# Presentation: 361034

## 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

- 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

- 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

- 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*

- 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

- Never

- Always

- Usually

- Half

- Sometimes

- % Physicians

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

## 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)

- 0

- 75-100

- 50-74

- 25-49

- 1-24

- % patients

- % Physicians

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

## 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 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

- P=.02

- P=.17

- P=.04

**Percent**

- N=358

- N=1595

- N=1860

## Partner treatment per index patient report

**Percent**

- P<.0001

- P<.0001

- P=.001

## 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

- 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

- References available as a handout.  If you have relevant material, feel free to send it to Matthew Hogben at _[mhogben@cdc.gov](mailto:mhogben@cdc.gov)__.  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.