Temkin, Elizabeth MSN; Klassen, Ann C. PhD; Mmari, Kristin MA, DrPH; Gillespie, Duff G. PhD
Expedited partner therapy (EPT) in its most common form, patient-delivered partner therapy, allows patients diagnosed with curable sexually transmitted diseases (STD) to bring medication to their sex partners without requiring the partner to undergo medical evaluation. EPT has the following 2 goals: the clinical goal of preventing reinfection of the index patient and the public health goal of reducing STD transmission.1 As of September 2010, EPT is permissible in 26 US states, prohibited in 8 states, and has uncertain legal status in 16 states.2
In 5 randomized controlled trials (RCTs) of EPT in the United States, index patients reported on the likelihood that their partners had taken the medication. Among patients in the EPT arm, the proportion of partners believed to have taken the medication ranged from 56% to 85%.3–7 Although little is known about how patients decide whether and how to deliver EPT to their partners, previous qualitative studies have examined the decision-making involved in STD disclosure to their partners.8–10 Reasons for notifying a partner of an STD included (1) a concern for the partner's health, (2) a feeling of responsibility, and (3) a desire to avoid being reinfected and to prevent further transmission. Reasons for not notifying a partner included (1) a fear of gossip, stigma, or partner violence; (2) retaliation against a partner who was perceived to have transmitted the disease; and (3) termination of the relationship. In general, patients were more likely to disclose curable rather than chronic STDs and to regular rather than casual partners.
To examine whether decision-making about EPT follows similar reasoning, we conducted what is, to our knowledge, the first qualitative study to explore how patients use EPT. In this article, we describe how study participants at the Baltimore City Health Department (BCHD) STD clinics made decisions about EPT and what they did with the EPT medication packs dispensed to them.
MATERIALS AND METHODS
EPT is not expressly legal in Maryland, but in April 2007, the General Assembly of the state authorized EPT in the BCHD clinics as a 3-year pilot project.11 Recent legislation extended the program to 2015. The health department's 2 free STD clinics began offering EPT in September 2007. To be eligible for EPT, patients must have a laboratory-confirmed diagnosis of gonorrhea or chlamydial infection. In keeping with guidelines issued by the Centers for Disease Control and Prevention, men who have sex with men are excluded (because of insufficient efficacy data on EPT in this population and because of the high risk that partners may be coinfected with undiagnosed HIV).12 Patients may take EPT for up to 3 partners. The medications are single-dose azithromycin for chlamydial infection and single-dose cefixime plus azithromycin for gonorrhea. EPT packs include an instruction sheet that warns partners not to take the medications if they are allergic to them and advises females to seek treatment if they have symptoms of pelvic inflammatory disease. The sheet also encourages partners to be examined and lists contact information for the STD clinics. In 2008, 1251 patients were eligible for EPT, of which 492 (39%) declined and 759 (61%) accepted. Of those accepting EPT, 519 (68%) took packs for 1 partner, 187 (25%) took packs for 2 partners, and 53 (7%) took packs for 3 partners (unpublished data; BCHD).
The first author recruited and interviewed study participants at BCHD's 2 STD clinics between September 2009 and April 2010. Clinic patients were eligible for the study if they had received EPT on the day of their visit or in the previous 3 months, were 16 to 50 years old, and spoke English. Participants who received EPT on the day of recruitment returned 1 week later for a single in-depth interview; participants who had received EPT at a previous visit were interviewed on the day of recruitment. Interviews were audiotaped with the participant's consent. The interviews followed a semistructured guide consisting of questions about recent sexual partnerships, reasons for choosing EPT, experiences giving EPT to partners, and opinions about EPT as a treatment option.
The study was approved by the Johns Hopkins School of Medicine Institutional Review Board and BCHD's Public Health Review Program. Oral consent was obtained from all participants.
Taped interviews were transcribed verbatim and coded using ATLAS.ti 6 qualitative software. Saturation was achieved when no new codes were identified. After all the codes were identified, categories of similar codes were created and mapped onto the following 3 overarching research questions: Why do patients accept or decline EPT?, What happens once patients get the EPT packs?, and What happens once partners are given the EPT packs? This analytic approach not only allowed the content to be analyzed and summarized by key themes, but also allowed for identification of similarities and differences across the interviewees. A decision-making “map” was also created (Fig. 1) to illustrate the process of accepting and delivering the EPT packs to various partners.
