WASHINGTON -- A bold national initiative is needed to reduce the enormous health burden of sexually transmitted diseases (STDs) in the United States, according to a new report from a committee of the Institute of Medicine. The report says there currently is no effective national system to combat STDs, even though five of the 10 most common diseases reported to the Centers for Disease Control and Prevention (CDC) last year were STDs. Although all of these diseases are preventable, each year STDs lead to thousands of deaths and can cause cancer and other serious health problems.

"We need to fight this hidden epidemic by bringing together entire communities to promote healthy sexual behaviors, protect adolescents, provide high-quality clinical services, and energize strong leadership in the fight against STDs," said committee chair William T. Butler, chancellor, Baylor College of Medicine, Houston. "Even though all of these diseases are preventable, the United States has the highest rate of curable STDs of any developed country." STDs cost taxpayers at least $10 billion annually, not including costs associated with sexually transmitted HIV infection. The public sector spends only $1 to prevent and fight STDs for every $43 spent on treatment and other costs. 

STDs refer to any of the dozens of diseases that can result from unprotected sex -- including chlamydial infection, syphilis, gonorrhea, and hepatitis B virus. STDs are a hidden epidemic that is difficult to track, treat, and prevent because these diseases often are symptomless and many people -- including health professionals -- are uncomfortable discussing STDs. Health consequences range from mild acute illnesses such as pelvic pain to life-threatening conditions such as cancers of the cervix and liver or ectopic pregnancy. Women and infants especially are affected by the health consequences of STDs.

At present, primary responsibility for tracking and preventing STDs is handled by the U.S. Department of Health and Human Services, including CDC, and state and local health departments. However, because the public sector is hampered by resource constraints and the logistics involved in fully implementing a national system of STD-related services, it is critical that the entire community, especially private-sector organizations and clinicians, assume more leadership and responsibility for STD prevention, the report says.

Federal, state, and local governments and the private sector should increase funding and support for prevention, and ensure that all people have access to comprehensive, high-quality STD-related services, the report says. CDC should take the lead in improving the surveillance of STDs and their associated complications, and collaborate with state and local agencies to monitor the effectiveness of prevention programs. In addition, an independent national roundtable should be established as a neutral forum for public- and private-sector agencies and organizations to develop and implement a comprehensive system of STD-related services in the United States.

Quality health services 

Effective prevention of these diseases also requires greater responsibility on the part of health plans -- including managed care plans -- which should take steps to integrate treatment and prevention of STDs in the mainstream of primary care, the report says. With very few exceptions, health plans do not place high priority on STDs, and few plans are involved in activities to prevent STDs in the larger community beyond plan members, the report says. Health plans should provide better training for primary care providers, and they should provide for or cover comprehensive STD-related services for all plan members and their sex partners, regardless of the partner's insurance status. Services should include screening, diagnosis, treatment, and counseling on how to avoid risky sexual behavior.

There is wide variation in the quality, scope, accessibility, and availability of services provided by publicly funded clinics that provide STD treatment, and some clinics do not provide high-quality services, according to the report. Part of the problem results from the fact that local health departments historically have operated STD clinics that are isolated from other health services, and lack the ability to monitor and assess quality. While public STD clinics should continue to function as a "safety net" provider of services, health departments operating these clinics should collaborate with other community-based health providers and pursue partnerships with university and hospital medical centers, and private health care professionals, the report says.

Because each community differs widely in its needs and capacity to support STD services, local areas must tailor their own system of services to meet their requirements.

Focusing on adolescents

One-quarter of the 12 million new STD cases each year occur among adolescents, who are at greater risk because they are more likely to engage in unprotected sex and other high-risk sexual behaviors than adults, and because adolescent girls and young women are more susceptible to cervical infections. In addition, adolescents often lack access to adequate health care services. One quarter of adolescents and young adults have no health insurance. The success of STD prevention programs depends on the ability to change awareness and behavior patterns over time, especially among young people. By the 12th grade, nearly 70 percent of adolescents have had sexual intercourse, and approximately one-quarter of all students have had sex with four or more partners. Adolescents should be strongly encouraged to delay sexual intercourse until they are emotionally mature enough to take responsibility for it, the report says. However, many adolescents will be sexually active and it is critical that they also have access to information about STDs and ways to prevent them. 

