Does funding for HIV and sexually transmitted disease prevention matter? Evidence from panel data

An Interactive Modeling Tool for Projecting the Health and Direct Medical Cost Impact of Changes in the Sexually Transmitted Diseases Prevention Program Budgets

CONTEXT

Estimating the return on investment for public health services, tailored to the state level, is critical for demonstrating their value and making resource allocation decisions. However, many health departments have limited staff capacity and expertise to conduct economic analyses in-house.

PROGRAM

We developed a user-friendly, interactive Excel-based spreadsheet model that health departments can use to estimate the impact of increases or decreases in sexually transmitted infection (STI) prevention funding on the incidence and direct medical costs of chlamydia, gonorrhea, syphilis, and STI-attributable HIV infections. Users tailor results to their jurisdictions by entering the size of their population served; the number of annual STI diagnoses; their prior annual funding amount; and their anticipated new funding amount. The interface was developed using human-centered design principles, including focus groups with 15 model users to collect feedback on an earlier model version and a usability study on the prototype with 6 model users to finalize the interface.

IMPLEMENTATION

The STI Prevention Allocation Consequences Estimator ("SPACE Monkey 2.0") model will be publicly available as a free downloadable tool.

EVALUATION

In the usability testing of the prototype, participants provided overall positive feedback. They appreciated the clear interpretations, outcomes expressed as direct medical costs, functionalities to interact with the output and copy charts into external applications, visualization designs, and accessible information about the model's assumptions and limitations. Participants provided positive responses to a 10-item usability evaluation survey regarding their experiences with the prototype.

DISCUSSION

Modeling tools that synthesize literature-based estimates and are developed with human-centered design principles have the potential to make evidence-based estimates of budget changes widely accessible to health departments.

Estimating the Association Between Public Health Spending and Sexually Transmitted Disease Rates in the United States: A Systematic Review

ABSTRACT

Public health spending is important for managing increases in sexually transmitted diseases (STDs) in the United States. Although previous studies suggest that a beneficial link exists between public health spending and changes in STD rates, there have been no systematic reviews synthesizing existing evidence regarding the association for STDs at the population level. The objective of this study was to synthesize evidence from studies that assessed the associations between general and STD-specific public health spending and STD rates. We conducted a systematic review using Ovid-Medline, EMBASE, CINAHL, Cochrane Library, Web of Science, and EconLit for relevant studies that examined the association between public health spending and gonorrhea, syphilis, chlamydia, and chancroid rates following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 5 articles (2 regarding general public health spending and 3 regarding STD-specific public health spending) met our inclusion criteria. There was a significant decrease in gonorrhea, syphilis, chlamydia, and chancroid rates associated with increased public health spending. We also found that STD-specific public health spending has a greater effect on STD rates compared with general public health spending. Our review provides evidence that increases in general and STD-specific public health spending are associated with a reduction of STD rates. Such research regarding estimates of the impact of STD prevention spending can help policy makers identify priority funding areas and inform health resource allocation decisions.

Analytic Approaches to Assess the Impact of Local Spending on Sexually Transmitted Diseases

OBJECTIVE

To compare the estimated associations between annual STD (sexually transmitted diseases) expenditures per capita and STD rates among Florida and Washington local health departments (LHDs) from 2001-2017, using two approaches--a longitudinal regression model with lagged STD spending, and a regression model with the Arellano-Bond panel estimator.

DATA SOURCES

Secondary data for LHDs were obtained from Florida and Washington state government offices and combined with county sociodemographic and health system data from the federal government.

STUDY DESIGN

We examined LHDs in Florida and Washington using a longitudinal panel study design to estimate ecological relationships between annual STD expenditures per capita and annual STD incidence rates from 2001 to 2017 with LHDs as the unit of analysis. We compared two regression models: generalized estimating equations (GEE) and the Arellano-Bond panel estimator (an instrumental variable approach).

DATA COLLECTION

The secondary data were combined to build a longitudinal panel database for LHDs in Florida and Washington from 2001 to 2017.

PRINCIPAL FINDINGS

In the GEE model with both states, greater STD spending in a prior year was associated unexpectedly with greater STD incidence rates in succeeding years. The Arellano-Bond models for both states had the expected inverse associations but were not significant. In the Arellano-Bond models for Florida, a $1 increase in STD spending in previous years was followed by decreases in STD incidence rates ranging between 29 and 59 points in succeeding years (0.09 ≥ p ≥ 0.04).

