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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Sten H. Vermund, Amy B. Geller, and Jeffrey S. Crowley, Editors Committee on Prevention and Control of Sexually Transmitted Infections in the United States Board on Population Health and Public Health Practice Health and Medicine Division A Consensus Study Report of PREPUBLICATION COPY—Uncorrected Proofs

THE NATIONAL ACADEMIES PRESS   500 Fifth Street, NW   Washington, DC 20001 This activity was supported by a contract between the National Academy of Sciences and the Centers for Disease Control and Prevention through the National Association of County and City Health Officials (#2019-011503). Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13: 978-0-309-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/25955 Library of Congress Control Number: 2021935093 Additional copies of this publication are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2021 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2021. Sexually transmitted infections: Adopting a sexual health paradigm. Washington, DC: The National Academies Press. https://doi.org/10.17226/25955. PREPUBLICATION COPY—Uncorrected Proofs

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org. PREPUBLICATION COPY—Uncorrected Proofs

Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo. PREPUBLICATION COPY—Uncorrected Proofs

COMMITTEE ON PREVENTION AND CONTROL OF SEXUALLY TRANSMITTED INFECTIONS IN THE UNITED STATES STEN H. VERMUND (Chair), Dean and Anna M.R. Lauder Professor of Public Health, Yale School of Public Health; Professor of Pediatrics, Yale School of Medicine, Yale University MADINA AGÉNOR, Gerald R. Gill Assistant Professor of Race, Culture, and Society, Department of Community Health, Tufts University CHERRIE B. BOYER, Professor and Associate Director for Research and Academic Affairs, Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco MYRON S. COHEN, Yeargan-Bate Professor of Medicine, Microbiology, and Epidemiology; Associate Vice Chancellor for Medical Affairs and Global Health; Director, Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill JEFFREY S. CROWLEY, Program Director, Infectious Disease Initiatives, Adjunct Professor of Law, O’Neill Institute for National and Global Health Law, Georgetown University CHARLOTTE A. GAYDOS, Professor Emerita, Former Director, Johns Hopkins University Center for Development of Point-of-Care Tests for Sexually Transmitted Infections, Division of Infectious Diseases, Medicine, Johns Hopkins University VINCENT GUILAMO-RAMOS, Professor and Associate Vice Provost of Mentoring and Outreach Programs, Director and Founder, Center for Latino Adolescent and Family Health, New York University EDWARD W. HOOK III, Emeritus Professor of Infectious Disease, Department of Medicine, The University of Alabama at Birmingham PATRICIA KISSINGER, Professor, School of Public Health and Tropical Medicine, Associate Dean for Faculty Affairs and Development, Tulane University GUILLERMO (“WILLY”) J. PRADO, Vice Provost, Faculty Affairs, Dean, Graduate School, Professor, Nursing and Health Studies, University of Miami CORNELIS (“KEES”) RIETMEIJER, President, Rietmeijer Consulting, LLC ALINA SALGANICOFF, Senior Vice President and Director, Women’s Health Policy, Kaiser Family Foundation JOHN SCHNEIDER, Professor, Medicine and Epidemiology, Departments of Medicine and Public Health Sciences, University of Chicago NEERAJ SOOD, Professor, Vice Dean for Faculty Affairs and Research, Sol Price School of Public Policy, University of Southern California JESSICA WILLOUGHBY, Associate Professor, The Edward R. Murrow College of Communication, Washington State University v PREPUBLICATION COPY—Uncorrected Proofs

