Does Patient-Delivered Partner Treatment Improve Disclosure for Treatable Sexually Transmitted Diseases?

Abstract

The objective of this research was to determine the factors associated with disclosure of three treatable sexually transmitted diseases (STDs). Data were obtained from two intervention trials to determine the ideal means of partner referral. Men diagnosed with urethritis and women diagnosed with trichomoniasis at public clinics in New Orleans, Louisiana were randomly assigned to partner referral (PR), booklet-enhanced partner referral (BEPR), or patient-delivered partner treatment (PDPT). Participants were asked about sex partners at baseline, then whether they disclosed to them at follow-up. The male trial was conducted from December 2001 to March 2004 and the female trial from December 2001 to August 2004. Data on men and women were analyzed separately. Nine hundred seventy-seven men and 463 women—reporting information on 1991 and 521 sex partners—were respectively enrolled in each trial. Disclosure occurred to 57.8% and 87.3% of their partners, respectively. Most men (68.3%) reported having two or more partners and disclosure was more likely to occur in: those who reported only one sex partner (adjusted odds ratio [aOR] 95% confidence interval [CI]: 1.54 [1.10, 2.16]); those in steady relationships (OR [95% CI]: 1.37 [1.08,1.74]); and those assigned PDPT [OR [95% CI]: 2.71 [1.93,3.82]). Most women reported having only one partner (86.8%) and disclosure was more likely to occur in steady relationships (OR [95% CI]: 2.65 [1.24,5.66]), and when sex was reinitiated with partners during the follow-up period (OR [95% CI]: 3.30 [1.54,7.09]). The provision of PDPT was associated with increased STD disclosure among men but not among women. Both men and women were less likely to disclose to casual partners. Women had high rates of disclosure irrespective of intervention arm.

Introduction

R ates of sexually transmitted disease (STD) infections in the United States remain at levels in excess of the Healthy People 2010 objectives.¹ Public health measures are focused on reducing further spread within sexual networks, as well as preventing reinfection of the index case. To achieve the latter, partners of an index case should be diagnosed and treated appropriately. Partner notification (PN)—a process whereby sex partners of STD index patients are informed of their exposure to an STD and the need to seek medical evaluation^2,3—has been used in the United States for the control of syphilis since the 1930s and for HIV since 1985.^3
–5 Despite advocating the use of PN for chlamydia and gonorrhea control, low PN coverage for these STDs has been demonstrated even in high-morbidity areas.^6

–10

Provider referral is a PN strategy performed by public health professionals who identify and locate sex partners of STD index patients. It may be the most effective means of notifying partners and having them treated for their infection, but it is impractical for STDs that are as highly prevalent as chlamydia, gonorrhea, and trichomoniasis.¹¹ Millions of new STD infections occur annually in the United States.^12
–14 Partner referral by index patients is the method most used by health-care professionals to prompt partners to seek care,^15,16 but this also has been demonstrated as having very limited success. Interventions, such as contact slips (booklet-enhanced partner referral [BEPR]) or patient-delivered partner treatment (PDPT), have successfully been used to improve partner treatment.^15

–18 In particular, PDPT has the additional benefit of providing immediate treatment for the partner. Disclosure, defined in this study as verbally informing a sex partner that they were exposed to an STD, is intrinsic to any successful attempt at partner referral. It also allows partners of index patients to make informed choices about seeking treatment, reinitiating sexual contact, or practicing protected sex. Subsequently, increased levels of partner treatment can also decrease the likelihood of reinfection in the index case.

The purpose of this research is to determine if PDPT or BEPR increased disclosure to sex partners in two settings: (1) urethritis infection in men enrolled in a free, public STD clinic, and (2) trichomoniasis in women enrolled in a public family planning clinic. Previous publications from these trials^17,19 focused on reinfection of the index patients and partner treatment—this analysis has a novel focus as it specifically examines the correlates of disclosure.

Methods

Data used in this study are from separate, randomized intervention trials conducted in the above two settings in New Orleans, Louisiana. Both studies were designed to determine the most effective method of partner treatment, and informed consent was obtained from all participants.

