Questions, Answers, and Best Practices for Expedited Partner Therapy (EPT)

Date of current publication: April 15, 2022
Lead authors: Jason E. Zucker, MD, and Marguerite A. Urban, MD
Writing group: Joseph P. McGowan, MD, FACP, FIDSA; Steven M. Fine, MD, PhD; Rona Vail, MD; Samuel T. Merrick, MD; Asa Radix, MD, MPH, PhD; Christopher J. Hoffmann, MD, MPH; Charles J. Gonzalez, MD
Committee: Medical Care Criteria Committee
Date of original publication: April 15, 2022

Sexually transmitted infections (STIs) are a significant cause of morbidity and mortality and may result in infertility, chronic abdominal pain, and an increased risk of acquiring HIV. In New York State, as of 2020, cases of chlamydia and gonorrhea, the most common bacterial STIs, had increased for the sixth consecutive year. Currently, New York State ranks 17th and 19th among all states for total number of cases of chlamydia and gonorrhea, respectively CDC 2023. People <24 years old, non-Hispanic Black individuals, and men who have sex with men have the highest rates of STIs in New York State; in 2019, rates also significantly increased among women NYSDOH 2021. It is imperative that all patients with STIs and their sex partners are treated to interrupt chains of transmission, help combat rising STI numbers, and move toward ending the STI epidemic. Expedited partner therapy (EPT) is an essential health service that can help combat the rising number of cases and is designed to be a low-barrier intervention. The New York State Department of Health (NYSDOH) encourages care providers to take steps to make EPT as available as possible NYSDOH 2022.

The answers to the frequently asked questions below offer guidance for clinicians in New York State who provide sexual health care, including testing and treatment for STIs. The goal is to inform clinicians about existing regulations that allow expedited treatment of sex partners of individuals diagnosed with gonorrhea, chlamydia, or trichomoniasis. EPT is not allowed for treatment of syphilis (see information regarding syphilis management in guidance section Definition, Legality, and Eligibility ).

More information is available through these resources:

• NYSDOH: Expedited Partner Therapy
• New York City Health: Expedited Partner Therapy
• Centers for Disease Control and Prevention (CDC): 2021 STI Treatment Guidelines
• Clinical Education Initiative

Expedited partner therapy, or EPT, is the clinical practice of providing prescription medication for STI treatment without a healthcare visit for the sex partners of patients with a newly diagnosed STI. In New York State, EPT is permissible for chlamydia, gonorrhea, and trichomoniasis NYSDOH 2022; CDC 2021. EPT is an opportunity to lower the threshold to an essential sexual health service and make treatment broadly available. EPT is not intended to replace clinic visits but to provide an alternative strategy for treating partners who are unable or unwilling to see a care provider for treatment. Clinic visits provide opportunities for STI screening in individuals who may require treatment for an STI other than the infection being treated with EPT. A visit with a care provider also offers the opportunity to provide additional services, such as risk-reduction counseling and HIV pre-exposure prophylaxis.

Yes, in New York State, EPT is explicitly legal under NYS Public Health Law 2312 and can be provided for treatment of chlamydia, gonorrhea, and trichomoniasis, as recommended by the CDC: 2021 STI Treatment Guidelines.

EPT is permissible or potentially allowable in 50 states. State laws determine the STIs covered, who can receive EPT, and how it can be provided. Clinicians should review state-specific guidance before providing EPT.

Sex partners of patients with a clinical or laboratory diagnosis of gonorrhea, chlamydia, and trichomoniasis (referred to as index patients) are eligible for EPT, which can be prescribed regardless of the sexual or gender identity of the index patient or their sex partner.

There is no age threshold for EPT in New York State. According to NYS Public Health Law 2305, individuals <18 years old may give effective informed consent for services related to screening, treatment, and prevention of STIs. Therefore, EPT is applicable for patients of any age and their sex partner(s).

The recommended management of partners of individuals diagnosed with syphilis varies significantly depending on the stage of syphilis in the index patient. No data support use of EPT to treat partners of patients with syphilis. Partner services offered through state or local health departments are available to assist with partner treatment for syphilis throughout New York State. Of note, a clinician may prescribe EPT for gonorrhea, chlamydia, and trichomonas to a patient while syphilis test results are pending or if they are unable to be tested (e.g., a symptomatic telehealth visit). If the diagnosis of syphilis was unknown at the time EPT was prescribed, there is no liability.

