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Payment and Coverage for the Prevention of Sexually Transmitted Infections (STIs)

There are an estimated 20 million new sexually transmitted infections (STIs) every year in the United States.1 Recently, the rates of reported STIs have been on the rise, reaching record-breaking levels in 2016.2 While all sexually active individuals are potentially at risk, rates are highest among youth between the ages of 15 and 24 as well as gay and bisexual men. Black and Hispanic populations are also disproportionately affected relative to population size. Increasing rates of STIs highlight the importance of prevention, as well as treatment and care, in curbing the spread of these infections and viruses. More people have health insurance than ever before under the Affordable Care Act (ACA), which emphasizes preventive care, including no-cost HIV and STI counseling and screening for recommended populations. This fact sheet examines trends and disparities in STI prevalence, reviews the STI screening and preventive care coverage policies for private insurance and public programs, and discusses coverage gaps and confidentiality concerns in the provision of these services.

Table 1: Sexually Transmitted Infections, by Selected Characteristics, 2016
Rate per 100,000 population

Gonorrhea

Chlamydia

Syphilis (primary and secondary stages)

 HIV
U.S. Total 145.8 497.3 8.7 14.7
Sex Men 170.7 330.5 15.6 24.4
Women 121.0 657.3 1.9 5.4
Race White 55.7 199.8 4.9 6.1
Black 481.2 1,125.9 23.1 53.8
Hispanic 95.9 374.6 10.9 21.5
Asian 28.3 119.3 3.9 6.4
American Indian/Alaska Native 242.9 749.8 8.0 10.8
Age 15-19 379.8 1,929.2 6.1 Age 13-24 — 16.9
20-24 607.5 2,643.8 22.7
25-29 450.9 1327.5 27.5 Age 25-34 — 29.3
30-34 265.9 613.9 19.7
Region Northeast 108.8 454.6 8.0 11.6
South 166.8 529.7 8.9 16.8
Midwest 142.9 487.5 5.7 7.6
West 142.1 485.9 11.4 9.8
SOURCE: Centers for Disease Control and Prevention (CDC), Sexually Transmitted Disease Surveillance 2016; CDC, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) AtlasPlus, accessed November 2017.

Prevalence of Sexually Transmitted Infections

STIs are generally defined to include the Human Papillomavirus (HPV), HIV, genital herpes, gonorrhea, chlamydia, trichomoniasis, and syphilis. It is estimated that HPV, the most common STI in the United States, will be contracted at some point during the lifespan of nearly every sexually active individual.3 Because some STIs are frequently asymptomatic, particularly in women, they often go undiagnosed. For this reason, preventive measures and routine screenings are important for the early identification of these infections in order to engage in treatment as well as to prevent further transmission and more serious complications. Untreated STIs can result in pelvic inflammatory disease (PID), infertility, and an increased risk for HIV and other STIs. Certain strains of HPV are linked to cervical, throat, penile, and anal cancers.

Figure 1: Rates of Sexually Transmitted Infections Have Been Rising

Pregnant women with an STI face increased risk of complications. Exposure to an STI during pregnancy can result in preterm labor, low birth weight, premature rupture of membranes, and transmission to the infant during delivery causing severe infection. HIV and syphilis are particularly serious if transmitted to newborn infants. With consistent treatment and use of antiretrovirals (ARVs), the chances of passing HIV to a baby from either a mother or father with HIV is highly unlikely today.4 However, up to 40% of babies born to women with untreated syphilis may be stillborn or die from the infection,5 and congenital syphilis cases have increased 87% since 2012, rates not seen since 1988.6 In addition, the Zika virus poses particular risks to pregnant women. The majority of cases are transmitted by mosquito, but it can also be passed through sexual transmission even though many people with the virus do not experience symptoms. Of the 254 total symptomatic Zika cases reported in the US between January and September 2017, only three were acquired through sexual transmission.7 Infection with Zika during pregnancy can cause severe birth defects, such as microcephaly.

