HIV Partner Counseling

and Referral Services

Guidance

December 30, 1998

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service  Centers for Disease Control and Prevention 

National Center for HIV, STD, and TB Prevention  Divisions of HIV/AIDS Prevention
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HIV Partner Counseling and Referral Services

Preface

This guidance is intended to assist state and local health department HIV

prevention cooperative agreement grantees and HIV prevention community

planning groups in planning, implementing, and evaluating the services provided

to persons living with HIV and their sex and needle-sharing partners. External

consultants and CDC staff collaborated in the development of this guidance, which

is intended to supplement current CDC cooperative agreement guidance for HIV

prevention programs. The development process included input based on reviews of

the relevant scientific literature, actual program experience, and expert recommendations from within and outside CDC.

This guidance uses new terminology to label the process of reaching and

serving sex and needle-sharing partners. As opposed to contact tracing and partner

notification, the term partner counseling and referral services (PCRS) is used in this

document because it better reflects the type and range of public health services that

are recommended for sex and needle-sharing partners. These services are vital to

any communitys HIV prevention efforts. This guidance should assist in developing programs, planning services, or prioritizing resource allocation for PCRS, and

state and local programs supported with CDC funds should adapt it to meet their

local policies, needs, and circumstances.

The principles listed on the following pages constitute the basis for PCRS

and are applied to issues discussed throughout this document. Principles 111

apply to partner counseling and referral services associated with partner services

for all sexually transmitted diseases, including HIV. Principles 1213 apply to

partner counseling and referral services associated with HIV in particular.

The reader can refer to Appendix B, Glossary of Terms Associated with

PCRS, for clarification on how some terms are used in this document. For

example, the term PCRS provider is used to refer to any qualified health care

personnel, including physicians, nurses, counselors, or disease intervention specialists, who might be involved in serving HIV-infected clients, their partners, and

affected communities. Guidance in this document assumes and strongly recommends that PCRS providers be specifically trained in delivering these services.

For technical assistance or inquiries, PCRS providers should contact their

state health department. State health departments should contact their CDC

project officers.
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HIV Partner Counseling and Referral Services

 1. Voluntary. PCRS is voluntary on the

part of the infected person and his or

her partners.

 2. Confidential. Every part of PCRS

is confidential.

 3. Science-Based. PCRS activities are

science-based and require knowledge,

skill, and training.

 4. Culturally Appropriate. PCRS is to be

delivered in a nonjudgmental, culturally

appropriate, and sensitive manner.

 5. A Component of a Comprehensive

Prevention System. PCRS is one of a

number of public health strategies to

control and prevent the spread of HIV

and STDs. Other strategies include

access to clinical services, outreach to

and targeted screenings of at-risk

populations, behavioral interventions,

and educational programs.

 6. Diverse Referral Approaches. PCRS

may be delivered through two basic

approaches: provider referral, whereby

the PCRS provider locates and informs

sex or needle-sharing partners of their

exposure, and client referral, whereby the

infected person takes responsibility for

informing his or her partners. Sometimes

a combination of these approaches is used.

 7. Support Services and Referral. PCRS is

delivered in a continuum of care that

includes the capacity to refer sex and

needle-sharing partners to HIV counseling, testing, and treatment, as well as

other services, e.g., STD treatment,

family planning, violence prevention,

drug treatment, social support, housing.

Principles Associated with Providing PCRS for

All Sexually Transmitted Diseases, Including HIV

 8. Analysis and Use of PCRS Data. PCRS

program managers should collect data on

services provided and use the data for

evaluating and improving program efficiency, effectiveness, and quality.

 9. Counseling and Support for Those

Who Choose To Notify Their Own

Partners. Counseling and support for

those who choose to notify their own

partners is an essential element of PCRS.

Such efforts can assist in ultimately

reaching more partners and minimizing

unintended consequences of notification.

Assistance to clients in deciding if, how,

to whom, where, and when to disclose

their infection can help them avoid

stigmatization, discrimination, and other

potential negative effects. Working with a

client to think through what it means to

notify a partner and creating a specific

plan to ensure he or she successfully

accomplishes the notification is a vital

role of the provider.

10. Client-Centered Counseling. Providing

client-centered counseling for HIVinfected individuals and their partners can

reduce behavioral risks for acquiring or

transmitting HIV infection. In addition,

client-centered counseling will help the

provider understand the readiness of the

client to notify partners. This will allow

the provider to offer services to assist the

client in successfully notifying partners

without adverse consequence.

11. Increased Importance as New Technologies Emerge. As new technologies

emerge, such as rapid diagnostic tests,

vaccines, behavioral interventions, and

even more effective therapies, PCRS

will become an increasingly important

prevention tool.
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HIV Partner Counseling and Referral Services

12. Ongoing Access to PCRS for HIVInfected Individuals and Partners.

PCRS should not be a one-time service.

It should be offered as soon as an HIVinfected individual learns his or her

serostatus and made available throughout

that persons counseling and treatment. If

new partners are exposed in the future,

PCRS should be made available again.

HIV-infected individuals should have the

ability to access PCRS whenever needed.

Principles Associated with Providing PCRS,

Particularly for HIV

13. Assistance in Accessing Medical Evaluation and Treatment To Prolong Life.

Sex and needle-sharing partners might

already be HIV-infected but be unaware

of or deny their risks. They can be assisted through PCRS in learning their

status, and in obtaining earlier medical

evaluation and treatment for HIV disease

and opportunistic infections. PCRS

provides an opportunity for HIV primary prevention interventions for those

partners not infected with HIV and an

opportunity for secondary prevention for

those partners living with HIV.
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HIV Partner Counseling and Referral Services

How To Use This Document

The standards and guidance in this document describe the core elements

that are essential for successful PCRS programs at publicly funded sites. Even

though HIV and STD programs share many common goals, policies, and

activities, PCRS is designed specifically for HIV prevention programs. It is

not intended to replace or modify CDC guidance for partner notification for

other STDs.

The two levels of recommendations in this document are Standards and

Guidance:

Standards. Specific standards are provided in several sections and are

intended to be applied consistently. Standards must be followed by CDC grantees in virtually all cases where CDC funds are used to support services. To

assist the reader, each standard is set apart from the other text in

In addition, Appendix A is a concise listing of all the PCRS standards in

the order discussed in the main part of the document.

Guidance. The main text of this document provides overall guidance for

PCRS programs. This guidance should be followed in most cases, but can be

tailored to fit the individuals and affected communities being served as

well as the program needs. Providers are urged to follow this guidance but

have flexibility to modify or adapt based on state or local needs, policies,

or circumstances.

Other organizations providing PCRS or other HIV prevention service

providers might also find this document a useful guide. CDC recommends that

the guidance be shared with providers and consumers of services in local areas.

Managers of PCRS programs are urged to work closely with STD prevention,

violence prevention, drug treatment, reproductive health, and other state agencies

in planning, implementing, and evaluating their program and services.

reverse type on a

black background.
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HIV Partner Counseling and Referral Services

CONTENTS

PREFACE .......................................................................................................................... i

Principles Associated with Providing PCRS for All

 Sexually Transmitted Diseases, Including HIV .............................................................. ii

Principles Associated with Providing PCRS,

 Particularly for HIV ..................................................................................................... iii

How To Use This Document ............................................................................................ iv

1.0 PARTNER COUNSELING AND REFERRAL SERVICES FOR HIV PREVENTION 

AN OVERVIEW ........................................................................................................1

1.1 How HIV PCRS Has Evolved ................................................................................ 1

1.2 What Are the Goals of PCRS? .............................................................................. 1

1.3 Is PCRS Cost-effective? ....................................................................................... 2

1.4 Who Benefits from PCRS? ................................................................................... 2

1.5 What Activities Are Involved in PCRS? ................................................................. 3

2.0 AVAILABILITY OF PCRS ..........................................................................................4

2.1 Making Services Available to All HIV-infected Persons ......................................... 4

2.1.1 Services for Those Persons Tested Anonymously .................................................. 5

2.1.2 Inability to Pay .................................................................................................... 5

2.2 Accommodating Requests from Other Health Jurisdictions .................................. 6

3.0 DECIDING ON A PCRS PLAN AND SETTING PRIORITIES ..........................................6

3.1 Encouraging Client Participation ......................................................................... 6

3.1.1 Fully Informing and Reassuring Clients ............................................................... 6

3.1.2 Developing an Atmosphere of Trust ..................................................................... 6

3.1.3 Introducing PCRS ............................................................................................... 7

3.2 Formulating a PCRS Plan .................................................................................... 7

3.2.1 Taking a Closer Look at Client Referral ................................................................ 8

3.2.2 Taking a Closer Look at Provider Referral ............................................................ 9

3.2.3 Taking a Closer Look at Combined Referral Approaches ..................................... 10

3.3 Setting Priorities for Reaching Partners ............................................................. 10

3.4 Considering Other Options and Special Circumstances ..................................... 12

3.4.1 Other Persons Who Might Need To Be Contacted ............................................... 12

3.4.2 But, I Do Not Want My Partner To Be Contacted! ............................................ 13

3.4.3 PCRS for Needle-sharing Partners ..................................................................... 13
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HIV Partner Counseling and Referral Services