Table 1, below, summarizes preferred and alternative regimens for EPT, which are aligned with the CDC: 2021 STI Treatment Guidelines. EPT treatment for an index patient and their sex partner(s) may not be the same.

The index patient’s and sex partner’s EPT regimens may differ based on individual patient factors. For guidance on the treatment of the index patient, see CDC: 2021 STI Treatment Guidelines.

Clinicians may dispense EPT medications in person at the point of care or may provide a prescription for the medications.

Partner packs, dispensed in person, are preferred. Partner packs include medication for the index patient and the sex partner along with informational materials.

Per New York State law, when dispensed, partner packs must be labeled with the name and address of the dispenser, directions for use, date of delivery, the proprietary or brand name of the drug, and the strength of the contents.

However, not all clinical environments may be able to dispense EPT in this way. When partner packs are not available, clinicians can provide a prescription to the index patient for their partner, along with informational materials and clinic contact information.

Prescribed (“Prescription – EPT”): If providing a prescription for EPT, the prescription must have “EPT” in the comments below the care provider information and above the medication, the dosage, refills (0), and instructions for use. The prescription may be issued electronically or on an official New York State prescription form. No identifiable information is required; per NYS Public Health Law Section 2312, a pharmacist can fill a prescription with the designation of “EPT” even when a sex partner’s name, address, and date of birth are not listed on the prescription. See the NYSDOH document EPT FAQs for Health Care Providers and Pharmacists for answers to common questions from health care providers regarding EPT prescriptions. Information on electronic prescribing rules, regulations, and allowable exemptions (including EPT) in New York State can be found on the NYSDOH Electronic Prescribing webpage.

Medication costs are the responsibility of the sex partner and may be paid for in cash or through health insurance coverage. The index patient’s insurance cannot be billed for medications for a partner. If an index patient’s partner is uninsured, then the best approach is to provide the EPT medications in person when available. When EPT medications cannot be provided in person, partners should be sent to a local health department to cover the cost of the prescription.

Contact the index patient and, with consent, their partner by phone to ensure they have or will pick up the medications and that symptoms resolve. Schedule follow-up visits for index patients if symptoms persist or at 3 months for repeat testing because of the risk of reinfection. Advise that sex partners follow up for comprehensive sexual health services as soon as they are able.

• Advise index patients to inform their sex partner(s) that they may have been exposed to an STI (chlamydia, gonorrhea, and/or trichomoniasis) and should seek evaluation and treatment even if they do not have symptoms.
• Emphasize that partners should read the educational information provided before they take the EPT medication.
• Make clear that the partner should seek medical care before starting the EPT medication if they:
  • Are allergic to antibiotics
  • Have abdominal pain, pelvic pain, testicular pain, fever, nausea, vomiting, or other symptoms of serious illness that require evaluation and may require treatment beyond EPT
  • Are pregnant or could be pregnant
  • Have serious health problems
  • Are taking prescription or nonprescription drugs, because potentially dangerous drug-drug interactions could occur
• Educate index patients and partners about:
  • The possibility that additional treatment may be needed if the patient or partner has an STI that is not covered by the delivered EPT
  • Abstaining from sexual activity for at least 7 days after treatment is ended to decrease the likelihood of reinfection
  • Prevention of STIs in the future, including the use of barrier protection and PrEP for prevention of HIV
  • The preferred approach to STI care for partners, which is to see a health care provider for a complete STI evaluation, including HIV testing, even if they take the EPT medications

New York State offers free educational materials for distribution to partners in English and Spanish. These materials may be distributed with a digital link or a QR code or ordered through the NYSDOH website.

• The best practice for STI care is to see and evaluate the sex partner(s) of an index patient diagnosed with an STI. An index patient may, if asked, be able to bring their sex partner(s) with them when they come for treatment.
• EPT is a legal alternative STI treatment strategy for sex partners of patients with a clinical or laboratory diagnosis of gonorrhea, chlamydia, or trichomonas (not syphilis) and who are not able or not willing to be seen for medical care.
• When possible, EPT should be provided as a partner pack that includes medication, informational materials, and clinic contact options.
• When a partner pack is not available, a clinician can provide the index patient with a prescription for their partner(s) along with informational materials and clinic contact options.
• If a prescription for EPT is provided instead of a partner pack, the partner is responsible for the cost of the medications.
• Azithromycin is the EPT option for treatment of chlamydia in a partner who is or could be pregnant.
• Follow up by phone with the index patient to ensure that they have their medications or will be able to get them, and if appropriate, to ask if symptoms have resolved.
• With consent, also follow up with the partner(s) who received EPT.

