Hello, and welcome to the California Family Health Council’s webcasts about Patient Delivered Partner Therapy, or PDPT. I’m Linda Creegan, family nurse practitioner with the California STD/HIV Prevention Training Center.
This webcast is Part 1 of a 3-part series. In this segment, I’ll be discussing the important background information about chlamydia and gonorrhea infections, and about partner delivered partner therapy. Please listen to Parts 2 and 3 for more information about the specifics of using PDPT in your clinic settings, and about California law as it relates to PDPT, and the California Family Health Council’s Azithromycin distribution program for PDPT.
Let’s start with a few basics about chlamydia and gonorrhea infections.
Chlamydia and gonorrhea are the most common reportable sexually transmitted diseases in the U.S. It’s estimated that there are about 3 million cases of chlamydia every year in the U.S., and about 1 million cases of gonorrhea. These infections are concentrated in young people, particularly females under the age of 26, and most cases in women give no symptoms at all.
But untreated, chlamydia and gonorrhea can ascend from the cervix into the uterus and fallopian tubes, to cause the more widespread infection called pelvic inflammatory disease, or PID. Some women with this upper genital tract infection have acute symptoms – lower abdominal pain, irregular bleeding, fever – but PID can occur as a silent problem as well, causing damage without giving any symptoms. The long-term consequences of PID include infertility, ectopic pregnancy and chronic pelvic pain.
Because these infections are so commonly asymptomatic, screening really is one of the cornerstones of chlamydia and gonorrhea prevention. The recommendation in California is to screen all sexually active females 25 years of age and younger annually. Because these infections are considerably less common in women over age 25, routine screening is NOT recommended for all women 26 years of age and older. Instead, a risk assessment should guide our decision about whether to test in this somewhat older, and lower risk, population. For a woman over age 25 who has multiple partners, or who knows or suspects that her partner has other partners, screening may be indicated. And all pregnant women should be screening for chlamydia and gonorrhea.
But we know that reinfection shortly after treatment for chlamydia or gonorrhea is extremely common. These are sexually transmitted infections, so there is always at least one partner in the picture, who also needs management. Let’s talk in more detail about partner management and retesting for chlamydia and gonorrhea.
Multiple studies have shown that reinfection rates for women within 2-6 months after an initial diagnosis and treatment are very high, ranging from 10-20%. Many of these reinfections occur because of sex with a previous partner who did not himself receive treatment. And the serious sequelae we talked about early, like PID and ectopic pregnancy, are in fact more likely to happen with these subsequent, repeat infections than from the first infection.
So all sexual partners that a patient has had in the 2 months prior to the positive test must receive treatment. Ideally, they would receive comprehensive care, including testing, education and counseling, and treatment on the day of the visit, without having to wait for the results of their own tests. But seeing that this happens, being sure that all partners do receive treatment, can be quite challenging for patients. Rather than expecting one method of partner management to fit all, it’s more realistic to offer a “menu” of options, so to speak, and to allow the patient to chose the method she thinks will work best for each of her partners.
So here you see that “menu”: Patients can talk with their partner or partners, inform them of the diagnosis, and ask them to seek care with their own health care provider or at a local clinic. But there are plenty of “cracks” to fall thru with this method: finding where to go, getting the appointment, explaining about the contact to the clinician, paying for the visit and the medication. So this method is not always successful or dependable. Patients can offer to bring a partner in with her to your clinic setting for evaluation and treatment. We call this “BYOP”: bring your own partner. Because when he comes into your clinic, you KNOW he will get good care: the proper testing, treatment, education and counseling. A third option is called Expedited Partner Therapy. Patients are given medication or a prescription to take to their partner or partners. We’ll talk more about this method in the next few slides. Clinicians can also refer patients to the local health department for help in notifying their partners. And there are some methods for anonymously notifying partners, such as the online service called InSPOT.
Here’s the definition of Expedited Partner Therapy from the Centers for Disease Control: the practice of treating sex partners of persons with sexually transmitted diseases without an intervening medical evaluation or professional prevention counseling.” Some states have evaluated programs by which partners can access medication via a pharmacy, but the most common method of EPT is patient delivered partner therapy.
The CDC supports expedited partner therapy, while acknowledging that health care programs differ, so that when and how PDPT is implemented will vary from site to site. It’s important to regard PDPT as ONE POSSIBLE OPTION for partner management, though it won’t be appropriate for all patients or for all partners. And along with the medication, the partner should receive educational materials and information about where he or she can go for testing and care.
So to reiterate, PDPT involves providing your patient with medication, information and educational materials to take to her sexual partner or partners, and should be regarded as an alternative to the traditional approach of referring partners for their own testing and treatment.
California law also supports the practice of PDPT. Since the passage of SB __ in 2001, the law has explicitly allowed PDPT for partners of women and men diagnosed with chlamydia. This was extended to PDPT for gonorrhea with SB __ in 2007. Now you might think, what about patients with syphilis: is PDPT feasible for them? But because the optimal treatment for syphilis requires an injection of penicillin, PDPT is not recommended in cases of syphilis.
For chlamydia, the antibiotic that is used for PDPT is the same that you would usually use for your patient: azithromycin 1 gram taken by mouth in a single dose. For gonorrhea, there is a stronger preference for getting partners into care for evaluation and treatment rather than using PDPT. WHY?... because the preferred treatment for gonorrhea includes an injection of ceftriaxone. However, in cases where it just does not seem feasible or likely that a partner will manage to get to a health care provider, PDPT for gonorrhea would consist of 2 antibiotics: cefixime 400 mg, and azithromycin 1 gram, both taken by mouth as single doses.
