Partner management for sexually transmissible infections: better options and guidelines please

A cornerstone in the control of sexually transmissible infection (STIs) includes the testing and treatment of sexual partners of patients diagnosed with treatable STIs – widely referred to as partner notification or contact tracing. At its most basic level, partner notification simply involves a clinician discussing with a patient the need for partners to be tested and treated appropriately. Testing of sexual partners of individuals diagnosed with STIs generally yields a higher rate of STIs compared with individuals unselectively screened for STIs, warranting efforts supporting partner notification. Furthermore, treatment of partners reduces the likelihood of index patients being re-infected and most likely further transmission and complications from untreated infection. ^{1 , 2} Partners who are made aware of their situation are also given the opportunity to seek information and counselling and to adopt preventative measures.

In practice though, partner notification is often carried out poorly, if at all. While health care providers may feel they bear responsibility for discussing partner notification, most are unsure about how best to assist their patients. Commonly reported difficulties include: poor knowledge and lack of guidance on best practice; discomfort discussing matters of a sexual nature; and uncertainty over patients’ ability or willingness to contact their partners. ^{3 – 7} Moreover, while individuals diagnosed with STIs feel letting their partners know is the right thing to do, ⁸ understandably many find it difficult with only a fraction of recent partners informed of their risk. ^{8 , 9} Research suggests that more guidance, resources and support for both practitioners and their patients would improve the outcomes from partner notification. ^{3 , 7 , 9}

In this issue of Sexual Health, Shackleton et al. ¹⁰ investigate the acceptability among clinicians working in London general practice of innovative measures aimed at improving the notification and management of partners of patients diagnosed with STIs. The novelty of their intervention is to be commended.

New attempts to expedite the treatment of partners, who are either the source of the infection or at risk themselves, have evolved as a pragmatic response to the failure of partners to attend clinical services for testing and treatment. One approach is patient-delivered partner therapy (PDPT), where a practitioner gives a patient diagnosed with an STIs medication or a prescription to give to their partners, without the partner being assessed by the practitioner. While studies suggest that PDPT is likely to reduce re-infection of the index patient, ¹¹ concerns have been raised about this approach. While around half of Australian general practitioners have used PDPT for chlamydia, ³ many express mixed feelings about the practice in an environment where PDPT is neither supported by guidelines or specific legislation. ^{3 , 7}

This practice, which involves a major departure from the traditional doctor–patient relationship, worries general practitioners because partners do not get checked for complications or contraindications to antibiotics and they are not screened for other STIs. ^{3 , 7} Do antibiotics get to the intended recipient? Does the partner understand what they are being treated for? Also, in practice, the range of STIs that could be treated using PDPT in Australia is limited. While treatment for uncomplicated chlamydia is possible using a single dose oral antibiotic, there are currently no oral remedies in Australia that are considered first line treatment for gonorrhoea or syphilis. However, studies suggest that PDPT could result in more partners being treated, and treated earlier. ⁹

In the ideal world all partners would attend clinical services for testing and treatment, but the reality is rather different. Hence the liberal use of PDPT by many Australian general practitioners, despite the overlying legal cloud and general practitioners’ own personal misgivings. ^{3 , 5 , 12} Specific legislation supporting PDPT, as has been put forward in several states in the USA, but which is currently lacking in Australia, is required to protect practitioners. ^{13 , 14} Clinical guidelines dealing with PDPT would also be welcome. If PDPT received such endorsement it would allow the practice to be undertaken in the best possible way: by well informed practitioners imparting all the necessary information and support to patients and their partners.

The model of accelerated partner therapy put forward by Shackleton et al. ¹⁰ would go some way towards alleviating some of these concerns as partners would be assessed directly by a health professional, although without a physical examination, which would for example be required to exclude pelvic inflammatory disease. As such an approach requires additional resources, the effectiveness and cost-effectiveness of this model are of interest.

Short of these, we should not lose sight of simple measures that will help to optimise partner management. The well informed patient who understands the reasons why his or her partner needs assessment and who is given options for informing their partners is more likely to follow through with notifying their partners. At the time of writing, the Australasian Contact Tracing Manual is being revised and updated with the hope that it will be more accessible to general practitioners. Other resources include internet-based partner notification services such as Let Them Know (www.letthemknow.org.au; verified August 2010), Drama Down Under (www.thedramadownunder.info; verified August 2010) and Inspot (www.inspot.org; verified August 2010), which allow individuals to send either named or anonymous emails and SMS messages to their partners. Evaluation of these services has shown good uptake and few hoaxes. While studies suggest that many individuals prefer to tell their partners in person or by telephone, a proportion of individuals prefer email and SMS as it is less confronting or a more convenient alternative. ^{9 , 15}

New approaches to and greater guidance on partner management are required. Such efforts would translate into a smoother operation and better outcomes for all involved.

None declared.