The Hidden Epidemic -- Copyright -- Preface -- Acknowledgments -- Contents -- Executive Summary -- CONCLUSIONS AND RECOMMENDATIONS -- Strategy 1: Overcome barriers to adoption of healthy sexual behaviors -- Catalyzing Change Through Open Discussion and Promoting Awareness and Balanced Mass Media Messages -- Improving Professional Skills in Sexual Health Issues -- Supporting Sexual Health Behavior Research -- Strategy 2: Develop strong leadership, strengthen investment, and improve information systems for STD... -- Developing Leadership and Catalyzing Partnerships -- Strengthening Investment -- Improving Surveillance and Other Information Systems -- Strategy 3: Design and implement essential STD-related services in innovative ways for adolescents and underserved… -- Focusing on Prevention -- Focusing on Adolescents -- Establishing New Venues for Interventions -- Strategy 4: Ensure access to and quality of essential clinical services for STDs -- Ensuring Access to Services in the Community -- Improving Dedicated Public STD Clinics -- Involving Health Plans and Purchasers of Health Care -- Improving Training and Education of Health Care Professionals -- Improving Clinical Management of STDs -- 1 Introduction and Background -- STUDY METHODS -- FOCUS OF REPORT -- FOCUS OF CHAPTERS -- REFERENCES -- 2 The Neglected Health and Economic Impact of STDs -- BROAD SCOPE AND IMPACT OF STDS -- Routes of Transmission -- Summary of Common STDs -- Human Papillomavirus Infection -- Herpes Simplex Virus Infection -- Viral Hepatitis -- Syphilis -- Gonorrhea -- Chlamydial Infection -- Impact of STDs on Women's Health -- Greater Risk of STDs Among Adolescents -- Other Groups at Risk -- STDs as Emerging Infections -- International Comparisons and the Global Scope of STDs -- HEALTH CONSEQUENCES OF STDS -- Cancers Caused by STDs -- Cervical Cancer.

Other STD-Related Cancers -- Reproductive Health Problems -- Pelvic Inflammatory Disease -- Ectopic Pregnancy -- Infertility -- Health Consequences for Pregnant Women and Infants -- Health Consequences for Infected Infants -- Health Consequences for Infected Pregnant Women -- Health Consequences for Men -- Deaths Associated with STDs -- IMPACT OF STDS ON HIV TRANSMISSION -- Epidemiological Evidence -- Explaining the Association Between STDs and HIV Infection -- Evidence of Effect of STD Prevention on HIV Prevention -- Estimating the Impact of STDs on HIV Transmission -- ECONOMIC CONSEQUENCES OF STDS -- Estimating STD-Associated Costs -- Sources of Payment for STD-Related Costs -- CONCLUSIONS -- REFERENCES -- 3 Factors that Contribute to the Hidden Epidemic -- BIOLOGICAL FACTORS -- Asymptomatic Infections -- Lag Time to Complications -- Increased Susceptibility of Women and Female Adolescents -- Other Biological Factors -- SOCIAL FACTORS -- Poverty and Inadequate Access to Health Care -- Substance Use -- Impact of Crack Cocaine on STD Transmission -- How Drug Use Increases STD Transmission -- Association Between Alcohol Use and STDs -- Sexual Abuse and Violence -- STDs Among Disenfranchised Populations -- Sex Workers -- Homeless Persons -- Adolescents in Detention -- Adults in Detention -- Migrant Workers -- SECRECY AS A CONTRIBUTING FACTOR -- Sexuality and Secrecy in the United States -- Impact of Secrecy on STD Prevention -- Impact on Sexuality Education for Adolescents -- Impact on Communication Between Sex Partners -- Impact on Mass Media Messages -- Impact on Clinical Preventive Services -- Impact on Community Activism -- Experiences of Other Countries -- Research and Training Issues in Sexuality -- Trends in Sexual Activity -- Knowledge and Awareness of STDs -- CONCLUSIONS -- REFERENCES -- 4 Prevention of STDs -- ISSUES IN PREVENTION.

