Continuing Need for Sexually Transmitted Disease Clinics After the Affordable Care Act

State-level trends in access to Medicaid family planning services, 2008-2023

OBJECTIVE

To characterize the landscape of policies that determine eligibility for family planning services through Medicaid programs and describe trends in eligibility and its determinants over time.

DATA SOURCES AND STUDY SETTING

Secondary data were collected for all states in the United States for the years 2008 through 2023. Data on economic and demographic characteristics came from the American Community Survey (ACS).

STUDY DESIGN

Our descriptive study characterized state adoptions of Medicaid family planning section 1115 waivers and state plan amendments (SPA) and their eligibility criteria. We then estimated the proportion of women aged 19-44 years who were eligible for family planning services through Medicaid and identified the key determinants of changes in eligibility, by state and year.

DATA COLLECTION/EXTRACTION METHODS

Information on state Medicaid policies was extracted from documentation on the Centers for Medicare & Medicaid Services website. When estimating the eligible population sizes, the denominator was women aged 19-44 years, the group most likely to be eligible for Medicaid family planning programs. Supplemental data on program enrollment or utilization were collected from states' websites and reports.

PRINCIPAL FINDINGS

Though eligibility limits for family planning through Medicaid generally increased over time, the proportion of women aged 19-44 years eligible for at least limited benefits decreased from 45.0% in 2012 to 39.4% in 2022, largely because of increases in household income. Trends varied considerably across states and by eligibility pathway. Among women with incomes below the poverty level, the proportion who were not eligible for Medicaid family planning services decreased from 6.3% in 2013 to 1.5% in 2022.

CONCLUSIONS

Our data demonstrated substantial geographic and temporal variation in eligibility for family planning services through Medicaid. We identified key drivers of eligibility changes that may have important implications for health services analyses of means-tested public programs.

Expanding access to STI care with free of charge, convenient services in sexual health walk-in clinics

Background: Sexually transmitted infections (STIs) are a long-standing public health issue with increasing incidence in recent years even though most STIs can be effectively treated or even cured with inexpensive medications.Purpose/Design: In this manuscript, we discuss factors that contribute with this concerning scenario, including modifications in the model of STI care in the United States; barriers for diagnosis and treatment; and scarcity of targeted STI prevention messages. We then describe the approach adopted by AIDS Healthcare Foundation to mitigate STI trends, with a focus on sexual health Wellness Centers.Results: The main characteristics of this program include free and convenient services with large volume capacity, sex-positive culture, advertisement of available resources, and accessibility to key populations at higher risk for STI acquisition.Conclusions: This experience could be adapted and expanded to other settings, supporting the public health mission of controlling the spread and detrimental outcomes of STIs.

The effect of teach-back method training on the prevention behaviors of reproductive age women against sexually transmitted diseases

The aim of this research was to examine the effect of teach-back method-based training provided to reproductive-age women to protect them from sexually transmitted diseases (STDs) on their protective behaviors. Sexually transmitted diseases cause significant health problems for many women every year. The transmission of sexually transmitted diseases can be prevented through health education, which is among the preventive health services. Nurses are the leading health educators. Nurses should learn new education systems and models and use them in their practice. This study has a randomized controlled design. The teach-back method and face-to-face training were provided to women of reproductive age experimentally for protection from sexually transmitted diseases. In this research, the teach-back method in which there were 42 participants in each group, an identifying information form for women in three groups who were provided face-to-face training and not trained, the Behavioral Scale for Protection from Sexually Transmitted Diseases were applied pre-training, fifteen days and three months after the training. Participants' socio-demographic data in the intervention and control groups were compared. The mean age of the teach-back group had been 30.64 ± 5.73, the average age of the face-to-face group had been 29.83 ± 5.49, and the mean age of the non-trained group had been 28.16 ± 5.09. These groups had displayed similar characteristics. The mean score of the Behavioral Scale for Protection from Sexually Transmitted Diseases was found to be 75.57 ± 12.78 pre-training, 82.54 ± 9.59 fifteen days after the training and 81.85 ± 9.28 three months after the training in women who were trained with the teach-back method; 76.92 ± 10.03 pre-training, 80.78 ± 8.72 fifteen days after the training and 80.21 ± 8.77 three months after the training in women who received face-to-face training, while it was found in women who did not receive face-to-face training to be 75.73 ± 6.14 pre-training, 75.61 ± 6.01 fifteen days after the training and 75.54 ± 6.09 three months after the training and there was a statistically significant relationship between them (F = 6.736; p < 0.001). As a result of the research, it was found that the training provided to women with the teach-back method had a positive effect on women's behaviors and was more effective than face-to-face training.

A Participatory Approach to Identifying Gaps in and Recommendations for Sexually Transmitted Infection and Preexposure Prophylaxis Clinical Services in Pierce County, Washington

BACKGROUND

Pierce County, Washington, has a high burden of sexually transmitted infections (STIs) relative to Washington State and the United States. We used a participatory approach to identify gaps in STI and preexposure prophylaxis (PrEP) service provision in Pierce County and generate recommendations to address these gaps.

METHODS

In collaboration with the Tacoma-Pierce County Health Department (TPCHD), we conducted 14 key informant interviews with local STI/PrEP providers from varied clinical settings. Using rapid qualitative analysis, we identified key gaps and strengths in service provision. Local, state, and national HIV/STI subject matter experts (SMEs) prioritized the gaps and recommendations to address them via an online survey.

RESULTS

The primary 6 gaps ranked by SMEs (N = 32) in order of importance included the following: (1) inadequate availability of STI and PrEP services, (2) lack of awareness of STI and PrEP services, (3) need for free/low cost STI and PrEP care, (4) need for stronger relationships among providers and TPCHD, (5) reduced accessibility related to geographically distributed population and centralized services, and (6) frequent referrals pose a service barrier. Subject matter experts prioritized recommendations for each gap as follows: (1) create an STI specialty clinic, (2) implement an STI/PrEP service availability outreach campaign, (3) strengthen referral relationships between TPCHD and free/low-cost providers, (4) develop a provider support network, (5) create a mobile STI clinic, and (6) develop an STI specialty clinic.

CONCLUSIONS

Sexually transmitted infection specialty clinics were prioritized by SMEs to improve access to STI and PrEP care in Pierce County, and to serve as a resource for local providers.

Unmet Healthcare Needs among College Students during the COVID-19 Pandemic: Implications for System-Wide and Structural Changes for Service Delivery

Background: During the COVID-19 pandemic, college students faced health disparities in addition to a negative burden on academic performance; however, little is reported in the literature regarding healthcare utilization. Methods: A cross-sectional survey was conducted among consenting college student participants aged 18 or older from a Hispanic-serving institution. Descriptive and bivariate statistics were used to analyze demographic characteristics and the types of healthcare services needed by such characteristics. Logistic regression was used to adjust for noted sex differences in associations between reporting limited healthcare services and types of healthcare services. Results: The study population of 223 participants was mostly Hispanic/Latino (65%) and female (73%). Of the population, 11% reported they could not obtain needed healthcare services, with time being reported as the most common reason. Significant associations were found between seeking general healthcare services/routine screening, seeking mental health services, and seeking sexual health services with reporting limited healthcare services, with sex-adjusted odds ratios and 95% confidence intervals of 1.90 (95% CI: 1.08, 3.36), 3.21 (95% CI: 1.44, 4.15), and 2.58 (95% CI: 1.05, 6.35), respectively. Conclusions: Availability and inability to obtain health services may exacerbate college student health disparities. Targeted interventions are needed in the population to mitigate the potential burdens of unmet healthcare needs, particularly among minority college students.