SEAN D. YOUNG, Executive Director, University of California Institute for Prediction Technology, Associate Professor, Departments of Emergency Medicine and Informatics, University of California, Irvine    CARMEN D. ZORRILLA, Professor, Obstetrics and Gynecology, School of Medicine, University of Puerto Rico; Principal Investigator, Maternal-Infant Studies Center Study Staff AMY B. GELLER, Study Director AIMEE MEAD, Associate Program Officer SOPHIE YANG, Research Associate HAYAT YUSUF, Senior Program Assistant (until March 2020) HARIKA DYER, Research Assistant (from April 2020) ANNA W. MARTIN, Administrative Assistant (until April 2020) Y. CRYSTI PARK, Administrative Assistant (from April 2020) MISRAK DABI, Financial Associate ROSE MARIE MARTINEZ, Senior Board Director TASHA BIGELOW, Editor Consultants ADAM S. BENZEKRI, Center for Latino Adolescent and Family Health, New York University MARIE A. BRAULT, School of Public Health, Yale University YANNINE ESTRADA, School of Nursing and Health Studies, University of Miami ANIRUDDHA HAZRA, Pritzker School of Medicine, University of Chicago LEANNE LOO, Tufts University ALYSSA LOZANO, Miller School of Medicine, University of Miami SHERINE A. POWERFUL, Harvard T.H. Chan School of Public Health SARAH E. RUTSTEIN, School of Medicine, University of North Carolina MARCO THIMM-KAISER, Center for Latino Adolescent and Family Health, New York University LAUREN L. TINGEY, Johns Hopkins Center for American Indian Health GABRIELA WEIGEL, School of Medicine, University of California, San Francisco vi PREPUBLICATION COPY—Uncorrected Proofs

Reviewers This Consensus Study Report was reviewed in draft form by indi- viduals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical com- ments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We thank the following individuals for their review of this report: JAMILLE FIELDS ALLSBROOK, Center for American Progress JOSÉ A. BAUERMEISTER, University of Pennsylvania GINA M. BROWN, Gilead Sciences, Inc. RALPH JOSEPH DICLEMENTE, New York University TAMAR GINOSSAR, University of New Mexico MATTHEW GOLDEN, University of Washington CHAQUETTA T. JOHNSON, Louisiana Department of Health ALLYSHA C. MARAGH-BASS, Duke University JEANNE MARRAZZO, The University of Alabama at Birmingham DAVID H. MARTIN, Louisiana State University Health Sciences Center INA PARK, University of California, San Francisco vii PREPUBLICATION COPY—Uncorrected Proofs

viii REVIEWERS NAVEEN PATIL, Arkansas Department of Health CUI TAO, The University of Texas Health Science Center at Houston JUDITH N. WASSERHEIT, University of Washington Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft before its release. The review of this report was overseen by CLAIRE D. BRINDIS, University of California, San Francisco, and ELAINE L. LARSON, Columbia University. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies. PREPUBLICATION COPY—Uncorrected Proofs

Contents PREFACE xv ACKNOWLEDGMENTS xix ACRONYMS AND ABBREVIATIONS xxi ABSTRACT xxv SUMMARY 1 1 ADDRESSING STI EPIDEMICS: INTEGRATING SEXUAL HEALTH, INTERSECTIONALITY, AND SOCIAL DETERMINANTS 21 Introduction, 22 Urgency of Addressing STIs, 23 Committee’s Approach, 24 Changes in the STI Landscape in the Past 20 Years, 38 Study Process and Report Overview, 43 Concluding Observations, 47 References, 48 ix PREPUBLICATION COPY—Uncorrected Proofs

x CONTENTS 2 PATTERNS AND DRIVERS OF STIs IN THE UNITED STATES 53 Introduction, 54 Interpretation of Surveillance Data, 54 Patterns of STIs in the United States, 59 Drivers of STI Outcomes and Inequities, 79 Concluding Observations, 93 References, 94 3 PRIORITY POPULATIONS 113 Introduction, 114 STIs Across the Life Span, 115 Pregnancy and Infancy, 115 Children, 118 Adolescents, 119 Cisgender Heterosexual Adults, 133 Sexual and Gender Diverse Populations, 138 Men Who Have Sex with Men, 138 Transgender and Gender Diverse Adults, 141 Lesbian, Bisexual, and Other Sexual Minority Women, 147 Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ+) Youth, 151 Other Populations That Require Focused Consideration, 157 American Indian/Alaska Native People, 157 People with Military Experience, 165 People with Disabilities, 173 People with Criminal Legal System Involvement, 175 Concluding Observations, 180 References, 181 4 STI ECONOMICS, PUBLIC-SECTOR FINANCING, AND PROGRAM POLICY 219 Introduction, 219 Role of Government in Prevention and Control of STIs, 221 Overview of Federal Programs, 222 State and Local Efforts, 236 Economic Burden of STIs, 238 Conclusions, 240 References, 241 PREPUBLICATION COPY—Uncorrected Proofs