Date of current publication: August 8, 2023
Lead authors: Jessica Rodrigues, MS; Jessica M. Atrio, MD, MSc; and Johanna L. Gribble, MA
Writing group: Steven M. Fine, MD, PhD; Rona M. Vail, MD; Samuel T. Merrick, MD; Asa E. Radix, MD, MPH, PhD; Christopher J. Hoffmann, MD, MPH; Charles J. Gonzalez, MD
Committee: Medical Care Criteria Committee
Date of original publication: August 8, 2023

Throughout its guidelines, the New York State Department of Health (NYSDOH) AIDS Institute (AI) Clinical Guidelines Program recommends “shared decision-making,” an individualized process central to patient-centered care. With shared decision-making, clinicians and patients engage in meaningful dialogue to arrive at an informed, collaborative decision about a patient’s health, care, and treatment planning. The approach to shared decision-making described here applies to recommendations included in all program guidelines. The included elements are drawn from a comprehensive review of multiple sources and similar  attempts to define shared decision-making, including the Institute of Medicine’s original description [Institute of Medicine 2001]. For more information, a variety of informative resources and suggested readings are included at the end of the discussion.

The benefits to patients that have been associated with a shared decision-making approach include:

• Decreased anxiety [Niburski, et al. 2020; Stalnikowicz and Brezis 2020]
• Increased trust in clinicians [Acree, et al. 2020; Groot, et al. 2020; Stalnikowicz and Brezis 2020]
• Improved engagement in preventive care [McNulty, et al. 2022; Scalia, et al. 2022; Bertakis and Azari 2011]
• Improved treatment adherence, clinical outcomes, and satisfaction with care [Crawford, et al. 2021; Bertakis and Azari 2011; Robinson, et al. 2008]
• Increased knowledge, confidence, empowerment, and self-efficacy [Chen, et al. 2021; Coronado-Vázquez, et al. 2020; Niburski, et al. 2020]

Collaborative care: Shared decision-making is an approach to healthcare delivery that respects a patient’s autonomy in responding to a clinician’s recommendations and facilitates dynamic, personalized, and collaborative care. Through this process, a clinician engages a patient in an open and respectful dialogue to elicit the patient’s knowledge, experience, healthcare goals, daily routine, lifestyle, support system, cultural and personal identity, and attitudes toward behavior, treatment, and risk. With this information and the clinician’s clinical expertise, the patient and clinician can collaborate to identify, evaluate, and choose from among available healthcare options [Coulter and Collins 2011]. This process emphasizes the importance of a patient’s values, preferences, needs, social context, and lived experience in evaluating the known benefits, risks, and limitations of a clinician’s recommendations for screening, prevention, treatment, and follow-up. As a result, shared decision-making also respects a patient’s autonomy, agency, and capacity in defining and managing their healthcare goals. Building a clinician-patient relationship rooted in shared decision-making can help clinicians engage in productive discussions with patients whose decisions may not align with optimal health outcomes. Fostering open and honest dialogue to understand a patient’s motivations while suspending judgment to reduce harm and explore alternatives is particularly vital when a patient chooses to engage in practices that may exacerbate or complicate health conditions [Halperin, et al. 2007].

Options: Implicit in the shared decision-making process is the recognition that the “right” healthcare decisions are those made by informed patients and clinicians working toward patient-centered and defined healthcare goals. When multiple options are available, shared decision-making encourages thoughtful discussion of the potential benefits and potential harms of all options, which may include doing nothing or waiting. This approach also acknowledges that efficacy may not be the most important factor in a patient’s preferences and choices [Sewell, et al. 2021].

Clinician awareness: The collaborative process of shared decision-making is enhanced by a clinician’s ability to demonstrate empathic interest in the patient, avoid stigmatizing language, employ cultural humility, recognize systemic barriers to equitable outcomes, and practice strategies of self-awareness and mitigation against implicit personal biases [Parish, et al. 2019].

