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The viruses that cause herpes and human papilloma virus disease have been implicated as one of the cofactors in causing cervical dysplasia, which is a precursor toward carcinoma of the cervix. Whether this proves to be a preventable situation we as yet do not know.

But one of the few preventable causes of infertility is pelvic inflammatory disease when it is caused by an undetected sexually transmitted disease. Almost 150,000 women are stricken with infertility each year because of these sexually transmitted diseases. Most of them are due to gonorrhea and to chlamydia. By treating the STD's,

we can also prevent many cases of infant mortality and disability. If an infected woman passes a sexually transmitted disease to her child during pregnancy or delivery, that child can suffer serious physical and mental damage, even death.

The cases of congenital syphilis continue to rise across the country, with 7,000 cases last year. Untreated, syphilis in mothers results in two-thirds of the babies being stillborn and the survivors are damaged, many to the point of death.

The relationships of the STD's and the increased susceptibility to HIV infection seems quite strong in Africa. This association is now beginning to appear in the United States, particularly in the inner cities. Many health professionals believe that an important element of a program to control the spread of HIV is a stepped up program to control other sexually transmitted diseases.

You asked Dr. David about the coordination between AID, the World Health Organization, and many of the things in the Public Health Service. I think this is a good example of where that coordination is working. The techniques of venereal disease control that have been developed in centers in this country, many of them supported by NIH research grants, are now being applied in Africa both by programs funded by AID and by the World Health Organization, trying to determine whether doing something about venereal disease or sexually transmitted disease can prevent HIV infection.

The problem of the sexually transmitted diseases has become so acute that this year a group of national organizations with special interest in disease prevention has highlighted the need to increase our efforts to prevent the spread of STD's and their devastating impact on the lives of people.

As the president of the American Public Health Association mentioned in his testimony earlier today, the American Social Health Association is part of the APHA coalition that has made the recommendation that a $37 million increase in the Centers for Disease Control budget be earmarked for sexually transmitted disease, with $12 million of that going for the control of syphilis and $25 million for the control of infertility, chlamydia, and gonorrhea activities.

It is strongly urged that, of that total amount of $37 million, $3 million be set aside for the maintenance of the programs, the internal programs on sexually transmitted disease activity at the Centers for Disease Control.

The coalition recommends $64 million, an increase of $24 million, for the National Institute of Allergy and Infectious Disease. This increase would allow for expanded research in pelvic inflammatory disease, the development of less expensive testing methods for the STD's, and studies of the human papilloma virus that I mentioned earlier and its relationship to cancer, as well as further investigations on the relationship of HIV and STD's.

PREPARED STATEMENT I know that this committee shares our concern, as they have in the past, about the spread of all of the STD's, and it is for this reason that we urge that both the research efforts and the prevention actions of the Federal Government be given the support requested above.

Again, I thank you for this opportunity to appear before you and I would be glad to try and answer any questions you may have, sir.

Senator INOUYE. Thank you very much. [The statement follows:)

STATEMENT OF DR. DAVID J. SENCER My name is David Sencer and I am president of the Board of Directors of the American Social Health Association, the only non-profit organization dedicated solely to the control of all sexually transmitted diseases (STD's). For 75 years, ASHA has provided information and referral services, education facilities and research funds to aid the millions of Americans who contract a STD each year. It is my pleasure to appear before this Subcommittee to offer ASHA's views on funding for the Centers for Disease Control's Division of STD/HIV Prevention and the National Institute of Allergy and Infectious Diseases's STD Branch.

ASHA's activities include running the AIDS hotline, under contract from the federal government, and several other STD hotlines. Our staff speaks with thousands of people each day to offer much needed information and counseling. In addition, as past Di or of the Cen

Disease Control, I have worked with STD clinics throughout the country, and I can tell you first-hand that, contrary to popular belief, STD's do not just affect the urban poor. They affect people from all age groups and from all backgrounds taking their greatest toll on women, babies, minorities, adolescents and college students. Further, many are surprised to learn that STD's are not minor medical problems. They can have horrifying consequences—they can cause brain damage, physical deformities, sterility, even death. As I will outline in my statement, what is particularly tragic is that we have the ability to prevent these outcomes but often fail to do so because of inadequate resources.

