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A prescription for sexually transmitted diseases.

Sexually transmitted diseases (STDs) pose a growing threat to America's public health. Twelve million new cases occur each year; in addition, an estimated 56 million Americans are infected with incurable viral STDs other than AIDS. At current rates, at least one in four Americans will contract an STD at some point in his or her life.

The country's STD rates are among the highest in the industrialized world. In most industrialized countries, syphilis and gonorrhea have virtually disappeared. In the United States, however, infectious syphilis is at its highest level in 40 years. The incidence of other STDs has increased even more dramatically: Chlamydia, which was relatively unknown a decade ago, has become the nation's most common STD, with 4 million new cases per year. Doctor visits for treatment of genital herpes and genital warts have also risen sharply since the mid-1960s.

Some of the most common STDs are not curable: Herpes, human papilloma virus (HPV), which causes genital warts, and hepatitis B are, like AIDS, caused by viruses and can result in chronic infection. Bacterial infections, which include syphilis, gonorrhea, chlamydia, and trichomoniasis, can be cured once they are detected; the problem is that all too often they go undetected until serious symptoms develop. Thus, bacterial as well as viral STDs can have serious, even life-threatening complications, including infertility, ectopic pregnancy, several types of cancer, liver disease, and recurrent or chronic pain. Some can also significantly increase an individual's risk of becoming infected with HIV if he or she is exposed to the virus.

In addition to taking a toll in human suffering, STDs cost society more than $5 billion per year in direct and indirect expenses. Clearly, prevention of STDs, early diagnosis, and treatment are major public health imperatives.

Yet the federal program designed to combat the spread of STDs does not adequately address many of these needs. The program targets resources to historically prevalent STDs, when other infections have become far more common. It focuses on treating infected individuals and notifying their sexual partners, rather than helping people avoid infection in the first place. It allocates resources in a way that fails to reach many women, who are far more likely than men to suffer serious problems if an STD is not diagnosed and treated early. Finally, the program lacks sufficient funding to effectively combat the current array of serious infections.

In light of the dramatically expanded spectrum of STDs in recent years, Congress and the STD program's administrator, the Centers for Disease Control (CDC), should reassess strategies, priorities, and funding, with a view toward making the program more effective in addressing today's problems.

Widespread risk

Until the early 1980s, the roster of recognized STDs included only five infections: syphilis, gonorrhea, chancroid, lymphogranuloma venereum, and granuloma inguinale. Today, more than 50 organisms and syndromes are known to be transmitted sexually, and some STDs have become extremely common. Whereas certain diseases, especially syphilis and gonorrhea, are particularly widespread among low-income racial and ethnic minority populations, other infections, including chlamydia, HPV, and genital herpes, are diffused throughout the population. The assumption that STDs are confined to prostitutes, immigrants, the urban poor, and--with the advent of AIDS--drug addicts and homosexuals, is simply wrong.

Studies have found, for example, that up to 5 percent of middle-class pregnant women and 8 percent of female college students are infected with chlamydia. Several small studies of female college students seeking routine gynecological services indicate that anywhere from 17 percent to 46 percent have HPV. Many of these young women are infected with a strain of the virus strongly associated with cervical cancer and other genital cancers. Some STDs, including syphilis and chlamydia, are increasing rapidly among teenagers of all incomes, races, and ethnic groups.

Anyone who is sexually active, which includes virtually all adults and more than half of adolescents ages 15 to 19, can acquire an STD. Certain behaviors, however, greatly increase an individual's degree of risk. For example, individuals who have multiple sexual partners--either over a given period in their lives or over the course of their lifetimes--increase their risk of encountering a person who is infected with an STD. Most Americans fall into this category: On average, American adults have seven lifetime partners. In a study of women ages 15 to 44 who had had sexual intercourse, two-thirds had had more than one partner, and most had had at least four partners.

