A qualitative study of patients' use of expedited partner therapy

Expedited Partner Therapy: A Multicomponent Initiative to Boost Provider Counseling

BACKGROUND

Expedited partner therapy prescription remains low and highly variable throughout the United States, leading to frequent reinfections with Chlamydia trachomatis and Neisseria gonorrhoeae . We examined provider counseling on expedited partner therapy before and after an electronic smart tool-based initiative.

METHODS

In this quasi-experimental interrupted time-series study, we implemented an initiative of electronic smart tools and education for expedited partner therapy in March 2020. We reviewed the records of patients with chlamydia and/or gonorrhea at an urban, academic obstetrics and gynecology clinic in the preimplementation (March 2019-February 2020) and postimplementation (March 2020-February 2021) groups. Descriptive statistics and an interrupted time-series model were used to compare the percent of expedited partner therapy offered by clinicians to patients in each group.

RESULTS

A total of 287 patient encounters were analyzed, 155 preintervention and 132 postintervention. An increase in expedited partner therapy counseling of 13% (95% confidence interval [CI], 2%-24%) was observed before the intervention (27.1% [42 of 155]) versus after the intervention (40.2% [53 of 132]). Significant increases in provider counseling were seen for patients who were single (15%; 95% CI, 3%-26%), 25 years or older (21%; 95% CI, 6%-37%), receiving public insurance (15%; 95% CI, 3%-27%), seen by a registered nurse (18%; 95% CI, 4%-32%), or seen for an obstetrics indication (21%; 95% CI, 4%-39%). No difference was seen in patients' acceptance of expedited partner therapy ( P = 1.00).

CONCLUSIONS

A multicomponent initiative focused on electronic smart tools is effective at increasing provider counseling on expedited partner therapy. Further research to understand patient perceptions and acceptance of expedited partner therapy is critical.

Facilitators and Barriers to Patient-Delivered Partner Therapy Acceptance for Chlamydia trachomatis Among Young African American Men Who Have Sex With Women in a Southern Urban Epicenter

BACKGROUND

Chlamydia trachomatis (Ct) disproportionately affects African American young people living in the Southern United States and can have negative consequences if left untreated. Patient-delivered partner therapy (PDPT) is an evidence-based practice in which individuals diagnosed with Ct can provide treatment directly to their sex partners. However, PDPT acceptance rates need improvement. Although reasons for PDPT acceptance have been explored previously, the facilitators and barriers to expedited partner therapy acceptance among young southern African American men who have sex with women have not yet been examined.

METHODS

Twenty semistructured interviews were conducted as part of a community-based Ct screening and treatment intervention among African American men aged 15 to 25 years who had female sex partners. Participants were asked about why they did or did not accept PDPT for their sex partners. Data were transcribed and analyzed in NVivo qualitative software using an inductive thematic approach.

RESULTS

Participants' decision making was multifaceted. Facilitators for PDPT acceptance included being able to cure their partner, convenient access to treatment, believing it was the right thing to do, having a close relationship with a partner, concern for the partner's well-being, and the perceived severity of Ct. Barriers to PDPT acceptance were the belief that a partner did not need treatment, not having a close relationship with the partner, being unable to contact the partner, and fear of conflict.

CONCLUSIONS

Findings had similarities to other studies, indicating some universal messaging may be warranted alongside culturally tailored interventions for specific patient populations to increase PDPT acceptance. Implications for patient-provider communication are provided.

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

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.

Follow the Sex: Influence of Network Structure on the Effectiveness and Cost-Effectiveness of Partner Management Strategies for Sexually Transmitted Infection Control

BACKGROUND

It is well established that network structure strongly influences infectious disease dynamics. However, little is known about how the network structure impacts the cost-effectiveness of disease control strategies. We evaluated partner management strategies to address bacterial sexually transmitted infections (STIs) as a case study to explore the influence of the network structure on the optimal disease management strategy.

METHODS

We simulated a hypothetical bacterial STI spread through 4 representative network structures: random, community-structured, scale-free, and empirical. We simulated disease outcomes (prevalence, incidence, total infected person-months) and cost-effectiveness of 4 partner management strategies in each network structure: routine STI screening alone (no partner management), partner notification, expedited partner therapy, and contact tracing. We determined the optimal partner management strategy following a cost-effectiveness framework and varied key compliance parameters of partner management in sensitivity analysis.

