6
Establishing an Effective National System to Prevent STDs

The committee concludes that prevention of STDs is technically feasible today in the United States, but an effective national system for STD prevention currently does not exist, and, as a result, STDs are a severe health burden in the United States. Many components of an effective system for STD prevention (described in Chapters 4 and 5), such as a surveillance system to measure STD incidence, public and private sector clinical services, and public education programs, exist in many areas in various stages of development, but these and other components are neither adequate nor coordinated locally, statewide, or nationally.

As outlined in the previous chapters, the current strategy for preventing STDs is based primarily on categorical STD programs run by state and local health departments with guidance and funding from the CDC. Other federal agencies, including the U.S. Department of Justice (Bureau of Prisons), the Agency for Health Care Policy and Research, the Food and Drug Administration, the Health Care Financing Administration, the Health Services and Resources Administration, the Indian Health Service, the National Institutes of Health, the Office of Population Affairs (Department of Health and Human Services), and the Substance Abuse and Mental Health Services Administration, also provide or support STD-related services or research, as do their state and local counterparts.

Public health agencies, private practitioners and medical groups, and community-based clinics all provide STD-related services, but many providers work in relative isolation. Dedicated public STD clinics, family planning clinics, and other community-based clinics serve the uninsured and other populations at high risk for STDs, but often do not coordinate their services. Publicly sponsored STD



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--> 6 Establishing an Effective National System to Prevent STDs The committee concludes that prevention of STDs is technically feasible today in the United States, but an effective national system for STD prevention currently does not exist, and, as a result, STDs are a severe health burden in the United States. Many components of an effective system for STD prevention (described in Chapters 4 and 5), such as a surveillance system to measure STD incidence, public and private sector clinical services, and public education programs, exist in many areas in various stages of development, but these and other components are neither adequate nor coordinated locally, statewide, or nationally. As outlined in the previous chapters, the current strategy for preventing STDs is based primarily on categorical STD programs run by state and local health departments with guidance and funding from the CDC. Other federal agencies, including the U.S. Department of Justice (Bureau of Prisons), the Agency for Health Care Policy and Research, the Food and Drug Administration, the Health Care Financing Administration, the Health Services and Resources Administration, the Indian Health Service, the National Institutes of Health, the Office of Population Affairs (Department of Health and Human Services), and the Substance Abuse and Mental Health Services Administration, also provide or support STD-related services or research, as do their state and local counterparts. Public health agencies, private practitioners and medical groups, and community-based clinics all provide STD-related services, but many providers work in relative isolation. Dedicated public STD clinics, family planning clinics, and other community-based clinics serve the uninsured and other populations at high risk for STDs, but often do not coordinate their services. Publicly sponsored STD

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--> programs consider containment of STDs to be their primary mission, but collaborate with other public sector health programs infrequently and even less often with private sector health programs. Federal demonstration projects to prevent infertility associated with chlamydial and gonococcal infections, however, are beginning to improve service coordination among family planning clinics, dedicated public STD clinics, and public sector laboratories. In addition, private sector health care professionals often do not recognize the importance of their role in preventing STDs. The lack of an effective system is particularly acute for noncurative prevention programs for STDs, which are far less developed than programs for curative services. In addition, despite the interrelationship between STDs, HIV infection, unintended pregnancy, and cancer, prevention programs for these health conditions are typically neither integrated nor coordinated. The fragmented system of STD-related services directly hinders effective prevention of STDs in many ways. For example, as described in Chapter 5, the national surveillance system collects information regarding reportable STDs among persons who use public STD clinics and community-based services. However, information about the privately insured population is incomplete because many private clinicians do not report STD cases and some cases are presumptively treated. Without a comprehensive system for surveillance that involves all potential caregivers for STDs, it is difficult to accurately monitor disease trends or effectiveness of interventions. A fragmented system of clinical services can result in lapses in coverage and ineffective treatment. As documented in Chapter 5, STD-related clinical care is provided by a variety of clinicians in many settings, and the training of these clinicians, including physicians, in diagnosis, treatment, and prevention of STDs is inadequate. Despite the growing role of private sector primary health care professionals in delivering services, there are large gaps in health professional school training and continuing education regarding STD-related skills. Inadequate training and poor awareness of STDs perpetuates the lack of involvement in prevention activities, such as evaluation and treatment of sex partners, by health plans and private practice clinicians. Inadequate training and poor awareness of STDs among health care professionals also result in clinicians who may fail to diagnose and treat STDs or do not have the skills or confidence to promote behavior change in their patients. The failure to adequately diagnose and treat STDs or become involved in certain prevention activities, therefore, leads to lost clinical opportunities to prevent STDs, and thus, to incomplete or fragmented clinical services. As discussed in Chapter 5, because health plans do not assume responsibility for those who are not plan members, there is no assurance that sex partners of infected plan members will receive appropriate evaluation and treatment. In prisons and jails, prisoners may be screened and found to be positive for an STD, but may be released before treatment is given. Without linkages to community providers,

