Sexually Transmitted Diseases:
The Real World of STD Prevention
Adolescents’ Attitudes Toward Expedited Partner Therapy for Sexually Transmitted Infections
Radovic, Ana MD, MSc*; Burstein, Gale R. MD, MPH†; Marshal, Michael P. PhD*; Murray, Pamela J. MD, MHP‡; Miller, Elizabeth MD, PhD*; Sucato, Gina S. MD, MPH*
From the *Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA; †SUNY at Buffalo Department of Pediatrics, Buffalo, NY; and ‡West Virginia University School of Medicine, Morgantown, WV;
Acknowledgments: Adolescent Medicine Clinics at Children’s Hospital of Pittsburgh and Women and Children’s Hospital of Buffalo; Jennifer Hodges, Karen Franklin, Ashley Baskin, and Christine Hall for their assistance in implementing this study; J. Dennis Fortenberry, MD, MS, for use of the sexually transmitted infection notification self-efficacy scale. Everyone who has contributed significantly to this work has been listed.
Conflict of interest/support statement: There are no conflicts of interest for any author. There was no form of payment given to produce this manuscript. This project was supported by a T32 training grant from the Agency for Healthcare Research and Quality Grant No. T32 HS019486-01 (principal investigator: Kevin Kraemer, MD).
Correspondence: Ana Radovic, MD, MSc, Adolescent Medicine Department, 3420 Fifth Ave, Pittsburgh, PA 15213. E-mail: firstname.lastname@example.org.
Received for publication May 21, 2013, and accepted August 19, 2013.
Abstract: Adolescents (N = 392) attending 2 urban adolescent health clinics in 2010 were surveyed regarding likelihood completing expedited partner therapy (EPT), by bringing a partner exposed to chlamydia a prescription. Eighty-five percent (330/387; 95% confidence interval, 81%–89%), reported acceptance of EPT. Adjusted analyses showed higher education, notification self-efficacy, and romantic partner were associated with EPT acceptance.
Adolescents experience a disproportionate burden of chlamydia and gonorrhea1 and often become reinfected through contact with an untreated or new partner.2–4 Usual clinical practice for treating an exposed partner is patient referral: the patient advises sexual partner(s) to seek medical evaluation and treatment. Expedited partner therapy (EPT) is an alternative that involves the clinician providing medication or a prescription for the patient to distribute to partner(s), foregoing the necessity of an office visit.
Several randomized controlled trials (RCTs) comparing EPT with patient referral for chlamydia infection partner management demonstrated a small decrease in recurrent and persistent chlamydia infection rate and increased rates of partner treatment in heterosexual partners.5–8 One large multicenter RCT including 729 adolescent girls 14 to 19 years old demonstrated a trend toward decreasing chlamydia prevalence at follow-up (13% vs. 17%; P = 0.09), although few adolescents were younger than 16 years.6 Several national organizations agree that EPT may improve adolescent partner treatment, recognizing that EPT legality varies by state.9–12
In prior studies, adolescents with a romantic or regular partner13 and with high self-efficacy related to notifying a partner of an STI (notification self-efficacy) have experienced more successful partner notification,14–16 and this may be related to EPT acceptance. We sought to determine whether adolescents in an outpatient adolescent health clinic setting would report likelihood to use EPT and whether acceptance of this option would be influenced by type of sexual partner and by notification self-efficacy.
Participants were a convenience sample of patients 13 to 22 years old who attended clinical or research visits at 2 urban university hospital-affiliated adolescent medicine clinics in July to August 2010. The research teams (A.R. in Pittsburgh and G.B. in Buffalo) approached and asked patients during consecutive clinics for 2 to 4 weeks to complete a 10-minute 17-question anonymous survey in the patient’s room. A waiver of parental permission was obtained and care was taken to allow confidential completion. The study was approved by the institutional review boards at the University of Pittsburgh and University at Buffalo.
A hypothetical scenario written by the investigators involved the participant being informed of a chlamydia infection and offered different options to notify and treat a partner. Participants were asked to think about the last person with whom he/she had voluntary sex, defined as “putting a penis into the vagina or anus.” If not sexually experienced, he/she was asked to imagine someone he/she would like to have as a boyfriend/girlfriend. The participants were given the following options for treatment of their partners: patient referral (“your doctor asks you to tell your partner”), provider referral by a doctor (“your doctor offers to call your partner for you”), provider referral by the health department (“your doctor offers to have the health department call your partner”), EPT prescription (“your doctor hands you a prescription to give to your partner to get treated”), and EPT medicine (“your doctor hands you the actual medicine to give to your partner to take”). The primary outcome variable was the proportion of adolescents reporting EPT acceptance by prescription, as most clinicians will not have medication available to dispense on-site.
