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--> The Hidden Epidemic Confronting Sexually Transmitted Diseases Thomas R. Eng and William T. Butler, Editors Committee on Prevention and Control of Sexually Transmitted Diseases INSTITUTE OF MEDICINE Division of Health Promotion and Disease Prevention NATIONAL ACADEMY PRESS Washington, D.C. 1997
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--> National Academy Press 2101 Constitution Avenue, N.W. Washington, D.C. 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for this report were chosen for their special competencies and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. Funding for this project was provided by Centers for Disease Control and Prevention, Glaxo Wellcome, Inc., The Henry J. Kaiser Family Foundation, National Institute of Allergy and Infectious Diseases, NIH Office of Research on Women's Health, Ortho-McNeil Pharmaceutical, and SmithKline Beecham Pharmaceuticals. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organization or agencies that provide support for the project. Additional copies of this report are available from the National Academy Press, 2101 Constitution Avenue, N.W., Box 285, Washington, D.C. 20055. Call 800-624-6242 (or 202-334-3313 in the Washington metropolitan area), or visit the NAP on-line bookstore at http://www.nap.edu. Library of Congress Cataloging-in-Publication Data Institute of Medicine (U.S.). Committee on Prevention and Control of Sexually Transmitted Diseases. The hidden epidemic: confronting sexually transmitted diseases / Thomas R. Eng and William T. Butler, editors; Committee on Prevention and Control of Sexually Transmitted Diseases, Institute of Medicine, Division of Health Promotion and Disease Prevention. p. cm. Includes bibliographical references and index. ISBN 0-309-05495-8 1. Sexually transmitted diseases—United States. I. Eng, Thomas R. II. Butler, William T. III. Title. [DMLM: 1. Sexually Transmitted Diseases—prevention & control—United States. 2. Sexually Transmitted Diseases—epidemiology—United States. 3. Health Policy—United States WC 144 159 1997] RA644.V4I495 1997 614.5'47'0973—dc21 DNLM/DLC for Library of Congress First Printing, April 1997 Second Printing, July 1998 97-4218 CIP Copyright 1997 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staalichemuseen in Berlin.
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--> Committee on Prevention and Control of Sexually Transmitted Diseases William T. Butler,* Chair,Chancellor, Baylor College of Medicine, Houston, Texas Nancy E. Adler,* Director, Health Psychology Program, and Vice Chair, Department of Psychiatry, University of California, San Francisco, California E. Richard Brown, Director, Center for Health Policy Research, and Professor of Public Health, School of Public Health, University of California, Los Angeles, California Virginia A. Caine, Director, Marion County Health Department, Indianapolis, Indiana David D. Celentano,Professor of Social and Behavioral Sciences, Department of Health Policy and Management, Johns Hopkins University School of Hygiene and Public Health, Baltimore, Maryland Paul D. Cleary,*Professor of Health Care Policy and Social Medicine, Harvard Medical School, Boston, Massachusetts Margaret A. Hamburg,*Health Commissioner, New York City Department of Health, New York, New York King K. Holmes,* Director, Center for AIDS and STD, and Professor of Medicine, University of Washington, Seattle, Washington Edward W. Hook III, Professor of Medicine and Epidemiology, Schools of Medicine and Public Health, University of Alabama, Birmingham, Alabama Loretta Sweet Jemmott,Associate Professor of Nursing, and Director, Office of HIV Prevention Research, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania Dorothy Mann, Executive Director, Family Planning Council, Philadelphia, Pennsylvania Patrick H. Mattingly,Senior Vice President of Planning and Development, Harvard Pilgrim Health Care, Brookline, Massachusetts Kathleen E. Toomey,State Epidemiologist and Director, Epidemiology and Prevention Branch, Division of Public Health, Georgia Department of Human Resources, Atlanta, Georgia A. Eugene Washington, Professor and Chair, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, California * Institute of Medicine member.
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--> Catherine M. Wilfert, Professor of Pediatrics and Microbiology, Department of Pediatrics, Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina Jonathan M. Zenilman,† Associate Professor of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland Staff Thomas R. Eng, Senior Program Officer Leslie M. Hardy, Senior Program Officer (through July 1995) Jennifer K. Holliday, Project Assistant Marissa Weinberger Fuller, Research Associate Michael A. Stoto, Director, Division of Health Promotion and Disease Prevention † Served through September 1995.