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--> their infections will likely go untreated and spread to others in the community at large. As a final example, a fragmented system of information and educational services for STDs can result in inadequate awareness and misperceptions of risk. Data presented in Chapters 3 and 4 show that awareness of STDs in the United States is low and misperceptions of risk are common, even among those at highest risk for STDs. This is likely a result of the lack of open public education about STDs and the failure of the mass media to provide accurate information regarding the consequences of high-risk sexual behavior. To develop an effective system for STD prevention, many existing programs need to be redesigned and improved through innovative approaches and closer collaboration. In addition, new programs and initiatives that address important gaps in the current fragmented system of prevention services need to be designed and implemented. In this chapter, the committee proposes an effective national system of STD prevention that can be developed from the currently fragmented set of services and funding streams for STDs. Unless otherwise indicated, the background and support for the committee's strategic plan for reducing the adverse health and economic impact of STDs in the United States are found in Chapters 2 through 5. Laying The Foundation For A National System In formulating a national strategy to prevent STDs, the committee developed the following vision statement and principles to guide its deliberations (Box 6-1). To realize this vision, the committee recommends that: An effective national system for STD prevention be established in the United States. The committee uses the word ''system" to describe an interacting or independent group of services and organizations that function as a whole. By an "effective" system, the committee means a system that is coherent, comprehensive, and coordinated. A coherent system is founded on a clear strategy for prevention that ensures that the components of the system are logically consistent and synergistic. A comprehensive system fully utilizes all types of relevant approaches and effective interventions. A coordinated system ensures that the components of the system relate to each other in order to maximize efficiency and effectiveness. By a "national" system, the committee means a system that is based on a national policy coordinated at all levels and composed of local, state, and national (including federal) programs. A nationally coordinated system is necessary because STDs are a threat to the nation's health and do not recognize geographic borders. In addition, many interventions are most effectively or efficiently developed and implemented at the national level. It is expected that state and local systems will be developed and implemented concurrently and coordinated at all levels. Coordination

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--> of interventions for HIV infection and other STDs, in particular, is an important aspect of an effective national system. An effective national system for STD prevention should: (a) provide comprehensive curative and noncurative preventive services; (b) provide STD-related services in the context of primary care; (c) coordinate public and private sector services; (d) coordinate local, state, and federal programs; and (e) ensure universal access to STD-related services for all persons in the United States. The committee proposes a model for carrying out the functions of a national system for prevention in the context of community and individual roles and responsibilities in Figure 6-1. In the context of the model, the term "community" refers to all persons and entities that have a potential role in STD prevention besides the individual. The committee's model is based on the recognition that both individuals and the community have a role and responsibilities in preventing STDs. In some cases, such as reducing high-risk behaviors, the degree of individual responsibility may exceed that of the community. Even then, however, the community plays a role in setting social norms and providing the knowledge and resources needed for behavior change to occur. In other cases, such as ensuring access to health care, the community's responsibility is clearly greater. Many responsibilities and functions are best shared; many overlap and are related; and some will likely change as the system evolves or as conditions warrant. In addition, responsibilities for specific functions need to be tailored to the local community environment. In the case of STDs, the committee believes that communities have a special responsibility to become involved because STDs and other communicable diseases threaten the health of the community at large, not just the infected individual. In addition, many of the underlying factors that contribute to the STD epidemic, such as lack of awareness, lack of access to health care, and unbalanced messages regarding sexual behavior, are most effectively addressed through community-based interventions. The committee believes that it is inappropriate to advocate that the STD epidemic be solved by individuals without the support of community interventions. It is the community's responsibility to provide individuals with the support, information, and tools that are needed to prevent STDs. Many factors that are often beyond the control of the individual, especially sociocultural factors, directly influence individual behavior and risk of STDs (Wasserheit, 1994). It has been proposed that the various biomedical and behavioral health professionals currently involved in STD prevention, including clinicians, epidemiologists, public health workers, microbiologists, psychologists, and social scientists, develop and participate in interdisciplinary approaches to prevention (Sparling and Aral, 1991). The committee proposes that an even wider range of individuals and institutions is needed. In addition to the professionals mentioned above, health plans, pharmaceutical and medical device companies, educators, and other individuals and entities that have not traditionally been involved in

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--> BOX 6-1 Vision and Guiding Principles for a National System for STD Prevention Vision An effective system of services and information that supports individuals, families, and communities in preventing STDs including HIV infection, and ensures comprehensive, high-quality STD-related health services for all persons Guiding Principles Prevention STDs can be prevented by implementing individual- and population-based interventions that: decrease exposure to infected persons by delaying sexual intercourse among adolescents and by reducing the prevalence of high-risk sexual behaviors; decrease the probability of STD transmission during sexual intercourse by promoting the use of barrier methods, especially condoms; and decrease the duration of infection by improving knowledge and promoting awareness of STDs and their consequences; promoting utilization of health care services for symptoms of STDs; encouraging early detection and effective treatment; and ensuring access to essential clinical services. Responsibility In an effective system for STD prevention: individuals and the community share responsibility for prevention; the community has a responsibility to promote social norms that encourage healthy sexual behaviors and to provide access to education, services, and resources that enable individuals to adopt these behaviors; individuals must have the necessary knowledge, skills, and resources to practice healthy behaviors in order to assume full responsibility for their health; and the public sector is ultimately responsible for preventing transmission of communicable diseases in the population. Implementation/Operational Issues An effective system for STD prevention should have: strong leadership; integrated and coordinated components; programs for monitoring access and performance and for ensuring quality of services; comprehensive educational programs for all persons; interventions that are multisectoral (e.g., involve both private and public sectors in health, education, and other sectors), multidisciplinary (e.g., involve health professionals from various disciplines as well as nonhealth professionals), and multifaceted (e.g., involve coordinated behavioral and biomedical approaches); and partnerships among the various stakeholders in the community. Access and Financing An effective system for STD prevention should have: curative and other preventive services that are confidential, comprehensive, of high quality, and accessible to all, particularly the uninsured, adolescents, and disenfranchised groups; no financial disincentives for accessing essential services, especially those that have a potential impact on the spread of disease and adequate and reliable funding. STD prevention should also become involved. These include mass media companies, social service agencies, employers and businesses, labor unions, religious organizations, and other community-based organizations. A list of potential stakeholders in the community envisioned in the model system is presented in Table 6-1. Given the wide spectrum of stakeholders in STD prevention, the committee advocates a substantial emphasis on coordination and collaboration (IOM, 1996a). The committee's proposed system is founded on the simple infectious disease prevention model of (a) preventing exposure to infection, (b) preventing acquisition of infection when exposed, and (c) preventing transmission to others once infected. In this system, there are multiple points at which to intervene and multiple approaches or interventions at both the individual and the community levels. Programs that focus only on preventing exposure, acquisition, or transmission are unlikely to succeed because no single intervention is totally effective in isolation. Although existing interventions are not perfect, they can have an additive impact in reducing the risk of STDs in the population (Cates, 1996). Therefore,