Caveats: It is important for clinicians to recognize and be sensitive to the inherent power and influence they maintain throughout their interactions with patients. A clinician’s identity and community affiliations may influence their ability to navigate the shared decision-making process and develop a therapeutic alliance with the patient and may affect the treatment plan [KFF 2023; Greenwood, et al. 2020]. Furthermore, institutional policy and regional legislation, such as requirements for parental consent for gender-affirming care for transgender people or insurance coverage for sexual health care, may infringe upon a patient’s ability to access preventive- or treatment-related care [Sewell, et al. 2021].

Health equity: Adapting a shared decision-making approach that supports diverse populations is necessary to achieve more equitable and inclusive health outcomes [Castaneda-Guarderas, et al. 2016]. For instance, clinicians may need to incorporate cultural- and community-specific considerations into discussions with women, gender-diverse individuals, and young people concerning their sexual behaviors, fertility intentions, and pregnancy or lactation status. Shared decision-making offers an opportunity to build trust among marginalized and disenfranchised communities by validating their symptoms, values, and lived experience. Furthermore, it can allow for improved consistency in patient screening and assessment of prevention options and treatment plans, which can reduce the influence of social constructs and implicit bias [Castaneda-Guarderas, et al. 2016].

Clinician bias has been associated with health disparities and can have profoundly negative effects [FitzGerald and Hurst 2017; Hall, et al. 2015]. It is often challenging for clinicians to recognize and set aside personal biases and to address biases with peers and colleagues. Consciously or unconsciously, negative or stigmatizing assumptions are often made about patient characteristics, such as race, ethnicity, gender, sexual orientation, mental health, and substance use [Avery, et al. 2019; van Boekel, et al. 2013; Livingston, et al. 2012]. With its emphasis on eliciting patient information, a shared decision-making approach encourages clinicians to inquire about patients’ lived experiences rather than making assumptions and to recognize the influence of that experience in healthcare decision-making.

Stigma: Stigma may prevent individuals from seeking or receiving treatment and harm reduction services [Tsai, et al. 2019]. Among people with HIV, stigma and medical mistrust remain significant barriers to healthcare utilization, HIV diagnosis, and medication adherence and can affect disease outcomes [Turan, et al. 2017; Chambers, et al. 2015], and stigma among clinicians against people who use substances has been well-documented [Stone, et al. 2021; Tsai, et al. 2019; van Boekel, et al. 2013]. Sexual and reproductive health, including strategies to prevent HIV transmission, acquisition, and progression, may be subject to stigma, bias, social influence, and violence.

In addition to the references cited below, the following resources and suggested reading may be useful to clinicians.

References

Acree ME, McNulty M, Blocker O, et al. Shared decision-making around anal cancer screening among black bisexual and gay men in the USA. Cult Health Sex 2020;22(2):201-16. [PMID: 30931831]

Avery JD, Taylor KE, Kast KA, et al. Attitudes toward individuals with mental illness and substance use disorders among resident physicians. Prim Care Companion CNS Disord 2019;21(1):18m02382. [PMID: 30620451]

Bertakis KD, Azari R. Patient-centered care is associated with decreased health care utilization. J Am Board Fam Med 2011;24(3):229-39. [PMID: 21551394]

Castaneda-Guarderas A, Glassberg J, Grudzen CR, et al. Shared decision making with vulnerable populations in the emergency department. Acad Emerg Med 2016;23(12):1410-16. [PMID: 27860022]

Chambers LA, Rueda S, Baker DN, et al. Stigma, HIV and health: a qualitative synthesis. BMC Public Health 2015;15:848. [PMID: 26334626]

Chen CH, Kang YN, Chiu PY, et al. Effectiveness of shared decision-making intervention in patients with lumbar degenerative diseases: a randomized controlled trial. Patient Educ Couns 2021;104(10):2498-2504. [PMID: 33741234]

Coronado-Vázquez V, Canet-Fajas C, Delgado-Marroquín MT, et al. Interventions to facilitate shared decision-making using decision aids with patients in primary health care: a systematic review. Medicine (Baltimore) 2020;99(32):e21389. [PMID: 32769870]