RESULTS

For the same average number of contacts and disease parameters in our setting, community-structured networks had the lowest incidence, prevalence, and total infected person-months, whereas scale-free networks had the highest without partner management. The highly connected individuals were more likely to be reinfected in scale-free networks than in the other network structures. The cost-effective partner management strategy depended on the network structures, the compliance in partner management, the willingness-to-pay threshold, and the rate of external force of infection.

CONCLUSIONS

Our findings suggest that contact network structure matters in determining the optimal disease control strategy in infectious diseases. Information on a population's contact network structure may be valuable for informing optimal investment of limited resources.

Guidance on Expedited Partner Therapy: A Content Analysis of Informational Materials for Providers, Pharmacists, Patients, and Partners

BACKGROUND

The rates of sexually transmitted infections have steadily increased in the United States over the last 5 years. The Centers for Disease Control and Prevention has endorsed the use of expedited partner therapy (EPT) as an evidence-based practice to prevent chlamydial reinfection in index patients and lower barriers to treatment for partners. State health departments release guidance on EPT for providers, but it is unclear if information is available for other key stakeholders, for example, pharmacists, patients, and partners. The primary objective of this study was to conduct a review of state and territory health department websites to ascertain the availability, readability, utility, and content of EPT informational materials.

METHODS

A content analysis of 84 EPT informational materials was conducted using validated tools to measure readability, adherence to design standards, and EPT content inclusion. Results were stratified for each target audience.

RESULTS

Only 64% of states where EPT is allowable had informational materials available. The materials targeted providers (51.2%) and partners (35.7%). Little information targeted pharmacists (7.1%) or index patients (4.8%). The average reading level was 11th grade. Mean design score was 9.57 points of a possible 13 points. Most provider and pharmacist materials did not meet the content criteria; index and partner materials did not thoroughly describe cost of EPT, how to communicate with sex partners about EPT/chlamydia, or how to fill an EPT prescription.

CONCLUSIONS

To better support the uptake of EPT, existing resources for EPT should be improved in their design, readability, content, and availability for all target audiences.

ADOPTing a new method of partner management for genital chlamydia in New South Wales: findings from a pilot implementation program of patient-delivered partner therapy

Background Patient-delivered partner therapy (PDPT) for chlamydia is an effective and safe additional partner management strategy. Some Australian regulatory changes have been made to support PDPT, but implementation guidance is lacking. This paper describes a pilot implementation program of PDPT in New South Wales (NSW), the Australian Development and Operationalisation of Partner Therapy (ADOPT).

METHODS

ADOPT involved: (1) clarification of the NSW PDPT legal and policy framework; (2) development and implementation of PDPT service models, resources and data collection tools for select publicly funded sexual health services (PFSHS) and Family Planning (FP) NSW clinics; and (3) evaluation of PDPT uptake.

RESULTS

PDPT can be undertaken in NSW if accompanied by adequate provider, patient and partner information. Regulatory amendments enabled medication prescribing. The pilot implementation took place in four PFSHS and five FPNSW clinics from January to December 2016. In PFSHS, 30% of eligible patients were offered PDPT and 89% accepted the offer. In FPNSW clinics, 42% of eligible patients were offered PDPT and 63% accepted the offer. Most partners for whom PDPT was accepted were regular partners.

CONCLUSIONS

A close collaboration of researchers, policy makers and clinicians allowed successful implementation of a PDPT model for chlamydia in heterosexual patients at select PFSHS and FPNSW clinics, providing guidance on its use as standard of care. However, for the full public health benefits of PDPT to be realised, it must be implemented in general practice, where most chlamydia is diagnosed. Further work is recommended to explore feasibility, develop guidelines and promote the integration of PDPT into general practice.

Testing the Interpersonal-Behavior model to explain intentions to use patient-delivered partner therapy

Background

Patient-delivered partner therapy (PDPT) is an evidence-based method of partner treatment, but further research was needed to understand theoretical underpinnings of potential PDPT use.

Purpose

We sought to develop and test a theoretical framework to understand PDPT intentions.

Methods

A Midwestern sample of sexually transmitted infection clinic patients were recruited to participate in a three-phase study incorporating semi-structured interviews (n = 20, total), cognitive interviews (n = 5), and surveys (n = 197; M_age = 31.3, 61% male, 91% Black or African-American). Thematic analysis was conducted to identify major themes, which guided development and testing of a theoretical framework on PDPT intentions using structural equation modeling.

