Your patient has an STI: How do you tell her partner?

When a woman presents with a sexually transmitted infection (STI),naturally your first steps involve diagnosis and treatment. But your next stepsought to include something about partner management, for a woman whose partneror partners remain untreated is quite likely to become infected again.

That's especially important given the associations between repeat infectionsand complications such as ectopic pregnancy.¹ The Centers for DiseaseControl and Prevention's position on STIs is that management of sex partners isintegral to patient care, as the agency's STI treatment guidelines show (Table1).²

Partner notification in a nutshell

Partner notification is nothing new in public health. For decades, publichealth professionals (Disease Intervention Specialists: DIS) have interviewedpatients with syphilis to get their partner's identifying and locatinginformation and have then "traced" those partners and notified them oftheir exposure to syphilis.³ They also draw blood for syphilistesting, make appointments with partners for health-care visits for evaluation,and even track down those who miss their appointments. When properly done, DIS-basednotification (including for gonorrhea) works quite well, but is labor-intensivecompared to alternatives.^4-8

This means that, compared with syphilis (a few thousand incident cases ayear), the process occurs less frequently for gonorrhea (a few hundred thousand)and less frequently yet for chlamydial infections (a few million). Thestatistics reflect the fact that public health programs typically lack theresources to trace partners of people diagnosed with chlamydial or gonococcalinfections: estimates of their successful partner interviewing rates for theseSTIs are 12% to 17%, compared to 89% for syphilis.⁹

Thus, it often falls to the health-care provider to deal with notifying thepartner. However, few obstetrician and gynecologist offices can routinely offerpartner notification services, so they have to pass the job on to theirpatients. While most clinicians will offer basic instructions to a patient toinform her partner(s) herself (this is known as patient referral),³few offices are keen on collecting information about the patients' partner,contacting partners, and so forth.¹⁰ (Providers tend to feel itinterferes with patient relationships and doesn't work any better than patientreferral.¹¹) Some retrospective studies suggest that 30% to 60% ofpatients actually do inform their partners, and women are probably betterat this task than are men.¹² Nevertheless, patient referral withoutsome sort of enhancement isn't very effective. Enhancements could go a long wayto ensuring that the partners notified actually get evaluated and treated.

Enhancing partner management in your office

Our purpose here is to describe enhancements that ob/gyns can implement intheir offices. Although we discuss provider referral and using referral cards toimprove patient referral, we devote the most space to a more recently evaluatedenhancement to patient referral: giving medications or prescriptions to patientsto deliver to their partners before those partners receive a medical evaluation:Expedited Partner Therapy (EPT).

PROVIDER REFERRAL

That so many providers are ill-equipped or ill-disposed toward providerreferral doesn't mean every provider has to leave it alone. As an ob/gyn, youwould have to interview the infected patient for her partners' names,identifying information, and location; attempt to contact those partners; andassure their evaluation. When the patient has only one partner, the process canbe fairly straightforward, although it still tends to take up the morning'svisit (and surely to collect the information confers some responsibility tofollow-up?demanding more time).

DIS receive special training to manage patients who report multiple oranonymous partners or who withhold information: Even a glance at the CDC'sProgram Operation Guidelines shows what a complex and time-consuming processinterviews and follow-up can be.³ Moreover, the notification processmust remain confidential; notified partners are not entitled to be told whichob/gyn named them. Currently, there is no recognized mechanism to specificallybill for partner notification services.

PATIENT REFERRAL

We wouldn't discourage you altogether from provider referral, but it's easyto see why patient referral is the most frequently used partner notificationstrategy. While a straightforward and short verbal instruction is feasible,additional simple interventions can increase partner notification and treatmentrates. A commonly used strategy is giving patients referral cards to give toeach partner along with basic notification. Without relying on extensivefear-arousal, the referral card should provide:

• 1 notification of the exposure,

• 2 available treatment options, and

• 3 locations where treatment is available.

A referral card is certainly an inappropriate place to lecture or chide theexposed individual about sexual behavior. The example at left in Figure 1alludes to local clinics as treatment options. If you cite a location other thanyour own office, be sure the information is accurate. Ideally, providers in agiven area will make it a point to ensure that partners are not presentingreferral cards to providers who have no idea of their origin.

