October 2009 | Back to Table of Contents

Clinical and Health Affairs

Expedited Partner Therapy: A New Strategy for Reducing Sexually Transmitted Diseases in Minnesota

By Candy Hadsall, R.N., M.A., Melissa Riedesel, M.P.H., Peter Carr, M.P.H., and Ruth Lynfield, M.D.

Abstract
Chlamydia and gonorrhea are the two most commonly reported communicable diseases in Minnesota and the United States. Treatment of sexual partners is essential for control and prevention of these and other sexually transmitted diseases (STDs). However, traditional strategies for getting partners into treatment such as patient referral, physician referral, or referral from the health department are not always successful. Expedited partner therapy (EPT) is the practice of treating the sexual partners of persons with STDs without medical evaluation. This article describes the evidence that EPT reduces persistent chlamydial and gonococcal infections and the Centers for Disease Control and Prevention’s recommendations for EPT for heterosexual partners of patients with chlamydia and/or gonorrhea. It also addresses legislation that removed the last-known legal barrier to EPT in Minnesota as well as concerns about implementation of this treatment strategy.

Chlamydia and gonorrhea are the two most commonly reported communicable diseases in Minnesota and the United States. Although Minnesota’s sexually transmitted disease (STD) rates are low compared with those in many other states, Minnesota saw a record number of new cases of chlamydia last year. Since 1996, the rate of chlamydial infection in the state more than doubled from 115 cases per 100,000 population to 292 cases per 100,000 population in 2008; after steady increases over the past seven years, there is no indication that the rates are leveling.¹

Untreated and recurrent gonococcal and chlamydial infections can lead to complications such as pelvic inflammatory disease (PID) and ectopic pregnancy in women, and infertility in members of both sexes. Gonococcal and chlamydial infections also can increase the risk of sexual transmission of HIV. Therefore, treatment is critically important and very effective. However, treating only the index patient does little to reduce the prevalence of STDs in the community or the risk for reinfection. The sexual partners of a patient with an STD need to be treated as well.

When a person is diagnosed with an STD, typically his or her partners are notified about possible exposure by the patient, physician, clinic, or the health department. Clinicians are strongly encouraged to discuss with patients the urgency of notifying all sexual partners regarding the diagnosed STD and the importance of prompt treatment. Websites such as inspot.org make it easy for patients to send electronic notices to their partners informing them that they may have been exposed to an STD and urging them to get tested. Under section 4605.7700 B of the Minnesota Communicable Disease Rule, physicians who treat persons infected with chlamydia, gonorrhea, syphilis, or chancroid are required to ensure that those patients’ partners are treated or provide the names and addresses of those individuals to the Minnesota Department of Health for follow up.

However, for a number of reasons, partners do not always find out that they have been exposed. Patients may be uncomfortable discussing the STD diagnosis with them, clinicians may be too busy to follow up with their patients’ partners, and health departments may not have enough staff to contact all persons who have been diagnosed with an STD and their sexual partners. Even if they are notified, sexual partners may be reluctant to get medical care because of psychological, social, time, transportation, or financial barriers.

Expedited partner therapy (EPT) is the practice of treating the sexual partners of persons with STDs without medical evaluation. It typically involves a health care provider giving the index patient medication or a prescription for medication for their sexual partner or partners. Although nothing can replace the benefits of a thorough medical examination and STD testing, EPT can help ensure that people who might not otherwise get treatment are provided with the medications they need. It should be viewed as a strategy for effectively treating sexual partners who are unwilling or unlikely to seek medical care for an STD exposure, as it allows for treatment of people with undiagnosed and perhaps asymptomatic illness who otherwise would not receive care.

Expedited partner therapy appears to be effective. Three randomized controlled trials of EPT for management of gonococcal and chlamydial infection in heterosexual populations conducted in the United States suggest that EPT leads to significantly reduced infection rates as compared with standard partner referral practices.^2-4 A study of both chlamydia and gonorrhea among males and females in Seattle found that the rate of re-infection with either organism was reduced by 24% in those receiving EPT as compared with those who received traditional referrals (OR: 0.76, 95% CI: 0.59-0.98, P=0.04).² A similar study of males with urethritis in New Orleans found that the prevalence of infection with either chlamydia, gonorrhea, or both during follow-up was also significantly reduced in those who received EPT (OR: 0.38, 95% CI: 0.19-0.74, P<0.001).³

As a result, the Centers for Disease Control and Prevention (CDC) as well as the American Medical Association (AMA) support the use of EPT when other treatment options for partners are impractical or have been unsuccessful.^5,6 Likewise, the Minnesota Department of Health has developed guidance for medical providers on the implementation of EPT in heterosexual populations,⁷ and the Minnesota Medical Association has supported EPT as a tool for managing STDs in partners of patients.⁸ Furthermore, a review of state statutes indicates that 19 states allow the use of EPT for treatment of chlamydial or gonococcal infections, and three states—California, Washington, and Colorado—now include EPT in their standard toolkit for managing the partners of people who test positive for STDs.⁹

It is important to note that both the Minnesota Department of Health and the CDC recommend EPT as an additional tool for partner management rather than as a substitute for examination, testing, and ongoing clinical management of the partner. In addition, current evidence supports EPT only for gonococcal and chlamydial infections. It is not recommended for the partners of patients with syphilis or HIV because of the complexity of treatment courses, nor is it indicated for homosexual populations because of the higher rate of HIV infection in the partner population seen in observational studies.¹⁰

Concerns about EPT

In June of 2008, EPT became legal in Minnesota when pharmacy statutes were amended so that the patient no longer had to be named on the prescription.¹¹ The amendment allows physicians to provide treatment to partners whom patients may not know or whom they may be unwilling to name. This is a dramatic shift in practice for many clinicians as well as pharmacists. Despite the evidence for EPT, its implementation is not without challenges. Although EPT is legal, concerns about adverse drug reactions and the potential for liability, missing comorbidities, and payment for treatment have been raised.