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--> Complete Box on previous page. resources committed to multiple intervention points are necessary. An effective system must have both behavioral and biomedical approaches that are complementary and intertwined. Biomedical interventions may be ineffective without behavioral components to support them, and behavioral approaches must incorporate biomedical tools for prevention. The committee's model is consistent with the multifaceted, holistic approaches for STD and HIV prevention previously advocated by several experts in STDs (Sparling and Aral, 1991; Wasserheit, 1994; Stryker et al., 1995; Cates, 1996). Similar approaches cited in Chapter 4, such as Wisconsin's comprehensive chlamydial prevention program, have been successful. While primarily a screening program, this initiative included public-private partnerships, leadership from legislators, expanded laboratory services, expanded screening in family planning and STD clinics, education of health care professionals, and integrated information systems. Another example of a successful multifaceted program implemented on a national level is the Thai "100% Condom Program" as described

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--> FIGURE 6-1 A model for community and individual roles and responsibilities in STD prevention.

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--> TABLE 6-1 Potential Community Stakeholders in STD Prevention Academic Health Centers Schools of medicine, dentistry, nursing, pharmacy, public health, allied health, and related other health-disciplines Biomedical and Social Science Researchers Universities; private industry; government agencies Biomedical Industry Pharmaceutical, biotechnology, and medical device companies Businesses and Organized Labor Small businesses; corporations; labor unions Clinical Laboratories Public sector laboratories; hospital and private laboratories Community-Based Organizations Voluntary organizations; churches, synagogues, and other religious organizations; private social service agencies and programs for women, children, runaways, homeless, migrants Government Agencies and Programs Federal agencies (e.g., AHCPR, CDC, FDA, HCFA, HRSA, IHS, NIH, SAMSHA, Department of Justice); state and local health departments; government social service agencies and programs for special populations (e.g., women, children, runaways, homeless, migrants) Health Care Professionals and Organizations Physicians, nurses, pharmacists and other health care professionals; managed care organizations and other health plans; hospitals (emergency rooms); community health centers; health professional organizations, including medical societies and member organizations Health Programs for High-Risk Populations Juvenile detention health services; jail and prison health services; drug and alcohol treatment programs; migrant health programs; health programs for the homeless Individuals and Families Mass Media Television; radio; print and electronic media; commercial sponsors and advertisers Policymakers Federal, state, and local legislators; government health agency leaders; private health care sector leaders Private Foundations Purchasers of Health Services Private employers; government employee benefits groups; purchasing coalitions; Medicaid and other publicly sponsored programs School-Based Programs K-12 school-based programs; educators; school administrators; school boards; college and university health services STD-Related Programs and Clinics Dedicated public STD clinics; family planning clinics, prenatal clinics, HIV clinics

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--> in Chapter 4. With a mass media advertising campaign to change risky sexual behaviors, increased access to condoms, and environmental interventions, this initiative seemed to be highly successful because it involved high-level government and community leaders, different sectors of government (e.g., health, education, and law enforcement agencies), and businesses (owners of commercial sex establishments). Coupled with programs to provide STD-related services, this initiative led to substantial positive behavior change among young men, and the incidence of HIV infections declined. Formulating a National Policy and Strategy A national system for STD prevention must be based on sound national policy and a coherent strategy. Currently, a comprehensive national policy regarding STD prevention does not exist. The elements of a national strategy to prevent bacterial STDs are more fully developed than those needed to prevent viral STDs, for which a national strategy for prevention is not well articulated. Furthermore, a national strategy to prevent STD risk behaviors has not been developed. Since almost all sexually transmitted pathogens that infect people do not have animal reservoirs, many STDs can theoretically be eradicated. Although this goal is probably not attainable in the near future for many STDs, it may be an appropriate intermediate-term goal for some STDs. For example, Sweden has virtually eliminated transmission of three major STDs (syphilis, gonorrhea, and chancroid) among the native population, and several U.S. states have reduced transmission of syphilis and chancroid to very low levels. The committee believes that elimination of ongoing transmission of syphilis within the United States is an attainable goal that should now be attempted. To establish a national system for STD prevention, the committee recommends four major strategies for public and private sector policymakers at the local, state, and national levels: Overcome barriers to adoption of healthy sexual behaviors. Develop strong leadership, strengthen investment, and improve information systems for STD prevention. Design and implement essential STD-related services in innovative ways for adolescents and underserved populations. Ensure access to and quality of essential clinical services for STDs. The establishment of an effective national system for STD prevention and implementation of these strategies is a difficult, long-term process that involves intermediary steps. Efforts consistent with these strategies should be initiated immediately and concurrently. The committee suggests that the Department of Health and Human Services consider the goals and strategies outlined in this

