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STD treatment: Time to get on board with expedited partner therapy
New CDC toolkit assists states in promoting supportive policies
Your next patient is a young woman who was in two months ago for a chlamydia infection. You provided her with a prescription and asked that she have her partner come in for evaluation, testing, and treatment. Today's test results are positive for chlamydia. When you discuss the results, the patient tells you her partner never came in for tests or treatment.
For sexually transmitted disease (STD) clinical management to be effective, treatment of patients' current partners must occur to prevent reinfection and curtail further transmission. The standard approach to care has relied on clinical evaluation in a health care setting, with partner notification accomplished by the index patient, by the provider or an agent of the provider, or a combination of these methods.
It might be time to change that approach to care, say public health officials. Chlamydia and gonorrhea are among the most commonly reported infectious diseases in the United States. In 2009, there were more than 1.2 million cases of chlamydia and more than 300,000 cases of gonorrhea reported to the Centers for Disease Control and Prevention (CDC), says Charlotte Kent, PhD, acting director of the Division of STD Prevention in the CDC's National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention.
Expedited partner therapy (EPT) is the clinical practice of treating the sex partners of patients diagnosed with chlamydia or gonorrhea by providing prescriptions or medications to the patient to take to his/her partner without the health care provider first examining the partner. It is permissible in 27 states. (Go to the CDC EPT web site, www.cdc.gov/std/ept. Select "Legal Status of EPT by Jurisdiction" to see a breakdown of state standings on EPT.) To aid clinicians and policy makers in adding new states to the list, the Centers for Disease Control and Prevention has issued a new toolkit designed to cover the key issues related to EPT authorization and implementation. (Go to the CDC Expedited Partner Therapy web site, www.cdc.gov/std/ept. Select "Legal/Policy Toolkit for Adoption and Implementation of Expedited Partner Therapy.)
CDC considers expedited partner therapy an additional strategy to ensure the treatment of sexual partners of persons with chlamydia or gonorrhea, says Kent. This treatment assurance for sexual partners is key to reducing re-infection of the index patient, curtails further transmission, and prevents long-term consequences of untreated chlamydia and gonorrhea infections, she notes.
Untreated gonorrhea and chlamydia are the leading preventable causes of pelvic inflammatory disease in women, which can lead to infertility, ectopic pregnancy, and chronic pelvic pain. Serious outcomes of chlamydia and gonorrhea are uncommon in men. However, at a population level, men generally are more efficient STD transmitters than women, and preventing recurrent infections in men might be important in reducing continued transmission in the community, says Kent.
Expedited partner therapy "does not replace traditional partner management or any other partner treatment strategy," she says. "Personal medical evaluation of partners is always preferred when practical, but EPT can be used to treat partners as an option when other management strategies are impractical or unsuccessful."
Data supports EPT
If a patient diagnosed with chlamydia or gonorrhea indicates her partner or partners are unlikely to seek evaluation and treatment, providers can offer patient-delivered partner therapy (PDPT), a form of expedited partner therapy which partners of infected persons are treated without previous medical evaluation or prevention counseling.
The evidence supporting PDPT is based on three clinical trials that included heterosexual men and women with chlamydia or gonorrhea.1-4 Results of the trials and meta-analyses indicate the magnitude of reduction in reinfection of index case-patients compared with patient referral differed according to the STD and the sex of the index case-patient. Across the trials, reductions in chlamydia prevalence at follow-up were approximately 20%; reductions in gonorrhea at follow-up were about 50%. Rates of notification increased in some trials and were equivalent to patient referral without PDPT in others.5
According to the CDC, expedited partner therapy is potentially allowable in 15 states: Alabama, Connecticut, Delaware, Georgia, Hawaii, Idaho, Indiana, Kansas, Maryland, Massachusetts, Montana, Nebraska, New Jersey, South Dakota, and Virginia. It also is potentially allowable in the District of Columbia and Puerto Rico. The EPT toolkit, which was developed by the Arizona State University's Sandra Day O'Connor College of Law, Public Health Law and Policy Program, in collaboration with CDC's Division of STD Prevention, contains four sections:
In addition, the CDC Expedited Partner Therapy web site also provides links to materials from other states that have implemented EPT policies, such as Illinois, Texas, and New Mexico.
The toolkit offers resources to assist states that are interested in adopting laws supportive of expedited partner therapy, as well aids states that have adopted such laws with addressing barriers to their full implementation, says the CDC. It is intended as a resource for voluntary use by government officials at the state and local levels, their public and private sector partners, and others who are interested in adopting or facilitating the implementation of statutes or regulations that permit EPT in clinical practice.
What are the benefits?
How can expedited partner therapy legislation benefit clinicians? There are numerous advantages, says Jo Ann Woodward, MH, WHNP-BC, who co-authored a recent journal article on the subject.6
"I think EPT legislation in place can help clinicians take better care of their patients, have less risk of pelvic infection because of untreated patients, and have more patient satisfaction, as well as the patients being satisfied because they see the nurse practitioner as a resource for health care," says Woodward.
Woodward believes the sample legal language provided in the CDC EPT Toolkit should address a concern shared by many nurse practitioners regarding the provision of medication to a patient that they have not seen. "If they give medication to a patient they have not seen, indeed does that make them liable if a reaction takes place?" Woodward notes. Referring to the sample state legislative language on liability issues, she says, "I'm not an attorney, but I believe that it relieves a lot of anxiety."
Nurse practitioners should operate within the guidelines of their facilities, says Woodward. However, the resources offered through the CDC Expedited Partner Therapy web site can help clinicians who are interested in spearheading EPT legislation in their states get the ball rolling, she notes.
Robert Hatcher, MD, MPH, professor of gynecology and obstetrics at Emory University School of Medicine in Atlanta, says that for years he provided some women he was treating for sexually transmitted infections with a prescription that provided adequate medication for their partners as well. "I've always believed a little bit of civil disobedience was desirable," says Hatcher. "After all, I was providing services at Grady Memorial Hospital, just a few blocks from Ebenezer Baptist Church, the church of Martin Luther King Jr."