Expedited Partner Therapy for STDs Works in One State; Why Not Others?

Patients who acquire sexually transmitted diseases (STDs) in California can help sexual partners in ways not yet possible in all 50 United States, even though most states already have legalized expedited partner therapy (EPT).

"Expedited partner therapy is a harm-reduction strategy and the clinical practice of treating the sex partners of persons with diagnosed chlamydia or gonorrhea who are unable or unlikely to seek timely treatment, by providing medications or prescriptions to the patient as allowable by law," according to treatment guidelines released in 2021 by the Centers for Disease Control and Prevention (CDC). "Patients then provide partners with these therapies without the healthcare provider having examined the partner."

The guidelines instruct medical providers to offer EPT to chlamydia patients when they can't ensure that all of a patient's sex partners from the previous 60 days will seek timely treatment and to make EPT available for the patient's most recent sex partners if the patient abstained from sex 60 days prior to diagnosis. Likewise, EPT for gonorrhea should be offered to partners unlikely to access timely evaluation after linkage is explored, according to the CDC.

EPT has been shown to be safe, effective and accepted by patients and their partners, according to Melissa Papp-Green, M.P.H., a health program analyst with the Los Angeles County Department of Public Health Division of HIV and STD Programs.

In California, EPT for chlamydia has been allowed since 2001 and it's been available for gonorrhea since 2007, she explained.

"It is known as a standard of care to ensure timely partner treatment when the partners are unable or unlikely to access clinical care on their own, and [it's] really a critical component of avoiding reinfection," Papp-Green explained.

But is EPT really an effective protocol worth adopting widely? If so, what makes it such a good fit in California, and what's standing in the way of EPT implementation in all states?

Before you feel overwhelmed with acronyms, here's a brief explanation:

"While EPT can be considered an umbrella term for the clinical practice of treating sex partners of persons diagnosed with one of the three aforementioned STDs, patient-delivered partner therapy [PDPT] refers to a subset of the protocol in which the diagnosed patients deliver the medication or prescription to their partners," Papp-Green noted. "EPT, as with its most common form, PDPT, offers providers the next-best option to professional evaluation of the partner."

How it works in California

Papp-Green said EPT is used in California because it's codified in state law and administered through the Family PACT, a medical program established in 1997 to provide reproductive healthcare and family planning services at no cost to low-income patients. It's also available through Medi-Cal, from clinics that purchase their own supplies of medication for EPT, through cash-pay prescriptions and through the Essential Access Health EPT Distribution Program.

"It has served 1.1 million income-eligible men and women of childbearing age through a network of 2,400 public and private providers," she said. Family PACT did not cover PDPT initially. "But starting in February of 2020, they did, which was a huge game changer."

As Papp-Green explained, PDPT enabled authorized professionals to either give the appropriate medication to the "index patient," the diagnosed person who then can give it to a sex partner, or write a prescription for the index patient that enables them to acquire the partner therapy for gonorrhea or chlamydia.

In California, an organization called Essential Access Health helps facilitate EPT and PDPT.

"We partner with both the California Department of Public Health and the L.A. County Division of HIV and STD Programs, as they are our funders," said Erin Crowley, M.P.H., director of STI prevention programs at Essential Access Health. "They fund us to administer the expedited partner therapy distribution program throughout California and Los Angeles County."

Essential Access Health has worked with the state health department since 2005 to distribute EPT. Currently, more than 200 clinic sites participate in the program and offer coverage in all sections of the Golden State, from the San Francisco Bay area to the Central Valley to Southern California's Inland Empire, according to Kala Heekin, the organization's STI prevention program manager. She acknowledged there is less presence in the Sierras and portions of rural Northern California, however.

Following the CDC guidelines for STIs, Crowley said the organization distributes doxycycline and azithromycin for the treatment of chlamydia, and the program provides cefixime, an oral medication, to treat gonorrhea through EPT.

The focus remains on those evidence-based treatments for bacterial STDs for now.

