Sexually transmitted diseases (STDs)
are hidden epidemics of tremendous health and economic consequence
in the United States. They are hidden from public view because
many Americans are reluctant to address sexual health issues in
an open way and because of the biological and social factors associated
with these diseases. In addition, the scope, impact, and consequences
of STDs are underrecognized by the public and health care professionals.
Of the top ten most frequently reported
diseases in 1995 in the United States, five are STDs. Rates of
curable STDs in the United States are the highest in the developed
world and are higher than in some developing regions. Approximately
12 million new cases of STDs, 3 million of them among teenagers,
occur annually. The committee estimates that the annual direct
and indirect costs of selected major STDs are approximately $10
billion or, if sexually transmitted HIV infections are included,
$17 billion. Along with the human suffering associated with STDs,
this cost is shared by all Americans through higher health care
costs and taxes. STDs represent a growing threat to the nations
health and national action is urgently needed.
The term STD denotes the more than
25 infectious organisms that are transmitted through sexual activity,
along with the dozens of clinical syndromes that they cause. The
spectrum of health consequences ranges from mild acute illness
to serious long-term complications such as cervical, liver, and
other cancers and reproductive health problems. Women and infants
bear a disproportionate burden of STD-associated complications.
A variety of womens health problems, including infertility, ectopic
pregnancy, and chronic pelvic pain, result from unrecognized or
untreated STDs. From 1973 through 1992, more than 150,000 U.S.
women died of causes associated with STDs (including HIV infection)
and their complications. Women are particularly vulnerable to
STDs because they are more biologically susceptible to certain
sexually transmitted infections than men and are more likely to
have asymptomatic infections that commonly result in delayed diagnosis
and treatment. Active infection with STDs during pregnancy may
result in a range of serious health problems among infected infants,
including severe central nervous system damage and death. Adolescents
are at greatest risk of STDs because they frequently have unprotected
sexual intercourse, are biologically more susceptible to infection,
and are likely to have social problems that significantly increase
their risk.
STDs are difficult public health
problems because of the hidden nature of these diseases. The sociocultural
taboos related to sexuality are a barrier to STD prevention efforts
on a number of levels. Effective STD prevention efforts also are
hampered by biological characteristics of STDs, societal problems,
unbalanced mass media messages, lack of awareness, fragmentation
of STD-related services, inadequate training of health care professionals,
inadequate health insurance coverage and access to services, and
insufficient investment in STD prevention.
Although the barriers to STD prevention are formidable, STDs can be prevented by intervening at multiple points with behavioral, biomedical, and structural interventions on both individual and community levels. These and other effective interventions, however, are not being fully implemented or utilized. Because STDs are complex diseases that are associated with a variety of social issues and involve a wide spectrum of stakeholders in the community, a collaborative, multifaceted approach to STD prevention is essential.
The committee concludes that 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 the system need to be redesigned and improved
through innovative approaches and closer collaborations. In addition,
programs that address important gaps in the current fragmented
system of services have not yet been designed and implemented.
The committees recommendations are outlined below and presented
in complete detail in Chapter 6.
In formulating a strategy to prevent
STDs, the committee developed the following vision statement to
guide its deliberations.
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.
This vision and the committees proposed
model for improving STD prevention are founded on a multifaceted
approach to prevention, shared responsibility and active participation
by individuals and the community, coordination of related programs,
and adequate resources and support for implementation.
To realize this vision, the committee recommends that:
The committee envisions a system
based on national policy, coordinated at all levels, and composed
of local, state, and national prevention programs. A national
system is essential because STDs are a threat to the nations health,
because many interventions are most effectively or efficiently
developed and implemented at the national level, and because STDs
do not recognize geographic borders.
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.
2. Develop strong leadership, strengthen investment, and improve
information systems for STD prevention.
3. Design and implement essential STD-related services in innovative
ways for adolescents and underserved populations.
4. Ensure access to and quality of essential clinical services
for STDs.
Before describing the recommended tactics for these four strategies, the committee makes the following recommendations regarding two important concepts that need to be incorporated into a national strategy to prevent STDs: the impact of STDs on HIV transmission and the impact of STDs on cancer.
Strategy 1: Overcome barriers
to adoption of healthy sexual behaviors.