4.0 LOCATING AND NOTIFYING PARTNERS ................................................................. 14

4.1 Preparing the PCRS Provider ............................................................................. 14

4.2 Setting Activities in Motion ................................................................................ 15

4.3 Maintaining Confidentiality ............................................................................... 15

4.4 Helping Partners Access Services ...................................................................... 16

4.5 Addressing Community Concerns ...................................................................... 16

5.0 COLLECTING, ANALYZING, AND USING PCRS DATA ............................................... 17

5.1 Why Collect Program Data? ............................................................................... 17

5.2 What Data Should Be Collected? ....................................................................... 17

6.0 ENSURING THE QUALITY OF PCRS ........................................................................ 18

6.1 Training ............................................................................................................ 18

6.2 Quality Assurance and Evaluation .................................................................... 18

6.3 How Can CDC Help? ......................................................................................... 19

REFERENCES .................................................................................................................. 20

APPENDICES ................................................................................................................... 22

A. PCRS Programmatic Standards ......................................................................... 22

B. Glossary of Terms Associated with PCRS ........................................................... 24

ACKNOWLEDGMENTS ............................................................................................................ 26

Contents (continued)
HIV Partner Counseling and Referral Services

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1.0 PARTNER COUNSELING

AND REFERRAL SERVICES

FOR HIV PREVENTION

AN OVERVIEW

1.1. How HIV PCRS Has Evolved

Once known as contact tracing,

outreach activities for finding, diagnosing, and

treating partners of persons infected with

sexually transmitted diseases (STDs) have long

been used by public health workers as a prevention activity. In the 1930s, U.S. Surgeon

General Thomas Parran advocated the use of

contact tracing to help prevent new chains of

[syphilis] infection (Parran, 1937). Contact

tracing was later expanded to include partners

of persons infected with gonorrhea and other

STDs, including the human immunodeficiency

virus (HIV), and came to be known in the

1980s as partner notification (West and

Stark, 1997).

In the 1980s, when public health workers were

first being confronted with the rapid spread of

HIV, the virus that causes acquired immunodeficiency syndrome (AIDS), informing persons

of their possible exposure to HIV and offering

counseling, testing, and referral services were

already recognized as an important disease

prevention effort that could help stem the tide

of HIV infection. As HIV prevention activities

have evolved, so has the terminology for

informing the HIV-infected persons sex and

needle-sharing partners of their possible exposure to the virus. Today, the term HIV partner

counseling and referral services (PCRS) more

accurately reflects the range of services available to HIV-infected persons, their partners,

and affected communities through this public

health activity.

Of necessity, PCRS for HIV differs from

partner services for other STDs because the

epidemiological, biological, and clinical

characteristics of HIV are different (West and

Stark, 1997). Despite recent advances in treatment, we do not yet have a cure for AIDS, so

HIV remains a lifelong issue for those infected.

Furthermore, because society frequently

stigmatizes and sometimes discriminates

against HIV-infected persons and their families

and friends, the affected communities may be

concerned about the potential negative impact

of PCRS. HIV prevention programs need

affected communities to be involved in and

understand PCRS for the overall prevention

efforts to be accepted and effective.

Federal and state legislative mandates in the

1990s have underscored the importance of

notifying sex and needle-sharing partners of

their possible exposure to HIV. Recent examples include the federal requirement to

notify spouses of HIV-infected persons (Public

Law 104-146, Section 8[a] of the Ryan White

CARE Reauthorization Act of 1996) and state

legislation to require health departments to

offer HIV partner notification services to

newly reported HIV-infected persons (National Council of State Legislators, 1998). Legal

and ethical concepts such as the rights of

individuals to know their risk of infection, to

learn their HIV status anonymously or confidentially, and to be protected against discrimination if HIV-infected, will continue to drive

public health policies and legislative action on

HIV PCRS (West and Stark, 1997). Public

health policies and legislative actions related to

the above concepts will determine, at least in

part, how PCRS is conducted.

1.2 What Are the Goals of PCRS?

PCRS is a prevention activity with the

following goals:

1. Providing services to HIV-infected persons and their sex and needle-sharing

partners so they can avoid infection or, if

already infected, can prevent transmission

to others.

2. Helping partners gain earlier access to

individualized counseling, HIV testing,
HIV Partner Counseling and Referral Services

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medical evaluation, treatment, and other

prevention services.

Through PCRS, persons  many of whom are

unsuspecting of their risk  are informed of

their exposure or possible exposure to HIV.

Notified partners can choose whether to be

tested, and if not tested or if found to be

uninfected, can receive counseling about

practicing safer behaviors to avoid future

exposure to HIV. If, however, they are found

to be infected, they can seek early medical

treatment and practice behaviors that help

prevent transmission of HIV to others and

reduce the risk of becoming infected with

other STDs.

PCRS can be instrumental in identifying

sexual and drug-injecting networks at high risk

for transmission of HIV or other sexually

transmitted diseases (Fenton and Peterman,

1997; West and Stark, 1997). These networks

are made up of individuals who share social

relationships involving sex or drug use. Such

networks can be identified and described at

least partly through information obtained by

PCRS activities (West and Stark, 1997). Future

prevention interventions can then be more

effectively directed, and the HIV risks within

the network(s) potentially reduced. Network

research, combined with new methods of virus

typing and identification of recently infected

persons (Janssen, et al., 1998), will contribute

to a greater understanding of HIV transmission (Fenton and Peterman, 1997).

1.3 Is PCRS Cost-effective?

Some have raised concerns about the

high potential cost of PCRS and have questioned on these grounds whether or not it

should be supported. In fact, although the

relative investment per person reached might

be greater than other public health activities,

PCRS is likely to be highly cost-effective. A

simple threshold analysis illustrates the probable cost-effectiveness of PCRS to society.

Assuming an estimated current $154,402

lifetime cost in the United States of a person

acquiring HIV infection and eventually dying

from HIV-related illness (Holtgrave and

Pinkerton, 1997) and a conservatively estimated average $3,205 cost of PCRS to reach

one infected person (Toomey et al., 1998),

PCRS must prevent 1 infection out of every

51 HIV-infected partners reached through

PCRS to be cost-effective. As PCRS links

HIV-infected partners to client-centered counseling and other interventions proven or likely

to be effective, this appears to be a threshold

relatively easy to achieve by programs.

Greater effectiveness, such as preventing only

23 infections for every 51 HIV-infected

partners reached through PCRS, would convey substantial cost savings to society.

1.4 Who Benefits from PCRS?

Clearly, three distinct beneficiaries of

PCRS are (1) persons with HIV infection;

(2) their spouses and other sex and/or needlesharing partners; and (3) affected communities

(Fenton and Peterman, 1997). Through a

client-centered approach, HIV-infected persons

can receive counseling about their risk behavior and be offered a range of choices and

support in informing their partners of the

possibilities of exposure to HIV (CDC, 1994).

Studies have shown that a client-centered

counseling approach can result in behavior

change, thereby decreasing the likelihood of

HIV transmission to others (Kamb et al., 1998

and Fenton and Peterman, 1997). HIV-infected

persons can also benefit from referrals to other

social and medical services, such as couples

counseling, prevention case management, and

antiretroviral therapy.

For the partners of HIV-infected persons, one

basic benefit comes from being informed that

they are at risk. This will be particularly

helpful information for those who do not even

suspect that they might have been exposed.

Once informed, the partner can decide to

access available HIV prevention counseling
HIV Partner Counseling and Referral Services

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and testing services. If not infected with HIV,

partners can be assisted in changing their risk

behavior, thus reducing the likelihood of

acquiring the virus. Or, if already HIVinfected, the partners prognosis can be improved through earlier diagnosis and treatment.

The role of PCRS, earlier diagnosis, and

prevention and treatment services might have

prevention benefits at the community level in

reducing future rates of HIV transmission.