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--> Preface This report focuses on the hidden epidemic of sexually transmitted diseases (STDs) in the United States: the reasons why it has not been controlled, and what we, as a nation, need to do differently to confront this problem. The main objective of this report is to educate health professionals, policymakers, and the public regarding the truths and consequences of STDs in the United States. This report is also a call for a bold national effort to prevent these diseases. Through this report, we hope to improve awareness and knowledge regarding the scope and impact of STDs and demonstrate why all Americans should be concerned about these diseases. At a minimum, we hope to ignite open discussion in both private and public arenas regarding STDs and their prevention. We believe that encouraging open discussion around STD prevention will eventually lead to greater understanding, closer cooperation, improved STD-related services, and lower rates of STDs in the United States. THOMAS R. ENG, STUDY DIRECTOR WILLIAM T. BUTLER, COMMITTEE CHAIR WASHINGTON, D.C. 1997
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--> Acknowledgments This report represents the collaborative efforts of many organizations and individuals, without whom this study would not have been possible. The committee extends its warm thanks to the organizations and individuals mentioned below. The staff of the following organizations and agencies provided critical advice and data in preparing this report: Advocates for Youth (Kent Klindera), the Agency for Health Care Policy and Research (David Atkins and Carolyn DiGuiseppi), Alan Guttmacher Institute (Pat Donovan, Jackie Forrest, Lisa Kaeser, and Dave Landry), the American Academy of Pediatrics (Victor Strasburger), the American Cancer Society, the American Medical Association, the American Social Health Association (Peggy Clarke, Joan Cates, and Nikki Vagnes), Association of Reproductive Health Professionals, Association of State and Territorial Health Officers, Center for Media and Public Affairs (Dan Amundson), the Centers for Disease Control and Prevention (Susan DeLisle, Shahul Ebrahim, Alan Friedlob, Joel Greenspan, Robert Johnson, William Kassler, William Levine, Judy Lipshutz, Frank Mahoney, Eric Mast, John Miles, John Moran, Craig Shapiro, Jack Spencer, Mike St. Louis, Cathleen Walsh, Judy Wasserheit, and Gary West), East Coast Migrant Health Project (Oscar Gomez), The Henry J. Kaiser Family Foundation (Suzanne Delbanco), National Association of Nurse Practitioners in Reproductive Health (Susan Wysocki), the National Cancer Institute, the National Center for Farm Worker Health (Bobbi Ryder), the National Commission on Correctional Health Care (Ed Harrison), the National Institutes of Health, Ogilvy Adams & Rinehart, Planned Parenthood Federation of America, Sexuality Information and Education Council of the U.S. (SIECUS)
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--> (Carolyn Patierno), State Family Planning Administrators (Lynn Peterson), and the World Health Organization (Antonio Gerbase and Kevin O'Reilly). The following colleagues also provided valuable assistance to the committee: Jane Brown, Margaret Chesney, Jim Kahn, Laura Koutsky, and Richard Rothenberg. The following persons generously shared their knowledge with the committee through their active participation in the committee workshops: Sevgi Aral, Cornelius Baker, Bobbi Baron, Marie-Claude Boily, Stanley Borg, Robert Bragonier, Allan Brandt, Ward Cates Jr., William Darrow, Gray Davis, Frank Beadle de Palomo, Caswell Evans, Jonathan Freedman, Mindy Thompson Fullilove, Carol Glaser, James Goedert, James Haughton, William Kassler, Paul Kimsey, Janet Kirkpartick, Edward Laumann, William Levine, Steve Morin, Kevin O'Reilly, Frank Plummer, John Potterat, Gary Richwald, Tracy Rodriguez, Philip Rosenberg, Alfred Saah, Marilyn Keane Schuyler, Stanley Shapiro, Sten Vermund, and Maria Wawer. The directors and staff of the following facilities and programs graciously hosted the committee during its site visits to Atlanta and Chicago. In Atlanta: The Center for Black Women's Wellness; DeKalb County Board of Health (Stuart Brown); Emory/Grady Teen Services Program; Fulton County Health Department STD Clinic (Ruby Lewis-Hardy and Pradnya Tambe); Georgia Department of Human Resources, Epidemiology and Prevention Branch (Jack Kirby and Mark Schrader); Grady Memorial Hospital Family Planning Program; Kaiser Permanente, Prevention and Practice Analysis Department; SisterLove, Inc., West Central Health District (Dee Cantrell); West End Medical Centers, Inc.; and Women's AIDS Project. In Chicago: Austin Community Academy Teen Health Clinic; Blue Cross Blue Shield of Illinois; Chicago Department of Public Health (John Wilhelm); Chicago STD/HIV Prevention Program (Romina Kee and Lisa Krull); Cook County Hospital HIV Primary Care Center, Smart Start Program, Women and Children HIV Program; Erie Family Health Center; Illinois Department of Public Health (John Lumpkin and Charlie Rabins); Night Ministry; Ounce of Prevention Fund, Toward Teen Health Program, Orr Adolescent Health Center; Planned Parenthood of Chicago; Stop AIDS Chicago; Vida Sida; and West Town Neighborhood Health Center, Young Adult Clinic. The following individuals participated in the planning meeting for the study: Charles Carpenter (chair), Peggy Clarke, Jim Curran, Mary Faye Dark, Gray Davis, patsy Fleming, Helene Gayle, H. Hunter Handsfield, Maurice Hilleman, Penny Hitchcock, Mark Hounshell, James Kahn, Lawrence Lewin, Heather Miller, Constance Nathanson, Geoff Nichol, Michael Osterholm, Nancy Padian, Thomas Quinn, Mark Smith, P. Frederick Sparling, Beth Unger, Judy Wasserheit, Roy Widdus, and Zeda Rosenberg. Of particular note, the following individuals directly contributed to the report by drafting commissioned papers in their areas of expertise. A review paper on the relationship between substance use and STDs by John Beltrami, Linda Wright-DeAguero, Mindy Thompson Fullilove, and Brian Edlin was critical to