Barriers to effective
STD prevention efforts include biological, social, and structural
factors. One of the primary obstacles is this countrys reluctance
to openly confront issues regarding sexuality and STDs. Failure
to acknowledge and discuss sexuality impedes STD education programs,
open communication between parents and their children and between
sex partners, balanced messages from mass media, education and
counseling activities of clinicians, community activism for STDs,
and behavioral research.
Catalyzing Change Through Open
Discussion and Promoting Awareness and Balanced Mass Media Messages
A new social norm of healthy sexual
behavior should be the basis for long-term prevention of STDs.
This is because in one way or another all interventions to prevent
STDs are partly dependent on, and must be integrated with, healthy
behaviors. In order for societal norms regarding sexual behavior
to change, open discussion of and access to information regarding
sexual behaviors, their health consequences, and methods for protecting
against STDs must occur. Therefore, the committee believes that
a significant national campaign to foster social change toward
a new norm of healthy sexual behavior in the United States is
necessary. An independent entity is needed to promote a social
norm of healthy sexual behavior because, based on experience with
past initiatives, limitations on government agencies regarding
public education programs related to sexuality are particularly
problematic.
Lack of awareness regarding STDs
and misperception of individual risk and consequences are major
barriers to healthy sexual behavior, especially among adolescents
and young adults. Lack of open communication and information regarding
sexuality and STDs fosters misperceptions and may actually encourage
high-risk 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.
A national campaign to increase public and health care provider
awareness of STDs requires active participation of both private
and public agencies and organizations to succeed.
Despite their current lack of involvement
in promoting healthy sexual behaviors, the mass media can be extremely
powerful allies in efforts to prevent STDs by increasing knowledge
and changing behavior. Mass media messages that promote healthy
sexual behaviors will facilitate needed changes in social norms
regarding sexual behaviors because mass media help define these
norms. Children and adolescents are particularly exposed and susceptible
to explicit and implicit messages in such media. Many adolescents
are not receiving appropriate information regarding STDs and sexual
behavior from their parents or other sources. Therefore, mass
media companies should disseminate information regarding STDs
and healthy sexual behaviors, including delaying sexual intercourse
and using condoms, with a special focus on reaching adolescents
and young adults. Comprehensive public health messages regarding
STDs, including HIV infection; sexual abuse; and unintended pregnancy
are essential.
With respect to the above issues, the committee makes the following recommendations:
Improving Professional Skills
in Sexual Health Issues
It is important that clinicians and
other professionals develop knowledge and awareness of sexual
health issues and become comfortable discussing them. This will
enable clinicians to utilize clinical opportunities to effectively
counsel patients regarding healthy sexual behaviors, and therefore
improve clinical care for STDs. Communicating effectively with
patients regarding sexual health is a particularly critical skill
for clinicians and other professionals, but most are not adequately
trained in communication and counseling skills.
With respect to the above issues, the committee makes the following recommendation:
Supporting Sexual Health Behavior
Research
Population-based surveys and studies
of STD-related health behaviors are critical for monitoring population
trends in health behaviors, developing effective interventions,
and evaluating program effectiveness. Such research, however,
have been severely criticized by some policymakers and interest
groups. This committee, while recognizing the sincere concerns
expressed, strongly believes that research regarding STD-related
health behaviors, especially among adolescents, is critical to
STD prevention. Federal funding and support for sexual health
behavior research is essential. The committee found no evidence
that asking questions regarding sexual activity increases sexual
activity among survey respondents. Restrictions on collecting
behavioral information from adolescents would seriously jeopardize
behavioral research and the ability to prevent high-risk behaviors
among adolescents. The committee also believes that the objectivity
and integrity of the peer-review process for scientific research
should be protected.
With respect to the above issues, the committee makes the following recommendation:
Strategy 2. Develop strong leadership,
strengthen investment, and improve information systems for STD
prevention.
Developing Leadership and Catalyzing
Partnerships
To build an effective national system,
highly visible and strong leadership and support are needed from
both the public and private sectors, and especially from elected
officials. Among public agencies, the Department of Health and
Human Services, especially the Centers for Disease Control and
Prevention (CDC), and state and local health departments have
critical leadership roles. The public sector must continue to
play a major role in preventing STDs, but does not have the resources
or the organizational reach to fully implement a national system
of STD-related services. The private sector must therefore take
more responsibility.
