Reported cases of several sexually transmitted diseases (STDs)—chlamydia, gonorrhea, primary and secondary syphilis, and congenital syphilis—have increased from 2013 to 2017 in the U.S.¹ STDs are common and can have serious sequelae if untreated.¹ STDs have also been linked to HIV acquisition. Approximately 10% of HIV infections among men who have sex with men (MSM) are due to chlamydia and gonorrhea.² Subpopulations at the highest risk for STDs include young people, racial and ethnic minorities, and those with lower incomes.^1,3 These populations may also lack healthcare access and be uninsured or underinsured.^4,5 Thus, safety-net STD clinical services are important for STD prevention as they often provide services to populations at elevated STD risk.

Public health departments are the primary organizations accountable for a community’s health, regardless of whether they provide healthcare services directly.^6,7 Link-age to healthcare services, or the provision of health care when services are unavailable in the community, is 1 of 10 essential public health services.⁸ Although most health departments have insufficient funding,⁹ many often fulfill this essential public health service, which may be especially important in smaller areas.⁷ In some areas, federally qualified health centers may provide safety-net healthcare services in place of health departments.¹⁰

A 2013−2014 survey of local health departments (LHDs), limited to those that previously reported providing STD testing or treatment, had examined safety-net STD clinical services capacity. In most of these jurisdictions, combination STD−family planning clinics (31%), general public health clinics (26%), and STD clinics (22%) were the LHD’s primary referral point for STD services.¹¹ Nearly two-thirds of the STD primary referral clinics provided same-day services, which is important to halt STD transmission. However, publicly funded STD and combination STD−family planning clinics were more likely than other types of clinics to report providing some key services, such as extragenital STD testing and some types of gonorrhea testing.¹¹ The study was limited in its scope as LHDs had to provide some STD testing or treatment to be included. In addition, it included a limited number of clinical services (STD testing only) and had a small sample size.

Therefore, an examination of STD safety-net clinical services among a larger sample of LHDs is needed to better characterize safety-net STD services across the U. S. The purpose of this study is to examine (1) the national availability of safety-net STD services, and (2) a broader range of key STD services offered by U.S. safety-net providers, including same-day appointments, and point-of-care (POC) testing and treatment as they are important to prevent transmission.

A total of 326 LHDs responded to the survey for a 49% response rate. Most responding LHDs were from small jurisdictions (61.7%), and 32.5% were from medium-sized jurisdictions and 5.7% from large jurisdictions (p=0.01) (Table 1). Of small jurisdictions, the highest percentage of LHDs was from the Midwest (38.7%). The highest percentages of LHDs from medium-sized jurisdictions were from the South (35.6%) and Midwest (31.2%), and large jurisdictions were from the South (42.8%). Respondents did not differ from nonrespondents by U.S. Census region but differed by population size with more nonresponders from small jurisdictions (p=0.04).

Of responding LHDs, 64.4% reported that there was a clinic in their jurisdiction that provided safety-net STD services, whereas 18.5% reported that they did not have such a clinic, and 17.1% were unsure (Appendix Table 1, available online). Having a clinic in their jurisdiction that provided safety-net STD services was more commonly reported by LHDs that had an STD program (84.6%) and in medium (88.2%) and large jurisdictions (95.9%). LHDs in states that expanded Medicaid before 2018 (77.0%) were less likely to report having a provider of safety-net STD services than states that had not expanded to Medicaid before 2018.

The LHDs also reported the clinic type that provides most safety-net STD services. The general public health clinic was the most common response (34.3%) followed by a combination of STD−family planning clinic (23.4%) and STD clinic (17.1%) (Table 2). The most common responses by jurisdiction size (p<0.05) were general public health clinic for small (39.1%) and medium-sized (30.3%) jurisdictions, and STD clinic for large jurisdictions (37.1%).

Using the recoded STD clinic measure, 40.5% of primary safety-net STD providers were STD clinics, and 59.5% were other clinics; this was examined by STD morbidity and jurisdiction population size (Table 3). LHDs from 51 areas with highest STD morbidity had higher reports of having an STD clinic (88.2%, p<0.001) as the primary provider of safety-net STD services compared with 35.4% of the remaining LHDs. No LHDs from small jurisdictions were in the high morbidity areas. For medium-sized jurisdictions, 92.5% of those in high morbidity areas had STD clinics as a primary safety-net provider compared with 39.2% of LHDs outside of high morbidity areas. For large jurisdictions, no differences were detected in clinic type by morbidity level.

