The Views of Patients and Partners Toward Patient-Delivered Partner Therapy for Chlamydia: A Systematic Review

Abstract

Background 

The majority of research on patient-delivered partner therapy (PDPT) has focused on its impact on reinfections. This study aimed to systematically review the evidence regarding the acceptability of PDPT by patients and partners for chlamydia infection.

Methods 

Three electronic databases were searched in March 2019 using terms related to PDPT. Studies were included if they reported on patient or partner acceptance of PDPT for chlamydia and were conducted in high-income countries. Actual and perceived acceptabilities of PDPT were assessed.

Results 

Thirty-three studies were included: 24 quantitative, 3 qualitative, and 6 mixed methods. Most were clinic based. Quantitative data showed that participants' perceived willingness to give PDPT to their partner(s) ranged from 44.7% to 96.3% (median, 84%), and 24% to 71% (median, 65%) of people who offered PDPT for their partner(s) accepted it. Partners' perceived willingness to accept ranged from 42.7% to 67% (median, 62%), and actual acceptance ranged from 44.7% to 80% (median, 77%). Those in longer-term relationships were generally more likely to accept PDPT; however, beyond this, we identified few clear trends. Qualitative studies found that convenience of PDPT and assurance of partner treatment were benefits, whereas partners not seeing a health care professional was viewed as a downside. Packaging that appeared legitimate and coaching on delivering PDPT were facilitators.

Conclusions 

Because patients bear responsibility for the success of PDPT, this information is crucial in clinical settings. Acceptance, perceived and real, of PDPT was generally high. Patients are best placed to determine whether PDPT is appropriate for them, and it should be offered as an option.

In Brief

A systematic review of patient and partner views toward patient-delivered partner therapy for treating chlamydia yielded mixed results in factors associated with acceptance and use.

Patient-delivered partner therapy (PDPT) for chlamydia is the practice of a health care provider providing their patient who is diagnosed with a sexually transmitted infection (STI; the index patient) an extra prescription (prescription-PDPT) or extra medication (medication-PDPT) to give to their sexual partner(s) without the health care provider seeing those partners.¹ Varying terminology is used to refer to PDPT including expedited partner therapy (EPT) in the United States and accelerated partner therapy (APT) in the United Kingdom. There is also variation in the use and models of delivery for PDPT. In the United States, EPT for chlamydia is permissible in 44 states and recognized as a useful method of facilitating partner notification by the Centers for Disease Control and Prevention, with health care provider use currently estimated at around 50%.^2,3 In the United Kingdom, there are 2 models for APT for chlamydia that comply with United Kingdom–prescribing guidelines including APTHotline (involving telephone consultation) and APTPharmacy (involving pharmacy consultation).⁴ In the Canadian guidelines on STIs, PDPT is recognized as a potentially valuable method of partner management.⁵ Australian guidance for PDPT for uncomplicated chlamydia infection has been provided in 3 of 8 states and territories, with PDPT largely recommended for situations where other partner notification methods have failed or considered likely to fail.¹ Currently the use of PDPT in Australia is low, with many health care providers being uncertain of the legality of PDPT and how and when to provide it.^6,7

Multiple large randomized control trials (RCTs) have investigated the effectiveness of PDPT, with a Cochrane review finding that it led to a greater reduction in chlamydia reinfection compared with simple patient referral.⁸ The success of PDPT is contingent upon the index patient obtaining PDPT from their health care provider, providing it to their partner(s) and their partners accepting it. It is therefore crucial to understand the views of health consumers toward PDPT, if uptake is to be improved. Two reviews have considered the evidence on acceptability of PDPT to patients and partners. Schillinger et al.³ created an “EPT continuum” for patient acceptance and delivery of PDPT; however, they excluded studies in which uninfected patients considered whether they would accept PDPT if diagnosed with chlamydia. It is important to capture these views because they may be future patients requiring PDPT. Furthermore, although this review included qualitative studies, it did not provide a thematic analysis of the qualitative data and therefore did not capture a more in-depth exploration of why patients did or did not accept PDPT. Gannon-Loew et al.⁹ included patient attitudes in their review of PDPT; however, they focused only on adolescents. Therefore, the aims of this systematic review was to investigate the actual and perceived acceptability of PDPT for chlamydia by patients and partners and to undertake a thematic analysis of any qualitative data to further understand reasons for acceptance and potential barriers and facilitators.

