Special Analysis aged over time and thus present unique treatment chal- lenges. Furthermore, individuals living with chronic viral Family Planning Clinics STDs or with untreated bacterial infections can transmit them to their sexual partners even when they are asymp- And STD Services tomatic or unaware that they are infected. Publicly supported family planning pro- Role of Family Planning Providers viders play a significant role in the effort STDs disproportionately affect women, racial and ethnic minorities, and teenagers—population groups that tend to bring testing and treatment services for to rely heavily on family planning clinics for their sexually transmitted diseases to young and reproductive health care. Women are not only biologi- low-income Americans. Yet, family planning cally more susceptible than men to some STDs but also agencies currently face enormous financial may suffer more serious consequences. Because STDs are less likely to produce symptoms in women, those and programmatic challenges that threaten who have been infected are more likely to go undiag- their ability to serve those in need. Such nosed until only after they have developed serious challenges include keeping pace with health problems, such as cervical cancer or pelvic increasing STD caseloads, affording state- inflammatory disease (which in turn can cause chronic pain, infertility and ectopic pregnancy). Additionally, of-the-art technologies, integrating family STDs in pregnant women can result in miscarriage, low planning and HIV services, and expanding birth weight and congenital and neonatal infections. services to include men. Some STDs are more common among minority groups. By Cynthia Dailard For example, gonorrhea and syphilis rates are as much as 30 times higher among blacks than among whites. Sexually transmitted diseases (STDs) are a major public Blacks account for more than half (54%) of all new HIV health problem in the United States. According to esti- cases in the United States, although they make up only mates by the American Social Health Association 13% of the U.S. population; Hispanics constitute 19% of (ASHA), there are approximately 15 million new STD new HIV cases, but only 12% of the population. cases in this country each year (see table). STD rates among teens are also particularly high. Many STDs—namely bacterial infections, such as According to ASHA estimates, roughly four million chlamydia, gonorrhea and syphilis—are treatable and teenagers acquire an STD annually, and about a quarter curable; however, countless Americans live with the long- of all new cases of STDs each year occur among teens. lasting health consequences that occur when these dis- By age 24, at least one in three sexually active people eases go untreated. Additionally, as many as 65 million have contracted an STD, and youth aged 15–19 account Americans are currently living with viral STDs, including for at least one-third of all cases of gonorrhea and genital herpes, human papillomavirus (HPV) and HIV. chlamydia. Teens are at such great risk for STDs These diseases cannot be cured but often can be man- because they typically have relationships of short dura- tion (and thus have multiple sex partners over time) INCIDENCE AND PREVALENCE OF SEXUALLY and because they frequently engage in unprotected TRANSMITTED DISEASES intercourse; teenage women are also biologically more susceptible to cervical infections than adult women. STD INCIDENCE PREVALENCE (New cases (People currently every year) infected) Clinical STD services are largely delivered at dedicated CHLAMYDIA 3,000,000 2,000,000 STD clinics or at other community-based clinics that GONORRHEA 650,000 NA are supported by a patchwork of different federal and HEPATITIS B77,000 750,000 state programs. STD clinics are generally operated by HERPES 1,000,000 45,000,000 state and local health departments and mostly serve HIV20,000 560,000 men who seek treatment for specific symptoms. HPV 5,500,000 20,000,000 SYPHILIS 70,000 NA As women are less likely than men to have STD symp- TRICHOMONIASIS 5,000,000 NA toms, they are far more likely to have their infections Source: American Social Health Association, Sexually detected in the context of a routine health screen or Transmitted Disease in America: How Many Cases and What contraceptive or prenatal visit. Family planning Cost?, December 1998. providers play a particularly important role. Indeed, the The Guttmacher Report on Public Policy A ugust 2002 8 STD SCREENING gram guidelines of which strongly encourage clinics to provide extensive STD services, have a considerable Whether family planning agencies perform routine STD screening or record of their own. In 2000 alone, Title X–funded clin- screen only high-risk clients varies by type of disease. ics administered 4.8 million STD tests, 428,000 HIV tests and 2.9 million Pap smears to low-income clients. Chlamydia Gonorrhea Key Challenges Syphilis Despite this impressive record, family planning providers today face several serious challenges