DOI: 10.1111/j.1471-0528.2008.01971.x www.blackwellpublishing.

com/bjog

Commentary

Patient-delivered partner therapy for chlamydia a realistic public health measure in the UK
ST Camerona,b
of Reproductive and Developmental Sciences, University of Edinburgh, Royal Inrmary of Edinburgh, Edinburgh, UK Terrace Family Planning Clinic, Edinburgh, UK Correspondence: Dr ST Cameron, Dean Terrace Family Planning Clinic, 18 Dean Terrace, Edinburgh, EH4 1NL, UK. Email sharon.cameron@ed.ac.uk
b Dean a Department

Accepted 10 July 2008.

Please cite this paper as: Cameron S. Patient-delivered partner therapy for chlamydiaa realistic public health measure in the UK. BJOG 2009;116:345346.

The problem of chlamydia in the UK

In the past decade, the UK has witnessed a dramatic rise in the number of cases of uncomplicated Chlamydia trachomatis.1 Increasingly, this is being managed in general practice and community and hospital gynaecological settings as well as in genitourinary medicine (GUM) clinics.2 Treatment of patients is usually straightforward with a single dose of azithromycin. However, ensuring that sexual partners are treated is often challenging. Timely treatment of partners is important to prevent the index patient from becoming re-infected. This is particularly important for women because repeat infection is more likely to lead to complications such as tubal infertility.3 Partner notication has been the traditional means for arranging partner treatment. This usually involves patient-referral, whereby the patients themselves inform their sexual partners of the possibility of infection and of the need to attend a clinic for treatment and testing. Usually this involves partners attending a GUM clinic where specialised staff offer testing, advice and education and often give empirical treatment at the same time.4 However, partners may be reluctant to undergo testing and treatment for an asymptomatic condition and may be deterred from attending GUM clinics in view of the stigma associated with having a sexually transmitted infection (STI).5 In many parts of the UK, patients may wait several weeks for an appointment to be seen at a GUM clinic.6 Resumption of sexual intercourse with an untreated partner during this time period to be seen can thus result in re-infection in the index woman, increasing the likelihood of infective sequelae. Furthermore, sex with an untreated partner necessitates repeat treatment that may result in a labour-intensive cycle for health professionals of treating index patient, testing and treating partner and then re-testing and re-retreating index patient. Clearly, partner notication with a consultation with specially trained staff may be the gold standard of care. How-

ever, this is no longer a realistic option for all partners, given the number of people infected (the majority asymptomatic) and the fact that existing GUM services are struggling to cope with increasing workloads. Given the importance of preventing tubal infertility in women as a result of re-infection, novel partner interventions are now necessary. An obvious solution to prevent re-infection is to expedite partner treatment. Patient-delivered partner therapy (PDPT) is an example of such a strategy. This involves the index patient delivering a dose of antichlamydial therapy (usually azithromycin) to each sexual partner. This approach has been used in Sweden and is currently in use in some parts of the USA.7,8 Large randomised controlled trials conducted in the USA have shown that it is as least as effective as patient referral, both in terms of re-infection rates in index patients and in proportion of sexual contacts treated.9,10 Clearly, this is a controversial practice because it involves the clinician providing antibiotics for an individual they have neither laid eyes on nor been able to assess clinically. In the UK, the practice of PDPT would encounter legislative difculties because it is in conict with the General Medical Council guidelines on good prescribing and Medicines Act.11 Legislative change has been possible in the USA, so that PDPT is now legal in 14 states for treating partners of women with uncomplicated chlamydia.7 In the USA, PDPT is supplied with a comprehensive datasheet clearly listing the contraindications to its use and instructions on when and how to seek medical advice.12 Fortunately, azithromycin is a well-tolerated antibiotic and with a good safety record and low incidence of allergic reactions. Increased use of PDPT has raised concerns about possible increased antibiotic resistance. However, this strategy involves single dose treatment only and so may not carry the same risk of resistance from failure to complete a course of antibiotics. Indeed, a greater threat to antibiotic resistance is likely to come from veterinary medicine and animal husbandry, which account for more than half of the worldwide

