Committee Opinion Header
Number 506, September 2011


Committee on Adolescent Health Care
Committee on Gynecologic Practice
This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.

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Expedited Partner Therapy in the Management of Gonorrhea and Chlamydia by Obstetrician-Gynecologists

ABSTRACT: Expedited partner therapy is the clinical practice of treating the sex partners of patients, in whom sexually transmitted infections are diagnosed, by providing prescriptions or medications to the patient to take to his or her partner(s) without the health care provider first examining the partner(s). The American College of Obstetricians and Gynecologists supports expedited partner therapy in the management of gonorrhea and chlamydial infections when the partner is unlikely or unable to otherwise receive in-person evaluation and appropriate treatment. The legality of expedited partner therapy is ambiguous in some states and overt legal impediments exist in others; analysis suggests that the practice is permissible in 27 states. Clinicians practicing in states where expedited partner therapy is legal should use it for eligible patients. In states, territories, and other jurisdictions where expedited partner therapy is not legal or the legal status of expedited partner therapy is unclear or ambiguous, clinicians are encouraged to advocate for its legality and implementation and work with their health departments to develop protocols for the use of expedited partner therapy. All health care providers should advocate for greater availability of sexually transmitted infection services.


Background

Sexually transmitted infections (STIs) disproportionately affect women and create a preventable threat to their fertility. In the United States, adolescent girls and young women aged 15–24 years consistently have the highest number of cases of gonorrhea and chlamydial infections (1). One of the contributing factors to these high rates is reinfection from an untreated sexual partner. Studies in adolescent girls and young women have demonstrated rates of reinfection of 14–26% within 12 months of an initial chlamydial infection (2–6). Increased risk of reinfection was associated with a younger age at the time of infection and an untreated partner. Expedited partner therapy has been advocated as one approach to address this issue. This practice involves treating the sex partners of patients, in whom STIs are diagnosed, by providing prescriptions or medications to the patient to take to his or her partner(s) without the health care provider first examining the partner(s) ie, patient-delivered partner therapy (7, 8).

Evidence indicates that expedited partner therapy can decrease reinfection rates compared with standard partner referrals for examination and treatment (7, 9). This approach is associated with desirable clinical and behavioral outcomes when used to treat gonorrhea, chlamydial infection, or both in heterosexual men and women. To date, there is insufficient evidence about the effectiveness of expedited partner therapy for same-sex partners or for the treatment of trichomoniasis or syphilis (7).

Consistent with the endorsement of other organizations such as the American Medical Association (AMA) (10), Society for Adolescent Health and Medicine (11), American Academy of Pediatrics (11), and American Bar Association (ABA) (12), the American College of Obstetricians and Gynecologists (the College) supports the implementation of expedited partner therapy as outlined in the Centers for Disease Control and Prevention (CDC) recommendations (7). Expedited partner therapy should be used for the treatment of gonorrhea and chlamydial infections in heterosexual partners when they are unlikely or unable to otherwise receive in-person evaluation and appropriate treatment.

Barriers to Routine Use of Expedited Partner Therapy

Despite the effectiveness of expedited partner therapy,numerous legal, medical, practical, and administrative barriers hinder its routine use by obstetrician–gynecologists. Analysis suggests that as of November 2, 2010, expedited partner therapy is permitted in 27 states and one city, potentially permitted in 15 states, and prohibited in 8 states (13, 14) (See Table 1). The CDC maintains a web site (http://www.cdc.gov/std/EPT) with information about the legal status of expedited partner therapy in all 50 states and other jurisdictions (14). Different legal provisions in the states—statutes, regulations, judicial decisions, and administrative opinions—affect the use of expedited partner therapy by clinicians. In many states, legal provisions are ambiguous. In some states, regulations by medical or pharmacy boards prohibit health care providers from prescribing medicine and pharmacists from dispensing medicine to patients that the clinician has not evaluated. In other states, medical licensing laws may be a barrier to expedited partner therapy. A statute that expressly permits expedited partner therapy is preferable in all jurisdictions. Obstetrician–gynecologists should rely on state or local legal counsel to determine whether they are allowed to practice expedited partner therapy in their locales.

