Transcript EPT - STD Prevention Online

Expedited Partner
Therapy: Background
& Current Status
Matthew Hogben PhD
Centers for Disease Control and Prevention
(404) 639-1833
[email protected]
February 9, 2010
The findings and conclusions in this presentation are those of the authors and do not
necessarily represent the views of the Centers for Disease Control and Prevention
Overview
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Context and Background
Expedited partner therapy (EPT) definition and principles
Historical use of EPT
Evidence of EPT efficacy and effectiveness
 RCT results: index patient reinfection and behavior
 Composite estimates
Implementation of EPT as a strategic option
 Core requirements and coverage issues
 Barriers
 Implementation progress
Next steps
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Partner Referral Approaches
No Public Health
Involvement Required
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Nothing
Public Health Involvement
Required
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Provider referral
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Self referral or patient
referral
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Patient is intended to notify
partners of exposure (with
varying levels of provider
encouragement)
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A public health professional
elicits partners’ identifying
information and contacts and
notifies partners
Contract or conditional
referral
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Patient gets initial chance to
contact and notify partners, but
professional will do so if
patients do not (within a
specified time frame)
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Historical PN
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“Contact tracing”
 Even in the absence of therapy, useful for interrupting
transmission (1930s)
 In conjunction with therapy, rapid drop in syphilis (1940s and
1950s)
 Conducted largely by trained public health staff
Seems to work for
syphilis between
1945 - 1965
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Piling on the work…
Wigfield. Brit J Ven Dis 1972.
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Case reports per 100,000 (US)
450
400
350
300
2006
2007
2008
250
200
150
100
50
0
Syphilis
Gonorrhea
Chlamydia
STD Surveillance Report (2009), Tables 3, 13, 25.
http://www.cdc.gov/std/stats08/toc.htm
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www.cdc.gov/nchhstp/partners
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Tailored tactics for different
diseases
All
New HIV (contract)
Early Syphilis (provider)
Repeat GC (provider)
All
STD clinic-based GC
Follow-up
Interview
FDT
Internet
Notification
Other GC, All CT (EPT)
Re-interview
subset
Using all those evaluation $$
One of multiple possible program
approaches to PN
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Definition and
Principles
Questions so far?
Expedited Partner Therapy
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Core elements
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A STD that is treatable via oral medication
A point of origin in which medications or prescriptions can
be disbursed
A mechanism through which either can be brought to sex
partners of infected people
CDC. Expedited partner therapy. 2006
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EPT Referral Strategies
Basic Strategy
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(1) Patient referral or self
referral
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(1) PDPT
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Patient is intended to notify
partners of exposure (with
varying levels of provider
encouragement)
(2) Provider referral
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EPT “addition”
Provider (meaning public
health staff as default) is
intended to notify partners of
exposure
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Patient carries prescription or
medication for partner along
with instructions
(2) Field-delivered
therapy
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Provider notifies and delivers
prescription or medication
(plus instructions, etc.)
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Historical use: 1999 to present
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Several local surveys and one national
survey
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Across estimates: widespread, not common
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At least half of respondents (physicians, nurse
practitioners) had used PDPT at least once
Approximately 11 – 15% used PDPT “frequently”
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Usually or always (National survey)
74 – 100% of patients (Seattle, WA)
Larger proportions in CA (>40% routinely) and NYC
(25%+)
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NEJM 1977
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Efficacy and
Effectiveness
Questions so far?
Establishing Efficacy: Key
Outcomes
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Effect on clinically relevant outcomes establishes
EPT efficacy
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Index patient reinfection rates
Treatment rates
 Notification rates
Patient and partner behaviors
 Collateral benefits or harms
These are the same outcomes by which one would
judge any PN intervention or program
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Reinfection rates
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
Trelle et al. BMJ 2007.
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Treatment rates
Trelle et al. BMJ 2007
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GC and CT outcomes (Seattle)
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Gonorrhea
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6 of 179 (EPT)
19 of 179 (Control)
RR = 0.32 (0.13 – 0.77)
Chlamydial infection
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86 of 797 (EPT)
105 of 798 (Control)
RR = 0.82 (0.62 – 1.07)
Note the similarity to the 6-city RCT:
These are probably minimum effect sizes
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Patient and Partner Behaviors
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CDC Guidance
From the 2006 Review and Guidance
http://www.cdc.gov/std/ept/default.htm
See also:
2006 STD Treatment Guidelines
http://www.cdc.gov/std/treatment/
2008 Recommendations for Integrated
Partner Services
http://www.cdc.gov/nchhstp/partners/
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Guidance for Use of EPT
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Heterosexual males and females
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Gonorrhea and chlamydial infection
Accompany with written instructions
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Men who have sex with men
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How to take meds, allergies, seek evaluation
More caution (fewer data, more HIV comorbidity)
Trichomoniasis, syphilis
Much more caution, “last resort”
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Implementation
Questions so far?