But not all partners will follow through with preventive treatment by any method. Or patients may have sex with new partners, often from the same sexual network, and be at risk for acquiring an infection again. So it is strongly recommended that any patient diagnosed with chlamydia or gonorrhea be tested again in about 3 months, so as to identify those reinfections as soon as possible.
But a lot can happen in three months, and patients don’t always return for retesting. Sometimes this is because patients move away, or change their insurance coverage, but as clinicians, we want to do everything we can to assure that patients understand WHY retesting is so important. So counseling about the possibility of those serious consequences, and the fact that repeat infections are MORE LIKELY to give those serious consequences, is really important. Given written materials, making an appointment in advance, arranging for your clinic to send the patient a reminder at 3 months by phone, or email, or text, whatever that patient chooses, all those can help. I like to ask my patients to put it right into their phone calendars: three months from today, go SOMEWHERE for another test.
So that covers the basic introduction to PDPT for chlamydia and gonorrhea infections. In the next 2 short webcasts, we’ll be covering more about implementing PDPT in your clinic practice, about the law in California, and about the California Family Health Council’s PDPT Distribution program, whereby your Title X clinic can receive azithromycin, free of charge, specifically to use for PDPT. Thanks for listening, and thanks for the work you do.
Patient Delivered Partner Therapy (PDPT) 101What You Need to Know About PDPT advocate facilitate evaluate educate research
CFHC’s PDPT Trainings• This is Part 1 of a 3-part series on PDPT – Part 1: Background information about PDPT – Part 2: Using PDPT for Partner Management – Part 3: PDPT Law in California and CFHC PDPT Guidelines• For more information on PDPT:http:// www.cdph.ca.gov/pubsforms/Guidelines/Documents/CA-STD-PDPT-Guidelines-1- advocate facilitate evaluate educate research
The Basics of Chlamydia &Gonorrhea advocate facilitate evaluate educate research
Chlamydia and Gonorrhea: Persistent Threats to Women’s Health CT and GC are the most common reportable STDs in the United States CT: Estimated 3 million cases annually, US GC: Estimated 1 million cases annually, US advocate facilitate evaluate educate research
Risk of PID and AssociatedSequelae in Females Infertility Acute PIDUntreated genitalCT or GC Infection Ectopic Pregnancy Silent PID Chronic Pelvic Pain advocate facilitate evaluate educate research
California Screening Recommendations:Chlamydia and Gonorrhea in Women All sexually active females 25 years of age and younger annually Females 26 and older according to risk All pregnant females advocate facilitate evaluate educate research
Reinfection, Partner Managementand Retesting advocate facilitate evaluate educate research
The Importance of Partner Management High rates of reinfection occur after an initial diagnosis and treatment Many reinfections result from sex with a previous partner who did not receive treatment Serious sequelae are more likely with repeat infection 2x odds of ectopic pregnancy* 4x odds of PID*Hillis et al 1997 advocate facilitate evaluate educate research
All Recent Partners Must ReceiveTreatment Treat ALL sexual partners from the 2 months prior to the positive test Provide a variety of options to allow client to customize her plan for getting each partner treated advocate facilitate evaluate educate research
Partner Management Options:Chlamydia and Gonorrhea Infections Patient refers partner(s) for exam, test and treatment Asking patient to bring partner to clinic (BYOP) Expedited partner therapy (EPT) Patient delivered partner therapy (PDPT) Medication Prescription Pharmacy access programs Local health department referral Anonymous partner referral advocate facilitate evaluate educate research
What is Expedited Partner Therapy?CDC: Review and Guidance report, 2006“Expedited partner therapy (EPT) is the practice of treating the sex partners of persons with sexually transmitted diseases (STD) without an intervening medical evaluation or professional prevention counseling.”Most common method of EPT is Patient-Delivered Partner Therapy (PDPT). advocate facilitate evaluate educate research
CDC Supports EPT!“EPT should be available to clinicians as an option for partner management” When and how EPT is used will vary from site to site Does not replace other partner management strategies Along with medication, EPT should be accompanied by: Educational materials Information that advises recipients about how to seek personal health care in addition to EPT advocate facilitate evaluate educate research
What is PDPT? Patient delivered partner therapy (PDPT) is one form of EPT. PDPT involves providing the index client with the appropriate medication, information and educational materials for sexual partners exposed to the index client’s STI(s). PDPT is an alternative to traditional partner notification methods for testing and treatment of STIs. advocate facilitate evaluate educate research
PDPT and California Law Chlamydia trachomatis (since 2001) Neisseria gonorrhoeae (since 2007) Because optimal treatment of syphilis requires an injection, PDPT is not recommended for syphilis. advocate facilitate evaluate educate research
Antibiotics for PDPT Chlamydia: Azithromycin 1 gram orally once Gonorrhea: Cefixime 400mg orally once + Azithromycin 1 gram orally once advocate facilitate evaluate educate research
Retesting Client re-testing for chlamydia and gonorrhea at 3 months post-treatment is strongly recommended, regardless of whether the patient believes all of his/her partners have been treated. advocate facilitate evaluate educate research
Getting clients back in for retesting Counseling at treatment visit Written materials Advance appointments Traditional reminder systems (telephone and postcards) Text message and/or email reminders advocate facilitate evaluate educate research
Questions? For CFHC PDPT Program information, please contact: Aileen Barandas MSN, NP STD Programs Director firstname.lastname@example.org 510.486.0412 ext 2334 advocate facilitate evaluate educate research
Medical and scientific consultation for this webcast was provided by the CaliforniaDepartment of Public Health, STD Control Branch For more information, please visit www.std.ca.gov advocate facilitate evaluate educate research