By Kim Krisberg

Public health director Kerran Vigroux sounds almost matter-of-fact when she talks about having to shut down her department’s screening services for sexually transmitted diseases. As she talks about the prevention and education opportunities that packed up and left along with the testing services, there’s that familiar, barely audible public health tone to her voice — the one that says “this makes no sense at all.”

Vigroux directs public health services in the New Hampshire city of Nashua, and she isn’t alone in having to shutter her department’s STD services. New Hampshire legislators recently eliminated state funding for STD prevention and testing, leading to public health clinic closures in the city of Manchester as well. While the Nashua public health website advises residents to seek STD testing services via their primary care provider, at the local community health center or emergency department, Vigroux said there will be very real gaps that medical providers just aren’t equipped, positioned or able to fill.

“With public health, it’s that contact, it’s the grassroots, it’s the work that happens every day,” Vigroux told me. “It’s the face in your community that people know they can come to.”

About 1,000 people a year sought out free and confidential STD testing services at the Nashua public health clinic. They came from all walks of life, all races, ages and levels of income and education, Vigroux said. Along with the loss of clinical services, Vigroux said Nashua public health practitioners are losing an opportunity to impart health and prevention education, collect STD data and do contact tracing, which involves finding a person’s sexual partners and bringing them in for screening as well.

“Anytime you lose the opportunity to have one-on-one conversations with someone, the door to other opportunities is closed as well,” Vigroux said.

Unfortunately, the situation in Nashua isn’t too surprising considering national trends. According to a National Coalition of STD Directors survey, between 2008 and 2009, 69 percent of state and local STD programs reported funding cuts and 39 clinics supported by such programs had to close their doors. It’s a frustrating situation as demand for such services are only going up, the coalition reported. In terms of STD rates, data from the Centers for Disease Control and Prevention finds that while U.S. rates of gonorrhea have declined, rates for syphilis and chlamydia have gone up, though CDC said that the uptick in chlamydia is likely due to better screening efforts and not necessarily a true increase in disease. Overall, there are about 19 million new STD infections in the United States every year, with a health care price tag of more than $16 billion, CDC said.

“This is a big issue,” William Smith, executive director of the National Coalition of STD Directors, told me. “STD care is specialty care and people go to an STD clinic for a reason — they want confidentiality.”

STDs have a stigma and, regardless of a person’s insurance status, the diseases aren’t necessarily a topic people want to discuss with their primary care providers and have in their permanent records, which is why confidential public health services are critical to both treatment and prevention. To illustrate the point, Smith pointed to the Netherlands — home to universal health care and known for being sexually liberal — where there is still a functioning network of STD clinics because policy-makers recognized that having access to medical care does not mean people will ask their primary doctor for an STD test. He also noted that in Massachusetts, where budget cuts shuttered the state’s publically funded STD clinics, there’s been a dramatic uptick in reportable STDs despite the fact that the state is home to near universal insurance coverage. As New Hampshire’s Vigroux mentioned, the societal stigmas attached to STDs don’t discriminate, which breaks down any preconceived notions about those who access publicly funded STD services.

In general, Smith said he is worried that U.S. policy-makers will view the nation’s new health reform law as a substitute for public health services and use increasing insurance rates to justify continued cuts to public health budgets. This assumption that better access to medical care will displace the demand for free, confidential and non-judgmental STD services is simply not supported by the evidence, said Smith, adding that the challenges of “health care reform will either be a blessing or bring us a whole heap of trouble.”

“We’re only touching the tip of the deeper iceberg,” Smith said regarding diagnosing and treating STDs in the United States. “We have so much more to do.” And yet, he warned that we can expect to see more STD clinic closures in the future.

Kim Krisberg is a freelance reporter living in Austin, Texas, and has been writing about public health for almost a decade. While her education is in journalism, her heart is in public health.