Associate Professor, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women and Infants Hospital, Providence, RI

Dr. Allen reports she is a Nexplanon trainer for Merck.

Expedited partner therapy (EPT) is defined as treating the heterosexual partners of patients diagnosed with chlamydia or gonorrhea by providing the medication or a prescription for the patient to give to the partner without a healthcare provider first examining the partner.¹ EPT is endorsed by the Centers for Disease Control and Prevention (CDC), the American College of Obstetricians and Gynecologists (ACOG), the American Academy of Family Physicians, the American Academy of Pediatrics, the American Bar Association, and the Society for Adolescent Health and Medicine. Although referral of the partner for a full sexual health examination is preferred, often there are barriers for partners to receive treatment, such as cost, lack of health insurance, or no established relationship with a physician. EPT offers an alternative to ensure that the partner receives treatment and does not re-infect the index patient. EPT is legal in 42 states and potentially allowable in six states and one territory.¹ (See Table 1.) Of note, EPT is not yet recommended for the management of sexually transmitted infections (STIs) in men who have sex with men because of the concern of missing STI and HIV coinfections in this population.²

Renewed focus has been placed on EPT as STI rates have soared recently in the United States. In 2016, there were 1.6 million cases of chlamydia, 470,000 cases of gonorrhea, and almost 28,000 cases of primary and secondary syphilis.³ This was the highest number of chlamydia cases ever reported to the CDC.⁴

This increase in cases is attributable partially to the decreased funding of the U.S. public health infrastructure. State health departments are underfunded and many have had to decrease their direct clinical services that offer STI testing and treatment.⁵ In my own state of Rhode Island, the only free and confidential state-funded STI clinic was closed because of budget cuts in 2011. Untreated STIs particularly are harmful to women, as they can lead to pelvic inflammatory disease, chronic pelvic pain, and infertility. Adolescent and young women between 15 and 24 years of age accounted for 46% of the reported chlamydia cases in 2016. Therefore, any OB/GYN provider plays a direct role in combatting this epidemic with screening, treatment, and EPT. ACOG recommendations cover the following aspects of EPT implementation.⁶

• Offer EPT to a patient’s recent sexual partners who are unable or unlikely to access medical services. Specifically, the offer includes a patient’s last sexual partner and any within the previous two months.
• Provide patient counseling and written instructions for the partners offered EPT.
• Provide encouragement for the partners to seek additional medical evaluation, including testing and treatment for HIV infection and other STIs.
• Instruct patients to abstain from intercourse for seven days after treatment is complete for them and their partners.
• When considering EPT, assess the risk of intimate partner violence associated with STI notification.
• Do not offer EPT in cases of suspected child abuse or sexual assault.

For OB/GYN providers, implementing EPT is simplest for women diagnosed with chlamydia infection. A prescription for 1 gram of azithromycin can be written easily for their male partner with instructions to the pharmacist to screen for allergies. However, for women diagnosed with gonorrhea infection, the situation is a little more complicated. As of 2012, the CDC no longer recommended oral cefixime for the treatment of gonorrhea. Currently, the only CDC-recommended treatment of gonorrhea is combination therapy with a single intramuscular dose of ceftriaxone 250 mg plus a single dose of azithromycin 1 gram orally. Since intramuscular injections are not used in EPT, the CDC has stated that “if a provider considers it unlikely that a heterosexual partner of a gonorrhea patient will access timely evaluation and treatment, EPT with cefixime and azithromycin still should be considered, as not treating partner(s) is significantly more harmful than is the use of EPT for gonorrhea.”⁷

Clearly, more work needs to be done to implement EPT in our clinical practices. Barriers to EPT include the stigma surrounding STIs, patients being unaware of EPT or not feeling comfortable contacting their partners, the cost of prescriptions for EPT, and providers not offering EPT.⁴ Certainly, more providers need to be trained on the legality, safety, effectiveness, and implementation of EPT. Electronic medical record reminders also could serve as a useful tool in this area, and the cooperation of pharmacists is critical. Let’s try to make EPT a routine part of clinical care for our patients to halt the wave of chlamydia and gonorrhea infections currently inundating the country.

REFERENCES

1. Centers for Disease Control and Prevention. Expedited Partner Therapy. Available at: https://www.cdc.gov/std/ept/default.htm. Accessed Oct. 1, 2018.
2. Centers for Disease Control and Prevention. Expedited partner therapy in the management of sexually transmitted diseases. Atlanta, GA: US Department of Health and Human Services, 2006. Available at: https://www.cdc.gov/std/treatment/eptfinalreport2006.pdf. Accessed Oct. 1, 2018.
3. Centers for Disease Control and Prevention. STDs at record high, indicating urgent need for prevention. Sept. 26, 2017. Available at: https://www.cdc.gov/media/releases/2017/p0926-std-prevention.html. Accessed Oct. 1, 2018.
4. Jamison CD, Chang T, Mmeje O. Expedited partner therapy: Combating record high sexually transmitted infection rates. Am J Public Health 2018;108:1325-1327.
5. Leichliter JS, Heyer K, Peterman TA, et al. US public sexually transmitted disease clinical services in an era of declining public health funding: 2013-14. Sex Transm Dis 2017;44:505-509.
6. ACOG Committee Opinion No. 737. Expedited Partner Therapy. June 2018. Available at: https://www.acog.org/-/media/Committee-Opinions/Committee-on-Gynecologic-Practice/co737.pdf?dmc=1&ts=20180810T2200380552. Accessed Oct. 1, 2018.
7. Centers for Disease Control and Prevention. Guidance on the use of expedited partner therapy in the treatment of gonorrhea. Available at: https://www.cdc.gov/std/ept/gc-guidance.htm. Accessed Oct. 1, 2018.