1 Center for American Progress | Ensuring Access to Sexually Transmitted Infection Care for All

Ensuring Access to Sexually

Transmitted Infection Care for All
By Donna Barry and McKinley Sherrod October 16, 2014
At some point in their lives, most sexually active people will be infected with a sexu-
ally transmited infection, or STI.
1
About 20 million new cases of STIs are diagnosed
annually.
2
Despite being a common, preventable, and treatable health problem, a lack
of information, shame, and stigma tend to characterize the nations discussions about
STIseven though they represent a severe risk to the public and economic health of
the United States.
Several U.S. populationsincluding women, people of color, those living in rural com-
munities, and lesbian, gay, bisexual, and transgender, or LGBT, individualsare espe-
cially at risk and are also less likely to have access to testing and treatment. Given the
number of people afected by STIs and the billions of dollars in annual costs associated
with STIs, it is imperative that policymakers continue to support a wide range of health
care professionals and facilities, as well as increase and expand funding sources to meet
the health needs of both patients and the public.
Tis issue brief begins by discussing the disparities in access to sexual and reproductive
health care, including the glaring disparities in how STIs afect people of color. It then
investigates how $16 billion dollars is spent annually on STI treatment and complica-
tions, as well as the personal stigma experienced by individuals diagnosed with an STI.
Te third section explores the types of health care facilities that provide the best care
for STIs and the importance of multiple funding streams for STI testing and treatment.
Lastly, the brief ofers several policy recommendationsincluding the need to expand
Medicaid, increase Title X funding, and sustain a variety of health care funding options
and facilitiesthat would ensure that everyone who needs STI testing and treatment is
able to access those services.
2 Center for American Progress | Ensuring Access to Sexually Transmitted Infection Care for All
STI rates
Commonly transmited diseases such as chlamydia, gonorrhea, and syphilis are all on
the rise, with increased rates of infection between 2011 and 2012.
3
(see Table 1) Te
rise in gonorrhea rates is particularly concerning since the infection has progressively
developed resistance to treatment.
4
Human papillomavirus, or HPV, which can lead to
health complications such as genital warts and cancer, continues to be the most com-
mon STI, accounting for the highest number of annual and existing cases.
5
According to
health ofcials, nearly all sexually active individuals will be infected with HPV at some
point, despite the fact that there is now a vaccine that prevents it.
6

TABLE 1
Incidence and rates of STIs in the United States
STI Total cases, 2012
Incidence, per 100,000
people in 2012
Percent increase,
20112012
HPV 20 million Data unavailable Data unavailable
Chlamydia 1.4 million 456.7 0.7%
Gonorrhea 334,826 107.5 4.1%
Syphilis, primary
and secondary
15,667 5 11.1%
Sources: For HPV data, see Ofce on Womens Health, Human Papillomavirus (HPV) and Genital Warts Fact Sheet, available at http://www.women-
shealth.gov/publications/our-publications/fact-sheet/human-papillomavirus.html#b (last accessed August 2014). For all other data,
see Centers for Disease Control and Prevention, Sexually Transmitted Disease Surveillance 2012 (U.S. Department of Health and Human Services, 2012),
available at http://www.cdc.gov/std/stats12/surv2012.pdf.
Disparities in STI rates and access to care
STIs disproportionately burden certain segments of the population, including some
racial and ethnic groups, people living in rural and Southern regions of the United
States, the LGBT community, and women.
Race
Nearly all STIs afect blacks and Hispanics at higher rates than whites. Te chlamydia
rate among Hispanics, for example, is more than twice the rate among whites: 380.3
cases per 100,000 people compared with 179.6 cases per 100,000 people, respectively.
7

Te gonorrhea rate among blacks462 cases per 100,000 peopleis an alarming 15
times the rate among whites31 cased per 100,000 people.
8
Moreover, the rate of
syphilis for blacks is 6.1 times that of whites, at 16.4 cases versus 2.7 cases per 100,000
people, respectively.
9

