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The Expedited Partner Therapy Continuum: A Conceptual Framework to Guide Programmatic Efforts to Increase Partner Treatment

Schillinger, Julia Ann MD, MSc*†; Gorwitz, Rachel MD, MPH; Rietmeijer, Cornelis MD, PhD, MSPH; Golden, Matthew R. MD, MPH§¶∥

doi: 10.1097/OLQ.0000000000000399
Review

Background Expedited partner therapy (EPT) is a partner treatment strategy wherein health care providers give patients antibiotics or a prescription to deliver to their sex partners as treatment, without an intervening medical evaluation.

Methods We used PubMed and the Cochrane database to systematically identify published articles about EPT after 2006 and randomized controlled trials before that date; we also sought conference abstracts and unpublished data from 2013 to 2014. We described key steps in a hypothetical “EPT continuum,” beginning with diagnosis of Chlamydia trachomatis or Neisseria gonorrhoeae in a patient and ending with treatment for the patient's sex partner(s) with EPT. All reports were abstracted for a set of defined measures and related interventions.

Results We reviewed 100 published articles, unpublished data reports, and conference abstracts; 42 met the inclusion criteria and provided measures of the following: provider uptake and offer of EPT, patient acceptance and receipt of EPT, patient delivery of EPT to sex partners, and partner receipt of EPT and treatment. Implementation phase, populations, settings, and methodologies varied across reports. Providers' uptake and offer of EPT are rate-limiting steps in the EPT continuum and were the focus of all 5 programmatic interventions we identified. There were 7 population-based measures of patient receipt of EPT; however, several of the patient populations overlapped.

Conclusions A heterogenous body of literature describes EPT, and variation in study population, setting, and metrics limit generalizability. Programs seeking to increase partner treatment should focus their efforts on provider uptake and offer and should use population-based measures to monitor EPT use.

From the *Division of STD Prevention, National Center for HIV, Hepatitis, TB, and STD Prevention, Atlanta, GA; †Bureau of STD Control, New York City Department of Health and Mental Hygiene, New York, NY; ‡Rietmeijer Consulting LLC, Denver, CO; §Public Health-Seattle & King County, Seattle, WA; ¶Department of Medicine, University of Washington, Seattle, WA, and ∥Center for AIDS and STD, University of Washington, Seattle, WA

The authors would like to thank Sophie Sebajwe, MSPH, for providing aggregate data from the Baltimore City Sexually Transmitted Diseases Clinics, and Tom Peterman, MD, MSc, for generously giving his time to discuss this manuscript in its formative and later stages, and for sharing his insights.

Conflicts of Interest and Source of Funding: Julia A. Schillinger (none declared), Rachel Gorwitz (none declared), Cornelis Rietmeijer (none declared for this work; receives funds as a consultant for Denver Public Health Department, University of Washington, Sentient Research, University of Zimbabwe), Matthew Golden (none declared for this work; has received past funding to his institution from Meilinta Pharmaceuticals, and Cempra Pharmaceuticals).

Correspondence: Julia A. Schillinger, MD, MSc, Bureau of STD Control, New York City Department of Health and Mental Hygiene, 42-09 28th St, New York, NY 11101. E-mail: jus8@cdc.gov.

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BACKGROUND

Untreated sex partners of index patients with Chlamydia trachomatis (Ct) and Neisseria gonorrhoeae (GC) infection can contribute to continued disease transmission in the community and to reinfection of the index patient (patient). Reinfection is common among women with Ct and GC infection1,2 and has been associated with an increased risk of complications and sequelae.3,4 Traditional partner notification methods for sexually transmitted diseases (STDs) exist along a continuum from unassisted patient referral, in which the patient is instructed to notify their partner(s) to seek treatment but is not offered specific assistance, to provider referral, in which a public health professional or health care provider (HCP) contacts the patient's partner(s) directly and notifies them of the need for treatment.5

Expedited partner therapy (EPT) is a partner treatment strategy whereby an HCP treating a patient for an STD provides treatment for the patient's sex partners without an intervening medical evaluation of the partners. The ultimate goal of EPT is partner treatment. Several different models of EPT have been described, including giving a patient antibiotics to deliver to sex partners (patient-delivered partner therapy [PDPT]), giving a patient a prescription to deliver to sex partners (“prescription-EPT”), or providing medication for sex partners via a commercial pharmacy or directly by mail. Most reports of EPT have described PDPT. Three of 4 randomized controlled trials comparing PDPT to unassisted partner referral6–9 have demonstrated that PDPT reduces repeat infection among heterosexuals with Ct (from 15% to 12%9 and from 13% to 11%7) and GC (from 11% to 3%7), and either Ct or GC (from 24% to 14%8). Patient-delivered partner therapy has been shown to be cost-effective,10 may decrease ongoing transmission of Ct and GC at the community level,11 and (in one trial) increased men's disclosure of STD to female partners.12 In actual practice, providers commonly give patients a prescription to deliver to their sex partners, rather than medication13–18; however, the efficacy and cost-effectiveness of prescription-EPT have not been evaluated.