CONTENTS xi 5 INTERSECTION OF HIV AND STIs 247 Introduction, 248 History, 248 Consequences of STIs in People Living with HIV, 260 Important Lessons from the HIV Epidemic, 261 Conclusions, 263 References, 265 6 ROLE OF TECHNOLOGY AND NEW MEDIA IN PREVENTING AND CONTROLLING STIs 283 Introduction, 284 Technologies, 290 Implementation Considerations: Costs and Feasibility, 317 Implementation Considerations: Ethics and the Rapidly Changing Environment, 318 Conclusion and Recommendation, 319 Concluding Observations, 322 References, 324 7 BIOMEDICAL TOOLS FOR STI PREVENTION AND MANAGEMENT 337 Introduction, 338 Tools for STI Diagnosis, 342 Antimicrobial Tools for STI Treatment, 353 Tools for STI Prevention, 365 Conclusions and Recommendation, 382 Concluding Observations, 384 References, 385 8 PSYCHOSOCIAL AND BEHAVIORAL INTERVENTIONS 399 Introduction, 400 Contributions of Psychosocial and Behavioral Interventions on STI Prevention and Control, 402 Psychosocial and Behavioral Interventions, 405 Individual-Level Interventions, 405 Interpersonal-Level Interventions, 413 Community-Level Interventions, 421 Cost Effectiveness of Psychosocial and Behavioral Interventions, 428 Technology-Based Interventions, 429 Dissemination of Evidence-Based Behavioral Interventions, 438 Implementation Science, 440 Conclusions and Recommendation, 444 References, 446 PREPUBLICATION COPY—Uncorrected Proofs

xii CONTENTS 9 STRUCTURAL INTERVENTIONS 463 Introduction, 464 Structural Interventions to Decrease STIs in Marginalized U.S. Groups and Reduce STI Inequities, 466 Macro-Level Structural Interventions to Decrease STIs in the U.S. Population Overall, 471 Meso-Level Structural Interventions to Decrease Overall STI Rates and STI Inequities, 474 Community Mobilization for Structural Change Related to STIs and HIV, 477 Conclusions and Recommendation, 487 References, 489 10 PAYING FOR AND STRUCTURING STI SERVICES 497 Introduction, 498 Paying for STI Prevention and Treatment Services, 498 Health Insurance Coverage Requirements, 505 Assessing Systems of Care and Accountability, 511 Clinical STI Services, 515 STI Systems of Care, 527 Conclusions and Recommendation, 535 Concluding Observations, 537 References, 538 11 SUPPORTING AND EXPANDING THE FUTURE STI WORKFORCE 547 Introduction, 548 Sexual Health and Ethics as an Organizing Framework for the STI Workforce, 548 Current STI Workforce in the United States, 549 Leveraging Health Care Systems and Practitioners Not Traditionally Involved in STI Service Delivery, 555 Strengthening the National Public Health Workforce, 560 STI Workforce Gaps and Needs, 563 STI Workforce Education and Development, 564 Conclusion and Recommendation, 570 References, 573 12 PREPARING FOR THE FUTURE OF THE STI RESPONSE 581 Introduction, 582 Review of Recently Published Reports Addressing STI Prevention in the United States, 583 National Academy of Public Administration STI Reports, 583 PREPUBLICATION COPY—Uncorrected Proofs

CONTENTS xiii Treatment Action Group Gonorrhea, Chlamydia, and Syphilis Pipeline Report 2019, 585 STI National Strategic Plan for the United States (2021–2025), 587 Charting a Path Forward, 592 Adopt a Sexual Health Paradigm, 593 Broaden Ownership and Accountability for Responding to STIs, 597 Bolster Existing Systems and Programs for Responding to STIs, 622 Embrace Innovation and Policy Change to Improve Sexual Health, 633 Concluding Observations, 640 References, 641 APPENDIXES A CHARACTERISTICS OF MAJOR STIs IN THE UNITED STATES 655 B STI SCREENING AND TREATMENT GUIDELINES ISSUED BY HEALTH PROFESSIONAL SOCIETIES 663 C MEASURING THE IMPACT OF WORRYING ABOUT STIs ON QUALITY OF LIFE 687 D PUBLIC MEETING AGENDAS 701 E COMMITTEE MEMBER AND STAFF BIOGRAPHIES 711 PREPUBLICATION COPY—Uncorrected Proofs