CONCLUSIONS

In longitudinal panel data for LHDs in two states, the Arellano-Bond estimator, or other instrumental variable approach, is preferred over conventional regression models to obtain unbiased estimates of the relationship between annual STD spending rates and annual STD rates. Future studies will require accurate, standardized, and detailed longitudinal data and rigorous analytic approaches, such as those illustrated in our study. This article is protected by copyright. All rights reserved.

The Estimated Impact of Implementing a Funding Allocation Formula on the Number of Gonorrhea Cases in the United States, 2014 to 2018

BACKGROUND

The Centers for Disease Control and Prevention (CDC) allocates funds annually to state and local programs in the United States to monitor and prevent sexually transmitted diseases (STDs). In 2014, a funding formula was implemented to allocate prevention funds to jurisdictions according to their STD burden and population size. We estimated the effect of implementing the funding formula in terms of gonorrhea cases averted from 2014 to 2018, a period during which inflation-adjusted CDC STD prevention funding declined.

METHODS

Our model assumed that STD prevention funds have a measurable effect on subsequent reported gonorrhea case rates, and the magnitude of this effect was as estimated in an empirical analysis of decades of state-level gonorrhea rates. In applying this equation-based model, we assumed all factors affecting jurisdictions' gonorrhea rates were constant over time except for their STD prevention funding allocations. We used data on CDC STD prevention funding allocated to each jurisdiction over time. We estimated gonorrhea rates under the "funding formula" scenario compared with a hypothetical "status quo" funding scenario, which reflected traditional methods to allocate prevention funds.

RESULTS

In the model, gonorrhea cases increased from 2014 to 2018 by approximately 6% because of a decline in prevention funding, regardless of how funds were allocated. However, the estimated increase in gonorrhea cases was 5222 (range, 1181-9195) cases less in the funding formula scenario than in the status quo scenario.

CONCLUSIONS

By shifting resources toward jurisdictions with greater disease burden, the funding formula averted a substantial number of gonorrhea cases at no additional cost.

Provision of STD Services in Community Settings After the Loss and Return of State Funding to Support Service Provision: Observations From Select Providers in Massachusetts, 2010 and 2013

CONTEXT

In 2008, the $1.2 M sexually transmitted disease (STD) services line item supporting STD clinical services by the Massachusetts Department of Public Health was eliminated, forcing the cessation of all state-supported STD service delivery.

OBJECTIVE

To determine the impact on community provision of STD services after the elimination of state funds supporting STD service provision.

DESIGN AND SETTING

Rapid ethnographic assessments were conducted in May 2010 and September 2013 to better understand the impact of budget cuts on STD services in Massachusetts. The rapid ethnographic assessment teams identified key informants through Massachusetts's STD and human immunodeficiency virus programs.

PARTICIPANTS

Fifty providers/clinic administrators in 19 sites (15 unique) participated in a semistructured interview (community health centers [n = 10; 53%], hospitals [n = 4; 21%], and other clinical settings [n = 5; 26%]).

RESULTS

Results clustered under 3 themes: financial stability of agencies/clinics, the role insurance played in the provision of STD care, and perceived clinic capacity to offer appropriate STD services. Clinics faced hard choices about whether to provide care to patients or refer elsewhere patients who were unable or unwilling to use insurance. Clinics that decided to see patients regardless of ability to pay often found themselves absorbing costs that were then passed along to their parent agency; the difficulty and financial strain incurred by a clinic's parent agency by providing STD services without support by state grant dollars emerged as a primary concern. Meeting patient demand with staff with appropriate training and expertise remained a concern.

CONCLUSIONS

Provision of public health by private health care providers may increase concern among some community provision sites about the sustainability of service provision absent external funds, either from the state or from the third-party billing. Resource constraints may be felt across clinic operations. Provision of public health in the for-profit health system involves close consideration of resources, including those: leveraged, used to provide uncompensated care, or available for collection through third-party billing.

Differential Association of HIV Funding With HIV Mortality by Race/Ethnicity, United States, 1999-2017

OBJECTIVE

Federal funds have been spent to reduce the disproportionate effects of HIV/AIDS on racial/ethnic minority groups in the United States. We investigated the association between federal domestic HIV funding and age-adjusted HIV death rates by race/ethnicity in the United States during 1999-2017.

