BACKGROUND:Syphilis cases continue to climb in the United States, with a 159% increase among women between 2018 and 2022. Congenital syphilis (CS) cases continued along the same trajectory, with a 183% increase over the same time frame. Adherence to the screening guidelines may assist in reducing this trend. Our analysis aimed to determine the proportion of commercially insured women receiving syphilis screening during pregnancy. MATERIALS AND METHODS:We analyzed the 2022 Merative MarketScan Database containing commercially insured medical claims to determine syphilis screening rates among insured pregnant women aged 18 to 49 years, insured for 8 months before childbirth. Screening events were classified into 3 categories: first (1-13 weeks), second (14-27 weeks), and third (28+ weeks). Percentages and odds ratios were calculated for pregnancy categories by age category, trimester, Centers for Medicare & Medicaid Services regions, employment, and type of health insurance. RESULTS:Of the 170,005 pregnant women in the sample, 79.6% were screened for syphilis at least once, and 95.1% resided in a state requiring syphilis testing during pregnancy. The highest percentage of pregnant women was screened during the third trimester, and the majority of those screened received at least 2 tests during pregnancy. Women in states with laws had 14% greater odds for receiving any screening during pregnancy. DISCUSSION:Despite Centers for Disease Control and Prevention syphilis screening recommendations, only 79.6% received screening among this insured population. Effective communication on the importance of syphilis screening for all medical providers and their patients may increase the screening rates and decrease the incidence of CS.

Objectives. To estimate the association of state policies that define prenatal substance use as child abuse and mandate that health care professionals report prenatal substance use to child protective services with congenital syphilis case rates. Methods. We used 2018 to 2022 US data on congenital syphilis case notifications to the National Notifiable Diseases Surveillance System. We conducted linear regression with a generalized estimating equation approach to compare congenital syphilis case rates in states with a child abuse policy only, a mandated reporting policy only, and both polices to rates in states with neither policy. Results. After adjustment for confounders, the rate of congenital syphilis cases was, on average, 23.5 (95% confidence interval = 2.2, 44.8) cases per 100 000 live births higher in states with both a child abuse policy and a mandated reporting policy for prenatal substance use than in states with neither policy. Rates were similar in states with a child abuse policy only and a mandated reporting policy only compared to states with neither policy. Conclusions. The combination of state child abuse policies and mandated reporting policies for prenatal substance use potentially contributes to higher congenital syphilis case rates. ( Am J Public Health. Published online ahead of print February 13, 2025:e1–e9. https://doi.org/10.2105/AJPH.2024.307951 )

We examined the relationship between local health department sexually transmitted disease (STD) program staffing and budget changes and county-level sociodemographic characteristics. We found 2 population-level sociodemographic characteristics associated with STD budget cuts. Although staffing cuts were observed, none of the sociodemographic characteristics examined were associated with STD staffing cuts.

We examined the relationship between Local Health Department STD program staffing and budget changes and county-level sociodemographic characteristics. We found two population-level sociodemographic characteristics associated with STD budget cuts. Although staffing cuts were observed, none of the sociodemographic characteristics examined were associated with STD staffing cuts.

OBJECTIVE:To characterize the landscape of policies that determine eligibility for family planning services through Medicaid programs and describe trends in eligibility and its determinants over time. DATA SOURCES AND STUDY SETTING:Secondary data were collected for all states in the United States for the years 2008 through 2023. Data on economic and demographic characteristics came from the American Community Survey (ACS). STUDY DESIGN:Our descriptive study characterized state adoptions of Medicaid family planning section 1115 waivers and state plan amendments (SPA) and their eligibility criteria. We then estimated the proportion of women aged 19-44 years who were eligible for family planning services through Medicaid and identified the key determinants of changes in eligibility, by state and year. DATA COLLECTION/EXTRACTION METHODS:Information on state Medicaid policies was extracted from documentation on the Centers for Medicare & Medicaid Services website. When estimating the eligible population sizes, the denominator was women aged 19-44 years, the group most likely to be eligible for Medicaid family planning programs. Supplemental data on program enrollment or utilization were collected from states' websites and reports. PRINCIPAL FINDINGS:Though eligibility limits for family planning through Medicaid generally increased over time, the proportion of women aged 19-44 years eligible for at least limited benefits decreased from 45.0% in 2012 to 39.4% in 2022, largely because of increases in household income. Trends varied considerably across states and by eligibility pathway. Among women with incomes below the poverty level, the proportion who were not eligible for Medicaid family planning services decreased from 6.3% in 2013 to 1.5% in 2022. CONCLUSIONS:Our data demonstrated substantial geographic and temporal variation in eligibility for family planning services through Medicaid. We identified key drivers of eligibility changes that may have important implications for health services analyses of means-tested public programs.

