12

Preparing for the Future of the STI Response

INTRODUCTION

Overcoming the biological, social, economic, financial, and other barriers that impede an effective national response to sexually transmitted infection (STI) prevention and control is daunting. With so many STIs of concern and new ones emerging, the scope of the challenge can appear insurmountable. In the 1960s, the meteorologist Edward Lorenz described the Butterfly Effect, wherein small changes can produce big impacts within complex systems (a butterfly flapping its wings could eventually produce a typhoon). The committee believes that similar subtle, concerted, but significant changes in policy and outlook can lead over time to transformative results. Effective STI prevention and control emerges from a holistic, sexual health perspective involving many levels of society and a variety of approaches. An integrated approach is needed that acknowledges the centrality of biological pathogens, yet also involves taking action throughout the entire population and at all levels of the prevention and care continua. Ultimately, these actions can lead to better prevention, screening, and treatment.

REVIEW OF RECENTLY PUBLISHED REPORTS ADDRESSING STI PREVENTION IN THE UNITED STATES

Implied by its title and expanded on in Chapter 1, the committee was guided in its deliberations by the idea that an effective approach to STI prevention and control should be grounded in a holistic view of sexual health as a component of overall health and a positive construct of sexual activity as a normal and even essential component of humanity. The committee’s perspective is that this view can achieve greater success than a traditional disease model. Furthermore, the committee views the STI epidemic as a societal problem requiring a societal solution. The committee embraced a social ecological approach to develop a set of comprehensive recommendations targeting all levels of society, including public and private agencies, providers, parents, educators, faith and community leaders, and priority populations disproportionally affected by STIs.

It is through this expansive lens that the committee has reviewed four recently published reports that also specifically address the STI epidemic in the United States, including two expert panel reports from the National Academy of Public Administration (NAPA), and a report on the STI research pipeline by the Treatment Action Group (TAG), all three of which were commissioned by the National Coalition of STD Directors (NCSD). Perhaps most significantly, the committee reviewed the STI National Strategic Plan from the Department of Health and Human Services (HHS) that was formally released in December 2020 and that will guide federal efforts to improve STI outcomes (HHS, 2020). In the following section, the committee identifies and builds on the specific conclusions and recommendations in each report and in the STI National Strategic Plan (STI-NSP). The committee believes that rather than being duplicative, its report complements and builds on these reports and can serve to both expand on and go further than the STI-NSP, which is focused on efforts within HHS, as well as highlight opportunities to bolster its implementation. The release of these reports in a relatively short time frame encourages a broad-based discussion on the future of STI prevention and control in the United States.

NATIONAL ACADEMY OF PUBLIC ADMINISTRATION STI REPORTS

The two reports NAPA commissioned by NCSD were developed and released in 2018 (Phase 1) and 2019 (Phase 2), respectively (NAPA, 2018, 2019). An overview, including where they align with this report, follows.

The 2018 report The Impact of Sexually Transmitted Diseases on the United States: Still Hidden, Getting Worse, Can Be Controlled recommended the following six “Actions for Consideration” (NAPA, 2018):

1. Designate a national STD champion to coordinate federal, state, and local efforts and to lead the development and implementation of a national STD strategy.
2. Change the STD narrative.
3. Unify the field as a necessary step.
4. Develop better data and more evaluation to learn about what works—and what does not work—and to foster implementation of best practices, which is essential.
5. Education and awareness.
6. Expanded funding and resources are necessary, given the scale of the STD epidemic.

The committee is largely in agreement with the NAPA-recommended actions. It recognizes the desire for a national champion and the appeal of successful models in other areas, such as the “policy czars” at the White House or within the federal government in other areas. The committee also recognizes, however, the political and administrative challenges with such models. This committee’s report emphasizes the need for enhanced leadership and accountability for STIs within the health system and outside of the health sector, including at the community level, which is not inconsistent with a national champion, and also seeks to elevate and demand more from existing STI champions, including at the Centers for Disease Control and Prevention (CDC). The 2018 NAPA report’s recommendation to destigmatize STIs and emphasize sexual health as “an important dimension of overall health and wellness” also provides a central emphasis of this report. The NAPA report argues for better integration between existing STI and HIV programs at the federal level and within state and local health departments. It makes a compelling case for the costs associated with not maintaining a more holistic approach, such as the tunnel vision of responding aggressively to HIV prevention in pregnancy without attention to syphilis or herpes simplex virus type 2.

