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Resources for Health Professionals and Local Health Departments

Partner Counseling

The Use of Expedited Partner Therapy (EPT) to Reduce Sexually Transmitted Infections in Colorado

 

Introduction

In response to the recommendations and barriers related to use of EPT, the Colorado Department of Public Health and Environment Sexually Transmitted Infection/HIV Section staff have assembled information about the use of EPT in Colorado to assist health departments, public and private healthcare providers and others in exploring the implementation of  EPT as a partner management strategy.

 

Background

Types of partner management strategies for patients diagnosed with a sexually transmitted infection (STI) include provider referral (in which the health department or provider notifies a partner of an STI exposure with or without the assistance of the original patient) and patient referral (in which the original patient attempts to assure his/her partner receives appropriate medical
follow-up without assistance from the health department or provider). Expedited partner therapy may use either or both types of partner management referrals to provide treatment to partners
exposed to an STI without an examination and without counseling messages.

 

Recommendation

In spite of identified and perceived barriers to implementing EPT, expedited partner therapy is legal in Colorado, and the Colorado Department of Public Health and Environment encourages healthcare providers to address and overcome these barriers to EPT to reduce the burden of STI in Colorado.

 

Contact Information

Kelly O’Keefe Voorhees, MSPH

STI/HIV Section, Disease Control and Environmental Epidemiology Division

Colorado Department of Public Health and Environment

303-692-2658
Evidence Supporting Partner Counseling

As a means to assure that exposed partners are adequately treated, health departments and providers in many areas are practicing expedited partner therapy (EPT) by which partners of STI patients are treated without an examination and without counseling messages. Among EPT practices, some providers are utilizing patient-delivered partner therapy (PDPT) in which patients diagnosed with STI deliver medications to their partners. To encourage more widespread consideration of these partner management options, the CDC published its 2006 guidance report, Expedited Partner Management in the Treatment of Sexually Transmitted Diseases.

 

The guidance summarized evidence based on the results of four randomized controlled trials (RCT) for the efficacy of EPT in preventing recurrent chlamydia and gonorrhea infections after initial treatment and in assuring that partners are notified and receive treatment. Additionally, the RCT demonstrated that EPT was associated with a decreased likelihood that a patient would have sex with an untreated partner. The following salient findings related to EPT are found within the CDC guidance:

 

  • In one six-city multi-center study, female patients diagnosed with chlamydia that were provided azithromycin to give to their partners were statistically no more likely to have persistent or recurrent chlamydia infections at one-month and four-month follow-up than were women who were provided a list of clinics where their partners could be examined.

  • In Seattle-King County, persistent or recurrent gonorrhea and chlamydia infections were found less often among male and female patients assigned to deliver medications to their partners than among patients assigned to patient referral or provider referral arms of the study. EPT was shown to be more effective at preventing recurrent gonorrhea infections
    than chlamydia infections.

  • In New Orleans, among a subset of 977 men with symptomatic urethritis who were diagnosed with gonorrhea, chlamydia, or both, those assigned to the PDPT arm of the study were significantly less likely to experience a recurrent infection upon follow-up testing.

  • PDPT was slightly more costly than patient referral when considering only program costs. However, when the costs from preventing infection sequelae such as PID are considered, EPT was shown to be more cost effective.

 

The CDC has been joined by the American Medical Association in recommending that EPT be considered and implemented as a partner management strategy. (Region VIII Infertility Prevention Project)

 

Centers for Disease Control and Prevention. Expedited Partner Therapy in the Management of Sexually Transmitted Diseases. Atlanta, GA: US Department of Health and Human Services, 2006.
Operational Barriers to Partner Counseling

A number of barriers remain to be addressed in assuring more widespread and consistent use of expedited partner therapy (EPT). A 2005 survey of various clinical sites in the Region VIII Infertility Prevention Project2 identified a number of these barriers including:

 

  • Information regarding the partner is secondhand. The original patient may have no knowledge of a partner’s allergy history or if the partner is currently taking other medications.

  • Partner treatment cannot be tied to a specific person. One clinic that was in the process of implementing an electronic system for generating prescriptions noted that there would be no tie to a patient record number when the partner was not also a patient at the clinic. In another clinic, EPT was deemed problematic because no social security number or other identifier would be available to link the treated partner with the prescribed treatment.

  • Clinicians were unsure whether EPT is good medical practice and feared that practicing EPT might result in losing their license to practice.

  • EPT was so rarely practiced that clinicians had little experience with its use.

  • Clinic directors were described as often being resistant to EPT and in need of information about why EPT is desirable and how it should be implemented.

  • Clinics did not know whether EPT was a practice that was recommended by their state health department.

 

Additional barriers to EPT have also been cited. Similar to situations involving more traditional Disease Intervention Specialist (DIS)-mediated partner notification, a diagnosed patient may refuse to deliver medications or a prescription to a partner because the patient: 1) does not know or has no locating information for the partner; 2) does not like the partner; or 3) is afraid of the partner.

