EPT: What Does It Mean and Who Is It For?
Transcript
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[00.00] Introduction
Hello everyone. My name is Meena Ramchandani. I’m an infectious disease physician at the University of Washington in Seattle. This podcast is dedicated to an STD [sexually transmitted disease] literature review for health care professionals who are interested in remaining up-to-date on the diagnosis, management, and prevention of STDs.
[00.20] Background
The topic of EPT or expedited partner therapy has come up a lot in recent conversations. So, what is EPT? It’s a strategy for treating sex partners of persons diagnosed with chlamydia or gonorrhea when the partner is unable or unlikely to seek timely treatment. In this setting, antibiotics or a prescription for antibiotics is provided to the sex partner without requiring them to undergo an evaluation by a health care provider. EPT has been found to be a useful option. It can facilitate partner management, prevent reinfection of the index patient, prevent further transmission of an STI, and is recommended by the CDC 2021 STI Treatment Guidelines when it’s permitted by state law. As of 2021, EPT is permissible in 46 states and potentially allowable in the other four states.
The current recommendations for EPT in the STI Treatment Guidelines are cefixime 800 mg as a single dose for gonorrhea and oral doxycycline 100 mg twice a day for 7 days or 1 gram of oral azithromycin as a single dose for chlamydia infection. Of note, doxycycline should not be given to persons who may be pregnant. There are a number of studies that support the use of EPT (specifically looking at cefixime and/or azithromycin) in women and heterosexual patients. On the other hand, there are limited data for the use of EPT for partners of MSM [men who have sex with men] who are diagnosed with gonorrhea or chlamydia. Since these partners have a significant risk for coexisting infections, including syphilis and undiagnosed HIV, when possible, it is advised that partners of MSM have an in-person medical evaluation for additional testing that can only be accomplished with a blood draw. However, the 2021 STI Treatment Guidelines recommend shared decision-making to determine if EPT should be used for partners of MSM, balancing the risks of missing syphilis or HIV with the benefits of providing treatment for gonorrhea and chlamydia. Our practice has been to recommend EPT primarily for heterosexual patients, but I can understand in rare situations, EPT might be the best option, including for partners of MSM. For this podcast, I’m going to dive back a few years and focus on some of the literature on EPT for women and heterosexual couples.
Golden MR, Whittington WL, Handsfield HH, et al. Effect of expedited treatment of sex partners on recurrent or persistent gonorrhea or chlamydial infection. N Engl J Med. 2005 Feb 17;352(7):676-85. [PubMed Abstract]
This first article for review was published in the New England Journal of Medicine in February of 2005 by Dr. Matthew Golden and colleagues. It is titled “Effect of expedited treatment of sex partners on recurrent or persistent gonorrhea or chlamydia infection.”
- So, this was a study that enrolled over 1,800 women and heterosexual men diagnosed with gonorrhea or chlamydia infection who were randomly assigned to have either EPT or a standard referral for their sex partners to get treated. For the EPT group, the index patient was offered medication to give up to three partners, or if they preferred, they could ask study staff to contact the partners and provide partners with medication without a clinical examination and at no cost.
- Partner packs included a single 400-mg dose of cefixime as well as a 1-gram dose of azithromycin for treatment of gonorrhea infection and only azithromycin for the treatment of chlamydia infection.
- The standard-referral group were advised to refer partners for evaluation and treatment by a health care provider, and patients were offered assistance to notify partners. Index patients were then tested for either chlamydia and gonorrhea about 10 to 18 weeks after treatment to see if they had persistent or recurrent infections with one of these pathogens. A positive test suggested that the index patient had resumed sex with a untreated partner.
- Overall, the authors found that gonorrhea or chlamydia infection was significantly less common at follow-up among patients in the EPT group than among patients in the standard-referral group and that had a relative risk of 0.76. Persistent or recurrent gonorrhea or chlamydia infection occurred in 13% of the index patients assigned to the standard partner referral and 10% assigned to the EPT group.
- Now, for the index patients diagnosed with gonorrhea, EPT was very effective and was associated with a 73% reduction compared to the standard-referral group in the presence of gonorrhea at follow-up testing. For persons diagnosed with chlamydia infection, EPT was also effective, but a little less so, with a 15% reduction compared with the standard-referral group in the presence of chlamydia infection at follow-up testing.
- Overall, the authors concluded that the index patients who were assigned to the EPT group were significantly more likely to report that all of their partners were treated and significantly less likely to report having sex with an untreated partner than those assigned to the standard referral of partner treatment.
So, while partner notification is one of the central pieces of control of STIs in the U.S., most patients have to arrange partner treatment without the assistance from a health care professional. EPT is a key way to provide partners with timely treatment for those who are unlikely to seek care. These drugs have a low risk of anaphylaxis, and the medications in the study were dispensed with instructions about adverse effects. Overall, this study showed that EPT of sex partners of patients who received a diagnosis of gonorrhea or chlamydia infection reduced the rate of persistent or recurrent infection in a large group of participants and increased the proportion of partners treated.
Slutsker JS, Tsang LB, Schillinger JA. Do prescriptions for expedited partner therapy for chlamydia get filled? Findings from a multi-jurisdictional evaluation, United States, 2017-2019. Sex Transm Dis. 2020 Jun;47(6):376-382. [PubMed Abstract]
The second article to discuss was published in Sexually Transmitted Diseases by Jennifer Slutsker and colleagues in June of 2020. It is titled “Do prescriptions for expedited partner therapy for chlamydia get filled? Findings from a multi-jurisdictional evaluation, United States, 2017-2019.” This study was looking at the efficacy of prescription EPT.