METHODS

We analyzed HIV funding data from the Kaiser Family Foundation by federal fiscal year (FFY) and US age-adjusted death rates (AADRs) by race/ethnicity (Hispanic, non-Hispanic white, non-Hispanic black, and Asian/Pacific Islander and American Indian/Alaska Native [API+AI/AN]) from Centers for Disease Control and Prevention WONDER detailed mortality files. We fit joinpoint regression models to estimate the annual percentage change (APC), average APC, and changes in AADRs per billion US dollars in HIV funding, with 95% confidence intervals (CIs). For 19 data points, the number of joinpoints ranged from 0 to 4 on the basis of rules set by the program or by the user. A Monte Carlo permutation test indicated significant (P < .05) changes at joinpoints, and 2-sided t tests indicated significant APCs in AADRs.

RESULTS

Domestic HIV funding increased from $10.7 billion in FFY 1999 to $26.3 billion in FFY 2017, but AADRs decreased at different rates for each racial/ethnic group. The average rate of change in AADR per US billion dollars was -9.4% (95% CI, -10.9% to -7.8%) for Hispanic residents, -7.8% (95% CI, -9.0% to -6.6%) for non-Hispanic black residents, -6.7% (95% CI, -9.3% to -4.0%) for non-Hispanic white residents, and -5.2% (95% CI, -7.8% to -2.5%) for non-Hispanic API+AI/AN residents.

CONCLUSIONS

Increased domestic HIV funding was associated with faster decreases in age-adjusted HIV death rates for Hispanic and non-Hispanic black residents than for residents in other racial/ethnic groups. Increasing US HIV funding could be associated with decreasing future racial/ethnic disparities in the rate of HIV-related deaths.

Recent Changes in Prevention Funding to Areas With High Racial and Ethnic Disparities in Sexually Transmitted Disease Rates

We examined changes in federal sexually transmitted disease funding allocations to areas with high racial/ethnic disparities in sexually transmitted diseases after the implementation of a funding formula in 2014. The funding formula increased prevention funding allocations to areas with high relative racial/ethnic disparities. Results were mixed for areas with high absolute disparities.

The Impact of Budget Cuts on Sexually Transmitted Disease Programmatic Activities in State and Local Health Departments With Staffing Reductions in Fiscal Year 2012

Staffing reductions in state and local health departments in fiscal year 2012 were concentrated in disease investigation specialists and clinicians (local) and disease investigation specialists and administrative staff (state). Local health departments with budget cuts were significantly more likely to report reduced partner services if they had staffing reductions.

Impacts of Federal Prevention Funding on Reported Gonorrhea and Chlamydia Rates

INTRODUCTION

The Centers for Disease Control and Prevention allocates funds annually to jurisdictions nationwide for sexually transmitted infection prevention activities. The objective of this study was to assess the effectiveness of federal sexually transmitted infection prevention funding for reducing rates of reported sexually transmitted infections.

METHODS

In 2017-2018, finite distributed lag regression models were estimated to assess the impact of sexually transmitted infection prevention funding (in 2016 dollars per capita) on reported chlamydia rates from 2000 to 2016 and reported gonorrhea rates from 1981 to 2016. Including lagged funding measures allowed for assessing the impact of funding over time. Controls for state-level socioeconomic factors, such as poverty rates, were included.

RESULTS

Results from the main model indicate that a 1% increase in annual funding would cumulatively decrease chlamydia and gonorrhea rates by 0.17% (p<0.10) and 0.33% (p<0.05), respectively. Results were similar when stratified by sex, with significant decreases in rates of reported chlamydia and gonorrhea in males of 0.33% and 0.34% (both p<0.05) respectively, and in rates of reported gonorrhea in females of 0.32% (p<0.05). The results were generally consistent across alternative model specifications and other robustness tests.

CONCLUSIONS

The significant inverse associations between federal sexually transmitted infection prevention funding and rates of reported chlamydia and gonorrhea suggest that federally funded sexually transmitted infection prevention activities have a discernable effect on reducing the burden of sexually transmitted infections. The reported sexually transmitted infection rate in a given year depends more on prevention funding in previous years than on prevention funding in the current year, demonstrating the importance of accounting for lagged funding effects.

Neighborhood Health Care Access and Sexually Transmitted Infections Among Women in the Southern United States: A Cross-Sectional Multilevel Analysis

INTRODUCTION

The United States has experienced an increase in reportable sexually transmitted infections (STIs) while simultaneously experiencing a decline in safety net services for STI testing and treatment. This multilevel study assessed relationships between neighborhood-level access to health care and STIs among a predominantly Human Immunodeficiency Virus (HIV)-seropositive cohort of women living in the south.