Sexual risk behaviour reduction interventions in primary care in Organization of Economic Cooperation and Development countries. A systematic review

BACKGROUND

Sexually transmitted infections are a major public health issue, both in France and worldwide. Primary healthcare professionals play a key role in sexual health and prevention, but few take on this subject. Prevention strategies are diverse, thus risk reduction strategies focussing on behavioural changes are still needed.

PURPOSE

We conducted a systematic review to analyse risk reduction interventions focussing on behavioural change in OECD countries in primary healthcare settings to help develop a prevention tool easy to apply in primary care.

METHODS

We searched for English- or French-language controlled trials in PubMed, Cochrane Library, Scopus, PsycINFO, PsycArticle, PBSC, SocINDEX, Google Scholar, and CAIRN, supplemented with the bibliographies of previous systematic reviews. Thirty controlled, randomized, or nonrandomized trials were included in the systematic review. We did not conduct any meta-analysis due to the diversity of populations, outcomes and study designs.

RESULTS

There are efficient interventions in primary healthcare settings for reducing sexual risk behaviours and/or incident STI. Their efficiency seems to grow with the length and intensity of the intervention. Most interventions target only young, high-risk patients, and their long-term impact is uncertain. Most included studies had an overall risk of bias estimated as high or with some concerns.

CONCLUSIONS

Some tools could be used in primary care, with possible efficiency though results are difficult to generalize, and value should be assessed in daily practice. Future research should also focus on older population given the epidemiological evolutions, but also lower-risk population to target all patients seen in primary care settings.

Characterizing Financial Sustainability of Sexually Transmitted Disease Clinics Through Insurance Billing Practices

CONTEXT

Sexually transmitted infections (STIs) continue to increase in the United States. Publicly funded sexually transmitted disease (STD) clinics provide important safety net services for communities at greater risk for STIs. However, creating financially sustainable models of STI care remains a challenge.

OBJECTIVE

Characterization of clinic insurance billing practices and patient willingness to use insurance.

DESIGN

Cross-sectional survey assessment of clinic administrators and patients.

SETTING

Twenty-six STD clinics and 4138 patients attending these clinics in high STD morbidity metropolitan statistical areas in the United States.

PARTICIPANTS

Clinic administrators and patients of these clinics.

INTERVENTION

Survey assessment.

MAIN OUTCOME MEASURE

Insurance billing practices of STD clinics and patient insurance status and willingness to use their insurance.

RESULTS

Fifteen percent of clinics (4/26) indicated that they billed only Medicaid, 58% (15/26) billed both Medicaid and private insurance, 27% (7/26) did not bill for any health insurance, and none (0%) billed only private health insurance companies. Of 4138 patients surveyed, just more than one-half of patients (52.6%) were covered by some form of health insurance. More than one-half (57.2%) of all patients covered by health insurance indicated that they would be willing to use their health insurance for that visit. After adjusting for patient demographics and clinic characteristics, the patients covered by government insurance were 3 times as likely (odds ratio: 3.16; 95% confidence interval, 2.44-4.10) than patients covered by private insurance to be willing to use their insurance for their visit.

CONCLUSION

Opportunities exist for sustainable STI services through the enhancement of billing practices in STD clinics. The STD clinics provide care to large numbers of individuals who are both insured and who are willing to use their insurance for their care. As Medicaid expansion continues across the country, efforts focused on improving reimbursement rates for Medicaid may improve financial sustainability of STD clinics.

Availability of Sexually Transmitted Disease and HIV Clinical Services: Ending the HIV Epidemic Versus Non-Ending the HIV Epidemic Jurisdictions, 2018

ABSTRACT

We assessed sexually transmitted disease/human immunodeficiency virus (HIV) service availability at the primary sexually transmitted disease safety net clinic by phase I Ending the HIV Epidemic jurisdiction status. HIV testing was >90%. In Ending the HIV Epidemic jurisdictions, 22% of primary safety net clinics initiated and/or provided preexposure prophylaxis (PrEP), 46.6% provided PrEP education or referral only, and 29.9% did not provide any PrEP services.

Acceptability of a Gonococcal Vaccine Among Sexually Active Men Who Have Sex With Men

BACKGROUND

Prospects for a gonococcal vaccine have advanced. Vaccine acceptability is crucial to maximizing population-level protection among key groups, such as men who have sex with men (MSM). We assessed the prevalence of gonococcal vaccine acceptability among sexually active MSM in the United States.

METHODS

We used data from the American Men's Internet Study conducted from August 2019 to December 2019. We calculated frequencies of sociodemographic characteristics, vaccine acceptability, and preferred location for vaccine receipt. Using log-binomial regression analyses, we calculated unadjusted prevalence rates (PRs) and 95% confidence intervals (CIs) to evaluate factors associated with vaccine acceptability.

RESULTS

Of 4951 MSM, 83.5% were willing to accept a vaccine and 16.5% were unwilling. Preferred vaccination locations were primary care provider's clinics (83.5%) and sexually transmitted disease (STD) clinics (64.6%). Vaccine acceptability was greater among young MSM (15-24 years [PR, 1.09; 95% CI, 1.05-1.12], 25-29 years [PR, 1.13; 95% CI, 1.09-1.17], and 30-39 years [PR, 1.10; 95% CI, 1.05-1.14] compared with MSM ≥40 years), MSM living with HIV (PR, 1.05; 95% CI, 1.02-1.09), and MSM who reported (in the past 12 months) condomless anal sex (PR, 1.09; 95% CI, 1.06-1.12), a bacterial STD test (PR, 1.18; 95% CI, 1.15-1.21), HIV preexposure prophylaxis use (PR, 1.17; 95% CI, 1.14-1.19), a bacterial STD diagnosis (PR, 1.04; 95% CI, 1.02-1.07), or a health care provider visit (PR, 1.11; 95% CI, 1.06-1.16). Men who have sex with men who reported ≤high school education (PR, 0.93; 95% CI, 0.91-0.97) were less willing to accept a vaccine compared with those with >high school education.

CONCLUSIONS

Most respondents were willing to accept a gonococcal vaccine. These findings can inform the planning and implementation of a future gonococcal vaccination program that focuses on MSM.

Demographic, Behavioral, and Clinical Characteristics of Persons Seeking Care at Sexually Transmitted Disease Clinics - 14 Sites, STD Surveillance Network, United States, 2010-2018

PROBLEM

Sexually transmitted diseases (STDs) are a major cause of morbidity in the United States, with an estimated $15.9 billion in lifetime direct medical costs. Although the majority of STDs are diagnosed in the private sector, publicly funded STD clinics have an important role in providing comprehensive sexual health care services, including STD and HIV screening, for a broad range of patients. In certain cases, STD clinics often are the only source of sexual health care for patients, particularly among gay, bisexual, and other men who have sex with men (MSM).

PERIOD COVERED

2010-2018.