In addition, some drug users, especially users of crack cocaine, support their addiction by trading sex for drugs, which often results in sexual contact with a large number of partners. Teen-age girls who have become dependent on drugs will often turn to this practice. Along with prostitution, this behavior obviously increases the risk of exposure to STDs and, in fact, is implicated in the rise of syphilis and gonorrhea in the inner cities.

There is compelling evidence that using condoms significantly reduces a person's chances of acquiring an STD. Yet most people who have multiple partners do not use condoms. In one recent study, for example, only 17 percent of heterosexual adults who had multiple sexual partners used condoms all the time; nearly 40 percent never used them.

It is also important to recognize that women are more susceptible to infection than men. Once they are infected, the consequences of infection are likely to be more severe. That is because women are less likely to experience symptoms; as a result, they are far more likely than men to suffer serious complications from undiagnosed infections.

Each year, for example, more than 1 million women suffer an episode of pelvic inflammatory disease (PID), which occurs when a cervical infection, usually caused by chlamydia or gonorrhea, ascends to the uterus, fallopian tubes, or ovaries. An estimated 100,000 to 150,000 American women become infertile each year as a consequence of an STD infection that developed into PID. In addition, women who have had PID are 6 to 10 times as likely as other women to have an ectopic pregnancy, a potentially life-threatening condition in which a fertilized egg cannot pass into the uterus because of scarring in a fallopian tube and instead implants in a tube or, more rarely, in an ovary or another part of the abdomen. Ectopic pregnancy is a major cause of maternal mortality in the United States and is the leading cause among black women. About half of the more than 88,000 ectopic pregnancies that occur annually are caused by previous STD infections and their complications.

Infected women can also transmit an STD to their offspring during pregnancy or childbirth, sometimes with devastating results. Chlamydia, for example, can cause premature labor and delivery; it can be transmitted to the child and is a major cause of infant pneumonia, which is potentially life-threatening and can lead to long-term respiratory complications. Gonorrhea can cause blindness, meningitis, or septic arthritis in infants who are infected during delivery. About 25 percent of babies born to mothers with active syphilis will die. In all, between one-quarter and two-thirds of pregnant women with serious, active STD infections will have miscarriages or stillbirths, or will deliver babies who are premature, of low birth weight, or infected with an STD themselves.

Five steps to reform

The national program to combat the spread of STDs began in 1938 with enactment of the National Venereal Disease Control Act. Today, the program is administered by the Division of STD/HIV Prevention, part of the CDC's National Center for Prevention Services. It provides financial and technical assistance to state and local health agencies to support STD and HIV testing, partner notification, disease surveillance, risk reduction education, epidemiological and behavioral research, training, and program evaluation. The CDC also develops guidelines for diagnosis and treatment of STDs.

Although awareness of the number of STDs and the scope of the problems they present has increased substantially in recent years, the program continues to rely on strategies that have been used for decades. Some of these strategies need to be updated to better reflect today's problems.

Broaden the disease focus. Syphilis and gonorrhea have always dominated the federal STD program and continue to do so, despite the fact that other potentially serious STDs are now more common. In fiscal year 1992, syphilis received about 43 percent of the available funding. This reflects the CDC's decision in 1990 to make reduction of infectious syphilis a priority because of its link to HIV transmission and the severe consequences for children born to infected mothers. Another 29 percent of the budget was targeted to gonorrhea. By contrast, chlamydia received 27 percent of the budget, even though it is 90 times more common than infectious syphilis and four times more common than gonorrhea. It is also considerably more likely to be asymptomatic, and the consequences of an undiagnosed infection can be severe.

The CDC has recognized the dimensions of the chlamydia epidemic for nearly a decade, yet it has not implemented a national control program. In part, this is because of a lack of resources: The CDC estimates that such a program would cost from $50 million to $200 million. Another reason is that a simple, accurate, low-cost test for chlamydia became available only in the mid-1980s. Even today, however, many federally supported STD clinics do not routinely offer diagnostic or screening tests for chlamydia. (Similarly, most STD clinics do not provide Pap smears, which are an important tool in detecting precancerous changes in the cervix caused by HPV.) As the most prevalent and one of the most damaging of all curable STDs, chlamydia warrants significantly greater attention than it currently receives.