that HIV threaten their ability to continue delivering high quality HPV STD services to those in need of subsidized care. Herpes Increasing STD caseloads. Family planning providers 020406080100routinely report that they are seeing more STDs in their Routine High-risk only patients than they did in the past. Deborah Gordis, vice Source: Finer LB, Darroch JE and Frost JJ, U.S. agencies providing publicly funded contraceptive services president for government programs at Planned in 1999, Perspectives on Sexual and Reproductive Health, 2002, 34(1):15–24. Parenthood of Metropolitan Washington, says that family planning clinics are seeing far more chlamydia, particu- larly among young women, as well as an increasing rate large majority of the nation’s more than 3,000 family of abnormal or inconclusive Pap smears suggesting HPV. planning agencies, which run more than 7,000 clinic This statement is echoed by Jane Wilson, a family plan- sites serving approximately seven million women each ning and reproductive health nursing care consultant year, either routinely screen all of their clients for with the Washington State Department of Health, who chlamydia and gonorrhea or screen those considered to says that between 1996 and 2000, chlamydia and gonor- be at high risk (see chart). Of agencies that use risk fac- rhea rates in her state rose 35% and 14%, respectively. tors as screening criteria, 97% screen clients with multi- ple sexual partners, 77% screen clients with new sexual To some extent, the observed rise in STD rates may be partners, 64% screen based on youth (with the typical attributed to more and better testing, particularly for age ceiling of 21), 27% screen clients with a history of asymptomatic STDs. “In the past,” says Gordis, “testing STDs and 25% screen clients who are single. for STDs was based much more on presenting symptoms. Now, with many STDs asymptomatic and the prevalence Whether a family planning agency provides treatment so high, testing has become much more routine.” for a given STD is a more complicated issue than Furthermore, calls for routine screening are growing: whether it provides screening, since such treatment can Recent guidelines issued by the U.S. Preventive Services range from providing antibiotics for gonorrhea or Task Force and the Centers for Disease Control and chlamydia to the long-term management of HIV-related Prevention (CDC) now urge that all sexually active disease. Different types of family planning agencies vary women in their teens and early 20s be screened for in their ability to provide these services: For example, chlamydia, with the CDC also urging that all women with hospitals are far better equipped to care for HIV-infected chlamydia be rescreened 3–4 months following treatment. individuals than are Planned Parenthood clinics. Thus, it is not surprising that there is considerable diversity in Better tests at higher cost. While family planning service treatment services by agency type (see chart, page 10). providers are moving to screen larger populations of women, new STD tests are improving detection rates, Overall, providers have an impressive record delivering enhancing patient care. These state-of-the-art tests, how- STD services to low-income women and teens. Research ever, are expensive. For example, there are new DNA- published by The Alan Guttmacher Institute in 2001 based chlamydia tests on the market that are noninva- found that women receiving contraceptive or other sive and easy to use, because they involve a urine related services at family planning clinics are one-third sample rather than a pelvic exam. While these tests more likely than those receiving such services from pri- could, in theory, greatly facilitate routine screening, they vate physicians to report that they obtained an STD ser- are twice the cost of current tests. Jessica Pollak, the vice. Each year, family planning clinics serve one in director of family planning for the Louisiana Department three women of reproductive age who obtain testing or of Health and Hospitals, says that because reinfection treatment for STDs, one in four who obtain an HIV test with chlamydia is so common, the state of Louisiana ini- and one in seven who obtain a Pap smear. tiated a pilot project that used the urine-based test to test for reinfection among women who had received The 4,500 family planning clinics that receive funding prior treatment for the disease and returned for Depo- under Title X of the Public Health Service Act, the pro- The Guttmacher Report on Public Policy A ugust 2002 9 much more expensive: Leslie Tarr Laurie, CEO and pres- STD TREATMENT ident of Tapestry Health, an independent family plan- Different types of family planning agencies vary in ning agency serving western Massachusetts, reports that their ability to offer treatment for key STDs. the single-dose treatment costs her agency more than 10 % who treat times the cost of the seven-day regimen ($17.64 com- Chlamydia pared to $1.50), making it financially prohibitive.