Disconnect between knowledge of STIs and behaviors to reduce risk

In my opinion, people are often too embarrassed to see their doctor about sexually transmitted infections (STIs)—in my opinion.

“In my opinion” is one of the most dangerous phrases in science. But when in comes to attitudes toward STIs, the data are scarce. STI’s are very much a “behavior”-based disease, so knowing what attitudes prevail can help us design effective prevention strategies. Attitudes toward HIV have been studied, especially in the early period of the pandemic and on non-US populations, but finding recent data on STIs in the U.S. is a frustrating endeavor. Much of the data that are out there are on adolescents, and while this age group has a high STI rate, we are finding that certain older populations are at increasing risk.

One of the trends seen in the research is a disconnect between knowledge of STIs and behaviors to reduce risk. In a clever study (cited below), condom coupons were given to patients at an STI clinic in New York, with an overall redemption rate of only 22%. Other studies show that primary care physicians (PCPs) don’t do a great job of screening for STIs.

So patients’ regular doctors do a poor job of screening, and patients do a poor job of changing their behavior. Still, when patients have symptoms, they do often seek out care. In my experience (!) that care is often delivered by a walk-in clinic rather than by the patient’s regular doctor. Since I spend some of my time at a walk-in clinic, I often treat STIs. Since the patients aren’t “mine”, and in my experience (!!) it is often hard to reach them with test results, I do quite a bit of empiric therapy.

Empiric therapy—treating the most likely problem without lab results—has the advantage of allowing for “directly observed therapy”. I can treat someone for gonorrhea and chlamydia while they are sitting in front of me, insuring proper treatment without worrying about losing the patient to follow up.

But what about the partners? If I don’t treat the sex partners, my patient is likely to be re-infected, and the partner is likely to continue to spread disease.

Standard practice is to advise the patient to inform their sexual partners that they have or are suspected to have an STI, and to encourage these partners to seek out medical care. How often do you think this happens? Studies have shown that public health services seldom successfully notify partners, and that patients rarely notify their partners. And it is unequivocally unethical for a clinician to notify a patient’s sexual partner without the patient’s permission.

Enter “expedited partner therapy” (EPT, known in California as ”patient-delivered partner therapy”). With EPT, the clinician treats the patient, and gives them a prescription or a medication to take to their partner. This not only treats another affected patient, but prevents re-infection of your patient. This is how a typical encounter would work: a young woman comes to see me complaining of a vaginal discharge. She is sexually active with one male partner and not pregnant. On exam, she has typical findings of gonorrhea or chlamydia, and I send a sample of her vaginal secretions to the lab. The results won’t be available for a day or two, and based on relatively arbitrary criteria I decide to treat her for gonorrhea and chlamydia without the final lab result (the criteria may include the high rate of chlamydia carriage in her age group, and the fact that she is not my regular patient which may decrease my ability to get in touch with her when results are available). I then hand her a packet of pills to take to her partner.

This sounds like a great idea in many ways, but like many ideas in medicine, simply being a good idea is different than being proved to be a good idea. A study published this month in Sexually Transmitted Diseases examined this question, and confirmed previous data that EPT is effective at preventing reinfection (the study’s other stated goal of detecting differences between various subgroups gave favorable but not statistically significant results).

So why aren’t we all doing it?

There are some obvious reasons to favor EPT, and some important reasons to be wary. Any time you treat someone that you don’t know, you risk mis-treating them. If the partner is allergic to the medication, I can cause them harm. I also lose the ability to counsel him on STIs and to test him for other common STIs such as syphilis and HIV. But given the high rates of gonorrhea and chlamydia, and the benefit to my patient via preventing reinfection, this could be a win.

Except that it’s illegal in my state, and maybe in yours. Since physicians are obligated to actually have a clinical relationship with a patient in order to treat them, specific legislation is usually needed to allow EPT. And while the legislation may allow EPT, it does not insulate a clinician from liability arising from using EPT. The evidence favoring EPT has been accumulating for several years, so it may be time for the rest of the country to allow it.

PalMD is an internal medicine physician who blogs at White Coat Underground.