Expedited Partner Therapy: Moving From Research to Practice

Expedited partner therapy (EPT) refers to the practice of treating the sex partners of persons with curable sexually transmitted infections without requiring the partner to first seek a medical evaluation. In most instances, EPT involves giving a patient a medication or a prescription to give to their sex partner(s), a practice called patient-delivered partner therapy (PDPT). Over the last 10 years, at least in the United States, EPT has moved from the arena of research to the arena of clinical and public health practice. By the standards of medicine and public health, the change has been swift.

In 1999, John Potterat wrote that partner notification was the sick man of public health.¹ The practice, long a central component of public health sexually transmitted disease (STD) control efforts, was underfunded and understudied. In the United States, health department partner notification efforts were the work of Disease Intervention Specialists (DIS), public health staff who interview people with STDs and try to assure that their partners receive treatment. The DIS system was originally developed to control syphilis in the 1940s, but the number of federally employed DIS began to shrink in the 1980s,² and by the late 1990s state and local health departments provided partner notification services to <20% of persons reported with gonorrhea or chlamydial infection.³ Moreover, even a superficial assessment of the traditional public health approach to partner notification leads one to the conclusion that it could not form the basis for a comprehensive system. Using traditional procedures, a single DIS works approximately 400 cases per year. In 2006, US health departments received almost 1.5 million case reports on persons with gonorrhea, chlamydial infection, syphilis, and human immunodeficiency virus (HIV).^4,5 Thus, to provide services to 75% of these cases, the United States would need approximately 2800 DIS at a cost of approximately $200 million annually. [The Centers for Disease Control and Prevention (CDC) budget for STD control in 2007 was approximately $108 million.]

Sometime in the mid- to late-1990s, things began to change. It’s hard to know what led to that change and many factors certainly contributed to it, but at least 2 things stand out as being catalytic. First, the Institute of Medicine report on STD drew explicit attention to the inadequacy of the US STD control system in general, and to our approach to partner notification specifically.⁶ Second, CDC and National Institutes of Health funded a series of studies evaluating new approaches to partner notification. These studies included 4 randomized controlled trials of EPT.^7–10 The results of these studies have been reviewed elsewhere,^11–13 but they consistently found that EPT results in significantly more partners receiving treatment than standard approaches to partner notification, and that EPT can decrease index patients’ risk for reinfection with gonorrhea or chlamydial infection.

Since these trials were published, the focus of work related to EPT has shifted to the arena of public health practice. In collaboration with the Center for Law and the Public’s Health at Georgetown and Johns Hopkins Universities, CDC evaluated the legal status of EPT in the 50 US states and Puerto Rico, and posted findings from that evaluation on the Internet (http://www.cdc.gov/std/ept/legal/default.htm). CDC developed a guidance document related to EPT,¹² and the American Medical Association subsequently passed a resolution supporting that guidance and encouraging state and local health departments to promote the practice.¹⁴ A similar resolution is under consideration by the Society for Adolescent Medicine.

State and local health departments have likewise been active. Denver has instituted an EPT program in their STD clinic and Colorado is developing a state guidance document; Baltimore City has approved a trial EPT program in their public health clinics; in New Mexico, the Medical Board has adopted new rules making EPT permissible, and the Department of Health is developing a program to promote EPT; and legislation to make EPT legal has been introduced or is under development in New York State, Arizona, and Missouri. Internationally, a systematic review conducted under the auspices of the U.K. National Institute for Health and Clinical Excellence concluded that EPT improves partner notification outcomes.¹³ Also, recent studies performed in the United Kingdom found that patients and medical providers support the use of EPT^15,16 and that, as in the United States, Australia, and Denmark,^17–19 the practice is common among medical providers.

