Policy-makers eye STI partner therapy
By Adam Sonfield
Senior Public Policy Associate
Guttmacher Institute
Washington, DC
In response to record-breaking reported cases of chlamydia infection this decade, public health authorities and advocates, led by the Centers for Disease Control and Prevention (CDC), have intensified efforts to combat the sexually transmitted infection (STI). Emerging as a central tool in this effort is expedited partner therapy (EPT), in which the original patient's provider provides a supply of or prescription for antibiotics to the partner without actually diagnosing the partner.
EPT has received endorsements by the CDC and the American Medical Association, among others, which cite recent evidence that it can break the cycle of reinfection and save scarce public health resources.1,2 Policy-makers also are getting into the act.
There were 1.1 million reported U.S. cases of chlamydia in 2007. which is the largest number of cases ever reported to the CDC for any condition, and experts estimate that most cases still go unreported. Gonorrhea is the second most commonly reported STI, with 356,000 cases in 2007.3 Both infections, if left untreated, can lead to pelvic inflammatory disease (PID) and eventually infertility or other serious complications. Like many STIs, they also can lead to adverse pregnancy outcomes and increased susceptibility to HIV transmission.
Efforts to combat chlamydia and gonorrhea have focused in part on increasing condom use and discouraging multiple partners to help people avoid infection. Yet, because the progression from infection to disease typically occurs over years and antibiotic treatment will eliminate the infection and stop the progression of PID, public health experts also have strongly promoted "secondary prevention" efforts involving screening and treatment. The U.S. Preventive Services Task Force recommends widespread screening for both STIs among young women.4,5
Also crucial to secondary prevention is screening and treatment of a patient's sexual partner (or partners) to prevent reinfection and to reduce STI rates in the broader community. Tracing, notifying, and treating the partners of infected patients was a central piece of earlier anti-gonorrhea efforts that cut prevalence by three-quarters between the mid-1970s and the mid-1990s.3
Getting a patient's often-asymptomatic partners to come in for testing and treatment is difficult. Partner tracing and related services are labor-intensive and expensive, and thus they usually are limited to syphilis, HIV, and high-risk cases of other STIs.
EPT is a response to both of those problems. It works well for infections such as chlamydia and gonorrhea due to the availability of effective single-dose therapies that minimize the chance of improper or incomplete treatment. Studies indicate EPT has been widely, if quietly, practiced by providers.
EPT has significant drawbacks as well. Some providers, along with the CDC, cite such issues as the possible presence of other STIs, missed opportunities for counseling, difficulties in obtaining funding or reimbursement, and EPT's legal status.1
The CDC's Division of STD Prevention has taken numerous steps in recent years to expand screening and treatment for chlamydia and other STIs, such as its participation in the anti-chlamydia Infertility Prevention Program and the 2008 launch of the National Chlamydia Coalition. To facilitate EPT for chlamydia and gonorrhea, the CDC has worked to eliminate the legal confusion surrounding the practice. The CDC has partnered with researchers at Georgetown and Johns Hopkins universities to analyze state laws and joined with the American Bar Association to push for changes, when necessary, to clarify state law.6,7
Since 2006, 12 states (Arizona, California, Illinois, Iowa, Louisiana, Minnesota, New Mexico, New York, North Dakota, Oregon, Utah, and Vermont) have heeded this call and adopted policies that allow and encourage EPT.8 The high prevalence and reinfection rates of both STIs and strong support from provider associations, local health departments, public health groups, and frontline clinicians have helped garner support, even among lawmakers representing conservative counties and states.9 Efforts to change state law also have been aided by evidence of EPT's effectiveness, including a January 2009 report out of Baltimore that a pilot program authorized by the state in 2007 had contributed to a 41% decline in three-month reinfection rates for gonorrhea and chlamydia clients.10
Despite this progress, government and outside experts acknowledge that EPT alone cannot stem the STI epidemics. Many have advocated for other legislative changes, including mandating insurance coverage of STI screening; removing legal barriers to home STI testing kits; and expanded funding for outreach, education, testing, and treatment. Fighting STIs, some emphasize, also will require addressing the broader problems in a community, including poor health care access and infrastructure. None of these goals will be easy to achieve, particularly in the face of states' current fiscal crises and the continuing demonization of reproductive health services and providers by some conservative policy-makers.
References
- Centers for Disease Control and Prevention (CDC). Expedited Partner Therapy in The Management of Sexually Transmitted Diseases. Atlanta: U.S. Department of Health and Human Services, 2006. Accessed at www.cdc.gov/std/treatment/EPTFinalReport2006.pdf.
- American Medical Association Council on Science and Public Health. Expedited Partner Therapy (Patient-Delivered Partner Therapy): An Update. Report 7-A-06. Accessed at www.ama-assn.org/ama/no-index/about-ama/16410.shtml.
- Centers for Disease Control and Prevention (CDC). Trends in Reportable Sexually Transmitted Diseases in the United States, 2007: National Surveillance Data for Chlamydia, Gonorrhea, and Syphilis. Atlanta: CDC. Accessed at www.cdc.gov/STD/stats07/trends.htm.
- U.S. Preventive Services Task Force. Agency for Healthcare Research and Quality. Screening for Chlamydial Infection. Rockville, MD, June 2007. Accessed at www.ahrq.gov/clinic/uspstf/uspschlm.htm.
- U.S. Preventive Services Task Force, Department of Health and Human Services, Screening for Gonorrhea. Rockville, MD, May 2005. Accessed at www.ahrq.gov/clinic/uspstf/uspsgono.htm.
- Centers for Disease Control and Prevention (CDC). Legal Status of Expedited Partner Therapy (EPT). Accessed at www.cdc.gov/std/ept/legal/default.htm.
- American Bar Association House of Delegates. Resolution 116A. August 2008. Accessed at www.abanet.org/health.
- Guttmacher Institute, unpublished data, 2009.
- Sonfield A. For some sexually transmitted infections, secondary prevention may be primary. Guttmacher Policy Review 2009; 12:2-7.
- Desmon S. Pilot program appears to cut STD reinfection rate. Baltimore Sun, Jan. 9, 2009:A4.
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