Current STD-related services and activities in the United States comprise several components, including the delivery of clinical services by health care providers, disease surveillance and information systems, training and education of health care professionals, and funding of activities and programs. Most of the components are publicly sponsored programs; but some programs, such as training and education of health professionals, are carried out by both the public and private sectors. Components such as national health surveys are directed and supported by the federal government, while others, such as disease surveillance, involve all levels of government and the private sector. Although the private sector is primarily involved in delivery of clinical services to persons with private health care insurance, this situation is rapidly changing and may have significant implications for the delivery of STD-related services.
Clinical services for STDs—screening, diagnosis and treatment of STDs, patient counseling, and partner notification and treatment—are provided primarily in one of three settings:
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--> 5 Current STD-Related Services Highlight The total annual costs associated with selected STDs are approximately 43 times the total national investment in STD prevention and 94 times the national investment in biomedical and clinical research on STDs every year. Current STD-related services and activities in the United States comprise several components, including the delivery of clinical services by health care providers, disease surveillance and information systems, training and education of health care professionals, and funding of activities and programs. Most of the components are publicly sponsored programs; but some programs, such as training and education of health professionals, are carried out by both the public and private sectors. Components such as national health surveys are directed and supported by the federal government, while others, such as disease surveillance, involve all levels of government and the private sector. Although the private sector is primarily involved in delivery of clinical services to persons with private health care insurance, this situation is rapidly changing and may have significant implications for the delivery of STD-related services. Clinical Services Clinical services for STDs—screening, diagnosis and treatment of STDs, patient counseling, and partner notification and treatment—are provided primarily in one of three settings: dedicated public STD clinics, operated by local health departments; 1 1 The committee uses the term "dedicated public STD clinics" to refer to publicly funded clinics whose main purpose is to provide STD-related services. Other clinics that provide STD-related services in the context of other services, such as community health centers, family planning clinics, migrant health centers, and school-based clinics, are not considered to be dedicated public STD clinics. The term "categorical STD clinics" is not used because it invites confusion with "categorical funding."
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--> community-based health clinics, operated by community-based health professionals or agencies that usually receive public funds; and private health care settings, including private physician offices, health-plan-affiliated facilities, private clinics, and private hospital emergency rooms. The public, community-based, and private settings for STD-related care serve somewhat different, albeit overlapping, population groups, each of which has different needs related to STD prevention. Health Care Professionals and Prevention Activities There is a broad range of health care professionals involved in STD-related care. Most clinicians who provide STD-related care in public or private settings emphasize diagnosis and treatment and, to a lesser extent, management of sex partners rather than other approaches to STD prevention (Bowman et al., 1992). Most clinicians do not provide adequate STD risk assessment, prevention counseling, or other STD-related education, despite the fact that they may include some STD screening in their patients' medical evaluation (Lewis and Freeman, 1987; Lewis et al., 1987; Gemson et al., 1991; Bowman et al., 1992; Russell et al., 1992). In a 1986 survey of California internists, only 10 percent reported asking new patients questions that were specific enough to assess their risk of STDs (Lewis and Freeman, 1987). In a more recent national survey of primary care physicians and other health care providers (registered nurses, nurse practitioners, nurse midwives, and physician assistants), only 39 percent of physicians and 49 percent of other primary care providers reported conducting risk assessment for STDs for all or most of their new adult patients (ARHP and NANPRH, 1995). A survey of 961 physicians in the Washington, D.C., area found that only 37 percent of respondents reported regularly asking new adult patients about their sexual practices and that 60 percent did so for new adolescent patients (Boekeloo et al., 1991). Reasons typically cited for these deficits, as mentioned elsewhere in this report, include (a) health professionals' common skepticism of the efficacy of health education and behavioral interventions; (b) pressures to see large numbers of patients in a brief amount of time; (c) personal discomfort regarding taking accurate, nonjudgmental sex and STD histories, attributed to lack of training and other reasons; and (d) a widespread misconception that STDs and issues related to sexuality are too "sensitive" to discuss. The last perception is not correct; one study found that patients who were asked questions about sexual and STD histories at their initial visit to primary health care providers tended to leave those interactions with a greater sense of confidence that their providers would provide high-quality care compared to patients who did not have such histories taken (Lewis and Freeman, 1987). It has been suggested that simulated patients be used to improve clinician skills in risk assessment and counseling (Rabin et al., 1994).
