Screening

Screening programs for many STDs are cost-effective and, sometimes, cost-saving (Handsfield et al., 1986; Arevalo and Washington, 1988; Trachtenberg et al., 1988; Randolph and Washington, 1990; Britton et al., 1992; Hillis, Nakashima, et al., 1995; Scholes et al., 1996). For example, using a decision model, Trachtenberg and colleagues (1988) estimated net savings of more than $60 million (in 1986 dollars) over the first five years of a California statewide chlamydial-screening program for asymptomatic women in family planning clinics. The CDC estimates that approximately $12 in costs associated with the complications of chlamydial and gonococcal infection could be saved for every $1 spent on early detection and treatment (CDC, DSTD/HIVP, 1995).

There are many examples of successful comprehensive screening programs. The Wisconsin chlamydial prevention program is a comprehensive program supported by state funding that includes public-private collaborations, screening in family planning and STD clinics, low-cost laboratory services, integrated information systems, and evaluation of program effectiveness (Addiss et al., 1994; Hillis, Nakashima, et al., 1995). In Wisconsin, substantial declines in the prevalence and incidence of chlamydial infections were observed statewide after the implementation of selective chlamydial screening in family planning clinics and universal screening in large STD clinics, in conjunction with other statewide interventions. Rates of positive laboratory tests for chlamydial, hospitalization for pelvic inflammatory disease, and ectopic pregnancy also declined. In addition, an Indianapolis chlamydial program that included screening demonstrated a 63 percent decrease in chlamydial infections among adolescent girls attending adolescent health clinics for the first time during the 8.75 years of the program (Katz et al., 1996).

The success of a CDC and Office of Population Affairs initiative begun in 1988 in Public Health Service Region X to reduce chlamydial rates led to the Preventive Health Amendments of 1992 that authorized federal funding for expansion of activities to prevent infertility associated with chlamydial and gonococcal infections. Appropriated funds of $12.2 million in fiscal year 1995 have allowed the CDC to screen and treat at least half of at-risk women and their sex partners using family planning and STD clinics in 4 of 10 regions; to initiate screening and treatment services in the other 6 regions; and to implement research and evaluation activities at 5 sites (CDC, Division of STD Prevention, unpublished data, 1996). The CDC estimates that $175 million per year, including $90 million in public funding, is needed to fully implement a national chlamydial prevention program to screen and treat all female adolescents and women between 15 and 34 years of age (CDC, DSTD/HIVP, 1995).

In the primary care setting, screening and treating women at increased risk for asymptomatic chlamydial infection significantly reduces the rate of subsequent pelvic inflammatory disease (Scholes et al., 1996). The U.S. Preventive



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