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W7 Expedited Partner Therapy for Management of Certain Sexually Transmitted Infections Hogben

W7 Expedited Partner Therapy for Management of Certain Sexually Transmitted Infections Hogben






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  • This is just a slide to show that the issues around workload and burden of disease are international and date back at least 40 years! This problem illustrates the need to be able to use an alternative to provider referral in many instances.
  • Relative burden of syphilis, GC, CT. Even assuming resources permitted some DIS-based inquiry into a proportion of GC cases (note the NY state work on core areas and the work on proportion interviewed as a predictor of subsequent incidence), there remains a large burden of infection.
  • A reference to current CDC recommendations and a front page note on EPT and the need for patient-mediated notification and referral strategies.
  • The point of this slide is to embed EPT into the context of existing partner services. EPT is not a categorically different approach to partner treatment; it is an enhancement of existing approaches. Grasping this point helps drive programmatic changes to guide the use of EPT in its various forms.
  • This slide is actually more important than it might look at first glance. Reinfection is usually the outcome that we treat as most important. In partner notification, however, the key rationales are generally built around partner treatment – does anyone track index reinfection as a routine indicator of partner services success? It’s certainly not common. So examining the effect of EPT upon treatment rates is really just about as important as index patient reinfection. Looking at other behaviors lets us know something about collateral benefits and harms – unintended consequences.
  • This and the following slide are from an independent meta-analysis. Note they included Kissinger’s (1998) study in which a provider in a practice was randomized to discuss PDPT with female patients. They also include the trich RCT (Kissinger 2006), so the overall effect, RR = 0.73, incorporates an extra infection and an arguably non-RCT. If those two studies are excluded, the effect is almost identical.
  • The Nuwaha RCT may have an exaggerated effect size because the control arm was based on clinical attendance and the trial arm was based around index report. Note also the smaller effect for trich (Kissinger 2006).
  • Summary of the guidance in the 2006 report.
  • Programs should look for specific numbers in treatment improvements and partner positivity based on their own data (I apologize if this seems like a lecture or, worse, a familiar lecture!). Once programs have those estimates, however, they can work out the amount of coverage – measured as uptake? – that would provide a certain level of prevention impact.
  • This is the study in which patients and physicians discussed PDPT. Note the effect size is bigger than the RCT estimates for CT. But what has happened to coverage? What this study adds in value is the balancing and the overlap between efficacy and coverage measurements.
  • These are a mix of the most commonly cited issues.
  • Peer to peer technical assistance…
  • The paper underlying these recommendations is Hodge et al. (2008) Am J Public Health. Do check the website at www.cdc.gov/std/ept.
  • In terms of basic availability, CDC and other efforts have been highly effective. Given the 23 states include California, Texas and New York, this almost certainly amounts to >50% of the US population.
  • Probably outdated by now, so, again check the website!
  • Early data from implementation in STD clinics in Baltimore. The 2010 STD Prevention conference in Atlanta in March should reveal an update to these data.
  • A USPSTF recommendation might ease cost issues through enabling reimbursement. Certainly CDC’s priority is to get other federal agencies aligned with keeping/making EPT cost-feasible everywhere it is legal practice.
  • One intervention at a time does look stupid when you are considering moving furniture.
  • So we solve it all with a bigger diagram! Well, it’s a start. This is all about intervention along a continuum of services (or you could define the continuum by needs) in a way that captures the real eligible population. And then you enable policies that give 100% coverage with respect to service delivery and aim for a level of coverage measured by service uptake that results in meaningful prevention impact. Job well done and off you ride into the sunset.

W7 Expedited Partner Therapy for Management of Certain Sexually Transmitted Infections Hogben W7 Expedited Partner Therapy for Management of Certain Sexually Transmitted Infections Hogben Presentation Transcript

