Challenges and Opportunities to STD Prevention in the US


1
Challenges and Opportunities to STD Prevention in
the US

• CDC HRSA Advisory Committee on HIV and STD
• 20 May 2009
• John M. Douglas Jr. MD
• Director
• Division of STD Prevention

2
Challenges and Opportunities to STD Prevention in
the US

• Challenges
• Chronic underfunding
• Economic recession
• Opportunities
• Health care reform

3
Recession
4
Federal Investment in STD Prevention 1973-2009
(millions US)
Funding adjusted for inflation to 2009
US (Reduction 2003-9 22)
Funding (millions)
Funding per 200 million US population adjusted
for inflation to 2009 US (Reduction 2003-9
26)
Funding unadjusted for inflation (Reduction
2003-9 10)
Year
5
State Investment in STD Prevention (Lisa Gilbert
ASHA)

• Survey by ASHA of members of NCSD APHL AIM
  NASTAD 2007-8
• Median levels of funding
• 0.14 per capita state STD prevention
• 34.60 per capita state PH funding
• 0.30 of state PH funding for STD prevention
• Federal funding for STD prevention 0.60 per
  capita (81 total)

6
Economic Recession and Health Care Reform Not a
Good Time to Be Hidden

• STDs are hidden epidemics of tremendous health
  and economic consequences in the U.S. They are
  hidden from public view because many Americans
  are reluctant to address sexual health issues in
  an open way and because of the biological ands
  social factors associated with these diseases. In
  addition the scope impact and consequences of
  STDs are underrecognized by the public and health
  care professionals.

7
Reactions to the Stimulus Package

• Drudge Report lays out the facts (1/28/09)
• --Democrats may have eliminated provisions in
  the job stimulus on birth control and sod for
  the National Mall -- but buried on page 147 of
  the bill is economic stimulation for the
  prevention of STD!
• --The House Democrats bill includes 335
  million for STD education prevention programs
  at CDC the DRUDGE REPORT has learned.
• --In the past CDC has used STD education
  funding for programs that many Members of
  Congress find objectionable and arguably
  unrelated to a mission of economic stimulus such
  as funding events called Booty Call and Great
  Sex put on by an organization that received
  698000 in government funds.
• --Whether this funding has merit is not the
  question the point is it has no business in an
  economic plan supposedly focused on job
  creation says a stimulated Hill source.

8
31 March 2008
9
The National Economic Crisis Issues and
Consequences for State and Local Public Health
(CDC Forum 2/13/09)

• Michael Sage Director CDC Portfolio Management
  Program
• On average federal dollars make up about 50 of
  a states health budget
• 33 of states expect to lay off health department
  workers in the upcoming year 60 expect reduced
  services 30 expect programs to be eliminated
• 22 of states expect a budget cut of at least 10
  in FY09
• Situation even worse for local health
  departments over 50 expect layoffs and NACCHO
  estimates a total loss of approximately 7000
  local public health workers nationwide.
• Given severity of budget constraints states may
  be rethinking fundamental commitment to public
  health (eg Utah is considering eliminating state
  department of public health).

10
The National Economic Crisis Issues and
Consequences for State and Local Public Health
(CDC Forum 2/13/09)

• Mark Horton. Health Commissioner State of
  California
• From 07/08 to 08/09 state funds for public
  health dropped 10.7 although federal funds
  increased. Across-the-board reductions required
  10 cut in all state funded health
  expenditures.
• Forprimarily federally-funded programs (eg
  vaccines) the state cutbacks had less impact (a
  10 reduction of 10 of program funding).
• For programs primarily state-funded (eg state
  labs) cutbacks more notable (a 10 reduction of
  85 of the programs funding).
• 10 reduction was imposed 3 months into the FY
  so that the reduction in the remaining 9 months
  had to be 10.
• Furloughs of state workers (2 days/month) started
  early Feb with strict travel restrictions.

11
STD Prevention under Stress

• Information in from 52 of 65 project areas
  (04/24/09))
• Staffing cuts-- 53
• Furloughs (planned or actual)--22
• Hiring freezes --51
• Service impacts (cutbacks in services)--87
• Total of 239 positions were cut in these project
  areas
• All categories of jobs
• DIS most severely impacted (44 all)
• Service reductions or eliminations in all
  categories of services
• 91 cut community-based activities
• 87 reduced lab services
• 51 reduced partnerships
• Project area estimates of funding needed to
  replace cuts 61.5 million.

12
Local Health Agencies Hurt by Cuts Brace for
Flu RiskBy KEVIN SACK Published April 29
2009

• The recession has drained hundreds of millions of
  dollars and thousands of workers from the state
  and local health departments that are now the
  front line in the countrys defense against a
  possible swine flu pandemic.
• Health officials in affected states said they had
  thus far been able to manage the testing and
  treatment of infected residents and mount
  vigorous public education campaigns. But many
  said they had been able to do so only by shifting
  workers from other public health priorities and
  some questioned how their depleted departments
  might handle a full-fledged pandemic.

13
Local Health Agencies Hurt by Cuts Brace for
Flu Risk(NYT 5/29/09 cont.)

• Dr. Richard E. Besser the acting director of the
  federal Centers for Disease Control and
  Prevention said the public health system was in
  a tough situation.
• We hear about tens of thousands of state public
  health workers who are going to be losing their
  jobs because of state budgets he said. It is
  very important that we look at that resource
  because this outbreak was identified because of a
  lot of work going on around preparedness.
• NACCHO estimates that local health departments
  lost about 300 million in financing and 7000
  workers in 2008 a year when more than half of
  all agencies shed employees. There were about
  160000 health department workers in 2005
  according to the group. Mr. Pestronk said he
  expected to lose at least another 7000 jobs this
  year.
• State public health agencies lost an additional
  1500 workers through layoffs and attrition from
  July 2008 to January 2009 according to the
  Association of State and Territorial Health
  Officials. The group anticipates 2600 job losses
  in the coming fiscal year.