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Preface Sexually transmitted infections (STIs), although largely preventable, are common in the United States, and their incidence rates have been ris- ing steadily for more than a decade. They can have serious negative health impacts in both the short and long terms, yet service uptake is often sub- optimal due to low diagnosis rates and various barriers to care and treat- ment. For example, congenital syphilis is a grave and often lethal threat to newborns that provides a dramatic and tragic indicator of public health failure; while it is preventable with quality prenatal care, diagnoses have increased 2.6-fold from 2013 to 2018 in the United States. Although STIs can affect anyone who is sexually active, the heavy burden on persons of color, including Black, American Indian and Alaska Native, and Latino/a individuals, highlights structural inequities that pervade U.S. society and impede an effective STI response, as does the disproportionate impact of STIs on many lesbian, gay, bisexual, transgender, and queer or question- ing (LGBTQ+) individuals. This committee report seeks to highlight and disentangle some of the complexities of U.S. society, including its patchwork health care financ- ing system, that result in some of the highest STI rates among higher- income nations. This report does not provide recommendations to prevent and control HIV because the report sponsors—the Centers for Disease Control and Prevention and the National Association of County and City Health Officials—asked the committee to focus its recommendations on STIs other than HIV, given the alarming increasing rates of non-HIV STIs. The committee concludes that the nation needs a new paradigm for xv PREPUBLICATION COPY—Uncorrected Proofs

xvi PREFACE confronting STIs. Historically, STIs have focused on individual risks and interventions, with biomedical goals of screening, treatment, and clinical engagement of sexual partners and attention to individual risk factors and conduct. Biomedical approaches remain constrained. Except for human papillomavirus and hepatitis B virus, the nation lacks STI vaccines. STI therapies are suboptimal in too many instances, and point-of-care diag- nostics are not deployed widely. Focusing on sexual risk has proven a lim- iting paradigm, given that sexual risk can be incurred without personal volition or awareness of risk. While the efficiency and reach of STI services are vital elements of success, a more positive and holistic approach to prevent STI spread is needed. The committee adopted a Modified Social Ecological Framework of Sexual Health and STI Prevention, Control, and Treatment that moves beyond individual-level behavioral or biomedical constructs toward a comprehensive framework to address the interconnected and mutually reinforcing structural and social determinants of health and health ineq- uities. Since 2006, the working definition of sexual health at the World Health Organization1 has been a state of physical, emotional, mental, and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction, or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled. “Sexual health” is a term referring to the salutary and positive view of responsible and mutually consensual sex as a part of joy, desired pro- creation, love, and pleasure available to all humankind, the antithesis of disease and attendant suffering caused by STIs. STI control that is viewed within a healthy sexual life is likely to be more successful than the traditional medical and public health model that is steeped in blame, stigma, marginalization, and discrimination. In this report, the committee considers the interplay between biomedical, psychosocial and behavioral, and structural interventions and the need for them to be understood and addressed synergistically—not in silos—for greatest impact. In 1997, the Institute of Medicine published a report titled The Hid- den Epidemic: Confronting Sexually Transmitted Diseases to “educate health professionals, policy makers, and the public regarding the truths and 1 See https://www.who.int/reproductivehealth/topics/sexual_health/sh_definitions/en (accessed November 10, 2020). PREPUBLICATION COPY—Uncorrected Proofs

PREFACE xvii consequences of STDs in the United States.” This important report was influential in mobilizing additional attention toward STIs in the govern- ment and in academic circles, but it did not reflect the influence of HIV/ AIDS on the field. In many respects, changes that have come about since that time have been astounding, such as the development and deploy- ment of effective therapeutics for HIV, the development of a vaccine for human papillomavirus, and fundamental changes in American society’s understanding of homosexuality and diversity of gender expression that creates new opportunities for dialogue and action to improve sexual health. Yet, too frequently, STIs remain hidden and neglected. It is the committee’s hope that this report, Sexually Transmitted Infections: Adopting a Sexual Health Paradigm, will ignite productive debates and new com- mitments toward effectively and efficiently controlling STIs by nurturing sexual health and wellness in the United States. Sten H. Vermund, Chair Committee on Prevention and Control of Sexually Transmitted Infections in the United States PREPUBLICATION COPY—Uncorrected Proofs