Results

We identified themes of information (knowledge); motivation (individual and partner protection beliefs, partner and provider motivation-to-comply); social support (sexual health and general); and behavioral skills (partner notification, medication delivery, and communication skills self-efficacy) in thematic analysis. The developed Interpersonal-Behavior model demonstrated good model fit in structural equation modeling [χ2(36) = 95.56, p<0.01; RMSEA = 0.09 (0.07–0.11, 90%C.I.); CFI = 0.94; SRMR = 0.05]. Information was associated with motivation (β = 0.37, p<0.001) and social support (β = 0.23, p = 0.002). Motivation was associated with social support (β = 0.64, p<0.001) and behavioral skills (β = 0.40, p<0.001), and social support was associated with behavioral skills (β = 0.23, p = 0.025). Behavioral skills were associated with higher PDPT intentions (β = 0.31, p<0.001), partially mediated the association of motivation with intentions (β_direct = 0.53, p<0.001; β_indirect = 0.12, 95%CI: 0.03–0.30), and fully mediated the association of social support with intentions (β_indirect = 0.07, 95%CI: 0.00–0.21).

Conclusions

The Interpersonal-Behavior model seems appropriate for PDPT intentions but should be tested longitudinally with PDPT outcomes and other interpersonal health behaviors.

Patient initiated partner treatment for Chlamydia trachomatis infection in the Netherlands: views of patients with and partners notified for Chlamydia

Patient-initiated partner therapy (PIPT) for Chlamydia is not practiced in the Netherlands. We aimed to explore PIPT-willingness in patients infected with Chlamydia and persons notified for Chlamydia (partners) at sexual health clinics (SHCs) and general practitioners’ offices. We performed interviews among 20 heterosexual patients and 21 partners regarding real or hypothetical situations. The interviews were taped, transcribed verbatim and coded using ATLAS.ti7 software for qualitative research. Despite challenges in notifying partners in some cultural groups and some partner types, most patients and partners would cooperate with PIPT. Perceived barriers included unnecessary treatment, risking untreated other sexually transmitted infections and breaking the notification chain. Most patients and partners opted for home-based test-kits before treatment. Partners desired proper packaging of the test and the medication, along with an information insert, a supportive letter from the SHC, information on the internet and the possibility to contact a professional. Although PIPT may support partner notification (PN), many patients and partners prefer a diagnosis before treatment. PIPT with medication or a prescription combined with a home-based test-kit may be the way forward. However, PN seems to be influenced by type of partner and cultural background, requiring differentiated PN and partner therapy methods.

A pill for the partner via the chlamydia patient? Results from a mixed method study among sexual health care providers in the Netherlands

Background

Chlamydia prevalence in the Netherlands remains high despite targeted efforts. Effective Partner Notification (PN) and Partner Treatment (PT) can interrupt transmission and prevent re-infections. Patient Initiated Partner Treatment (PIPT) may strengthen chlamydia control. This study explores the current practice of PN and PT, and benefits of, and barriers and facilitators for PIPT among professionals in sexual health care in the Netherlands.

Methods

A qualitative study was performed among GPs, GP-assistants (GPAs), physicians and nurses working at Sexual Health Clinics (SHC) and key-informants on ethnical diversity using topic lists in focus groups (N = 40) and semi-structured questionnaires in individual interviews (N = 9). Topics included current practices regarding PN and PT, attitude regarding PIPT, and perceived barriers and facilitators for PIPT. Interviews were taped, transcribed verbatim, and coded using ATLAS.ti. A quantitative online questionnaire on the same topics was sent to all physicians and nurses employed at Dutch SHC (complete response rate 26% (84/321)).

Results

The qualitative study showed that all professionals support the need for more attention to PN, and that they saw advantages in PIPT. Mentioned barriers included unwilling PN-behaviour, Dutch legislation, several medical considerations and inadequate skills of GPs. Also, concerns about limited knowledge of cultural sensitivity around PN and PT were raised. Mentioned facilitators of PIPT were reliable home based test-kits, phone-contact between professionals and notified partners, more consultation time for GPs or GPAs and additional training. The online questionnaire showed that SHC employees agreed that partners should be treated as soon as possible, but also that they were reluctant towards PIPT without counselling and testing.

Conclusions

Professionals saw advantages in PIPT, but they also identified barriers hampering the potential introduction of PIPT. Improving PN and counselling skills with specific focus on cultural sensitivity is needed. PIPT could be considered for specific partners. PIPT in combination with home based testing and using e-healthcare should be further explored and developed.

