Expedited Partner Therapy: What HCPs Need to Know About Legal and Medical Considerations
Key takeaways:
Expedited partner therapy (EPT) encourages treatment for sexual partners of people diagnosed with certain sexually transmitted infections (STIs) who might otherwise not get care.
EPT is supported by the CDC and many other professional organizations as a strategy to prevent people from being reinfected with STIs.
Only chlamydia and gonorrhea are currently treated with EPT, which involves a healthcare provider (HCP) giving a prescription or medications to the patient to take to their partner.
Sexually transmitted infections (STIs) are an ongoing healthcare challenge. About half of Americans will acquire an STI during their lifetime. Despite being preventable, about 20 million new cases of STI occur in the United States annually. Chlamydia and gonorrhea continue to be the two most commonly reported STIs. Without proper treatment, chlamydia and gonorrhea can lead to complications.
Proper treatment of STI is imperative to prevent these complications. Both the infected individual and their partners must receive treatment. However, treatment of partners can often prove difficult. Expedited partner therapy (EPT) is a treatment option that has been found to reduce reinfection rates of chlamydia and gonorrhea by up to 29%.
Let’s explore the details of EPT and its role in improving access to STI treatment.
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What is expedited partner therapy (EPT)?
EPT is the practice of treating the sexual partners of an individual diagnosed with chlamydia or gonorrhea, without them being examined by a healthcare provider (HCP). The HCP gives a prescription or medications to the patient to take to their partner.
At present only cases of chlamydia and gonorrhea are regularly treated with EPT, because of inconclusive findings on the reinfection rates of trichomoniasis. However, in some states, local health department guidelines may support EPT for trichomoniasis treatment, as well.
While not intended as a first-choice management strategy, EPT provides a useful alternative for when partners are unable or unwilling to seek treatment.
It’s preferable that partners undergo a complete clinical evaluation, including:
STI screening and HIV testing
Counseling
Treatment
Where is expedited partner therapy legal?
EPT is currently permitted in 46 states and “potentially allowable” in the other four (Alabama, Kansas, Oklahoma, South Dakota). EPT is also potentially allowable in Guam and Puerto Rico.
Potentially allowable means that the state or territory has no specific statutes that address EPT or subject EPT to additional policies. No states specifically prohibit EPT.
Evidence supporting EPT
When an STI is diagnosed, the patient is often expected to notify their sexual partners and advise them to seek treatment. When using this practice, called standard partner referall, only about 36% of male partners in heterosexual relationships actually get treated, leading to high reinfection rates. However, studies have shown a 20% reduction in chlamydia prevalence and 50% reduction in gonorrhea at follow-up when EPT is used.
EPT is not recommended for men who have sex with men (MSM) because of concerns regarding the need for additional STI testing, and for HIV testing in particular. However, when EPT was given to MSM, STI incidence was reduced by 27%.
The practice of EPT is endorsed by:
How do you write a prescription for EPT?
To prescribe EPT, you’ll need to check your state’s regulations to ensure that EPT prescriptions are exempt from e-prescribing mandates. In most states, they are. By bypassing the requirement to send a prescription electronically, an HCP can generate a paper prescription for a patient that may not be in their electronic medical record (EMR) system.
When prescribing EPT:
Provide a separate written prescription to your patient for each partner that requires treatment.
If available, write the partner's name, address, and date of birth in the designated areas of the prescription.
In some instances, the patient may not know or be willing to disclose the partner's name. In this case, you may write “EPT” in the name field.
In the body of the prescription, write "EPT" as well as the name and dosage of the medication.
You are not allowed to add extra doses to a patient’s prescription for them to distribute to a partner or partners.
Refer to the current CDC guidelines for medication guidance and dosage recommendations for EPT.
The current recommended treatment for uncomplicated urogenital gonorrhea is monotherapy with a single dose of intramuscular ceftriaxone 500 mg. If EPT by injection is not possible, then a single dose of cefixime 800 mg is recommended.
Chlamydia infection is treated with doxycycline 100 mg twice a day for 7 days. If there are concerns about completing a course of medication, a single dose of azithromycin 1 g may be given, but it has a lower efficacy against rectal chlamydia.
The patient’s sexual partners from the past 2 months should be treated. If no partners existed in that time frame, the last partner should be treated. Additionally, patients and those treated with EPT should be provided with:
Guidance on how to inform partners about the infection
Written patient counseling and treatment instructions
Encouragement to seek medical evaluation to screen for other STIs, including HIV
Instructions to abstain from sexual intercourse for 7 days after both they and their partners have completed treatment
Legal and medical considerations surrounding EPT
EPT is currently not recommended for:
Cases in which the patient may be co-infected with syphilis or HIV
MSM
Partners with known allergies to STI treatment antibiotics
Suspected sexual assault, intimate partner violence, or child abuse cases
Situations in which there are concerns about a patient’s safety
Cases of pharyngeal or rectal chlamydia or gonorrhea
Unfortunately, there are barriers and implementation challenges that sometimes limit the practice of EPT. For example, retail pharmacies may be unaware of or unfamiliar with EPT and refuse to fill prescriptions that don’t include a patient’s name.
In one Wisconsin study, these prescriptions were refused at pharmacies over half of the time, even though EPT has been a legal practice in the state since 2009. In another study, less than 18% of pharmacists in Baltimore were aware of EPT as a treatment option; only 12% knew it was legal in Maryland, despite it passing in 2015.
Other implementation challenges include:
State variations: Differences in wording and varying interpretations of the law can affect HCPs’ understanding of specific regulations.
STI stigmatization: Patients are often unwilling to discuss their concerns, and providers pressed for time might not initiate discussions around sexual health.
Awareness: Patients may not be aware of the option for EPT or know how to request it for their partners.
Unfilled or unused prescriptions: Partners may not fill prescriptions because of high out-of-pocket costs or lack of insurance coverage. Or they may not take the prescriptions once they’ve been filled. In the first scenario, support from GoodRx can help make the out-of-pocket costs more affordable.
HCP reluctance to prescribe EPT: HCPs may prefer to see or contact each partner they prescribe for.
Infrastructure barriers: Pharmacies and EMR systems may not be equipped to implement or support the widespread practice of EPT.
The bottom line
A complete clinical evaluation that includes STI screening, HIV testing, counseling, and treatment is the preferred method for treatment of STIs. However, in cases in which partners may experience barriers in accessing care or may not be willing to seek care, EPT allows for a mechanism to prevent reinfection and complications of untreated chlamydia and gonorrhea. EPT is not explicitly prohibited in any state, but clinicians and pharmacies may not be familiar with the practice. Efforts to increase awareness of EPT will increase access to treatment for exposed partners.
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