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--> report in developing and updating its national health objectives (e.g., Healthy People 2000) related to STDs. In the committee's strategic plan for an effective national system for STD prevention, four strategies and a number of tactics are presented. Because of the comprehensive nature of the committee's approach, implementation of all the recommended tactics may seem daunting to some communities. While the committee believes that each component of the national system identified in its deliberations is essential to preventing STDs, it recognizes that not all communities will be able to, or need to, implement every tactic described in this chapter. In addition, it is likely that many communities will need to adapt some of the committee's recommendations to maximize their effectiveness under local conditions. The committee purposely has not prioritized the recommendations in this report because it believes that this process should be locally driven. Which interventions are most effective for a particular community will vary depending on the local epidemiology of STDs, the status of STD-related services, and the prevalence of STD risk behaviors. For example, in areas where rates of STDs and risky behaviors are low and access to clinical services for STDs is problematic, improving training of and access to primary care providers and interventions to maintain low rates of risky behaviors may be emphasized. In contrast, in communities where rates of STDs and risky behaviors are high, outreach to health plans, improving public STD clinics, and community-based behavioral interventions may be priorities. The committee proposes that the local health department and community representatives collaboratively prioritize the recommended tactics in this chapter. The committee's recommendations for accomplishing its vision for STD prevention are presented in the remainder of this chapter. Before turning to these recommendations, however, the committee first discusses and makes recommendations about two important concepts that need to be considered in formulating a national strategy for STD prevention: the impact of STDs on HIV transmission and the impact of STDs on cancer. Recognizing the Impact of STDs on HIV Transmission Studies cited in Chapter 2 show that STDs increase the risk of HIV acquisition and transmission. Individuals infected with an STD are more likely to acquire HIV infection when exposed, and individuals coinfected with HIV and another STD are more likely to transmit HIV to their sex partners. Mathematical models and epidemiologic and biologic data collectively provide strong evidence that improved prevention of STDs would reduce sexual transmission of HIV in this country. A major study has shown that improved management of STDs through extensive training of primary health workers, ensuring treatment for STDs, and promoting health-seeking behavior for STDs can significantly reduce the incidence of HIV infection in communities (Grosskurth et al., 1995). Although initial studies documenting the impact of STD prevention on HIV transmission

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--> have been conducted in other countries, current estimates suggest that a large proportion of heterosexually transmitted HIV infections could be prevented by reducing the prevalence of STDs in the United States. The interrelationship between HIV infection and other STDs is clearly documented and supports the concept that prevention of other STDs should be an essential component of HIV prevention programs. As discussed in Chapters 2 and 3, many of the populations at high risk for STDs are also at high risk for HIV infection. Interventions designed to increase awareness of HIV infection or other STDs and to reduce high-risk sexual behavior (such as condom promotion) are likely to have a positive impact on prevention of both HIV infection and other STDs. Therefore, programs for HIV and STD prevention, especially those focused on similar populations, need to be coordinated to maximize the effectiveness and efficiency of both intervention efforts. Educational programs for HIV prevention should disseminate information related to other STDs without making the message too diffuse. Examples of public messages that may not be widely known include: (a) HIV infection is not the only STD with serious health consequences, (b) other STDs increase the risk for HIV infection, (c) condoms and safer sex behaviors prevent both HIV infection and other STDs, (d) the cardinal signs of STDs (e.g., genital sores or discharge or pelvic pain in women), and (e) prompt treatment for STDs prevents complications. Similarly, STD and HIV surveillance systems and research studies need to improve monitoring and assessment of the impact of interventions on both HIV infection and other STDs. For example, population-based serosurveys for HIV infection should also include testing for other STDs, and both HIV and other STD infection rates should be used as outcome measures when evaluating effectiveness of interventions as appropriate. The committee also believes that greater access to STD-related services in clinical HIV programs could reduce sexual transmission of HIV. During the past several years, far more attention has been given to developing HIV prevention than to other STD prevention programs. The strong interest in HIV prevention is justified, but inadequately addresses the prevention of other STDs. HIV prevention programs should support the incorporation of STD prevention activities into HIV prevention efforts. It is important to integrate and coordinate STD and HIV prevention activities without weakening either effort. The intent of the committee is not to divert resources away from HIV prevention efforts to prevention of other STDs, but rather to increase investment in prevention of all STDs. Therefore, the committee makes the following recommendation: Improved prevention of STDs should be an essential component of a national strategy for preventing sexually transmitted HIV infection. As part of this effort, federal, state, and local health agencies should review current HIV and STD programs and should coordinate STD and HIV activities related to health education and prevention, clinical services, surveillance, and research and

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--> surveillance data and knowledge of the populations or geographic prevalence of STDs. These expanded programs should utilize diagnostic tests that are appropriate for screening persons in a variety of settings. Family planning clinics, prenatal clinics, facilities that provide pregnancy termination services, and other settings where obstetric or gynecological care is available should screen and treat women and their partners for sexually transmitted infections. Premarital testing for syphilis, as a requirement for marriage licenses, is unnecessary and contributes little to containing syphilis because persons applying for marriage licenses are generally at lower risk for syphilis compared with the general population. Although these tests represent a source of revenue for some states, studies cited in Chapter 4 indicate that the number of previously undetected cases identified through premarital testing is extremely low; the tests are not cost-effective; and they have little public health impact. In addition, unnecessary testing may undermine public support for more appropriate screening programs, such as syphilis screening of women during early pregnancy. Therefore, the committee makes the following recommendations: All primary care providers, including managed care organizations and other health plans, should implement the recommendations of the U.S. Preventive Services Task Force and the CDC regarding clinical screening and management of STDs. The CDC, the Agency for Health Care Policy and Research, the National Institutes of Health, and other federal agencies should collaborate with health professional organizations and representatives of health plans to develop comprehensive, consensus clinical practice guidelines for primary care clinicians for STD-related services including screening, risk assessment, and counseling and other clinical interventions to promote healthy sexual behaviors. These guidelines should build on the work of the U.S. Preventive Services Task Force and the CDC STD treatment guidelines. These agencies and organizations should also work together to minimize any differences in current recommendations regarding clinical screening and management of STDs and to promote consistent clinical guidelines. States that still have laws requiring premarital syphilis testing as a condition for marriage licenses should repeal these laws. Resources devoted to such testing would be more effective if used in other ways. States that rely heavily on revenue generated by such testing should consider alternative sources of revenue. Improving Diagnosis and Treatment The CDC's STD Treatment Guidelines are a valuable resource that represent the standard for treatment of STDs. Such treatment guidelines help to promote appropriate therapy for STDs on a national basis. Compliance with treatment guidelines is important because it helps ensure that patients receive the most

