A report card for screening for sexually transmitted diseases: bis dat qui cito dat.

"To encourage right choices, we must be willing to confront the dangers young people face--even when they're difficult to talk about. Each year, about 3 million teenagers contract sexually transmitted diseases that can harm them, or kill them, or prevent them from ever becoming parents. In my budget, I propose a grassroots campaign to help inform families about these medical risks. We will double federal funding for abstinence programs, so schools can teach this fact of life: Abstinence for young people is the only certain way to avoid sexually-transmitted diseases ... Decisions children now make can affect their health and character for the rest of their lives."--President George W. Bush, State of the Union address, January 20, 2004.

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Few diseases have had the distinction of being mentioned by the president at the nation's highest and most important policy-making speech of the year. Diseases like anthrax and other agents of biologic warfare are certainly close to the heart of the national security team, for obvious reasons. HIV/AIDS has been mentioned countless times by presidents and high cabinet members at local, national, and international policy sessions, including the United Nations, because of the raging pandemic and its visible global consequences. But why did President Bush mention sexually transmitted diseases (STDs) in his 2004 state of the union address? It is crystal clear that this act by the president places STDs in the United States in the category of "high politics" and major national health priorities. This act is most commendable of the commander-in-chief, regardless of our differences of political affiliation.

STDs have been causing significant morbidity and mortality for years, as a hidden epidemic with very little attention at the national level. It is only with the advent of the human immunodeficiency virus (HIV) that STD control is now receiving higher priority in both developed and developing countries. (1,2) The indisputable fact that STDs produce serious economic, social, and health consequences--a fact made more clear by STDs' association with HIV--and the fact that all STDs are preventable and many curable, make it incumbent on governments, communities, and donors to meet the challenge of STD prevention and control. (2) The estimated yearly global incidence of curable STDs in 15- to 49-year-olds ranges from 1 to 2% in Western Europe to 3% in North America, and up to 11 to 35% in Africa. Among the World Health Organization-estimated 333 million annual new cases of curable STDs in adults, there are 12 million new cases of syphilis, 62 million new cases of gonorrhea, 89 million new cases of chlamydial infection, and 170 million new cases of trichomoniasis. (1) For several decades, STDs have ranked among the top five categories for which adults in developing countries seek health care services. (3) Although in Northern and Western Europe there has been a spectacular decline in the incidence of STDs, particularly gonorrhea and syphilis, the situation in North America is more variable, with increases continuing in inner-city minority populations. (4)

In developing countries, both the prevalence and incidence of STDs are still very high, with STDs making up the second cause of healthy life lost in women of 15 to 45 years of age after maternal morbidity and mortality. (5) In men, if HIV and other STDs are combined, sexually transmitted infections account for nearly 15% of all healthy life lost in this age group. (6) Five of the 10 most frequently reported diseases in the United States in 1995 were STDs, with approximately 15 million cases of STDs reported in the United States annually. (7) About 150,000 women in the United States died as a result of STD-related complications from 1973 through 1992. The economic burden of STDs on society is enormous, with an estimated cost of $17 billion annually. (8)

Sexually transmitted diseases include curable and incurable diseases. The common curable STDs are gonorrhea, chlamydial infection, syphilis, trichomoniasis, chancroid, lymphogranuloma venereum, and donovanosis. The STDs that are preventable but not curable are the viral STDs and include human immunodeficiency virus, human papilloma virus, hepatitis B virus, and herpes simplex virus. The clinical consequences of untreated STDs include pelvic inflammatory diseases, infertility (with its devastating psychosocial sequel), urethral stricture, cervical and anorectal cancers, and various multi-systemic complications of diseases like gonorrhea, chlamydial infection, and syphilis. (9) Pregnant women, children and adolescents are especially vulnerable groups. Adolescents are at greater risk for STDs because they frequently have unprotected intercourse, are biologically more susceptible to infection, are engaged in partnerships often of limited duration, and face multiple obstacles to utilization of health care. Younger adolescents (ie, persons aged less than 15 years) who are sexually active are at particular risk for infection. Despite the prevalence of STDs among adolescents, providers frequently fail to inquire about sexual behavior, assess risk for STDs and counsel about risk reduction, and screen for asymptomatic infection during clinical encounters. (9)

