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Optimizing the Impact of Expedited Partner Therapy.

A central tenet of sexually transmitted disease (STD) control is that the sex partners of a patient with a bacterial STD must be treated to interrupt the ongoing spread of infection in the community, and to protect the original (index) patient from becoming reinfected by an untreated partner. Expedited partner therapy (EPT) is a partner treatment strategy designed to reach partners who are unable or unlikely to seek timely medication attention. Expedited partner therapy enables a health care provider to treat an index-patient's sex partners without clinical assessment of those partners. Most commonly, this is accomplished by asking index-patients to deliver treatment to their sex partners themselves in the form of either medication or prescription. Expedited partner therapy was studied inmultiple randomized clinical trials (RCTs), before being endorsed by the US Centers for Disease Control in 2006 as an efficacious strategy for preventing repeat Chlamydia trachomatis (chlamydia) and Neisseria gonorrhoeae (gonorrhea) infections in heterosexual partnerships. It is widely permissible through legislation, andmedical and pharmacy board decisions across the United States, and has been legal for more than 15 years in one state. So how can we optimize the impact of EPT? The answer may lie in understanding the difference between how EPT was studied and how it has been implemented in the real world. The RCTs that established the efficacy of EPT delivered partner treatment in the form of medication; 2 of the trials gave index-patients antibiotics to hand-deliver to their sex partners (medicationEPT), whereas a third gave out antibiotics in-hand, or used a pharmacy chain or direct mailing to distribute “partner packs” containing antibiotics to index-patients or sex partners. In all 3 RCTs, informational materials for the partners were dispensed along with the medication, including information on the medication, contraindications to its use, and the locations of nearby free sexually transmitted infection clinics. In the realworld, providers commonly give index-patients prescriptions for their sex partners (prescription-EPT). There are few population-based measures of index-patient receipt of EPT by any mechanism. However, 2 reports that distinguished betweenmedicationand prescription-EPT found that prescription-EPT was used the majority of the time EPT is practiced: among chlamydia patients in Massachusetts for whom EPTwas provided (as reported by their provider at the time of disease report), 57% were given a prescription for at least one sex partner, and in New York City (NYC), 52% of interviewed adolescent and young adult women treated for chlamydia who received EPT for their most recent sex partner reported that they were given prescription-EPT. The practice of patient-delivered prescription-EPT has never been evaluated by RCT, and there are several reasons it might not work as well as medication-EPT. Prescription-EPT is more complicated thanmedication-EPT because there are more steps to achieve partner treatment.With medication-EPT, an index-patient can deliver medication directly to their sex partners at no cost to the index-patient or the partners. However, with prescription-EPT, either the index-patient or the sex partner needs the time and means to go to a pharmacy to present and pick up the prescription, and to cover the medication cost, with cash or insurance (which may include a copay). The average cost of EPT treatment of chlamydia is estimated to be $23 to $30 (for generic azithromycin, 1 g, taken as four 250-mg tablets), a substantial outof-pocket cost for adolescents, who represent a large portion of the EPT-eligible population and whomay be reluctant—for reasons of confidentiality—to use their drug coverage plans if they are still covered by their parents' insurance. This EPT practice also includes an encounter with a health care professional (a pharmacist), which adds further complications or potential barriers, including the cost of the encounter (in the form of a medication-dispensing fee) and the potential embarrassment of the encounter for some individuals, given the public setting in which it occurs. If an index-patient is given prescription-EPT for more than 1 sex partner, the logistical costs of partner treatment and challenges could be magnified.