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City considers unusual tactic against STDs

The Baltimore Sun

Battling high rates of sexually transmitted diseases, Baltimore health officials want authority to send patients home with medication that their partners would use, even though the partners hadn't seen a doctor or been prescribed the drugs.

Baltimore Health Commissioner Joshua M. Sharfstein is seeking legislation in Annapolis for a five-year pilot project.

Acknowledging that the approach is a "little unconventional," he said it would help cut cases of gonorrhea and chlamydia.

Medical personnel in city clinics treat patients for gonorrhea and chlamydia and send them home with a "partner notification card" asking the partner to come in for treatment. But that seldom works. Instead, Sharfstein said, the patient "would have sex with their partner again and get another STD [sexually transmitted disease]. So people would come again and again, with the same STDs. It's very frustrating for a clinician."

Under the proposed law, awaiting a House of Delegates hearing tomorrow, patients would be allowed to take an extra course of the antibiotics directly to their partners without requiring that the partners be seen and evaluated by a clinician.

The practice, known as expedited partner therapy, was endorsed by the federal Centers for Disease Control and Prevention last year for controlling the spread of chlamydia and gonorrhea, said Matthew Hogben, a CDC health scientist

California and Tennessee have enacted legislation permitting the practice, and up to 10 other states have laws that make it permissible in some form, he said. There is no law specifically prohibiting the practice in Maryland. But Sharfstein said the state's Medical Practice Act makes it "questionable."

He won over the city's Senate delegation in a recent presentation to the group in Annapolis.

"When we first heard about it, we all thought, 'What in the world?' But then we heard what he had to say and we thought it was a great idea," said Sen. Nathaniel J. McFadden, a sponsor of the bill.

McFadden said the program will help combat infection among people who remain largely unaware of the risks: "We have a whole new generation of young people who don't realize how serious the problem is."

Baltimore leads the state in the number of gonorrhea and chlamydia cases, state figures show. The number of new chlamydia cases in Baltimore jumped from 5,433 in 2000 to 6,380 in 2005, while new gonorrhea cases dropped from 5,603 in 2000 to 3,489 in 2005, according to state figures.

Statewide, chlamydia cases increased from 14,533 to 18,308 in those years; gonorrhea cases decreased from 9,837 to 7,047.

Anna Jeffers, legislation and regulation manager of the Maryland Board of Pharmacy, said the board supports the legislation despite concerns focused on providing prescription medicine to people who haven't been evaluated. Medications could prompt allergic reactions or interact badly with other drugs, she said:

"I think it's a great idea; we all do. There are just some concerns about prescribing for someone without seeing them."

The board asked legislators to consider adding regulations in the future to address that concern, Jeffers said.

Benefits vs. risks

But Sharfstein said the practice has been thoroughly reviewed, implemented successfully elsewhere and the benefits far outweigh the risks.

"I can't emphasize enough that this is based on evidence that it works. It's not just that we'd like to give it a try," Sharfstein said. "We have the types of STD problems in Baltimore that appear very amenable to this strategy."

Nationally, the practice was tested in three clinical trials, involving more than 5,000 patients in several states, and no adverse effects were reported from the antibiotics used to treat the two diseases, cefixime and azithromycin, said the CDC's Hogben.

Additionally, a hot line set up in California for the reporting of adverse reactions has yet to record any problems, he said.

"It's not a replacement for seeing a doctor, but it's a useful option," Hogben said.

In one of the trials, a study in Seattle, researchers found that the practice reduced gonorrhea re-infection rates by 68 percent. For chlamydia the reduction was much lower and not statistically significant.

But together the reductions came to 30 percent, according to Dr. Emily Erbelding, an associate professor at Hopkins and clinical director of Baltimore's STD program.

Under the proposed law, patients diagnosed with chlamydia or gonorrhea who have multiple partners could be given multiple treatment packages. The antibiotics are generally "very well tolerated," Sharfstein said, and consist of a single dose.

Wider treatment

Each package also would contain instructions, educational materials and directions on how to obtain testing and treatment for HIV and syphilis. That's information that sexual partners who don't visit a clinic would not otherwise receive, Erbelding said.

"We want them all to get treated," Erbelding said.

Along with cutting rates of gonorrhea and chlamydia, Sharfstein anticipates an impact on other diseases.

"When people have STDs and HIV, they're much more likely to transfer the HIV" to their sexual partners, he said. "We would expect to reduce HIV infection in the city."

Also, "when people have STDs when they're pregnant, they're more likely to give birth prematurely," he said. So by cutting STD rates, "we're also ... fighting infant mortality and low birth weight."

Dr. Laura Herrera, the health department's chief medical officer and assistant commissioner for its clinical division, said the failure of the current system has become all too evident.

"When we would leave at the end of the day, we would find partner notification cards all over the parking lot," she said. "They're not comfortable giving the cards to their partners, but then they often continue to engage in sex with them, and they're re-infected weeks later."

If left untreated, chlamydia can damage a woman's reproductive organs and lead to infertility, according to the CDC. In men, it can cause a burning sensation when urinating. Men might also have burning and itching around the opening of the penis. An estimated 2.8 million Americans are infected with chlamydia each year.

Gonorrhea affects up to 700,000 people each year and symptoms in men include a burning sensation when urinating, or a white, yellow or green discharge from the penis. In women, symptoms can be mistaken for a bladder infection, but if left untreated they can lead to inflammatory pelvic disease that can mean long-lasting, chronic pelvic pain and infertility, the CDC says.

Sun reporter Chris Emery contributed to this article .

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