What if I told this Subcommittee that I know a way to prevent AIDS cases? I bet this subcommittee and many others would jump at the chance to do so. You may be surprised to learn that by preventing the spread of syphilis, we can reduce the spread of AIDS. Studies have shown that the large number of syphilis cases among homosexual white men in the early 1980s was a strong indicator for the rapid spread of AIDS among this population that occurred a few years later. We have strong circumstantial evidence that those same people who have syphilis have a good chance of getting AIDS. And in 1991, these people are primarily heterosexual minorities. There were over 100,000 cases of syphilis reported last year representing a 50 percent jump from five years ago. In Mississippi, for example, the number of reported early syphilis cases jumped 53 percent in only the first six months of 1990, and Arkansas suffered a 37 percent increase in 1990. We know how to prevent the spread of syphilis and if adequate resou ræs are provided, we can prevent tens of thousands of AIDS cases.

In addition to syphilis, we have learned that the presence of other STD's has been shown to increase the chances of acquiring HIV. STD's that cause genital ulcers create an environment favorable to the introduction of HIV. This is both positive and negative news. On the one hand, it is a great relief to be able to identify groups that can be targeted for HIV prevention. On the other hand, over 10 million Americans have STD's that cause genital ulcers, and it is frightening to realize that, given the current budget for STD prevention, many of these people will not be reached.

By tackling STD's, not only can we prevent many cases of AIDS, we can also prevent many cases of infant mortality and infertility. If an infected woman passes a STD on to her child during pregnancy or delivery, the child can suffer serious physical and mental damage, even death. Such cases are currently on the rise. The number of cases of congenital syphilis has increased dramatically from less than 300 cases reported in the early 1980's to over 7,000 cases reported in 1990-a 23-fold increase. If left untreated, congenital syphilis can kill the newborn. What is most disturbing is that congenital syphilis is preventable if the pregnant women receive treatment sufficiently in advance of delivery. Other STD's that severely damage or kill infants include chlamydia, genital herpes, and the human papillomavirus-the latter two being viruses which an estimated 30 to 40 million Americans carry today. Again, if these diseases were detected and treated early in women, thousands of babies could be spared.

We can also prevent a sizeable portion of infertility cases by controlling the spread of STD's. In fact, the only preventable cause of infertility is the complication of pelvic inflammatory disease (PID), which is often caused by an undetected STD. Almost 150,000 women are stricken with infertility each year because of STD-related PID, particularly from chlamydia, which often has no symptoms, or gonorrhea. In some areas of the country, the risk of infertility from STD infection may prove quite devastating. In Pennsylvania, approximately 15 percent of adolescents tested had chlamydia. In Iowa, 11 percent of women tested at family planning clinics had chlamydia. Such cases in women need to be identified quickly, as early treatment for these thousands of women is their best chance of avoiding infertility and having the chance to bear a child later in their lives.

STD's have also been associated with several forms of cancer. Scientists have found that up to 90 percent of cervical cancer cases are associated with the human papillomavirus (HPV). This is particularly dangerous because HPV-infected women often show no visible symptoms, making the disease difficult to detect absent regu. lar screening. Other cancers thought to be related to HPV are vulvar cancer and cancer of the penis.

Preventing STD's will also save tremendously on health care costs. Studies conducted by the National Academy of Sciences and the Institute of Health Policy Studies of the University of California at San Francisco estimate the annual costs of gonorrhea at $1 billion, chlamydia at $2.4 billion and PID caused by gonorrhea, chlamydia or other organisms at $4.2 billion. In contrast, current funding for the CDC's Division of STD/HIV Prevention is at $85.1 million.

Current efforte at CDC have already prevented thousands of additional cases of STD's and saved significantly on related health care costs. Intervention efforts have prevented over 50,000 cases of chlamydia and over 60,000 cases of gonorrhea at a total savings of $38.5 million. Over 17,000 cases of STD-related pelvic inflammatory disease were prevented in 1990 saving $75 million. Efforts geared towards syphilis control have prevented an estimated 12,000 new infections saving over $10 million. Total estimated savings from STD prevention activities in 1990 come to $127.6 million. In fiscal year 1990, the federal government spent $81.3 million on STD prevention. That means that for every two dollars spent by the federal government, three are saved.