3 Center for American Progress | Ensuring Access to Sexually Transmitted Infection Care for All
FIGURE 1
Reported cases of chlamydia by race and ethnicity, 2012
Source: Centers for Disease Control and Prevention, Sexually Transmitted Disease Surveillance 2012 (U.S. Department of Health and Human Services,
2012), available at http://www.cdc.gov/std/stats12/surv2012.pdf.
Male
Female
0
100,000
Blacks Hispanics Whites
200,000
300,000
FIGURE 2
Reported cases of gonorrhea by race and ethnicity, 2012
Source: Centers for Disease Control and Prevention, Sexually Transmitted Disease Surveillance 2012 (U.S. Department of Health and Human Services,
2012), available at http://www.cdc.gov/std/stats12/surv2012.pdf.
Male
Female
0
30,000
Blacks Hispanics Whites
60,000
90,000
0
1,000
2,000
3,000
4,000
5,000
FIGURE 3
Reported cases of syphilis by race and ethnicity, 2012
Source: Centers for Disease Control and Prevention, Sexually Transmitted Disease Surveillance 2012 (U.S. Department of Health and Human Services,
2012), available at http://www.cdc.gov/std/stats12/surv2012.pdf.
Male
Female
Blacks Hispanics Whites
4 Center for American Progress | Ensuring Access to Sexually Transmitted Infection Care for All
Not only are members of some racial and ethnic groups more likely to be infected with
an STI, they are also less likely to receive treatment and more likely to be reinfected
once they have been treated. From a behavioral perspective, it is much harder to avoid
STIs when many of ones potential sex partnersothers in the communityare
infected.
10
Tis situation is compounded by the fact that many racial and ethnic groups
also face more barriers to caresuch as cost, language obstacles, lack of access to infor-
mation, and logistical barriers, including limited clinic hours and a shortage of transpor-
tation options.
11
From a structural viewpoint, such barriers are connected to poverty,
low education atainment, and a mistrust of the health care system, all of which contrib-
ute to the cyclical continuation of these racial and ethnic disparities.
12

Region
Te Southern and Midwestern regions of the United States also experience an increased
prevalence of STIs. According to the Centers for Disease Control and Prevention, or
CDC, the rates for chlamydia and gonorrhea are highest in the South and Midwest,
while rates for syphilis are highest in the South and Northeast, suggesting similar struc-
tural barriers to health care access as those mentioned above.
13
HPV vaccination rates
in the South are also incredibly low, a trend that has caused signifcant concern among
the reproductive health and medical communities. In comparison to the Northeast
where HPV vaccine initiation and completion rates for girls were 37 percent and 23
percent, respectively, in 2010the initiation rate in the South was only 14 percent and
the completion rate just 6 percent.
14
In order to receive the maximum efect of the HPV
vaccine, one must receive all three doses. Many young people start or initiate but do not
complete the series due to fnancial reasons, changing providers, or family relocation.
Tese fndings are particularly worrisome because rates of cervical cancer are also higher
in the South than in other regions of the United States.
15
If low rates of HPV vaccination
in the South continue, the region could experience a strain on their resources for cervical
cancer treatment.
16
However, not all women in the South are at the same risk for develop-
ing HPV-related cervical cancer; white women are more likely than women of other races
or ethnicities to initiate and complete the vaccine.
17
Tis trendlikely due to some of the
barriers to access discussed abovedemonstrates the ways in which factors such as race
and place can intersect to further restrict access to important sexual health care.
Although the same HPV vaccine initiation and completion data are not available for
adolescent boys in the South, a CDC study on U.S. teens ages 13 to 17 revealed that the
vaccination initiation rate for boys nationwide has increased 13.8 percentfrom 20.8
percent in 2012 to 34.6 percent in 2013.
18
However, the vaccination completion rate is
much lower, increasing from 6.8 percent in 2012 to just 13.9 percent in 2013.
19
While
HPV is traditionally seen as a greater risk for women because of its association with
cervical cancer, HPV also places menespecially those who have sex with menat
risk for anal and throat cancer.
20
5 Center for American Progress | Ensuring Access to Sexually Transmitted Infection Care for All
LGBT
LGBT people, especially men who have sex with men and transgender women, are at
greater risk for STIs. While individual behaviors such as unprotected sex play a role
in increasing STI risk, so too do systemic factors. For the LGBT population, similar
to other populations disproportionately afected by STIs, low socioeconomic status,
discrimination at individual and institutional levels, and ones power and position in
society factor into heightened risk.
21
LGBT people may face discrimination, ignorance,
and stigma at clinics and medical ofces, making it less likely that they will seek and
return for treatment.
22
Two trends within the LGBT community are particularly alarming:

