The Hidden Epidemic Confronting Sexually Transmitted Diseases, Summary (1997) / Chapter Skim
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Pages 1-54
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Public awareness atd knowledge regardmg STDs are dangerously low, but there has not been a comprehensive national public education campaigm to address this deficiency. The disproportionate impact of STDs on women has not been widely recognized Adolescents and young adults are at greatest risk of acquiring m STD, but STD prevention efforts for adolescents remam unfocused atd controversial m the United States.
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Some STDs, such as hepatius B vi us infection and EflV infection, are also transmitted by parenteral routes particularly among intravenous drug users through contaminated injecting drug equipment. In addition, pregnant women with sexually transmitted infections may pass their infection to infants in the uterus, during birth, or through breast-feeding.
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STDs as Emerging infections STDs ate not a stations y group of infections and syndromes; eight new sexually transmitted pathogens have been identified since 1980, including HIV. In contrast to newly recognized viral STDs, some bacterial STDs, such as syphilis and gonorrhea, have been documented for centuries and have recently reemerged in the United States along with a spectrum of bamets to prevention (Wasserheit 1994)
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. New sexually transmitted infections appear on a regular basis in the United States and are likely to continue to do so as long as the rates of risky sexual behaviors remain high and global economic and demographic factors continue to promote the emergence of STDs.
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. Sexually transmitted pathogens that have serious consequences among adults tend to cause even more
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The high rate of viral STDrelated deaths and morbidity and the high costs of managing viral STDs and their complications in the United States underscore the impo lance of effective prevention programs for viral STDs. IMPACT OF STDS ON HIV TRANSMISSION Both "ulcerative" STDs, such as chancroid, syphilis, and genital hem, es, and "inflammatory" STDs, such as gonorrhea, chlamydial infection, and trichomoniasis, increase the risk of HIV infection.
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Doily has developed a model that shows that HIV infection could not be established m the general U.S. heterosexual population m the absence of chlamydial infection (or other STDs with comparable effects on HIV tnmsmission)
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from initial mfection until the appeanmce of clinical problems, such as m the cases of hu nag papillomavrus mfection and genital cancer, and hepatitis B vr us infection and liver cancer, often results m failure to attribute cases of STDrelated cancers and other long-term complications to sexually transmitted infections. This failure, m tum, reduces the perceived seriousness of STDs md the motivation to undertake preventive action.
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; these factors may lengthen the duration of infectiousness. A number of studies have reported strong associations between alcohol use and high-risk sexual behaviors among the general population (Anderson and Dahlberg, 1992; Caetano and Hines, 1995)
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. SECRECY AS A CONTRIBUTING FACTOR Although sex and sexuality pervade many aspects of American culture and sexuality is a normal aspt ct of human functionmg, sexual behavior is a private— and secret—matter m the United States.
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On the other hand, sexuality remams an extremely private and uniquely complex sphere of human behavior with sociocultural taboos and rules of behavior that make talking openly and comfortably about sexuality difficult. The secrecy surrounding sexuality and STDs adversely impacts on STD prevention m the United States by impeding sexuality and STD education programs for adolescents, hindering commumcation between parents and their children and between sex pawners, promoting unbalanced sexual messages m mass media, compromismg education and counseling activities of health care professionals, hindering community activism regarding STDs, and inpeding research on sexual behaviors.
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. Research and Training issues in Sexuality Despite the recent surge of research activity regarding sexual behaviors in response to the HIV epidemic, comprehensive data on contemporary sexual behaviors, attitudes, and practices are limited, and it is not understood how these factors are shaped by different societal, cultural, and familial contexts.
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. Furthermore, societal ambivalence regarding sexuality poses substantial obstacles to sexual behavior research.
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For example, in the 1993 national survey mentioned pteviously, 84 percent of women surveyed were not concerned about acquiring am STD, including 72 percent of young women (age 18 to 24) and 78 percent of women who reported having had "many" sex partners (EDK Associates, 1994)
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The intent of behavioral interventions is to reduce the incidence of new STDs by assisting individuals in changing behaviors in ways that decrease risk of contracting STDs, such as increasing condom use, delaying initiation of sexual intercourse, or reducing number of panders. A review of federally funded HIV prevention studies that evaluated the Impact of individualand community-based behavioral interventions found that most interventions had positive effects on knowledge of AIDS and sexual behavior aoM.
