Sexually Transmitted Diseases:
Sources of Recent Sexually Transmitted Disease (STD)-Related Health Care for STD Clinic Patients
LAWRENCE, JEAN M. ScD, MPH, MSSA,*; ZENILMAN, JONATHAN MD,†; KAMB, MARY L. MD, MPH,‡; IATESTA, MICHAEL MPA,§; DOUGLAS, JOHN M. Jr. MD,‖‖; RHODES, FEN PhD,¶; BOLAN, GAIL MD,#; FISHBEIN, MARTIN PhD,**; PETERMAN, THOMAS MD, MSc,‡; FOR THE PROJECT RESPECT STUDY GROUP
From the *Permanente Research and Evaluation, Kaiser Permanente, Southern California, Los Angeles, California; the †Department of Infectious Diseases, School of Medicine, Johns Hopkins University, Baltimore, Maryland; the ‡Division of HIV/AIDS Prevention and the **Division of STD Prevention, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia; the §New Jersey Department of Health and Social Services, Newark, New Jersey; the ‖‖Denver Department of Health and Colorado Department of Public Health and Environment, Denver, Colorado; the ¶Long Beach Department of Health and Human Services and California State University, Long Beach, California; and the #San Francisco Health Department, San Francisco, California
Correspondence: Mary L. Kamb, MD, MPH, CDC, Division of HIV/AIDS Prevention, Mailstop E-46, 1600 Clifton Rd., NE, Atlanta, GA 30333. E-mail: firstname.lastname@example.org. Reprint requests: National Center for HIV, STD, and TB Prevention, Office of Communications, Mailstop E-06, Centers for Disease Control and Prevention, 1600 Clifton Rd., Atlanta, GA 30333
Received for publication November 22, 2000, revised February 26, 2001, and accepted March 1, 2001.
Project RESPECT Study Group members: Baltimore: Carolyn Erwin-Johnson, MA (Intervention Coordinator [IC]); Andrew L. Lentz, MPA (Project Manager [PM]); Mary A. Staat, MD, MPH (co-principal investigator [co-PI]); Dawn Sweet, PhD (IC); Jonathan M. Zenilman, MD (principal investigator [PI]). Denver: John M. Douglas (PI); Tamara Hoxworth, PhD (IC); Ken Miller, MPH (PM); William McGill, PhD. Long Beach: Ruth Bundy, PhD (co-PI); Laura A. Hoyt, MPA (PM); C. Kevin Malotte, DrPH (IC); Fen Rhodes, PhD (PI). Newark: Michael Iatesta, MA (PM); Eileen Napolitano (co-PI); Judy Rogers, MS (IC); Ken Spitalny, MD (PI). San Francisco: Gail A. Bolan, MD (PI); Coleen LeDrew; Kimberly A. J. Coleman (IC); Luna Hananel, MSW (IC); Charlotte K. Kent, MPH (PM). NOVA, Inc. Bethesda: Robert Francis, PhD (PI); Christopher Gordon; Nancy Rosenshine, MA (PI and IC); Carmita Signes. CDC: Sevgi Aral, PhD; Frankie Barnes, MPH; Robert H. Byers, PhD; Beth Dillon, MSW; Martin Fishbein, PhD; Sandra Graziano, PhD; Russ Havlak; Mary L. Kamb, MD, MPH; William Killean; Robin MacGowan, MPH; James Newhall, PhD; Daniel Newman, MS; Thomas A. Peterman, MD, MSc; Karen L. Willis, RN.
Dr. Lawrence was an Epidemic Intelligence Service Fellow with the Centers for Disease Control and Prevention, Atlanta, Georgia, when this work was done.
UNDERSTANDING WHERE PEOPLE GO for sexually transmitted disease (STD) screening, diagnosis, and treatment is important for public health planning and research. Some people seek care at public clinics, where STD-related services are inexpensive or free, readily available, and confidential. 1 Other sources of care for STD diagnoses and treatment include private physicians’ offices, emergency rooms, and family planning clinics. The aim of this study was to learn where STD clinic patients who reported having an STD in the past year went for their care.
The data for this study came from STD clinic patients enrolled in an HIV prevention counseling study (Project RESPECT). 2,3 From August 1993 through June 1995 the study enrolled 5815 patients from five urban STD clinics in the following cities: Baltimore, Denver, Long Beach, Newark, and San Francisco. Eligible persons included heterosexual men and women who were HIV-negative, who spoke English, who had come to the clinic for a diagnostic examination, who reported having engaged in vaginal sex in the past 30 days, and who agreed to an HIV test on the day of enrollment. According to earlier analyses, participants and those who refused to participate were similar in race and age. However, more women (55%) than men (37%) agreed to participate. 4
After enrollment and signing of informed consent, participants were assigned randomly to receive an HIV/STD prevention intervention: either information or risk-reduction counseling. Structured questionnaires were administered at enrollment (baseline) and at 3-month intervals for 12 months after intervention. All interviews were administered in a private setting by trained interviewers.