Destigmatization and patient-centered care to bolster EPT

According to Papp-Green, female partners often come in for STD testing. The index patient or would-be index patient might express reluctance to participate in patient-delivered partner therapy, perhaps out of fear a partner will react angrily to the revelation of the infection or leave them.

"So we are trying to work with our patients and kind of strategize on how they can tell their partner and how patient-delivered partner therapy can be a really effective way to avoid reinfection and get their partner treated," she said, adding that the public health department aims to "ease the burden and stigma" associated with STDs.

The effectiveness of EPT

"Data supporting EPT for heterosexual partners of patients with chlamydia or gonorrhea is particularly compelling," stated the PDPT guidance given to medical providers by the California Department of Public Health in 2016.

The guidance document suggests evidence for EPT's efficacy abounds. The state health department cited a 2003 randomized controlled trial published in the journal Sexually Transmitted Diseases, a 2005 study in the New England Journal of Medicine and another trial featured in the journal Clinical Infectious Diseases in 2005.

"A meta-analysis that included five clinical trials showed an overall reduced risk of recurrent infection in patients with chlamydia or gonorrhea who received EPT, compared with those who received standard partner treatment methods," the state health department added, citing a systematic review published in 2007 in the BMJ.

Subsequent research, including an article published in 2011 in the journal Current Infectious Disease Reports, highlighted a minimum of seven randomized clinical trials that had evaluated the efficacy of EPT.

"These trials have included heterosexual men and women and examine EPT for Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis," the authors explained. "These studies demonstrated either superiority for percentage of partners being treated, for a reduction in repeat infections, or cost benefit for EPT compared to the standard partner referral method, and reported no adverse events."

Why not implement EPT elsewhere?

The introduction and availability of EPT and PDPT happened prior to 2020 in California. That's also when Family PACT started covering PDPT and when, according to Heekin, it became a covered Medi-Cal benefit.

Once it became available via Family PACT and Medi-Cal, other states might have adopted it in a similar fashion. But EPT and PDPT did not become available everywhere in the U.S. after that.

"It may not happen because of the political will around reproductive healthcare," she noted.

Other states also lack funding mechanisms and programs like Family PACT.

L.A. County also received money from the state of California to purchase the medication for patient-delivered partner therapy that is then distributed through a PDPT portal to agencies that sign up to be distribution sites, Papp-Green explained.

Organizations accessing information from the now eight-year-old portal include Planned Parenthood in Los Angeles, Pasadena and the San Gabriel Valley. Papp-Green said a total of 17 organizations in L.A. County access PDPT through it.

As Crowley explained, the free medication program through Essential Access Health and the insurance coverage for Family PACT and Medi-Cal beneficiaries favorably position California to offer EPT and PDPT in ways other states are not equipped to do. A jurisdiction in Orange County in New York has started a similar free medication program, she noted.

Heekin added that California is fortunate to have Family PACT and Medi-Cal include EPT as a covered benefit.

"I haven't come across a private insurance or student insurance plan that covers EPT," Heekin said. "So I think that one big barrier is just the coverage itself."

General concerns regarding liability can also account for the absence of EPT elsewhere, she explained.

"Some states do have explicit provider coverage for protection from liability when it comes to offering EPT, but the landscape is pretty mixed in the U.S.," Heekin added.

In addition, EPT in California received a boost from legislation such as Senate Bill 306, passed in 2021 and effective as of January 2022.

"It strengthens the state law allowing EPT by including explicit liability protections for providers and for pharmacists and allowing prescriptions to be written with the wording, 'expedited partner therapy' or 'EPT' if the provider doesn't have the partner's name," Crowley said.

She encouraged other states to explore free medication program options, and advocates to support EPT through organizing and efforts to pass legislation.

Her colleague Heekin noted that identifying people who champion the provision of EPT within a health system or clinic can help create the potential for change and aid in implementation.

"We're not the only experts, but I would say, like, 'Talk to us,'" she said. "I guess that's what I would say is, like, 'Let's think about it together.' I mean, that's something we've explored with other health departments. We've collaborated, of course, within California but also outside of our state trying to figure out the similarities and also unique barriers or challenges or opportunities in other areas that are different from us."