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

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.

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