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

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

Lead authors: Jason E. Zucker, MD, and Marguerite A. Urban, MD
Publication date: April 15, 2022
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

Purpose

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 (NYS), as of 2020, cases of chlamydia and gonorrhea, the most common bacterial STIs, had increased for the sixth consecutive year. Currently, NYS ranks 17th and 19th among all states for total number of cases of chlamydia and gonorrhea, respectively [CDC 2022]. People <24 years old, non-Hispanic Black individuals, and men who have sex with men have the highest rates of STIs in NYS; in 2019, rates also significantly increased among women [NYSDOH 2021b]. 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. NYSDOH encourages care providers to take steps to make EPT as available as possible [NYSDOH 2021a].

The answers to the frequently asked questions below offer guidance for clinicians in NYS 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 below for more information regarding syphilis management).

More information is available through these resources:

What is EPT?

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 NYS, EPT is permissible for chlamydia, gonorrhea, and trichomoniasis [CDC 2021; NYSDOH 2021a]. 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 NYS, EPT is explicitly legal under NYS Public Health Law 2312 [NYS Senate 2020] and can be provided for treatment of chlamydia, gonorrhea, and trichomoniasis, as recommended by the 2021 CDC STI Treatment Guidelines [Workowski, et al. 2021].

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.

Who is eligible for 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 NYS. 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 [NYS Senate 2014b]. Therefore, EPT is applicable for patients of any age and their sex partner(s).

Box: Eligibility for Expedited Partner Therapy (EPT) [a]
Eligible for EPT Not eligible for EPT
  • Patients with a clinical (without laboratory confirmation) or laboratory diagnosis of chlamydia, gonorrhea, and trichomoniasis (referred to as index patients) and their sex partners
  • All sex partners exposed within 60 days before the index patient’s symptom onset or diagnosis
  • The most recent sex partner, if the index patient has had no sex partners within 60 days of the diagnosis
  • Patients known to have syphilis in addition to gonorrhea, chlamydia, and trichomoniasis
  • Cases involving suspected or confirmed abuse (i.e., child abuse, sexual assault, or sexual abuse)

Note:

  1. Per New York State law, individuals <18 years old may give effective informed consent for services related to screening, treatment, and prevention of sexually transmitted infections [NYS Senate 2014b]. See Guidance: Adolescent Consent to HIV and STI Treatment and Prevention.

Why are patients known to have syphilis not eligible for EPT?

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 NYS. 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.

Which medications should be used for EPT?

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

Table: Preferred and Alternative Regimens for Expedited Partner Therapy (EPT)
CDC. 2021 Sexually Transmitted Infections Treatment Guidelines [Workowski, et al. 2021]
STI Preferred
EPT Regimen
Alternative
EPT Regimen
Comments
Chlamydia

Doxycycline 100 mg by mouth twice daily for 7 days

OR

Azithromycin 1 g by mouth in a single dose

Levofloxacin 500 mg by mouth daily for 7 days
  • Doxycycline and levofloxacin are contraindicated in pregnancy
  • Azithromycin is recommended for treatment of chlamydia in patients with unknown pregnancy status
Gonorrhea Cefixime 800 mg by mouth in a single dose Treat for chlamydia if it has not been excluded
Trichomoniasis

Metronidazole 2 g by mouth in a single dose

OR

Tinidazole 2 g by mouth in a single dose

Metronidazole 500 mg by mouth twice daily for 7 days Counsel symptomatic pregnant patients with trichomoniasis regarding the potential risks and benefits of treatment

Is the treatment for an index patient and a sex partner always 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, please review the 2021 CDC STI Treatment Guidelines [Workowski, et al. 2021].

How do I provide EPT medications?

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 NYS law [NYS Senate 2014a], 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 NYS 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 NYS can be found on the NYSDOH Electronic Prescribing webpage.

NEW YORK STATE LAW
  • Medications 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 [NYS Senate 2014a].

Who is responsible for paying for EPT medications?

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.

What points should be covered in EPT educational materials?

  • 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

Where can I find free educational materials?

NYS 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.

How should I follow up?

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.

BEST PRACTICE REMINDERS FOR EXPEDITED PARTNER THERAPY (EPT)
  • 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.
Refences

CDC. Expedited partner therapy. 2021 Apr 19. https://www.cdc.gov/std/ept/default.htm [accessed 2022 Feb 24]

CDC. 2020 STD surveillance report: State ranking tables. 2022 Mar 24. https://www.cdc.gov/std/statistics/2020/tables/2020-STD-Surveillance-State-Ranking-Tables.pdf [accessed 2022 Apr 14]

NYS Senate. Article 137, Section 6807. Pharmacy: Exempt persons; special provisions. 2014a Sep 22. https://www.nysenate.gov/legislation/laws/EDN/6807 [accessed 2022 Mar 3]

NYS Senate. New York State Public Health Law Article 2305: Sexually transmitted diseases; treatment by licensed physician or staff physician of a hospital; prescriptions. 2014b Sep 22. https://www.nysenate.gov/legislation/laws/PBH/2305 [accessed 2022 Feb 24]

NYS Senate. New York State Public Health Law Article 2312: Expedited partner therapy for chlamydia trachomatis infection and other sexually transmitted infections. 2020 Jan 10. https://www.nysenate.gov/legislation/laws/PBH/2312 [accessed 2022 Feb 24]

NYSDOH. Expedited partner therapy. 2021a Dec. https://www.health.ny.gov/diseases/communicable/std/ept/ [accessed 2022 Feb 24]

NYSDOH. Sexually transmitted infections surveillance report, New York State, 2019. 2021b May 5. https://www.health.ny.gov/statistics/diseases/communicable/std/docs/sti_surveillance_report_2019.pdf [accessed 2022 Feb 25]

Workowski KA, Bachmann LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep 2021;70(4):1-187. [PMID: 34292926