The prevention and control of STDs is based on the following five major concepts: 1) education and counseling of persons at risk on ways to adopt safer sexual behavior; 2) identification of asymptomatically infected persons and of symptomatic persons unlikely to seek diagnostic and treatment services; 3) effective diagnosis and treatment of infected persons; 4) evaluation, treatment, and counseling of sex partners of persons who are infected with an STD; and 5) pre-exposure vaccination of persons at risk for vaccine-preventable STDs. (9) Primary prevention of STDs begins with changing the sexual behaviors that place persons at risk for infection. Moreover, because STD control activities reduce the likelihood of transmission to sex partners, screening and treatment of infected persons constitutes primary prevention of spread within the community. Clinicians have a unique opportunity to provide all these services to their patients as part of the clinical interview. (9) A hard fact of life is the limitation clinicians have in preventing potentially detrimental sexual encounters, ie, those that increase the risk for STDs.

Our great opportunity lies in screening for this silent epidemic and preventing the aforementioned deleterious consequences. So how did we perform and why do we falter? Doctors Wimberly and Hogben in this issue of the Journal are providing us with a report card of our practice pattern as it relates to STD screening. (10) Their study, which is timely and in line with the president's message on prevention and control of STDs, was part of the 1999 to 2000 Centers for Disease Control and Prevention and Battelle Centers national probability-based survey of 7,300 physicians randomly selected from five American Medical Association specialties (general/family practice, obstetrics and gynecology, emergency medicine, pediatrics, and internal medicine). About 4,233 (70%) of physicians reached responded nationwide. Wimberly and Hogben focused their analysis on 1,306 (31.9%) of physicians practicing in the southern quadrant of the United Sates, based on the US Public Health Service categorizations. The southern quadrant states include Texas, Oklahoma, Arkansas, Louisiana, Mississippi, Alabama, Florida, Georgia, South Carolina, North Carolina, Tennessee, Kentucky, Commonwealth of Virginia, West Virginia, Delaware, Maryland and the District of Columbia.

The differences in physicians' screening rates for STDs as broken down by gender, race, and speciality are interesting. Gynecologists have a universal practice standard of screening pregnant women and thus may be more inclined to screen for STDs even outside pregnancy. Beyond practice standards, differences in curriculum content are important considerations. There is a clear need for strengthening of the curriculum of the various subspecialties relating to STD diagnosis, management, and screening. Wherever HIV/AIDS is mentioned, STDs should follow closely to ensure proper focus. Additional postgraduate training in public health-related programs should enhance the inclination of clinicians to screen more for various diseases including STDs. This study did not address this factor.

An unanswered question is the racial and gender differences in screening patterns for STDs. Are female physicians and African-American physicians more sensitive to or informed regarding the causes and effects of STDs? There is no evidence to suggest as much thus far on a large scale. More studies, particularly focus group analyses of various physician groups, are needed to further clarify this matter. Differences in the patient populations themselves, and the perceived susceptibility of various populations to STDs of varying severity might account for some differences in screening patterns among physicians. In addition, health systems factors--including adequate access to care, cost and medical insurance coverage for patients, and reimbursement for physicians--and the personal experiences of physicians must be explored as viable factors that dictate screening practices. The paper by Wimberly and Hogben also calls for routine screening for STDs in emergency departments, and increased reimbursement for screening in general. Mehta et al in Baltimore have shown the cost-effectiveness of large scale emergency department screening for STDs. (11)

In a study designed to evaluate the delivery of STD/HIV preventive services to adolescents by primary care physicians in the State of California, Millstein et al (12) showed that 40% of physicians reported screening all of their adolescent patients for sexual activity, and 31% reported educating all of their adolescent patients about STD/HIV transmission. For their sexually active adolescent patients, 36% of physicians always provided STD/HIV education, 17% always screened for the number of previous sexual partners, 12% always screened for sexual orientation, and 10% always screened for frequency of casual sex. In addition, they found that higher levels of preventive services delivery were associated with female physician gender, specialization in obstetrics-gynecology, and more recent date of medical school graduation. Physicians practicing in health maintenance organizations reported providing significantly higher rates of preventive services to sexually active adolescents than did physicians in private practice. Similarities can thus be seen with the current study.

