Expedited Partner Therapy for STDs vs. Traditional Care

PUBLIC HEALTH POLICY IN AMERICA

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You are listening to Reach MD XM 157, The Channel for Medical Professionals. For many years, the treatment of those infected with sexually transmitted diseases, has included recommendations for including the notification and treatment of partners. Lately, medical researchers and legal minds are studying how patient's partners are assessed and treated by the medical system. They are proposing more effective methods for disease prevention and control. Welcome to the Clinician's Roundtable, I am Dr. Kathleen Margolin and joining me from Baltimore, Maryland, is attorney James Hodge and joining us from Seattle, Washington is Dr. Matthew Golden. Mr. Hodge is with the Center for Law and Public's Health. Johns Hopkins Bloomberg School of Public Health and Dr. Golden is an associate professor of medicine at the University of Washington, School of Medicine. He is also Director of the STD Control Program for public health in Seattle in King County's in Washington.

DR. MARGOLIN:

Welcome, James Hodge and Dr. Golden.

MR. HODGE AND DR. GOLDEN:

Thank you. Thanks a lot.

DR. MARGOLIN:

Before, we discuss partner and treatment issues, Dr. Golden, could you please give us some current figures on the incidence of sexually transmitted diseases in the US.

DR. GOLDEN:

Well, when you say incidence, I think what you say is we have roughly, I think, it is 3 million cases of chlamydial infection annually and roughly a million cases of gonorrhea reported in the US annually. So, about 6% of women in Family Planning Clinics, in my part of the country, are infected with chlamydial infection, probably a little bit higher nationally and a substantially smaller proportion of women in Family Planning Clinics would be infected with gonorrhea.

DR. MARGOLIN:

What is traditional partner management for sexually transmitted diseases?

DR. GOLDEN:

For the most part, I think what clinicians have done for gonorrhea and chlamydia, is tell the patient they need to get their partners treated and that is about where it ends. For syphilis, quite a bit of more tests have been done.

DR. MARGOLIN:

Can you tell us, what is expedited partner therapy for STDs?

DR. GOLDEN:

Expedite partner's therapy refers to the practice of treating sex partners without requiring that they first seek a complete medical evaluation or see a clinician and in most instances, that means giving patient's medication or a prescription medication to give to their sex partners.

DR. MARGOLIN:

Mr. Hodge, what are the main legal concerns regarding expedited partner therapy?

MR. HODGE:

Well, anytime you are talking about the provision of medical services or pharmaceutical products to some portions of the population, they obviously raised legal issues, thereabout the way in which those specific medicines are delivered. With EPT, what you have here is literally the bypassing of a direct physician contact with a potential patient that being the partner here, to deliver safe and effective antibiotics to their partner, but when you bypass that traditional root of dispensing pharmaceutical medications in the United States, you raise the potential issues of whether that goes beyond existing medical practice and/or may be implicating that liability concerns as well.

DR. MARGOLIN:

In the Centers for Disease Control, they evaluated numerous studies of expedited partner therapy and concluded that is useful. Doctor, can you tell us more about that research and how much more effective is expedited partner therapy compared with traditional management?

MR. HODGE:

So, what was done and again here we are talking about gonorrhea and chlamydia is treatments almost control trials have evaluated the practice of giving people medications to give to their sex partners for the most part. What we saw across the 3 trails was that all 3 observed decreases in reinfection rates for people who are given medications versus those who did not. That said, the decrease in chlamydia is relatively small. So, you are talking about decline from about 13% or so to about 10% in that neighborhood. For gonorrhea, the declines are pretty big, so about 10% to about 3% in terms of reinfection rates. In terms of getting more partners treated, the impact tends to be quite a bit bigger. So, probably in the 20-30% more partners getting treated.

DR. MARGOLIN:

Mr. Hodge, as you mentioned, physicians generally do not prescribe medicines to individuals without first examining them, but there are exceptions to that where medications are given to the patient through someone else and they are not legal complications. Tell us about some of these situations.

MR. HODGE:

Sure, that is a great question because it is really kind of highlights what we were trying to do in regards to assess the legal environment for conducting the EPT nationally, but one of the things we had first noted is, you know, despite that sort of the general recognition, the doctors are not well positioned to dispense medications outside a direction physician-patient relationship or clinical examination. The types of examples that are prevailing out there in regards to how that happens nationally are really quite well known. When you are dealing with patients, for example, of limited debilities, persons with mental disabilities, persons with physical disabilities, persons who are senior in status or age, it may very well be the case that the doctors are well positioned to provide those medications to their caretakers without directly having seen those patient those patients and that’s sometime that is quite common in regards to how we may feel to expedite the provision of care there. There are all sorts of ways in which specific types of medications are dispensed regularly without advanced clinical examination. The flu vaccine is just a common example of that. Yes, it does impose some risk for some person, but yet we have routinely dispensed it to the millions of persons without some sort of advanced clinical determination and even some prescription medications can be purchased by the partners of persons who would mostly need the drugs without those partners having any prove in regards to delivery of those medications to the actual patient and by herself. These types of examples have underlined a very common theme and that is to protect the public's health. We do not want to insert various different legal mechanisms that would actually hamper or in somehow limit the ability of those patients who needs the medication most, actually getting access to them. This is especially true or safe and effective medication like the types of antibiotics that may be used in treating chlamydia or gonorrhea, as Dr. Golden notes them.

