Sexually Transmitted Disease Services Research Articles

Sexual Behavior and Sexual Decision-Making Among Gay, Bisexual, and Other Men Who Have Sex with Men During the COVID-19 Pandemic: Observations from a Rapid Ethnographic Assessment in Marion County, Indiana, October-November 2021.

From 2020 to 2021, Marion County, Indiana, USA, saw an increase in early syphilis diagnoses, primarily among gay, bisexual, and other men who have sex with men (GBMSM). This rapid ethnographic assessment combines survey data from GBMSM with data from key informant interviews with multiple groups of stakeholders, including GBMSM, to describe how COVID-19 impacted sexual behaviors, sexual decision-making, and access to sexually transmitted disease (STD) services among GBMSM in Marion County, Indiana. A total of 62 virtual, semi-structured qualitative interviews with 72 key respondents including health department staff, medical providers, community-based organization staff, and GBMSM were conducted from October 14 to November 22, 2021. Modifications to partner-seeking and sexual behaviors attributable to the pandemic were associated with the way in which individuals reacted to the pandemic in general. Some GBMSM adopted mitigation strategies to avoid COVID-19 when meeting sex partners, such as creating a "sex pod." Effects on mental health included increased loneliness, heightened anxiety, and a sense of hopelessness regarding the perceived inevitability of acquiring COVID-19. For some, the latter prompted decreased engagement in preventive measures when engaging in sexual activity. The pandemic decreased access to STD services and significantly curtailed public health outreach efforts, which may have limited access to needed STD treatment and care. Efforts focusing on ongoing public health concerns during extreme health events like COVID-19 may want to consider the many ways these events affect ancillary behaviors, such sexual decision-making and sexual behaviors. The role of mental health is key; messaging and guidance may benefit from a trauma-informed approach.

Effect of Sexually Transmitted Disease Services in Type B Hospitals on Patient Self-Treatment

Background: Self-treatment is still a problem in disease treatment (Rakhmawati and Anggraini, 2010). This is supported by the large availability of drugs that are sold over the counter (Hadi, et. Al., 2010). However, there is not much research data regarding self-treatment by patients with sexually transmitted diseases (STD) and its relationship to hospital services. This study aimed to examine the effect of sexually transmitted disease ambulatory units services at Type B Hospital on patients self-treatment. Methods : The study was an analytic cross-sectional study. A total of 60 patients had their disease checked at the Sexually Transmitted Infectious Diseases Unit at the Dermatology and Venereology Department of the Regional General Hospital Dr. Soetomo Surabaya were selected consecutively and were interviewed about their experience with STD ambulatory services at type B hospitals and self-treatment. Simple and multiple logistic regression analyses were performed to prove the effect of the services on self-treatment at a significance level of 0.05. Results : Self-treatment was performed by 71.7% of the respondents. The distance to STD services of type B hospital that more than 8 km increased self-treatment (p = 0.042 OR = 4.043 95% CI = 1.050 - 15.568), while age (p = 0.063), gender (p = 0.126), treatment staff (p = 0.197), satisfaction (p = 0.298), type of disease (p = 0.967), duration of illness (p = 0.201) had no effect on self-treatment. Conclusions : Sexually transmitted disease services in type B hospitals did not affect the patients self-treatment behavior, but the distance of more than 8 km to the service increased patients self-treatment. STD services need to be expanded in such a way that the distance to the service is less than 8 kilometers.

Rise of syphilis surge amidst COVID-19 pandemic in the USA: A neglected concern

IntroductionSyphilis is a treatable but highly contagious sexually transmitted disease (STI) that has a long history of infecting millions of people from diverse ethnicities and is mainly considered promiscuity. An uprise in syphilis cases is noted in the Coronavirus pandemic. This short communication discerns salient factors precipitating the syphilis upsurge, implications, current efforts, and recommendations. DiscussionA decrease in funds and investments for public health clinics during COVID-19 because the funds have been diverted for treating COVID-19 has resulted in a dramatic rise in syphilis. The main determinants of the increased spread of syphilis during the COVID-19 pandemic include unsafe sexual activities, reduced STI screening, lack of sufficient staff during the pandemic, and abandoning of STI programs and services. RecommendationsWe recommend high-risk screening clinics and effective telehealth programs to combat against rising STI burden in the US.