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Recent data indicate that environmental mterventions that adequately address st uctural or other barriers to behavior chance are necessary for the adoption of healthy sexual behaviors (Nelson et al., 1996)
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. There are only limited data on the effectiveness of schoolbased condom availability programs to Increasing health-protective sexual behaviors and decreasing STD rates, since these programs are relatively few and newly established Kirby, 1993; St yker et al., 1994)
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. Partner Nohficahon and Treatment Partner notification has been a component of STD programs in the United States for many years (Rothenberg and Potterat, 1990)
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estimated a net savmgs of more than S60 million (1986 dollars) over the first five years of a California statewide chlaunydia screening program for asymptomatic women m family planning clinics.
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CURRENT STD-RELATED SERVICES Clinical services for STDs are provided m dedicated public STD clmicsi2 operated by local health departments, community-based health clmics operated by co mnunin based health professionals or public agencies, and private health care settings. Most clinicians providing STD-related care in public or private settings emphasize diagmosis md treatment and, to a lesser extent, management of sex partners, rather than other approaches to STD prevention (Bowlnan et al., 1992)
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. A substamhal number of patients in dedicated public STD clmics have private health insurance coverage, md many privately insured patients use public STD clinics without acknowledging their health insurance status.
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Services in Managed Care Organizations and Other Health Plans The rapid growth of managed care orgamzationsi3 in the United States (GHAA, 1995) and the rapid pace of conversion of state Medicaid programs to prepaid managed care plans (The Kaiser Commission on the Future of Medicaid, 1995)
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. The potential concerns regarding the increased role of managed care organizations in STD prevention include the following: STDs are not a high priority for most managed care organizations; there is a wide range of technical ability among such organizations in delivering services; managed care organizations may be reluctant to provide STD-related services that have not been shown to be costsaving; persons with STDs may prefer to receive care outside of the plan for confidentiality or other reasons; and managed care organizations may not provide services to sex partners of plan members if the padner is not a plan member.
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Other health behavior surveys and studies that are not periodically administered, such as the National Health and Social Life Survey dLaumann, Gagnon, et al., 1994) , have also produced important data regarding sexual behavior.
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Cotmnunirybased health facilities such as family planning clinics and community health centers receive federal and other support to provide STD-related care. Local health departments only receive reimbursement for services provided by public STD clinics to persons with private insurance to the extent allowed by law or under written contract.
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NOTE: The estimate for investment in STD prevention provided here represents public funding for all interventions, behavioral, curative, or otherwise, that are needed to reduce the spread of infection in a popu at on. SOURCES: Toted cost of i bness estimate was crUcu ated by the IOM Committee on Prevention and Control of STDs: estimate of federal, state, and locrd investment in STD prevention was based on unpublished data from the CDC, Division of STD Prevention, 1996: and estimate of national investment in research was based on unpublished data from the National Institutes of Heath, 1996.
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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: 1. Overcome barriers to adoption of healthy sexual behaviors.
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redoc5 onbalanced mass media messades . pmvide heath inhrmabon and access tO heowmes .
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Lack of open communication and infommation regarding sexuality and STDs fosters misperceptions and may actually encourage high-nsk sexual behaviors. Increased awareness regarding STDs should result in increased individual motivation to prevent STDs and should improve the detection and management of STDs by clinicians.
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Therefore, mass media compames should dissemmate information regarding STDs md healthy sexual behaviors, including delaying sexual mtercourse md using condoms, with a special focus on reaching adolescents and young adults. Comprehensive public health messages regarding STDs, including EflV infection; sexual abuse; md unintended pregnancy are essential.
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With respect to the above issues, the committee makes the following recommendation: · The National institutes of Health and other federal agencies should continue to support research on health behaviors, including sexual behaviors, and their relationship to STDs. Strategy 2.
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The ha riers to m effective national system for STD prevention are found in government, private sector organizations, and political factors and social norms. Overcommg these barriers is a challenge that requrres the active pa ticipation of all levels of government, the private health care sector, businesses, labor leaders, the mass media, schools, and many commumtybased organizations.
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Special emphasis should be placed on educating clinicians about reporting and on collaborating with and collecting data from private sector providers, including health plans. With respect to the above issues, the committee makes the following recommendations: · The CDC should lead a coordinated national effort to improve the surveillance of STDs and their associated complications and improve the monitoring of STD prevention program effectiveness.
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Prevention-related research allows program managers and policymakers to maximize the effectiveness of mterventions md available resources. Areas of prevention-related research that should be emphasized include detemminants of sexual behavior and sustained behavior change; detemflnanrs of initiation of sexual intercourse among adolescents; influence of social md other community-related factors on risk of STDs; interventions to improve condom use md reduce high-risk behaviors; effectiveness of sexual risk behavior assessment and counseling; biomedical interventions such as vaccines that do not rely pnmarily on individual behavior; female-controlled prevention methods; cost effectiveness of interventions; methods for preventing STDs among disenfranchised populations; interventions for preventing STDs among persons of all sexual orientations; and methods to assess prevention program effectiveness.