Inadequate funding is hurting treatment efforts as well as prevention. For example, every month in Texas over 2,000 people are turned away from an STD clinic because there just aren't enough resources to care for them. In Pennsylvania, over 1,000 people must be turned away each month. In California, an outreach program succeeded in bringing pregnant women at risk for syphilis to STD clinics. Unfortunately, in just one day, 13 of these women could not get into the clinic because of overcrowding.

The STD problem has become so acute that this year a varied group of organizations with special interest in preventing the spread of STD's and their devastating impact on the lives of people of all socio-economic groups have united. The group is recommending specific levels of funding for the SŤD prevention and control program of the CDC and the STD research

program

at NIH. For fiscal year 1992, the American Social Health Association endorses the following recommendations of the STD Coalition: -For the STD/HIV Prevention Division of CDC, we recommend $122 million, a

$37 million increase above the current year. Of this, $12 million would go towards control of syphilis, which as I stated above, was diagnosed in over 7,000 newborn infants last year alone. In addition, $25 million would go for infertility

prevention, specifically focused on control of chlamydia and gonorrhea. -For the STD Branch of the National Institute of Allergy and Infectious Dis. eases, we recommend $66.4 million, an increase of $24.2 million over fiscal year 1991. This increase would allow for expanded research on pelvic inflammatory disease, the development of less expensive STD diagnostic tests, studies of human papillomavirus and its relationship to cancer, and the further investigation of the relationship of HIV and other STD's. I hope that this subcommittee shares our concern about the spread of all sexually transmitted diseases and that you will support increased funding for the STD prevention and research programs. Thank you for the opportunity to express the views

of the American Social Health Association. I would be happy to answer any questions.

Senator INOUYE. I think in some way we Americans have succeeded in convincing ourselves that we have found the cure for syphilis and gonorrhea, all these miracle drugs. And we may have to go on a campaign again to tell the folks that there is danger lurking around here.

When did we first come across chlamydia?

Dr. SENCER. The chlamydias have been around a long time, but they have been very difficult to diagnose. The laboratory methods have been very cumbersome and it has only been within the last 5 to 8 years that there has been a relatively simple laboratory test available.

It still is not an instant test. So many of the problems in the control of the sexually transmitted diseases is that you test today and do not get the answer back for 3 to 5 days. It would be nice if you could get the answer at the time, so that you could treat the people who are in need of treatment.

This is one of the reasons that we are urging increased support for the National Institute of Allergy and Infectious Disease, to try and find tests that will shorten this diagnostic time.

Before they were called chlamydias, they were called mycoplasma, and are a cause of pneumonia in children as well as sexually transmitted disease.

Senator INOUYE. This chlamydia just has this negative effect upon women and not on men?

Dr. SENCER. It is a silent infection in men usually. There have been many cases reported of what they call a nongonococcal urethritis, which is a discharge from which they cannot identify gonorrhea. It used to be thought that all of the male discharges, penile discharges, were caused by gonorrhea. Now they know that many of them are not, and chlamydia is becoming more and more associated with those.

It is a relatively minor affliction for men, but as long as men are infected they can continue to pass it on. So unfortunately the woman is again the victim, as she is in so many of the problems. She remains asymptomatic until she gets the complications.

Senator INOUYE. Well, I will most certainly discuss this matter with my colleagues on this committee, because I am old enough to remember in World War II the War Department required every man and woman in uniform whenever he or she went out on pass to have available condoms. You do not have that rule any more.

Dr. SENCER. No, sir; I well remember that, too. I was a pharmacist's mate in the Navy and had to stand duty at the prophylaxis stations at Mare Island on sailors coming back from their liberties. It is not a pleasant memory.

Senator INOUYE. Well, apparently we convinced ourselves that there is no problem any more.

Dr. SENCER. Right.

Senator INOUYE. Well, we will do our best to get the danger flag out again.

Dr. SENCER. Fine.
Senator INOUYE. Thank you very much.
Dr. SENCER. Thank you very much, sir.

SUBCOMMITTEE RECESS

Senator INOUYE. The subcommittee will stand in recess until tomorrow morning at 9:30 a.m., Thursday, April 25, when we will meet in SD-192 to continue our public witness hearings on the administration's fiscal year 1992 budget request.

[Whereupon, at 3:06 p.m., Wednesday, April 24, the subcommittee was recessed, to reconvene at 9:30 a.m., Thursday, April 25.]

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