STD Quarterly
Evidence supports use of patient-delivered partner therapy for sexually transmitted diseases
Programs must overcome legal, financial barriers
As you tell the patient in front of you that she has a positive test for chlamydia, you explain the importance of having her boyfriend treated. You encourage her to have the boyfriend come in for care, but what are the odds that you will see him?
Not too good, according to research findings.1-3 Many partners of patients fail to receive treatment for sexually transmitted diseases (STDs) such as as chlamydia and gonorrhea, and reinfection and further disease transmission are common occurrences.4-7 Just-published research indicates that a new model of expedited partner care can change the equation by decreasing the patient’s risk of reinfection and increasing the number of treated partners.8
Researchers at the Public Health — Seattle & King County and the University of Washington, both in Seattle, and the Centers for Disease Control and Prevention (CDC) developed a system whereby STD patients diagnosed with gonorrhea or chlamydial infection were given medications to give to their partners. This system allowed the partners to get treated without first seeing a medical provider. To conduct the study, researchers randomly assigned women and heterosexual men diagnosed with gonorrhea or chlamydial infections to receive partner medications or be given standard referrals to have partners seek medical care.
Patients provided with medications to give to their partners were more likely to report that all their partners were treated than those assigned to a standard referral procedure. In addition, they were less likely to report having sex with an untreated partner.8
No progress has been made in this decade toward achieving the goals of lower gonorrhea and chlamydia rates as set forth by the Department of Health and Human Services’ Healthy People 2010 initiative, state authors of an editorial accompanying the new research.9 Expedited partner therapy may provide a way to help reach those goals, says Matthew Golden, MD, MPH, acting director of the STD Control Program at Public Health — Seattle & King County and an assistant professor of medicine at the University of Washington’s Center for AIDS & STDs.
"We have a multimillion-dollar program to fight chlamydial infection in this country," says Golden, who served as lead author of the new research. "Are we willing to spend an increment more to increase partner treatment? I would say that is probably a good investment."
Review the research
More than 1,800 women and heterosexual men were involved in the new study. All of them were newly diagnosed with chlamydia, gonorrhea, or both, and claimed at least one untreated partner within the previous 14 days. The study was conducted at the University of Washington in Seattle from September 1998 to March 2003.
Patients assigned to the standard referral group were advised to have partners seek treatment at a free clinic. Those patients receiving expedited treatment were offered free packets of medication, a written prescription, or directly mailed medication for up to three partners. The treatment packets included medications for gonorrhea (cefixime, 400 mg) and chlamydia (azithromycin, 1 g), as well as condoms and health information on STD transmission and medication side effects. Participants in both groups were retested and interviewed three months later to determine who had received treatment and who may have been reinfected.
The expedited treatment group showed a 3% reinfection rate of gonorrhea compared to 11% among the standard referral group. With chlamydia, those receiving expedited care had an 11% reinfection rate, compared to 13% of those receiving standard referrals.
Is model in practice?
Whether you call it expedited partner therapy (EPT) or patient-delivered partner therapy (PDPT), know that this method is widely but inconsistently used in the United States. According to a survey of more than 3,000 physicians, about half reported ever using PDPT for gonorrhea and chlamydial infection, and less than 15% said it was a customary practice.10
While some health departments have adopted the practice, very few states have enacted specific laws allowing its use. Legislation specifically articulating the legality of EPT has been passed in California and Oregon.11 California was first to draft such legislation; its 2001 action allows providers to prescribe or dispense antibiotic therapy for the partners of patients with genital chlamydia infection.
Results of a 2004 survey of state pharmacy and medical examiner boards indicate that new laws may be needed if PDPT is to be widely instituted.12 According to the survey results, the legal status of PDPT is poorly defined, and the practice is considered illegal in much of the United States.12
Some providers may hesitate providing treatment without direct examination, since PDPT may result in missed opportunities for the diagnosis and treatment of comorbid conditions, says Golden. Findings from a just-published study may help to allay some of those fears: They suggest that comorbidities in heterosexuals are relatively uncommon.13
Who will pay?
Instituting proper medico-legal procedures for expedited therapy is one portion of the treatment puzzle, but funding of such practice is another matter. Many third-party payers will not pay for prescriptions to partners who may not be covered by the patient’s plan or who might not be insured at all.9 In California, HMOs have been very reluctant to pay for nonmembers’ medication, says Anita Nelson, MD, professor in the obstetrics and gynecology department at the University of California in Los Angeles (UCLA) and medical director of the women’s health care clinic and nurse practitioner training program at Harbor — UCLA Medical Center in Torrance.
For now, Public Health — Seattle & King County is picking up the costs for partner therapy, says Golden. However, when weighed against the burden of untreated STD infection, the costs of expedited therapy represent a step forward in effective care, he says.
"This expedited care model may help redesign the current national partner notification system to treat more partners," states Golden. "Currently, approximately half of gonorrhea or chlamydia patients’ sex partners do not get treated."
References
- Landis SE, Schoenbach VJ, Weber DJ, et al. Results of a randomized trial of partner notification in cases of HIV infection in North Carolina. N Engl J Med 1992; 326:101-106.
- Oh MK, Boker JR, Genuardi FJ, et al. Sexual contact tracing outcome in adolescent chlamydial and gonococcal cervicitis cases. J Adolesc Health 1996; 18:4-9.
- Macke BA, Maher JE. Partner notification in the United States. Am J Prev Med 1999; 17:230-242.
- orr DP, Langefeld CD, Katz BP, et al. Behavioral intervention to increase condom use among high-risk female adolescents. J Pediatr 1996; 128:288-295.
- Kjaer HO, Dimcevski G, Hoff G, et al. Recurrence of urogenital Chlamydia trachomatis infection evaluated by mailed samples obtained at home: 24 weeks’ prospective follow-up study. Sex Transm Infect 2000; 76:169-172.
- Whittington WL, Kent C, Kissinger P, et al. Determinants of persistent and recurrent Chlamydia trachomatis infection in young women: Results of a multicenter cohort study. Sex Transm Dis 2001; 28:117-123.
- Schillinger JA, Kissinger P, Calvet H, et al. Patient-delivered partner treatment with azithromycin to prevent repeated Chlamydia trachomatis infection among women: A randomized, controlled trial. Sex Transm Dis 2003; 30:49-56.
- Golden MR, Whittington WL, Handsfield HH, et al. Effect of expedited treatment of sex partners on recurrent or persistent gonorrhea or chlamydial infection. N Engl J Med 2005; 352:676-685.
- Erbelding EJ, Zenilman JM. Toward better control of sexually transmitted diseases. N Engl J Med 2005; 352:720-721.
- Hogben MH, McCree DH, Golden MR. Patient-delivered partner therapy for sexually transmitted diseases as practiced by U.S. physicians. Sex Trans Dis 2005; 32:101-105.
- Handsfield HH, Golden MR. Epidemiologic and therapeutic data point to opportunities for improved STD control. Medscape coverage of: 2003 International Society for Sexually Transmitted Disease Research Congress. Accessed at: www.medscape.com/viewarticle/461194.
- Anukam U, Handsfield HH, Williams D, et al. Legal status of patient delivered partner therapy (PDPT) in the U.S.: A national survey of state pharmacy boards and boards of medical examiners. Presented at the 2004 National STD Prevention Conference. Philadelphia; March 2004.
- Stekler J, Bachmann L, Brotman RM, et al. Concurrent sexually transmitted infections (STIs) in sex partners of patients with selected STIs: Implications for patient-delivered partner therapy. Clin Infect Dis 2005; 40:787-793.
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