Presented by Gail Bolan, MD, Director, Division of STD Prevention, CDC, at the 2012 National Chlamydia Coalition meeting

1. Forecast for the Federal Budget:
Implications for STD Prevention
Gail Bolan, M.D.
Director, Division of STD Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention
Centers for Disease Control and Prevention
National Chlamydia Coalition Annual Meeting
January 26, 2012
No conflicts of interest
National Center for HIV/AIDS, Viral Hepatitis, STD & TB Prevention
Division of STD Prevention

2. U.S. STD Prevention : The Approach
 Health education, promotion and behavior change
 Vaccination
 Identify and treat infected individuals through
 Screening of asymptomatic individuals & linkage to care
 STD clinics for symptomatic care
 HD partner notification and treatment
 Individually-based interventions
 Public sector responsibility
 STD clinic and DIS focus

3. STDs and their Consequences
Most STDs
HIV
transmission
e.g. Impaired
Chlamydia fertility
STDs Adverse
pregnancy
outcomes
e.g.
Syphilis
Gonorrhea HSV-2
Reproductive
tract
cancer
19 million $17 billion
estimated annual e.g. estimated annual
new cases HPV direct costs

4. Estimated Annual Burden and Cost of
STDs in the U.S.
Estimated Annual
Estimated Annual Direct Costs
Reported Cases, 2009 New Cases** (millions)***
Chlamydia 1,244,180 2.8 million $701
Gonorrhea 301,174 718,000 $138
HIV* 42,959 60,000§ $8,900
Syphilis 13,997 70,000 $25
Hepatitis B* 4,033 80,000 $47
HPV NA 6.2 million $5,8 00
Genital Herpes NA 1.6 million $1,100
Trichomoniasis NA 7.4 million $198
Total 1,606,343 18.9 million $17 billion
* HIV and Hepatitis B estimates include costs of sexually-acquired cases only
**US annual estimated new cases (Weinstock H, Berman S, Cates W Jr. Sexually transmitted diseases among American youth: incidence and prevalence
estimates, 2000. Perspect Sex Reprod Health. 2004 Jan-Feb;36(1):6-10.)
§ Annual new HIV cases, 2008 estimate ; all other annual cases are 2004 estimates (1Hall HI, Ruiguang S, Rhodes P, et al. Estimation of HIV incidence in the
United States. JAMA. 2009;300:520-529.)
***Updated to 2010 $US using medical care component of CPI. Total may differ from sum of all diseases due to rounding.
Adapted from: Chesson HW, Blandford JM, Gift TL, Tao G, and Irwin KL. The estimated direct medical cost of sexually transmitted diseases among American
youth, 2000. Perspectives on Sexual and Reproductive Health 2004, 36(1): 11-19.

5. Populations at Greatest Risk for STDs
 Youth
 Nearly 50% of STDs estimated to occur in 15-24 year olds
 Men who have sex with men (MSM)
 Account for 62% of syphilis cases in 2009
 High rates of HIV co-infection
 Racial/ethnic minorities
 STDs among highest of all racial/ethnic health disparities
 African-Americans: 71% of gonorrhea, 48% chlamydia, 52%
syphilis
 Over last 5 years syphilis cases increased more than 150%
among young African American men

6. FY11 Appropriation
State Allocation (CSPS)
3% 1%
DA - PHA Field Staff
11% 1%
Prevention Training Centers
3%
0%
Demonstration Projects
4%
State Surveillance Activities
Partnerships
17%
Research and Evaluation
60%
CDC Support
DSTDP Staff/Operations
Total = $154.666 million

7. Rationale for Rethinking STD
Prevention in a Transformed Health
System

8. Drivers of Change: Opportunities
 Potential
shift of vulnerable, at risk populations
because of investment in the health care system
 Increased proportion of people with insurance
coverage
 Expansion of community health centers and their
likely role as primary care providers for priority STD
populations
 Interest in quality of care
 Investment in health information technology in
the transformed health care system

9. Drivers of Change: Challenges
 Federal emphasis on no duplication of
effort or services
 Need to maximize efficiencies based on the
most cost-effective and feasible approaches
(FIT) and develop a business case for
investment (the so what factor)
 Declining public health dollars and
infrastructure and competing priorities

10. Drivers of Change: The Declining STD Public
Health Infrastructure
 In 2008-2009, majority (69%) of state/local STD
programs experienced funding cuts and reduced
services in:
 Disease investigative services (26/65) 40%
 Laboratory services (24/65) 37%
 Clinical care and screening services (21/65) 32%
 HIV tests or hepatitis B vaccinations (4/65) 5%
 In 2008-2009, state/local governments enacted:
 Salary freezes and/or reductions (45/65) 69%
 Furlough and/or shutdown days (32/65) 50%
 Layoffs 17/65 (28%)

11. Strategic Priorities Informing
DSTDP Priorities
 National
 National Prevention Strategy
• 4 pillars: Health Equity
• Six targeted priorities: Reproductive & Sexual Health
 National HIV/AIDS Strategy
• Health Equity
 IOM Report on Women’s Preventive Services
• Well-women visits
• Counseling for STIs
• Contraception methods and counseling
• HIV, IPV, and HPV

12. Strategic Priorities Informing
DSTDP Priorities
 CDC
 Winnable Battles- domestic (2/7)
• HIV prevention
• Teen Pregnancy Prevention
 Winnable Battles- global (1/4)
• Congenital Syphilis Elimination
 Infrastructure
• Surveillance
• State/local Infrastructure
• Ensure high quality data
• Support population health approaches
• Working toward measurable progress