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--> effective therapy. However, as documented in Chapter 5, there is limited awareness of, and compliance with, these guidelines, especially among private sector health care professionals in some regions. Appropriate diagnosis and treatment of STDs is most effectively accomplished by improving awareness and training of clinicians. Clinicians are ultimately responsible for ensuring that patients and their sex partners who are diagnosed with STDs are appropriately followed up and treated. When the diagnosis of an STD is laboratory-based, a mechanism for communicating results and following up on treatment should be established between the patient and the clinician. Single-dose therapy for bacterial STDs is important in preventing complications and further transmission of STDs because it averts the problems of ineffective treatment associated with the failure of infected individuals to return for subsequent treatment or to take multiple doses of drugs. This attribute is especially valuable when treating disenfranchised persons. Single-dose therapy is most effective when it is directly provided and observed by the clinician, thereby ensuring patient compliance. Although single-dose therapy is more expensive than multidose therapy, it may be more cost-effective from a public health perspective for those populations in which compliance or follow-up are problematic. Therefore, the committee makes the following recommendations: All clinicians should follow STD treatment guidelines recommended by the CDC and national medical professional organizations. The CDC should continue to publish and update the STD Treatment Guidelines. All health plans and national and state professional organizations, such as the American Medical Association, the American Academy of Pediatrics, the American College of Obstetrics and Gynecology, and the American Academy of Family Practitioners, should assist in the dissemination of these guidelines to their members and clinical staff. Single-dose therapy for bacterial and other curable STDs should be available and reimbursable in all clinical settings where STD-related clinical care is routinely provided to populations in which treatment compliance or follow-up are problems. Such therapy should be reimbursed by Medicaid programs and private health insurance plans. Although the pharmaceutical industry has been willing to provide single-dose therapies to public STD clinics at reduced contract prices, some public STD clinics and other public programs still lack sufficient funds to offer single-dose therapy in all situations where it is clinically indicated. Therefore, the pharmaceutical industry should consider further price reductions for public providers of STD treatment. Improving Counseling and Education Risk reduction counseling and education of patients during routine clinical encounters and during evaluations for potential STDs are important components

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--> of STD clinical management. The U.S. Preventive Services Task Force and other professional organizations have recommended that all primary care providers counsel patients regarding the avoidance of high-risk sexual behaviors as part of the periodic health examination. The committee believes that although the ability of clinician counseling in primary care settings to change behavior is unproven, focused counseling in both specialized and general clinical settings has great potential for changing behaviors related to the transmission of STDs. The effectiveness of client-centered counseling for STD prevention in a randomized behavioral intervention trial (Project RESPECT) was mentioned in Chapter 4. Thus, counseling is most likely to be highly effective when it is tailored to the individual and is provided in the context of, and reinforced by, other individual-focused and community-based interventions. The experience of STD infection presents an important opportunity to motivate behavior change. Counseling and education are especially important for adolescents and other groups at high risk of STDs. Major barriers described in Chapters 4 and 5 that hinder clinicians from providing counseling are primarily lack of training and skills in counseling, lack of time allocated for counseling, and lack of reimbursement for such services. To maximize the time available for individualized counseling, new methods of providing information, such as interactive computer software programs and use of other clinic-based counseling staff, should be used to supplement person-to-person counseling by time-constrained clinicians. It is important to develop and evaluate such innovative approaches to counseling and education because some clinicians may be unable, for various reasons, to provide comprehensive preventive services in all the primary care areas that are expected from them. These approaches not only reinforce prevention messages delivered directly by clinicians, but also allow clinicians an opportunity to provide more effective, individually tailored prevention messages. Therefore, the committee makes the following recommendation: All health care professionals should counsel their patients during routine and other appropriate clinical encounters regarding the risk of STDs and methods for preventing high-risk behaviors. Counseling for STDs, including HIV infection, should be reimbursed without copayments or other financial disincentives by Medicaid programs, managed care organizations, and other health plans. The recommendations of the U.S. Preventive Services Task Force regarding counseling for high-risk sexual behaviors should be implemented. Clinical encounters, such as the new diagnosis of an STD or unintended pregnancy, evaluation for HIV infection, or the prescribing of contraceptives, present unique teaching opportunities, when patients may be particularly receptive to health education and counseling; these opportunities should be utilized.