During the enrollment interview, participants were first asked: “Have you ever been told by a doctor or nurse that you had any of these illnesses?” All the participants then were asked specifically about syphilis, gonorrhea, chlamydia, and genital herpes. The men also were asked about nongonococcal urethritis, and the women were asked about trichomonas and pelvic inflammatory disease. If the participants responded affirmatively to any of these STDs, they were asked: “Were you treated in the past 12 months?” Those treated were asked: “Where were you treated?” Responses were coded 1 (this STD clinic [study site]), 2 (another STD clinic or health department), 3 (emergency room), 4 (private physician’s office or clinic), 5 (jail or detention center), 6 (army, military, or job corps), 7 (family planning clinic), or 8 (another location).
The place where patients had received STD-related care during the 12 months before study enrollment was determined, and with the use of odds ratio estimates, gender, age, and employment were considered as potential predictors of receiving care in settings other than STD clinics. The model was adjusted for the geographic location of the study site. No information about client insurance was collected. Variables associated with care provided exclusively in settings other than the study sites, and for which probability was 0.10 or less, were used in the final multivariable model.
Complete data on STD care were available for 5673 participants (98%). Of the 2452 women and 3221 men interviewed, 1456 (59%) women and 1898 (56%) men reported having had one or more of the study-defined STDs in their lifetime (excluding the current visit). Of the participants who reported having had an STD, 514 (35%) women and 567 (31%) men reported that they had been treated in the past 12 months. These 1081 persons ranged in age from 14 to 67 years (mean age: men, 27.6 ± 8.7 years; women, 24.8 ± 7.6 years). More than half (58%) were unemployed (49% of the men and 64% of the women), and one fourth of the respondents not working were in school. Some respondents (13% of the men and 26% of the women) reported having had more than one STD in the past 12 months.
Most of the men (428/567; 75%) and half of the women (256/513; 50%) who reported having an STD in the 12 months before study enrollment had received treatment at the study site at least once during that time. Women were more than twice as likely as men to have received treatment outside the study STD clinics (adjusted odds ratio [ORa], 2.7; 95% CI, 2.1–3.6). As compared with participants older than 30 years, adolescents (<20 years; ORa, 1.4; 95% CI, 1.0–2.1) and young adults (20–29 years; ORa, 1.2; 95% CI, 0.9–1.6) were slightly more likely to have received treatment exclusively in settings other than STD clinics during the past year. Employment was not associated with where people had sought STD-related care in the past year (ORa, 1; 95% CI, 0.7–1.3).
The 567 men reported a total of 650 STD cases during the 12 months before study enrollment (Table 1). Gonorrhea was the disease most frequently reported (44% of the men), followed by NGU (40%), chlamydia (20%), herpes (7%), and syphilis (3%). Compared with other STDs, proportionately more nongonococcal urethritis (87% of the cases) and less genital herpes (61% of the cases) were diagnosed and treated at the study clinics. For most STDs, men not treated at the STD clinic study site were treated in another STD clinic or health department. In fact, with the exception of genital herpes, more than 80% of each type of infection in men was diagnosed and treated in an STD clinic. Genital herpes represented only 7% of all the reported STD cases (n = 38), and in most (63% of the cases), men still sought care at either the study clinic or another STD clinic. For the remaining herpes cases, men sought care in emergency rooms (16% of the cases) and physicians’ offices (13% of the cases). Few men had received diagnoses or treatment of STDs in jails or detention centers, although 50% of the participants reported having been incarcerated in the past 12 months.
The 514 women reported a total of 681 STD cases during the 12 months before study enrollment (Table 2). Chlamydia was the disease most frequently reported (40% of the women), followed by gonorrhea (32%), trichomonas (30%), pelvic inflammatory disease (18%), herpes (7%), and syphilis (6%). Syphilis, gonorrhea, trichomonas, and pelvic inflammatory disease were treated at the study sites with similar frequency (range, 56–59%), and 70% or more of cases for each of these STDs were treated in an STD clinic setting. However, for chlamydia infections, women sought care in an STD clinic (usually the study site) in just 55% of the cases, receiving diagnosis and treatment in emergency rooms and physicians’ offices in 36% of the cases. Genital herpes accounted for few reported infections (n = 37). Women with recent herpes reported having sought care in STD clinic settings in less than half (41%) of the cases, while seeking care in other settings such as physicians’ offices, family planning clinics, or emergency rooms more often than for other STDs.
