I have a power point due. I need proofreading and someone who is an expert on apa. That is where all my points are deducted from.

are under way. There has been a gradual transition to acceptance and even support for the program.

The coordination of postrelease care is a challenge. Individuals going to correctional facilities not offering MAT (federal or out of state) have to be weaned off MAT. Release to the community is often un- predictable. However, individuals can immediately continue treat- ment because they are already en- rolled as CODAC patients.

VIABILITY The Rhode Island state bud- get for 2017 ofﬁcially contained $2 million for the implementa- tion of the MAT expansion program and has been funded again through 2018. Governor Raimondo has highlighted the program’s efforts as a signiﬁcant component of her statewide overdose and addiction pre- vention plan. 4 System-wide changes also ensure that the program willbecome a part of RIDOC’s standard health care services.

Provider time has been increased and additional providers have been hired. To facilitate com- munication between adminis- tration, security, rehabilitative services, and medical staff, pro- gram leaders established an MAT process team. Members serving on the Governor’s Overdose Prevention and Intervention Task Force provide the public insight on program challenges and changes. CONCLUSIONS The increase in illicit use of heroin and other illicit opioids is a serious public health concern.

Despite justice-involved persons being especially vulnerable to overdose and relapse upon re- lease, prisons and jails have been slow to allow this population access to MAT. Rhode Island’s statewide comprehensive pro- gram expansion at the RIDOCshows that MAT is feasible in correctional settings, and pre- liminary outcomes suggest strong rates of treatment retention after release. In the face of a severe public health crisis related to illicit opioid use, continuing and initi- ating MAT in correctional facili- ties with seamless linkage to care in the community should be a top priority for any community con- cerned about illicit opioid use and overdose deaths. Jennifer G. Clarke, MD, MPH Rosemarie A. Martin, PhD Shelley A. Gresko, BA Josiah D. Rich, MD, MPH CONTRIBUTORSJ. G. Clarke requested and obtained the funding. J. G. Clarke, R. A. Martin, and J. D. Rich designed the study and meth- odologies. J. G. Clarke and J. D. Rich provided input on subsequent drafts. R. A.

Martin and S. A. Gresko wrote theﬁrst draft of the editorial. All authors con- tributed to and approved theﬁnal version.

REFERENCES1. Green TC, Clarke JG, Brinkley- Rubinstein L, et al. Postincarceration fatal overdoses after implementing medicationsfor addiction treatment in a statewide correctional system.JAMA Psychiatry.

2018;75(4):405–407.

2. Degenhardt L, Bucello C, Mathers B, et al. Mortality among regular or de- pendent users of heroin and other opioids:

a systematic review and meta-analysis of cohort studies.Addiction. 2011;106(1):

32–51.

3. Merrall EL, Kariminia A, Binswanger IA, et al. Meta-analysis of drug-related deaths soon after release from prison.

Addiction. 2010;105(9):1545–1554.

4. Prevent Overdose RI. The task force.

Available at: http://preventoverdoseri.

org/the-task-force. Accessed June 11, 2018.

5. Schuckit MA. Treatment of opioid-use disorders.N Engl J Med. 2016;375(4):

357–368.

6. Sharma A, O’Grady KE, Kelly SM, Gryczynski J, Mitchell SG, Schwartz RP.

Pharmacotherapy for opioid dependence in jails and prisons: research review update and future directions.Subst Abuse Rehabil.

2016;7:27–40.

7. Deck D, Wiitala W, McFarland B, et al.

Medicaid coverage, methadone mainte- nance, and felony arrests: outcomes of opiate treatment in two states.J Addict Dis. 2009;28(2):89–102. Expedited Partner Therapy:

Combating Record High Sexually Transmitted Infection Rates Expedited partner therapy (EPT) is an underused practice to address the record high rates of sexually transmitted infections (STIs) in the United States. There were more than 1.59 million re- ported cases of chlamydia in 2016, the highest number of annual cases of any condition ever re- ported to the Centers for Disease Control and Prevention (CDC). 1 The continued increase in rates of chlamydia, gonorrhea, and syphilis is particularly sur- prising in light of the numerous gainsthathavebeenmadeinotherareas of reproductive health. Ac- cess to contraception has in- creased, unintended pregnancy rates have decreased, age atﬁrst sexual activity has increased, and access to online health information has continued to improve; so why are STI rates worsening? 2The answer is not simple, although the lack of partner treatment plays an important role.