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--> Dedicated Public STD Clinics The earliest public STD clinics were established in the 1910s, despite substantial resistance by organized medical societies (Brandt, 1985). The concept of dedicated public STD clinics is based on evidence that many persons with STDs prefer anonymous and confidential services, cannot afford to obtain care elsewhere, and are unable to obtain care from private sector health care professionals who are unable or unwilling to provide STD care. These clinics are often seen as the "safety net" for STD-related services. Historically, the stigma associated with having a disease associated with sexual intercourse has discouraged more universal use of public STD clinics and prompt health-seeking behavior for symptoms of STDs in general (Brandt, 1985). Public STD clinics and HIV programs provide the largest proportion of specialized STD-related care in the United States. Various government agencies support STD prevention activities by providing funds, setting standards, or by directly providing care. Public STD clinics usually receive a combination of federal, state, and local funds. The only federal agency that supports dedicated public STD clinics is the CDC, which primarily funds patient education, partner notification, outreach, and other prevention services rather than direct clinical services. State and local health departments also provide financial support for these clinics and programs and are often given responsibility for operating the clinics under federal policies and guidelines. Persons Served A recent five-center survey of more than 2,500 patients attending dedicated public STD clinics in the United States showed that users of such clinics are generally young (38 percent under 25 years of age), disproportionately of certain racial or ethnic groups (49 percent African American), and at high risk for multiple STDs (Celum et al., 1995). Approximately 15 to 20 percent of patients attending these clinics are adolescents; the median age of patients attending these clinics is approximately 23 years. The clinics generally provide care for approximately twice as many men as women. Persons who use dedicated public STD clinics tend to have a high prevalence of other health problems, including HIV infection, unintended pregnancy, and drug and alcohol use (Kassler et al., 1994; Zenilman et al., 1994; Weinstock et al., 1995). For example, in one inner-city public STD clinic, 46 percent of women attending the clinic were not using contraception and two-thirds had at least one prior pregnancy (Upchurch et al., 1987). A significant proportion of dedicated public STD clinic patients have private insurance coverage. In the survey by Celum and others (1995) mentioned above, approximately 31 percent of male and 24 percent of female patients seen in dedicated public STD clinics had private health insurance (Figure 5-1). These data suggest that a large number of privately insured patients use public STD
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--> Figure 5-1 Distribution of health insurance status among persons using public STD clinics, 1995. SOURCE: Celum CL, Hook EW, Bolan GA, Spauding CD, Leon P, Henry KW, et al. Where would clients seek care for STD services under health care reform? Results of a STD client survey from five clinics. Eleventh Meeting of the International Society for STD Research, August 27-30, 1995, New Orleans, LA [abstract no. 101]. clinics without acknowledging their health insurance status. In such situations, the local health department ends up paying the cost of the services (Gary Richwald, Los Angeles County STD Program, personal communication, November 1995). Patients may be referred to public STD clinics by health care providers who either have made a diagnosis requiring treatment or feel that the STD can be better managed by health care providers in public STD clinics. Reasons cited by clinic patients for seeking medical care included genitourinary symptoms (55-70 percent of individuals); notification of recent sexual contact with a partner diagnosed with an STD (15-20 percent); and perceived risk and desire for STD screening (approximately 20 percent) (Celum et al., 1995). Services Provided Publicly funded STD-related services are provided both by dedicated public STD clinics and within the context of primary care by community-based programs. Dedicated public STD clinics are located in every state, every major city,
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--> and the majority of smaller cities and counties throughout the United States. Based on published data, the committee's interactions with other health professionals, site visits, results of site assessments conducted by the CDC, and personal experience working with dedicated public STD clinics, the quality of care, scope of services provided, and other characteristics of these clinics are quite variable. Some clinics, commonly those affiliated with academic institutions, seem to offer comprehensive, high-quality STD-related services, whereas other clinics do not provide either comprehensive or high-quality care. In addition, the scope and level of services provided by many clinics are limited by available resources. In some locations, these clinics are high-volume, full-time clinics administered by local health departments or in partnership with medical schools. In contrast, in many rural settings and smaller population centers, dedicated public STD clinics are staffed by individuals who have numerous other responsibilities; these clinics may be open only on a part-time basis, sometimes only a few days a week. Most public clinics charge only a nominal fee or have a sliding fee scale for services. The services provided in dedicated public STD clinics emphasize diagnosis and treatment, and partner notification for a limited number of STDs (Stein, 1996). Much of this diagnostic effort focuses on gonorrhea, nongonococcal urethritis, clinically defined cervicitis, pelvic inflammatory disease, and genital ulcer disease (i.e., syphilis, chancroid, and genital herpes). These clinics often conduct STD screening for gonorrhea, syphilis, or, more