METHODS

This cross-sectional multilevel analysis included baseline data from HIV-seropositive and HIV-seronegative women enrolled in the Women's Interagency HIV Study sites in Alabama, Florida, Georgia, Mississippi, and North Carolina between 2013 and 2015 (N = 666). Administrative data (eg, United States Census) described health care access (eg, percentage of residents with a primary care provider, percentage of residents with health insurance) in the census tracts where women lived. Sexually transmitted infections (chlamydia, gonorrhea, trichomoniasis, or early syphilis) were diagnosed using laboratory testing. Generalized estimating equations were used to determine relationships between tract-level characteristics and STIs. Analyses were conducted using SAS 9.4.

RESULTS

Seventy percent of participants were HIV-seropositive. Eleven percent of participants had an STI. A 4-unit increase in the percentage of residents with a primary care provider was associated with 39% lower STI risk (risk ratio, 0.61, 95% confidence interval, 0.38-0.99). The percentage of tract residents with health insurance was not associated with STIs (risk ratio, 0.98, 95% confidence interval, 0.91-1.05). Relationships did not vary by HIV status.

CONCLUSIONS

Greater neighborhood health care access was associated with fewer STIs. Research should establish the causality of this relationship and pathways through which neighborhood health care access influences STIs. Structural interventions and programs increasing linkage to care may reduce STIs.

Methods for Sexually Transmitted Disease Prevention Programs to Estimate the Health and Medical Cost Impact of Changes in Their Budget

BACKGROUND

The purpose of this article was to describe methods that sexually transmitted disease (STD) programs can use to estimate the potential effects of changes in their budgets in terms of disease burden and direct medical costs.

METHODS

We proposed 2 distinct approaches to estimate the potential effect of changes in funding on subsequent STD burden, one based on an analysis of state-level STD prevention funding and gonorrhea case rates and one based on analyses of the effect of Disease Intervention Specialist (DIS) activities on gonorrhea case rates. We also illustrated how programs can estimate the impact of budget changes on intermediate outcomes, such as partner services. Finally, we provided an example of the application of these methods for a hypothetical state STD prevention program.

RESULTS

The methods we proposed can provide general approximations of how a change in STD prevention funding might affect the level of STD prevention services provided, STD incidence rates, and the direct medical cost burden of STDs. In applying these methods to a hypothetical state, a reduction in annual funding of US $200,000 was estimated to lead to subsequent increases in STDs of 1.6% to 3.6%. Over 10 years, the reduction in funding totaled US $2.0 million, whereas the cumulative, additional direct medical costs of the increase in STDs totaled US $3.7 to US $8.4 million.

CONCLUSIONS

The methods we proposed, though subject to important limitations, can allow STD prevention personnel to calculate evidence-based estimates of the effects of changes in their budget.

US Public Sexually Transmitted Disease Clinical Services in an Era of Declining Public Health Funding: 2013-14

BACKGROUND

We examined the infrastructure for US public sexually transmitted disease (STD) clinical services.

METHODS

In 2013 to 2014, we surveyed 331 of 1225 local health departments (LHDs) who either reported providing STD testing/treatment in the 2010 National Profile of Local Health Departments survey or were the 50 local areas with the highest STD cases or rates. The sample was stratified by jurisdiction population size. We examined the primary referral clinics for STDs, the services offered and the impact of budget cuts (limited to government funding only). Data were analyzed using SAS, and analyses were weighted for nonresponse.

RESULTS

Twenty-two percent of LHDs cited a specialty STD clinic as their primary referral for STD services; this increased to 53.5% of LHDs when combination STD-family planning clinics were included. The majority of LHDs (62.8%) referred to clinics providing same-day services. Sexually transmitted disease clinics more frequently offered extragenital testing for chlamydia and/or gonorrhea (74.7%) and gonorrhea culture (68.5%) than other clinics (52.9%, 46.2%, respectively; P < 0.05). The majority of LHDs (61.5%) reported recent budget cuts. Of those with decreased budgets, the most common impacts were fewer clinic hours (42.8%; 95% confidence interval [CI], 24.4-61.2), reduced routine screening (40.2%; 95% CI, 21.7-58.8) and reductions in partner services (42.1%; 95% CI, 23.6-60.7). One quarter of those with reduced STD budgets increased fees or copays for clients.

