Partner notification of sexually transmitted infections among pregnant women

Approach to Managing Sex Partners of People with Sexually Transmitted Infections

Partner management of sexually transmitted infection (STIs) is essential to identify and treat new cases, prevent reinfection in the index case, interrupt chains of transmission, reduce STI-related morbidity, and target STI screening and treatment interventions. The responsibility for partner notification and treatment falls on the health care provider. Approaches to partner management include patient referral, provider referral, contractual referral, and expedited partner therapy (EPT), with EPT and enhanced partner referral outperforming other methods. This article provides an overview of clinical recommendations regarding partner management, with particular emphasis on EPT, and an update on new and emerging evidence in the field.

Patient-Delivered Partner Treatment for Chlamydia, Gonorrhea, and Trichomonas Infection Among Pregnant and Postpartum Women in Kenya

BACKGROUND

Patient-delivered partner treatment (PDPT) for sexually transmitted infections (STIs) increases rates of partner treatment and decreases reinfection, but has not been evaluated during pregnancy.

METHODS

This prospective cohort was nested within a larger study of peripartum HIV acquisition. Participants with microbiologic diagnosis of Chlamydia trachomatis, Neisseria gonorrhoeae, and/or Trichomonas vaginalis were screened for participation. Questionnaires were administered to determine PDPT acceptability and barriers. Women were reassessed at least 30 days to determine partner treatment and reinfection. Women whose partners did or did not receive PDPT were compared.

RESULTS

One hundred twelve (22.2%) women in the parent cohort had a treatable STI; 78 within the PDPT study period, of whom 66 were eligible and 59 (89.3%) accepted PDPT. Fifty-one women had PDPT outcome data, 37 (73%) of whom reported partners treated with PDPT. Fourteen women (27%) refused or did not deliver partner treatment. Median age was 22 years (interquartile range, 20-26 years) and 88% were married. Compared with women who delivered PDPT, those who did not were more likely to have a partner living far away (23% vs. 0%, P = 0.004) and to report current intimate partner violence (14% vs. 0%, P = 0.02). Reported PDPT barriers included fear of partner's anger/abuse (5%) and accusations of being STI source (5%).

CONCLUSION

Patient-delivered partner treatment was acceptable and feasible for pregnant/postpartum Kenyan women and may reduce recurrent STIs in pregnancy.

Strategies for partner notification for sexually transmitted infections, including HIV

BACKGROUND

Partner notification (PN) is the process whereby sexual partners of an index patient are informed of their exposure to a sexually transmitted infection (STI) and the need to obtain treatment. For the person (index patient) with a curable STI, PN aims to eradicate infection and prevent re-infection. For sexual partners, PN aims to identify and treat undiagnosed STIs. At the level of sexual networks and populations, the aim of PN is to interrupt chains of STI transmission. For people with viral STI, PN aims to identify undiagnosed infections, which can facilitate access for their sexual partners to treatment and help prevent transmission.

OBJECTIVES

To assess the effects of different PN strategies in people with STI, including human immunodeficiency virus (HIV) infection.

SEARCH METHODS

We searched electronic databases (the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE) without language restrictions. We scanned reference lists of potential studies and previous reviews and contacted experts in the field. We searched three trial registries. We conducted the most recent search on 31 August 2012.

SELECTION CRITERIA

Published or unpublished randomised controlled trials (RCTs) or quasi-RCTs comparing two or more PN strategies. Four main PN strategies were included: patient referral, expedited partner therapy, provider referral and contract referral. Patient referral means that the patient notifies their sexual partners, either with (enhanced patient referral) or without (simple patient referral) additional verbal or written support. In expedited partner therapy, the patient delivers medication or a prescription for medication to their partner(s) without the need for a medical examination of the partner. In provider referral, health service personnel notify the partners. In contract referral, the index patient is encouraged to notify partner, with the understanding that the partners will be contacted if they do not visit the health service by a certain date.

DATA COLLECTION AND ANALYSIS

We analysed data according to paired partner referral strategies. We organised the comparisons first according to four main PN strategies (1. enhanced patient referral, 2. expedited partner therapy, 3. contract referral, 4. provider referral). We compared each main strategy with simple patient referral and then with each other, if trials were available. For continuous outcome measures, we calculated the mean difference (MD) with 95% confidence intervals (CI). For dichotomous variables, we calculated the risk ratio (RR) with 95% CI. We performed meta-analyses where appropriate. We performed a sensitivity analysis for the primary outcome re-infection rate of the index patient by excluding studies with attrition of greater than 20%. Two review authors independently assessed the risk of bias and extracted data. We contacted study authors for additional information.

MAIN RESULTS

We included 26 trials (17,578 participants, 9015 women and 8563 men). Five trials were conducted in developing countries. Only two trials were conducted among HIV-positive patients. There was potential for selection bias, owing to the methods of allocation used and of performance bias, owing to the lack of blinding in most included studies. Seven trials had attrition of greater than 20%, increasing the risk of bias.The review found moderate-quality evidence that expedited partner therapy is better than simple patient referral for preventing re-infection of index patients when combining trials of STIs that caused urethritis or cervicitis (6 trials; RR 0.71, 95% CI 0.56 to 0.89, I(2) = 39%). When studies with attrition greater than 20% were excluded, the effect of expedited partner therapy was attenuated (2 trials; RR 0.8, 95% CI 0.62 to 1.04, I(2) = 0%). In trials restricted to index patients with chlamydia, the effect was attenuated (2 trials; RR 0.90, 95% CI 0.60 to 1.35, I(2) = 22%). Expedited partner therapy also increased the number of partners treated per index patient (three trials) when compared with simple patient referral in people with chlamydia or gonorrhoea (MD 0.43, 95% CI 0.28 to 0.58) or trichomonas (MD 0.51, 95% CI 0.35 to 0.67), and people with any STI syndrome (MD 0.5, 95% CI 0.34 to 0.67). Expedited partner therapy was not superior to enhanced patient referral in preventing re-infection (3 trials; RR 0.96, 95% CI 0.60 to 1.53, I(2) = 33%, low-quality evidence). Home sampling kits for partners (four trials) did not result in lower rates of re-infection in the index case (measured in one trial), or higher numbers of partners elicited (three trials), notified (two trials) or treated (one trial) when compared with simple patient referral. There was no consistent evidence for the relative effects of provider, contract or other patient referral methods. In one trial among men with non-gonococcal urethritis, more partners were treated with provider referral than with simple patient referral (MD 0.5, 95% CI 0.37 to 0.63). In one study among people with syphilis, contract referral elicited treatment of more partners than provider referral (MD 2.2, 95% CI 1.95 to 2.45), but the number of partners receiving treatment was the same in both groups. Where measured, there was no statistical evidence of differences in the incidence of adverse effects between PN strategies.

AUTHORS' CONCLUSIONS

The evidence assessed in this review does not identify a single optimal strategy for PN for any particular STI. When combining trials of STI causing urethritis or cervicitis, expedited partner therapy was more successful than simple patient referral for preventing re-infection of the index patient but was not superior to enhanced patient referral. Expedited partner therapy interventions should include all components that were part of the trial intervention package. There was insufficient evidence to determine the most effective components of an enhanced patient referral strategy. There are too few trials to allow consistent conclusions about the relative effects of provider, contract or other patient referral methods for different STIs. More high-quality RCTs of PN strategies for HIV and syphilis, using biological outcomes, are needed.