1. 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.

2. 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.

3. 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.

4. 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.

5. Study Design Cross-sectional Inclusion/exclusion criteria:
Lab-confirmed CT-infected women
Aged 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.

6. 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.

7. 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

8. 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.

9. 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.

10. 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.

11. 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.

12. 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 ( )
3.5 ( )
PDPT
2.8 ( )
6.0 ( )
Patient referral
1.4 ( )
2.0 ( )
None
1.0
*OR adjusted for patient’s age and race/ethnicity

13. 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.

14. 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.

15. 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.

16. 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.