Studies measuring the effectiveness of referral cards have yielded mixedresults. One trial, which involved a card similar to those at right in Figure 1,showed only small improvements in reported notification and partner treatmentrates among those receiving referral instructions and "care cards,"compared to those receiving referral instructions alone, although patientreinfection rates were significantly lower in the care card arm.¹³

EXPEDITED PARTNER THERAPY

As the name suggests, the EPT approach is expedited because partners receiveit without a prior physical exam or assessment by a health-care provider. Mostrelevant to clinicians outside public health settings is the subset known aspatient-delivered partner therapy (PDPT), in which providers give their STI-infectedpatients either medications or prescriptions to give to their sex partners. TheCDC suggests that providers consider EPT (and specifically PDPT) as a partnermanagement option for uncomplicated gonococcal and chlamydial infections. Youcan find guidance at www.cdc.gov/std/treatment/EPTFinalReport2006.pdf.^2,12

EPT appears at least as effective (for chlamydial infection) or moreeffective (for gonorrhea) in reducing reinfection, compared to basic patientreferral.^13-15 Moreover, a multi-city trial showed increasednotification rates for chlamydia-infected women who were given medications topass on to their partners,¹⁴ and a trial enrolling men and women inSeattle showed increased treatment rates (but not notification rates) forparticipants receiving prescriptions for partners.¹⁵ Another arm of aNew Orleans trial of men diagnosed with urethritis showed substantialimprovements in notification and treatment using PDPT.¹³

In keeping with CDC guidelines, EPT should be accompanied by written materialfor partners. It should provide clear and specific instructions for taking themedication and the advice to abstain from sexual activity during a specifiedtime frame and to seek a complete sexual health evaluation (especially forfemale partners).¹² Verbal instruction to the patients and writteninstructions for their partners are recommended. Table 2 gives an example ofpatient instructions from the state of California (see also www.dhs.ca.gov/dcdc/STD/docs/PDT_GUIDELINES_19.pdf, pp.4-5).

Could EPT open up a legal minefield?

Admittedly, there is the potential for harm as a result of the sex partnertaking the prescribed medication, although adverse consequences of drugsrecommended to treat gonorrhea and chlamydia are mostly confined to mildgastrointestinal distress.¹⁶ One should also consider the legality oftreatment without a documented medical evaluation. In a 2003 survey, statedirectors of medical practice or pharmacy boards?or both?classified EPT asexplicitly legal in only four states (California, Tennessee, Colorado, andWashington), whereas it was illegal in 30.¹⁷ However, respondentstypically expressed some uncertainty and stated:

A that the issue had never been directly addressed in their states, and

B they did not know if anything would happen to a person who practiced EPT.

Also, those surveyed were neither authorities for making decisions, nordrawing upon an established body of regulation. This lack of clear statutory orregulatory authority or case law support places providers at risk for liabilityif partners sue in the event of adverse outcomes. However, several states (NewMexico, for example) have recently moved toward permitting EPT: CDC assessed allstates' positions via a legal analysis and has posted a summary of this analysisfor each state at www.cdc.gov/std/ept.Readers should note that these summaries are primarily intended for policymakersconsidering a formal approach to EPT, not as definitive legal guidance forclinicians.

Other considerations to providing EPT (some specific to EPT, some generic topartner management) include potential obligations to report sex with minors byolder partners in selected states,¹⁸ the financial burdens of payingfor the medication, partners taking medications in lieu of undergoing a completeSTI assessment and potentially missing other infections, as well as missedopportunities for counseling partners. Nevertheless, EPT is already widespreadpractice. Respondents from a national probability sample of more than 4,000physicians in five specialties (emergency medicine, general/family practice,internal medicine, obstetrics/gynecology, and pediatrics) were asked if theyever gave patients medications to pass on to their sex partners. Among those whohad diagnosed gonorrhea or chlamydia in the past year, 50% and 56%,respectively, had ever practiced PDPT; 11% and 14% did so "usually" or"always."¹⁹ The corresponding figures for the subset of ob/gynswere, for gonorrhea and chlamydial infections, 56% and 65% (ever), and 18% and22% (usually or always).

Management of sex partners is a potentially powerful tool to reduce STIreinfection and to control rates. Private-sector providers must (and frequentlydo) implement sexual health-care tasks traditionally handled by healthdepartments, including partner notification. Systematic patient referral, withor without EPT, can be implemented in the ob/gyn office-based setting to helpprevent recurrent STIs and improve the sexual health of our patients.