The barriers to an effective national
system for STD prevention are found in government, private sector
organizations, and political factors and social norms. Overcoming
these barriers is a challenge that requires the active participation
of all levels of government, the private health care sector, businesses,
labor leaders, the mass media, schools, and many community-based
organizations. In developing and implementing a national system
for STD prevention, it is important that stakeholders be involved
in all steps of the process; however, a formal mechanism for collaboration
among agencies and organizations does not exist. Therefore, a
neutral forum is needed to maximize the range of participants
and to catalyze the collaborative process.
With respect to the above issues, the committee makes the following recommendations:
Strengthening Investment
To establish an effective system
of STD prevention, a substantially greater investment from both
the public and private sectors is needed. The current national
public investment in STD prevention is not commensurate with the
health and economic costs of STDs. The committee estimates that
only $1 is invested in STD prevention for every $43 spent on the
STD-associated costs every year. Similarly, only $1 is invested
in biomedical and clinical research for every $94 in STD-related
costs. For every $1 spent on early detection and treatment of
chlamydial infection and gonorrhea, $12 in associated costs could
be saved. Investing in preventive services and research will avert
substantial human suffering and save billions of dollars in treatment
costs and lost productivity. Additional funding for STD prevention
should come from local, state, and federal governments and from
the private sector. Private health plans, in particular, need
to increase support for STD-related services that benefit their
enrolled population and ultimately benefit the health plans financial
status. In addition, because STDs are emerging infections and
a global public health problem, the United States has a national
interest in preventing STDs worldwide. Despite the problems in
the current system of categorical funding for STDs, moving to
a system of block grants for STDs would have a devastating impact
on STD prevention because STDs will fare poorly in competing with
other more visible and acceptable health conditions for funding.
With respect to the above issues, the committee makes the following recommendations:
Improving Surveillance and Other
Information Systems
National surveillance and other information
systems for STDs are important in monitoring and evaluating a
national system for prevention. Data from these information systems
are critical to long-term program planning as well as to day-to-day
management of programs. The current surveillance system needs
enhancement because it does not give accurate estimates of disease
incidence. This is because not all persons with STDs seek medical
care and because many clinical encounters with health care professionals,
especially in private sector settings, are not reported. It is
critical that a systematic, comprehensive evaluation of the national
surveillance system be conducted to describe the attributes of
the system and to provide guidance for future improvements. STD
surveillance systems should include and link information from
public sector, community-based, and private health care professionals.
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:
Strategy 3: Design and implement
essential STD-related services in innovative ways for adolescents
and underserved populations.
Adolescents and underserved populations
require special emphasis in an effective national system for STD
prevention because they are at high risk for STDs and they do
not have adequate access to STD-related services. Innovative methods
for delivering STD-related services to such populations should
immediately be designed and implemented because these groups are
difficult to reach through traditional clinical settings and approaches.
Focusing on Prevention
A national strategy for STDs should
emphasize prevention because averting illness is desirable, many
STDs are incurable, and STD-related complications may be irreversible.
Effective prevention programs are usually the result of extensive
research and evaluation and continuous quality improvement. They
should be regularly modified based on the epidemiology of STDs
and continuous evaluation of programs. Prevention-related research
allows program managers and policymakers to maximize the effectiveness
of interventions and available resources. Areas of prevention-related
research that should be emphasized include determinants of sexual
behavior and sustained behavior change; determinants of initiation
of sexual intercourse among adolescents; influence of social and
other community-related factors on risk of STDs; interventions
to improve condom use and reduce high-risk behaviors; effectiveness
of sexual risk behavior assessment and counseling; biomedical
interventions that do not rely primarily on individual behavior
such as vaccines; 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.
With respect to the above issues, the committee makes the following recommendations:
Focusing on Adolescents
Although many of the severe health
consequences of STDs manifest themselves among adults, these complications
usually result from infections acquired or health behaviors initiated
during adolescence. By the twelfth grade, nearly 70 percent of
adolescents have had sexual intercourse, and approximately one-quarter
of all students have had sex with four or more partners. Therefore,
a national strategy to prevent STDs needs to focus on adolescents.
The committee believes that adolescents should be strongly encouraged
to delay sexual intercourse until they are emotionally mature
enough to take responsibility for this activity. However, most
individuals will initiate sexual intercourse during adolescence,
and they should have access to information and instruction regarding
STDs (including HIV infection) and unintended pregnancy and methods
for preventing them.
