Stamping out disease–from afar

In my opinion, people are often too embarrassed to see their doctor about sexually transmitted infections (STIs)—in my opinion.

“In my opinion” is one of the most dangerous phrases in science.  But when in comes to attitudes toward STIs, the data are scarce. STI’s are very much a “behavior”-based disease, so knowing what attitudes prevail can help us design effective prevention strategies.  Attitudes toward HIV have been studied, especially in the early period of the pandemic and on non-US populations, but finding recent data on STIs in the U.S.  is a frustrating endeavor.  Much of the data that are out there are on adolescents, and while this age group has a high STI rate, we are finding that certain older populations are at increasing risk.

One of the trends seen in the research is a  disconnect between knowledge of STIs and behaviors to reduce risk.  In a clever study (cited below), condom coupons were given to patients at an STI clinic in New York, with an overall redemption rate of only 22%.  Other studies show that primary care physicians (PCPs) don’t do a great job of screening for STIs.

So patients’ regular doctors do a poor job of screening, and patients do a poor job of changing their behavior.  Still, when patients have symptoms, they do often seek out care.   In my experience (!) that care is often delivered by a walk-in clinic rather than by the patient’s regular doctor.  Since I spend some of my time at a walk-in clinic, I often treat STIs.  Since the patients aren’t “mine”, and in my experience (!!) it is often hard to reach them with test results, I do quite a bit of empiric therapy.

Empiric therapy—treating the most likely problem without lab results—has the advantage of allowing for “directly observed therapy”.  I can treat someone for gonorrhea and chlamydia while they are sitting in front of me, insuring proper treatment without worrying about losing the patient to follow up.

But what about the partners?  If I don’t treat the sex partners, my patient is likely to be re-infected, and the partner is likely to continue to spread disease.

Standard practice is to advise the patient to inform their sexual partners that they have or are suspected to have an STI, and to encourage these partners to seek out medical care.  How often do you think this happens?  Studies have shown that public health services seldom successfully notify partners, and that patients rarely notify their partners.   And it is unequivocally unethical for a clinician to notify a patient’s sexual partner without the patient’s permission.

Enter “expedited partner therapy” (EPT, known in California as  “patient-delivered partner therapy”).   With EPT, the clinician treats the patient, and gives them a prescription or a medication to take to their partner.  This not only treats another affected patient, but prevents re-infection of  your patient. This is how a typical encounter would work:  a young woman comes to see me complaining of a vaginal discharge.  She is sexually active with one male partner and not pregnant.  On exam, she has typical findings of gonorrhea or chlamydia, and I send a sample of her vaginal secretions to the lab.  The results won’t be available for a day or two, and based on relatively arbitrary criteria I decide to treat her for gonorrhea and chlamydia without the final lab result (the criteria may include the high rate of chlamydia carriage in her age group, and the fact that she is not my regular patient which may decrease my ability to get in touch with her when results are available).  I then hand her a packet of pills to take to her partner.

This sounds like a great idea in many ways, but like many ideas in medicine, simply being a good idea is different than being proved to be a good idea.  A study published this month in Sexually Transmitted Diseases examined this question, and confirmed previous data that EPT is effective at preventing reinfection (the study’s other stated goal of detecting differences between various subgroups gave favorable but not statistically significant results).

So why aren’t we all doing it?

There are some obvious reasons to favor EPT, and some important reasons to be wary.  Any time you treat someone that you don’t know, you risk mis-treating them.  If the partner is allergic to the medication, I can cause them harm.  I also lose the ability to counsel him on STIs and to test him for other common STIs such as syphilis and HIV.  But given the high rates of gonorrhea and chlamydia, and the benefit to my patient via preventing reinfection, this could be a win.

Except that it’s illegal in my state, and maybe in yours.  Since physicians are obligated to actually have a clinical relationship with a patient in order to treat them, specific legislation is usually  needed to allow EPT.  And while the legislation may allow EPT, it does not insulate a clinician from liability arising from using EPT.   The evidence favoring EPT has been accumulating for several years, so it may be time for the rest of the country to allow it.

References

Jemmott, J., Jemmott, L., Fong, G., & Morales, K. (2010). Effectiveness of an HIV/STD Risk-Reduction Intervention for Adolescents When Implemented by Community-Based Organizations: A Cluster-Randomized Controlled Trial American Journal of Public Health, 100 (4), 720-726 DOI: 10.2105/AJPH.2008.140657

Ford CA, Jaccard J, Millstein SG, Viadro CI, Eaton JL, & Miller WC (2004). Young adults’ attitudes, beliefs, and feelings about testing for curable STDs outside of clinic settings. The Journal of adolescent health : official publication of the Society for Adolescent Medicine, 34 (4), 266-9 PMID: 15040995

O’Donnell L, San Doval A, Duran R, & O’Donnell CR (1995). Predictors of condom acquisition after an STD clinic visit. Family planning perspectives, 27 (1), 29-33 PMID: 7720850

Lindau, S., Schumm, L., Laumann, E., Levinson, W., O’Muircheartaigh, C., & Waite, L. (2007). A Study of Sexuality and Health among Older Adults in the United States New England Journal of Medicine, 357 (8), 762-774 DOI: 10.1056/NEJMoa067423

Shiely, F., Hayes, K., Thomas, K., Kerani, R., Hughes, J., Whittington, W., Holmes, K., Handsfield, H., Hogben, M., & Golden, M. (2010). Expedited Partner Therapy: A Robust Intervention Sexually Transmitted Diseases DOI: 10.1097/OLQ.0b013e3181e1a296