The transmission of un- diagnosed STIs may result in persistent or recurrent infections and can cause serious health complications. Women are atincreased risk for pelvic inﬂam- matory disease, chronic pelvic pain, and infertility. 3Untreated STIs also increase the risk of HIV acquisition. 4Adolescent women aged 15 to 24 years accounted for46% of reported chlamydia cases in 2016. 1Increasing rates among adolescents have the potential to diminish the reproductive health of future generations, as women with undiagnosed infections face serious health conquences. 1In addition to this epidemiological burden, STIs also carry a signiﬁcant economic burden. The total direct cost of chlamydia and gonorrhea in 2008 was $516.7 million and $162.1 million, respectively (on the basis of 2010 US dollars).

5 ABOUT THE AUTHORSCornelius D. Jamison is with the Department of Family Medicine, University of Michigan, Ann Arbor. Tammy Chang is with the Department of Family Medicine and the Institute for Healthcare Policy and Innovation, University of Michigan. Okeoma Mmeje is with the Department of Obstetrics and Gynecology, University of Michigan Correspondence should be sent to Cornelius D. Jamison, University of Michigan, National Clinician Scholars Program, 2800 Plymouth Road, Bld 14-G100, Ann Arbor, MI 48105 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the“Reprints”link.

This editorial was accepted May 22, 2018.

doi: 10.2105/AJPH.2018.304570 AJPHPERSPECTIVES October 2018, Vol 108, No. 10AJPHJamison et al.Editorial1325 This continued increase in STIs has occurred despite several prevention and research programs and organizations dedicated to decreasing their prevalence and transmission (e.g., the Infertility Prevention Project, the CDC, HORIZONS, US Health and Human Services). The CDC recommends annual STI screen- ing for chlamydia and gonorrhea for all sexually active women younger than 25 years. 6STI screening should be considered for men who report high-risk behaviors and in communities with a high burden of infection. 6 Health care providers are expected to counsel individuals on safe sex practices, offer STI screening as indicated, and recommend the use of condoms to everyone. Despite these programs and recommen- dations, rates of STIs continue to increase—suggesting that these efforts are just not enough.

There are continued concerns regarding the availability of health care and the coverage of services, including annual STI screening and treatment. At-risk individuals without health in- surance have diminished access to screening and treatment, leading to further increases in STI rates.

However, EPT has the potential to reverse this trend by allowing health care providers to reach exposed individuals who would otherwise be unable to access health care services.

EXPEDITED PARTNER THERAPY EPT is a health care practice that allows providers to give a prescription or medications to the heterosexual partners of pa- tients diagnosed with chlamydia or gonorrhea without testing or examining the partner. 7Al- though EPT is not a substitute fora full sexual health evaluation, partners of infected individuals often cannot or do not seek treatment. Of note, EPT is not recommended for the manage- ment of STIs in men who have sex with men because of the lack of data demonstrating EPT’sef- fectiveness and the concern of missing STI and HIV coinfections in this population. 7EPT is en- dorsed by the CDC and the following professional health organizations: American Academy of Family Physicians, American Academy of Pediatrics, Society for Adolescent Health and Medicine, and American Congress of Ob- stetricians and Gynecologists. Most importantly, EPT is a patient- centered, effective solution that is cost-effective and safe. 7,8 WHERE EXPEDITED PARTNER THERAPY IS PERMISSIBLE Several states enacted EPT legislation following the publi- cation of the CDC’s EPT guidelines on August 16, 2006. 7 Currently, EPT is permissible in 41 states and the District of Co- lumbia (a legal status of EPT map is available at https://www.cdc.

gov/std/ept/legal/default.htm).

With the passing vote on House Bill 360 in February 2017, Georgia became the most recent state to permit the practice of EPT. EPT is“potentially allow- able”in seven states and Puerto Rico. EPT is currently pro- hibited in South Carolina and Kentucky.

IMPLEMENTATION CHALLENGES Although EPT is largely per- missible in the United States, states struggle with its implementation.On the basis of each state’s wording and varying interpretation of the law, the implementation and de- livery of EPT may be limited and contribute to the increasing STI rates. 9There are obstacles to fully realizing EPT’s potential at every level of health care (Figure A, available as a supplement to the online version of this article at http://www.ajph.org). Stigma af- fects STI screening and treatment and may limit both patients’will- ingness to divulge concerns and providers’willingness to initiate discussions regarding sexual health.

