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Expedited Partner Therapy

Partner-delivered HIV self-testing through antenatal clinics: the way ahead for partner notification in low-resource settings?

23 Nov, 16 | by Leslie Goode, Blogmaster

A recently published, Kenya-based, randomized controlled study (Masters & Thirumurthy/STIs) (M&T) evaluates a novel intervention that appears to combine in a fresh way elements of various innovative interventions for HIV prevention.  Recently published studies (e.g. Kissinger/STIs; Estcourt & Cassell/STIs) have explored the potential of ‘expedited’, or ‘accelerated’ partner therapy – where the partner of an index STI-infected individual is offered therapy through the infected individual directly, without a clinic attendance, or with only a telephone interview. They have also evaluated the benefits of ‘self-testing’ for HIV (e.g. Pai & Dheda/STIs).  The intervention trialled by M&T – partner delivered HIV self-testing – combines elements of these two types of interventions.  A third crucial element is that it takes advantage of the unique opportunity offered by antenatal and postpartum clinics in low resource settings (see Azeze & Haile/STIs; Sombie & Dabis/STIs; Ganiyu & Mason/STIs) to make contact with HIV-infected individuals who might otherwise have little access to health services.

In M&T’s study, participants attending antenatal and postpartum clinics (ANC) who were assigned to the intervention arm of the study (n=284/570) were offered two oral-fluid-based HIVselfing kits, one for themselves, one for their partner.  Discussion about HIV, self-testing, couple testing, and awareness of partner’s result were subsequently reported by index patients at monthly follow-up meetings over a three-month period.  This ANC-based, partner-delivered HIV self-testing intervention was evaluated against a control group (n=286/570) who were given an invitation card for conventional clinic-based HIV testing and encouraged to distribute the card to partners.

The primary outcome was reported partner HIV testing which was 91% for the intervention as against 52% for the control.  The intervention looked at couple testing (42% difference between intervention group and control), and awareness of partner’s HIV status (difference=39%).  0% participants in either group reported intimate partner violence (IPV) as a consequence of HIV testing.

Concerns around interventions of this kind tend to centre upon two things.  First, the absence of any direct contact between partner and health services, and consequent loss of an opportunity to test for the full range of STIs and help ensure integration into treatment (Estcourt & Cassell/STIs).  Second, worries as to the likelihood of IPV related to testing.  On the first, concern may be less where the self-test is for HIV, and the partner misses out on testing for the other STIs (Kissinger/STIs), than it would be where, as in many non-African settings, the self-test would generally be for Chlamydia or gonorrhoea and HIV could remain undiagnosed.  Regarding IPV, the authors note its lack of association with testing in the study (despite base-line reported rates of 27%).  They also point to the large proportion of eligible declining to participate (715/1,315).  This – taken together with zero cases of IPV – they interpret as a possible indication of the ‘agency’ of these women, and their capacity to make their own judgments regarding the possible impact of participation on their relationships.  The problem of ensuring engagement with care among those self-tested for HIV, however, is one that the authors acknowledge as still needing to be resolved.

As for the study itself, a primary limitation is self-reporting.  But here the authors note that misreporting is hardly likely to account for the differences between intervention and control arm – which is the evidence that the authors principally emphasize.

 

Trialling innovative approaches to STI partner services: Partner-Delivered vv. Accelerated Partner Therapy

26 Feb, 15 | by Leslie Goode, Blogmaster

It is vital to treat partners of patients with curable STIs as quickly as possible.  But the effectiveness of interventions to achieve this proves hard to measure – and the case for increasing resources correspondingly difficult to make.  The inadequacy of the resources available to existing partner services has led some investigators in the US and UK to seek out innovative approaches to ensuring the treatment of partners which are less expensive.  One option – Patient-Delivered Partner Therapy (PDPT) – is to provide treatment for partners via the patient and without prior medical assessment of the partner.  The problems with this are: first, that PDPT may not conform to legal (Cramer & Leichliter (STI)) or professional guidelines; second, that concomitant infections (e.g. HIV) in the partner may go undiagnosed and untreated. An alternative solution – Accelerated Partner Therapy (APT) – is to treat the partner via the patient, but only after a medical assessment conducted by telephone or with a pharmacist (Golden & Estcourt (STI); Dombrowski & Golden (STI)).

The option of PDPT has been trialled in various US clinics (Mickievicz & Rietmeijer (STI); Sanchez & Schillinger (STI); but its impact is difficult to evaluate on a local level. Now, for the first time, Golden & Holmes have attempted a population-level randomized control trial of uptake and impact across 23 out of the 25 counties of Washington State.  This impressively large-scale operation had two elements.  The first was the provision of free PDPT, and involved: 1. informing all clinicians about the programme; 2. making stocks of free PDPT available to clinicians who had reported ≥ one case of Chlamydia or Gonorrhoea, and to certain large pharmaceutical chains; 3. visiting clinicians reporting frequent cases for the purpose of educating staff about the programme.  The second element was the possibility offered to diagnosing practitioners via routine report forms of having the provision of partner services handled by the state public health department. This intervention was rolled out in four successive waves to different counties in turn, thus enabling the impact of the intervention to be controlled against the default situation in the counties of each wave.