Figure 2: Young People Bear a Disproportionate Burden of Gonorrhea and Chlamydia Infections

While women still account for most cases of STIs (with the exception of HIV), men, in particular gay and bisexual men, saw greater increases in syphilis, chlamydia, and gonorrhea rates. Syphilis infections doubled among men from 2010 to 2016 (Figure 1). STIs also have a disproportionate impact on youth, ages 15-24, who account for 62% of all reported cases of gonorrhea and chlamydia despite only representing 25% of the sexually active population (Figure 2).8 Due to a combination of social and economic inequities, certain groups are disproportionately affected by HIV and other STIs (Figure 3). In 2016, Black Americans accounted for 51% of reported gonorrhea cases and 37% of primary and secondary (P&S) syphilis cases, despite comprising just 12% of the population. They also accounted for almost half (45%) of new HIV diagnoses in the U.S in 2015.9  Latinos are also disproportionately affected, accounting for 24% of persons newly diagnosed with HIV and representing 17% of the population in 2015. Gay and bisexual men of all races have also been heavily affected since the start of the HIV/AIDS epidemic. In 2015, men who have sex with men (MSM) accounted for more than two thirds (67%) of all HIV diagnoses in the U.S., representing 82% of cases among males. MSM also accounted for 81% of male P&S syphilis cases in 2016. The higher prevalence of HIV and other STIs in certain communities means risk of exposure is also greater, despite the greater use of protective actions, such as condoms, Pre-exposure prophylaxis (PrEP, discussed below), and testing, among these higher risk groups.10,11,12

Figure 3: There is Considerable Variation in Rates of STI infections Among Different Racial and Ethnic Groups

Insurance Coverage for STI Prevention and Treatment

The CDC estimates that annual direct medical costs in the US associated with STIs are nearly $16 billion.13  These costs are borne by private insurance, public programs, and by patients.

Private Insurance

The Affordable Care Act (ACA) requires most private health insurance plans to cover recommended preventive services with no cost sharing. For adults, this includes US Preventive Services Taskforce (USPSTF) recommendations receiving an A or B grade, vaccines recommended by the CDC’s Advisory Committee for Immunization Practices, and services for women recommended by the Health Resources and Services Administration (HRSA). The STI benefits covered by these recommendations include HIV and STI counseling and screening as well as vaccines for HPV and Hepatitis B for the recommended populations and those at higher risk (Table 2). The USPSTF recommendations also include syphilis, HIV, and Hepatitis B screening for all pregnant women.

Pre-exposure prophylaxis (PrEP), a daily pill approved by the FDA in 2012, is highly effective in protecting against HIV when taken as prescribed and is recommended by the CDC for those at high risk.  While PrEP is not currently included in the required covered no-cost preventive services, the USPSTF Task Force has released a final research plan for the use of PrEP in the prevention of HIV, and a recommendation statement is in progress. Most private insurance companies cover PrEP, typically with a prescription copay. Individuals on PrEP are required to have follow up visits and lab work, including being re-tested for HIV four times a year.  Some health departments offer programs for eligible individuals to help them obtain PrEP at low or no cost. Gilead, the manufacturer of Truvada (PrEP’s brand name), has a Co-Pay Payment Assistance Program, which provides up to $3600 per year with no monthly limits to cover out-of-pocket expenses, including co-pays, co-insurance and deductibles. The program does not restrict benefits based on income; however, it is not available for those on Medicaid, Medicare Part D, or any other government prescription programs.14 For those who have PrEP covered by insurance, including Medicare, the Patient Advocate Foundation may help pay for costs related to the prescription, income dependent, up to $7500 per year.

The Ryan White HIV/AIDS Program and its AIDS Drug Assistance Program (ADAP) may be available to provide additional assistance to people living with HIV.15 ADAPs can help with the cost of antiretroviral medications for those without insurance coverage and with some costs associated with coverage for those with insurance. ADAPs operate in every state and US territory and can assist those with low to moderate incomes (actual eligibility varies from state to state).16  While these programs are critically important to people living with HIV, they are not specifically preventive programs.

