programs consider containment of STDs to be their primary mission, but collaborate with other public sector health programs infrequently and even less often with private sector health programs. Federal demonstration projects to prevent infertility associated with chlamydial and gonococcal infections, however, are beginning to improve service coordination among family planning clinics, dedicated public STD clinics, and public sector laboratories. In addition, private sector health care professionals often do not recognize the importance of their role in preventing STDs.

The lack of an effective system is particularly acute for noncurative prevention programs for STDs, which are far less developed than programs for curative services. In addition, despite the interrelationship between STDs, HIV infection, unintended pregnancy, and cancer, prevention programs for these health conditions are typically neither integrated nor coordinated.

The fragmented system of STD-related services directly hinders effective prevention of STDs in many ways. For example, as described in Chapter 5, the national surveillance system collects information regarding reportable STDs among persons who use public STD clinics and community-based services. However, information about the privately insured population is incomplete because many private clinicians do not report STD cases and some cases are presumptively treated. Without a comprehensive system for surveillance that involves all potential caregivers for STDs, it is difficult to accurately monitor disease trends or effectiveness of interventions.

A fragmented system of clinical services can result in lapses in coverage and ineffective treatment. As documented in Chapter 5, STD-related clinical care is provided by a variety of clinicians in many settings, and the training of these clinicians, including physicians, in diagnosis, treatment, and prevention of STDs is inadequate. Despite the growing role of private sector primary health care professionals in delivering services, there are large gaps in health professional school training and continuing education regarding STD-related skills. Inadequate training and poor awareness of STDs perpetuates the lack of involvement in prevention activities, such as evaluation and treatment of sex partners, by health plans and private practice clinicians. Inadequate training and poor awareness of STDs among health care professionals also result in clinicians who may fail to diagnose and treat STDs or do not have the skills or confidence to promote behavior change in their patients. The failure to adequately diagnose and treat STDs or become involved in certain prevention activities, therefore, leads to lost clinical opportunities to prevent STDs, and thus, to incomplete or fragmented clinical services.

As discussed in Chapter 5, because health plans do not assume responsibility for those who are not plan members, there is no assurance that sex partners of infected plan members will receive appropriate evaluation and treatment. In prisons and jails, prisoners may be screened and found to be positive for an STD, but may be released before treatment is given. Without linkages to community providers,



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