Haley Buls

Expedited Partner Therapy to Reduce Incidence of Chlamydial Infection in African

American Women

Introduction

The burden of an STI on a population depends on sexual behaviors in order to transmit

the pathogen, and these behaviors often detract attention from the detrimental symptoms and side

effects that STIs produce. However, the effects of STIs are serious and may lead to infertility and

death, posing a serious public health concern. STIs and the populations that are

disproportionately affected by them demand attention and intervention. Expedited partner

therapy as an intervention should reduce the incidence of chlamydial infection in African

American women of all ages in developed countries.

Identification and Description of Population at Risk

African American women of all ages in developed are at a high-risk for all STIs. African

American women are at high-risk in part because of their lack of power in sexual relationships

and the hindrance on their decision-making ability based on their gender and minority status [1].

Women may face difficulties in negotiating safe sex, and ethnic minorities are often faced with a

lack of resources and access to health care, leading to a lack of testing or treatment for STIs.

Accordingly, African American women suffer from comparatively high rates of infection.

According to the data collected in 2014 by the Centers for Disease Control (CDC)

concerning incidence rates for chlamydia, black women aged 20-24 had an incidence rate of

7,122.5 per 100,000 population, while for comparison white women aged 20-24 had an incidence

rate of 1,728.2 per 100,000 population. This trend manifests itself in other STIs as well, such as
gonorrhea and primary and secondary syphilis. In the data collected by the CDC on gonorrhea in

2014, black women aged 20-24 had an incidence rate for gonorrhea of 1,799.9 per 100,000

population, compared to white women of the same age with a rate of 188.7 per 100,000

population. For syphilis, data reported to the CDC during 2014 revealed that the rate for black

women was 9.2 times that of white women [2].

Selection and Description of STI

Numerous STIs pose public health concerns, but for my assignment I will focus on

chlamydial infection. Chlamydia trachomatis are obligate intracellular parasites, and are a

bacterial pathogen belonging to the genus Chlamydia. They are confined to their host cell, and

depend on them to synthesize compounds. Consequently, their intracellular nature has limited the

study of this pathogen [3].

For the Americas, the incidence rate was 72.6 per 1,000 women in the year 2013. The

prevalence of the pathogen taken in the year 2013 in the Americas was 25.2 million individuals

[4]. Risk factors for this pathogen include the following: lack of barrier contraception during

sex, or incorrect use so there is slippage or breakage [5], new sexual partners, not having the

resources to screen for STIs, and being young, female, or a minority which leads to a lack of

power in sexual relationships [6].

Comparatively, African American women in the U.S. suffer under an exceptional burden,

with an incidence rate of chlamydial infection of 1,432.6 per 100,000 population, 5.7 times that

of white women in the U.S. [1]. Chlamydia untreated may lead to pelvic inflammatory disease

(PID), which may in turn cause infertility, ectopic pregnancy, and chronic pelvic pain. Because

the potential harms of untreated chlamydia are so drastic for women, and because African

American women of all ages are more effected than men or their white, female counterparts, it is
necessary to implement an intervention for this population. Additionally, chlamydia is often

asymptomatic, leading infected individuals to unknowingly spread the infection and

necessitating an intervention [7].

Description of Selected Intervention and Evidence Proven Effectiveness

Expedited partner therapy (EPT) is a public health control intervention that treats

individuals before they are clinically evaluated so as to prevent further transmission, with the

goal of reducing the incidence of infection. EPT was chosen based upon data provided in a study

in which it was tested against the effectiveness of standard-referral in reducing rates of

chlamydia and gonorrhea recurrent infection. In the first stage of the study, staff members

interviewed all patients and traced recent sexual partners, offering to notify past partners for the

patients if unwilling to do so. For those receiving EPT, staff members either used patient

delivered partner therapy, by giving partner packs directly to patients in person, or members

distributed the packets through commercial pharmacies to partners. Partner packets included

medicine to treat either chlamydia or gonorrhea (1-g sachet of azithromycin and 400-mg dose of

cefixime) along with other methods of treatment, such as condoms and information on STIs.