Background The functions of disease intervention specialists (DIS) represent core infectious disease control practices and have legal foundations in the United States. Although important for state and local health departments to understand this authority, these policies have not been systematically collected and analyzed. We analyzed the authority for investigation of sexually transmitted infections (STIs) across all 50 US states and the District of Columbia. Methods In January 2022, we collected state policies addressing the investigation of STIs using a legal research database. We coded these policies into a database on variables of interest: (1) whether the policy authorized/required investigation, (2) what type of infection triggers an investigation, (3) and the entity who is authorized/required to perform the investigation. Results All 50 US states and District of Columbia explicitly authorize/require investigation of cases of STI. Of these jurisdictions, 62.7% require investigations, 41% authorize investigations, and 3.9% both authorize and require investigations. Sixty-seven percent authorize/require investigations for cases of communicable disease (inclusive of an STI), 45.1% authorize/require investigations for cases of STIs generally, and 3.9% authorize/require investigations for cases of a specific STI. Eighty-two percent of jurisdictions authorize/require the state to investigate, 62.7% authorize/require local governments to investigate, and 39.2% authorize/require investigations by both state and local governments. Conclusions State laws that establish authority or duties regarding the investigation of STIs differ across states. It may be useful for state and local health departments to examine these policies relative to the morbidity of their jurisdiction and their STI prevention priorities.

Congenital syphilis (CS) is on the rise in the United States and is a growing public health concern. CS is an infection with Treponema pallidum in an infant or fetus, acquired via transplacental transmission when a pregnant woman has untreated or inadequately treated syphilis. Pregnant women with untreated syphilis are more likely to experience pregnancies complicated by stillbirth, prematurity, low birth weight, and early infant death, while their children can develop clinical manifestations of CS such as hepatosplenomegaly, bone abnormalities, developmental delays, and hearing loss. One of the ways CS can be prevented is by identifying and treating infected women during pregnancy with a benzathine penicillin G regimen that is both appropriate for the maternal stage of syphilis and initiated at least 30 days prior to delivery. In this article we discuss many of the challenges faced by both public health and healthcare systems with regards to this preventable infection, summarize missed opportunities for CS prevention, and provide practical solutions for future CS prevention strategies.

Background and Objective: Community mitigation strategies could help reduce COVID-19 incidence, but there are few studies that explore associations nationally and by urbanicity. In a national county-level analysis, we examined the probability of being identified as a county with rapidly increasing COVID-19 incidence (rapid riser identification) during the summer of 2020 by implementation of mitigation policies prior to the summer, overall and by urbanicity. Methods: We analyzed county-level data on rapid riser identification during June 1?September 30, 2020 and statewide closures and statewide mask mandates starting March 19 (obtained from state government websites). Poisson regression models with robust standard error estimation were used to examine differences in the probability of rapid riser identification by implementation of mitigation policies ( P-value .05); associations were adjusted for county population size. Results: Counties in states that closed for 0?59 days were more likely to become a rapid riser county than those that closed for 59 days, particularly in nonmetropolitan areas. The probability of becoming a rapid riser county was 43% lower among counties that had statewide mask mandates at reopening (adjusted prevalence ratio = 0.57; 95% confidence intervals = 0.51?0.63); when stratified by urbanicity, associations were more pronounced in nonmetropolitan areas. Conclusions: These results underscore the potential value of community mitigation strategies in limiting the COVID-19 spread, especially in nonmetropolitan areas. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/4.0/ )