Of the 84 people who were recruited into the study, 31 returned for an interview. All 31 participants were black. Characteristics of the study sample are summarized in Table 1. The 31 participants reported 58 sexual partnerships in the 2 months before their STD diagnosis. The median duration of the partnerships was 1 year (range: 1 night–18 years). Figure 1 traces participants' actions regarding EPT. The following narrative expands on the boxes in the flow chart.
Why Do Patients Accept or Decline EPT?
Reasons for Accepting EPT for Partners.
Participants accepted EPT for 41 partners (71%). Most frequently, participants described EPT distribution to partners as an act of altruism. One man explained, “I wasn't just gonna take care of myself. I was gonna take care of her too.” Several participants talked about EPT as “the responsible thing to do.” Others focused on preventing their own reinfection. For 1 woman, concern for her own health led her to pursue EPT, even though she expected it to be difficult:
We argue a lot, maybe, cuz he accuse me of cheating or something like that. So, I didn't really want to give him the medicine but I knew I had to, to save myself. Because he always, I know he would accuse me, then I would accuse him .... But I still gave it to him cuz I didn't want to get reinfected.
Several participants spoke about stopping the chain of transmission. One man explained why he preferred to bring EPT to his partner rather than leave it up to her to seek treatment:
I think the most important reason to give her the medicine is like, even if me and her don't ever do anything ever again, if I was the type of person who was just like, “oh, if she don't wanna come get checked, that's on her.” I would feel bad because who's to say the next person she might start messing with wouldn't be one of my cousins or something? ... This is one small city, I learned.
Participants also brought up the practical considerations that made EPT attractive. Partners would not have to take time off of work to come to the clinic. Several women commented that EPT was a solution to men's general aversion to getting health care, whereas men noted that EPT spared women the embarrassment of being seen at the STD clinic.
Reasons for Declining EPT for Partners.
Although all participants accepted EPT for at least 1 partner, EPT was declined for a total of 17 of 58 reported partners. Two of these partners had already been treated. In some cases, EPT was declined due to the following practical reasons: the number of partners exceeded the 3-pack limit, participants did not know how to locate an ex-partner, or participants thought it was unnecessary to treat partners with whom they consistently used condoms.
Some participants made calculated decisions about which of their partners deserved EPT. One woman described not taking EPT for an ex-partner who previously had never sought treatment for a trichomonal infection: “I'm like, well, if he don't care about himself, why should I help him care?” Another woman recounted,
I ain't get no phone calls or none of that saying that he was feeling any kind of way [i.e., having STD symptoms]. I mean, if he had it, then he'd probably think it was somebody else. Because I know he be with a lot of women. So I didn't feel like I had to be responsible for even telling him.
Accepting EPT for Someone Other Than a Partner.
Six EPT packs were accepted by participants with the intention of giving them to someone other than a partner. One man took 2 packs for his partners and a third pack “for the future, just in case.” Another participant, his 2 brothers, his nephew, and a friend all had sex, consecutively, with the same woman. After he was diagnosed with gonorrhea, he brought EPT to 3 of the other men (but not to the woman, whom he did not know). He described his role this way: “I guess they was, you know, using me as a stunt dummy since I came down here. If I'm complaining, they all complaining!” A third participant took 1 pack for a partner and 2 packs “just so I could have them.”
What Happens Once Patients Get the EPT Packs?
EPT Delivered to Partners.
Of the 41 packs that participants accepted for their partners, 30 were delivered directly by participants to their partners. Many participants described of being anxious as they prepared for the meeting.
I didn't know what to do. I mean, I didn't know what to do. For one, we had just started dating. And we used protection but it did pop, of course. And I was like, “oh my God, what am I supposed to tell him? I don't know what I'm gonna tell him. (laughs) So, I mean, he came, I told him.”
Similarly, one man recounted:
I was kind of scared, like, cuz I didn't know how it was gonna go. I didn't know if she was going to try to do something to me, or, like, try to beat me up, but I'm just like, I gotta be a man about it. Just do what you gotta do.
Several participants found it easiest to downplay the possibility of infection. One man, a mechanic, talked to his partner using language from his trade:
I said, this doesn't actually say you have it, but just in case that you do have it, it's really just, um, it's just really, I have to say preventive maintenance, I guess. Yeah. So it's not actually saying that you have anything, but just in case if you do have something, then this should help you.
Other participants chose a straightforward approach that was careful to avoid blame. One man told his partner, “The doctor told me that you should take this, just to make sure that we don't have to go through this anymore. And to be clear on your side and my side.”
EPT Not Delivered to Partners.
