In 1997, the institue of medicine called for creative new methods for the prevention and control of sexually transmitted disease (STD).1 2–4 5 6 7 8 9
In 2006 and again in 2007, proposed legislation was submitted to the New York State (NYS) Legislature to legalize PDPT for Chlamydia ,10,11
The primary purpose of this study was to survey important key informants in STD control, in NYS’s county health department STD programs, and to provide information to lawmakers. The survey assessed programs’ understanding and perspectives of proposed alternatives to current practices that have been studied in the United States, including PDPT, provision of educational materials, and express passes in STD clinics for partners. The surveyed programs provide STD clinical services to clients through either direct provision of, or referrals to care. They also provide community education and outreach including PN, provided directly or in collaboration with State Health Department personnel.
NYS, excluding New York City (NYC), is a large and diverse state covering an area of over 50,000 square miles with approximately 11 million residents living in diverse communities (i.e., densely populated urban, low-density urban, suburban, and rural areas).12,13 Chlamydia . For Chlamydia , investigative priority (i.e., health department-conducted PN) is given to teens and pregnant women followed by adults less than 25 years of age. All other cases are instructed to self-refer contacts. In 2007, 54 of 57 counties in NYS outside of NYC reported 29,975 case of Chlamydia infection; 3465 (11.6%) of these cases were interviewed for PN in 52 counties. Three thousand fifty-seven partners were identified and assigned from these interviews; 1851 (60.5%) were examined and treated. In addition, 9439 cases were assigned to DIS for follow-up to assure treatment; 9318 (98.7%) were confirmed either as treated or brought for examination and treated. For gonorrhea a specific focus is also placed on core geographic areas.14
MATERIALS AND METHODS
NYS has 62 counties, 5 of which are within NYC and served by the NYC Department of Health and Mental Hygiene. This study focuses on the 57 counties outside of NYC. County websites were reviewed for information related to STD services. Additionally, each county health department was called and asked to participate in a 15-minute interview about services available and to elicit perspectives on alternative methods of notification and treatment of partners. The number of reported STD cases per county for 2004 were obtained from the NYSDOH website.15,16
For the website review, researchers visited the 57 county websites to assess the types of information available to residents about STD-related services, including contact information (phone number, address, and email), range of STD testing provided (specifically, Chlamydia , gonorrhea, syphilis, trichomoniasis, Candida , and bacterial vaginosis), location and time of availability of clinical services, and PN information. Websites were reviewed in January and February, 2007.
A list of county STD programs with specified contact persons was provided by the NYSDOH Bureau of Sexually Transmitted Disease Control. Research assistants called the contact persons for each county, informed them about the intent of the survey, and inquired as to their willingness to participate. If the listed county contact information was not current or correct (e.g., listed person left program, someone else was more knowledgeable about clinical services and PN), the information was updated and the appropriate person was contacted. The telephone survey was administered in February and March, 2007.
The survey covered STD testing and treatment information including location, method of provision of clinical services (i.e., either through a county-operated clinic, contract facility, or county paid fee-for-service referral agreement), hours of operation, services provided, type of STD tests available, and whether medications were provided free of charge. For DIS-delivered PN (DIS-PN), the county officials were asked “do county staff conduct partner notification?” Those counties where DIS-PN is not completed by county staff were asked if they refer cases to the State’s Regional STD Program staff for follow-up.
Respondents were asked about their perspectives on alternative methods to DIS-PN, including the index patient providing the partner(s) the following: (1) solely with written educational materials, (2) a coupon for expedited testing and treatment, (3) medication or a prescription (i.e., PDPT) in conjunction with written educational materials, or (4) PDPT coupled with both educational materials and subsequent DIS follow-up to document partner treatment status. Because PDPT is relatively new and not yet legal in NYS, a description of it was provided to all respondents: “Patient delivered partner therapy is the practice of treating partners of index patients with STDs by giving the index patient medication or a prescription to personally deliver to their partners.” Follow-up questions were asked about why key informants supported, or did not support, PDPT. Finally, respondents were asked to rate their level of support or lack of support for several scenarios under a hypothetical circumstance where PDPT was legalized. For example, would their level of support be influenced by having a tracking system in place or by allowing PDPT for minors?
Statistical Analysis
The data collected from the website review were entered into Microsoft Excel (2003) and survey data were entered into Epi-Info v.3.3.2. Data were imported into SAS (v.9.1.3, SAS institute, Cary, NC) for analyses. Proportions were computed to determine the services available across the state and learn county preferences toward alternative methods for PN, diagnosis, and treatment. To further interpret the data, counties were stratified based on the number of combined Chlamydia and gonorrhea cases (<100, 100–399, 400+) reported in 2004, and their responses to the survey were reexamined. For cross-tabulations, statistical associations were determined using Fisher exact test.