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--> Improving Partner Notification and Treatment As discussed in Chapter 4, identification and treatment of partners is an essential component of STD clinical management because it reduces further transmission of STDs, prevents reinfection, and reduces risk of long-term complications of STDs in the infected partner. The case-finding activities of STD disease intervention specialists have been effective in containing outbreaks of bacterial STDs in discrete communities by promptly identifying and treating infected partners. In some countries, such as Sweden, partner notification for gonorrhea, syphilis, and chlamydial infection has been highly effective. However, the current methods of partner notification utilized by public STD clinics in the United States are extremely resource-intensive, inefficient, and in need of redesign. This is especially important given the high incidence of STDs among persons whose partners are unidentifiable, not easily reached, or uncooperative (and often participate in extended sexual networks). No single model for partner notification is appropriate for all communities. One approach is to identify sex-partner networks in high morbidity areas and screen and treat members of the network. Another option is to replace the current method of notification with a combination of outreach efforts to identify partners and other individuals at high risk for STDs. The optimal combination of activities that are most effective at reaching persons at risk for STDs will vary depending on the local epidemiology of STDs, available resources, and the spectrum of local public and private health care professionals treating STDs. STD programs need to develop new strategies and techniques for community outreach in partnership with other health care professionals rather than relying solely on health department or public STD clinic staff. It is essential that disease intervention specialists be sensitive to the local community. Other approaches include involving community-based organizations, designing and implementing outreach and screening activities, motivating private health care professionals to assist in partner notification, and assisting and motivating index patients to notify and assist their partners in seeking treatment. Limited data are available regarding the effectiveness and potential benefits of different approaches to partner notification, and further research is urgently needed to identify innovative and more cost-effective strategies for partner outreach at the individual and community levels. As reflected in the committee's model, notifying partners of potential exposure to an STD should be a major responsibility of those persons who are infected. Community norms regarding the roles of groups or individuals in patient and partner referral need to be changed. However, health professionals need to recognize that certain individuals, especially adolescents and women, may experience difficulty notifying their partners and will require assistance in doing so. Few efforts have been made to explore the factors that affect the willingness or

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--> ability of individuals to participate in patient referral, and research in this area is important to improve the overall effectiveness of patient referral. Partner treatment should be addressed as part of the comprehensive STD care of anyone with an STD, whether managed in the private or public sector. A comprehensive strategy for partner outreach needs to include private sector health care professionals, because they treat a large proportion of STDs. Health care professionals who primarily treat patients of one gender (e.g., obstetricians and gynecologists) should be given appropriate training to improve clinical management of sex partners. Managers of clinical settings need to identify and address other potential clinic-specific barriers to effective partner diagnosis and treatment. The concept that partner treatment is part of standard STD clinical management should be reinforced among private sector clinicians as well as among health plans. The committee believes that health care professionals and health plans have an ethical and public health obligation to ensure that the sexual contacts of their patients with STDs are notified promptly of potential exposures, counseled regarding risk factors for infection, and offered diagnostic testing and treatment. The responsibility for these activities in private health care settings historically has been relegated to public health agencies. This is often an inappropriate or ineffective method of ensuring prompt notification, counseling, testing, and treatment. The committee also believes that this obligation extends beyond health plan members because health plans have a responsibility to improve the health of the communities from which they draw their revenue (Showstack et al., 1996). As previously mentioned, treating partners in the community is in the long-term interest of both the health plan and health plan members. Therefore, the committee makes the following recommendations: State and local health departments, with the assistance of the CDC, should redesign current partner notification activities for curable STDs in public health clinics to improve outreach, mobilize public health staff in new ways, and enlist support from community groups or other programs that provide services to high-risk populations. Changes in the system should be driven by results of cost-effectiveness research and formal prevention intervention trials on innovative approaches to partner notification. Communities and clients should also be involved in designing partner notification approaches to improve effectiveness and acceptability. Identifying sex-partner networks in high morbidity areas, with screening and outreach activities occurring within high-risk networks, should be one component of refocused partner notification activities. The CDC should support research to identify and evaluate innovative and cost-effective strategies for partner outreach and to determine those factors that may influence personal behavior or responsibility related to patient referral. In addition, local health departments should promote the coordination of partner notification

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--> activities by establishing linkages with other public agencies and private health plans. All health plans and clinicians should take responsibility for partner treatment and provide STD diagnosis and treatment to sex partners of plan members or others under their care as part of standard clinical practice. Diagnosis and treatment of partners should be reimbursable by third-party payers, including Medicaid, or by the partner's health plan if he or she is insured. All health plans and appropriate private health care professionals should participate, and develop capacity, in partner notification. Health professional organizations should educate their members regarding the importance of partner diagnosis and treatment. Improving Availability and Capability of Laboratory Services As reviewed in Chapter 4, access to appropriate laboratory testing is critical for accurate diagnosis of STDs and STD screening programs. Clinicians may have limited access to materials for diagnosis or laboratories with appropriate diagnostic tests. Therefore, qualified laboratories need to be available on a regional basis and do not need to be located in every clinical facility. Quality control and standardization of diagnostic tests are essential and should be systematically performed. Qualified public sector laboratories are available in many areas, but long-term availability of these laboratories may be jeopardized if health plans do not provide reimbursement for services or if competition with established commercial or hospital-based laboratories increases. Clinicians need to be aware that specimen adequacy and proper handling and transport of diagnostic specimens are needed to ensure accurate test results. Even with access to diagnostic testing, clinicians must have adequate training to appropriately select and interpret such tests. Use of nucleic acid detection rather than culture and sensitivity analysis, and syndromic diagnosis rather than laboratory-based diagnosis, may reduce the capability of public sector laboratories to perform certain public health functions such as the monitoring of antibiotic resistance of sexually transmitted pathogens. Public STD laboratory expertise should be maintained at the federal, state, and local levels to support clinical care of patients, monitor microbial resistance, and support surveillance of emerging STDs. Therefore, the committee makes the following recommendation: Public sector laboratories should be reimbursed for STD-related laboratory tests performed on persons who have private health insurance coverage. Such laboratories should develop mechanisms to bill health plans for laboratory services. State and local health departments should negotiate adequate reimbursement for such services from health plans. In addition, public sector laboratories should ensure that the quality and cost of their services are competitive with those in the private sector. Qualified STD reference laboratories should