Study participants—male urethritis trial

Men were enrolled between December 2001 and March 2004. The methods, with details on study recruitment, eligibility criteria, interventions, and follow-up are extensively described elsewhere.¹⁷ The unit of randomization was each month of the trial, rather than the individual participant. Men aged 16–44 years, who reported having at least one female sex partner within the 2 months prior to enrollment and who presented to the clinic with complaints of urethritis, were offered participation in this trial.

Study participants—female trichomoniasis trial

Women were enrolled between December 2001 to August 2004. The methods have been described elsewhere.¹⁹ Women aged 16–44 years, who reported at least one sex partner in the 2 months prior to enrollment and who tested positive for trichomoniasis via InPouch culture (BioMed Diagnostics, White City, OR),²⁰ were offered participation in this trial. Each woman was randomly assigned to one of the following interventions.

Partner treatment interventions

Participants were randomly assigned to 1 of 3 partner treatment interventions: partner referral (PR), BEPR, or PDPT. In the PR arm, participants were instructed to tell their partners that they needed to go to a clinic for STD evaluation and treatment. In the BEPR arm, participants were given a wallet-sized booklet that contained tear-out cards with information for the partner and treatment guidelines for their doctors. The partners could present this card to the doctor of their choice to request appropriate treatment. In the PDPT arm, participants were given packages containing medication for chlamydia/gonorrhea (for the trial in males¹⁷) or trichomoniasis (for the trial in females¹⁹) for up to four identified sex partners.

Data collection

Baseline questionnaires were administered using Audio Computer-Assisted Self-Interviews (A-CASI). Demographic information was collected on the study participants and behavioral information was collected on both the participants and on each of up to four sex partners from the 2 months prior. All enrolled participants consented to being contacted within 21–56 days to complete a follow-up A-CASI questionnaire assessing behaviors (such as sexual activity, condom usage, and disclosure) with each sex partner. Participants were given $10–$30 incentive for completion of various components of the study. The Institutional Review Boards of Tulane University, Louisiana State University, and the Centers for Disease Control and Prevention (CDC) approved the study.

Statistical analysis

Data from each trial were analyzed separately. The frequencies of both participant- and partner-level characteristics were determined. Given the clustering of observations (at least one partner within each index participants), crude and adjusted associations were determined using Generalized Estimating Equations (GEE) regression.²¹ All variables with p values less than 0.10 on crude analysis were considered in the final model. Age was added to the final model as it has been reportedly associated with disclosure for HIV.²² Analyses were performed using SAS 9.1 (SAS Institute, Carey, NC) and tests for significance were conducted at an α error rate of 5%.

Outcome

The primary outcome of this analysis was disclosure to sex partners of exposure to an STD, which was defined as an affirmative response to “Were you able to talk to your partner to tell them that they needed to get treated for this infection?”

Results

Male urethritis trial

Of the 977 men who participated in this trial, most were black (95.7%), and had graduated from high school (49.3%) or had some college education (22.6%). The median age was 24.2 years, and this value was used to categorize age into a binary variable for further analysis. More men were assigned to the BEFR and PDPT arms compared to the PR arm (35.6%, and 35.2% versus 29.2%, p = 0.02). Participants in these arms were similar with respect to all assessed variables. They reported a median number of 2 partners each, with a total of 1991 partners reported at baseline. Most men reported having only female partners (95.3%). Most partners were described as casual rather than steady; only 2.2% of the couples were married and 12.5% were cohabitating. In the majority (87.6%) of partnerships, the index men reported that they could contact the partner(s) if they wished.