Institutional Review Board Approval
The study was approved by the authors’ university Institutional Review Board.
RESULTS
Website Review
Of the 57 counties in Upstate New York, 55 (96%) county websites were successfully accessed; 2 were down for construction. All county government websites offered contact information, primarily phone numbers for the health departments. E-mail contact was listed by 26 (47%) health departments. HIV testing information was provided on 43 (78%) county websites, and general information about other STD testing was available on 39 (71%) websites. Only 36 counties (65%) listed specific HIV testing locations on their website (i.e., address) and fewer provided information about services for other STDs [e.g., 11 (20%) websites provided specific information on accessing testing for syphilis, Chlamydia , and gonorrhea]. Only 8 (15%) websites contained information regarding PN.
County Survey
Of the 57 counties, 55 (96%) participated. Table 1 summarizes the results of their responses on STD testing, treatment, and PN questions. Thirty-two (56%) county health departments operate free STD clinics and provide STD clinical services directly, 29% contract with a local health center (e.g., community health center) and 15% maintain a list of physicians and health centers, where STD care compensated by the county health departments can be obtained. Nineteen (35%) respondents reported that staff located within their county health department conducted PN, whereas 36 (65%) counties (primarily rural) lacking their own cadre of field staff refer cases to the State’s regionally based DIS for follow-up.
TABLE 1: Chlamydia and Gonorrhea Infections, NYS Excluding NYC County Health Department Sexually Transmitted Disease Control Programs, 2007
County STD program representatives were evenly divided in their opinion of PDPT, with 45% in favor of its use, 45% against, and 10% unsure (Table 2 ). The primary reasons cited for supporting PDPT were the beliefs that more infected individuals would be reached (61%) and it would help to control the diseases in the community (29%). Those opposed to PDPT were most concerned with the following: potential side effects or contraindications of medication (28%); that the medication would not reach the partners (28%); and that malpractice or ethical issues were not being addressed (20%). To assess whether the level of STD morbidity within the county might be influencing responses, we stratified the analysis by the total number of reported gonorrhea and Chlamydia cases. Of counties with 400 or more, 100 to 399, and less than 100 cases per year, 33%, 42%, and 57%, respectively, supported PDPT (P = 0.06).
TABLE 2:
Four alternatives to DIS-PN, including 2 variations of PDPT, were posed for respondents to consider (Table 3 ). When presented individually, the highest level of support was given for providing the index patient a coupon for each partner to expedite partner examination and treatment (67%), followed by patient distribution of educational materials to their partners (45%) and PDPT combined with health department following up with partners to assess treatment compliance (45%). Patient who delivered partner therapy without health department follow-up with partners had the least support (34%). However, when asked which scenario was the “best,” PDPT with health department follow-up with partners was preferred by 46%, followed by expedited (i.e., priority) examination of partners presenting with coupons at STD treatment centers (28%), patient distribution of educational materials (20%), and PDPT alone (6%). No statistically significant differences were identified by county STD morbidity levels.
TABLE 3:
A series of questions were posed based on the premise that PDPT was legalized in NYS (Table 4 ). County respondents supported having some form of tracking system that could determine if partners actually received medications (74%), providing medication to minors for their partners (69%), as well as providing free medication to all partners (53%), and providing the index patient with a prescription for antibiotics with the partner’(s) name on it (41%).
TABLE 4:
The survey was concluded with an opportunity for additional comments. Forty-three (78%) respondents provided comments. Although some comments focused on emphasizing points made in the survey, others highlighted additional concerns that were not identified in the survey. Comments supporting PDPT included “there will be more access for treatment” and “you will get people who may not otherwise come in and get treated.” A representative from a low STD morbidity county stated, “This [PDPT] is a good idea in areas that see a lot of STDs” and PDPT is beneficial because “it is important to get people treated fairly and quickly.” Another respondent in support of PDPT stated, “While there is some concern of medicine reaching the partners, I believe treating a greater percentage of the population is great.” However, even from those who wrote supportive comments for some form of PDPT, 25 (92%) cited specific concerns regarding PDPT implementation [e.g., medication will not reach the partners (n = 10), side effects/contraindication (n = 4), and antibiotic resistance (n = 2)]. Other concerns with PDPT included fear of retaliation by the partner, a potential decreased ability to assess for domestic violence, and cases of rape.