In 2006, the Centers for Disease Control and Prevention issued a “white paper” endorsing EPT use among heterosexuals to prevent repeat infection and interrupt the ongoing transmission of Ct and GC,19 and the 2010 CDC STD treatment guidelines incorporated EPT into national STD treatment recommendations.20 In the years after CDC's endorsement, there was a rapid expansion in the number of states and jurisdictions in which EPT was permissible, by local law, regulation, or pharmacy or medical board decision,21 and numerous states developed local EPT guidelines. By June 2015, EPT was judged to be permissible in 38 states and the District of Columbia.22

Although legal barriers to EPT have been largely eliminated, real-world implementation of EPT has revealed a number of other obstacles at the systems, provider, and patient levels.23,24 For EPT in the form of PDPT to be effective at increasing partner treatment and preventing repeat infection, a number of things must occur. A provider must diagnose Ct or GC in a patient and treat that infection with an efficacious regimen. Providers must use EPT and offer it to the patient. Next, the patient must accept the offered EPT and deliver it to his/her sex partner(s). Finally, the partner(s) must accept and actually take the medication. Taken together, these steps can be conceptualized as a continuum (Fig. 1A). When EPT is provided in the form of a prescription, multiple additional contingencies are introduced (Fig. 1B). In this study, we introduce the “EPT continuum” as a conceptual framework for STD programs to use to identify opportunities to improve partner treatment rates using EPT.

FIGURE 1

FIGURE 1

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METHODS

Literature Review and Data Collection

We conducted a search of PubMed and the Cochrane database using the terms: “expedited partner therapy,” “expedited partner treatment,” “patient delivered partner therapy,” “patient delivered partner treatment,” “patient-delivered partner therapy,” and “patient-delivered partner treatment.” The search was limited to the English language literature published during January 1, 2006, to May 15, 2015. We used 2006 as the lower limit for our main search because the 2006 CDC white paper endorsing EPT use initiated a rapid expansion in the legality of EPT in the United States, such that articles published after that date reflect the most current, relevant issues related to EPT. A PubMed search for articles published before 2006 used the same search terms but was limited to randomized clinical trials.

All abstracts were reviewed; full articles were sought and reviewed if the abstract considered EPT for Ct or GC infection among heterosexuals in high-income countries.25 We also reviewed articles cited as references if they appeared relevant, regardless of publication date. Finally, we sought unpublished data and abstracts from scientific conferences held from 2013 to 2014; we excluded abstracts for which we could not obtain a poster or slide presentation.

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Definitions

We defined EPT-eligible patients as heterosexuals with laboratory-confirmed Ct or GC (depending on whether local policy or regulations allowed EPT use for one or both pathogens). Provider uptake was defined as the proportion of providers who report EPT use in qualitative terms (e.g., “ever” used or “frequently” used); this measure distinguishes between providers who do and do not use EPT, but does not translate directly into a number of patients provided EPT. Provider offer percentages were defined as the proportion of EPT-eligible patients to whom an EPT-practicing provider offers EPT and patient acceptance percentage as the proportion of patients who accept EPT when it is offered. Patient receipt, defined as the proportion of EPT-eligible patients who receive EPT, is a function of both provider offer and patient acceptance. Partner treatment percentage was defined as the proportion of patients who had at least 1 sex partner treated by EPT.

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Data Abstraction

We abstracted information from reviewed articles/reports about each of the continuum measures, as well as obstacles to EPT use, legal, and policy issues, and cost-effectiveness. We did not abstract reports in which only hypothetical use or acceptance was described, and in general, we excluded research studies because we were interested in real-world measures of EPT implementation. However, because very few reports described patient delivery of EPT to sex partners, partner acceptance, and partner treatment, individual level randomized clinical trials were abstracted for information on these measures. We characterized each report with regard to the data source, study design, population/setting, and pathogens considered, and organized our findings to correspond with key steps in the EPT continuum (Fig. 1), describing what is known about each key step. Whenever possible, we present data separately for Ct and GC, and specify if EPT was performed by PDPT vs. prescription-EPT. We present only select factors associated with continuum measures, those we judged modifiable or that indicated a point of possible intervention. Articles and abstracts were classified as programmatic interventions to increase EPT use if the authors reported EPT use before, as well as during or after an intervention, or if they included at least one comparison group that did not receive the intervention. We included one randomized trial as an intervention because it was conducted at the community level and assessed the impact of an array of programmatic interventions.11 Percentages were rounded to the nearest whole number.

