Toward Better Control of Sexually Transmitted Diseases
http://www.100md.com
《新英格兰医药杂志》
Proper clinical and public health treatment of patients with gonorrhea or chlamydial infection must include the treatment of their sexual partners. Such partners are often asymptomatic and, unless treated, will reinfect the index patient or spread infection to others. A traditional approach has been to deploy members of the health department field staff to notify exposed sex partners and bring them (at times literally) in for treatment. However, many health department resources are strained by the increasing prevalence of human immunodeficiency virus (HIV) infection and emerging threats, such as bioterrorism. Given these challenges and staffing shortages, health departments in many areas have stopped notifying the partners of patients with sexually transmitted diseases (STDs) other than syphilis and HIV infection. The areas with limited services for partners are often those communities with the highest rates of STDs.1 The current standard approach to gonorrhea and chlamydial infection is to request that patients themselves notify their sexual partners, who are then expected to seek medical evaluation and treatment. This approach has largely been a failure.2,3,4 Although gonorrhea rates are at an all-time low in the United States, the disease has a heterogeneous distribution, and it continues to be hyperendemic in many of our poorest communities.5 We have made no meaningful progress since 2000 toward the goals for rates of gonorrhea and chlamydial infection set by the Department of Health and Human Services in the Healthy People 2010 initiative as benchmarks for the current decade. We have little that is innovative to apply as new tools in STD management. If we are to achieve our goals for public health, we clearly need to develop and implement more efficient and effective models of partner care.
In this issue of the Journal, Golden et al. report success with a new model of partner care.6 They gave patients who were being treated for gonorrhea or chlamydial infection the means to deliver antibiotics directly to sex partners on their own. In this randomized, controlled trial, patients in both the public and private sectors of King County, Washington, either were given "partner packets" by treating clinicians or were allowed to pick them up at participating pharmacies. If patients were unable or unwilling to provide treatment to their partners, members of the study staff contacted the partners by telephone and arranged for them to pick up the partner packet from a pharmacy or to have it delivered through the mail. Whatever the means of antibiotic delivery in the expedited-therapy group of this trial, formal clinical or medical evaluation was not a required step for the exposed partner to receive treatment.
Outcomes among index patients (the original patients with gonorrhea or chlamydial infection) assigned to expedited treatment of partners were compared with those assigned to standard referral of partners, meaning referral by the patients to a clinic for evaluation and treatment. After three months, those in the group whose partners received expedited treatment had better outcomes than those whose partners received the standard approach to referral. Patients in the former group were much more likely to report that their sex partners had been treated and less likely to have additional contact with an untreated sex partner. They were also less likely to have recurrent gonorrhea or chlamydial infection at follow-up testing, which is the most convincing outcome in this trial in terms of weighing the effects of this strategy and predicting its ability to improve disease control at a population level. We can conclude that the use of expedited approaches designed to circumvent traditional evaluation by a clinician increases the chance of an exposed partner's receiving proper therapy and, most important, reduces the original patient's risk of reinfection.
Although very promising, this approach to partner care is not universally applicable. It offers no benefit to those whose sex partners are anonymous or cannot easily be located. It is unlikely to be feasible when parenteral therapy is the recommended treatment option, as with syphilis. There is the remote possibility of preventable adverse drug reactions among partners who forgo a clinical evaluation. The benefits of expedited treatment of partners will need to be balanced against potential lost opportunities for the prevention of STDs or HIV infection. Clinic visits offer an opportunity to provide other prevention services — testing for other STDs, risk-reduction counseling, hepatitis vaccination, screening for evidence of domestic violence and cervical cancer, contraception, and drug-abuse counseling.
Golden et al. focused exclusively on heterosexuals. However, in many communities, gay or bisexual men are emerging as the highest risk group for the acquisition of STDs, especially antibiotic-resistant gonorrhea, syphilis, and HIV infection.7,8 Circumventing a complete clinical evaluation to expedite treatment for gonorrhea or chlamydial infection may lead to missed opportunities in this population for early intervention in cases of syphilis and HIV infection. Nevertheless, the findings presented by Golden et al. represent a major advance for the control and prevention of STDs.
