available data suggest that the patterns of diseases seen in these settings may be quite different from those seen in public clinics. In 1994, while public STD clinics reported 1.93 times more syphilis than all non-STD reporting sites (including private sector providers and community-based facilities), non-STD clinic sites reported 1.93 times the number of chlamydial infections (CDC, DSTDP, 1995).

In addition to the lack of disease surveillance data from private sector settings, there is limited information regarding the distribution and types of care and the costs and expenditures for STD diagnosis and management in these settings. Undoubtedly, patients with acute STD syndromes may be seen in emergency rooms as well as by private practitioners or other clinics. However, the distribution and allocation of patients among these services are unknown. Similarly, how often and how well patients are screened for STDs is unknown, although the prevailing opinion is that screening for STDs is relatively uncommon in the private sector. For example, a survey of 19 hospital-based emergency centers in Los Angeles County revealed that only 5 implemented a policy for cervical cancer screening (Marcus et al., 1990).

There are few data regarding what proportion of patients seen in private settings are given recommended therapy for STDs or whether partner notification and treatment practices are routinely conducted (Winkenwerder et al., 1993; Celum et al., 1995). One recent study provides some information regarding compliance of primary care physicians in California with the CDC recommendations regarding the management of pelvic inflammatory disease (Hessol et al., 1996). Of 553 physicians responding, 55 percent reported treating at least one case of pelvic inflammatory disease during the previous 12-month period, and of these physicians, 52 percent were either unsure of or did not follow the CDC's treatment guidelines for this STD. Partner notification is not well supported in private sector settings, probably because most private sector clinicians do not accept responsibility for partner notification; there is no reimbursement for care of sex partners; and providers may be reluctant or not trained to interview their patients regarding sexual practices.

Most private practitioners emphasize acute care and provide screening when mandated by standards of practice, but, as discussed previously, most clinicians do not routinely conduct STD risk assessment and many do not provide counseling for behavior change (Lewis and Freeman, 1987; Boekeloo et al., 1991; ARHP and NANPRH, 1995). Complicating private practitioners' management of STDs is that, although there are national treatment guidelines for STDs (CDC, 1993) and practice guidelines for STD clinics (CDC, 1991), there are no generally accepted clinical practice guidelines or standards for STD screening and risk assessment. In addition, private practitioners generally are ill-prepared to assess their patients' risks, educate and counsel them, or notify and treat their sex partners.



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