The changing paradigm of sexually transmitted disease control in the era of managed health care

Sexually Transmitted Diseases and Managed Care: An Inquiry and Review of Issues Affecting Service Delivery

To understand the potential role of managed care organizations (MCOs) in prevention and control of sexually transmitted diseases (STDs), we conducted a systematic review of articles on STDs and managed care and sought qualitative information from MCOs on STD-related activities. The review focused on prevention, risk assessment, patient education, counseling, screening, and costs of care, but revealed relatively few published articles. Barriers to STD service delivery included competing priorities, lack of time or supporting organizational structures, and differing mandates of health departments and MCOs. Facilitators included collaboration between health departments and MCOs, regulatory and performance incentives, buy-in from key stakeholders, availability of infrastructure to support data collection, and inclusion of chlamydia screening in the Health Employer Data and Information Set to monitor plan performance. Because of the shift of STD service delivery from the public to private sector, incentives need to maximize interest and cooperation of patients, clinicians, and MCOs in STD prevention.

Defining and Assessing Organizational Competence in Serving Communities at Risk for Sexually Transmitted Diseases

This study sought to develop an assessment tool to help health agencies enhance their capacity to provide sexually transmitted disease (STD) care to communities at risk and close the gap of racial disparities in health. Specifically, the study sought to (a) define the organizational competence of agencies serving communities at risk for STDs, and (b) develop a method to assess an agency’s organizational competence. In a rural Southern county, qualitative action research methods including key informant interviews, observation, and document review were used to assess four health agencies’ competence in responding to the needs of high STD-risk communities. Nine dimensions of organizational competence were identified: community participation, assessment of community needs, ensured access to services, community outreach, cultural competence, interagency collaboration, policy development, resource acquisition, and organizational commitment to serve. A competent organization was conceived as one that (a) is committed to serve, (b) works with communities at risk, (c) understands and appropriately responds to their needs, and (d) advocates on their behalf.

Role of community group exposure in reducing sexually transmitted infection-related risk among female sex workers in India

Background

Empowering female sex workers (FSWs) to address structural barriers and forming community groups (CGs) through community mobilization are seen as essential components of HIV prevention programs in India. Taking the membership of a CG as an exposure intervention, we hypothesized whether participation in a CG lead to reduced sexually transmitted infections (STIs) and increased treatment-seeking behavior among FSWs in three selected states of India — Andhra Pradesh, Maharashtra and Tamil Nadu.

Methods and Findings

The propensity score matching (PSM) approach examined the effect of CG membership, as against no membership, on STI-related risk, described as selected outcome measures — presence of any STI, self-reported STI symptoms, and treatment-seeking behavior among FSWs. A cross sectional bio-behavioral survey was administered in 2009–2010 and covered 7,806 FSWs through two-stage probability-based conventional and time location cluster sampling in 23 administrative districts of Andhra Pradesh, Maharashtra and Tamil Nadu. Only 2,939 FSWs were reported to be members of a CG and among them 4.5% had any STIs. A majority of FSWs were aged above 24 years (86.4%), had ever been married (73%), operated from a public place for solicitation (81.5%), and had ever received HIV test results (75.6%). The average effect of CG exposure was reduction in STI prevalence by 4%, while self-reported STI symptom treatment-seeking behavior increased by 13.7%.

Conclusion

FSWs who were exposed to a CG were at a substantially lower risk of STIs than those who were unexposed. The FSWs exposed to a CG had a higher chance of seeking STI treatment from public and private health facilities. Collectivization related challenges must be overcome to provide access to tailored STI prevention and care services.

Assessing the role of prevention partnerships in STD prevention: a review of comprehensive STD prevention systems progress reports

Systematic analysis of STD programme data contributes to a national portrait of sexually transmitted disease (STD) prevention activities, including research and evaluation specifically designed to optimise programme efficiency and impact. We analysed the narrative of the 2009 annual progress reports of the US Comprehensive STD Prevention Systems cooperative agreement for 58 STD programmes, concentrating on programme characteristics and partnerships. Programmes described 516 unique partnerships with a median of seven organisations cited per STD programme. Non-profit organisations (including service providers) were most frequently cited. Higher gonorrhoea morbidity was associated with reporting more partnerships; budget problems were associated with reporting fewer. Challenges to engaging in partnerships included budget constraints, staff turnover and low interest. Data provide a source of information for judging progress in programme collaboration and for informing a sustained programme-focused research and evaluation agenda.