ASHTON, M., COOK, R., WIESENFELD, H., KROHN, M., ZAMBORSKY, T., SCHOLLE, S., & SWITZER, G. (2002). Primary Care Physician Attitudes Regarding Sexually Transmitted Diseases Sexually Transmitted Diseases, 29 (4), 246-251 DOI: 10.1097/00007435-200204000-00011

Nurutdinova, D., Rao, S., Shacham, E., Reno, H., & Overton, E. (2010). STD/HIV Risk Among Adults in the Primary Care Setting: Are We Adequately Addressing Our Patientsʼ Needs? Sexually Transmitted Diseases DOI: 10.1097/OLQ.0b013e3181e9afda

JOHNSON, L., ROZMUS, C., & EDMISSON, K. (1999). Adolescent sexuality and sexually transmitted diseases: Attitudes, beliefs, knowledge, and values Journal of Pediatric Nursing, 14 (3), 177-185 DOI: 10.1016/S0882-5963(99)80006-2

Golden, M., Whittington, W., Handsfield, H., Hughes, J., Stamm, W., Hogben, M., Clark, A., Malinski, C., Helmers, J., Thomas, K., & Holmes, K. (2005). Effect of Expedited Treatment of Sex Partners on Recurrent or Persistent Gonorrhea or Chlamydial Infection New England Journal of Medicine, 352 (7), 676-685 DOI: 10.1056/NEJMoa041681
http://www.cdc.gov/std/ept/

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7 Comments

  1. aek

     /  October 6, 2010

    Great idea, but how frustrating that it has so many barriers.

    Way back when, my university health service had a walk in self diagnosis/treatment option for students with sx of colds/viruses. Students completed a checklist of signs and symptoms, and if they showed signs of bacterial/sepsis type infections, they were automatically screened out and saw a nurse practitioner or physician. Otherwise, they picked up their treatment pack (which contained patient teaching sx management and prevention tools, too) and were on their way.

    I wonder if this type of self management wouldn’t lend itself to some STI tx? Demographics could be collected, but the patient could remain anonymous, the treatment packet would contain the meds along with allergy precautions, and the patient teaching packet would contain instructions on notifying partners (as well as condoms). If a computer entry system was used, the database could populate appropriate public health reporting fields.

    ATBs are already handed out like candy, so I don’t think that overuse is too much of a concern/risk here and for a sexually active population. This model might get more people to walk in, and if they self-assessed pos. for sx of advanced STI or multiple/other health problems, the self assessment could identify that and triage them to an MD visit.

    What am I missing?

  2. Is is possible to share a practice with a physician from another state where it is legal, and could that physician from that state then write a prescription for the bf of the woman with the STI?

    For example I notice that Oregon is a state that allows EPT. Could you and Mark Crislip have a joint STI treating practice where you do the exam of the woman, write her prescription for treatment and then Mark Crislip writes a prescription for treatment of the bf?

    I appreciate that such a work around is not desirable.

  3. Dianne

     /  October 7, 2010

    I’m not sure how I feel about this one. Decreasing the number of people infected with STDs is clearly a good thing. And this approach appears to be effective. At the same time, treating a person you’ve never seen strikes me as risky. What if the partner has allergies to the prescribed antibiotic (something he/she may not have discussed with his/her partner)? What if they don’t take the med as prescribed and end up with a resistant infection-a risk with any outpatient med but likely higher when direct counseling is not given? What if they have a pre-existing resistant infection and go about spreading it, believing that they are “cured” by the previous treatment? The data look promising for this technique to be an overall win, but I’m still concerned about the details in individual cases.

  4. Isabel

     /  October 8, 2010

    I find it a little hard to believe that people have a confirmed STD either 1) don’t tell their partners or 2) they do and their partners refuse to be examined by a doctor – wtf?? This is what needs to be studied. Also, I think a huge deal with young people is cost of treatment. Examination and treatment of STDs should be free.

    A side note: As a former naturally open and honest patient I find myself increasingly put off by the way such information is collected (sexual practices, sexual history): the last time, during my first routine examination at a new facility, the nurse practitioner typed my answers word for word into some on-line database as I spoke, barely making eye contact because she was so focused on *permanently* recording every detail, both from the form I’d filled out and her follow-up questions. I suddenly (and yes, irrationally) regretted my openness, and at that moment decided, automatically and almost unconsciously, to be less “generous” with personal information from now on. This occurred in a facility that mainly treats young people.

    I wonder if young people are LESS open than they were in the past? Could the fact that confidentiality seems more like a naive fantasy these days have anything to do with it? And how does price affect cooperation?

  5. PalMD

     /  October 8, 2010

    Well, some of those very questions are the subject of an upcoming post.

  6. I could easily imagine one party in a relationship not wanting to disclose that they had an STI to their partner. It brings up the issue of infidelity. Where did the STI come from? If it is a long term relationship, then one of them had unprotected sex with someone else and got infected.

  7. Vicki

     /  October 8, 2010

    Even if it isn’t a long-term monogamous relationship, “where did they get that?” can be problematic. Not everyone wants to deal with the idea that their partner had a sex life before them. (I suspect this is worse for women with male partners, because of various forms of double standard.) That’s going to come up especially in new (or only recently exclusive) relationships.

    Even in a non-exclusive relationship, someone may fear being judged for having chosen the “wrong” other partner, that is, one who gave them an STD.

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