Partner Management for Chlamydia-Infected Women in Family Planning Clinics California, 2005-2006 Ying-Ying Yu 1 2, J Frasure 1, G Bolan 1, EF Dunne 3, L Markowitz 3, A Amey 4, M Deal 4, J Lifshay 1, L Packel 1, H Bauer 1 California Department of Public Health, Sexually Transmitted Disease Control Branch 1 CDC, Epidemic Intelligence Service 2 CDC, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention 3 California Family Health Council 4 Good morning.

Chlamydia Most common reportable STD 6-month reinfection in women: 10%-15% Multiple infections lead to complications Partner treatment important CT is the most common reportable sexually transmitted disease in CA and nation wide. In CA, there’s about 100k cases reported in women annually. For women, the 6-month re-infection rate is 10-15%. Multiple infections in women can lead to further complications, such as pelvic inflammatory disease, ectopic pregnancy, and infertility. For men, the infection is usually asymptomatic, but to prevent re-infection in women, it is important to have their male sex contacts treated.

Partner Management Strategies Traditional strategies Patient referral Provider referral Health department referral Patient-Delivered Partner Therapy (PDPT) BYOP referral – Bring Your Own Partner Commonly used partner management strategies are outlined here. Traditional strategies include patient referral, which means at time of treatment, the provider tells the patient to inform their sex partner of the importance of getting proper medical care. There’s also provider referral and HD referral, in which case either the provider or health department staff would try and inform the partners to prevent further spread of the infection. note that with the huge number of CT cases, managing direct follow-up with the partners is an impossible challenge to public health resource. Patient-delivered partner therapy, what we call PDPT, refers to the clinical practice that the infected patients are given meds or prescription to take to their sex partners, it was legalized in CA for treating CT in 2001 and recommended as a 2nd-line strategy when the partner is otherwise unlikely to be treated. BYOP here stands for bring your own partner referral, it is an unofficial term that the CA std control branch uses to refer to the practice in family planning clinics where clinic staff, when they call to notify the patient of her + lab results, encourage the patient to bring her sex partner with her to the clinic when she comes in for treatment.

Objectives Evaluate PDPT and other partner services provided to CT infected women in family planning clinics Describe frequency of use Evaluate outcome of partner management strategies Identify factors that may affect choice of strategy and outcome The goal of this project was to evaluate patient delivered partner therapy and other partner management services provided to CT infected women in family planning clinics. We wanted to first describe what kind of partner management strategies were being used and frequency of use; then to evaluate partner treatment outcome for each strategy used; we also wanted to identify factors that may affect clinician’s choice of management strategy and treatment outcome.

Study Design Cross-sectional Inclusion/exclusion criteria: Lab-confirmed CT-infected women Aged 16-35 yrs Permission to be interviewed Excluded women co-infected with other STDs 8 family planning clinics in CA This was a cross-sectional evaluation. We included women with lab-confirmed ct infection, between the ages of 16 and 35, who gave permission to be interviewed and had no other STD infections. I will be using the terms women and patients interchangeably in my talk, and they both mean study subjects. We recruited 8 family planning clinics throughout CA with high CT morbidity and some use of PDPT in order to evaluate this strategy.

Data Collection and Analysis Telephone interviews with patients at 2 and 6 weeks post treatment Data collected on up to 3 partners Partner management strategy provided Outcome: Partner took medication for CT Statistical methods Descriptive Multivariable regression Stratification on relationship type We collected data with 2 phone interviews with participating patients, at 2 and 6 weeks post treatment. Data were collected on up to 3 partners in the previous 2 months from each patient. For each partner, the patient was asked how the clinic suggested getting her partner treated. The outcome of interest was whether the partner took his medication, and we classified the outcome based on what the patient reported of her partner. We used descriptive statistics and multivariable regression in data analysis, and also did stratified analyses on relationship type, which was a variable indicating whether or not the partner was considered a steady partner by the patient.

