Institute of Medicine

Division of Health Promotion and Disease Prevention

The Hidden Epidemic:

Confronting Sexually Transmitted Diseases

Executive Summary

Thomas R. Eng and William T. Butler, Editors

Executive Summary


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.

Conclusions and Recommendations

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:

Institute of Medicine

Division of Health Promotion and Disease Prevention