The committee also concurs with the call to action for modernizing both data collection and evaluation of best practices. Internet sources, such as social media, and expanding electronic medical record systems can help with both aims. The committee’s report includes recommendations on both. The emphasis on “tailored awareness campaigns, focused on groups at higher risk” to improve “screening, testing, and treatment” is also consistent with this report, as is the recommendation that “medical professionals must be encouraged to screen for STDs as a routine practice.”

The 2019 NAPA Phase 2 report The STD Epidemic in America: The Frontline Struggle recommended four more “Actions for Consideration” (NAPA, 2019):

1. Reform federal funding to enhance program agility across STD programs.
2. Expand access to care, with a focus on delivering community-sensitive and patient-centered care.
3. Enable more rapid data release and results of research.
4. Implement science-based, health-centric education and awareness campaigns to reduce stigma and encourage healthy behaviors.

The committee observes that the 2019 NAPA report was prescient, as the public health and medical care system failed to coordinate adequately in the early days of the COVID-19 response. As with that acute pandemic, a mounting STI toll reinforces the need for the nation to enable far better interagency coordination and give local jurisdictions greater ability to respond to outbreaks and unfavorable trends. The 2019 NAPA report highlighted health-system-level limitations that inhibit priority populations and communities from receiving needed interventions. Eliminating insurance and payment obstacles, implementing expedited partner therapy (EPT), expanding “telemedicine, in combination with mail-in testing kits, remote diagnosis and prescription of medication,” enhancing privacy, expanding clinic hours, and providing better transportation are all logical elements of an STI reduction plan. This report offers its own recommendations that run parallel to the NAPA recommendations.

The committee also concurs with NAPA in its emphasis on the unacceptably slow collection, processing, and release of STI data, both service process variables and surveillance reports, including drug resistance information. This report cites and builds on NAPA’s recommendations in this regard. Furthermore, the 2019 NAPA report supports school-based, out-of-school, Internet, and other forms of educational outreach, stating that “[t]his education must be community-sensitive and address at-risk groups directly, with LGBTQIA+ considerations included” (NAPA, 2019, p. 24). New community partnerships are essential to break down decades of mistrust; to address public health issues, such as human sexuality, human-centered design approaches incorporated into community-based participatory research partnerships and projects hold the best promise (Chen et al., 2020a). Including religious, educational, political, and parent and youth perspectives has the best promise of breaking down the suspicions of past decades that have stigmatized not only persons with STIs but sexual health education itself.

TREATMENT ACTION GROUP GONORRHEA, CHLAMYDIA, AND SYPHILIS PIPELINE REPORT 2019

NCSD commissioned a report from TAG concentrating on documenting and addressing the “sparse research pipeline of new treatment,

prevention, and diagnostic options” (TAG, 2019), and TAG made seven recommendations focused on rising gonorrhea, chlamydia, and syphilis rates. The committee abbreviates them here and refers readers to the full TAG report for details.

1. Advocacy to fight STIs must be more than repackaging condoms and behavioral interventions.
2. HIV pre-exposure prophylaxis (PrEP) and Undetectable = Untransmittable (U=U) activists must understand that their success is integrally linked to STI advocacy.
3. Substantially more investment in new prevention modalities—particularly vaccine research—will be necessary.
4. Doxycycline should be seriously considered for scale-up as a PrEP and/or post-exposure prophylaxis for syphilis and chlamydia.
5. Discussions on accessing zoliflodacin for treatment of multidrug-resistant and extensively drug-resistant gonorrhea should begin now.
6. Reliable, easy-to-use, change to Clinical Laboratory Improvement Amendments (CLIA)-waived rapid tests for chlamydia, gonorrhea, and syphilis should be developed and made widely available.
7. Infrastructure for the delivery of sexual health services remains highly underfunded in the United States, and declining funding for sexual health clinics must be addressed.