MATERIALS AND METHODS

A systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was conducted.¹⁰

Eligibility Criteria

Both quantitative and qualitative studies were eligible for inclusion. Studies were included if they were conducted in high-income countries, to allow for comparison of findings from similar socioeconomic contexts; reported on chlamydia, as PDPT practice and regulation may differ for different STIs; reported on PDPT or EPT or APT; and reported on patient or partner acceptability of PDPT or reports on explanatory factors for why patients or partners would accept or reject PDPT. Studies were ineligible if they only considered the effectiveness of PDPT without reporting on acceptability; did not distinguish PDPT from other partner notification methods; were not written in English; and only considered men who have sex with men, as Australian and American clinical guidelines do not recommend using it in this population.^1,11

Information Sources and Search Terms

MEDLINE, Embase, and PsycINFO databases were searched by E.A.L. for any studies published up until March 1, 2019. The reference lists of relevant reviews were also screened. Search terms included combinations of “patient-delivered partner therapy” or “expedited partner therapy” or “accelerated partner therapy” (and their various spellings), or “partner notification” and “partner management” in conjunction with “chlamydia.” Search terms were consistent across each database, and results were restricted by English language.

Study Selection and Data Extraction

All articles were downloaded into endnote, and duplicates were removed. Articles were screened for eligibility based on title and abstract by E.A.L. and A.V., and any disagreements were resolved by discussion. For the remaining articles, the full text was obtained and screened by E.A.L. and A.V., with any disagreements resolved by J.H.. E.A.L. extracted the following data for each study (Supplementary Table 1s, https://links.lww.com/OLQ/A564): first author, year of publication, study design, setting, participant characteristics, relevant findings, and quality assessment. A.V. confirmed extracted data.

Data Synthesis and Analysis

Before commencing the review, we formulated several questions to answer. These included determining what patients and their partners liked about PDPT and what made it easier for patients and partners to use PDPT (Supplementary Table 2s, https://links.lww.com/OLQ/A536). We differentiated between actual (experienced PDPT) and perceived (not experienced PDPT) acceptability. For quantitative studies, we conducted a frequency analysis to investigate the proportion of patients or partners who would accept or did accept PDPT. We did not conduct a meta-analysis because of the variability in study designs and definitions of acceptance of PDPT. For qualitative studies, we conducted a thematic analysis using the results of each study to understand why patients and their partners might accept or reject PDPT. E.A.L. conducted the quantitative analysis and an initial thematic analysis of qualitative studies, with A.V. randomly allocating 6 articles to read and validate E.A.L.'s summary of findings and impression of the themes emerging from the data. E.A.L. and A.V. discussed the thematic analysis with J.H. and reached consensus on the main and recurrent themes that had emerged.

Assessment of Quality

For studies with a quantitative component, we assessed potential for within-study bias using a combination of the evaluation criteria adopted by Sanderson et al.⁴⁴ and the critical appraisal tool for cross-sectional studies.⁴⁵ For each study, we commented on selection bias, response bias, measurement bias, or chance (sample size). Qualitative studies were assessed using the critical appraisal checklist for qualitative research studies used by Treloar et al.⁴⁶

RESULTS

Study Selection

Our search on March 1, 2019, identified 1106 articles, of which 387 were identified from MEDLINE, 666 from Embase, and 53 from PsycINFO. Of these, 391 were duplicates and removed. Screening of the title and abstracts removed an additional 654 articles. The most common reasons for failing preliminary screening were irrelevance and failing to meet the inclusion criteria (namely, report on patient or partner PDPT acceptance as an outcome). The full texts of the remaining 61 studies were reviewed. A further 28 failed to meet the inclusion criteria, most commonly for not reporting patient or partner PDPT acceptance or explanatory factors. In total, 33 studies were included in the review (Fig. 1).

Figure 1: Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram.

Study Characteristics

Detailed study characteristics and the main findings are described in Supplementary Table 1s, https://links.lww.com/OLQ/A564. Of the eligible studies, a total of 24 (73%) were conducted in the United States,^{12,14–21,23–25,29–37,40,41,43} 7 (21%) in the United Kingdom,^{4,13,22,27,28,39,42} and 1 each in Australia³⁸ and Canada.²⁶ The study methods can loosely be categorized as follows: patient surveys and interviews (24 [73%] studies),^{12–26,30,34,37–43} retrospective chart reviews (2 [6%] studies),^33,36 pilot studies and evaluations of PDPT implementation (5 [15%] studies),^{4,28,29,31,35} and RCTs (2 [6%] studies).^27,32 Twenty-four (73%) studies were quantitative, predominantly cross-sectional surveys^4,15–37; 3 (9%) were qualitative, predominantly semistructured interviews,^12–14 and 6 (18%) used mixed methods.^38–43 Most studies (88%) recruited participants from clinical settings.^{4,12–15,17–30,32,33,35–42} The mean age of participants was between 20 and 30 years, with 7 (21%) studies focusing specifically on adolescents.^{15,23,25,26,30,35,43} Seven (21%) studies exclusively recruited women,^{15,21,27,34,35,37,43} and 3 (9%) exclusively recruited men.^18,20,32 Sample sizes ranged from 46 to 2887 in quantitative studies^19,35 and 31 to 64 in qualitative studies.^12,14

