Expedited Partner Therapy in Wisconsin STD Control Section Wisconsin Division of Public Health June 2010

Overview Epidemiology of trichomoniasis, gonorrhea and Chlamydia trachomatis infections Epidemiology of trichomoniasis, gonorrhea and Chlamydia trachomatis infections Partner Services Partner Services Expedited partner therapy (EPT) Expedited partner therapy (EPT) EPT legislation in Wisconsin EPT legislation in Wisconsin

Sexually Transmitted Diseases In the Nation: In the Nation: More than 1.5 million cases of gonorrhea and Chlamydia trachomatis infections were reported to the CDC in 2008 More than 1.5 million cases of gonorrhea and Chlamydia trachomatis infections were reported to the CDC in 2008 Approximately 50% of new gonorrhea and Chlamydia trachomatis infections occurring each year remain undiagnosed and unreported Approximately 50% of new gonorrhea and Chlamydia trachomatis infections occurring each year remain undiagnosed and unreported Trichomoniasis is the most common curable STD in young, sexually active women in the U.S., and an estimated 7.4 million new cases occur each year in both men & women Trichomoniasis is the most common curable STD in young, sexually active women in the U.S., and an estimated 7.4 million new cases occur each year in both men & women

Reported STD cases, by disease Wisconsin, 2008 In Wisconsin there are more bacterial sexually transmitted diseases (STDs) reported than all other reportable communicable diseases combined. Disease Cases Rate* Chlamydia 20, Gonorrhea 6, Syphilis Total 27, * Cases per 100,000 population.

STD Rates, Milwaukee, 2006: 2 nd highest of 50 big cities in the U.S. Combined rates* for chlamydia, gonorrhea and primary and secondary syphilis for the 50 largest metropolitan areas, 2006, CDC data Milwaukee (2 nd ) Chicago Detroit Minneapolis * Cases per 100,000 population.

Disproportionate Impact of STDs For Example: For Example: Adolescents Adolescents In Milwaukee, among adolescents years of age, 1 in 18 were reported with a Chlamydia trachomatis infection and 1 in 50 with gonorrhea in 2008 In Milwaukee, among adolescents years of age, 1 in 18 were reported with a Chlamydia trachomatis infection and 1 in 50 with gonorrhea in 2008 Communities of Color Communities of Color The rate of reported STDs among black adolescents years of age is 18 times that of whites in Wisconsin The rate of reported STDs among black adolescents years of age is 18 times that of whites in Wisconsin

Complications of STDs STDs cause at least 24,000 women in the U.S. each year to become infertile STDs cause at least 24,000 women in the U.S. each year to become infertile Untreated trichomoniasis, gonorrhea and Chlamydia trachomatis infections can lead to: Untreated trichomoniasis, gonorrhea and Chlamydia trachomatis infections can lead to: Pelvic inflammatory disease (PID) Pelvic inflammatory disease (PID) Ectopic pregnancy leading to fetal death Ectopic pregnancy leading to fetal death Infertility Infertility Systemic infection of gonorrhea causing arthritis Systemic infection of gonorrhea causing arthritis Perinatal transmission leading to pneumonia or conjunctivitis Perinatal transmission leading to pneumonia or conjunctivitis Increased risk of acquiring and transmitting HIV Increased risk of acquiring and transmitting HIV Continued spread of infection Continued spread of infection

Cost of STDs STDs cost the U.S. health care system an estimated $15.9 billion annually STDs cost the U.S. health care system an estimated $15.9 billion annually A single oral pill for treatment of Chlamydia trachomatis infection costs $30/patient while treatment for infertility can cost thousands of dollars per patient A single oral pill for treatment of Chlamydia trachomatis infection costs $30/patient while treatment for infertility can cost thousands of dollars per patient A single oral pill for treatment of gonorrhea costs $19/patient while treating PID costs over $1000 per patient A single oral pill for treatment of gonorrhea costs $19/patient while treating PID costs over $1000 per patient

STD Re-infection is Common Re-infection rates among women treated for CT 1 : Re-infection rates among women treated for CT 1 : 15% re-infected within 6 months 15% re-infected within 6 months 30% re-infected within 12 months 30% re-infected within 12 months Re-infection rates among women treated for GC 2 : Re-infection rates among women treated for GC 2 : 14% re-infected within 6 months 14% re-infected within 6 months 27% re-infected within 12 months 27% re-infected within 12 months Re-infection rates among men with CT & GC 3 : Re-infection rates among men with CT & GC 3 : 15% re-infected at 6 months 15% re-infected at 6 months 21% re-infected at 8 months 21% re-infected at 8 months 1 Review of 17 active cohort studies 2 Review of 7 active and passive cohort studies 3 Fung et al, STI 2007

Partner Services in Wisconsin Local Health Officers are required to perform interviewing and investigation for cases of reportable STDs Local Health Officers are required to perform interviewing and investigation for cases of reportable STDs A universally difficult task, sex partners are not always being notified and treated for STDs A universally difficult task, sex partners are not always being notified and treated for STDs Funding/staffing Funding/staffing Overwhelming burden of disease Overwhelming burden of disease Accuracy of sex partner information Accuracy of sex partner information Compliance of sex partners to seek medical attention Compliance of sex partners to seek medical attention This is where EPT comes in... This is where EPT comes in...

