VI.      Award Administration Information ……………………………87

VII.      Agency Contacts………………………………………………90

VIII.      Other Information…………………………………………….92

Background:  

Sexually transmitted diseases (STDs) remain among the most challenging public health problems facing the United States.  CDC estimates that approximately 19 million new sexually transmitted infections occur each year and that almost half of them are among young people ages 15 to 24.  Untreated, chlamydia and gonorrhea increase a woman’s risk for pelvic inflammatory disease (PID) and infertility.  Furthermore, most STDs facilitate the sexual transmission of human immunodeficiency virus (HIV).   In addition to the physical and psychological consequences of STDs, these diseases exact a tremendous economic toll; direct medical costs associated with STDs in the United States are estimated to be as much as $14.7 billion annually.  The substantial physical, emotional, and fiscal costs are unnecessary because STDs are preventable, and early detection and treatment through routine screening can forestall costly and severe complications.

Although rates of STD infections vary by jurisdiction and region of the country, on a national level, African American, American Indian/Alaska Natives, and Hispanic populations suffer disproportionately from STDs. In addition, there is considerable STD morbidity among Whites and Asian/Pacific Islanders. Race and ethnicity, by themselves, are not risk factors for sexually transmitted infections, however, because of a complex set of historical, structural, environmental, and cultural factors, African Americans, even when compared to others with similar risk behaviors, are at greater risk for STDs. In 2006, compared to whites, African Americans were approximately six times more likely to be infected with syphilis, eight times more likely to be infected with chlamydia, and 18 times more likely to be infected with gonorrhea.  Among African American adolescents, the persistent heavy burden of STDs is even more critical. In 2006, young African American women (15-19 years old) had the highest reported gonorrhea rate of any group (2,898 per 100,000) and young African American men (15-19 years old) had a reported gonorrhea rate (1,503 per 100,000) that is 39 times higher than their white peers. In addition, the rates of chlamydia among American Indian/Alaska Natives in 2006, were more than five times higher than whites, and gonorrhea rates for Hispanics were more than two times higher than whites.

Men who have sex with men (MSM) are another population with a heavy burden of STDs.  This increased disease burden includes HIV infection, which compounds the problem and complicates prevention, detection, and medical management of STDs.  In 2006, an estimated two-thirds of primary and secondary (P&S) syphilis cases were among MSM.

Addressing these disparities will require significant efforts from health departments, health care providers, and affected communities.  It will also require health departments to collect and assess morbidity, behavioral, and other data to identify significant trends for each STD.  This information should be used to develop plans and implement activities designed to best reduce morbidity and related disparities. Concurrently, health departments, through direct services and clear guidance to medical institutions and other care providers, must strive to ensure the consistent delivery of comprehensive STD prevention services (fully integrated STD, HIV, and hepatitis prevention services), especially to individuals and communities disproportionately affected by STDs.

CDC’s Division of STD Prevention (DSTDP) works to help people be safer and healthier through prevention and control of STDs and their complications.  DSTDP’s priority disease prevention goals and strategies are:  (1) Prevention of STD-related infertility and other complications of PID by screening and treating at-risk persons, primarily women <26 years of age, and by working to reduce racial/ethnic disparities in gonorrhea and chlamydia; (2) Prevention of STD-related outcomes of pregnancy by reducing congenital syphilis, reducing adult male and female syphilis, increasing screening and treatment of syphilis, testing for chlamydia, gonorrhea and syphilis during pregnancy, and reducing neo-natal herpes; (3) Prevention of STD-related cancers by decreasing human papilloma virus (HPV) infection and its sequelae and increasing adult hepatitis B vaccination; and (4) Prevention of STD-related HIV transmission and acquisition and other STD-HIV interactions by decreasing bacterial STDs, increasing HIV screening among those with STD and those with behavioral risks, ensuring routine STD screening among HIV infected persons, and reducing genital herpes.   Achieving these specific disease prevention goals will involve understanding the social determinants of health in the promotion of sexual health and the primary prevention of sexually transmitted infections.

