Date of Award

8-1-2022

Language

English

Document Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

College/School/Department

Department of Public Administration and Policy

Content Description

1 online resource (vii, 285 pages) : illustrations (some color)

Dissertation/Thesis Chair

Erika Martin

Committee Members

Ashley Fox, Luis Luna-Reyes, Rachel Hart-Malloy

Keywords

Chlamydia, Cost effectiveness, Expedited partner therapy, Gonorrhea, Promotion, Reinfection, Chlamydia infections, Sexually transmitted diseases, Medical referral, Contact tracing (Epidemiology), Public health administration

Subject Categories

Gender and Sexuality | Medicine and Health Sciences | Public Policy

Abstract

Despite decades of concerted efforts to prevent their spread, chlamydia andgonorrhea remain two of the most prevalent sexually transmitted infections in the United States (U.S.) — exacting a high toll in terms of human health and healthcare expenditure. Though easily cured with antibiotics, both infections may lead to damaging secondary health conditions – known as sequelae – if untreated, including infertility among females. However, treating diagnosed individuals (known as “index patients”) is not enough—it is critical to also care for their recent sex partners as well, lest they reinfect the treated patient. Partner referral is the traditional approach to partner treatment that has been used since at least the 1970s. Under partner referral, patients are recruited to ask their sex partners to present themselves for testing, which puts a burden on the partner to seek out care and may therefore contribute to undertreatment. By contrast, expedited partner therapy (EPT) is a promising newer clinical practice whereby healthcare practitioners provide treatment, without prior clinical examination or diagnosis, to exposed sex partners of index patients—reducing barriers to treatment. EPT may be given as a prescription or as a medicine (med-in-hand) for index patients to deliver to their sex partners. However, EPT is not without its potential downsides. These include EPT’s potential to leave females with pelvic inflammatory disease (PID) and other sequelae undiagnosed (and untreated) and to treat individuals who are not infected (exacting a financial cost). The three papers of this dissertation explore different aspects of EPT promotion and its impact. The first paper seeks to model the effectiveness of increasing EPT use relative to partner referral on total annual chlamydia diagnoses and underlying chlamydia prevalence among young adults 18-24 years old with sex partners of the opposite sex using a system iii dynamics simulation model. Building upon the simulation model constructed in the first paper, the second paper conducts a cost-effectiveness analysis comparing EPT to partner referral and estimates the total societal costs of EPT use versus partner referral. The third paper uses an inductive qualitative approach to document the experiences and perspectives of state health department directors and staff who worked to implement EPT policies and promote EPT use in their states. Paper 1 finds that increased EPT use would lead to a decrease in the number of annual diagnoses of chlamydia compared with partner referral (the standard of care). Additionally, the overall number of females with PID in the modeled population would be lower due to a decrease in underlying chlamydia prevalence when EPT use increases. Paper 2 finds that EPT use is cost-effective compared to partner referral, especially when used to treat male sex partners of female index patients. The third paper identifies strategies used by state health departments to promote EPT use, as well as the barriers and facilitators of these strategies. These papers together make valuable contributions to a comprehensive understanding of the implementation of EPT. These papers also contribute to the theoretical literature on implementation science and policy implementation by demystifying why EPT (a seemingly more effective practice of partner treatment) has not been more widely adopted and whether greater adoption ought to be pursued.

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