The Epidemic of Sexually Transmitted Diseases Under the Influence of COVID-19 in China.

Background: Prevention and control of HIV/AIDS and other sexually transmitted diseases (STDs) are major public health priorities in China, but are influenced by the COVID-19 epidemic. In this study, we aimed to quantitatively explore the impact of the COVID-19 epidemic and its control measures on five major STD epidemics in China.Methods: A monthly number of newly reported cases of HIV/AIDS, hepatitis B and C, gonorrhea, and syphilis from January 2010 to December 2020 were extracted to establish autoregressive integrated moving average (ARIMA) models. Each month's absolute percentage error (APE) between the actual value and model-predicted value of each STD in 2020 was calculated to evaluate the influence of the COVID-19 epidemic on the STDs. Pearson correlation analysis was conducted to explore the confirmed COVID-19 case numbers and the COVID-19 control measures' correlations with the case numbers and the APEs of five STDs in 2020.Results: The actual number of five STDs in China was more than 50% lower than the predicted number in the early days of the COVID-19 epidemic, especially in February. Among them, the actual number of cases of hepatitis C, gonorrhea, and syphilis in February 2020 was more than 100% lower than the predicted number (APE was −102.3, −109.0, and −100.4%, respectively). After the sharply declines of STDs' reported cases in early 2020, the case numbers recovered quickly after March. The epidemic of STDs was negatively associated with the COVID-19 epidemic and its control measures, especially for restrictions on gathering size, close public transport, and stay-at-home requirements (p < 0.05).Conclusion: COVID-19 had a significant but temporary influence on the STD epidemic in China. The effective control of COVID-19 is vital for STD prevention. STD services need to be improved to prevent STDs from becoming a secluded corner in the shadow of COVID-19.

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

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

Changes in Sexual Behavior, PrEP Adherence, and Access to Sexual Health Services Because of the COVID-19 Pandemic Among a Cohort of PrEP-Using MSM in the South.

The coronavirus disease 2019 (COVID-19) pandemic has had unforeseen consequences on the delivery of HIV and sexually transmitted disease (STD) prevention services. However, little is known about how the pandemic has impacted pre-exposure prophylaxis (PrEP)-using men who have sex with men (MSM). Data come from an online cohort of PrEP-using MSM in the Southern United States from October 2019 to July 2020. Participants were administered 10 surveys in total, including 1 ad hoc survey specifically on COVID-19. We conducted a cross-sectional analysis of this ad hoc survey (n = 56) and present changes in sexual behaviors and utilization of and access to sexual health services. Using linear mixed-effect regression models, we also analyzed data from the larger cohort and document how sexual behaviors and PrEP use varied longitudinally across several months. A fifth of participants discontinued or changed how often they take PrEP because of COVID-19. A quarter of the cohort documented challenges when attempting to access PrEP, HIV testing, or STD testing. For all sexual behaviors examined longitudinally-number of male sexual partners, anal sex acts, condomless anal sex, and oral sex (all measured in the past 2 weeks)-there was a decrease from February to April followed by an increase from April to June. Our findings suggest reduced access to and utilization of STD and HIV services coupled with a continuation of behaviors which confer STD/HIV risk. Ensuring appropriate delivery of STD/HIV prevention services during this pandemic is imperative.

Home-Based Testing for Sexually Transmitted Infections: Leveraging Online Resources During the COVID-19 Pandemic.

Home-Based Testing for Sexually Transmitted Infections: Leveraging Online Resources During the COVID-19 Pandemic.

Recommendations for Providing Quality Sexually Transmitted Diseases Clinical Services, 2020.