CONCLUSIONS

Findings demonstrate gaps and reductions in US public STD services including clinical services that play an important role in reducing disease transmission. Furthermore, STD clinics tended to offer more specialized STD services than other public clinics.

Cost Analysis and Performance Assessment of Partner Services for Human Immunodeficiency Virus and Sexually Transmitted Diseases, New York State, 2014

OBJECTIVE

To estimate the programmatic costs of partner services for HIV, syphilis, gonorrhea, and chlamydial infection.

STUDY SETTING

New York State and local health departments conducting partner services activities in 2014.

STUDY DESIGN

A cost analysis estimated, from the state perspective, total program costs and cost per case assignment, patient interview, partner notification, and disease-specific key performance indicator.

DATA COLLECTION

Data came from contracts, a time study of staff effort, and statewide surveillance systems.

PRINCIPAL FINDINGS

Disease-specific costs per case assignment (mean: $580; range: $502-$1,111), patient interview ($703; $608-$1,609), partner notification ($1,169; $950-$1,936), and key performance indicator ($2,697; $1,666-$20,255) varied across diseases. Most costs (79 percent) were devoted to gonorrhea and chlamydial infection investigations.

CONCLUSIONS

Cost analysis complements cost-effectiveness analysis in evaluating program performance and guiding improvements.

An evaluation of the SD Bioline HIV/syphilis duo test

Many health agencies now recommend routine HIV and syphilis testing for pregnant women and most-at-risk populations such as men who have sex with men. With the increased availability of highly sensitive, low cost rapid point-of-care tests, the ability to meet those recommendations has increased, granting wider access to quick and accurate diagnoses. Using blood specimens collected from a Baltimore City Health Department (BCHD) sexually transmitted infection clinic, we evaluated the SD Bioline HIV/Syphilis Duo, a rapid test that simultaneously detects antibodies to HIV and syphilis and has the potential to further benefit clinics and patients by reducing costs, testing complexity, and patient wait times. SD DUO HIV sensitivity and specificity, when compared to BCHD results, were 91.7 and 99.5%, respectively. SD DUO syphilis sensitivity and specificity, when compared to rapid plasma reagin, were 85.7 and 96.8%, respectively, and 69.7 and 99.7%, respectively, when compared to Treponema pallidum particle agglutination (TPPA). SD DUO syphilis sensitivity and specificity, when compared to a traditional screening algorithm, improved to 92.3 and 100%, respectively, and improved to 72.9 and 99.7%, respectively, when compared to a reverse screening algorithm. The HIV component of the SD DUO performed moderately well. However, results for the SD DUO syphilis component, when compared to TPPA, support the need for further testing and assessment.

Violent crime rates as a proxy for the social determinants of sexually transmissible infection rates: the consistent state-level correlation between violent crime and reported sexually transmissible infections in the United States, 1981-2010

BACKGROUND

Numerous social determinants of health are associated with violent crime rates and sexually transmissible infection (STI) rates. This report aims to illustrate the potential usefulness of violent crime rates as a proxy for the social determinants of STI rates.

METHODS

For each year from 1981 to 2010, we assessed the strength of the association between the violent crime rate and the gonorrhoea (Neisseria gonorrhoeae) rate (number of total reported cases per 100?000) at the state level. Specifically, for each year, we calculated Pearson correlation coefficients (and P-values) between two variables (the violent crime rate and the natural log of the gonorrhoea rate) for all 50 states and Washington, DC. For comparison, we also examined the correlation between gonorrhoea rates, and rates of poverty and unemployment. We repeated the analysis using overall syphilis rates instead of overall gonorrhoea rates.

RESULTS

The correlation between gonorrhoea and violent crime was significant at the P<0.001 level for every year from 1981 to 2010. Syphilis rates were also consistently correlated with violent crime rates. In contrast, the P-value for the correlation coefficient exceeded 0.05 in 9 of the 30 years for the association between gonorrhoea and poverty, and in 17 of the 30 years for that between gonorrhoea and unemployment.

CONCLUSIONS

Because violent crime is associated with many social determinants of STIs and because it is consistently associated with STI rates, violent crime rates can be a useful proxy for the social determinants of health in statistical analyses of STI rates.

Local public health systems and the incidence of sexually transmitted diseases

OBJECTIVES

We examined the associations of local public health system organization and local health department resources with county-level sexually transmitted disease (STD) incidence rates in large US health jurisdictions.