Medicaid

Medicaid, the national health coverage program for low-income individuals, is financed and operated jointly by the federal and state governments. For states that have adopted the full-scope Medicaid expansion, STI counseling, screenings, and preventive vaccinations must be covered at no cost for the newly eligible populations under the ACA just as they are for enrollees in private insurance plans (Table 2). However, this requirement does not apply to populations covered by Medicaid through other pathways where coverage for specific STI screenings and treatments is determined by the state. For example, research has found that most states do cover cervical cancer services, including the HPV vaccine and pap testing under their full-scope Medicaid programs.17 However, only 14 out of 23 states that have limited-scope Medicaid funded family planning programs cover the HPV vaccine for enrollees.18 While several states cover condoms, they require prescriptions for this over-the-counter product. Medicaid is the largest provider of HIV treatment and care, and state Medicaid programs pay for PrEP for eligible low-income individuals who do not have HIV to protect against the virus.  Medicaid funds have also been extended to provide resources to prevent Zika transmission through mosquitos and sexual contact. However, there is currently no vaccine or medication to prevent or treat the Zika virus.

Table 2: No-Cost Preventive Care Benefits Under the ACA

Men who are sexually active or at higher risk

Women who are sexually active/at higher risk

Pregnant women

Adolescents

Gonorrhea screening X
Chlamydia screening X
Syphilis screening X X X
HPV DNA Testing X – 30 years and older
HPV vaccine X – 11 to 26 years X – 11 to 26 years X – 11 to 26 years
Hepatitis B screening X X X – at first prenatal visit X
Hepatitis B vaccine X X X – children under 18 years
STI prevention counseling X X X – if sexually active
HIV screening and counseling X – 15 to 65 years, all at higher risk X – 15 to 65 years, all at higher risk X X
Pap Test (cervical cancer screening) X – All women ages 21 to 65
NOTES: Population covered and definition of high risk vary by condition. Coverage without cost sharing required in new private plans and Medicaid expansion groups. See Kaiser Family Foundation’s Preventive Services Tracker for more information
Uninsured

Despite expanded coverage under the ACA, roughly 28 million individuals, 9% of the population, remained uninsured in 2016.19 Some states have extended access to STI services to uninsured populations through the Medicaid family planning expansion program that provides Medicaid coverage solely for family planning services to women and men who do not qualify for full Medicaid benefits. Most of these programs cover STI screenings, but some do not cover treatment if diagnosed.20

STI clinics funded by federal, state, and local governments, such as those that receive funding from the federal HRSA or the Title X family planning program, remain an important site of care for STI prevention and treatment. As part of the safety-net healthcare network, STI clinics provide a disproportionate number of high-risk individuals with same-day, low-cost care by experts in the counseling, diagnosis and treatment of STIs. Research suggests that clinicians at these clinics are also more likely to provide routine STI care and discuss the use of condoms with patients than private providers.21 Furthermore, some individuals with private insurance report being unwilling to use their insurance for STI services. Confidentiality is one of the fundamental principles of the Title X program, underlining the ability of Title X-funded STI clinics to provide the confidentiality essential for sensitive services.22 Planned Parenthood is a primary Title X provider, serving approximately one third of all Title X patients annually,23 and a major provider of STI services. In 2015, STI services made up 45% of the health services offered at Planned Parenthood clinics, including roughly 4.2 million tests and treatment for STIs and HIV.24

Gilead offers a Medication Assistance Program for PrEP that may provide the medication at no cost based on income. The program may also be available to those on Medicare who do not have Part D prescription drug coverage. In addition, some city and state health departments, and foundations offer navigation and other support services, as well as financial assistance to make PrEP free or low cost.

