HEALTHExtra medications for sex partners one approach in public health struggle to curb ChlamydiaInnovative strategies are raising legal and ethical questions.By Victoria Stagg Elliott, amednews staff. April 9, 2001. A San Francisco health plan is working out an arrangement that would allow its physicians to write prescriptions, paid for by the plan, for the anonymous partners of patients diagnosed with chlamydiosis. This unorthodox experiment is one of several strategies being advanced in locations across the country. The examples sometimes push the envelope in terms of accepted medical practice and screening policies. The underlying goal, however, is to rein in this sexually transmitted disease, which has become the most commonly reported infectious disease in the United States, according to the Centers for Disease Control and Prevention's report, "Tracking the Hidden Epidemics: Trends in STDs in the United States, 2000." Most experts attribute the high numbers to increased rates of screening and improvements in screening technology. However, they also maintain that the statistics reflect the sheer difficulty involved in controlling an infection that usually has no symptoms, is highly contagious and primarily affects adolescents and young adults. There are other challenges in play. Treatment is simple and inexpensive, with many patients cured after a single dose of antibiotics. The CDC estimates that every dollar spent on screening and treatment saves $12 that would be spent in treating complications down the road. But at the same time, Chlamydia infection is so prevalent that contact tracing by public health departments to find infections and provide necessary treatment is financially and logistically impossible.
$1 spent on screening and treatment can save $12 in treating complications.
Moreover, untreated chlamydiosis has dire and costly consequences, particularly for women. Of those with untreated infections, 40% develop pelvic inflammatory disease; 9% will have a life-threatening tubal pregnancy. Recent studies have also linked the infection to increased susceptibility to cervical cancer and HIV. In total, the CDC estimates the annual cost of the infection's consequences to be more than $2 billion. The move by the San Francisco Health Plan, a nonprofit that covers more than 28,000 lower-income individuals, is a response to all these forces. It comes on the heels of new legislation in California allowing doctors to write a prescription for the partner of someone who is diagnosed with chlamydiosis without being vulnerable to charges of unprofessional conduct under the state's Medical Practice Act. With this issue effectively resolved, the plan decided to pay for the additional prescriptions because an estimated 40% of its patients with chlamydiosis return three months later with a new infection. "We believe that's a reinfection, not a lack of taking their pills ... or that the drug didn't work," said Karen K. Smith, MD, medical director of the plan. "Often you can't get the partner in for care." Still, questions remain about whether the state's pharmacists will be able to fill a prescription without a patient's name on it. Those involved in treating sexually transmitted diseases say extra medicine has been handed out unofficially for years, but that it is still better to try to get the male partner in for a checkup to look for additional STDs and to attempt to track down additional sexual contacts who may also need treatment. "The upsides probably outweigh the downsides, but the downsides have to be remembered," said Michael Rein, MD, professor of medicine at the University of Virginia, Charlottesville. He also runs a small STD clinic. "If you're not interviewing the partner, then you're not doing the contact tracing that ... may lead you into a whole network of infection." In addition, some warned that because the plan will pay for only one male partner, medication may be divided among multiple partners, leaving them all undertreated. There is also the possibility that unseen partners may be allergic to the prescribed antibiotic or that it may interact with their other medications. Other strategiesWhile the San Francisco Health Plan is struggling with treatment strategies to control the disease, others are debating ways to increase screening among those age groups at highest risk. A state legislator in Connecticut proposed legislation in January that would require all high school seniors to be tested for Chlamydia. The details have not been worked out, but a spokeswoman said she expected that proof of screening would be required at the beginning of the school year, much as students currently provide evidence of vaccinations. Connecticut is holding hearings about the bill, proposed by Democratic State Senator Toni Harp, chair of the public health committee. It has triggered mixed reactions from physicians. Some have expressed concerns that such widespread screening could lead to an unacceptable rate of false-positives. At the same time, many favor the effort to get more people screened. On another front, a public health expert at Johns Hopkins University in Baltimore published a study in February suggesting that all sexually active women younger than 25 be screened -- an expansion of the CDC recommendations both in terms of the number of people and frequency of testing -- to bring the disease under control. CDC guidelines recommend annual screening for all sexually active women age 16 to 19, and for those age 20 to 25 who have additional risk factors such as multiple sex partners. Several studies, however, including one in the February Sexually Transmitted Infections, found that screening every six months may be more effective in controlling the spread of the disease. Although many maintain that such frequency is not practical, the researchers insist that it can be done. "It is more challenging to get adolescents in to see providers, especially adolescents whom we consider to be at high risk," said Gale R. Burstein, MD, MPH, primary author and adjunct assistant professor at Johns Hopkins University. "But rescreening every six months really is our best option for control. There are opportunities such as when an adolescent comes in for birth control. We need to take advantage of [those times]." Experts believe, however, that it will not be possible to control chlamydiosis without developing screening strategies for men, who, although they rarely experience any long-term ill effects, are the main source of infection and reinfection of women. "If we're only screening the females, that's only half the problem," said Dr. Burstein. ADDITIONAL INFORMATION:Chlamydia by the numbers3 million - Estimated infections annually
Source: Centers for Disease Control and Prevention WeblinkCDC's Division of Sexually Transmitted Diseases page (http://www.cdc.gov/nchstp/dstd/dstdp.html) San Francisco Health Plan (http://www.sfhp.org/) Full text of "Predictors of repeat Chlamydia trachomatis infections diagnosed by DNA amplification testing among inner city females," Sexually Transmitted Infections, February (http://sti.bmjjournals.com/cgi/content/full/77/1/26) Copyright 2001 American Medical Association. All rights reserved.
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