DR. MARGOLIN:

Mr. Hodge, as you have just mentioned, there are many presidents of physicians being able to prescribe without direct contact with the patients under certain circumstances and with regards to doing this for STDs, you have pointed out that the prescriptions are safe. What is it about expedited partner therapy that has some physicians concerns regarding liability?

MR. HODGE:

That’s a great question because if these medications and antibiotics that we traditionally used to treat these conditions, are so safe, why will we, you know, in anyway should be concerned about dispensing to the person that we haven’t seen. Well, doctors particularly know in regards to, you know, what will be anticipated standards for practice are in their specific jurisdiction, that no matter how safe a prescription medication may be, there really are standardized rules to what they may be prescribed. An EPT does not follow that standardized rule. It literally says you can double dose the antibiotic for your patient and have that patient delivered to their partner, you know, the equivalent dose, so that they can jointly treat the STD in this particular case. That feels wrong, that seems wrongs and it's certainly not something that we would utilize in other specific types of medications. It might raise heightened risks. There are a couple of other issues with it as well. Notably are there in some states, very specific mandates against this specific practice, something we have study very systematically as it belongs to the public health, but other medical practitioners along the way may also had impediments to implementing EPT; for example, pharmacist. They may be under very strict constraints to not issue or to provide drugs to person, who do not have an identified prescription for that drug. So, it may be very hard for the partner to go in and receive a prescription or have the prescription filled by a pharmacist, who is aware and knows that that partner has not actually undergone clinical evaluation to verify that they are legitimate user of that particular drug. These types of impediments coupled with the sheer nature of doctors concerns about potentially liability of the partner somehow having an adverse reaction to the antibiotics or other types of conditions related to that, is what sometimes drives a concern about whether EPT is legal or illegal in this specific jurisdiction.

DR. MARGOLIN:

Can you clarify a bit more about the involvement of pharmacist? If the patient presents to a pharmacist with a prescription and its signed by the physician, where is the dilemma for the pharmacist?

MR. HODGE:

Like you know, EPT is practiced differently in various jurisdiction and Dr. Golden, he is well positioned, I can assure you, to tell us how its done at Washington State and other jurisdictions as well, but you know none other ways, it may be done is to hold. It may be that the patient who has actually seen the doctor, receives a single prescription and just as you need 2 times the dosage of the antibiotic because we have instructed you to provide the second dose to your partner. You know, but he might also say we are going to give you 2 prescriptions, 1 for you and 1 for your partner and then the partner has to literally be named in that specific second prescription, the partner has to come in often and actually fill the prescription. Its one step removed from what we would probably desire to expedite the receipt of the drugs here, but in the same case, it may be required by state law. When you have that circumstance then fill for it. The pharmacist may get a sense that one party along this exchange has not been adequately evaluated. When a pharmacist these are double dosage of this specific antibiotic, I may not be there to question whether the doctor was right or wrong to issue it, but they are there to try to protect the patient's interest, so they may raise various concerns as well. This might particularly be true in some smaller locales, not necessarily large urban there is, but smaller locales where pharmacist and patient can have a more direct work knowledge of each other and their health status. Its an impediment to disagree to which it prohibits or limits the ability of the pharmacist to accurately fill that prescription.

DR. MARGOLIN:

I see, Dr. Golden, in your research, you looked at traditional partner management and Metropolitan Health Department and found some interesting numbers when it came to notifying partners of those with STD.

DR. GOLDEN:

Well, I mean, I think there are couple of issues that you are alluding to. One is that health department mostly don’t provide per our services for people with gonorrhea and chlamydia and I think that’s an important thing for the physicians and other providers to realize that overall fewer than 20% people with gonorrhea and chlamydia are ever going to have contacts with the health department about their partners. So, basically the health department in the US are leaving this up to the doctors and the doctors have been leaving it up to the patients. When we looked at this in a study where we contacted 150 providers in Seattle, who had recently diagnosed a case of chlamydia infection. Only 17% of the providers had any idea of whether or not their patient's partner had been treated. So, really, I think what ended up happening was the health department left up to the providers and the providers have left it up to the patients and then there is no followup. So, its in that context, that I think one has to consider expedited partner therapy, that we don’t really have a system beyond simply telling the people you need to get your partner treated to assure that happens.

DR. MARGOLIN:

If you could put into place the expedited partner therapy, what would you anticipate would be some of the clinical factors or barriers?

DR. GOLDEN:

We have put it into place, so where I live in Seattle, we are actually doing this state wise in the state of Washington. The health department is providing the medications for the partner for free for the entire state. We provided those medications prepackaged with information from the sex partner and some condoms to meet the state pharmacy board requirements and to meet the various requirements related to the law. So, where I live and James who is alluding to this, it is not legal to simple write for 2 doses with the index patient for the person you originally diagnosed. Every person who is supposed to receive antimicrobial needs a prescription written for them. It is permissible for somebody to pick up medications for their sex partner as long as the medications are provided with information including a drug allergy warning and so we have sort of arranged for all that information to be prepackaged.

DR. MARGOLIN:

I would like to thank my guest, Dr. Mathew Golden and James Hodge.

MR. HODGE AND DR. GOLDEN:

Thank you. Thanks.

DR. MARGOLIN:

I am Dr. Kathleen Margolin. You have been listening to a special segment, Focus On Health Care Policy on ReachMD XM 157, The Channel for Medical Professionals. Be sure to visit our web site at reachmd.com featuring on-demand cog test of our entire library. For comments and questions, please call us toll free at 888-MD XM 157 and thank you for listening.

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