Table 1. Legal Status of Expedited Partner Therapy in All 50 states and Other Jurisdictions*†
Expedited Partner Therapy
is Permissible
Expedited Partner Therapy
is Potentially Allowable
Expedited Partner Therapy
is Prohibited
Alaska
Alabama
Arkansas
Arizona
Connecticut
Florida
California
Delaware
Kentucky
Colorado
District of Columbia
Michigan
Illinois
Georgia
Ohio
Iowa
Hawaii
Oklahoma
Louisiana
Idaho
South Carolina
Maine
Indiana
West Virginia
Minnesota
Kansas
 
Mississippi
Maryland
 
Missouri
Massachusetts
 
Nevada
Montana
 
New Hampshire
Nebraska
 
New Mexico
New Jersey
 
New York
Puerto Rico
 
North Carolina
South Dakota
 
North Dakota
Virginia
 
Oregon    
Pennsylvania    
Rhode Island    
Tennessee    
Utah    
Vermont    
Washington    
Wisconsin    
Wyoming    

*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 expedited partner therapy in a given jurisdiction. It represents information from the Centers for Disease Control and Prevention web site as of June 23, 2011. For updates, go to http://www.cdc.gov/std/EPT/legal.

No information is currently available about the legal status of expedited partner therapy in American Samoa, Guam, Commonwealth of the Northern Mariana Islands, Republic of Palau, Marshall Islands, Federal States of Micronesia, or Virgin Islands.

Exception: Expedited partner therapy is permissible in Baltimore, Maryland.

 

In addition to legal barriers, reluctance to implement expedited partner therapy is related to concerns that by providing treatment without prior examination of the partner, the opportunity to detect human immunodeficiency virus (HIV) or other sexually transmitted coinfections may be missed, as well as concerns about adverse effects of antibiotics in expedited partner therapy recipients (7). The CDC and several state health departments have issued guidelines for practicing expedited partner therapy (7, 15–20). These guidelines and endorsements from professional organizations such as the College, AMA, Society for Adolescent Health and Medicine, ABA, and the American Academy of Pediatrics are important elements in establishing a standard of care, which is the primary medical–legal standard for appropriate practice. Ideally, the partners of patients in whom gonorrhea, chlamydial infection, or both are diagnosed should receive a complete in-person clinical evaluation before prescribing antibiotics for treatment of those infections. If the partner is unlikely or unable to otherwise receive in-person evaluation and expedited partner therapy is provided, the partner should be encouraged to seek medical evaluation, which can help prevent underdiagnosis, undertreatment, and subsequent development of STI sequelae (7).

Some obstetrician–gynecologists may be concerned about medical–legal ramifications in the event of adverse outcomes in the recipients of expedited partner therapy. Evidence suggests that the benefits of expedited partner therapy in preventing gonorrhea and chlamydial reinfections in individuals whose partners are otherwise unable or unlikely to seek care outweigh the risks that may include adverse effects of antibiotics, development of antibiotic resistance due to poor treatment adherence, or missed care opportunities (7). The risk of serious adverse reactions after recommended antibiotic treatment of gonorrhea or chlamydial infection is relatively low (8, 21–23), and can be further minimized by accompanying expedited partner therapy with clear written instructions and printed information on contraindications and sources of care in case of adverse reactions (7). The instructions should explain the need for the medication, how to take the medication, and encourage the partner to seek clinical evaluation as soon as possible. In expedited partner therapy programs that monitor adverse events, no drug-related adverse events or lawsuits arising from expedited partner therapy have been documented (11). State immunity can protect physicians using this therapy. Laws permitting expedited partner therapy passed from 2008 to 2010 in some states (Illinois, Maine, Missouri, New York, Rhode Island, Utah, and Wisconsin) protect clinicians from civil liability.

Other challenges of expedited partner therapy implementation may include the lack of billing codes for reimbursement for the health care provider's time; documentation issues for dispensing treatment for nonindex patients; concerns regarding patient confidentiality; and compliance with reporting requirements (7, 11). These practical and administrative barriers can be addressed by the development of model protocols, recommendations, hospital procedures, and algorithms.

Additional barriers to using expedited partner therapy with minors involve consent to treatment issues for the male partner if also a minor. Although all 50 states and the District of Columbia allow minors to consent to STI testing and treatment, 11 states require a minor to be of a certain age before being allowed to consent (24). Other barriers may include the legal requirement for reporting sexual activity or statutory rape. Every state has laws that specify when sexual activity with a minor is illegal. Most states use age parameters in defining whether sexual intercourse with a minor is illegal under the state's criminal code; these laws often are referred to as statutory rape laws. The state child abuse reporting laws vary widely in terms of whether or not they require reporting sexual activity of a minor—or statutory rape—as child abuse (25). Cases in which the health care provider is required to obtain the name and age of a partner in order to prescribe or dispense expedited partner therapy may result in the need for mandatory reporting of sexual activity, if statutory rape is identified. This could have the unintended consequence of reducing the likelihood an adolescent will gain access to care and receive appropriate treatment. Clinicians must be compliant with the reporting requirements of their states, which could involve balancing the protection of adolescents from predatory sexual behavior against issues of STI reduction and access to care (11). Expedited partner therapy is not intended for cases of suspected child abuse, sexual assault or abuse, or in situations where there is a question of the patient's safety.