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--> be preserved at the regional level and strengthened where regional capabilities are lacking. Outsourcing and collaboration with private or university-based STD reference laboratories should be considered in sustaining and developing public sector reference laboratory capabilities. Collaborating To Improve Services In this section, the committee describes potential models for how the various providers of clinical services can work together to improve access to, and quality of, clinical services. In examining potential models for delivering services, the committee considered the many ongoing programs that they visited and heard about during the course of the study. The committee believes that the programs summarized in Appendix I serve as valuable models for agencies and organizations that are planning to develop collaborative activities. Because most of these programs have not been systematically evaluated for effectiveness, the committee does not necessarily endorse these specific programs, but rather encourages agencies and organizations to use these examples as the basis for developing collaborations to improve services. Collaborating with Other Public Sector Health Programs As in the case of community-based and private sector clinics, local health departments that provide STD-related clinical services should ensure that such services are provided in primary care settings, including reproductive health programs. The DeKalb County health department in Georgia, for example, has integrated STD and HIV screening and counseling services and is beginning to provide both services in family planning and primary care clinics. Some of the most promising efforts to provide STD-related services along with other public health services are focused on high-risk populations. For example, the Teen Services Program, sponsored by Emory University at Grady Memorial Hospital in Atlanta, and the Young Adult Clinic, operated by the Chicago Health Department with Vida/Sida, a community outreach program, target high-risk adolescents and young adults in inner-city communities. These projects focus on the comprehensive health and social needs of populations and individuals within the community, not just STDs. They bring together high-priority services for adolescents and young adults, such as STD screening and treatment, HIV testing and counseling, and contraceptive services and pregnancy testing, in a comprehensive health care setting. Although the Chicago project focuses on STDs, including HIV infection, and the Atlanta project focuses on pregnancy prevention, both emphasize education and behavior change related to sexuality. They are also both closely linked to schools; the Grady program is closely aligned with the Atlanta middle-school curriculum. Both programs also utilize ''peer experts" who provide outreach and education to other adolescents.

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--> These various models reflect many of the characteristics of the Youth Clinics implemented in Sweden in 1972. There are 187 such clinics in existence in Sweden-a country with a population under nine million. These clinics provide comprehensive services to adolescents and are credited with a major positive impact on prevention of STDs and unintended pregnancy. Collaborating with Community-Based Health Programs Community-based health providers such as community health centers, family planning programs, and school-based health clinics are potentially important sources of STD-related services because they serve a patient population with a high prevalence of STDs. Although many community-based health programs currently provide STD-related clinical services, most have not made STD prevention a priority, despite its high prevalence in their patient population, and some do not have expertise in providing such services. There are, however, some notable exceptions to this observation. Programs that provide family planning services, for example, have long recognized the importance of integrating STD clinical and educational services into family planning services, although not all programs provide STD-related services. In Chicago, Planned Parenthood provides STD- and HIV-related services in the context of comprehensive primary care for women and adolescents, while focusing on reproductive health. Using a population-based public health approach, the Chicago Planned Parenthood program provides outreach and education services directly to several high schools and through its clinics. The West End Community Health Center in Atlanta has developed a substantial STD program and provides STD-related services along with extensive primary care services. In this comprehensive model, clients receive STD screening, diagnosis, and treatment through their primary care provider of choice. Outreach, follow-up, and special counseling and education are available through clinic-based staff in collaboration with the local health department STD program staff. Most important, services are centered on the patient, coordinated by a primary care provider, documented in a single medical record, and monitored by relevant public health agencies. In addition, local health departments in several cities (e.g., Baltimore, Boston, Denver, Minneapolis, and Portland) have developed collaborative pilot programs linking school-based health centers sponsored by the health department with local managed care organizations (Schlitt et al., 1995; Zimmerman and Reif, 1995). These programs provide comprehensive primary care, easily accessed at school, and multidisciplinary health education, health promotion, and mental health and social services. All routine STD- and reproductive-health-related care is provided through these centers. Agreements with the participating managed care organizations have enabled the providers in the school-based health center to

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--> act as primary care providers, referring plan enrollees to other plan services as needed. An example of an effort to promote collaboration at the national level is the CDC's National Partnership to Prevent STD-Related Infertility, which is intended to prevent infertility and other serious complications of chlamydial and gonococcal infections. The partnership seeks to prevent these infections through collaborations with a variety of traditional and nontraditional stakeholders in STD prevention. The action plan for the partnership focuses on coordination and integration of STD-related services, public education, health professional education, quality assurance for diagnosis and treatment, community-level behavior change, and surveillance and program evaluation (CDC, DSTD/HIVP, 1995). In addition, the demonstration projects cosponsored by the CDC and the Office of Population Affairs are increasing collaboration among dedicated public STD clinics, family planning clinics, and public laboratories. The committee believes that these types of collaborative approaches should be expanded to all STDs. Concluding Statement STDs are hidden epidemics of tremendous health and economic consequence in the United States. They are hidden because many Americans are reluctant to address sexual health issues in an open way and because of the biologic and social characteristics of these diseases. STDs are diseases of national and global importance that have a dramatic impact on local communities. All Americans have an interest in STD prevention because all communities are impacted by STDs, and all individuals directly or indirectly pay for the costs of these diseases. STDs are public health problems that lack easy solutions because they are rooted in human behavior and fundamental societal problems. Indeed, there are many obstacles to effective prevention efforts. The first hurdle will be to confront the reluctance of American society to openly address issues surrounding sexuality and STDs. Despite the barriers, there are existing individual- and community-based interventions that are effective and can be implemented immediately. Although these interventions are not perfect, they can have a synergistic, positive impact in reducing the risk of STDs in the population. That is why a multifaceted approach is necessary at both the individual and community levels. Populations at high risk, such as adolescents and disenfranchised persons, will need special attention. An effective system of STD prevention in the United States will have to be developed at the local, state, and national levels, with full participation of both the public and private sectors. Many of the essential components of an effective system already exist, but they need to be integrated or coordinated, particularly at the local level. Many of these components also need to be improved and redesigned in order to maximize effectiveness and optimize resources. This means that many stakeholders need to redefine their mission, refocus their efforts, modify