recently, chlamydial infection. Voluntary HIV counseling and testing, which may be offered either in the context of an STD evaluation or as a "stand-alone" service, is offered at most, but not all, clinics. While there has been increasing interest in, and emphasis on, counseling and health education in dedicated public STD clinics, providers receive little training in techniques and skills for conducting education or counseling (Lewis et al., 1987; Roter et al., 1990). In the fast-paced environment found in most of these clinics, there is little time allocated for, or little emphasis on, counseling (Stein, 1996). "Disease intervention specialists" are often charged with much of the counseling and health education responsibilities in these facilities, as well as with collection of partner information and partner notification. These staff, as discussed later in this chapter, typically emphasize partner notification responsibilities over patient education activities. In dedicated public STD clinics, partner notification activities are primarily focused on patients with syphilis, HIV infection, and, to a highly variable degree, gonorrhea, chlamydial infection, or pelvic inflammatory disease. Ideally, the process of interviewing index patients to obtain both the names and locations of sex partners begins with counseling and education, but it is unclear how consistently this is done. Little or no counseling is provided in dedicated STD clinics for risk reduction or management of chronic or other incurable viral STDs other than HIV infection. One study found that 28 percent of dedicated public STD clinic patients did not receive any information
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--> regarding prevention during their clinic visit (Roter et al., 1990). Several states mandate counseling of patients, using a prescribed content outline, before to HIV testing; however, there is no method for ensuring that these regulations are followed. Data on the specific types of STD-related services provided by local health departments through public STD clinics are limited. The Alan Guttmacher Institute, with support from the CDC, however, has recently conducted a survey to provide national estimates describing the STD-related activities of local public health agencies in the United States (Box 5-1). BOX 5-1 STD-Related Services Among Local Health Agencies, 1995 A stratified, random sample of 800 local health departments that were identified as providing STD treatment were sent a questionnaire in September 1995 regarding various characteristics of their programs and policies related to STD-related clinical services. Approximately 77 percent of the eligible agencies responded. Results indicate that 50 percent of 2,888 local health departments provide treatment for STDs. Of these providers, 74 percent integrate STD-related services with HIV/AIDS-related services; 21 percent offer STD- and HIV-related services in separate programs; and 5 percent provide STD-related services but do not provide HIV screening or testing. Almost half (49 percent) of the local health departments that offer services for STDs offer both dedicated STD sessions and sessions where such services are integrated with other services, such as family planning. An additional 37 percent always integrate STD sessions with other clinic services such as family planning, and 14 percent provide only STD-related services in dedicated sessions. Only 23 percent of agencies offered services after 6 p.m. and only 5 percent had weekend hours. Regarding testing and treatment services for chlamydial infection, gonorrhea, and syphilis, a greater percentage of agencies reported treating chlamydial infection (97 percent) than testing for it at all or some sites (82 percent). The percentages of agencies testing and treating for gonorrhea and syphilis at all sites were all over 98 percent. Agencies were also asked to report what type of client history, risk assessment, and educational/counseling services they routinely provide patients making an initial STD visit (Table below). More than 90 percent of agencies reported routinely collecting information on a client's sexual, STD, and contraceptive history. A smaller proportion of agencies routinely query patients regarding any history of substance abuse (78 percent). While approximately 97 percent of STD agencies reported routinely providing educational services regarding risk factors of STDs and HIV, far smaller percentages of agencies reported routinely providing services on how to use contraceptive methods effectively or how to negotiate condom use (66-70 percent). Although more than 70 percent of health departments that provide services for STDs in integrated sessions reported routinely providing education and counseling regarding contraceptive use, less than half (47 percent) of agencies that only provide services in separate sessions provide this service. It should be noted that the survey results represent only health departments that offered treatment for STDs and that the quality and consistency of services provided were not evaluated. In addition, most agencies that reported integration of STD-related services with other services were in nonmetropolitan areas with relatively low caseloads. Distribution of Local Health Agencies Providing STD Risk Assessment and Educational and Counseling Services by Type of Service, 1995 Type of Service Total No. of Agencies Routinely Provided (%) Provided Only on Indication or Request Not Provided (%) (%) Client history Client sexual history 575 98.9 1.1 0.0 Client contraceptive history 579 93.9 5.9 0.2 Client/partner substance use history 575 77.8 18.6 3.6 Client/partner STD history 578 97.3 2.1 0.6 Education/counseling services How to use contraceptive method effectivelya 577 69.6 26.0 4.4 Risk factors for STDs-HIV 580 97.4 2.6 0.0 Condom negotiation skills 576 66.4 29.6 4.0 a This question was generally worded and may have been interpreted by respondents to mean education and counseling regarding contraceptive use generally or to prevent STDs only, or both. SOURCE: Landry DJ, Forrest JD. Public health departments providing sexually transmitted disease services. Fam Plann Perspect 1996;28:261-6.
