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Suggested Citation:"FRONT MATTER." Institute of Medicine. 1997. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Washington, DC: The National Academies Press. doi: 10.17226/5284.
×

The Hidden Epidemic

Confronting Sexually Transmitted Diseases

Thomas R. Eng and William T. Butler, Editors

Committee on Prevention and Control of Sexually Transmitted Diseases

INSTITUTE OF MEDICINE

Division of Health Promotion and Disease Prevention

NATIONAL ACADEMY PRESS
Washington, D.C.
1997

Suggested Citation:"FRONT MATTER." Institute of Medicine. 1997. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Washington, DC: The National Academies Press. doi: 10.17226/5284.
×

National Academy Press
2101 Constitution Avenue, N.W. Washington, D.C. 20418

NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for this report were chosen for their special competencies and with regard for appropriate balance.

This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine.

The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine.

Funding for this project was provided by Centers for Disease Control and Prevention, Glaxo Wellcome, Inc., The Henry J. Kaiser Family Foundation, National Institute of Allergy and Infectious Diseases, NIH Office of Research on Women's Health, Ortho-McNeil Pharmaceutical, and SmithKline Beecham Pharmaceuticals. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organization or agencies that provide support for the project.

Additional copies of this report are available from the National Academy Press, 2101 Constitution Avenue, N.W., Box 285, Washington, D.C. 20055. Call 800-624-6242 (or 202-334-3313 in the Washington metropolitan area), or visit the NAP on-line bookstore at http://www.nap.edu.

Library of Congress Cataloging-in-Publication Data

Institute of Medicine (U.S.). Committee on Prevention and Control of Sexually Transmitted Diseases.

The hidden epidemic: confronting sexually transmitted diseases / Thomas R. Eng and William T. Butler, editors; Committee on Prevention and Control of Sexually Transmitted Diseases, Institute of Medicine, Division of Health Promotion and Disease Prevention.

p. cm.

Includes bibliographical references and index.

ISBN 0-309-05495-8

1. Sexually transmitted diseases—United States. I. Eng, Thomas R. II. Butler, William T. III. Title.

[DMLM: 1. Sexually Transmitted Diseases—prevention & control—United States. 2. Sexually Transmitted Diseases—epidemiology—United States. 3. Health Policy—United States WC 144 159 1997]

RA644.V4I495 1997

614.5'47'0973—dc21

DNLM/DLC for Library of Congress

First Printing, April 1997

Second Printing, July 1998

97-4218

CIP

Copyright 1997 by the National Academy of Sciences. All rights reserved.

Printed in the United States of America.

The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staalichemuseen in Berlin.

Suggested Citation:"FRONT MATTER." Institute of Medicine. 1997. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Washington, DC: The National Academies Press. doi: 10.17226/5284.
×

Committee on Prevention and Control of Sexually Transmitted Diseases

William T. Butler,* Chair,Chancellor,

Baylor College of Medicine, Houston, Texas

Nancy E. Adler,* Director,

Health Psychology Program, and

Vice Chair,

Department of Psychiatry, University of California, San Francisco, California

E. Richard Brown, Director,

Center for Health Policy Research, and

Professor of Public Health, School of Public Health,

University of California, Los Angeles, California

Virginia A. Caine, Director,

Marion County Health Department, Indianapolis, Indiana

David D. Celentano,Professor of Social and Behavioral Sciences,

Department of Health Policy and Management, Johns Hopkins University School of Hygiene and Public Health, Baltimore, Maryland

Paul D. Cleary,*Professor of Health Care Policy and Social Medicine,

Harvard Medical School, Boston, Massachusetts

Margaret A. Hamburg,*Health Commissioner,

New York City Department of Health, New York, New York

King K. Holmes,* Director,

Center for AIDS and STD, and

Professor of Medicine,

University of Washington, Seattle, Washington

Edward W. Hook III,

Professor of Medicine and Epidemiology, Schools of Medicine and Public Health, University of Alabama, Birmingham, Alabama

Loretta Sweet Jemmott,Associate Professor of Nursing, and Director,

Office of HIV Prevention Research, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania

Dorothy Mann, Executive Director,

Family Planning Council, Philadelphia, Pennsylvania

Patrick H. Mattingly,Senior Vice President of Planning and Development,

Harvard Pilgrim Health Care, Brookline, Massachusetts

Kathleen E. Toomey,State Epidemiologist and Director,

Epidemiology and Prevention Branch, Division of Public Health, Georgia Department of Human Resources, Atlanta, Georgia

A. Eugene Washington, Professor and Chair,

Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, California

*  

Institute of Medicine member.