2009 The Authors Journal compilation RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology

345

Cameron

use of antibiotics.13 Although clinicians may also have concerns about over-treatment with PDPT (treating partners who might have a negative test result), many GUM clinics in the UK already practice epidemiological treatment for partners, which involves giving antibiotic treatment at the same time as testing on the assumption that the test will be positive. A possible disadvantage of failure to test partners and thus conrm chlamydia positivity is that it may reduce the likelihood that other sexual contacts that the partner may have had will be notied and treated. Conversely, if partners are not tested then this removes the difculty that may arise in explaining discordant results among couples and the suspicion of indelity that may develop in such situations. A further concern is that use of PDPT would remove the opportunity to test partners for other STIs. Clearly, however, the value of this will depend on the local prevalence of other STIs. A recent survey of health professionals (general practitioners, gynaecologists, family planning doctors and practice nurses) in the UK who are increasingly involved in managing women with chlamydia revealed an overwhelming openness of using PDPT in this way.14 Furthermore, one in four doctors surveyed in this study admitted that they had previously used PDPT.14 For the health service, PDPT is an inexpensive option because it involves the cost of antibiotic therapy only. In the current issue of the journal, Melvin et al. report the preferences of men and women towards different partner interventions for chlamydia. Most women stated that they would prefer PDPT for a partner and for themselves in the reverse situation where a partner was rst to test positive. Men, however, seemed to prefer (at least in theory) to be tested before being treated for reasons which are discussed in the paper. There is a growing realisation that given many societal changes (shift work, single parent families and childcare difculties), patients require greater choice in how, where and when, health care is delivered to them. Given the difculty of access to GP surgeries and GUM clinics, especially at weekends and evenings, surely partners require greater exibility in how they can access treatment for uncomplicated chlamydial infection? Expediting partner treatment by using PDPT would seem to offer an alternative exible approach to treatment. Partners who prefer to have a test result before treatment (or to be tested for other STIs) could still choose to attend a healthcare setting for this or be treated with PDPT and subsequently attend for testing (nucleic acid amplication test for chlamydia may remain positive for up to 6 weeks after treatment).4

would appear to be legislative change to enable health professionals to use it in this way. Legislative change has been possible in 14 states of the USA, so surely now the time has come for us in the UK to follow suit.

Disclosure of interests
The author has no nancial, personal, political, intellectual or religious conicts of interest. j

References
1 Health Protection Agency and the UK Collaborative Group for HIV and STI Surveillance. Mapping the Issues. HIV and Other Sexually Transmitted Infections in the United Kingdom: 2005. London: London Health Protection Agency, 2005. 2 Cassell JA, Mercer CH, Sutcliffe L, Petersen I, Islam A, Brook MG, et al. Trends in sexually transmitted infections in general practice 1990-2000: population based study using data from the UK general practice research database. BMJ 2006;332:3324. 3 Patton DL, WolnerHanssen P, Cosgrove SJ, Holmes KK. The effects of Chlamydia trachomatis on the female reproductive tract of the macara memestrina after a single tubal challenge following repeated inoculations. Obstet Gynecol 1990;76:64350. 4 British association for sexual health and HIV. UK national guideline for the management of genital infection with Chlamydia trachomatis. 2006. [www.bashh.org/documents/61/61.pdf]. Accessed 2 October 2008. 5 Mercer CH, Sutcliffe L, Johnson AMWhite PJ, Brook G, Ross JD, et al. How much do delayed health care seeking, delayed care provision and diversion from primary care contribute to the transmission of STIs? Sex Transm Infect 2007;83:4005. 6 Alder M. Sexual health. BMJ 2003;327:62. 7 Ramstedt K, Forssman L, Johannisson G. Contact tracing in the control of genital Chlamydia trachomatis infection. Int J STD AIDS 1991;2: 116118. 8 Legal status of expedited partner therapy (ept). Centers for Disease Control and Prevention. [www.cdc.gov/std/ept/legal/default.html]. Accessed 2 October 2007. 9 Golden MR, Whittington WLH, Handseld H, Hughes JP, Stamm WE, Hogben M, et al. Effect of expedited treatment of sex partners on recurrent or persistent gonorrhoea or chlamydial infection. N Engl J Med 2005;352:67685. 10 Schillinger JA, Kissinger P, Calvet H, Whittingtom WL, Ransom RL, Sternberg MR, et al. Patient-delivered partner treatment with azithromycin to prevent repeated Chlamydia trachomatis infection among women. Sex Transm Dis 2003;30:4956. 11 General Medical Council. Good practice in prescribing medicines. 2006. [www.gmc-uk.org/guidance/current/library/prescriptions]. Accessed 2 October 2008. 12 Patient delivered partner therapy for Chlamydia trachomatis and Neisseria gonorrhoea. Guidance for medical providers in California. 2007. [www.cdph.ca.gov/healthinfo/discond/Documents/Chlamydia-PDPTGuidelines-Ptnr-Info.pdf]. Accessed 2 October 2008. 13 The world health report 2007. A safer future: global public health security in the 21st century. [www.who.int/whr/2007/en/index/html]. Accessed 2 October 2008. 14 Cameron ST, Melvin L, Glasier A, Scott G, Johnstone A, Young H. Willingness of gynaecologists, doctors in family planning, GPs, practice nurses and pharmacists to adopt novel interventions for treating sexual partners of women with chlamydia. BJOG 2007;114:151621.

Conclusion
PDPT for treating partners of women with uncomplicated chlamydia is a realistic, inexpensive public health measure in the UK. It has been shown to be effective, acceptable to relevant health professionals and (in this issue of the journal) acceptable to patients. The only barrier to its implementation

346

2009 The Authors Journal compilation RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology