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sources of public information. These barriers have not been systematically addressed and require innovative solutions.
Prevention of STDs has important implications for HIV prevention. Studies show that STDs enhance the risk of sexually transmitted HIV infection (Cameron et al., 1989; Plummer et al., 1991; Wasserheit, 1992; Laga et al., 1993). The role and impact of improved STD prevention on HIV transmission needs to be included in national HIV prevention strategies.
Many physicians and other health care professionals do not have adequate skills or training to obtain an accurate sexual history, diagnose and treat STDs, or counsel patients regarding high-risk sexual behavior (Stamm et al., 1982; Merrill et al., 1990; Boekeloo et al., 1991; MacKay et al., 1995). In addition, training and education programs for health care professionals in STD clinical management are inadequate.
Many screening and treatment services for STDs are currently provided through dedicated public STD clinics that are operated by public health departments. These STD programs traditionally have been oriented towards diagnosis and treatment but not towards prevention by behavioral interventions. The focus and role of these clinics have not been reexamined in light of recent developments in the delivery of health services and the epidemiology of STDs.
Changes in health care delivery and financing, especially the national trend towards managed care, coupled with recent initiatives to shift Medicaid populations into managed care plans, may have a significant impact on the delivery of public health services, including STD-related services. Roles and responsibilities of the public and private health sectors and of primary care professionals in providing these services need to be redefined.
In light of these developments, the IOM convened the 16-member Committee on Prevention and Control of Sexually Transmitted Diseases to examine these issues. Committee members include nationally recognized experts in one or more of the following fields: epidemiology, behavioral and social sciences, infectious diseases, public health, pediatrics, women's health, STD program management, family planning, health services administration, and health care policy. The committee was charged to "(a) examine the epidemiological dimensions of STDs in the United States and factors that contribute to the epidemic; (b) assess the effectiveness of current public health strategies and programs to prevent and control STDs;2 and (c) provide direction for future public health programs, policy, and research in STD prevention and control. 3"
Although the committee examined the effectiveness of major strategies and programs in STD prevention, it did not conduct a systematic, in-depth evaluation of every STD-related program in the public and private sector. In this report, the committee focuses its discussions on effective strategies and highlights major effective programs.
The terms "STD prevention" and "STD control" have been traditionally used by public health workers without clear distinction. These terms have been commonly used to refer to behavioral interventions (e.g., counseling for behavior change), treatment of symptomatic disease, and other interventions that prevent the spread of infection (e.g., partner notification). The committee believes that most interventions for STDs both "prevent" and "control" STDs, and all prevent acquisition or transmission of STDs in a population. Essentially, effective prevention of STDs brings STDs under control. Therefore, in this report, the committee uses the term ''STD prevention" rather than "STD prevention and control" to encompass all interventions, whether behavioral, curative, environmental, or otherwise, that are needed to reduce the spread of infection in a population.