"And let me see them damn papers!" The role of STI/AIDS screening among urban African American and Puerto Rican youth in the transition to sex without a condom

Common strategies employed in preventing STI/AIDS transmission among young adults in America include abstinence, monogamy and safer sex. These strategies require a high level of vigilance and responsibility and, according to inner city participants in Project PHRESH.comm, neither option is always desirable, available, or rational in the context of their lived experiences. This article reports findings from Project PHRESH.comm, a mixed-method, ethnographic study incorporating data from focus group discussions, semi-structured interviews, coital diaries, systematic cultural assessments and a structured survey designed to explore concepts of risk and decision making about condom use among at risk African American and Puerto Rican young adults aged 18-25 years in Hartford, CT. We found that many young adults from our study population rely on a strategy of using clinic-sponsored STI/AIDS screening when wanting to discontinue condom use with a partner. While our data suggest that screening is a common strategy used by many couples to transition to having sex without a condom, the data also show that most youth do not maintain monogamy even in long-term, serious relationships. Thus, sharing test results may provide a false sense of security in the sexual culture of inner city, minority youth.

Providers' perceived barriers to sexually transmitted disease care in 2 large health maintenance organizations

GOAL

To identify providers' perceived barriers to sexually transmitted disease (STD) care in 2 health plans and plan-, clinician-, and patient-level factors that were associated with these barriers in order to inform quality improvement interventions.

STUDY DESIGN

Surveys were mailed to a stratified sample of 1000 physicians, physician assistants, and nurse practitioners at 2 large health plans in 1999-2000. Of the 743 (82%) providers who received questionnaires and responded, data were analyzed from 699 with complete specialty information.

RESULTS

Ninety-five percent of providers identified at least 1 barrier to STD care. The most commonly cited barriers in both plans related to insufficient time and staff to address STDs, to counsel patients or manage sex partners, to keep current with managing high-risk patients, and to monitor patient adherence to recommendations to abstain from sex or use condoms during treatment. Nurse practitioners and specialists in obstetrics and gynecology were more likely to cite these barriers. Providers in staff models were more likely to cite the most common patient-level barriers. Few cited barriers related to diagnostic and treatment services.

CONCLUSIONS

Interventions in health plans are necessary to address constraints related to time and staff performing STD related care, keeping current with managing high-risk patients, and supporting patient adherence to provider recommendations.

Gonorrhea prevention and clinical care in the private sector: lessons learned and priorities for quality improvement

We reviewed literature on gonorrhea prevention and clinical care in the private sector, the setting where most gonorrhea cases in the United States are now diagnosed. Although most private-sector health settings had a low prevalence of gonorrhea (0.1-2.5%), some private emergency departments and specialty clinics that serve a large number of high-risk or infected patients had prevalences ranged from 1.7% to 11.0%. Studies of diverse settings and populations suggest that, in general, diagnostic testing of symptomatic patients (69-83%), appropriate treatment (61-100%), and case reporting (64-94%) are delivered more commonly than risk assessment for asymptomatic patients (15-28%), routine screening of pregnant women (31-77%), risk-reduction counseling (35-78%), and sex partner management (0-82%). To sustain the recent declines in gonorrhea incidence in the United States, private-sector providers and health systems must continue to offer gonorrhea prevention and clinical services and consider implementing interventions to improve delivery of risk assessment, risk-reduction counseling, and partner management services.

Evaluation of Clinician-Reported Adherence to Centers for Disease Control and Prevention Guidelines for the Treatment of Chlamydia trachomatis in Two U.S. Health Plans

OBJECTIVE

The objective of this study was to assess clinician adherence to Centers for Disease Control and Prevention-recommended treatments for Chlamydia trachomatis (CT) in two health plans.

STUDY DESIGN

Using hypothetical scenarios, a 1999-2000 mail survey questioned clinicians about how they would treat a cervicitis patient (CT and gonorrhea treatment recommended) and two patients with laboratory-confirmed CT: an injection drug user (single-dose azithromycin promotes adherence) and a pregnant patient (nonteratogenic drugs recommended).

