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.

A recent paper by a Belgian team discusses the health impact of the Millennium Development Goals (MDG) in sub-Saharan Africa, and highlights the potential short-termism of a strategic approach focussed on “quick wins”.  Many of the health issues discussed touch on sexual health.

The year 2001 saw poverty become the focus of the global political agenda, when the 189 countries of the UN in the General Assembly established eight goals to be achieved by 2015. The goals (MDG) have given rise to funding instruments called Global Health Initiatives (GHI) which have tended to favour “very high short-term impact that can be immediately implemented” over more complicated and long-term developments.

The MDGs directly affecting sexual health are: MDG 6 – eradicate HIV/AIDS & Malaria; MDG 4 – reduce child mortality (because of vertical transmission of HIV/AIDS); MDG 5 – improve maternal health (because the 2005 World Summit included within this goal “achieving universal access to reproductive health”).  Indirectly and in the longer term, MDG 2 – achieve universal primary education and MDG 3 – empower women affect issues of behaviour change likely to impact on sexual health.  MDG 1 – eradicate hunger, 7 – ensure sustainability, 8 – develop global partnership primarily affect health issues other than sexual health.

In general, the paper argues that an emphasis on “quick impact” interventions is not always beneficial:

-          Initiatives have been developed in parallel to, rather than in integration with, the existing health systems, with resulting distortions in provision of care.

-           The focus on short term, community-based initiatives can result in deployment of resources away from longer-term strategies that require indigenous health services development and inter-sectoral approaches to health planning.

-          The assessment of progress on the basis of data that is not disaggregated for socio-economic status and other equity parameters can result in strategies that achieve global targets at the cost of neglecting the neediest population sub-groups.

A glance at the recent (2011) UNAIDS report will reveals the tension between this “high-

impact intervention” approach and much current thinking in the health policy area.

More specifically, the authors argue that while anti-retrovirals therapy (ART) may appear to be a “quick impact” intervention, sustaining progress in this area is going to require health service development in the longer term.  Expanding access to sexual and reproductive health services, while classed as a health-related “quick win”, has actually suffered a decrease in funding over the decade.  The paper also gives the example of contraceptive use in Kenya as a case of how apparent improvements overall can mask a deterioration in the situation of the most underprivileged (those classed “no education”).

The recommendations of this paper include:

-          More attention to health systems development essential to the future delivery of the aims embodied in MDGs 4, 5 and 6;

-          Not neglecting the role of MDGs 2 & 3 (universal education and empowering women) in securing improved maternal and child health long term;

-          Not allowing achievement of MDGs to be at the expense of continued efforts to improve the social determinants of health.

Fabienne Richard et al., “Sub-Saharan Africa and the health MDGs: the need to move beyond the “quick impact” model”, Reproductive Health Matters, Vol. 19, Issue 38, November 2011

http://www.sciencedirect.com/science/article/pii/S0968808011385795

Far more needs to be done to diagnose incident Hepatitis C (HCV) in HIV-infected men in the era highly active anti-retroviral therapy (HAART).  This is the message coming out of a recent US long-term study (http://cid.oxfordjournals.org/content/early/2011/01/29/cid.ciq201.full).

Current US Public Health Service HIV guidelines endorse HCV testing only at initial HIV diagnosis – maybe because of low rates of HCV transmission in heterosexual couples.  But, according to the authors of this study, this does not respond to the importance of male to male transmission, and strong possibility, indicated by this study and others, that intravenous drug use is not the dominant means of transmission.  HCV in HIV-infected people is a serious cause of morbidity and mortality, but clinically silent until an advanced stage.  In order to be able to intervene at the acute stage where the disease is responsive to treatment, and to contain epidemiological spread, it is imperative, the authors argue, to develop new approaches to diagnosis and treatment.

Of the 1830 men engaged in the study (94% in HAART) 36 sero-converted, amounting to an incidence of .51 cases in 100 person years.  Sero-conversion was also associated with IDU history (25%) and poor HIV suppression.  This suggests nonparenteral transmission, and possibly a tendency to poor adherence to HAART, suggestive of risk-taking behaviour.

What would be the optimal interval of routine HCV anti-body surveillance for at risk HIV infected persons?  This remains to be determined – but our authors cite the recommendation of the New York State Department of Health AIDS Department, which is for annual serological testing.

Lynn E. Taylor, “Incident Hepatatis C Virus Infection among US HIV Infected men enrolled in Clinical Trials”, Clinical Infectious Diseases, March 2011

http://cid.oxfordjournals.org/content/early/2011/01/29/cid.ciq201.full

A recent judgment by a federal judge in Baltimore US marks the another move in the ongoing political struggle around Crisis Pregnancy Centres (CPCs), or Limited Service Pregnancy Centres (http://www.washingtontimes.com/news/2011/jan/28/pregnancy-disclaimer-law-ruled-unconstitutional/).

