Patient-Delivered Partner Therapy for STD: Evidence and Prospects for Implementation

1. Patient-Delivered Partner Therapy for STD: Evidence and Prospects for Implementation National STD Conference 2004 Matthew Hogben, CDC Matthew R Golden, U Washington and PHSKC Patricia Kissinger, Tulane U Janet S St. Lawrence, CDC

2. Questions • Why consider dispensing medications or prescriptions to patients to give to their sex partners? • What do we know about the prevalence of PDPT? • What do we know about how well it works? • Using which measures of effectiveness?

3. Why consider PDPT • The standard of care is self-referral, which does not capture all partners • Meta-analyses suggest DIS-assisted notification is more effective than self-referral • But STD morbidity is too high for universal DIS-assisted referral • 89% of syphilis cases, but only 17% of GC and 12% of CT cases were interviewed in high morbidity areas* • PDPT is a possible alternative or complementary strategy *Golden, Hogben et al. (2003). Sex Transm Dis

4. PDPT Prevalence • Vague status of PDPT means data have been sparse – or vice versa • Legal (more civil than criminal) • Professional opinions surrounding physical evaluations of patients • A recent national survey has yielded more information

5. Survey Sample* • Five AMA specialties diagnosing 85% of STD in the USA • 4233 respondents (70% response rate) • 71% male, 76% White, 46 years old • 87% in private settings, 69% primary care offices • In the past year:** • 54% had diagnosed GC • 73% had diagnosed CT *St. Lawrence, Montano, et al (2002). Am J Public Health. **McCree, Liddon, et al (2003). Sex Transm Inf.

6. PDPT by physicians: National survey % Physicians Never Sometimes Half Usually Always N=2,538 CT N=1,873 GC

7. Correlates of PDPT • PDPT practice was most common among: • Ob/gyns and family/general practitioners (least common among ER physicians) • Physicians with higher proportions of female patients • Also correlated with forms of “provider referral.” • Collecting partner information and contacting partners • Collecting partner information and sending it to HD • Less common in circumstances where STD is most prevalent • Negatively correlated with proportion of Black or African American patients • Least common in Southern US (Federal quadrant)

8. Seattle: Proportion of patients with CT infection who received medications for their partners(n=150) % Physicians 0 1-24 25-49 50-74 75-100 Source: Golden et al (1999). Sex Transm Dis % patients

9. PDPT Effectiveness • Reinfection rates • Among US studies reinfection of index cases is lower among those exposed to PDPT than among those receiving SOC • Statistical significance varies by trial and STD • For example: • Schillinger et al. (2003): 20% reduction, OR = .80, p = .10 • Golden et al. (in prep): 24% reduction, OR = .76, p = .04

10. PDPT Effectiveness • Notification rates* • Equivalent among those exposed to PDPT than among those receiving SOC • But those exposed to PDPT more likely to say that partners were “very likely” to have been treated or tested negative, OR = 1.6, p < .001 • And more likely to have avoided sex with any partner they believed not “very likely” to have been treated or tested negative, OR = 0.5, p <.001 *Golden, Whittington, et al. (in prep).

11. Infection during follow-up among 1860 persons completing the randomized trial P=.04 P=.17 P=.02 Percent N=358 N=1595 N=1860

12. Partner treatment per index patient report P<.0001 P<.0001 Percent P=.001

13. Other Factors Relevant to PDPT • Medication sharing • Undertreatment • Uninfected partners • Overtreatment • Potential partner violence • How does this differ from the risk posed by SOC? • STD reporting rates • Relevant if sex partners do not present for evaluation • Implementation requirements • DIS (or other staff) training • Structural changes (policy, law, public/private cooperation)

14. More Work to be Done • Using existing data • Meta-analysis will help establish • A more robust mean effect • Moderating effects on an overall mean • Descriptive multi-level modeling • Allows structural and individual influences and correlates to be assessed together • With whom does PDPT work best? • In conjunction with which other partner management strategies?

15. Reference list • References available as a handout. If you have relevant material, feel free to send it to Matthew Hogben at mhogben@cdc.gov. That includes references and ideas. • Golden MR, Hogben M et al. Sex Transm Dis 2003;30:490-496 • Golden MR, Whittington WLH et al. Sex Transm Dis 2001;28:658-665. • Kissinger P, Brown R et al. Sex Transm Inf 1998;74:331-333. • Klausner JD, Chaw JK. Sex Transm Dis 2003;30:509-511. • Macke B, Maher J. Am J Prev Med 1999;17:230-242. • McCree DH, Liddon NC et al. Sex Transm Inf 2003;79:254-256. • Oxman AD, Scott EAF et al. Can J Public Health 1994;85 (supp 1):S41-S47. • Schillinger JA, Kissinger P et al. Sex Transm Dis 2003;30:49-56. • St. Lawrence, Montano et al. Amer J Public Health 2002;92:1784-1788.