Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.
School of Social and Community Medicine, University of Bristol, Bristol, UK.
Health Technol Assess. 2014 Jan;18(2):1-100, vii-viii. doi: 10.3310/hta18020.
BACKGROUND: Partner notification is essential to the comprehensive case management of sexually transmitted infections. Systematic reviews and mathematical modelling can be used to synthesise information about the effects of new interventions to enhance the outcomes of partner notification. OBJECTIVE: To study the effectiveness and cost-effectiveness of traditional and new partner notification technologies for curable sexually transmitted infections (STIs). DESIGN: Secondary data analysis of clinical audit data; systematic reviews of randomised controlled trials (MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials) published from 1 January 1966 to 31 August 2012 and of studies of health-related quality of life (HRQL) [MEDLINE, EMBASE, ISI Web of Knowledge, NHS Economic Evaluation Database (NHS EED), Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA)] published from 1 January 1980 to 31 December 2011; static models of clinical effectiveness and cost-effectiveness; and dynamic modelling studies to improve parameter estimation and examine effectiveness. SETTING: General population and genitourinary medicine clinic attenders. PARTICIPANTS: Heterosexual women and men. INTERVENTIONS: Traditional partner notification by patient or provider referral, and new partner notification by expedited partner therapy (EPT) or its UK equivalent, accelerated partner therapy (APT). MAIN OUTCOME MEASURES: Population prevalence; index case reinfection; and partners treated per index case. RESULTS: Enhanced partner therapy reduced reinfection in index cases with curable STIs more than simple patient referral [risk ratio (RR) 0.71; 95% confidence interval (CI) 0.56 to 0.89]. There are no randomised trials of APT. The median number of partners treated for chlamydia per index case in UK clinics was 0.60. The number of partners needed to treat to interrupt transmission of chlamydia was lower for casual than for regular partners. In dynamic model simulations, >10% of partners are chlamydia positive with look-back periods of up to 18 months. In the presence of a chlamydia screening programme that reduces population prevalence, treatment of current partners achieves most of the additional reduction in prevalence attributable to partner notification. Dynamic model simulations show that cotesting and treatment for chlamydia and gonorrhoea reduce the prevalence of both STIs. APT has a limited additional effect on prevalence but reduces the rate of index case reinfection. Published quality-adjusted life-year (QALY) weights were of insufficient quality to be used in a cost-effectiveness study of partner notification in this project. Using an intermediate outcome of cost per infection diagnosed, doubling the efficacy of partner notification from 0.4 to 0.8 partners treated per index case was more cost-effective than increasing chlamydia screening coverage. CONCLUSIONS: There is evidence to support the improved clinical effectiveness of EPT in reducing index case reinfection. In a general heterosexual population, partner notification identifies new infected cases but the impact on chlamydia prevalence is limited. Partner notification to notify casual partners might have a greater impact than for regular partners in genitourinary clinic populations. Recommendations for future research are (1) to conduct randomised controlled trials using biological outcomes of the effectiveness of APT and of methods to increase testing for human immunodeficiency virus (HIV) and STIs after APT; (2) collection of HRQL data should be a priority to determine QALYs associated with the sequelae of curable STIs; and (3) standardised parameter sets for curable STIs should be developed for mathematical models of STI transmission that are used for policy-making. FUNDING: The National Institute for Health Research Health Technology Assessment programme.
背景:性传播感染综合病例管理的关键是伴侣通知。系统评价和数学模型可用于综合新干预措施的效果信息,以增强伴侣通知的结果。 目的:研究针对可治愈性传播感染(STI)的传统和新型伴侣通知技术的有效性和成本效益。 设计:临床审计数据的二次数据分析;系统评价随机对照试验(MEDLINE、EMBASE 和 Cochrane 对照试验注册中心),时间从 1966 年 1 月 1 日至 2012 年 8 月 31 日;健康相关生活质量(HRQL)研究的系统评价[MEDLINE、EMBASE、ISI 网络知识、NHS 经济评估数据库(NHS EED)、疗效摘要数据库(DARE)和卫生技术评估(HTA)],时间从 1980 年 1 月 1 日至 2011 年 12 月 31 日;临床有效性和成本效益的静态模型;以及动态建模研究,以改进参数估计并检验有效性。 设置:一般人群和泌尿生殖医学诊所就诊者。 参与者:异性恋男女。 干预措施:传统的由患者或提供者推荐的伴侣通知,以及新的通过加速伴侣治疗(EPT)或其英国等效方法,即加速伴侣治疗(APT)的伴侣通知。 主要观察指标:人群患病率;指数病例再感染;以及每例指数病例治疗的伴侣人数。 结果:增强的伴侣治疗降低了可治愈 STI 指数病例的再感染率,优于单纯的患者转诊[风险比(RR)0.71;95%置信区间(CI)0.56 至 0.89]。目前尚无关于 APT 的随机试验。在英国诊所中,每例衣原体感染病例治疗的伴侣中位数为 0.60。在性伴侣为偶然伴侣而非固定伴侣的情况下,需要治疗的伴侣人数更少,才能阻断衣原体的传播。在动态模型模拟中,有 10%以上的伴侣在潜伏期长达 18 个月的情况下衣原体呈阳性。在存在衣原体筛查计划降低人群患病率的情况下,治疗当前伴侣可实现由于伴侣通知而导致的患病率额外降低的大部分。动态模型模拟表明,同时检测和治疗衣原体和淋病可降低这两种 STI 的患病率。APT 对患病率的额外影响有限,但降低了指数病例再感染的发生率。本项目中,用于伴侣通知成本效益研究的经过质量调整的生命年(QALY)权重质量不足。使用诊断出的感染成本/每例作为中间结果,将伴侣通知的疗效从每例 0.4 名治疗到 0.8 名治疗,比增加衣原体筛查覆盖率更具成本效益。 结论:有证据支持 EPT 在降低指数病例再感染方面的临床效果改善。在一般的异性恋人群中,伴侣通知可以发现新的感染病例,但对衣原体患病率的影响有限。与固定性伴侣相比,通知偶然性伴侣可能会对泌尿生殖医学诊所人群产生更大的影响。未来研究的建议是:(1)进行随机对照试验,评估 APT 的有效性和增加 APT 后 HIV 和 STI 检测的方法;(2)优先收集 HRQL 数据,以确定与可治愈性传播感染的后果相关的 QALYs;(3)为用于决策的性传播感染传播的数学模型开发针对可治愈性传播感染的标准化参数集。 资金来源:英国国家卫生研究院卫生技术评估计划。
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