Focus on primary prevention. The STD program is basically a program aimed at disease control--what health officials term secondary prevention--rather than a primary prevention program. Instead of designing interventions to help individuals avoid infection, it focuses on activities aimed at reducing the pool of infection within communities. These include the testing of symptomatic individuals, treatment of those who are found to be infected (usually paid for by state and local health departments), and notification of their partners, who may be unaware of their exposure to an STD. The CDC has made no major effort to increase the public's awareness of STDs by providing information about the potential for transmission, the possible health consequences, or ways to minimize the risk of infection. Nor does it fund community-based organizations to carry out STD risk-reduction activities focused on at-risk individuals. At clinics, even basic primary prevention strategies, such as distributing condoms and advocating their use, often take a back seat to testing and treatment.

In part, the emphasis on secondary prevention reflects the program's historic focus on syphilis and gonorrhea, which can be cured with antibiotics, rather than on incurable viral diseases such as herpes and HPV. For these diseases, the only alternative is to prevent infection. Viral STDs, especially HPV, can have serious long-term consequences. Given the fact that persons infected with a viral STD can pass the infection on to their sexual partners for the remainder of their lives, the STD program should place greater priority on primary prevention.

Moreover, even when an STD can be treated, individuals with asymptomatic infections may not realize that they are infected and come in for testing and treatment. Because the consequences of untreated chlamydial and gonorrheal infections are so severe, primary prevention is important for these kinds of diseases as well. The CDC should develop interventions designed to persuade people at risk to change behaviors that may lead to acquiring an STD and to use condoms. These interventions should be tailored to specific target groups, taking age, gender, and cultural and ethnic background into account.

In contrast to the STD program, the much newer HIV program, which is also administered by the Division of STD/HIV Prevention, focuses heavily on interventions aimed at preventing infection by reducing or eliminating high-risk behaviors among individuals and by changing community norms concerning high-risk behavior. To accomplish these objectives, the agency funds a wide range of community-based organizations to develop and implement risk-reduction messages and other interventions aimed at specific populations who have an increased risk of HIV infection. Obviously, this priority on prevention reflects the fact that HIV cannot be cured and will eventually lead to AIDS and death.

To some degree, HIV prevention activities may have a beneficial impact on the incidence of all sexually transmitted infections, since all STDs have common behavioral roots. However, the CDC's national AIDS information campaign has been disappointing. Television spots intended to raise awareness about AIDS among teenagers, young adults, and individuals living outside large metropolitan areas did not mention sex or condoms and provided no information on how to prevent HIV transmission. Moreover, individuals who do not consider themselves at risk for HIV may dismiss or ignore messages that focus on HIV--a situation that may apply to most adults. According to a recent survey of AIDS knowledge and attitudes, 96 percent of persons 18 and older thought that their risk of acquiring HIV was low or nonexistent. There is no way of knowing whether this estimate is accurate, but if respondents make the same assumptions about their chances of contracting another STD, they are almost certainly understating their risk. The fact that most adults have several sexual partners over the course of their lives, that most people who have multiple partners do not use condoms, and that the pool of people already infected with STDs is so large significantly increases their chances of contracting an STD other than AIDS.

Expand access to STD services. One of the striking features of the federal HIV program is its support for screening in a wide variety of settings where people at risk for AIDS routinely seek medical care. The program funds counseling, testing, and referral services in free-standing HIV counseling and testing sites, family planning clinics, and drug treatment programs.

The STD program, by contrast, supports services provided almost exclusively in STD clinics operated by state and local health departments. There are about 4,000 STD clinics nationwide, ranging from freestanding facilities open five days a week to a space in a health department where STD services are offered a few hours a day, one or two days a week. Unquestionably, these clinics serve an important need; indeed, the demand often outstrips the clinics' ability to provide services. In some areas, as many as 25 percent of those seeking services have to be turned away and told to return the next day.

