1
Introduction and Background

Sex is a normal human function that can involve the expression of love and emotional feelings, and does provide a means for reproduction. Sexual intercourse, however, is not without potential harmful or unintended consequences. Two major potential health consequences of sexual intercourse are unintentional pregnancy and sexually transmitted diseases (STDs), including HIV infection. These harmful consequences can be dramatically reduced through effective prevention programs and by openly confronting these problems on a national level. A previous Institute of Medicine (IOM) report has described the national epidemic of unintentional pregnancies and recommended a strategy for prevention (IOM, 1995a). The current report focuses on the hidden epidemic of STDs in United States and presents a national strategy for how these diseases can be confronted on many levels.1

1  

The committee considers STDs to be "epidemic" (i.e., the occurrence of disease in excess of that normally expected) in the United States for the following reasons. While some STDs seemed to be declining in the last several years (e.g., gonorrhea), other STDs are increasing (e.g., genital herpes, heterosexually transmitted HIV infection) and are epidemic in the general population (Wasserheit and Aral, 1996). Rates of many STDs, especially viral STDs, are higher than they were three decades ago (CDC, DSTDP, 1996). Among the reportable diseases, five of the top ten most frequently reported diseases are STDs (CDC, 1996). In some population groups (e.g., drug users and their partners, and certain racial and ethnic groups), rates of certain STDs are clearly much higher than in the general population. In addition, if STD rates in other developed countries (i.e., western and northern European countries, Canada, Japan, and Australia) are used as the basis for comparison, then STDs are epidemic in the United States.



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--> 1 Introduction and Background Sex is a normal human function that can involve the expression of love and emotional feelings, and does provide a means for reproduction. Sexual intercourse, however, is not without potential harmful or unintended consequences. Two major potential health consequences of sexual intercourse are unintentional pregnancy and sexually transmitted diseases (STDs), including HIV infection. These harmful consequences can be dramatically reduced through effective prevention programs and by openly confronting these problems on a national level. A previous Institute of Medicine (IOM) report has described the national epidemic of unintentional pregnancies and recommended a strategy for prevention (IOM, 1995a). The current report focuses on the hidden epidemic of STDs in United States and presents a national strategy for how these diseases can be confronted on many levels.1 1   The committee considers STDs to be "epidemic" (i.e., the occurrence of disease in excess of that normally expected) in the United States for the following reasons. While some STDs seemed to be declining in the last several years (e.g., gonorrhea), other STDs are increasing (e.g., genital herpes, heterosexually transmitted HIV infection) and are epidemic in the general population (Wasserheit and Aral, 1996). Rates of many STDs, especially viral STDs, are higher than they were three decades ago (CDC, DSTDP, 1996). Among the reportable diseases, five of the top ten most frequently reported diseases are STDs (CDC, 1996). In some population groups (e.g., drug users and their partners, and certain racial and ethnic groups), rates of certain STDs are clearly much higher than in the general population. In addition, if STD rates in other developed countries (i.e., western and northern European countries, Canada, Japan, and Australia) are used as the basis for comparison, then STDs are epidemic in the United States.