Gaps in Coverage and Privacy protections

Confidentiality

Confidentiality is a crucial factor in the provision of STI screening and treatment services. For minors in particular, it can be a challenge. Although all fifty states and DC allow minors to consent to STI services, 18 states allow physicians to inform a parent or guardian that the minor is seeking these services (Figure 4).25

Figure 4: All States Permit Minors to Consent to STI Services, but Some Allow Parental Notification

With the passage of the ACA, many more young adults were covered under a provision that allowed dependents to remain covered under their parent’s plan up to the age of 26. In 2016, approximately 11.9 million young adults aged 19-25 were covered as dependents in an ESI policy.26 Although this policy has expanded coverage for young adults, it has raised concerns about privacy and confidentiality in the use of sensitive health services such as STI screening and treatment for young adults covered as dependents. According to a 2013 Kaiser Family Foundation survey, 71% of women ages 18 to 25 rated confidentiality as important to them, but only 37% understood that an Explanation of Benefits (EOB) summary is sent to the primary policyholder when health services are used.27 However, some states have implemented laws to ensure confidentiality for minors seeking sensitive services such as STI screenings. For example, in 2013 California enacted the Confidential Health Information Act, which requires health insurance plans to honor confidential communications requests submitted by dependents in order to prevent the primary plan holder (a parent or spouse) from receiving information about the sensitive health services they receive. Nonetheless, this would still require a minor to be aware of the policy, submit a request, and that the issuer have mechanisms in place to honor such requests.

Expedited Partner Therapy

Many states have laws allowing expedited partner therapy (EPT), which permits the treatment of partners of patients diagnosed with an STI without examination. The CDC has recommended this practice since 2006 in certain circumstances due to its success in reducing gonorrhea reinfection rates.28 Currently 37 states and DC allow physicians to provide at least some treatment to the partner of a patient diagnosed with a STI.29 Among publicly funded clinics, 79% provided expedited therapy for the client’s partner at the same visit in 2015.30 However, even in states where EPT has been legalized, many do not allow the patient’s insurance coverage to be billed for the partner’s treatment, which creates a financial barrier to care.

Prevention

All STIs, including HIV, are preventable and treatable. Many, such as syphilis, chlamydia, and gonorrhea, are curable. As discussed earlier, the HPV vaccine provides protection against nine types of the virus that are associated with cancers in men and women as well as genital warts and are covered by many Medicaid programs and by private insurance. Condoms, which are highly effective in reducing the risk of HIV and many STIs,31 are not included in the mandatory benefits under the ACA as a preventive method for STIs nor as a contraceptive. Some states report using their own Medicaid funds to pay for condoms for some groups of beneficiaries.32 PrEP is also not included among the no-cost preventive services required by the ACA, despite the fact that it is recommended by the CDC.33 In a major study of gay and bisexual men as well as transgender women, daily PrEP use lowered their risk of HIV by an estimated 99 percent when taken daily.34,35 Another study focusing on sex between men and women showed PrEP reduced the risk of getting HIV by at least 90 percent.36 Although most private insurance and Medicaid covers PrEP, private plans may still charge significant copays. In addition to improving health outcomes, antiretrovirals (ARVs), the medications used to treat HIV, also prevent the spread of the virus. ARVs work to lower the viral load of individuals with HIV often to levels that are undetectable by standard lab tests. Studies show when the viral load is below 200 copies of virus per milliliter of blood, sexual transmission of the virus to others is extremely unlikely, if impossible.37,38

Conclusion

High and, in some cases, rising rates of STIs over the last couple of decades have become a cause of public health concern. Women, people of color, and youth experience the highest rates of infection. Gay and bisexual men account for the majority of the increase between 2000 and 2015.

Publicly funded clinics, many funded by the Title X and Ryan White programs, including health centers, STI clinics, and Planned Parenthood clinics, provide confidential STI, including HIV, care to at-risk and uninsured populations. With the passage of the ACA, most private health insurance plans and Medicaid expansion programs are now required to cover HIV and STI counseling and screening without cost sharing. In addition to coverage, access to and the availability of STI/HIV care will likely depend on a number of factors, including public funding for safety-net providers, adoption of practices aimed at the reduction of transmission such as patient education, expedited partner therapy, consistent routine screenings, and treatment.

Endnotes
  1. The Centers for Disease Control and Prevention (CDC). Reported STDs in the United States, 2016.

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  2. CDC. Sexually Transmitted Disease Surveillance 2016.

