clinician diagnosis. Expense is especially problematic in publicly sponsored facilities, and accessibility is also difficult in remote areas.

Geographic factors also present challenges to diagnosis and treatment of STDs. Specifically, some regions of the United States and rural areas have to overcome unique obstacles in ensuring access to STD-related services. For example, states along the national borders may have difficulty in identifying and reaching partners because of language and cultural barriers. These regions may also have difficulty in ensuring effective treatment of STDs as people seek care on both sides of the border. In rural areas, low population density makes it difficult to ensure convenient access to STD-related services and to maintain a ready group of health care professionals who are adequately trained and available to provide such services, especially during outbreak situations. In anticipation of sporadic demands for services, some health departments have organized provider networks.

Conclusions

There are many behavioral interventions that have been shown to change health risk behaviors, including sexual behavior. There also are biomedical interventions that are highly effective. If these interventions could be widely implemented in a comprehensive fashion, they would likely have a substantial impact on the prevention of STDs. The three primary goals of both individual- and population-based interventions are to prevent exposure to an STD, prevent acquisition of infection once exposed, and prevent transmission of the infection to others. Given the variety of factors that influence the risk for STDs, it is clear that a multifaceted approach to prevention that integrates both biomedical and behavioral interventions is needed.

Individual factors that increase risk of STDs, such as high-risk sexual behavior, misperception of risk, and lack of personal skills, need to be targeted on a national basis because of the high prevalence of these factors in the general population. Individual behavior, however, is clearly influenced by social factors such as inadequate access to health care. Many individual- and community-level behavioral interventions have been shown to be effective in changing risk behaviors for STDs. Promotion of condom use, in particular, will continue to be a central strategy for preventing STDs. Given the high rates of sexual activity among adolescents, school-based health programs deserve particular emphasis. Although not all school-based programs to reduce risky sexual behaviors have been effective, there is little evidence of adverse outcomes. Interventions that involve the mass media also can have beneficial effects on knowledge and health behavior, especially for adolescents. Clinical methods that are effective in preventing exposure and reducing transmission include prophylaxis and partner notification and treatment. Although treatment of sex partners of infected persons is critical to STD prevention, the traditional methods for identifying partners



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