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Mamy schoolbased programs and mass media campaigns are effective m improving knowledge regarding STDs and m promotmg healthy sexual behaviors, and these two interventions should be major components of m STD prevention strategy. The committee believes that there is strong scientific evidence in support of schoolbased programs for STD prevention, that adolescence is the critical period for adopting healthy behaviors, and that schools are one of the few venues available to reach adolescents.
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· AD school districts in the United States should ensure that schools provide essential, age-appropriate STD-related services, including health education, access to condoms, and readily accessible and available conical services, such as scbool-based conical services, to prevent STDs. · AD health plans, chniciareli, and publicly sponsored health cynics should provide or arrange for hepatitis B immunizations for their infant, adolescent, and adult patients according to the Advksory Committee on immunization Practices (ACIP)
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Depending on epidemiologic patterns, health insurance coverage, population density, and other community charactenstics, they may continue to support dedicated public STD clinics, or may shift such services to community-based clinics or the private sector.
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With respect to the above issues, the committee makes the following recommendations: · Based upon local conditions and health department determination, dedicated public STD cynics should continue to function as a "safeb net" provider of STD-related services for uninsured and disenfranchised persons and for those who prefer to obtain care from such cynics. · The CDC, in collaboration with state and local health departments, should ensure that services provided by dedicated public STD clinics are of high quality · Health professional schools, including schools of medicine, nursing, and physician assistants, should partner with a local health department for purposes of STD clinic staffing, management, and professional training.
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· Federal, state, and local health agencies should educate employers, Medicaid programs, and of her purchasers of health care regarding the broad scope and impact of STDs and the effectiveness of preventive services for STDs. · Health plans, including managed care organizations, should develop collaborative agreements with local public health agencies to coordinate STD-related services, including payment for STD-related services provided to plan enrollees by public sector providers, including public STD cynics.
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cation.~9 Improving Clinical Management of STDs Major components of effective clinical management of STDs include screening, diagnosis and treatment, risk reduction counseling and education, identiflcation and treatment of partners, and access to quality laboratory services for STDs. Screening allows for the detection of infected persons who would otherwise remain undetected, develop complications of STDs, and transmit the infection to their sex partners.
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National treatment guidelines for STDs help promote appropriate therapy for STDs. However, because there is limited awareness of and compliance with these guidelines, especially among private sector health care professionals, such guidelines should be more widely disseminated.
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With respect to the above issues, the committee makes the following recommendation: · State and local health departments, with the assistance of the CDC, should redesign current partner notification activities for curable STDs in public health cynics to improve outreach, mobilize public health staff in new ways, and enlist support from community groups or other programs that provide services to higb-risk populations. Partner diagnosis md treatment should be provided as pa t of standard STDrelated care, regardless of the clinical setting.
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No one agency, organization or sector can effectively do it alone; all members of the community must do their pa t. A successful national initiative to confront and prevent STDs requires widespread public awareness and participation and bold national leadership from the highest levels.
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AIDS hr historical perspecave: fom lessons fiom Lhe hisLmy of sexuaRy transmitted diseases.
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SUhthfARY 45 Cameron DW, Simonsen JN, D'Costa LJ, Ronald AR, Maitha GM, Gakinya MN, et al. Female to male transmission of human immtmodefciencyvims tyle 1: riskfactms for seroconversion in men.
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DoR DC. Tatooing in prison md HIV infection [letter]
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Cm mimic gion ctmpaigns for HIV pttwenoon: using mass media in whe nett decade. ht Iasotute of Medicine.
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IOM. Undergmding the Deetminmrs of HIV Risk 3ehavior.
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Kirby D, Was tak C, Ziegler J Six school-based clinics: their teproducave healh set tioes tnd impact on sexual behavior.
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et al. Nonulcemrive sexually transmitted diseases as nsk fackors fm HIV-I ttantmission in wmmen rettuts fimm a cohmt gudy.
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SUhthfARY 51 Moss G3, Overbaugh J Welch M, ReiRy M, 3wayo J
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"Men I mess with don't h we tatythittg tn do with AIDS": Using ethno themy to uttdetsttald sexual risk percephon. Sociol Q 1995-36:483-504.
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SUhthtARY 53 Scholes D, Stelgachis A, Hddtich FE, AndtiDa H Hohmes KK, Stamm WE.
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54 THElilDDEVEPlDEhtlC TmTkrRT 2d, Rowbenberg R3, Coyle S Dtug abuse mdHIV pnevemiontesettch: exptnding ptt digms mdnetwmk conttibunons to nskteducoon.
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