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Forecast for the Federal Budget: Implications for STD Prevention
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
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
Notas del editor
PCSI:Expand programmatic flexibility for PCSIAlign surveillance, policies, standards and procedures for PCSI Promote integrated trainingDevelop policies and activities to enhance PCSIConduct research and evaluation on PCSI
PCSI:Expand programmatic flexibility for PCSIAlign surveillance, policies, standards and procedures for PCSI Promote integrated trainingDevelop policies and activities to enhance PCSIConduct research and evaluation on PCSI
PCSI:Expand programmatic flexibility for PCSIAlign surveillance, policies,standards and procedures for PCSI Promote integrated trainingDevelop policies and activities to enhance PCSIConduct research and evaluation on PCSI
PCSI:Expand programmatic flexibility for PCSIAlign surveillance, policies, standards and procedures for PCSI Promote integrated trainingDevelop policies and activities to enhance PCSIConduct research and evaluation on PCSI
PCSI:Expand programmatic flexibility for PCSIAlign surveillance, policies, standards and procedures for PCSI Promote integrated trainingDevelop policies and activities to enhance PCSIConduct research and evaluation on PCSI
PCSI:Expand programmatic flexibility for PCSIAlign surveillance, policies, standards and procedures for PCSI Promote integrated trainingDevelop policies and activities to enhance PCSIConduct research and evaluation on PCSI
PCSI:Expand programmatic flexibility for PCSIAlign surveillance, policies, standards and procedures for PCSI Promote integrated trainingDevelop policies and activities to enhance PCSIConduct research and evaluation on PCSI
PCSI:Expand programmatic flexibility for PCSIAlign surveillance, policies, standards and procedures for PCSI Promote integrated trainingDevelop policies and activities to enhance PCSIConduct research and evaluation on PCSI
PCSI:Expand programmatic flexibility for PCSIAlign surveillance, policies, standards and procedures for PCSI Promote integrated trainingDevelop policies and activities to enhance PCSIConduct research and evaluation on PCSI
PICSI:Expand programmatic flexibility for PCSIAlign surveillance, policies, standards and procedures for PCSI Promote integrated trainingDevelop policies and activities to enhance PCSIConduct research and evaluation on PCSI