Support Materials for Applicants for SHS

CDC-RFA-PS13-1308 Applicant Support Materials

Key Sexual Health Services (SHS)

Rationale:
In 2010, young people aged 13–24 accounted for 26% of all new HIV infections in the United States,1
and nearly half of the 19 million new sexually transmitted diseases (STD) reported each year are among
young people ages 15–24.2 Roughly 25% of women aged 14–19 have had a human papillomavirus
(HPV) infection, the most common STD, which is linked to negative health outcomes including genital
warts and cervical, vaginal, vulvar, anal, penile, and oral cancers. 3 Many adolescents engage in sexual
risk behaviors that can result in such unintended health outcomes. For example, among U.S. high
school students surveyed in 2011, almost half reported ever having had sex. Of those sexually active in
the previous 3 months, about a third did not use a condom. 4
Preventive services provided by medical providers can have a significant impact on reducing risk
behavior and the testing and treatment of infections to help stop the spread of STD and HIV. Several
official and national guidelines for adolescent preventive care specifically include recommendations for
the provision of sexual and reproductive health services for adolescents to attend to these health
problems and to provide preventive services5-8 including HIV testing beginning at age 13 in areas more
affected by HIV; gonorrhea and Chlamydia screening of sexually active females ages 25 and younger,
and Human Papilloma Virus vaccination beginning at ages 11-12. Guidelines for HIV and STD testing
emphasize adolescents because of the increased burden among this age group and the importance of
establishing a pattern of routine testing early in life.9-11 CDC guidelines recommend routine vaccination
of young adolescents12-13 against HPV, largely because first infection is often acquired shortly following
sexual initiation14 and because people have better immune response to HPV vaccine at younger ages.15
Schools in the United States have a critical role to play in facilitating delivery of such needed preventive
services for adolescents; schools have direct daily contact with more than 30 million adolescent
students16 and are an appropriate venue for HIV, STD, and teen pregnancy prevention programs.17
Many U.S. schools already have healthcare service infrastructure in place and can play an important
role in providing adolescents access to sexual health services. A recent census report indicated that
73,697 registered nurses work in schools,18 and approximately 2,000 school-based health centers
(SBHCs) serve at least one grade of adolescents (sixth grade or higher).19 There is evidence that such
resources have some impact on increasing adolescent use of sexual health services. For instance,
adolescents in a school with a school-linked clinic and on-campus counselors had a lower pregnancy
rate than students in a comparison school.17 There is also some evidence that a school-based referral
program helped school nurses connect students to adolescent-friendly community providers and
increased adolescent use of reproductive health services (contraception, STD testing, counseling),
especially among sexually active females.20
These resources, however, may be constrained by budgets, local policies on service provision, limited
staff, and other issues. A 2008 survey of school nurses found that less than half of schools have a fulltime registered nurse on staff, and most nurses serve multiple schools. In addition, students with
exceptional medical needs—whose numbers have been increasing—take up a major proportion of

CDC-RFA-PS13-1308 Applicant Support Materials

nurses’ time. The average number of total students served per nurse is 1,151.21 SBHCs are somewhat
limited in number and geographic location, and not all are permitted to provide on-site testing and
treatment for STDs (68%) or HIV testing (64%); about one third (60%) are prohibited from providing
contraceptive services.19
One way to help schools meet the physical health needs of students within these constraints is to
strengthen schools’ ability to provide services or to connect students to community resources. For
these reasons, one of DASH’s key programmatic strategies is to improve schools’ capacity to increase
adolescents’ access to key preventive sexual health services via either direct provision of on-site
services or referrals to adolescent-friendly community-based health service providers.
Definitions:
1. Key Sexual Health Services (SHS): For the purpose of this FOA, key SHS include anticipatory
guidance for prevention, including delaying the onset of sexual activity; promoting HIV and STD
testing, counseling, and treatment, and the dual use of condoms and highly effective
contraceptives among sexually active adolescents; HIV and STD testing, counseling, and
referral; pregnancy testing; and HPV vaccinations.
2. Linkage: For the purpose of this FOA, linkage describes an organizational partnership, whether
formal or informal, between schools and adolescent-friendly providers to improve student
access to preventive health services.
3. Referral: For the purpose of this FOA, the term “referral” is used to describe a process of
assisting students in obtaining preventive health services through a variety of activities,
including, but not limited to, connecting students to adolescent-friendly providers on the basis
of an identified need.
4. School-Based Health Centers (SBHC): According to 42 USCS § 1397jj [Title 42. The Public Health
and Welfare; Chapter 7. Social Security Act; Title XXI. State Children's Health Insurance
Program], school-based health center means “a health clinic that -- (i) is located in or near a
school facility of a school district or board or of an Indian tribe or tribal organization; (ii) is
organized through school, community, and health provider relationships; (iii) is administered by
a sponsoring facility; (iv) provides through health professionals primary health services to
children in accordance with State and local law, including laws relating to licensure and
certification; and (v) satisfies such other requirements as a State may establish for the
operation of such a clinic.”
5. School-Linked Health Centers (SLHC): Youth-focused health care programs (e.g., clinics, health
service providers) commonly characterized by the following attributes: are located off school
grounds; often serve more than one school; have established methods of referral,
communication, and follow-up with SBHC partners; often have extended hours beyond the
school day; and often provide a broader scope of services than those available through SBHC.22
6. Sexually Transmitted Disease (STD): A disease transmitted by sexual contact, such as syphilis,
gonorrhea, chlamydia, viral hepatitis, genital herpes, and trichomoniasis. Individuals who are

