Hidden Epidemic Confronting STD's

There is a tendency to look on AIDS and HIV and other sexually transmitted diseases as issues largely of the developing world, particularly sub-Saharan Africa and Southern and South East Asia. However, some rich industrialised countries, particularly the United States, have an epidemic of sexually transmitted diseases (about 12 million new cases annually, of which 3 million occur in teenagers), and no national coordinated control programme of education and clinical services.

The Hidden Epidemic is the report of a 16 member committee on prevention and control of sexually transmitted diseases set up by the Institute of Medicine to assess the current impact of such diseases and to "provide direction for future public health programmes, policy and research in STD prevention and control."

The committee is clear that a national system for preventing sexually transmitted diseases needs to be established and that it makes economic sense to do so. The report estimates that only $1 is invested in preventing sexually transmitted diseases for every $34 spent on managing such diseases (direct and indirect costs), and it calls for a system based on a national coordinated policy, made up of local, state, and national programmes. The report recognises that to do this will require policymakers (in both public and private sectors) to show strong leadership built through alliances and will need to overcome barriers to adopting healthy sexual behaviour, with particular emphasis on adolescents and other populations who often fail to access services.

The report stresses the need to prevent sexually transmitted diseases, and that this means that interventions should focus on adolescents before sexual activity is started. It states that all school districts in the United States should see that schools provide appropriate services, including health education, access to condoms, and readily available clinical services, which could be school based.

The report finally addresses the issue of how to ensure access to and quality of essential clinical services for sexually transmitted diseases. Unlike in Britain, no network of clinic based specialist service exists. The report does not recommend this particular system and, interestingly, calls for a mixed model of integrated and specialist services which is more akin to that used in the developing world. The committee members therefore recommend that comprehensive services for sexually transmitted diseases should be incorporated into primary care and reproductive health services. To complement this, they call for improvement in dedicated public clinics for sexually transmitted diseases.

Finally, the issue of who pays is crucial to any control programme. Ideally, when dealing with a major public health problem with associated stigma, it is best that services are open access and free. In the United States this is largely not so, and the report examines ways in which health plans and managed care organisations could tackle this financial issue, but it does not go so far as to suggest that all services should be free and centrally funded.

The book is intended for a wide audience involved directly or indirectly in preventing sexually transmitted diseases or who have an interest in general public health policy. This is an excellent book that lays down the foundations, backed by evidence, of what needs to be done rather than how this can be achieved. It will provide an essential text for those wishing to act as advocates for the setting up of control programmes in the United States. Since much of the background information contained in the book relates to North America, it is probably not of a wider use for programme managers. However, for those interested in the public health issues related to sexually transmitted diseases, it does provide good background information on the epidemic and economic social issues in the United States.

Michael Adler, professor of genitourinary medicine/sexually transmitted diseases, University College London Medical

School, London