The prevalence of HIV among transgender women: Transgender women are 49 times
more likely to have HIV than other adults of reproductive age.
23
While transgender
individuals are some of the most stigmatized members of the LGBT community and
society at large, specifc individual risks ofen include being the receptive partner in
anal sex and using unsafe needles for hormone treatments.
24


The lack of research on lesbian, gay, or bisexual women: While extensive research
exists about men who have sex with men and STIs, women who have sex with
women are rarely mentioned in the scientifc literature, perhaps due to the com-
mon misconception that STIs cannot be passed between women. However, women
who have sex with women can transmit STIs during sexual contact. STIs commonly
found in women who engage in same-sex contact include chlamydia, herpes, HPV,
lice, and trichomonaisis.
25
While some of these STIs are not commonly discussed,
it is nonetheless important for all women to receive education about their risk level.
Furthermore, providers must rely on a thorough medical history instead of labels. A
woman who identifes as gay or lesbian may not only have sex with women. Similarly,
a woman who currently only has sex with women may not have been gender exclusive
in the past. Previous or concurrent sexual encounters with men may increase the risk
of some STIs in both parties.
26

Gender
STIs naturally discriminate between men and women, as well as some transgender
people, on the basis of anatomy. For instance, the vagina is more susceptible to infec-
tion because of its thin tissue. Furthermore, women are less likely to notice STIs, either
because they are not symptomatic or because the symptoms are easily confused with nor-
mal vaginal discharge.
27
Women may also have increased STI risk because of factors such
as poverty, as well as the social norms that dictate womens acquiescence to unsafe sex.
28

6 Center for American Progress | Ensuring Access to Sexually Transmitted Infection Care for All
Women with STIs ofen develop more serious complications than men, some of which
can severely afect their fertility. For example, 10 percent to 20 percent of women
infected with chlamydia or gonorrhea develop pelvic infammatory disease, or PID,
which can lead to infertility, ectopic pregnancy, and chronic pelvic pain if they do not
receive treatment.
29
Given that more than 80 percent of chlamydial infections and up
to 80 percent of gonococcal infections in women are asymptomatic, regular screening
is integral to avoiding future complications.
30
Chlamydia and gonorrhea can also cause
negative pregnancy outcomes, such as neonatal ophthalmiainfammation or infection
of the newborns eyelid tissueor neonatal pneumonia. Syphilis infections can be trans-
mited in utero, resulting in fetal death or an infant born with disabilities. Screening for
and treating STIs throughout pregnancy, however, can prevent all of these outcomes.
31
The cost of STIs
It is easy to dismiss STI prevention and testing as too expensive. While data on the exact
costs of preventive screening have not been calculated, they likely vary by region, testing
site, insurance, and type of test. However, STIs and their complications amount to about
$16 billion annually in direct medical costs. HIV imposes the largest fnancial burden,
costing $12.6 billion in direct medical costs, followed by HPV at $1.7 billion, chlamydia
at $156.7 million, gonorrhea at $162.1 million, and syphilis at $39.9 million.
32

Te amount that each individual pays out of pocket for STI-related health services varies
based on insurance statuswhether the person is uninsured, privately insured, or cov-
ered by Medicaid. Under the Afordable Care Act, many reproductive health care services
are covered as preventive services and provided with no additional cost to patients.
33

Medicaid also covers annual screening and counseling for some populations, particularly
those designated as being at increased risk.
34
While this policy is a step in the right direc-
tion, annual screening may not be adequate, especially for those at increased risk for STIs
who are more likely to require multiple screenings throughout a given year.
TABLE 2
Preventive services covered by the Affordable Care Act without cost sharing
STI care for men, women, and adolescents
Services Men Women
Women at
increased risk
Pregnant
women Adolescents
Chlamydia screening
Gonorrhea screening
Hepatitis B screening
HIV screening
HPV vaccine
STI counseling
Syphilis screening
Source: HealthCare.gov, Preventive health services for adults, available at https://www.healthcare.gov/what-are-my-preventive-care-benefts/#part=1
(last accessed August 2014); HealthCare.gov, Preventative health services for women, https://www.healthcare.gov/preventive-care-benefts/women/
(last accessed August 2014).
7 Center for American Progress | Ensuring Access to Sexually Transmitted Infection Care for All
However, the lifetime cost of an STI is not universal; it is ofen much higher for indi-
viduals who develop complications due to an untreated STI. Unfortunately, women
bear the brunt of this fnancial inequality since they have an increased likelihood of
complications. For instance, chlamydia and gonorrhea can both result in PID, which
has a host of complications noted above. Because of this, the lifetime cost per case of
chlamydia can be more than $360 for women, while it is usually around $30 for men.
36

