Gear up to fight STD hidden epidemic’

It’s going to take a full-scale assault to fight what’s been termed the "hidden epidemic" of sexually transmitted diseases (STDs), and family planning clinicians are being called to lead the battle.

"It’s important for family planning clinicians to be advocates for STD prevention, because who else is going to do it? What other group will?" asks Felicia H. Stewart, MD, director of reproductive health programs at Kaiser Family Foundation in Menlo Park, CA. "Don’t think that [patients with STDs] are going to get out there. It’s doubly important for us in the health care field, since it’s our patients who are wounded by these diseases."

According to the recently released The Hidden Epidemic: Confronting Sexually Transmitted Diseases, five of the United States’ top 10 most frequently reported diseases in 1995 were STDs.1 The report represents the findings of the Committee on Prevention and Control of Sexually Transmitted Diseases, a panel of public health experts convened by the Institute of Medicine (IOM) in Washington, DC.

Three important messages

Stewart, whose organization served as a sponsor of the report, says family planning clinicians need to take home three important messages from the IOM committee’s findings:

• STDs are more common and serious than even health professionals had been aware of.

• STDs can be cured or treated — and it’s much more cost-effective to detect and treat them than to deal with their outcomes.

One of the more striking findings from the study comes from a mathematical model developed by Canadian scientist Marie-Claude Boily of the Center for Research at the Hospital of St. Sacrement and Department of Social and Preventive Medicine at the University of Laval in Quebec City. The model predicts that during 1990-1994, more than 86% and 95% of the heterosexual AIDS and HIV cases, respectively, in the United States could have been prevented by treating chlamydial infections.2 Because STDs compromise the mucosal surface of the genital tract, they may increase susceptibility to HIV. By detecting and treating chlamydia, the most common bacterial STD, exposure to HIV and AIDS would be lessened, the model projects.

• Public acceptance of STD prevention is strong, so don’t be afraid to discuss it, not only with your patients, but within your local communities, as well.

One way family planning clinicians can aid the STD fight is to move STD screening higher up the priority list into every patient’s care, says Stewart. Many of your patients already may believe they are being tested for infections as a part of their annual exam.

"So we have a little bit of a don’t ask, don’t tell’ situation here, where the patients aren’t asking because they’re assuming it’s being done, and the clinicians aren’t asking because they may be reluctant to do so," Stewart notes.

Incorporate STD screening and counseling guidelines from the U.S. Preventive Services Task Force3 and the Centers for Disease Control and Prevention (CDC) into your standard practice, says Thomas R. Eng, VMD, MPH, IOM senior program officer and co-editor of The Hidden Epidemic. These guidelines are based on the age of the patient and risk category and allow clinicians to choose from specific recommended interventions to best meet their patients’ health needs.

Enhance your skills by attending courses at one of CDC’s diagnostic training session centers, suggests Joel R. Greenspan, MD, MPH, assistant director of the CDC’s division of STD prevention. These "centers of excellence," which help clinicians update their STD clinical skills, are located around the country, with distance-based learning available to transmit training via satellite for local inservice sessions. (For more information on the STD centers, see the resource list, this page.)

Partner treatment, dual protection key

It’s important to treat your patients for STDs, but what’s happening with their partners? The IOM committee advocates partner treatment to break the chain of STD transmission, says Eng.

"Partner treatment needs to be a standard of care wherever a woman is treated, whether it’s at a family planning clinic, STD clinic, or prenatal clinic," Greenspan concurs.

Remind your family planning patients that while they may be using an effective form of birth control such as oral contraceptives, unless they employ a second method, such as condoms, they remain at risk for STD infection, Eng suggests. Explain to them that no single method offers maximum coverage against unintended pregnancy or STDs, so dual protection is vital.

Americans are especially supportive when it comes to STD prevention and education for teens, one of the most affected populations. According to a Kaiser Family Foundation survey, 95% of those questioned think high schools should provide teens with information on STDs, and 53% support the availability of condoms in high schools to help teens protect themselves against such infections.4 More than 60% oppose recent federal and state legislative attempts to require teens to get their parents’ permission for STD testing.

With these findings in tow, family planners need to "take the message to the streets" by talking up STD prevention not only with patients, but also with community members, Stewart says. Share the information from the IOM report with people outside the reproductive health scene, such as civic organizations and church groups. Don’t pre-program yourself to receive torrents of opposition, because, as the study shows, the public is behind STD prevention.

"It’s true of many of the areas that we work in that the level of public support for efforts in tackling major public health problems, like STDs or unintended pregnancy, is very broad and very deep," Stewart notes. "It is just simply not as controversial as we often imagine it to be."

References

1. The Institute of Medicine. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Washington, DC: National Academy Press; 1996.

2. Boily M-C. "Transmission Dynamics of Co-existing Chlamydial and HIV Infections in the United States." In: The Institute of Medicine. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Washington, DC: National Academy Press; 1996.

3. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services. Second ed. Washington, DC: U.S. Department of Health and Human Services; 1996.

4. Kaiser Family Foundation. Kaiser Family Foundation Survey on Public Knowledge and Attitudes About STDs Other Than AIDS. Menlo Park, CA; 1996.