SummaryThis report (hereafter referred to as STD QCS) provides CDC recommendations to U.S. health care providers regarding quality clinical services for sexually transmitted diseases (STDs) for primary care and STD specialty care settings. These recommendations complement CDC’s Sexually Transmitted Diseases Treatment Guidelines, 2015 (hereafter referred to as the STD Guidelines), a comprehensive, evidence-based reference for prevention, diagnosis, and treatment of STDs. STD QCS differs from the STD Guidelines by specifying operational determinants of quality services in different types of clinical settings, describing on-site treatment and partner services, and indicating when STD-related conditions should be managed through consultation with or referral to a specialist. These recommendations might also help in the development of clinic-level policies (e.g., standing orders, express visits, specimen panels, and reflex testing) that can facilitate implementation of the STD Guidelines. CDC organized the recommendations for STD QCS into eight sections: 1) sexual history and physical examination, 2) prevention, 3) screening, 4) partner services, 5) evaluation of STD-related conditions, 6) laboratory, 7) treatment, and 8) referral to a specialist for complex STD or STD-related conditions.CDC developed the recommendations by synthesizing relevant, evidence-based guidelines and recommendations issued by other experts; reviewing current practice in the United States; soliciting Delphi ratings by subject matter experts on STD care in primary care and STD specialty care settings; discussing the scientific evidence supporting the proposed recommendations at a consultation meeting of experts and institutional stakeholders held November 20, 2015, in Atlanta, Georgia; conducting peer reviews of draft recommendations and supporting evidence; and discussing draft recommendations and supporting evidence during meetings of the CDC/Health Resources and Services Administration Advisory Committee on HIV, Viral Hepatitis, and STD Prevention and Treatment STD Work Group. These recommendations are intended to help health care providers in primary care or STD specialty care settings offer STD services at their clinical settings and to help the persons seeking care live safer, healthier lives by preventing and treating STDs and related complications.

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.

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. To determine the impact on community provision of STD services after the elimination of state funds supporting STD service provision. 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. 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 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. 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.

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

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

Presenting to the Emergency Department Versus Clinic-Based Sexually Transmitted Disease Care Locations for Testing for Chlamydia and Gonorrhea: A Spatial Exploration.

Rates of sexually transmitted diseases (STDs) including chlamydia and gonorrhea are increasing in the United States while public health funding for STD services is decreasing. Individuals seek care in various locations including the emergency department (ED). The objective of this study is to investigate whether there are more physically proximal clinic-based STD care locations available to individuals who present to the ED in a major metropolitan area. Addresses of EDs, clinics, and patients 13 years or older in St. Louis City or County given a nucleic acid amplification test and assigned an STD diagnosis (n = 6100) were geocoded. R was used to analyze clinics within 5 radii from the patients' home address and assess missed clinic opportunities (open, no charge, with walk-in availability) for those living in an urban versus suburban area. In urban areas, 99.1% of individuals lived closer to a clinic than the ED where they sought STD services; in suburban areas, 82.2% lived closer to a clinic than the ED where they presented. In the region, 50.6% lived closer to the health department-based STD care location than the hospital where they presented. Up to a third of ED patient visits for STD care could have occurred at a clinic that was closer to the patient's home address, open, no charge, and available for walk-in appointments. Clinic availability is present for most of the individuals in our study. Clinics providing STD services can increase advertising efforts to increase public awareness of the services which they provide.

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?

To assess staff attitudes, knowledge, and current practices in billing third-party payers for sexually transmitted disease (STD) services in public health departments/districts. 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. The survey measured attitudes, knowledge, and current billing practices for STD services. Analysis of data was performed at both individual and agency level. 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. 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.

Chlamydia, Gonorrhea, and Human Immunodeficiency Virus Infection Among Transgender Women and Transgender Men Attending Clinics that Provide Sexually Transmitted Disease Services in Six US Cities: Results From the Sexually Transmitted Disease Surveillance Network.

Transgender women and transgender men are disproportionately affected by human immunodeficiency virus (HIV) infection and may be vulnerable to other sexually transmitted diseases (STDs), but the lack of surveillance data inclusive of gender identity hinders prevention and intervention strategies. We analyzed data from 506 transgender women (1045 total visits) and 120 transgender men (209 total visits) who attended 26 publicly funded clinics that provide STD services in 6 US cities during a 3.5-year observation period. We used clinical and laboratory data to examine the proportion of transgender women and transgender men who tested positive for urogenital and extragenital chlamydial or gonococcal infections and who self-reported or tested positive for HIV infection during the observation period. Of the transgender women tested, 13.1% tested positive for chlamydia and 12.6% tested positive for gonorrhea at 1 or more anatomic sites, and 14.2% were HIV-infected. Of transgender men tested, 7.7% and 10.5% tested positive for chlamydia and gonorrhea at 1 or more anatomic sites, and 8.3% were HIV-infected. Most transgender women (86.0% and 80.9%, respectively) and more than a quarter of transgender men (28.6% and 28.6%, respectively) with an extragenital chlamydial or gonococcal infection had a negative urogenital test at the same visit. Publicly funded clinics providing STD services are likely an important source of STD care for transgender persons. More data are needed to understand the most effective screening approaches for urogenital, rectal, and pharyngeal Chlamydia trachomatis and Neisseria gonorrhoeae infections in transgender populations.

