Sexually Transmitted Diseases:
The Real World of STD Prevention
Enhancing HIV/AIDS, Viral Hepatitis, Sexually Transmitted Disease, and Tuberculosis Prevention in the United States Through Program Collaboration and Service Integration: The Case for Broader Implementation
Steiner, Riley J. MPH*; Aquino, Gustavo MPH*; Fenton, Kevin A. MD, PhD, FFPH*†
From the *Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Atlanta, GA; and †Public Health England, Health and Wellbeing Directorate, London, UK
The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Conflict of interest statement: Conflicts of interest do not exist for any of the listed authors.
Correspondence: Kevin A. Fenton, MD, PhD, FFPH, 4th Floor, 133-155 Wellington House, Waterloo Road, London SE1 8UG, UK. E-mail: Kevin.Fenton@phe.gov.uk.
Received for publication March 22, 2013, and accepted May 23, 2013.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site ( http://www.stdjournal.com).
HIV infection, viral hepatitis, sexually transmitted diseases, and tuberculosis in the United States remain major public health concerns. The current disease-specific prevention approach oftentimes has led to narrow success and missed opportunities for increasing program capacity, leveraging resources, addressing social and structural determinants, and accelerating health impact—suggesting a need for greater innovation to prevent related diseases. The National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention’s Program Collaboration and Service Integration (PCSI) strategic priority aims to strengthen collaborative engagement across these disease areas and to integrate services at the client level. In this review, we articulate the 5 principles of PCSI—appropriateness, effectiveness, flexibility, accountability, and acceptability. Drawing upon these principles and published literature, we discuss the case for change that underlies PCSI, summarize advances in the field since 2007, and articulate key next steps. Although formal evaluation is needed to fully assess the health impact of PCSI, available evidence suggests that this approach is a promising tool to advance prevention goals.
The persistent and pervasive epidemics of human immunodeficiency virus (HIV) infection, viral hepatitis, sexually transmitted diseases (STDs), and tuberculosis (TB) in the United States remain major public health concerns. There are more than 1 million Americans living with HIV and as many as 5.3 million persons living with chronic viral hepatitis.1,2 Sexually transmitted diseases are also highly prevalent within the general population, with an estimated 110 million prevalent infections among women and men in 2008.3 More than 11 million Americans have latent TB infection,4 although incidence of TB is now at the lowest level ever recorded.5 Despite the considerable gains that have been made in reducing the overall incidence of these conditions,6 the increasing epidemic concentration among minorities, the socioeconomically disadvantaged, and those with poor access to services is concerning.7
The continued burden and deepening health disparities associated with these diseases suggest a need for greater efficiency and innovation to enhance traditional control efforts. The current disease prevention approaches rely on funding for disease-specific programs, largely designed to focus capacity on high-priority conditions. This has resulted in considerable success in reducing the population burden of disease by doing a few important things well and developing a cadre of national, state, and local specialists. However, over time, this focused effort has created silos of technical excellence with a number of unintended consequences including limited collaboration, failure to address co-occurring epidemics (or syndemics), and missed opportunities to comprehensively leverage the capacity, expertise, and resources required to address these complex conditions across populations.8
Nationwide, however, there has been a critical examination of how health services are organized and delivered, resulting in the implementation and evaluation of innovative approaches to increase health impact.9 Simultaneously, there has been discussion of moving from solely “vertical,” disease-specific prevention programs toward the addition of “horizontal,” integrated approaches and even “diagonal” frameworks in which specific prevention and treatment priorities drive overarching improvements in the health system.10
The Centers for Disease Control and Prevention’s (CDC’s) National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) has led US efforts to more efficiently and effectively prevent those infectious diseases in the overlapping populations at risk. In 2007, NCHHSTP introduced Program Collaboration and Service Integration (PCSI)—a strategic priority that aims to strengthen collaborative engagement across these disease areas and integrate services at the client level. In this review, we articulate the 5 principles of PCSI—appropriateness, effectiveness, flexibility, accountability, and acceptability.8 Drawing upon these principles and published literature, we discuss the case for change that underlies PCSI, summarize advances in the field since 2007, and articulate key next steps.
