Key messages

What is already known on this topic:

What this study adds:

Digital partner notification (PN) is a poorly defined concept, which includes various digital interventions for notifying partners, facilitating partner testing and/or supporting partner treatment (comprehensive partner management).

Most current digital PN focuses on notification rather than comprehensive partner management.

How this study might affect research, practice or policy:

Existing evidence suggests that digital PN could increase the number of partners notified but robust evidence of effectiveness is lacking.

Studies are needed to determine how best to use digital PN within a wider menu of PN options, which include in-person approaches.

Introduction

Partner notification (PN), also known as contact tracing, is a complex intervention involving contacting, testing and sometimes treating partners of people with diagnosed sexually transmitted infections (STIs) including HIV.1 2 PN is an important strategy for identifying asymptomatic infection in people at risk of STIs. This can prevent adverse health consequences through early treatment of infection and can be an opportunity for the provision of prevention interventions, such as vaccinations, HIV pre- and post-exposure prophylaxis as well as behavioural interventions and health counselling.3 4

The two main types of PN are (1) patient referral, where the index patient informs their sexual partner/s about the infection and advises them to access testing and treatment2 and (2) provider referral, where a healthcare professional (HCP) informs the sexual partner/s about the infection and facilitates testing and treatment. Provider referral often anonymises the index patient’s identity.5

Digital technologies could improve the effectiveness and efficiency of PN by reducing the time to notify partners, such as through short message service (SMS), email or instant messaging. If combined with remote self-sampling for STI and HIV testing,6 digital interventions could also facilitate partner testing and treatment access via electronic prescriptions or vouchers. Since 2007, improved access to mobile internet7 makes digital health interventions feasible across many settings and could improve PN outcomes.8

Although several digital PN technologies have been evaluated,9–11 there are no published reviews systematically synthesising findings from the peer-reviewed evidence base, across multiple health systems, and including STIs and HIV. To inform the design of a novel online STI PN and comprehensive partner management system, we conducted a scoping review to: (1) summarise the types of digital PN technologies used and describe the study designs; (2) describe the outcomes measured; (3) to understand the acceptability of and (4) preferences for digital PN in comparison to non-digital PN for index patients and partners.

MethodsDesign

A systematic scoping review was conducted, as the nature and content of available literature suggested considerable heterogeneity of study design and outcomes assessed. The review is reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis extension for Scoping Reviews guidelines (online supplemental appendix A).12

Eligibility

As digital health is a developing field, broad inclusion criteria were set to ensure all relevant articles were sourced, including hypothetical preference studies (see box 1). Digital PN was defined as PN occurring through SMS, emails, purpose-built PN websites, smartphone apps and websites for geosocial networking (GSN)/dating/social networking/instant messaging and online sexual health clinics. When used for the purposes of PN, this paper will refer to these technologies as digital interventions. There was a step change in digital technology and internet access from 2007, with the introduction of smartphones, and as there is a lag between the introduction, uptake and evaluation of interventions utilising these technologies, articles that collected data from January 2010 were reviewed.

Box 1 Inclusion and exclusion criteriaInclusion criteria

Full-text available online.

Available in English.

Digital partner notification and/or management.

Patient or provider initiated.

Outcome data for digital partner notification (PN) (including hypothetical).

Peer-reviewed articles.

Exclusion criteria

Type of digital PN intervention not specified.

Non-digital PN.

Telephone call PN where this was the only digital PN intervention offered.

Data collected prior to 2010.

Search strategy

A systematic search and data extraction were conducted on three occasions (4 March 2021, 3 December 2021 and 27 July 2023), across eight databases: CINAHL Plus, Cochrane Library, Embase, Medline, NHS Evidence, PsycINFO, Scopus and Web of Science. Additional papers were sourced via an institutional database, Google Scholar and manual reference list searching. Detailed search terms are listed in online supplemental appendix B.

Source selection

Search results were exported to Endnote and duplicates were removed. Titles and abstracts were screened, and full-texts were assessed for eligibility. The screening of the articles was led by one person (CW, SB, AM-D) and was done in conjunction with the research team (JG, KCL, JS). Where there was uncertainty, full-texts were reviewed by at least one other member of the team and consensus was reached through discussion. A data extraction table was used to summarise study characteristics, the digital PN intervention, study design and outcomes. Findings were organised into themes describing acceptability of and preferences for digital PN in comparison to non-digital PN.

Appraisal and analysis

Articles were appraised by CW using the Mixed Methods Appraisal Tool (MMAT),13 which accounts for study heterogeneity (online supplemental appendix C). Quantitative and qualitative data were synthesised and analysed thematically using an inductive approach, where themes were iteratively defined and refined throughout the analysis.

Discussion

This paper is the first to systematically synthesise findings related to digital PN across STI and HIV service delivery systems. This review updates and expands previous reviews of digital PN, which were limited by the available literature, poor generalisability10 11 and weaker search strategy methods.9 Included studies were heterogeneous and mainly conducted in high-income countries. Many hypothetical preference studies were found. Digital PN was a poorly defined concept, covering a wide range of interventions including SMS, email, purpose-built PN websites and apps, with anonymous and index patient identifiable PN options. Most studies focused (and reported outcomes) on enhancing notification of partners about their risk of STIs/HIV and partner acceptability of receiving this notification, with fewer studying partner testing and treatment. Additionally, the majority of partner-related outcome data were sourced from provider-led PN, specifically DIS in the USA.