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--> The genesis of this study lies in the following observations regarding STDs in the United States: With approximately 12 million new cases of STDs occurring annually (CDC, DSTD/HIVP, 1993), STDs are some of the most commonly reported diseases in the United States and affect all population groups (CDC, 1994). The scope of the STD epidemic, however, remains underappreciated, and the epidemic is largely hidden and excluded from public discourse. There is a general lack of public awareness and knowledge regarding STDs. Some STDs are initially asymptomatic but may cause serious health problems years after infection. The lag between initial infection and serious complications contributes to the lack of awareness of the impact of STDs. Surveys show that public awareness and knowledge regarding STDs, even among persons at high risk, is dangerously low (ASHA, 1995; EDK Associates, 1995). However, there has not been a comprehensive national public education campaign for STDs. STDs can lead to long-term health consequences that are often irreversible and are costly in both human and economic terms. Potential health consequences include serious long-term complications such as cervical and liver cancer and infertility (Holmes and Handsfield, 1994). STDs during pregnancy may result in fetal death or significant physical and developmental disabilities, including mental retardation and blindness (Brunham et al., 1990). In addition, the economic consequences of STDs are substantial (IOM, 1985; Washington et al., 1986; Washington et al., 1987; Washington and Katz, 1991), but neither the health nor economic impact of STDs is widely recognized. Women are particularly vulnerable to STDs because they are more biologically susceptible to certain sexually transmitted infections than men and because they are more likely to have asymptomatic infections that result in delayed diagnosis and treatment (Aral and Guinan, 1984; Cates, 1990). In addition, women develop more serious sequelae and long-term complications compared to men. The disproportionate impact of STDs on the health of women, however, is not widely understood. Adolescents and young adults are at greatest risk of acquiring an STD. Every year, approximately 3 million teenagers acquire an STD, and many of them will have long-term health problems as a result (CDC, DSTD/HIVP, 1993). Approximately two-thirds of persons who acquire STDs are under age 25. Despite the fact that high-risk sexual behaviors are usually initiated during adolescence, STD prevention efforts for adolescents in the United States remain unfocused and controversial. Campaigns to increase public awareness of STDs and behavioral interventions to promote condom use and other healthy behaviors have been implemented with varying success. Obstacles to effective prevention efforts include behavioral impediments, sociocultural taboos, and inadequate, sometimes conflicting,

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--> sources of public information. These barriers have not been systematically addressed and require innovative solutions. Prevention of STDs has important implications for HIV prevention. Studies show that STDs enhance the risk of sexually transmitted HIV infection (Cameron et al., 1989; Plummer et al., 1991; Wasserheit, 1992; Laga et al., 1993). The role and impact of improved STD prevention on HIV transmission needs to be included in national HIV prevention strategies. Many physicians and other health care professionals do not have adequate skills or training to obtain an accurate sexual history, diagnose and treat STDs, or counsel patients regarding high-risk sexual behavior (Stamm et al., 1982; Merrill et al., 1990; Boekeloo et al., 1991; MacKay et al., 1995). In addition, training and education programs for health care professionals in STD clinical management are inadequate. Many screening and treatment services for STDs are currently provided through dedicated public STD clinics that are operated by public health departments. These STD programs traditionally have been oriented towards diagnosis and treatment but not towards prevention by behavioral interventions. The focus and role of these clinics have not been reexamined in light of recent developments in the delivery of health services and the epidemiology of STDs. Changes in health care delivery and financing, especially the national trend towards managed care, coupled with recent initiatives to shift Medicaid populations into managed care plans, may have a significant impact on the delivery of public health services, including STD-related services. Roles and responsibilities of the public and private health sectors and of primary care professionals in providing these services need to be redefined. In light of these developments, the IOM convened the 16-member Committee on Prevention and Control of Sexually Transmitted Diseases to examine these issues. Committee members include nationally recognized experts in one or more of the following fields: epidemiology, behavioral and social sciences, infectious diseases, public health, pediatrics, women's health, STD program management, family planning, health services administration, and health care policy. The committee was charged to "(a) examine the epidemiological dimensions of STDs in the United States and factors that contribute to the epidemic; (b) assess the effectiveness of current public health strategies and programs to prevent and control STDs;2 and (c) provide direction for future public health programs, policy, and research in STD prevention and control. 3" 2   Although the committee examined the effectiveness of major strategies and programs in STD prevention, it did not conduct a systematic, in-depth evaluation of every STD-related program in the public and private sector. In this report, the committee focuses its discussions on effective strategies and highlights major effective programs. 3   The terms "STD prevention" and "STD control" have been traditionally used by public health workers without clear distinction. These terms have been commonly used to refer to behavioral interventions (e.g., counseling for behavior change), treatment of symptomatic disease, and other interventions that prevent the spread of infection (e.g., partner notification). The committee believes that most interventions for STDs both "prevent" and "control" STDs, and all prevent acquisition or transmission of STDs in a population. Essentially, effective prevention of STDs brings STDs under control. Therefore, in this report, the committee uses the term ''STD prevention" rather than "STD prevention and control" to encompass all interventions, whether behavioral, curative, environmental, or otherwise, that are needed to reduce the spread of infection in a population.