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

Positive messages

Because prevention of STDs is linked directly to personal behavior, the committee recommended a national campaign to promote a new social norm of healthy sexual behavior in the United States. This campaign should be led by highly visible opinion leaders, including those in the entertainment industry, sports figures, and elected officials, to promote public discussion and awareness of healthy sexual behavior. The campaign should enlist public health experts, mass media, advertising executives, public communications experts, and consumer representatives to work to increase knowledge and awareness of STDs and to help mass media incorporate responsible messages about healthy sexuality. The report recommends that television, radio, print, music, and other media organizations accept advertisements and sponsor public service messages that encourage condom use and other means of protecting against STDs and unintended pregnancy, including delaying sexual intercourse. Adolescents may be especially susceptible to media-generated messages because they spend more time watching television than they do in school and they receive a considerable amount of unbalanced information about sexuality from the mass media.

A committee roster follows. The study was sponsored by the Centers for Disease Control and Prevention, Glaxo Wellcome Inc., the Henry J. Kaiser Foundation, the National Institute of Allergy and Infectious Diseases, the Office of Research on Women's Health of the National Institutes of Health, Ortho-McNeil Pharmaceutical, and SmithKline Beecham Pharmaceuticals. The Institute of Medicine is a private, non-profit organization that provides health policy advice under a charter granted to the National Academy of Sciences.

Copies of Confronting Sexually Transmitted Diseases are available at www.nap.edu or by calling 202-334-3313  or 1-800-624-6242.   Contacts: Dan Quinn and Molly Galvin, Media Relations Associates
Shannon Flannery, Media Relations Assistant
(202) 334-2138; news@nas.edu

INSTITUTE OF MEDICINE
Division of Health Promotion and Disease Prevention
Committee on Prevention and Control of Sexually Transmitted Diseases
William T. Butler*(chair)
Chancellor
Baylor College of Medicine
Houston

Nancy E. Adler*
Director, Health Psychology Program, and
Vice Chair, Department of Psychiatry
University of California
San Francisco

E. Richard Brown
Director, Center for Health Policy Research, and
Professor of Public Health
School of Public Health
University of California
Los Angeles

Virginia A. Caine
Director
Marion County Health Department
Indianapolis

David D. Celentano
Professor of Social and Behavioral Sciences
Department of Health Policy and Management
Johns Hopkins School of Hygiene and Public Health
Baltimore

Paul D. Cleary*
Professor of Health Care Policy and Social Medicine
Harvard Medical School
Boston

Margaret A. Hamburg*
Health Commissioner
New York City Department of Health
New York City

King K. Holmes*
Director, Center for AIDS and STD, and
Professor of Medicine
University of Washington
Seattle

Edward W. Hook III
Professor of Medicine and Epidemiology
Schools of Medicine and of Public Health
University of Alabama
Birmingham

Loretta Sweet Jemmott
Associate Professor of Nursing, and
Director, Office of HIV Prevention Research
University of Pennsylvania School of Nursing
Philadelphia

Dorothy Mann
Executive Director
Family Planning Council
Philadelphia

Patrick H. Mattingly
Senior Vice President of Planning and Development
Harvard Pilgrim Health Care
Brookline, Mass.

Kathleen E. Toomey
State Epidemiologist and Director
Epidemiology and Prevention Branch
Division of Public Health
Georgia Department of Human Resources
Atlanta

A. Eugene Washington
Professor and Chair
Department of Obstetrics, Gynecology, and Reproductive Sciences
University of California
San Francisco

Catherine M. Wilfert
Professor of Pediatrics and Microbiology
Department of Pediatrics
Division of Infectious Diseases
Duke University Medical Center
Durham, N.C.

Jonathan M. Zenilman+
Associate Professor of Medicine
Division of Infectious Diseases
Johns Hopkins University School of Medicine
Baltimore

Institute of Medicine Staff

Thomas R. Eng
Senior Program Officer

Jennifer K. Holliday
Project Assistant

Michael A. Stoto
Director, Division of Health Promotion and Disease Prevention

(*) Member, Institute of Medicine
(+) Served through September 1995