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--> Complete Box on previous page. Effectiveness Dedicated public STD clinics provide services to large numbers of patients at little or no cost to the patient. One of the guiding principles of these clinics is that no patient should be turned away because of cost considerations. However, it has been estimated that as many as 25 percent of those presenting for care cannot be accommodated because of inadequate clinic capacity (CDC, DSTD/HIVP, 1992). The performance of these clinics is usually evaluated on the basis of quantitative measures, such as numbers of patients seen and number of cases of
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--> specific diseases diagnosed, rather than on quality of care measures. Based on the committee's site visits and personal experience working with dedicated public STD clinics, there is little emphasis on, and almost no reporting of, quality-related indicators such as consistency of risk-reduction counseling or numbers of patients with positive STD screening tests who are successfully treated as opposed to simply having been screened. Systems for evaluation of clinic services tend to be developed in reaction to increasing STD rates or other evidence of perceived failure. This may also be related to the clinics' emphasis on quantitative performance measures. There has been little effort to measure potential positive impact of dedicated STD clinic services on populations using their services. The CDC has not conducted routine on-site quality assessments of public STD clinics and programs since 1993. Federal oversight of quality in such clinics and programs currently consists of a yearly review of written program activities (submitted annually as a requirement for federal funding), periodic telephone and on-site technical assistance consultations, and the work of federal program consultants who are stationed in some project areas. There are few data regarding the perceptions of care provided to STD clinic patients. In a study by Celum and others (1995), a high proportion of patients attending these clinics stated they would preferentially attend public STD clinics should they need further STD care. The most common reasons cited for preferring to use the public STD clinic were walk-in/same-day appointments, lower costs, privacy or confidentiality concerns, convenient location, and expert care (Figure 5-2). Confidentiality concerns are a primary determinant of whether adolescents seek health care for potential STDs. Federal Role As mentioned earlier, nonclinician public health professionals referred to as ''disease intervention specialists" (previously known as "contact tracers") have played a special role within state and local STD programs. These personnel include federal employees assigned as field staff in local programs and state and local government employees. The provision of federal field staff is referred to as "direct [federal] assistance" and "in lieu of cash," as opposed to "financial assistance," which is given to the states through the STD prevention cooperative agreements. Historically, disease intervention specialist positions served as the entry level for all management staff within federal public health programs. Disease intervention specialists initially began at the lowest federal civil service entry levels as personnel in state or local public health field assignments, largely performing provider referral field work. Eventually, many staff were reassigned to new positions and given supervisory responsibilities within other state and local STD programs. Federal public health advisors are typically recruited back to the CDC
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--> Figure 5-2 Reported main reasons for utilizing public STD clinics among clinic users in five U.S. cities, 1995. Categories are not mutually exclusive; respondents were allowed to indicate up to three reasons. SOURCE: Celum CL, Hook EW, Bolan GA, Spauding CD, Leone P, Henry KW, et al. Where would clients seek care for STD services under health care reform? Results of a STD client survey from five clinics. Eleventh Meeting of the International Society for STD Research, August 27-30, 1995; New Orleans, LA [abstract no. 101]. and to other divisions outside of the STD division and seem to have formed a useful managerial infrastructure for the agency. Many problems existed with the system of management training for federal staff. The mixing of state, local, and federal staff often created conflict in local areas because federal salaries were higher than most local and state salaries, leading to staff resentment. Since management positions were often given to
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--> these transient federal assignees, local staff felt that promotional opportunities were hindered by the presence of federal staff, and they questioned the loyalties of the assignees to state or local programs. Because the assignees were part of the federal cooperative agreement, many states and local areas depended, in part or fully on, federal support to maintain core program functions. This federal training program may have inhibited the development of local and state STD program capacity, because states became dependent on federal assignees to fill key service delivery and program management positions, thereby limiting the development and training of local or state staff. As a result of these problems and the feeling that disease intervention specialist training was too narrow and not flexible enough to adapt to the future role of public health, recruitment and initial training of CDC federal nonphysician field assignees are being restructured in ways currently being defined (CDC, 1995a). CDC is initiating a transitional training program for current disease intervention