At follow-up, participants reported having seen 57.8% of the partners reported at baseline, to have re-initiated sex with 35.6% of them, and to have checked whether 51.5% of partners were treated. Disclosure occurred to the partners of 57.8% of all male participants. By arm, disclosure occurred to 49.1%, 52.8%, and 70.6% of the partners of men assigned to PR, BEPR, and PDPT, respectively (p < 0.0001). On bivariate analysis (Table 1), disclosure was more likely to occur to partners of: men at least 24 years of age (52.1% versus 44.0%, p = 0.02), men with only one partner (23.3% versus 12.6%, p < 0.001), those in steady relationships (42.4% versus 25.5%, p < 0.001), those who were married to the partner (2.9% versus 1.4%, p = 0.03), those who were living with their partners (15.6% versus 9.0%, p < 0.001), those who reported seeing their partners during follow-up (79.7% versus 27.9%, p < 0.001), those whose partner had a discharge (46.7% versus 10.2%, p < 0.001), those who reinitiated sex with their partners (48.5% versus 17.9%, p < 0.001), those who used a condom with all sex acts (52.5% versus 36.5%, p = 0.004), those who did not acquire a new sex partner during follow-up (87.8% versus 81.0%, p = 0.008), and those assigned PDPT (42.0% versus 24.0%, p < 0.001).

Table 1.

Crude Associations with Disclosure: Male Urethritis Trial (n = 1991) and Female Trichomoniasis Trial (n = 521)

	Male urethritis			Female trichomoniasis
	Disclosed (n = 878) %	Did not disclose (n = 641) %	p value	Disclosed (n = 399) %	Did not disclose (n = 58) %	p value
African American	96.2	94.7	0.23	99.0	98.3	0.61
Education level < high school	76.5	80.2	0.22	58.6	65.5	0.36
Age ≥24 years	52.1	44.0	0.02^a	49.4	34.5	0.05^b
1 partner reported at baseline	23.3	12.6	<0.01^b	81.7	55.2	0.004^b
Steady partner	42.4	25.5	<0.01^b	86.9	56.1	0.0003^b
Married to partner	2.9	1.4	0.03^a	9.0	5.2	0.22
Cohabitating with partner	15.6	9.0	<0.01^b	31.3	10.3	<0.0001^b
At follow-up
Saw partner	79.7	27.9	<0.01^b	88.0	37.9	<0.0001^b
Partner experienced discharge	46.7	10.2	<0.01^b	1.6	5.3	0.49
Reinitiated sex with partner	48.5	17.9	<0.01^b	47.0	15.5	<0.0001^b
Used condom every time	52.5	36.5	<0.01^b	57.1	77.8	0.19
Checked to see if partner treated	82.8	8.7	<0.01^b	81.2	10.3	<0.0001^b
No new partners reported	87.8	81.0	<0.01^b	95.5	85.2	0.04^a
Self-report of partner taking meds	67.6	15.6	<0.01^b	75.9	15.8	<0.0001^b
Saw partner take meds	52.7	13.0	<0.01^b	37.7	8.8	<0.0001^b
Intervention—PDPT	42.0	24.0	<0.01^b	35.1	25.9	0.51
BEPR	32.3	39.6	0.52	30.8	41.4	0.37
PR	25.6	36.3	(ref )	34.1	32.8	(ref )

p < 0.05.

p < 0.01.

Note: All data above the “Steady partner” row are index-level data.

PDPT, patient-delivered partner treatment; BEPR, booklet-enhanced partner referral; PR, partner referral.

On the multivariable model (Table 2), there were significant adjusted associations between disclosure and older age (OR [95% CI]: 1.39 [1.07,1.83]), having one sex partner at baseline (OR [95% CI]: 1.54 [1.10,2.16]), being in a steady relationship (OR [95% CI]: 1.37 [1.08,1.74]), reinitiating sex with a partner during follow-up (OR [95% CI]: 3.74 [2.83,4.94]), and being assigned PDPT (OR [95% CI]: 2.71 [1.93,3.82]).

Table 2.