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RESULTS

We identified and reviewed 100 published articles, reports, and abstracts using our search criteria. These could be loosely categorized as follows: provider surveys, patient surveys, evaluations of EPT implementation, programmatic interventions to increase EPT, legal/policy issues, obstacles to EPT, EPT research, and cost-effectiveness. Forty-two percent of reviewed reports met our criteria for being abstracted, and we included data from each of these reports in alphabetical order in structured tables displaying information related to provider uptake (Table 1) and offer (Table 2), patient acceptance (Table 3) and receipt (Table 4), partner acceptance (Table 5) and treatment (Table 6), and interventions to increase EPT use (Table 7). Articles could be included in more than one table.

TABLE 1

TABLE 1

TABLE 2

TABLE 2

TABLE 3

TABLE 3

TABLE 4

TABLE 4

TABLE 5

TABLE 5

TABLE 6

TABLE 6

TABLE 7

TABLE 7

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Patients Are Treated by an HCP Who Uses EPT (Step 1 in Continuum)

We found 11 articles that reported the percent of providers using EPT (“provider uptake”); however, not all articles presented provider uptake separately for Ct and GC (Table 1).13,15,17,26–33 Measures of the percentage of HCP who “ever use(d) EPT” for Ct varied from 8% among nurses in the UK in 200513 to 91% of California family planning providers in 2007,17 although most measures clustered around 50%.15,27,28,30,32,33 Routine use of EPT for Ct was reported by 14% to 73% of providers.15,17,26,28–30 The lowest rate of provider uptake was reported by providers in a country where EPT was not legal at the time of survey13; conversely, among the highest rates of provider uptake were those reported from California, where EPT has been legal since 2001.17,29 There were fewer measures of the percentage of providers reporting that they had “ever used” EPT for GC; however, the range was narrow (30%–51%),15,17,27,28,30 and routine use for GC was reported in only 2 articles (11%,28 and 23%30). A survey examining provision of EPT at the health system, rather than individual provider level, found that 80% of clinics in federally qualified health center networks in New York City (NYC) provided EPT.14

The legal status of EPT seems to be an important factor influencing provider utilization. Provider uptake has been associated with EPT being legally permissible,27 with having received information about a statue allowing EPT33 and with provider knowledge of such laws.17 Having a written policy permitting EPT and a clinic medical director who supports the practice have also been associated with a higher rate of provider use.14,17 Other notable factors associated with increased provider uptake include the following: affiliation with an agency that provides free prepackaged medication for EPT and a higher volume of Ct diagnoses per month.17

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Provider Offers Patients EPT (Step 2 in the Continuum)

To date, the most rigorous and representative measures of provider offer rates were those made in the context of a community-level randomized trial of strategies promoting EPT use in Washington State.11 Based on interviews with a population-based random sample of Ct- and GC-infected heterosexuals, providers were more likely to offer EPT to Ct- (52%) than to GC-infected patients (38%).

In clinical settings where HCPs have taken up the practice of EPT, the percent of eligible patients to whom EPT is offered (“provider offer percentage”) varies, depending on the practices of individual providers and on how EPT eligibility is defined (Table 2). In the Baltimore STD clinic system, the provider offer percentage for Ct was 27% (unpublished data, Baltimore County Health Department); in the NYC STD clinic system, the provider offer percentage was 99% when presumptively treated patients were considered ineligible for EPT,35 but 31% (very close to the Baltimore rate) when eligibility criteria were expanded to include presumptively treated patients.34 These relatively low provider offer rates highlight a phenomenon that can be called the “presumptive treatment gap,” whereby a large proportion of Ct-infected patients are not offered EPT because they are treated before Ct infection is laboratory confirmed, and the patients do not return to the clinic to pick up EPT for their partner(s). The NYC STD clinics do not offer EPT for GC, but in Baltimore, the provider offer percentage for GC was 65% (unpublished data, Baltimore County Health Department).

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Patient Acceptance of EPT and Patient Receipt of EPT (Step 3 in Continuum)

Patient Acceptance of EPT

There has been only one population-level measure of patient acceptance reported; in Seattle-King County from 2004 to 2005, 42% of patients with an untreated sex partner accepted EPT.37 Other reports of the proportion of index patients who accept EPT describe acceptance rates measured in clinical settings (Table 3)35,38,39

Pathogen-specific acceptance rates were available in 2 reports.35 (unpublished data, Baltimore country Heaith Department). In both the NYC and Baltimore STD clinics, 55% of patients accepted EPT for Ct, and in Baltimore, 38% of patients accepted EPT for GC (unpublished data, Baltimore County Health Department). Overall measures of EPT acceptance (Ct and GC together) ranged from 61% to 70%.38,39 A common reason patients cite for EPT refusal is that the partners have already been treated or are in the clinic for treatment (suggesting that EPT is not necessary).35,52 Vaidya et al.35 calculated patients' acceptance rates 2 ways and found that rates were higher (69% vs. 55%) when the analysis excluded patients whose partner(s) had already been treated or was at the clinic to be treated.

