Sexually transmitted disease control in the era of managed care: "magic bullet" or "shadow on the land"?

Sexually transmitted diseases (STDs) are a major public health problem. In the United States, nearly 12 million STD infections occur annually, generating estimated direct annual health care costs exceeding $12 billion. Lifetime costs may total $88 billion. Meanwhile, inflation-adjusted public funding for STD clinical care and control decreased over the past two decades. Previous STD control officials warned that declining support for STD control programs would result in program elimination and increased rates of STDs ("Brown's Law"). Effective public health and primary prevention efforts have been difficult to implement because of societal sensitivities about sexuality, and the curative rather than preventive focus of our health care system. Proven cost-effective medical interventions, such as chlamydia screening, have not been universally implemented because of health care system inefficiencies, whereby public STD clinical services generate private sector savings not reinvested into these public prevention programs. However, the dramatic growth in managed care presents opportunities, as well as risks, for better STD management.