County representatives expressed concern with the legality of PDPT, including the question of “Who is ultimately responsible for administering such a program?” and “How would this come back to the provider [regarding potential] law suits from side effects and allergies?” Several representatives referred to PDPT as “a big risk on our licenses,” that also “doesn’t treat other diseases they may have.” Another issue raised by 6 respondents was, “Who is fiscally responsible?” One respondent elaborated, “Counties should [only] pay for their own resident’s treatment.”
DISCUSSION
STD control programs need to periodically reevaluate their approaches and continually work to identify new methods to reach those exposed to infection and are untreated. There is evidence that traditional health department-based PN programs are effective in reducing the incidence of STDs14,17,18
Local health departments in NYS are split along morbidity burden lines on their perspectives regarding PDPT. Because NYC,19 20 21 Chlamydia and gonorrhea cases each year are opposed (67%) to the idea of PDPT compared to 37.5% among those with lower morbidity levels. Several reasons may explain why our hypothesis was incorrect. First, NYS prioritizes STD core gonorrhea areas and, where resources allow, teenage female Chlamydia cases for DIS-PN, and the majority of counties with 400+ cases a year of Chlamydia and gonorrhea conduct their own DIS-PN. Thus, counties with core areas have disproportionately more of their own resources to reach partners, whereas other areas refer high priority cases (i.e., HIV, syphilis, gonorrhea) to the state DIS for follow-up. A second possibility may be that many representatives may have a strong sense of comfort with their current PN system, and change may be a perceived lowering of public health standards. This is evidenced by comments such as “this sounds good, but, things seem to be working and I don’t see the need for change.” Whether education and experience with PDPT change these perspectives will be worthy of future study.
Representatives in counties with a lower STD morbidity were more favorable toward PDPT. These counties have limited funding support for DIS-PN for Chlamydia and gonorrhea (beyond $0.36 per dollar spent on public health activities provided by the state generally), thus they primarily rely on patient referral. Also, although gonorrhea rates are declining in high morbidity counties with clearly defined urban centers they are rising in lower morbidity, rural counties, a circumstance potentially driving the expressed interest in alternative approaches.
Overall, PDPT linked with DIS follow-up of partners was considered the “best” option of the 4 scenarios provided (46%), whereas PDPT without DIS follow-up was considered the least favored option. This indicates that most NYS county health departments, regardless of morbidity levels, believe that DIS should continue to be an integral part of the PN process no matter how current programs may be modified in the future. An alternative that received a high level of support was having index patients receive “coupons” to give to their partners for expedited treatment. An option to consider may be having local clinics develop expedited lines so that partners of index patients would receive prompt treatment in an effort to further control the spread of these diseases. Another option to consider is patient referral with distribution of educational materials, as studied by Kissinger et al.8,22 23
Although not reported on the survey, when we presented preliminary findings of this study to local health department representatives, 2 issues were identified related to PDPT. The first was undocumented workers. As public health is seen more and more linked with homeland security, the ability to reach undocumented workers is further limited, resulting in a reservoir of disease in many communities across the state. Undocumented workers may not seek treatment in the United States for STDs, especially from a government sponsored clinic for fear of immigration services. Patient-delivered partner therapy could eliminate this substantial barrier to treatment, thus allowing this subpopulation to receive treatment and allay fear of government sanctions. The second issue was those without access to health care services. These individuals are unlikely to seek treatment for various reasons (e.g., no health insurance, lack of financial resources, lack of knowledge of free clinics). Patient-delivered partner therapy could increase their treatment and reduce the potential for this subpopulation to be a reservoir for STDs.
The following limitations are noteworthy. First, PDPT has not been widely discussed in health departments in the region, and thus many respondents may have had limited knowledge of it before the survey. However, the perceived benefits and concerns stated are consistent with those reported previously.24 Chlamydia and gonorrhea. Assessment of responses from the 15 counties with substantial caseloads found that PDPT is not largely supported; DIS-PN is preferred. Although this could be in part because of a potential fear of losing valuable DIS resources should PDPT be implemented, STD staff in NYS are largely passionate in their desire to help those afflicted by STDs and believe partner notification is a valuable tool. Third, this study was conducted solely in the public sector and did not include comments from the private sector where more support may or may not exist.
This study also had several strengths. The response to this survey was excellent (96%); we were able to interview STD professionals in almost every county. This resulted in representation of all areas of NYS, excluding NYC. Although sample size was restricted by the number of local health departments, the analysis by STD morbidity level provided an opportunity to understand how morbidity was related to support for alternative notification and treatment options.
At the time of this writing, PDPT was legal in 11 states, and of uncertain legality in the majority of other states.7,25,26
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