PROGRAM COLLABORATION AND SERVICE INTEGRATION
Program Collaboration and Service Integration promotes the organizing and blending of separate activities and services for interrelated health issues, using new and established linkages, to maximize public health impact and facilitate service delivery ( http://links.lww.com/OLQ/A75).8 Unlike categorical programs that focus at the outset on a specific disease, this syndemic orientation to prevention begins with populations or communities and considers how to comprehensively address the conditions that affect health.8 Program collaboration describes individuals, groups, and systems planning together and sharing resources at a much higher degree than just through coordination or cooperation.11 Service integration refers to a distinct pattern of service delivery that offers multiple, related services to populations at risk for multiple infections, including features such as common intake and elimination of repeated registration procedures, waiting periods, or other administrative barriers.12 These 2 practices—program collaboration and service integration—describe mutually reinforcing approaches to public health. Service integration cannot exist without program collaboration, and collaboration is usually undertaken to better coordinate or integrate services. For more detailed descriptions of these key PCSI terms, refer to Table 1.
For maximum impact, PCSI efforts should be appropriate, flexible, effective, acceptable, and accountable. These 5 principles form the basic implementation framework for PCSI. Appropriateness refers to the extent to which collaboration across programs and integration of prevention services are consistent with disease epidemiology, evidence for intervention effectiveness, and programmatic objectives. As disease epidemiology changes, along with demographic characteristics, technology, and policies, the flexibility of PCSI efforts must be demonstrated by the ability to adapt to dynamic contexts. Given limited prevention resources, PCSI initiatives should promote evidence-based interventions that are effective and cost-effective; to be effective, PCSI must also be acceptable to both clients and providers. Finally, PCSI activities should be monitored to ensure accountability for expended resources, accomplishment of objectives, and continuous quality improvement.7 Using the principles of PCSI as a guiding framework, we draw on peer-reviewed publications and federal government policy documents that provide conceptual and empiric rationale for further implementation and evaluation of PCSI. The literature cited focuses on infectious diseases within the scope of NCHHSTP responsibilities in the United States; however, key findings from studies outside the United States that are relevant to the US context are included. Gaps in the evidence base are also described.
Where syndemic approaches to prevention are appropriate, PCSI makes epidemiologic, strategic, and programmatic sense. HIV, viral hepatitis, STD, and TB are syndemic in the United States, with individuals at risk for acquiring any one of these diseases being at risk for acquiring others and becoming coinfected. Given shared transmission routes between HIV, hepatitis B, and hepatitis C, high rates of coinfection are not surprising.13,14 In addition to shared transmission risk between HIV and other STD, there is a strong association between STD infection and increased risk of HIV transmission.15 Also, HIV and TB coinfection is frequently observed given that HIV is a strong risk factor for progression from TB infection to active TB disease.16 Generally, high-risk populations such as injection drug users,17 racial/ethnic minorities,18 and correctional facility inmates19 experience higher rates of coinfection and the associated health consequences, indicating the need for a syndemic approach.
Recent US national strategic responses to HIV/AIDS and viral hepatitis have clearly articulated the need to more effectively address coinfections and common contextual drivers.20,21 Although these strategic directions may facilitate collaboration and integration, especially between HIV and TB, hepatitis C, and STD prevention programs, there are opportunities to enhance these interactions. In particular, opportunities for new collaborations, including between viral hepatitis and STD prevention programs, or viral hepatitis and TB programs, should be examined.