METHODS

We linked annual county STD incidence data (2005-2008) to local health department director responses (n = 211) to the 2006 wave of the National Longitudinal Study of Local Public Health Systems, the 2005 national Local Health Department Profile Survey, and the Area Resource File. We used nested mixed effects regression models to assess the relative contribution of local public health system organization, local health department financial and resource factors, and sociodemographic factors known to be associated with STD incidence to county-level (n = 307) STD incidence.

RESULTS

Jurisdictions with local governing boards had significantly lower county-level STD incidence. Local public health systems with comprehensive services where local health departments shoulder much of the effort had higher county-level STD rates than did conventional systems.

CONCLUSIONS

More integration of system partners in local public health system activities, through governance and interorganizational arrangements, may reduce the incidence and burden of STDs.

Methods in public health services and systems research: a systematic review

CONTEXT

Public Health Services and Systems Research (PHSSR) is concerned with evaluating the organization, financing, and delivery of public health services and their impact on public health. The strength of the current PHSSR evidence is somewhat dependent on the methods used to examine the field. Methods used in PHSSR articles, reports, and other documents were reviewed to assess their methodologic strengths and challenges in light of PHSSR goals.

EVIDENCE ACQUISITION

A total of 364 documents from the PHSSR library met the inclusion criteria as empirical and based in the U.S. After additional exclusions, 327 of these were analyzed.

EVIDENCE SYNTHESIS

A detailed codebook was used to classify articles in terms of (1) study design; (2) sampling; (3) instrumentation; (4) data collection; (5) data analysis; and (6) study validity. Inter-coder reliability was assessed for the codebook; once it was found reliable, the available empirical documents were coded.

CONCLUSIONS

Although there has been a dramatic increase in the amount of published PHSSR recently, methods used remain primarily cross-sectional and descriptive. Moreover, although appropriate for exploratory and foundational work in a new field, these approaches are limiting progress toward some PHSSR goals. Recommendations are given to advance and strengthen the methods used in PHSSR to better meet the goals and challenges facing the field.

Evidence links increases in public health spending to declines in preventable deaths

Public health encompasses a broad array of programs designed to prevent the occurrence of disease and injury within communities. But policy makers have little evidence to draw on when determining the value of investments in these program activities, which currently account for less than 5 percent of US health spending. We examine whether changes in spending by local public health agencies over a thirteen-year period contributed to changes in rates of community mortality from preventable causes of death, including infant mortality and deaths due to cardiovascular disease, diabetes, and cancer. We found that mortality rates fell between 1.1 percent and 6.9 percent for each 10 percent increase in local public health spending. These results suggest that increased public health investments can produce measurable improvements in health, especially in low-resource communities. However, more money by itself is unlikely to generate significant and sustainable health gains; improvements in public health practices are needed as well.

Are local health department expenditures related to racial disparities in mortality?

This study estimated whether 1990-1997 changes in expenditures per capita of local health departments (LHDs) and percentage share of local public revenue allocated to LHDs were associated inversely with 1990-1997 changes in mortality rates for Black and White racial/ethnic groups in the US. Population was 883 local jurisdictions with 1990 and 1997 mortality rates for Black and White racial populations from the Centers for Disease Control and Prevention Wonder Compressed Mortality File and LHD expenditures from the National Association of County and City Health Officials. Using a time-trend ecologic design, changes in LHD expenditures per capita and percentage share of public revenue were not related to reductions in Black/White disparities in total, all-cause mortality rates. Increased LHD expenditures or percentage share were associated with reduced Black/White disparities for adults aged 15-44 and males. LHD expenditures or percentage share were related to absolute reductions in mortality for infants, Blacks, and White females but did not close Black-White mortality differences for these groups. Therefore, disparities in Black and White mortality rates for subgroups with the greatest mortality gaps may be more likely to be reduced by public investment in local health departments than disparities in Black and White total, all-cause mortality rates.

Public health delivery systems: evidence, uncertainty, and emerging research needs

The authors review empirical studies published between 1990 and 2007 on the topics of public health organization, financing, staffing, and service delivery. A summary is provided of what is currently known about the attributes of public health delivery systems that influence their performance and outcomes. This review also identifies unanswered questions, highlighting areas where new research is needed. Existing studies suggest that economies of scale and scope exist in the delivery of public health services, and that key organizational and governance characteristics of public health agencies may explain differences in service delivery across communities. Financial resources and staffing characteristics vary widely across public health systems and have expected associations with service delivery and outcomes. Numerous gaps and uncertainties are identified regarding the mechanisms through which organizational, financial, and workforce characteristics influence the effectiveness and efficiency of public health service delivery. This review suggests that new research is needed to evaluate the effects of ongoing changes in delivery system structure, financing, and staffing.