Some reports describe differences in EPT acceptance by sex and other characteristics, but findings have not been consistent.35,37

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Patient Receipt of EPT

Patient receipt of EPT is not an individual step on the EPT continuum (Fig. 1), but, the number of patients who receive EPT should approximate the number who were offered EPT by an EPT-practicing HCP, and accepted it. Population-based measures of patient receipt of EPT were as follows: 23% for Ct (Massachusetts),18 17% for Ct and 14% for GC 37 (Seattle-King County, Washington, in 2004–2005), 9% in New Orleans, Louisiana,41 and 7%47 and 10% for GC at select sites in a sentinel STD surveillance network (SSuN). An overall EPT receipt rate of 44% was measured across multiple Washington State counties during an 8-year intervention trial promoting EPT for which both HCPs and public health partner services staff offered EPT.11 In a survey of US physicians in 5 specialties conducted from 1999 to 2000, patient-receipt of EPT was estimated using providers' report of the frequency of providing EPT, and the number of Ct and GC infected patients providers diagnosed; estimates ranged from 13% to 20% for Ct, and 9% to 15% for GC.28 Factors associated with patient receipt included the presence of laws and policies authorizing EPT and the presence of professional board policy statements supporting EPT and clinic or facility type (Table 4).40

Clinic-based measures of patient receipt of EPT are generally higher than population-based estimates; probably because clinic-based evaluations are typically conducted in clinics with programs designed to promote EPT use, whereas population-based measures include patients treated by providers not practicing EPT. Patient receipt of EPT for Ct ranged from 18% to 75%, and for GC, from 32% to 46%.16,41,43–46,48–50 One report that did not distinguish between Ct and GC estimated that 39% of patients received EPT,41 and in a Denver STD clinic, patient receipt reached 48% after a required, structured data field was added to the electronic health record.45 There were several characteristics associated with lower rates of patient receipt, including: having been presumptively treated and diagnosing clinic type.

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Patients Deliver EPT to Sex Partner(s) (Step 4 in PDPT Continuum)

In 2 randomized trials of EPT that used PDPT for Ct, most index patients (85%–100%) reported giving antibiotics to at least one of their sex partners6,9 (Table 5). In one trial of PDPT for both Ct and GC among men and women, 93% of patients reported giving PDPT to at least 1 partner,7 and in another trial among men only, treatment was reportedly given in 70% of sexual partnerships.8 A high rate of delivering EPT to sex partners (89%) was also reported by young, recently incarcerated women.38 In one qualitative study of patients' use of EPT, participants reported delivering 30 (73%) of 41 doses of PDPT.39 Only one report described interviewing sex partners directly about whether they received EPT in the form of PDPT; in an evaluation of the NYC STD clinic EPT program, program staff contacted sex partners for whom EPT for Ct was intended and 74% (49/66) reported they had received the medication; however, only about a third of the partners were interviewed, so this measure may not be representative.51

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Partners Take EPT (Step 5 in PDPT Continuum)

Three of the 9 measures of sex partner treatment with EPT are derived from randomized trials of PDPT and are based on the report of the patient, not the partner7–9 (Table 6). In one trial of PDPT for Ct, 86% of female patients given EPT reported it “very likely” that at least one of their partners took the medication.19 In a trial of PDPT for Ct and GC, 61% of patients reported it “very likely” that all their partners were treated (or tested negative for Ct and/or GC).7 In a third trial of PDPT for male urethritis (mostly due to Ct or GC infection), male patients reported that the partner told them they had taken the EPT medication in 56% of partnerships.8 An evaluation of partner service strategies for Ct in California family planning clinics found that women reported partner treatment for 80% of partners for whom EPT was provided16. Finally, among a small convenience sample of men who received EPT from a community clinic in NYC, 88% (14/16) reported that their partner had taken the medication.40

In only 2 reports did investigators communicate directly with sex partners to measure partner treatment via EPT (provided as PDPT). In the first, a study of PDPT for Ct among young women in Scotland, 37% (46/125) of male partners mailed back a paper slip confirming they had taken the antibiotic.6 In the second, an evaluation of PDPT provided in NYC STD clinics; project staff spoke directly with the sex partners for whom PDPT had been provided and found that 94% (46/49) of partners who received PDPT for Ct reported that they took the antibiotic.51

We found only one report describing evaluation of a strategy similar to prescription-EPT.52 In that Scottish study, Ct-infected patients were given pharmacy vouchers (rather than medication) that their partners could redeem for free treatment (azithromycin, 1 g) at any 1 of 90 participating pharmacies. Overall, 577 vouchers were issued, nd 40% were redeemed, a median of 2 days after issue. Voucher redemption rates did not differ by sex of the index patient (male index: 41 vs female index: 45%)