13. Strategic Priorities Informing
DSTDP Priorities
 NCHHSTP: use a more holistic and combined prevention
approach through:
 Prevention through Healthcare
 Program Collaboration and Service Integration (PCSI)
 Promote health equity and address social determinants of health
 Improve sexual health
 DSTDP: using NCHHSTP cross cutting frameworks
 Reduce burden of STDs among adolescents and young women
 Reduce burden of STDs among MSM
 Address the threat of resistant gonorrhea
 Eliminate congenital syphilis

14. DSTDP Vision for STD Prevention
in the United States1
A future in which all Americans regardless of
gender, age, race/ethnicity, sexual
orientation are
knowledgeable, empowered, and have
ready access to a network of culturally
competent, high quality, evidence-based
and confidential STD prevention services
and highly trained professionals to
prevent, treat and manage Sexually
Transmitted Infections (STIs)
1. Vision Statement: A succinct “elevator speech” which summarizes what
you are working towards

15. DSTDP Strategic Map for 2-3 Years
Program Program Support Areas
Support • Essential or core functions of national and
Areas local STD programs
• Allows for comprehensive strategic
planning on strategic priorities
• Helps organize programmatic response to
Programmatic the STD urgent threats and realities
Priorities
ADOLESCENTS/YOUNG ADULTS GC RESISTANCE
MSM SEXUAL HEALTH CONGENITAL SYPHILIS
High Priority “PROGRAMMATIC
PRIORITIES”
PH • High burden, persistent and pervasive
Workforce inequity
•Urgent action needed to reduce burden
and costs
•Resistance and Urgent Threat
Science & •Evidence of impact with targeted, scaled
interventions
Evidence
POLICY, STRUCTURAL AND HEALTH SYSTEM INTERVENTIONS
ENVIRONMENTAL ACTIONS AND SUPPORT

16. Questions
 How should STD prevention take advantage of the
changes that are occurring?
 Expand access to comprehensive STD services
 Improve quality and coverage of STD services
 All by leveraging health care delivery resources
 What is STD prevention’s role in identifying and addressing
gaps as a result of the changes?
 Define safety net or unmet need
 Provide services to vulnerable populations not served by the health
care delivery system
 Provide evidenced-based clinical and prevention interventions
 Centers of excellence
• PTCs, enhanced surveillance, program innovation and best practices

17. Future of STD Prevention Programs
 Less direct service delivery if those services can be provided
by the health care delivery system
 More investment in assessment, assurance and policy
development to ensure quality STD screening, timely
treatment and partner services are provided by the health
care delivery system
 Identify and address barriers
 Provide guidance, tools, training and technical assistance
 Foster partnerships /collaboration between public health
programs and health care providers serving at-risk
populations

18. Future of STD Prevention Programs
 Strengthen surveillance, assessment, assurance and CQI
initiatives through HIT
 Quality of care measures could be the basis for population STD
prevention measures
 Electronic health records provide comprehensive, longitudinal
data on well-defined patient populations
 Monitor access to health care and identify STD
prevention safety net needs
 Develop better STD prevention program impact metrics
 Enhance workforce capacity
 Need for surveillance, quality improvement, evaluation and policy
staff
 Incorporate cross cutting frameworks into STD
Prevention approaches

19. Cross Cutting Frameworks
 Advancing Prevention through Healthcare
 Partnerships and collaboration between public health and
healthcare
 Leverage prevention priorities with HHS Operating Divisions
 Monitor performance and quality of prevention services
 Promote innovative systems and health-based approaches
 Seek opportunities for a more holistic and combined prevention
approach
 Improving Program Collaboration and Service Integration
(PCSI)
 A structural intervention to improve synergies between
prevention programs and to provide more holistic services to
clients

20. Cross Cutting Frameworks
 Promoting Health Equity and Reducing Health Disparities
 Incorporating social determinants of health and structural
approaches to STD prevention such as:
• Community engagement and mobilization
• Policy interventions
• Promoting science on disparities and social determinants of health
 Optimizing Sexual Health
 Shifting from a disease-focus to a more positive health-based
approach through emotional and mental wellbeing, healthy
relationships, reproductive health, disease avoidance and violence
avoidance
 Normalizing conversations regarding contributions of sexuality
and sexual behavior to overall health

21. Advantages of Using Health Equity, Sexual
Health, PCSI and PTHC Approaches
 More holistic
 Reduce stigma
 Use combined prevention approaches
 Leverage wider networks and resources
 Enhance involvement by new stakeholders
 Efficiency of resource utilization
 Evolving health and policy environments

22. STDs as an Health Equity Issue
 Youth
 Nearly 50% of STDs estimated to occur in 15-24 year olds
 Men who have sex with men (MSM)
 Account for 62% of syphilis cases in 2009
 High rates of HIV co-infection
 Racial/ethnic minorities
 STDs among highest of all racial/ethnic health disparities
 African-Americans: 71% of gonorrhea, 48% chlamydia, 52%
syphilis
 Over last 5 years syphilis cases increased more than 150%
among young African American men

23. Question
 What should STD prevention look like in 2014
and beyond?

24. In Summary:
Looking Forward
 PTHC is coming and provides an opportunity for scale up
and more up stream, holistic approaches
 Public private partnership are critical
 Assessment, assurance and policy development should be
more of a focus
 Safety net services need to be defined and financed
 HIT should be more of a focus to strengthen
surveillance, assessment and assurance activities
 STD prevention impact metrics are needed
 Our efforts must increasingly address sexual health and
the underlying drivers of STD risk and vulnerability

25. Thank you!
Questions?
gyb2@cdc.gov
For more information please contact Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333
Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348
E-mail: cdcinfo@cdc.gov Web: www.cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily represent the official
position of the Centers for Disease Control and Prevention.
National Center for HIV/AIDS, Viral Hepatitis, STD & TB Prevention
Division of STD Prevention