Recently, while William, 21, was manning the chicken-wing fryer at a fast-food restaurant in suburban Seattle, he pulled aside his sort-of girlfriend, 18, a pizza deliverer there. He had bad news.
He had tested positive for gonorrhea and chlamydia. That meant she was very likely infected.
Loud, insult-fueled cross-accusations ensued. But the conversation did not disintegrate, as might otherwise be expected.
That is because William, who asked to be identified by his middle name to protect his privacy, was able to include some good news. The sort-of girlfriend — his term — would not need to face the hassle and embarrassment of being tested.
His clinic had issued prescriptions for them both; William himself could give her the antibiotics. For free. Immediately.
She scoffed but grabbed the pills. After work, she even offered him a ride home.
“I am very glad I had the opportunity to give her the drugs, because it saved her a lot of time and money,” William said. “We’re both young and poor.”
To reduce rates of gonorrhea and chlamydia, at least 31 states permit health care providers to treat patients’ sexual partners without ever seeing them in person, a public health intervention known as “expedited partner therapy,” or E.P.T.
When a patient tests positive for a sexually transmitted infection, the clinician provides medication not just for the patient, but for the patient to give to the partner as well (in some jurisdictions, up to five partners). Alternately, the clinician may call the partner’s prescription into a pharmacy. In Washington, the state also purchases the medication, regardless of the partner’s ability to pay.
A large study of Washington’s E.P.T. program, just published in the journal PLOS Medicine, suggests that the strategy lowered infection rates by 10 percent. But though many national health organizations have endorsed E.P.T., most prominently the Centers for Disease Control and Prevention, it remains underused because most states do not cover the medications’ cost and many doctors are uncomfortable treating patients they have not evaluated.
In a few states that have regulations mandating direct doctor-patient contact, E.P.T. is illegal. And though some states, like Hawaii, Arizona, Colorado, Nebraska, and, as of last month, Michigan, explicitly authorize the practice of E.P.T., its status is legally ambiguous in at least 10 states.
In Pennsylvania, where regulations neither prohibit nor recommend E.P.T., Elian A. Rosenfeld, a public health researcher, surveyed Pittsburgh providers. Only 11 percent of 112 providers regularly used E.P.T. While most thought the practice beneficial, they expressed reservations about not evaluating their patients’ partners.
Many were fearful that E.P.T. might violate medical ethics and make them vulnerable to lawsuits.
Many doctors she interviewed, Ms. Rosenfeld said, “wanted to make sure that their patient was in a safe relationship before providing E.P.T. and felt they did not have the necessary training to do so.”
Dr. Chris Stolle is a gynecologist as well as a state delegate in Virginia, where legislative efforts supporting E.P.T. have stalled. He supports aspects of E.P.T. but says that doctors need to have some connection with the partner.
“You’d want to talk to the partner before prescribing antibiotics to make sure they don’t have allergies,” he said. “You just can’t hand out prescriptions. At least have phone contact!”
C.D.C. experts say that when the antibiotics azithromycin and cefixime have been given as E.P.T., there have been no documented cases of allergic reactions. The medications come with directions and allergy warnings.
The public health rationale for E.P.T. is straightforward. According to the C.D.C., in 2013, there were 1.4 million reported cases of chlamydia and 333,000 of gonorrhea. Actual numbers may be at least twice as high. The infections disproportionately affect people ages 15 to 24.
Chlamydia is often asymptomatic. Left untreated in women, chlamydia and gonorrhea can lead to pelvic inflammatory disease, ectopic pregnancy and infertility. In men, they can cause discharge, painful urination and swollen testicles.
Yet of all sexually transmitted infections, these two are among the most treatable, swiftly and cheaply.
While experts estimate that about 50 percent of patients’ partners who learn they have been exposed will seek treatment, many will not because of inconvenience, loss of privacy and cost. Although E.P.T. is not preferable to direct screening, experts add, it may often be more feasible.
But many clinicians, trained to care for individual patients, are not focused on broader public health considerations.
Dr. Gail Bolan, the director of sexually transmitted disease prevention at the C.D.C., said that given the damage chlamydia can cause women, E.P.T. could indeed be thought of as individual doctor-patient care after all. “It’s a strategy for women to prevent reinfection so they don’t have complications,” she said.
Studies as far back as 1998, and a 2005 study in The New England Journal of Medicine, show that when a patient can give a partner the medication, that individual’s rate of reinfection declines. In 2013, a survey of 387 urban teenagers showed that 85 percent were willing to follow such a regimen.
Some states authorize EPT only for chlamydia. One barrier to including gonorrhea is that the C.D.C.’s latest recommendation for its treatment includes an injection, which is not appropriate for expedited partner therapy. But if E.P.T. is the best way to ensure that a partner receives treatment, the C.D.C. says that oral medication may be used.
So far, the C.D.C. has endorsed E.P.T. only for heterosexual partners. Dr. Bolan said E.P.T.s effectiveness has not been studied in men who have sex with men.
But more significant, she said, because gonorrhea and chlamydia infections in these patients could also be associated with syphilis or H.I.V., public health officials prefer to concentrate limited resources on encouraging their partners to receive a comprehensive screening.
Washington’s E.P.T. program may be the most robust in the country. The key to its success, concluded Dr. Matthew Golden, the lead author of last month’s study and director of the public health H.I.V. and S.T.D. program in Seattle, is that the state buys the medication as a public good.
“Think of it like a vaccine,” he said. He estimated the state’s cost to be about $150,000. For William, the program not only heals a medical problem, but an emotional one. Although he is not sure of his infections’ source, he concedes that the unprotected sex he had with a stripper about a month before meeting his pizza-deliverer friend could have been a contributing factor.
“I felt very good that I was able to take care of this problem that I may have caused,” he said.