Acceptability of PDPT

The proportion of patients and partners who accept or prefer PDPT over other partner notification methods is displayed in Table 1. It includes both quantitative and qualitative studies that measured perceived willingness to accept PDPT, actual acceptance of PDPT, and preference of PDPT over other partner notification methods.

TABLE 1 - Findings in Relation to Research Questions About the Acceptability and Preference of Patient-Delivered Partner Therapy (PDPT) Among Patients and Partners

`	Themes	Findings	References
What proportion of index patients find PDPT acceptable?	Perceived willingness to give PDPT (medication and/or prescription) to a partner	44.7%–96.3% (median, 84%; IQR, 76%–87.5%) of people perceived that they would be willing to give PDPT to give to their partners	12,15,16,18,20,21,23,25,26,38
	Actual acceptance of EPT for partners	24%–71% (median, 65%; IQR, 48.4%–68.5%) of people accepted EPT from a health care provider to give to their partners	14,29–31,35,36,43
What proportion of sexual partners find PDPT acceptable?	Perceived willingness to accept PDPT from a partner diagnosed with chlamydia	42.7%–67% (median, 62%; IQR, 53.4%–67.6%) of people perceived that they would be willing to accept PDPT from their partners.	12,16,18,24
	Actual acceptance of PDPT by partners of a patient with chlamydia	48% engaged with APTHotline and 34% APTPharmacy, 35% assumed treated by APTHotline, and 34% APTPharmacy.4 80% of EPT medication packs definitely or probably taken14 53% of partners EPT was delivered to were observed taking the medication35 44.7% reported partner took medication, 32.2% saw them take it32 79.5% of index patients receiving medication-EPT and 77.1% of index patients receiving prescription-EPT reported their sex partner accepted EPT. No significant difference between them34 19% managed with PDPT.37 40% of vouchers redeemed at pharmacies.28 37% of male partners sent back a slip confirming they had been treated.27	4,14,27,28,32,34,35,37
What proportion of patients prefer PDPT over other partner notification methods?	Proportion of people who would choose PDPT over other partner notification methods	1.8%–67% (median, 14%; IQR, 7.2%–38.4%) of patients would choose PDPT over other partner notification methods	15,17–19,22
	Proportion of people who chose PDPT for treating their sexual partners	APT chosen method for 61% of sex partners4	4

What Proportion of Index Patients Find PDPT Acceptable?

Ten studies asked participants about their perceived willingness to give PDPT as a prescription and/or medication to their partners.^{12,15,16,18,20,21,23,25,26,38} Overall, 44.7% to 96.3% (median, 84%; interquartile range [IQR], 76%–87.5%) of people perceived that they would be willing to give PDPT to their partners.

Seven studies measured the actual acceptance of PDPT as a prescription and/or medication by patients when offered by their health care provider.^{14,29–31,35,36,43} Overall, 24% to 71% (median, 65%; IQR, 48.4%–68.5%) of patients accepted PDPT for their partners. Actual acceptance of medication-PDPT compared with prescription-PDPT was measured separately in 4 studies^15,18,21,25: 3 studies finding acceptance of prescription-PDPT to be lower than medication-PDPT^15,18,21 and 1 finding it to be higher.²⁵

What Proportion of Sexual Partners Find PDPT Acceptable?

Four studies asked participants about their perceived willingness to accept PDPT as a prescription and/or medication if offered by their partner.^12,16,18,24 Overall, 42.7 to 67% (median, 62%; IQR, 53.4%–67.6%) of people perceived that they would be willing to accept PDPT from their partner.

