Last Updated on June 4, 2020 by Saurabh Sethi, MD, MPH
This guest post was written by one of our contributors, Social & Behavioral Health Expert, Janelle Knowlton, MPH.
For decades, the central component of STI prevention (sexually transmitted infection prevention) has been STI treatment for the sexual partners of people with STIs. Traditional practice has relied on patients or health care providers to notify the partner(s) of persons with infections of their exposure to an STI. Once notified, the partner would have to go to a clinic or an STI testing facility to be properly evaluated and treated, where necessary. This system has significant flaws and barriers to assure that all partners receive appropriate STI treatment.
An alternative approach is expedited partner therapy (EPT) and has been endorsed by many health organizations including the American Medical Association (AMA), the Centers for Disease Control and Prevention (CDC), the American Academy of Pediatrics (AAP), and the American Congress of Obstetricians and Gynecologists (ACOG). This alternative method involves treating the partner(s) of persons with diagnosed STIs by providing necessary prescriptions or medications to the person to take to his/her partner(s) without having to examine the partner(s). Current recommendations suggest EPT is most effective in treating chlamydia and gonorrhea.
Why Chlaymydia & Gonorrhea?
Chlamydia and gonorrhea are two of the most commonly reported STIs in the United States. Rates are highest among adolescents and young adults, ages 15-24 years. Recent CDC surveillance data estimates that among this population, 800,000 chlamydia cases and 370,000 gonorrhea cases are not being diagnosed and reported. Treatment is very simple for chlamydia and gonorrhea, although they are often asymptomatic, meaning that the individual with the infection has no symptoms. Left untreated, these STIs can cause permanent health problems, many of which affect women more than men.
Benefits of Using EPT
Traditional STI treatment practices are resource and time intensive with a limited reach, but EPT can reduce that burden.
Effectiveness Shown Through Research
Of four randomized trials, three found that EPT was associated with a reduced risk of persistent or recurrent bacterial STIs (namely, chlamydia and gonorrhea). EPT increased the reported treatment of partners despite partner type; partners were treated in 83% of ongoing partnerships, 58% of partnerships that were over but lasted greater than one day, and 36% of partnerships that lasted one day.
Many individuals who get diagnosed and treated for an STI return home and resume sexual activity with an untreated partner; this is especially true with chlamydia and gonorrhea. Studies have found 14% – 26% of adolescent and young adult women are re-infected with chlamydia 12 months after their initial infection, and evidence indicates that EPT can decrease those reinfection rates compared to standard partner referrals.
Cost-effective STI Treatment
An estimated $850 million is spent annually treating chlamydia and gonorrhea. Left untreated, chlamydia and gonorrhea can progress to PID in women, and treatment cost for PID is around $1,167 per case. Individuals who are infected with STIs are at least two to five times more likely than uninfected individuals to acquire an HIV infection when they are exposed to the virus through sexual contact. For every HIV infection that is prevented, an estimated $355,000 is saved from the cost of providing lifetime HIV treatment – this results in significant cost-savings for the healthcare system.
Currently Utilized by Physicians with NO Adverse Reports
In Washington state, over one-third of all heterosexuals with chlamydia or gonorrhea receive EPT for partners. In California, half of physicians and nurse practitioners report using EPT. In 2001, California was also the first state to authorize EPT, and since then, no adverse reports have been documented. Since, the CDC has provided guidelines for practitioners on providing EPT, also referred to as patient-delivered partner therapy (PDPT).
Concerns of Using EPT
While EPT has been proven effective in its treatment of chlamydia and gonorrhea, there are still some complex concerns regarding its use in clinical practice.
Adverse Drug Effects
Adverse drug and allergic reactions in sexual partners treated without medical supervision is always a potential concern. While rare in the treatment of chlamydia and gonorrhea, educational information regarding potential drug side effects should always accompany a prescription. There have been newer concerns with EPT treatment of gonorrhea because of its resistance to certain medications, however, the CDC still states, ‘not treating partners is significantly more harmful than is practicing EPT for gonorrhea.’
Legality and Liability
The CDC, in conjunction with legal scholars at Georgetown and John’s Hopkins Universities, assessed the legal framework concerning EPT across all 50 states and other jurisdictions. While laws seem to be in support of EPT, studies have shown that physicians and pharmacists have misconceptions and uncertainties surrounding the legal status of EPT. Healthcare providers are concerned about substantial liability when it comes to prescribing medications without examining the partner. In EPT programs that have been monitored for adverse events since 2001, no drug-related adverse effects or lawsuits arising from this method of care have been noted. Alternatively, there is some potential for legal action against a provider for negligence through not providing EPT and a partner subsequently developing adverse effects from an STI.
Executive Directoristrative and Cost Challenges
Our current medical system does not provide a protocol for EPT programs. Challenges include how to record the medication dispensed and patient documentation for unseen patients. The cost of the additional medication is another drawback for some providers, as there is no billing code for EPT or reimbursement procedures.
One major concern of most providers in implementing EPT are missed opportunities to evaluate and educate patients exposed to an STI. Once medication is dispensed through EPT, there may be less of an incentive for partner(s) to seek medical care. This is problematic with the concern of co-infections that may not get treated with the dispensed medication. Another possible problem is that patients and their partners may not comply fully with the recommended STI treatment guidelines, thus diminishing effectiveness. A notice should be included with the prescription or discussed with a pharmacist regarding potential for co-infections, educational information, and where to get further testing.
Moving Forward with EPT
While the benefits of EPT outweigh the problems, there is an opportunity for improvement among current recommendations that would provide physicians with options for overcoming their concerns. Perhaps the biggest concern from the medical community is changing the basic system of providing care while missing opportunities for patient evaluation and education. I would argue that the patients who would be missed by providing EPT would potentially be missed without providing it, especially due to the asymptomatic nature of STIs. However, more current studies are needed to analyze the effectiveness of EPT and the potential long-term effects on chlamydia and gonorrhea rates along with the possible reduction in associated problems of untreated STIs, such as pelvic inflammatory disease (PID) in women.
To find out if EPT is practiced in your state, go here!
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Janelle Knowlton, MPH strives to cultivate healthy attitudes, beliefs, and behaviors surrounding sexual health. While completing her BS in Health Education from the University of Arizona, Janelle traveled to Tanzania, Africa to teach HIV/AIDS education to youth and adults. After working for a year in the mental health field, she returned to school to complete her Masters in Public Health from Boston University. Her unique blend of experience and education allows her to view health problems through a multidimensional lens. To read her full bio, along with links to her recent posts, check out our contributors page. You can find more information about Janelle Knowlton on her website or by visiting her on LinkedIn.
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Have you also wondered about expedited partner therapy (EPT) or why people are advocating for one approach over another? Did this help answer your questions? Share your thoughts in the comments section below!