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