Suggested Citation:"FRONT MATTER." Institute of Medicine. 1997. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Washington, DC: The National Academies Press. doi: 10.17226/5284.
×

Catherine M. Wilfert, Professor of Pediatrics and Microbiology,

Department of Pediatrics, Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina

Jonathan M. Zenilman, Associate Professor of Medicine,

Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland

Staff

Thomas R. Eng, Senior Program Officer

Leslie M. Hardy, Senior Program Officer (through July 1995)

Jennifer K. Holliday, Project Assistant

Marissa Weinberger Fuller, Research Associate

Michael A. Stoto, Director,

Division of Health Promotion and Disease Prevention

  

Served through September 1995.

Suggested Citation:"FRONT MATTER." Institute of Medicine. 1997. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Washington, DC: The National Academies Press. doi: 10.17226/5284.
×

Preface

This report focuses on the hidden epidemic of sexually transmitted diseases (STDs) in the United States: the reasons why it has not been controlled, and what we, as a nation, need to do differently to confront this problem. The main objective of this report is to educate health professionals, policymakers, and the public regarding the truths and consequences of STDs in the United States. This report is also a call for a bold national effort to prevent these diseases.

Through this report, we hope to improve awareness and knowledge regarding the scope and impact of STDs and demonstrate why all Americans should be concerned about these diseases. At a minimum, we hope to ignite open discussion in both private and public arenas regarding STDs and their prevention. We believe that encouraging open discussion around STD prevention will eventually lead to greater understanding, closer cooperation, improved STD-related services, and lower rates of STDs in the United States.

THOMAS R. ENG, STUDY DIRECTOR

WILLIAM T. BUTLER, COMMITTEE CHAIR

WASHINGTON, D.C. 1997

Suggested Citation:"FRONT MATTER." Institute of Medicine. 1997. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Washington, DC: The National Academies Press. doi: 10.17226/5284.
×
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Suggested Citation:"FRONT MATTER." Institute of Medicine. 1997. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Washington, DC: The National Academies Press. doi: 10.17226/5284.
×

Acknowledgments

This report represents the collaborative efforts of many organizations and individuals, without whom this study would not have been possible. The committee extends its warm thanks to the organizations and individuals mentioned below.

The staff of the following organizations and agencies provided critical advice and data in preparing this report: Advocates for Youth (Kent Klindera), the Agency for Health Care Policy and Research (David Atkins and Carolyn DiGuiseppi), Alan Guttmacher Institute (Pat Donovan, Jackie Forrest, Lisa Kaeser, and Dave Landry), the American Academy of Pediatrics (Victor Strasburger), the American Cancer Society, the American Medical Association, the American Social Health Association (Peggy Clarke, Joan Cates, and Nikki Vagnes), Association of Reproductive Health Professionals, Association of State and Territorial Health Officers, Center for Media and Public Affairs (Dan Amundson), the Centers for Disease Control and Prevention (Susan DeLisle, Shahul Ebrahim, Alan Friedlob, Joel Greenspan, Robert Johnson, William Kassler, William Levine, Judy Lipshutz, Frank Mahoney, Eric Mast, John Miles, John Moran, Craig Shapiro, Jack Spencer, Mike St. Louis, Cathleen Walsh, Judy Wasserheit, and Gary West), East Coast Migrant Health Project (Oscar Gomez), The Henry J. Kaiser Family Foundation (Suzanne Delbanco), National Association of Nurse Practitioners in Reproductive Health (Susan Wysocki), the National Cancer Institute, the National Center for Farm Worker Health (Bobbi Ryder), the National Commission on Correctional Health Care (Ed Harrison), the National Institutes of Health, Ogilvy Adams & Rinehart, Planned Parenthood Federation of America, Sexuality Information and Education Council of the U.S. (SIECUS)

Page viii Cite
Suggested Citation:"FRONT MATTER." Institute of Medicine. 1997. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Washington, DC: The National Academies Press. doi: 10.17226/5284.
×

(Carolyn Patierno), State Family Planning Administrators (Lynn Peterson), and the World Health Organization (Antonio Gerbase and Kevin O'Reilly). The following colleagues also provided valuable assistance to the committee: Jane Brown, Margaret Chesney, Jim Kahn, Laura Koutsky, and Richard Rothenberg.

