The Issue:

Today's STD program is supported by public funds and has traditionally been focused on controlling the spread of STDs through secondary prevention -- treating infected persons and helping to identify and treat those who they may have been infected.

Primary prevention measures designed to help individuals avoid infection in the first place -- such as education and condom advocacy -- tend to receive less attention than they warrant. This is frequently due to understaffed and underfunded clinics. Most STD services have primarily been provided through public health STD clinics. These clinics tend to be utilized more by men than by adolescents or women, two populations most severely affected by STDs and their complications.

Those populations which do not typically seek services through public STD clinics tend not to seek care until complications have developed. In contrast to men, the majority of STD-infected women are asymptomatic, and therefore do not realize that they need treatment. In addition, seeking care for STDs remains far more stigmatizing for women than for men. Teenagers seek routine health care less often than any other age group and are even less likely to seek care for stigmatizing health problems such as STDs.

For those who try to attend public STD clinics (mostly men), access can be severely limited:

• Waiting times frequently amount to multiple hours or an entire day.
• Many people are never seen due to limited clinic capacity. While some efforts to expand routine STD services into non-STD specific clinics have begun in an effort to increase access to those most poorly served by the existing infrastructure, these efforts are woefully inadequate. In addition, the organization of medical care is moving toward more managed care organizations where all health care is provided and coordinated through one primary care provider as opposed to providing some services categorically.

The Opportunities:

1. The growth of managed care programs for both employed and Medicaid dependent persons can increase the breadth of services offered to participants, including STD services.
2. Public health departments have the opportunity to either develop a collaborative relationship with managed care programs to provide STD services or to contract their funds to managed care programs to provide STD services within their facilities.

The Challenges:

1. Though STD services may be available through Medicaid or employer-based managed care, there will still be people who are not eligible for either and will have no source of STD service except publicly-funded STD clinics.
2. Categorical STD funding has remained level for several years, yet the number and complexity of STDs has been on the rise during this same period.
3. Health care providers outside of reproductive health care or STD-specific clinics are typically not well-trained in STD treatment and prevention.
4. Few medical schools provide adequate STD training. A survey conducted by CDC in 1992 indicated that less than half of medical schools offer training in STDs.

Recommendations:

1. Expand the proportion of resources committed to STD primary prevention activities in a fashion that is complementary to necessary STD secondary prevention services.
2. Expand the STD infrastructure to include routine STD treatment and prevention services through organizations that have the best access to populations at greatest risk for STDs, especially those that serve women and adolescents.
3. Assure that primary care, community health center, fee-for-service, teen health care and other providers outside STD clinics are trained to diagnose, treat, and promote prevention of STDs. This training is particularly important for providers in managed care programs that include a growing share of the health care providers.