Report urges HIV and STD clinics to work closer

Condom distribution and television ads urged

After years of marginalizing sexually transmitted diseases (STDs) within STD clinics, greater cooperation is needed from HIV facilities and private physicians to help the clinics fight an epidemic that helps spread the AIDS virus and costs taxpayers more than $10 million a year.

"What I hope this report will do is generate some dialogue and greater collaboration between public health and private providers on all levels," says Kathleen Toomey, MD, state epidemiologist for Georgia. "Surprisingly, the relationship between STD and HIV prevention still has not become public or working knowledge."

Toomey sits on the Washington, DC-based Institute of Medicine’s committee on prevention and control of STDs. The committee recently released a report calling for a national initiative to reduce the U.S. rate for curable STDs, which is the highest among industrialized nations.

"We need to fight this hidden epidemic by bringing together entire communities to promote healthy sexual behaviors, protect adolescents, provide high-quality clinical services, and energize strong leadership in the fight against STDs," says committee chair William T. Butler, MD, chancellor of Baylor College of Medicine in Houston.

The report points out the lack of an effective national system to combat STDs, even though five of the 10 most common diseases reported to the Centers for Disease Control and Prevention last year were STDs. Although all STDs are preventable, only $1 is spent to prevent STDs for every $43 spent for treatment and other costs.

"We plan to take this report very seriously," Judith Wasserheit, MD, director of the CDC’s division of STD prevention, tells AIDS Alert. "Some of the best minds in STD prevention have worked on this for 18 months, so we really need to sit down and think about how we can move forward to it."

Because the public sector is hampered by resource constraints and the logistics involved in fully implementing a national system of STD-related services, it is critical that private-sector organizations and clinicians assume more leadership and responsibility for STD prevention, Wasserheit says.

"The basic message — that there needs to be more societal will to address STDs as a broader set of issues in the context of sexual health — is something we see as very positive," Wasserheit says. "The response has to go beyond the health sector to include educators, media, lay community leaders, and religious community leaders — a mix that to date really has not been brought effectively to the table in dealing with STDs."

Federal, state, and local governments, as well as the private sector, should increase funding and support for prevention, and ensure that all people have access to comprehensive, high-quality STD-related services, the report says. The CDC should take the lead in improving surveillance of STDs and their associated complications, and collaborate with state and local agencies to monitor the effectiveness of prevention programs.

Syphilis linked to HIV in Southeast

Better control of STDs is imperative to preventing the spread of HIV, CDC officials say. For example, the syphilis epidemic in 1990 is believed to be directly responsible for the waves of HIV infection reported in the Southeast (through exposure from syphilis lesions). Although the national rate for syphilis is just over 6 per 100,000, it is 20 per 100,000 in the Southeast. Trends in non-HIV STDs, such as rectal gonorrhea, also act as indirect markers for HIV transmission in gay communities. But there currently is no reporting of rectal gonorrhea at the state level, Wasserheit points out.

The report comes out when both syphilis and gonorrhea rates are at historic lows in this country, yet their rates are still higher than in other industrialized countries.

"What this is says is the biological, biomedical, and behavioral intervention tools are there. Other countries have done this, and in fact, in parts of this country we have managed to do it," Wasserheit explains. "But we have a lot more to do, and it’s going to take the incremental jump that is called for in the report."

One of the first areas of improvement is in chlamydia control and prevention. Chlamydia is the most common bacterial STD in the country, yet there is no national chlamydia prevention program because of the failure to commit resources to it, Wasserheit says.

Effective prevention of these diseases also requires greater responsibility on the part of health plans — including managed care plans — which should take steps to integrate treatment and prevention of STDs into the mainstream of primary care, the report says. With few exceptions, health plans do not place high priority on STDs, and few plans are involved in activities to prevent STDs in the larger community beyond plan members, the report says.

Health plans should provide better training for primary care providers, and they should provide for or cover comprehensive STD-related services for all plan members and their sex partners, regardless of the partner’s insurance status. Services should include screening, diagnosis, treatment, and counseling on how to avoid risky sexual behavior.

"Private physicians have the potential to be very active players in STD prevention, but they may not have the training they need," Toomey says. "Many providers don’t have a comfort level with the discussion of sexuality or sexual issues."

Addressing the wide variability in quality of STD treatment at public facilities, Toomey notes how STD clinics historically have been isolated from other health services. While public STD clinics should continue to function as "safety net" providers of services, health departments operating these clinics should collaborate with other community-based health providers, and pursue partnerships with university and hospital medical centers and private health care professionals, the report says.

Developing a closer relationship between STD and HIV clinics also is imperative, Toomey says. She mentions a recent study of women in Tanzania showing that treatment of non-HIV STDs lead to a 40% decline in HIV as well.

"There is still a tendency to marginalize HIV as someone else’s problem," she says. "In many state health departments the AIDS program and the STD program are two separate programs."

Because AIDS is a high-profile disease, it has overshadowed other STDs and made it difficult to compete for prevention dollars, Toomey notes. The committee, she adds, took a strong stance against federal block grants to states because "if you go head to head with AIDS there is no way that STD prevention activities will ever be able to win."

With one-quarter of the 12 million new STD cases each year occurring among adolescents, the report emphasizes the need to focus STD prevention efforts on adolescents, offering them better access to health services (one quarter of adolescents and young adults have no health insurance) and more education about STDs.

The report notes that by the 12th grade, nearly 70% of adolescents have had sexual intercourse, and approximately one-quarter of all students have had sex with four or more partners. Adolescents should be strongly encouraged to delay sexual intercourse until they are emotionally mature enough to take responsibility for it, the report says. However, many adolescents will be sexually active, and it is critical that they also have access to information about STDs and ways to prevent them.

The report recommends that all school districts in the United States ensure that schools provide age-appropriate services, including health education, access to condoms, and clinical services to prevent, diagnose, and treat STDs. School districts should require that information on prevention of STDs and unintended pregnancy be part of a health education curriculum that is sequential, age-appropriate, and given every year. Condoms should be made available as part of a comprehensive STD prevention program, the report states, adding that there is no evidence that condom availability, or school-based education programs to prevent STDs, promote sexual activity.

Leaders must send positive messages

Because prevention of STDs is linked directly to personal behavior, the committee recommended a national campaign to promote a new social norm of healthy sexual behavior in the United States. This campaign should be led by highly visible opinion leaders, including those in the entertainment industry, sports figures, and elected officials, to promote public discussion and awareness of healthy sexual behavior. The campaign should enlist public health experts, mass media, advertising executives, public communications experts, and consumer representatives to work to increase knowledge and awareness of STDs and to help mass media incorporate responsible messages about healthy sexuality.

The report recommends that television, radio, print, music, and other media organizations accept advertisements and sponsor public service messages that encourage condom use and other means of protecting against STDs and unintended pregnancy, including delaying sexual intercourse.

[Editor’s note: Copies of The Hidden Epidemic: Confronting Sexually Transmitted Diseases are available from National Academy Press by calling (202) 334-3313 or (800) 624-6242. The cost of the report is $45 (prepaid) plus shipping charges of $4 for the first copy and $.50 for each additional copy.]