The TAG report takes a strong stand to “focus much more aggressively on the structural, social, financial, and research barriers that undermine our ability to successfully use existing tools and develop essential new tools.” It demonstrates how rising STI rates can undermine support for scale-up of HIV PrEP programs, as well as U=U campaigns to expand “treatment as prevention” programs for HIV control. It highlights the need for new investments for STI vaccines and other biomedical primary prevention approaches. Public–private partnerships (PPPs) in the form of government-guaranteed market demand are encouraged to incentivize industry to bring safe and effective products to the public. The TAG report also cites the widespread use of doxycycline for acne suppression as a rationale for its more aggressive use for STI prevention.¹ Specific mention of STI suppression (syphilis and chlamydia) accompanying HIV PrEP and post-exposure prophylaxis suggests synergies for the many persons at dual risk of HIV and STIs. Based on the Phase 2 trial (Taylor et

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¹ In regard to doxycycline use for acne, the American Academy of Dermatology states the need for antibiotic stewardship to minimize resistance; see https://www.aad.org/member/clinical-quality/guidelines/acne (accessed January 26, 2021).

al., 2018), the TAG report is optimistic about the promise of zoliflodacin and highlights the preparatory work needed to efficiently roll out this new oral, single-dose alternative to intramuscular ceftriaxone for gonorrhea. The TAG authors assert that zoliflodacin “must be priced in a way that ensures rapid and broad access while also providing a reasonable return on investment for Entasis Therapeutics” (TAG, 2019, p. 25). Near the time the TAG report was published, a number of other agents were investigated (Barbee and Golden, 2020; Chen et al., 2019; Hook et al., 2019; Ross et al., 2019). The TAG report joins the decades-long chorus urging further development and widespread deployment of point-of-care (POC), simple diagnostics to transform STI screening, diagnosis, and care. The TAG report advocates for “sexual health clinics in the United States, provider education, and appropriate curricula for providers-in-training.” This sexual health paradigm is distinct from the classic STI clinic model of care. While TAG’s contribution is more narrowly focused on the therapeutics pipeline than this report, the committee welcomes it and finds that it is broadly consistent with this report.

STI NATIONAL STRATEGIC PLAN FOR THE UNITED STATES (2021–2025)

In 2019, HHS announced that it was developing the first-ever STI-NSP (HHS, 2020). The committee reviewed a draft toward the end of its deliberations that was released for public comment in September 2020, and it was able to update this discussion based on the final STI-NSP that was released in December 2020. There are strong synergies between the issues that the STI-NSP (an internal governmental report) cites as high priorities for the next 5 years and what the committee’s report highlights as necessary for an effective national response. This committee’s composition of nonfederal staff and its broader charge means that, unsurprisingly, this report diverges in some respects from the focus of the STI-NSP. Perhaps the principal difference is that the committee’s report highlights the importance of responding to STIs through a sexual health lens, seeking to incorporate positive messages of love, pleasure, and life-affirming aims as a way to enhance STI risk-reducing actions by all parties engaging in consensual sexual activity. In addition, the committee recognizes that STI control falls at not only the individual level, but also the interpersonal, institutional, community, and structural levels, as described in the committee’s conceptual framework and that these factors intersect in dynamic and important ways (see Chapter 1). Five central “high-level” goals are highlighted in the draft STI-NSP (with 16 subgoals):

The STI-NSP makes clear why revitalized federal, state, and local efforts are essential to decrease the increasing rates of human papillomavirus (HPV), primary and secondary syphilis, congenital syphilis, gonorrhea, and chlamydia.

Similar to this report, the STI-NSP discusses the need to address individual, community, and structural factors that contribute to STIs, including stigma and health disparities. Specific actions are undefined, although it is hoped that a promised forthcoming STI-NSP implementation plan will provide greater details, especially actions identified in this report tailored to address the diversity of the U.S. population in terms of gender, gender identity, and sexual orientation. The development of the STI-NSP implementation plan also provides a timely opportunity to incorporate the sexual health approach and recommendations provided in this report to increase impact of the STI-NSP (using principles of implementation science). The committee also notes the influence of the Internet (with its virtual and social media platforms) and technology (including telemedicine and artificial intelligence) on STI risk and risk mitigation. Thus, the committee’s report offers insights into using modern technology and media as a tool, alongside other types of interventions (see Chapter 6). The lack of adequate integration between public health STI programs and the health care system, including private insurance, Medicaid, Medicare, and other safety net programs, represents both a challenge and opportunity for better STI control. The committee’s report provides information about these programs’ importance and may be useful for informing the STI-NSP implementation plan.

