II. Peer Referral

Before a solution can be offered, target high risk populations must first be identified.  To find Pittsburgh residents with HIV, two major issues must be addressed.  The first is partner referral, which is an extremely effective way to find new HIV cases that allows newly seroconverted patients to make a contact list of social or sexual contacts they feel may also be at risk of infection.  In Pennsylvania, the Confidentiality Of HIV-Related Information Act, P.L. 585, Act No. 148 of 1990, Senate Bill No. 1162 states that after any test, positive or negative, the subject must be offered access to counseling pertaining to the significance of the results, how to prevent transmission, the benefits of contacting individuals who could have transmitted HIV, and what services exist for such measures (5).  Currently all AIDS and HIV case data in Pittsburgh is sent to the Allegheny County Health Department, which handles the surveillance of cases in the County.  Most partner referral is handled by the Department, which uses either names or a unique identifier code to handle referral services and has a solid set of guidelines for reporting (20).  While most clinics and public-run organizations handle partner referral through the Health Department, the option exists for physicians to handle the partner referral themselves.  This choice is generally not as effective as the Health Department, an organization which has access to more resources and can better handle the referral services.  An additional guideline forcing physicians to handle partner referral through the Health Department would increase the efficiency of the system.                      

These partner referral and notification services are vital to tracing the epidemiology of the disease and to tracking down other at-risk individuals.  Numerous studies have shown that these programs are highly effective at increasing the number of HIV seropositive cases discovered by testing programs, including an increase of 8% in King County, Washington (6).  This is comparable to the increases in discovered cases created by additional HIV RNA testing of 8.6% in King County, Washington (7), and 8.8% in San Francisco (8).  However, this method of testing cost $17,515 per case in North Carolina (13), which is much higher than the $4,929 per case from peer referral in the Golden et al study (6).  An additional bonus of peer referral in Pittsburgh is the relatively small size of the target communities.  The MSM population in the city is highly interconnected and centered around a few major gay bars and clubs.  The tightly-knit nature of a community can make peer referral more effective and cheaper.  For example, in a study of intravenous drug users, many of whom were incarcerated, peer referral yielded positive cases in 36% of referred contacts at a cost of only $583 per new case (14).  While this situation is different because the prison population in this study was at greater risk than MSM are in Pittsburgh, it nevertheless shows that the peer referral technique is highly effective in concentrated populations.  Peer referral is a cost-effective and relatively simple way of increasing the effectiveness of HIV testing.

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