At Long Last, D.C. Legalizes Care for Partners of Patients With Some STIs

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Analysis Health Systems

At Long Last, D.C. Legalizes Care for Partners of Patients With Some STIs

Jonathan Neeley

Expedited partner therapy is now legal in Washington, D.C., thanks to the passage of Bill 20-343. It's a progressive step for a medical practice whose day is long overdue.

When patients in California are diagnosed with chlamydia or gonorrhea, doctors can send them home with medication not only for themselves, but also for their partners. It’s a practice called expedited partner therapy, and it’s legal in 35 states as well as the city of Baltimore.

And now, thanks to Bill 20-343, the Expedited Partner Therapy Act of 2013, you can add Washington, D.C., to that list. Introduced by D.C. city council members David Grosso, Anita Bonds, and Tommy Wells and co-sponsored by six others, the bill passed its final reading last Tuesday. It is now awaiting Mayor Vincent Gray’s expected signature and the completion of a 30-day Congressional review process. The city council expects the bill to become law in April or May.

“It’s an important issue,” said Grosso, a former board member at Planned Parenthood Metro Washington. “We have to get control over our STD issues in the District.”

The reality of those issues, according to the D.C. Committee on Health’s report on the bill, is dire. From 2010 to 2011, chlamydia and gonorrhea diagnoses rose 18 and 22 percent, respectively. Seventy-one percent of chlamydia cases and 62 percent of gonorrhea cases occur in people between ages 15 and 24. Executive witness Michael Kharfen, an interim senior deputy director for the D.C. Department of Health’s HIV/AIDS, Hepatitis, STD and TB Administration (HAHSTA), noted two points in his testimony: that prescribing medication without first examining patients is acceptable in cases of emergencies and epidemics, and that the rate of sexually transmitted infections (STIs) in D.C. is reason to approve the use of expedited partner therapy (EPT).

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The Centers for Disease Control and Prevention’s (CDC) 2013 “Threat Report” lists chlamydia and gonorrhea as the two most common bacterial infections in the United States. Both can cause complications with pregnancy, increase the chance of infertility, and make those who are infected more susceptible to HIV infection. Yet their treatment often requires only a single dose of medication or, at most, a week-long cycle. “These diseases are very easy to cure,” said Stephanie Arnold Pang, director of policy and communications at the National Coalition of STD Directors (NCSD). “The drugs come with very low side effects. This is just another tool in the toolbox.”

It would be optimal if everyone with chlamydia or gonorrhea saw a health-care provider first-hand (this is referred to as an index patient) and received treatment from that visit (called a provider-assisted referral). But the reality is that this isn’t always possible. The CDC started recommending the use of EPT in 2005 because many individuals, particularly those from low-income communities, which are most affected by chlamydia and gonorrhea, face limited resources that keep them out of doctors’ offices; jobs with inflexible hours, lack of access to transportation, and insufficient or no insurance are common barriers to doctor visits. While EPT is not the best way to treat chlamydia and gonorrhea, the alternative—those who cannot or will not go to a health-care provider remaining untreated—is far worse.

EPT is also beneficial for index patients because treating infected partners is crucial to preventing reinfection. Put more plainly, if two people have sex and one has an STI, treating only one of the two partners makes for a job half-finished. The D.C. bill painted a clear picture of the reinfection problem, noting thatthe 12-month reinfection rate of chlamydia among adolescents and young women [in D.C.] is as high as 26%, often due to untreated male sexual partners.” In addition, “nearly one in five [D.C.] teens diagnosed with chlamydia or gonorrhea had a prior diagnosis within 12 months and nearly one third had a prior diagnosis in the preceding two years.”

“The evidence is utterly clear that [EPT] is effective in preventing reinfection,” NCSD Executive Director Bill Smith told Rewire. “If we have a patient come in, and they test positive for chlamydia and go home and have sex with the same partner, they’re going to get reinfected. We can drive those infection rates down significantly by providing EPT.”

In 2001, California became the first state to authorize EPT. An NCSD fact sheet notes that nearly half of California’s doctors and nurse practitioners report using EPT. It also shows that the state has an 80 percent partner treatment rate with EPT—“the same partner treatment rate for those who agreed to bring their partners with them to the clinic”—and that EPT can reduce the estimated $850 million that is spent annually to fight chlamydia and gonorrhea by curbing infection rates and, in turn, reliance on public services to treat STIs.