specialists and has begun to reduce their total number. Thus, the total number of federal field assignees for STD prevention will be reduced by nearly half from 1996 through 2000, but remaining assignees will receive further training and new recruits will have more extensive training. Transition from a direct service delivery role to a technical assistance and local capacity-building role for federal assignees is being planned (CDC, DSTDP, 1996). The CDC is currently developing criteria for evaluating state and local government requests for replacement of federal assignees and conversion of direct assistance funds to financial assistance funds. As a result of federal downsizing, in most cases, direct assistance vacancies will not be filled on a one-to-one basis and requests for converting direct assistance to financial assistance will not result in a dollar-for-dollar conversion. A major concern of STD program managers is that the former federal disease intervention specialists, whose number is now being reduced, have represented significant support for many STD programs and have served in key STD program management positions. Federal assignees from CDC to state and local governments have decreased in number from 1993 through 1996 as a result of the CDC downsizing program and the freeze on hiring for new positions. This resulted in closing the four training programs for new disease investigation specialists, so that the greatest decrease in federal assignees occurred in Florida, Georgia, the city of Chicago, and California, where these training programs and positions were located. These federal positions have not been replaced by reciprocal federal or state resources to hire or contract for replacement disease intervention specialists or management staff. No state or county resources are currently available to replace these positions, nor could they be used, even if available, where states are currently experiencing a hiring freeze. In essence, a major portion of the federal support that has been provided as direct assignment of disease investigation specialists is being redirected to states for other types of disease control activities (e.g., chlamydial prevention, training, and local recruitment). This may
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--> potentially leave state and local STD programs, many in high morbidity areas such as the South, at least temporarily without the resources to conduct adequate STD surveillance and program management activities. To maintain local capacity, it will be essential for state and local governments to use both federal financial assistance and their own resources to develop local capacity as the number of federal assignees is reduced, and not simply withdraw state and local funds as federal financial assistance is received. There is no evidence that initiatives to increase funding from local sources will generate adequate resources to replace federal positions being withdrawn from local agencies. In an effort to expand prevention efforts beyond those delivered through public STD clinics, the CDC launched the STD Accelerated Prevention Campaigns grant program for selected states and local health departments in 1994 (Noegel et al., 1993). The program seeks to (a) increase links between STD clinic activities and other health programs and community-based programs, (b) promote innovative approaches to STD prevention, (c) encourage commitment of local resources to prevention, and (d) develop cost-effective methods of prevention. Activities funded by the campaign are encouraged to focus on populations that are disproportionately impacted by STDs, including women, infants and adolescents, and certain racial and ethnic groups. Community-Based Clinics Many types of community-based clinics, such as family planning clinics, prenatal clinics, youth and teen clinics, homeless programs, community-based health centers, and school-based clinics, also provide STD-related services. Like dedicated public STD clinics, community-based clinics that treat STDs tend to be high-volume clinics that provide services at relatively little or no cost to the patient. STDs are not the primary focus for these clinics, but rather are dealt with in a context of providing general or specific (e.g., family planning) health care services. Although the populations served by community-based clinics overlap substantially with public STD clinic patients, there is surprisingly little communication between these facilities. Similar to dedicated public STD clinics, community-based clinics generally serve young patients of certain ethnic and racial groups from lower socioeconomic class communities. A major difference between persons attending community-based clinics and those attending dedicated public STD clinics, however, is that some persons attending community-based clinics rely on these clinics for regular health care, that is, they attend on a scheduled basis rather than the episodic, problem-oriented basis that characterizes utilization of dedicated public STD clinics. Even more so than for dedicated public STD clinics, the scope of STD-related clinical services in these community-based clinics is highly variable. These clinics identify proportionally more STDs through screening activities
