STD-Free but Pregnant

Health care reform will likely coordinate much of patients' care. Yet STD and contraception counseling, which seem like a natural pairing, may remain separate.

As federal and state officials begin to implement health care reform, they will experiment with coordinated care. In this "whole patient" approach to medicine, specialists communicate with each other and primary care providers serve as figurative medical homes, managing a patient's varied health care needs. But in the area of sexual health, a longstanding divide between STD prevention and pregnancy prevention may inhibit a coordinated approach.

Along with Alcohol Awareness Month and Irritable Bowel Syndrome Awareness Month, April is also STD Awareness Month, making this the perfect time of year to consider the most effective way to reduce the 19 million new STDs occurring annually in the US. Like many health problems, STDs are more common in non-white and poor communities, but risky behavior is also high among the mostly white women who rely on oral contraceptives to prevent pregnancy. (Dual use of condoms and the pill is highest among young African Americans.)

Counseling and services for protection against STDs (including HIV) and unwanted pregnancy are often decoupled -- a silo approach reflecting the separate priorities of different funding sources, according to Bill Smith, executive director of the (curiously named) National Coalition of STD Directors. The Department of Health and Human Services' Office of Population Affairs supports publicly funded family planning services while the Center for Disease Control's (CDC) National Center for Chronic Disease Prevention and Health Promotion handles clinics that deal only with STDs. This division poses a problem for coordinated care, often meaning that STD clinics lack resources and expertise on pregnancy prevention.

Individual behavior also complicates dual protection. In a 2003 report on the use of condoms and hormonal birth control, Perspectives on Sexual and Reproductive Health found that "the more effective the primary method is at pregnancy prevention, the less likely women and their partners are to use, or to intend to use, male condoms consistently." To extrapolate higher STD rates from such data is too narrow an interpretation, considering that STDs and pregnancy do not have identical risk factors (number of partners is the primary risk factor for STDs). The data are also vague -- as reported in the same study, dual-protection methods are used by anywhere from 3 percent to 42 percent of respondents. The study indicates that providers who offer counseling and services for birth control are not always talking about STD prevention, not that women using hormonal birth control are having more unprotected sex. Related services for managing HIV, other STDs, and birth control overlap less frequently than they should.

The CDC's Program Collaboration and Service Integration is responsible for STDs, including HIV, and tuberculosis. While there is a direct correlation between TB infections and HIV infections, the institutional relationships among HIV, other STD, and pregnancy prevention fail to keep pace with the physiological connections. Untreated STDs like chlamydia and gonorrhea, which are largely asymptomatic, can increase susceptibility to HIV and can also cause more serious infections resulting in infertility. But patients who go to HIV clinics for regular screenings may never be tested for syphilis, which is on the rise, or gonorrhea, which is developing antibiotic resistance.

With health care reform's new focus on coordinated care, will STD and pregnancy prevention resources remain separate? Bill Smith thinks so, at least when it comes to STD-only clinics, which have a more male demographic than family planning providers. New and still unpublished findings from Massachusetts, which shuttered its STD-only clinics in favor of broader care, show that some of the patients who used these facilities have simply stopped seeking sexual health care. Ensuring that men get the sexual health care they need has always been a challenge. If STD-only clinics are the most effective way to do this, they will probably stick around for a while.