  • Expedited Partner Therapy: Background & Current Status Matthew Hogben PhD Centers for Disease Control and Prevention (404) 639-1833 [email_address] May 26, 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
    • Context and Background
    • Expedited partner therapy (EPT) definition and principles
    • Evidence of EPT efficacy and effectiveness
      • Composite estimates
    • Implementation of EPT as a strategic option
      • Core requirements and coverage issues
      • Barriers
      • Implementation progress
    • Next steps
  • PN in the big picture CAN YOU GET INFECTED PEOPLE TREATED AT A RATE FASTER THAN THE RATE AT WHICH THEY INFECT OTHERS? Infected Patient Partner notification Partner treated Maybe!
  • Networks of exposure and transmission (Artist’s conception) It’s OK, I’m not infected. . I told the guy sitting down already. I got tested and treated.
  • What you actually get.
  • Partner Referral Approaches
    • No Public Health Involvement Required
    • Nothing
      • It works some of the time.
    • Self referral or patient referral
      • Patient is intended to notify partners of exposure (with varying levels of provider encouragement)
    • Public Health Involvement Required
    • Provider referral
      • A public health professional elicits partners’ identifying information and contacts and notifies partners
    • Contract or conditional referral
      • Patient gets initial chance to contact and notify partners, but professional will do so if patients do not (within a specified time frame)
  • It takes a lot of (underappreciated) work. Wigfield. Brit J Ven Dis 1972.
  • Case reports per 100,000 (US) STD Surveillance Report (2009), Tables 3, 13, 25. http://www.cdc.gov/std/stats08/toc.htm
  • www.cdc.gov/nchhstp/partners
  • Expedited Partner Therapy
    • Core elements
      • 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
  • EPT Referral Strategies
    • Basic Strategy
    • (1) Patient referral or self referral
      • Patient is intended to notify partners of exposure (with varying levels of provider encouragement)
    • (2) Provider referral
      • Provider (meaning public health staff as default) is intended to notify partners of exposure
    • EPT “addition”
    • (1) PDPT
      • Patient carries prescription or medication for partner along with instructions
    • (2) Field-delivered therapy
      • Provider notifies and delivers prescription or medication (plus instructions, etc.)
  • Establishing Efficacy: Key Outcomes
    • Effect on clinically relevant outcomes establishes EPT efficacy
      • 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
  • Reinfection rates Trelle et al. BMJ 2007. IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
  • Treatment rates Trelle et al. BMJ 2007
  • Guidance for Use of EPT
    • Heterosexual males and females
      • Gonorrhea and chlamydial infection
      • Accompany with written instructions
        • How to take meds, allergies, seek evaluation
    • Men who have sex with men
      • More caution (fewer data, more HIV comorbidity)
    • Trichomoniasis, syphilis
      • Much more caution, “last resort”
  • Prevention Impact framework Effective level of coverage Contribution of groups to population health outcome Efficacy or effectiveness (in targeted groups) PREVENTION IMPACT = X X Abridged/adapted from: Aral et al. Behavioral Interventions 2007; St. Louis & Holmes Sexually Transmitted Diseases (3 rd ed.) . 1999
  • Achieving impact with EPT COVERAGE CONTRIBUTION Partners have 20% to 75% positivity (program data) EFFICACY Tx rate: 20% To 100% increase Reinfection: 20% to 50% decrease X X Key Issue
  • Patients and Physicians Discuss PDPT Probable maximum effect, balanced by reduced coverage
  • Those Barriers to Coverage
    • Not sure how to get started logistically
    • Discomfort with no health provider face to face contact with partner
    • Legal landscape in jurisdiction
    • Costs
  • Protocols and other resources
  • “ Legal” implementation advice
    • Explicit endorsement through laws
    • Create exceptions to existing prescription requirements
    • Increase professional board and association support
    • Facilitate 3 rd party payment
  • Has coverage increased?
    • 2006
      • 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
      • The corresponding numbers are 23 (+ Baltimore), 8, and 19 (- Baltimore)
  • Evolving Landscape of EPT: Legal Status Summary EPT is Potentially Allowable EPT is Likely Prohibited EPT is Permissible Legislation Pending CA OR WA NV NM UT AZ WY CO NB KS MO AR OK FL GA AL MS LA TX WI IA MN ID MT ND SD NC VA WV KY TN OH MI IN IL VT AK HI ME NY PA RI MA NJ CT NH SC DE DC MD ( Baltimore only) CA OR WA NV NM UT AZ WY CO NB KS MO AR OK FL GA AL MS LA TX WI IA MN ID MT ND SD NC VA WV KY TN OH MI IN IL VT AK HI ME NY PA RI MA NJ CT NH SC DE DC MD 2006 2010
  • Baltimore implementation
    • Implementation (as of Jan 2009)
      • STD clinics
      • Medications dispensed
      • GC/CT, 3 extra dose maximum
    • Evaluation
      • 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
  • Current and near future (selected)
    • Toolkit: Needs assessment to inform content for states interested in legal provisions and subsequent policies (May 13)
    • Incorporation into Best Practices (DSTDP/PTB)
    • Engagement with other federal agencies (CMS)
      • National CT Coalition support
    • Effectiveness rating
      • Possible USPSTF review in larger context of STD prevention)
  • The bigger picture: Shifting furniture
    • It looks heavy
      • 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.
  • All together now… Coverage Something for everyone Contribution STD clinic Other public sector Private sector Intervention Mix Along Continuum of Services Efficacy Screening/Testing Patient Treatment Partner Notification & Treatment Counseling and other Interventions Follow-up Care X X
  • Thank You Questions and comments welcome now or later!