Approximately 5 years ago, we wrote an editorial in Sexually Transmitted Diseases arguing that the United States needs to sustain its network of sexually transmitted disease (STD) clinics.1 At that time, the economic situation in the country was dire, and many health departments were closing STD clinics in the face of substantial budget deficits. Although health care reform was being hotly debated, congress had not yet passed the Affordable Care Act (ACA). A lot has changed since then.
The economy is now growing, unemployment is declining, and overall state government spending is increasing.2 The extent to which this change has slowed or halted the trend toward health departments decreasing their direct provision of STD care is uncertain. The largest contributor to the rebound in state health care budgets is enactment of the ACA and the associated expansion of Medicaid, the program that supports health care for low-income Americans. The ACA has increased the proportion of nonelderly adults with health insurance, but that effect has been uneven, in part due to the decision by 22 states not to expand Medicaid.3 In the first year after full adoption of the ACA, the number of uninsured persons in states that have expanded Medicaid has declined almost 40% compared with less than 10% in states that have not expanded eligibility for the program.4 Of note, 11 (65%) of 17 southern states (including the District of Columbia) have yet to expand Medicaid, compared with 11 (32%) of 34 states in other parts of the United States. Thus, legislation designed to diminish economic disparities in access to care is likely to increase geographical disparities, at least in the near term. Persons in the southern United States, the area where STD rates are generally highest, less often have health insurance than persons in other parts of the country, and the disparate adoption of Medicaid expansion has the potential to exacerbate that difference.
The epidemiology of HIV/STD and our approach to disease control has also changed. At long last, many parts of the United States are reporting declines in new HIV diagnoses.5 However, that success seems to be inconsistent. Not all areas are observing declines among men who have sex with men (MSM), and HIV appears to be replicating the US experience with other STDs, growing more concentrated among African Americans, particularly African American MSM in the south.6 Meanwhile, our response to HIV increasingly mirrors our approach to other STDs, emphasizing biomedical interventions: condoms, widespread and frequent HIV testing, treatment of infected persons, and preexposureprophylaxis.
Within this changing context, revisiting the role of STD clinics in the nation's HIV/STD control infrastructure is timely. In this issue of the journal, Pathela and colleagues from the Sexually Transmitted Diseases Surveillance Network (SSuN) present data characterizing the patients seen in 40 STD clinics in 12 US areas.7 The clinics included in the study are heterogeneous. Some are highly specialized STD clinics, whereas others are really venues that serve a wider clinical function that includes STD care. The extent to which the clinics are representative of US STD clinics is uncertain, only 3 SSuN sites are in the southern United States, and some very large states (e.g., Texas and Florida) do not participate in the project, a significant limitation to the network that may be worth addressing in the future. Despite that, the existence of SSuN represents progress and is a useful source of information.
Two findings stand out. First, STD clinics provide care to populations that are underserved, and these clinics play a critical role in addressing racial disparities in health. The patients seen in STD clinics are disproportionately male and minority. Indeed, more than half of all patients seen in the clinics included in the study were African American, and in 4 areas more than 80% of patients were African American. Sexually transmitted diseases are among the most glaring examples of a racial disparity in health.8 Clearly, the existence of these clinics has not resolved the problem of racial disparities, but imagine how bad that problem might be in the absence of this dedicated infrastructure. Although SSuN did not report data on what proportion of STD clinic patients had health insurance, studies undertaken before enactment of Medicaid expansion in New York and San Francisco found that more than half of STD clinic patients were uninsured.9,10 New York and San Francisco have relatively low levels of uninsured persons, so information from these clinics may represent a lower bound estimate of the proportion of STD clinic patients without health insurance, demonstrating that the clinics play a critical safety net function.
Second, the SSuN investigators found that 10% of patients seen in STD clinics were MSM. MSM comprise 2% to 3% of the general population,11 but a much larger proportion of persons with STD, and two-thirds of all persons diagnosed as having HIV infection in 2013.12 The clinics' success in serving MSM was highly variable. Clinics in Seattle, San Francisco, and Chicago had much larger MSM patient populations than the other clinics and were the only sites in which more than 10% of patients were MSM. Some of the observed difference between SSuN sites may reflect patients' willingness to report the gender of their sex partners, and some jurisdictions almost certainly have clinical sites and programs that ensure that MSM have good access to STD care outside STD clinics. However, insofar as the SSuN data are accurate, we believe the finding suggests that we may have a significant problem. Many of our STD clinics do not seem to be doing a good enough job serving MSM.
To us, these 2 observations highlight a fundamental dilemma. What is the STD clinic mission? Is the mission primarily to provide safety net services to low income persons with STD? If so, the clinics are likely to serve primarily heterosexuals at high risk for gonorrhea, chlamydial infection, and bacterial vaginosis, but a population that is often at relatively low risk for HIV and syphilis. Or is the mission more focused on HIV and syphilis, in which case the population of greatest interest is likely MSM. Of course, STD clinics serve many purposes, and ideally they would address the needs of both populations, but the SSuN paper suggests that many clinics may not be doing that.
The STD clinic mission is shaped, at least in part, by the rest of the health care system, which brings us back to Medicaid expansion. In areas that are expanding the program, we believe that STD clinics need to specialize. They should develop the infrastructure to bill insurance and focus on MSM, other populations at high risk for HIV and syphilis, and the shrinking population of persons who are uninsured. To address the needs of the broader population, and in particular to construct an improved and more comprehensive system of women's health, health departments should promote more and better STD care—particularly care for chlamydia, gonorrhea, warts, herpes, and vaginitis—in primary care settings. The ACA requires private insurance plans to cover recommended preventive services without any patient cost-sharing, and this provision of the law should help assure patients' access to care and provide a foundation on which to build improved STD services for most of the population.
The harder problem relates to the role of STD clinics in areas without Medicaid expansion. Medicaid in many US states essentially excludes all nondisabled adult men. These men, a disproportionate number of whom are African American, do not have access to routine medical care, so the Centers for Disease Control and Prevention's recommendation to test them for HIV as part of routine care is virtually meaningless. African American MSM, our number 1 priority for HIV testing, are hidden within this larger population of men. We need to build a safe, effective clinical infrastructure for these men. Sexually transmitted disease clinics can and should be part of that, but do the clinics have the capacity to change to meet the needs of this population and continue to play the role they currently play? It is not clear.
The United States needs a stronger clinical infrastructure related to STD. The ACA lays a foundation to build that infrastructure. We strongly believe that we will continue to need our STD clinics even in areas that are fully implementing the ACA, but in these areas one can see a path forward. It is much harder to see the path forward without Medicaid expansion, but there are some options. First, states that have not expanded Medicaid can do so. To us, that is the obvious solution, but there is clearly a diversity of opinion on the subject and the political barriers to universal Medicaid expansion are formidable. Second, the federal government can augment funding for HIV/STD in areas that are not expanding Medicaid. If states will not act, perhaps the federal government should. As evidenced by Centers for Disease Control and Prevention's expanded HIV testing program, this is already happening, at least to a limited extent. Finally, states without Medicaid expansion can improve the existing STD clinical infrastructure through some combination of greater efficiency, a narrower focus on priority populations, and perhaps reallocation of HIV prevention funding to sustain improved STD clinics that focus more directly on high-impact HIV prevention objectives (e.g., HIV testing in MSM, preexposure prophylaxis, partner notification, and linkage and retention to HIV care). The challenge with this approach is in defining priorities. Resources are limited, and promoting efficiency is unlikely to be a complete solution. Do states in which Medicaid is not expanding want to focus on MSM and potentially diminish their services to women? It is a terrible choice to have to make.
Pathela and colleagues' analysis is an important step in better understanding the role of STD clinics in the United States, but more is required. State and local health departments should thoroughly evaluate what their STD clinics are currently accomplishing. How many patients do these clinics see? Who are they? What diagnoses do clinics make, and in particular, how many new HIV diagnoses are made in these clinics and at what cost per case identified? More broadly, given local clinical infrastructure, what role are the clinics playing? Are they playing a safety net function that only they can play? Are they advancing the goals of high-impact HIV prevention, can they better align with those goals, and are there opportunities to better support STD clinics by using HIV prevention funds?
We believe that the ACA has fundamentally changed the US health care landscape for the better, but the inconsistent adoption of Medicaid expansion has resulted in uneven improvements in access to care and affects how health departments need to think about their role. In writing this editorial, we tried mightily to come up with a solution to how one addresses the HIV/STD problem in the absence of universal health insurance. Ultimately, we do not think it can be done. We strongly believe that STD clinics are a critical part of an effective public health–focused health care system, but they cannot be the whole system. Universal health insurance is not a complete solution to the US HIV/STD problem, but it is a critical part of the solution. In the absence of universal health insurance, we have to do the best we can to focus our resources on priority problems and populations, but what we really need is a nationwide system of universal health insurance.
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