HPV can cause cervical cancer, which can lead to an enormous increased lifetime
cost. Of course, men are not immune to developing STI complications. HPV can be
particularly dangerous, leading to higher rates of anal and throat cancers in men who
have sex with men and people with HIV.
37
Stigma
For many people, STIs have more than just an economic cost, causing societal, interper-
sonal, and emotional costs as well. Aside from the secondary health problems that can
result from having an untreated STI, the stigma associated with STIs can afect emo-
tional health and sexual relationships. Jenelle Mariethe founder of Te STD Project, a
website aimed at reducing the shame associated with STIsfrequently writes about her
experience living with an STI:
Diagnosed and shamed by my family doctor, I rode home with my mother in tears
convinced I would never have a normal sex life, a loving partner, or a healthy relation-
ship ever again. In the years that followed, I was cast out of the church and labeled a
harlot, made to sleep separately fom fiends during overnight stays for fear of trans-
mission, and called a bevy of names.
38
Stigma is not only emotionally harmful, it can also be a powerful barrier to seeking
care,
39
especially if the disapproval comes from or is perceived to come from a health
care provider.
40

STI testing and treatment sites
Te fact that STIs are easily preventable and treatable makes the increasing rates of
gonorrhea, chlamydia, syphilis, and HPV especially alarming. In addition to more
comprehensive education about how STIs are transmited, policymakers must ensure
that all populations, especially those at higher risk, have access to a variety of testing and
treatment sites. Testing and treatment sites for STIs and HIV include the following:
Based on guidelines from the U.S.
Preventive Services Task Force, the
Centers for Medicare and Medicaid
Services determines increased-
risk sexual behaviors as any of the
following:
35

Multiple sex partners

Using barrier protection incon-
sistently

Having sex under the inuence
of alcohol or drugs

Having sex in exchange for
money or drugs

Engaging in sexual activity at age
24 or younger

Having an STI in the past year

IV drug use (increased risk only
for hepatitis B)

Men who have sex with men
What does increased
risk mean?
8 Center for American Progress | Ensuring Access to Sexually Transmitted Infection Care for All

Private providers

Health maintenance organizations, or HMOs

Publicly funded clinics, which may or may not receive Title X funds

Community clinics, such as federally qualifed health centers, or FQHCs

Independent reproductive health clinics, such as Planned Parenthood

Hospital outpatient clinics

School-based clinics

Public health clinics

Other

Employer or company clinics

Inpatient treatment in hospitals

Emergency rooms

Urgent care facilities
Lets look more closely at publicly funded clinics, which provide care to some of the
highest-risk and most-afected populations and do a beter job of screening for STIs than
private providers.
Publicly funded clinics
While a majority of women who received any sexual or reproductive health service from
2006 to 2010 received the service from a private doctor, women increasingly rely on
other service sites such as publicly funded clinics.
41

1995
2002
20062010
Private provider Title X funded clinic Non-Title X funded clinic Other
FIGURE 4
Site of care for women receiving any sexual or reproductive health service,
19952010
Source: Jennifer J. Frost, U.S. Womens Use of Sexual and Reproductive Health Services: Trends, Sources of Care and Factors Associated
with Use, 19952010 (New York: Guttmacher Institute, 2013), available at http://www.guttmacher.org/pubs/sources-of-care-2013.pdf.
77% 10% 7% 6%
76% 10% 10% 4%
72% 11% 12% 5%
9 Center for American Progress | Ensuring Access to Sexually Transmitted Infection Care for All
Publicly funded clinics have seen an increase in patients over the past two decades. In
1995, 17 percent of women who received any sexual or reproductive health service did
so from a publicly funded clinic.
42
Tat share rose to nearly 25 percent in 2006 through
2010, according to the most up-to-date available data.
43
Furthermore, patients at publicly
funded clinics are more likely to receive STI care at these facilities. From 2006 to 2010,
nearly half of women who sought services at publicly funded clinicsindependent
reproductive health clinics, health department clinics, and community clinicsreceived
an STI or HIV service,
44
while only about 31 percent of women who visited a private pro-
vider or HMO for their sexual and reproductive health care received STI or HIV care.
45