Adjusted Associations with Disclosure: Male Urethritis Trial (n = 1991) and Female Trichomoniasis Trial (n = 521)

	Male urethritis—adjusted OR (95% CI)	p value	Female trichomoniasis—adjusted OR (95% CI)	p value
Age <24 years	0.72 (0.55, 0.94)	0.02^a	0.58 (0.29, 1.13)	0.11
≥2 partners (at baseline)	0.65 (0.46, 0.91)	0.01^a	0.62 (0.28, 1.40)	0.25
Casual partner	0.73 (0.58, 0.92)	0.01^a	0.38 (0.18, 0.81)	0.01^a
Reinitiated sex	3.74 (2.83, 4.94)	< 0.001^b	3.30 (1.54, 7.09)	0.002^b
Acquired new partner	0.81 (0.55, 1.19)	0.28	0.43 (0.15, 1.21)	0.11
Intervention—PDPT	2.71 (1.93, 3.82)	<0.001^b	1.62 (0.72, 3.68)	0.25
BEPR	1.10 (0.80, 1.52)	0.56	0.63 (0.30, 1.32)	0.22
PR	(ref )	—	1.00	(ref )

p < 0.05.

p < 0.01.

PDPT, patient-delivered partner treatment; BEPR, booklet-enhanced partner referral; PR, partner referral.

Female trichomoniasis trial

Of the 463 women enrolled in this trial, most were black (99.1%), and had at least a high school education (87.3%). The median age was 23.7 years, and this value was used to categorize age into a binary variable for further analysis. There were 155, 154, and 154 women assigned to the PR, BEPR, and PDPT arms, respectively. Women in the three arms were similar with respect to all assessed variables. Most participants (86.8%) reported having 1 partner, with a total of 521 partners reported at baseline. Most partners (97.6%) were male. Most partners (82.5%) were described as steady, 8.3% were spouses, and 28% lived with the index patient. Most women said they could contact the partners if they wished (89.0%).

At follow-up, participants reported having seen 81.7% of the partners reported at baseline, to have reinitiated sex with 43.1% of them, and to have checked whether 72.3% of partners were treated. Disclosure occurred to the partners of 87.3% of female participants. By arm, disclosure occurred to 87.8%, 83.7%, and 90.3% of the partners of women assigned to PR, BEPR, and PDPT, respectively (p = 0.27). On bivariate analysis (Table 1), disclosure was more likely to occur to partners of women: with only one partner (81.7% versus 55.2%, p = 0.004), in steady relationships (86.9% versus 56.1%, p = 0.0003), living with their partner (31.3% versus 10.3%, p < 0.001), who reported seeing their partners during follow-up (88.0% versus 37.9%, p < 0.001), who reinitiated sex with their partners (47.0% versus 15.5%, p < 0.001), and who did not acquire a new sex partner during follow-up (95.5%, versus 85.2%, p = 0.04). When compared to PR, assignment to either the PDPT or the BEPR arms was not significantly associated with disclosure (p = 0.51 and p = 0.37, respectively).

On multivariable analysis (Table 2), there were significant adjusted associations between disclosure of trichomoniasis to sex partners and being in a steady relationship (OR [95% CI]: 2.65 [1.24,5.66]), and reinitiating sex with a partner during follow-up (OR [95% CI]: 3.30 [1.54,7.09]). There was no significant adjusted association between intervention and disclosure.

Discussion

In this sample of mostly African American, urban individuals presenting with treatable STDs to public clinics, disclosure of STD exposure occurred to the partners of 57.8% of the male study participants and 87.3% of the female participants, respectively. With the remarkably high incidence of STD infection in the southeastern United States, higher rates of disclosure to sex partners may increase the rates of partner referral and treatment. This is particularly important as many gonorrhea, chlamydia, and trichomoniasis infections are asymptomatic, and partners may be unaware of their infection. All three partner treatment modalities in this study required some level of interaction with partners to varying degrees, and it was hypothesized that BEPR and PDPT were additional tools to help facilitate PN beyond the standard PR.

Most males (68.3%) reported having two or more sex partners within the 2 months prior to baseline interview and disclosure was more likely to occur in those reporting only one sex partner as well as those in steady relationships. Screening for men engaged in multiple casual relationships may help identify core transmitters of infection in this population. In a related publication from this trial,¹⁷ it was found that men in both the PDPT and BEPR arms were significantly more likely to report that their partners were treated for the infection. Men assigned PDPT were significantly more likely to disclose. This suggests that PDPT may serve a twofold purpose: facilitating disclosure to sex partners as well as achieving expedited partner treatment. Furthermore, of all men assigned PDPT, the medication was given to 10.2% of partners even in the absence of disclosure.