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--> how they deliver services, and accept new responsibilities. In this process, strong leadership, innovative thinking, partnerships, and adequate resources will be required. The additional investment required to effectively prevent STDs may be considerable, but it is negligible when compared with the likely return on the investment. The process of preventing STDs must be a collaborative one. No one agency, organization, or sector can effectively do it alone; all members of the community must do their part. A successful national initiative to confront and prevent STDs requires widespread public awareness and participation and bold national leadership from the highest levels. References AGI (Alan Guttmacher Institute). Lawmakers grapple with parents' role in teen access to reproductive health care. Issues in Brief. New York and Washington, D.C.: AGI, 1995. AMA (American Medical Association). Policy compendium on reproductive health issues affecting adolescents. Gans Epner JE, ed. Chicago: AMA, 1996. Aral SO, Holmes KK, Padian N, Cates W. Overview: individual and population level approaches to the epidemiology and prevention of sexually transmitted diseases and human immunodeficiency virus infection. J Infect Dis 1996;174(Suppl 2):S127-33. ASTHO (Association of State and Territorial Health Officials). Access and managed care: oxymoron or reality? Washington, D.C.: ASTHO, Managed Care Monograph Series, November, 1995a. ASTHO. Communicable disease control in a managed care environment. Washington, D.C.: ASTHO, Managed Care Monograph Series, November, 1995b. ASTHO. Ensuring and improving the quality of care in a managed care environment. Washington, D.C.: ASTHO, Managed Care Monograph Series, November, 1995c. Cates W Jr. Contraception, unintended pregnancies, and sexually transmitted diseases: why isn't a simple solution possible? Am J Epidemiol 1996;143:311-8. CDC (Centers for Disease Control and Prevention). Trends in sexual risk behavior among high school students-United States, 1990, 1991, and 1993. MMWR 1995;44:124-5, 131-2. CDC, DSTD/HIVP (Division of STD/HIV Prevention). Plan for a national partnership to prevent STD-related infertility. Draft internal document, January 10, 1995. County of Los Angeles Department of Health Services. Draft agreement between the County of Los Angeles and plan. March 29, 1995. Grosskurth H, Mosha F, Todd J, Mwijarubi E, Klokke A, Senkoro K, et al. Impact of improved treatment of sexually transmitted diseases on HIV infection in rural Tanzania: randomized controlled trial [see comments]. Lancet 1995;346:530-6. Halpern CT, Udry JR, Suchindran C. Effects of repeated questionnaire administration in longitudinal studies of adolescent males' sexual behavior. Arch Sex Behav 1994;23:41-57. IOM (Institute of Medicine). The future of public health. Washington, D.C.: National Academy Press, 1988. IOM. Healthy communities: new partnerships for the future of public health. Stoto MA, Dievler A, Abel C, eds. Washington, D.C.: National Academy Press, 1996a. IOM. Primary care: America's health in a new era. Donaldson MS, Yordy KD, Lohr KN, Vanselow NA, eds. Washington, D.C.: National Academy Press, 1996b. IOM. Improving health in the community: a role for performance monitoring. Durch JS, Bailey LA, Stoto MA, eds. Washington, D.C.: National Academy Press, 1977. NACCHO (National Association of County and City Health Officials). Blueprint for a healthy community: a guide for local health departments. Washington, D.C.: NACCHO, July 1994.

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--> NCASH (National Commission on Adolescent Sexual Health). Facing facts: sexual health for America's adolescents. New York: SIECUS, 1995. NIH (National Institutes of Health). NIH AIDS Research Program Evaluation. Behavioral, social science, and prevention research area review panel. Findings and recommendations. Bethesda, MD: National Institutes of Health, 1996. NRC (National Research Council). Assessment of performance measures in public health. Phase 1 report. Washington, D.C.: National Academy Press, in press. Russell LB. Educated guesses. Making policy about medical screening tests. Berkeley, CA: University of California Press, 1994. SAM (Society for Adolescent Medicine). Special issue on guidelines for adolescent health research. J Adolesc Health 1995;17:259-332. Schlitt JJ, Rickett KD, Montgomery LL, Lear JG. State initiatives to support school-based health centers: a national survey. J Adolesc Health 1995;17:68-76. Scholes D, Stergachis A, Heidrich FE, Andrilla H, Holmes KK, Stamm WE. Prevention of pelvic inflammatory disease by screening for cervical chlamydial infection. New Engl J Med 1996;334:1362-6. Showstack J, Luire N, Leatherman S, Fisher E, Inui T. Health of the public. The private-sector challenge. JAMA 1996;276:1071-4. Sparling PF, Aral SO. The importance of an interdisciplinary approach to prevention of sexually transmitted diseases. In: Wasserheit JN, Aral SO, Holmes KK, Hitchcock PJ, eds. Research issues in human behavior and sexually transmitted diseases in the AIDS era. Washington, D.C.: American Society for Microbiology, 1991:1-8. Stryker J, Coates TJ, DeCarlo P, Haynes-Sanstad K, Shriver M, Makadon HJ. Prevention of HIV infection. Looking back, looking ahead. JAMA 1995;273:1143-8. Wasserheit JN. Effect of changes in human ecology and behavior on patterns of sexually transmitted diseases, including human immunodeficiency virus infection. Proc Natl Acad Sci 1994;91:2430-5. 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. Wasserheit JN, Hitchcock PJ. Future directions in sexually transmitted disease research. In: Quinn TC, ed. Sexually transmitted diseases. New York: Raven Press Ltd., 1992:291-325. Zimmerman DJ, Reif CJ. School-based health centers and managed care health plans: partners in primary care. J Public Health Manage Prac 1995;1:33-9.