Tis trend could be due to several factors. While the higher STI screening rates at a
publicly funded clinics suggest that private providers lag behind on implementing cur-
rent protocols or fail to inform patients of STI screening options, they also refect the
standards and regulations of care that come with Title X fundingwhile not all publicly
funded clinics receive Title X funds, more than 4,100 do.
46
Title X clinics, for example,
must provide patients with screenings for symptomatic and asymptomatic STIs.
47
Tese
screenings are ofen performed concurrently with other reproductive and sexual health
care at publicly funded clinics, meaning that they ofer patients comprehensive care.
All types of publicly funded clinics were more likely to provide STI care in their mix of
services than private providers.
48
Publicly funded clinic visits also involve a discussion
of condomsthe only way to protect against STIs other than abstinencemore ofen
than visits to a private provider.
49
Title X funded clinics serve approximately 5 million clients annually,
50
many of whom
would otherwise fall through the cracks. Title X clinics are particularly appealing to sev-
eral at-risk populations, including low-income individuals, people with substance-abuse
problems, people with limited English abilities, the LGBT community, and adolescents.
51

A key reason for the appeal of Title X clinics is that many of their staf receive specifc
training on how to serve at-risk populations, which helps to create a more welcoming and
culturally sensitive environment to which at-risk individuals are more likely to return.
52

Paying for STI care
In addition to reliably providing STI services, publicly funded clinics are also crucial to
meeting the fnancial needs of patients. At Title X sites, 24 percent of patients are pub-
licly insured, 9 percent are privately insured, and 64 percent are uninsured.
53
In 2012,
Title X clinics served more than 4.8 million clients, most of whom were female, poor,
uninsured, and younger than 25 years oldin other words, populations that are at risk
for STIs on multiple levels.
54
Many patients who access Title X funded services do not
meet the eligibility requirements for Medicaid, meaning that they rely on Title X fund-
ing to subsidize their care.
55
10 Center for American Progress | Ensuring Access to Sexually Transmitted Infection Care for All
Tose who do meet the eligibility requirements for Medicaid or Medicare can utilize
coverage for STI testing, treatment, and counseling. Medicaid and Medicare cover chla-
mydia and gonorrhea screening for pregnant women and women who are at increased
risk; syphilis screening for pregnant women and at-risk individuals, both men and
women; and hepatitis B screening for pregnant women. Under certain circumstances,
these plans also cover up to two individual in-person counseling sessions, which focus
on STI education and prevention, annually.
56

Not only does public insurance provide STI care for millions of patients, its enrollees are
more willing to have their insurance cover services at an STI clinic than those who were
uninsured or privately insured, according to a New York City study.
57
Because Medicaid is
not employer funded and does not send explanations of benefts, or EOBs, enrollees are
assured of privacy and confdentiality. For these and other reasons, including the com-
prehensive and preventive STI care ofered through public insurance, Medicaid and the
expansion of Medicaid under the Afordable Care Act are extremely important, particu-
larly when it comes to ensuring that people continue to be tested and treated for STIs.
Similar information on private insurance coverage and STI care is lacking, most likely
because privately funded STI care programs are not tracked nationally. However, the
CDC has explicit guidelines for STI services, recommending annual testing for HIV,
chlamydia, and gonorrhea for certain populations, as well as syphilis, HIV, chlamydia,
and hepatitis B screening for pregnant women.
58
Unlike Title X clinics, however, these
recommendations do not necessarily become practices for private providers.
Policy recommendations
1. Increase Title X funding: Title X funding has decreased more than $31 million dol-
lars since 2010.
59
Appropriating more funds to Title X would ensure that safety net
programs remain in place for people who may not be insured under the Afordable
Care Act or qualify for Medicaid. Title X funded clinics also ofer a more comprehen-
sive package of services than many other health care providers, ensuring their patients
receive comprehensive sexual and reproductive health care.
2. Expand Medicaid in all states: 23 states have not yet expanded Medicaid coverage,
leaving millions of people uninsured.
60
More than 4 million adults will fall into the
coverage gap,
61
including nearly 3 million women.
62
In order to provide adequate care
for the populations most vulnerable to STIs, all states must expand Medicaid.
3. Promote education for primary care providers: Only 46 percent of women who saw a
private provider for STI testing, treatment, or counseling reported that their provider
discussed condom use with them.
63
Primary care providers must remain educated
about STI rates and risks, as well as incorporate questions about sexual and reproduc-
tive health care into regular visits.
11 Center for American Progress | Ensuring Access to Sexually Transmitted Infection Care for All
4. Present accurate information about STIs as part of sex education curricula: Sex
education is particularly important because young people are at extremely high risk
for STIs.
64
Comprehensive sex education has been shown to reduce STI rates.
65

