Vincent Guilamo-Ramos, MSN'17, incoming DUSON dean, contributed to Sexually Transmitted Infections: Adopting a Sexual Health Paradigm, which has now been released. 

Press Release

Despite Increasing Rates of STIs, Federal Investment Has Been Flat; Report Recommends Approach to Address Structural Drivers of STIs While Expanding No-Cost Care Services, New Vaccines and Diagnostics

Sexually transmitted infections (STIs) impose billions of dollars in medical costs in the U.S., but STI prevention and control is chronically underfunded, stigmatized, and siloed from efforts to promote overall health and well-being, says a new report from the National Academies of Sciences, Engineering, and Medicine. The report calls for modernizing national STI surveillance and monitoring systems, bolstering the STI workforce, developing and scaling up structural and behavioral interventions, and accelerating the development of vaccines, diagnostics, and therapeutics. Taking these strategic actions would also better position the U.S. to respond to COVID-19, HIV/AIDS, and future infectious disease outbreaks, the report says.

The prevention and control of STIs requires a more holistic approach that promotes sexual health and expands access to comprehensive prevention and treatment services — rather than focusing on individual behaviors or blaming people who acquire STIs, says Sexually Transmitted Infections: Adopting a Sexual Health Paradigm.

Despite the economic burden and alarming increase of STI rates over the last 20 years, the Centers for Disease Control and Prevention’s STI funding has remained flat. Although HIV is an ongoing and highly significant concern, the mandate of the committee that wrote the report was to focus its recommendations on STIs other than HIV, due to increasing rates of chlamydia, gonorrhea, and syphilis. However, the report discusses the interplay between HIV and other STIs, and ways HIV and STI services can collaborate or integrate their prevention, care, and research efforts.

One in five people in the United States will have an STI in a given year. Many cases can be asymptomatic, and therefore go undiagnosed and unreported. Left untreated, STIs can lead to chronic pelvic pain, infertility, miscarriage or newborn death, increased risk of HIV infection, genital and oral cancers, and neurological and rheumatological consequences. The COVID-19 pandemic has also set back efforts to control STIs, the report notes. People are delaying routine STI screenings and may have undiagnosed and more advanced cases. Furthermore, STI clinic staff and resources have been diverted to the COVID-19 response.

The report emphasizes the need for easier access points for STI care. Specifically, the U.S. Department of Health and Human Services (HHS) and state governments should ensure that STI prevention and treatment is available through multiple venues, such as comprehensive sexual health clinics, pharmacies, urgent care settings, and telehealth visits. These settings should also address concerns about confidentiality, particularly among adolescents and young adults on their parents’ health insurance plans.

HHS should also broaden no-cost care options for STI prevention and treatment, as many individuals experience financial barriers to STI services. The report recommends HHS consider implementing approaches such as Medicaid expansion incentives, expanding eligibility for Medicaid family planning services, and updating program guidance of the 340B Drug Pricing Program to expand access to HIV PrEP and expedited partner therapy (i.e., providing prescriptions to sex partners of individuals with STIs without a doctor visit).

“Although STIs are common, there is still pervasive blame, embarrassment, and shame attached to them. Instead, we should be framing sexual health as a key part of overall physical, mental, and emotional health,” said Sten Vermund, dean of the Yale School of Public Health and chair of the committee that wrote the report. “With the release of this report and the creation of the first-ever HHS STI National Strategic Plan in December 2020, we have many opportunities to address structural barriers to STI prevention and care, minimize exposure to STIs, and ensure that services are easily available in welcoming, stigma-free environments.”

The national response to STIs must also consider the root causes of poor health — racism, poverty, homophobia and transphobia, and a lack of access to medical care, education, and transportation. STI programs and services should prioritize the needs of marginalized communities, including youth, LGBTQ+ people, Black, Latino, and Indigenous communities, sex workers, incarcerated people, and people living with mental health and substance use disorders. Faith organizations, barbershops, and local sports leagues are just a few examples of trusted, culturally relevant community venues that could help reach underserved populations and disseminate educational resources.

The report recommends several additional actions to improve STI control for the future:

• Build the pipeline of STI diagnostics and treatments: Given growing concerns about antimicrobial resistance, the National Institutes of Health (NIH) should promote public-private partnerships to develop new antimicrobials for STI treatment, and expedite development of vaccines for prevention of chlamydia, gonorrhea, syphilis, and herpes. NIH should also prioritize development of rapid point-of-care diagnostic tests and improved diagnostics for syphilis that distinguish untreated, active infection from previously treated infection.

• Support the workforce and unify STI/HIV and COVID-19 services: The STI workforce has deep expertise in infectious diseases that require testing, treatment, and partner notification — key components of the COVID-19 response. Unifying STI/HIV and COVID services would cultivate a workforce that can address these current crises and pivot to respond to infectious disease outbreaks. CDC should also identify federal and state policy actions that would remove practice barriers so more providers can deliver STI services. The existing health care infrastructure could draw on an estimated 600,000 primary care doctors, 3.5 million nurses, 300,000 community pharmacists, and hundreds of thousands of behavioral health practitioners, the report says. Relevant licensing bodies should also formulate a minimum sexual-health skill set that is reflected in provider training programs.

• Engage parents and guardians: Despite their influence on decision-making, parents receive little guidance on how to talk to their children about sexual health, the report says. The CDC’s Division of Adolescent and School Health should partner with parents, parent-teacher associations, and school boards to establish guidelines for school-based sexual health education that are evidenced-based, medically accurate, age-appropriate, and culturally inclusive. Providers should also receive training on facilitating discussions about sexual health between parents and their children.

• Harness big data and artificial intelligence (AI): AI holds the potential for enhancing the STI response. AI can comb through massive amounts of data from electronic health records, insurance claims databases, search engines, social media, and dating apps to predict local rates of STIs, spot trends in risk factors to better tailor interventions, and flag online misinformation. CDC should recruit digital behavior change and data science professionals to inform future efforts.

• Leverage apps and social media: Some might worry that the advent of social media platforms and dating apps has elevated STI risks. However, these platforms can be leveraged to prevent STIs, speed diagnosis, and lead people to treatment. For example, dating apps could host targeted ads for STI testing and include fields for testing status and timing. Digital contact tracing and exposure notification apps — which have become commonplace during COVID — could be used for STI prevention and control.

The report acknowledges the important leadership and commitment of the CDC and its state, local, and tribal health department partners. It recommends actions that CDC can take to update existing STI programs and services, apply lessons learned from HIV and the COVID-19 response, and provide more prescriptive accountability targets for state and local grantees.

The study — undertaken by the Committee on Prevention and Control of Sexually Transmitted Infections in the United States — was sponsored by the Centers for Disease Control and Prevention through the National Association of County and City Health Officials. The National Academies are private, nonprofit institutions that provide independent, objective analysis and advice to the nation to solve complex problems and inform public policy decisions related to science, technology, and medicine. They operate under an 1863 congressional charter to the National Academy of Sciences, signed by President Lincoln.