The state of STI treatment is fluid. Currently, this is especially truefor gonorrhea treatment. Cefixime is not generally available for lack of amanufacturer, and quinolones are no longer recommended for treatment in the US.Cefpodoxime (400 mg) is mentioned in the 2006 Treatment Guidelines, butdefinitive guidance for use is not yet available.

DR. HOGBEN is Chief, Behavioral Interventions and Research Branch,Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta,Ga.

DR. BURSTEIN is Medical Director, Epidemiology and Surveillance, ErieCounty Department of Health, Buffalo, N.Y. [Authors' Note: The findings andconclusions in this report are those of the authors and do not necessarilyrepresent the views of the Centers for Disease Control and Prevention.]

REFERENCES

1. Hillis SD, Owens LM, Marchbanks PA, et al. Recurrentchlamydial infections increase the risks of hospitalization for ectopicpregnancy and pelvic inflammatory disease. Am J Obstet Gynecol.1997;176:103-107.

2. Centers for Disease Control and Prevention; Workowski KA,Berman SM. Sexually transmitted disease treatment guidelines, 2006. MMWRRecomm Rep. 2006;55(RR-11):1-100.

3. Centers for Disease Control and Prevention. Programoperation guidelines for STD prevention: Partner services. Atlanta, GA: USDepartment of Health and Human Services, 2000.

4. Macke BA, Maher JE. Partner notification in the UnitedStates: an evidence-based review. Am J Prev Med. 1999;17:230-242.

5. Mathews C, Coetzee N, Zwarenstein M, et al. A systematicreview of strategies for partner notification for sexually transmitted diseases,including HIV/AIDS. Int J STD AIDS. 2002;13:285-300.

6. Han Y, Coles B, Muse A, et al. Assessment of ageographically targeted field intervention on gonorrhea incidence in two NewYork state counties. Sex Transm Dis. 1999;26:296-302.

7. Woodhouse DE, Potterat JJ, Muth JB, et al. Acivilian-military partnership to reduce the incidence of gonorrhea. PublicHealth Rep. 1985;100:61-65.

8. Du P, Coles FB, Gerber T, et al. Effects of partnernotification efforts on reducing gonorrhea incidence rate. Sex Transm Dis.2007;34:189-194.

9. Golden MR, Hogben M, Handsfield HH, et al. Partnernotification for HIV and STD in the United States: low coverage for gonorrhea,chlamydial infection, and HIV. Sex Transm Dis. 2003;30:490-496.

10. St Lawrence JS, Montano DE, Kasprzyk D, et al. STDscreening, testing, case reporting, and clinical and partner notificationpractices: a national survey of US physicians. Am J Pub Health.2002;92:1784-1788.

11. Hogben M, St. Lawrence JS, Montano D, et al. Physicianopinions of three forms of STD partner notification: responses from a nationalsurvey. Sex Transm Infect. 2003;80:30-34.

12. Centers for Disease Control and Prevention. Expeditedpartner therapy in the management of sexually transmitted diseases: review andguidance. Atlanta, GA: US Department of Health and Human Services, 2006.

13. Kissinger PK, Mohammed H, Richardson-Alston G, et al.Patient-delivered partner treatment for male urethritis: a randomized controlledtrial. Clin Infect Dis. 2005;41:623-629.

14. Schillinger JA, Kissinger PK, Calvet H, et al.Patient-delivered partner treatment with azithro-mycin to prevent repeatedChlamydia trachomatis infection among women. Sex Transm Dis.2003:30:49-56.

15. Golden MR, Whittington WL, Handsfield HH, Hogben M, et al.Effect of expedited treatment of sex partners on recurrent or persistentgonorrhea or chlamydial infection. N Engl J Med. 2005;352:676-685.

16. Lea AP, Lamb HM. Azithromycin. A pharmacoeconomic reviewof its use as a single-dose regimen in the treatment of uncomplicated urogenitalChlamydia trachomatis infections in women. Pharmacoeconomics.1997;12:596-611.

17. Golden MR, Anukam U, Williams DH, et al. The legal statusof patient-delivered partner therapy for sexually transmitted infections in theUnited States: a national survey of state medical and pharmacy boards. SexTransm Dis. 2005;32:112-114.

18. Hogben M, Burstein GR. Expedited partner therapy foradolescents diagnosed with gonorrhea or chlamydia: a review and commentary. AdolescMed Clin. 2006;17:687-695.

19. Hogben M, McCree DH, Golden MR. Patient-delivered partnertherapy as practiced by US physicians. Sex Transm Dis. 2005;32:101-105.