Counseling on STI Referral Is Linked to Increase In Partner Testing Rate
Providing STI clinic attendees with a single brief counseling session on the importance of referring their partners increases by about 30% the likelihood that their partners will come to the clinic for STI testing.1 In a quasirandomized trial conducted at six STI clinics in Bangladesh, 37% of clients who underwent the counseling session referred their partners for treatment, compared with 27% of those who simply received a referral card. Clients who were aged 18–25, had lower incomes or reported having commercial sex partners were less likely than others to refer their partners for STI testing.
The trial was conducted in 2007 at three public hospitals and three nongovernmental organization (NGO) clinics in the districts of Dhaka and Chittagong. Clients aged 18 or older were eligible for the study if they had a newly diagnosed STI and had been sexually active in the previous three months. Those who agreed to participate received the facility's standard care, which included clinical consultation and prescriptions for free or subsidized medicine, as well as referral cards to be given to their partners. After treatment, participants provided information on their demographic and other characteristics and on their sexual behavior, and were instructed to tell their partners to bring the referral cards back to the clinic within one month so that the partners could be tested for STIs. Those assigned to the counseling group then received a 10–15 minute session on the importance of referring partners for STI testing; topics included the frequency of asymptomatic infections, the risk of developing complications from untreated infections and the possibility of reinfection if partners are not treated at the same time.
The researchers compared partner referral rates between clients who received counseling and those who did not. Univariate and multivariate regression analyses were conducted to examine the effect of counseling on referral rates. The researchers note that the study was a quasirandomized, rather than randomized, study, because clients were not randomly assigned to the counseled or noncounseled groups; instead, the first participant at each clinic was randomly assigned to one of the groups, the next participant was assigned to the other group, and subsequent assignments alternated accordingly.
In all, 1,339 clients accepted referral cards, and 675 received counseling. The counseled and noncounseled groups were similar in most respects: About 55% of participants were female, 74% were married, 95% were Muslim and 53% were attending an NGO clinic. In addition, the two groups had similar proportions of participants who cohabited with their partner (65%), had concurrent partners (44%), had had more than one partner in the previous three months (22%), had had a commercial sex partner in the previous three months (39%) and had used a condom at last sex (8%). However, a higher proportion of counseled than noncounseled clients accepted referral cards (84% vs. 79%); regardless of whether they received counseling, most of those who declined the cards were male (92%), were single (79%) and reported having had commercial sex partners (86%).
Thirty-two percent of participants referred their partner for treatment, but the proportion was significantly higher in the counseled than the noncounseled group (37% vs. 27%). In both groups, the rate of partner referral increased with clients' age and income, and was higher among participants using NGO clinics than among those using public hospitals, higher among those who had had one partner in the past three months than among those with multiple partners, and higher among those who had not had any commercial sex partners than among those who had. However, in each of these categories, referral rates were elevated among participants who received counseling. For example, among clients aged 30 or older, 42% of those in the counseled group referred their partner, compared with 33% of those in the noncounseled group.
These findings were mirrored in the multivariate analysis. Participants in the counseled group were more likely to refer their partners for STI testing than were those in the noncounseled group (prevalence ratio, 1.3). Clients aged 18–25 were less likely than those aged 30 or older to refer their partners (0.8). Those with lower incomes (0–5,000 or 5,001–10,000 taka) were less likely than those in the highest income category (10,001 taka or more) to refer their partners (0.7 and 0.5, respectively). Finally, those who reported having had at least one commercial sex partner in the past three months were less likely than those who did not to refer their partners for testing (0.5).
The researchers acknowledge some limitations of their study. Participants in the noncounseled group, like their counterparts in the counseled group, received referral cards; this may have increased partner referral rates for both groups and reduced any differences between them. In addition, because the interviewer who provided the counseling sessions also collected participant information from both groups, some "information contamination" concerning the importance of referrals may have occurred that diluted the effects of the counseling. Despite these limitations, the researchers believe that any differences between the groups can be attributed to the counseling session. They conclude that more research is needed to identify "the most effective counseling strategies to maximise partner referral, especially for low-income cases."
1. Alam N et al., Effect of single session counselling on partner referral for sexually transmitted infections management in Bangladesh, Sexually Transmitted Infections, 2011, 87(5):46–51.