As regards uptake, percentage of persons receiving PDPT from clinicians rose in intervention periods from 18% to 34%, and percentage receiving partner services from 25% to 45%.  This is broadly comparable with what has been achieved by more local interventions in the US.  Unfortunately, it is one thing for a pack to be accepted by the index patient, another for a partner to be successfully treated.  Hence the interest of G&S’s attempt to evaluate population-level impact – through testing in sentinel clinics in the case of Chlamydia, and through incidence of reported infection in the case of Gonorrhoea. It was undoubtedly ambitious of G&S to seek an indicator of population level impact for a comparatively brief intervention.  It is no surprise that the results are less than overwhelming. Chlamydia test positivity and gonorrhoea incidence in women declined respectively from 8.2% to 6.5% and from 59.6 to 26.4 per 100,000. The latter more impressive reduction is unfortunately hard to distinguish from a strong secular trend in the same direction in various states.

There are more general problems, however – such as knowing whether the handing over of PDPT packs is resulting in the successful treatment of disease, or whether it may even be contributing to an ongoing failure to diagnose concomitant partner infections.  These might weigh in favour of the alternative approach recently developed in UK clinics: APT.  Estcourt & Johnson (STI) report uptakes of 66% and 59% for versions of APT as against 36% for conventional PS.  Sending a treatment pack following a telephone interview would seem to offer a better guarantee of partner treatment, than offering a pack on the basis of nothing more than a stated willingness of the index patient to deliver it.  At the same time, interviewing the partner averts the risk of doing harm by pre-empting consultations at which a fuller diagnosis of the partner’s condition would have been possible.  A population-level trial of the impact of APT has yet to be undertaken.

Expedited Partner Therapy (EPT): Why in the US and not in the UK?

9 Nov, 12 | by Leslie Goode, Blogmaster

Expedited Partner Therapy (EPT) in sexual health is the practice of prescribing for the partner(s) of the patient without prior medical evaluation.  In many countries (e.g. UK and Australia) the practice is not current, since it does not comply with prescribing guidance.  But in the US it is being actively promoted by professional bodies (e.g. the American Association of Pediatrics (AAP)), and is currently employed in certain states, as a response to serious need which could not otherwise be met.

A recent paper (Hsii, Golden et al.) (http://pediatrics.aappublications.org.libproxy.ucl.ac.uk/search?fulltext=Neville+Golden&submit=yes&x=34&y=9) presents the results of a survey of junior doctors (residents) on pediatric training schemes in California (the first state to clarify the legality of EPT (2001)) regarding their knowledge of – and attitudes to – EPT. This is interesting for two reasons.  Firstly, the light it sheds  on an EPT itself, as one among a number of alternatives to conventional treatment practice sometimes proposed as a more effective means to meet public health need.  Second, on how the policy change required to implement the alternative approach tends to impact professional knowledge and behaviour over the longer term.

Key findings of the paper are: 52% of trainees claim to have used EPT, though 30% felt uncomfortable doing so – and only 8% were “fully aware” of the legal status of EPT in California.  For those of us living in countries where EPT is unfamiliar, the surprise is that EPT should be current practice at all – especially in the context of adolescents with all the associated problems of child protection.  The ill-ease of the trainees seems understandable given the complexity of issues surrounding EPT, which include, in addition to the question of its legal status and child protection issues, also problems around who pays for the prescription and how the partner’s treatment is dealt with administratively (see AAP position paper: http://www.adolescenthealth.org/AM/Template.cfm?Section=Position_Papers&Template=/CM/ContentDisplay.cfm&ContentID=1473).  No doubt an objective of the paper, which is published in the journal of the AAP, is to encourage the further embedding of EPT in the everyday practice of young physicians.

So why is the US heading off down this route faster than everyone else – and what are the chances that the rest of us – the UK, for instance – will one day find ourselves following in its wake?        Golden and Estcourt usefully set out some of the diverse challenges facing  implementation of EPT and related approaches the US and the UK (http://sti.bmj.com/content/87/Suppl_2/ii37.full); they also refer at some length, in the case of the UK, to a related alternative approach, Accelerated Partner Therapy (APT), pioneered in a recent exploratory trial in the UK, in which the medical evaluation of the partner takes place by telephone (see Roberts and Estcourt: http://sti.bmj.com/content/88/1/16.abstract).

The complexities around alternative referral approaches are considerable.  Furthermore, it really is the treatment of the adolescent population that is envisaged by recent US initiatives (a population excluded from the recent UK exploratory trial on account of child protection issues).  Child protection, of course, is no less a concern in the US (http://www.jahonline.org/article/S1054-139X(04)00200-9/fulltext).  If such initiatives are hard to imagine in the UK, this may simply be because the problem of unmet need has nowhere attained the scale it has in the US, where it would justify over-riding the counter-balancing concerns.  Another source of difference between the US and the UK, not mentioned by Golden & Estcourt, may be the absence of a professional interest group (like the paediatricians of the AAP) who feel themselves charged with lobbying specifically on behalf of the sexual health needs of adolescents (12+).  Ultimately, though, it is probably the sheer scale of the US adolescent chlamydia epidemic – as yet unmatched in the UK – that has driven the recourse in the US to unorthodox solutions.  If and when alternative referral practices – APT, for instance – become more widespread in the UK, it may not be in the same contexts as in the US, or for the same purposes.  At least we hope not.

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