DESCRIPTION OF THE SYSTEM

The STD Surveillance Network (SSuN) is an ongoing sentinel surveillance system for monitoring clinical information among patients attending STD clinics. SSuN is a collaboration of competitively selected state and city health departments that conduct facility-based sentinel surveillance in STD clinics. Information routinely collected through the course of patient encounters is obtained for all patients seeking care in the participating STD clinics. This information includes demographic, behavioral, and clinical characteristics (e.g., STD and HIV tests performed and STD and HIV diagnoses). This report presents 2010-2018 SSuN data from 14 STD clinics in five cities (Baltimore, Maryland; New York City, New York; Philadelphia, Pennsylvania; San Francisco, California; and Seattle, Washington) to describe the patient populations seeking care in these STD clinics. Estimated numbers and percentages of patients receiving selected STD-related health services were calculated for each year by using an inverse variance weighted random-effects model, adjusting for heterogeneity among SSuN jurisdictions. Trends in receipt of selected STD-related health services were examined and included HIV screening after an acute STD diagnosis among persons not previously known to have HIV infection, annual chlamydia screening among adolescent and young females, and extragenital chlamydia and gonorrhea screening among MSM.

RESULTS

During 2010-2018, the total number of annual visits made in the 14 participating STD clinics decreased 29.8% (from 145,728 to 102,275 visits), and the total number of unique patients examined in the clinics decreased 35.1% (from 94,281 to 61,172 patients). Decreases in the number of unique patients occurred both among men who have sex with women only (42.4%; from 37,842 in 2010 to 21,781 in 2018) and among females (51.4%; from 36,485 in 2010 to 17,721 in 2018). The decreases in the number of female patients were observed across all age groups, although they were more pronounced among females aged ≤24 years (66.4%; from 17,721 in 2010 to 5,962 in 2018). In contrast, the number of patients identified as MSM increased 44.0% (from 12,859 in 2010 to 18,512 in 2018), with the greatest increase among MSM aged ≥25 years (58.6%; from 9,918 in 2010 to 15,733 in 2018). Among visits during which an acute STD (defined as chlamydia, gonorrhea, or primary or secondary syphilis) was diagnosed, the percentage of visits during which an HIV test was performed within approximately 14 days of the STD diagnosis increased from 58.2% in 2010 to 70.2% in 2018. Among those patients tested, 1,672 HIV infections were identified, of which 84.0% were among MSM. Among females aged 15-24 years, the percentage screened for chlamydia in any calendar year increased from 88.6% in 2010 to 90.6% in 2018. However, because fewer females aged 15-24 years attended these clinics during the study period, the crude number of adolescent and young females tested for chlamydia decreased from 14,249 in 2010 to 4,507 in 2018. During 2010-2018, the percentage of females retested after their first positive chlamydia diagnosis during the same year ranged from 11.4% to 13.3%. During 2010-2018, the percentage of MSM tested for rectal chlamydia and rectal gonorrhea increased (from 54.7% to 57.8% and from 55.0% to 58.4%, respectively). During the same period, increases were noted in the percentage of MSM with diagnosed rectal chlamydia (from 15.5% in 2010 to 17.7% in 2018) and rectal gonorrhea (from 13.3% in 2010 to 17.1% in 2018). In contrast with pharyngeal chlamydia, pharyngeal gonorrhea screening was more common (from 69.5% in 2010 to 74.6% in 2018), and the percentage positive doubled during the study period (from 7.3% in 2010 to 14.8% in 2018). Pharyngeal chlamydia testing also increased (from 50.3% in 2010 to 72.9% in 2018), with concurrent decreases in positivity (from 4.2% in 2010 to 2.6% in 2018).

INTERPRETATION

During 2010-2018, changes occurred in the demographic composition of patients attending STD clinics participating in SSuN. Understanding trends in the demographic profile of STD patients and services provided can help identify addressable gaps in STD control efforts and direct public health action. Overall, fewer females, especially those aged 15-24 years, accessed care in these STD clinics during the study period. Untreated STDs among adolescent and young females can have serious consequences, including pelvic inflammatory disease and infertility. Additional efforts to monitor where adolescent and young females seek care and to ensure they are receiving quality STD-related health services are needed, especially considering increases in reported cases of STDs among females. Increases in the number of MSM attending STD clinics present a unique opportunity to reach this population with STD and HIV prevention services. Although a large percentage of STD cases are diagnosed outside of STD clinics, publicly funded STD clinics are an important safety-net provider of STD-related health services and provide vital STD-related health services for patient populations at risk for the consequences of STDs and HIV infection.

PUBLIC HEALTH ACTIONS

STD-related health services represent effective strategies for preventing STD and HIV transmission and acquisition or STD-related sequelae. Ensuring that all persons receive quality HIV and STD prevention and treatment services is vital for an effective public health approach to reducing STDs. STD clinics provide crucial safety-net services for preventing STD-related morbidity, including timely identification and treatment of curable STDs such as chlamydia, gonorrhea, and syphilis. Increases in the numbers of MSM attending STD clinics participating in SSuN provide additional opportunities for linking patients to high-impact HIV preventive services (e.g., pre-exposure prophylaxis), and the clinics are positioned to facilitate initiation or resumption of treatment among persons living with HIV.

Influences on Women's Care Seeking at Planned Parenthood Health Centers in Two Southern States

INTRODUCTION

In the context of a shifting health care landscape, better understanding of the factors that motivate women to seek services from specialized family planning clinics like Planned Parenthood (PP) can provide insights about potential changes in the role of specialized family planning clinics.

METHODS

We surveyed 725 women seeking services at two PP health centers in Louisiana and Kentucky from March 2016 to May 2017. We examined differences in care-seeking between women who had varying levels of access including those who did and did not have insurance instability or a regular source of care (RSOC) besides the clinic.

RESULTS

More than 60% of women attending the health centers did not have a regular source of care and nearly 40% experienced instability in insurance. Women who experienced insurance instability and a lack of a regular source of care more frequently sought primary preventive services such as pap tests and well-woman care at PP than women with better access. For women with better access, PP health centers also served important roles for those seeking contraceptive and sexually transmitted infection-related services. The most frequent reasons for choosing the PP were that it was faster to get an appointment, wanting to go to the PP clinic more than other clinics, and the confidentiality of services.

CONCLUSIONS

Our analysis suggests that PP health centers in Southern states still provide vital services for women with and without other sources of care and are critical for women needing access to timely services for preventative and sexually transmitted infection-related care.

Sexually transmitted disease clinics in the United States: Understanding the needs of patients and the capabilities of providers

Reports of bacterial sexually transmitted infections are at the highest levels ever reported in the United States, and state and local budgetary issues are placing specialized sexually transmitted disease (STD) care at risk. This study collected information from 4138 patients seeking care at 26 STD clinics in large metropolitan areas across the United States with high levels of reported STDs to determine patient needs and clinic capabilities. Surveys were provided to patients attending these STD clinics to assess their demographic information as well as reasons for coming to the clinic and surveys were also provided to clinic administrators to determine their operational capacities and services provided by the clinic. For this initial study, we conducted univariate analyses to report all data collected from these surveys. Patients attending STD clinics across the country indicated that they do so because of the relative ease of getting an appointment; including walk-in and same-day appointments as well as the welcoming environment and expertise of the staff at the clinic. Additionally, STD clinics provide specialized care to patients; including HIV testing and counseling as well as on-site, injectable medications for the treatment of gonorrhea and syphilis in an environment that helps to reduce the role of stigma in seeking this kind of care. Sexually transmitted disease clinics continue to play an important role in helping to curb the rising epidemic of sexually transmitted infections.