A total of 8 studies measured the actual acceptance of PDPT as a prescription and/or medication by patients when offered by their partner.^{4,14,27,28,32,34,35,37} This was measured indirectly via the index patient in 4 studies, with the results ranging from 44.7% to 80% (median, 71.1%; IQR, 48.9%–79.8%).^14,32,34,35 Oliver et al.³⁴ found no difference between partner acceptance of medication-EPT and prescription-EPT. An evaluation of EPT acceptance among partners found 40% of collected EPT pharmacy vouchers,²⁸ and in an RCT of PDPT effectiveness, 32% of partners returned a slip confirming treatment.²⁷ A medical record review found that 19% of partners accepted PDPT,³⁷ and the comparative study of 2 APT models reported that 35% of partners were assumed treated by APTHotline and 34% by APTPharmacy.⁴

Do Patients Prefer PDPT Over Other Partner Notification Methods?

A total of 5 studies asked participants their perceived preference for partner notification.^{15,17–19,22} Overall, 1.8% to 67% (median, 14%; IQR, 7.2%–38.4%) of patients preferred PDPT over other partner notification methods. In an APT comparative study, the use of either APT model was chosen for 61% of participants' sexual partners.⁴

Findings Pertaining to Why Patients and Partners Might Accept or Reject PDPT

The research questions related to why patients/partners accept PDPT are displayed in Table 2. Thematic analysis of the summarized findings revealed recurrent themes that include personal characteristics and beliefs, health, relationship with sexual partners, logistics, and interaction with health care providers.

TABLE 2 - Findings in Relation to Research Questions About Reasons That Patients/Partners Do or Do Not Accept or Prefer Patient-Delivered Partner Therapy (PDPT), Grouped Into Themes

	Personal Characteristics and Beliefs	Health	Relationship With Sexual Partners	Interaction With Health Care Provider	Logistics
What factors make it more likely that patients and their partners will accept PDPT?	Female17,33 Male24 If they have higher education levels including health literacy16,17,23 White30,33 Higher notification self-efficacy score23 Higher number of sexual partners26,43	Previous positive STI diagnosis17,18,21,24,26,43 If they have symptoms of chlamydia26,36,39	Relationship satisfaction16 If their current/most recent partner is long term or steady partner12,32,37,39	If they have previously had an STI clinic visit or STI test22,33
What do patients and partners like about PDPT?	Belief it is an altruistic and responsible thing to do14,43	Prevents reinfection in themselves12,14 Ensures their partner is treated12,16,22,23,38,41 Reduces spread of chlamydia in community16		Partner can avoid going to a clinic- good for those who are: unlikely to attend, health care averse, embarrassed or for whom it's difficult to attend14,22,41,42	Convenience12–14,22,38,41,42 Cost12 Faster treatment4,22,38
What do patients and partners not like about PDPT?		Medication/prescription for medication is given out from someone other than a doctor13,18,21,36,39		Partners do not get full STI testing or sexual health counseling from a doctor12,18,21 Embarrassment discussing chlamydia management with a pharmacist if prescription-PDPT13
What makes it easier for patients and partners to use PDPT?			If they trust their partner12,16	Coaching on how to present the information and preparedness for unforeseen reactions14,40	If PDPT is permissible in their jurisdiction12 Well-perceived commercial materials including having it sealed in an official package12,16 Having instructions on how to take it16 A note from health care provider16
What can get in the way of patients and partners usingPDPT?	Stigma of having an STI including embarrassment and shame12 Do not believe the medication works for treating chlamydia14	Concerns over patient safety including side effects and allergies of medication12,16,39,41	Casual partner, friends with benefit or ex-partner12,16,23,36,39,43 Not wanting to see their partner again14,22 If they do not want to disclose STI diagnosis to partner35 Fear of partner response including risk of intimate partner violence14,40 Implications of infidelity12 If they use condoms14,23		Geographical distance between patient and partner14 Unable to contact partner12,14 Pharmacy location inconvenient4