Attempts to integrate interventions such as the expedited delivery of antibiotics to sexual partners into standard public health policy will require substantial effort and will inevitably hit some roadblocks. Few community-based models for pharmacy networks exist to deliver a public health intervention such as the one described. Establishing the extensive public–private partnership of participating pharmacies in the King County community to support the study protocol was in itself an innovation. Furthermore, statutes governing medical practice in many states may explicitly prohibit physicians from prescribing medication without an established physician–patient relationship. Pharmacy boards may be similarly restrictive in permitting the dispensing of antibiotics on standing orders by public health authorities for broad exposure indications. Overcoming these legal and regulatory barriers may require substantial advocacy and perseverance. And even if widely endorsed, current barriers to effective partner care could still preclude implementation in the private sector. Many third-party payers do not fund prescriptions to exposed sex partners who may not be covered by the index patient's plan or who might not be insured at all. And finally, although most of the data on expedited treatment of partners come from industrialized countries, this approach may have its greatest effect in the developing world, where complications from STDs are extraordinarily common and resources to provide clinical services are scarce.
The decision to implement expedited treatment of sexual partners for gonorrhea and chlamydial infection into general practice will require some compromises. In the eyes of many clinicians, it will fall short of the perfect model. However, continuing to accept the status quo in many of our communities — with high rates of transmission of gonorrhea and chlamydial infection and their attendant health consequences — may represent a greater compromise with even more serious health costs. Expedited care of partners is a management model that holds great promise for the improved control and prevention of STDs.
Source Information
From the Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore.
References
Golden MR, Hogben M, Handsfield HH, St Lawrence JS, Potterat JJ, Holmes KK. Partner notification for HIV and STD in the United States: low coverage for gonorrhea, chlamydial infection, and HIV. Sex Transm Dis 2003;30:490-496.
Landis SE, Schoenbach VJ, Weber DJ, et al. Results of a randomized trial of partner notification in cases of HIV infection in North Carolina. N Engl J Med 1992;326:101-106.
Oh MK, Boker JR, Genuardi FJ, Cloud GA, Reynolds J, Hodgens JB. Sexual contact tracing outcome in adolescent chlamydial and gonococcal cervicitis cases. J Adolesc Health 1996;18:4-9.
Macke BA, Maher JE. Partner notification in the United States. Am J Prev Med 1999;17:230-242.
STD surveillance 2003. (Accessed January 28, 2005, at http://www.cdc.gov/std/stats/toc2003.htm.)
Golden MR, Whittington WLH, Handsfield HH, et al. Effect of expedited treatment of sex partners on recurrent or persistent gonorrhea or chlamydial infection. N Engl J Med 2005;352:676-685.
Increases in fluoroquinolone-resistant Neisseria gonorrhoeae among men who have sex with men -- United States, 2003, and revised recommendations for gonorrhea treatment, 2004. MMWR Morb Mortal Wkly Rep 2004;53:335-338.
Primary and secondary syphilis -- United States, 2002. MMWR Morb Mortal Wkly Rep 2003;52:1117-1120.(Emily J. Erbelding, M.D.,)
In this issue of the Journal, Golden et al. report success with a new model of partner care.6 They gave patients who were being treated for gonorrhea or chlamydial infection the means to deliver antibiotics directly to sex partners on their own. In this randomized, controlled trial, patients in both the public and private sectors of King County, Washington, either were given "partner packets" by treating clinicians or were allowed to pick them up at participating pharmacies. If patients were unable or unwilling to provide treatment to their partners, members of the study staff contacted the partners by telephone and arranged for them to pick up the partner packet from a pharmacy or to have it delivered through the mail. Whatever the means of antibiotic delivery in the expedited-therapy group of this trial, formal clinical or medical evaluation was not a required step for the exposed partner to receive treatment.
Outcomes among index patients (the original patients with gonorrhea or chlamydial infection) assigned to expedited treatment of partners were compared with those assigned to standard referral of partners, meaning referral by the patients to a clinic for evaluation and treatment. After three months, those in the group whose partners received expedited treatment had better outcomes than those whose partners received the standard approach to referral. Patients in the former group were much more likely to report that their sex partners had been treated and less likely to have additional contact with an untreated sex partner. They were also less likely to have recurrent gonorrhea or chlamydial infection at follow-up testing, which is the most convincing outcome in this trial in terms of weighing the effects of this strategy and predicting its ability to improve disease control at a population level. We can conclude that the use of expedited approaches designed to circumvent traditional evaluation by a clinician increases the chance of an exposed partner's receiving proper therapy and, most important, reduces the original patient's risk of reinfection.
