Discussion
This qualitative study of HCPs' perspectives on EPT in one US state found that all participants felt EPT was beneficial but most did not use it. Many HCPs had limited knowledge about the legal status of EPT and some had concerns about its potential harms, including not being able to counsel patients' partners. Several HCPs preferred to speak to the patient's partner on the phone before prescribing medication.
There are several limitations to this exploratory qualitative study. Findings may not be generalisable to providers from other regions. Nevertheless, they apply to jurisdictions in which there is no specific legislation, either authorising or prohibiting EPT. This study relied on self-selected pool of providers, thus interviews may be biased towards individuals who are particularly favourable towards or especially concerned about EPT. However, our sample of HCPs did provide a wide range of opinions and knowledge about EPT. Another limitation of the study is that our definition of EPT differed from the interventions that tested the effectiveness of EPT as our definition did not include providing condoms and written information about STIs for partners. As such, we did not assess adherence to EPT protocol; with this qualitative study, we probed HCPs to explain how they understood and practised EPT. A strength of this study is the participation of providers from multiple specialties including adolescent medicine, internal medicine, family medicine and obstetrics/gynaecology, from diverse clinical settings.
The majority of HCPs interviewed did not use EPT, although no laws in Pennsylvania specifically prohibit its use. This situation generates confusion about the legal status of EPT and concerns about liability for treating patients with whom they do not have a provider–patient relationship. In California, the first state where legislation expressly authorised EPT in 2001, EPT is routinely used by >50% of physicians and nurse practitioners and by >70% of family planning providers. A survey conducted in Arizona found that obstetricians/gynaecologists who received information about changes in state statutes about allowing EPT use were more likely to practise EPT.
Participants spontaneously raised the issue of the potential harms of EPT, which has not been systematically reported in EPT trials to date. HCPs noted harms such as not being able to counsel patients' partners, patients not giving their partners the medication and the possibility of intimate partner violence. While providers had positive perceptions of the benefits of EPT, they also have a number of concerns for the safety of their patients and their patients' partners. Every form of partner notification has benefits and the potential for harm; a systematic review of randomised control trials on partner notification strategies, including EPT, found that the majority of trials do not report on or measure such harms. Further research on the potential magnitude of such harms should be considered, especially as EPT is disseminated in clinical practices.
Several HCPs interviewed on their own determined that they preferred to speak to patients' partners on the phone when providing EPT. HCPs sought ways to counsel patients' partners about sexual behaviours, STIs and establish a provider–patient relationship; speaking to them on the phone was considered the most effective means to do so. Given that speaking on the phone to patients' partners makes providers more comfortable using EPT, the CDC's EPT recommendations could include the use of phone calls as part of their guidelines. In the UK, EPT is not permitted because patients must be medically assessed by providers before provision of medication. However, recently a form of EPT that complies with UK prescribing guidelines, accelerated partner therapy (APT), in which patients' partners are either contacted via phone or receive consultation from a community pharmacist, has been assessed. Research has found that providers are willing to use APT and prefer the phone approach.
Barriers and facilitators to using EPT centred around fears about being sued for adverse patient outcomes or being somehow liable for treating a patient they do not have a relationship with and the need to clarify the legality of EPT to alleviate those fears. Our findings around barriers and facilitators to EPT were similar to the findings of studies conducted in the UK and Australia. A qualitative study conducted with general practitioners about their views on EPT and partner notification to treat chlamydia in Australia, a country that has no specific legislation about EPT, found that providers had concerns about treating a patient without evaluating their medical history and asserted that clarity around the legality of EPT would facilitate its use. A survey in the UK found that 22% of providers had used EPT, around one-third were opposed to the practice, providers felt that speaking on the phone with the partner was important, and the largest barrier to its use was the legality of EPT.
This qualitative study demonstrates the way in which providers are willing to use EPT and have positive attitudes about the practice in a state where EPT is permissible but not expressly authorised. Barriers to EPT, including concerns about counselling patients' partners and the legal status of EPT, can be overcome. Our study identified that providers have found ways to provide EPT in a manner they feel comfortable, by speaking to patients' partner on the phone, enabling them to counsel patients' partners. Providers desire clarity around the legal status of EPT; Pennsylvania could follow the lead of states such as California, New York and Arizona, and implement legislation that expressly allows EPT. Research is needed to examine how provider perspectives differ across states where EPT regulations differ. Further investigation should also quantify the frequency and impact of harms related to the provision of EPT. To make EPT more widely adopted, steps must be taken to ensure providers feel safe using this practice.