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Ept talk texas 5 10r
Ept talk texas 5 10r
Ept talk texas 5 10r
Ept talk texas 5 10r
Ept talk texas 5 10r
Ept talk texas 5 10r
Ept talk texas 5 10r
Ept talk texas 5 10r
Ept talk texas 5 10r
Ept talk texas 5 10r
Ept talk texas 5 10r
Ept talk texas 5 10r
Ept talk texas 5 10r
Ept talk texas 5 10r
Ept talk texas 5 10r
Ept talk texas 5 10r
Ept talk texas 5 10r
Ept talk texas 5 10r
Ept talk texas 5 10r
Ept talk texas 5 10r
Ept talk texas 5 10r
Ept talk texas 5 10r
Ept talk texas 5 10r
Ept talk texas 5 10r
Ept talk texas 5 10r
Ept talk texas 5 10r
Ept talk texas 5 10r
Ept talk texas 5 10r
Ept talk texas 5 10r
Ept talk texas 5 10r
Ept talk texas 5 10r
Ept talk texas 5 10r
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Ept talk texas 5 10r

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  • 1. Expedited Partner Therapy for Gonorrhea & Chlamydia Matthew R. Golden MD, MPH Center for AIDS & STD, University of WA Public Health – Seattle & King County
  • 2. Overview • Clinical issues and barriers to EPT • Experience with EPT rollout in Washington State
  • 3. Barriers • Is this legal, and what is my liability? • Is this an acceptable standard of medical care? • Will EPT promote antimicrobial resistance? • Is this ethical?
  • 4. Liability • You can always be sued • Are you acting in a manner that is consistent with standards of care in your community? • Can you be sued for not providing EPT?
  • 5. Is EPT a Good Standard of Care? • A complete evaluation of all partners would be best • Are we missing concurrent diagnoses? • Are we placing partners at significant risk of adverse drug reactions?
  • 6. STD diagnoses in persons presenting as contacts to gonorrhea, chlamydia or NGU/MPC Seattle, Baltimore, Birmingham and Denver Women Heterosexual Men Men who Have (n=2507) (n=3511) Sex with Men (n=460) Gonorrhea* 3.9% 3.1% 6.1% PID 3.7% NA NA New HIV 0 0.2% 5.5% Early Syphilis <0.1% 0 0.4% * GC excludes contacts to GC. Source: CID 2005;40:787
  • 7. Adverse Drug Reactions • Anaphylaxis to macrolides is very rare • PCN – Anaphylaxis with cephalosporins is rare (0.1-0.0001%) – ~10% of people report having a PCN allergy – Cross reactivity to 3rd gen cephalosporins 1-3% – Only avertable reactions are those occurring in persons with a known allergy who take meds despite written warnings • No cases anaphylaxis to date in CA and WA
  • 8. Antimicrobial Resistance • No known chlamydial resistance to azithro • Cephalosporin resistant GC – Some evidence rising MICs in Japan – No true resistance in U.S., though some isolates have decreased susceptibility • Standard of care is to treat contacts to GC & chlamydia without awaiting test results – EPT primarily increases antimicrobial use by increasing appropriate treatment of partners • In 2005, 55 million prescriptions for Azithro; 3 million cases of chlamydia in U.S.
  • 9. Ethics Respect for Patient Autonomy Beneficence Nonmaleficence Justice • Insofar as RCTs show decreased reinfection in index cases given EPT, EPT is a superior standard of care • Is EPT better for the partner? Can partners make an informed decision?
  • 10. History of EPT in Washington State Year WA State Pharmacy Board Rules that EPT is 1997 Legal King County EPT Randomized Trial 1998-2003 Washington State & Public Health – Seattle & 2003 King County Recommend Routine Use of EPT in Heterosexuals PHSKC makes free medication available to all 2004 medical providers for EPT Start State-wide Community-level Trial of EPT 2007
  • 11. Washington State Community-level Randomized Trial of EPT • $2.5 million NIH funded study • Goal - to define whether an EPT program can decrease the prevalence of chlamydia and/or the incidence of gonorrhea in the population • No intervention to control STD has been shown to do this • Design – stepped-wedge community-level randomized trial • Order in which LHJs start intervention randomly assigned • Comparison of trends in places with and without the intervention • Outcome • CT prevalence in Infertility Prevention Planning clinics • Reported incidence of gonorrhea
  • 12. EPT System • Case-report based triage of DIS services • Widespread access to prepacked medication for EPT
  • 13. Proportion of Patients with Untreated Partners at Time of Study Interview 100 Percent with untreated partner 80 60 40 20 + Risk Factor No Risk Factor 0 0 2 4 6 8 10 12 14 Days Between Treatment & Interview Source: STD 2001;28:658 Risk factors: > 1 sex partner 60 days or pt does not anticipate sex with partner in future
  • 14. PN CT & GC: where do we go from here?
