HIV/STD integration: New data help forge linkage

CDC plans new blueprint for coordinating services

When it comes to treating sexually transmitted diseases, the inconvenience patients must bear and the inefficiency providers put up with is notorious. A patient visiting an HIV clinic often can’t receive testing or treatment for syphilis, and the same holds true in reverse. But as the clinical and epidemiological links between HIV and other STDs have become more firmly established, coordination of services is being pushed more aggressively.

For more than a year, the Centers for Disease Control and Prevention has been discussing recommendations for STD and HIV "integration." The agency’s ideas on how services should be coordinated will be published later this year, as a first step in inaugurating a nationwide effort to speed the process up.

Judith Wasserheit, MD, MPH, director of the CDC’s division of STD prevention, prefers the term "coordination" rather than "integration," pointing out that the focus isn’t on organizational structure but on delivery of services.

"What we are talking about is how we can better harness what we now know about STD detection and treatment to improve HIV prevention, and how to translate that knowledge into services at the user end," she tells AIDS Alert. "That means actually providing routine STD detection and treatment for individuals who are HIV-infected or HIV high-risk without having them go to three different places and 12 different providers."

In efforts to spread the growing recognition that effective STD prevention is an essential part of effective HIV prevention, the CDC plans to publish in its Morbidity and Mortality Weekly Report a document that will help guide policy and practices for STD/HIV coordination, synthesizing the growing body of evidence showing how the two are interconnected.

"We see it as the leading edge in trying to move providers and policy-makers in this new direction — new, unfortunately, for the United States," she explains.

The guidelines are an outgrowth of research on the impact of co-infection with HIV and other STDs, coupled with a changing epidemiology in this country for HIV. "There is a recognition that the HIV epidemic in the U.S. is beginning to look more and more like the epidemic in a lot of the developing world," Wasserheit explains. "Rates are stabilizing among gay and bisexual men, while the most sharp increases are in heterosexuals."

With heterosexual contact, STD infection becomes more pertinent to HIV infection than for sexual contact between men, where anal sex is such an overwhelming risk factor, she adds. Indeed, the linkage between HIV and STD prevention has been much stronger in other countries, and recent studies have documented this synergy. (See story, p. 29.)

"We now have very compelling data from four countries, including North America, indicating that doing an effective job on STD prevention is one of the key strategies for HIV prevention," Wasserheit says.

The data also coincide with an emphasis on treating and reporting HIV as early as possible after transmission, and with concerns that successful treatment with protease inhibitors is resulting in relapses to unsafe sex.

Finally, last year’s publication of The Hidden Epidemic, a report from the Institutes of Medicine (IOM) confronting the growing health and economic burden of STDs in the United States, garnered widespread publicity on how STD programs and services are underfunded.1 Recommending an independent, long-term national awareness campaign for STDs, the report pointed out that only $1 of every $43 spent on STD programs each year goes toward prevention, and that the United States spends less on STD programs than other industrialized nations.

The report comes at a time when some STDs in this country are at their lowest rates in decades, while others are reaching epidemic proportions. Cases of chlamydia and genital herpes, both of which have been linked to increasing the risk of HIV transmission, are at their highest levels ever. On the other hand, after a nationwide epidemic that peaked in 1990, primary and secondary syphilis has reached the lowest nationwide level since data for it started being reported more than 25 years ago. The success against syphilis has been so overwhelming that the CDC is talking of implementing a plan to eliminate the disease in the United States, possibly within the next decade, Wasserheit adds. (See STD rates, above.)

As the first step toward what could become the establishment of guidelines for integrating STD/ HIV programs, the CDC document planned for publication is seen by many STD/HIV experts as an important and timely response.

A preliminary draft of the document was presented to the CDC’s Advisory Committee for AIDS and STD Prevention in November, at which time its members expressed concerns that it was heavy on surveillance and technical information and light on practical steps an STD or HIV program should take to become more integrated.