Prevention Impact framework
Efficacy or
effectiveness
(in targeted
groups)
Contribution of groups
to population health
outcome
X
=
X
Effective level of
coverage
PREVENTION
IMPACT
Abridged/adapted from: Aral et al. Behavioral Interventions
2007; St. Louis & Holmes Sexually Transmitted Diseases
(3rd ed.). 1999
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Achieving impact with EPT
EFFICACY
Tx rate:
20% To
100%
increase
Reinfection:
20% to 50%
decrease
CONTRIBUTION
X
Partners have 20% to
75% positivity
(program data)
X
COVERAGE
Key Issue
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Patients and Physicians
Discuss PDPT
Probable maximum effect,
balanced by reduced coverage
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Core elements
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A STD that is treatable via oral medication
 GC and CT in this case
A point of origin in which medications or prescriptions can
be disbursed
A mechanism through which either can be brought to sex
partners of infected people
Barriers to coverage: What gets
in the way?
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Those Barriers to Coverage
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Not sure how to get started logistically
Discomfort with no health provider face to
face contact with partner
Legal landscape in jurisdiction
Costs
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Protocols and other resources
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Some PH contact: Field-delivered therapy
Steiner AJPH 2003
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Legal landscape
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Basic legal inhibitions center around
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Prescribing rules, dispensing rules, established
patient relationship
Review of legality
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Yields a spreadsheet with facilitators and barriers in
laws, regulations, policy statements, AG statements,
judicial rulings
Published as a website – “The information presented
here is not legal advice, nor is it a comprehensive
analysis of all the legal provisions that could implicate
the legality of EPT in a given jurisdiction.”
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“Legal” implementation advice
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Explicit endorsement through laws
Create exceptions to existing prescription
requirements
Increase professional board and association
support
Facilitate 3rd party payment
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Has coverage increased?
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2006
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10 states had express legislation/permission (3) or other
legal conditions not prohibiting the practice (7)
13 had clear legal conditions prohibiting the practice (not
aimed at EPT specifically)
The remainder had no clear position one way or another
2010
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The corresponding numbers are 23 (+ Baltimore), 8, and
19 (- Baltimore)
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Evolving Landscape of EPT:
Legal Status Summary
WA
VT
MT
ND
ME
MN
OR
ID
WI
SD
IL
UT
RI
WV
KS
AZ
VA
CT
KY
NC
TN
OK
NM
AK
MO
A
R
MS
AL
EPT is Permissible
NJ
SC
DE
GA
EPT is Likely Prohibited
MD
LA
TX
2006
MA
OH
IN
CO
CA
NH
PA
IA
NB
NV
NY
MI
WY
DC
FL
EPT is Potentially Allowable
HI
Legislation Pending
WA
VT
MT
ND
ME
MN
OR
ID
WI
SD
PA
IA
NB
NV
IL
UT
NY
MI
WY
RI
WV
KS
AZ
OK
NM
AK
MO
VA
KY
NC
TN
A
R
SC
MS
TX
AL
GA
LA
FL
HI
2010
MA
OH
IN
CO
CA
NH
CT
NJ
DE
MD
DC
(Baltimore
only)
Baltimore implementation
Implementation (as of Jan 2009)
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STD clinics
Medications dispensed
GC/CT, 3 extra dose maximum
Evaluation
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Uptake = 1046/1533 (68%)
Modal extra doses: women = 1; men = 2
Active assessment of adverse events in STD clinics +
passive reporting from other providers
 No adverse events (again)
Repeat infection rate = 2.3% in 2008 (compared to 3.9% in
2007 w/o EPT, p = .10)
 41% reduction, has been further followed up
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Next Steps
Questions so far?
Current and near future
(selected)
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Toolkit: Needs assessment to inform content
for states interested in legal provisions and
subsequent policies
Incorporation into Best Practices
Engagement with other federal agencies
(CMS)
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National CT Coalition support
Effectiveness rating
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Possible USPSTF review
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The bigger picture: Shifting
furniture
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It looks heavy
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Let’s send Mr. Screening
to move it
Bother. Let’s give Mr.
PN a go
Fine. Mr. Behavioral
Interventions?
Um, Mr. EPT?
Oh well.
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All together now…
Intervention Mix
Along Continuum
of Services
Efficacy
Screening/Testing
Patient Treatment
Partner Notification &
Treatment
Counseling and other
Interventions
Follow-up Care
Contribution
X
STD clinic
Other public sector
Private sector
Coverage
X
Something for
everyone
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Contact information
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Matthew Hogben
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(404) 639-1833
[email protected]
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