Provide information on STI consequences. Several surveys and studies4,6,9 have shown that most patients would like additional information about symptoms, treatment, and consequences of various STIs. The research suggests that you should tell patients which STIs are curable, merely treatable, or life threatening.9 Include information on asymptomatic conditions, carrier states, and false-negative results that can occur when testing for human immunodeficiency virus (HIV) and herpes virus.6
Set aside your biases and assumptions. Avoid using labels and making gender-role assumptions. Pay attention to the patient’s (and parent’s) emotions, mannerisms, omissions, and comprehension.10 Note nonverbal cues, and keep in mind that your own attitude and subtle nonverbal communication will be detected, and may determine how patients respond. (Cultural competence training is often invaluable in establishing rapport and avoiding an unintended connotation.)
Getting treatment to partners: The expedited partner therapy option
Evaluation, testing, and treatment are indicated for partners of a patient who has Chlamydia, gonorrhea, granuloma inguinale, or lymphogranuloma venereum, and who had unprotected intercourse with the patient within 60 days preceding the index patient’s symptom onset. In the case of chancroid, partner evaluation is warranted even for asymptomatic individuals if sexual activity occurred within 10 days of the index patient’s onset of symptoms. Similarly, partners of patients diagnosed with syphilis, HIV, or herpes should seek immediate medical evaluation.
Partners can be notified by the provider, the patient, or both—with the patient notifying partners, and the provider following up. Card referral is another option, in which the patient is given appointment cards to hand out to partners.3,17
Despite these efforts, partners often fail to come to the office for an evaluation. An alternative is expedited partner therapy (EPT), with patient-delivered partner therapy (PDPT) the most common means of implementation.17 For PDPT, the provider gives the index patient a prescription or drug samples, and offers precautions and instructions for treating the partners without prior clinical assessment.3,17,18
Evidence supports the use of EPT in treating gonorrhea and Chlamydia.17 Evidence also suggests that EPT decreases recurrence and incidence rates for gonorrhea and Chlamydia.17 Evidence is insufficient, however, to advocate EPT for syphilis, trichomoniasis, or gonorrhea/Chlamydia in men who have sex with men.17 In addition, EPT has led to beneficial behavioral changes, such as decreased unprotected intercourse with untreated partners and reduction of high-risk sexual behaviors.17
However, EPT comes with its share of obstacles. Noting a partner’s information and treatment plan in the index patient’s chart may violate HIPAA regulations. Also, adverse drug reactions are possible in a person whom the clinician has not interviewed or examined. There is no way to know if medications are taken as prescribed; thus, the potential exists for drug resistance or inappropriate use of the unused portions. Another concern is the legal implication of providing treatment to a person with whom there is no doctor-patient relationship.
Know the law, as far as it is knowable
Treating individuals without establishing a patient-provider relationship is illegal in many states; in other states it is not, but may be assumed to be illegal by physicians and pharmacists practicing in these states.17,18 Some states have no formal legal guidelines, and even those that do may not publicize them clearly or may have conflicting guidelines from different medical, legal, and public health societies.
Despite these legal complications, the Centers for Disease Control and Prevention advocates EPT in situations where there is clear medical benefit.3,17 The list below provides some general guidance on where individual states stand on EPT,2,3,18 although you should contact your local state medical board or Department of Health and Human Services for specific guidelines.
- EPT is permitted in the following states: California, Colorado, Maryland, Minnesota, Mississippi, Nevada, New Mexico, Pennsylvania, Tennessee, Utah, Washington, and Wyoming.
- EPT is potentially allowable in the following locations: Alabama, Alaska, Connecticut, Delaware, District of Columbia, Georgia, Hawaii, Idaho, Indiana, Iowa, Kansas, Maine, Massachusetts, Missouri, Montana, Nebraska, New Hampshire, New Jersey, New York, North Carolina, Oregon, Puerto Rico, Rhode Island, South Dakota, Texas, Virginia, and Wisconsin.
- EPT is probably prohibited in the following states: Arizona, Arkansas, Florida, Illinois, Kentucky, Louisiana, Michigan, North Dakota, Ohio, Oklahoma, South Carolina, Vermont, and West Virginia.
Speak with patients alone, or with parents? It is not unusual for parents or teens who have not had much experience discussing physical anatomy to become embarrassed or anxious when the topic of sexuality comes up. Counseling teens alone or with their parents depends on the nature of the conversation.