The 2 main predictors measured were partner type and STI notification self-efficacy. Partner type (i.e., romantic, friend, casual acquaintance, or parent of a baby) was asked in reference to the last partner with whom the participant had voluntary sexual intercourse. Self-efficacy questions on STI notification (Cronbach α = 0.76) were adapted from a multi-item scale developed by Fortenberry et al.,16 which has demonstrated predictive validity in predicting partner notification in adolescents diagnosed as having STI. The total score was added (range, 3–12), a higher score indicating greater self-efficacy. Other demographic and sexual history variables were obtained (Table 1).
We calculated descriptive statistics for the proportion of participants responding positively to EPT prescription dichotomized into “likely” and “very likely” versus the other options. We performed analyses comparing the 2 clinic sites by χ2 and t tests. We used univariate logistic regression to examine relationships between covariates and EPT prescription. We created a multiple logistic regression model by including potential covariates in the model if they were significant at a level of P < 0.10 in univariate analyses; we also adjusted for clinic site.
An equal number of adolescents were recruited from both sites. A total of 256 participants were asked to participate in Pittsburgh; 27 were ineligible because of developmental, cognitive, or emotional disorders or age younger than 13 years. Of the remaining 229, 30 refused, resulting in an 87% response rate. Response rate information is not available from Buffalo owing to inadequate staffing. Site comparisons are shown in Tables 1 and 2. Data were combined from the 2 sites because there were no differences for acceptance of EPT prescription. Total sample statistics are shown in Table 1. There was a large correlation between age and years of education, with a Pearson correlation coefficient of 0.77, although several older participants had finished less schooling than expected for their age. Characteristics of the sexually active group are shown in Table 2. The mean (SD) notification self-efficacy score was 9.3 (2.3), indicating overall high levels of comfort.
Eighty-five percent (330/387; 95% confidence interval [CI], 81%–89%) of adolescents responded that they would be “likely” or “very likely” to treat their partner by EPT prescription, similar to EPT medicine (85% [331/388; 95% CI, 81%–89%]). Acceptance of patient referral was slightly higher (89.5% [349/390; 95% CI, 86%–92%]). In comparison, acceptance of provider referral, with the provider contacting the partner directly, by a physician (56% [216/386; 95% CI, 51%–61%) or by health department (50% [192/386; 95% CI, 45%–55%]) was substantially lower.
In univariate analyses, higher education level, needing to treat a romantic partner, and notification self-efficacy score were associated with acceptance of EPT prescription (Table 3). In the multiple regression model, notification self-efficacy remained significantly associated with EPT prescription acceptance (odds ratio [OR], 1.24 [95% CI, 1.05–1.47]; P = 0.01), as did higher education level as compared with 7 to 10 years (13–16 years; OR, 2.92 [95% CI, 1.09–7.79]; P = 0.03). Expedited partner therapy prescription was less likely with condom use (Table 4). Compared with romantic partners, those with friend (OR, 0.40 [95% CI, 0.17–0.98]; P = 0.04) and casual types of partners (OR, 0.20 [95% CI, 0.05–0.88]; P = 0.03) were less likely to accept EPT prescription. Although there was no a priori plan to restrict multivariate analyses, all predictors except education were only asked of sexually experienced participants, and therefore, the multiple regression model was restricted to that group. Notification self-efficacy was also associated with acceptance of patient and provider referrals; additional details of predictors of secondary outcomes are available upon request.
In this survey of adolescents’ attitudes toward EPT, 85% of adolescents reported a high likelihood of bringing a partner a prescription or medication for treatment, similar to rates of reported completion in RCTs, which included adolescents with STI.6,7 Our study, based on a hypothetical scenario, showed similar rates of EPT acceptance in a male and female adolescent sample including respondents with no history of STI and those who were not yet sexually experienced. In high-risk urban adolescent populations, 25% of females acquire chlamydia within 1 year of initiating sexual intercourse2; this makes knowledge of sexually inexperienced adolescents’ partner treatment preferences especially relevant. In a multiple predictor model, adolescents with a higher education level and greater notification self-efficacy score were more accepting of EPT prescription, similar to prior studies in adolescents and adults.16,17
Limitations of this study include that it was a cross-sectional survey based on a hypothetical scenario rather than a prospective study measuring actual EPT adherence and also that it may not be generalizable to clinical settings outside academic adolescent medicine. Patients may encounter practical barriers when transporting a medication or prescription to a partner that interfere with partner adherence. We did not ask about intimate partner violence, which affects willingness to use EPT among adolescent18 and adult women,19 although the Schillinger trial did not find any instances of violence.6 Before offering EPT, clinicians should screen for intimate partner violence and provide appropriate counseling and resources. Expedited partner therapy legal status11 and its dynamic nature is caused by advocacy efforts to increase permissibility.20,21 The Centers for Disease and Control Prevention presents each state’s EPT legal status and offers a legal/policy toolkit at www.cdc.gov/std/ept/legal.
Most clinicians recommend postponing further sexual activity until both the patient and the partner complete therapy.22 However, adolescents’ sexual networks provide opportunities for sexual interactions with the same or a different infected partner23 and risk of repeat infection.4 National guidelines recommend EPT for partners who are unlikely or otherwise unable to receive treatment.5,12 Because it is unclear which adolescents would be most likely to use EPT, ensuring that youth are educated about and have access to EPT is likely needed to reduce STI prevalence. Future research should investigate actual uptake of EPT by age in clinical settings, which serve adolescents who present with STI and assess the partners’ treatment uptake; recurrent infection; safety problems including misuse of medication and adverse reactions; perceived protection of confidentiality; and understanding of diagnosis, treatment plan, and follow-up instructions without provider interaction. Considering EPT legality within their state, clinicians may elect to offer EPT as an option to treat partners of heterosexual adolescents infected with chlamydia.
1. Centers for Disease Control and Prevention. Sexually Transmitted Diseases Surveillance 2010. Atlanta: U.S. Department of Health and Human Services, 2011.
2. Tu W, Batteiger BE, Wiehe S, et al. Time from first intercourse to first sexually transmitted infection diagnosis among adolescent women. Arch Pediatr Adolesc Med 2009; 163: 1106–1111.
3. Batteiger BE, Tu W, Ofner S, et al. Repeated Chlamydia trachomatis
genital infections in adolescent women. J Infect Dis 2010; 201: 42–51.
4. Whittington WL, Kent C, Kissinger P, et al. Determinants of persistent and recurrent Chlamydia trachomatis
infection in young women: Results of a multicenter cohort study. Sex Transm Dis 2001; 28: 117–123.
5. Centers for Disease Control and Prevention. Expedited Partner Therapy in the Management of Sexually Transmitted Diseases. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2006.
6. 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: 49–56.
7. 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: 676–685.
8. 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: 623–629.
10. Committee opinion no. 506: Expedited partner therapy in the management of gonorrhea and chlamydia by obstetrician-gynecologists. Obstet Gynecol 2011; 118: 761–766.
11. Hodge JG Jr, Pulver A, Hogben M, et al. Expedited partner therapy for sexually transmitted diseases: Assessing the legal environment. Am J Public Health 2008; 98: 238–243.
12. Burstein GR, Eliscu A, Ford K, et al. Expedited partner therapy for adolescents diagnosed with chlamydia or gonorrhea: A position paper of the Society for Adolescent Medicine. J Adolesc Health 2009; 45: 303–309.
13. Furman W, Shaffer L. Romantic partners, friends, friends with benefits, and casual acquaintances as sexual partners. J Sex Res 2011; 48: 554–564.
14. van de Laar MJ, Termorshuizen F, van den Hoek A. Partner referral by patients with gonorrhea and chlamydial infection. Case-finding observations. Sex Transm Dis 1997; 24: 334–342.
15. Yu YY, Frasure-Williams JA, Dunne EF, et al. Chlamydia partner services for females in California family planning clinics. Sex Transm Dis 2011; 38: 913–918.
16. Fortenberry JD, Brizendine EJ, Katz BP, et al. The role of self-efficacy and relationship quality in partner notification by adolescents with sexually transmitted infections. Arch Pediatr Adolesc Med 2002; 156: 1133–1137.
17. Gursahaney PR, Jeong K, Dixon BW, et al. Partner notification of sexually transmitted diseases: Practices and preferences. Sex Transm Dis 2011; 38: 821–827.
18. Decker MR, Miller E, McCauley HL, et al. Intimate partner violence and partner notification of sexually transmitted infections among adolescent and young adult family planning clinic patients. Int J STD AIDS 2011; 22: 345–347.
19. Diaz-Olavarrieta C, Garcia SG, Feldman BS, et al. Maternal syphilis and intimate partner violence in Bolivia: A gender-based. Sex Transm Dis 2007; 34 (7 suppl): S42–S46.
20. Hogben M, Kidd S, Burstein GR. Expedited partner therapy for sexually transmitted infections. Curr Opin Obstet Gynecol 2012; 24: 299–304.
21. Cramer R, Leichliter JS, Stenger MR, et al. The legal aspects of expedited partner therapy practice: Do state laws and policies really matter? Sex Transm Dis 2013; 40: 657–662.
22. McCree DH, Liddon NC, Hogben M, et al. National survey of doctors’ actions following the diagnosis of a bacterial STD. Sex Transm Infect 2003; 79: 254–256.
23. Ellen JM, Brown BA, Chung SE, et al. Impact of sexual networks on risk for gonorrhea and chlamydia among low-income urban African American adolescents. J Pediatr 2005; 146: 518–522.
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