Few studies considered partner perspectives or outcomes on index patient-initiated PN. Many studies included hypothetical preference designs, which may not translate into real-world choices. Indeed, there was a contrast in findings between hypothetical PN interventions and implemented interventions in the type of PN used. Few studies separated digital PN for bacterial STIs from HIV PN, which is conducted differently in many healthcare settings.3

In general, index patients preferred face-to-face PN,15 31 41 but might choose digital PN for casual partners15 16 21 35 and particular infections.16 20 However, a lack of partner contact details guided the choice by reducing feasible options.17 19 41 Two studies concluded that digital PN was preferable from a partner perspective17 27 and two studies suggested that an anonymous function would increase PN rates.15 42 Nevertheless, anonymous PN was not preferred by partners.17 20 Few studies reviewed differences in partners’ intention to seek consultation/testing following different PN types.17 18 For HIV PN,15–20 23 24 27–30 34 35 40 42 acceptability and uptake of digital interventions were inconclusive; a single study showed no statistically significant differences in use of the digital PN intervention versus other options.23

Overall, the finding that digital PN is potentially advantageous in reaching partners not currently reached by traditional PN but may continue to be used as a secondary option where face-to-face PN is available, is consistent with the conclusions from a previous review.9 As reported in previous reviews,10 11 the evidence base has continued to report improved PN success with HCP/DIS-initiated PN, where digital PN is mostly used when traditional methods are not available. This review adds that available contact information may influence partner-initiated PN as well. Anonymous notification was not preferred by partners,17 20 however the effect on partner outcomes remains unclear. This finding is consistent with a previous review,9 despite the increase in acceptability studies. A novel finding in this review is that privacy concerns and fear of misuse of digital PN are important influencers of digital PN acceptability. The lack of standard definitions for digital PN, such as internet PN, and partner types and the limited descriptions of the digital interventions provided, made comparisons between studies challenging in this and previous reviews.

Strengths and weaknesses

This study uses robust methodology to review a disparate evidence base.13 Findings could assist countries grappling with STI control and those seeking to achieve HIV transmission elimination.3 4 To our knowledge, this is the first systematic scoping review of digital PN for STIs including HIV, in diverse population groups, from any healthcare and income setting, However, the literature on which this review is based remains limited. Restricting the search strategy to articles written in English and available online may have excluded useful studies.

Future interventions

Although digital PN is acceptable and may be preferable in certain circumstances, most reported interventions focused solely on notification did not offer facilitation of sex partner management and did not assess sex partner or health economic outcomes.22 24 39 As with non-digital PN, choices and outcomes may be more related to partner type than demographics and/or sexual behaviours.43

Index patient and sex partner acceptability and preferences for different types of PN both digital and non-digital did not always overlap. Hypothetical acceptability suggested that anonymous PN would increase PN rates. However, anonymous notification was not preferred by partners17 20 and, therefore, might not increase partner testing or treatment, partly due to legitimacy concerns. This highlights the importance of considering both index patient and partner perspectives when providing PN services.

Blended interventions with both digital and non-digital components might increase acceptability for a wide range of partner types, for example, index patients could inform their established partners in person and then link them to digital interventions to help them access testing and treatment, such as electronic treatment vouchers32 and prescriptions22 or providing clinic information and the ability to share results directly to clinicians.34 Whilst digital interventions may improve accessibility and effectiveness of interventions, integrating these with preventative services is necessary.

Future research

A standard classification of partner types would help determine which PN methods work best for whom.44 A common set of PN outcome measures would enable more robust comparison of outcomes between studies.45 This level of understanding will be essential to inform optimal partner management in ‘high stakes’ bacterial infections such as multidrug resistant Neisseria gonorrhoeae, and Mycoplasma genitalium, where partner management and intensity of PN effort may vary depending on partner characteristics.

Internet PN should be clearly defined to be inclusive of different technologies used to enable comparison of the associated strengths, weaknesses and acceptability.

The place of digital PN in HIV PN is unclear. The appropriateness of digital interventions could vary substantially across countries, reflecting factors such as HIV criminalisation.45 Future research is needed to assess the suitability of digital PN interventions across different settings.

A cost-effectiveness analysis of digital PN is required, particularly when digital PN is used in combination with traditional services.

Conclusions

Although index patients and their sex partners expressed an overall preference for non-digital (face-to-face) PN, digital PN interventions could play a useful role in improving PN and partner outcomes for one-off or casual partners and for bacterial STIs rather than HIV. To improve PN outcomes more broadly, digital PN should be offered as part of a menu of options, which include interventions which may require tailoring to different partner types and to different infections (bacterial infections as compared with HIV). Current digital PN interventions could be enhanced to incorporate sex partner testing, sharing of results with prospective partners, reminders for vaccines/screening and linkage to sexual health services. However, to understand how best to provide digital PN, high-quality evidence is needed from prospective studies of implemented digital PN interventions, which consider multiple perspectives (index patient, HCP, partner), include health economic evaluations and provide detailed descriptions of the PN interventions studied.