Understanding attitudes, barriers and challenges in a small island nation to disease and partner notification for HIV and other sexually transmitted infections: a qualitative study

Background: In Barbados sexually transmitted infections (STIs) including HIV are not notifiable diseases and there is not a formal partner notification (PN) programme. Objectives were to understand likely attitudes, barriers, and challenges to introducing mandatory disease notification (DN) and partner notification (PN) for HIV and other STIs in a small island state. Methods: Six key informants identified study participants. Interviews were conducted, recorded, transcribed and analysed for content using standard methods. Results: Participants (16 males, 13 females, median age 59 years) included physicians, nurses, and representatives from governmental, youth, HIV, men's, women's, church, and private sector organisations. The median estimated acceptability by society of HIV/STI DN on a scale of 1 (unacceptable) to 5 (completely acceptable) was 3. Challenges included; maintaining confidentiality in a small island; public perception that confidentiality was poorly maintained; fear and stigma; testing might be deterred; reporting may not occur; enacting legislation would be difficult; and opposition by some opinion leaders. For PN, contract referral was the most acceptable method and provider referral the least. Contract referral unlike provider referral was not "a total suspension of rights" while taking into account that "people need a little gentle pressure sometimes". Extra counselling would be needed to elicit contacts or to get patients to notify partners. Shame, stigma and discrimination in a small society may make PN unacceptable and deter testing. With patient referral procrastination may occur, and partners may react violently and not come in for care. With provider referral patients may have concerns about confidentiality including neighbours becoming suspicious if a home visit is used as the contact method. Successful contact tracing required time and effort. With contract referral people may neither inform contacts nor say that they did not. Strategies to overcome barriers to DN and PN included public education, enacting appropriate legislation to allow DN and PN, good patient counselling and maintaining confidentiality. Conclusions: There was both concern that mandatory DN and PN would deter testing and recognition of the benefits. Public and practitioner education and enabling legislation would be necessary, and the public needed to be convinced that confidentiality would be maintained.