Context: Sexually transmitted infections (STIs) continue to increase in the United States. Publicly funded sexually transmitted disease (STD) clinics provide important safety net services for communities at greater risk for STIs. However, creating financially sustainable models of STI care remains a challenge. Objective: Characterization of clinic insurance billing practices and patient willingness to use insurance. Design: Cross-sectional survey assessment of clinic administrators and patients. Setting: Twenty-six STD clinics and 4138 patients attending these clinics in high STD morbidity metropolitan statistical areas in the United States. Participants: Clinic administrators and patients of these clinics. Intervention: Survey assessment. Main Outcome Measure: Insurance billing practices of STD clinics and patient insurance status and willingness to use their insurance. Results: Fifteen percent of clinics (4/26) indicated that they billed only Medicaid, 58% (15/26) billed both Medicaid and private insurance, 27% (7/26) did not bill for any health insurance, and none (0%) billed only private health insurance companies. Of 4138 patients surveyed, just more than one-half of patients (52.6%) were covered by some form of health insurance. More than one-half (57.2%) of all patients covered by health insurance indicated that they would be willing to use their health insurance for that visit. After adjusting for patient demographics and clinic characteristics, the patients covered by government insurance were 3 times as likely (odds ratio: 3.16; 95% confidence interval, 2.44-4.10) than patients covered by private insurance to be willing to use their insurance for their visit. Conclusion: Opportunities exist for sustainable STI services through the enhancement of billing practices in STD clinics. The STD clinics provide care to large numbers of individuals who are both insured and who are willing to use their insurance for their care. As Medicaid expansion continues across the country, efforts focused on improving reimbursement rates for Medicaid may improve financial sustainability of STD clinics.

Chlamydia, gonorrhea, and syphilis are all detectable and treatable, yet rates of these 3 bacterial sexually transmitted infections (STIs) are soaring in the United States.1 If left untreated, both chlamydia and gonorrhea can lead to costly and burdensome complications, including pelvic inflammatory disease and infertility.2,3 Untreated primary syphilis can lead to severe sequelae including death, and congenital syphilis can lead to miscarriage, stillbirth, prematurity, low birthweight, and death.4,5 People who develop these complications because of untreated STIs have high medical costs throughout their lifetime.6,7 Although rates of chlamydia, gonorrhea, and syphilis have been rising among all racial/ethnic groups, African American and Latinx people have persistently higher burdens of infection than White people.8 STIs are also associated with an increased risk of acquisition and transmission of HIV. Their effect on the HIV epidemic is substantial: a 2019 study estimated that 1 in 10 HIV infections among men who have sex with men in the United States is attributable to chlamydia and gonorrhea infection.9 In response to these challenges, the US Department of Health and Human Services released its first-ever STI Federal Action Plan in December 2020.10 The Medicaid program could be a crucial partner in implementing that strategy. Medicaid covers 73 million people and is the dominant payer for family planning services and prenatal care for lowincome women.11,12 In addition, Medicaid eligibility overlaps with critical markers for STI risk; for example, a 2013 study found elevated STI risk among young adults at lower income levels compared with young adults at higher income levels.13 The program is already playing an important role: Medicaid pays for a disproportionate share of STIrelated visits compared with other payers, and people with Medicaid or other public health insurance are more likely to receive STI screening than people with private or no health insurance.14,15 However, more work needs to be done. An enhanced focus on STIs through the Medicaid program could have a substantial effect on the STI epidemic. Medicaid’s role will be particularly important in light of policy shifts in the Title X federal family planning program, a major funder of STI and other reproductive health services. Recent regulatory changes in program scope and structure have led hundreds of health departments, nonprofit organizations, and community health centers to withdraw from the program rather than adapt their services to the new requirements.16,17 A team of researchers from the George Washington University School of Public Health recently completed a research project for the Centers for Disease Control and Prevention (CDC), Division of STD Prevention, that identified ways to expand access to STI screening and treatment services through the Medicaid program. Focusing on 4 states with high STI rates, researchers at George Washington University spoke with Medicaid agency staff members, public health officials, STI service providers, and national experts in STIs and Medicaid. In addition, the team took a national perspective by reviewing a broad range of peerreviewed and policy documents. Because more than twothirds of Medicaid beneficiaries are enrolled in managed care,18 which offers opportunities and challenges for influencing the delivery of services, the team reviewed model contracts between states and Medicaid managed care organizations (MCOs).19 Drawing on that project’s findings, we offer a roadmap for state Medicaid agencies and Medicaid MCOs to initiate state-level actions to strengthen STI services. These step-bystep considerations are intended to guide collaborative efforts by public health agencies, Medicaid offices, and MCOs. A full report of the project’s findings is also available.19 985476 PHRXXX10.1177/0033354920985476Seiler et al article-commentary2021