Purpose:  

The purpose of this program is to enhance the prevention and control of STD by supporting and improving the ability of public health departments to (1) design, implement, and evaluate Comprehensive STD Prevention Systems (CSPS); (2) implement the Infertility Prevention Project (IPP) and promote interventions that prevent STD-related infertility; (3) implement the Syphilis Elimination Effort (SEE) in designated high morbidity areas (HMAs) to enhance activities to prevent, control and eliminate syphilis; and (4) implement the Gonococcal Isolate Surveillance Project (GISP) in eligible jurisdictions.  Grantees implementing these programs must primarily focus their efforts on the prevention of chlamydia, gonorrhea, and syphilis among disproportionately impacted populations.  Grantees also have the option of applying for additional funds under the Chlamydia Evaluation Initiative (CEI), a project designed to support program evaluation activities to estimate chlamydia screening and partner treatment rates.

The ‘Comprehensive STD Prevention Systems^’ (CSPS) provides an overarching framework on which grantees may develop their comprehensive STD prevention program plans, regardless of funding source.  CSPS is comprised of eight essential functions; as outlined in the Program Operations Guidelines (POG), they are:  (1) Community and Individual Behavior Change Services, (2) Medical and Laboratory Services, (3) Partner Services, (4) Leadership and Program Management, (5) Surveillance and Data Management, (6) Training and Professional Development, (7) STD Outbreak Response, and (8) Program Evaluation. (For more information about the essential functions, please access DSTDP’s Program Operations Guidelines, http://www.cdc.gov/std/program/#resources.).   

Although CSPS has a firm foundation in the eight essential functions contained in the Program Operations Guidelines, the ordering of these strategies have been realigned in this program announcement in the following format:

The purpose of this reformatting is to emphasize the importance of using key surveillance, program, and other data to effectively focus prevention efforts on the populations currently at greatest risk for STDs.  CDC recognizes that, because funding is limited, grantees will need to prioritize their activities within the CSPS essential functions and tailor them to the at-risk populations identified by local epidemiology.  The data used to develop the epidemiological profile must be of a high quality in order to ensure that significant morbidity trends and service gaps are identified and addressed.  In turn, implementing effective, high quality interventions requires ongoing assessment of program activities.  Program managers must routinely review epidemiological, behavioral, and program data so that programs can be modified and updated in response to changing epidemiology or implementation weaknesses.    

STD control programs typically have broad responsibilities within their jurisdictions beyond the scope of this announcement for surveillance, subject matter expertise, medical services, professional and public education, and guidance of other STD prevention activities.  Funds provided by this program announcement are not sufficient to achieve all of the goals of STD prevention. Investments from other sources (e.g., state and local governments and the health care delivery sector) in STD programming are necessary and critical to providing comprehensive STD prevention services to persons and communities in need. Given the need for comprehensive services, to maximize efficient use of limited resources and to provide high quality prevention services to persons in need, grantees should engage in meaningful collaborations with appropriate public and private health care and other non-medical partners, particularly organizations serving at-risk populations. Furthermore, while epidemiologists and program managers need to carefully investigate morbidity and individual interventions for each STD, grantees must also ensure that services are comprehensive, tailored to the needs of the populations they serve,  and fully integrated at the client services level (e.g., STD screening and treatment, HIV testing, hepatitis B vaccination). To enhance such collaborations, grantees should consider the recommendations made by the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention’s (NCHHSTP) strategy calling for Program Collaboration and Service Integration (PCSI).  PCSI promotes improved comprehensive services at the client level through enhanced collaboration at the program level, thereby offering opportunities to (1) increase efficiency, reduce redundancy, and eliminate missed opportunities; (2) increase flexibility and better adapt to overlapping epidemics and risk behaviors; and (3) improve operations through the use of shared data. Examples of collaborative activities include: providing opt-out HIV testing in STD clinics; normalizing comprehensive STD/HIV testing in emergency departments, jails, family planning and other medical settings serving populations at increased risk; collaborating on structural interventions to increase adherence to chlamydia screening guidance in clinical settings; offering adult hepatitis B vaccination and STD screening in high prevalence areas or settings where high risk individuals seek services; and promoting HPV immunization in populations for whom the vaccine is recommended. Grantees should collaborate with programs addressing HIV prevention, viral hepatitis prevention, HIV treatment, immunizations, and reproductive health care to routinely offer comprehensive STD services and disseminate holistic prevention messages for populations at-risk for multiple problems.     