A taxonomy of the scope and organization of local sexually transmitted disease services for policy and practice.

Local health departments (LHDs) and their organizational partners play a critical role in controlling sexually transmitted diseases (STDs) in the United States. We examine variation in the differentiation, integration, and concentration (DIC) of STD services and develop a taxonomy describing the scope and organization of local STD services. LHD STD programs (n = 115) in Alabama (AL) and California (CA) responded to surveys assessing STD services available in 2014. K-means cluster analysis identified LHD groupings based on DIC variation. Discriminant analysis validated cluster solutions. Differences in organizational partnerships and scope of STD services were compared by taxonomy category. Multivariable regression models estimated the association of the STD services organization taxonomy and five-year (2010–2014) gonorrhea incidence rates, controlling for county-level sociodemographics and resources. A three-cluster solution was identified: (1) low DIC (n = 74), (2) moderate DIC (n = 31), and (3) high DIC (n = 10). In discriminant analysis, 95% of jurisdictions were classified into the same types as originally assigned through K-means cluster analysis. High DIC jurisdictions were more likely (p < 0.001) to partner with most organizations than moderate and low DIC jurisdictions, and more likely (p < 0.001) to conduct STD needs assessment, comprehensive sex education, and targeted screening. In contrast, contact tracing, case management, and investigations were conducted similarly across jurisdictions. In adjusted analyses, there were no differences in gonorrhea incidence rates by category. Jurisdictions in CA and AL can be characterized into three distinct clusters based on the DIC of STD services. Taxonomic analyses may aid in improving the reach and effectiveness of STD services.

Improving Insurance and Health Care Systems to Ensure Better Access to Sexually Transmitted Disease Testing and Prevention.

Despite ongoing national efforts and advances in testing and treatment, sexually transmitted diseases (STDs) including human immunodeficiency virus (HIV), chlamydia, gonorrhea, and syphilis remain a significant public health challenge in the United States.1 Approximately 20 million cases of STDs and 40,000 cases of HIV are diagnosed annually,2,3 contributing an estimated $15.6 billion in total direct healthcare costs each year.4 As of 2015, new cases of syphilis, gonorrhea, and chlamydia are at the highest peak in the past decade.1 STDs and HIV infections continue to disproportionately impact historically marginalized individuals, including African American/Black, Hispanic/Latino, and sexual minority groups.1,5 Improved efforts are needed to address HIV/STD prevention, including facilitating testing and treatment approaches while minimizing barriers. There are a number of barriers to HIV/STD testing and prevention, including pre-exposure prophylaxis (PrEP) for reducing risk of HIV infection,6–9 that may be effectively addressed through reduced costs, elimination of unnecessary prior authorization requirements, and enhanced privacy in electronic medical records (EMRs). Cost and privacy barriers to STD care have historically been addressed by public STD clinics that, unlike traditional primary care or private sector settings, have provided anonymous services at no or minimal costs.10 However, declining public health funds, rising healthcare costs, and increased numbers of insured individuals following Medicaid expansion have pushed many settings to implement payment structures, including billing insurance for services.7,10–12 Thus, clinics previously providing services free of charge regardless of insurance status have adopted insurance use requirements that, while offsetting the burden of decreasing public health dollars, present a new set of challenges to patients. Paramount among these barriers is the out-of-pocket cost of services in the form of insurance copayments, coinsurance, and deductibles. Studies on patient willingness to use insurance at publicly funded STD clinics found that patients consistently report out-of-pocket costs as a major impediment to using insurance for STD services.7,13 Furthermore, patients with insurance may not want to use their insurance due to confidentiality concerns.7,13 In this commentary, we describe how insurance policies and currently employed EMRs deter patients, especially those from disadvantaged groups, from engaging in HIV/STD testing and prevention. We conclude with potential solutions that can aid healthcare practices, health information technology experts, and policymakers in improving access to these services.