Overall, there was a wide range in specific STD services offered at the primary safety-net clinic for STDs in local areas (Table 4). Most of LHDs (67.9%, 95% CI=61.0%, 74.7%) had same-day services for individuals who were symptomatic or who had a partner with an STD. Among LHDs who had any same-day appointments, the median percentage of appointments set aside was 73.1% (IQR=27.3, 99.3). Services that were offered by fewer than one-quarter of primary safety-net clinics included syphilis testing (darkfield microscopy; POC RPR testing) and POC gonococcal urethritis testing using Gram stain testing or MB/GV stain microscopy for symptomatic men. Services offered by 50%−74% of primary safety-net clinics included HBV vaccination, POC trichomoniasis testing for women (vaginal wet mount with KOH preparation), extragenital chlamydia and/or gonorrhea testing, and gonorrhea culture. Services offered by ≥75% of LHDs included HPV vaccination, onsite ceftriaxone 250 mg (for gonorrhea), and onsite benzathine penicillin G (Bicillin-LA) 2.4 million units (for syphilis). Services that were more commonly offered by STD clinics compared with other clinics, respectively, included same-day services (79.0%, 95% CI= 69.3%, 88.7% vs 60.4%, 95% CI=51.1%, 69.6%), HBV vaccination (53.4%, 95% CI=42.0, 64.6 vs 68.5%, 95% CI =59.5%, 77.5%), POC RPR testing for syphilis (30.5%, 95% CI=20.5%, 40.5% vs 15.2%, 95% CI=8.9%, 21.4%), any POC testing for gonococcal urethritis in men (32.3%, 95% CI=22.0%, 42.7% vs 10.4%, 95% CI=5.2%, 15.5%), POC Gram stain testing for gonococcal urethritis in men (31.9%, 95% CI=21.5%, 42.2% vs 10.1%, 95% CI=5.0%, 15.3%), POC MB/GV stain microscopy for gonococcal urethritis in men (12.5%, 95% CI=4.9%, 20.2% vs 3.9%, 95% CI=0.6%, 7.3%), POC trichomoniasis testing using vaginal wet mount with KOH preparation (70.7%, 95% CI=60.1%, 81.3% vs 41.3%, 95% CI=31.8%, 50.9%), and extragenital chlamydia and/or gonorrhea testing (82.1%, 95% CI=72.9%, 91.3% vs 60.0%, 95% CI=50.2%, 69.7%).

Finally, there were some differences in the availability of POC STD testing by LHD- and state-level characteristics (Appendix Table 2, available online). By the U.S. Census region, POC trichomoniasis testing using a vaginal wet mount with KOH preparation for women differed with the highest reports in the South (67.3%, 95% CI=57.0%, 77.6%) and Northeast (59.6%, 95% CI=37.7%, 81.4%). By jurisdiction population size, large jurisdictions had the highest reports for POC RPR testing for syphilis (48.2%, 95% CI=35.2%, 61.3%) and Gram stain testing for gonococcal urethritis in men (44.3%, 95% CI=31.3%, 57.3%); medium-sized jurisdictions had the highest reports for POC trichomoniasis testing using vaginal wet mount with KOH preparation (69.9%, 95% CI=60.7%, 79.1%). Jurisdictions that had an STD program in the LHD had higher reports of POC trichomoniasis testing using a vaginal wet mount with KOH preparation (57.0%, 95% CI=49.4%, 64.7%). There were no differences in POC testing by whether or not the state expanded Medicaid by 2017.