RESULTS

Seven hundred forty-three (82%) of the 907 nonretired clinicians receiving the survey completed it. Eighty-one percent (N=599) reported providing recent CT care. Of these, 70.1% reported they would presumptively treat patients with cervicitis for CT and gonorrhea, 17.1% for CT only, and 11.7% for neither pathogen. Of the 580 clinicians addressing drug injectors, 61.7% reported they would prescribe azithromycin. Most (88.8%) of the 343 clinicians seeing pregnant patients reported they would prescribe Centers for Disease Control and Prevention (CDC)-recommended antibiotics. Reported adherence varied by clinician specialty and sources of treatment guidance.

CONCLUSIONS

Most clinicians reported treatment consistent with CDC guidelines.

Sexually Transmitted Disease Care in Managed Care Organizations

Most STD cases in the United States are managed in health sectors dominated by commercial and Medicaid MCOs. To sustain the recent declines in bacterial STD incidence in the United States and to control expansion of the prevalent viral STD, MCOs will need to contribute substantially to control efforts. Applied researchers and quality improvement specialists must work with clinicians, patients, and health systems to develop and scale-up interventions to improve STD prevention and control.

Estimates of Primary and Secondary Syphilis Rates in Persons With HIV in the United States, 2002

BACKGROUND

In the United States, there is a high rate of HIV coinfection in persons with syphilis.

GOAL

The goal of this study was to estimate the rate of primary and secondary (P&S) syphilis in persons living with HIV in the United States in 2002.

STUDY

We approximated the number of new cases of P&S syphilis in HIV-infected persons and divided this by the estimated number of persons living with HIV. Values for the calculations were obtained from national syphilis and HIV/AIDS surveillance reports and other published sources.

RESULTS

We estimated the rate of new cases of P&S syphilis at 186 per 100,000 persons living with HIV in 2002, 25 per 100,000 HIV-infected women, 60 per 100,000 HIV-infected men who have sex with women only, and 336 per 100,000 HIV-infected men who have sex with men. Of the 6862 reported cases of P&S syphilis in 2002, an estimated 1718 (25%) occurred in persons coinfected with HIV.

CONCLUSIONS

The estimated rate of P&S syphilis in persons with HIV is considerably higher than that of the general population. These findings highlight the importance of providing sexually transmitted disease prevention and control services to HIV-infected persons.

Differences in demographics and risk factors among men attending public v non-public STD clinics in Baltimore, Maryland

OBJECTIVE

To compare the demographics and risk factors of men who utilise the services of a municipal public sexually transmitted disease (STD) clinic with those who utilise the services provided by a non-public men's STD clinic operated by a not for profit primary care clinic.

METHODS

A record based review of the characteristics and STD prevalence of men who visited a non-public STD clinic in Baltimore, Maryland, compared with those of a random sample of male attendees of a public STD clinic. Data abstracted from the records included information on age, race/ethnicity, self reported risk behaviours, and STD tests and results. We used chi2 analysis as well as bivariate and multivariate modelling to compare differences in categorical factors between clinics groups.

RESULTS

Men who utilised the services at the non-public STD clinic were more often white (71% v 3%, p<0.001), MSM (65% v 2%, p<0.001), and presented for general screening (52% v 15%, p<0.001) compared to those at the public clinic. In addition, they more frequently reported > or =3 partners (22% v 11%, p=0.005), and having an HIV positive partner (10% v 3%, p=0.005). Factors independently associated with attendance at non-public clinic in multivariate analysis were general screening as reason for visit (OR = 11.0, p<0.001), having 3+ partners in past month (OR=10.5, p=0.002), and "sometimes" using condoms (OR=3.6, p=0.033).

CONCLUSIONS

Non-public STD clinics can reach a distinct segment of the male population with high risk sexual behaviours that might not attend public STD clinics.

Gonorrhea Surveillance

BACKGROUND

Little is known about the epidemiology of gonorrhea in the United States, except for basic demographics of reported cases. Knowing the proportion of reported gonorrhea cases identified through screening, the diagnostic test used, and patient behavioral risk factors might help to better explain changes in gonorrhea rates over time.

GOAL

The goal of this study was to implement and evaluate a gonorrhea sample survey surveillance methodology in San Diego, California.

STUDY DESIGN

Healthcare providers caring for a representative sample of all gonorrhea patients reported during August 16 through October 18, 2001 were interviewed by telephone about patient demographics, risk factors, and management.