Expedited Partner Therapy EPT is a treatment alternative for partners of a patient diagnosed with sexually transmitted diseases (STDs) without a medical evaluation of the partner EPT is a treatment alternative for partners of a patient diagnosed with sexually transmitted diseases (STDs) without a medical evaluation of the partner EPT allows the patient to deliver oral medication or prescriptions to their sexual partner who might not otherwise seek care EPT allows the patient to deliver oral medication or prescriptions to their sexual partner who might not otherwise seek care EPT prevents re-infection to the original patient, thus reducing the burden of STDs in the community EPT prevents re-infection to the original patient, thus reducing the burden of STDs in the community

Summary of CDC’s Guidance for Expedited Partner Therapy in the Management of Sexually Transmitted Diseases EPT was effective in reducing persistent or recurrent infections due to chlamydia and gonorrhea EPT was effective in reducing persistent or recurrent infections due to chlamydia and gonorrhea EPT was associated with higher likelihood of partner notification and partner treatment EPT was associated with higher likelihood of partner notification and partner treatment Preliminary economic analysis suggest that EPT is a cost-saving and cost-effective partner management strategy Preliminary economic analysis suggest that EPT is a cost-saving and cost-effective partner management strategy EPT represents an additional strategy for partner management that does not replace other strategies EPT represents an additional strategy for partner management that does not replace other strategies

EPT is supported by: Nationally: Nationally: CDC CDC American Medical Association American Medical Association Society of Adolescent Medicine Society of Adolescent Medicine National Association of County and City Health Officials National Association of County and City Health Officials The Council of State Governments The Council of State Governments The National Bar Association The National Bar Association 22 states including Minnesota, Illinois, and Iowa 22 states including Minnesota, Illinois, and Iowa In Wisconsin: The Department of Health Services Medical Examining Board Medical Society of WI WI Academy of Family Physicians American College of Nurse- Midwives WI Nurses Association Wisconsin Public Health Association Planned Parenthood

2009 EPT Legislation in Wisconsin Explicitly allows medical providers to dispense medication or prescribe EPT and pharmacists to dispense medication Explicitly allows medical providers to dispense medication or prescribe EPT and pharmacists to dispense medication Limits liability for all providers as long as EPT is provided in accordance with the Act Limits liability for all providers as long as EPT is provided in accordance with the Act Allows the prescription to be written for “EPT” when the patient does not know or is unwilling to give the partner’s name Allows the prescription to be written for “EPT” when the patient does not know or is unwilling to give the partner’s name Requires written materials be developed by DHS and be provided with EPT prescription about trichomoniasis, gonorrhea and Chlamydia trachomatis infections, their treatment and the risk of drug allergies Requires written materials be developed by DHS and be provided with EPT prescription about trichomoniasis, gonorrhea and Chlamydia trachomatis infections, their treatment and the risk of drug allergies

Potential Concerns Adverse drug and allergic reactions Adverse drug and allergic reactions Paying for the medication Paying for the medication Spread of antibiotic resistance Spread of antibiotic resistance Risk of undiagnosed disease in the partner Risk of undiagnosed disease in the partner

Current Status of Legislation in Wisconsin Act 280 was signed into law by Governor Doyle on May 11, 2010 Act 280 was signed into law by Governor Doyle on May 11, 2010 Effective May 26, 2010 Effective May 26, 2010 The Act requires written materials (an ‘information sheet’) be distributed to the patient by the medical provider, for use by the partner receiving EPT. The Act requires written materials (an ‘information sheet’) be distributed to the patient by the medical provider, for use by the partner receiving EPT.

Information Sheet The Information Sheet distributed by the clinician to the patient, for the sex partner receiving treatment shall include: The Information Sheet distributed by the clinician to the patient, for the sex partner receiving treatment shall include: Information about STDs and their treatment Information about STDs and their treatment The risk of drug allergies from the treatment The risk of drug allergies from the treatment A statement advising persons with questions to contact his/her physician, pharmacist, or local health department A statement advising persons with questions to contact his/her physician, pharmacist, or local health department

Coming Soon... EPT Provider Guidance – specific information on EPT for medical providers EPT Provider Guidance – specific information on EPT for medical providers FAQ sheet for local health departments, medical providers, and pharmacists FAQ sheet for local health departments, medical providers, and pharmacists

For further information visit: Please visit the Wisconsin STD Control Section website for implementation materials at: or call

Questions? For more information or questions regarding EPT legislation please contact Marisa Stanley at or For questions regarding the STDs and implications of EPT for health departments please contact, Loriann Wunder at or