Intentions to use patient-initiated partner notification and acceptability of provider-initiated partner notification for Sexually Transmitted Infections – A cross-sectional survey among minibus taxi drivers in Gauteng Province, South Africa

Background In South Africa, utilization of patient-initiated partner-notification (PN) using referral-slip in the management of sexually transmitted infections (STIs) is limited and only a limited number of sexual partners are ever notified. The study assessed the use of patient-initiated PN method using notification and referral slips and measured the level of acceptability of provider-initiated PN using short-message-service (SMS) to personal mobile phones of sexual partners. Methods A quantitative survey using anonymous structured self-administered and researcher assisted questionnaires was conducted among minibus taxi drivers in the nine major taxi ranks in Gauteng province, South Africa. Results The sample consisted of 722 minibus taxi drivers with a mean age of 37.2 years old, 284 (59.5%) had multiple sexual partners, 368 (52.2%) did not use a condom during last sexual act, 286 (42.8%) reported inconsistent use of condoms, and 459 (65%) tested for HIV in the past 12 months. Majority (n=709, 98.2%) understood the importance of PN once diagnosed with STI, but would prefer delivering PN referral slip (n=670, 93.2%) over telling a partner face to face if they themselves were diagnosed with STI. Acceptability of provider-initiated PN using SMS was 452 (62.7%) and associated with history of HIV testing in the past year (OR=1.72, p=0.002, CI: 1.21-2.45). The perceived use of PN referral-slip from sexual partner to seek treatment was 91.8% (n=659). About a third (n=234, 32.5%) were not in favor of provider-initiated PN by SMS and preferred telling partners face to face. Conclusion There were contrasting findings on the acceptability and utilization of existing patient-initiated PN and the proposed PN using SMS from health providers. The preference of delivering PN referral slip to sexual partner over face-to-face PN renders communicating about STIs the responsibility of health providers. Therefore, they have an opportunity to provide patients with options to choose a PN method that is best suited to their relationships and circumstances and modify PN messages to encourage partners to use the different PN to prevent STIs.


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South Africa's burden of disease due to sexually transmitted infections (STIs) is currently one of 58 the largest in the world and this is true for all STIs, including HIV and human papilloma virus [1]. 59 The significantly high prevalence of sexually transmitted infections (STIs) in Sub-Saharan Africa 60 poses a threat because of the increased risk of HIV transmission [2]. In the African region, among 61 the population group of 15 -49 year of age, STI prevalence and incidence for four curable STIs 62 (chlamydia, gonorrhea, syphilis and trichomonas) was 19.4% and 24.1% [3][4][5]. The prevalence of 63 syphilis among attendees of antenatal care in South Africa was 1.5% in 2011 [6]. From 2010From -2011 the STI incidence for South Africa was 3.9% [7]. Kenyon and colleagues reported prevalence of 65 syphilis and male urethral discharge in South Africa at 8.3% and 13.8% respectively [4]. as patient-initiated PN using a notification and referral slip [11]. The process of PN using referral 83 slips starts as the healthcare provider gathers the number of sexual partners from the patient and 84 issues the relevant number of anonymous referral slips. The anonymous referral slips contains 85 information about the risk of STI to the sexual partner and an invitation to receive treatment at a 86 convenient health facility for sexual partners. The patients are then required to deliver the slips to 87 their sexual partner within a period of a week and hence the name patient-initiated PN [11].

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The utilization of patient-initiated PN is limited due to under-reporting of the number of sexual 90 partners by the patients. Under-reporting the number of sexual partners reflects HCWs issuing less 91 notification and referral slips [12,13]. Under-reporting occurs due to reluctance to openly discuss 92 sexual issues, the biological nature and characteristics of the STIs, and due to fear of moral 93 judgment [1,5]. Moreover, individuals rarely inform their sexual partners after diagnosis and 94 treatment for STIs and in cases of multiple and concurrent sexual partnerships, the patient may not 95 have the contact details of the casual sexual partner or they may not particularly care for the 96 partner and hence see no need to notify them [12,15,[17][18][19][20]. Failure to inform sexual partners of 97 their exposure to STIs increase the risk of STI transmission to other sexual partners who remain 98 asymptomatic, and continuous infection of new partners and re-infections [19].

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The extent of the STI problem and the association with HIV transmission highlights the need to 101 continue and strengthen prevention and control of STIs [4]. The effective treatment and control of 102 STIs depends on screening to detect and treat STIs among the sexual partners of the STI infected 103 patients, which is dependent on the patient-initiated PN practices using referral slips in the South 104 African treatment protocol. In addition to the patient-initiated PN practices, provider initiated PN 105 such as text messaging, the internet, and phone calls are promising strategies to expand PN 106 services [14,15,18]. The benefits of provider-initiated PN are that electronic messages may 107 enhance rapid notification because they can reach partners who may be geographically dispersed, 6 108 are likely to be used with partners who may not be notified otherwise, and come at a low cost [18].

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Provider-initiated PN using short-message-service (SMS) presents as an additional and promising 110 strategy for control and prevent STIs in South Africa [12,13,15]. . HIV infection amongst minibus taxi drivers is a concern, because of the occupational demand 115 of being away from their families for long times and in some cases being exposed to unhealthy  A quantitative survey using anonymous structured self-administered and researcher assisted 163 questionnaires was conducted. The survey was the first stage of a large formative evaluation 164 project, which utilized a mixed method approach employing quantitative and qualitative methods 165 to assess the acceptability and feasibility of implementing STI provider-initiated PN using SMS.

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High-risk populations were the target population for the study and they include minibus taxi 167 drivers, out of school youth and young adults accessing primary health facilities, and university 168 students in Tshwane District, Gauteng province, South Africa. This paper presents the findings frm a 169 sample of the minibus taxi drivers.

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Study population and sample 172 The survey was conducted in nine major minibus taxi ranks and all drivers working in the selected 173 ranks formed the study population. Systematic random sampling of taxis that were waiting to load 174 passengers was performed. The driver of the first minibus taxi was randomly selected from a list of 175 taxi queue controllers, and then the driver of every third minibus taxi in the queue was requested to 176 participate in the study.  provider-initiated PN in developed countries [13,18]. The barriers to successful implementation of 260 patient-initiated PN using referral slips were mentioned earlier in the manuscript. The concern is 12 261 that South Africa has a high burden of STIs but it still relies on this strategy since the

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The findings further suggest that PN could even be less in developing countries since the current 303 PN and referral practices using referral slips fail to reach the majority of partners [16,27,28]. Delivering a partner notification referral slip together with using a PN referral slip received from a 360 sexual partner were preferred by the minibus taxi drivers. Another important finding is that over a 361 third of minibus taxi drivers were not in favor of PN by SMS from a health care provider and 362 preferred telling partners face to face. These findings raise concern on why now is the current 363 patient initiated PN using referral slip is not working if it is the preferred method. This suggest that 16 364 PN protocol should be flexible to allow health care providers to provide patients with options of a 365 PN method that is best suited for the patient relationship and circumstance.

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The challenges to notify the partner about a STI diagnosis face-to-face might explain the high 367 acceptability of provider-initiated PN using SMS from a healthcare provider. Using SMS has an 368 element of anonymity that delinks the index case from the STI diagnosis while offering the partner 369 the opportunity to seek treatment. This would make sense in high-risk populations with multiple 370 sexual partners and casual sexual relationships such as the current study sample.