CDC-RFA-PS13-1308 Applicant Support Materials

infected with STD are at least two to five times as likely as uninfected individuals to acquire HIV
infection if they are exposed to the virus through sexual contact.23
7. Youth-Friendly Services: “Services with policies and attributes that attract young people to
them, create a comfortable and appropriate setting, and meet young people’s needs”.24 Youthfriendly services ensure confidentiality, respectful treatment, and delivery of culturally
appropriate care in an integrated fashion at no charge or low cost; and are easy for youth to
access.
Resources:
 Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in
Health-Care Settings
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm



CDC Vital Signs: HIV Among Youth in the US
http://www.cdc.gov/vitalsigns/HIVAmongYouth/



Fact Sheet on HIV Testing Among Adolescents: What Schools and Education Agencies Can Do
http://www.cdc.gov/healthyyouth/sexualbehaviors/pdf/hivtesting_adolescents.pdf



STD Treatment Guidelines, 2010, Special Populations (includes screening of adolescents)
http://www.cdc.gov/std/treatment/2010/specialpops.htm



How to Obtain Medicaid Funding for School-Based Services: A Guide for Schools in Systems of
Care Communities
http://www.tapartnership.org/docs/obtainingMedicaidFunding.pdf



CMS Medicaid School-based Administrative Claiming Guide
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Financing-andReimbursement/Downloads/2003_SBS_Admin_Claiming_Guide.pdf

References:
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CDC. Vital Signs: HIV infection, testing, and risk behaviors among youth – United States. MMWR 2012;61(47):971–
976. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6147a5.htm?s_cid=mm6147a5_w.
Weinstock H, Berman S, Cates W Jr. Sexually transmitted diseases among American youth: incidence and
prevalence estimates, 2000. Perspectives on Sexual and Reproductive Health 2004;36(1):6–10.
Dunne EF, Unger ER, Sternberg M, McQuillan G, Swan DC, Patel SS, et al. Prevalence of HPV infection among
females in the United States. Journal of the American Medical Association 2007;297(8):813–819.
CDC. Youth risk behavior surveillance—United States, 2011. MMWR 2012;61(SS-4). Available at
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U.S. Public Health Service. Clinician’s Handbook of Preventive Services: Put Prevention into Practice. 2nd edition.
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Elster AB, Kuznets NJ, editors. AMA Guidelines for Adolescent Preventive Services (GAPS): Recommendations and
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Screening for Gonnorhea, Topic Page. October 2011. U.S. Preventive Services Task Force. Available at
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Screening for Chlamydial Infection, Topic Page. June 2007. U.S. Preventive Services Task Force. Available at
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Winer RL, Feng Q, Hughes JP, O’Reilly S, Kiviat NB, Koutsky LA. Risk of female human papillomavirus acquisition
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Block S, Nolan T, Sattler C, Barr E, Giacoletti KED, Colin DM, et al. Comparison of the immunogenicity and
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United States Census Bureau. School Enrollment. U.S. Department of Commerce, Census Bureau Web site.
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Zabin LS, Hirsch MB, Smith EA, Streett R, Hardy JB. Evaluation of a pregnancy prevention program for urban
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