Laboratory Perspective on Racial Disparities in Sexually Transmitted Infections

BACKGROUND

Rates of sexually transmitted infections (STI) have risen steadily in recent years, and racial and ethnic minorities have borne the disproportionate burden of STI increases in the United States. Historical inequities and social determinants of health are significant contributors to observed disparities and affect access to diagnostic testing for STI.

CONTENT

Public health systems rely heavily on laboratory medicine professionals for diagnosis and reporting of STI. Therefore, it is imperative that clinicians and laboratory professionals be familiar with issues underlying disparities in STI incidence and barriers to reliable diagnostic testing. In this mini-review, we will summarize contributors to racial/ethnic disparity in STI, highlight current epidemiologic trends for gonorrhea, chlamydia, and syphilis, discuss policy issues that affect laboratory and public health funding, and identify specific analytic challenges for diagnostic laboratories.

SUMMARY

Racial and ethnic disparities in STI in the US are striking and are due to complex interactions of myriad social determinants of health. Budgetary cuts for laboratory and public health services and competition for resources during the COVID-19 pandemic are major challenges. Laboratory professionals must be aware of these underlying issues and work to maximize efforts to ensure equitable access to diagnostic STI testing for all persons, particularly those most disproportionately burdened by STI.

A need for trauma informed care in sexually transmitted disease clinics

OBJECTIVE

This review examines trauma from violence as a risk factor for sexually transmitted diseases (STDs) among women attending STD clinics. The review also aims to suggest trauma informed care (TIC) integrated into STD clinics might more effectively address traumatic effects of violence linked to sexual risk behaviors among this population.

DESIGN AND SAMPLE

A systematic literature review was conducted to identify empirical studies examining the relationship between multiple forms of violence and sexual risk behaviors among women attending STD clinics.

RESULTS

All studies found high rates of violence including childhood sexual abuse, intimate partner violence, and/or community violence associated with high rates of sexual risk behaviors among women attending these settings. Researchers recommend screening for multiple forms of violence, interdisciplinary STD clinic services, and more trauma informed sexual risk reduction interventions to address multiple forms of violence found prevalent among this population.

CONCLUSION

Women attending STD clinics very often experience multiple forms of violence during their lifetime. TIC to address traumatic effects of violence might reduce sexual risk behaviors and sexually transmitted disease rates for improved health outcomes among this population.

Get In, Get Tested, Get Care: STD Services in Urban Urgent Care Centers

BACKGROUND

Recent evidence indicates increased use of urgent care centers (UCCs) for sexually transmitted disease (STD) testing. We sought to learn more about STD services in UCCs in a large metropolitan area.

METHOD

Using a modified rapid gap assessment approach, we interviewed staff from 19 UCCs in metro Atlanta, GA. The UCCs were identified using two online search engines. We focused on a 50-mile radius around Atlanta. We then excluded duplicates and closed UCCs, and the ones outside Atlanta's five contiguous counties. Using a prioritization process, we visited UCCs in or adjacent to areas with mid to high local STD morbidity, or facilities from which STD cases were reported the year prior. We collected checklist-based data on STD testing, treatment, and preventive services, as well as supportive services (eg, substance use/mental health referrals). Checklist data, notes, and open-ended questions were summarized and analyzed descriptively.

RESULTS

All UCCs (n = 19) reported offering basic to comprehensive STD testing. Although most could treat on-site for chlamydia and gonorrhea, most relied on referrals, or prescriptions and "return to facility" practices to treat syphilis. Sources for STD information/management included the health department/Centers for Disease Control and Prevention, online medical sites, and electronic medical record embedded information. Challenges UCCs acknowledged included staying up-to-date with treatment guidance and laboratory reporting requirements, inadequate time for sexual risk reduction counseling, and linking patients with extended care needs (eg, HIV+ case management, supportive services), or following up with patients.

CONCLUSIONS

Urgent cares are STD testing resources. Service availability varies, but opportunities exist to enhance STD services in UCC settings and in communities.

Availability of Safety-net Sexually Transmitted Disease Clinical Services in the U.S., 2018

INTRODUCTION

Safety-net sexually transmitted disease services can prevent transmission of sexually transmitted disease. This study assesses the availability of safety-net sexually transmitted disease clinical services across the U.S.

METHODS

A 2018 survey of U.S. local health departments examined the availability of safety-net providers and the availability of specific sexually transmitted disease clinical services, including point-of-care testing and treatment. In 2019, Rao-Scott chi-square tests were used to compare service availability by clinic type (sexually transmitted disease clinic versus other clinics).

RESULTS

A total of 326 local health departments completed the survey (49% response rate). Of respondents, 64.4% reported that a clinic in their jurisdiction provided safety-net sexually transmitted disease services. Having a safety-net clinic that provided sexually transmitted disease services was more common in medium and large jurisdictions. Sexually transmitted disease clinics were the primary provider in 40.5% of jurisdictions. A wide range of specific sexually transmitted disease services was offered at the primary safety-net clinic for sexually transmitted diseases. Most clinics offered human papillomavirus vaccination and appropriate point-of-care treatment for gonorrhea and syphilis. Fewer than one-quarter of clinics offered point-of-care rapid plasma reagin or darkfield microscopy syphilis testing. Compared with other clinics, services more commonly offered at sexually transmitted disease clinics included same-day services, hepatitis B vaccination, rapid plasma reagin testing (syphilis), any point-of-care testing for gonorrhea, point-of-care trichomonas testing, and extragenital chlamydia or gonorrhea testing.

CONCLUSIONS

One-third of local health departments reported no safety-net sexually transmitted disease services or were not aware of the services, and availability of specific services varied. Without an expansion of resources, local health departments might explore collaborations with healthcare systems and innovations in testing to expand sexually transmitted disease services.

"The right place and the right time": A qualitative study of the decision-making process of self-initiated HIV testing among young adults

Young adults continue to have very low rates of human immunodeficiency virus (HIV) testing, which contribute to transmission, late diagnoses, and poor health outcomes. The access and uptake of HIV testing among young adults can be improved by promoting self-initiated testing (i.e., testing without the immediate recommendation of a clinician). Little is known, however, about how young adults self-initiate HIV testing. The purpose of this study was to explore the decision-making process of young adults who self-initiated HIV testing. A qualitative descriptive study was conducted with 30 young adults aged 18-24 years. The findings from this study describe how young adults acknowledge their vulnerability to HIV infection and navigate the process of deciding to self-initiate testing. Some subcategories include Self-Convincing, Conversation Prompts, and The Right Place and Right Time. Findings from this study are pivotal for subsequent studies to further understand self-initiated HIV testing among young adults and design targeted interventions that will improve testing uptake.

Patient Disengagement From an HIV Preexposure Prophylaxis Program in a Sexually Transmitted Disease Clinic

Among 307 patients enrolled in an HIV preexposure prophylaxis (PrEP) program in the Public Health-Seattle & King County STD Clinic, 52 patients (17%) did not fill their PrEP prescription and 40% of those who started PrEP discontinued it at least once within 12 months.