Infrequent chlamydial testing among young adults: financial and regional differences

OBJECTIVES

Chlamydia prevalence varies regionally but is highest in the South, which could be the result of regional differences in testing behavior. We describe the national and regional prevalence of self-reported chlamydial infection (Ct) testing and examine how financial resources might be associated with Ct testing.

METHODS

We conducted a cross-sectional analysis of data from 12,334 sexually experienced young adults who participated in wave III of the National Longitudinal Study of Adolescent Health (2001-2002). We estimated the prevalence of Ct testing by region and gender, and calculated prevalence odds ratios for the relationship between income or insurance status and Ct testing.

RESULTS

Among women, Ct testing in the past year was low (27.3%; 95% CI, 25.5-29.2) and lowest in the South (24.8%). Compared with publicly insured females, privately insured (OR, 0.72; 95% CI, 0.57-0.92) and uninsured females (OR, 0.63; 95% CI, 0.48-0.88) were less likely to report testing. Young women with low income were more likely to report testing than those with a higher income (OR, 1.36; 95% CI, 1.12-1.66). Men reported similar testing patterns.

CONCLUSIONS

The South has the highest chlamydia prevalence and the lowest levels of Ct testing in the United States. Reducing infection prevalence and regional disparities in the burden of this infection requires region-focused funding and innovative strategies to increase testing and treatment programs.

HIV prevention for injecting drug users: the first 25 years and counting

During the last three decades, both the injection of illicit psychoactive drugs and HIV infection among injecting drug users (IDUs) have spread throughout industrialized and developing countries. Extremely rapid transmission of HIV has occurred in IDU populations with incidence rates of 10 to 50/100 person-years. In sharp contrast, there are many examples of very effective HIV risk reduction for IDUs, both in preventing initial epidemics and in bringing existing epidemics under control. IDUs are capable of learning basic information about HIV/AIDS and modifying their behavior to protect both themselves and their peers. Effective HIV prevention for IDUs requires programs that treat IDUs with dignity and respect, provide accurate information and the means for behavior change-access to sterile injection equipment, condoms, and drug abuse treatment. Programs that provide these services need to be implemented on a public health scale for IDU populations at risk for HIV infection.

Decreasing age disparities in syphilis and gonorrhea incidence rates in the United States, 1981--2005

BACKGROUND

Compared to older age groups, teenagers and young adults in the United States are at high risk of acquiring sexually transmitted diseases (STDs). Although the disparity in STD rates across age groups is well documented, changes in the degree of disparity in STD rates across age groups over time have not been examined in detail.

METHODS

We examined age-, sex-, and race-specific incidence rates of syphilis and gonorrhea in the United States (excluding New York owing to incomplete age- and race-specific data) from 1981 to 2005. STD rates in younger age groups (ages 15-29 years) were compared to STD rates in older age groups (ages 40-54 years) for each year over the 25-year period. We used regression analyses to examine the trend in the age rate ratio (STD rate in the younger age group divided by STD rate in the older age group) over time, adjusting for autocorrelation.

RESULTS

The age disparity in syphilis and gonorrhea declined from 1981 to 2005. The estimated annual decline in the age rate ratio was 5.3% for syphilis and 2.0% for gonorrhea for all races overall (P <0.01). Overall, the age disparity in STD rates was more pronounced for females than males.

CONCLUSIONS

Future research is needed to clarify the main determinants of the relative decline in STD rates in younger persons and to inform programmatic responses to the changing age disparity in STD rates.

HIV incidence and CDC's HIV prevention budget: an exploratory correlational analysis

BACKGROUND

The central evaluative question about a national HIV prevention program is whether that program affects HIV incidence. Numerous factors may influence incidence, including public investment in HIV prevention. Few studies, however, have examined the relationship between public investment and the HIV epidemic in the United States.

METHODS

This 2006 exploratory analysis examined the period from 1978 through 2006 using a quantitative, lagged, correlational analysis to capture the relationship between national HIV incidence and Centers for Disease Control and Prevention's HIV prevention budget in the United States over time.

