The Challenge of STD Prevention in the United States
Globally, an estimated 333 million new cases of curable STDs occur each year among adults. Over the past four decades a great deal of progress in STD prevention has been made in the United States. Rates of gonorrhea and syphilis have recently been brought to historic lows. Yet the U.S. still has the highest rates of STDs in the industrialized world, with rates that are 50-100 times higher than other industrialized nations. There are an estimated 12 million new cases of STDs in the U.S. each year. Of these, 3 million occur among teenagers, 13 to 19 years old. A recent CDC report documented that over 85% of the most common infectious diseases in the U.S. are sexually transmitted.
The immediate and long-term disease burden and costs associated with STDs globally and in the U.S. are immense. STDs are one of the most critical challenges in the nation today because of their severe and costly consequences for woman and infants, their tremendous impact on the health of adolescents and young adults (especially among minority populations), and the integral role other STDs play in the transmission of HIV infection. Conversely, an investment in STD prevention is leveraged several ways--it improves the health of women, infants, and young people, and slows down the spread of HIV infection in our most vulnerable and disadvantaged populations. In addition to the human costs, STDs add $17 billion dollars to the nation's health care costs each year.
Dangerous and Deadly Consequences
Most Americans are aware of HIV infection and AIDS, the most deadly of all STDs. But, for much of society, the other serious risks related to unsafe sexual behaviors may have been forgotten. There are over 20 diseases that are transmitted sexually. Many have serious and costly consequences.
Some of the most common and serious STDs include:
Chlamydia An estimated 4,000,000 new cases each year
Gonorrhea An estimated 800,000 new cases each year
If not adequately treated, 20-40 percent of women infected with chlamydia and 10-40 percent of women infected with gonorrhea develop upper genital tract infection, also called pelvic inflammatory disease (PID). Among women with PID, scarring will result in involuntary infertility in 20 percent, potentially fatal ectopic pregnancy in 9 percent, and chronic pelvic pain in 18 percent. Ectopic pregnancy is the leading cause of first trimester pregnancy-related deaths among American women. The ectopic pregnancy rate could be reduced by as much as 50% by early detection and treatment of STDs.
- Human Papillomavirus (HPV) An estimated 500,000-1,000,000 new infections each year
Sexually transmitted HPV is the single most important risk factor for cervical cancer, which was responsible for approximately 5,000 deaths in American women in 1995. Pap smears can identify early signs of cell abnormalities and precancerous conditions. In addition, there are non-cancer-inducing types of HPV that cause genital warts. There are many treatments, but no cures for genital warts. The warts may go away, but the virus remains and others can be infected. There are likely more than 24 million Americans infected with HPV.
- Genital Herpes An estimated 200,000-500,000 new cases each year
Herpes may be the most common STD in the United States. It is estimated that as many as 30 million Americans may now carry the herpes virus. There is no cure, but there are drugs to reduce the pain and length of outbreaks and reduce the likelihood of infecting a sexual partner.
Syphilis An estimated 101,000 new cases each year
Congenital Syphilis An estimated 3,400 new cases each year
(babies born who need syphilis treatment)
_Fetal or neonatal death occurs in up to 40 percent of pregnant women who have untreated syphilis. As many as 40 percent of live-born infants of women with untreated early syphilis suffer irreversible health consequences. The genital sores caused by syphilis in adults make it easier to transmit and acquire HIV infection sexually. _
- HIV An estimated 40,000-80,000 new infections each year
Sixty-four percent of all people diagnosed with AIDS, to date, have died. Exciting new advancements in the treatment of HIV disease, namely combination therapy, appear to increase the quality of and prolong life for people with HIV infection. But we must remember that prevention remains our best and most cost-effective tool for saving lives and bringing the epidemic under control. We cannot lose sight of the ultimate goal of preventing HIV infection, so that people don't have to undergo complex and costly treatment regimens.
Disproportionate Impact on Women, Infants, Young People, and Minorities
Women bear a disproportionate burden of STD-related complications. For women, STDs can lead to PID, infertility, potentially fatal ectopic pregnancies, and cancer of the reproductive tract.
In the U.S., chlamydia and gonorrhea are responsible for the majority of PID, which, in turn, is the leading cause of preventable infertility and ectopic pregnancy.
Tubal scarring from PID increases the risk of ectopic pregnancy. The number of ectopic pregnancies in the U.S. in 1992 (108,800) was the highest level in nearly two decades.
For infants infected by their mothers during gestation or birth, STDs can result in irreparable lifetime damage, including blindness, bone deformities, mental retardation, and death. Most congenital syphilis could be eliminated if all pregnant women had access to prenatal care where syphilis screening and treatment were a standard of care.
- In 1995, ninety-one percent of all babies born with congenital syphilis were Black or Hispanic, yet Black and Hispanic women represent only 21% of the female population.
Adolescents and young adults, especially minorities, are disproportionately affected by STDs. A number of factors may play a role in the high rates of STDs among minorities. Race and ethnicity are not risk factors but are risk markers that correlate with fundamental determinants of health, such as poverty, limited access to quality health care, illicit drug use, and living in communities with high prevalence of STDs.
The highest rates of gonorrhea and chlamydia in women are in 15- to 19-year-olds.
The rate of syphilis and gonorrhea among blacks was nearly 60 and 40 times that in whites, respectively. The syphilis rate among Hispanics was about 4 times that in whites.
The proportion of blacks ever infected with genital herpes infection is 2-3 times that in whites (1991).
STD Prevention Works
Compared to the U.S. (which has among the highest STD rates in the industrialized world), Canada and some countries in Western Europe have nearly eliminated infectious syphilis. U.S. rates of gonorrhea are 50 to 100 times higher than rates in Sweden.
Large-scale screening programs have rapidly, dramatically, and reproducibly reduced chlamydia prevalence in women. For example, screening programs in family planning clinics in four states in the Pacific Northwest (WA, ID, OR, AK) have demonstrated almost a 60% decline in chlamydia positivity within the first 5 years of implementation.
A study of chlamydia screening in a managed care setting suggest that such screening programs can also reduce the incidence of PID by as much as 56% within one year.
A community-level, randomized trial in a rural African community in Tanzania demonstrated a 42% decrease in new, heterosexually transmitted HIV infections in communities with improved STD treatment as compared to communities with minimal STD services.
For more information on the link between HIV and other STD
CDC National AIDS Clearinghouse
P.O. Box 6003
Rockville, MD 20849-6003
CDC National AIDS Hotline
CDC National STD Hotline