Acknowledgments The committee wishes to thank and acknowledge the many individu- als and organizations that contributed to the study process and devel- opment of this report. To begin, the committee would like to thank the Centers for Disease Control and Prevention and the National Association of County and City Health Officials—the study sponsors—for their sup- port of this work. The committee found the perspectives of many individuals and groups immensely helpful in informing its deliberations through presentations and discussions that took place at the committee’s public meetings. Speakers provided presentations on the state of sexually transmitted infection (STI) science and policy: Emilie Alirol, Kevin Ault, Lynn Barclay, Eliav Barr, José Bauermeister, Georges Benjamin, Kim Blankenship, Gail Bolan, Laura Cheever, Liz Chen, Harrell Chesson, Eli Coleman, Demetre Daskalakis, Henry de Vries, Carolyn Deal, Meg Doherty, Evgeniy Gabrilovich, Sami Gottlieb, David Harvey, Sean Howell, Carol S. Jimenez, Seth Kalichman, Jeffrey Klausner, Brenda Korte, Shannon McDevitt, Leandro Mena, John Pachankis, Ina Park, Naveen Patil, Emmett Patterson, Manos Perros, Raul Romaguera, Elizabeth Ruebush, Joanna Shaw-KaiKai, Susan Sherman, Shoshanna Sofaer, Melanie Taylor, Maria Trent, Krishna Upadhya, Barbara (Bobbie) Van Der Pol, George Walton, Kate Washburn, Gretchen Weiss, Janet Wilson, Dan Wohlfeiler, and Gail Wyatt. The committee also received important insights and information from Andria Apostolou, Judith Harbertson, Kenneth Mayer, and Sara Rosenbaum. The committee xix PREPUBLICATION COPY—Uncorrected Proofs

xx ACKNOWLEDGMENTS received helpful and timely background information from many staff at the Department of Health and Human Services throughout the study process, including Sevgi Aral, Gail Bolan, Harrell Chesson, Thomas Gift, Melissa Habel, Carol S. Jimenez, Kristen Kreisel, Jennifer Ludovic, Raul Romaguera, Ian Spicknall, and Hillard Weinstock. The committee’s work was enhanced by the technical expertise, writing contributions, data evaluation, and other support provided by Adam Benzekri, Marie Brault, Matthew Crane, Yannine Estrada, J. Dennis Fortenberry, Aniruddha Hazra, Andrew Hidalgo, Dan Li, Leanne Loo, Alyssa Lozano, Sherine Powerful, Sarah Rutstein, Marco Thimm-Kaiser, Lauren Tingey, Zachary Wagner, and Gabriela Weigel, who served as consultants. Importantly, the committee heard from a number of individuals who shared their personal stories and experiences about STIs and sexual health with the committee. These discussions helped ground the committee in the lived experiences of the complex issues that needed to be tackled in this report, and the committee is incredibly grateful for their courage in sharing their experiences in a public forum. The committee is thankful to the organizations that helped to identify individuals for these discus- sions: CCF College and Community Fellowship, Cherokee Nation Health Services, FHI 360, HIPS, My Brother’s Keeper, Nationz Foundation, Real Talk Promising Futures, SisterLove, and University of Chicago. The committee thanks the National Academies of Sciences, Engi- neering, and Medicine staff who contributed to producing this report, especially the extraordinary, creative, and tireless study staff Amy Geller, Aimee Mead, Sophie Yang, Harika Dyer, Hayat Yusuf, Anna Martin, Crysti Park, and Rose Marie Martinez. Thanks go to other staff in the Health and Medicine Division (HMD) who provided additional support, including Kat Anderson, Alina Baciu, Zaria Fyffe, and Justin Jones. The committee thanks the HMD communications staff, including Sadaf Faraz, Andrew Grafton, and Devona Overton. This project received valuable assistance from Stephanie Miceli (Office of News and Public Information); Misrak Dabi (Office of Financial Administration); and Clyde Behney, Tina Seliber, Lauren Shern, and Taryn Young (HMD Executive Office). The committee received valuable research assistance from Rebecca Morgan, Senior Research Librarian (National Academies Research Center), as well as Christopher Lao-Scott and Maya Thomas. Finally, the National Academies staff offers thanks to committee mem- bers’ executive assistants and support staff, without whom scheduling the multiple committee meetings and conference calls would have been nearly impossible: Jacqueline Campoli, Robin Criffield, Ivette Gomez, Alexis Goodly, Jacqueline Lopez, Martha Pagan, Clovis Sarmiento, and Rashonda Winters. PREPUBLICATION COPY—Uncorrected Proofs