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Interventions to Increase Partner Treatment Through EPT

Five reports met the criteria for inclusion as an intervention11,37,40,45,53 (Table 7). Two were closely related population-based interventions,11,37 2 were conducted in STD clinics,45,53 and the fifth was an ecologic analysis that examined the association between state EPT laws on patient receipt of EPT for GC.40

Building on the success of a set of interventions promoting EPT (PDPT) use in Seattle King County,37 Golden and colleagues11 undertook an extensive “public health intervention” promoting EPT use for heterosexuals in Washington State. This included (1) free medication (in prepackaged “PDPT packs”) for providers' offices and commercial pharmacies so EPT was free for partners; (2) letters to Ct and GC-diagnosing providers informing them of how to obtain free medication, how to prescribe free EPT, and how to access free EPT medications using Ct and GC case report forms; (3) visits to providers that diagnosed a large number of Ct and GC infections to educate them and provide free EPT partner packs; and (4) working the state's largest health maintenance organization and large family planning organizations to promote EPT use. Finally, the Ct/GC case report form was modified to give providers the option to request assistance with partner management, and public health disease investigators (DISs) contacted select Ct- and GC-infected individuals and their partners and offered them free EPT. To assess the impact of these efforts, a 20% random sample of patients was surveyed, with the finding that providers offered EPT to 52% and 38% of index patients with Ct or GC, respectively. Patient receipt of EPT from medical providers increased significantly from 18% before to 34% during the intervention period (44% when EPT received from DIS was included).

Another intervention took place in a Denver STD clinic. Using a quality assurance protocol and providing feedback to clinic providers increased patient receipt of EPT from 17% to 24%. Adding a structured data field in the electronic medical record further increased measurable receipt to 48%.45 It is not clear if the measured increases in patient receipt were due to providers offering EPT more frequently, to better documentation, or both. However, it is likely that structured data fields prompt providers to consider and offer EPT.

A third intervention was designed to address the EPT “presumptive treatment gap” in NYC STD clinics. The intervention used an existing automated system that allowed patients to access their test results via telephone or Web site. Presumptively treated patients with laboratory-confirmed Ct infection who accessed the automated system were given a message to return to clinic to pick up EPT for their partners. Eleven percent of presumptively treated patients who retrieved the EPT message returned to pick up EPT for their partners, compared with 4% of those who did not retrieve the message. The EPT message was more effective for men (13.4% returned) than for women (3.5 %). Problems included the following: providers assigned EPT messages for only 37% of eligible patients, message assignment was often delayed, and only 32% of patients retrieved their EPT message.53

We did not find any reports comparing EPT use before and after EPT was legalized. However, one ecologic analysis compared patient receipt of EPT in states where EPT was legal versus illegal (or not permissible54).40 Interviews with GC case-patients found that patient receipt of EPT was higher in jurisdictions that had a law authorizing EPT for GC and where EPT was considered permissible (13%), compared with jurisdictions that did not have an EPT law but where EPT was considered permissible (5%), and jurisdictions that did not have an EPT law for GC and where EPT was not considered permissible (1.0%). These findings were statistically significant in multivariate analysis. Among states that did not have a law authorizing EPT, having state medical board and other nonmedical board opinions permitting EPT were also associated with higher rates of index patient receipt of EPT.

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DISCUSSION

We have presented the EPT continuum as a conceptual framework for programs to use to target efforts to increase EPT use. Looking at the continuum and considering the proportion of providers who report using EPT and the proportion of patients to whom it is offered (even in clinical settings where EPT use is promoted), it is obvious that provider's uptake and offer of EPT are significant rate-limiting steps. When patient acceptance is factored in, the opportunity for EPT to reach sex partners is further reduced. When all the process steps involved in EPT are considered, it is not surprising that recent population-based estimates of patient receipt are as low as 23% for Ct 18 and 7% for GC.47

Our review leads to several recommendations (Fig. 2). First, STD programs should work with legislatures, and medical and other licensing boards to remove legal obstacles to EPT and to seek clarity where the legal status is ambiguous.54 Second, STD programs should use varied approaches to promote EPT, including provider outreach, and education to assure that providers are aware of the legality and practice of EPT; programs should provide access to EPT-specific patient and partner fact sheets and should be prepared to address the ethical considerations of partner management in general, and of EPT specifically.5,55 Expedited partner therapy promotion efforts should initially focus on providers who report large numbers of Ct or GC infections and on increasing the number of providers who offer EPT; all 5 of the interventions we identified sought to address these early and important steps in the continuum. Third and most importantly, health departments and health care organizations should work to remove logistical and financial barriers that inhibit providers from offering patients EPT.