Beyond accurate screening, counseling, diagnosis, and treatment, physicians are equally charged with the task of partner notification "contact tracing" handled directly or with assistance from state and local health departments, and accurate and timely reporting of STDs, while ensuring strict confidentiality for all clients in accordance with various statutory requirements. These additional responsibilities are vital for surveillance purposes and resources allocation. Physicians, while acting locally, must think globally, and thus strive in all ways possible to promote global intervention strategies for STD control. This must include considerations for migration and rapid urbanization, poverty and gender inequality, which foster the need for some women to turn to commercial sex as a means of survival. (13) In addition, the impact of civil insurrections, displaced populations along with war in many parts of the world, the absence of diagnostic and treatment services for STDs, and the impact of HIV on STD epidemiology all must be addressed. A particularly striking modeling of the dynamic effect of STD prevention or cure on subsequent HIV and STD rates illustrates a dramatic effect. By curing or preventing one hundred cases of syphilis among an STD high-risk (core) group, approximately 109 new HIV infections and 4,132 new syphilis cases could be prevented in the next ten years. (14) Thus is it clear that physicians who screen and treat for STDs do twice as much as those who only treat. Bis dat qui cito dat.

Constant attention by a good nurse may be just as important as a major
operation by a surgeon.
--Dag Hammarskjold

Accepted February 5, 2004.

Copyright [c] 2004 by The Southern Medical Association

0038-4348/04/9707-0619

Please see "Physicians' STD Diagnosis and Screening Practices in the South" on page 624 of this issue.

References

1. World Health Organization press release, WHO/64. Sexually transmitted diseases three hundred and thirty-three million new, curable cases in 1995. Geneva: World Health Organization, 1995.

2. Merson MH. Slowing the spread of HIV: agenda for the 1990s. Science 1993;220:1266-1268.

3. Technical report series no 810. Management of patients with sexually transmitted diseases. Geneva: World Health Organization, 1991.

4. Aral SO, Holmes KK. Sexually transmitted diseases in the AIDS era. Scientific American 1991; 264:62-69.

5. World Development Report 1993: investing in health. The World Bank. New York: Oxford University Press, 1993.

6. Weekly Epidemiologic Record. Geneva: World Health Organization, July 7, 1995.

7. Institute of Medicine. The Hidden Epidemic. Confronting Sexually Transmitted Diseases. Committee on Prevention and Control of Sexually Transmitted Diseases. Washington, DC: National Academy Press; 1997.

8. American Social Health Association. Facts and answers about STDs. Available at www.ashastd.org. Accessed on February 2, 2004.

9. Centers of Disease and Control and Prevention. Sexually Transmitted Disease Treatment Guidelines. MMWR May 2002;5:RR-6.

10. Wimberly YH, Hogben M. Physicians STD diagnosis and Screening Practices in the South. Southern Medical Journal 2004;97:624-630.

11. Mehta SD, Bisha D, Howell MR et al. Cost Effectiveness of five strategies for gonorrhea and chlamydia control among females and male emergency department patients. Sex Trasm Dis 2002;29(2):83-91.

12. Millstein SG, Igra V, Gans J. Delivery of STD/HIV preventive services to adolescents by primary care physicians. J Adolesc Health 1996; 19(4):249-257.

13. STDs: Global Burden and Challenges for Control. Family Health International. Available at www.fhi.org. Accessed on February 2, 2004.

14. Over M, Piot P. HIV infection and sexually transmitted diseases, in Jamison DT, Mosley WH, Measham AR, Babadilla JL (eds): Disease control priorities in developing countries. New York: Oxford University Press, 1993, pp 445-529.

Zakari Yusufu Aliyu, MD, MSC, MPH

From the Department of Global Health, George Washington University, Washington, DC, and the Department of Internal Medicine, Saint Agnes Hospital, Baltimore, MD.

Reprint requests to Zakari Yusufu Aliyu, MD, MSc, MPH, Attending Physician, Internal Medicine, Saint Agnes Hospital, Baltimore, MD 21229. EMail: [e-mail]