Personal Characteristics and Beliefs

There were 19 studies that considered associations of personal characteristics and beliefs on PDPT acceptability.^{12,14,16–19,23–26,28,30,32,33,35,36,39,42,43} Only one study found an association with age and PDPT acceptability, with those younger than 20 years being less likely to accept PDPT,³⁸ and 13 studies found no association between age and PDPT acceptance.^{16–18,23–26,30,32,33,36,42,43} The association of sex and PDPT acceptance varied between studies, with 2 studies finding that women were more likely to accept PDPT than men,^17,33 1 study finding men were more likely to accept PDPT than women,²⁴ and 9 finding there was no difference between sexes in PDPT acceptability.^{16,19,23,25,28,30,36,39,42} Two studies found that Whites were more likely to accept PDPT than African Americans,^30,33 and 5 found no association between race and acceptability.^{16,17,23,32,36} Level of education/health literacy was positively correlated with PDPT acceptability in 3 studies,^16,17,23 and there was no association in 2 studies.^16,32 Having a higher number of sexual partners increased the likelihood of acceptability in 2 studies,^26,43 there was no association in 4 studies,^23,24,33,36 and there was an inverse correlation in 1 study.¹⁶ Notification self-efficacy (an individual's belief in their capacity to notify a partner) was positively associated with PDPT acceptability in one study,²³ and there was no association in another.³⁵ Personal beliefs also seemed to influence people's choice to use PDPT, with the belief that it is an altruistic and responsible thing to do being reported as a positive quality of PDPT,^14,43 whereas the perception of stigma relating to having chlamydia and not believing the treatment will work could stop people using PDPT.^12,14

Impact on Health

Consideration of the health of the patient and partner was a highly pervasive theme and explored in 16 studies.^{12–18,21,24,26,32,36,39,41–43} Patients/partners who had previously been diagnosed with an STI were more likely to accept PDPT in 6 studies,^{17,18,21,24,26,43} and there was no association in 3 studies.^15,16,42 Patients/partners who currently had symptoms of an STI were more likely to accept PDPT in 8 studies,^{17,18,21,24,26,36,39,43} and 2 studies found no association.^32,42 Patients reported liking that PDPT could have a positive impact not just on their own health by preventing reinfection^12,14 but on the health of their partners^{12,16,22,23,38,41} and the wider community by reducing the spread of chlamydia.¹⁶ This same concern for health could also preclude patients giving and accepting medication, as they worried about the adverse effects and allergies associated with taking it,^12,16,39,41 as many did not like that the partner did not get the prescription or medication from a doctor directly.^{13,18,21,36,39}

Relationship With Sexual Partners

The type and nature of the relationship between sexual partners were an important factor, with 13 studies looking at it.^{12,14,16,17,21–23,32,36,37,39,40,43} Having a long-term or steady partner facilitated PDPT acceptance in 4 studies,^12,32,37,39 and having an ex-partner, casual partner, or friends with benefits was mentioned as a barrier to PDPT in 6 studies.^{12,16,23,36,39,43} Only one study found that PDPT was the preference for more women whose last partner was casual,²¹ and 2 studies found partner type to have no association with PDPT acceptability.^17,24 Patients not wanting to see their partner again was a barrier to PDPT use,^14,22 whereas relationship satisfaction and trust between partners was a facilitator to PDPT use,^12,16 with patients who use condoms less likely to use PDPT.^14,23 Fear of the partners response could also act as a deterrent, including implications of infidelity and a risk of intimate partner violence.^12,14,40

Logistics

In 9 studies, logistics arose as either a benefit or a barrier to PDPT use.^{4,12–14,16,22,38,41,42} The convenience of having a ready-made script or medication as a partner was often cited as a major upside to PDPT,^{12–14,22,38,41,42} allowing for faster treatment^4,22,38 and avoiding the cost of seeing a health care professional and/or the cost of the medication.¹² It was suggested that uptake would be further encouraged with well-perceived commercial materials, instructions on how to take the medication, a note from a health care provider, and policies/guidelines that support its use.^12,16 Potential logistical barriers to exchanging the medication included the following: being unable to contact sexual partners,^12,14 geographical distance between patient and partner,¹⁴ and the pharmacy being in an inconvenient location.⁴

Interaction With Health Care Providers

The content of the interaction between health care provider and patient was an influencer of PDPT acceptability in 10 studies, with the ability to circumvent this interaction being stated as both an upside and a downside to PDPT.^{12–14,18,21,22,33,40–42} Patients who had previously interacted with a health care practitioner to have an STI test performed were more accepting of using PDPT than patients who had not.^22,33 Patients perceived the ability to circumvent a health care provider as a positive aspect of PDPT when they thought their partners were unlikely to visit a clinic, health care averse, or too embarrassed to talk to a doctor or pharmacist.^{13,14,22,41,42} Conversely, many patients were against PDPT as they wanted their partners to see a doctor for STI testing and treatment directly.^12,18,21 Finally, coaching by the health care professional on how to give PDPT to sexual partners was mentioned as a potential facilitator to PDPT use.^14,40

Table 3 summarizes the findings of quantitative associations sort between patient or partner acceptance of PDPT and the following measured factors: sex, Whites race, higher education level, higher number of sexual partners, partner type, previous or current STI diagnosis, symptoms of an STI, and notification self-efficacy (Table 3). Associations by author can be found in Supplementary Table 3s, https://links.lww.com/OLQ/A536.