In addition, significant prevention opportunities exist in certain venues, such as sites where risk behaviors occur or where individuals meet their drug using or sexual partners. These are important places because they offer opportunities to provide at-risk individuals with prevention messages or services.  Often, these risk-associated venues are identified through partner elicitation interviews with infected persons.  Identifying risk-associated venues is an essential first step to enhancing STD prevention messages and services for social and sexual networks of persons at increased risk for STDs, including HIV.  For MSM in particular, sexually focused internet sites are increasingly identified as venues where men meet other men to arrange sexual encounters that are often unsafe. Health departments should ensure that staff have the tools and skills needed to conduct Internet Partner Services and provide prevention messages on-line. Developing and maintaining these new essential capacities will require considerable training, technical assistance, protocol and policy development, and ongoing strong support from health department leadership. 

This program addresses “Healthy People 2010” focus area 25, Sexually Transmitted Diseases (STD), http://www.healthypeople.gov/document/html/volume2/25stds.htm . It also supports the overarching goals of Healthy People 2010:  (1) to increase years and quality of healthy life and (2) eliminate disparities among subgroups of the population.

This program also addresses the CDC Health Protection Goals of:  healthy people in every stage of life, and healthy people in healthy places.

Measurable outcomes of the program will be in alignment with one (or more) of the following performance goals for the Coordinating Center for Infectious Diseases (CCID), National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP):  (1) Reduce the rates of non-HIV sexually transmitted diseases in the United States. Furthermore, this program supports the NCHHSTP programmatic imperatives of program collaboration and service integration, and reduction of health disparities.

This announcement is only for non-research activities supported by CDC.  If research is proposed, the application will not be reviewed.  For the definition of research, please see the CDC Web site at the following Internet address:  http://www.cdc.gov/od/science/regs/hrpp/researchDefinition.htm 

Activities: 

Award amount may vary in subsequent years commensurate with changes in public health needs, changes in information technology, emerging trends in STDs and related risk behaviors, and future availability of funding.

Comprehensive STD Prevention Services (CSPS)

CSPS Activities

In order to reduce rates of reportable STDs in their jurisdictions, grantees must develop program plans with goals, measurable objectives, and monitoring plans that address the program announcement’s purposes.  In developing program plans within the context of the CSPS framework, grantees must:

e.   Improve program evaluation, i.e., collecting, analyzing and using data to guide program activities and developing strong monitoring and evaluation plans for surveillance and program interventions. 

I.          Surveillance

A.        Surveillance and Data Management

Surveillance is the ongoing and systematic collection, analysis, interpretation, and dissemination of standardized health data for the purpose of public health action. Data management is the conversion of information into usable or storable form. Through surveillance and data management activities, STD programs identify populations affected by syphilis, gonorrhea, and chlamydia, including racial and ethnic minorities, MSM, adolescents, and persons living in areas with high morbidity.  Programs also need to identify co-infection rates with other STDs (i.e., HIV, hepatitis B) as well as rates of repeat STD infections. High quality surveillance and data management are essential to the implementation of effective STD prevention programs and should include the following activities:

1.         Establish and maintain information systems to monitor incidence of reportable STDs by relevant geographic and subpopulation categories including sex, race/ethnicity, provider type, and sexual orientation. Information systems should allow for routine assessment of STD/HIV co-infections and support the monitoring and evaluation of program activities, evidence-based action plans, and Performance Measures.