RESULTS

The healthcare providers of 248 gonorrhea patients were contacted; data were obtained on 224 (90%) patients. Major reasons for testing included symptoms (68%), partner referral (14%), and screening (12%). Gonococcal culture, DNA probe tests, and nucleic acid amplification tests were used to diagnose 40%, 34%, and 21% of patients, respectively. At minimum, 36% of male gonorrhea patients were men who have sex with men (MSM); MSM with gonorrhea were rarely diagnosed with rectal or pharyngeal gonorrhea outside of sexually transmitted disease (STD) clinics. Estimated local resources required to conduct this survey were $12 per completed interview.

CONCLUSION

Healthcare provider telephone interviews regarding recently reported gonorrhea patients are feasible and can provide important additional information to STD programs, which could be used to direct intervention strategies and monitor trends. Ultimately, a national sampling approach could be explored and incorporated into ongoing gonorrhea surveillance.

Adherence to CDC STD guideline recommendations for the treatment of Chlamydia trachomatis infection in two managed care organizations

BACKGROUND

The extent of adherence to the Centers for Disease Control and Prevention (CDC) STD guidelines by clinicians practicing in managed care settings is unknown. GOAL The goal was to assess adherence to the CDC guideline recommendations for the treatment of genital chlamydial infection, by clinicians at two group model managed care organizations.

DESIGN

Retrospective cohort study of men and women with laboratory-confirmed chlamydial infection. Patients were members of either the Kaiser Permanente Foundation Health Plan of Colorado or HealthPartners of Minneapolis/St. Paul who had tested positive for cervical or urethral chlamydial infection during the period from January 1, 1998, through June 30, 1999.

RESULTS

During the study period, 1,078 patients with positive tests for genital Chlamydia trachomatis were identified. More than 97% of men and nonpregnant women and more than 98% of pregnant women were prescribed treatment, consistent with current CDC guidelines.

CONCLUSION

Adherence to CDC-recommended therapy was high for patients with genital chlamydial infections at these two managed care organizations.

Partner management for gonococcal and chlamydial infection: expansion of public health services to the private sector and expedited sex partner treatment through a partnership with commercial pharmacies

BACKGROUND

Public health partner notification (PN) services currently affect only a small minority of patients with gonorrhea or chlamydial infection and new approaches to PN are needed.

OBJECTIVES

To expand PN for gonorrhea and chlamydial infection to private sector patients and to assess the feasibility of treating sex partners through commercial pharmacies.

METHODS

Selected patients were offered PN assistance and were randomly offered medication to deliver to their partners.

RESULTS

Providers permitted the health department to contact 3613 (91%) of 3972 potentially eligible patients, and 1693 (67%) of 2531 successfully contacted patients consented to interview. Of these, 1095 (65%) reported at least one untreated partner. Most patients (90%) wished to notify partners themselves. Patients were more likely to have partners who had not yet been treated and to request PN assistance if they had more than one sex partner in the preceding 60 days or a partner they did not anticipate having sex with in the future. These two factors characterized 49% of all patients interviewed, 70% of those with a partner that was untreated 7 or more days after index patient treatment, and 83% of those accepting PN assistance. Among 458 randomly selected patients with untreated partners at time of study interview, 346 (76%) agreed to deliver treatment to a partner. Of these, most (266) chose to obtain medication for a partner at a pharmacy, of whom 223 (84%) successfully did so.

CONCLUSION

A substantial minority of private sector patients have untreated partners more than 7 days after their own treatment; some need help with PN, but most will agree to deliver medication to partners themselves.

Adolescent chlamydia testing practices and diagnosed infections in a large managed care organization

GOAL

To determine chlamydia screening practices and the resulting positive test results for adolescents enrolled in a large nonprofit managed care organization.

STUDY DESIGN

The electronic medical records of all 12- to 19-year-olds enrolled in a large nonprofit managed care organization serving a demographically diverse patient population from January 1998 through December 1999 were reviewed retrospectively.

RESULTS

Among the 43,205 female and 44,133 male managed care organization members, ages 12 to 19 years in 1998-1999, 7575 adolescents (8.7%) (6914 females [16%] and 661 males [1.5%]) were tested for chlamydia. Among the members tested, chlamydia was diagnosed in 1109 adolescents (14.6%) (983 females [14.2] and 126 males [19.1%]); 761 (68.6%) adolescents were retested for chlamydia; and 182 (16.4%) had repeat positive test results. The median time to diagnosis of a repeat infection was 6 months.

CONCLUSIONS

Chlamydia imposes a large disease burden in the private, organized healthcare sector. Managed care organizations can use operational data to enhance chlamydia prevention services by defining testing practices and local disease prevalence.