Comprehensive sex education programs, with open and fact-based discussion about
sex, do not encourage earlier sexual initiation or increase the number of sexual part-
ners among sexually active teens.
66

5. Protect patient information: Guaranteeing privacy and confdentiality is more impor-
tant than ever now that young adults can stay on their parents health insurance plans
up to age 26. Te National Chlamydia Coalition cites EOBs as a major threat to conf-
dentiality for minors and young adults.
67
EOBs are currently sent to the policyholder
in an efort to prevent fraud but may inadvertently notify parents that their dependents
are seeking STI services.
68
Policy changes that should be considered include determin-
ing if EOBs can be provided directly to the patient or if EOBs are necessary at all.
6. Expand expedited partner therapy, or EPT: In 2006, the CDC recommended that
providers who treat a patient for chlamydia or gonorrhea also provide treatment
for the patients partner without examining the partner. As of July, 28 states and the
District of Columbia allow EPT in some or all STI cases.
69
7. Explore funding from private grants for public programs and expand the rollout
of successful pilot programs: Te lack of federal funding for sexual and reproduc-
tive health services means that policymakers must explore other options. Te New
York City Department of Health and Mental Hygiene pioneered a novel efort by
partnering with the New York Community Trusta private entityto fund a
pilot program for in-school STI testing.
70
Because private funders are not bound
by some government restrictions, they may be able to fund programs considered
controversial or unorthodox.
Conclusion
Given the sheer number of individuals who seek STI care at publicly funded clinics
whether community, independent, health department, or Title X clinicsas well as the
fact that the most-comprehensive STI care is provided at these clinics, it is absolutely
imperative to the health of the nation that all service sites remain open and accessible
even with expansion of people covered by private insurance. Tese sites should work in
conjunction with private providers and educational services to prevent the spread of STIs
and promote their treatment. Trough these eforts, individuals who are afected by STIs
will have the necessary access to treatment and care that they need, and the nation will
begin to see progress in decreasing the rates of infection and stigma associated with STIs.
Donna Barry is the Director of the Womens Health and Rights Program at the Center for
American Progress. McKinley Sherrod was an intern with the Womens Health and Rights
Program at the Center.
12 Center for American Progress | Ensuring Access to Sexually Transmitted Infection Care for All
Endnotes
1 C.L. Satterwhite and others, Sexually transmitted infections
among US women and men: prevalence and incidence
estimates, 2008, Sexually Transmitted Diseases 40 (3) (2013):
187193.
2 Ibid.
3 Centers for Disease Control and Prevention, Sexually Trans-
mitted Disease Surveillance 2012 (U.S. Department of Health
and Human Services, 2014).
4 Ibid.
5 U.S. Department of Health and Human Services, Human
papillomavirus (HPV) and genital warts fact sheet, available
at http://www.womenshealth.gov/publications/our-
publications/fact-sheet/human-papillomavirus.html#b (last
accessed August 2014).
6 Satterwhite and others, Sexually transmitted infections
among US women and men.
7 Centers for Disease Control and Prevention, Sexually Trans-
mitted Disease Surveillance 2012.
8 Ibid.
9 Ibid.
10 Centers for Disease Control and Prevention, 2011 Sexually
Transmitted Diseases Surveillance: STDs in Racial and Ethnic
Minorities, available at http://www.cdc.gov/std/stats11/
minorities.htm (last accessed August 2014).
11 Health Resources and Services Administration, Womens
Health USA 2011 (U.S. Department of Health and Human
Services, 2011), available at http://www.mchb.hrsa.gov/
