In this issue of the journal, Batteiger et al1 describe the clinical settings where men and women get tested for chlamydia and gonorrhea in the Indianapolis metropolitan area. The study is unique in that it involves the merging of different data sources that together provide detailed information on client demographics, testing patterns, test results, and location of testing. Although the study findings are specific to the Indianapolis region and therefore not directly generalizable to other jurisdictions, the research methodology as well as the study findings should be of interest to public health officials confronting rising rates of sexually transmitted infections (STI) in other regions.
In studies related to the provision of medical care for STI in the United States, researchers often use data from the Centers for Disease Control and Prevention (CDC) to show an ongoing decline in the proportion of services provided in publicly funded STI clinics. Citing surveillance from 2015 (proximate to the years of their study) Batteiger et al. show that only 7% of chlamydial infections and 12% of gonorrhea cases were reported from public STI clinics that year nationally. More recent CDC data suggest a further decline.2 In contrast to the CDC data, the results from their study indicate that STI clinics still play an important role in the provision of STI services in the Indianapolis area, especially for men. Indeed, the majority of men in this study reported STI clinics as the place they go to for STI care. In addition, STI clinics had the highest gonorrhea and chlamydia positivity rates, suggesting that, at least for men, the largest proportion of these infections are still diagnosed in STI clinics. What are the reasons for the apparent discrepancy with the CDC data? Perhaps, as the authors indicate, urban areas are different with greater access to STI clinics, especially if they have well-functioning STI specialty clinics (like the Bell Flower Clinic in Indianapolis). It should also be pointed out that CDC data are incomplete with increasing numbers of infections reported from unidentified sites. Regardless of underlying reasons, anyone interested in STI care utilization patterns, especially those who make decisions on local public health priorities, should be studying local STI utilization data and, following the lead of Batteiger et al., evaluate or develop additional data sources to better assess the need for STI services in their jurisdiction, and CDC and recipients of CDC STI prevention funding should be encouraged to assist with these efforts.
Another finding in this study invites comment. The authors report that STI visits to emergency departments are increasing, not only in number but also in positivity rate, especially among males, “presenting a unique opportunity to intervene in disease transmission.” The authors suggest that, among other factors, decreased stigma—when visiting a location not dedicated to STI care—may be related to the shift from STI clinics to emergency departments. The appropriateness of using emergency departments for STI care is debatable. Nonetheless, this development may be compounded in the future and elsewhere by the discontinuation of publicly funded STI care based on the misbegotten perception that in the era of the Affordable Care Act and Medicaid expansion with promises of greater access to (primary) care, such services are no longer necessary. The shift form STI clinics to other care providers, including emergency departments may thus becoming a self-fulfilling prophecy, as patients will no longer have STI clinics to go to.
Although it is good policy to work with primary and other care providers to enhance STI screening in patient populations that are increasingly able to access health care, it would be a mistake for public health STI control efforts to rely on care providers whose priorities lie elsewhere, which is especially true for emergency departments, or on providers who generally lack expertise in managing STIs they encounter infrequently. For example, with over 200,000 primary care physicians in the United States3 and slightly more than 30,500 cases of primary and secondary syphilis reported in 2017,2 the average primary care doctor will rarely see a case of early syphilis, if at all. Moreover, many patients seeking STI services will continue to prefer STI clinics even if they are insured, in part because of the expertise, but even more importantly because of the confidentiality and easy access these clinics offer.4 Finally, STI clinics serve growing numbers of men who have sex with men and other populations at high risk for gonorrhea, syphilis and human immunodeficiency virus (HIV) and are thus becoming an increasingly important venue for the provision of HIV prevention services, including HIV diagnosis and linkage to HIV care, as well as preexposure and postexposure HIV prophylaxis.5
The rising rates of STIs in the United States present a public health priority and require a public health response. In addition to prevention programs, diagnosis and treatment will continue to play a critical role in STI control and underscore the rationale for the ongoing provision of STI clinical services as a public health intervention.Rather than marginalize publicly funded STI clinics as “safety net” providers that will no longer be relevant once universal health insurance is achieved, these clinics should instead be the focus of renewed attention, quality improvement, and investment of resources. In the end, they represent the critical hubs for expert STI clinical services, referral and consultation, sentinel surveillance, research, and workforce capacity building. In this vision, publicly funded STI clinics must be viewed as an indispensable collection of regional STI centers of excellence that serve as the backbone of STI prevention and control in the communities they serve.
1. Batteiger TA, Dixon BE, Wang J, et al. Where do people go for gonorrhea and chlamydia tests: A cross-sectional view of the Central Indiana population, 2003–2014. Sex Transm Dis 2019; 46:132–136.
2. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2017. Atlanta: U.S. Department of Health and Human Services:2018.
4. Mettenbrink C, Al-Tayyib A, Eggert J, et al. Assessing the changing landscape of sexual health clinical service after the implementation of the affordable care act. Sex Transm Dis 2015; 42:725–730.
5. Golden MR, Kerndt PR. What is the role of sexually transmitted disease clinics? Sex Transm Dis 2015; 42:294–296.