FIGURE 2

FIGURE 2

The effort and cost of filling an EPT prescription are probably significant obstacles to partner treatment. Sexually transmitted disease programs may help to increase patient acceptance and partner treatment rates by recommending providers give EPT by medication, rather than prescription, and, where legal, encouraging providers to prescribe medication for the index patient and partner(s) on the same prescription. Electronic prescribing mandates56 may further complicate prescription-EPT.

Free EPT needs to be made much more available. This can be accomplished through a variety of mechanisms. Ideally, health departments would purchase medication for EPT at discounted rates and distribute those medications directly to medical providers, beginning with providers and settings that diagnose a high volume of Ct and/or GC, and serve an uninsured or underinsured population. This approach is similar to how many states purchase and distribute vaccines and can be supplemented through the use of commercial pharmacies with contracts, allowing them to distribute publically funded EPT at no cost to patients or partners. Absent such a system, health departments should work with large systems and networks of HCPs to make free EPT available to patients to give to their partners.

Additional structural interventions that can increase providers' use of EPT include adding required, structured data fields and “prompts” to medical records to ensure providers consider EPT, and establishing policies and procedures to address the “presumptive treatment gap” by inviting patients who receive presumptive GC/Ct treatment to return for EPT.

Public health STD programs should establish population-based measures to monitor EPT use. The single best measure is probably patient receipt of EPT at the population level. This has been done in at least 3 jurisdictions by adding questions about EPT to the provider Ct and GC case report forms,11,18 (J. Schillinger, personal communication). This can also be measured by interviewing randomly selected patients reported with Ct and/or GC, as the SSuN has done for GC.40,47 The number of patients offered EPT could be measured at the same time.

Several areas warrant further research and evaluation. The effectiveness of EPT hinges on partners taking the medication. Ideally, future evaluations of EPT programs should measure partner behavior directly in a representative sample of EPT recipients. Investigators should compare the impact on partner treatment of providing EPT using prescriptions versus medication. Practices that use messaging systems to recall patients for EPT should evaluate these systems and report their impact on patient receipt of EPT. Research is also needed on how to finance large-scale distribution of EPT, and among the remaining states where EPT is not allowed, evaluation of barriers is warranted. Regulatory constraints on specific entities, such as Federally Qualified Health Centers, should be addressed at the national level.

This review is subject to several limitations. The reports we found were from jurisdictions in different phases of EPT implementation and varied in terms of sample sizes, populations, settings, and the definitions used for various metrics. Because of this heterogeneity and the paucity of data from representative samples of persons eligible for EPT and receiving EPT, we decided that available data could not be aggregated to produce a single estimate for each step on the EPT continuum. Also, we could not exclude men who have sex with men from some of the reports we abstracted because the population was not well enumerated. Different approaches to calculating a common measure (e.g., index patient receipt of EPT) resulted in varying estimates, highlighting the importance of using common metrics and pointing to the lack of representativeness of clinic-based evaluations. We included data abstracted from scientific conference presentations that had not been through the same peer-review process as published articles; we did so because the literature was scant, and evaluations of EPT are few; however, readers should not give undue importance to these reports. Many of the measures in the continuum rely upon self-reported data from patients, which may be inaccurate and affected by social desirability bias. Although the 2 final steps in the continuum are tied to the behavior of the sex partner, we used the patient as the unit of analysis so as to be consistent with the preceding steps; a more meaningful measure for the final step of the continuum could be the proportion of all partners who needed and received treatment via EPT. A final and substantial limitation to this review is that there are virtually no data for the continuum steps specific to prescription-EPT.

The ultimate goal of EPT is partner treatment. Interventions to increase the number of patients offered EPT are critical because provider's offer of EPT is a rate-limiting step in the continuum; however, direct measures of whether partners accept and take EPT, and what factors influence this behavior are needed. Evaluations should examine the intricacies of each of the continuum steps and their dependencies on one another. Sexually transmitted disease programs seeking to increase EPT use in their jurisdictions should establish one or more measures of steps in the EPT continuum, ideally using population-based metrics in common with other STD programs, and use interventions that can maximize partner treatment achieved with EPT.