Many school-based programs and mass
media campaigns are effective in improving knowledge regarding
STDs and in promoting healthy sexual behaviors, and these two
interventions should be major components of an STD prevention
strategy. The committee believes that there is strong scientific
evidence in support of school-based 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. Given the high rates of sexual intercourse among
adolescents and the significant barriers that hinder the ability
of adolescents to purchase and use condoms, condoms should be
available in schools as part of a comprehensive STD prevention
program. There is no evidence that condom availability or school-based
programs for sexuality or STD education promote sexual activity.
STD-related clinical services for
adolescents, including hepatitis B immunization, should be expanded
through school and student health clinics, because adolescents
are less likely than adults to have health insurance and they
infrequently use regular health care facilities. Adolescents who
are not enrolled in school also need access to clinical services.
Because confidentiality is a major concern for adolescents, they
should be able to consent to STD-related services without parental
knowledge.
With respect to the above issues, the committee makes the following recommendations:
Establishing New Venues for Interventions
Although services for disenfranchised
groups, including substance users, sex workers, the homeless,
prisoners, and migrant workers, do not have popular support, these
populations represent reservoirs of infection for the entire community.
Innovative methods and alternate venues for intervention are needed
because these groups are difficult to reach through traditional
health care settings. Nontraditional venues for delivering STD-related
services, such as prisons, drug treatment clinics, the streets,
and other sites where high-risk persons gather, are appropriate
sites for preventive services. Health departments should establish
linkages with programs that serve populations at high risk for
STDs, and government agencies should coordinate their various
STD-related programs because the lack of coordination and unevenness
of services have resulted in critical gaps in service coverage.
To contain persisting epidemics of STDs among disenfranchised
persons, new biomedical, epidemiological, and behavioral tools
should be developed collaboratively by the public and private
sector.
With respect to the above issues, the committee makes the following recommendations:
Strategy 4. Ensure access to and
quality of essential clinical services for STDs.
Both public and private
sector clinical services for STDs are currently fragmented, inadequate,
and, sometimes of poor quality. This situation leads to coverage
gaps, inadequate access to services, and ineffective clinical
care.
Ensuring Access to Services in
the Community
Access to services is
facilitated by expanding the availability of STD-related services
through primary care and by coordinating services at the local
level. Universal and timely access to curative and preventive
services are supported by eliminating financial barriers to obtaining
health services, minimizing other barriers, ensuring that patients
are not stigmatized, and ensuring that services are culturally
appropriate. Given the broad spectrum of risk groups, access to
STD-related services in multiple settingsincluding private sector
clinics, family planning clinics, prenatal clinics, adolescent
and school-based clinics, HIV clinics, community health centers,
and other settings not traditionally targeted by STD programsis
important. STD-related services need to be incorporated into primary
care because primary care fosters ongoing relationships between
the clinician and the individual, increasing the likelihood of
effective preventive interventions and early detection of STDs.
In addition, incorporating STD-related services into primary care
may increase access to and improve quality of STD-related care.
Each community has responsibility
for ensuring universal access to comprehensive STD-related services.
However, because communities differ widely in their health needs
and capacity to support a system of STD-related services, the
organization of community STD-related services should be tailored
to local needs and conditions. Depending on local situations,
health departments should incorporate STD-related services into
public and private primary health care services. Depending on
epidemiologic patterns, health insurance coverage, population
density, and other community characteristics, they may continue
to support dedicated public STD clinics, or may shift such services
to community-based clinics or the private sector.
With respect to the above issues, the committee makes the following recommendations:
Improving Dedicated Public STD
Clinics
There is wide variation in the quality,
scope, accessibility, and availability of services provided by
dedicated public STD clinics, and these clinics need significant
improvement. Many local health departments operate dedicated public
STD clinics that are isolated from other public health and clinical
services and for which quality monitoring and assessment have
not been priorities. The committee supports incorporating STD-related
services in primary care settings, but it also believes that dedicated
public STD clinics should continue to be an important component
of STD prevention. In some situations these clinics are the primary
providers of STD-related services for the uninsured and provide
an important focus for STD prevention in the community. In all
cases, health departments operating dedicated public STD clinics
should ensure that these clinics collaborate with community-based
health clinics (including family planning clinics and school-based
programs), university and hospital medical centers, and private
sector health care professionals to improve access and quality
of care. Standards to maintain access to confidential services
and to monitor quality should be developed for STD-related services
provided by public STD clinics, health plans, and public-private
sector arrangements.