Public Health Reports 2020, Vol. 135(Supplement 1) 32S-37S © 2020, Association of Schools and Programs of Public Health All rights reserved. Article reuse guidelines: sagepub. com/ journalspermissions DOI: 10. 1177/ 0033 3549 20931832 journals. sagepub. com/ home/ phr Using Mixed Methods and Multidisciplinary Research to Strengthen Policy Assessments Focusing on Populations at High Risk for Sexually Transmitted Diseases

Introduction: Chlamydia and gonorrhea are the most commonly reported notifiable infections in the U.S., with direct medical costs for the treatment of these infections exceeding $700 million annually. Medicaid currently covers approximately 80 million low-income Americans, including a high percentage of racial and ethnic minorities. Studies have shown that racial and ethnic minority populations, particularly those with low SES, are at an increased risk of acquiring a sexually transmitted disease. Therefore, as Medicaid expands, there will likely be a greater demand for sexually transmitted disease services in community-based physician offices. To determine demand for these services among Medicaid enrollees, this study examined how often Medicaid was used to pay for sexually transmitted disease services received in this setting. Methods: This study combined 2014 and 2015 data from the National Ambulatory Medical Care Survey and tested for differences in the proportion of visits with an expected payment source of Medicaid when sexually transmitted disease services were and were not provided. All analyses were conducted in October 2018. Results: During 2014-2015, an estimated 25 million visits received a sexually transmitted disease service. Medicaid paid for a greater percentage of sexually transmitted disease visits (35.5%, 95% CI=22.5%, 51.1%) compared with non-sexually transmitted disease visits (12.1%, 95% CI=10.8%, 13.6%). Logistic regression modeling, controlling for age, sex, and race of the patient, showed that visits covered by Medicaid had increased odds of paying for a sexually transmitted disease service visit (OR=1.97, 95% CI=1.12, 3.46), compared with other expected payment sources. Conclusions: Focusing sexually transmitted disease prevention in Medicaid populations could reduce sexually transmitted disease incidence and resulting morbidity and costs. (C) 2019 Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine.

PURPOSE:Primary and secondary (P&S) syphilis in men who have sex with men (MSM) has been increasing; however, there is a lack of research on geographic factors associated with MSM P&S syphilis. METHODS:We used multiple data sources to examine associations between social and environmental factors and MSM P&S syphilis rates at the state- and county-level in 2014 and 2015, separately. General linear models were used for state-level analyses, and hurdle models were used for county-level models. Bivariate analyses (P < .25) were used to select variables for adjusted models. RESULTS:In 2014 and 2015 state models, a higher percentage of impoverished persons (2014 β = 1.24, 95% confidence interval, 0.28-2.20; 2015 β = 1.19; 95% confidence interval, 0.42-1.97) was significantly associated with higher MSM P&S syphilis rates. In the 2015 county model, policies related to sexual orientation (marriage, housing, hate crimes) were significant correlates of MSM P&S syphilis rates (P < .05). CONCLUSIONS:Our state-level findings that poverty is associated with MSM P&S syphilis are consistent with research at the individual level across different subpopulations and various sexually transmitted diseases. Our findings also suggest that more research is needed to further evaluate potential associations between policies and sexually transmitted diseases. Geographic-level interventions to address these determinants may help curtail the rising syphilis rates and their sequelae in MSM.