whusa11/more/downloads/pdf/w11.pdf.
12 Centers for Disease Control and Prevention, Health Dispari-
ties in HIV/AIDS, Viral Hepatitis, STDs, and TB, available
at http://www.cdc.gov/nchhstp/healthdisparities (last
accessed August 2014).
13 Centers for Disease Control and Prevention, Sexually Trans-
mitted Disease Surveillance 2012.
14 HealthDay, HPV Vaccine Rates Lagging in Southern U.S.,
Study Finds, November 5, 2013, available at http://health.
usnews.com/health-news/news/articles/2013/11/05/hpv-
vaccine-rates-lagging-in-southern-us-study-fnds.
15 Ibid.
16 Ibid.
17 University of Texas Medical Branch at Galveston, HPV vac-
cination rates alarmingly low among young adult women
in South, Press release, October 30, 2013, available at
http://www.eurekalert.org/pub_releases/2013-10/uotm-
hvr103013.php.
18 Centers for Disease Control and Prevention, Teen Vaccina-
tion Coverage, available at http://www.cdc.gov/vaccines/
who/teens/vaccination-coverage.html (last accessed
September 2014).
19 Ibid.
20 Centers for Disease Control and Prevention, Human
Papillomavirus (HPV): HPV and Men Fact Sheet, available
http://www.cdc.gov/std/hpv/stdfact-hpv-and-men.htm (last
accessed August 2014).
21 Centers for Disease Control and Prevention, 2011 Sexually
Transmitted Diseases Surveillance: STDs in Men Who Have
Sex with Men, available at http://www.cdc.gov/std/stats11/
msm.htm (last accessed August 2014).
22 Usha Ranji and others, Health and Access to Care and
Coverage for Lesbian, Gay, Bisexual, and Transgender Indi-
viduals in the U.S. (Menlo Park, CA: Henry J. Kaiser Family
Foundation, 2014), available at http://kf.org/disparities-
policy/issue-brief/health-and-access-to-care-and-coverage-
for-lesbian-gay-bisexual-and-transgender-individuals-in-
the-u-s/.
23 Frits van Griensven, Prempreeda Pramoj Na Ayutthaya, and
Erin Wilson, HIV surveillance and prevention in transgender
women, The Lancet Infectious Diseases 13 (3) (2013):
185186.
24 Ibid.
25 U.S. Department of Health and Human Services, Lesbian
and bisexual health fact sheet, available at http://wom-
enshealth.gov/publications/our-publications/fact-sheet/
lesbian-bisexual-health.html#e (last accessed August 2014).
26 Ibid.
27 Centers for Disease Control and Prevention, 10 Ways STDs
Impact Women Diferently from Men (U.S. Department of
Health and Human Services, 2011), available at http://www.
cdc.gov/nchhstp/newsroom/docs/STDs-Women-042011.
pdf.
28 Centers for Disease Control and Prevention, Sexually Trans-
mitted Disease Surveillance 2012.
29 Ibid.
30 Ibid.
31 Ibid.
32 Ibid.
33 U.S. Department of Health and Human Services, Preven-
tive Services Covered Under the Afordable Care Act,
available at http://www.hhs.gov/healthcare/facts/fact-
sheets/2010/07/preventive-services-list.html#CoveredPreve
ntiveServicesforAdults (last accessed August 2014).
34 Centers for Medicare and Medicaid Services, Decision Memo
for Screening for Sexually Transmitted Infections (STIs) and
High-Intensity Behavioral Counseling (HIBC) to prevent STIs
(U.S. Department of Health and Human Services, 2011),
available at http://www.cms.gov/medicare-coverage-
database/details/nca-decision-memo.aspx?NCAId=250.
35 Ibid.
36 K. Owusu-Edusei Jr. and others, The estimated direct
medical cost of selected sexually transmitted infections in
the United States, 2011, Sexually Transmitted Diseases 40 (3)
(2013): 197201.
37 Centers for Disease Control and Prevention, Human Papil-
lomavirus (HPV): HPV and Men Fact Sheet.
38 Jenelle Marie, Op-Ed: Yes, I Have an STD, But It Shouldnt
Be a Scarlet Letter,TakePart, February 22, 2013, available at
http://www.takepart.com/article/2013/02/22/new-scarlet-
letter-why-im-talking-about-living-std.
39 J. Dennis Fortenberry and others, Relationships of Stigma
and Shame to Gonorrhea and HIV Screening, American Jour-
nal of Public Health 92 (3) (2002): 278281.
40 J.J. Kinsler and others, The efect of perceived stigma from a
health care provider on access to care among a low-income