10Patients may not be aware of EPT and therefore cannot re- questitfortheirsexualpartners or may not feel comfortable pro- viding it to their partners. Partners may notﬁll the prescriptions (be- cause of, e.g., high out-of-pocket cost, lack of insurance coverage) or take the medication after it is given to them.

11Cost continues to be a barrier, as many insurance com- panies currently do not cover EPT.

Many health care providers may notbeawareoftheavailabilityof EPT or how to provide it in the context of their current practice. 12 Providers may also be resistant to prescribing EPT, as they may prefer to physically see or contact every patient. 12Barriers in the health care infrastructure also limit EPT use, because pharmacies and electronic medical records are of- ten not equipped to implement andsupportthewidespreadprac- tice of EPT. THE FUTURE OF IMPLEMENTATION In light of rising health care costs and the increasing burden of STIs, strengthening the imple- mentation of effective STI treatment and prevention strat- egies is critical to tackle the STI epidemic. This is most importantfor high-risk individuals and communities with a high preva- lence of STIs. Health care pro- viders are at the front line of these efforts, including leading pro- grams and policies to increase knowledge and usage of EPT.

Additional research is warranted to improve the implementation of EPT, including research to further the understanding of the facilitators and barriers among health care providers and within complex health care systems.

Training programs for physicians, nurses, and physician assistants could include education on the effectiveness and speciﬁc pro- cesses needed to provide EPT in their communities. Electronic medical records that remind providers and automate pre- scription of treatment of sexual partners concurrently with the index patient are promising ad- vances to promote EPT uptake.

In addition to clinical practice, research is needed to understand what inﬂuences patient uptake of EPT, to understand effective ways to assist patients in educat- ing their sexual partners, and to evaluate EPT implementation in high-risk populations, such as men who have sex with men and transgender individuals. In states where EPT is only potentially allowable or prohibited, clear communication of the efﬁcacy of EPT on STI rates is needed to inform decision-making.

The United States is at a crossroads. STIs are rampant, especially among youths, and access to health care services continues to be limited for many. Although health care policies often lag behind clinical practice innovations, policies related to EPT are distinctly different. With 41 EPT per- missible states in the United States, health care policies are well aligned to meet the needs of patients. EPT provides AJPHPERSPECTIVES 1326EditorialJamison et al.AJPHOctober 2018, Vol 108, No. 10 conﬁdential and convenient treatment—two critical com- ponents of STI care. Therefore, it is time for state and local public health departments and health care providers to advance clinical processes and practice to fully realize the potential of EPT to address the worsening STI crisis.

Cornelius D. Jamison, MD, MSPH Tammy Chang, MD, MPH, MS Okeoma Mmeje, MD, MPH CONTRIBUTORSThe authors contributed equally to the conceptualization, writing, and revision of the editorial, and all of the authors ap- proved theﬁnal version. REFERENCES1. Centers for Disease Control and Prevention.Sexually Transmitted Disease Surveillance 2016. Atlanta, GA: US Department of Health and Human Services; 2017.

2. Finer LB, Zolna MR. Declines in un- intended pregnancy in the United States, 2008–2011.N Engl J Med. 2016;374(9):

843–852.

3. Centers for Disease Control and Pre- vention. Pelvic inﬂammatory disease (PID)—CDC fact sheet. Available at:

https://www.cdc.gov/std/pid/stdfact- pid.htm. Accessed August 14, 2017.

4. Hayes R, Watson-Jones D, Celum C, van de Wijgert J, Wasserheit J. Treatment of sexually transmitted infections for HIV prevention: end of the road or new beginning?AIDS. 2010;24(suppl 4):

S15–S26.

5. Owusu-Edusei K Jr, Chesson HW, Gift TL, et al. The estimated direct medicalcost of selected sexually transmitted in- fections in the United States, 2008.Sex Transm Dis. 2013;40(3):197–201.

6. Centers for Disease Control and Pre- vention. STD & HIV screening recom- mendations. Available at: https://www.

cdc.gov/std/prevention/screeningreccs.

htm. Accessed August 14, 2017.

7. Centers for Disease Control and Pre- vention. Expedited partner therapy in the management of sexually transmitted dis- eases. Available at: https://www.cdc.gov/ std/treatment/eptﬁnalreport2006.pdf.

Accessed August 14, 2017.

8. Ferreira A, Young T, Mathews C, Zunza M, Low N. Strategies for partner notiﬁcation for sexually transmitted infections, including HIV.Cochrane Database Syst Rev.2013;(10):

CD002843.