 

EPT may also be resisted because it is seen as a missed opportunity to test for other STI and to provide counseling messages to an exposed partner. Although the risk of adverse reactions to therapy has been shown to be low, providers may be reluctant to tolerate even a low risk given possible legal and medical ramifications of an adverse event. Additionally, EPT is not feasible in many settings because of operational barriers, including the lack of clarity regarding the legality of practicing EPT in many states. (Region VIII Infertility Prevention Project)

 

2The 2005 EPT survey obtained data from IPP sites located in Colorado, Montana, and South Dakota. The survey was designed to identify how often EPT was being practice, the circumstances when EPT was practiced, barriers to implementing EPT, and what clinics would need to implement EPT as a more standard practice. One community health center, five STI clinics, and over twenty-four family planning clinics provided survey information.
Guidance for Partner Counseling

From The Centers for Disease Control and Prevention. Expedited Partner Therapy in the Management of Sexually Transmitted Diseases. Atlanta, GA: US Department of Health and Human Services, 2006.

 

Expedited Partner Therapy (EPT) is at least equivalent to patient referral in preventing persistent or recurrent gonorrhea or chlamydial infection in heterosexual men and women, and in its association with several desirable behavioral outcomes. These conclusions support the following recommendations:

 

  • Gonorrhea and chlamydial infection in women: EPT can be used to treat partners as an option when other management strategies are impractical or unsuccessful. Symptomatic male partners should be encouraged to seek medical attention, in addition to accepting therapy by EPT, through counseling of the index case, written materials, and/or personal counseling by a pharmacist or other personnel.

  • Gonorrhea and chlamydial infection in men: EPT can be used to treat partners as an option
    when other management strategies are impractical or unsuccessful. Female recipients of EPT should be strongly encouraged to seek medical attention, in addition to accepting therapy. This should be accomplished through written materials that accompany medication, by counseling of the index case and, when practical, through personal counseling by a pharmacist or other personnel. It is particularly important that female recipients of EPT who have symptoms that suggest acute PID, such as abdominal or pelvic pain, seek medical attention.

  • Gonorrhea and chlamydial infection in men who have sex with men: EPT should not be
    considered a routine partner management strategy, because data are lacking on the efficacy in this population, and because of a high risk of co-morbidity, especially undiagnosed HIV infection, in partners. EPT should only be used selectively, and with caution, when other partner management strategies are impractical or unsuccessful.

  • Women with trichomoniasis: EPT is not recommended for routine use in the management of women with trichomoniasis, because of a high risk of STI co-morbidity in partners, especially gonorrhea and chlamydial infection. EPT should only be used selectively, and with caution, when other partner management strategies are impractical or unsuccessful.

  • Syphilis: EPT is not recommended for routine use in the management of patients with infectious
    syphilis.
Additional Info for Partner Counseling

To support health departments, public and private healthcare providers and others in exploring
whether, how, and when to implement expedited partner therapy (EPT) as a partner management strategy, the
following resources and related internet links are provided:

 
Client-Based Prevention Services Program

STI/HIV Client-Based Prevention Program

The Client Based Prevention Services program provides statewide follow-up to ensure persons infected with, or at high risk for, STD and HIV receive test results, treatment, risk-reduction counseling, referrals, partner notification services, and prevention case management for HIV infected/affected individuals. The program provides additional activities including public information, selected group level interventions, client satisfaction assessment and advocacy to improve services and referrals and decrease disease transmission and content expertise and preceptorships.

 

Program Description

What It Does

Provides highly focused statewide outreach with STD and/or HIV infected and exposed persons, technical assistance, capacity building for and oversight of Partner notification (PN) services.

 

  • Follow-up to ensure that untreated STD-infected and uncounseled HIV infected persons receive test results, counseling and treatment

  • Prevention case management

  • Partner counseling and referral services (HIV, syphilis, gonorrhea, chlamydia, persons co-infected with Hepatitis C and HIV )

  • Counseling and testing, including social network testing

  • Differential screening; identification of needed services

  • Referral to contracted, community and other Colorado Department of Public Health and Environment services

  • Service of public health orders

  • Support for chlamydia testing, counseling and treatment of high risk persons and their partners in STD and Title X family planning clinics and outreach settings

  • Collection, review, summary of operational data to improve services

  • Provide content expertise in services provided 

 

Whom the Program Serves

  • Persons with HIV infection that are unaware of their serostatus

  • Persons with HIV that are not in care or treatment or are continuing to participate in risk behaviors

  • Persons co-infected with Hepatitis C and HIV

  • Persons with syphilis

  • Selected persons with a diagnosis of gonorrhea or chlamydia

  • Persons at risk for chlamydia

  • Partners and persons in the social and behavioral networks of those above

Office Phone Numbers:

  • Denver Regional Office: 303-692-2963

  • Grand Junction Regional Office: 970-248-7146

  • Pueblo Regional Office: 719-545-4650

Mission:

To treat, control, and prevent the spread and complications of Sexually Transmitted Diseases (STD) including HIV and other designated diseases that are transmitted sexually or through intravenous drug use.

 

Statutory Reference

CRS 25-4-1401 et seq (HIV/AIDS); CRS 25-4-4 et seq (STD); CRS 25-1-122 (Communicable diseases); CRS 25-1-107 (Communicable diseases); CRS 19-3-304 (Child abuse reporting by CDPHE). The full text of these statutes is available at the Colorado Department of Public Health and Environment regulations.
Additional Materials
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