Federally funded sexually transmitted disease programs and managed care: a review of current and planned partnerships

BACKGROUND

The Centers for Disease Control and Prevention requested that sexually transmitted disease (STD) programs report their current activities and plans to collaborate with managed care organizations in their 1999 applications for federal funding.

GOAL

To review CDC STD program applications for funding to assess the number of activities between STD programs and managed care organizations.

METHODS

Narrative data on managed care topics were abstracted from 59 funding applications (50 states, 7 cites or counties, and 2 US territories), using standard qualitative methods. A coding system was applied to categorize each managed care activity into one of nine categories (interrater reliability, 93%). An expert panel ranked activities by complexity, and these scores were used to develop an overall complexity score for each program.

RESULTS

All but 9 of the 59 applicants reported managed care organization activities. Altogether, 208 activities were specifically documented, 45% of which were classified as operational in 1999. The most frequently reported activities involved gathering and giving information and promoting STD care through legislation and state Medicaid activities.

CONCLUSIONS

Considerable information transfer and policy action between STD programs and managed care organizations are taking place. Further integration of services and policies should be studied and encouraged to promote the effective treatment of STD.

Adolescent enrollees in Medicaid managed care: the provision of well care and sexual health assessment

PURPOSE

(1) To estimate the proportion of adolescents receiving outpatient care, well care, and sexual health assessment during 12 months of continuous enrollment in Medicaid managed care. (2) To investigate factors associated with provision of these categories of service.

METHODS

Chart reviews were completed for a statewide random sample of adolescent Medicaid enrollees in Washington State. Multivariate logistic regression models included age, gender, race, language, residence, enrollment plan, and service level as independent variables. Dependent variables were receipt of outpatient care, well care, and sexual health assessment.

RESULTS

Of 2000 enrollees' records, 78.3% provided evidence of outpatient service, 30.5% included well care, and 20.8% documented a sexual health assessment. Among adolescents who obtained service, younger enrollees and non-Whites were more likely to receive well care; females, older enrollees, and those with well care were more likely to have sexual health assessments. Use of standardized charting tools increased the likelihood that sexual health assessments would be documented. The variable most strongly associated with provision of outpatient service was plan of enrollment. Plan rankings on provision of outpatient care were not associated with organizational descriptions, such as for-profit status or plan structure.

CONCLUSION

The low rates of well care and sexual health assessment documented for adolescents in Medicaid managed care suggest that interventions are needed.

Management of urethritis in health maintenance organization members receiving care at a multispecialty group practice in Massachusetts

BACKGROUND

Cost containment has led to a concern that health maintenance organization-insured patients presenting with complaints of urethritis may be treated without being tested.

GOAL

To determine the proportion of men presenting with symptoms of urethritis who are tested for Chlamydia trachomatis and Neisseria gonorrhoeae.

STUDY DESIGN

Reviews were performed on 196 randomly selected patient records with an outpatient visit and a diagnostic code consistent with urethritis between 1995 and 1997. Data were collected on demographics, diagnostic testing, and treatment.

RESULTS

Diagnostic testing for C trachomatis and N gonorrhoeae was performed, respectively, in 92.3% and 83.2% of the men presenting at an initial visit with complaints of urethritis. Altogether, 98.2% of the patients who met the Centers for Disease Control criteria for documenting urethritis were tested for C trachomatis and N gonorrhoeae.

CONCLUSION

Diagnostic testing for C trachomatis and N gonorrhoeae is nearly universal in this multispecialty group practice setting, facilitating surveillance and public health efforts.

Screening for sexually transmitted infections among economically disadvantaged youth in a national job training program

PURPOSE

To evaluate results of screening for syphilis, gonorrhea, and chlamydia among youth in a federally funded job training program.

METHODS

Data were evaluated from medical records of 12,881 randomly selected students in 54 U.S. job training centers during 1996. The intake medical evaluation includes serologic testing for syphilis. The policy was for females to receive a pelvic examination with gonorrhea and chlamydia testing and for males to be first screened with a urine leukocyte esterase (LE) assay, with follow-up gonorrhea and chlamydia testing for those with positive LE results.