These volunteer run centres have established themselves with some social service agencies as an appropriate referral for women facing unintended pregnancy.  According to their detractors (e.g. Planned Parenthood), they supply ideologically motivated misinformation about pregnancy, STIs and contraception, and have been accused of withholding the results of pregnancy tests (http://www.ppvw.org/pressReleases/LSPCReportWebFINAL.pdf).

The judgment relates to an ordinance that took effect in Baltimore last year, requiring CPCs to post signs saying they do not provide abortions. The Baltimore judge ruled that the ordinance violated the Freedom of Speech Clause of the US Constitution.  The judgment, which is likely to be challenged on appeal, is a setback for the ongoing campaign to curb the influence of CPCs elsewhere in the US. Washington State, for example, with more than 40 CPCs, has just introduced similar legislation to ensure centres provide “accurate information about the services offered”.

Accurate sexual health information is, it seems, a valuable resource; some may find it hard to obtain when they need it most.

“Pregnancy disclaimer law ruled unconstitutional”, The Washington Times, Friday 28th January

http://www.washingtontimes.com/news/2011/jan/28/pregnancy-disclaimer-law-ruled-unconstitutional/

Better access to reproductive health care in the US: a promise stillborn?
A Step Forward. Obama’s health reform (PL111-148), while conceding nothing to the pro-choice lobby, offers genuine promise of better access to sexual health care. This is thanks to Barbara Mikuski’s provision requiring all new health insurance plans to cover preventive services for women with no out-of-pocket cost to patients. The general terms of the provision leave open the question of which services should be included. The matter is currently before an expert committee due to report in August.

Two Steps Back. This promise of better access may be stifled, and even existing levels of access imperilled, as healthcare reform becomes a battleground for Congress and many State legislatures, now dominated, thanks to the recent electoral sea-change, by opposition to “Obamacare” and undiscriminating conservative hostility towards any institution that could be remotely linked to a pro-choice position. According to author, Sharon Lerner, anti-abortion moderates, formerly favourable to family planning, have been voted out, or are susceptible to intense pressure, with a resulting polarization towards extreme positions.
The abortion issue is being deployed as a means of attacking the Obama reform. The Senate’s Democratic majority has pledged to block the repeal bill. But the lower House will then take up a resolution, calling on key committees to draft bills to replace elements of the reform law. The resolution (H.Res 9) calls for these efforts to include “provisions that prohibit taxpayer funding of abortions and provide conscience protections for health care providers”. The Mikulski provision, and any gains to be derived from it, will be especially vulnerable.
Anti-abortion measures could also pose a threat to sexual health provision, quite independently of their impact on the health reform law. The strongly conservative composition of Congress may be the ideal opportunity for the kind of anti-abortion legislation, such as the recently tabled bill by Representative Mike Pence, which failed to pass in 2007 and 2009). Pence’s bill would block federal funding to organizations that perform abortions, so that groups such as Planned Parenthood would no longer receive federal money for family planning. Already, at state level, with many conservative-dominated State legislatures strapped for cash, funding for reproductive health services is on the block. The outlook for reproductive healthcare provision has ceased to look so good.

See Sharon Lerner, “Does Contraception Count as Prevention?” The Nation, 18.01.11

Muslim leaders move against female circumcision
In Mauretania a meeting of 34 religious leaders convened by the Forum of Islamic Thought have issued a fatwa condemning female genital mutilation. Female circumcision is common in areas of Mauretania, as it is in other Islamic countries in Africa, notably Egypt, Sudan, Somalia and Eritrea (where it is now banned). In Egypt surveys have indicated that as many as 80% of women may have undergone a form of circumcision.
Fatwas are published opinions by Muslim religious scholars. They are non-binding in law, but Muslim believers are expected to follow them. Three recent fatwas relating to female circumcision have been issued in Egypt (1949, 1951, 1981), the two most recent being favourable to the practice. More recently (2007), the Grand Mufti issued a prohibition. Female circumcision is still far from being a thing of the past. The hope is that, in the words of Dr Sheiky Ould Zein Ould Imam of the Forum: (the fatwa) “removes the mask such practices were hiding behind”.

