Partner notification (PN) is the process whereby the sexual partner(s) of a patient diagnosed with a sexually transmitted infection (STI) who presents for care is identified and informed of his/her exposure. The partner(s) is then invited to attend for testing, counselling, and, where necessary, treatment.1

Although several studies analyse interventions to prevent transmission of HIV among men who have sex with men (MSM)2–6 based on new information and communication technologies, most explore rates of HIV testing. Very few explore PN practices. Evidence-based reviews show the effectiveness of PN in identifying persons at risk of STIs/HIV infection,7 and the public health benefits of PN have recently been highlighted in Europe1. Nevertheless, websites have been used to facilitate PN in Canada and the USA,8 Australia,9 Romania8, and the Netherlands.10

The results of studies evaluating one of these sites, “in SPOT”,11–13 are controversial. While some authors find limited evidence of its effectiveness for PN among MSM, others emphasize the higher accessibility to at-risk populations with Internet PN using pseudonyms14 and the broad acceptability of receiving and sending a notification e-mail15,16 or SMS.17

PN in Spain is by voluntary verbal notification from patients to partners following advice from a clinician. The increasing use of the Internet and other new communication technologies to seek sexual contacts highlights the potential for exploring how these technologies could facilitate PN and thus prevent transmission of STIs/HIV infection.18

Anonymous sexual partnering makes PN almost impossible; however, finding ways to optimize notification among traceable partners based on new communication technologies may increase the number of partners identified. In some Spanish autonomous communities, such as Catalonia, patient referral PN is already in place in the main STI Units, despite significant difficulties in regularly assessing the “yield” of PN in both MSM and heterosexuals. Nowadays, medical and public health practitioners are convinced of the need to strengthen and update this practice, using both traditional methods and new communication technologies (e-Cards, mobile phone, blogs, social networking sites).19

Internet-based PN methods for MSM have proved to be well accepted20 and effective21 in the USA, although not much is known about their acceptability in Spain, or even in Europe.

Among MSM, the rise in the incidence of STIs22 and risky sexual behaviours, the association between searching for sexual partners’ on the Internet and an increased risk of STIs,23 and low levels of PN24 justify a study to explore the intention to use new communication technologies for PN in Spain.

The aim of this study was to describe current PN practices and assess the intention to use new information and communication technologies for notifying partners of STI/HIV infection among MSM in Spain.

We conducted a survey that was administered in two formats. The first format was an online survey advertised on three web pages: one for sexual contacts (Chueca) (http://www.chueca.com), an online magazine (Universo gay) (http://www.universogay.com) and a lesbian, gay, transgender and bisexual web page for Barcelona (http://www.stopsida.org). The questionnaire was administered to participants throughout Spain using an online survey service (http://www.surveymonkey.com) from 27th June to 1st October 2013. The second format was a centre-based survey, which involved a pen and paper questionnaire and was offered at three different venues in Barcelona: an STI Unit, an HIV outreach program run by the Public Health Agency of Barcelona for the users of a gay sauna and a lesbian, gay, transgender and bisexual social facility. Informed consent was obtained for both formats of the study.

The study measures and procedures were approved by the Clinical Research Ethics Committee of University Hospital Germans Trias i Pujol in Badalona, Catalonia, Spain.

This survey used a convenience sample of at least 100 questionnaires completed at the STI Unit, 50 at the lesbian, gay, transgender and bisexual social facility and 50 at the HIV outreach program of the Public Health Agency of Barcelona.

Participants were recruited opportunistically when attending the centre and were eligible if they were 18 years of age or older, living in Spain and had had sex with another man any time in their lives.

In this study, we used online and centre-based questionnaires to explore what was and would be done in the event of being diagnosed with an STI or HIV infection, whether PN would vary by type of relationship (stable or casual) and what the preferences would be for the use of new technologies. Sociodemographic characteristics differ depending on the source of information (online or centre), with centre-based respondents being older and more frequently having had a previous STI/HIV infection. The intention to notify is higher among centre-based respondents and within stable relationships. Conversely, the intention to use a web page to notify was highest among online respondents. On the other hand, neither age group nor educational level seems to affect the intention to use a web page for PN.

Participants recruited through the STI Unit were guided by STI specialists and were more likely to notify their partners of a recently diagnosed STI.

Of note, respondents reported that they did not notify partners for the following reasons: “I didn’t know how to do it”, “My doctor didn’t advise me” and “I never thought about it”. Consequently, raising awareness among GPs and other medical staff combined with counselling for STI/HIV infection could improve PN.