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--> Although public recognition of AIDS and the public health response to the disease were initially very poor (IOM, 1986), it is now probably the most recognized STD in the United States. Because HIV prevention is relatively better funded and HIV prevention efforts are more visible compared to other STDs, the committee was charged to focus its study on STDs other than HIV infection. However, because the prevention of sexually transmitted HIV infection and other STDs are inextricably linked, the committee presents information on and provides recommendations concerning HIV infection as it relates to other STDs in this report in the following areas: costs of sexually transmitted HIV infections (Chapter 2), biological and epidemiological relationship between HIV infection and other STDs (Chapter 2), prevention efforts for sexually transmitted HIV that may be relevant for other STDs (Chapter 4), coordination of STD and HIV programs (Chapter 6), and coordination of interventions related to sexually transmitted HIV infection and other STDs (Chapter 6). A comprehensive analysis and discussion of HIV prevention beyond its relationship with other STDs is outside the charge of this committee, and this issue has been addressed by other IOM committees. Readers who desire additional information regarding national policy regarding the prevention of HIV infection should consult recent studies conducted by the IOM and the National Research Council (NRC, 1990, 1991, 1993; IOM, 1991, 1994, 1995b; NRC, IOM, 1995). Study Methods During the 18-month course of the study, the full committee met five times. To directly observe how STD-related services are delivered on the local level, the committee conducted site visits to public STD clinics and other STD programs in Atlanta and Chicago in the summer of 1995. During these visits, staff of these STD clinics and programs described their activities, provided perspectives on the adequacy and effectiveness of existing services, and suggested ways to improve current efforts against STDs. The committee also conducted two workshops during this study. The first was a public workshop held in Washington, D.C., in July 1995 to examine the potential impact of STDs on HIV transmission. The committee invited various

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--> experts, representing a broad array of disciplines, to present data and perspectives. The main purpose of the workshop was to examine the inextricable links between HIV infection and other STDs. Issues discussed included the biological and epidemiological relationships between other STDs and HIV infection, the potential impact of reducing STDs on HIV transmission, and integration of preventive strategies for STDs and HIV infection. The second workshop, held in the Los Angeles area in November 1995, was a workshop to explore the potential role of managed care organizations in the prevention of STDs. The committee invited a small number of representatives from managed care organizations, public health agencies, and an employer-purchaser coalition to advise the committee on potential roles and responsibilities of the public and private health care sectors in STD prevention. Because data regarding STD-related services in managed care organizations are limited, the committee subsequently conducted a brief survey of managed care organizations to collect information regarding STD-related services. During the course of the study, the committee identified several critical issues that were not adequately addressed by published scientific literature and other available data. Accordingly, the committee commissioned papers from several national and international experts on the economic costs of STDs, the epidemiology of substance use and STDs, the potential impact of reducing STDs on HIV transmission in the United States, and the theoretical basis for behavior change interventions. In some cases, parts of the commissioned papers were incorporated into the body of the report, and two of these papers are published as appendices to this report. Focus of Report Recognizing the complexity of the STD epidemic and the fact that STDs encompass dozens of infections and syndromes, the committee chose to focus its work on fundamental, cross-cutting issues in STD prevention, that is, the underlying issues that need to be addressed in order to effectively prevent STDs. In developing this report, the committee identified the following major questions that eventually became the focus of the present report: What are the health and economic impacts of STDs? What are the central characteristics of the epidemic? What are the underlying factors explaining why the United States has performed poorly relative to other developed countries in its efforts to contain the epidemic? What tools can be used to effectively fight the epidemic? What are the essential components of an effective national system for STD prevention?