- This study used a single-use pharmacy voucher to cover the cost of azithromycin for chlamydia partner treatment in order to track EPT prescription fill rates when the cost barrier is removed. The clinical sites that were present in New York City, New York State, Maryland, and in California all participated, and these are all states in which EPT is permitted by law.
- They found that 32 clinical sites distributed 931 treatment vouchers from September of 2017 to January 2019. The majority of vouchers (82%) were distributed to partners who were older than 18 years, and 71% of the vouchers were distributed to female partners. Overall, they found that 41% of the vouchers were redeemed.
- Vouchers were more likely to be redeemed if they were given to females compared with males. But the authors found that only 30% of vouchers were redeemed when the partner was found to be 18 years or younger. Vouchers were significantly more likely to be redeemed if they were issued at a student health center and at clinical sites with an onsite pharmacy.
- The study found that 56% of the vouchers were redeemed on the same day they were given to the individual index patient, and 54% were redeemed at pharmacies that were located within one mile of the clinical site, suggesting that a close geographic location of the pharmacy is important.
Although EPT is effective, providing patients with a prescription, even if the cost consideration is removed, may not result in people taking the medication. This study used pharmacy voucher redemption as a proxy measure for EPT prescription fulfillment and found that less than half of the vouchers were redeemed. This suggests that possibly only a minority of partners get treated when EPT is provided in the form of a prescription for chlamydia infection, especially in those 18 years of age or younger. It also suggests that novel methods are needed to decrease barriers to implementing EPT.
Jamison CD, Waselewski M, Gogineni V, et al. Youth knowledge and perspectives on expedited partner therapy. J Adolesc Health. 2022 Jan;70(1):114-119. [PubMed Abstract]
So an important question has come up—if adolescents have low voucher redemption for EPT for chlamydia infection, are they actually interested in EPT? So, an article was recently published in the Journal of Adolescent Health in January of 2022 by Dr. Cornelius Jamison and colleagues who addressed this issue. It is titled “Youth knowledge and perspectives on expedited partner therapy.”
- This study was done in August of 2018 when the authors used a national text message survey called MyVoice to survey more than a thousand youth aged 14 to 24 years to assess EPT knowledge and perceptions. Participants were recruited through social media advertisements, with the goal of recruiting youth not reached by traditional research recruiting methods.
- The authors posed five open-ended questions about EPT, and 835 participants responded to at least one question. So, this was a response rate of 75%.
- The study found that the majority of youth (92%) felt that if they tested positive for chlamydia or gonorrhea, it would be important to help their partners get treatment. Most participants (or 86%) were unaware of EPT as an option for partner treatment.
- The authors found that 81% of youth supported the policy of EPT, stating it was convenient, reduced stigma, and increased access to medications for their partners. And the majority stated they would be interested in asking their provider for EPT if they were ever diagnosed with chlamydia or gonorrhea infection.
- For those that thought EPT would be useful, they recommended advertising (such as billboards or commercials) or increasing awareness through social media would be most effective for increasing knowledge about EPT in their age group.
Studies have shown that youth are at increased risk of acquiring STIs for a number of reasons, including multiple sex partners and decreased condom use. EPT is a great way to get partners of youth treated, and this study suggests that the majority of youth ages 14-24 years evaluated in this text message survey are very supportive of EPT, even though most of them were not aware EPT is available as an STI partner treatment option. This suggests that lack of knowledge or understanding about EPT may contribute to lack of uptake of EPT in this age group.
Schillinger JA, Gorwitz R, Rietmeijer C, Golden MR. The expedited partner therapy continuum: A conceptual framework to guide programmatic efforts to increase partner treatment. Sex Transm Dis. 2016 Feb;43(2 Suppl 1):S63-75. [PubMed Abstract]
To conclude, I’d like to summarize some key points from this session:
- EPT or expedited partner therapy is a partner treatment strategy where antibiotics or a prescription to treat gonorrhea or chlamydia infection are delivered to sex partners without an intervening medical evaluation. It’s used in the setting when the partner is unable or unlikely to seek timely treatment.
- For the articles we covered in this episode, expedited treatment of sex partners reduces the rates of persistent or recurrent gonorrhea or chlamydia infection in women and heterosexual men.
- Additional studies are needed to understand the risk or benefit for EPT use in partners of MSM.
- While EPT provided as a prescription may be best in some settings, one study showed that less than half of EPT prescriptions were filled, even when the medication was free. This suggests EPT may be better provided with packaged oral medication.
- Most youth aged 14-24 years feel EPT is a good way to get treatment for partners, but they are just not aware of it as an option.
If you’re interested in learning more, I suggest a wonderful review article by Dr. Julia Schillinger that was published in Sexually Transmitted Diseases in February of 2016. This article describes the EPT continuum, and it provides a conceptual framework for STD programs to identify opportunities to improve partner treatment rates using EPT.
[11.35] Credits
This podcast is brought to you by the National STD Curriculum, the University of Washington STD Prevention Training Center, and is funded by the Centers for Disease Control and Prevention.
Transcripts and references for this podcast series can be found on our website, the National STD Curriculum, at www.std.uw.edu. Thank you for listening, and have a wonderful day.