Key informant perspectives on a centralised contact tracing system for sexually transmitted infections

Contact tracing played a vital role in limiting the transmission of COVID-19 during Aotearoa New Zealand’s (Aotearoa) pandemic response.¹ Contact tracing is defined by the World Health Organization as “the process of identifying, assessing, and managing people who have been exposed to a disease to prevent onward transmission”.² This process helps identify other potential cases and is used in the control of infectious diseases including tuberculosis, measles, HIV and other sexually transmitted infections (STIs) such as syphilis, gonorrhoea and chlamdyia.³ Initiation of contact tracing (or partner notification) for STIs is the responsibility of the diagnosing clinician. All contacts at risk need to receive testing.⁴ Cases often choose to tell contacts themselves (“patient referral”) or providers may do so anonymously on their behalf (“provider referral”). For STIs, these processes are usually referred to as partner notification rather than contact tracing. The terms have been used interchangeably in this report. STIs are diagnosed in a range of services in Aotearoa including general practice, family planning, youth and student health services, maternity and prison services. New Zealand Sexual Health Society guidelines recommend that in situations where contact tracing is complex, support is sought from sexual health or public health services.⁴

In the United Kingdom (UK) and United States (USA), regional responses to COVID-19 involved re-deployment of skilled contact tracers working in sexual health to support COVID-19 contact tracing efforts.⁵ In some instances this diversion of expertise came at a cost to STI case management, leaving a shortage of staff to manage an already high and increasing workload.⁶ Unlike the UK or USA, there was no dedicated workforce of specialised sexual health contact tracers with capacity to be reassigned in Aotearoa. Contact tracing for COVID-19 was initially undertaken by the 12 public health units (PHUs), but as the workload soon exceeded capacity a National Close Contact Service was set up to support PHUs (March 2020).⁷ That service was also quickly overloaded,^7,8 and with additional resourcing, the National Investigation and Tracing Centre (NITC) was established, which supported PHUs in their contact tracing and took on a “finding service” to locate individuals who, to that point, were uncontactable. To facilitate this national work, a cloud-based national electronic database (the “National Contact Tracing Solution”) was developed to store details of cases, contacts and exposure events, and to assist in locating individuals by linking to contact details held in the National Enrolment Service.^8,9

While some research looked to sexual health contact tracing experience to inform approaches to contact tracing for COVID-19 in the first years of the pandemic,¹⁰ we consider here how Aotearoa’s experience with COVID-19 contact tracing might inform the future of STI control. Aotearoa has ongoing high rates of curable STIs including chlamydia, gonorrhoea and syphilis^11,12 and, with the exception of HIV and syphilis,^13,14 there has been no significant undertaking to reduce STI prevalence. Evidence from clinic-based studies suggests partner notification for chlamydia and gonorrhoea is often incomplete, under-resourced and needs to be improved in Aotearoa.^15–18 We sought key informant views on whether contact tracing for STIs would benefit from a centralised approach as used for COVID-19, with particular consideration of effectiveness for priority populations in Aotearoa (Māori, Pasifika, and gay, bisexual and other men who have sex with men [GBM]).

Methods

Participants

Purposive sampling was used to select potential participants to take part in a one-off key informant interview, and included people working in roles or services where STI contact tracing is undertaken, and/or were known to be knowledgeable on this topic. This included individuals working in primary care, sexual health, public health and research roles. A target of 12 interviews was set due to time constraints of the project, with 21 invitations sent out (three declined or passed the request to a colleague; six did not reply). Ethical approval was granted by the University of Otago Human Ethics Committee (reference D21/313, 14 October 2021).

Data collection and analysis

Interviews were conducted by CM between December 2021 and March 2022; 10 via Zoom and two in-person (audio-recorded with permission). CM has a background as a clinician in family planning, where sexual healthcare is a core part of service delivery. Interviews followed a semi-structured schedule and sought participant views on use of a centralised workforce for STI contact tracing as part of a wider discussion about contact tracing. The data presented here relate to discussion about a centralised system, while the rest of the data are reported in a separate paper to enable full presentation of participant views.

View Box 1, Table 1–3.

Data were analysed using reflexive thematic analysis guided by Braun and Clarke’s six-phased approach.¹⁹ At the conclusion of each interview, brief reflective notes were made to facilitate recollection of the circumstances of the interview. Participants were asked if they wanted a copy of the transcript so they could check that it was an accurate account. The interviews were transcribed verbatim and read by CM and SR while listening to the audio recordings. CM did the initial coding looking for sections in the transcripts that related to the issue, and coded these with their explicit or implicit meaning. The codes, along with supporting quotes, were stored in a Microsoft Excel file and reviewed by SR. Themes were developed and refined. Quotes were selected by CM and SR to illustrate salient points.

Results

The characteristics of the 12 participants are described in Table 1. The mean interview duration was 38 minutes (range 28–50 minutes). An alphanumeric code (shown in brackets after roles) was assigned to each participant to denote their role or expertise when presenting illustrative quotes. Some comments have been edited for brevity and to ensure anonymity (e.g., names, fillers and repetitions removed).