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--> What barriers must be addressed and what specific actions can we take immediately to build an effective national and local system for prevention? This report is not intended to be a comprehensive review of STDs or a textbook on STDs. Readers who desire more detailed biomedical information on specific STDs should consult a medical textbook on STDs (e.g., Quinn, 1992; Holmes et al., in press). Health care providers who need information on appropriate diagnosis and treatment of STDs should consult a textbook or the latest STD treatment guidelines (e.g., CDC, 1993; Celum et al., 1994). In addition, persons who need more data on reported rates of STDs should consult published national STD surveillance data (CDC, DSTDP, 1996). The intended audience for this report is anyone who is involved directly or indirectly in STD prevention or who has an interest in general public health policy. STD prevention involves a spectrum of healthand nonhealth-related disciplines and organizations and therefore makes an excellent case study of a major public health problem whose solution requires the cooperation of the public and private sectors and various interest groups. The committee hopes to reach a multidisciplinary audience, including policymakers, public and private sector health care professionals, government agencies, epidemiologists, social scientists, allied health professionals, school health professionals, STD clinicians, health educators, employers, purchasers of health care, and health program managers. This broad audience reflects the spectrum of individuals, agencies, and organizations that are involved in various aspects of STD prevention. Focus of Chapters Chapter 2 describes the significant, but not commonly recognized, health and economic impact of STDs in the United States. The committee highlights the major health consequences of STDs, such as cervical and liver cancer and reproductive health problems. The disproportionate impact of STDs on women and infants is described. Evidence that other STDs increase the risk of HIV transmission and that reducing STDs will prevent a substantial number of HIV infections is presented. In addition, the committee presents estimates of the economic costs of STDs in the United States. The broad reach of STDs throughout the general population, especially among women and adolescents, is underscored. In Chapter 3, the committee presents information regarding the reasons why the United States, unlike most other developed countries, has been unable to confront STDs. The committee identifies and describes biological and social factors that contribute to the STD epidemic, including the lag time from infection to complications, inadequate access to health care, and substance use. The problem of STDs among disenfranchised populations is summarized, and the public health consequences of not preventing STDs among these groups are demonstrated. From the committee's perspective, a fundamental reason for the nation's

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--> failure to successfully prevent STDs is the inability of American society to openly confront issues regarding sexuality and the adverse impact of this inability on STD prevention efforts. In the last section of the chapter, data regarding current trends in sexual behavior are presented. Chapter 4 describes the individual factors that influence personal risk for STDs and summarizes effective interventions that, if fully exploited, offer great promise for preventing STDs. These interventions include various individual-and community-based prevention strategies that can reduce exposure to, acquisition of, and transmission of STDs. Strategies to promote healthy sexual behavior include individual-focused interventions, school-based programs, and mass media campaigns. Clinical methods for prevention include prophylaxis, partner notification and treatment, and screening. At the end of the chapter, the importance of reducing the duration of infection by early detection and treatment of STDs using appropriate diagnostic and therapeutic tools is described. Chapter 5 addresses the assortment of STD prevention services that are currently in place in the United States. These include clinical services for STDs provided through public STD clinics, community-based programs, and private sector health care settings. There is a particular emphasis on the potential role of managed care organizations and other health plans in delivering services. The importance of disease surveillance and other information systems and of health behavior research in STD prevention is documented. The committee also describes the status of STD-related training and educational activities for health care professionals. Following that is a discussion of the pros and cons of existing and proposed funding mechanisms, including block grants, for state and local STD programs. In Chapter 6, the committee presents its assessment of the current system of STD prevention, a vision for an effective national system, and recommendations for how an effective system can be built in the context of four major strategies. The committee begins by describing a model for an effective national system and the need to incorporate STD prevention as a strategy for HIV and cancer prevention. Under the first strategy, the committee details how barriers to the adoption of healthy sexual behaviors, including the reluctance of many Americans to openly confront issues related to sexuality and STDs, can be overcome by increasing public and health professional awareness of STDs and by a bold role for the mass media. Under the second strategy, the importance of establishing both private and public sector leadership, investing in STD prevention, and developing effective information systems are emphasized. The third strategy relates to the need to focus on preventing STDs among adolescents and underserved groups, using innovative methods. The fourth strategy involves ways for ensuring access to, and the quality of, STD-related clinical services. This strategy includes ensuring access to services at the community level, incorporating STD-related clinical services into primary care, improving dedicated public STD clinics, expanding the role and responsibilities of health plans, and improving training and education

