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

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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