Of the 41 packs that participants accepted for their partners, 7 were never delivered. Three ex-partners did not respond to participants' emails asking them to get in touch; the participants had no other way to contact them. One participant had not delivered EPT by the time of his interview, but intended to once he got his HIV tests results; he preferred to present all the information to his partner at the same time. One participant did not deliver the pack she took for her partner because he lives in the western half of Baltimore, and she lives in the eastern half: “I don't feel like traveling all the way up there.” Another participant feared her partner's response and felt unable to broach the topic: “It's like, I don't know the words and I don't even know how to say it without having to go through yelling, arguing, and a bunch of accusations.” She suspected him of cheating, but she was worried that discussing EPT would be an admission of her own infidelity:
I even thought about chopping it [the medication] up, putting it in the dinner, putting it in a drink so he could just get it in him. Cuz just actually saying “you have to take these, this is what happened.” And then what if he's not cheating? So that means I'm telling on myself.
She decided against slipping the antibiotics into her partner's food because she was unsure if they would still work if crushed. Instead, she was saving the pills to retreat herself if she developed symptoms, because she had had unprotected sex with this partner (the condom slipped) since her initial treatment. She and this partner were involved in a threesome with another woman. The participant had also taken an EPT pack for her, but never delivered it because she assumed this partner was uninfected: “As her being a female, if she had it, she should be feeling symptoms like I am .... She hasn't been complaining about anything.”
EPT Delivered Through a Third Party.
Two participants delivered EPT through a third party. One participant did not know how to contact his ex-partner, so gave the pack to a friend of the ex-partner and asked her to deliver it. Another participant talked to his partner on the phone about EPT, but had his sister bring the medication to her because he was worried about coping with her response face-to-face:
Cuz you never know how somebody will react when something like that – it's kinda personal. And I don't think a lot of people want to accept the fact that that's what they have or that's what happened. So I thought it would be harder to be like, “here, well, take this.”
Neither participant knew if their partners had taken the medication.
EPT Delivered But Refused by Partner.
Two participants tried to bring EPT to their partners, who refused to take it. One partner did not believe that the single-dose oral EPT medications would work, because she had previously been treated for gonorrhea with an injection and a 7-day course of pills. The participant tried to convince her that the clinic would not dispense ineffective treatment, but she refused the EPT and missed several appointments to get treated at the clinic. The participant concluded, “That's letting me know that she really don't care, or she might be really, really embarrassed for other people to see her up here.” The second participant's partner refused to meet him to pick up EPT, but subsequently sought care and tested negative for gonorrhea. According to the participant, “if I wasn't so angry with her [over the infection], if we wouldn't have left off on the wrong foot, she would have probably met me.”
EPT Delivered to Someone Other Than Partners.
The man who had shared a sex partner with 4 other men delivered EPT to 3 of them. He regretted that he did not have additional packs to distribute to the fourth man and 2 men's steady sex partners who had already been exposed. Another participant, who had taken extra packs just to have them, became an informal community educator about STDs:
I have some younger guys in my neighborhood who I know are having unprotected sex. So I let them know: if you get a discharge or anything does not look right, you can tell me or you can go get it checked out.
In response to this announcement, one acquaintance disclosed that he was having symptoms and the participant gave him an EPT pack. In addition, “I told him to have his lady friend, if she needs one, then I have another one for her. Unless she's gonna come into the clinic.”
EPT Kept for Self Use.
The man who had taken an extra EPT pack “for the future, just in case” took the medication himself shortly after he was treated in the clinic. He decided, “I might as well take it myself, to make sure it's out of my system quicker. Cuz I don't like feeling like this.” Another man who had taken extra packs with no particular recipient in mind intended to keep one pack for himself as a memento, comparing it with getting a tattoo: “It's just something that reminds you of what you've been through.”
What happened to the undelivered packs? When asked about their overall impressions of the EPT program, several participants raised the possibility that the medications would be sold on the street. One man described Baltimore's black market of street pharmacies, whose advantage over formal health care he explained this way:
It's just like going to McDonald's as opposed to going to, let's say, IHOP. You go to IHOP, you gotta sit down, wait for the meal to be prepared .... You go to McDonald's, you go through the drive-through, you get it, you're gone, that's good.
However, no participants reported selling their EPT or had heard of EPT being available on the street.
What Happens Once Partners are Given the EPT Packs?
EPT Medications Definitely Taken.
Of the 30 EPT packs that were delivered directly by participants to their partners, 21 were definitely used; the participants observed their partners swallowing the medication. None of the partners had serious side effects, though 6 had nausea or stomach pain. Fifteen partners read the instructions included in the EPT pack before taking the medication.
