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- Chlamydia infections/epidemiology/prevention & control
- sexual partners
- contact tracing
- cost-benefit analysis
- public health
- clinical STI care
- HIV clinical care
- epidemiology (general)
- partner notification
- health service research
Over the last decade, a growing body of literature has described and evaluated interventions designed to improve partner notification and treatment for curable sexually transmitted infections (STIs). For the most part, these studies have described expedited partner therapy (EPT), interventions meant to increase partner treatment by making it easier for partners to receive medication.1 The need for new approaches to partner treatment grew out of widespread recognition of the mismatch between the size of the STI problem and the paltry resources available for traditional partner services (PS). To date, EPT has most often involved patient delivered partner therapy (PDPT), the practice of giving persons diagnosed with an STI (index patients) medication for their sex partners. Although interest in the subject has probably been greatest in the USA, EPT studies have also come from the UK, Australia and Brazil.2–4 Available evidence suggests that EPT increases partner treatment and decreases rates of STI reinfection.1 However, these gains come at a price. Some partners who receive PDPT forgo medical evaluation, which may lead to missed diagnoses, fewer opportunities to diagnose and treat additional sex partners, and lost counselling opportunities. Furthermore, PDPT is not legal in many areas. Given these realities, it is important to develop and evaluate new low-cost, scalable models for partner treatment.
Two recent articles in Sexually Transmitted Infections provide a preliminary evaluation of a new model of EPT, accelerated partner therapy (APT). As described by Estcourt, APT includes two related approaches that diminish barriers to treatment while accommodating UK prescribing regulations by ensuring a limited interaction between partners and medical providers. In the APT Hotline strategy, partners call a health adviser or nurse who assesses them using a standard guide and directs persons deemed to be eligible to collect a treatment pack from the clinic reception staff. In the APT Pharmacy strategy, partners see a trained pharmacist for assessment and dispensation of treatment packs. Both strategies include an ‘assertive invitation’ to partners to seek HIV and syphilis testing.
In an exploratory, non-randomised trial undertaken in two sexual health clinics, Estcourt's group evaluated the two APT strategies compared with routine PS for partners of persons with chlamydial infection, gonorrhoea or non-gonococcal urethritis and at least one contactable sex partner.5 Routine PS consisted of an interview with a health advisor or nurse and some provision of written information. Index patients chose a PS method for each of their contactable sex partners, but partners assigned to APT were free to seek routine clinical care instead of treatment through APT. Of the 296 contactable partners, index patients chose the APT Hotline for 46% of partners, APT Pharmacy for 15% of partners and routine PS for the remaining 39% of partners, demonstrating that APT was acceptable to, and likely preferred by, most index patients. Based on a composite measure derived from recorded interactions with clinic and pharmacy staff and interviews with index patients and partners, the percentage of partners treated was significantly higher among partners allocated to the APT Hotline (59%) or APT Pharmacy (66%) compared with standard PS (36%).
In a second paper, the investigators conducted a cost-consequence analysis of APT.6 Both APT models were somewhat more costly than routine partner notification. Treating partners via the APT Hotline, APT Pharmacy and routine PS cost an estimated £54, £53 and £46 per partner treated, respectively. The 95% CIs on these costs overlapped and given the inevitable imprecision associated with estimating the cost of providing a clinical service, the strategies should probably be considered to have similar costs. Moreover, treating partners is inexpensive relative to chlamydial screening. Identifying and treating a case of chlamydial infection through the English National Chlamydia Screening Programme is estimated to cost £506.7 Approximately half of the evaluated partners of persons with gonorrhoea or chlamydial infection are typically infected. Thus, regardless of which strategy one employs, PS cost vastly less per case treated than screening. Roberts did not directly evaluate the cost-effectiveness of APT, but a US EPT analysis found the intervention to be cost-effective from a societal perspective based on a cost of £41–96 per partner treated.8 Some controversy persists about whether chlamydial control programmes are cost-effective,9 but within those programmes, all models of EPT are likely to be cost-effective, so the selection of strategies should probably be driven primarily by safety considerations and their comparative effectiveness in ensuring that partners receive good care and curative treatment.
One argument for regulations that prohibit PDPT in the UK and elsewhere is that even a limited medical evaluation prior to treating partners represents a standard of care superior to that of PDPT. Ideally an evaluation allows partners to get at least some information about STI and to be tested. This is an appealing aspect of APT. How much APT improves the safety of partner treatment compared with PDPT, however, is uncertain. All of the partners who initiated the APT Pharmacy strategy in Estcourt's trial received medication, so screening by pharmacists did not identify partners who would have been poor candidates for PDPT. Thus, the APT Pharmacy intervention probably did not do much to improve the safety of partner treatment. On the other hand, 22% of partners who sought APT via the hotline were found to be ineligible. If a substantial number of these persons actually had infections requiring management different from administration of the treatment pack medication, this would be a compelling argument that APT provided better care than what partners might have received through PDPT. Alternatively, the determination of ineligibility for APT may have been too restrictive. Defining medical outcomes in partners ineligible for APT will be an important part of future research.
Like PDPT, APT does not appear to be a good intervention for men who have sex with men (MSM). A recent small trial of PDPT in MSM found that it decreased partner testing for HIV and syphilis.10 Estcourt found that virtually none of the partners who received APT were tested for HIV or syphilis. Together, these findings argue against routine use of PDPT or APT in MSM and other populations at high risk for HIV infection.
Estcourt and colleagues have presented a new model of EPT which creatively addresses legal limitations in the UK, appears to increase partner treatment rates and is probably cost-effective compared with routine PS. These are promising findings that justify the randomised trial the authors propose. In designing that trial, it will be critical to consider how APT might best be widely instituted. As illustrated by the USA's declining commitment to the widespread institution of evidence-based counselling interventions to prevent HIV infection, scalability is often the Achilles' heel of public health interventions. An APT hotline should be feasible in large genitourinary medicine clinics, but might be difficult to institute in primary care practices. Assuming that counselling and testing procedures are extremely simple, pharmacy APT should be scalable, though the APT investigators described some problems in maintaining staffing with trained pharmacists during the trial. These issues require careful consideration as APT is modified.
Although more data are needed, APT is a promising strategy for reducing STI morbidity in the UK, and the results of the forthcoming randomised controlled trial will be of great interest to those working to address the sizeable mismatch between the need for PS and the resources available to provide them.
- Health services research