Provision of STD Services in Community Settings After the Loss and Return of State Funding to Support Service Provision: Observations From Select Providers in Massachusetts, 2010 and 2013.

CONTEXT: In 2008, the $1.2 M sexually transmitted disease (STD) services line item supporting STD clinical services by the Massachusetts Department of Public Health was eliminated, forcing the cessation of all state-supported STD service delivery. OBJECTIVE: To determine the impact on community provision of STD services after the elimination of state funds supporting STD service provision. DESIGN AND SETTING: Rapid ethnographic assessments were conducted in May 2010 and September 2013 to better understand the impact of budget cuts on STD services in Massachusetts. The rapid ethnographic assessment teams identified key informants through Massachusetts's STD and human immunodeficiency virus programs. PARTICIPANTS: Fifty providers/clinic administrators in 19 sites (15 unique) participated in a semistructured interview (community health centers [n = 10; 53%], hospitals [n = 4; 21%], and other clinical settings [n = 5; 26%]). RESULTS: Results clustered under 3 themes: financial stability of agencies/clinics, the role insurance played in the provision of STD care, and perceived clinic capacity to offer appropriate STD services. Clinics faced hard choices about whether to provide care to patients or refer elsewhere patients who were unable or unwilling to use insurance. Clinics that decided to see patients regardless of ability to pay often found themselves absorbing costs that were then passed along to their parent agency; the difficulty and financial strain incurred by a clinic's parent agency by providing STD services without support by state grant dollars emerged as a primary concern. Meeting patient demand with staff with appropriate training and expertise remained a concern. CONCLUSIONS: Provision of public health by private health care providers may increase concern among some community provision sites about the sustainability of service provision absent external funds, either from the state or from the third-party billing. Resource constraints may be felt across clinic operations. Provision of public health in the for-profit health system involves close consideration of resources, including those: leveraged, used to provide uncompensated care, or available for collection through third-party billing.

Sexually Transmitted Disease Program Evolution in Response to Changes in the Public Health Environment: A Massachusetts Example.

BACKGROUND: In 2008, the line item supporting sexually transmitted disease (STD) services in the Massachusetts state budget was cut as a result of budget shortfalls. Shortly thereafter, direct provision of STD clinical services supported by the Massachusetts Department of Public Health (MDPH) was suspended. Massachusetts Department of Public Health requested an initial assessment of its internal response and impact in 2010. A follow-up assessment occurred in September 2013. METHODS: In 2010 and 2013, 39 and 46 staff, respectively, from MDPH and from clinical partner agencies, were interviewed about changes in the role of the MDPH, partnerships, STD services, challenges, and recommendations. Interview notes were summarized, analyzed, and synthesized by coauthors using qualitative analysis techniques and NVivo software. RESULTS: The withdrawal of state funding for STD services, and the subsequent reduction in clinical service hours, erected numerous barriers for Disease Intervention Specialists (DIS) seeking to ensure timely STD treatment for index cases and their partners. After initial instability, MDPH operations stabilized due partly to strong management, new staff, and intensified integration with human immunodeficiency virus services. Existing contracts with human immunodeficiency virus providers were leveraged to support alternative STD testing and care sites. Massachusetts Department of Public Health strengthened its clinical and epidemiologic expertise. The DIS expanded their scope of work and were outposted to select new sites. Challenges remained, however, such as a shortage of DIS staff to meet the needs. CONCLUSIONS: Although unique in many ways, MA offers experiences and lessons for how a state STD program can adapt to a changing public health context.

Substance use and sexual risk behaviors among american Indian and alaska native high school students.

BACKGROUND: We describe the prevalence of behaviors that put American Indian and Alaska Native (AI/AN) high school students at risk for teen pregnancy and sexually transmitted infections (STIs) and the relationships among race/ethnicity and these behaviors. METHODS: We analyzed merged 2007 and 2009 data from the national Youth Risk Behavior Survey, a biennial, self-administered, school-based survey of US students in grades 9-12 (N = 27,912). Prevalence estimates and logistic regression, controlling for sex and grade, were used to examine the associations between race/ethnicity, and substance use, and sexual risk behaviors. RESULTS: Of the 26 variables studied, the adjusted odds ratios (AOR) were higher among AI/AN than White students for 18 variables (ranging from 1.4 to 2.3), higher among AI/AN than Black students for 13 variables (ranging from 1.4 to 4.2), and higher among AI/AN than Hispanic students for 5 variables (ranging from 1.4 to 1.5). Odds were lower among AI/AN than Black students for many of the sexual risk-related behaviors. CONCLUSIONS: The data suggest it is necessary to develop targeted, adolescent-specific interventions aimed at reducing behaviors that put AI/AN high school students at risk for teen pregnancy, STI/HIV, and other health conditions.

