PICC-UP: Patient Initiated Contact treatment for Chlamydia: Understanding the Potential for increased effectiveness of Partner treatment in the Netherlands

In the Netherlands, the number of chlamydia infections remain high.[1] Chlamydia screening has been discontinued, instead experts advised to focus on testing of high risk groups and case management. Chlamydia re-infections are common, and related to an increased risk of adverse reproductive outcomes.[2,3] One third of the re-infections is caused by untreated partners.[1,4,5] Younger age groups, those with lower education, and with Surinamese/Antillean ethnicity are at higher risk for (re-)infections.[4] To reduce reinfections rates and prevent onward transmission, partner notification (PN) and partner therapy (PT), so called partner management, are crucial in STI control.[6,7] At Public health service STI clinics, sexual partners are reached through ‘traditional’ PN. In case of chlamydia, patients usually notify their partners themselves. Not all notified partners are willing to get tested and hence remain a source of re-infection for the index patient. Despite improvement of PN at STI clinics, amongst them the “partnernotification.nl” website [9], PT remains challenging. Moreover, there is often delay between the index case treatment and notified partners presenting for testing at the STI clinic. While in the Netherlands general practitioners (GPs) do 2/3 of all STI consultations, insight into partner management performed by GPs is lacking. Recently innovative ways of PT for chlamydia have been implemented in other countries: handing out medication to the partner by the index-case, so called patient delivered partner therapy (PDPT), or providing an accelerated prescription for the partner with medical history gained through a telephone-hotline or at a pharmacy (APT). A large RCT in the US showed that an intervention promoting the use of PDPT substantially increased its use, which was associated with a 10% reduction in chlamydia and gonorrhoea incidence.[18] Inspired by these innovations we designed our project: “PICC–UP: Patient initiated Contact treatment for Chlamydia: Understanding the Potential for increased effectiveness of Partner therapy in the Netherlands”, further called “patient initiated PT”. Patient initiated PT, defined as treatment of partners which is achieved through the index patient in contrast to providing therapy for the partner in a personal consultation, may be an important key in chlamydia control. The goal of this study is to gain insight into the current partner management practices in GP practices and STI clinics, and to explore the possibilities of patient initiated PT for chlamydia in the Netherlands. We will explore international experiences with and advantages/disadvantages of PDPT and APT by an extensive literature study for input in the development of qualitative and quantitative surveys. This will cover views of health care providers and patients, as well as legal aspects and regulations in various countries, and possibilities within the current Dutch legal regulations. Specifically we will investigate the way how in the US PDPT was legalized. In qualitative studies we will explore the current practice of partner management, especially PT, among GPs and STI clinic professionals, and their concerns and views about possible strategies for patient initiated PT. Guided by this qualitative studies, we will quantitatively assess PN, patient initiated PT through a ‘test case’ description in the NIVEL Primary Care Database, by an internet questionnaire to 400 GP practices. Prescription data (2009-13) in this database will be investigated for double dosage of chlamydia treatment as indicator for PDPT. In 40 NIVEL sentinel GP practices for STI/HIV testing, partner management will be assessed in all chlamydia consultations. A quantitative assessment by an internet questionnaire will also be performed among all doctors and nurses in the STI clinics. In STI Clinic data we will also assess which chlamydia patients would be eligible for patient initiated PT, focusing on potentially missed infections. Last but not least we will hold interviews with chlamydia patients and their partners. As chlamydia (re)-infection is most common in young persons from specific migrant groups and with lower education, we will focus on these groups in our qualitative study. The results of the quantitative and qualitative studies will be used to develop models for patient initiated PT at both Dutch healthcare settings, describing legal, ethical, financial and practical possibilities and barriers, and covering the following issues: 1) description of target group patients, 2) description of partner types (current/ ex, known/unknown to provider), 3) ways to check medical history of partner, 4) ways to provide treatment (medication or prescription) including financing this treatment. The various models for patient initiated PT will be described in a guidance, which can be an addendum for the national STI clinics guide “partner management”, which can also be used by GPs.