Views of a centralised system for contact tracing

The data centred around four key themes: i) potential benefits of a centralised system, ii) concerns and considerations, iii) meeting the needs of priority populations and iv) sharing experience gained from COVID-19. The extent to which participants working in clinical roles undertook comprehensive contact tracing was variable and impacted by time, resources, type of STI and status as a notifiable disease. There was consensus that more effective approaches are needed, with some supporting one well-delivered national contact tracing system; others felt a choice of approaches would enable a more patient-centred response.

Themes 1 and 2: potential benefits, concerns and considerations

The potential benefits of a centralised system identified by participants are drawn together in Table 2. Concerns that would need to be addressed if a centralised approach were utilised for STI contact tracing are summarised in Table 3.

Theme 3: meeting the needs of priority populations

Trust, relationships and cultural responsiveness were seen as key to meeting the needs of priority populations. Participants noted that for many Māori, the experience of ongoing and historic racism and related deep-rooted mistrust of the health system impacts on willingness to engage with health services. Establishing trusting relationships between providers, cases and contacts was identified as essential to effective engagement.

From a Māori point of view that trust with the provider is probably even more important. And I think continuity of care is particularly important for Māori, more so than others because of the systemic, multi-generational trauma that these people, on the whole, have experienced. (GP/PH2)

Interacting with contact tracers who are known to, and have existing relationships with, Māori was deemed likely to have the most success in reaching people for contact tracing:

The best people that generally contact these marginalised communities isn't going to be the public health unit. It's going to be the nanny who works with the clinic who knows the community, who knows that [name] attends the RSA at five o'clock on a Sunday and doesn't have a phone number but answers his Facebook Messenger. (GP/PH2)

However, a participant suggested this was not necessarily the case for Pasifika people, citing the example that a lack of any pre-existing relationship between the contact tracer and case was often preferred with respect to COVID-19 contact tracing:

The other learning is that for Pasifika, a lot of them do not want Pasifika people … they are a very close, close-knit community and there's a suspicion that the information will be shared. Some people prefer a completely fresh face that's nothing to do with that community whatsoever. (M1)

Several participants regarded community-generated solutions as having more potential for success than a centralised approach. Having the skills to approach contact tracing in a way that supports the mana and upholds the integrity of individuals was identified as key.

I think it would be really good if you can upskill Māori health workers to be whānau champions in this area. Maybe build close relationships with those Māori providers … especially the nurses and the community workers, because they know the community and they know the language that they use. (PHR2)

Some interviewees expressed concern over whether a centralised approach would be sensitive enough to the needs of GBM. A non-judgemental approach, which reflects understanding of and respect for the community, was regarded as critical to ensure GBM feel safe and supported to facilitate disclosure. Those in contact tracing roles need to ensure that their language, terminology and tone is appropriate and suggested that employing some GBM contact tracers would help this.

We consistently do get this feedback, that there is value in knowing that the person you're talking to has lived experience, you're not talking to someone who doesn't get it, or who's going to cast judgment. (M3)

Some participants explained that many cases have sexual contacts that are difficult to follow-up (“anonymous contacts”) and that the proportion of anonymous contacts is higher among GBM due to the way sexual encounters are often facilitated using hook-up apps (which do not require names or contact details), at cruising sites or at public parks. In some situations, carefully considered interventions by those with local knowledge and cultural awareness may be needed.

If it’s someone who’s in the GBM context at a cruising park, you can’t contact them other than being there, so if it’s really important to get someone, you need some specialists in the community or peer educators to know where to go and to do that carefully and sensitively. (PHR1)

Theme 4: experience gained from COVID-19

Participants reflected on the public’s willingness, on the whole, to co-operate with contact tracing for COVID-19, suggesting a collective understanding of the advantages of quarantining contacts for community benefit. They felt this could potentially translate into a willingness to engage with contact tracing for STIs. There was recognition that contact tracers had developed skills and been effective in supporting people to disclose information about their contacts. Participants expressed a desire for the lessons learnt from COVID-19 contact tracing to be shared with other providers.

A participant involved in the NITC identified a number of strengths of the service, including: good staff training, use of a structured but flexible approach and the ability to review, adapt and improve processes. They explained that the NITC team had gained expertise in delivering information, supporting people to make choices and refer if needed. Staff were trained to quickly develop rapport, establish trust and had developed ways to engage and encourage people to share pertinent information.

The case investigators become experts in reading people very quickly, and knowing … what are the hooks to get them to engage with the information, get them to trust. (M1)

The NITC optimised approaches; analysing optimal times to phone people, when to call back and what to include in a text message to facilitate contact. Some people reportedly felt more confident talking to a “stranger” than to someone already known to them (e.g., their GP) because it felt more private. However, it was also noted that having a trusted brand and established reputation as a contact tracing service became an important way to reassure those people being contacted that it was not a hoax call.

A participant involved with the NITC stressed that they had sought guidance and worked closely with Māori and Pasifika providers to ensure contact tracers tailored their approach to the needs of Māori and Pasifika. Examples of this were: establishing relationships before asking for information, giving feedback to show they were being heard and use of “storytelling”.