Most of the STD clinic patients who had received STD-related care in the past year had sought it at the STD clinic where they were enrolled in the study. Most who had sought STD care elsewhere had gone to other public STD clinics. These data provide evidence that STD clinic-based cohort studies screening prospectively for incident STD study outcomes can identify most of the bacterial STDs among both men and women. Linking patient records with nearby public STD clinics would allow detection of additional STDs.
These results also provide some particulars about sources of STD-related care. First, although care can be obtained in a variety of settings, most STD clinic patients, especially men, seek STD-related care in STD clinics. 1 Perhaps this is because STD clinics offer fewer financial barriers for treatment (although no association with employment was found, data on insurance were not available), availability of free or low-cost antibiotics, perceived confidentiality and anonymity, or a familiarity with the clinic. Celum et al 5 found that about one third of the men and one fourth of the women seen in the King County STD clinic in Seattle, Washington, had private insurance, and that patients sought care at the clinic because of its same-day appointments, low cost, concerns about privacy, and convenient location.
Second, regardless of STD diagnosis, women are more likely than men to have received STD care at places other than STD clinics, such as physicians’ offices and emergency rooms. This is not unexpected because neither antenatal nor contraceptive care are typically provided at STD clinics, so many women must access other facilities for their gynecologic care. It was surprising to note that relatively few women had received STD care at family planning clinics.
Third, chlamydia and genital herpes are the diseases most likely to be diagnosed in settings other than STD clinics. This observation may be related to the lack of routine screening for Chlamydia trachomatis or herpes simplex virus in many public clinics during the time of the study. In many STD and family planning clinics, diagnostic tests for these conditions were not available, which would have led to underreporting of specific chlamydia and herpes diagnoses (as opposed to syndromic diagnoses) at these sites. Furthermore, genital herpes frequently is not recognized as an STD. 6 This may have led some women to seek care at private providers or emergency rooms. Also, herpes is a chronic condition that involves recurrences for some infected persons. Although most public clinics provide free or low-cost antibiotics for bacterial STDs and genital warts, they seldom provide medications to treat genital herpes. Patients who seek care for recurrent genital herpes at STD clinics must have prescriptions filled off-site, and thus may be less inclined to go to public clinics.
The current study had some limitations. The analysis was based on self-report of STD diagnoses and care-seeking. It is not known whether the self-reports reflected the actual seeking of STD-related care. It also is not known whether the STDs reported were concurrent. The disease-specific visits (shown in Tables 1 and 2) may not have been separate visits. Finally, the study participants did not represent all the people with STDs who seek health care and perhaps were not even representative of all STD clinic patients.
Despite the limitations, the study results suggest some missed potential opportunities for STD prevention in the public and private sectors. Many men and women were repeat visitors to the STD clinics, suggesting that prevention strategies at public clinics need to be evaluated and, where lacking, strengthened. Many men reported having been incarcerated, but few had received an STD diagnosis or treatment during that time. Although one fourth of the study population was younger than 20 years of age, diagnosis and treatment at teen clinics were rare. These types of facilities may be underutilized for STD screening, diagnosis, and treatment.
In addition, the finding that some study participants, particularly women, received STD diagnoses in emergency rooms and physicians’ offices suggests an opportunity for trying routine STD screening and treatment in selected private physicians offices, managed care organizations, emergency rooms, and urgent care centers. This finding also underscores the importance of making sure that the providers at these facilities are aware of the STD services they might access in the public sector, such as partner notification and treatment, prevention counseling, and single-dose, directly observed therapy. The most compelling message suggested in these data, however, is that most men and women who seek STD-related care at a public STD clinic are likely to go to a public clinic for diagnosis and treatment of a future STD.
1. Eng TR, Butler WT, eds. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Washington, DC: National Academy Press, 1997.
2. Kamb ML, Dillon BA, Fishbein M, et al. Quality assurance of HIV prevention counseling in a multicenter randomized controlled trial. Public Health Rep 1996; 111 (suppl 1): S99–S107.
3. Kamb ML, Fishbein M, Douglas JM, et al. Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: a randomized controlled trial. JAMA 1998; 280: 1161–1167.
4. Graziano SL, Hoyt L, Iatesta M, et al. A Multicentered Randomized Trial of 3 HIV Prevention Interventions: Who Chooses to Participate? Presented at the XI International Conference on AIDS, July 12, 1996; Vancouver. Abstract 4386.
5. Celum CL, Hook EW, Bolan GA, et al. Where would clients seek care for STD services under healthcare reform? Results of a STD client survey from five clinics. In: Program and Abstracts of 11th Meeting of the International Society for STD Research, August 27–30, 1995, New Orleans, Louisiana. Abstract 101.
6. Fleming DT, McQuillan GM, Johnson RE. Herpes simplex virus type 2 in the United States, 1976 to 1994. N Engl J Med 1997; 37: 1105–1111.
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