New Human Immunodeficiency Virus Diagnoses Among Men Who Have Sex With Men Attending Sexually Transmitted Disease Clinics, STD Surveillance Network, January 2010 to June 2013

To estimate new human immunodeficiency virus (HIV) diagnosis rates among HIV negative men who have sex with men (MSM) who are repeatedly tested for HIV in sexually transmitted disease (STD) clinics and assess the impact of demographic and disease-specific characteristics that are associated with higher HIV diagnosis rates.

STUDY DESIGN

Retrospective analysis using 2010 to 2013 data from the STD Surveillance Network (SSuN), a sentinel surveillance system comprised of health departments in 12 cities conducting sentinel surveillance in 40 STD clinics. We analyzed data from all MSM repeatedly (≥2 times) tested for HIV, with an initial negative HIV test required for staggered cohort entry. Follow-up time was accrued from the date of the first negative HIV test to the most recent negative test or the first positive HIV test. The STD diagnoses during the follow-up period were reviewed. We estimated HIV diagnoses rates (number of HIV diagnoses/total number of person-years [PY] at risk) by demographic and clinical characteristics with 95% confidence intervals (CI) using an inverse variance weighted random effects model, adjusting for heterogeneity between SSuN jurisdictions.

RESULTS

Overall, 640 HIV diagnoses occurred among 14,824 individuals and 20,951.6 PY of observation, for an adjusted incidence of HIV diagnosis of 3.0 per 100 PY (95% CI, 2.6-3.4). Rates varied across race/ethnicity groups with the highest rate among Blacks (4.7/100 PY; 95% CI, 4.1-5.3) followed by Hispanics, whites, and persons of other races/ethnicities. Men who have sex with men having a diagnosis of primary or secondary (P&S) syphilis on or after the first negative HIV test had a higher new HIV diagnosis rate (7.2/100 PY; 95% CI, 5.8-9.0) compared with MSM who did not have a P&S syphilis diagnosis (2.8/100 PY; 95% CI, 2.6-3.1). Men who have sex with men who tested positive for rectal gonorrhea (6.3/100 PY; 95% CI, 5.7-6.9) or rectal chlamydia (5.6/100 PY; 95% CI, 4.6-6.6) had higher rates of new HIV diagnosis when compared to those with negative test results.

CONCLUSIONS

Men who have sex with men attending SSuN STD clinics have high rates of new HIV diagnoses, particularly those with a previous diagnosis of P&S syphilis, rectal chlamydia, and/or gonorrhea. Sexually transmitted disease clinics continue to be important clinical setting for diagnosing HIV among MSM populations.

Understanding Quality of Care and Satisfaction With Sexual and Reproductive Healthcare Among Young Men

OBJECTIVE

Sexual and reproductive healthcare (SRHC) guidelines recommend the delivery of quality preventive SRHC to males beginning in adolescence. A quality of care (QOC) framework was used to examine factors associated with young male's perceptions of QOC and satisfaction with care, which can influence their engagement and use of SRHC.

METHODS

Cross-sectional surveys were conducted from August 2014 to September 2016 with 385 male patients aged 15-24 years, recruited from primary care and sexually transmitted disease (STD) clinics. Surveys measured QOC received, satisfaction with care, and domains of a QOC framework. Poisson regression analyses examined associations between domains of quality and perceived QOC as well as satisfaction with care.

RESULTS

Over half of males reported QOC as excellent (59%) and were very satisfied with the services (56.7%). Excellent QOC and high satisfaction with services was associated with timely care, higher Clinician-Client Centeredness, and being a bisexual male. Excellent QOC was also associated with greater comfort in the clinic, being tested for human immunodeficiency virus/STDs, attending primary care settings, and receipt of higher number of SRHC services.

CONCLUSIONS

Using a QOC framework as part of providing SRHC to young males can be important in improving their perceptions of QOC and satisfaction with services.

Advancing the HIV Pre-Exposure Prophylaxis Continuum: A Collaboration Between a Public Health Department and a Federally Qualified Health Center in the Southern United States

Uptake of pre-exposure prophylaxis (PrEP) has been limited among black and Latino men who have sex with men (MSM), especially in the southern United States. Public health departments and federally qualified health centers (FQHCs) serving predominantly uninsured populations are uniquely positioned to improve access. We evaluated a novel PrEP collaboration between a public health department and an FQHC in North Carolina (NC). In May 2015, a PrEP program was initiated that included no-cost HIV/sexually transmitted infection screening at a public health department, followed by referral to a colocated FQHC for PrEP services. We profiled the PrEP continuum for patients entering the program until February 2018. PrEP initiators and noninitiators were compared using Wilcoxon rank-sum test for continuous variables and chi-square or Fisher's exact tests for categorical variables. Of 196 patients referred to the FQHC, 60% attended an initial appointment, 43% filled a prescription, 38% persisted in care for >3 months, and 30% reported >90% adherence at follow-up. Among those presenting for initial appointments (n = 117), most were MSM (n = 95, 81%) and black (n = 62, 53%); 21 (18%) were Latinx and 9 (8%) were trans persons. Almost half (n = 55) were uninsured. We found statistically significant differences between PrEP initiators versus noninitiators based on race/ethnicity (p = 0.02), insurance status (p = 0.05), and history of sex work (p = 0.05). In conclusion, this collaborative model of PrEP care was able to reach predominantly black and Latino MSM in the southern United States. Although sustainable, program strategies to improve steps along the PrEP care continuum are vital in this population.

Changes in Patient Visits After the Implementation of Insurance Billing at a Sexually Transmitted Diseases Clinic in a Medicaid Expansion State

BACKGROUND

Medicaid expansion has led to unique opportunities for sexually transmitted disease (STD) clinics to improve the sustainability of services by billing insurance. We evaluated changes in patient visits after the implementation of insurance billing at a STD clinic in a Medicaid expansion state.

METHODS

The Rhode Island STD Clinic offered HIV/STD screening services at no cost to patients until October 2016, when insurance billing was implemented. Care for uninsured patients was still provided for free. We compared the clinic visits in the preinsurance period with the postinsurance period using t-tests, Poisson regressions, and a logistic regression.

RESULTS

A total of 5560 patients were seen during the preinsurance (n = 2555) and postinsurance (n = 3005) periods. Compared with the preinsurance period, the postinsurance period had a significantly higher average number of patient visits/month (212.9 vs. 250.4, P = 0.0016), including among patients who were black (36.8 vs. 50.3, P = 0.0029), Hispanic/Latino (50.8 vs. 65.8, P = 0.0018), and insured (106.3 vs. 130.1, P = 0.0025). The growth rate of uninsured (+0.10 vs. +4.11, P = 0.0026) and new patients (-4.28 vs. +1.07, P = 0.0007) also increased between the two periods. New patients whose first visit was before the billing change had greater odds (adjusted odds ratio, 2.68, 95% confidence interval, 2.09-3.44; P < 0.0001) of returning compared with new patients whose first visit was after the billing change.

CONCLUSIONS

Implementation of insurance billing at a publicly funded STD clinic, with free services provided to uninsured individuals, was associated with a modest increase in patient visits and a decline in patients returning for second visits.

Current challenges and opportunities to providing sexually transmitted disease services in STD clinics: A public health leadership perspective

OBJECTIVE

To assess leaders' perceptions of challenges and opportunities to providing sexually transmitted disease (STD) services in public health departments.