State Laws Related to Billing Third Parties for Health Care Services at Public Sexually Transmitted Disease Clinics in the United States

Health departments (HDs) cite state laws as barriers to billing third parties for sexually transmitted disease (STD) services, but the association between legal/policy barriers and third-party HD billing has not been examined. This study investigates the relationship between laws that may limit HDs' ability to bill, clinic perceptions of billing barriers, and billing practices. Two surveys, (1) clinic managers (n = 246), (2) STD program managers (n = 63), conducted via a multiregional needs assessment of federally funded HD clinics' capacity to bill for STD services, billing/reimbursement practices, and perceived barriers were combined with an analysis of state laws regarding third-party billing for STD services. Statistical analyses examined relationships between laws that may limit HDs' ability to bill, clinic perceptions, and billing practices. Clinic managers reported clinics were less likely to bill Medicaid and other third parties in jurisdictions with a state law limiting their ability to bill compared with respondents who billed neither or 1 payer (odds ratio [OR], 0.31; 95% confidence interval [CI], 0.10-0.97) and cited practical concerns as a primary barrier to billing (OR, 2.83; 95% CI, 1.50-5.37). The STD program managers report that the staff believed that STD services should be free (OR, 0.34; 95% CI, 0.13-0.90) was associated with not billing (not sure versus no resistance to billing); confidentiality concerns was not a reported barrier to billing among either sample. Practical concerns and clinic staff beliefs that STD services should be free emerged as possible barriers to billing, as were laws to a lesser extent. Attempts to initiate HD billing for STD services may benefit from staff education as well as addressing perceived legal barriers and staff concerns.

Methods for Sexually Transmitted Disease Prevention Programs to Estimate the Health and Medical Cost Impact of Changes in Their Budget.

The purpose of this article was to describe methods that sexually transmitted disease (STD) programs can use to estimate the potential effects of changes in their budgets in terms of disease burden and direct medical costs. We proposed 2 distinct approaches to estimate the potential effect of changes in funding on subsequent STD burden, one based on an analysis of state-level STD prevention funding and gonorrhea case rates and one based on analyses of the effect of Disease Intervention Specialist (DIS) activities on gonorrhea case rates. We also illustrated how programs can estimate the impact of budget changes on intermediate outcomes, such as partner services. Finally, we provided an example of the application of these methods for a hypothetical state STD prevention program. The methods we proposed can provide general approximations of how a change in STD prevention funding might affect the level of STD prevention services provided, STD incidence rates, and the direct medical cost burden of STDs. In applying these methods to a hypothetical state, a reduction in annual funding of US $200,000 was estimated to lead to subsequent increases in STDs of 1.6% to 3.6%. Over 10 years, the reduction in funding totaled US $2.0 million, whereas the cumulative, additional direct medical costs of the increase in STDs totaled US $3.7 to US $8.4 million. The methods we proposed, though subject to important limitations, can allow STD prevention personnel to calculate evidence-based estimates of the effects of changes in their budget.

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

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

A Survey of 25 North Carolina Health Departments/Districts on Knowledge, Attitudes, and Current Practices to Seeking Reimbursement From Third-Party Payers for Sexually Transmitted Disease Services.

North Carolina Administrative Code 10A Chapter 41A.0204 (a) states "local health departments shall provide diagnosis, testing, treatment, follow-up, and preventive services for syphilis, gonorrhea, chlamydia, … These services shall be provided upon request and at no charge to the patient." Although health departments/districts may bill governmental or nongovernmental insurance providers for sexually transmitted disease (STD) services, current billing practices are unknown. Because of its high STD morbidity, the eastern region of North Carolina was targeted. Using a Qualtrics Survey developed to measure attitudes as well as knowledge and reimbursement practices, this descriptive study was performed with staff from 25 eastern North Carolina health departments/districts. Snowball sampling was used to allow for greater inclusion. Analysis of data was performed at the individual and agency level based on types of questions in the survey. For knowledge, 87% of the respondents reported being aware of the possibility of reimbursement from third-party payers/commercial insurance carriers for STD services. In regard to current billing of these services, 20 health departments/districts (80%) reported they were billing these payers. When asked about their attitude of seeking reimbursement from commercial insurance, 92% reported it was acceptable or very acceptable. But when asked if STD services should remain a free service at the health department, 55% supported and 45% did not. These data provide a knowledge base for assisting health departments/districts to move forward in improving STD services as well as maximizing reimbursement from third-party payers/commercial insurance carriers when possible.

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

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