BACKGROUND:Criminal justice system involvement has been associated with health issues, including sexually transmitted disease. Both incarceration and sexually transmitted disease share associations with various social conditions, including poverty, stigma, and drug use. METHODS:United States state laws (including Washington, D.C.) regarding drug possession and consequences of drug-related criminal convictions were collected and coded. Drug possession policies focused on mandatory sentences for possession of marijuana, crack cocaine and methamphetamines. Consequences of drug-related convictions included ineligibility for public programmes, ineligibility for occupational licences and whether employers may ask prospective employees about criminal history. We analysed correlations between state sexually transmitted disease rates and percentage of a state's population convicted of a felony. RESULTS:First-time possession of marijuana results in mandatory incarceration in one state; first-time possession of crack cocaine or methamphetamines results in mandatory incarceration in 12 (23.5%) states. Many states provide enhanced punishment upon a third possession conviction. A felony drug conviction results in mandatory ineligibility for the Supplemental Nutrition Assistance Program and/or Temporary Assistance for Needy Families in 17 (33.3%) states. Nine (17.6%) states prohibit criminal history questions on job applications. Criminal convictions limit eligibility for various professional licences in all states. State chlamydia, gonorrhoea and syphilis rates were positively associated with the percentage of the state population convicted of a felony (p < 0.05). CONCLUSION:While associations between crime, poverty, stigma and health have been investigated, our findings could be used to investigate the relationship between the likelihood of criminal justice system interactions, their consequences and public health outcomes including sexually transmitted disease risk.

Objectives This study assesses U.S. state laws related to prenatal syphilis screening, including whether these laws align with CDC screening recommendations and include legal penalties for failing to screen. Methods Statutes and regulations regarding syphilis screening during pregnancy and at delivery effective in 2016 were examined for all 50 U.S. states and the District of Columbia (DC). Targeted search terms were used to identify laws in legal research databases. The timing of the screening mandates for each state law was coded for: (1) first visit, (2) third trimester, and (3) delivery. Descriptive statistics were calculated to examine the number of states with each type of requirement and whether requirements adhered to the CDC STD treatment guidelines. Results Only six states (11.8%) do not require prenatal syphilis screening. Of states with screening requirements (n = 45), the majority (84.3%) require testing at first prenatal visit or soon after. 17 states (33.3%) require screening during the third trimester with five requiring screening only if the patient is considered at high risk. 8 (15.7%) states require screening at delivery with five requiring testing only if the woman is at high risk. 14 (27.5%) states include punishments for failing to screen (civil penalties, criminal penalties and license revocation). Conclusions for Practice Most states had prenatal syphilis screening requirements; a minority corresponded to or extended CDC recommendations. States vary in when they require testing, who must be tested, and whether a failure to screen could result in a punishment for the provider.

BACKGROUND:Health departments (HDs) cite state laws as barriers to billing third parties for sexually transmitted disease (STD) services, but the association between legal/policy barriers and third-party HD billing has not been examined. This study investigates the relationship between laws that may limit HDs' ability to bill, clinic perceptions of billing barriers, and billing practices. METHODS:Two surveys, (1) clinic managers (n = 246), (2) STD program managers (n = 63), conducted via a multiregional needs assessment of federally funded HD clinics' capacity to bill for STD services, billing/reimbursement practices, and perceived barriers were combined with an analysis of state laws regarding third-party billing for STD services. Statistical analyses examined relationships between laws that may limit HDs' ability to bill, clinic perceptions, and billing practices. RESULTS:Clinic managers reported clinics were less likely to bill Medicaid and other third parties in jurisdictions with a state law limiting their ability to bill compared with respondents who billed neither or 1 payer (odds ratio [OR], 0.31; 95% confidence interval [CI], 0.10-0.97) and cited practical concerns as a primary barrier to billing (OR, 2.83; 95% CI, 1.50-5.37). The STD program managers report that the staff believed that STD services should be free (OR, 0.34; 95% CI, 0.13-0.90) was associated with not billing (not sure versus no resistance to billing); confidentiality concerns was not a reported barrier to billing among either sample. CONCLUSIONS:Practical concerns and clinic staff beliefs that STD services should be free emerged as possible barriers to billing, as were laws to a lesser extent. Attempts to initiate HD billing for STD services may benefit from staff education as well as addressing perceived legal barriers and staff concerns.