Assessing spatial gaps in sexually transmissible infection services and morbidity: an illustration with Texas county-level data from 2007.

BACKGROUND: In the United States, sexually transmissible infection (STI) and family planning (FP) clinics play a major role in the detection and treatment of STIs. However, an examination of the spatial distribution of these service sites and their association with STI morbidity and county-level socioeconomic characteristics is lacking. We demonstrate how mapping and regression methods can be used to assess the spatial gaps between STI services and morbidity. METHODS: We used 2007 county-level surveillance data on chlamydia (Chlamydia trachomatis), gonorrhoea (Neisseria gonorrhoeae) and syphilis. The geocoded STI service (STI or FP clinic) locations overlaid on the Texas county-level chlamydia, gonorrhoea and syphilis morbidity map indicated that counties with high incidence had at least one STI service site. Logistic regression was used to examine the association between having STI services and county-level socioeconomic characteristics. RESULTS: Twenty-two percent of chlamydia high-morbidity counties (>365 out of 100000); 32% of gonorrhoea high-morbidity counties (>136 out of 100000) and 23% of syphilis high-morbidity counties (≥4 out of 100000 and at least two cases) had no STI services. When we controlled for socioeconomic characteristics, high-morbidity syphilis was weakly associated with having STI services. The percent of the population aged 15-24 years, the percent of Hispanic population, the crime rate and population density were significantly (P<0.05) associated with having STI services. CONCLUSION: Our results suggest that having an STI service was not associated with high morbidity. The methods used have demonstrated the utility of mapping to assess the spatial gaps that exist between STI services and demand.

Association between HIV-related risk behaviors and HIV testing among high school students in the United States, 2009.

OBJECTIVE: To identify the human immunodeficiency virus (HIV)-related risk behaviors associated with HIV testing among US high school students who reported ever having sexual intercourse. DESIGN: Secondary analysis of a cross-sectional study. SETTING: The 2009 national Youth Risk Behavior Survey. PARTICIPANTS: A total of 7591 US high school students who reported ever having sexual intercourse. MAIN EXPOSURES: Risk behaviors related to HIV. MAIN OUTCOME MEASURE: Having ever been tested for HIV. RESULTS: Among the 7591 students who reported ever having sexual intercourse, 22.6% had been tested for HIV. Testing for HIV was most likely to be done among students who had ever injected any illegal drug (41.3%; adjusted odds ratio, 1.70; 95% CI, 1.14-2.56), had ever been physically forced to have sexual intercourse (36.2%; adjusted odds ratio, 1.43; 95% CI, 1.19 -1.72), did not use a condom the last time they had sexual intercourse (28.7%; adjusted odds ratio, 1.28; 95% CI, 1.08-1.51), and had sexual intercourse with 4 or more persons during their life (34.7%; adjusted odds ratio, 2.32; 95% CI, 1.98-2.73). CONCLUSIONS: Most sexually active students, even among those who reported high-risk behaviors for HIV, have not been tested for HIV. New strategies for increasing HIV testing among the adolescent population, including encouraging routine voluntary HIV testing among those who are sexually active, are needed.

County-level sexually transmitted disease detection and control in Texas: do sexually transmitted diseases and family planning clinics matter?

BACKGROUND: Sexually transmitted disease (STD) detection and control have traditionally been performed by STD and family planning (FP) clinics. However, the magnitude of their impact (or the lack thereof) has not been examined. We examine the association between having STD and/or FP clinics and county-level STD detection and control in the state of Texas. METHODS: We used county-level STD (chlamydia, gonorrhea, and primary and secondary syphilis) morbidity data from the National Electronic Telecommunications System for Surveillance for 2000 and 2007. We applied spatial regression techniques to examine the impact of the presence of STD/FP clinic(s) (included as dichotomous variables) on STD detection (i.e., morbidity) and control. We included county-level demographic characteristics as control variables. RESULTS: Our results indicated that counties with STD or FP clinics were associated with at least 8% (P < 0.05) increase in the transformed chlamydia and gonorrhea rates, 20% (P < 0.01) increase in transformed syphilis rates in 2000, and at least 6% (P < 0.05) increase in transformed gonorrhea and Chlamydia rates in 2007. From 2000 to 2007, the transformed incidence rates of chlamydia declined by 4% (P < 0.10), 8% (P < 0.01) for gonorrhea, and 8% (P < 0.05) for primary and secondary syphilis for the counties that had at least 1 STD or FP clinic. CONCLUSIONS: The results from this ecological study are associations and do not establish a causal relationship between having an STD/FP clinic and improved STD detection and control. Finer level analyses (such as census block or cities) may be able to provide more detail information.

