IN THIS ISSUE OF Sexually Transmitted Diseases, Kahn et al. report on their experiences with the use of a mobile clinic to screen for sexually transmitted diseases (STD) among high-risk populations in Baton Rouge, Louisiana. 1 This paper adds to the growing literature on community-based STD outreach testing in the past decade. The time has come to take stock and begin to think about what role such activities might play in the future of STD prevention, especially in a time when economic woes do not bode well for public health investments.
Public health outreach has a long and rich tradition, ranging from infectious disease outbreak investigations involving field-testing among exposed subjects to in-home maternal and infant check-ups. Even the idea of a mobile clinic is not entirely new: in the 1950s in Holland, the appearance of the “dentist bus” on school parking lots and playgrounds was as common as it was feared by the students [unpublished observation by the author]. Still, testing for STDs outside the clinical setting has a more limited history. In the past, outreach testing focusing on high-risk populations has included screening among gay men in saunas and bath houses in the 1970s and 1980s 2,3 and among sex workers in brothels. 4 However, obtaining urethral, cervical, and rectal samples in less than ideal circumstances was a challenge from the perspectives of both quality control as well as client acceptance, and these outreach efforts were more or less abandoned as many STDs went into decline in the post-HIV era.
Two developments have led to a reincarnation of STD outreach testing. First, there has been an increasing appreciation of the fact that most sexually transmitted infections are asymptomatic and that prevention strategies hinging on self-referral to STD clinics or other healthcare providers are doomed to fail, in particular among populations (such as adolescents) who are reluctant to seek health care, even if symptomatic. Second, the development of nucleic acid amplification testing (NAAT) for Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) allowed noninvasive testing of urine samples and self-obtained vaginal swabs outside the traditional clinical setting. This technological innovation rekindled interest in STD outreach testing in the mid-1990s and resulted in screening programs in numerous nontraditional settings, including schools, 5 correctional facilities, 6 community-based organizations, 7 and street outreach. 8,9 The most important lesson from these experiences is that noninvasive testing is acceptable by at-risk populations as is reflected by the (sometimes incredibly) high rates of CT and GC infections among them. Furthermore, these strategies can be cost-efficient, especially if partnerships are developed with institutions and agencies who have access to high-risk populations and who may include STD testing as part of the array of services offered. As a result, many public health departments have started to develop such partnerships. The Centers for Disease Control and Prevention (CDC) has stimulated this development, for example, through their Adolescent Women Reproductive Health Monitoring Project, 10 by providing seed money to public health agencies to offer NAAT CT and GC screening for high-risk populations. Many of these agencies have been able to sustain these efforts, often times on a shoestring, by obtaining additional grant support, by cost-shifting, or through other creative ways. However, these programs are now being threatened by reductions in public health funding. Locally, for example, budget cuts have forced the institution of a nominal fee in the Denver STD clinic, where traditionally these services had been offered without costs to the patient. This has resulted in a 30% reduction of clinic visits, disproportionally affecting adolescents and minority populations. 11
Dwindling public health resources devoted to STD care and prevention may lead to a retreat behind the walls of the health department, i.e., consolidating resources to safeguard the provision of clinical services and cutting back on innovative outreach activities. However, negative developments such as these may also present an opportunity. The implication for STD control is that this may be a time to revisit our objectives. With the limited resources we have, we cannot continue to be everything to all people, i.e., we cannot continue to offer all possible STD prevention services to the public regardless of risk. We have to make some hard choices based on the epidemiology of different STDs, their cost to society both in terms of economic impact as well as morbidity and suffering, and the likelihood that these can be reduced by our interventions. Such considerations may lead us to refocus our prevention efforts on the curable bacterial STDs, chlamydia and gonorrhea in particular. This is where outreach testing has proven most successful in identifying and serving high-risk populations and in developing STD prevention collaborations with nontraditional partners. If economic considerations must lead to the realignment of STD prevention services, outreach testing should be considered as a core component of STD control rather than an interesting idea that is expendable when the going gets tough.
1. Kahn R, Moseley K, Johnson G, Farley T. Community-based screening and treatment for STDs: results from a mobile clinic initiative. Sex Transm Dis 2003; this issue.
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10. Wang S, Rietmeijer C, Matson S, et al. Monitoring STD prevalence and reproductive health care among adolescent women in special settings in the United States, 1999-2001. Presented at the National STD Prevention Conference. San Diego, CA, 2002.
11. Alfonsi G, McEwen D, Douglas J. Reduction in attendance and detection of STD/HIV morbidity after institution of fees for service in an STD clinic. Presented at International Society for STD Research Congress. Ottawa, Canada, 2003.