9. Mmeje O, Wallett S, Kolenic G, Bell J.

Impact of expedited partner therapy (EPT) implementation on chlamydiaincidence in the USA.Sex Transm Infect.

2017; Epub ahead of print.

10. Ford JV, Ivankovich MB, Douglas JM Jr, et al. The need to promote sexual health in America: a new vision for public health action.Sex Transm Dis. 2017;44(10):

579–585.

11. Schillinger JA, Gorwitz R, Rietmeijer C, Golden MR. The expedited partner therapy continuum: a conceptual frame- work to guide programmatic efforts to increase partner treatment.Sex Transm Dis. 2016;43(2 supp 1):S63–S75.

12. Rosenfeld EA, Marx J, Terry MA, Stall R, Pallatino C, Miller E. Healthcare providers’perspectives on expedited partner therapy for chlamydia: a qualita- tive study.Sex Transm Infect. 2015;91(6):

407–411. Ebola Virus Disease Preparations Do Not Protect the United States Against Other Infectious Outbreaks The 2014–2016 West African Ebola virus disease (EVD) epidemic took the world by surprise. While 11 patients were treated in the United States, it challenged public health, health care, and emergency response infrastructures. 1 The outbreak highlighted the need for robust systems of screening and care for patients with highly hazard- ous communicable diseases (HHCDs), especially because the outbreak showed how modern travel hastens in- ternational disease spread.

The May 2018 EVD out- break in the Democratic Republic of Congo rein- forces this need and demon- strates the uphill battle against emerging and reemerging diseases.

In the beginning of the 2014 outbreak, most health care facilities in the United Stateswere unprepared to identify, isolate, and provide care for patients who presented to their facilities with suspected EVD. 1 Responding to this deﬁciency, the United States, led by the Assistant Secretary for Preparedness and Response and the Centers for Disease Control and Prevention (CDC), developed a tiered EVD care system that outlined the mini- mum expected capabilities for frontline hospitals, assessment hospitals, and Ebola treatment centers. 2Designated assessment hospitals and Ebola treatment centers collectively made signif- icant modiﬁcations to their facilities to enhance infection control, purchased greater quantities of personal pro- tective equipment, and en- hanced staff training. 3In addition, the Assistant Secretary for Preparedness and Response designated and funded onehospital in each of the 10 Department of Health and Human Services regions as a regional Ebola and other special pathogens treat- ment center (RESPTC), requiring these facilities to make more upgrades than the other two tiers to receive designation asﬁrst-choice locations to provide care for patients with conﬁrmed EVD.

These efforts resulted in signiﬁ- cant progress in our domestic capability to safely care for patients with EVD. 1 CURRENT STATUS After more than three years of efforts, and in light of the new EVD outbreak, policy- makers and the public likely expect that the United States will sustain the new capabilities that it has paid for and developed to care for patients with EVD.

It is also likely they believe this infrastructure can safely be used to accommodate patients during future out- breaks of other HHCDs, such as Middle East Respiratory Syndrome and other viral hemorrhagic fevers, such as Lassa.

It is true that the upgraded facilities, personal protective equipment, enhanced trainings, and disease surveillance, in tandem with updated federal guidance, bolstered funding, ABOUT THE AUTHORSShawn Gibbs and Aurora Le are with the Department of Environmental and Occupational Health, Indiana University School of Public Health, Bloomington. John Lowe and Jocelyn Herstein are with the Department of Environmental, Agricultural, and Occupational Health, University of Nebraska Medical Center College of Public Health, and the Nebraska Bio- containment Unit, Nebraska Medicine, Omaha. Paul Biddinger is with Massachusetts General Hospital Boston, and Harvard Medical School, Boston.

Correspondence should be sent to Shawn G. Gibbs, Indiana University School of Public Health, 1025 E Seventh St, PH 111C, Bloomington, IN 47405 (e-mail: gibbss@indiana.

edu). Reprints can be ordered at http://www.ajph.org by clicking the“Reprints”link.

This editorial was accepted July 15, 2018.

doi: 10.2105/AJPH.2018.304667 AJPHPERSPECTIVES October 2018, Vol 108, No. 10AJPHGibbs et al.Editorial1327 Copyright ofAmerican JournalofPublic Health isthe property ofAmerican PublicHealth Association anditscontent maynotbecopied oremailed tomultiple sitesorposted toa listserv without thecopyright holder'sexpresswrittenpermission. However,usersmayprint, download, oremail articles forindividual use.