Patient delivered partner therapy for std evidence and prospects for implementation
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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. Questions.

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Patient-Delivered Partner Therapy for STD: Evidence and Prospects for Implementation

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Patient delivered partner therapy for std evidence and prospects for implementation

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


Questions

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?


Why consider pdpt

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


Pdpt prevalence

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


Survey sample

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.


Pdpt by physicians national survey

PDPT by physicians: National survey

% Physicians

Never

Sometimes

Half

Usually

Always

N=2,538 CT N=1,873 GC


Correlates of pdpt

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)


Seattle proportion of patients with ct infection who received medications for their partners n 150

Seattle: Proportion of patients with CT infection who received medications for their partners(n=150)

% Physicians

0

1-24

25-49

50-74

75-100

Source: Golden et al (1999). Sex Transm Dis

% patients


Pdpt effectiveness

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


Pdpt effectiveness1

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).


Infection during follow up among 1860 persons completing the randomized trial

Infection during follow-up among 1860 persons completing the randomized trial

P=.04

P=.17

P=.02

Percent

N=358

N=1595

N=1860


Partner treatment per index patient report

Partner treatment per index patient report

P<.0001

P<.0001

Percent

P=.001


Other factors relevant to pdpt

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)


More work to be done

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?


Reference list

Reference list

  • References available as a handout. If you have relevant material, feel free to send it to Matthew Hogben at [email protected] That includes references and ideas.

    • 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.


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