Clinical Advisory:

Utilizing Expedited Partner Therapy (EPT) 
for Chlamydia Infection in Massachusetts

Updated JANUARY 28, 2022

Expedited partner therapy (EPT) is the practice of treating the sex partners of people diagnosed with chlamydia infection without first examining or testing the partner. EPT helps interrupt the spread of disease by getting treatment to people who might otherwise remain untreated. Massachusetts law (M.G.L. c. 111 § 121B) authorizes certain healthcare providers to prescribe or dispense antibiotics to treat the unexamined sex partners of patients with chlamydia infection. The regulations governing EPT in Massachusetts are 105 CMR 700.003(J) and 105 CMR 721.000. The authorization for EPT applies only to chlamydia infection.

Background on Chlamydia Infection and EPT

Chlamydia infection is the most commonly reported sexually transmitted infection (STI) in the United States. In Massachusetts, the number of reported cases has more than tripled in twenty years, from 8,725 in 1999 to 31,634 in 2019. In 2019, the incidence of reported chlamydia infection in Massachusetts among adolescents (ages 15-19) and young adults (ages 20-24) exceeded 1900 per 100,000. This contrasts with the overall Massachusetts chlamydia infection rate of 459 per 100,000.

Despite its prevalence, chlamydia infection is frequently undiagnosed because a high proportion of affected individuals are asymptomatic. Patients with chlamydia infection are at increased risk for reinfection after treatment if their sex partners are not also treated. EPT helps prevent reinfection by increasing the likelihood that sex partners are effectively treated, even if they are unwilling or unable to seek medical care on their own. This is particularly true for adolescents, who may be afraid to seek medical care or disclose their infection to their parents.

EPT has been shown to be safe and effective in the treatment of sex partners. Research has demonstrated that EPT is more effective in reducing persistent and recurrent chlamydia infection than traditional partner notification (Golden 2005). States, including ours, with long-standing EPT programs also have had no reports of adverse events.

Compared with data on opposite-gender sex partners, data are limited regarding use of EPT for chlamydial infections among male sex partners of males (MSM) with chlamydia infection. Published studies, including recent data regarding extragenital testing, indicated that male partners of MSM with diagnosed gonorrhea or chlamydia might have other bacterial STIs (gonorrhea or syphilis) or HIV. Studies have reported that 5% of MSM have a new diagnosis of HIV when evaluated as partners of men with gonococcal or chlamydial infections; however, more recent data indicate that, in certain settings, the frequency of HIV infection is much lower. Considering limited data and potential for other bacterial STIs among MSM partners, shared clinical decision-making regarding EPT is recommended. 

Standard Treatment Protocol

The standard treatment for chlamydia infection is 100 mg of doxycycline, orally twice a day for seven days. This is the recommended first line treatment for patients with known chlamydia infection and their sex partners in both adults and adolescents. While microbiologic treatment efficacy is better with 7 days of doxycycline than a single oral dose of 1 gram of azithromycin, either 7 days of doxycycline or 1 dose of azithromycin may be used for EPT.

Implementation Options

MDPH recommends three options for prescribing clinicians implementing EPT:

1.	The clinician dispenses medication directly, to be delivered by the patient to the sex partner(s).  Separate, properly labeled containers are to be used for the dose(s) for each sex partner. Providing patients with packaged oral medication is the preferred approach because the efficacy of EPT using prescriptions has not been evaluated, obstacles to EPT can exist at the pharmacy level, and many persons (especially adolescents) do not fill the prescriptions provided to them by a sex partner.ii
2.	The clinician provides a written prescription for a named sex partner(s) of the infected patient.
3.	The clinician provides a written prescription using, in place of the partner’s name and address, “Expedited Partner Therapy,” “E.P.T.” or “EPT,” which the partner can have filled at any Massachusetts pharmacy.

If an electronic medical record (EMR) or other e-prescribing system does not permit an electronic prescription for “Expedited Partner Therapy,” “E.P.T.” or “EPT,” an information sheet listing fields required by 105 CMR 721.000 is available online to assist prescribers with generating a written prescription  https://www.mass.gov/info-details/elements-of-a-written-prescription. Providers may also wish to consider contacting a prescription form vendor to obtain blank prescription forms.

