put all individuals at risk. Race- and ethnic-specific rates of STD should not be used to stigmatize specific groups as high-risk populations, but rather they should be used to justify adequate attention and allocation of resources to reduce STD rates among these population groups. The committee recognizes that by its emphasis on behaviors common among all groups, it is possible that funds may be diluted and redirected away from certain high-risk communities to more general, lower-risk populations. The committee, however, does advocate focusing interventions on certain high-risk groups as discussed later in this section. The notion of focusing on behaviors that put all persons at risk rather than certain high-risk groups is reflected in current health policies. For example, the recommendation to screen all pregnant women for HIV, rather than screen only certain groups of pregnant women, reflects the notion that all pregnant women have had unprotected sexual intercourse. In order to appropriately address target behavioral risk factors, however, surveillance of sexual behaviors and STDs is essential.

Most of the research regarding drugs, alcohol, and STD transmission cited in Chapter 3 is cross-sectional in nature and does not allow for determination of cause and effect. The committee, therefore, cannot definitively estimate the impact of substance use on STD transmission. The associations between drug and alcohol use and STD transmission, however, are substantial and have important implications for improving STD prevention. Substance use increases the risk of STDs on an individual level by making it more difficult for persons to take protective actions against STDs. In the case of crack cocaine, drug use not only increases personal risk for STDs, but also has an effect on the prevalence of STDs in certain communities by altering social structures. An increased emphasis on outreach services for substance users is indicated because health services for such persons are fragmented and often not accessible. STD prevention efforts need to include individuals who are at risk for substance use and specifically target venues where substance users can be effectively reached with tailored interventions.

The increasing number of persons in correctional facilities represents a growing pool of people at risk of STDs and a potential source of infection for others when inmates are released. Data cited in Chapter 3 indicate that screening and treatment of all prisoners and detainees is an important public health strategy for the following reasons: (a) the prevalence of STDs is extremely high in this population; (b) treatment may reduce the spread of STDs in the community once detainees are released; (c) detention represents an ideal opportunity to screen for health problems in a population that does not ordinarily have access to health care; and (d) treatment reduces spread of STDs within detention facilities and averts associated long-term health care costs. Rapid screening and treatment of persons in detention facilities represent an opportunity to effectively contain STDs in a high-risk group. Because of lags in obtaining laboratory results, rapid turnover of detainees, poor treatment compliance, drug contraindications during pregnancy, and other issues, the optimal screening and treatment program for

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