Evidence is accumulating that antiretroviral

therapy reduces the amount of HIV in genital

secretions and fluids and thus might reduce the

infectivity of HIV (Gupta P, et al., 1997;

Vernazza PL, et al., 1997; Vernazza PL, et al.,

1997; Musicco M, et al., 1994). However,

concern may be well justified that some might

misinterpret antiretroviral therapy as a cure

for HIV and thus be less concerned about

adopting safe behaviors or exposing others

(Kalichman SC, et al., 1998; Kelly JA, et al.,

1998; Remien RH, et al., 1998; Remien RH, et

al., 1998). Efforts to link HIV-infected persons

to treatment must also continue to emphasize

safe behavior during the course of treatment.

Effective PCRS also can improve disease

surveillance, identify social sexual networks at

high risk that can then be targeted for prevention (Fenton and Peterman, 1997), and potentially assist a comprehensive program in lowering the transmission rate of HIV. In addition,

PCRS can benefit service providers in the community by increasing their access to individuals in need of their services, especially people

who would not come to them on their own.

1.5 What Activities Are Involved

in PCRS?

PCRS should be introduced at the

point an individual seeks HIV prevention

counseling and testing. A brief overview of the

activities associated with PCRS is included in

this section, but more detailed discussions are

provided throughout the remainder of

this document.

w Person Seeks HIV Prevention Counseling and Testing. PCRS begins when

persons seek, either through private care

providers or publicly funded programs,

HIV prevention counseling and testing.

As they enter services, they should be

assisted first, ideally through clientcentered counseling techniques, in 

1. assessing their risks of acquiring or

transmitting HIV, and

2. negotiating a realistic and incremental

plan for reducing risk.

During the initial counseling and testing

session, the provider should also explain

(1) how HIV testing will be conducted if

the client does choose to be tested, and

(2) all the available options for PCRS.

The provider must assist clients in understanding their responsibility, if their HIV

test results are positive, for ensuring that

their partners are informed of their

possible exposure, and referring those

partners to HIV prevention counseling,

testing, and other support services

(CDC, 1994).

w Client Tests Positive and Chooses To

Participate in PCRS. Once a clients test

results are confirmed positive, that person

should be provided the earliest appropriate opportunity to receive partner counseling and referral services. Reactions to

learning one is infected with HIV vary,

and personal circumstances differ among

individuals. PCRS providers need to

recognize and accommodate those clients

who need other issues resolved before

being ready to participate in PCRS. This

might mean, for some individuals, scheduling a follow-up appointment to discuss

PCRS issues more thoroughly.

w PCRS Provider and Client Together

Formulate a Plan and Set Priorities.

The PCRS provider (who might not be

the counseling and testing provider)

counsels the client on if, how, and when
HIV Partner Counseling and Referral Services

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specific partners should be informed of

their risk of exposure. The provider

should present partner referral options

(Section 3.2). Then, the client and PCRS

provider together can develop a plan for

reaching partners that uses one or more of

the referral options. The plan should be

one that will result in each partner being

(1) informed of possible exposure to HIV;

(2) provided with accurate information

about HIV transmission and prevention;

(3) informed of benefits of knowing ones

serostatus; (4) assisted in accessing counseling, testing, and other support services;

and (5) cautioned about the possible

negative consequences of revealing their

own or others serostatus to anyone else.

As the individualized plan is developed,

the PCRS provider and client prioritize

which partners should be reached first

(Section 3.0 provides a discussion of how

priorities are set).

w HIV-Infected Client Voluntarily Discloses Information About Partners. The

HIV-infected client is encouraged to

voluntarily and confidentially disclose the

identifying, locating, and exposure information for each sex or needle-sharing

partner that the PCRS provider or the

client will attempt to inform.

w Client and/or Provider Informs Each

Partner of Possible Exposure to HIV.

The client and/or the PCRS provider

informs each sex or needle-sharing

partner who can be located of his or her

possible exposure to HIV. Ideally, the

partner is always informed confidentially

face-to-face, but this cannot necessarily

be ensured when the client chooses

to inform the partner without the

providers assistance.

w Client and/or Provider Assists Partner

in Accessing Counseling, Testing, and

Other Support Services. At the core of

PCRS is referring the now-informed

partner to counseling, testing, and needed

social and medical services. If on-the-spot

counseling and/or testing for HIV and

other STDs is not practical or not desired

at this time, each partner should receive,

immediately upon being informed of

possible exposure to HIV, a specific

referral for obtaining client-centered

counseling and testing. Some partners

will also need immediate referrals for

medical evaluation, substance abuse

treatment, mental health, or other support services to enhance or sustain riskreducing behaviors.

How each PCRS activity is conducted might

have a direct impact on how communities

perceive the value of such efforts to themselves

and to public health. Quality assurance for

services provided, routine staff and program

evaluations, and network analysis are, therefore, necessary components of PCRS. For

example, ensuring that strict confidentiality is

maintained for all persons involved in PCRS

will encourage community support and involvement. (See Sections 4.3, 4.5, and 6.2)

2.0 AVAILABILITY OF PCRS

2.1 Making Services Available to

All HIV-infected Persons

People can learn

that they are HIVinfected through a

variety of sources,

including confidential

and anonymous testing

sites, private care physicians, or home collection kits. However,

regardless of where and

how persons have been

tested, PCRS must be

made easily accessible to

all HIV-infected persons.

For example, an HIV-infected person who

has been tested by a private provider might

seek services from a CDC-funded provider.

All CDCfunded HIV

prevention

counseling

and testing

sites, both

confidential

and anonymous, must

make PCRS

available to

all HIVinfected

persons.
HIV Partner Counseling and Referral Services

Page 5

Although verified evidence of HIV infection

should always be presented to the PCRS

provider before partners are contacted,

PCRS must be made available to the HIVinfected person.

The client who has just been informed of

being HIV-infected will, of course, need to

have PCRS offered at the earliest appropriate

time, but the PCRS provider will encounter

many others to whom services should be

offered. For example, those persons could

include a previously identified HIV-infected 

w client who in the past was not

offered PCRS;

w sex or needle-sharing partner who the

PCRS provider learns is continuing to

have unprotected sex and who has

partners other than the original HIVinfected client;

w client who now has new sex or needlesharing partners;

w client who is now seeking additional STD

or family planning services or substance

abuse treatment; or

w client who in the past refused or only

partially participated in PCRS but has

now decided to participate fully.

Health department HIV prevention program

staff should ensure that health care and prevention providers in the community and HIVinfected persons in the area are aware that

PCRS is available at publicly funded sites and

are aware of how to access those services.

Furthermore, health departments can expand

access to PCRS by developing agreements with

private providers. These agreements could

specify that the private providers will deliver

PCRS to their HIV-infected clients. In such

situations, these providers should be given

relevant information, training, and support to

successfully deliver the services.

2.1.1 Services for Those Persons

Tested Anonymously

Opportunities to

access PCRS must be

provided to HIVinfected clients who

have been tested

anonymously and

choose to remain

anonymous. Program

experience has indicated that PCRS can

be conducted in an

anonymous setting

(Hoffman, et al., 1995). CDC requires that,

unless prohibited by state law or regulation,

grantees must provide reasonable opportunities for anonymous testing. Clients who test

HIV-positive in anonymous settings must be

counseled on how to enter a confidential

system and be strongly encouraged to do so.

This will assist them in receiving medical care

and other services, including PCRS.

Recent reports show that persons who enter

anonymous HIV testing programs do so

earlier in their HIV infection and are more

likely to begin medical care while still comparatively well (Bindman et al., 1998;

Nakashima et al., 1998). CDC currently recommends that persons initially testing positive

for HIV in an anonymous setting be counseled

and informed about how to enter a confidential medical care system.

2.1.2 Inability To Pay

CDC-funded PCRS programs must

provide access to PCRS regardless of clients or

partners ability to pay (CDC, 1993).

CDC-funded

programs must

provide access

to PCRS for

persons testing

anonymously

without

requiring that

the infected

client disclose

his or

her identity.
HIV Partner Counseling and Referral Services

Page 6

2.2 Accommodating Requests

from Other Health Jurisdictions

PCRS providers

might sometimes be

asked to contact the

partner of an HIVinfected person residing

in another health jurisdiction. Such contacts

with other jurisdictions

is the role of the state

health department. For example, a PCRS

provider might request that the staff in a neighboring state health department assist in locating

and informing a previous partner or former

spouse of an HIV-infected client. A reasonable

effort must be made to accommodate that

request if it complies with state and local

regulations and policies, and confidentiality

is maintained.

3.0 DECIDING ON A PCRS

PLAN AND SETTING

PRIORITIES

3.1 Encouraging Client

Participation

3.1.1 Fully Informing and

Reassuring Clients

 The PCRS provider

should explain the purpose and process of PCRS

before PCRS activities can

begin. The HIV-infected

person serves as the gatekeeper to his or her

partners. Program experience indicates that once a

person understands the

benefits both to themselves and their partners,

they willingly participate

in PCRS. Therefore,

ensuring that the HIV-infected person fully

understands the PCRS process and its benefits

is important.

