Infecting approximately 12 million Americans each year, sexually transmitted diseases (STDs) present a highly significant problem for this country. Providing STD prevention and control services requires care for individuals and attention to the general public -- both patient-based and population-based approaches. To reduce STD rates and costly complications of STDs, critical services must be available to every community. They must be developed and implemented in cooperation with the community. Cultural and language preferences should be observed to maximize involvement of those for whom services are intended. Some services can be provided in the private sector. Other services require government intervention because these activities can only be accomplished with legal power invested in public health agencies. A full complement of services includes:

1. Screening high-risk populations for prevalent STDs. Because the prevalence of STD infections varies from place to place, private sector providers may benefit from consulting with public health professionals on disease prevalence in their community in order to select cost-effective strategies for providing relevant STD screening services.
2. Treating individuals with diagnosed and presumptive infections. Recommendations of STD experts on treatment regimens for STDs should be readily available to health care providers. Quality assurance programs should be implemented to ensure that STD treatment is consistent with the state-of-the-art medicine.
3. Providing prevention counseling and education. Both public and private providers are needed to provide STD prevention counseling and education to individual patients in order to reach those affected by STDs. Such services are essential to reach sexual partners, to address future infections, as well as to ensure that medication is taken properly and that patients return for follow-up care. Community education about STD prevention is also important for beginning to change risky behavior before infection occurs.
4. Notifying, treating and educating partners of persons diagnosed with STDs. A sexual partner who has been exposed to an STD should be informed of his or her potential infection by the infected person, his or her health care provider, the provider's staff, or public health staff trained in partner notification. In most states, the law protects public health personnel in the notification process but does not protect other persons. Private providers and public health personnel may work together to provide sexual contacts with information on all aspects of needed care. Notification is a key step to prevent re-infection and further spread of STDs.
5. Reporting STD cases to assist in planning, evaluating, resource allocating, and coordinating efforts. Health departments monitor and analyze reported STDs to identify problems in specific communities, to evaluate the effects of control measures, and to detect changes in trends. Complete and accurate reporting is essential so that the partnership of private providers and public health personnel can appropriately address STD problems. Laws in every state require providers to report some STDs. Most states require reporting of gonorrhea, syphilis, chlamydia, and AIDS. Several require reporting of herpes, HIV infection, or STD complications such as PID. Under-reporting of STDs results in failure to note disease trends and inadequate planning to address STD problems.

RATIONALE FOR ENSURING AVAILABILITY OF CRITICAL COMPONENTS

1. Screening for and treatment of STDs prevent significant complications in the future. When left untreated, STDs can result in severe consequences including infertility, tubal pregnancy, chronic pain, cancer, prematurity, low birth-weight, congenital infections in newborns, and even death. In addition, HIV transmission is much more likely when other STDs are present making STD treatment an important intervention for prevention of HIV infection. For example:
   
   In the United States, chlamydia -- which infects approximately 4 million people each year -- causes the majority of uterine and fallopian tube infections or pelvic inflammatory disease (PID) in women. PID is the leading cause of preventable infertility and tubal pregnancy. Tubal pregnancy, in turn, is the leading cause of first-trimester pregnancy-related death in African American women.
   
   Prospective epidemiological studies have repeatedly demonstrated twofold to fivefold increases of HIV transmission when other STDs are present. In addition, other STDs have been demonstrated to increase HIV susceptibility in women by increasing the cells targeted by HIV (CD4 cells) in their cervical secretions. Other STDs have also been shown to increase the probability that HIV will be transmitted from an HIV-infected person to another person. A recent study demonstrated that in communities with improved STD treatment, HIV transmission was reduced by 42 percent.
2. STD screening and early treatment are cost-effective. The cost of untreated STDs far exceeds the cost of prevention services. For example, evidence indicates that chlamydia screening and treatment decreases the incidence of costly complications, such as PID. A randomized trial of chlamydia screening demonstrated a 60% reduction in the incidence of PID in the screened group in the 12 months following testing. Treatment of the consequences of chlamydia (e.g., PID, infertility, ectopic pregnancy) is estimated to be 12 times greater than the cost of screening and treatment.
3. A healthier population. STDs are strongly linked to long-term health complications. For example, the association between human papillomavirus and cervical cancer is well-documented. STDs are one of the most important preventable causes of adverse outcomes of pregnancy, including low birth weight/prematurity, congenital infection, stillbirth, and postpartum infection. The two leading causes of preventable infertility are chlamydia and gonorrhea. Women, adolescents, and people of color are disproportionately affected by STDs and their consequences. STD prevention services could dramatically lower the incidence of STDs, their long term consequences, and their significant cost. The overall health of Americans would improve with the routine availability of these components of STD prevention.

RECOMMENDATIONS

1. A partnership of private providers and public health personnel is needed so that all components of STD prevention and control services are available in the community. Non-clinical services, such as partner notification and case-reporting, might otherwise be overlooked.
2. The provision of high quality clinical and non-clinical STD services requires on-going education and training of private health providers and public health personnel.

References available from Division of STD Prevention, NCHSTP, CDC (404-639-8260 or e-mail: jel6@.cdc.gov).