RESULTS

Adjusting for our sampling strategy, among females, an estimated 9.2% had a positive chlamydia test, 2.7% a positive gonorrhea test, and 0.4% had a positive syphilis test. Gonorrhea and chlamydia rates among females were highest in African-American followed by Native American students. Chlamydia infection was most common in younger women < or = 17 years of age. An estimated 0.1% of males had a positive syphilis test, and 4.8% of males a positive urine LE test. Of 103 LE-positive males tested for gonorrhea and chlamydia, only 27 (26%) had a positive test for one of these STDs.

CONCLUSIONS

Our study supports routine screening of adolescents for gonorrhea and chlamydia, including those youth from socioeconomically disadvantaged backgrounds. Because individuals from such backgrounds may not regularly interact with traditional clinical health care systems, screening and treatment should be offered in alternative settings, such as the job training program described in this study.

The contributions of managed care plans to public health practice: evidence from the nation's largest local health departments

OBJECTIVE

The authors examine the extent and nature of managed care plans participating in local public health activities.

METHODS

In 1998, the authors surveyed the directors of all US local health departments serving jurisdictions of at least 100,000 residents to collect information about public health activities performed in their jurisdictions and about organizations participating in the activities. Multivariate logistic and linear regression models were used to examine organizational and market characteristics associated with managed care plan participation in public health activities.

RESULTS

Managed care plans were reported to participate in public health activities in 164 (46%) of the jurisdictions surveyed, and to contribute to 13% of the public health activities performed in the average jurisdiction. Plans appeared most likely to participate in public health activities involving the delivery or management of personal health services and the exchange of health-related information. Managed care participation was more likely to occur in jurisdictions with higher HMO penetration, fewer competing plans, and larger proportions of plans enrolling Medicaid recipients. Participation was positively associated with the overall scope and perceived effectiveness of local public health activities.

CONCLUSIONS

Although plans participate in a narrow range of activities, these contributions may complement the work of public health agencies.

Implementing a syphilis elimination and importation control strategy in a low-incidence urban area: San Diego County, California, 1997-1998

OBJECTIVES

This study assessed a strategy designed to contain imported cases of syphilis and prevent reestablishment of ongoing transmission.

METHODS

Reported syphilis cases during an endemic period (1990-1992) and an elimination period (1997-1998) were compared in San Diego, Calif. The elimination strategy, which focuses on rapid reporting of infectious syphilis cases by clinicians, prompt partner and sexual network management, outreach to marginalized populations, and implementation of an outbreak containment plan, was evaluated.

RESULTS

Infectious syphilis incidence rates declined from 18.3 per 100,000 in 1998 to 1.0 per 100,000 in 1998. Of the 46 cases involving probable infection during 1997-1998, 19 (41%) were imported, mostly (79%) from Mexico. Outbreak containment procedures were implemented successfully for 2 small clusters. Outreach workers provided sexually transmitted disease information to a large number of individuals; however, no cases of infectious syphilis were identified, suggesting that syphilis transmission was not occurring among marginalized groups.

CONCLUSIONS

This syphilis elimination and importation control strategy will require monitoring and adjustments. Controlling syphilis along the US-Mexico border is a necessary component of syphilis elimination in the United States.

Urine screening for gonococcal and chlamydial infections at community-based organizations in a high-morbidity area

BACKGROUND

Increasing availability of urine testing for Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) offers expanded opportunities to collaborate with community-based organizations (CBOs) to screen high-risk populations for sexually transmitted diseases (STDs).

GOAL

To determine the prevalence and correlates of genital tract gonococcal and chlamydial infection among CBO clients, and to assess the feasibility of implementing widespread community-based STD screening programs.

DESIGN

Free, voluntary, confidential first-catch urine screening was conducted at 20 CBOs serving disadvantaged populations in St. Louis, MO. Brief demographic, behavioral, and sexual contact data were obtained from all participants. Urine samples were tested by ligase chain reaction (LCR). Persons testing positive were promptly notified and directed to seek treatment.

RESULTS

A GC and/or CT infection was identified in 24 of 277 persons (8.7%) screened; 2 persons were infected with GC only, 17 with CT only, and 5 with GC and CT. Treatment was documented for 22 persons (91.7%) testing positive. The highest rates of infection were found at shelters (12.3%) and residence facilities (11.1%). Costs of screening were $38 per sample collected and $453 per case identified.

CONCLUSION

Community-based urine testing successfully identified GC and CT infections, and was well accepted by community members and CBOs. Community-based screening can significantly impact STD epidemiology by facilitating early detection, treatment, and interruption of transmission.