Assessing Different Partner Notification Methods for Assuring Partner Treatment for Gonorrhea: Looking for the Best Mix of Options

CONTEXT

Partner notification for gonorrhea is intended to interrupt transmission and to bring people exposed to infection to care. Partner notification may be initiated through public health professionals (disease intervention specialist: DIS referral) or patients (patient referral). In some cases, patients may carry medications or prescriptions for partners (patient-delivered partner therapy: PDPT).

OBJECTIVE

To examine how patterns of notifying and treating partners of persons with gonorrhea differ by partner notification approach.

DESIGN

From published literature (2005-2012), we extracted 10 estimates of patient referral data from 7 studies (3853 patients, 7490 partners) and 5 estimates of PDPT data from 5 studies (1781 patients, 3125 partners). For DIS referral estimates, we obtained 2010-2012 data from 14 program settings (4581 patients interviewed, 8301 partners). For each approach, we calculated treatment cascades based on the proportion of partners who were notified and treated. We also calculated cascades based on partners notified and treated per patient diagnosed.

RESULTS

Proportions of partners notified and treated were, for patient referral, 56% and 34%; for PDPT, 57% and 46%; for DIS referral, 25% and 22%. Notification and treatment estimates for patient referral and PDPT were significantly higher than for DIS referral, but DIS referral was more efficacious than the other methods in assuring treatment among those notified (all Ps < .001). The notification and treatment ratios per patient seen were, for patient referral, 0.96 and 0.61; for PDPT, 0.90 and 0.73; for DIS referral, 0.45 and 0.40.

CONCLUSION

Patient-based methods had higher proportions of partners treated overall, but provider referral had the highest proportion treated among those notified. These data may assist programs to align the most efficacious strategies with the most epidemiologically or clinically important cases while assuring the best scalable standard of care for others.

Barriers and Facilitators of Partner Treatment of Chlamydia: A Qualitative Investigation with Prescribers and Community Pharmacists

Chlamydia trachomatis is the most frequently-notified sexually transmitted infection in Australia. Effective and timely partner treatment of chlamydia is essential to reduce overall prevalence and the burden of infection. Currently in most of Australia, the only avenue for partner treatment of chlamydia (“standard partner therapy”) is a tedious, and often inconvenient, process. The barriers and facilitators of standard partner therapy, and newer models of accelerated partner therapy (APT), need to be identified in the Australian setting. Additionally, the potential role of community pharmacists need to be explored. Semi-structured interview guides for two key stakeholder groups (prescribers and pharmacists) were developed and piloted. Eleven prescribers (general practitioners, sexual health clinicians and nurse practitioners) and twelve pharmacists practicing in the Perth metropolitan region were interviewed. Key reported barriers to standard partner therapy were lack of or delayed chlamydia testing. Key facilitators included ability to test and educate sexual partner. Key barriers for APT included prescribers’ legal responsibility and potential for medication-related adverse effects. Healthcare provider consultation and chlamydia testing were seen as potential facilitators of APT. Pharmacists were receptive to the idea of expanding their role in chlamydia treatment, however, barriers to privacy must be overcome in order to be acceptable to prescribers and pharmacists.

Perceived Risk of Intimate Partner Violence Among STI Clinic Patients: Implications for Partner Notification and Patient-Delivered Partner Therapy

Patient-delivered partner therapy (PDPT) is the practice of providing patients diagnosed with a bacterial sexually transmitted infection (STI) medication to give directly to their partner for treatment without requiring the partner to participate in diagnostic testing and counseling. Despite a growing body of evidence in support of PDPT, literature is limited to date on the influence of perceived risk of intimate partner violence (IPV) on PDPT use. We analyzed mixed-method data from 196 quantitative surveys (61% male, M age = 31.2, 92% Black or African-American) and 25 qualitative interviews to better understand the barriers and facilitators associated with PDPT delivery for patients attending a Midwestern, publicly funded STI clinic in the U.S. Nearly a third of surveyed patients (29; 34% of women, 26% of men) expressed worry about IPV when delivering PDPT. Patients had concerns about infidelity worry, embarrassment, and anxiety (referred to as IWEA hereafter) associated with partner notification and PDPT delivery. We found IWEA was highly correlated with IPV concerns in a fully adjusted logistic regression model. Women had 2.43 (95% CI = 1.09-5.42) times greater odds of worrying about IPV than men; other significant factors associated with IPV worry included higher condom use, no prior STI diagnosis, and being uninsured (as compared to having Medicare/Medicaid insurance). Encouraging communication between healthcare providers and their patients about the potential for IPV could facilitate patient triaging that results in the consideration of alternative partner referral mechanisms for patients or partners at risk of harm and better outcomes for patients and their partners.

