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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

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

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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