14
Impact of Recession on STD Prevention Summary

• Serious cutbacks at state/local level resulting
  in loss of STD prevention staff and reduction of
  services have exacerbated a chronically
  underfunded situation
• This may impact other prevention programs (eg
  HIV testing partner services HBV immunization
  etc)
• Situation worsened by H1N1 outbreak which will
  likely be heightened fall/winter 2009-10.
• No increase in reportable STD yet (though
  reductions will reduce testing and may worsen
  surveillance)

15
Health Care Reform
16
Percentage of Nonelderly Americans Without Health
Insurance Coverage 1987-2006
Source Employee Benefit Research Institute
estimates from the Current Population Survey
March 1988-2007 Supplements.Note 1987-2003 data
are adjusted for Census correction announced in
March 2007.
17
Chlamydia Screening Among Sexually Active Young
Female Enrollees of Health Plans United States
2000-2007

• Annual screening rate increased 25.3 in 2000 to
  43.6 in 2006
• Slight decrease in 2007 to 41.6
• Variation by region
• Northeast 46
• South 37
• Limitation does not include uninsured
• 18 16-20 yo
• 28 21-25 yo
• Less access to care CT scrg

18
Health Insurance and Chlamydia

• Prevalence of CT testing (Nguyen STD 2008)
• Add Health Study 2001-2
• Testing history lower in uninsured (OR 0.63) and
  privately insured (OR 0.72) vs publically insured
• Reducingregional disparities requiresstrategies
  to increase testing RX
• Prevalence of CT infection (Geisler STD 2006)
• Add Health Study 2001-2
• CT prevalence lower in F and M in those
  continously insured (past 12 m) vs. uninsured
• Improved health care access for young people
  could help reduce CT-associated reproductive
  health morbidity

19
Safety Net Services for STD Care/Sexual Health
Massachusetts Experience

• Massachusetts
• First state to develop approach to universal
  access to health care ( 97 insured)
• First state to discontinue publically funded STD
  clinic services
• MA plans to (T Bertram K Cranston MA DOH
  Personal communication)
• Rely on existing and emerging systems of care and
  care access to partially supplement this lost
  capacity (eg CHCs primary HCPs urgent care
  clinics

20
Safety Net Services for STD Care/Sexual Health
Massachusetts Experience (T Bertram K Cranston
MA DOH Personal communication)

• Recognized potential limitations
• Not all covered have PCP
• Appointment wait times can be lengthy
• Not all with STD risks will be comfortable
  discussing with PCP or using health insurance
• PCPS may not have requisite training to dx/rx STD
  or on-hand supplies (eg dx/rx syphilis)
• PCPs may be primarily focused on individual
  health not community health (eg partner
  services)
• Success of health care reform to ensure complete
  identification of STD and to interrupt chains of
  transmission depends on willingness of patients
  to use health care coverage for RX of STD and on
  adequate training reimbursement and monitoring
  of PCPs to enable them to fully respond to public
  health challenges presented by STD

21
Patients Attending STD Clinics in an Evolving
Health Care Environment (Celum et al. STD 1997)

• Cross-sectional survey of 2490 clients attending
  5 urban STD clinics
• Insurance 59 none 27 private 14 Medicaid
• Prior HC 50 prior STD clinic 81 other HCP
  for non-STD services past 3 yrs
• Reason for using STD clinic services
• Walk-in services68
• Low costs59
• Confidentiality concerns43
• Convenient location40
• Expert care34
• If medical care were free where would you have
  gone today for STD services
• 68 STD Clinic
• Predictors prior STD clinic care private
  insurance/Medicaid lack of use of PCP past 3 yrs
• Conclusions a more integrated HC system that
  delivers primary care is desirable but certain
  traditional core PH functions including capacity
  for STD clinical services will need to be
  maintained.

22
Confronting the Public Health Workforce Crisis
ASPH Statement on the Public Health Workforce
(3/5/08)

• By 2020 US will need 220000 more PH workers to
  match 1980 rate and 86000 to match 2000 rate
• Challenge is compounded by the fact that 23 of
  the current workforce almost 110000 workers
  are eligible to retire by 2012.
• Shortages in many areas public health
  physicians public health nurses
  epidemiologists health care educators and
  administrators.

23
STD Prevention in the Era of Health Reform
Priorities

• Health system reform not just health care reform
• Maximizing population health depends on more than
  access
• Intentional focus on prevention
• Attention to public health infrastructure (both
  for formal PH roles as well as leveraging broad
  prevention partnerships)
• Bolstering program evaluation
• Toward more cost-effective impactful and
  measurable programs
• Prioritizing program activities and resources
• Research on comparative effectiveness
• Needs to include focus on translating
  disseminating and scaling prevention
  intervention not just clinical services
• Attention to replenishing workforce
• Issue of safety net STD/Sexual Health Services

24
Acknowlegements

• Zina Peters
• Vanessa Cox
• Dayne Collins
• Harrell Chesson
• Tom Gift

The findings and conclusions in this presentation
are those of the author and do not necessarily
represent the views of the CDC/ATSDR