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--> Allergy and Infectious Diseases and other divisions at the National Institutes of Health, which are responsible for supporting most STD-related biomedical and clinical research activities in the federal government, invested approximately $105.4 million in the same year for biomedical and clinical research in STDs. In addition, other federal agencies, such as the Health Resources and Services Administration, Office of Population Affairs, the Health Care Financing Administration (primarily through its Medicaid program), and the Indian Health Service, all directly support or provide STD-related clinical services. The amount of funds that support STD-related services in these agencies, however, is unclear because such services are provided in the context of primary care or other programs and are not allocated or accounted for separately. The proportion of federal funds that is used to support prevention activities versus other services is likewise unclear, but it is reasonable to broadly categorize funds allocated for the Division of STD Prevention at the CDC and National Institutes of Health STD-related grants as related to noncurative prevention services and to research, respectively, and funds originating from the other federal agencies as primarily used to support clinical services for STDs. The precise amount of financial support for STD-related programs, including both curative and noncurative services at the state and local levels, is unknown because there is no matching requirement for most federal funding. State and local governments vary widely in their financial support for STD-related programs. Some jurisdictions spend several times more than they receive from the CDC, while others only provide a small proportion of the total funding for such programs in their area. Based on an informal CDC survey of state and local health departments regarding their contributions to STD program funding in 1994, the total state and local contribution to STD-related programs was approximately $125.6 million or approximately 58 percent of combined state, local, and federal funding (CDC, Division of STD Prevention, unpublished data, April 1994). State and local contributions, as a percentage of combined state, local, and federal funding in the respective area, ranged from 0 percent ($0) to 90 percent ($22.7 million). These estimates are sensitive to variability in how STD program funding is categorized in state and local government budgets. However, in order to provide a rough estimate of public investment in STD prevention (including STD treatment),7 it is reasonable to use the estimated state and local contribution in 1994 ($125.6 million) and the actual CDC contribution to state and local STD programs in federal fiscal year 1995 ($91.8 million). 7 The term "STD prevention," as used in this report, refers to all interventions, behavioral, curative, or otherwise, that are needed to reduce the spread of infection in a population. Therefore, the estimate provided here represents public funding for all these types of interventions. The formula used for estimating public investment in STD prevention is as follows: Public investment = the CDC contribution to states/local governments plus the CDC staff support funds plus the estimated state/local contribution. Therefore, total public investment in 1994 = $91.8 + $13.4 + $125.6 = $230.8 million.
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--> Given the assumptions mentioned above, the total national public investment in STD prevention in fiscal year 1995 was approximately $230.8 million, and approximately $105.4 million was invested in biomedical and clinical research in STDs. Comparing these estimates to the estimated total costs of selected STDs, excluding AIDS ($9.954 billion), the total cost associated with STDs in the United States in 1994 was approximately 43 times the total national public investment in STD prevention and 94 times the total national investment in STD-related research (Figure 5-3). Again, it should be noted that the estimate of public investment in STD prevention and research does not include all publicly funded prevention or research programs that are related to STDs or STD-related programs funded by the private sector.8 Similarly, the estimate of total costs for STDs does not include costs for all STDs. Even if the true public investment in STD prevention and research is several times higher than that estimated by the committee, the public investment would still be extremely low compared to the total costs of STDs in the United States. Categorical Funding Funding for state and local health departments comes from the CDC cooperative agreements and state and local governments. The legislative authority for the prevention of STDs in the United States stems from Section 318 of the Public Health Service Act, which authorizes the Department of Health and Human Services to make grants to and assist states, their political subdivisions, and public and nonprofit private entities for STD prevention research, demonstrations, public information and education programs, and training, education, and clinical skill improvement of health care providers. The Department of Health and Human Services is also authorized to make grants to states and their political subdivisions to carry out prevention programs. A list of prevention programs funded by the CDC's Division of STD Prevention in fiscal year 1996 is presented in Table 5-1. The Preventive Health Amendments of 1992 modified Section 318 and authorized the CDC to make grants and provide assistance for activities to reduce STDs that can cause infertility in women. These amendments also authorized grants for the purpose of conducting research to improve the delivery of STD-related infertility prevention services. Reimbursement for STD-related services in the private sector comes from 8 For example, public investment in cervical cancer or hepatitis B prevention programs was not included because, as for many STDs that can be also transmitted by other means, it is not possible to determine the proportion of the program that is focused on prevention of sexually transmitted infections versus infections acquired by other means. In the case of hepatitis B, for example, vaccination programs are intended to prevent both sexually transmitted infections and nonsexually transmitted cases.
