1. Patient-Delivered Partner Therapy for STD: Evidence and Prospects for Implementation National STD Conference 2004 Matthew Hogben, CDC Matthew R Golden, U Washington and PHSKC Patricia Kissinger, Tulane U Janet S St. Lawrence, CDC

2. Questions Why consider dispensing medications or prescriptions to patients to give to their sex partners? What do we know about the prevalence of PDPT? What do we know about how well it works? –Using which measures of effectiveness?

3. Why consider PDPT The standard of care is self-referral, which does not capture all partners Meta-analyses suggest DIS-assisted notification is more effective than self-referral –But STD morbidity is too high for universal DIS- assisted referral –89% of syphilis cases, but only 17% of GC and 12% of CT cases were interviewed in high morbidity areas* PDPT is a possible alternative or complementary strategy *Golden, Hogben et al. (2003). Sex Transm Dis

4. PDPT Prevalence Vague status of PDPT means data have been sparse – or vice versa –Legal (more civil than criminal) –Professional opinions surrounding physical evaluations of patients A recent national survey has yielded more information

5. Survey Sample* Five AMA specialties diagnosing 85% of STD in the USA 4233 respondents (70% response rate) 71% male, 76% White, 46 years old 87% in private settings, 69% primary care offices In the past year:** –54% had diagnosed GC –73% had diagnosed CT *St. Lawrence, Montano, et al (2002). Am J Public Health. **McCree, Liddon, et al (2003). Sex Transm Inf.

6. PDPT by physicians: National survey NeverAlwaysUsually Half Sometimes % Physicians N=2,538 CT N=1,873 GC

7. Correlates of PDPT PDPT practice was most common among: –Ob/gyns and family/general practitioners (least common among ER physicians) –Physicians with higher proportions of female patients Also correlated with forms of “provider referral.” –Collecting partner information and contacting partners –Collecting partner information and sending it to HD Less common in circumstances where STD is most prevalent –Negatively correlated with proportion of Black or African American patients –Least common in Southern US (Federal quadrant)

8. Seattle: Proportion of patients with CT infection who received medications for their partners (n=150) 075-10050-7425-491-24 % patients % Physicians Source: Golden et al (1999). Sex Transm Dis

9. PDPT Effectiveness Reinfection rates –Among US studies reinfection of index cases is lower among those exposed to PDPT than among those receiving SOC Statistical significance varies by trial and STD For example: –Schillinger et al. (2003): 20% reduction, OR =.80, p =.10 –Golden et al. (in prep): 24% reduction, OR =.76, p =.04

10. PDPT Effectiveness Notification rates* –Equivalent among those exposed to PDPT than among those receiving SOC But those exposed to PDPT more likely to say that partners were “very likely” to have been treated or tested negative, OR = 1.6, p <.001 And more likely to have avoided sex with any partner they believed not “very likely” to have been treated or tested negative, OR = 0.5, p <.001 *Golden, Whittington, et al. (in prep).

11. Infection during follow-up among 1860 persons completing the randomized trial P=.02 P=.17 P=.04 Percent N=358N=1595 N=1860

12. Partner treatment per index patient report Percent P<.0001 P=.001

13. Other Factors Relevant to PDPT Medication sharing –Undertreatment Uninfected partners –Overtreatment Potential partner violence –How does this differ from the risk posed by SOC? STD reporting rates –Relevant if sex partners do not present for evaluation Implementation requirements –DIS (or other staff) training –Structural changes (policy, law, public/private cooperation)

14. More Work to be Done Using existing data –Meta-analysis will help establish A more robust mean effect Moderating effects on an overall mean –Descriptive multi-level modeling Allows structural and individual influences and correlates to be assessed together With whom does PDPT work best? In conjunction with which other partner management strategies?

15. Reference list References available as a handout. If you have relevant material, feel free to send it to Matthew Hogben at mhogben@cdc.gov. That includes references and ideas.mhogben@cdc.gov –Golden MR, Hogben M et al. Sex Transm Dis 2003;30:490-496 –Golden MR, Whittington WLH et al. Sex Transm Dis 2001;28:658- 665. –Kissinger P, Brown R et al. Sex Transm Inf 1998;74:331-333. –Klausner JD, Chaw JK. Sex Transm Dis 2003;30:509-511. –Macke B, Maher J. Am J Prev Med 1999;17:230-242. –McCree DH, Liddon NC et al. Sex Transm Inf 2003;79:254-256. –Oxman AD, Scott EAF et al. Can J Public Health 1994;85 (supp 1):S41-S47. –Schillinger JA, Kissinger P et al. Sex Transm Dis 2003;30:49-56. –St. Lawrence, Montano et al. Amer J Public Health 2002;92:1784- 1788.