Sexually transmitted diseases program performance measures: how are they performing?

BACKGROUND: Performance measures were developed in order to improve the performance of sexually transmitted disease (STD) prevention programs. METHODS: A consultant worked with persons from STD programs and Centers for Disease Control and Prevention to identify possible measures. Measures were pilot tested for feasibility and relevance in several programs, then implemented nationwide in 2004. Data were collated and shared with programs and presented at national meetings. Site visits, webinars, and technical assistance focused on program improvement related to the measures. Reported data were analyzed to see if national performance improved on the activities measured. RESULTS: Some measures were dropped or revised, and quality of reported data improved over time. There was little evidence that overall program performance improved. CONCLUSIONS: Performance measures are one way to monitor performance, and might contribute to program improvement, but additional efforts are needed to improve performance.

The direct cost of chlamydial infections: estimates for the employer-sponsored privately insured population in the United States, 2003-2007.

Claims data between 2003 and 2007 were used to estimate the direct medical cost per case of chlamydial infections. Estimated total cost per episode for those who were treated was $142 (male, $157; female, $141). This estimate does not include intangible cost, lost productivity, and the cost of potential sequelae.

Health behaviors among American Indian/Alaska Native women, 1998-2000 BRFSS.

BACKGROUND AND OBJECTIVE: Minority populations, including American Indians and Alaska Natives (AI/AN), in the United States generally experience a disproportionate share of adverse health outcomes compared with whites. The prevalence of risk behaviors associated with these adverse health outcomes among AI/AN women is not well documented, especially for those who live outside areas serviced by Indian Health Service. We sought to describe the prevalence of selected health risk behaviors among AI/AN women, document the disparities between AI/AN women and all U.S. women, and demonstrate the efforts needed for AI/AN women to reach Healthy People 2010 goals. METHODS: Age-adjusted prevalence estimates for selected sociodemographic characteristics, current smoking, obesity, lack of leisure time physical activity, and binge drinking were calculated using Behavioral Risk Factor Surveillance System (BRFSS) data from 1998 to 2000, combined. Comparisons were made between prevalence estimates for AI/AN women and all women who participated in the BRFSS and Healthy People 2010 goals. RESULTS: The prevalences of current smoking (27.8%) and obesity (26.8%) were significantly higher among AI/AN women than among all U.S. women. AI/AN women did not meet Healthy People 2010 goals for current smoking, obesity, leisure time physical activity, or binge drinking. CONCLUSIONS: These data highlight both disparities in health risk behaviors between AI/AN women and all U.S. women and improvements needed for AI/AN women to meet Healthy People 2010 goals. This project demonstrates the overwhelming need for culturally appropriate and accessible prevention programs to address health risk behaviors associated with the leading causes of death among urbanized AI/AN women.

Attempted suicide and associated health risk behaviors among Native American high school students.

Suicide represents the second-leading cause of death among American Indian/Alaska Native (AI/AN) youth aged 15-24 years. Data from the 2001 Bureau of Indian Affairs (BIA) Youth Risk Behavior Survey were used to examine the association between attempted suicide among high school students and unintentional injury and violence behaviors, sexual risk behaviors, tobacco use, and alcohol and other drug use. The study included students in BIA-funded high schools with 10 or more students enrolled in grades 9-12. Overall, 16% of BIA high school students attempted suicide one or more times in the 12 months preceding the survey. Females and males who attempted suicide were more likely than females and males who did not attempt suicide to engage in every risk behavior analyzed: unintentional injury and violence behaviors, sexual risk behaviors, tobacco use, and alcohol and other drug use. These data enable educators, school health professionals, and others who work with this population to better identify American Indian youth at risk for attempting suicide by recognizing the number and variety of health risk behaviors associated with attempted suicide.