Acronyms and Abbreviations ACA Patient Protection and Affordable Care Act ACIP Advisory Committee on Immunization Practices AFAB assigned female at birth AI/AN American Indian/Alaska Native AIDS acquired immunodeficiency syndrome AMAB assigned male at birth AMR antimicrobial resistance ASHA American Sexual Health Association C2P Connect to Protect CDC Centers for Disease Control and Prevention CHAC Advisory Committee on HIV, Viral Hepatitis, and STD Prevention and Treatment CLIA Clinical Laboratory Improvement Amendments CMS Centers for Medicare & Medicaid Services DIS disease intervention specialists DOD Department of Defense DOJ Department of Justice DSTDP Division of STD Prevention (CDC) ECHO Evidence for Contraceptive Options and HIV Outcomes EHE Ending the HIV Epidemic EPT expedited partner treatment xxi PREPUBLICATION COPY—Uncorrected Proofs

xxii ACRONYMS AND ABBREVIATIONS FDA Food and Drug Administration HBV hepatitis B virus HEDIS Healthcare Effectiveness Data and Information Set HHS Department of Health and Human Services HIV human immunodeficiency virus HPV human papillomavirus HRSA Health Resources and Services Administration HSV herpes simplex virus HSV-1 herpes simplex virus type 1 HSV-2 herpes simplex virus type 2 IHS Indian Health Service IOM Institute of Medicine IUD intra-uterine contraceptive device LGBT lesbian, gay, bisexual, and transgender LGBTQ+ lesbian, gay, bisexual, transgender, and queer (or question- ing) and others LGV lymphogranuloma venereum MPT multipurpose prevention technology MSM men who have sex with men NAAT non-culture nucleic acid amplification test NACCHO National Association of County and City Health Officials NAPA National Academy of Public Administration NCHHSTP National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention (CDC) NCSD National Coalition of STD Directors NHANES National Health and Nutrition Examination Survey NIAID National Institute of Allergy and Infectious Diseases NIH National Institutes of Health OASH Office of the Assistant Secretary for Health OPA Office of Population Affairs PID pelvic inflammatory disease POC point of care PrEP pre-exposure prophylaxis PSA prostate-specific antigen RPR rapid plasma reagin PREPUBLICATION COPY—Uncorrected Proofs

ACRONYMS AND ABBREVIATIONS xxiii SAMHSA Substance Abuse and Mental Health Services Administration STD sexually transmitted disease STI sexually transmitted infection STI-NSP Sexually Transmitted Infections National Strategic Plan USPSTF United States Preventive Services Task Force VA Department of Veterans Affairs VDRL Venereal Disease Research Laboratory WASH World Association for Sexual Health WHO World Health Organization YRBSS Youth Risk Behavior Surveillance Survey PREPUBLICATION COPY—Uncorrected Proofs

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Abstract The Centers for Disease Control and Prevention (CDC) estimates that one in five people in the United States had a sexually transmitted infection (STI) on any given day in 2018, totaling nearly 68 million estimated infections. Although STI rates have increased across all U.S. populations, marginalized groups—youth, women, members of the lesbian, gay, bisexual, transgender, and queer community, and Black, Latino/a, American Indian/ Alaska Native, and Native Hawaiian/other Pacific Islander people— continue to experience a disproportionate share of cases. In 1997, the Institute of Medicine released a report, The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Although significant scientific advances have been made since that time, many of the problems and barriers described in that report persist today; STIs remain an underfunded and comparatively neglected field of public health practice and research. The committee reviewed the current state of STIs in the United States to provide advice on future public health programs, policy, and research. It organized its work under four action areas and makes the following eleven recommendations (see the Summary or the report for a full exposi- tion of each recommendation): I. Adopt a Holistic Sexual Health Paradigm 1. Develop a vision and action plan for sexual health and well-being that aligns sexual health and well-being with other dimensions of health—physical, mental, and emotional. (12-1) xxv PREPUBLICATION COPY—Uncorrected Proofs