“EPT is highly effective,” said Heidi Bauer, chief of the California Department of Public Health’s Center for Infectious Diseases STD Control Branch. “Several research studies, including randomized clinical trials, have demonstrated that [it] is safe and as effective as other partner management strategies in facilitating partner notification and reducing recurrent infection among index cases. We have had no calls regarding adverse reactions.”

Despite EPT’s success, its ease of use among the states where it is legal varies. In Georgia, for example, prescriptions that are faxed or emailed have to include a patient’s name and address—a requirement that can be difficult to meet for patients with no direct contact with doctors. And in Massachusetts, dispensing prescription medications requires “the physical act of delivery of a drug to an ultimate user.” In some states, doctors send patients home with doses of medication for their partners, while in others they send prescriptions. (This also varies based on whether the provider is a public health center or a private practice.)

Of the remaining 15 states, the CDC lists nine where EPT is “potentially allowable,” which often means that there is conflicting regulation information. On one hand, prescriptions might not require a name, which would allow a doctor to practice EPT. But on the other hand, they may be limited to one per patient, which would prevent it. The D.C. report cites testimony from doctors who “candidly explained they have bypassed the District’s lack of EPT laws by writing prescriptions to patients that contained two doses and prepared to justify it as a preventative measure ‘just in case the patient got sick and vomited’ while taking the first dose.” But without explicit permission—the CDC’s benchmark for listing a state as having permissible EPT—doctors who use EPT are at risk.

“Physicians’ hands are tied without this legislation,” said Annette Mercatante, a board-certified family practice physician and the medical director at Michigan’s St. Claire County Health Department. “A lot of physicians opt to do EPT rather than treat the same patient four or five times in a row. I think most physicians do the right thing, but it’d be nice to have the legal health code back us up on it.”

Kentucky, Michigan, and West Virginia, three of the six states where EPT is outright prohibited, are on the verge of making progress: In Kentucky and Michigan, EPT bills have passed in the house and are awaiting votes in the senate, and in West Virginia a bill is in the House Judiciary Committee. Each faces the slow but steady process of illuminating the EPT issue and clarifying misinformation.

“I realized [what EPT was] because I started going to conferences where the NCSD spoke about it,” said Rep. Mary Lou Marzian (D-Louisville), the sponsor of Kentucky’s EPT bill. “It was something I had been unaware of, and I’ve been here 20 years.” Marzian went on to acknowledge the political struggle characteristic of any issue relating to sex or prescription drugs—let alone both at once. “Sometimes legislators are so backward,” she said, “that anything that has to do with sex they sort of giggle like it’s kindergarten.”

In Michigan, Sen. Jim Marleau (R-Lake Orion), chair of the senate’s Health Policy Committee, has not brought the EPT bill to a vote because the health department in his home county—Oakland, an influential Detroit suburb—has raised concerns that treating gonorrhea with EPT could lead to the bacteria becoming drug-resistant. But in its 2013 “Threat Report,” the CDC stated that the best way to stave off such a scenario is to keep gonorrhea infection rates low; EPT, the report said, is a key means of doing so.

Mercatante is optimistic that Michigan’s bill will pass. “Most health departments are solidly in favor of this because they realize the benefit of treatment outweighs the risk of gonorrhea resistance,” she said. “Our job is to treat diseases, so whatever we could do to improve treatment compliance, we’d be supportive of a policy like that.”

Before the D.C. bill passed, Yvette Alexander, a council member and chair of the health committee, was wary that once the District started using EPT, authorities would be unable to track the number of positive STI diagnoses in D.C. According to health committee Director Rayna Smith, Alexander’s concerns were quelled with an addition requiring providers to report prescriptions for both index patients and partners to the D.C. Department of Health.

Its recent passage is not all that puts D.C.’s bill in the EPT legislative forefront. Bill 20-343 allows EPT for not only chlamydia and gonorrhea, but also trichomoniasis, an STI with a rising infection rate and dangerous symptoms that is, like chlamydia and gonorrhea, easily cured. While the CDC has not yet approved EPT for treating trichomoniasis, states like Vermont and Wisconsin have added similar provisions that allow it.

D.C.’s legalization of EPT is a progressive step for a medical practice whose day is long overdue. The bill received overwhelming support and no opposition throughout its vetting process, and once Alexander’s concerns were addressed it passed through council vote easily. With wheels turning in West Virginia, and EPT being potentially allowable in Maryland and Virginia, D.C.’s new law could be a step in the right direction for not only the District but also the region.

“It was more than time for the District to take this important step,” said Christina Henderson, Grosso’s deputy chief of staff, “and join these other states in what has been proven to be a good thing for the public health of residents.”