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--> Figure 5-3 Comparison of estimated annual direct and indirect costs for selected STDs and their complications in 1994 versus national public investment in STD prevention and research in federal fiscal year 1995. 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 population. SOURCES: Total cost of illness estimate was calculated by the IOM Committee on Prevention and Control of STDs; estimate of federal, state, and local 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 Health, 1996. third party reimbursement, such as private health insurance and Medicaid. STD-related care provided in community-based health facilities, such as family planning clinics and community health centers, receive federal and other support. Local health departments receive reimbursement for services provided by public STD clinics to persons with private insurance only to the extent allowed by law or under written contract.
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--> TABLE 5-1 STD Prevention Programs Funded by the Division of STD Prevention, Centers for Disease Control and Prevention (CDC), Fiscal Year 1996 Program Funding Level ($) Preventive Health Services STD Accelerated Prevention Campaign 69,954,310 Prevention of Infertility Caused by STDs 9,798,309 Intra-agency Agreement: Office of Population Affairs and the CDC 1,700,000 The National AIDS, STD, and National Immunization Program Hotline 715,390 Intra-agency Agreement: Indian Health Service (IHS) and the CDC 325,000 Human Resources Development STD/HIV Prevention Training Centers 4,008,547 Public Health Graduate Training Certification Program 2,965,623 Sexually Transmitted Diseases Faculty Expansion Program 648,070 Association of Schools of Public Health (ASPH) 400,000 Association of Teachers of Preventive Medicine (ATPM) 22,500 Extramural Research and Demonstrations STD Accelerated Prevention Campaign Enhanced Projects 1,463,510 Research and Evaluation Issues in Prevention of Infertility Due to STDs 1,275,000 STD Accelerated Prevention Campaign: Enhanced Projects for STD Prevention in High-Risk Youth 1,025,188 Innovations in Syphilis Prevention in the United States: Reconsidering the Epidemiology and Involving Communities 1,000,000 Development and Feasibility Testing of Interventions to Increase Health-Seeking Behaviors in, and Health Care for, Populations at High Risk for Gonorrhea 750,000 STD APC Enhanced Projects: Jail STD Prevalence Monitoring 125,000 Total Program Funding 96,176,447 SOURCE: CDC, Division of STD Prevention. Unpublished data, October 1996. Block Grant Proposals Current proposals from the Department of Health and Human Services would consolidate many federal categorical programs into block grants that each state would allocate among competing health needs and among local public and private sector agencies. A Senate legislative proposal would consolidate and replace 12 CDC categorical programs with 1 or 2 block grants. The Department of Health and Human Services advocates consolidating these CDC programs into three new public health "Performance Partnership Grants," including one for HIV/AIDS, STD, and TB. Performance Partnership Grants are essentially block grants that
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--> require states to set health objectives in an interactive process with the Department of Health and Human Services, providing some federal oversight but few constraints on state policies, programs, or funding. Arguments for Block Grants Proponents of block grants argue that categorical funding has forced programmatic rigidity and excess administrative costs on local programs. Categorical funding, proponents of block grants argue, imposes a bureaucratic straitjacket on public health and safety-net programs, forcing local programs and services into one-size-fits-all national models, ignoring local conditions and slowing innovation. In addition to restraining innovation and modifications to meet local needs, grant applications for federal funding are time-consuming, imposing substantial administrative costs on local agencies. State allocation of block grant funds may simplify the application process. Categorical funding also encourages narrowly defined programs even when it is logical to merge staff and services. For example, many states have kept HIV and STD prevention programs completely separate, although most observers acknowledge that it is logical to coordinate programs to prevent HIV infection and other STDs because they share common modes of transmission and risk groups and many common interventions. By measuring accountability in terms of the number of persons who receive a service or educational program, federal categorical funding encourages state and local agencies to keep programs separate. Some observers believe that block grants will free local communities from the rigidity and administrative burdens of categorical funding. States, they argue, will allocate funds based on locally and professionally determined health and social needs and will be responsive to state and local conditions. Whereas categorical programs subordinate local needs to uniform federal requirements imposed by distant bureaucrats, block grant supporters believe state officials will allocate federal and state moneys guided by the technical assessments of state health agencies, the judgments of the public health professionals, and the views of local communities. Arguments Against Block Grants Opponents of consolidating STD funding into a block grant along with other public health programs believe that STDs will suffer in competition with less controversial public health problems or other state priorities. In the real world of allocating budgets and setting priorities, they are concerned that elected state officials will make funding decisions based more on political considerations than on assessments by public health professionals and agencies. STD programs traditionally have weak political constituencies and will suffer in competition with