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--> of health professionals. A central tactic of the fourth strategy also involves assurance of effective clinical management of STDs. At the end of Chapter 6, brief descriptions of how some agencies and organizations have collaborated to improve access to, and quality of, STD-related services are presented as potential models for others. The nine appendixes that follow Chapter 6 provide additional information about several major issues discussed in Chapters 2 through 6. References Aral SO, Guinan ME. Women and sexually transmitted diseases. In: Holmes KK, Mårdh P-A, Sparling PF, Wiesner PJ, eds. Sexually transmitted diseases. 1st ed. New York: McGraw-Hill, Inc., 1984:85-9. ASHA (American Social Health Association). International survey reveals lack of knowledge about STDs. STD News. A quarterly newsletter of the American Social Health Association. Fall 1995;3:1,10. Boekeloo BO, Marx ES, Kral AH, Coughlin SC, Bowman M, Rabin DL. Frequency and thoroughness of STD/HIV risk assessment by physicians in a high-risk metropolitan area. Am J Public Health 1991;81:1645-8. Brunham RC, Holmes KK, Embree JE. Sexually transmitted diseases in pregnancy. In: Holmes KK, Mårdh P-A, Sparling PF, Weisner PJ, Cates W Jr, Lemon SM, et al., eds. Sexually transmitted diseases. 2nd ed. New York: McGraw-Hill, Inc., 1990:771-801. Cameron DW, Simonsen JN, D'Costa LJ, Ronald AR, Maitha GM, Gakinya MN, et al. Female to male transmission of human immunodeficiency virus type 1: risk factors for seroconversion in men. Lancet 1989; 2:403-7. Cates W Jr. Epidemiology and control of sexually transmitted diseases in adolescents. In: Schydlower M, Shafer MA, eds. AIDS and other sexually transmitted diseases. Philadelphia: Hanly & Belfus, Inc., 1990:409-27. CDC (Centers for Disease Control and Prevention). 1993 Sexually transmitted diseases treatment guidelines. MMWR 1993;42(No. RR-14):56-66. CDC. Summary of notifiable diseases, United States, 1994. MMWR 1994;43:3-12. CDC. Ten leading nationally notifiable infectious diseases—United Sates, 1995. MMWR 1996;45:883-4. CDC, DSTD/HIVP (Division of STD/HIV Prevention). Annual report 1992. U.S. Department of Health and Human Services, Public Health Service. Atlanta: Centers for Disease Control and Prevention, 1993. CDC, DSTDP (Division of STD Prevention). Sexually transmitted disease surveillance 1995. U.S. Department of Health and Human Services, Public Health Service. Atlanta: Centers for Disease Control and Prevention, September 1996. Celum CL, Wilch E, Fennell C, Stamm WE. The management of sexually transmitted diseases. 2nd ed. Seattle: University of Washington, Health Sciences Center for Educational Resources, 1994. EDK Associates. The ABCs of STDs. New York: EDK Associates, 1995. Holmes KK, Handsfield HH. Sexually transmitted diseases. In: Isselbacher KJ, Braunwald E, Wilson JD, Martin JB, Fauci AS, Kasper DL, eds. Harrison's principles of internal medicine. 13th ed. New York: McGraw-Hill, Inc., 1994:534-43. Holmes KK, Sparling PF, Mårdh PA, Lemon SM, Stamm WE, Piot P, Wasserheit JN, eds. Sexually transmitted diseases. 3rd ed. New York: McGraw-Hill, Inc., in press. IOM (Institute of Medicine). New vaccine development: establishing priorities; vol. I, Diseases of importance in the United States. Washington, D.C.: National Academy Press, 1985. IOM. Confronting AIDS: directions for public health, health care, and research. Washington, D.C.: National Academy Press, 1986.