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REFERENCES

1. Batteiger BE, Tu W, Ofner S, et al. Repeated Chlamydia trachomatis genital infections in adolescent women. J Infect Dis 2010; 201: 42–51.
2. Hosenfeld CB, Workowski KA, Berman S, et al. Repeat infection with Chlamydia and gonorrhea among females: A systematic review of the literature. Sex Transm Dis 2009; 36: 478–489.
3. Hillis SD, Owens LM, Marchbanks PA, et al. Recurrent chlamydial infections increase the risks of hospitalization for ectopic pregnancy and pelvic inflammatory disease. Am J Obstet Gynecol 1997; 176( 1 Pt 1): 103–107.
4. Bakken IJ, Skjeldestad FE, Lydersen S, et al. Births and ectopic pregnancies in a large cohort of women tested for Chlamydia trachomatis. Sex Transm Dis 2007; 34: 739–743.
5. Centers for Disease Control and Prevention (CDC). Recommendations for partner services programs for HIV infection, syphilis, gonorrhea, and chlamydial infection. MMWR Recomm Rep 2008; 57: 1–83.
6. Cameron ST, Glasier A, Scott G, et al. Novel interventions to reduce re-infection in women with chlamydia: A randomized controlled trial. Hum Reprod 2009; 24: 888–895.
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.
9. 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.
10. Gift TL, Kissinger P, Mohammed H, et al. The cost and cost-effectiveness of expedited partner therapy compared with standard partner referral for the treatment of chlamydia or gonorrhea. Sex Transm Dis 2011; 38: 1067–1073.
11. Golden MR, Kerani RP, Stenger M, et al. Uptake and population-level impact of expedited partner therapy (EPT) on Chlamydia trachomatis and Neisseria gonorrhoeae: The Washington State community-level randomized trial of EPT. PLoS Med 2015; 12: e1001777.
12. Mohammed H, Leichliter JS, Schmidt N, et al. Does patient-delivered partner treatment improve disclosure for treatable sexually transmitted diseases? AIDS Patient Care STDS 2010; 24: 183–188.
13. Cameron ST, Melvin L, Glasier A, et al. Willingness of gynaecologists, doctors in family planning, GPs, practice nurses and pharmacists to adopt novel interventions for treating sexual partners of women with chlamydia. BJOG 2007; 114: 1516–1521.
14. Introcaso CE, Rogers ME, Abbott SA, et al. Expedited partner therapy in federally qualified health centers—New York City, 2012. Sex Transm Dis 2013; 40: 881–885.
15. Hsii A, Hillard P, Yen S, et al. Pediatric residents' knowledge, use, and comfort with expedited partner therapy for STIs. Pediatrics 2012; 130: 705–711.
16. 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.
17. Jotblad S, Park IU, Bauer HM, et al. Patient-delivered partner therapy for chlamydial infections: practices, attitudes, and knowledge of California family planning providers. Sex Transm Dis 2012; 39: 122–127.
18. Smock L, Barker K, Hsu K. Expedited partner therapy for chlamydia infection is underutilized and underreported, Massachusetts, 2012. Presented at: National STD Prevention Conference [3B.3]; 2014; Atlanta.
19. Centers for Disease Control and Prevention. Expedited partner therapy in the management of sexually transmitted diseases: US Department of Health and Human Services.
20. Workowski KA, Berman S; Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep 2010; 59: 1–110.
21. Golden MR. Expedited partner therapy: Moving from research to practice. Sex Transm Dis 2008; 35: 320–322.
22. Centers for Disease Control. Legal status of expedited partner therapy. Available at: http://www.cdc.gov/std/ept/legal/. Accessed June 25, 2015.
23. Golden MR, Estcourt CS. Barriers to the implementation of expedited partner therapy. Sex Transm Infec 2011; 87(suppl 2): ii37–ii38.
24. Schillinger JA. Treating contacts to gonorrhea and chlamydia without a clinic visit: the efficacy and effectiveness of different models Presented at: International Society for Sexually Transmitted Diseases Research [S06.1]; 2013; Vienna.
25. World Bank definitions of country income levels using the World Bank Atlas Method. Available at: (http://data.worldbank.org/about/country-and-lending-groups#High_income). Accessed November 3, 2015.
26. Bilardi JE, Hopkins CA, Fairley CK, et al. Innovative resources could help improve partner notification for chlamydia in primary care. Sex Transm Dis 2009; 36: 779–783.
27. Cramer R, Hogben M, Handsfield HH. A historical note on the association between the legal status of expedited partner therapy and physician practice. Sex Transm Dis 2013; 40: 349–351.
28. Hogben M, McCree DH, Golden MR. Patient-delivered partner therapy for sexually transmitted diseases as practiced by U.S. physicians. Sex Transm Dis 2005; 32: 101–105.
29. Packel LJ, Guerry S, Bauer HM, et al. Patient-delivered partner therapy for chlamydial infections: Attitudes and practices of California physicians and nurse practitioners. Sex Transm Dis 2006; 33: 458–463.
30. Rogers ME, Opdyke KM, Blank S, et al. Patient-delivered partner treatment and other partner management strategies for sexually transmitted diseases used by New York City healthcare providers. Sex Transm Dis 2007; 34: 88–92.