In contrast, the overwhelming majority of female study participants reported having only one partner (86.8%), and most relationships were described as steady (82.5%). Disclosure was significantly more likely to occur in steady relationships and when women reinitiated sex with their partners during the follow-up period. The finding that disclosure was less likely to occur to casual partners is consistent with the previous disclosure research for other STDs such as HIV and genital herpes.^22

–25 There was no significant association between intervention and disclosure, but there was a trend for increased disclosure among women in the PDPT arm, and a puzzling trend for decreased disclosure for women in the BEPR arm. This group of women, engaging in mostly steady relationships, may generally be more likely to disclose to their male sex partners, regardless of their assigned intervention.

Our definition of disclosure implies an act of “direct disclosure,” whereby the index patient verbally informs the partner that they were exposed to an STD. There were 138 men (6.9%), however, who complied with the assigned intervention (gave the booklet or treatment to their partner) without reporting disclosure. This may be a case of indirect disclosure (leaving the booklet or medication somewhere visible, without actively discussing the STD exposure).²⁶ Although (direct) disclosure did not occur in these cases, the goal of achieving partner treatment may have been achieved. Of these 138 partnerships, 53.6% reported that the partner took medication for chlamydia or gonorrhea. Most of these partners were of participants assigned BEPR (61.6%), suggesting the effectiveness of the tear-out cards in facilitating PR. In comparison, disclosure was far more common among women irrespective of assigned intervention; there were only 8 women who complied with their assigned intervention without directly disclosing.

This study is not without its limitations. Our definition of disclosure implied the disclosure of potential exposure to an STD, rather than an admission of the index's status. However, telling a partner that they require treatment for an STD may achieve similar behaviors as classical disclosure. Once the partner is aware of the exposure, they may be prompted to practice protected sex and seek testing. Additionally, although this was a randomized trial, there were significantly fewer men assigned to the PR arm. This was as a result of the randomization scheme utilized for this trial, such that the unit of randomization was each month of the trial, rather than the individual participant. Obtaining personal information on sexual behavior can be a challenge, but this was addressed by offering A-CASI to all participants. Furthermore, the data collected on disclosure is through index self-report. Although this may not be the perfect measure, it may be the most reliable and feasible means of assessing disclosure in the absence of partner interviews. Both trials had high acceptance rates (85.1% for males and 82.0% for females) and relatively low losses to follow-up (20.0% for males and 11.0% for females). In both trials, there were no significant differences in baseline characteristics between those who did or did not do a follow-up interview. Another major strength of this research is its novel focus in examining disclosure of treatable STDs to sex partners. A substantial body of research into HIV disclosure exists but, to our knowledge, there are few published studies on disclosure for other STDs.^25,27,28 Although chlamydia, gonorrhea, and trichomoniasis are very different from HIV in terms of prevalence, infectiousness, curability, the extent of stigma and other long-term ramifications, they are indicative of high-risk behaviors and are stigmatizing diseases with the potential for relationship disruption.

PDPT is now recommended by the CDC as an option for partner treatment for chlamydia and gonorrhea in women and heterosexual men.²⁹ However several issues, such as the treatment of partners without direct medical supervision, and concerns over the privacy of partners hinder widespread implementation.³⁰ Although more emphasis is placed on HIV,^31
–33 disclosure is imperative regardless of the STD. It affords exposed partners the opportunity for medical evaluation and treatment, thus potentially limiting further spread of the infection. PDPT has already been demonstrated to increase the rates of partner treatment, and its usage may serve a dual purpose in also facilitating disclosure.

Footnotes

Acknowledgments

We would like to thank Mrs. Gwangi Richardson-Alston for her contribution to the Male Urethritis Trial.

Supported by Centers for Disease Control and Prevention (cooperative agreement R30/CCR619146 “Optimizing Partner Treatment Strategies”).

Author Disclosure Statement

No competing financial interests exist.

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