The following persons generously shared their knowledge with the committee through their active participation in the committee workshops: Sevgi Aral, Cornelius Baker, Bobbi Baron, Marie-Claude Boily, Stanley Borg, Robert Bragonier, Allan Brandt, Ward Cates Jr., William Darrow, Gray Davis, Frank Beadle de Palomo, Caswell Evans, Jonathan Freedman, Mindy Thompson Fullilove, Carol Glaser, James Goedert, James Haughton, William Kassler, Paul Kimsey, Janet Kirkpartick, Edward Laumann, William Levine, Steve Morin, Kevin O'Reilly, Frank Plummer, John Potterat, Gary Richwald, Tracy Rodriguez, Philip Rosenberg, Alfred Saah, Marilyn Keane Schuyler, Stanley Shapiro, Sten Vermund, and Maria Wawer.

The directors and staff of the following facilities and programs graciously hosted the committee during its site visits to Atlanta and Chicago. In Atlanta: The Center for Black Women's Wellness; DeKalb County Board of Health (Stuart Brown); Emory/Grady Teen Services Program; Fulton County Health Department STD Clinic (Ruby Lewis-Hardy and Pradnya Tambe); Georgia Department of Human Resources, Epidemiology and Prevention Branch (Jack Kirby and Mark Schrader); Grady Memorial Hospital Family Planning Program; Kaiser Permanente, Prevention and Practice Analysis Department; SisterLove, Inc., West Central Health District (Dee Cantrell); West End Medical Centers, Inc.; and Women's AIDS Project. In Chicago: Austin Community Academy Teen Health Clinic; Blue Cross Blue Shield of Illinois; Chicago Department of Public Health (John Wilhelm); Chicago STD/HIV Prevention Program (Romina Kee and Lisa Krull); Cook County Hospital HIV Primary Care Center, Smart Start Program, Women and Children HIV Program; Erie Family Health Center; Illinois Department of Public Health (John Lumpkin and Charlie Rabins); Night Ministry; Ounce of Prevention Fund, Toward Teen Health Program, Orr Adolescent Health Center; Planned Parenthood of Chicago; Stop AIDS Chicago; Vida Sida; and West Town Neighborhood Health Center, Young Adult Clinic.

The following individuals participated in the planning meeting for the study: Charles Carpenter (chair), Peggy Clarke, Jim Curran, Mary Faye Dark, Gray Davis, patsy Fleming, Helene Gayle, H. Hunter Handsfield, Maurice Hilleman, Penny Hitchcock, Mark Hounshell, James Kahn, Lawrence Lewin, Heather Miller, Constance Nathanson, Geoff Nichol, Michael Osterholm, Nancy Padian, Thomas Quinn, Mark Smith, P. Frederick Sparling, Beth Unger, Judy Wasserheit, Roy Widdus, and Zeda Rosenberg.

Of particular note, the following individuals directly contributed to the report by drafting commissioned papers in their areas of expertise. A review paper on the relationship between substance use and STDs by John Beltrami, Linda Wright-DeAguero, Mindy Thompson Fullilove, and Brian Edlin was critical to

Suggested Citation:"FRONT MATTER." Institute of Medicine. 1997. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Washington, DC: The National Academies Press. doi: 10.17226/5284.
×

the report, and sections of their paper were replicated in the discussion of substance use and STDs. A paper by Jeffrey Kelly provided important background for the drafting of sections regarding behavioral interventions in STD prevention. Marie-Claude Boily's important work on modeling the impact of STDs on HIV transmission is included as an appendix. In addition, Joanna Siegel's major review of the economic costs of STDs was the primary basis for the committee's cost estimates and is also included in the appendix of the report.

Numerous staff at IOM, the National Research Council, and the National Academy Press (NAP) contributed to the development, production, and dissemination of this report. Leslie Hardy served as study director during its first year; Marissa Fuller organized the committee's site visits and provided research assistance; Jennifer Holliday provided comprehensive administrative support; Mike Stoto, Karen Hein, and Ken Shine provided valuable advice and direction; Mona Brinegar handled the financial accounting of the study; Mike Edington provided editorial assistance; Claudia Carl and Janice Mehler coordinated the report review process; and Dan Quinn and Molly Galvin coordinated press activities. NAP staff included Dawn Eichenlaub (book production); Barbara Kline Pope and Brooke O'Donnell (marketing); Estelle Miller (page layout); Francesca Moghari (cover design); Terrence Randell (Internet listing); and Sally Stanfield (editor). In addition to IOM staff, we are grateful to Andrea Posner for her numerous valuable editorial contributions, to Caroline McEuen for copy-editing, to Kim Greene for assistance with the survey of managed care organizations, to Linnea Eng for proofreading, and to Mary Fielder and Ron Nelson for their research assistance.