Coulter A, Collins A. Making shared decision-making a reality: no decision about me, without me. 2011. https://www.kingsfund.org.uk/sites/default/files/Making-shared-decision-making-a-reality-paper-Angela-Coulter-Alf-Collins-July-2011_0.pdf

Crawford J, Petrie K, Harvey SB. Shared decision-making and the implementation of treatment recommendations for depression. Patient Educ Couns 2021;104(8):2119-21. [PMID: 33563500]

FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics 2017;18(1):19. [PMID: 28249596]

Greenwood BN, Hardeman RR, Huang L, et al. Physician-patient racial concordance and disparities in birthing mortality for newborns. Proc Natl Acad Sci U S A 2020;117(35):21194-21200. [PMID: 32817561]

Groot G, Waldron T, Barreno L, et al. Trust and world view in shared decision making with indigenous patients: a realist synthesis. J Eval Clin Pract 2020;26(2):503-14. [PMID: 31750600]

Hall WJ, Chapman MV, Lee KM, et al. Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review. Am J Public Health 2015;105(12):e60-76. [PMID: 26469668]

Halperin B, Melnychuk R, Downie J, et al. When is it permissible to dismiss a family who refuses vaccines? Legal, ethical and public health perspectives. Paediatr Child Health 2007;12(10):843-45. [PMID: 19043497]

Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. 2001. https://www.ncbi.nlm.nih.gov/books/NBK222274/

KFF. Key data on health and health care by race and ethnicity. 2023 Mar 15. https://www.kff.org/racial-equity-and-health-policy/report/key-data-on-health-and-health-care-by-race-and-ethnicity/ [accessed 2023 May 19]

Livingston JD, Milne T, Fang ML, et al. The effectiveness of interventions for reducing stigma related to substance use disorders: a systematic review. Addiction 2012;107(1):39-50. [PMID: 21815959]

McNulty MC, Acree ME, Kerman J, et al. Shared decision making for HIV pre-exposure prophylaxis (PrEP) with black transgender women. Cult Health Sex 2022;24(8):1033-46. [PMID: 33983866]

Niburski K, Guadagno E, Abbasgholizadeh-Rahimi S, et al. Shared decision making in surgery: a meta-analysis of existing literature. Patient 2020;13(6):667-81. [PMID: 32880820]

Parish SJ, Hahn SR, Goldstein SW, et al. The International Society for the Study of Women’s Sexual Health process of care for the identification of sexual concerns and problems in women. Mayo Clin Proc 2019;94(5):842-56. [PMID: 30954288]

Robinson JH, Callister LC, Berry JA, et al. Patient-centered care and adherence: definitions and applications to improve outcomes. J Am Acad Nurse Pract 2008;20(12):600-607. [PMID: 19120591]

Scalia P, Durand MA, Elwyn G. Shared decision-making interventions: an overview and a meta-analysis of their impact on vaccine uptake. J Intern Med 2022;291(4):408-25. [PMID: 34700363]

Sewell WC, Solleveld P, Seidman D, et al. Patient-led decision-making for HIV preexposure prophylaxis. Curr HIV/AIDS Rep 2021;18(1):48-56. [PMID: 33417201]

Stalnikowicz R, Brezis M. Meaningful shared decision-making: complex process demanding cognitive and emotional skills. J Eval Clin Pract 2020;26(2):431-38. [PMID: 31989727]

Stone EM, Kennedy-Hendricks A, Barry CL, et al. The role of stigma in U.S. primary care physicians’ treatment of opioid use disorder. Drug Alcohol Depend 2021;221:108627. [PMID: 33621805]

Tsai AC, Kiang MV, Barnett ML, et al. Stigma as a fundamental hindrance to the United States opioid overdose crisis response. PLoS Med 2019;16(11):e1002969. [PMID: 31770387]

Turan B, Budhwani H, Fazeli PL, et al. How does stigma affect people living with HIV? The mediating roles of internalized and anticipated HIV stigma in the effects of perceived community stigma on health and psychosocial outcomes. AIDS Behav 2017;21(1):283-91. [PMID: 27272742]

van Boekel LC, Brouwers EP, van Weeghel J, et al. Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: systematic review. Drug Alcohol Depend 2013;131(1-2):23-35. [PMID: 23490450]