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--> the report, and sections of their paper were replicated in the discussion of substance use and STDs. A paper by Jeffrey Kelly provided important background for the drafting of sections regarding behavioral interventions in STD prevention. Marie-Claude Boily's important work on modeling the impact of STDs on HIV transmission is included as an appendix. In addition, Joanna Siegel's major review of the economic costs of STDs was the primary basis for the committee's cost estimates and is also included in the appendix of the report. Numerous staff at IOM, the National Research Council, and the National Academy Press (NAP) contributed to the development, production, and dissemination of this report. Leslie Hardy served as study director during its first year; Marissa Fuller organized the committee's site visits and provided research assistance; Jennifer Holliday provided comprehensive administrative support; Mike Stoto, Karen Hein, and Ken Shine provided valuable advice and direction; Mona Brinegar handled the financial accounting of the study; Mike Edington provided editorial assistance; Claudia Carl and Janice Mehler coordinated the report review process; and Dan Quinn and Molly Galvin coordinated press activities. NAP staff included Dawn Eichenlaub (book production); Barbara Kline Pope and Brooke O'Donnell (marketing); Estelle Miller (page layout); Francesca Moghari (cover design); Terrence Randell (Internet listing); and Sally Stanfield (editor). In addition to IOM staff, we are grateful to Andrea Posner for her numerous valuable editorial contributions, to Caroline McEuen for copy-editing, to Kim Greene for assistance with the survey of managed care organizations, to Linnea Eng for proofreading, and to Mary Fielder and Ron Nelson for their research assistance. The following agencies and organizations and key staff generously provided funding and generated support within their institutions for this study: the Centers for Disease Control and Prevention (Jim Curran [now with Emory University], Helene Gayle, Jack Spencer, and Judy Wasserheit), Glaxo Wellcome, Inc. (Gray Davis), the Henry J. Kaiser Family Foundation (Suzanne Delbanco and Mark Smith), the National Institute of Allergy and Infectious Diseases of the National Institutes of Health (NIH) (Penny Hitchcock), the Office of Research on Women's Health of NIH (Vivian Pinn and Anne Bavier), Ortho-McNeil Pharmaceutical (James Kahn), and SmithKline Beecham Pharmaceuticals (Vincent Ahonkai, Paul Blake, and Geoff Nichol). Their willingness to sponsor a study on the prevention and control of sexually transmitted diseases is no small commitment, given the sensitive and controversial nature of this public health issue. Their encouragement and support are gratefully acknowledged.
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--> Contents Executive Summary 1 1 Introduction and Background 19 Study Methods 22 Focus of Report 23 Focus of Chapters 24 2 The Neglected Health and Economic Impact of STDs 28 Broad Scope and Impact of STDs 30 Health Consequences of STDs 41 Impact of STDs on HIV Transmission 49 Economic Consequences of STDs 58 Conclusions 60 3 Factors that Contribute to the Hidden Epidemic 69 Biological Factors 69 Social Factors 73 Secrecy as a Contributing Factor 86 Conclusions 107 4 Prevention of STDs 118 Issues in Prevention 118 Reducing Exposure and Transmission 123 Reducing Duration of Infection 157 Conclusions 163
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--> 5 Current STD-Related Services 175 Clinical Services 175 National Surveillance and Information Systems 196 Training and Education of Health Professionals 204 Funding of Services 208 Conclusions 214 6 Establishing an Effective National System to Prevent STDs 220 Laying the Foundation for a National System 222 Strategy 1: Promote Healthy Sexual Behaviors 232 Strategy 2: Develop Leadership 241 Strategy 3: Focus on Adolescents and Underserved Populations 261 Strategy 4: Ensure Access to Services 274 Collaborating to Improve Services 298 Concluding Statement 300 APPENDIXES A Sexually Transmitted Pathogens and Associated Diseases, Syndromes, and Complications 305 B Characteristics of Major STDs in the United States 311 C Transmission Dynamics of Coexisting Chlamydial and HIV Infections in the United States 316 D Estimates of the Economic Burden of STDs: Review of the Literature with Updates 330 E Summary of Empirical Studies of HIV Prevention Mass Media Campaigns 357 F Recommended Interventions During the Periodic Health Examination for the Prevention of STDs, U.S. Preventive Services Task Force, 1996 363 G Summary of Workshop on the Role of Managed Care Organizations in STD Prevention 370 H STD-Related Services Among Managed Care Organizations Serving High-Risk Populations 383 I Examples of Community-Based Programs for Providing Clinical Services for STDs 394 J Committee and Staff Biographies 400 Index 411
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The Hidden Epidemic
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