Expedited Partner Therapy: A Review for the Pediatric Nurse Practitioner

The rate of sexually transmitted infections in the United States increased in 2015 for the second year in a row. Adolescents bear an undue portion of this burden because of increased physiologic susceptibility, higher rates of reinfection, and developmental age. Despite expedited partner therapy (EPT) being legalized in 39 states, health care providers still report infrequently providing EPT to their adolescent patients. Patients who benefit most from EPT include those with high-risk sexual behavior, a steady relationship status, higher education level, or an established relationship with the provider. This article will review the barriers to providing EPT and factors associated with patient acceptance or refusal, highlight current legal issues, and discuss the role of the pediatric nurse practitioner addressing specific strategies for implementation in practice. EPT is a valuable tool for the pediatric nurse practitioner to promote treatment and prevent reinfection with sexually transmitted infections.

A Review of Expedited Partner Therapy for the Management of Sexually Transmitted Infections in Adolescents

Adolescents are at high risk of acquiring and becoming reinfected with sexually transmitted infections. Partner notification and treatment are essential to preventing the spread of sexually transmitted infections. Expedited partner therapy (EPT) is a method of partner treatment used by medical providers to treat patients' sexual partners without direct medical evaluation or counseling. The objective of this article is to review the current literature regarding EPT effectiveness, patients' attitudes and acceptance of EPT, and providers' views and practices surrounding the use of this method of partner treatment. In this article potential concerns associated with EPT use, current policy statements, and the legal status of EPT are discussed. EPT results in improved or equivalent rates of reinfection in adolescents and adults with Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis. Overall, patients are accepting of this method of partner treatment, however, providers continue to have concerns that limit its routine use. Additional studies in adolescents will help providers better understand if EPT is a useful method to prevent reinfection in this population.

The Expedited Partner Therapy Continuum: A Conceptual Framework to Guide Programmatic Efforts to Increase Partner Treatment

BACKGROUND

Expedited partner therapy (EPT) is a partner treatment strategy wherein health care providers give patients antibiotics or a prescription to deliver to their sex partners as treatment, without an intervening medical evaluation.

METHODS

We used PubMed and the Cochrane database to systematically identify published articles about EPT after 2006 and randomized controlled trials before that date; we also sought conference abstracts and unpublished data from 2013 to 2014. We described key steps in a hypothetical "EPT continuum," beginning with diagnosis of Chlamydia trachomatis or Neisseria gonorrhoeae in a patient and ending with treatment for the patient's sex partner(s) with EPT. All reports were abstracted for a set of defined measures and related interventions.

RESULTS

We reviewed 100 published articles, unpublished data reports, and conference abstracts; 42 met the inclusion criteria and provided measures of the following: provider uptake and offer of EPT, patient acceptance and receipt of EPT, patient delivery of EPT to sex partners, and partner receipt of EPT and treatment. Implementation phase, populations, settings, and methodologies varied across reports. Providers' uptake and offer of EPT are rate-limiting steps in the EPT continuum and were the focus of all 5 programmatic interventions we identified. There were 7 population-based measures of patient receipt of EPT; however, several of the patient populations overlapped.

CONCLUSIONS

A heterogenous body of literature describes EPT, and variation in study population, setting, and metrics limit generalizability. Programs seeking to increase partner treatment should focus their efforts on provider uptake and offer and should use population-based measures to monitor EPT use.

Understanding patient choices for attending sexually transmitted infection testing services: a qualitative study

Objectives

To establish which aspects of sexually transmitted infection (STI) testing services are important to STI testing service users.

Methods

10 focus groups consisting of previous or existing users of STI testing services were conducted in community settings in the south east of England. Groups were quota sampled based on age, gender and sexual orientation. Data were analysed using Framework Analysis.

Results

65 respondents (58% men) participated. Perceived expertise of staff was the key reason for attendance at genitourinary medicine services rather than general practice. Although some respondents voiced a willingness to test for STIs within general practice, the apparent limited range of tests available in general practice and the perceived lack of expertise around sexual health appeared to discourage attendance at general practice. The decision of where to test for STIs was also influenced by past experience of testing, existing relationships with general practice, method of receiving test results and whether the patient had other medical conditions such as HIV.

Conclusions

No one type of STI testing service is suitable for all patients. This is recognised by policymakers, and it now requires commissioners and providers to make services outside of genitourinary medicine clinics more acceptable and attractive to patients, in particular to address the perceived lack of expertise and limited range of STIs tests available at alternative testing sites.