Appendix I Examples of Community-Based Programs for Providing Clinical Services for STDs
The following are brief descriptions of innovative programs for providing STD-related clinical services that were visited by the committee during its site visits to the Chicago and Atlanta areas in June 1995. Because most of these programs have not been systematically evaluated for effectiveness, the committee does not necessarily endorse these specific programs but rather encourages agencies and organizations to consider these examples as a basis for developing collaborations to improve STD-related services.
West End Medical Centers, Inc. Atlanta, GA
The West End Medical Centers, Inc., has been providing comprehensive primary health care services to residents in low-income communities since the early 1970s. The health center was established in 1972 by Atlanta University Center to serve its students as well as employer groups, the medically indigent, and Medicare and Medicaid beneficiaries. In 1976, reincorporated as the independent West End Medical Centers, Inc., the health center refocused its services on the nearly 49,000 residents in the West End and Nash/Washington communities. In addition to its main health center, West End Medical Centers operates health centers in several public housing projects and communities, including an AIDS clinic in an inner-city high-rise apartment building, and serves approximately 28,000 residents. The centers also operates a school-based clinic at a local high school, which provides a full range of episodic care for teenagers.
The centers provides primary care pediatrics, internal medicine and obstetrics/gynecology
services, dental care, nutritional counseling, health education, social services, radiology, and laboratory services. Of 55,000 patient visits annually, approximately 45 percent are for pediatric care, 28 percent are for obstetrics/gynecology services, 10 percent are for dental care, and the remaining 17 percent are for adult medicine, including geriatrics. All 12 physicians at the centers have admitting privileges at two or more hospitals and provide 24-hour coverage for health center patients. The centers emphasizes preventive care, including nutrition counseling, management of chronic health problems to improve quality of life, and participation in community health fairs and screening programs. The centers provides WIC vouchers and, under an arrangement staffed by the county, conducts WIC certification at the centers.
The centers have a well-developed and comprehensive STD program. STD-related services are provided through regular primary health care services rather than through a separate STD clinic. All persons seeking family planning and obstetrics services are offered STD testing. Individuals who suspect they may have an STD make an appointment with their regular provider, who conducts an examination and orders all necessary lab tests. At the time of the diagnosis the client receives counseling. Follow-up is conducted by the staff social worker, and a staff member conducts partner notification and contact-tracing in cooperation with the Fulton County STD program. The West End Medical Centers, Inc., appears to represent a model community-based program, with strong community ties and a high-quality medical and public health program.
Planned Parenthood/Chicago Area Chicago, IL
Planned Parenthood of the Chicago Area (PP/CA) operates six health centers that provide reproductive health care services to approximately 16,000 women annually. These services include birth control education and contraceptives, pregnancy testing, screening and treatment for STDs, and HIV counseling and testing. Three of the health centers are operated on a standard fee basis, and the others are operated on fees based on a sliding scale of income. PP/CA offers comprehensive medical services for women and adolescents, linking the adolescents to communities through their school-based programs. Funded by Title X funds, state funds, private donations, and grants from a local foundation, the aim of PP/CA is to provide the highest quality services in a comfortable and attractive environment, regardless of a client's ability to pay. The program offers a wide range of preventive screening including chlamydial, gonorrhea, syphilis, HIV counseling and testing, and Pap smears, in addition to contraception counseling and services. The program seeks to provide a "medical home" for adolescents, and many teenagers have become accustomed to receiving services at the Planned Parenthood Clinics.
PP/CA operates a community outreach program in several high schools called
the "Linked Services Project." This program provides sexuality education to ninth-grade students using a seven-week curriculum. Topics include anatomy, basic sexuality, responsible health, HIV and other STD prevention, and birth control. The project employs educators who are from the same communities as the students, thus creating a level of trust between the teenagers and the educators. One of the goals of the program is to help link students to medical services at either a Planned Parenthood clinic or other community health center. The Linked Services project attempts to link all aspects of the teens' lives through their school, home, and community. The Linked Services Project evolved out of a request received in 1987 from the Chicago Vocational High School to assist them in developing an innovative teenage pregnancy prevention program. The pilot program took three years to develop and serves as a model for similar projects in other local schools. PP/CA is expanding the program, initially to the schools in communities that already have Planned Parenthood clinics. This program appears to be successful and has a high level of community involvement and support from school administrators.
West Town Neighborhood Health Center: Young Adult Clinic (Chicago Department of Public Health) Chicago, IL
The Young Adult Clinic is an STD clinic for teenagers, located in the West Town Neighborhood Health Center, a Chicago public health clinic. The Young Adult Clinic is staffed by a bilingual, bicultural nurse clinician and is operated by the Chicago Department of Public Health. The Young Adult Clinic was established to reduce the risk of HIV infection and other STDs among Hispanic youth, specifically Puerto Rican youth. The clinic provides comprehensive health services, including STD screening, HIV counseling and testing, pregnancy testing, condom distribution, and family planning services. Located across the street from Roberto Clemente High School, the Young Adult Clinic has established close ties with the students and school administration. The clinic is open on weekdays and two evenings per week. Sex partners of STD patients are also evaluated in the clinic. As a publicly sponsored facility, the clinic utilizes the state public heath laboratory, and disease reporting is automated. The clinic also works closely with Vida/SIDA's peer educators (see below).