DESIGN AND SAMPLE

Semi-structured interviews were conducted in 2017 with health directors and other designated leaders in 19 public health departments who have an STD clinic. Purposive sampling accounted for geographical differences, providing balanced representation of urban, suburban, and rural agencies in North Carolina.

MEASUREMENT

Audiotaped interviews were transcribed verbatim. All transcripts were independently coded, with cross comparison and agreement between researchers. Rigorous thematic and content analyses were performed.

RESULTS

Perceived stigma, funding constraints, and client-centered issues were identified as the greatest challenges to providing services. Opportunities to improve these services were offering comprehensive screening methods, quality improvement, and public health accreditation. Focused training on revenue and billing practices for staff was acknowledged as the most needed technical assistance. A "culture of free services", perceived by clients and staff, was revealed throughout several themes.

CONCLUSIONS

Leaders in publicly funded STD clinics face many challenges and opportunities to providing clinical services. Health directors often serve as change agents and improving the sexual health of communities remains a priority. Results of this study will assist in crafting future policy and practice for STD clinics in the public health sector.

Medicaid Coverage of Sexually Transmitted Disease Service Visits

INTRODUCTION

Chlamydia and gonorrhea are the most commonly reported notifiable infections in the U.S., with direct medical costs for the treatment of these infections exceeding $700 million annually. Medicaid currently covers approximately 80 million low-income Americans, including a high percentage of racial and ethnic minorities. Studies have shown that racial and ethnic minority populations, particularly those with low SES, are at an increased risk of acquiring a sexually transmitted disease. Therefore, as Medicaid expands, there will likely be a greater demand for sexually transmitted disease services in community-based physician offices. To determine demand for these services among Medicaid enrollees, this study examined how often Medicaid was used to pay for sexually transmitted disease services received in this setting.

METHODS

This study combined 2014 and 2015 data from the National Ambulatory Medical Care Survey and tested for differences in the proportion of visits with an expected payment source of Medicaid when sexually transmitted disease services were and were not provided. All analyses were conducted in October 2018.

RESULTS

During 2014-2015, an estimated 25 million visits received a sexually transmitted disease service. Medicaid paid for a greater percentage of sexually transmitted disease visits (35.5%, 95% CI=22.5%, 51.1%) compared with non-sexually transmitted disease visits (12.1%, 95% CI=10.8%, 13.6%). Logistic regression modeling, controlling for age, sex, and race of the patient, showed that visits covered by Medicaid had increased odds of paying for a sexually transmitted disease service visit (OR=1.97, 95% CI=1.12, 3.46), compared with other expected payment sources.

CONCLUSIONS

Focusing sexually transmitted disease prevention in Medicaid populations could reduce sexually transmitted disease incidence and resulting morbidity and costs.

Same-Day HIV Pre-Exposure Prophylaxis (PrEP) Initiation During Drop-in Sexually Transmitted Diseases Clinic Appointments Is a Highly Acceptable, Feasible, and Safe Model that Engages Individuals at Risk for HIV into PrEP Care

Objective

Strategies to increase pre-exposure prophylaxis (PrEP) uptake are needed. We hypothesized that same-day PrEP initiation in a sexually transmitted diseases (STD) clinic would be acceptable, feasible, and safe, and that individuals would engage in ongoing PrEP care.

Method

Individuals aged ≥ 18 years were evaluated for PrEP. Exclusion criteria were HIV, history of renal dysfunction or chronic hepatitis B infection, pregnancy, indications for HIV post-exposure prophylaxis, or positive screen for acute HIV symptoms. One hundred individuals received a free 30-day PrEP starter pack and met with a patient navigator to establish ongoing care. Bivariate analysis and multivariable logistic regression were used to compare individuals who did and did not attend at least 1 PrEP follow-up appointment within 180 days of enrollment. Client satisfaction surveys were given 3 months after enrollment.

Results

The majority (78%) of participants completed at least 1 PrEP follow-up appointment, and 57% attended at least 2 follow-up appointments. After adjusting for race and ethnicity, age, health insurance status, and annual income, only income was associated with follow-up appointment attendance. Each additional $10,000 increase in income was associated with a 1.7-fold increase in the odds of attending a PrEP follow-up appointment (95% confidence interval, 1.07–2.66, P = .02). The majority (54%) of individuals completed the satisfaction survey and all respondents liked the option of same-day PrEP initiation.

Conclusions

Our study suggests STD clinic-based, same-day PrEP initiation is acceptable, feasible, safe, and links a high proportion of individuals into ongoing PrEP care. Additional resources may be needed to support low-income individuals’ retention in care.

Existence, Distribution, and Characteristics of STD Clinics in the United States, 2017

OBJECTIVES

Studies of sexually transmitted disease (STD) clinics have been limited by the lack of a national list for representative sampling. We sought to establish the number, type, and distribution of STD clinics and describe selected community characteristics associated with them.

METHODS

We conducted a 2-phased, multilevel, online search from September 2014 through March 2015 and from May through October 2017 to identify STD clinics in all 50 US states and the District of Columbia. We obtained data on clinic name, address, contact information, and 340B funding status (which requires manufacturers to provide outpatient drugs at reduced prices). We classified clinics by type. We also obtained secondary county-level data to compare rates of chlamydia and HIV, teen births, uninsurance and unemployment, and high school graduation; ratios of primary care physician to population; health care costs; median household income; and percentage of population living in rural areas vs nonrural areas. We used t tests to examine mean differences in characteristics between counties with and without STD clinics.

RESULTS

We found 4079 STD clinics and classified them into 10 types; 2530 (62.0%) clinics were affiliated with a local health department. Of 3129 counties, 1098 (35.1%) did not have an STD clinic. Twelve states had an STD clinic in every county, and 34 states had ≥1 clinic per 100 000 population. Most STD clinics were located in areas of high chlamydia morbidity and where other surrogate needs were greatest; rural areas were underserved by STD clinics.

CONCLUSIONS

This list may aid in more comprehensive national studies of clinic services, STD clinic adaptation to external policy changes (eg, in public financing or patient access policy), and long-term clinic survival, with special attention to clinic coverage in rural areas.

Sexually transmitted disease services and third-party payer reimbursement: Attitudes, knowledge, and current practices among 60 health departments/districts. Why does this matter to public health nurses?

OBJECTIVE

To assess staff attitudes, knowledge, and current practices in billing third-party payers for sexually transmitted disease (STD) services in public health departments/districts.

DESIGN AND SAMPLE

A cross-sectional, online survey was administered to staff at 60 urban and rural health departments/districts. Snowball sampling was used for greater representation. There were 311 staff responses from 56 agencies represented in the data analysis. Of the 311 responses, 106 were public health nurses and seven of the health directors had nursing backgrounds.

MEASUREMENT

The survey measured attitudes, knowledge, and current billing practices for STD services. Analysis of data was performed at both individual and agency level.

RESULTS

Almost 90% reported it was acceptable to bill insurance. However, 56% felt these services should remain a "free" service in the agency. Most agencies were billing Medicaid for STD services (95%) and 70% bill private third-party payers.

CONCLUSIONS

Current funding for public STD clinics is not sustainable and other viable income streams such as third-party payer reimbursement must be utilized. Public health nurses play a pivotal role in developing policies and procedures in billing third-party payers for STD and other clinical services. Understanding the interactions between attitudes, knowledge and practice are vital in this development.