TABLE 3 - Summary of Factors Found to Be Associated With PDPT Acceptance, Stratified Into Patient and Partner Acceptance*

Factor Investigated	Patient Acceptance		Partner Acceptance
	Studies Investigating an Association, Total No.	Studies Reporting an Association†, No. (%)	Studies Investigating an Association, Total No.	Studies Reporting an Association†, No. (%)
Age	10	0 (0)	4	1 (25)
Sex	9	2 (22.2)	2	1 (50)
White race	6	2 (33.3)	1	0 (0)
Higher education level	3	2 (66.7)	1	0 (0)
Higher number of sexual partners	6	3 (50)	1	0 (0)
Partner type	3	2 (66.7)	3	2 (66.7)
Previous or current STI diagnosis	8	5 (62.5)	1	1 (100)
Symptoms of an STI	1	1 (100)	1	0 (0)
Notification self-efficacy	2	1 (50)	0	0 (0)

*See Supplementary Table X, https://links.lww.com/OLQ/A536 for further detail of these studies.

^†Either a positive or negative association.

Quality of Studies

Quality of studies varied considerably (Supplementary Table 1s, https://links.lww.com/OLQ/A564). Most studies with a quantitative component had considerable selection bias because the participants were recruited from high-risk settings such as STI clinics, reducing their generalizability to the wider population However, 13.3% of these reported that they recruited consecutive patients, reducing selection bias within the study setting. Only 67% of studies reported a response rate, and one study provided a sample size calculation. Not all studies had clearly defined definitions of PDPT, with it being unclear if they were measuring prescription-PDPT or medication-PDPT, and few studies compared the 2. This meant we were unable to meaningfully comment on and compare the 2 models separately, and figures relating to acceptability are a summation of both.

DISCUSSION

To our knowledge, this is the first systematic review to examine perceived and actual acceptability of PDPT by patients and their partners. Overall, PDPT was found to be generally acceptable to patients and greater than acceptance reported by partners, although there was considerable heterogeneity in the data. Perceived willingness to use PDPT as an index patient was also generally higher than what was reported in studies measuring actual acceptance. This suggests that, although the idea of PDPT is generally acceptable to patients, unforeseen barriers may preclude successful uptake in some instances.

Across studies, those in longer-term relationships were generally more likely to accept PDPT than those with casual partners or friends with benefits. This may be a consequence of a presumed higher level of trust between longer-term partners, a quality that was reported to make it easier to perform PDPT.^12,16 Longer-term partners are also more likely to have regular contact with one another, overcoming the reported barrier of being unable to contact a partner or not wanting to see a partner again.^14,22 However, beyond this, we found a lack of clear trends. In addition, some patients seem to use a broad range of determinants when deciding whether PDPT is appropriate for their circumstances (i.e., partner trust, relationship satisfaction), which may be difficult for a clinician to assess. This is clinically significant, as attempting to limit PDPT to particular groups or people in particular types of relationships may be inappropriate. Given these findings, we conclude that patients themselves are best placed to determine whether PDPT is suitable for their circumstances, and it is crucial that PDPT is offered as part of a suite of partner management options for patients diagnosed with chlamydia.

Strengths and Limitations

This research is subject to limitations. We only included studies written in English, and most studies (73%) were set in the United States and were conducted in specialized sexual and reproductive health clinics. As our quality assessment showed, such selection bias reduced the generalizability of our results to a more mainstream primary care setting; however, many studies recruited consecutive patients, minimizing selection bias within specialized clinic settings. More research from other countries and settings is needed. The strength of this review includes its mixed-study design, which facilitated a greater depth of understanding and corroboration, as the findings across both methodological approaches strongly supported each other.

CONCLUSIONS

Our review provides some lessons for implementing an effective PDPT program for patients and their partners. When considering the use of PDPT, health care providers could target those in long term relationships or patients whose partners are unlikely to present for testing. However, patients themselves are in the best position to determine whether PDPT is appropriate for their circumstances and should be offered the option. More research is required from countries other than the United States and from nonsexual health clinic settings. It is also important to better understand patient views on prescription-PDPT versus medication-PDPT. In summary, it is the patients who bear the responsibility and success of PDPT, and therefore, implementation should be guided by their views.