PURPOSE:Adolescents' concerns about confidential service receipt have been linked to avoidance of sexual and reproductive healthcare. Healthcare system changes allowing young adults to remain on a parent's health insurance plan up to age 26 may have extended these concerns to young adults. This study examines: (1) The association between the relationship of young women to primary health plan policy holder (parent or self) on receipt of reproductive health services and chlamydia screening. (2)Changes, over time, in the proportion of young women who are parentally- versus self-insured. METHODS:Cross-sectional analysis of commercially insured young women (18-25) enrolled ≥330days in health plans included in the Truven Health MarketScan commercial claims and encounters database (2007-2014). RESULTS:Between 2010 and 2014, the proportion of parentally-insured young women increased significantly across all age groups (AOR = 4.32, CI = 4.29, 4.33). Compared to self-insured young women, parentally-insured young women were less likely to receive a reproductive health service (AOR = .66, CI = .66, .67) and sexually active parentally-insured young women were less likely to receive chlamydia testing (AOR = .75, CI = .75, .76) using their parent's insurance. CONCLUSIONS:Young women who are insured through a parent are less likely to receive reproductive health services or chlamydia testing using their parent's insurance, which could suggest that concerns about confidential receipt of health services may result in missed care. Various policies, including those related to explanation of benefits sent to a plan policy holder outlining services received, may affect the receipt of confidential healthcare by young adults.

Background Young adults, including college students, have higher rates of chlamydia than the general population. Patient-delivered partner therapy (PDPT) is a partner treatment option for sex partners of individuals diagnosed with chlamydia or gonorrhea. We examined college health center use of PDPT in a national sample of colleges. Methods During 2014 to 2015, we collected data from 482 colleges and universities (55% of 885 surveyed), weighting responses by institutional characteristics abstracted from a national database (eg, 2-year vs 4-year status). We asked whether the school had a student health center and which sexual and reproductive health (SRH) services were offered. We also assessed the legal and perceived legal status of PDPT in states where schools were located. We then estimated PDPT availability at student health centers and measured associations with legal status and SRH services. Results Most colleges (n = 367) reported having a student health center; PDPT was available at 36.6% of health centers and associated with perceived legality of PDPT in the state in which the college was located (odds ratio [OR], 4.63; 95% confidence interval [CI], 1.17–18.28). Patient-delivered partner therapy was significantly associated with availability of SRH services, including sexually transmitted disease diagnosis and treatment of STI (56.2% vs 1.1%), gynecological services (60.3% vs 12.2%), and contraceptive services (57.8% vs 7.7%) (all P < .001). Compared with schools taking no action, PDPT was more likely to be available at schools that notified partners directly (OR, 8.29; 95% CI, 1.28–53.85), but not schools that asked patients to notify partners (OR, 3.47; 95% CI, 0.97–12.43). Conclusions PDPT was more likely to be available in colleges that offered SRH services and where staff believed PDPT was legal. Further research could explore more precise conditions under which PDPT is used.

OBJECTIVE:In this study, we examined state-level monthly gonorrhea morbidity and assessed the potential impact of existing expedited partner therapy (EPT) laws in relation to the time that the laws were enacted. STUDY DESIGN:Longitudinal study. METHODS:We obtained state-level monthly gonorrhea morbidity (number of cases/100,000 for males, females and total) from the national surveillance data. We used visual examination (of morbidity trends) and an autoregressive time series model in a panel format with intervention (interrupted time series) analysis to assess the impact of state EPT laws based on the months in which the laws were enacted. RESULTS:For over 84% of the states with EPT laws, the monthly morbidity trends did not show any noticeable decreases on or after the laws were enacted. Although we found statistically significant decreases in gonorrhea morbidity within four of the states with EPT laws (Alaska, Illinois, Minnesota, and Vermont), there were no significant decreases when the decreases in the four states were compared contemporaneously with the decreases in states that do not have the laws. CONCLUSION:We found no impact (decrease in gonorrhea morbidity) attributable exclusively to the EPT law(s). However, these results do not imply that the EPT laws themselves were not effective (or failed to reduce gonorrhea morbidity), because the effectiveness of the EPT law is dependent on necessary intermediate events/outcomes, including sexually transmitted infection service providers' awareness and practice, as well as acceptance by patients and their partners.