Emphasis on the need for risk reduction through individual-level changes, as captured in the STI-NSP, is a vital part of the STI control narrative. Based on the committee’s review of the evidence, however, individual-level changes are insufficient without addressing interpersonal, institutional, community, and structural opportunities to better prevent, recognize, and/or mitigate STI harms. In particular, this report reflects the committee’s view that forthrightly addressing structural racism and other social and structural inequities is an essential component

for strengthening STI prevention and control. This is consistent with the STI-NSP discussion on the importance of addressing the social determinants of health to improve health outcomes for racial, ethnic, and sexual minority groups and its objective to improve data collection and surveillance of STIs in populations that are underrepresented in current data (strategy 4.3.3).

In emphasizing the challenges and opportunities facing the United States, the STI-NSP highlights five elements that include both existing challenges and new opportunities for deploying new tools and approaches:

1. Health disparities, stigma, and the role of social determinants of health;
2. Provider education, awareness, and training;
3. Program capacity and access to prevention and care services;
4. The need to accelerate progress in STI research, technology, and innovation; and
5. STIs, HIV, viral hepatitis, and substance use disorders—a holistic approach to the syndemic.

The committee shares the STI-NSP’s view that these five elements are fundamental for success in efforts to control STIs in the United States. The committee was pleased by the federal emphasis of potential return on investment from vaccines while cautioning about the potential for low consumer demand. Demand is a vital topic that the committee has addressed—namely, financing options for future STI vaccines and public awareness campaigns to increase uptake.

The STI-NSP recognizes syndemic elements of the STI crisis. The committee agrees that it is desirable to highlight that intersecting epidemics may reinforce and exacerbate each other. For example, advances in HIV treatments and prevention modalities, increases in mental health problems, including substance use, and stress heightened by a period of extreme racial divisiveness may concurrently lead to changes in sexual behaviors that may alter and potentially enhance STI risk.

The STI-NSP gives 5- and 10-year targets for identified indicators to track progress toward the five goals and is aligned with the Ending the HIV Epidemic: A Plan for America presidential initiative, which seeks to reduce new HIV infections by 90 percent by 2030. Annual reports are planned to document progress toward meeting these goals, with transparent accounting of all monitored indicators. The following section highlights where the committee’s report may offer additional insights that complement the STI-NSP’s five “high-level” goals.

Goal 1: Prevent New STIs

The STI-NSP proposes STI prevention based on a traditional, individual risk-based approach, with the committee endorsing a more holistic perspective, in part because risk is often hard to ascertain. The importance of engaging families and communities in prevention efforts is discussed in the STI-NSP and is well aligned with this report, which describes the opportunities to leverage parents, families, institutions, and communities. The committee is intrigued by the idea of a “whole-of-nation” response, which is consistent with its report’s recommendations to broaden ownership and accountability for responding to STIs. The STI-NSP implementation plan would be an excellent opportunity to further explore the whole-of-nation concept.

Goal 2: Improve the Health of People by Reducing Adverse Outcomes of STIs

The committee acknowledges the excellent elements in the STI-NSP, such as highlighting the importance of self-collection options and POC tests (see, for example, strategy 2.1.3 in the STI-NSP). In the forthcoming implementation plans, the committee urges pursuing self-collection options as a potential solution for STI prevention and control. The STI-NSP also cites the need for an expanded, and perhaps changing, role for disease intervention specialists (DIS) that incorporates greater use of technology. As discussed in Chapter 11, the committee suggests expanding DIS roles, including in the areas of field-based diagnosis and treatment. The STI-NSP implementation plan also would benefit from discussing how STI specialists within the National Network of STD Clinical Prevention Training Centers can be most effectively deployed to fill gaps in STI clinical care, a topic addressed in this report (Stoner et al., 2019) (see Chapter 11). The expressed objectives about expanding secondary prevention align with the committee’s commitment to the important role of STI specialty clinics.

Goal 3: Accelerate Progress in STI Research, Technology, and Innovation

The committee supports the focus on research and innovation and also seeks greater specificity in defining research priorities. The committee’s report discusses the need for partner services, including an EPT expansion and evaluation (e.g., see Chapters 7 and 10 of this report, and strategy 3.4.1 in the STI-NSP). A comprehensive assessment of gaps and needs in STI research, technology, and innovation can be found in Chapter 7 of this report and in the TAG report (2019).