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--> IOM. HIV screening of pregnant women and newborns. Hardy LM, ed. Washington, D.C.: National Academy Press, 1991. IOM. AIDS and behavior. Auerbach JD, Wypijewska C, Brodie HKH, eds. Washington, D.C.: National Academy Press, 1994. IOM. Best intentions: unintended pregnancy and the well-being of children and families. Brown SS, Eisenberg L, eds. Washington, D.C.: National Academy Press, 1995a. IOM. HIV and the blood supply: an analysis of crisis decision-making. Leveton LB, Sox HC, Stoto MA, eds. Washington, D.C.: National Academy Press, 1995b. Laga M, Manoka A, Kivuvu M, Malele B, Tuliza M, Nzila N, et al. Non-ulcerative sexually transmitted diseases as risk factors for HIV-1 transmission in women: results from a cohort study. AIDS 1993;7:95-102. MacKay HT, Toomey KE, Schmid GP. Survey of clinical training in STD and HIV/AIDS in the United States. Proceedings of the IDSA Annual Meeting, September 16-18, 1995, San Francisco [abstract no. 281]. Merrill JM, Laux LF, Thornby JI. Why doctors have difficulty with sex histories. Southern Med J 1990;83:613-7. NRC (National Research Council). AIDS: the second decade. Miller HG, Turner CF, Moses LE, eds. Washington, D.C.: National Academy Press, 1990. NRC. Evaluating AIDS prevention programs: expanded edition. Coyle SL, Boruch RF, Turner CF, eds. Washington, D.C.: National Academy Press, 1991. NRC. The social impact of AIDS in the United States. Jonsen AR, Stryker J, eds. Washington, D.C.: National Academy Press, 1993. NRC, IOM (National Research Council, Institute of Medicine). Preventing HIV transmission: the role of sterile needles and bleach. Normand J, Vlahov D, Moses LE, eds. Washington, D.C.: National Academy Press, 1995. Plummer FA, Simonsen JN, Cameron DW, Ndinya-Achola JO, Kreiss JK, Gakinya MN, et al. Cofactors in male-female transmission of human immunodeficiency virus type 1. J Infect Dis. 1991;163:233-9. Quinn TC, ed. Sexually transmitted diseases. New York: Raven Press, Ltd. , 1992. Stamm WE, Kaetz SK, Holmes KK. Clinical training in venereology in the United States and Canada. JAMA 1982;248:2020-4. Washington AE, Arno PS, Brooks MA. The economic cost of pelvic inflammatory disease. JAMA 1986;255:13:1735-8. Washington AE, Johnson RE, Sanders LL. Chlamydia trachomatis infections in the United States: what are they costing us? JAMA 1987;257:2070-2. Washington AE, Katz P. Cost of and payment source for pelvic inflammatory disease. Trends and projections, 1983 through 2000 [see comments]. JAMA 1991;266:2565-9. Wasserheit JN. Epidemiologic synergy. Interrelationships between human immunodeficiency virus infection and other sexually transmitted diseases. Sex Transm Dis 1992; 9:61-77. Wasserheit JN, Aral SO. The dynamic topology of sexually transmitted disease epidemics: implications for prevention strategies. J Infect Dis 1996; 174 (Suppl 2):S201-13.