Providers should create an environment that is

private, confidential, and comfortable enough

so that clients are encouraged to participate in

PCRS without feeling fearful or coerced.

Reminders of the voluntary nature of PCRS

and explanations of how privacy will be maintained for clients and partners alike will be

necessary before some individuals feel secure

enough to participate.

Each interaction a counseling and testing or

health care provider has with an HIV-infected

client is a potential opportunity to discuss the

importance of informing that persons sex or

needle-sharing partners of their possible exposure to HIV. Prevention counseling, prevention case management, and medical follow-up

sessions while clients are in treatment, all

provide opportunities to stress the importance

of getting partners involved in PCRS.

Community-level interventions provide other

opportunities to reach out to partners.

3.1.2 Developing an Atmosphere

of Trust

 The success of the

PCRS process hinges on

the trust and cooperation

of the persons infected

with HIV and their

partners. How well the

provider fosters an atmosphere of trust, respect,

and rapport with the

HIV-infected individual

will have a significant impact on PCRS. Clientcentered counseling techniques (CDC, 1994)

are highly recommended for developing this

relationship, not only with original clients but

also with their partners. The ability to develop

trust and rapport will also enhance the PCRS

providers effectiveness when working in

the community.

Requests for

PCRS from

other health

jurisdictions

must be

accommodated

whenever

practical.

PCRS providers must

ensure that

clients are

aware that all

information

disclosed by

them will be

kept strictly

confidential

and that

participation

is always

voluntary.

To foster an

atmosphere

of trust,

PCRS providers must

treat all HIVinfected

clients and

their partners

with respect.
HIV Partner Counseling and Referral Services

Page 7

3.1.3 Introducing PCRS

 During the

first visit, the

health care

provider, using

a client-centered

approach

(CDC, 1994),

should begin

discussions with

the client on the

risks to his or

her partners.

This visit

would typically be for HIV counseling and

testing. When clients choose to be tested and

the results are positive, then the provider must

offer, at the earliest appropriate opportunity,

to assist in formulating an individualized

PCRS plan. That plan is always based on the

personal circumstances of the HIV-infected

client and each of his or her partners.

When the provider demonstrates genuine

concern for the overall well-being of clients

and their partners during discussions about

PCRS, the provider encourages greater client

participation. Clients reactions vary significantly to learning that their HIV test results

are positive; therefore, the provider must

gauge the appropriate point at which to initiate the discussion about the PCRS plan. In

fact, other critical issues might need to be

resolved first. For example, the client might

express suicidal ideation or a fear of a violent

reaction from a partner. Because potentially

violent situations might be encountered,

collaboration between the PCRS program and

the appropriate state or local violence prevention programs is important. Such collaboration will help in developing plans and protocols for such situations and provide opportunities for the PCRS provider to learn about

relevant services.

3.2 Formulating a PCRS Plan

 HIV prevention programs use two

basic approaches

for reaching

partners (West

and Stark,

1997). In this

document, the

term client

referral is used

when HIVinfected individuals choose

to inform their partners themselves and refer

those partners to counseling and testing (see

Section 3.2.1). (NOTE: The terms patient

referral and self-referral are sometimes used

instead of client referral.) The term provider

referral is used in this document when the

PCRS provider, with the consent of the HIVinfected client, takes the responsibility for

contacting the partners and referring them to

counseling, testing, and other support services

(see Section 3.2.2).

Sometimes a combination of the two approaches is used. With the dual-referral approach, the HIV-infected client informs the

partner of his/her serostatus in the presence of

the PCRS provider. By having a professional

counselor present, this approach supports the

client and reduces other potential risks. In such

situations the PCRS provider must not reveal

the clients serostatus to the partners without

prior informed consent. With the contractreferral approach, the PCRS provider does the

informing only if the client does not notify the

partner within a negotiated time period (see

Section 3.2.3).

The PCRS provider should explain to clients

all available options for reaching their partners, including the advantages and disadvantages of each approach. Then, together they

Persons entering

CDC-funded HIV

prevention counseling and testing

programs must be

counseled at the

earliest opportunity

about PCRS and

options for informing sex and needlesharing partners of

possible exposure

to HIV.

The PCRS provider

must explain to the

HIV-infected client

the options for serving partners and then

assist that client in

deciding on the best

plan for reaching

each partner

confidentially and

referring him or her

to counseling,

testing, and other

support services.
HIV Partner Counseling and Referral Services

Page 8

can formulate a plan that can result in each

partner being confidentially informed and

encouraged to access counseling and testing or

other social or medical services. Some HIVinfected individuals will be reluctant to participate in PCRS. Client-centered counseling

techniques and reassurances of confidentiality

can encourage better participation. Resolving

problems through role-playing, for example,

might help clients overcome barriers to participating in PCRS and help them better prepare

for their part in those activities. No matter

which approach is chosen, the PCRS provider

should ensure the partners are actually informed of the exposure.

3.2.1 Taking a Closer Look at

Client Referral

When HIV-infected clients choose to

inform their partners themselves, they usually

need some assistance to succeed. Although the

majority of clients do not experience negative

consequences when notifying partners, the

PCRS provider can help the client minimize

any potentially negative consequences. The

provider should, therefore, be prepared to

assess the situation and ability of the HIVinfected client to make successful notification

and referrals. Based on this information,

clients might need to be coached on:

1. the best ways to inform each partner;

2. how to deal with the psychological and

social impact of disclosing ones HIV

status to others;

3. how to respond to a partners reactions,

including the possibility of personal

violence directed toward the client or

others; and

4. how and where each partner can access

HIV prevention counseling and testing.

Despite the providers coaching, however, the

clients lack of counseling skills and experience

might result in unsuccessful or ineffective

PCRS. Another disadvantage of the clientreferral approach is that the client might

unintentionally convey incorrect information

about HIV transmission, available support

services, confidentiality protections, or other

issues. The client also forfeits anonymity to

partners, increasing the potential for disclosure

of serostatus to third parties, subsequent

discrimination, or partner repercussion. The

findings of Landis et al. (1992) clearly indicate

that fewer partners are actually informed of

their possible exposure to HIV when the

client-referral approach is used. However,

because PCRS is a voluntary process, clients

should be able to choose this approach. The

PCRS program needs reasonable systems for

monitoring whether partners are actually

reached (see Contract Referral in Section

3.2.3). Also, more support to the client in

notifying their partners will enhance the

effectiveness of notifying partners.

For anonymous test sites, the client-referral

approach poses a slightly different problem

because some clients might be less likely to

give the provider information about partners.

Under these circumstances the provider will be

less likely to determine whether PCRS has

been successful. Although PCRS can be provided to anonymous clients, CDC currently

recommends providers encourage the client to

voluntarily enter a confidential setting for

PCRS and additional medical follow-up. Here

again, an appropriately detailed discussion

with anonymous clients of how confidentiality

will be maintained for themselves and their

partners can ease the transition of anonymous

clients to a confidential setting. That transition

will also be eased if clients are not required to

take another HIV test. If the anonymous and

confidential test sites are at separate facilities,

reciprocal agreements between the two might

be necessary so that the clients confirmed

positive test result can easily be transferred to

the confidential setting.

At confidential test sites, PCRS providers

should make every reasonable effort to follow

up with each HIV-infected client to assess how
HIV Partner Counseling and Referral Services

Page 9

well he or she has progressed with PCRS.

Whenever feasible, careful and confidential

monitoring of which of the clients partners

actually do access counseling and testing services can greatly enhance quality assurance and

program evaluation. This also will help ensure

that partners have actually been reached.

Despite its drawbacks, client referral is the

approach frequently chosen, and it can have

some advantages. Because the client is usually

more familiar with the identity and location of

the partner, this approach can allow some

partners to be referred for counseling and

testing more promptly. Also, some clients

choose this approach because they feel the best

way to preserve a current relationship is by

informing the partner themselves rather than

having a third party  the provider  do it.

Finally, when client referral is conducted

successfully, fewer staff are used and fewer

resources are consumed than with the

provider-referral approach, so the financial

burden for HIV prevention programs is reduced.

3.2.2 Taking a Closer Look at

Provider Referral

When the client chooses provider

referral, the provider will also need to assess

the situation regarding each partner, including

the best ways to inform them, how to locate

and contact them, suggestions on how to

approach them, how to predict the psychosocial impact of their learning their HIV

serostatus, and how to respond to partners

reactions. Research indicates that provider

referral is more effective in serving partners

than client referral (Landis et al., 1992). The

following are some of the advantages of using

the provider-referral approach:

1. The PCRS provider is able to readily

verify that partners have been confidentially informed and have received clientcentered counseling and testing services.