Goal 4: Reduce STI-Related Health Disparities and Health Inequities

The STI-NSP reviews individual-level factors (e.g., behaviors, socioeconomic status indicators, and widespread distrust of the health care system) that impact STI spread. The committee concludes that a deeper analysis of antecedent causes of individuals’ behaviors is needed and that institutional, community, and structural contributors to these behaviors need to be clarified (see Chapters 3 and 9 of this report for more information). Also needed is a broader discussion of specific groups or priority populations in society who have an acute need for enhanced STI prevention, testing, and treatment interventions, including women and men of color, men who have sex with men (MSM) and other sexual minority populations, transgender and gender-diverse persons, persons reentering society from carceral settings, adolescents and young adults, and undocumented immigrants. The STI-NSP plan to integrate STI care into social services is a potential game-changer for an implementation plan that could decrease U.S. STI rates (see Goal 4 of the STI-NSP), as noted throughout this report. Ideally, the federal implementation plan will address social determinants of health and co-occurring conditions with specific policies and linkages to STIs.

Goal 5: Achieve Integrated, Coordinated Efforts That Address the STI Epidemic

The discussion in the STI-NSP on integration and coordination of efforts would benefit from a broad discussion of deficits in the overall health system. The goal will not be met if, for example, the public health system is not integrated with Medicaid, Medicare, and private insurance. The emphasis on expanding surveillance to identify antimicrobial resistance is important. Moreover, the committee notes that the entire STI surveillance system is too slow, is difficult to interpret because of its case-based approach, and needs to be improved via modern technology strategies and data sciences (see Recommendation 12-4 and several related strategies in the STI-NSP, including 5.2.1 and 5.2.6). In the committee’s view, strategies for tracking progress that are highlighted by the STI-NSP need to be expanded by new data sources and both clinic- and social services–based performance measures. This report offers recommendations for better aligning public health with the health care delivery system and strengthening monitoring of STI epidemics, including through modernizing STI surveillance and placing a greater emphasis on the potential for implementation science to point toward more effective control strategies and interventions.

Indicators

Introducing concrete indicators and time-limited goals is an important aspect of the STI-NSP. Core indicators that address population and group disparities (e.g., region, race, sexual orientation, and gender identity) can be a next step. In some cases, the committee would encourage the STI-NSP implementation plan to set more ambitious goals; the committee believes that a broader sexual health approach can accelerate rates of change for the STI-NSP indicators. The committee does not have the forecasting models to make “best estimates” of what might be feasible for Core Indicator goals to reduce STI incidence in the STI-NSP. The indicators need to be more aspirational, however, to truly make a public health difference over the next 5–10 years. More ambitious goals could help to motivate policy makers and practitioners to improve the STI prevention and control landscape.

The STI-NSP is an important contribution to government efforts to turn the tide on rising STI rates and, given the synergies between the STI-NSP and this report, an important opportunity to implement the recommendations provided in this report to drastically reduce STIs in the United States. The committee commends the federal agency staff members who conceived, researched, and presented this historic plan.

CHARTING A PATH FORWARD

As discussed throughout this report, to enhance STI prevention and control, the committee concludes it is necessary to achieve the following:

1. Adopt a Sexual Health Paradigm
2. Broaden Ownership and Accountability for Responding to STIs
3. Bolster Existing Systems and Programs for Responding to STIs
4. Embrace Innovation and Policy Change to Improve Sexual Health

The remainder of this chapter is organized around these four actions, summarizes the recommendations presented in earlier chapters, and provides new, crosscutting recommendations to offer a comprehensive and strategic approach to increasing the effectiveness of the nation’s STI response.

For the sake of clarity, different types of interventions, including biomedical, psychosocial and behavioral, and structural interventions, have been discussed separately (see Chapters 7, 8, and 9, respectively). The aim of this chapter is to combine these complementary approaches into an integrated STI strategy that is most practical in each of its domains.

