Improving Clinical Operations: Can We and Should We Save Our STD Clinics?

Abstract

expenditures for the year 2009‐2010 is approximately $300 billion. 1 The anticipated 2010 shortfall represents almost 28% of states’ combined $109 billion budget, and recent projections look more dire still. Few state and local government programs are likely to go unaffected by the need for cutbacks, and STD clinics, which are funded almost entirely by nonfederal sources of revenue, are clearly vulnerable. Indeed, we are already feeling the effects of the fiscal crisis. A survey by the National Coalition of STD Directors found that 69% of STD programs experienced budget cuts in 2008, and that the number of categorical STD clinics in the United States declined by 10% over the last decade. 2 The current budget situation is likely to accelerate that trend. Given our predicament, it is a good time to consider the implications of this change and what we might do about it. First, how important are STD clinics? Table 1 shows the proportion of different reportable STDs diagnosed in categorical STD clinics in different cities and counties in the United States. The areas shown are a convenience sample of jurisdictions, and the presented data may be affected by reporting bias, but Table 1 demonstrates that in many areas of the country, STD clinics diagnose roughly 25% to 50% of primary and secondary syphilis cases, 15% to 35% of gonorrhea cases, 10% to 35% of HIV cases, and 5% to 20% of chlamydia cases. For bacterial STDs, these numbers are substantially higher than estimates based on patient reports, and suggest that STD clinics may be more important in the control of these infections, particularly syphilis and gonorrhea, than is generally thought. 3 Contemporary national data on the proportion of all HIV cases diagnosed in STD clinics are not available, but the information presented in Table 1 demonstrates that these clinics play a critical role in diagnosing HIV infection in many parts of the country. We have little empirical data on how closing STD clinics might affect rates of sexually transmitted infections in the population, 4 but case-finding and treatment are central to the control of STD, including HIV. Insofar as closing STD clinics leads infected persons to go undiagnosed or to be diagnosed later in the course of their infections, decreasing the health system’s capacity to provide care is likely to initiate a vicious cycle of increasing STD incidence, morbidity, and cost. 5 Of course, there are other reasons why these clinics are important. They often serve uninsured persons and socially marginalized populations, such as men who have sex with men and racial and ethnic minorities, and they disproportionately provide services to young men, who often have little other access to STD care or HIV testing. They allow patients to receive services that they might be reluctant to receive through their usual medical providers, and they provide subspecialty services (e.g., dark field testing, testing of rectal and pharyngeal sites, HIV RNA testing) that are not readily available in other settings. Also, CDC and health departments use STD clinics as sentinel surveillance sites to monitor antimicrobial resistance and risk behaviors within priority populations. The clinics provide needed clinical backup for community-based HIV/STD testing efforts, and are training sites for medical providers. Finally, STD clinics are a central component of the US national infrastructure for studying the diagnosis, treatment, and prevention of STD. We can probably develop alternative ways to provide at least some of these services if STD clinics disappear, but doing so will involve new costs, and our success is in no way certain. Proposed health care reform may decrease the demand for care in STD clinics, but it may not. High-income countries other than the United States have had universal health insurance for decades, and many (e.g., the Netherlands, United Kingdom, Australia) have elected to continue to support categorical STD clinics. We should