The following agencies and organizations and key staff generously provided funding and generated support within their institutions for this study: the Centers for Disease Control and Prevention (Jim Curran [now with Emory University], Helene Gayle, Jack Spencer, and Judy Wasserheit), Glaxo Wellcome, Inc. (Gray Davis), the Henry J. Kaiser Family Foundation (Suzanne Delbanco and Mark Smith), the National Institute of Allergy and Infectious Diseases of the National Institutes of Health (NIH) (Penny Hitchcock), the Office of Research on Women's Health of NIH (Vivian Pinn and Anne Bavier), Ortho-McNeil Pharmaceutical (James Kahn), and SmithKline Beecham Pharmaceuticals (Vincent Ahonkai, Paul Blake, and Geoff Nichol). Their willingness to sponsor a study on the prevention and control of sexually transmitted diseases is no small commitment, given the sensitive and controversial nature of this public health issue. Their encouragement and support are gratefully acknowledged.

Suggested Citation:"FRONT MATTER." Institute of Medicine. 1997. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Washington, DC: The National Academies Press. doi: 10.17226/5284.
×
This page in the original is blank.
Suggested Citation:"FRONT MATTER." Institute of Medicine. 1997. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Washington, DC: The National Academies Press. doi: 10.17226/5284.
×
Suggested Citation:"FRONT MATTER." Institute of Medicine. 1997. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Washington, DC: The National Academies Press. doi: 10.17226/5284.
×

5

 

Current STD-Related Services

 

175

   

Clinical Services

 

175

   

National Surveillance and Information Systems

 

196

   

Training and Education of Health Professionals

 

204

   

Funding of Services

 

208

   

Conclusions

 

214

6

 

Establishing an Effective National System to Prevent STDs

 

220

   

Laying the Foundation for a National System

 

222

   

Strategy 1: Promote Healthy Sexual Behaviors

 

232

   

Strategy 2: Develop Leadership

 

241

   

Strategy 3: Focus on Adolescents and Underserved Populations

 

261

   

Strategy 4: Ensure Access to Services

 

274

   

Collaborating to Improve Services

 

298

   

Concluding Statement

 

300

 

 

APPENDIXES

 

 

   

A Sexually Transmitted Pathogens and Associated Diseases, Syndromes, and Complications

 

305

   

B Characteristics of Major STDs in the United States

 

311

   

C Transmission Dynamics of Coexisting Chlamydial and HIV Infections in the United States

 

316

   

D Estimates of the Economic Burden of STDs: Review of the Literature with Updates

 

330

   

E Summary of Empirical Studies of HIV Prevention Mass Media Campaigns

 

357

   

F Recommended Interventions During the Periodic Health Examination for the Prevention of STDs, U.S. Preventive Services Task Force, 1996

 

363

   

G Summary of Workshop on the Role of Managed Care Organizations in STD Prevention

 

370

   

H STD-Related Services Among Managed Care Organizations Serving High-Risk Populations

 

383

   

I Examples of Community-Based Programs for Providing Clinical Services for STDs

 

394

   

J Committee and Staff Biographies

 

400

 

 

Index

 

411

Page xiii Cite
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The Hidden Epidemic

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The United States has the dubious distinction of leading the industrialized world in overall rates of sexually transmitted diseases (STDs), with 12 million new cases annually. About 3 million teenagers contract an STD each year, and many will have long-term health problems as a result. Women and adolescents are particularly vulnerable to these diseases and their health consequences. In addition, STDs increase the risk of HIV transmission.

The Hidden Epidemic examines the scope of sexually transmitted infections in the United States and provides a critical assessment of the nation's response to this public health crisis. The book identifies the components of an effective national STD prevention and control strategy and provides direction for an appropriate response to the epidemic. Recommendations for improving public awareness and education, reaching women and adolescents, integrating public health programs, training health care professionals, modifying messages from the mass media, and supporting future research are included.

The book documents the epidemiological dimensions and the economic and social costs of STDs, describing them as "a secret epidemic" with tremendous consequences. The committee frankly discusses the confusing and often hypocritical nature of how Americans deal with issues regarding sexuality—the conflicting messages conveyed in the mass media, the reluctance to promote condom use, the controversy over sex education for teenagers, and the issue of personal blame.

The Hidden Epidemic identifies key elements of effective, culturally appropriate programs to promote healthy behavior by adolescents and adults. It examines the problem of fragmentation in STD services and provides examples of communities that have formed partnerships between stakeholders to develop integrated approaches.

The committee's recommendations provide a practical foundation on which to build an integrated national program to help young people and adults develop habits of healthy sexuality.

The Hidden Epidemic was written for both health care professionals and people without a medical background and will be indispensable to anyone concerned about preventing and controlling STDs.

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