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Study finds evidence that expedited partner therapy is clinically more effective in reducing reinfection of index patients who have had chlamydia, gonorrhoea or trichomonas when compared with simple patient referral but not when compared with simple patient referral but not when compared with enhanced methods of patient referral. It is possible that partner notification for the current or most recent sexual partner has the greatest impact on reducing chlamydia transmission in heterosexual young adults.

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Christian L Althaus,1 Katherine ME Turner,2 Catherine H Mercer,3 Peter Auguste,4 Tracy E Roberts,4 Gill Bell,5 Sereina A Herzog,1 Jackie A Cassell,6 W John Edmunds,7 Peter J White,8,9 Helen Ward,10 Nicola Low,1,* 

1 Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
2 School of Social and Community Medicine, University of Bristol, Bristol, UK
3 Centre for Sexual Health and HIV Research, Research Department of Infection and Population Health, University College London, London, UK
4 Health Economics Facility, University of Birmingham, Birmingham, UK
5 Academic Directorate of Communicable Diseases, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
6 Brighton and Sussex Medical School, University of Brighton, Brighton, UK
7 Infectious Disease Epidemiology Unit, London School of Hygiene and Tropical Medicine, London, UK
8 Modelling and Economics Unit, Health Protection Agency (now Public Health England), London, UK
9 MRC Centre for Outbreak Analysis and Modelling, School of Public Health, Imperial College London, London, UK
10 Department of Infectious Disease Epidemiology, Faculty of Medicine, Imperial College London, London, UK
* Corresponding author ; Email:

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https://dx.doi.org/{{metadata.DOI}}

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Abstract

BACKGROUND

Partner notification is essential to the comprehensive case management of sexually transmitted infections. Systematic reviews and mathematical modelling can be used to synthesise information about the effects of new interventions to enhance the outcomes of partner notification.

OBJECTIVE

To study the effectiveness and cost-effectiveness of traditional and new partner notification technologies for curable sexually transmitted infections (STIs).

DESIGN

Secondary data analysis of clinical audit data; systematic reviews of randomised controlled trials (MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials) published from 1 January 1966 to 31 August 2012 and of studies of health-related quality of life (HRQL) [MEDLINE, EMBASE, ISI Web of Knowledge, NHS Economic Evaluation Database (NHS EED), Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA)] published from 1 January 1980 to 31 December 2011; static models of clinical effectiveness and cost-effectiveness; and dynamic modelling studies to improve parameter estimation and examine effectiveness.

SETTING

General population and genitourinary medicine clinic attenders.

PARTICIPANTS

Heterosexual women and men.

INTERVENTIONS

Traditional partner notification by patient or provider referral, and new partner notification by expedited partner therapy (EPT) or its UK equivalent, accelerated partner therapy (APT).

MAIN OUTCOME MEASURES

Population prevalence; index case reinfection; and partners treated per index case.

RESULTS

Enhanced partner therapy reduced reinfection in index cases with curable STIs more than simple patient referral [risk ratio (RR) 0.71; 95% confidence interval (CI) 0.56 to 0.89]. There are no randomised trials of APT. The median number of partners treated for chlamydia per index case in UK clinics was 0.60. The number of partners needed to treat to interrupt transmission of chlamydia was lower for casual than for regular partners. In dynamic model simulations, >10% of partners are chlamydia positive with look-back periods of up to 18 months. In the presence of a chlamydia screening programme that reduces population prevalence, treatment of current partners achieves most of the additional reduction in prevalence attributable to partner notification. Dynamic model simulations show that cotesting and treatment for chlamydia and gonorrhoea reduce the prevalence of both STIs. APT has a limited additional effect on prevalence but reduces the rate of index case reinfection. Published quality-adjusted life-year (QALY) weights were of insufficient quality to be used in a cost-effectiveness study of partner notification in this project. Using an intermediate outcome of cost per infection diagnosed, doubling the efficacy of partner notification from 0.4 to 0.8 partners treated per index case was more cost-effective than increasing chlamydia screening coverage.