xxvi ABSTRACT II. Broaden Ownership and Accountability for Responding to STIs 2. Equip parents and guardians with evidence-based guidance to engage in developmentally appropriate, comprehensive sexual health education and dialogue with their children. (12-2) 3. Encourage public dialogue in various community settings (such as with families, schools and educators, faith communities, community-based organizations, and workplaces) about how to be sexually healthy, and promote actions that lead to a greater understanding of healthy sexuality. (12-3) III. Bolster Existing Systems and Programs for Responding to STIs 4. Modernize core CDC STI activities to strengthen timely monitor- ing, ensure that treatment guidelines remain current as knowl- edge evolves, and leverage federal support to increase consis- tency and accountability across jurisdictions. (12-4) 5. Improve coordination and strengthen population outcomes by supporting local stakeholder engagement processes to develop and implement local plans for STI control and develop STI Resource Centers for clinical consultation, workforce develop- ment, and technical assistance. (12-5) 6. Develop innovative programs to assure that STI prevention and treatment services are available to individuals who face access barriers, including those who are ineligible for coverage, have affordability barriers (including high out-of-pocket costs), or will not access STI services without confidentiality guarantees. (10-1) 7. Incentivize and facilitate sexual health promotion as a focus area of practice for both the clinical workforce and important seg- ments of the nonclinical public health and social services profes- sions. (11-1) 8. Prioritize research in critical areas by developing point-of-care diagnostic tests to reduce the interval between testing and treat- ment, promoting development of diagnostic tests that distinguish untreated, active syphilis from previously treated infection, and subsidizing and encouraging public–private partnerships to develop new, readily accessible antimicrobials and expedite vac- cine development for high-priority STIs. (7-1) 9. Take steps to expand the reach of psychosocial and behavioral interventions to prevent and control STIs at the individual, inter- personal, and community levels. (8-1) PREPUBLICATION COPY—Uncorrected Proofs

ABSTRACT xxvii IV. Embrace Innovation and Policy Change to Improve Sexual Health 10. Develop a whole-of-government approach, in partnership with affected communities, to promote sexual health and eliminate structural racism and inequities that are barriers to STI preven- tion, testing, and treatment. (9-1) 11. Expand the capacity to use technology for STI prevention and control, including by developing timely, novel, and open data systems and using artificial-intelligence-based mass marketing. (6-1) The committee’s exploration of the complexities of the STI epidemic has instilled in its members a firm belief that it is possible to create a dif- ferent and better future where fewer people are infected, fewer babies are born with STIs, and people entering adolescence and continuing across the life span are taught the language and skills to conceptualize and enact their own vision for what it means to be sexually healthy. The committee’s recommended changes may be challenging, but a substantial reduction in the societal impact of STIs is a realistic goal. PREPUBLICATION COPY—Uncorrected Proofs

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One in five people in the United States had a sexually transmitted infection (STI) on any given day in 2018, totaling nearly 68 million estimated infections. STIs are often asymptomatic (especially in women) and are therefore often undiagnosed and unreported. Untreated STIs can have severe health consequences, including chronic pelvic pain, infertility, miscarriage or newborn death, and increased risk of HIV infection, genital and oral cancers, neurological and rheumatological effects. In light of this, the Centers for Disease Control and Prevention, through the National Association of County and City Health Officials, commissioned the National Academies of Sciences, Engineering, and Medicine to convene a committee to examine the prevention and control of sexually transmitted infections in the United States and provide recommendations for action.

In 1997, the Institute of Medicine released a report, The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Although significant scientific advances have been made since that time, many of the problems and barriers described in that report persist today; STIs remain an underfunded and comparatively neglected field of public health practice and research. The committee reviewed the current state of STIs in the United States, and the resulting report, Sexually Transmitted Infections: Advancing a Sexual Health Paradigm, provides advice on future public health programs, policy, and research.

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