Most participants who observed their partners taking EPT described the EPT negotiations as calm and straightforward. Many noted that their partners appreciated their honesty.
He was very calm and collected. He just said that he was happy that I came to him and told him what was going on, and that he just happy that everything is clear. We can go back to living a happy life.
One man said that bringing his partner EPT was an act of good faith that helped to defuse any anger she felt about the infection: “But that right there, that shows her what type of person I am. Not being a bad person, basically.” Couples succeeded at EPT when they found a way to put a positive spin on the situation.
So we talked about it and we laughed about it. He said, at least it's something that can be cured, so it's not that bad. Don't think about it being a bad thing. It's not that bad. And I was like, yeah, it's not that bad. At least we can be cured for it. Thank God for that.
As part of the discussion surrounding EPT, participants talked to 14 of these 21 partners about seeking follow-up medical care. By the time of these interviews, 5 partners had already got tested for HIV and syphilis.
EPT Medications Probably Taken.
In 3 cases, partners told participants that they took the medication, but the participants did not directly observe it. Although EPT is intended to stimulate a conversation about sexual risks and exposures, this did not always happen. One man told his partner that he was bringing her EPT and left the pack in her purse for her to discover.
We ain't never really sit down and talk about it [the infection] because I don't like to sit down and talk about stuff ‘cuz I can't stand when somebody's lying to me. So I just left it alone. We never really sat down to talk about it.
Partner Treatment Unknown.
For the remaining 6 of the 30 packs delivered directly to partners, participants did not know whether their partners had taken the medication. A common sentiment was that the participants had “done their part” by delivering EPT:
“I don't know if she took it or not. All I did was gave it to her. Now, if she choose not to take it, then that falls on her. I basically did my part.”
Successes and Challenges of the EPT Program
Although we cannot verify that our convenience sample is representative of all patients getting EPT at the Baltimore STD clinics, it is still informative to summarize the outcomes we observed. Partners definitely taking EPT, probably taking EPT, or getting treated elsewhere were considered successful outcomes. Of the 56 partners who had not already been treated, 26 (46%) had successful outcomes. Female participants had 27 untreated partners with 13 (48%) successful outcomes. Male participants had 29 untreated partners with 13 (45%) successful outcomes.
There was 1 incident of violence triggered by EPT. One participant brought EPT to his long-term partner:
I took [the EPT pack] out of my jacket pocket and gave it to her and she just felt so betrayed and she started screaming at me, told me she was gonna kill me. Yeah. She was like, how can I do this to her? And I'm like, “well, I haven't been sleeping with nobody else.” She tried to hit me a couple times.
A physical altercation occurred. The police were called and the participant spent time in jail. The partner saw her own physician for STD testing and treatment. This participant remarked that, compared with simply notifying a partner to seek treatment, EPT was more likely to lead to violence because partners react to the physical reality of the pack:
“Cuz they see that packet, they know it's serious business. Well, it is serious business, but I mean, she just looked at what was in my hands, looked at me, and she just went off.”
Suggestions for Improvement.
When asked how the EPT program could be improved to increase the likelihood of success, several participants suggested that patients could use more coaching or written scripts on how to present the information to their partners: “A lot of people don't know how to talk to people or what to say, especially about this subject. I think it would be better if you told people how to talk.” One participant, who took packs for 2 of her 4 partners, but delivered none of them, expressed frustration at her inability to carry out EPT: “I just, I wanted to take a packet for everybody, but it's just like, how can you sit and say this to somebody?”
This qualitative study complements the growing body of quantitative evidence in support of EPT as an alternative to standard partner notification.3–7,13 We found EPT being used amid a diversity of sexual partnerships. Patients value EPT and use it thoughtfully to protect their own health and their partners' health, and to limit the spread of disease in their sexual and social networks. In addition to being a method to distribute medication, EPT acts, in many cases, as a catalyst for discussion between partners. Patients were innovative about how to get medication to their partners and indicated a deep sense of concern and responsibility for their partners' health. The fact that 30 of the 41 packs of EPT were delivered directly to partners highlights this responsibility.