"There should be additional, practical steps around the assessments that programs would use. For instance, how do you actually identify co-infection of HIV and STDs, particularly in a state like California, where HIV is not reported?" asks Gail Boland, MD, chief of the STD control branch for the California Department of Health Services.

Boland also expresses concern that unless more funding becomes available for integrating HIV and STD services, one STD may compete against another. As an example, she mentioned how the California correctional system recently began a chlamydia screening project but lacked funds to test all prisoners. If a push came to screen men who have sex with men for gonorrhea or inflammatory STDs, it might take funds away from screening women for chlamydia, she notes.

Last year, Congress set aside an initial appropriation for starting several demonstration projects to reduce syphilis in areas with persistent high levels. Baltimore, for example, which has the nation’s highest syphilis rate at nearly 80 cases reported per 100,000 people, is receiving $710,000 this year in state and federal funds to control the emerging epidemic. As recognition grows regarding the importance of STD control in preventing HIV transmission, more funding should become available in certain subpopulations and geographic areas, Wasserheit predicts.

While more input — especially from state HIV and STD program directors — would be needed before a minimum-standards guideline is promulgated, several advisory committee members were adamant that the CDC should make a statement sooner rather than later.

"To just have the CDC say it is important to implement early diagnosis and treatment of STDs as one way of reducing HIV transmission would be an enormous step," notes King Holmes, MD, PhD, director of the Center for AIDS and STD at the University of Washington in Seattle and consultant for the IOM’s report.

The document also might increase its scope by adding a section that would provide a detailed list of activities that represent minimal components of an effective STD program. Such a list would include HIV counseling and education, as well as STD education outreach to schools, juvenile detention centers, prisons, and managed care organizations, he adds.

Holmes articulated what he called the four phases of evolution in STD/HIV integration — competition, communication, cooperation, and accommodation or integration. He saw the CDC as moving from the competition to the communication stage.

Programs often lack true partnership’

For those few state and local health programs that have evolved to the coordination stage, it is "often coordination in the sense of filing environmental impact statements — what the implication of an HIV program is in an STD area as opposed to coordination in the sense of true partnership," he says.

As an example, he notes how his Center for AIDS and STD has moved toward sharing staff and facilities, such as having its CDC-funded STD prevention training center work more closely with its AIDS education and training center, which is funded by the Health Resources and Services Administration. Turf protections and jealousies, however, have made it difficult to cross lines in some cases, he adds.

One impetus for bringing the two programs closer together has been a recent National Institutes of Health policy stipulating that areas peripheral to AIDS research, such as STD research, are now classified as AIDS-related research, allowing STD research to qualify for AIDS research grants.

Changes in the program announcements for STD prevention grants at the CDC also reflect how quickly the agency is moving away from competition and toward cooperation. This year’s grant announcements to its 65 project areas have sections calling for all STD programs to focus on STD treatment as an HIV prevention strategy. A similar statement may appear in grants for HIV prevention, Wasserheit says.

While King recommends that STD and HIV programs be integrated by policy, such that program advancements be made jointly by both the divisions of HIV and the division of STDs, Wasserheit thought that was going too far.

"It may be politically correct to talk about integration as a panacea term, but it’s not clear to me that integration in and of itself is always a solution," she said at a CDC advisory committee meeting in November. "Most of us would feel that at the service level, things need to come together to form a user-friendly package, but there are pros and cons of integration at all levels, particularly when thinking about advocacy, resource improvement, and impact evaluation."

The amount of integration would depend on the type of services offered. As an example, she mentions that services overlap between the two programs when it comes to promoting healthy sex behaviors. However, in the clinical domain, there is less common ground.

Robert Wood, MD, medical director of the AIDS project at Seattle-King County Department of Public Health, which Wasserheit named as a good example of increased integration, agrees that combining the programs completely could weaken their individual strengths. Until recently, he notes, HIV/AIDS prevention has required a behavioral approach, and its efforts are a response in some degree to the recent decline in many STDs, which have been controlled primarily through a biomedical approach.

Reference

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