2. The PCRS provider can better ensure the

HIV-infected clients anonymity since no

information about the client is disclosed

to his or her partners.

3. A well-trained PCRS provider is better

able to defuse the partners potential

anger and blame reactions as well as

accurately and more comprehensively

respond to the partners questions

and concerns.

4. Provider referral better facilitates learning

about sexual and drug-injection networks,

thus potentially enhancing overall HIV

prevention efforts in affected communities.

5. In many cases, the PCRS provider can

deliver on-site HIV testing to the partner.

Among the disadvantages of the providerreferral approach is the fact that PCRS providers are not always able to readily locate and

identify the partners. Because the provider is

less familiar with how to reach the partners,

actually locating them to discuss their possible

exposure to HIV can be more difficult. The

provider-referral approach also entails substantial financial costs and causes some ethical

concerns among leaders of affected communities (Fenton and Peterman, 1997; West and

Stark, 1997). For example, Fenton and Peterman (1997) found that financial costs for

provider referral are between $33 and $373 per

partner notified and between $810 and $3,205

per infected partner notified. This program

expense, however, is greatly offset in the long

run because PCRS frequently reaches persons

who do not suspect they have been exposed to

HIV and is likely cost-effective (see Section

1.3). Once informed, they can access prevention counseling and testing, and if HIVinfected, they can enter treatment earlier. It is

important to note that some infected people

who choose provider referral might still notify

some partners about their serostatus and will

thus need relevant counseling.
HIV Partner Counseling and Referral Services

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3.2.3 Taking a Closer Look at

Combined Referral Approaches

Two variations on provider and client

referral are the dual- and contract-referral

approaches. Potentially, combinations of

these approaches can enhance the advantages

of both approaches for the client while reducing the disadvantages.

Dual Referral. Some HIV-infected clients feel

that they and their partners would be best

served by having both the client and the

provider present when the partner is informed.

The dual-referral approach can work well for

these clients. The dual approach allows the

client to receive direct support in the notification process. The PCRS provider is available

to render immediate counseling, answer questions, address concerns, provide referrals to

other services, and in some cases potentially

minimize partner repercussions. Being present

also enables the provider to know which

partners have in fact been served, and to some

extent, learn about sexual and drug-injecting

networks. Whether the client or provider will

take the lead in informing the partner should

be worked out in advance of the notification.

The provider still needs to coach and support

the client as with the client-referral approach.

The provider and the HIV-infected client

need to consider, in particular, the partners

possible concerns about having his or her

relationship with the client revealed to the

provider. By considering this issue in advance,

the client and the provider can anticipate the

partners possible reactions and discuss how to

respond appropriately.

Contract Referral. The other variation on

provider and client referral, the contractreferral approach, might require more negotiation skill on the PCRS providers part. In the

contract-referral approach, the provider and

client decide on a time frame during which the

client will contact and refer the partners. If the

client is unable to complete the task within

that agreed-upon time period, the PCRS

provider then has the permission and information necessary to serve the partner. The provider must also have agreement with the client

about how to confirm that partners were

notified and what follow-up is required for

situations where the client does not make the

notification. Negotiation skill and a relationship of trust are needed so that the provider

will have the identifying and locating information immediately available if the client

does not inform the partner before the

time limit expires.

When the contract-referral approach is used,

the PCRS provider should also negotiate a

provision with the client whereby the partner

confirms in some way (e.g., telephone call,

appointment for services) to the provider that

he or she has been informed of being at risk.

Otherwise, the provider may have difficulty

knowing which partners have been informed

and whether or not provider referral or some

other assistance is now needed.

3.3 Setting Priorities for Reaching

Partners

 The PCRS plan

must include prioritizing which sex or

needle-sharing

partners need to be

reached first, based

on each clients and

partners circumstances. Ideally, all

partners should be

reached, but limited

program resources

usually dictate that priorities have to be set.

Priorities are determined by deciding (1) which

partners are most likely to be already infected

and to transmit infection to others; (2) which

partners are most likely to become infected;

and (3) which partners can be located. Priority

is also affected by federal and state laws. For

example, federal legislation requires that a

The PCRS provider and HIVinfected client

must prioritize

reaching partners

based on who is

most likely to

transmit infection to others

and who is most

likely to become

infected.
HIV Partner Counseling and Referral Services

Page 11

good-faith effort be made to notify any

individual who is the marriage partner of

an HIV-infected patient, or who has been

the marriage partner of that patient at any

time within the 10-year period prior to the

diagnosis of HIV infection. (Public Law

104-146, Section 8[a] of the Ryan White CARE

Reauthorization Act of 1996.)

A number of factors influence how the PCRS

provider and client decide which partners need

to be reached first. Obviously, if the client has

had only one partner during his or her lifetime, that partner is likely to be infected.

When the client has had more than one partner, other factors then have to be considered,

such as the following:

w Possible Transmission of HIV to

Others. The partner who is most likely

to transmit HIV to others must receive

highest priority. A partner who is a

pregnant woman should be reached as

soon as possible for counseling, testing,

and referral to medical treatment if infected, to avoid perinatal transmission.

Likewise, the partner who the client

knows has multiple other sex and needlesharing partners needs to be reached as

soon as possible to reduce the potential

for transmission of HIV to others.

w Partners of a Recently Infected Client.

If, for example, the client had a negative

HIV test result 6 months ago, but now

the test result is positive, partners within

that 6-month time period or in the potential window period that preceded the

negative test would receive priority.

These partners are more likely to have

acquired or been exposed to HIV than

any of the clients partners during the

period before the clients HIV negative

test. Other evidence of a recently infected

person might be indicated by the exposure history of the client, e.g., client with

a history of negative test results, findings

from less sensitive EIA or serologic

testing algorithm for recent HIV

seroconversion, or other evidence of

recent infection.

w Likelihood of the Partner Being Unaware of Exposure to HIV. Some individuals are less likely than others to

suspect a risk for HIV infection or to

understand what being at risk means.

For example, many heterosexual women

might be less aware of their HIV risk and

therefore less likely to access counseling,

testing, or other prevention services

without PCRS.

w Partners at Continued Risk. Reaching

the clients current, recurring, or recent

partners is a high priority because those

partners might be at continued risk of

becoming infected with HIV, if not

already infected.

w History of Other STDs. Either the

clients or partners history of other STD

infections is an important factor in setting

priorities. For example, if a partner was

treated for another STD, that partner is

more likely to also be infected with HIV

and, additionally, more likely to transmit

HIV to others. If the HIV-infected client

has a recent history of other STD infection, then his or her sex partners are more

likely to have been HIV-infected, especially those exposed during the STD

infection (Wasserheit, 1992).

w Transmission of Strains of HIV That

Are Resistant to Antiretroviral Therapies. If information or evidence exists that

the client is infected with a strain of HIV

resistant to antiretroviral therapies,

partners of this client would have high

priority for PCRS services.

The PCRS provider and client should begin by

noting current or recent partners and the

details of their exposure. Next, working back

in time, they should consider any other partners who need to be contacted. By briefly
HIV Partner Counseling and Referral Services

Page 12

noting the circumstances for each partner and

then moving quickly on to the next one, the

provider will be better able to stimulate the

clients memory. Then, together, they can

determine the priorities for reaching as many

partners as program resources might permit.

Because determining when a client was actually infected or the circumstances associated

with individual partners is often difficult or

impossible, some HIV prevention programs

routinely attempt to locate and counsel all

partners from a defined time period. This time

period, often 1-2 years, frequently is based on

availability of resources for PCRS. Programs

with greater amounts of resources, those with

lower morbidity, or those that give higher

priority to PCRS frequently attempt to reach

and counsel partners exposed over a longer

time period.

Once the provider and client have established

which partners are to be reached, they can

begin discussing a plan for reaching these

partners. For those partners the provider will

be contacting, exact locating information, plus

the dates, types, and frequency of exposure

should be noted (See Section 4.2). During this

phase, new information about partners might

come to light that necessitates adjustments in

the priorities previously established.

In addition to the factors listed previously, the

PCRS provider must also consider federal

legislation and relevant state laws that require

a good-faith effort be made in notifying current

spouses or persons who have been spouses of

a known HIV-infected person during the

10 years prior to the clients diagnosis of HIV

infection. Both the program policies of PCRS

and the efforts of individual providers contribute to the required good-faith effort.