ADOPT A SEXUAL HEALTH PARADIGM

As concluded in Chapter 1, the nation’s response to STIs since the beginning of the 20th century has mostly focused on individual risk factors and individual behavior change, largely neglecting the structural and social determinants impacting sexual behavior. This approach, because it has typically blamed the individuals with STIs, has tended to fuel stigma and shame and therefore has not led to successful STI prevention and control (see Conclusion 1-2). Furthermore, STI efforts to date have centered on treating infections and prevention. To successfully address STIs, a holistic approach that focuses on sexual health in the context broader health and well-being is needed. To carry out this change, meaningful efforts will be needed to eradicate stigma and to promote sexual health awareness (see Conclusion 1-3). See Box 12-1 for a summary of recommended actions to advance a sexual health paradigm.

The committee observes that men remain inadequately engaged in sexual and reproductive health services (Fine et al., 2017; Kalmuss and Tatum, 2007; Santa Maria et al., 2018; Vaidya et al., 2012), which creates a deficit in the ability to achieve population-level control of many STIs. More generally, women are introduced to the concept of periodic, ongoing, lifelong health care at puberty, which men are not. Attending to men’s sexual health needs will require more readily available male-centered

sexual health specialty services and integrating gender-inclusive sexual and reproductive health services into primary care (Santa Maria et al., 2018). This finding should not suggest that the committee proposes to prioritize men over women, adolescents, or other important priority populations. Rather, it seeks to spotlight a glaring shortcoming in a comprehensive and inclusive response to STI prevention and control.

While stigma and inattention to sexual health are widespread, members of sexual minorities are disproportionately impacted. For example, MSM are estimated to make up less than 3 percent of the population but account for the majority of cases of primary and secondary syphilis and are disproportionately impacted by gonorrhea (see Chapter 2). Notably, for persons living with HIV or at risk of HIV and receiving PrEP, current recommendations include periodic STI screening (Owens et al., 2019; Workowski and Bolan, 2015). While implementation has been incomplete, including STI screening in HIV treatment and prevention recommendations has demonstrably expanded STI screening and management services for some, mostly men (Montaño et al., 2019). This includes many MSM, as well as transgender women and men, who are at greatly elevated risk for many STIs, yet who represent a small subset of the overall population.

Societal discourse on sexuality, sexual health, and sexual rights has evolved over past decades (see the sexual health section of Chapter 1), notably leading to fundamental changes in law and policy. Examples include the legal recognition of same-sex marriage, upheld by the U.S. Supreme Court in 2015, and the related 2020 Bostock v. Clayton County decision that the Civil Rights Act of 1964 includes protection for workers regardless of sexual orientation or gender identity, further enforced through an executive order (Executive Order 13988) signed by President Biden in January 2021 (U.S. Supreme Court, 2020). The full implications of this decision on transgender rights and sexual orientation discrimination likely await policy changes to comport with this precedent and court decisions that will define the scope of protection beyond workplace settings. Still, these potentially wide-ranging decisions reflect important societal changes toward recognizing same-sex relationships and the civil rights of lesbian, gay, bisexual, transgender, and queer (LGBTQ+) persons. These and other legislative changes did not happen serendipitously, but were the results of long-standing, grassroots advocacy and hard-fought battles by diverse activists and LGBTQ+ community members, legal scholars, health care professionals, and others.

The committee looks to these as instructive examples for how legislation and social change can impact policy and seeks to glean lessons that can inform ways for society to embrace a fuller conception of sexual health to strengthen public policy responses to STI prevention and control. People living with HIV/AIDS have long been an essential part of the

advocacy coalition for both expanded civil rights protections for LGBTQ+ people and civil rights protections and critical investments in programs and services for communities heavily affected by HIV. For many, the acceptance of living with HIV, a life-threatening and highly stigmatized condition, has been transformative. Lessons learned from HIV/AIDS are now being applied in such fields as breast cancer and Alzheimer’s disease, where voices are more demanding than heretofore. Unfortunately, the STI field lacks such recognition and vigorous advocacy, partly because many STIs are episodic and most are treatable. Thus, admitting to an STI can be avoided and STI stigma evaded by not publicly acknowledging a current or past infection. People do not typically identify as “living with an STI.”

