Article Text

Download PDFPDF
Review: partner notification interventions can reduce sexually transmitted infections
  1. Stephen A Wilson, MD, MPH
  1. University of Pittsburgh Medical Centre,
 Pittsburgh, Pennsylvania, USA

    Statistics from Altmetric.com

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    
 
 Q In patients with sexually transmitted infections (STIs), is the addition of partner notification interventions more effective than patient referral alone for reducing persistent or recurrent infections (PRIs)?

    Clinical impact ratings GP/FP/Primary care ★★★★★☆☆ Infectious disease ★★★★★★☆ Gynaecology ★★★★★☆☆ Public health ★★★★★☆☆

    METHODS

    Embedded ImageData sources:

    Medline, EMBASE/Excerpta Medica, CINAHL, Cochrane Library, PsycINFO, Sigle, and DARE (all from 1990 to 2005); 2 electronic research registers (International Standard Randomised Controlled Trial Number Register and clinicaltrials.gov); and reference lists.

    Embedded ImageStudy selection and assessment:

    randomised controlled trials (RCTs) that compared patient referral alone with simple referral plus additional partner notification interventions, including patient-delivered partner therapy (PDPT) (ie, patients were given drugs or a prescription for their partners) in patients with STIs. Patient referral involved index patients informing their sexual partners about the infection and advising them to seek treatment, with or without clinic contact cards. 14 RCTs (n = 12 389; STIs included gonorrhoea, chlamydia, non-gonococcal urethritis, trichomoniasis, or an STI syndrome) evaluating 16 interventions met the selection criteria. Quality assessment of individual studies was based on randomisation, allocation concealment, fully defining outcomes, blinding outcome assessors, minimising cointerventions, reporting dropouts and withdrawals, and performing an intention-to-treat analysis.

    Embedded ImageOutcomes:

    PRIs in index patients. Secondary outcomes included number of partners treated, tested, or notified.

    MAIN RESULTS

    Meta-analysis showed that PDPT led to a lower PRI rate and more partners treated (table). Home sampling for partners (including sterile containers, information on how to collect specimens, and a prepaid envelope) increased the proportion of patients with partners tested (1 RCT, n = 1826, 562 consented, 22% v 10%, number needed to treat [NNT] 8, 95% CI 7 to 11) and the number of partners tested per patient (1 RCT, n = 1826, 562 consented, 0.16 v 0.04 for women, 0.31 v 0.14 for men; another RCT, n = 96, 0.98 v 0.37). 1 RCT (n = 633) found that written information for partners led to a lower PRI rate (5% v 12%, {NNT 14, CI 11 to 25}*) and a higher proportion of partners treated (46% v 35%, {NNT 10, CI 6 to 22}*); another RCT (n = 309) did not find any benefits. Several trials of education or counselling for index patients showed inconsistent results in terms of increasing rates of partner notification or treatment.

    Patient-delivered partner therapy (PDPT) plus patient referral (PR) v PR alone for sexually transmitted infections*

    CONCLUSIONS

    In patients with sexually transmitted infections, patient-delivered partner therapy and written information for partners can reduce the rate of persistent or recurrent infection.

    Abstract and commentary also appear in ACP Journal Club.

    Commentary

    The review by Trelle et al supports the need to consider treating the sexual partners of a person presenting with an STI. Partner notification interventions—PDPT, patient referral plus written information for partners, and sampling kits for partners of index patients—are superior to simple patient referral. PDPT decreased PRIs in index cases and is the simplest approach. However, PDPT may not be the optimal strategy for treating STIs in sexual partners.

    The relative risk reductions and NNTs for PDPT are not as robust as would be expected for medications known to be effective for STIs. This raises concerns about how often such medications are actually being delivered and taken as prescribed. Do some index patients keep the medications for personal future use, do they fear notifying their partners, do they frequently have either untraceable or anonymous partners (eg, prostitution or sex trafficking), or do partners refuse to accept the treatment?

    The CIs of the NNTs for PDPT and patient referral plus written information for partners overlap, indicating they may be similarly effective. Are index patients willing to deliver medications to their partners also the persons who would use patient referral plus written information for partners? If similar PRI decreases can be accomplished without increasing the risk of antibiotic resistance, already a problem with quinolones for gonorrhoea, then patient referral plus written information for partners instead of PDPT might be the more prudent long term public health approach.

    Dispensing medicines to unknown persons with unknown medical histories may leave some physicians and pharmacists uneasy, flying in the face of their training. Also, medical-legal culpability and ramifications vary from country to country.

    Because the included studies have important design issues or differences (eg, some had unclear allocation concealment, unblinded outcome assessors, and differences in treatment of control and experimental groups; some assessed PRI, whereas others assessed partner testing, notification, or treatment), the findings are not conclusive. Still, it is clear that health providers need to think beyond the patient with the STI and consider the partners who remain vectors for PRIs.

    View Abstract

    Footnotes

    • * Calculated from data in article.

    • For correspondence: Dr N Low, University of Bern, Bern, Switzerland. low{at}ispm.unibe.ch

    • Source of funding: UK National Institute for Health and Clinical Excellence.