Pharmacists

A prescription with “Expedited Partner Therapy,” “E.P.T.” or “EPT” in place of a name and address should be filled based on the regulation. A partner information sheet (described below) should be provided to patients whenever possible if not already provided by the prescriber. 

Patient Counseling and Information for Partners

To minimize disease transmission to sex partners, persons treated for chlamydia should be instructed to abstain from sexual intercourse for 7 days after single-dose therapy or until completion of a 7-day regimen and resolution of symptoms if present. To minimize risk for reinfection, patients also should be instructed to abstain from sexual intercourse until all of their sex partners have been treated.

All persons who receive a diagnosis of chlamydia infection and their sex partners, particularly MSM, should be tested for HIV, gonorrhea, and syphilis, and those at risk for HIV infection should be offered HIV PrEP (https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2017.pdf).ii

Regardless of which EPT implementation option a prescribing clinician chooses, the medication or written prescription for the partner(s) should be accompanied by a partner information sheet (whenever possible). An example of such a document is attached, and contains information about exposure to chlamydia, the need for treatment, instructions about treatment and potential allergic reactions, and the need for abstaining from sex during treatment.
Conclusions

EPT programs have demonstrated that EPT is both safe and effective for preventing reinfection in patients with chlamydia infection. The use of EPT is voluntary and MDPH continues to encourage all sex partners to seek clinical care regardless of whether EPT is used. However, MDPH recommends that prescribing clinicians use EPT when, in their clinical judgment, it would be beneficial for both the patient and the sex partner(s).

Additional References and Resources for Clinicians

1.	CDC, Expedited Partner Therapy in the Management of Sexually Transmitted Diseases: Review and Guidance (2006). http://cdc.gov/std/treatment/EPTFinalReport2006.pdf
2.	American Medical Association, Expedited Partner Therapy (Patient-delivered Partner Therapy): An Update (2006). http://www.ama-assn.org/ama/no-index/about-ama/16410.shtml
3.	American Bar Association, resolution supporting removal of legal barriers to the provision of EPT (August 15, 2008). Available at http://cdc.gov/std/ept/
4.	Matthew R. Golden, et al., Effect of Expedited Treatment of Sex Partners on Recurrent or Persistent Gonorrhea or Chlamydial Infection, N Eng J Med, 2005;352:676-85.
5.	Matthew R. Golden, Expedited Partner Therapy: Moving from Research to Practice, Sex Transm Dis, 2008;35:320-22.
6.	Julia A. Schillinger et al., Patient-Delivered Partner Treatment with Azithromycin to Prevent Repeated Chlamydia trachomatis Infection Among Women, Sex Transm Dis, 2003;30:49-56.
7.	K. McBride, et al., Formative Design and Evaluation of Patient-Delivered Partner Therapy Informational Materials and Packaging, Sex Transm Infect, 2009;85:150-155.
8.	James G. Hodge, et al., Expedited Partner Therapy for Sexually Transmitted Diseases: Assessing the Legal Environment, Am J Public Health, 2008;98(2): 238–243.
9.	Patricia Kissinger, Considering the Patient in Patient-Delivered Partner Therapy, Sex Transm Inf, 2009;85:80-81.
10.	Expedited Partner Therapy for Adolescents Diagnosed with Chlamydia or Gonorrhea: A Position Paper of the Society for Adolescent Medicine, J Adol Health, 2009;45:303-309. (Supported by the American Academy of Pediatrics.)

A Message for Partners about Chlamydia
Expedited Partner Therapy (EPT)

January 28, 2022

Important information about your sexual health: Please read both sides of this sheet carefully.  

If you have questions about the medicine for chlamydia, please contact your health care provider.  

For more information about chlamydia and other sexually transmitted diseases (STDs), visit the Massachusetts Department of Public Health website at www.mass.gov/dph/cdc/std.

