Patient delivered partner therapy for chlamydial infection—what would be missed?

Abstract

Reinfection of index patients by untreated sexual partners accounts for a significant proportion of incident bacterial sexually transmissible infections. The most widely practiced method of partner notification, whereby the index case contacts known sexual partners, results in relatively few sexual partners presenting for assessment.1 Alternative strategies that have been proposed to enhance conventional partner notification include patient delivered partner therapy (PDPT). PDPT requires the index case to give their contacts the treatment for the STI without the contact having to access a clinical service. This strategy has been shown to reduce the rate of reinfection in the index patient for gonorrhea and chlamydia.2–5 However, a limitation of this approach is that concurrent STIs in the contacts may remain undiagnosed and untreated. In addition, because there is no clinical interaction with a health care worker, there is no opportunity to identify other secondary contacts. To examine the extent to which these issues are relevant in an Australian urban sexual health clinic setting, we decided to investigate the concurrent STIs diagnosed in those who present as potential contacts of chlamydia and the number of other sexual partners who are identified. Sydney Sexual Health Centre is the major public sexually transmissible infections clinic for inner and eastern Sydney, Australia with between 15,000 and 17,000 patient attendances per year. The reason for presentation to the clinic is collected at each visit and entered into the clinic database. For the study period June 2003 until June 2006, the medical records of all those who presented as a contact of chlamydia, non-gonococcal urethritis (NGU), and pelvic inflammatory disease (PID) were extracted. Those who presented as contacts of more than one bacterial STI or HIV were excluded from the study. Clinic policy states that all those who present as sexual contacts of an STI are tested for other bacterial STI and HIV infection; however, this study did not determine the proportion of individuals who had each test performed. The files were reviewed for demographic information, sexual behavior data, and diagnoses of chlamydia infection, newly diagnosed HIV infection, infectious syphilis, gonococcal infection, and Trichomonas vaginalis infection. Only diagnoses that occurred as a consequence of the visit for assessment as a sexual contact of chlamydia were included. Contacts of gonorrhea were excluded in this study as no oral therapy for gonorrhea is available in Australia. For heterosexual patients who proved to have chlamydia, data were collected on whether other secondary contacts within the preceding 6 months were contactable and whether it was documented that they were successfully contact traced. It was not possible to determine from the medical record whether the secondary contacts were assessed or treated. Data were entered in an Excel spreadsheet. Descriptive statistics and Fisher exact test were applied to determine significance. Ethics approval was obtained for the study from South Eastern Sydney and Illawarra Area Health Service Ethics Committee. There were 626 contacts eligible for the study, 195 women and 431 men. Of the men, 188 (43.6%) were men who had sex with men. Of the total study population, 466 (74.4%) were contacts of chlamydial infection, 121 (19.3%) were contacts of NGU, and 39 (0.6%) were contacts of PID. Of the total, 199 (31.8%) tested positive for Chlamydia trachomatis by PCR. Of the 438 heterosexuals, there were few diagnoses of chlamydial complications or other bacterial STI, though higher rates of other STI diagnoses occurred in men who have sex with men (P <0.0001, Table 1). In heterosexual men, 2 (0.8%) were diagnosed with epididymitis. In women, 8 (4.1%) were diagnosed with PID or another bacterial STI. In MSM, 26 (13.8%) were diagnosed with another bacterial STI or HIV.TABLE 1: The Prevalence of Chlamydia-Associated Conditions, Other Bacterial STIs and HIV Infection, in Those Presenting as Sexual Contacts of Chlamydia trachomatis Infection, by Gender and Sexual OrientationOf the heterosexual contacts, 145 (33%) were subsequently diagnosed with chlamydia. Of these 62 (42.8%) identified no other sexual partners where contact tracing was determined to be necessary. Men (n = 33) were no more likely than women (n = 29) to have no other partners to notify (P = 0.23). In the remaining 83 cases where other contacts were identified as likely to be contactable, the mean number of other partners was 1.7, with a median of 2 and a range of 1 to 7. A total of 137 other contacts were identified. Of these cases, in 29 (34.9%) it was documented that these further contacts were notified: in 5 cases attempts by the patient to contact trace were unsuccessful and in the remaining 49 (57.8%) the outcome was not documented in the medical record. Our findings are similar to those reported by Stekler et al.6 In this study, the files of 8623 individuals w