  • 15. WA State EPT Program: Prescription Pad
  • 16. PDPT Distribution • Medication prepackaged to meet requirements of state pharmacy board – Allergy warning, info on STDs, complications & where to seek care, condoms • Stocked in high-volume clinics and in 157 pharmacies, statewide – Pharmacies paid $2-5 dispensing fee • Preprinted prescriptions on case-report form and on faxable forms
  • 17. WA State Local Health Jurisdictions Participating in A Community- Level Trial of EPT Whatcom Okanogan San Juan Pend Ferry Skagit Oreille Stevens Island Clallam Snohomish Chelan Jefferson p Douglas King Lincoln Spokane tsa King * Ki Grays Mason Harbor Kittitas Grant Pierce Adams Whitman Thurston Lewis Pacific Yakima Franklin Garfield Columbia * Cowlitz Benton * * Asotin Asotin Skamania Walla Walla Wahkiakum 5 Klickitat Clark Wave 1 – 10/07 Wave 2 – 6/08 Wave 3 – 1/09 Ferry, Stevens, Pend-Orielle elected not to participate Wave 4 – 8/09
  • 18. Evaluation of System • Random sample of cases defined at time case is entered into Internet case registry • Outcomes: 1) Association of provider’s partner notification plan as indicated on the case report form and a) Outcomes at time of initial index patient interview: partner notified, treated, receipt of PDPT from diagnosing provider b) Acceptance of PDPT or assistance from DIS 2) Use of PDPT by Providers • Statistics – Associations defined using GEE to adjust for correlated data
  • 19. Provider’s Partner Management Plan as Indicated on the Case Report Form (n=26,051) 25% 89% of Forms Completed with a Partner 54% Management Plan 21% Health Department Provider All Partners Treated
  • 20. Process Outcome Evaluation: WA State EPT Trial 31,399 Cases GC/CT in Heterosexuals 1/1/07-12/31/09 6650 (21%) Random Sample 3931 (59%) Interviewed 2719 (41%) Not Interviewed Not located 1446 (53%) Late report 506 (19%) 4304 Partners with Dispositions Patient refused 360 (13%) Language barrier or out of area 141 (5%) Provider refused 120 (4%) Missing 146 (5%)
  • 21. Association of PN Plan on Case Report Form with PN Outcomes All partners already treated Provider to assure PN Health dept. assistance requested 100 P<.0001 All Comparisons Health Dept. 91 Assistance vs. No Health Dept Assistance 80 88 72 Percent 64 60 48 60 40 89 56 26 20 10 29 22 0 Partner Notified at Time Partner Supplied PDPT from Partner Untreated at Time Initial Interview Clinician Initial Interview
  • 22. Association of PN Plan on Case Report Form with PN Outcomes All partners already treated Provider to assure PN 50 Health dept. assistance requested 40 P<.0001 All Comparisons Health Dept. Percent Assistance vs. No Health Dept Assistance 30 25 20 5 7 17 10 8 4 6 6 0 Partners Supplied PDPT by Health Dept. DIS Assistance Accepted
  • 23. Partner Receiving PDPT from the Diagnosing Provider, WA State EPT Community-Level Trial Wave 1 Wave 2 Wave 3 Wave 4 50 Intervention Intervention Begins Begins 40 Percent Intervention Begins 30 20 10 Intervention Begins 0 May-Aug Sep-Dec Jan-Apr May-Aug Sep-Dec Jan-Apri May-Aug Sep-Dec Jan-Apr 2007 2007 2008 2008 2008 2009 2009 2009 2010
  • 24. Medication Delivery • ~25,000 cases of GC and CT annually in WA State • ~ 15,000 medication packets distributed per year • 77% chlamydial infection • 75% direct to providers – 25% via pharmacies • 56% of heterosexuals with GC/CT offered PDPT • 34% of all heterosexual receive PDPT from their provider • 60% of those not referred to public health • Total cost of meds including distribution = $105,000/year
  • 25. Proportion of Partners Treated at Time of Initial Partner Notification Interview, Before and After Program Initiation 100 Preintervention p<.0001 80 Intervention Percent 60 56 40 48 20 0 Partners Treated
  • 26. Impact of DIS Services Among Persons Referred to Receive Partner Services 3/09-3/10 100 82 Initial Interview • 1290 partners provided Final Interview 80 72 PDPT 66 • 1147 partners treated 60 after receipt of DIS 40 34 services • Cost per partner treated 20 ~$500 0 • Probably roughly Notified Treated comparable to the cost per case treated via screening
  • 27. DIS Services • ~11,000 cases assigned and ~8000 interviews annually • Driven by high proportion of cases referred by case- reports to receive DIS services • 1290 partners received PDPT via DIS • ~750 partners notified by DIS • 10-12 DIS state-wide • Assigned 1000 cases each per year • Interview 50-60% • Total cost of DIS = ~$600,000/year
  • 28. Cost-Effectiveness of EPT Health Care QALYs Lost Cost- System effectiveness Costs ratio Index Men EPT $379 .0272 Cost-saving Standard $445 .0308 Index Women EPT $150 0.004 Cost-saving Standard $186 0.005
  • 29. EPT is cost saving to the system ~$50 per male index and $20 per female From payer’s perspective, it is only cost saving if at least 40% of partners receive care from the payer
  • 30. Tragedy of the Commons • Each person despoils a common resource because they as an individual pay little of the cost, and acting conscientiously does not benefit them • Two solutions • Regulation – all insurance companies have to pay • Pay in common – we buy the meds as a group
  • 31. Summary Community-level EPT Trial • Ongoing • Triage via case report form successful in directing DIS services to those most likely to benefit • Cost of these services remains high • Publicly financed free medication can promote widespread use of PDPT • Cost of medications, if purchased using 340b pricing, is relatively modest
  • 32. Conclusion • Routinely offering patients medication for their partners is a superior standard of care for the index case • Most heterosexual patients should be offered PDPT • Public Health programs should seek to make sure that provider have the tools to offer their patients PDPT in a way that is legal and the maximizes the likelihood that partners receiving information about STD & meds • Publicly financed partner medication is relatively inexpensive and can increase PDPT use • Assures legal compliance • Highest priority for funding in this area

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