HIV Care and Viral Load Suppression After Sexual Health Clinic Visits by Out-of-Care HIV-Positive Persons

Outcomes among people living with HIV (PLWH) in New York City (NYC) remain suboptimal. To assess the potential role of the city's sexual health clinics (SHCs) in improving HIV outcomes and reducing HIV transmission, we examined HIV care status and its correlates among HIV-positive SHC patients in NYC. Clinic electronic medical records were merged with longitudinal NYC HIV surveillance data to identify HIV-positive patients and derive their retrospective and prospective HIV care status. Evidence of HIV care and viral load suppression (VLS) after clinic visit were considered outcomes. Logistic regression models were used to assess their correlates. A third of the 1045 PLWH who visited NYC SHCs in 2012 were out of HIV care (OOC) in the 12 months preceding the clinic visit, and were less likely than those previously in HIV care (IC) to have subsequent evidence of HIV care (42% vs. 72%) or VLS in the 12 months after the visit (39% vs. 76%). VLS was particularly low among patients diagnosed with ≥2 sexually transmitted infections (46%). The odds of VLS were lowest among those OOC before the clinic visit [versus those IC, adjusted odds ratio (aOR): 0.21, 95% confidence interval (CI): 0.16-0.29], non-Hispanic blacks (versus non-Hispanic whites, aOR: 0.58, 95% CI: 0.37-0.90), and residents of high-poverty neighborhoods (>30% vs. <10%, aOR: 0.51, 95% CI: 0.29-0.89). Our findings suggest that SHCs could serve as an intervention point to (re-)link PLWH to HIV care. Real-time provider alerts about patients' OOC status could help achieve that goal.

Neighborhood Health Care Access and Sexually Transmitted Infections Among Women in the Southern United States: A Cross-Sectional Multilevel Analysis

INTRODUCTION

The United States has experienced an increase in reportable sexually transmitted infections (STIs) while simultaneously experiencing a decline in safety net services for STI testing and treatment. This multilevel study assessed relationships between neighborhood-level access to health care and STIs among a predominantly Human Immunodeficiency Virus (HIV)-seropositive cohort of women living in the south.

METHODS

This cross-sectional multilevel analysis included baseline data from HIV-seropositive and HIV-seronegative women enrolled in the Women's Interagency HIV Study sites in Alabama, Florida, Georgia, Mississippi, and North Carolina between 2013 and 2015 (N = 666). Administrative data (eg, United States Census) described health care access (eg, percentage of residents with a primary care provider, percentage of residents with health insurance) in the census tracts where women lived. Sexually transmitted infections (chlamydia, gonorrhea, trichomoniasis, or early syphilis) were diagnosed using laboratory testing. Generalized estimating equations were used to determine relationships between tract-level characteristics and STIs. Analyses were conducted using SAS 9.4.

RESULTS

Seventy percent of participants were HIV-seropositive. Eleven percent of participants had an STI. A 4-unit increase in the percentage of residents with a primary care provider was associated with 39% lower STI risk (risk ratio, 0.61, 95% confidence interval, 0.38-0.99). The percentage of tract residents with health insurance was not associated with STIs (risk ratio, 0.98, 95% confidence interval, 0.91-1.05). Relationships did not vary by HIV status.

CONCLUSIONS

Greater neighborhood health care access was associated with fewer STIs. Research should establish the causality of this relationship and pathways through which neighborhood health care access influences STIs. Structural interventions and programs increasing linkage to care may reduce STIs.

Three Years Post-Affordable Care Act Sexually Transmitted Disease Clinics Remain Critical Among Vulnerable Populations

INTRODUCTION

The purpose of the study is to examine whether demand for publicly funded sexually transmitted disease clinics changed after Affordable Care Act implementation.

METHODS

The percentages of total incident sexually transmitted infections in Baltimore City that occurred at publicly funded sexually transmitted disease clinics were compared between the 3 years prior to and following the 2014 Medicaid and private insurance expansions. Risk factors associated with diagnosis at sexually transmitted disease clinics were identified using log binomial regression. Statistical analyses were conducted in May 2017.

RESULTS

Post-Affordable Care Act, the relative proportion of total sexually transmitted infection diagnoses increased among private and hospital-affiliated clinics, remained unchanged at sexually transmitted disease clinics, and decreased at federally qualified health centers and other publicly funded programs (p<0.001). Multivariable analysis controlling for age, sex, race, and ethnicity showed an overall decline in the risk of diagnosis at sexually transmitted disease clinics post-Affordable Care Act compared with prior (adjusted relative risk=0.92, 95% CI=0.89, 0.96), but the risk among black and Latino men aged <25 years persisted (relative risk=1.03, 95% CI=0.96, 1.10).

CONCLUSIONS

The Affordable Care Act increased access to traditional health care, reducing burden on publicly funded programs. However, demand for sexually transmitted disease clinics remains substantial among priority patients. In the healthcare reform era, sexually transmitted disease clinic funding remains critical.

The state of sexual health services at U.S. Colleges and Universities

OBJECTIVE

To describe the array of sexual health care services provided at US colleges and universities.

PARTICIPANTS

During 2014-2015, 885 colleges were surveyed about their provision of sexual health services.

METHODS

55% of colleges responded. Data were weighted and stratified by minority-serving institutions (MSIs), 2-year and 4-year institutions.

RESULTS

70.6% of colleges reported having a health center (HC), of which 73.0% offered STI diagnosis/treatment (4 years vs. 2 years; 77.9% vs. 53.1%) and contraceptive services (70.1% vs. 46.4%), all p < .001. HCs less frequently offered LARC (19.7%), express STI testing (24.4%) and self-collection (31.4%). Condoms were available on 66.8% of campuses. HPV vaccination was available at more 4-year colleges (73.7% vs. 48.5%, p < .003) and non-MSIs (74.4% vs. 58.5, p = .019). Regarding MSM-targeted services, 54.6% offered pharyngeal and 51.8% rectal STI testing.

CONCLUSIONS

2-year colleges may require additional support with providing sexual health care. Improvements could entail increasing express testing, extra-genital STI testing, and LARC.

The Affordability of Providing Sexually Transmitted Disease Services at a Safety-net Clinic

INTRODUCTION

Sexually transmitted diseases continue to increase in the U.S. There is a growing need for financially viable models to ensure the longevity of safety-net sexually transmitted disease clinics, which provide testing and treatment to high-risk populations. This micro-costing analysis estimated the number of visits required to balance cost and revenue of a sexually transmitted disease clinic in a Medicaid expansion state.

METHODS

In 2017, actual and projected cost and revenues were estimated from the Rhode Island sexually transmitted disease clinic in 2015. Projected revenues for a hypothetical clinic offering a standard set of sexually transmitted disease services were based on Medicaid; private ("commercial") insurance; and institutional ("list price") reimbursement rates. The number of visits needed to cover clinic costs at each rate was assessed.

RESULTS

Total operating cost for 2,153 clinic visits was estimated at $255,769, or $119 per visit. Laboratory testing and salaries each accounted for 44% of operating costs, medications for treatment 7%, supplies 5%, and 28% of visits used insurance. For a standard clinic offering a basic set of sexually transmitted disease services to break even, a projected 73% of visits need to be covered at the Medicaid rate, 38% at private rate, or 11% at institutional rate.