Implementation

In jurisdictions where expedited partner therapy is legally permitted, the American College of Obstetricians and Gynecologists recommends the following principles of expedited partner therapy implementation in an obstetrics and gynecology practice:

  • Heterosexual partners of female patients in the previous 2 months (or, if no partners in that time frame, the last partner) who are unable or unlikely to personally access medical services should be offered expedited partner therapy. Providing guidance on how the patient can inform her partner(s) about the infection can be helpful.
  • Centers for Disease Control and Prevention treatment guidelines (8), local and state guidelines, or both should be used when choosing which medications are permissible and recommended for use.
  • Expedited partner therapy should be accompanied by counseling of the index patient. She should be provided with written treatment instructions to give to her partner. The specific language for the instructions may be regulated by statute. The instructions should explain the need for the medication, how to take the medication, and encourage the partner to seek clinical evaluation as soon as possible. When feasible and legally permissible, health care providers may attempt to contact the partner(s) of the index patient to discuss the diagnosis, prescription of expedited partner therapy, and any symptoms of STIs.
  • Depending on state laws and regulations, the health care provider can give medication to index patients to take to their partners or the health care provider can write a prescription for the partner.
  • Partners receiving expedited partner therapy should be encouraged to seek additional medical evaluation as soon as possible to discuss screening for other STIs and HIV infection.
  • Patients should be instructed to abstain from sexual intercourse until they and their sexual partner(s) havecompleted treatment. Abstinence should be continued until 7 days after a single-dose regimen or after completion of a 7-day regimen.
  • A mechanism should be in place for patients to report adverse events.

Documentation

In most states, health care providers are legally required to maintain medical records for all patients for whom they prescribe medication (11). Protocols for expedited partner therapy documentation vary by state and may establish a medical record process for physicians to document treatment of partners who have never been examined in their offices. Some of the examples of expedited partner therapy documentation from published protocols from selected states include the following:

  • Documenting in the index patient's chart the number of partners provided expedited partner therapy, the medication prescribed and dosage, and any known medication allergies that apply to the partner (15, 16, 18, 20).
  • Not creating a separate medical record for the partner nor listing the partner's name in the index patient's chart (15, 18, 20).
  • Reporting partners as part of the mandated STI reporting systems rather than naming partners in the index patients' medical record, thereby putting potential contact tracing in the arena of the public health system (15, 18).

Advocacy

Both the AMA House of Delegates (26) and the ABA House of Delegates (12) have passed resolutions urging the removal of legal barriers to implementing expedited partner therapy nationally. In states, territories, and jurisdictions where expedited partner therapy is not legally permitted or the legal status of expedited partner therapy is ambiguous, the College encourages members to advocate for legalization and work with their health departments to develop protocols for the use of expedited partner therapy. This involves active collaboration with stakeholders (other health care providers, the state STI director, pharmacy and medical boards, and state medical societies). An opinion or other ruling from the state medical and pharmacy boards indicating that expedited partner therapy is not unprofessional conduct may be easier to accomplish than passing a new statute. However, a discrete statute expressly permitting expedited partner therapy is the strongest legal authority.

There is also a need to evaluate the process and outcomes of expedited partner therapy implementation and disseminate best practices. The health care providers who practice expedited partner therapy and researchers are encouraged to document their findings and report implementation of their programs at conferences, scientific meetings, and in peer-reviewed publications. Physicians reporting their experiences to the members of their local and regional organizations and other health care provider groups, as well as sharing model protocols, may help to expand implementation of expedited partner therapy among health care providers. In addition to advocating for expedited partner therapy in states, territories, and other jurisdictions where it is not yet legally permitted or the legal status is ambiguous, health care providers also should advocate for greater availability of STI services to ensure that appropriate treatment is available to the partners of their patients.

Conclusions

The American College of Obstetricians and Gynecologists supports the use of expedited partner therapy in accordance with CDC guidelines as a method for preventing reinfection of patients with gonorrhea and chlamydia when their partners are unable or unwilling to otherwise seek medical care. Members practicing in states where expedited partner therapy is legal should use expedited partner therapy for eligible patients and encourage all partners treated with expedited partner therapy to seek clinical evaluation as soon as possible. Clinicians practicing in states, territories, or other jurisdictions where expedited partner therapy is not legal or where the legal status of expedited partner therapy is ambiguous, should advocate for laws permitting expedited partner therapy and work with their health departments to develop protocols for the use of expedited partner therapy. All health care providers should advocate for greater availability of STI services.

References

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ISSN 1074-861X

Expedited partner therapy in the management of gonorrhea and chlamydia by obstetrician–gynecologists. Committee Opinion No. 506. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;118:761–6.