Discussion

Key informants in this study saw value in the use of a centralised STI contact tracing system. Benefits identified included improved efficiency and consistency, reduced demands on clinician time and provision of a more comprehensive overview of transmission networks nationally. Concerns were raised that staff must have the knowledge, skills and understanding of cultural norms to communicate effectively with priority groups. Privacy and confidentiality were seen as paramount; lack of trust was identified as a potential concern for Māori and GBM, as was reluctance of cases and clinicians to release details of sexual contacts to an external provider. The potential for missed opportunities to link contacts with testing services and lack of local and contextual knowledge were also identified as limitations of a centralised service. Some participants expressed support for improved access to locally based expertise for STI contact tracing, particularly for Māori, whose experience of and trust in colonial systems that have maintained stark health inequities may not be good.²⁰ In the same way that Māori and Pacific communities designed and implemented successful approaches to COVID-19 vaccination, STI contact tracing services designed by and for Māori and Pacific communities are needed.²¹

Information shared about the NITC suggested that the concerns raised by many key informants had been considered and addressed or could be overcome if contact tracing for STIs was centralised. Referring clinicians would need a clear understanding of staffing, training, operational, privacy and data collection processes to have confidence in referring their patients to a centralised contact tracing service. Establishment or extension of a national service to accommodate STI contact tracing would need to involve co-design alongside priority groups.²¹ Participants’ support for a centralised service to assist with STI contact tracing aligns with calls made by other sexual health physicians to “utilise the newly created COVID-19 contact tracing workforce”.²² Furthermore, the Aotearoa New Zealand Sexually Transmitted and Blood Borne Infection Strategy 2023–2030 identified improved “capability and capacity to undertake contact tracing, including by using digital tools and learnings from COVID-19 contact tracing successes”²³ as a priority area for health service quality improvement.

The centralised STI contact tracing service could involve some or all the following elements that have been utilised in other countries or situations:

(i) Utilise Aotearoa’s NITC (or a similar model) to undertake high volumes of straightforward contact tracing where there is low overall risk to public health. For example, there were 32,326 chlamydia cases in 2019, and 26,045 in 2020;¹² many of these would have contacted partners themselves, but some would have opted for their clinician to assist with the contact tracing.

(ii) Provide expert contact tracing for situations where there is elevated public health risk or other complexities that may require cultural, medical and/or legal expertise. This approach would align with use of “disease intervention specialists” who are affiliated with public health departments in the USA to provide “partner services” to people diagnosed with infectious syphilis, HIV and drug-resistant gonorrhoea.²⁴ This would also be similar to the specially trained workforce of sexual health advisors in the UK who provide expert partner notification services, although they are based in sexual health or genitourinary medicine clinics.²⁵

(iii) Develop internet-based partner services, which are well developed in the USA and have the potential to reach otherwise “anonymous contacts”.^26,27 Such approaches require a high level of understanding of social media, technology and privacy and therefore may be best suited to a centralised system where expertise can be concentrated. There is also potential for central co-ordination of other digitally based partner notification services such as SXT, which is currently used in only one region of Aotearoa; its impact would be increased by universal uptake.²⁸

The recent health system reforms aim to provide equitable services. The 12 PHUs have been brought together into a National Public Health Service, and the National Contact Tracing Solution established for COVID-19 has been extended to manage measles. This provides an opportunity for STI contact tracing to be prioritised within these newly established services. In Aotearoa, the network of STI providers is fragmented with poor provision of services in rural areas.²⁹ A national STI contact tracing workforce could provide a consistent expert telehealth service, either directly to cases and contacts or by supporting local clinicians.

Strengths and limitations

Given experiences with COVID-19, mpox³⁰ and the health system reforms, this qualitative exploration of whether a centralised contact tracing system would work for STIs is timely, and has not previously been considered in Aotearoa literature. Participants were selected for their specific knowledge of clinical practice, public health and priority populations for whom effective contact tracing strategies are critical. The interviewer (CM) had clinical experience in sexual health and contact tracing so was able to tailor interviews to draw out salient information related to participants’ expertise. Limitations include the narrow geographical spread of participants, with input from only one rural provider, which might have narrowed the scope of perspectives. Attempts were made to interview a range of key informants but we did not secure participation by Pasifika interviewees, although some participants had extensive experience working with Pasifika. Our target of 12 interviews was set due to project constraints (time and scope of a dissertation), but data generated were sufficiently rich in breadth to provide us with a range of views on the topic. Future work could explore in more detail STI contact tracing in rural locations, primary care (where most chlamydia and gonorrhoea cases are diagnosed) and issues related to young people, who are disproportionately impacted by STIs. Understanding priority group perspectives on a centralised STI contact tracing system is needed and should be sought in future work.

Conclusion

This study has identified potential benefits of a centralised STI contact tracing service. Although simple in its objective, contact tracing for STIs can be complex to carry out successfully. The best outcomes may be achieved by the establishment of a centralised STI contact tracing service that also provides training and support for local practitioners. The lessons learnt from the COVID-19 public health response must be shared with other disciplines. Adequate resourcing and prioritisation are required to reduce the high and inequitable rates of STIs, and to facilitate a rapid response to new or emerging infections that can be spread via sexual contact.