A key element of PCSI involves ensuring flexibility to enable local jurisdictions to prioritize, target, and bring to scale the most appropriate syndemic approaches given the heterogeneous distribution and concentration of HIV, viral hepatitis, STD, and TB epidemics across the United States. Local assessments of priorities for action and ever-evolving prevention tools will serve to enhance the implementation of PCSI. Recent advances in diagnostic and treatment technologies now provide greater flexibility and opportunities for integrated services,22 especially in the community and other nonclinical settings. For instance, noninvasive, urine-based testing for chlamydia and gonorrhea provides the flexibility for service integration in correctional settings.23 In addition, CDC’s recommendations for partner services and routine HIV testing in clinical settings support efforts to integrate services across disease programs.24,25 Increased flexibility in using federal funding also reduces a previously identified barrier to service integration.26
Although robust impact evaluation is still needed, available evidence indicates that PCSI has the potential to not only eliminate many missed opportunities within categorical disease programs but also to strengthen program effectiveness in 3 specific ways: (1) improving primary prevention; (2) identifying undiagnosed, infected individuals; and (3) facilitating linkage to treatment and care services. In addition, a systematic review of 46 studies focusing on low- and middle-income countries identified a number of integrated HIV services that were cost-effective, although future research remains to be done particularly with high-risk populations.27
Studies suggest that PCSI can influence primary prevention and promote immunization,28 target risk behavior counseling, and improve provision of prophylaxis to prevent coinfection.29 As an example, service integration has been demonstrated to improve the uptake of the hepatitis B vaccine among at-risk adults30—a population often overlooked given that programs generally target children younger than 18 years.26
Among people who are already infected but unaware of their infection, integration of screening services can identify previously undiagnosed, infected persons. HIV counseling and testing rates among a sample of injection drug users were significantly higher when HIV and hepatitis C virus counseling and testing were offered together in contrast to offering HIV counseling and testing services alone (27.1% vs. 8.4%, respectively).31 Other assessments of HIV and STD and hepatitis C virus integration efforts have also found improvements in testing.32,33 This benefit of integration is particularly important given the documented low rates of testing for coinfections.34,35
Once individuals are diagnosed, integrated services can facilitate treatment and care services. For instance, integration of HIV and TB services in sub-Saharan Africa have resulted in an increase in antiretroviral enrollment, earlier treatment initiation, reduced loss to follow-up of coinfected clients, and improved TB treatment completion rates.36,37 In addition to these individual treatment benefits, we know that treatment enhances prevention efforts. Given the epidemiologic link between STD infection and HIV transmission and acquisition, optimizing treatment of STD through integration is an effective strategy to prevent coinfection and maximize antiretroviral treatment as prevention for HIV infection.38
In the United States, there is currently limited empirical evidence from formal evaluation studies of the acceptability of PCSI as either a strategic practice or programmatic priority. However, there are emerging data regarding acceptability of integrated clinical services. Internationally, assessment of the United Kingdom’s “one-stop-shop” approach to sexual health provision suggests that such an integrated approach is acceptable from the patient perspective. Acceptability may be related to convenience of integrated services, a more holistic approach, and improved continuity of care.39,40 It is anticipated that the appropriate combination of integrated services will improve patient satisfaction and, thereby, increase uptake of related preventive services. For instance, evidence has shown that offering clients hepatitis prevention services increases acceptance of STD and HIV testing services.31,41
From the provider perspective, service integration may increase job satisfaction when specialized skills are applied to a broader role, more diverse caseload, and potential for improved career opportunities.40 Service integration also may facilitate teamwork that enhances service acceptability.40 An example of integration in Zambia found that this approach strengthened organizational culture and staff relationships, which led to greater collaborative and motivated service delivery.42 As future research examines the acceptability of PCSI from both the client and provider perspectives, it will be important to understand how acceptability varies across groups, for example, differences between women and men, young people and older adults, and nurses and doctors. The available data on acceptability of integrated services highlight the importance of tailoring integration to best suit the needs of specific populations.
Accountability is a process of ensuring that program objectives are being met within time and resource constraints. When collaborating programs share resources, service integration targets, and outcome objectives, chains of accountability have to be reconciled. Organizing, prioritizing, and implementing syndemic approaches to prevention requires updated information systems and new leadership behaviors and technical capacity to ensure that collaborative partnerships are built and maintained and high-quality, integrated services are implemented and evaluated. New procedures for ensuring accountability, including grantee training, technical guidance, performance indicators, and reporting requirements, are essential to ensuring full-scale PCSI implementation across all NCHHSTP disease programs. In the United States, integration of viral hepatitis services with HIV and STD services required both new governance and partnership relationships at the national, state, and local levels,26 and new systems (surveillance and other strategic information systems) to hold programs and services accountable. Key indicators of service integration (eg, the proportion of persons with TB who reported HIV test results) have helped focus priority integration activities and enabled tracking of implementation progress. Examples from other country contexts suggest that PCSI can strengthen accountability efforts. Integration of HIV treatment and primary care outpatient services in Zambia resulted in a number of operational advantages including better teamwork and overall accountability.42 The United Kingdom’s one-stop-shop approach also promoted teamwork and allowed for greater management flexibility.40
Program Collaboration and Service Integration requires more strategic information to monitor progress and to guide and evaluate programs and services. A successful example of evaluation to scale-up implementation of integrated HIV and TB services has been documented in South Africa.43 In addition, integration of surveillance systems can strengthen the completeness, quality, and comparability of epidemiologic data.44 This is essential given that NCHHSTP, in response to the National HIV/AIDS Strategy’s call for maximizing accountability, is focusing on high-impact prevention and aligning resources with epidemiologic disease burden.45
PROGRESS TO DATE
In the more than 5 years since the launch of PCSI, there have been numerous accomplishments in the implementation of this new approach at national, state, and local levels in the United States (summarized in Table 2). These successes include the following: early prioritization of strategy and guidance development, revision of CDC funding opportunity announcements, grantee training and support, partner mobilization, and addressing PCSI opportunities in surveillance and program implementation. All have resulted in the growing awareness of the importance of and support for incorporating this syndemic approach. More recent availability of dedicated funds to pilot PCSI demonstration projects has created new communities of practice, promoted the sharing of promising approaches, and encouraged peer-to-peer technical assistance. The creation of and support for new governance and infrastructures to support PCSI (including PCSI coordinators, workgroups, and population in addition to disease-specific plans) at national, state, and local levels have helped to further instill this new approach into everyday practice.
Efforts to overcome key challenges are essential for continued success. Such challenges include the following: resistance from staff and management, including unease about the potential loss of identity, focus, and expertise; categorical funding streams and other resource limitations; disease-specific reporting requirements; and administrative and policy barriers to data sharing. Leadership at both the local and the national levels is key to overcoming these challenges. For example, CDC prioritized the development of the Data Security and Confidentiality Guidelines for HIV, Viral Hepatitis, Sexually Transmitted Disease, and Tuberculosis programs to help facilitate data sharing.46 In some cases, program collaboration may be a useful and more appropriate starting point to ensure stakeholder engagement and leverage resources that will facilitate service integration at a later time. Finally, the emergence of robust evaluation data will help clarify how to best collaborate and integrate. For instance, effective approaches to combining clinical interventions (eg, STD testing or hepatitis vaccination) with behavioral interventions (eg, condom promotion) can serve as models that can be adapted and replicated.8 Essentially, broader implementation, although it may be challenging initially, will help pave the way for future PCSI efforts.
The epidemiologic linkages between HIV, viral hepatitis, STD, and TB prevention underscore why PCSI is an appropriate approach to enhance traditional prevention efforts. Innovations in technology and updated guidelines and recommendations will provide flexibility, which is needed for PCSI to succeed. Although progress continues to be made in the prevention and control of HIV, viral hepatitis, STD, and TB in the United States, substantial challenges remain, requiring more effective approaches to accelerate impact. Outlining the implementation framework and related evidence for PCSI is only an initial step toward more impactful prevention activities. As a critical next step, impact evaluation of PCSI demonstration projects will provide evidence to inform scale-up of this approach. CDC’s Framework for Program Evaluation and associated materials outline key steps and standards for effective evaluation and can serve as a resource for evaluation efforts of combined approaches in the field, which will inherently require collaboration across programs.47 Evaluation data will fill gaps in our understanding of how PCSI can strengthen prevention and control of selected infectious diseases in the United States and could potentially support other integration effort outside the current scope of PCSI, such as the integration of HIV/STD and family planning services. Preliminary evidence suggests that PCSI is one approach worth exploring to improve the effectiveness of program implementation and service delivery by providing more comprehensive prevention, treatment, and care to clients.
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