Participation 1,121 CT + gave permission 348 unable to contact 773 (69%) interviewed 1,121 CT + gave permission 744 (66%) patients 348 unable to contact 29 had other STDs 957 male partners named From the 8 clinics, we had gotten permission to contact from a total of 1121 eligible patients. We were able to contact and interview 69% of those, some of whom were co-infected with other STDs and therefore excluded. As a result, we had 744 patients in this evaluation, who named 957 male sex partners at their phone interview

Partner Management Strategies (n=957) Overall, For the 957 partners, more than half were managed with traditional patient referral, which appeared to be the most commonly used strategy, followed by PDPT, and BYOP. For 10% of the partners, the patients reportedly had received no management strategy. Bear in mind that while the patients discussed partner information with our interviewer, they might not have discussed such information with their providers, and for partners not known to the provider, there’d be no partner management.

Partner Management Strategy by Relationship Type That leads to this slide, which is the use of management strategy by relationship type. whether the patient was in a steady relationship with the partner may not only affect their communication with her partner, but also with the provider, and therefore [may affect] the type of partner management they were offered. Among the 957 partners, 551 were reported by the women as someone with whom they had a steady relationship, and 404 were reported as someone with whom they did not have a steady relationship. 19% of the steady partners vs 6% of the non-steady partners were managed with the BYOP strategy, 27% of steady vs 11% of non-steady partners were managed with patient delivered partner therapy; and compared to steady partners, non-steady partners were more often managed with traditional patient referral or no management at all.

Partner Management Strategy Treatment Outcome by Partner Management Strategy Switching gear to the outcome of partner management, Overall, 53% of all named partners were said to have taken their medication. Yet there was noticeable difference By strategy, 79% of those who were managed with BYOP got treatment, 77% with pdpt, 40% with patient referral, and 12% with no management were said to have taken their medication.

Treatment Outcome by Management Strategy and Relationship Type There was again important differences by relationship type. For steady partners, the majority of those who were managed with BYOP got treatment, in comparison, also managed with BYOP, only 38% of the non-steady partners got treatment. With patient delivered partner therapy, 83% of steady and 57% of non-steady partners got treatment; and with traditional patient referral, 60% of steady vs 17% of non-steady partners got treatment. 44% of steady vs 5% of non-steady partners got treatment if no management strategy was documented.

Association of Treatment Outcome with Management Strategy by Relationship Type Partner Management Strategy Steady Partner (n=551) Non-steady Partner (n=404) OR (95%)* OR (95%CI)* BYOP 3.6 (1.8-7.4) 3.5 (1.7-7.0) PDPT 2.8 (1.4-5.4) 6.0 (3.3-10.8) Patient referral 1.4 (0.7-2.6) 2.0 (1.2-3.3) None 1.0 *OR adjusted for patient’s age and race/ethnicity

Limitations Self-reported management strategy Surrogate report of treatment Selection bias Family planning clinics Permission to be interviewed This evaluation had several limitations, first, type of partner management strategy used was based on patient’s self report, and the outcome, defined as whether the partner took the medication was also based on the patients’ report, which can be thought as surrogate report of the partners. Also, the results are subject to selection bias, our data were collected from family planning clinics and are not generalizable to other settings. Interviews were done with clients who agreed to participate, which may have resulted in a more compliant patient population and inflated treatment rate of partners.

Conclusions Traditional patient referral least effective, yet most commonly used BYOP most effective for steady partners PDPT most effective for non-steady partners In conclusion, traditional patient referral was the least effective partner management strategy in getting partners treated, yet the most commonly used. BYOP, or Instructing patients to bring their partners in when clinic notifies patient for treatment, was very effective in getting partners treated in these family planning clinics, especially for steady partners. If not feasible for the partner to come in for evaluation and treatment, pdpt was a very effective method, both for steady and non-steady partners.

Recommendations Encourage patients to bring their partners to clinic Casual/non-steady partners also need to be managed and treated Consider partner/relationship type Based on our evaluation, we recommend that at time of results notification, providers should advise patients to bring their partners to clinic for proper evaluation. Partner management should target all partners including casual and non-steady partners. Some management strategies may be more effective than others in the case of steady vs. non-steady partners, and providers should attempt to address these issues with the patient.

Acknowledgments CDPH STD Control Branch CDC Joan Chow Denise Gilson Erika Samoff Yuri Springer Linda Wool CDC Sheryl Lyss Planned Parenthood Mar Monte and San Bernardino Jill MacAfee Andrea Hernandez Delia Sandova Martha Robles Josefina Lopez The findings and conclusions in this presentation are those of the author(s) and do not necessarily represent the views of the Centers for Disease Control and Prevention.