Integration of Surveillance for STDs, HIV, Hepatitis, and TB: A Survey of U.S. STD Control Programs

Public health surveillance is “the ongoing systematic collection, analysis, and interpretation of outcome-specific data for use in planning, implementation, and evaluation of public health practice.”1 In the United States, surveillance systems generally focus on specific diseases and do not integrate information about different diseases at individual or population levels. This silo approach to disease surveillance has several benefits (e.g., data collection tailored appropriately to different disease processes, logistical simplicity based on following the organization of programs, funding, and subject matter expertise),2 but this approach has disadvantages as well. While many public health programs are organized around disease entities, most reporters of surveillance information (e.g., emergency room physicians and laboratories) are not. Redundancies and variation in data collection for different infections may create reporting burdens. In addition, individuals and populations are not limited in susceptibility to single diseases and can face multiple health threats with potentially synergistic effects. Some populations may be especially vulnerable to more than one infection. For example, men who have sex with men (MSM) and injection drug users (IDUs) have elevated incidences of sexually transmitted diseases (STDs), human immunodeficiency virus (HIV), and hepatitis; immigrants may face higher risks for tuberculosis (TB) and hepatitis; and prisoners are at risk for STDs, HIV, and TB. Separate surveillance systems may lead to missed opportunities to prioritize effective interventions. For example, other STDs may facilitate HIV transmission.3 Bacterial STDs among HIV-infected individuals suggest recent unprotected sex and can help identify where interventions might prevent new HIV infections. Co-infection alters treatment recommendations because of changes in clinical course and effects of treatment on drug resistance. These issues may be particularly important in international settings where limited resources for testing and clinical management mean country-specific regimens for HIV treatment are implemented without knowledge of other infections. Integrated surveillance might guide more effective and efficient public health action. Because STDs, HIV, and hepatitis can be spread by the same behaviors and limited by similar prevention messages and activities, public health resources (e.g., testing, counseling, and partner services) may be pooled. New services could also be offered for people with repeated or multiple infections. Such individuals may compose core groups among whom interventions would be most efficient in preventing new infections. Program collaboration and service integration for different infections is a priority for the Centers for Disease Control and Prevention's (CDC's) National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention.4 Several state and local programs have already integrated STD, HIV/AIDS, hepatitis, and/or TB prevention and control activities within the same administrative and programmatic infrastructure.2,5–7 The Outcome Assessment through Systems of Integrated Surveillance (OASIS) workgroup was established to promote innovative surveillance methods among STD programs, including integrated interpretation and use of surveillance data to improve public health programs.8 It is not known how many STD programs use integrated surveillance to guide program activities or how comprehensively surveillance is integrated within different programs. Providing effective, appropriately integrated services requires data about overlapping infections in each community. For example, there is evidence that adults seen in STD clinics are at sufficiently high risk for hepatitis B to justify vaccination;9 whether screening all STD clinic patients for hepatitis C is efficient depends on local data.10 Some questions may be resolved by limited special studies. However, for responsive interventions to evolving epidemics, and for continuing evaluation of interventions, ongoing surveillance is needed. We sought to determine the current level of surveillance integration in local STD control programs, to learn when integration has been useful, and to identify barriers to increased integration.