With respect to the above issues, the committee makes the following recommendations:
Involving Health Plans and Purchasers
of Health Care
The committee believes that if certain
concerns are adequately addressed, there is substantial potential
for managed care to improve the quality of, and access to, STD-related
services. Compared with other health plans, the structure and
resources of most managed care organizations allow for improved
coordination and integration of care, accountability of services,
incentives to provide preventive services, and monitoring of service
quality. However, the current performance of managed care in STD
prevention has not yet lived up to its potential. With very few
exceptions, STDs are not high priorities among health plans, and
few are involved in activities to prevent STDs in the larger community
beyond plan members. Managed care organizations and other health
plans should take on more responsibility for providing STD prevention
services, both among plan members and in the community in which
they operate. By supporting such activities among plan members
and the community, significant health care costs associated with
serious complications of STDs will be averted; health plan members
will be less likely to be exposed to infected partners or to acquire
reinfections; and long-term complications of STDs will be prevented
among current and future plan members in the community. Employers,
government agencies, and other purchasers of health care services
are vital to ensuring that health plans provide comprehensive,
high-quality STD-related services. Most local health departments
have not developed billing arrangements with health plans; since
most public sector providers are not in managed care networks,
their services are considered to be out of plan and not reimbursable.
With respect to the above issues, the committee makes the following recommendations:
Improving Training and Education
of Health Care Professionals
Well-trained primary care clinicians
are essential for effective STD diagnosis and treatment. The current
system of clinical training for health care professionals, however,
is inadequate in preparing clinicians to effectively manage patients
with STDs. Inadequate professional training contributes to the
widespread tendency of clinicians to oversimplify and underestimate
the importance of STDs. Familiarity with population-based health
promotion and disease prevention techniques, skills in evidence-based
clinical decision making, and patient communication skills are
all essential for every clinician. STD training programs should
be expanded at the primary care level to improve clinician skills
in both public and private settings to effectively prevent, diagnose,
and treat patients with STDs. Other factors that influence a clinician's
ability to provide comprehensive services, including practice
format constraints, also need to be addressed.
With respect to the above issues, the committee makes the following recommendation:
Improving Clinical Management
of STDs
Major components of effective clinical
management of STDs include screening, diagnosis and treatment,
risk reduction counseling and education, identification 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. Screening for STDs
is cost-effective and sometimes cost-saving. Some screening programs,
however, such as mandatory premarital testing for syphilis, are
not cost-effective and contribute little to STD prevention. Therefore,
screening should be appropriately focused and should be based
on surveillance data and knowledge of the populations or prevalence
of STDs. Screening programs for STDs such as chlamydial infection
need to be expanded, because such programs can dramatically reduce
rates of STD-related complications. Family planning clinics, prenatal
clinics, and other settings where obstetric or gynecological care
is available should screen and treat women and their partners
for STDs.
With respect to the above issues, the committee makes the following recommendations:
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. Single-dose therapy
for bacterial STDs is important in preventing 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.
With respect to the above issues, the committee makes the following recommendations:
Risk reduction counseling and education
of patients during routine clinical encounters and during evaluations
for potential STDs is an important component of clinical management.
Focused counseling in both specialized and general clinical settings
has substantial potential for changing STD-related behaviors,
particularly for adolescents and other high-risk groups. Major
barriers that hinder clinicians from providing counseling that
need to be addressed include inadequate training in counseling,
lack of time allocated for counseling, and lack of reimbursement
for such services.
With respect to the above issues, the committee makes the following recommendation:
Current methods of partner notification
are inefficient and extremely resource-intensive and should be
redesigned. The optimal combination of activities that are most
effective in reaching partners at risk for STDs will vary depending
on the local epidemiology of STDs, available staff and other resources,
and the spectrum of local health care professionals providing
STD-related care. STD programs need to develop new strategies
and techniques for community outreach in partnership with other
professionals rather than relying solely on public sector staff.
With respect to the above issues, the committee makes the following recommendation:
Partner diagnosis and treatment should
be provided as part of standard STD-related care, regardless of
the clinical setting. The committee believes that health plans
and clinicians have an ethical and public health obligation to
ensure that sex partners of infected patients are appropriately
identified, screened, and treated, regardless of health insurance
status. This belief is based on the concept that health plans
have a responsibility to improve the health of the communities
from which they draw their revenue and that treating partners
is in both the short- and long-term interest of the health plan.
By treating partners, health plan members will not return with
reinfections and the reservoir of infection in the community will
be reduced.
With respect to the above issues, the committee makes the following recommendations: