Services Task Force (1996) recently recommended a group of screening activities for primary care clinicians based on the age of the patient and risk category. A summary of the task force's recommendations related to STD screening and counseling is presented in Appendix F. These clinical guidelines were developed after an extensive review of data, studies, and expert opinions. It is important to note that the task force recommendations were based on evidence of prevention effectiveness rather than on cost-effectiveness or other considerations. Recognizing the limited amount of time available to primary care clinicians during patient visits, the task force only recommended interventions that were shown to be effective by peer-reviewed studies. The intent is that clinicians would choose from the specific recommended interventions and tailor them to the health needs of the individual patient. The task force evaluated and made specific recommendations for the following diseases and conditions related to sexual intercourse: hepatitis B virus infection, syphilis, gonorrhea, HIV infection, chlamydial infection, genital herpes, cervical cancer, and unintended pregnancy. Several medical professional societies, other organizations, and government agencies have also published guidelines regarding screening for STDs (U.S. Preventive Services Task Force, 1996). The recommendations of these organizations and agencies are very similar. For example, no major organizations recommend screening of the general population for chlamydial infection, genital herpes simplex virus, hepatitis B virus infection, or syphilis. The recommendations of these groups, however, often vary in the criteria recommended for selecting risk groups for screening.

Not all STD screening programs are cost-effective. State laws requiring premarital and prenatal screening in order to prevent syphilis transmission date back to the 1930s and 1940s (Brandt, 1985). As a result of data showing that only approximately 1 percent of syphilis infections were detected by premarital screening, many states have repealed their premarital testing requirements (Felman, 1981). As of 1996, however, 15 states still require premarital syphilis testing as a requirement for marriage licenses (CDC, Division of STD Prevention, unpublished data, 1996). The number of previously undetected cases of syphilis identified through premarital testing is extremely low (Felman, 1981; Haskell, 1984). In addition, studies show that premarital tests for syphilis or HIV infection are not cost-effective and have little public health impact (Haskell, 1984; Cleary et al., 1987; Peterson and White, 1990). In contrast, screening for syphilis during pregnancy has been shown to be cost-saving; the economic benefits of the national screening program in Norway were almost four times the program cost (Stray-Pederson, 1983).

Inadequate resources and other considerations may preclude implementation of widespread screening protocols or other intervention programs. In such situations, methods for identifying individuals or groups at particularly high risk are helpful in targeting interventions and maximizing effectiveness (Stergachis et al., 1993). For example, a study of public STD clinics in Dade County, Florida, found that it is possible to identify persons at highest risk for STDs using routinely



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