Findings from the 2018 survey focusing on STD infrastructure for safety-net clinical services highlighted some areas that may positively impact STD prevention efforts. Approximately two-thirds of responding LHDs had a primary referral site for safety-net STD clinical services, although this was more common if the LHD had an STD program, was not located in a small jurisdiction, and if the state did not expand Medicaid. This finding is somewhat inconsistent with previous research of maternal and child health services that found rural areas more likely to provide such services.¹³ Local jurisdictions may perceive less need for safety-net services in Medicaid expansion states. A future analysis focusing on safety-net STD patient flows may show changes with Medicaid expansion that would be consistent with patients seeking care in other settings. This study also found that providers of safety-net STD clinical services tended to be general public health clinics, STD clinics, or combination STD−family planning clinics. These clinic types may be under the more direct supervision of LHDs, which could help expand needed services. STD clinics were more common as a safety-net provider if they were located in high STD morbidity areas. Federally qualified health centers, previously associated with a lower probability of LHD-provided clinical services,¹⁰ were the primary referral points for safety-net STD services in 14% of local jurisdictions (18% of small jurisdictions). Finally, the overwhelming majority of safety-net STD providers offered same-day services, HPV vaccination, and important injectable medicines for gonorrhea and syphilis. Same-day services are vital for quickly halting transmission and were the most frequently reported reason for using STD clinics in previous studies.^5,14

Findings from the survey also demonstrated challenges for STD prevention efforts. One-third of responding LHDs do not have or are not aware of a primary referral point for safety-net STD services. Obtaining access to needed STD services may be more difficult in smaller jurisdictions and the one-third of jurisdictions that lack a safety-net provider for STDs. Only a few safety-net STD providers offered POC testing for syphilis. Rapid diagnosis of syphilis is important to administer injectable medication and implement partner services to disrupt transmission, especially when primary, secondary, and congenital syphilis are increasing.¹ Only 53% of safety-net providers offered gonorrhea culture, which is important given antimicrobial resistance for gonorrhea. Consistent with previous research that has found rural areas have less access to health care than urban areas,^15,16 smaller jurisdictions were less likely to have POC STD testing. Given the widespread availability of key STD treatments, it is possible that these clinics rely more on syndromic management than stat labs. Less timely access to proper STD testing and treatment may increase opportunities for transmission of STDs.

This study demonstrates the importance of STD clinics. However, only 4 in 10 of the primary safety-net STD providers reported by respondents were STD clinics. This finding is important as STD clinics were more likely to have same-day services and provide key POC STD testing. Previous research suggests that 10% of STD clinics closed during the early 2000s.¹⁷ In addition, a 2013−2014 study found that 53.5% of primary safety-net STD providers were STD clinics. However, half of responding LHDs in the earlier study were in the South; only 5% were in the Northeast.¹¹ The current study had a more even distribution across the 4 U.S. Census regions. Study findings revealed that STD clinics are important beyond POC STD testing and treatment services. STD clinics had higher reports of providing extragenital testing for chlamydia or gonorrhea than other safety-net STD providers. For sexually active MSM, at least annual extragenital screening for chlamydia and gonorrhea is recommended by the Centers for Disease Control and Prevention.¹⁸ Studies have found that 22% of male STD attendees were MSM but MSM comprise about 2%−4% of the U.S. male population.¹⁹⁻²¹ Thus, it may be especially important for STD clinics, as well as other safety-net clinics, to offer such testing.

The study findings underscore the extent of publicly funded STD services, as well as where resources may be useful to expand the availability of important STD safety-net services. Some of the subpopulations at highest risk of STD are uninsured or underinsured and may lack access to quality healthcare services.¹ Research has found that public funding for STD prevention efforts provided by the Centers for Disease Control and Prevention to state health departments and LHDs is associated with lower rates of chlamydia, gonorrhea, and syphilis in the following year.^22,23 However, determining local funding for STD services can be difficult (e.g., STD funding may be part of larger infectious disease or HIV funding). Even after recent healthcare reform, it has been estimated that annual costs for chlamydia services among uninsured individuals in need of STD services would range from $150 million to $154 million from 2016 to 2023.²⁴ Thus, safety-net services for STD are still essential to reduce the transmission of STDs and their sequelae.

Although two-thirds of responding LHDs reported that STD safety-net services were available in their jurisdiction, one-third either had no safety-net STD services or were not aware of the services. The availability of STD safety-net services varied, with vaccination and STD treatment among the most frequently reported services, whereas the availability of key STD testing varied. STD clinics tended to have better availability of STD testing. STDs are among the most commonly reported infectious diseases in the U. S. and funding has been associated with a reduction in STD rates in later years. In addition, STDs have been associated with HIV and poor pregnancy outcomes. Therefore, given the current funding environment, LHDs might explore collaborations with healthcare systems and innovations in testing to expand STD services.