Adverse reactions to the antibiotics used to treat gonococcal and chlamydial infections are very rare. The Minnesota Department of Health provides materials that can be used to educate patients and their partners about potential side effects, adverse reactions, and the necessary actions to be taken should one experience anaphylaxis. In addition, Department of Health officials urge clinicians to discuss anaphylaxis with the index patient and to provide him or her with information about it when EPT is the chosen partner-management strategy.

Even though the risk of anaphylaxis and damaging side effects is miniscule, many physicians remain concerned about the potential for litigation. The risk of litigation in a case where EPT is given is equal to the risk of being sued in association with providing any medical procedure or treatment. Additionally, the AMA has suggested that physicians may be subject to litigation if a patient becomes reinfected or has long-term sequelae from such reinfections because the physician failed to offer EPT.¹²

There also is concern that comorbidities or concurrent STD infections may be missed in partners who receive EPT. However, a multicenter observational study suggested that the rate of PID is low (less than 8%) as is the rate of trichomoniasis (less than 20%) in female partners.¹⁰ Likewise, the rate of discordant chlamydial or gonococcal infection is low (less than 23%) in heterosexual partners of either gender. Although the likelihood of discovering a comorbidity may be small, the physician’s aim should be to see partners for clinical evaluation even if they receive EPT.

The potential for the development of antimicrobial resistance with EPT has also been noted. At this time, C. trachomatis is not known to be resistant to azithromycin, and gonococcal resistance to indicated cephalosporins is extremely rare in the United States. Although unsupervised use of antibiotics will likely increase with EPT, it is important to note that the overall increase in antibiotic usage is likely to be relatively small, considering that more than 66 million prescriptions for azithromycin are written and only 1.1 million cases of chlamydia are reported in the United States each year.^13,14

Of the concerns associated with implementing EPT, those related to payment and billing for partner drugs present the biggest challenge. At this time, the cost of medications is typically paid out of pocket by the person filling the prescription. It is unknown how many insurers in Minnesota are willing to finance EPT for their enrollees’ sexual partners. To complicate matters further, it is not clear whether medications purchased through the federal 340b discount drug program may be used for partners.

Conclusion

Given the growing number of cases of chalmydia and gonorrhea in Minnesota, joint efforts between public health departments and health care professionals to treat people who are infected with or at risk of contracting these diseases are essential. Cooperation in the form of traditional strategies for informing and treating partners has played a significant role in preventing new cases of STDs. However, these approaches have limitations. Expedited partner therapy is an additional tool that physicians can use to reach individuals who may be at the core of the epidemic because they have not been diagnosed or treated. Because EPT has the capacity to change the course of STD incidence, clinicians, pharmacists, and public health officials must continue to discuss ways to overcome the barriers to and problems with implementing it. MM

Candy Hadsall is the STD screening specialist in the Minnesota Department of Health’s STD and HIV Section, Infectious Disease Epidemiology, Prevention and Control Division. Melissa Riedesel is a doctoral student in the University of Minnesota School of Public Health’s department of epidemiology and community health. Peter Carr is the section manager of the STD and HIV Section, Infectious Disease Epidemiology, Prevention and Control Division, Minnesota Department of Health. Ruth Lynfield is the state epidemiologist.
 

References
1. Minnesota Department of Health. Annual summary: 2008 Minnesota sexually transmitted disease statistics. 2008. Available at: www.health.state.mn.us/divs/idepc/dtopics/stds/stats/stdstats2008.html. Accessed August 31, 2009.
2. 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(7):676-85.
3. Kissinger P, Mohammed H, Richardson-Alston G, et al. Patient-delivered partner treatment for male urethritis: a randomized, controlled trial. Clin Infect Dis. 2005; 41(5):623-9.
4. 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(1):49-56.
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6. American Medical Association, Council on Science and Public Health. Expedited partner therapy: an update. Available at: www.ama-assn.org/ama/no-index/about-ama/16410.shtml. Accessed August 31, 2009.
7. Minnesota Department of Health. Expedited Partner Therapy (EPT) for Chlamydia trachomatis and Neisseria gonorrhoeae: Guidance for Medical Providers in Minnesota. Available at: www.health.state.mn.us/divs/idepc/dtopics/stds/ept/eptguidance.html. Accessed August 31, 2009.
8. Minnesota Medical Association, Minutes of Board of Trustees Meeting, St. Paul, MN. November 15, 2008.
9. Centers for Disease Control and Prevention. Legal Status of Expedited Partner Therapy (EPT). Updated July 30, 2009. Available at: www.cdc.gov/std/ept/legal/default.htm. Accessed September 3, 2009.
10. 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(6):787-93.
11. Minnesota Statutes. §151.37 (2008). Available at: https://www.revisor.leg.state.mn.us/statutes/?id=151.37. Accessed August 31, 2009.
12. American Medical Association, Council on Science and Public Health: Expedited Partner Therapy (Patient-delivered Partner Therapy). 2005. Available at: www.ama-assn.org/ama/no-index/about-ama/15334.shtml. Accessed August 31, 2009.
13. IMS Health. IMS Health National Prescription Audit PLUS: Seeking Alpha; 2009. Available at: http://seekingalpha.com/article/128003-u-s-prescription-drug-sales-grow-slowly-hydrocodone-most-prescribed?source=reuters. Accessed August 31, 2009.
14. Centers for Disease Control and Prevention.Sexually transmitted disease surveillance, 2007. Available at: www.cdc.gov/std/stats07/main.htm. Accessed August 31, 2009.