PCRS providers can satisfy the requirement of

a good-faith effort by (1) asking all HIVinfected clients if they have a current or past

marriage partner(s), (2) notifying these partners of their possible exposure to HIV, except

in situations when, in the judgment of public

health officials, there has been no sexual

exposure of a spouse to the known HIVinfected individual during the relevant time

frame; (3) referring them to appropriate

prevention services; and (4) documenting

these efforts. Programs need to have or

develop policies to guide providers in situations in which the HIV-infected client does

not give consent and will not allow the

provider to notify his or her current or

past marriage partner(s).

3.4 Considering Other Options

and Special Circumstances

3.4.1 Other Persons Who Might

Need To Be Contacted

While the PCRS plan is being developed and priorities are being set for reaching

partners, the provider should take special note

of any other persons being mentioned who

might be at risk. For example, during interviews or counseling sessions, the HIV-infected

client might discuss other persons who are not

sex partners but are involved in a sexual or

drug-injection network with high risks of HIV

transmission. Another example is children or

newborns who might have been exposed

perinatally or through breast-feeding. Although not direct sex or needle-sharing partners of the HIV-infected client, these other

persons should be offered HIV prevention

counseling and testing, if resources and program policies permit. General information

obtained through PCRS, not just a persons

name, can be used to identify high-risk places

and venues where PCRS programs can provide

outreach services. CDC encourages such

efforts to identify and lower risks of HIV and

other STDs within sexual or drug-injection

networks and is interested in working with

state and local health authorities to develop

methods and more detailed guidance on network identification, analysis, and intervention.
HIV Partner Counseling and Referral Services

Page 13

3.4.2 But, I Do Not Want My

Partner To Be Contacted!

 Unfortunately,

in some cases HIVinfected clients initially will simply not

want their partners

notified. For example, they might

fear loss of anonymity, the breakup of a

relationship, or other

adverse consequences.

Clients might say that

partners have already

been informed about

their risks or that partners would not be

interested in counseling, testing, or other

support services. Providers can encourage a

clients participation by explaining that the

partner benefits by knowing his or her HIV

status and being able to seek immediate treatment if infected. Also, if infected, the partner

can avoid transmitting the virus to others.

However, when a client is determined not to

disclose partner names, the PCRS provider

should counsel the client as if he or she has

chosen the client-referral approach.

Sometimes a client might not want his or her

partner notified because of fear of a violent

reaction from the partner. It is not uncommon

for persons receiving public health services to

report having experienced violence in their

lives (Maher, 1998). Therefore, providers

should be aware of the potential for partner

violence and should be prepared to make

appropriate referrals. If the provider has

indication of a potentially violent situation for

the client or others, the provider must make

an assessment prior to notifying the partner

and seek expert consultation before proceeding. States have varying legal requirements

about reporting situations such as those involving violence or child abuse. The PCRS

program must comply with relevant state laws

and local regulations.

In some cases, the provider knows of a partner

at risk even though the client has not identified

that partner. Whether or not a legal duty to

warn such partners (or identified partners

that the client did not want notified [see

Appendix B]) exists is best determined by

reviewing applicable state laws or regulations,

especially regarding spousal notification. All

states must have a policy established to guide

health department staff in situations in which

an HIV-infected client indicates he or she does

not plan to notify known partners and will

not provide the information necessary for the

health department staff to make the notification.

The Association of State and Territorial

Health Officials recommends in its 1988 Guide

to Public Health Practice: HIV Partner Notification Strategies that a health care provider may

invoke his or her privilege to disclose (see

Appendix B) when that provider knows of an

identifiable at-risk partner who has not been

named by the HIV-infected person. State and

local HIV prevention program managers

should consider the ASTHO recommendations and their own relevant laws when developing policies and procedures.

3.4.3 PCRS for Needle-sharing

Partners

Sharing of needles, syringes, and other

paraphernalia used for injection drug use (e.g.,

illicit drugs, steroids) carries high risk for

transmission of HIV. Throughout this document, the importance of providing partner

counseling and referral services to HIVinfected clients with needle-sharing partners is

emphasized. CDC recognizes that some HIV

prevention programs have relatively limited

experience in working with needle-sharing

partners and that special issues exist relating to

clients disclosing information about such partners, reaching such partners, deciding which

prevention interventions should be provided,

and referring them for needed services.

CDC-funded

PCRS providers

must review

with the HIVinfected client

in appropriate

detail the legal

and ethical

reasons for

informing sex

and needlesharing partners

of their possible

exposure to HIV.
HIV Partner Counseling and Referral Services

Page 14

Some state and local HIV prevention programs

have already gained considerable experience in

reaching and serving needle-sharing partners

and report that such services are feasible and

likely to be effective. For example, Levy and

Fox (1998) reported that injection drug users

infected with HIV want to notify their sex and

needle-sharing partners and are willing to

participate in the PCRS process. Information

provided by HIV-infected clients who are

injection drug users may help HIV prevention

program managers gain insight into the extent

and types of prevention service needs of injection drug users and how best to deliver and

target such services.

CDC will provide expanded guidance on

PCRS for needle-sharing partners in future

versions of this guidance.

4.0 LOCATING AND

NOTIFYING PARTNERS

4.1 Preparing the PCRS Provider

In large

part, the manner

in which PCRS

is provided to

and perceived

by the affected

communities

determines how

successful HIV

prevention programs will be (see Section 4.5).

Therefore, program managers and supervisors

should ensure that PCRS staff 

w are skilled and competent in providing

PCRS;

w are culturally competent and demonstrate

respect for the community to be served;

w are knowledgeable about HIV infection,

transmission, and treatment;

w are knowledgeable in local, state, and

federal laws regarding HIV and other

relevant issues of providing health

care, especially the right to privacy

and confidentiality;

w receive updated information and periodic

retraining as appropriate;

w have standards, objectives, and specific

guidelines for performance;

w are appropriately supervised and given

written and oral feedback about their

performance on a regular basis; and

w have appropriate problem-solving skills

to deal with situations that might be

encountered in a field setting, e.g., personal safety, violence to others.

In addition to receiving formal training, such

as CDCs training course on PCRS, an inexperienced PCRS provider should complete an

internship by being teamed with a more

experienced provider for a period of time

before conducting PCRS alone (see Section

6.1). Another way to enhance a providers

performance is through routine peer review

of selected cases.

Providers of successful PCRS programs regularly go outside the clinic or office setting to

reach partners. The inexperienced provider

will need training in deciding when to deliver

PCRS outside the office or clinic and when to

postpone PCRS. Benefits of delivering PCRS

in a partners home might include providing

the partner with a familiar environment and

helping the provider better understand the

personal circumstances of that partner.

Whether or not to do PCRS outside the clinic

or office, or whether it is best postponed until

an adverse situation can be resolved, must be

decided on a case-by-case basis. In addition,

training in avoiding confrontations, diffusing

anger, and mediating disputes will better

prepare any provider for handling potentially

violent situations.

Program managers

and supervisors

must ensure that

each PCRS provider

has the appropriate

training and skills to

effectively serve HIVinfected clients and

their partners.
HIV Partner Counseling and Referral Services

Page 15

4.2 Setting Activities in Motion

 For those

partners the provider will be

contacting, the

first step the

provider should

take is to verify

the identifying and

locating information given by the HIV-infected client. Locating

and notifying partners should begin as soon as

possible after the provider and HIV-infected

client have decided on the best approach to use

for each partner and priorities have been set

for reaching partners. If the client will be

informing partners, the client should be wellcoached on how to do so and should be provided opportunities to obtain additional

counseling, assistance, or other support during

the process.

4.3 Maintaining Confidentiality

 Confidentiality

for all persons involved in PCRS must

continue to be maintained. All attempts to

make contact with a

sex or needle-sharing

partner should be

confidential. This is

often difficult because

other community

members might ask the purpose of the

providers visit and why he or she is attempting to make contact. Nevertheless, providers

should not, for example, reveal to others why

they are trying to find a particular person.

Likewise, providers should never leave a note

or message that mentions HIV exposure as the

reason for attempting to make contact. In

addition, no other information should be

revealed that might lead to others learning the

reason for the contact or that might otherwise

lead to disclosure of sensitive information or

to a breach of confidentiality. As each partner

is located, he or she should be informed privately and face-to-face, if at all possible. However, if the person refuses to meet with the

provider, informing a partner by telephone

might become necessary. In such situations,

only limited information should be provided

to the partner, and the goal still should be to

arrange a face-to-face meeting if at all possible.

Informing a partner by telephone should only

be done as determined by state and local

jurisdictions and after every step has been

taken to ensure that the correct person has

been located, is on the telephone, and others

are not listening. Further attempts should be

made to arrange a meeting in person.

The original HIV-infected client will sometimes inquire about the results of the PCRS

providers activities regarding his or her partners. The provider, when requested, can reveal

whether a particular partner has been informed of his or her exposure to HIV, but

must not reveal any confidential information

about that partner, including whether the

partner decided to be tested or whether he or

she is HIV-infected.