CONCLUSIONS

Sexually transmitted disease clinics may be financially viable when a majority of visits are billed at a Medicaid rate; however, mixed private/public models may be needed if not all visits are billed. In this manner, sexually transmitted disease clinics can be solvent even if not all visits are billed to insurance, thus ensuring access to uninsured or underinsured patients.

Insurance Coverage and Utilization at a Sexually Transmitted Disease Clinic in a Medicaid Expansion State

BACKGROUND

In Rhode Island, the Patient Protection and Affordable Care Act has led to over 95% of the state's population being insured. We evaluated insurance coverage and barriers to insurance use among patients presenting for services at the Rhode Island sexually transmitted disease (STD) clinic.

METHODS

We analyzed factors associated with insurance coverage and utilization among patients presenting for STD services between July and December 2015.

RESULTS

A total of 692 patients had insurance information available; of those, 40% were uninsured. Patients without insurance were more likely than those with insurance to be nonwhite (50% among uninsured, compared with 40% among insured; P = 0.014) and Hispanic or Latino/a (25%, compared with 16%; P = 0.006), and less likely to be men who have sex with men (27%, compared with 39%; P = 0.001). Of those with health insurance, 26% obtained coverage as a result of the Affordable Care Act, and 56% of those were previously uninsured. Among uninsured individuals, barriers to obtaining health insurance included cost and unemployment. Among those with insurance, 43% reported willingness to use insurance for STD services. Barriers to insurance use included concerns about anonymity and out-of-pocket costs.

CONCLUSIONS

Despite expanded insurance access, many individuals presenting to the Rhode Island STD Clinic were uninsured. Among those who were insured, significant barriers still existed to using insurance. STD clinics continue to play an important role in providing safety-net STD services in states with low uninsured rates. Both public and private insurers are needed to address financial barriers and optimize payment structures for services.

US Public Sexually Transmitted Disease Clinical Services in an Era of Declining Public Health Funding: 2013-14

BACKGROUND

We examined the infrastructure for US public sexually transmitted disease (STD) clinical services.

METHODS

In 2013 to 2014, we surveyed 331 of 1225 local health departments (LHDs) who either reported providing STD testing/treatment in the 2010 National Profile of Local Health Departments survey or were the 50 local areas with the highest STD cases or rates. The sample was stratified by jurisdiction population size. We examined the primary referral clinics for STDs, the services offered and the impact of budget cuts (limited to government funding only). Data were analyzed using SAS, and analyses were weighted for nonresponse.

RESULTS

Twenty-two percent of LHDs cited a specialty STD clinic as their primary referral for STD services; this increased to 53.5% of LHDs when combination STD-family planning clinics were included. The majority of LHDs (62.8%) referred to clinics providing same-day services. Sexually transmitted disease clinics more frequently offered extragenital testing for chlamydia and/or gonorrhea (74.7%) and gonorrhea culture (68.5%) than other clinics (52.9%, 46.2%, respectively; P < 0.05). The majority of LHDs (61.5%) reported recent budget cuts. Of those with decreased budgets, the most common impacts were fewer clinic hours (42.8%; 95% confidence interval [CI], 24.4-61.2), reduced routine screening (40.2%; 95% CI, 21.7-58.8) and reductions in partner services (42.1%; 95% CI, 23.6-60.7). One quarter of those with reduced STD budgets increased fees or copays for clients.

CONCLUSIONS

Findings demonstrate gaps and reductions in US public STD services including clinical services that play an important role in reducing disease transmission. Furthermore, STD clinics tended to offer more specialized STD services than other public clinics.

Racial and Ethnic Disparities in Health and Health Care

A health disparity is defined as an increased burden of an adverse health outcome or health determinant within a specific subset of the population. There are well-documented racial and ethnic disparities throughout health care at the patient, provider, and health care system levels. As the minority populations within the United States grow to record numbers, it is increasingly important to invest in efforts to characterize, understand, and end racial and ethnic disparities in health care. Inequities in health outcomes and care pose real threats to the entire nation's well-being. Eliminating health disparities is fundamental to the well-being, productivity, and viability of the entire nation.

The Change in Insurance Status Among Patients Seeking Care at Chicago Sexually Transmitted Disease Clinics After Affordable Care Act Implementation

There was a 13% increase in the number of insured patients in Chicago sexually transmitted disease clinics 1 year after Affordable Care Act implementation. Major disparities in being insured persisted among those at higher risk for sexually transmitted diseases.

ABSTRACT

There was a 13% increase in the number of insured patients in Chicago sexually transmitted disease clinics 1 year after Affordable Care Act implementation. Insured patients were more likely to report having access to preventive (65% vs. 36%, P < 0.01) and sick care (72% vs. 44%, P < 0.01). Major disparities in being insured persisted among men, those aged 26 to 45 years, and racial minorities.

Continued Importance of Sexually Transmitted Disease Clinics in the Era of the Affordable Care Act

INTRODUCTION

Following the 2014 expansions of Medicaid and private health insurance through the Affordable Care Act, municipal sexually transmitted disease (STD) clinics-which have historically served predominantly uninsured patients-have been threatened with budget cuts nationwide. This study was conducted to evaluate the impact of the insurance expansions on the demand for STD clinic services.

METHODS

The proportion of total incident sexually transmitted infections in Baltimore City that were diagnosed at STD clinics was compared between 2013 and 2014, and a multivariate analysis was conducted to determine factors associated with diagnosis at an STD clinic. Analyses were conducted in July 2015.

RESULTS

There was no change in the overall proportion of sexually transmitted infection diagnoses made at STD clinics from 2013 to 2014 (relative rate, 1.03; 95% CI=0.95, 1.11). Hispanic ethnicity, black race, male sex, and age >24 years were associated with an increased likelihood of STD clinic utilization (p<0.0001).

CONCLUSIONS

Despite the Affordable Care Act's insurance expansion measures, the demand for STD clinics remained stable. These safety net clinics serve patients likely to face barriers to accessing traditional health care and their preservation should remain a priority.

Willingness to Use Health Insurance at a Sexually Transmitted Disease Clinic: A Survey of Patients at 21 US Clinics

OBJECTIVES

To survey patients of publicly funded sexually transmitted disease (STD) clinics across the United States about their willingness to use health insurance for their visit.

METHODS

In 2013, we identified STD clinics in 21 US metropolitan statistical areas with the highest rates of chlamydia, gonorrhea, and syphilis according to Centers for Disease Control and Prevention surveillance reports. Patients attending the identified STD clinics completed a total of 4364 surveys (response rate = 86.6%).

RESULTS

Nearly half of the insured patients were willing to use their health insurance. Patients covered by government insurance were more likely to be willing to use their health insurance compared with those covered by private insurance (odds ratio [OR] =  3.60; 95% confidence interval [CI] = 2.79, 4.65), and patients covered by their parents' insurance were less likely to be willing to use their insurance compared with those covered by private insurance (OR = 0.72; 95% CI = 0.52, 1.00). Reasons for unwillingness to use insurance were privacy and out-of-pocket cost.

CONCLUSIONS

Before full implementation of the Affordable Care Act, privacy and cost were barriers to using health insurance for STD services.

PUBLIC HEALTH IMPLICATIONS

Barriers to using health insurance for STD services could be reduced through addressing issues of stigma associated with STD care and considering alternative payment sources for STD services.