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  3. CDC. Genital HPV Infection Factsheet. March 2014.

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  4. U.S. Department of Health and Human Services (HHS). Preventing Mother-to-Child Transmission of HIV. May 2017.

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  5. CDC. Congenital Syphilis Factsheet.

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  6. CDC. Sexually Transmitted Disease Surveillance 2016.

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  7. Kaiser Family Foundation (KFF). Cases of Zika Virus Disease in the United States, Jan 1 - September 13, 2017. State Health Facts.

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  8. CDC. Sexually Transmitted Disease Surveillance 2016.

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  9. CDC. HIV in the United States: At A Glance.

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  10. KFF. HIV Awareness and Testing, 2013 and 2014.

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  11. Greater than AIDS. Get the Facts about HIV.

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  12. KFF (2014). HIV/AIDS in the Lives of Gay and Bisexual Men in the United States.

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  13. CDC. Reported STDs in the United States, 2016.

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  14. Gilead. The Gilead Advancing Access® Co-pay Program.

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  15. HHS, HIV.gov. Paying for HIV Care and Treatment.

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  16. Health Resources and Services Administration (HRSA). Part B: AIDS Drug Assistance Program.

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  17. The Kaiser Family Foundation (KFF) and Health Management Associates (HMA). Medicaid Coverage of Family Planning Benefits: Results from a State Survey. September 2016.

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  18. KFF and HMA. Medicaid Coverage of Family Planning Benefits: Results from a State Survey. September 2016.

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  19. Kaiser Family Foundation (KFF). Health Insurance Coverage of the Total Population. State Health Facts.

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  20. KFF and the George Washington University School of Public Health. State Medicaid Coverage of Family Planning Services. November 2009.

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  21. The Center for American Progress. Ensuring Access to Sexually Transmitted Infection Care for All. October 2014.

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  22. Hoover K et al. Continuing the Need for Sexually Transmitted Disease Clinics After the Affordable Care Act. American Journal of Public Health; 105(5): S690-S695. November 2015.

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  23. Planned Parenthood Action Fund. Title X: America’s Family Planning Program.

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  24. Planned Parenthood. 2015-2016 Annual Report.

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  25. Guttmacher Institute. Minor’s Access to STI Services. October 2016.

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  26. KFF analysis of Current Population Survey data 2016.

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  27. Salganicoff et al. KFF. Women and Health Care in the Early Years of the Affordable Care Act. May 2014.

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  28. CMS. Expedited Partner Therapy in the Management of Sexually Transmitted Diseases. 2006.

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  29. Guttmacher Institute. Partner Treatment for STIs. October 2016.

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  30. Guttmacher Institute. Publicly Funded Family Planning Clinics in 2015: Patterns and Trends in Service Delivery Practices and Protocols. November 2016.

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  31. CDC. Condoms and STDS: Fact Sheet for Public Health Personnel.

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  32. KFF and HMA. Medicaid Coverage of Family Planning Benefits: Results from a State Survey. September 2016.

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  33. CDC. PrEP 101.

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  34. Grant RM, et al. (2010). Preexposure Chemoprophylaxis for HIV Prevention in Men Who Have Sex with Men. The New England Journal of Medicine; 363:2587-2599.

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  35. Anderson PL, et al. (2012). Emtricitabine-tenofovir concentrations and pre-exposure prophylaxis efficacy in men who have sex with men. 4(151):151ra125.

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  36. Baeten JM, et al. (2012). Antiretroviral Prophylaxis for HIV Prevention in Heterosexual Men and Women. The New England Journal of Medicine; 367:399-410

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  37. Cohen MA, et al. (2016). Antiretroviral Therapy for the Prevention of HIV-1 Transmission. The New England Journal of Medicine; 375:830-839

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  38. Rodger AJ, et al, for the PARTNER Study Group. Sexual Activity Without Condoms and Risk of HIV Transmission in Serodifferent Couples When the HIV-Positive Partner Is Using Suppressive Antiretroviral Therapy. JAMA. 2016;316(2):171–181.

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