2.         Promptly investigate reports of STD from all sources to assure appropriate diagnosis, treatment and follow up of infected individuals and their partners.

3.         Assure complete laboratory and provider adherence to STD reporting regulations through written protocols to monitor and evaluate timeliness, completeness, and accuracy of reporting; and to provide regular feedback through periodic written updates, phone, and on-site visitation.

4.         Establish confidentiality and security guidelines for the collection, storage, and use of STD data received by the grantee.

5.         Routinely conduct, analyze, and report on STD prevalence monitoring activities.

6.         Routinely analyze and disseminate STD data by relevant geographic and subpopulation categories for the purposes of informing needs assessment, planning, and policy development, including standards setting and intervention strategy design; identify those populations and locales where prevention efforts should be implemented or enhanced.

7.         Establish and maintain written protocols for informing and updating physicians and other medical care providers on local morbidity trends and requirements for morbidity reporting.

8.         Identify or develop other potential sources of data for behavioral, clinical, laboratory, and/or programmatic information that can be used to guide STD prevention and control activities.

B.        Outbreak Response Plan

In order to detect and respond promptly to STD outbreaks, STD programs must create, maintain, and utilize Outbreak Response Plans.  Plans should include (1) standards for surveillance and procedures for analysis of data; (2) a timetable and schedule for review of disease trends; (3) disease thresholds for gonorrhea and syphilis at which the plan is to be initiated; (4) meaningful involvement of the affected community and their medical service providers in the effort; (5) proposed duties and activities for staffing including number, disciplinary mix, and specific responsibilities of members of response teams; (6) notification to CDC; (7) evaluation of the effectiveness of the outbreak response; and (8) schedule for the periodic review of both the outbreak plan and the surveillance system attributes. At a minimum, grantees should review age, race, gender, sexual orientation, provider type, and geographic information to identify populations experiencing increased incidence of gonorrhea and syphilis.

1.         Establish an STD Outbreak Response Plan that reflects the above-mentioned elements.

II.        Interventions

STDs are controlled and prevented through interventions that address detection and treatment of infections and provide services to exposed partners. Additionally, behavioral interventions enhance measures to reduce risk behavior. All STD prevention activities should be part of comprehensive STD prevention services, which includes STD, HIV, and viral hepatitis prevention activities.  Interventions (medical and laboratory, partner services and community and individual behavioral change services) should be focused on at-risk populations, especially those significantly impacted by health disparities (e.g., racial, ethnic, sexual orientation, or residing in areas with elevated morbidity rates), which are identified through  local morbidity, behavioral assessments and other data sources.  

A.        Medical and Laboratory Services:  High quality, accessible medical and laboratory services are essential elements in the prevention of STDs within any community. This intervention provides assurance of access to diagnostic and treatment services and targeted screening based on local and national recommendations in both public and private settings. Assurance of such services should consistently include the following:

1.         Ensure the provision of comprehensive STD diagnostic and treatment services in public STD clinics, i.e., implement high quality standards of care consistent with CDC’s guidelines and recommendations, including HIV opt-out testing. (See budget section for funding restrictions on clinical care) http://www.cdc.gov/std/treatment/2006/toc.htm

2.         Promote and implement the use of STD screening services recommended by CDC and other professional organizations with expert knowledge of STD screening practices, including annual chlamydia screening for sexually active women <26 years of age.

3.         Use local epidemiology to identify populations at greatest risk and locations where at-risk individuals can access STD screening, treatment, and other appropriate prevention services (e.g., promotion of enhanced gonorrhea screening by providers serving young adults in geographical areas with elevated prevalence).