Of equal importance is not revealing any

identifying information about the original

client to the partner, including the persons

sex, name or physical description, or time,

type, or frequency of exposure. Although the

PCRS provider will need to document the

results of his or her activities in a thorough,

concise, and timely manner, confidentiality

must still be maintained for all persons involved. Information that identifies partners

should be kept locked in a secure location.

Client and partner information, other than the

official record (as determined by state practice), should be destroyed when current PCRS

activities are concluded.

State or local areas should establish PCRS

record-keeping policies and procedures, and

Locating and

notifying activities

must begin

promptly once the

PCRS plan has

been formulated

and the priorities

set for reaching

partners.

While conducting PCRS

activities in the

community,

providers must

continue to

maintain confidentiality for

all HIV-infected

clients and their

partners.
HIV Partner Counseling and Referral Services

Page 16

client and partner information should be

maintained in accordance with these policies.

Many public health programs have developed

policies and procedures to safeguard sensitive

client or partner information. One example

can be found in CDCs Guidelines for HIV/

AIDS Surveillance, Appendix C, Security and

Confidentiality (as revised October 1998). In

developing their policies, PCRS managers can

choose to review and adapt the policies and

procedures in this document or those of other

public health programs.

4.4 Helping Partners Access

Services

 The PCRS

provider must be

well prepared to

handle the initial

reactions of the

person who is being

informed of possible exposure to

HIV. That person

will undoubtedly

need immediate

counseling, followed by referral to

additional HIV

prevention counseling. The provider

must be prepared

to answer the questions and concerns of

each partner without revealing any identifying information about the original HIVinfected client.

As described earlier, referring partners to

needed prevention, treatment, and other

relevant services is a goal of PCRS. Testing is a

very important issue to persons who have just

learned of possible exposure. The provider

must be prepared to, at a minimum, refer them

to counseling and testing services. For many

years, providers have taken blood specimens of

those who consent at the time of notification,

which requires specialized training. With the

current availability of oral fluid and urine

collection kits, and rapid testing systems,

program managers are encouraged to consider

providing on-the-spot collection of specimens

for HIV testing as each partner is informed. If

the partner has previously been tested, and

those results were negative, the PCRS provider

should stress the need to follow up with

another test if exposure history indicates

it is warranted.

However, many partners will need referrals

for other kinds of social and medical support

services beyond counseling and testing. The

PCRS provider should already have agreements in place and an up-to-date resource

guide so that immediate referrals can be made

to services such as substance abuse treatment,

family planning assistance, other STD treatment, domestic violence prevention, mental

health counseling, or housing assistance (CDC,

1993). Having agreements in place for collaboration between PCRS providers and referral

sources will help ensure that those services can

be successfully accessed. PCRS providers

should then follow up with each partner

contacted to ensure that test results and other

referral services have in fact been received. If

providers in another health jurisdiction have

been asked to contact a partner, health departments should follow up with that provider to

determine that services have been received.

4.5 Addressing Community

Concerns

The potential exists for PCRS to have a

negative impact on HIV-infected individuals,

their partners, or affected communities (Rothenberg and Paskey, 1995; West and Stark,

1997). Some community leaders view these

kinds of activities with suspicion and are

apprehensive about such issues as 

w whether disclosure of partner names is

done voluntarily;

w possible denial of health care or other

services if the HIV-infected client refuses

As each partner

is informed of

possible exposure to HIV, the

PCRS provider

must be prepared to assist

that person with

immediate counseling and referrals for more

intensive counseling as well as

testing and

other support

services.
HIV Partner Counseling and Referral Services

Page 17

to reveal partner names or otherwise

refuses to cooperate with the provider;

w unintended effects on personal

relationships, such as partnership

breakup or violence;

w potential for invasion of privacy or

loss of confidentiality for HIV-infected

clients and their partners; and

w possible discrimination if confidential information held by government agencies is

ever released, either accidentally or by law.

Although PCRS providers cannot always

resolve these issues, they can strive to build

relationships of trust between themselves and

those they serve, including the leaders of

affected communities. Working with HIV

prevention community planning groups and

others when determining and evaluating

priorities, policies, and procedures for PCRS

will help increase community support and

acceptance. PCRS providers should be prepared, whenever an opportunity arises, to

address legitimate concerns and dispel misconceptions about policies and practices

(West and Stark, 1997).

5.0 COLLECTING,

ANALYZING, AND

USING PCRS DATA

5.1 Why Collect Program Data?

PCRS data must be collected and used

(1) to assess the behavioral risks for sex and

needle-sharing partners of HIV-infected persons; (2) to evaluate the effectiveness of the

PCRS program as part of the overall HIV

prevention effort; and (3) to improve how

other HIV prevention activities, interventions,

and services are implemented.

Accurate and consistent data collection is a

critical component for evaluating how effective the PCRS program is, as well as how well

it enhances the overall HIV prevention intervention (CDC, 1994). Moreover, PCRS data

enable providers to better focus prevention

efforts on those persons most at risk. When

the data reveal information about networks of

people who are having sex or injecting drugs,

the dynamics of HIV transmission can be

better analyzed (Fenton and Peterman, 1997),

and more intensive prevention and education

efforts can be applied for specific high-risk

groups (West and Stark, 1997). To do all this,

however, the collected data must be relevant to

behavioral risks, HIV/AIDS prevalence, and

the demographics of affected communities.

With accurate and consistent data, the staff of

health departments and community-based

organizations and members of HIV prevention

community planning groups can establish an

effective mix of prevention strategies.

5.2 What Data Should Be

Collected?

 Any data collection tool used in a

PCRS program should

be designed so that

certain core information can be ascertained,

including answers to

the following:

w What proportion of

HIV-infected clients is

offered PCRS?

CDC-funded

PCRS providers

must collect

data that help

answer key

questions

about how

well the PCRS

program is

functioning,

the extent and

quality of services being

provided, the

degree to

which clients

and their

partners

accept and are

satisfied with

services, and

how PCRS and

other prevention services

can be

enhanced.

CDC-funded

PCRS providers

must use

standardized

data collection

tools throughout

the program

that maintain

the privacy or

confidentiality of

the original HIVinfected client

and his or her

partners.
HIV Partner Counseling and Referral Services

Page 18

w What are the reasons those clients either

reject or accept PCRS?

w What is the range of PCRS services (e.g.,

client referral, provider referral, combinations of referral approaches) offered to

and accepted by each client?

w How many sex or needle-sharing partners

are identified?

w What is the percentage of partners actually reached through PCRS, and how

many of those partners are HIV-infected?

Of those partners who are HIV-infected,

how many are being informed of their

infection for the first time?

w What are the demographics (e.g., marital

status, age, sex, race/ethnicity) of the

clients and partners actually served?

w How many partners are offered referral

services? How many receive these services? In what time frame do they receive

referral services?

And, perhaps most importantly, PCRS program managers should routinely assess what all

of this information means in regard to how

well PCRS is working for HIV-infected clients,

their partners, and the community at large.

Are clients served well? Are partners gaining

access to services that might not be otherwise

available? Are communities becoming more

supportive of public health efforts? Does

evidence exist that risks are being reduced?

Are other prevention program services better

targeted to communities in need?

The HIV prevention program managers in

each health jurisdiction should decide how

best to collect, analyze, and use PCRS data.

This should be done in a manner that is consistent with the policies and procedures that they

have developed to safeguard the security of the

data and the confidentiality of the client or

partner (see Section 4.3). Those managers

should keep in mind that misconceptions

about the collection and use of HIV data, in

addition to a general mistrust of publicly

funded agencies, are two of the biggest barriers

to HIV prevention efforts in affected communities. CDC plans to work with state and local

HIV prevention and STD prevention and

treatment programs to develop proposals for

standardizing the collection and analysis of

PCRS data.

6.0 ENSURING THE QUALITY

OF PCRS

6.1 Training

Of all the resources necessary for

the successful operation of PCRS programs, training is perhaps the most critical

(Fenton and Peterman, 1997). Each individual

PCRS provider must receive initial basic

training plus periodic updates on how to

conduct PCRS (including its scientific rationale), provide client-centered counseling,

protect individuals rights to privacy, use

scientific information in prioritizing partners,

administer HIV tests when appropriate, and

defuse potentially violent situations involving

clients, partners or staff (see Section 4.1).

PCRS providers also need to understand laws

regarding confidentiality of medical records.