Although very promising, this approach to partner care is not universally applicable. It offers no benefit to those whose sex partners are anonymous or cannot easily be located. It is unlikely to be feasible when parenteral therapy is the recommended treatment option, as with syphilis. There is the remote possibility of preventable adverse drug reactions among partners who forgo a clinical evaluation. The benefits of expedited treatment of partners will need to be balanced against potential lost opportunities for the prevention of STDs or HIV infection. Clinic visits offer an opportunity to provide other prevention services — testing for other STDs, risk-reduction counseling, hepatitis vaccination, screening for evidence of domestic violence and cervical cancer, contraception, and drug-abuse counseling.
Golden et al. focused exclusively on heterosexuals. However, in many communities, gay or bisexual men are emerging as the highest risk group for the acquisition of STDs, especially antibiotic-resistant gonorrhea, syphilis, and HIV infection.7,8 Circumventing a complete clinical evaluation to expedite treatment for gonorrhea or chlamydial infection may lead to missed opportunities in this population for early intervention in cases of syphilis and HIV infection. Nevertheless, the findings presented by Golden et al. represent a major advance for the control and prevention of STDs.
Attempts to integrate interventions such as the expedited delivery of antibiotics to sexual partners into standard public health policy will require substantial effort and will inevitably hit some roadblocks. Few community-based models for pharmacy networks exist to deliver a public health intervention such as the one described. Establishing the extensive public–private partnership of participating pharmacies in the King County community to support the study protocol was in itself an innovation. Furthermore, statutes governing medical practice in many states may explicitly prohibit physicians from prescribing medication without an established physician–patient relationship. Pharmacy boards may be similarly restrictive in permitting the dispensing of antibiotics on standing orders by public health authorities for broad exposure indications. Overcoming these legal and regulatory barriers may require substantial advocacy and perseverance. And even if widely endorsed, current barriers to effective partner care could still preclude implementation in the private sector. Many third-party payers do not fund prescriptions to exposed sex partners who may not be covered by the index patient's plan or who might not be insured at all. And finally, although most of the data on expedited treatment of partners come from industrialized countries, this approach may have its greatest effect in the developing world, where complications from STDs are extraordinarily common and resources to provide clinical services are scarce.
The decision to implement expedited treatment of sexual partners for gonorrhea and chlamydial infection into general practice will require some compromises. In the eyes of many clinicians, it will fall short of the perfect model. However, continuing to accept the status quo in many of our communities — with high rates of transmission of gonorrhea and chlamydial infection and their attendant health consequences — may represent a greater compromise with even more serious health costs. Expedited care of partners is a management model that holds great promise for the improved control and prevention of STDs.
Source Information
From the Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore.
References
Golden MR, Hogben M, Handsfield HH, St Lawrence JS, Potterat JJ, Holmes KK. Partner notification for HIV and STD in the United States: low coverage for gonorrhea, chlamydial infection, and HIV. Sex Transm Dis 2003;30:490-496.
Landis SE, Schoenbach VJ, Weber DJ, et al. Results of a randomized trial of partner notification in cases of HIV infection in North Carolina. N Engl J Med 1992;326:101-106.
Oh MK, Boker JR, Genuardi FJ, Cloud GA, Reynolds J, Hodgens JB. Sexual contact tracing outcome in adolescent chlamydial and gonococcal cervicitis cases. J Adolesc Health 1996;18:4-9.
Macke BA, Maher JE. Partner notification in the United States. Am J Prev Med 1999;17:230-242.
STD surveillance 2003. (Accessed January 28, 2005, at http://www.cdc.gov/std/stats/toc2003.htm.)
Golden MR, Whittington WLH, Handsfield HH, et al. Effect of expedited treatment of sex partners on recurrent or persistent gonorrhea or chlamydial infection. N Engl J Med 2005;352:676-685.
Increases in fluoroquinolone-resistant Neisseria gonorrhoeae among men who have sex with men -- United States, 2003, and revised recommendations for gonorrhea treatment, 2004. MMWR Morb Mortal Wkly Rep 2004;53:335-338.
Primary and secondary syphilis -- United States, 2002. MMWR Morb Mortal Wkly Rep 2003;52:1117-1120.(Emily J. Erbelding, M.D.,)