Even if STD clinics could serve everyone who appeared at their doors, however, they would not reach the majority of individuals who are at risk for an asymptomatic STD. Roughly two-thirds of clients at STD clinics are males; the female clients are generally partners of infected males who have been notified of their exposure and referred to the clinics. Although women are more severely affected by STDs, they generally do not go to STD clinics on their own initiative, either because they want to avoid the stigma associated with these infections or because they have no symptoms, or do not recognize the symptoms, and therefore do not realize that they are infected and need medical care.

On the other hand, millions of sexually active adult and teenage women regularly visit family planning and prenatal clinics and neighborhood health centers. Many of these community-based providers offer STD screening and treatment in the course of routine visits for contraceptive services, prenatal care, and other primary health services. In fact, studies indicate that access to family planning services is a key factor in the availability of STD services for women, especially women who are young or poor. Despite this, family planning clinics receive little or no support for these services.

The CDC is beginning to recognize that supporting a broader array of providers is crucial to slowing and reducing STD infection rates. But only recently has it begun to take even modest steps. More must be done.

Currently, the CDC is supporting two demonstration projects--one in Columbus, Ohio, and the other in Alaska, Idaho, Oregon, and Washington--that use a variety of providers to offer chlamydia screening. In both instances, chlamydia prevalence has declined significantly since the projects began. In the four western states, for example, the CDC is helping to support screening and treatment for more than 100,000 women and their partners annually in 150 family planning clinics. As a result, between 1988 and mid-1992, chlamydia infection rates dropped 54 percent.

Two other recent moves to expand access also indicate that the CDC and Congress are taking the subject more seriously. Beginning in fiscal year 1994, the agency hopes to award grants of up to $200,000 on a $2-for-$1 matching basis to as many as 22 state and local health departments willing to expand the availability of STD clinical services by collaborating with family planning, prenatal, and women's health clinics; migrant, community, and rural health centers; private providers; substance abuse programs; and prisons. The initiative depends, however, on an increase in the STD appropriation for fiscal year 1994.

In September 1992, meanwhile, Congress authorized a new program aimed at what the House-Senate conference report on the bill termed "the nationwide epidemic of chlamydia." Funding will go to state health departments as well as to other public and non-profit private agencies. No funds were appropriated for this year, however, because the legislation was approved after Congress had passed the fiscal year 1993 appropriations bill that funds the CDC.

Target teenagers. Every year, 3 million teenagers--one of eight young people between ages 13 and 19 and one of four who are sexually experienced--acquire an STD. Because such a high proportion of sexually active teenagers are infected, a teenager's likelihood of encountering an infected partner, even if he or she has only one partner, is higher than that of most groups of adults. A study in Atlanta, for example, found that 24 percent of adolescent women who had had only one sexual partner were infected with chlamydia.

In addition, some STDs, including chlamydia and gonorrhea, are more common among teenagers than among older men and women. And since these infections can result in infertility among women, the potential consequences of infection for young women are even more detrimental than for older women, who may have begun or completed childbearing.

Only one-third of sexually experienced women ages 15 to 19 are screened for an STD each year. Teenage males are probably even less likely to be screened, since they lack the formal access to reproductive health care available to young women through family planning and prenatal clinics. Thus, the STD program should earmark a share of its funds for services and other interventions aimed specifically at teenagers, much as the HIV program targets intravenous drug users. This could be done in settings such as adolescent health and family planning clinics and perhaps in school-based clinics.

One of the goals of the Public Health Service's Healthy People 2000 initiative is to cut STD infection rates by reducing the proportion of adolescents who are sexually active. Although this may be a worthy goal, measures to achieve it should not be substituted for the provision of services and risk-reduction messages aimed at teenagers who elect to become sexually active.

Increase funding. Over the past 30 years, federal funding has been the critical component in the campaign to control the spread of STDs. When federal support for syphilis control has increased, for example, a significant decline in the number of reported cases has followed. That trend has reversed when federal funding has been cut.