4.         Implement evidence-based, locally-driven screening activities.

5.         Facilitate screening and treatment of partners of STD-infected individuals.

6.         Ensure prompt treatment of persons with STDs through the adoption of protocols for presumptive treatment (e.g., epi-treat STD-associated syndromes) and the consistent availability of on-site, “stat” (immediate) STD laboratory tests (Clinical Laboratory Improvement Amendments [CLIA] adherence required) in laboratories in public STD clinics.

 7.        Enhance access to STD services by developing and disseminating information that addresses health services availability and facilitates health services utilization.

8.         Increase awareness of providers in both public and private sectors of CDC STD screening recommendations and local priority populations. Encourage all providers serving at-risk populations to consistently offer recommended STD screening and treatment services, and to report morbidity promptly and accurately. This can be accomplished through provider visitations, grand rounds, and regular updates. All providers should be strongly encouraged to offer HCV testing, hepatitis B vaccination, and HIV screening, to at-risk persons as part of comprehensive STD prevention services.

B.        Partner Services:  Partner Services is the process by which sex partners of an individual diagnosed with an STD are identified, contacted, and notified of their exposure, and promptly offered appropriate clinical services and treatment to reduce their risk of complications of infection or further transmission of the disease; and to identify unnamed partners or persons with symptoms or at-risk for disease.  Partner services are a set of key STD prevention activities designed to rapidly identify infected and exposed persons, ensure their prompt treatment and ultimately reduce the overall burden of disease. Assurance of such services includes the following activities:

1.         Conduct partner elicitation and notification activities for all cases of early syphilis, and assure prompt partner evaluation and treatment.

2.         Conduct partner elicitation and notification activities for gonorrhea and chlamydia, as indicated by local epidemiology and priorities. 

3.         Develop and implement strategies and innovative methods to assure and enhance prompt partner evaluation and treatment for all partners of patients with gonorrhea and chlamydia through approaches such as provider referral, patient referral (self-referral or provider-assisted), expedited partner therapy (EPT) where permitted, and presumptive interviews in a manner which minimizes time and effort required by health department staff and maximizes prompt treatment of exposed partners.

4.         Offer comprehensive STD/HIV partner services to individuals co-infected with HIV and those exposed to multiple diseases. 

5.         Assess effectiveness and productivity of partner services for each disease independently (e.g., HIV, syphilis, gonorrhea, and chlamydia).

6.         Assess the feasibility of offering EPT to partners of infected persons, and where appropriate and permitted by local statutes and regulations, develop and implement protocols.  

7.         Develop and implement protocols for Internet Partner Services (IPS).

8.         Ensure comprehensive STD services for all examined partners.

C.        Community and Individual Level Behavioral Change Services:  Behavioral interventions are an important part of STD prevention services. Used in conjunction with biomedical approaches for the treatment and prevention of STDs, behavioral interventions should complement and enhance these efforts.  Behavioral intervention components include health education and community and individual behavior change interventions. Assurance of these activities includes the following:

1.         Provide STD prevention education for at-risk individuals and populations to include:  the role of abstinence, behavioral and other types of risk reduction (reducing multiple concurrent partnerships), correct and consistent condom use, symptom recognition, routine recommended screening, vaccination against HBV and HPV, prompt health-care seeking behavior, and partner services. 

2.         Promote the use of appropriate health education materials for use by public and private health care providers, institutions, schools, community-based organizations, and other STD prevention partners.

3.         Collaborate with other prevention programs (i.e., HIV, viral hepatitis, Reproductive Health, Family Planning, and Immunization) to design and implement comprehensive STD prevention messages and health education materials for individuals and communities with multiple risks.

4.         Integrate STD prevention messages into HIV testing and treatment services, and HIV prevention and other evidence-based behavioral interventions.

5.         Collaborate with experts in the fields of communication, behavioral and social science, social marketing and advertising who are reaching at-risk populations to design and disseminate STD prevention messages.

6.         Refer individuals at-risk for HIV infection to appropriate HIV risk-reduction programs.

III.       Evaluation

10.              Implement initiatives to reduce health disparities (e.g., enhanced