Why am I getting medicine or a prescription for medicine?
Your sex partner has recently been treated for a sexually transmitted disease (STD) called chlamydia.  You may have it too.  That’s why your sex partner is bringing you a prescription or medicine to treat chlamydia.  You should take this medicine as soon as possible. 
What is chlamydia and what are the signs and symptoms?
Chlamydia is a very common infection that both men and women can get from having vaginal, anal, or oral sex.  For most people, there are no symptoms.  But if you have the infection, even if there are no symptoms, you can still pass it on to anyone you have sex with.  
Women with signs or symptoms might have:	Men with signs or symptoms might have:	
•	Yellow or white discharge from the vagina
•	Pain or bleeding during or after sex
•	Bleeding between periods
•	Burning or pain when you pee
•	Lower belly pain, cramps and back pain
•	Nausea
•	Fever	•	Yellow or white discharge (drip) from the penis
•	Burning or pain when you pee
•	Burning or itching at the opening of the penis
•	Pain or swelling in the testicles (balls)	
Chlamydia that is not treated can lead to infertility (not being able to have children).  In women, untreated chlamydia can cause Pelvic Inflammatory Disease (PID), which can be very painful.  In men, untreated chlamydia can cause infection and pain in the testicles.
What is the cure for chlamydia?
Chlamydia is usually cured with the antibiotics doxycycline or azithromycin.  These antibiotics do not treat other STDs like syphilis or gonorrhea. 
Today you are being given doxycycline or azithromycin, or a prescription to get the antibiotic from the drug store.  Before you take this medicine, please read the following information carefully.
1.	If you have any of these problems, get medical care  as soon as possible because you may need stronger medicine.
•	Belly pain
•	Cramps	•	Nausea
•	Throwing up	•	Fever
•	 Pain in the testicles (balls)	

2.	
Do not take this medicine before checking with your own health care provider or pharmacist if:
•	You are allergic to any medicines
•	You have serious health problems, such as kidney, heart, liver disease, or seizures
If you cannot take this medicine because of other health problems or allergies, get medical care as soon as possible to get the best chlamydia treatment for you.
3.	How do I take this medicine?
•	Doxycycline: Take 1 pill (100 mg) twice a day by mouth for 7 days.
•	Azithromycin: Take all the medicine at once by mouth.
•	If you throw up in the hour after taking the medicine, you will need to get more medicine from your clinic or health care provider because the medicine did not have time to work.
•	Do not share this medicine with anyone else.
4.	What if I am pregnant, or think I may be pregnant?
Chlamydia can be passed from a mother to her baby during pregnancy and can cause health problems for the baby.  If you are pregnant, you should only get azithromycin to treat chlamydia infection. See your health care provider as soon as you can.  Tell them you were treated because your sex partner has chlamydia. Do not take doxycycline if you are pregnant.
5.	What if I am taking birth control pills?
Birth control pills may not work as well if you are taking doxycycline. Use other forms of birth control while you are taking this medicine.
6.	What should I do after taking this medicine?
•	Do not have vaginal, anal, or oral sex until you AND your sex partner(s) have finished taking 7 days of doxycycline.  Do not have vaginal, anal, or oral sex for at least seven days after you AND your sex partner(s) have taken azithromycin.  It takes seven days for antibiotics to cure chlamydia.  You can get chlamydia again if you have sex before waiting for the medicine to work on you and your partner(s).
•	Get checked for other STDs.  This medicine does not treat other STDs.  Even if you take this medicine, it is important to get tested for other STDs because people can have more than one at a time.  Get checked by your health care provider for gonorrhea, syphilis, and HIV.
7.	What are the common side effects of this medicine?
All drugs may cause side effects. However, many people have no side effects or only minor side effects. Some possible side effects of doxycycline or azithromycin include diarrhea, upset stomach, belly pain, headache, and throwing up.  Remember that if you throw up in the hour after taking your medicine, you need to get more medicine.
8.	What if I have an allergic reaction after taking this medicine?
Very serious allergic reactions are rare, but can happen. 
If you have any of these problems after taking this medicine, call 911 or go to the emergency room:	
•	Trouble breathing/chest tightness
•	Closing of the throat	•	Swelling of the lips or tongue
•	Hives (bumps on the skin that itch)	
If you had an allergic reaction: when you feel better, send an e-mail to ept@state.ma.us so that the Department of Public Health can find out how many people had problems with the medicine.
How can chlamydia be prevented?
If you have sex, using a condom correctly EVERY TIME you have any kind of sex can lower the chances of you getting an STD.  Getting screened for STDs at least once a year is also a great way to stay healthy.