RESULTS

The analyses suggest that early HIV incidence rose in advance of the nation's HIV prevention investment until the mid-1980s (1-year lag correlation, r=0.972, df=2, p <0.05). From that point on, it appears that the nation's investment in HIV prevention became a strong correlate of HIV incidence (1-year lag correlation, r=-0.905, df=18, p <0.05).

CONCLUSIONS

This exploratory study provides correlational evidence of a relationship between U.S. HIV incidence and the federal HIV prevention budget over time, and calls for further analysis of the role of funding and other factors that may influence the direction of a nation's HIV epidemic.

The economic value of reductions in gonorrhea and syphilis incidence in the United States, 1990-2003

BACKGROUND

Prevention efforts can reduce the considerable health and economic burdens imposed by sexually transmitted diseases (STDs). The objective of this study was to estimate the reduction in direct medical costs associated with reductions in gonorrhea and syphilis incidence in the United States from 1990 to 2003.

METHODS

Using published estimates of the per-case costs of STDs, we estimated the annual costs from 1990 to 2003 of four main outcomes: primary and secondary (P&S) syphilis, congenital syphilis, gonorrhea, and HIV costs attributable to the facilitative effects of gonorrhea and syphilis on HIV transmission and acquisition.

RESULTS

Reductions in syphilis and gonorrhea from 1990 to 2003 have saved an estimated 5.0 billion dollars (in 2003 U.S. dollars): 1.1 billion dollars in costs associated with P&S syphilis, congenital syphilis, and gonorrhea, and 3.9 billion dollars in HIV costs attributable to syphilis and gonorrhea. In additional analyses, the estimated reductions in disease burden were substantially lower (1) when calculated incrementally (rather than cumulatively) and (2) when long-term costs of STDs were excluded.

CONCLUSIONS

These estimated reductions in the burden of gonorrhea and syphilis show the economic benefits of reducing the incidence of these STDs and preventing their resurgence.

Estimated Effectiveness and Cost-Effectiveness of Federally Funded Prevention Efforts on Gonorrhea Rates in the United States, 1971???2003, Under Various Assumptions About the Impact of Prevention Funding

BACKGROUND

Reported gonorrhea incidence rates in the United States declined by 75% from 1975 to 2003 after implementation of a federally funded gonorrhea control program in the mid-1970s. The purpose of this study was to (1) estimate national gonorrhea rates that might have occurred from 1971 to 2003 had there been no federally funded sexually transmitted disease (STD) prevention activities and (2) calculate crude estimates of the cost-effectiveness of these prevention activities.

METHODS

Hypothetical gonorrhea rates had there been no federally funded prevention efforts from 1971 to 2003 were estimated based on (1) the amount of federal funding allocated to state and local health departments for STD prevention and (2) a published estimate of the impact of funding on STD rates in the United States. Standard methods of cost-effectiveness analysis were used to calculate the cost per case of gonorrhea prevented.

RESULTS

Under base case assumptions about the impact of prevention funding on gonorrhea rates drawn from a published study, prevention efforts were cost saving, meaning that the program costs were less than the averted costs of treating gonorrhea and its associated sequelae. Over the 33-year period, an estimated 32 million cases of gonorrhea were averted by prevention efforts.

CONCLUSION

STD prevention efforts appeared to be cost saving when considering only the benefits of gonorrhea prevention. If other benefits were considered (such as the prevention of other STDs), the estimated effectiveness and cost-effectiveness of STD prevention in the United States would be even greater.

Assessing the impact of federal HIV prevention spending on HIV testing and awareness

OBJECTIVES

The United States allocates more than $900 million annually for the prevention of HIV infection. We assessed the impact of this funding on HIV testing and knowledge.

METHODS

We linked data from the Behavioral Risk Factor Surveillance System with tracking of Centers for Disease Control and Prevention (CDC) HIV prevention funding. We developed and validated regression models of the relation between HIV prevention funding to a respondent's state and the odds that the respondent (1) had been tested for HIV, and (2) was aware of methods to prevent mother-to-child HIV transmission (MTCT).

RESULTS

The odds of having been tested for HIV increased with increased CDC funding to states (P=.009), as did awareness of prevention of MTCT (P=.002). We estimate that CDC HIV prevention funds led to 12.8 million more people being tested for HIV between 1998 and 2003 than would have been tested had all states received funds equal to the lowest quintile of funding.

CONCLUSIONS

Federal HIV prevention funds independently correlate with increased HIV testing and knowledge of prevention of MTCT. Proposed reductions in HIV prevention spending would likely have adverse public health consequences.