other PN networks.14 More radically, a listing could be available in healthcare settings of master indices and exposure group for newly HIV diagnosed iPs who: (i) do not enlist in clinical care; or (ii) are too ill to engage in partner notification; or (iii) whose partners were mainly anonymous; or (iv) who for their own reasons choose not to assist in PN. Such a listing, preferably by consent, would provide an additional means of alerting potential or past sexual (and injecting) partners of their specific HIV risk, and the need for them to establish their personal HIV status.
An at-risk contact would be alerted if one of their sexual consorts (current or past) has/had a master index which matched one of those listed as pertaining to a person who has been recently HIV diagnosed and for whom PN had not been undertaken. Since many surnames [Bird, Bard, Baird, Bert, Birt, Burt, Board and so on] map onto the same soundex [B630], redundant HIV tests may be requested for reassurance by anxious individuals whose sexual consort shares the master index of a recently HIV-diagnosed individual, but is not that individual. There is therein a danger that false assumptions may be made about the HIV status of a sexual consort; or, more problematically for medical confidentiality, correct deductive disclosure may be made of the identity of recently HIV-diagnosed individuals. These are reasons to initiate public and professional debate about duty of care for individual patients and in alerting at-risk contacts, rather than be resigned to routine PN failure of outreach to specifically-exposed partners. The published and current European evidence that one in four of those who are tested as a result of PN are newly discovered HIV diagnoses cannot be gainsaid in preventing onward HIV transmission.
Index patients were themselves responsible for the majority of notifications in the European study. A comparative study by Landis et al.15 favoured provider referral, but the daily clinical situation is, as here, that most HIV-infected patients choose to inform at least their current partner themselves. Their willingness to do so does not, however, lower the burden on the iHCW, who should be prepared to conduct provider referral on the patient's behalf and to support patients who have chosen to inform partners themselves. Skilled iHCWs offer both individual counselling and information about the services available for patient and partners. Audit of PN practice, as here, allows reasoned improvements (a simple data-collection worksheet to assist healthcare workers in defining partner notification period) and new ideas (indirect, targeted methods of alerting at-risk individuals) to be proposed and debated.
In summary, the European Concerted Action on PN for HIV has highlighted the importance for individual patient care, for exposed partners, and for surveillance of the complex task that iHCWs perform in recognition of recent seroconverters, definition of a relevant PN period, and facilitation of PN notification which, for the most part, was done by iPs—more successfully for current than for ex-partners. Post-PN HIV status was missing for 68% of notified ex-partners who were not already known to be HIV-infected. This is of particular concern because, in our mid-1990s European study, post-PN HIV test result was positive for 29% (95%CI 21–37%) of notified partners (current and ex-) who were not already known to be HIV-infected and about whose HIV test result iHCWs were informed. We propose augmented surveillance for future HIV diagnoses in at-risk PN-untested individuals, and for their recurrence in other PN networks,14 and new partial-identifier measures to alert potential and past sexual partners of newly HIV-diagnosed individuals who are unable or unwilling to assist in PN.
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Membership of European Partner Notification Study Group |
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Writing Group and Steering Committee
A.-M. Worm, S.M. Bird, P. Holmstrom, E. Smith, S.-L. Valle
Investigators
H. Colpin, N. Clumeck, Division of Infectious Diseases, Saint-Pierre Hospital, Brussels, Belgium.
A.-M. Worm, Department of Dermato-Venerology, Bispeberg Hospital and E. Smith, Department of Epidemiology, Statens Serum Institut, Copenhagen, Denmark.
K. Fenton, R. French, Mortimer Market Centre, London, UK (England study).
P. Holmstrom, O. Haikala, National Public Health Institute, and S.-L. Valle, Helsinki University Central Hospital, Helsinki, Finland.
A. Roumeliotou, G. Papaevangelou, Athens School of Public Health, Athens, Greece.
H Moi, U Due-Tonnesen, Olafiaklinikken, Oslo, Norway.
S.M. Bird, MRC Biostatistics Unit, Cambridge, and N. Mir, A Scoular, Department of Genitourinary Medicine, Glasgow Royal Infirmary, Glasgow, UK (Scotland study).
K. Ramstedt, G. Raado, National Institute for Public Health, Stockholm, Sweden.
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Acknowledgments |
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Funded by the European Commission, BIOMED 1, Contract BMH1-CT94-1144.
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Notes |
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Address correspondence to Dr S.M. Bird, MRC Biostatistics Unit, Robinson Way, Cambridge CB2 2SR
*Members of the European Partner Notification Study Group are listed at the end of the paper.
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References |
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