Those receiving standard referral received counseling on how to seek treatment. In the second

stage of the study, staff members attempted to interview and test all patients 10 to 18 weeks after

treatment. The study population consisted of women and heterosexual men who had tested

positive for chlamydia or gonorrhea from 1998 to 2003, 2751 in total, aged 23.2 years on

average. Rates of STI recurrent infection were compared for the EPT group and the standard-

referral group. The outcome was measured by clinically examining patients at the second stage

of the study. Gonorrhea or chlamydial infection was significantly less common at follow-up

among patients in the expedited-treatment group than among patients in the standard-referral
group (relative risk, 0.76; 95% CI, 0.59 to 0.98), and it is based on this data that EPT was chosen

as my intervention [8]. Targeting individuals that may not know they are infected should be

effective against a pathogen that is both curable and asymptomatic, such as chlamydia. For

African American women, this would reduce the risk of infection in the case that they were

unable to practice safe sex and EPT had reduced the infectiousness of their partner before sex.

Impact of Intervention

EPT has been proven efficacious compared to standard referral for heterosexual women

and MSM, with a relative risk of reinfection of chlamydia and gonorrhea of 0.76 (95% CI, 0.59

to 0.98), and this data leads me to expect a reduction in the incidence rate of chlamydia in

African American women if EPT is implemented [8].

Assuming that this intervention will be efficacious, there will still be a number of risks

that will remain in place for this population. Individuals in this population may not have access

to health care and may not have access to the pharmacies that would administer EPT. There is

the risk that they will just not pick up the treatment because of personal preference. In the case

that they do receive EPT, they still may not use it correctly or at all. And, even if EPT is

effective in curing them of an infection, there is still the potential for reinfection through the

misuse of barrier contraceptives, unprotected sex or from a high number of sexual partners. It

should be kept in mind that female partners receiving treatment for chlamydia may have PID,

and if they receive EPT without getting clinically evaluated they would go undiagnosed. With

this in mind, I think that this intervention would have an effect on the population and would

significantly reduce the incidence of infection.

Conclusion

It is important to provide EPT as an intervention for African American women of all ages

in developed countries to reduce the incidence rate of chlamydial infection. African American

women are at risk for chlamydia because of their status as women and minorities, effecting their

ability to negotiate safe sex and their access health care resources that could treat chlamydial

infection. Chlamydia may result in PID and lead to dramatic health consequences for women,

making it important to use EPT to intervene and lower the infectiousness of individuals in order

to reduce incidence rates of the infection. Even with the risk factors that would be present after

providing this intervention, I still believe it is worthwhile to implement EPT with African

American women of all ages in developed countries.

References:

1. McMahon JM, Volpe EM, Klostermann K, Trabold N, Xue Y. A Systematic Review of

the Psychometric Properties of the Sexual Relationship Power Scale in HIV/AIDS
Research. Arch Sex Behav [Internet]. 2015; 44(2):267–294. Available from:
http://link.springer.com/10.1007/s10508-014-0355-6

2. CDC. STDs in Racial and Ethnic Minorities [Internet]. US Dep. Heal. Hum. Serv. 2014
[cited 2015 Oct 14]. Available from: http://www.cdc.gov/std/stats12/minorities.htm

3. Holmes KK, Sparling PF, Stamm WE, Piot P, Wasserheit JN, Corey L, et al., editors.
Sexually Transmitted Diseases. 4th ed. McGraw Hill; 2008.

4. World Health Organization D of RH and R. Global Incidence and Prevalence of Selected

Curable Sexually Transmitted Infections – 2008. World Health Organization; 2012.

5. Warner L, Stone KM, Macaluso M, Buehler JW, Austin HD. Condom Use and Risk of
Gonorrhea and Chlamydia: A Systematic Review of Design and Measurement Factors
Assessed in Epidemiologic Studies. Sex Transm Dis [Internet]. 2006; 33(1):36–51.
Available from:
http://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage&an=00007435-
200601000-00011

6. Ginocchio CC, Chapin K, Smith JS, Aslanzadeh J, Snook J, Hill CS, et al. Prevalence of
Trichomonas vaginalis and coinfection with Chlamydia trachomatis and Neisseria
gonorrhoeae in the United States as determined by the Aptima Trichomonas vaginalis
nucleic acid amplification assay. J Clin Microbiol [Internet]. 2012; 50(8):2601–8.
Available from:
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3421522&tool=pmcentrez&re
ndertype=abstract

7. CDC. Chlamydia - CDC Fact Sheet [Internet]. U.S. Dep. Heal. Hum. Serv. 2014 [cited
2015 Jan 1]. Available from: http://www.cdc.gov/std/chlamydia/stdfact-chlamydia.htm

8. Golden MR, Whittington WLH, Handsfield HH, Hughes JP, Stamm WE, Hogben M, et al.
Effect of expedited treatment of sex partners on recurrent or persistent gonorrhea or
chlamydial infection. N Engl J Med. 2005; 352(7):676–685.