This study also suggests that EPT use can deviate from protocol: giving EPT to non-partners within one's sexual network (an epidemiologically sound approach); giving EPT to acquaintances outside of one's sexual network; and index patients retreating themselves. One objection to EPT is that its misuse will exacerbate the problem of antibiotic-resistant gonorrhea.14,15 Is this likely? The confluence of the following 3 conditions favors the emergence and spread of antibiotic-resistant gonorrhea: the ready availability of antibiotics (e.g., in the informal health sector), suspect drug quality, and poor adherence to treatment, that is, taking less than the recommended dose.16 Our study revealed that Baltimore has an active informal health sector. Although there were no reports of EPT being sold on the street, some is being distributed haphazardly. However, the proportion of EPT being misused in this way is small: in our study, 1 pack of 47. The second condition, poor drug quality because of adulteration or lapses in manufacturing, does not apply to medications being dispensed from the STD clinics. Most important, the third condition, incomplete treatment, is not possible with the single-pill cefixime used for EPT. Therefore, it is unlikely that misuse of EPT will contribute to the spread of antibiotic-resistant gonorrhea as long as the current cefixime regimen remains effective. If multidrug or multidose regimens become necessary, it will be important to assess whether people taking EPT are as likely to complete treatment as people counseled directly by a clinician.17
Two frequently voiced concerns about EPT are that partners will have adverse drug reactions and will miss out on comprehensive STD testing and prevention counseling.5,12 In our study, as in the RCTs of EPT3–7 and reports of EPT in clinical practice,18 no partners experienced serious adverse drug reactions. Within a week of being given EPT, 5 of 21 partners had already sought further STD testing—-evidence that at least some partners do not regard EPT as a substitute for hands-on health care. We encountered 1 serious adverse event: an incident of EPT-related violence that resulted in the index patient's incarceration. Among the US-based RCTs of EPT, only Schillinger et al. reported on violence; in that trial, 6% of women in the EPT arm and 8% of the women in the self-referral arm voiced concern at the time of enrollment that their partners would hit or hurt them in response to the STD disclosure, but no violent events were reported.3 The Centers for Disease Control and Prevention recommends screening for potential partner violence before any type of partner notification is undertaken.19 In our study, careful screening of the participant before EPT was dispensed would not have averted this incident, because the couple had no history of violence. Further study and surveillance of violence related to EPT and other methods of partner notification is needed.
Our study also found that EPT only reached about half of the untreated partners. This success rate might be improved by enhancing the counseling that accompanies EPT. The patient and the clinician could plan ways to approach each partner and practice talking about the infection and the EPT. Clinicians should ask patients if they anticipate difficulties in delivering EPT and discuss how these might be overcome. Role-playing and sample disclosure scripts could be used. These counseling sessions need not be intensely time-consuming and may not be needed by many patients accepting EPT; for other patients, this coaching could make a seemingly impossible task manageable. Another efficient way to deliver this service would be a website that offers advice about talking to partners, sample scripts, and answers to frequently asked questions. This website could have sections targeted at people delivering EPT and at EPT recipients, and should include a contact number to call for individualized information and assistance. When patients refuse EPT or are unable to carry it out successfully, alternative strategies for partner notification should be available, such as provider-initiated notification by text message20 or anonymous online notification.21
This study has several limitations. First, partners of index patients were not interviewed. Participants' accounts of their interactions with their partners are unavoidably one-sided and subjective; partners may have recounted and interpreted the events quite differently. Future studies of EPT should attempt to enroll patients and their partners to learn how their perceptions of the EPT transaction agree and differ. Second, patients who declined EPT entirely were not included in this study. However, the clinics' electronic medical records shed some light on why patients declined EPT. In 2008, clinicians wrote brief explanatory notes in the charts of 209 (42%) of the patients who declined EPT. The main reasons given were as follows: partners were already treated or had plans to get treated (41%), the patient was no longer in contact with the partner (26%), the patient was unable to identify the partner (10%), and the partner was either out of state (9%) or in jail (4%) (unpublished data; BCHD). In a study conducted by McBride et al., STD clinic patients were shown sample EPT packs and asked if, theoretically, they would be willing to deliver them to their partners.22 Fewer than half agreed, and the main reason for their refusal was the belief that their partner should be treated by a doctor. In contrast, that was not a common concern voiced by patients who declined EPT in our clinics. A third limitation is that clinic patients who participated in this study are self-selecting; their experiences of EPT may have been more unusual or more straightforward than those of patients who did not return for an interview. Fourth, the findings from this small sample of Baltimore STD clinic patients may not be transferable to other populations. A strength of this study is that qualitative methods provide insight into the contexts in which EPT is carried out. For studies of behavior within sexual partnerships, qualitative methods uncover not only what happened, but why. They enable us to understand EPT from the patients' perspective and in the patients' own words.
In conclusion, in addition to preventing STD reinfection and interrupting STD transmission, EPT appears to have the additional benefit of enabling altruism. Patients value this treatment strategy and many of them use it well, observations that support expanding the legal status of EPT.