A Mathematical Model for Prevention -- Primary Versus Secondary Prevention -- Behavioral Versus Biomedical Approaches -- REDUCING EXPOSURE AND TRANSMISSION -- Individual Factors -- Sexual and Other Behaviors -- Perception of Risk -- Link Between Perceived Risk and Protective Behaviors -- Personal Skills -- Behavioral Methods -- Theoretical Approaches to STD and HIV Risk Reduction -- Individual-Focused Interventions -- Community-Based Interventions -- School-Based Interventions -- Mass Media Interventions -- Other Methods -- Prophylaxis -- Condoms -- Other Contraceptives and Dual Protection -- Partner Notification and Treatment -- Screening -- REDUCING DURATION OF INFECTION -- Early Diagnosis and Treatment -- Diagnostic Tests for STDs -- Culturing -- Microscopy -- Antibody Detection Tests -- Antigen Detection Tests -- Tests Based on Genetic Markers -- Treatment for STDs -- Barriers to Diagnosis and Effective Treatment -- CONCLUSIONS -- REFERENCES -- 5 Current STD-Related Services -- CLINICAL SERVICES -- Health Care Professionals and Prevention Activities -- Dedicated Public STD Clinics -- Persons Served -- Services Provided -- Effectiveness -- Federal Role -- Community-Based Clinics -- School- and University-Based Settings -- Private Sector Settings -- Managed Care Organizations and Other Health Plans -- Growing Role of Managed Care -- Effect of Managed Care on STD Prevention -- Services and Programs of Managed Care Organizations -- Government Initiatives Related to managed Care and STDs -- NATIONAL SURVEILLANCE AND INFORMATION SYSTEMS -- National Notifiable Disease Reporting -- Limitations of the Reporting System -- Surveillance and Public STD Programs -- Other Surveillance Systems -- Health Behavior Surveys -- Measuring and Evaluating Program Effectiveness -- Data Management, Utilization, and Limitations -- Information Systems Development.

Local Data Analysis Capacity -- TRAINING AND EDUCATION OF HEALTH PROFESSIONALS -- Medical School and Medical Graduate Education -- Primary Care Health Professional Training -- Federal Efforts in STD Training -- Advances in Information Technology -- FUNDING OF SERVICES -- Federal, State, and Local Government Funding -- Categorical Funding -- Block Grant Proposals -- Arguments for Block Grants -- Arguments Against Block Grants -- CONCLUSIONS -- REFERENCES -- 6 Establishing an Effective National System to Prevent STDs -- LAYING THE FOUNDATION FOR A NATIONAL SYSTEM -- Formulating a National Policy and Strategy -- Recognizing the Impact of STDs on HIV Transmission -- Recognizing the Impact of STDs on Cancer -- STRATEGY 1 PROMOTE HEALTHY SEXUAL BEHAVIORS -- Catalyzing Change Through Open Discussion -- Promoting Knowledge and Awareness -- Promoting Balanced Mass Media Messages -- Improving Professional Skills in Sexual Health Issues -- Supporting Sexual Health Behavior Research -- STRATEGY 2 DEVELOP LEADERSHIP -- Developing Leadership in the Private Sector -- Developing Leadership in the Public Sector -- Promoting Federal Leadership -- Promoting State Leadership -- Promoting Local Leadership -- Catalyzing Change Through Partnerships -- Strengthening Investment in STED Prevention -- Who Is Currently Paying and Who Should Pay? -- Evaluating and Improving Categorical Funding -- Strengthening Global STD Prevention Efforts -- Improving Surveillance and Other Information Systems -- Enhancing the Current System -- Utilizing Health Services Performance Measures -- STRATEGY 3 FOCUS ON ADOLESCENTS AND UNDERSERVED POPULATIONS -- Focusing On Prevention -- Expanding Prevention-Related Research -- Developing Female-Controlled Methods for Protecting Against STDs -- Focusing On Adolescents -- Ensuring Effective, Early Interventions and Confidentiality.

Expanding School-Based Programs -- Establishing New Venues for Interventions -- STRATEGY 4 ENSURE ACCESS TO SERVICES -- Ensuring Access to Community Services -- Incorporating STD-Related Services into Primary Care -- Coordinating Services at the Community Level -- Improving Dedicated Public STD Clinics -- Ensuring Access and Quality -- Collaborating with Academic Health Centers -- Involving Managed Care Organizations and Other Health Plans -- Involving Employers and Other Purchasers of Health Care -- Evaluating the Privatization of Services -- Improving Training and Education of Health Care Professionals -- Improving Clinical Management of STDs -- Improving and Expanding Screening Programs -- Improving Diagnosis and Treatment -- Improving Counseling and Education -- Improving Partner Notification and Treatment -- Improving Availability and Capability of Laboratory Services -- COLLABORATING TO IMPROVE SERVICES -- Collaborating with Other Public Sector Health Programs -- Collaborating with Community-Based Health Programs -- CONCLUDING STATEMENT -- REFERENCES -- Appendixes -- Appendix A Sexually Transmitted Pathogens and Associated Diseases, Syndromes, and Complications -- Twenty-Five Sexually Transmitted Pathogens And Associated Diseases Or Syndromes -- Selected Syndromes And Complications Of Sexually Transmitted Pathogens -- Appendix B Characteristics of Major STDs in the United States -- Appendix C Transmission Dynamics of Coexisting Chlamydial and HIV Infections in the United States -- Introduction -- Model And Parameter Assumptions -- Results -- Discussion -- References -- Appendix D Estimates of the Economic Burden of STDs: Review of the Literature with Updates -- Introduction -- Economic Burden Of Illness -- Why The Cost Of Illness Is Assessed -- Challenges To Assessing Economic Impact -- Methods -- Literature on the Economic Impact of STDs.

Adjustments.