See Mohamed Yahya Ould Abdel Wedoud for Magharebia, 15.01.11

Ethnicity bias in the screening for Chlamydia: is it really so irrational?
Chlamydia testing is recommended for adolescents by the US Preventive Services Task Force, though take-up is known to be low (about half of eligible women). But why should it be so much lower for eligible women who are white (45%) than for black women (65%) or Hispanics (72%)? A recent US longitudinal cohort study, based on computerized data deriving from 3 hospitals and 30 clinics (Indiana), provocatively raises the question of ethnic stereotyping behaviour among responsible health practitioners. It also contends that these biases in Chlamydia screening may contribute to higher reported rates among ethnic minorities.
Given this suggestion of medical prejudice feeding off itself, it is surprising to find that differential rates of positivity on screening for ethnic groups are not given – even for patients in the study group. Low rates of positivity for the screened Hispanics would presumably have clinched the argument nicely. And why are rates of positivity not deemed relevant to the authors’ extended discussion of stereotyping behaviour? The perception of risk by patients and practitioners is surely a factor which should enter into any genuine attempt to account for the dynamics of their interaction.
Should we conclude that practitioner behaviour is necessarily irrational where it does not accord with official screening guidelines?

Sarah E. Wiehe et al., “Chlamydia Screening Among Young Women: Individual- and Provider-Level Differences in Testing”, Pediatrics, Jan. 2011

Developing sexual health programmes: a framework for action, WHO, 2010
The framework itself occupies two pages; the bulk of the document concerns the development of a “programme-based approach” based on the framework. An appealing feature of the report is the range of real life examples from around the world which are used to illustrate what has been – and can be – achieved by elements of this approach.
The unspoken assumptions underlying the report are that a value neutral standpoint is possible, and that this value neutral standpoint is the one adopted by the report. Such assumptions may be integral to the hegemonic ambitions of a “holistic” approach (reinforcing contestable abstractions like “sexual health”); but they contrast disconcertingly with the contended realities currently afflicting US politics (see above). A more open, less “holistic” discourse might be more plausible in this difficult area.

WHO report

We at STI were delighted to see that  one of our research papers (http://sti.bmj.com/content/early/2010/06/07/sti.2009.041954.short?q=w_sti_ahead_tab )  had been picked up by the British Broadcasting Corporation `s news website ( http://news.bbc.co.uk/1/hi/health/10401029.stm). It reports a dutch study on STI rates amongst “swingers”  ( heterosexual couples who are practising mate swapping, group sex or visit sex clubs for couples). The study looked at rates of gonorrhoea and chlamydia and found that swingers represented more than half of the STI diagnoses in the over 45 years age group. This clinic ( South Limburg) were able to do this analysis because their clinic has been registering surveillance data on swinging since 2007. 12% of their attendees were recorded as belonging to this group.

Certainly this is not data which sexual health clinics in the UK have been obtaining routinely during consultations or reporting for national surveillance programmes. National guidelines for sexual history taking do not include a specific closed question on swinging so we would be reliant on the patient to volunteer that information, or at the least, disclose their total number of partners and concurrency  in the routine sexual history. Does anyone else work in a clinic or STI prevention service which targets this group ?

Source: medFASH

This month`s journal sees a stirring editorial by Dr. Celia Skinner (1) in support of the new UK standards for the management of Sexually Transmitted Infections ( 2), published by the medical sexual health charity “MedFASH” in collaboration with all the major players in the field. Many would see such a document as being rather dry but like Dr. Skinner I see it as a real opportunity. The internal market in healthcare within the UK National Health Service (NHS) can often seem to divide clinicians who could be working together for patients. The standards attempt to prise us apart from our economic sparring to look at the bigger picture.

The NHS “commissioning” process has had the potential to squeeze out those with more specialist expertise in sexually transmitted infection care in favour of greater population coverage from ( cheaper ) non-specialist services. The standards acknowledge this trend  to be appropriate in part but with the proviso that there remains a specialist – possessing a UK “Certificate of Completion of Training (CCT) in Genitourinary Medicine (GUM)- at the hub to deliver complex STI care ( termed “Level 3 “). It also reinforces and advances the patient safety and care quality movement which has existed in UK healthcare since the scandals of the 1990s.

These standards are potentially a  massive boost to our ability in the NHS  to provide high quality sexual health care in a unified manner. Of course, they are not legally binding so will require passion and vision for us to go beyond local squabbles to look after our patients better. Indeed the Australian Sexual Health Clinician Chris Fairley, who also writes an editorial in this issue (3), believes that their impact might even be international. I therefore call upon my UK colleagues in the field to keep an open mind and let the this document into their hearts !

1. Standards for the management of sexually transmitted infections (STIs). British Association for Sexual Health and HIV (BASHH) / Medical Foundation for AIDS and Sexual Health (MedFASH). January 2010. http://www.medfash.org.uk/activities/activities.html#BASHH
2. Standards for the Management of Sexually Transmitted Infections: will they have an impact ? Skinner C. Sex Transm Infect 2010;86:81-82. http://sti.bmj.com/content/86/2/81.extract
3. An international perspective of the newly published Standards for the Management of STIs. Fairley C. Sex Transm Infect 2010:86:80-81 http://sti.bmj.com/content/86/2/80.extract