Because the main reasons for not having notified a partner were “I didn’t know my partners” and “I didn’t know how to do it”, the main challenges in PN arise from anonymous or non-contactable partners. In this regard, new communication tools such as gay web pages, social networks and mobile applications may help to identify otherwise untraceable individuals. Encouragement by health professionals to contact partners by mobile phone while the patient is still in the clinic could speed up the consultation process and the diagnosis and treatment of partners.

Once an exposure is notified, half of the respondents would consult an STI specialist and 30% a family doctor. This indicates that the STI Unit and primary care centres are key locations for promoting alternative methods of PN as a complement to the standard notification card used in patient referral PN.

In the present study, 37% of respondents reported a clear intention to use a web page to notify partners, and 26% did not know whether they would use one. This finding may be attributable to cultural issues or a preference for face-to-face contact rather than technology-based communication.

The preferred web page was “one that was specifically designed to notify” followed by the “one linked to web pages used to look for sexual partners” and a “web page with the option of sending anonymous SMS”. These three options could be easily merged when designing a public health intervention. Cost issues related to staff training, monitoring and program evaluation could arise, although expert opinion suggests that online PN systems are relatively inexpensive25 and that there is potential for email and text-notification to improve the efficiency and cost-effectiveness of PN.26 Nevertheless, this hypothesis has to be assessed locally. Furthermore, a very recent evidence review of new technologies for PN of STI concludes that the importance of technology in the prevention and treatment of STI is expected to increase.27 Our results suggest that some types of new technology solutions for PN among MSM may be more acceptable than others depending on age, education level and type of relationship.

The fact that “shame or fear” is the main reason for not intending to notify a stable partner warrants further analysis in order to explore ways to overcome this barrier. For example, societal changes could be promoted to reduce the stigma of STI/HIV infection, and sexual health information could be provided on the benefits of PN. Not surprisingly, other studies28 have also found that up to one-third of patients fail to tell all their partners because of embarrassment or fear.

Consistent with the results of other studies,29 we found that the preferred method of notification is face to face, although most of the additional comments are along the lines of “as long as I get to know it, it doesn’t matter how”. “Identifiable SMS” and “a webpage using a pseudonym” or “SMS using a pseudonym” are also mentioned as good PN methods. Surprisingly, these methods differ substantially, and further research should be conducted to characterize discrepancies.

Experiences that enhance PN through new information and communication technologies are currently being used throughout the world. Examples include the use of Facebook in the USA,30 the “suggest a test” project/intervention in the Netherlands,31 and “Let them know”32 and “the Drama Downunder”33 in Australia. These experiences should lead to the revision of the PN strategies used to date in Spain.

“Canal Salut”34 is an evidence-based health-related website run by the Catalan Department of Health with a section on promotion of sexual health for young people that could host a section to support PN in both this group and in MSM.

First, we report on practices related to STI in general without differentiating between HIV and other STI; therefore, some of our findings may not be representative of HIV infection in general.

Second, online sampling may lead to biases in demographic characteristics and other risk factors,35,36 and although we tried to minimise this by using different survey delivery methods (online and centre-based), the sample sizes obtained in the different sub-groups of the centre-based questionnaire are too small to detect significant differences. Therefore, selection bias cannot be ruled out.

Many highly educated MSM respondents are more likely to use novel technologies for PN than those who have a lower educational level and less access to mobile applications or online partner referral. Therefore, because those recruited through the Internet may not be representative of all MSMs, the generalizability of the results is questionable.

Thirdly, the use of multiple-choice questions makes results difficult to interpret, thus limiting multivariate analysis and weakening the robustness of the analysis.

Finally, although unlikely, respondents may have participated more than once, as it was impossible to identify duplication directly on the web page or resulting from respondents completing both the centre-based questionnaire and the online questionnaire.

This is one of the first surveys to analyse the intention to use new communication technologies for PN among MSM in Spain.

Our data reveal differences depending on the source of information (online or centre) and type of partner (stable or casual). Patients attending an STI clinic tend to notify more frequently and to prefer personal approaches, and MSM are more likely to notify to their stable partners than their casual ones. Nevertheless, half of the respondents are open to new technologies (Internet, SMS, mobile phone apps) to notify their casual partners, indicating that this approach should be promoted among MSM and health professionals.

Fighting stigma and promoting alternative methods of PN through new technologies could increase the frequency of PN. Such an approach will improve early detection and reduce transmission of STIs/HIV in Spain.

Conceived and designed the study: DCP, MJB, PFD, PGO, RM, CJA and JC

Performed the study: DCP, MJB, PFD, PGO, RM, CJA, MPS, MGE, and EAM

Analysed the data: DCP

Wrote the manuscript: DCP and all the authors contributed with comments to the manuscript.

No funding

There is no conflict of interest