Sexually Transmitted Infections Adopting a Sexual Health Paradigm (2021) / Chapter Skim
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4 STI Economics, Public-Sector Financing, and Program Policy
4 STI Economics, Public-Sector Financing, and Program Policy
Pages 219-246
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4 STI Economics, Public-Sector Financing, and Program Policy Chapter Contents Introduction Role of Government in Prevention and Control of STIs • Cooperative Federalism and Public Health Overview of Federal Programs • Background • Overview of Federally Funded Public Health Programs State and Local Efforts Economic Burden of STIs Conclusions INTRODUCTION To offer recommendations for future public health programs, policy, and research, it is important to understand the historical experience and current status of public efforts to respond to sexually transmitted infections (STIs)
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If measuring and quantifying change signal the importance of progress toward the intended outcomes, then the inability BOX 4-1 Chapter Findings • Despite evidence that the burden of sexually transmitted infections (STIs) has increased, federal funding to address STIs has remained stagnant.
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The committee does not offer specific funding recommendations as it was beyond the scope of its work; however, the chapter points to funding barriers and opportunities for STI prevention and control. ROLE OF GOVERNMENT IN PREVENTION AND CONTROL OF STIs An important starting point to understanding the legal and operational underpinnings of how the current system addresses STIs is to examine which level of government is responsible for STIs and public health and how the leadership and financing for STI programs has evolved.
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Similarly, numerous federal, state, and local funding streams support STI prevention efforts, either as a standalone program or as a part of other health services funding programs (e.g., Title X funding for family planning and Section 330 of the Public Health Service Act [PHSA] for HRSA funding for qualifying health centers)
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Overview of Federally Funded Public Health Programs Most federal support for STI services is provided by HHS and underpins the operation of a wide range of programs funded and administered by CDC, the HHS Office of Population Affairs (OPA) , HRSA, SAMHSA, the Indian Health Service (IHS)
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224 FIGURE 4-1 Federal agencies that provide sexually transmitted infection funding. SOURCE: Adapted from NAPA, 2019, to reflect organization as of December 2020.
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FIGURE 4-2 Annual Centers for Disease Control and Prevention sexually transmitted infection prevention budget, inflationadjusted budget, and syphilis rates, fiscal years 2003–2019.
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CDC programming is primarily focused in the following areas: • Evidence-based scientific information for providers, pub lic health professionals, and patients and communities: CDC develops provider guidelines including Recommendations for Providing Quality Sexually Transmitted Diseases Clinical Services
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For example, the Strengthening STD Prevention and Control for Health Departments program provides cooperative agree ments/grants to state, local, and territorial health departments to address chlamydia, gonorrhea, and syphilis (CDC, 2018)
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OPA's primary responsibility has been to administer the Title X Family Planning program, which supports clinical family planning services (including STI and HIV prevention education, counseling, and testing) at sites nationwide that serve low-income patients (OPA, 2020)
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, state and county health departments, Planned Parenthood clinics, and specialized family planning providers. Participating sites receive federal support and are eligible for the federal 340B drug pricing program (see the relevant later section in this chapter for more details)
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STI clinics that receive funding from CDC under Section 318 of the PHSA are eligible recipients, as are FQHCs, Ryan White HIV/AIDS program grantees, and sites that receive Title X family planning funding (HRSA, 2020c)
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Although the clinic or health provider is defined as 340B eligible, the outpatient drug discount can only be secured for "eligible patients," defined by federal rules as those who meet the following criteria: • Have an established relationship with the covered entity, as dem onstrated by the covered entity maintaining a medical record for the patient; • Receive services from a health care professional who is either employed by the covered entity or provides health care under contractual or other arrangements (e.g., referral for consultation) such that responsibility for the care provided remains with the covered entity; and • Receive a service or a range of services from the covered entity, which is consistent with the grant funding or the FQHC look alike status that has been provided to the entity (GPO, 1996)
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Bureau of Primary Health The bureau administers the Health Center Program, which provides grants to support primary care and related services through a network of more than 1,400 health centers that operate at about 12,000 service delivery sites in every state, the District of Columbia, and the U.S. territories (McDevitt, 2019)
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. The Uniform Data System, the database that tracks the number and types of services that health centers provide, reports 376,840 visits for STI services and 256,203 visits with an STI diagnosis in 2018.1 Maternal and Child Health Bureau The bureau administers the Title V Maternal and Child Health Program, a block grant to improve maternal, child, and family health.
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It also publishes practice guidelines and data surveillance related to STIs and mental health. Its STI-related resources include the following: • Data Spotlight: a brief that highlights data on colocation of sub stance abuse treatment and STI screening (SAMHSA, 2013)
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Department of Justice Federal Bureau of Prisons The Federal Bureau of Prisons, an agency under the Department of Justice, is responsible for providing direct clinical services, including STI care, to individuals in the federal prison system. It also publishes clinical guidelines for preventing and treating STIs in prison settings, such as the following: • The Infectious Disease Management Program Statement states that (1)
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There are no categorical STI funding streams that benefit local public health programs, other than flow-through funding from PCHD grantees, especially in states where the state health departments are directly in charge of local STI programs. In addition, local STI programs and clinics depend on a number of other funding sources, including city/county and state transfers (often bundled with other funding)
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Important support for local STI programs and clinics comes from the CDC-funded National Network of STD Prevention Training Centers, consisting of eight regional centers that provide STI workforce training and technical assistance (Stoner et al., 2019)
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With the exception of HPV, the study estimated the direct medical cost burden of each STI by multiplying the lifetime medical costs per infection of treating each STI and its sequelae with the number of incident cases of each STI in 2018. The estimates of cases and costs were obtained from existing peer-reviewed studies.
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These costs are often ignored because they are difficult to measure, but they could be much higher than the direct medical costs of STIs. The committee commissioned a pilot study2 to explore methods that could be used to help quantify the impact of STIs on the quality of life of the uninfected, which could arise through multiple channels.
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. Similarly, at the local level, many STI programs have curtailed their services due to lack of funding or programmatic changes in policy, as is the case for the Title X program, even though increased health care coverage due to the Patient Protection and Affordable Care Act may be increasing access to STI care.
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2020. Recommendations for providing quality sexually transmitted diseases clinical services, 2020.
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2018. NOFO: Ps19-1901 strengthening STD prevention and control for health departments (STD PCHD)
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2017. 340B drug pricing program fre quently asked questions for Title X family planning agencies.
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2017. US public sexually transmitted disease clinical services in an era of declining public health funding: 2013-14.
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2020. Title X family planning annual report: 2019 national summary.
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2019. The national network of sexually transmitted disease clinical prevention training centers turns 40 -- a look back, a look ahead.
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