31. Rosenfeld EA, Marx J, Terry MA, et al. Healthcare providers' perspectives on expedited partner therapy for chlamydia: A qualitative study. Sex Transm Infect 2015; 91: 407–411.
32. Shivasankar S, Challenor R. Patient-delivered partner therapy in the UK: What do the professionals think? Int J STD AIDS 2008; 19: 437–440.
33. Taylor MM, Collier MG, Winscott MM, et al. Reticence to prescribe: Utilization of expedited partner therapy among obstetrics providers in Arizona. Int J STD AIDS 2011; 22: 449–452.
34. Schillinger JA, Jamison K, Rogers M. Potential biases when measuring repeat Chlamydia trachomatis infection rates to assess the real-world effectiveness of expedited partner therapy, New York City, 2011–2013 Paper presented at: National STD Prevention Conference [WP109]; 2014; Atlanta.
35. Vaidya S, Johnson K, Rogers M, et al. Predictors of index patient acceptance of expedited partner therapy for Chlamydia trachomatis infection and reasons for refusal, sexually transmitted disease clinics, New York City, 2011 to 2012. Sex Transm Dis 2014; 41: 690–694.
36. LaSee C, Aubin M, Simon J. Provider-offered Expedited Partner Therapy for Chlamydia and Gonorrhea in Washington State: Research to Sustainable Practice. National STD Prevention Conference [WP18]; 2014; Atlanta.
    37. Golden MR, Hughes JP, Brewer DD, et al. Evaluation of a population-based program of expedited partner therapy for gonorrhea and chlamydial infection. Sex Transm Dis 2007; 34: 598–603.
    38. Ricks JM, Swartzendruber AL, Sales JM, et al. Acceptance of and experiences utilising expedited partner therapy among African-American juvenile girls. Sex Health 2015 Epub date: Jun 29 2015. doi: 10.1071/SH15050.
    39. Temkin E, Klassen AC, Mmari K, et al. A qualitative study of patients' use of expedited partner therapy. Sex Transm Dis 2011; 38: 651–656.
    40. 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.
    41. Holloway IW, Jones HE, Bell DL, et al. Men's preferences for sexually transmitted infection care services in a low-income community clinic setting in New York City. Am J Mens Health 2011; 5: 208–215.
    42. Jesperson M, Rhahman M, Welch K, et al. Expedited partner therapy receipt reported by individuals with gonorrhea—Louisiana, 2009–2013 Presented at: National STD Prevention Conference [WP100]; 2014; Atlanta.
      43. Jones HE, Pressman EJ, Bell DL, et al. Managing chlamydia infections in young men: results from an audit of a public men's clinic in New York City. Int J STD AIDS 2011; 22: 581–584.
      44. Kerns JL, Jones HE, Pressman EJ, et al. Implementation of expedited partner therapy among women with chlamydia infection at an urban family planning clinic. Sex Transm Dis 2011; 38: 722–726.
      45. Mickiewicz T, Al-Tayyib A, Thrun M, et al. Implementation and effectiveness of an expedited partner therapy program in an urban clinic. Sex Transm Dis 2012; 39: 923–929.
      46. Schumacher CM, Ghanem KG. Retreatment rates for uncomplicated gonorrhea infection: Comparing ceftriaxone and azithromycin versus ceftriaxone and doxycycline. Sex Transm Dis 2013; 40: 539–545.
      47. Stenger MR, Kerani RP, Bauer HM, et al. Patient-reported expedited partner therapy for gonorrhea in the United States: Findings of the STD Surveillance Network 2010–2012. Sex Transm Dis 2015; 42: 470–474.
      48. Stephens SC, Bernstein KT, Katz MH, et al. The effectiveness of patient-delivered partner therapy and chlamydial and gonococcal reinfection in San Francisco. Sex Transm Dis 2010; 37: 525–529.
      49. Taylor MM, Reilley B, Yellowman M, et al. Use of expedited partner therapy among chlamydia cases diagnosed at an urban Indian health centre, Arizona. Int J STD AIDS 2013; 24: 371–374.
      50. Teplow-Phipps R, Stockwell MS, Soren K. Adolescent chlamydia infection: Treatment, expedited partner therapy, and testing for reinfection. Clin Pediatr (Phila) 2015; 54: 1383–1386.
      51. Rogers M, Mulder T, Mehta M, et al. Expedited partner therapy: Do partners get it? Findings form partner follow-up surveys in New York City STD clinics Paper presented at: National STD Prevention Conference [LB.2]; 2012; Minneapolis.
      52. Cameron ST, Glasier A, Muir A, et al. Expedited partner therapy for Chlamydia trachomatis at the community pharmacy. BJOG 2010; 117: 1074–1079.
      53. Schillinger JA, Jamison K, Rogers M, et al. Expanding expedited partner therapy among patients presumptively treated for Chlamydia trachomatis infection in public STD clinics, New York City, 2013 Paper presented at: National STD Prevention Conference [5F.1]; 2014; Atlanta.
      54. 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.
      55. Golden MR, Hogbe M, Levine MA. Ethics of expedited partner therapy. Virtual Mentor 2008; 10: 708–718.
      56. Mandatory electronic prescribing in New York State. Available at: http://www.op.nysed.gov/news/advisory-notices.html#electronic. Accessed July 31, 2015.
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