(CDC, 1993a; Thorpe et al., 1996; Zenilman, 1996). Some single-dose therapies, however, are substantially more expensive than standard multiple-dose medications.7

Various clinical encounters for potential health problems other than STDs can provide a valuable opportunity for clinicians to evaluate and, if appropriate, treat persons for STDs. In particular, persons seeking health services for unintended pregnancy, contraception, or potential HIV infection are also at high risk for STDs. In addition, such encounters provide ''teaching moments" where patients are more likely to be receptive to prevention messages (Bigelow et al., 1986). Thus, examples of underutilized opportunities to both prevent and treat STDs are clinical encounters for family planning services, evaluation of an unintended pregnancy, and encounters for HIV testing and counseling. Newer technologies, such as noninvasive diagnostic tests for STDs, would make the evaluation of patients in the above clinical venues much more practical.

Barriers to Diagnosis and Effective Treatment

Although many useful diagnostic tests and effective drugs for STDs are available, they have not been successfully used on a national basis. Several major barriers prevent early diagnosis and treatment of infected persons. These include inadequate access to health care, lack of health-care-seeking behavior, inadequate training of health care providers, inadequate financial and physical access to laboratory tests, and geographic factors.

Inadequate access to effective health care, as discussed in Chapter 3, is the major impediment to appropriate diagnosis and treatment of STDs, particularly because the young and certain ethnic and racial groups, who have the highest rates of STDs, are the least likely to have health insurance coverage. In the United States, diagnosis and treatment cannot occur without the direct assistance of a licensed health care provider. Factors that prevent persons from seeking health care for potential STDs, including lack of perception of risk, misinformation and lack of knowledge about STDs, and the social stigma of STDs, are mentioned in Chapter 3. Inadequate training of health care providers is a serious barrier to early diagnosis and treatment of STDs because it results in clinicians who are not aware of the scope of STDs and lack the clinical skills necessary for diagnosing and managing an STD. This issue is discussed further in Chapter 5. In addition, although newer laboratory tests hold much promise for improved screening and diagnosis, financial and physical accessibility to these tests presents a barrier to


The CDC-negotiated price (only available to public STD clinics and family planning programs) for azithromycin, the single-dose therapy for chlamydial infection, is $9.50 per dose, compared to approximately $2 (average cost to public STD clinics and family planning programs) for multipledose doxycycline (Cathleen Walsh, CDC, Division of STD Prevention, personal communication, June 1996).

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