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--> programs that have powerful constituencies. As discussed in Chapter 3, advocacy for STD funding has been traditionally weak because many patients infected with STDs are unaware of the infection, and those who are rarely want to disclose their infection in public, let alone organize public support for STD funding. Opponents of block grants are particularly concerned that socially conservative interest groups will prevail in lobbying against STD programs at the state level. Allowing states to set funding allocations would also increase the already wide variability in STD programs among the states, because some states may seriously neglect STD programs. In addition, consolidating STD funding into a block grant may also result in the dissolution of the relatively weak constituency groups fighting for STD funding. The Coalition to Fight STDs, an alliance of more than 40 groups organized by the American Social Health Association, monitors public sector efforts against STDs and advocates at the national level for funding for STD prevention, treatment, and research. STD coalitions at the state or local level are rare, although they are emerging in some states, such as North Carolina, to improve STD funding. Lastly, opponents suggest that past experience with other block grants may portend the fate of STD programs in a consolidated state grants program. For example, in 1981, the categorical Lead-Based Paint Poisoning prevention program was folded into the newly created Preventive Health and Health Services block grant, and the Urban Rodent Control program was folded into the new Maternal and Child Health block grant. These efforts lost funds in virtually all states after the federal categorical programs that funded these services were folded into the block grants. Both of these programs were widely viewed as federal "big-city" programs that found little support in state legislatures dominated by rural representation. Programs that had state support before the advent of federal categorical programs fared better than those that previously had little or no state funding (U.S. General Accounting Office, 1984; Peterson et al., 1986; Elling and Robins, 1991). Conclusions Current STD prevention services comprise several disjointed components, including provision of clinical services, disease surveillance and information collection activities, training and education of health care professionals, and funding of activities and programs. Although these components are largely publicly sponsored programs, they involve all levels of government and the private sector. Dedicated public STD clinics have been instrumental in public efforts against STDs since they were established several decades ago. The quality and effectiveness of services delivered in these settings, however, are extremely variable and clearly need significant improvement. Until universal health care coverage is implemented in the United States, the function of public clinics as providers of
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--> care to the uninsured will need to be preserved. Unlike dedicated public STD clinics, community-based clinics and private health plans provide STD-related services in the context of primary care. However, the scope and quality of services provided in these environments are unknown. It is evident that clinical preventive services in both public and private health care settings need to be expanded and improved. Risk assessment and counseling to effect behavior change remain underutilized by primary care professionals, in part because the providers are poorly trained in their use. Data regarding the scope and quality of STD-related services among managed care organizations and other health plans are limited, but data collected by the committee and other information suggest that, with several notable exceptions, even managed care organizations that serve high-risk populations are not providing comprehensive services to infected persons and their partners in a consistent manner. Most managed care organizations and other health plans do not currently give STDs sufficiently high priority. One of the more notable potential advantages of increasing the role of managed care organizations in providing STD-related services is the opportunity to increase accountability, particularly with the support of employers and other purchasers of health care. The traditional role of dedicated public STD clinics and some of the functions of public health agencies will likely change given the national trend towards managed care, especially the increasing enrollment of Medicaid beneficiaries into managed care plans. This change in the health care delivery environment is both an opportunity to improve services and a cause for concern that the "safety net" for essential public health services will be eroded. Surveillance and information systems provide the basis for public health decision-making and function as the backbone for an effective system of STD prevention. An extensive system of data collection has been developed based on passive surveillance (with biases and incomplete data), sentinel surveys, and population-based surveys. However, specific improvements in these components are needed. Improvements are also needed in the current system for training and educating health professionals to deliver high-quality STD-related clinical services. Even in an era of shrinking federal and state budgets, the current investment in STD prevention is extremely low when compared to the enormous economic consequences of these diseases. Proposals to consolidate federal funding for STD programs to the states in the form of block grants have serious flaws, given the lack of adequate accountability. The current system of categorical funding, however, needs to be substantially improved. References Anderson JE, McCormick L, Fichtner R. Factors associated with self-reported STDs: data from a national survey. Sex Transm Dis 1994;21:303-8.
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Representative terms from entire chapter: