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Case Report

Assessing Sexually Transmitted Disease Partner Services in State and Local Health Departments

Cuffe, Kendra M. MPH*; Leichliter, Jami S. PhD*; Gift, Thomas L. PhD*

Author Information
Sexually Transmitted Diseases: June 2018 - Volume 45 - Issue 6 - p e33-e37
doi: 10.1097/OLQ.0000000000000803

Across the United States, partner services are often provided by sexually transmitted disease (STD) programs in health departments to reduce transmission of STDs.1,2 Partner services include notifying, testing, and treating sex partners, and performing linkages to care for partners testing positive for human immunodeficiency virus (HIV) during field testing.1,2 Disease intervention specialists (DIS) or communicable disease investigators (CDI) are often at the forefront of STD prevention services by providing some of these key partner services.1,2 The STD programs at state health departments (SHDs) and local health departments (LHDs) have experienced budget cuts, reduced staffing and program capacity, clinic closures, and reduced clinic operational hours.3–6 Consequently, program cuts may negatively impact the provision of partner services that have been shown to play a key role in interrupting the chains of transmission for STDs. Although there are national-level studies assessing clinical services and HIV-related services provided by STD programs, there has been a lack of national studies that demonstrate the extent of partner services provided by health departments and the impact of program reductions.7,8 As a result, a national-level survey was conducted to understand the infrastructure of STD programs, including the scope of partner services offered by health departments and the impact reductions in staff and funding had on partner services.

METHODS

A national survey entitled “Assessing STD Programs and Services in State and Local Health Departments survey” (Supplemental Digital Content 1 https://links.lww.com/OLQ/A247) was conducted from December 2013 to January 2014. The web-based survey assessed program infrastructure in STD programs located in SHDs and LHDs. Topics covered in the survey included partner, clinical, and HIV services provided by STD programs. Two other analyses assessing clinical and HIV services provided by STD programs have been published as part of the larger survey.7,8

Local health departments were selected from 1225 LHDs that provided STD screening or treatment on the 2010 National Profile of Local Health Departments survey4 and included cities and counties with the top 50 highest number of reported STD cases or rates in 2010. The survey was sent to primary contacts for STD programs in a random sample of 311 LHDs and all SHDs from December 2013 to January 2014. Measures to increase survey response rates were implemented. Health departments that were not responsive to the initial survey request were sent 2 follow-up emails. After 2 unsuccessful attempts by email, a final attempt to contact the nonresponsive health department was made by telephone.

Among the several topics covered by the larger survey, topics related to partner services were analyzed for this study. For LHD analyses, weights based on US Census region, jurisdiction size (small, < 50,000; medium = 50,000–500,000; large, > 500,000 or more), and nonresponse were used. For comparisons between LHDs and SHDs, all SHDs were assigned a value of “1” for the weight. Respondents within SHDs were asked to answer survey questions for activities or staff under their direct supervision only (ie, they were instructed that they should not respond for LHD activities within their state). Budget cuts were defined as a decrease in STD prevention funding from government sources during fiscal years 2011 and 2012. Health departments reporting budget cuts were then asked about impacts of budget cuts on partner services. Pearson χ2 tests were used to compare provision of STD partner services by health department type (state vs local) and LHD jurisdiction size. Analyses were conducted in SAS 9.3 (Cary, NC).

RESULTS

Thirty-four (61%) SHDs including directly funded cities and 148 (48%) LHDs responded to the survey. Local health departments represented small (39.2%) followed by medium (35.1%) and large jurisdictions (25.7%). The LHD respondents were located in the south (35.8%), followed by midwest (28.4%), west (21.0%), and northeast (14.9%).

Partner services were provided by most STD programs—80.9% of responding LHDs and 84.6% of responding SHDs (Table 1). The LHDs and the SHDs significantly differed in the main providers of partner services (P < 0.0001), with LHDs often using public health nurses (50.8%) and SHDs largely using DIS/CDI (90.9%). Although not statistically different, 69.0% of LHDs and most (66.6%) SHDs had staff that were trained in providing field phlebotomy services. A majority of LHDs (72.0%) and SHDs (70.6%) provided other forms of partner services (eg, expedited partner therapy (EPT), internet partner services). The only type of other partner services that differed by health department type was internet partner services (P < 0.0001). Significantly more SHDs (50.0%) provided internet partner services than LHDs (13.6%). Among LHDs, 45.5% reported providing EPT for chlamydia and 32.0% for gonorrhea; provision of EPT was lower for SHDs, although the difference was not statistically significant. Approximately one third (36.6%) of LHDs and 29.6% of SHDs – had STD staff temporarily reassigned for non–STD-related activities (eg, public health emergencies). Of LHDs who had staff reassigned for non–STD-related activities, most reported that staff reassignment had a minor (56.7%) or major impact (22.4%) on programmatic activities. Fewer SHDs reported a negative impact from temporary staff reassignments.

TABLE 1
TABLE 1:
Partner Services Provided by STD Programs in LHDs and SHDs, 2013

A substantial minority—17.5% of LHDs and 25.9% of SHDs—reported having reductions in staffing (full-time equivalents [FTEs]) in fiscal year (FY) 2012. Among these programs, approximately half (47.6% of LHDs and 57.1% of SHDs) had reductions in DIS FTEs. Finally, 28.8% of LHDs and 25.9% of SHDs reported that budget cuts led to reductions in partner services activities in FY2011-12. Among programs who reported negative impacts from budget cuts, the most common impact was fewer partner services for chlamydia, gonorrhea, or other STD cases in both LHDs (21.3%) and SHDs (40.0%) (P = .0391). The second most common reduction was in STD case treatment follow-up for both LHDs (10.1%) and SHDs (15.0%).

Among LHDs, partner services activities were examined by LHD jurisdiction size. There was no significant difference in the overall provision of partner services by jurisdiction size (Table 2). However, significant differences in main providers of partner services were detected in LHDs with medium (49.1%) and large (78.9%) jurisdictions using DIS/CDI as main providers of partner services and smaller jurisdictions (68.2%) using public health nurses (P < 0.0078). Jurisdiction size was not significantly associated with the provision of field phlebotomy services or other forms of partner services with the exception of serologic testing of syphilis contacts in the field (P = 0.0471). Medium (32.3%) and large (28.0%) LHDs had significantly higher reports of serologic testing of syphilis contacts in the field compared to small LHDs (14.7%). Temporary reassignments of program staff for non–STD-related activities did not differ by jurisdiction size and was reported by 26.5% to 45.4% of LHD respondents (P = .2200). Among those who had staff temporarily reassigned, both small (14.6%) and medium (21.5%) jurisdictions reported major program impacts. The LHDs in large jurisdictions were significantly more likely to report that temporary reassignments had a minor impact (78.8%) on programmatic activities compared to 51.0% of small and 56.4% of medium size jurisdictions (P = 0.0039).

TABLE 2
TABLE 2:
Partner Services Provided by STD Programs in LHDs and Directly Funded Cities by Jurisdiction Size, 2013

Finally, changes in staffing and impacts of budget cuts were also examined by LHD jurisdiction size. Overall, net decreases in staffing levels in FY2012 were reported by 41.4% of large, 20.4% of medium and 10.9% of small LHDs (Table 2). Among LHDs who indicated a decrease in FTE staffing, 94.6% of large LHDs report a reduction in DIS staff; this was significantly higher than reports from medium jurisdictions (28.9%, P = .0491). Additionally, regarding the impact of budget cuts, large jurisdictions (32.7%) had significantly higher reports of fewer STD case treatment follow-ups compared with medium (9.4%) and small (5.1%) jurisdictions (P = 0.1073).

DISCUSSION

Findings suggest that STD programs at both the state and local levels provide an array of partner services, including EPT and field delivered treatment for chlamydia and gonorrhea, serologic testing of syphilis contacts in the field and internet partner services. The main provider of partner services differed with most SHDs using DIS/CDI and LHDs using public health nurses; however, large LHDs also tended to use DIS/CDI. For specific services, it is not surprising that EPT for chlamydia and gonorrhea was more often provided in LHDs compared to SHDs. Local health departments typically provide clinical services to patients within their jurisdictions through public clinics.5,6 Additionally, we found that EPT services were provided by less than half of LHDs and less than one third of SHDs; this supports previous research that found low use of EPT for gonorrhea patients.9 Half of SHDs now provide internet partner services compared to 15% of LHDs, this may be explained by different staff types and a different focus for LHDs and SHDs. A previous study found extensive variation in internet service protocols but did not provide information on the extent of internet services provided.10

Study findings suggest that temporary staff reassignments (eg, for public health emergencies), and budget cuts may have impacted staffing and partner services at some LHDs and SHDs. Of LHDs who had staff on temporary reassignments, only 18.4% to 22.1% reported that there was no impact on programmatic activities. Reductions in staffing at SHDs and LHDs could impact the ability of LHDs and SHDs to respond to reassignment needs. A substantial minority of LHDs and SHDs reported decreases in staffing (FTEs) during the 2012 fiscal year. Among these programs, DIS/CDI staffing levels decreased for approximately half of LHDs and SHDs. Additionally, among LHDs and SHDs who reported budget cuts, there were negative impacts on partner services activities such as fewer partner services for chlamydia, gonorrhea, or other STD cases and reduced STD case treatment follow-up. Many partner services activities are essential for disrupting the chain of transmission for STDs.2 Reductions in these services may lead to delays in diagnosis and treatment, which often lead to preventable complications from disease sequelae2 and further disease transmission. It may be useful to evaluate the impact of reduced services on STD rates.

This study has a few limitations. The response rate for this survey among LHDs was less than ideal; however, our survey response rate is in alignment with recent studies that show declining trends in national survey response rates and lower response rates for organizations.11–14 To help increase generalizability of results to the population of LHDs providing STD testing and treatment, weights based on region, jurisdiction size, and nonresponse were applied. An additional limitation is that EPT uptake might have been affected by the legal status of EPT in a state.15 Finally, the sample size for LHDs was relatively small, and some 95% confidence intervals [CIs] were wide.

State health departments and LHDs provided a range of STD-related partner services. Partner services are important for STD prevention efforts in that they can interrupt transmission through prompt testing and treatment of sex partners of those who have been diagnosed with a STD. However, temporary staff reassignments for non-STD activities, such as public health emergencies, budget cuts, and reductions in DIS staff in a substantial minority of SHDs and LHDs appeared to impact the provision of some essential partner services. Future research could assess the impact of budget cuts and temporary staff reassignments on STD morbidity. It may be useful for decision makers to track these reductions over time and continually assess their impact on STDs.

REFERENCES

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