In fiscal year 1992, Congress appropriated $88.8 million for the STD program. Adjusted for inflation, however, this funding level was 23 percent below the fiscal year 1950 amount, despite the dramatic increase in the spectrum of STDs that has occurred since that time.

One solution would be to allocate existing funds more fairly, to reflect the varying rates of incidence among different diseases. But this approach would result only in robbing Peter to pay Paul. Indeed, that is precisely what has happened since 1989, as the CDC has shifted resources from gonorrhea and barely increased funding for chlamydia in order to address the alarming increase in syphilis. Similarly, a portion of current resources could be directed to family planning and prenatal clinics, community health centers, and other community-based providers. But this approach would weaken the ability of health departments to meet the demand for services at their STD clinics.

Given the dimensions of the problem, a substantial increase in funding will be necessary to significantly reduce the incidence and serious effects of STD infections. At a minimum, Congress should fund the new program targeting chlamydia at the full $25 million authorized last fall. Not only would this program focus on the most common STD, and the one that is especially problematic for women, but it would--unlike the regular STD program--provide funding for treatment as well as screening, and it would expand access to services by making funding available to a broad range of providers. The regular STD program also needs additional funding, but major increases must be accompanied by the fundamental changes in strategies and priorities outlined above. (Congress has yet to take up President Clinton's proposal in the fiscal year 1994 budget to increase funding for STD services by 16 percent, or $14 million).

As Congress considers ways of cutting the U.S. budget deficit and reforming the health care system, it should keep in mind that increased funding for STDs would be extremely cost-effective. For instance, the estimated costs of diagnosing and treating uncomplicated gonorrhea and chlamydia in women in 1990 were $71 million and $127 million, respectively. That is a fraction of the estimated $2.7 million in medical costs associated with treatment of PID, ectopic pregnancy, and infertility caused by gonorrheal and chlamydial infections that are not diagnosed early.

Broader involvement needed

Although federal leadership and funding are crucial in the campaign against STDs, the federal government cannot conquer this problem alone. State and local governments and other public and private institutions must become more involved.

In theory, CDC grants are supposed to supplement state and local funding for STDs, but in reality, some states contribute little or nothing to STD control efforts. Comprehensive information on current state and local STD prevention efforts is not available. In 1989, the last year for which statistics are available, the states reported spending $31.5 million on STD services. The CDC estimates that, together, state and local governments spend about $50 million annually on STDs (excluding HIV). Since the federal program is predicated on the assumption that state and local governments and other local providers will pay for treatment of STDs, if Congress appropriates additional funds for the CDC program, the states and localities may be expected to pay expanded treatment costs. Whether they can reasonably be expected to do so is difficult to assess without more comprehensive information about current funding.

Schools, meanwhile, should offer more complete and up-to-date education about STDs. This information must be presented before students are likely to become sexually active. Churches should develop appropriate programs for young people, and parent organizations can help inform parents and, through them, their adolescent children that HIV is not the only STD to worry about.

Medical schools and residency programs should expand their instruction on STD detection and treatment and establish rotations through STD clinics. As recently as the late 1980s, medical schools averaged less than one hour of classroom instruction on STDs, and only one in nine had an arrangement with an STD clinic in which students could receive firsthand training. Professional medical organizations should offer more opportunities for continuing education to increase their members' knowledge and clinical skills in recognizing and treating STDs. The involvement of private physicians in STD services is likely to become increasingly important if health care reform occurs in the next few years and preventive services receive greater emphasis.

Finally, pharmaceutical companies and pharmacists should promote condom use more effectively and aggressively. The media, particularly the national television networks, should reverse their bans on condom advertising.

If policymakers at all levels of government and leaders in the private sector commit significant attention and resources to the problem of STD prevention, and if they adopt policies that realistically address the needs of those at risk of contracting STDs, our society can significantly reduce both the incidence of sexually transmitted infections and the severity of their effects.
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Author:Donovan, Patricia
Publication:Issues in Science and Technology
Date:Jun 22, 1993
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