6.2 Quality Assurance and

Evaluation

Quality assurance

for PCRS programs

entails ensuring that

appropriate and

standardized methods

are used for 

1. counseling HIVinfected clients

regarding the

notification of

their partners;

2. developing a PCRS plan with HIVinfected clients;

PCRS providers

must be well

trained to provide effective

PCRS services.

CDC-funded

PCRS programs

must have a

quality assurance plan.

CDC-funded

PCRS programs

must evaluate

their services.
HIV Partner Counseling and Referral Services

Page 19

3. prioritizing which partners are to

be reached;

4. locating and informing those partners of

their possible exposure to HIV;

5. providing immediate counseling and

testing services to informed partners

and/or referring them to other service

providers; and

6. collecting, analyzing, using, and storing

PCRS data.

Written job descriptions, including minimum

performance criteria, and comprehensive

procedures for delivering quality PCRS should

be developed and copies made available to all

personnel. Also, supervisors should directly

observe a new PCRS provider until confident

that the provider is proficient in serving clients

and their partners. Then, through periodic

supervisor observation, peer review of selected

cases, and customer satisfaction surveys, each

PCRS provider should be given constructive

oral and written feedback.

PCRS programs should include policies relevant to situations in which an HIV-infected

person knowingly exposes others to HIV.

These policies must comply with relevant state

or local laws.

The overall program should also be regularly

evaluated to determine the quality of effort and

the success in reaching the PCRS goals (Fenton

and Peterman, 1997) (see Section 1.2). Program

evaluations should include a comprehensive

assessment of all confidentiality procedures that

includes, at a minimum, record-keeping.

6.3 How Can CDC Help?

Many types of technical assistance are

available for designing, managing, or evaluating

PCRS through CDCs project officers, program consultants, and network of HIV prevention partners. In addition, training is provided

through CDC and its contractors that is designed to enhance PCRS providers skills

regardless of their level of experience. Finally,

information on the latest scientific findings

about HIV is available through the CDC

National Prevention Information Network

(toll-free, 800-458-5231).
HIV Partner Counseling and Referral Services

Page 20

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Fenton, Kevin A., and Peterman, Thomas A.

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REFERENCES (Continued)
HIV Partner Counseling and Referral Services

Page 22

 All PCRS programmatic standards are

listed here, followed by a reference to the section of this document where a discussion of

that standard and other related guidance can

be found.

w All CDC-funded HIV prevention counseling and testing sites, both confidential

and anonymous, must make PCRS available to all HIV-infected persons.

(Section 2.1)

w CDC-funded programs must provide

access to PCRS for persons testing anonymously without requiring that the infected client disclose his or her identity.

(Section 2.1)

w Requests for PCRS from other health

jurisdictions must be accommodated

whenever practical. (Section 2.2)

w PCRS providers must ensure that clients

are aware that all information disclosed

by them will be kept strictly confidential

and that participation is always voluntary.

(Section 3.1)

w To foster an atmosphere of trust, PCRS

providers must treat all HIV-infected

clients and their partners with respect.

(Section 3.1)

w Persons entering CDC-funded HIV

prevention counseling and testing programs must be counseled at the earliest

opportunity about PCRS and options for

informing sex and needle-sharing partners

of possible exposure to HIV. (Section 3.1)

w The PCRS provider must explain to the

HIV-infected client the options for serving partners and then assist that client in

deciding on the best plan for reaching

each partner confidentially and referring

him or her to counseling, testing, and

other support services. (Section 3.2)

w The PCRS provider and HIV-infected

client must prioritize reaching partners

based on who is most likely to transmit

infection to others and who is most likely

to become infected. (Section 3.3)

w CDC-funded PCRS providers must

review with the HIV-infected client in

appropriate detail the legal and ethical

reasons for informing sex and needlesharing partners of their possible exposure to HIV. (Section 3.4)

w Program managers and supervisors must

ensure that each PCRS provider has the

appropriate training and skills to effectively serve HIV-infected clients and their

partners. (Section 4.1)

w Locating and notifying activities must

begin promptly once the PCRS plan has

been formulated and the priorities set for

reaching partners. (Section 4.2)

w While conducting PCRS activities in the

community, providers must continue to

maintain confidentiality for all HIVinfected clients and their partners.

(Section 4.3)

w As each partner is informed of possible

exposure to HIV, the PCRS provider

must be prepared to assist that person

with immediate counseling and referrals

for more intensive counseling as well as

testing and other support services.

(Section 4.4)

w CDC-funded PCRS providers must

collect data that help answer key questions about how well the PCRS program

is functioning, the extent and quality of

services being provided, the degree to

which clients and their partners accept

and are satisfied with services, and how

PCRS and other prevention services can

be enhanced. (Section 5.2)

APPENDIX A

PCRS PROGRAMMATIC STANDARDS
HIV Partner Counseling and Referral Services

Page 23

w CDC-funded PCRS providers must use

standardized data collection tools

throughout the program that maintain

the privacy or confidentiality of the

original HIV-infected client and his or her

partners. (Section 5.2)

w PCRS providers must be well trained to

provide effective PCRS services.

(Section 6.1)

w CDC-funded PCRS programs must have

a quality assurance plan. (Section 6.2)

w CDC-funded PCRS programs must

evaluate their services. (Section 6.2)

PCRS PROGRAMMATIC STANDARDS (Continued)
HIV Partner Counseling and Referral Services

Page 24

APPENDIX B

GLOSSARY OF TERMS ASSOCIATED WITH PCRS

Client-Centered Prevention Counseling conducted in an interactive manner that is

Counseling responsive to the individuals needs. This approach requires

an understanding of the unique circumstances of the client 

behaviors, culture, knowledge, and social and economic

status.

Client Referral Approach A PCRS approach whereby the HIV-infected client informs

his or her partners of their possible exposure to HIV and

refers them to counseling, testing, and other support services.

Confidential Requirement that all personally identifying records be kept

secure in a locked file and that no information be released to

anyone without signed authorization from the client.

Contract Referral Approach A PCRS approach whereby, if the HIV-infected client is unable to inform a partner within an agreed-upon time, the provider has the permission and information necessary to do so.

Dual Referral Approach A PCRS approach whereby the HIV-infected client and the

provider inform the partner together.

Duty To Warn A legal concept indicating that a health care provider who

learns that an HIV-infected client is likely to transmit the

virus to another identifiable person must take steps to warn

that person; state laws determine what actually constitutes a

duty to warn.

Partner A person who shares sex or drug-injection needles with

another.

PCRS Partner counseling and referral services.

PCRS Provider A wide variety of qualified, trained health care professionals

including physicians, nurses, counselors, disease intervention specialists, and others.

Prevention Counseling Guiding a clients understanding of his or her perception of

risk for becoming infected with HIV and developing a plan

for reducing that risk for themselves and their partners.

Privilege To Disclose Guidance for a PCRS provider who knows the identity of a

partner at risk for HIV, whom the infected client is unable or

unwilling to inform; usually guided by state laws.

Provider Referral Approach A PCRS approach whereby, with the permission of the HIVinfected client, the provider informs the partner and refers

him or her to counseling, testing, and other support services.
HIV Partner Counseling and Referral Services

Page 25

Spouse A legal marriage partner as defined by state law (for purposes

of the requirements of the Ryan White CARE Act).

Window Period Period of time in between initial infection of HIV and development of a positive antibody test for HIV. The window

period can last anywhere from about 2 weeks to (rarely) a

year, although antibodies will usually be detected within 3 to

6 months.

GLOSSARY OF TERMS ASSOCIATED WITH PCRS (Continued)
HIV Partner Counseling and Referral Services

Page 26

ACKNOWLEDGMENTS

The following Centers for Disease Control and Prevention staff made substantial contributions in

the preparation of this document:

Dave Brownell, M.P.H.

Division of HIV/AIDS Prevention

Steven J. Davis

Division of HIV/AIDS Prevention

Susan DeLisle, A.R.N.P., M.P.H.

Division of STD Prevention

Linda Elsner

Division of HIV/AIDS Prevention

John H. Glover

Division of STD Prevention

Robert Janssen, M.D.

Division of HIV/AIDS Prevention

Robert Kohmescher, M.S.

Division of HIV/AIDS Prevention

Kellie E. Lartigue

Division of HIV/AIDS Prevention

Jill K. Leslie

Division of HIV/AIDS Prevention

Beth A. Macke, Ph.D.

Division of STD Prevention

Julie E. Maher, Ph.D.

Division of HIV/AIDS Prevention

C. Kay Smith-Akin, M.Ed.

Division of HIV/AIDS Prevention

Steven Stewart, M.S.

Division of HIV/AIDS Prevention

Gary R. West, M.P.A.

Division of HIV/AIDS Prevention

Linda Wright-DeAgüero, Ph.D.

Division of HIV/AIDS Prevention