T-cell epitopes in variable segments of Chlamydia trachomatis major outer membrane protein elicit serovar-specific immune responses in infected humans

We previously identified 18 stimulatory Chlamydia trachomatis major outer membrane protein (MOMP) peptides containing at least 23 epitopes presented with various HLA class II allotypes. Only one peptide contained an epitope localized in a variable segment (VS2). Continued studies reported here identified a total of five VS peptides containing T-cell epitopes that are distributed among MOMPs VS1, VS2, and VS4. Only MOMP-primed T-cell cultures from subjects infected with serovar E responded to the serovar E VS peptides, while the response of such cultures to constant-segment peptides was independent of the infecting serovar. Furthermore, MOMP-primed T cells proliferated in response only to the VS peptides encoded in serovar E but not to the corresponding peptides derived from serovar F, I, or J, confirming that these responses were serovar specific.

Sexually transmitted diseases in women. Chlamydia trachomatis and herpes simplex infections

C trachomatis infection is the most commonly reported STD in the United States, and the majority of women infected are asymptomatic. Screening is recommended for those at high risk, including women who are between 15 and 21 years of age, live in urban areas, are single, or have new or multiple sexual partners. The "gold standard" for diagnosis is chlamydial culture; however, techniques that use DNA and RNA amplification are nearly 100% sensitive and specific and may prove cost-effective. Doxycycline is a recommended first-line therapy, but certain other antibiotics may also be effective. Herpes simplex virus affects more than one third of the world's population. It is diagnosed by observation of shallow, tender ulcerations around the genitalia and by viral isolation using tissue culture. Initial treatment is with antiviral drugs, which may also be necessary episodically or as a suppressive regimen for recurrences. Patient education about prevention of these and other STDs, as well as the impact of such disease on sexual partners, is critical. Physicians should therefore become comfortable questioning and counseling patients about sexual issues and risks for STDs.

Estimates of the incidence and prevalence of sexually transmitted diseases in the United States. American Social Health Association Panel

BACKGROUND

Accurate, updated estimates of the incidence and prevalence of sexually transmitted infections in the United States remain elusive. The most widely quoted number of new sexually transmitted disease (STD) cases each year is 12 million. However, this figure has not changed in more than a decade, despite improvements in detection methods and the effects of STD control programs.

GOALS

To propose a system for weighing the strength of STD surveillance data and to estimate the incidence and prevalence of STDs in the United States for 1996, using the available published data.

RESULTS

We estimate that more than 15 million STD infections occurred in the United States in 1996. This number exceeds the earlier estimate primarily because improved detection techniques have allowed an assessment of previously undiagnosed infections.

CONCLUSIONS

Large numbers of new STDs continue to occur each year in the United States, with serious health and economic consequences. More than two thirds of our current estimate of 15 million STDs annually consists of two infections--trichomoniasis and human papillomavirus--for which we have only level III surveillance data. As the quality of our surveillance data improves, we can further refine the precision of our national estimates.

Prevention of sexually transmitted diseases. A model for overcoming barriers between managed care and public health. The IOM Workshop on the Role of Health Plans in STD Prevention

CONTEXT

The growth of managed care has spurred re-evaluation of the roles and responsibilities of public health agencies and private health plans for providing public health services. Although rates of curable sexually transmitted diseases (STDs) in the United States are the highest in the developed world, many clinicians and managed care organizations are not systematically providing high-quality, comprehensive STD-related services to their patients and the community.

OBJECTIVE

To examine issues around managed care and STD prevention as a model for overcoming barriers that impede managed care organizations from providing comprehensive public health services and collaborating with health agencies.

SETTING

Two-day invitational workshop.

PARTICIPANTS

Representatives from 18 health plans, 10 public health agencies, 6 academic institutions, 1 purchasing coalition, and 5 other health organizations.

RESULTS

Major obstacles include: turnover and heterogeneity in the health care system; deficiencies in clinical knowledge and skills; differences in organizational culture and language; low priority of STDs; inadequate public health surveillance data and performance measures; confidentiality concerns; and lack of coverage for sex partners.

CONCLUSIONS

Potential approaches for addressing these barriers include: requiring that STD-related services be covered by Medicaid managed care programs; implementing performance measures; requiring collaborative activities; promoting education of and outreach to stakeholders; funding of pilot projects; and researching the cost-benefit and cost-effectiveness of STD-related services for various populations.