HIV-positive population, AIDS Patient Care and STDs 21 (8)
(2007): 584592.
41 Jennifer J. Frost, U.S. Womens Use of Sexual and Reproduc-
tive Health Services: Trends, Sources of Care and Factors
Associated with Use, 19952010 (New York: Guttmacher
Institute, 2013).
13 Center for American Progress | Ensuring Access to Sexually Transmitted Infection Care for All
42 Ibid.
43 Ibid.
44 Ibid.
45 Ibid.
46 RTI International, Title X Family Planning Annual Report
(Washington: U.S. Department of Health and Human Ser-
vices, 2013).
47 U.S. Department of Health and Human Services, Program
Guidelines For Project Grants For Family Planning Services
(2001), available at http://www.hhs.gov/opa/pdfs/2001-ofp-
guidelines-complete.pdf.
48 Frost, U.S. Womens Use of Sexual and Reproductive Health
Services.
49 Ibid.
50 U.S. Department of Health and Human Services, History of
Title X, available at http://www.hhs.gov/opa/title-x-family-
planning (last accessed October 2014).
51 Adam Sonfeld, Kinsey Hasstedt, and Rachel Benson Gold,
Moving Forward: Family Planning in the Era of Health
Reform (New York: Guttmacher Institute, 2014), available
at http://www.guttmacher.org/pubs/family-planning-and-
health-reform.pdf.
52 U.S. Department of Health and Human Services, History of
Title X.
53 RTI International, Title X Family Planning Annual Report.
54 Ibid.
55 National Partnership for Women & Families, Title X (ten)
National Family Planning Program: Addressing the Critical
Need for Subsidized Reproductive Health Services (2008),
available at http://www.nationalpartnership.org/research-
library/repro/title-x-backgrounder.pdf.
56 Centers for Medicare and Medicaid Services, Decision Memo
for Screening for Sexually Transmitted Infections.
57 Kate Washburn and others, Insurance and billing concerns
among patients seeking free and confdential sexually
transmitted disease care: New York City sexually transmitted
disease clinics 2012, Sexually Transmitted Diseases 41 (7)
(2014): 463466.
58 Centers for Disease Control and Prevention, Sexually Trans-
mitted Diseases (STDs): STD & HIV Screening Recommenda-
tions, available at http://www.cdc.gov/std/prevention/
screeningReccs.htm (last accessed August 2014).
59 U.S. Department of Health and Human Services, Title X
Funding History, available at http://www.hhs.gov/opa/title-
x-family-planning/title-x-policies/title-x-funding-history/
(last accessed August 2014).
60 Henry J. Kaiser Family Foundation, Current Status of State
Medicaid Expansion Decisions, available at http://kf.org/
health-reform/slide/current-status-of-the-medicaid-expan-
sion-decision (last accessed September 2014).
61 Henry J. Kaiser Family Foundation, The Coverage Gap: Un-
insured Poor Adults in States that Do Not Expand Medicaid
(2014), available at http://kf.org/health-reform/issue-brief/
the-coverage-gap-uninsured-poor-adults-in-states-that-do-
not-expand-medicaid.
62 Danielle Garrett and Stephanie Glover, Mind the Gap:
Low-Income Women in Dire Need of Health Insurance
(Washington: National Womens Law Center, 2014), available
at http://www.nwlc.org/sites/default/fles/pdfs/nwlcmind-
thegapmedicaidreportfnal_20140122.pdf.
63 Frost, U.S. Womens Use of Sexual and Reproductive Health
Services.
64 Centers for Disease Control and Prevention, Sexually Trans-
mitted Disease Surveillance 2012.
65 Brigid McKeon, Efective Sex Education (Washington:
Advocates for Youth, 2006), available at http://www.advo-
catesforyouth.org/storage/advfy/documents/fssexcur.pdf.
66 Ibid.
67 National Chlamydia Coalition, Confdentiality of Sensitive
Services for Adolescents and Young Adults: Overview and
Next Steps for the NCCs Special Policy Group on Adolescent
Confdentiality (2012).
68 Ibid.
69 Guttmacher Institute, State Policies in Brief: Partner Treat-
ment for STIs (2014).
70 Len McNally and Rachael N. Pine, Partnering To Advance
Public Health: A Foundation Supports Public Programs,
Health Afairs 28 (2) (2009): 578583.