The California Guidelines for Expedited Partner Therapy for Chlamydia trachomatis and Neisseria gonorrhoeae published in this issue of Sexually Transmitted Diseases are an important further step in moving EPT into the realm of public health practice. The California State Department of Health has been a leader in promoting EPT, introducing legislation to make EPT legal in 2001, surveying providers about their partner notification practices,²⁰ establishing a hotline to monitor adverse events associated with EPT, and making written materials available to providers to facilitate EPT use (http://www.dhs.ca.gov/ps/dcdc/std/stdindex.htm). Like the CDC guidelines and guidelines promulgated in Washington State (http://www.doh.wa.gov/cfh/STD/EPT.htm), the California guidelines suggest that medical providers offer PDPT to patients for partners who are unable or unlikely to seek timely treatment in the absence of PDPT. Although the authors suggest some commonsensical criteria for defining who such partners are—index patient report that the partner lacks insurance or a medical provider or the perception that the partner will be unwilling to seek care—such criteria have not been validated. Providers typically do not know whether their patients’ partners are treated,²¹ and most probably cannot reliably predict it. As a result, I think it would be better to recommend that all patients be advised that their partners should seek complete medical evaluations, and that clinicians routinely offer their heterosexual patients PDPT to be dispensed with appropriate written materials for the partner.

One area where the existing guidelines somewhat differ is in the area of using EPT among men having sex with men (MSM). California law permits the use of EPT in MSM, but the state guidelines are vague on whether providers should use EPT in this population; they acknowledge that MSM face an elevated risk of concurrent STD/HIV that might go undiagnosed as a result of providing patients with EPT, but do not advise for or against routinely using EPT in that population. In contrast, CDC guidelines explicitly recommend against the routine use of EPT in MSM, and Washington State guidelines recommend that clinicians refer all MSM to health departments for traditional partner notification services. At present, virtually no data exist on the efficacy of EPT in MSM. Some MSM who are offered EPT accept it,²² but the practice has not been evaluated beyond that. Recent data from the United Kingdom suggest that MSM may be less interested in using PDPT than heterosexuals,¹⁵ a finding that is consistent with our anecdotal experience in Seattle. Because approximately 6% of previously HIV-negative MSM evaluated as contacts to gonorrhea or chlamydial infection newly test HIV-positive,²³ I do not believe MSM should be offered EPT except under very unusual circumstances or in the context of a clinical trial.

Over the last decade, we have made good progress in reshaping the US partner notification system for gonorrhea and chlamydial infection, but a lot remains to be done. In the area of research, we have evidence that EPT increases partner treatment and can decrease index patient reinfection rates, and we have some data to suggest that a public health EPT program can increase providers’ use of PDPT and can increase partner treatment at a population level.²⁴ Although these data will not be convincing to all public health officials and clinicians, they have clearly prompted some health departments to change practices, and they should be sufficient to justify additional operational research efforts evaluating model EPT programs. In the area of practice, CDC has done a superb job in taking the initial steps to move EPT research findings into mainstream practice. However, at present, there is no clear strategic plan of how to support or promote dissemination of EPT nationally, and no funds have been allocated for that purpose. We should develop such a plan. As first steps, I would advocate the following:

1. Each state department of health should clearly define the legal status of EPT in their state. CDC’s effort in this regard is a start, but many states are likely to require an independent assessment of the legal issues involved in EPT before adopting a policy. As part of their assessment, states that determine that EPT is not legal should define whether making EPT legal would require a new law or simply an administrative ruling. Administrative rulings have been deemed sufficient in Washington State, Colorado, and New Mexico. Maryland and California have enacted new laws. These rulings and laws could be templates for other states as they develop policies in this area.
2. States should develop explicit guidelines related to EPT. The California and Washington State Guidelines can serve as models in this regard.
3. CDC public health advisors should work with state STD control programs to devise policies and plans related to EPT and to assure that each state has addressed this issue. Part of this work can include disseminating existing examples of legislation, policy rulings, and professional society statements to areas wishing to develop EPT programs.
4. CDC should fund EPT demonstration projects to establish what measures can most effectively increase EPT use, and measure what impact such programs have on the proportion of partners treated and on STD morbidity. Projects should also attempt to monitor for adverse events related to EPT. This effort should prioritize areas with high STD morbidity affecting populations that have not been extensively studied in prior EPT research.

Over the past decade, partner notification has enjoyed a resurgence as a field of research and public health activity. Overall, I think we can be proud of our progress, but we still have a long way to go.