CONCLUSIONS

There is evidence to support the improved clinical effectiveness of EPT in reducing index case reinfection. In a general heterosexual population, partner notification identifies new infected cases but the impact on chlamydia prevalence is limited. Partner notification to notify casual partners might have a greater impact than for regular partners in genitourinary clinic populations. Recommendations for future research are (1) to conduct randomised controlled trials using biological outcomes of the effectiveness of APT and of methods to increase testing for human immunodeficiency virus (HIV) and STIs after APT; (2) collection of HRQL data should be a priority to determine QALYs associated with the sequelae of curable STIs; and (3) standardised parameter sets for curable STIs should be developed for mathematical models of STI transmission that are used for policy-making.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Abstract

BACKGROUND

Partner notification is essential to the comprehensive case management of sexually transmitted infections. Systematic reviews and mathematical modelling can be used to synthesise information about the effects of new interventions to enhance the outcomes of partner notification.

OBJECTIVE

To study the effectiveness and cost-effectiveness of traditional and new partner notification technologies for curable sexually transmitted infections (STIs).

DESIGN

Secondary data analysis of clinical audit data; systematic reviews of randomised controlled trials (MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials) published from 1 January 1966 to 31 August 2012 and of studies of health-related quality of life (HRQL) [MEDLINE, EMBASE, ISI Web of Knowledge, NHS Economic Evaluation Database (NHS EED), Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA)] published from 1 January 1980 to 31 December 2011; static models of clinical effectiveness and cost-effectiveness; and dynamic modelling studies to improve parameter estimation and examine effectiveness.

SETTING

General population and genitourinary medicine clinic attenders.

PARTICIPANTS

Heterosexual women and men.

INTERVENTIONS

Traditional partner notification by patient or provider referral, and new partner notification by expedited partner therapy (EPT) or its UK equivalent, accelerated partner therapy (APT).

MAIN OUTCOME MEASURES

Population prevalence; index case reinfection; and partners treated per index case.

RESULTS

Enhanced partner therapy reduced reinfection in index cases with curable STIs more than simple patient referral [risk ratio (RR) 0.71; 95% confidence interval (CI) 0.56 to 0.89]. There are no randomised trials of APT. The median number of partners treated for chlamydia per index case in UK clinics was 0.60. The number of partners needed to treat to interrupt transmission of chlamydia was lower for casual than for regular partners. In dynamic model simulations, >10% of partners are chlamydia positive with look-back periods of up to 18 months. In the presence of a chlamydia screening programme that reduces population prevalence, treatment of current partners achieves most of the additional reduction in prevalence attributable to partner notification. Dynamic model simulations show that cotesting and treatment for chlamydia and gonorrhoea reduce the prevalence of both STIs. APT has a limited additional effect on prevalence but reduces the rate of index case reinfection. Published quality-adjusted life-year (QALY) weights were of insufficient quality to be used in a cost-effectiveness study of partner notification in this project. Using an intermediate outcome of cost per infection diagnosed, doubling the efficacy of partner notification from 0.4 to 0.8 partners treated per index case was more cost-effective than increasing chlamydia screening coverage.

CONCLUSIONS

There is evidence to support the improved clinical effectiveness of EPT in reducing index case reinfection. In a general heterosexual population, partner notification identifies new infected cases but the impact on chlamydia prevalence is limited. Partner notification to notify casual partners might have a greater impact than for regular partners in genitourinary clinic populations. Recommendations for future research are (1) to conduct randomised controlled trials using biological outcomes of the effectiveness of APT and of methods to increase testing for human immunodeficiency virus (HIV) and STIs after APT; (2) collection of HRQL data should be a priority to determine QALYs associated with the sequelae of curable STIs; and (3) standardised parameter sets for curable STIs should be developed for mathematical models of STI transmission that are used for policy-making.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

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