Vida/SIDA Chicago, IL
Vida/SIDA, established in 1988 by the Puerto Rican Cultural Center, is an innovative community-based program dedicated to teaching youth about HIV and STD prevention. Vida/SIDA is an outreach program, largely designed and staffed by teens, that trains teens to become peer educators in HIV and STD
prevention. These teens serve as peer outreach workers in schools and the community and serve as "peer experts" not only for HIV and other STDs, but for other reproductive health and general health issues as well. The program has established a close working relationship with the Young Adult Clinic and encourages teens to use the clinic for HIV and other STD testing and treatment or general health care. Part of the teens' outreach work includes conducting presentations in various high schools in a five-part series that includes topics such as HIV, STD, and pregnancy prevention, substance abuse, and violence. The program has also extended its outreach presentations to middle schools. These activities are supported by the local school council.
To coordinate an effective prevention strategy in the West Town community of Chicago, Vida/SIDA brought together community health and educational organizations in West Town to form the West Town STD/HIV Prevention Network. The network brings together many community agencies that work together to develop new, interrelated prevention programs. Working with the Young Adult Clinic, Vida/SIDA is able to refer youths to the clinic for STD-related or other services. While the program appears to be running well, peer educators report that there is a common perception in the adolescent community that STDs are "no big deal." Although the program has strong support from the community and school board, it has not been formally evaluated. Vida/SIDA is currently working in collaboration with the CDC to establish a formal evaluation process.
West Central Health District Columbus, GA
The West Central Health District (District 7) is composed of 16 counties with a total population of approximately 450,000, with 22 percent of residents living below the federal poverty level. The largest health clinic in the district is located in Columbus and is staffed by "expanded role" nurses who work under the standing protocols and supervision of physicians. These nurses have been specifically trained in STD-related care at the regional STD training center and also receive periodic training updates at the center. Other counties in the district have health department clinics of varying sizes that provide STD screening and treatment. In two counties that do not have physicians available to treat STDs, patients frequently have to cross county lines for STD treatment.
Contact-tracing is conducted for syphilis only, but West Central Health District staff are skeptical of the effectiveness of this service. Staff have proposed that efforts should be focused in high morbidity areas within the district. STD screening and treatment and HIV testing and counseling are also integrated into family planning services provided by the health department. The Columbus Health Department operates separate clinics for teenagers that provide comprehensive health services such as prenatal care, STD screening, and pre- and post-HIV counseling and testing. In general, the private physicians in the community
have not been interested in providing STD-related services and prefer to refer patients to the health department. Public health officials from Columbus are currently conducting outreach to physicians in private practice to involve them more fully in the diagnosis and reporting of STDs.
The West Central Health District programs collect fees from the Medicaid program for services. The staff is very concerned about changes that will occur with the implementation of Medicaid managed care and is looking for a niche in a managed care environment. The staff also expressed concern about the impact of block grants for HIV, STD, and TB and agreed that STDs are not a high priority in rural area. They are in the process of working with private providers to arrange a public/private partnership and have begun discussions with a local hospital. The director of the program has personally approached all the private sector providers in the area to arrange a public/private partnership.
The Emory/Grady Teen Services Program Atlanta, GA
The Emory/Grady Teen Services Program, a collaboration between Emory University and Grady Memorial Hospital, is a nationally acclaimed program that seeks to provide continuity of care for adolescents at risk for unintended pregnancy. The program has a school-based education component and a clinical component. The Teen Services Program has a formal agreement with the Atlanta Public Schools to provide 10 classroom periods of reproductive health education to all eighth-grade students, most of whom are from low-income families. The program educates 4,500 students each year through this agreement. "Postponing Sexual Involvement" is a component of the 10-hour outreach program in the Atlanta schools designed to help teens avoid early sexual involvement. Five sessions of the "Postponing Sexual Involvement" educational series are taught by Grade 11 and 12 students under the supervision of the hospital staff. The teen-led sessions are designed to help younger teens develop skills and resist social and peer pressures to begin sexual intercourse before they are able to take full responsibility for the consequences of their actions. The older youth also serve as role models, showing that they can be successful teenagers without being sexually involved. One session of the educational series is devoted exclusively to HIV infection and other STDs. The program emphasizes prevention of high-risk behaviors and STDs rather than providing detailed information on each STD.
Two special after-school family planning clinics (supported by Title X funds) are held at Grady Hospital each week. Nearly 1,200 sexually active female adolescents age 16 and younger are seen in these clinics annually. Once enrolled, adolescents continue to receive their care in these clinics until age 18 or graduation from high school. At Grady Hospital, each counselor sees patients from assigned schools who come for family planning services at least three or four times a year. Teen Services' nurses and counselors are assigned responsibility for
a "case load" of individual schools and thus are able to have consistent interactions with teachers and students at those schools. Male adolescents also come to the clinic for counseling and condoms, but other reproductive health services for them are handled through referrals. In addition, STD education, screening, and treatment are available in the family planning clinic. While STD prevention is not the focus of the Teen Services Program, it has been integrated into education and clinical services.
Results of evaluations of the school education component of the program indicate that teens who have participated in the program are five times more likely to postpone sexual activity in the eighth grade, and the rate of initiation of sexual intercourse is reduced by a third through the ninth grade (Howard and McCabe, 1990). In the service/clinical program, 80 percent of young mothers remain pregnancy-free during their teenage years. The program has recently begun a comprehensive message, "Free to Be," which means drug-free, HIV-free, and pregnancy-free. The program is based on the notion that the same skills are needed to avoid drugs, drinking while driving, sexual involvement, and unprotected sexual intercourse.
Howard M, McCabe JB. Helping teenagers postpone sexual involvement. Fam Plann Perspect 1990;22:21-6.