There are several public health organizations in the United States that advocate for STI treatment and prevention, specifically the American Sexual Health Association (ASHA), focusing on the general public; NCSD, focusing on STI public health programs; the American STD Association, focusing on STI care providers and researchers; and several others, including the American Public Health Laboratories, the National Association of County and City Health Officials, and the American Public Health Association, all of which include a sexual health focus. Some of these have had a long-standing history of advocacy, especially at the federal level; their reach has been limited, however, and expansion and new partnerships could grow their influence with policy makers. Furthermore, while many of these groups make laudable efforts to engage with and elevate the voices of people with STIs, such efforts have not yet had the same moral force or impact on the public as have people living with HIV/AIDS.

Where the power of local-level activism and advocacy is mobilized, however, results can be impressive, as with the restructuring, improvement, and rebranding of the New York City Sexual Health Clinics (NYC Health, 2017). In some local U.S. jurisdictions, sexual health alliances are forming, composed of different medical and nonmedical disciplines from a variety of service areas, including STI clinics, family planning, adolescent medicine, and state and local health department staff to discuss issues of mutual interest and develop a common agenda (STI Regional Response Coalition, 2020). Mutual outreach between these alliances and national organizations, including ASHA, NCSD, and the American STD Association, could foster local-level support and higher-level state and national advocacy. These alliances could develop policy agendas and engage with elected officials and with organizations that address the rights and health of marginalized communities to further these agendas to strengthen flagging STI prevention, treatment, and education programs. Despite local and noteworthy successes, these generally are not scaled or duplicated and do not happen in all jurisdictions. More coordinated national guidance, metrics, and expectations are needed.

Conclusion 12-1: Current approaches to address sexual health and to control the spread of STIs have not met the needs of the nation. This is most notable in the lack of tailored clinical services to meet the needs of diverse populations and in the lack of evidence-based practices integrated within existing delivery systems.

Conclusion 12-2: The clinical focus in current STI control efforts is primarily on the harmful impacts of STIs on women and children, with little focus on men and their role in transmitting STI infections. There is a need for public policies in STI control to also address men’s sexual health needs, which will not only improve men’s sexual health, but may have protective effects on the health of women and children.

Recommendation 12-1: The Department of Health and Human Services (HHS) should develop a vision and blueprint for sexual health and well-being that can guide the incorporation of a sexual health paradigm across all HHS programs, including the major public insurance programs (Medicaid, Medicare, and the Children’s Health Insurance Program), as well as the public health programs operated throughout the department, including the Centers for Disease Control and Prevention, the Health Resources and Services Administration, the Indian Health Service, and the Substance Abuse and Mental Health Services Administration. The plan should align sexual health and well-being with other dimensions of health—physical, mental, and emotional.

• A holistic approach to sexual health programs should include new approaches and strategies for specifically engaging men (including men who have sex with men) with readily available male-centered sexual health specialty services and the implementation of sexual and reproductive health services in primary care.
• The plan should include strategies for improving sexual health services that address the needs of priority populations, such as women, adolescents, and young adults, and expand attention and resources to underserved populations including Black, Latino/a, and Indigenous populations; people who use drugs; people who engage in sex work; transgender; and gender-expansive populations.

HHS has an important role in catalyzing the shift the committee recommends, but it is imperative that other partners and leaders within the federal government, health systems, and society adopt and implement it.

This includes critical actions by health professional organizations, health regulators and accreditation bodies, and other entities, such as the American Medical Association, the National Medical Association, the American College of Physicians, the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, the American Nurses Association, the National League for Nursing, the American Academy of Emergency Medicine, the Society for Adolescent Health and Medicine, the American Public Health Association, the American Osteopathic Association, the American Academy of Physician Assistants, and other key professional organizations in such disciplines as pharmacy, laboratory medicine, and social work. While HHS should provide leadership and guidance, this vision and action plan needs to include local action and engagement. In developing this vision, HHS should consult broadly with agencies within and outside of its department, including tribal, state, and local governments, and a diversity of other external stakeholders. It will be essential to develop and effectively communicate what is meant by sexual health embedded in a broader conceptualization of healthy living.

The vision and action plan should include discussion of actions for individuals, health care providers, and other stakeholders to promote positive sexual health over the life span by giving individuals more agency over their personal preferences and choices, acknowledging the role of culture in influencing these choices, and highlighting structural inequities and barriers to optimal health.

To address the gap in sexual health care for men, this action plan also should examine and make recommendations for essential sexual-health-related vaccinations and diagnostic and screening services across the life span for cisgender and transgender men; identify underused intervention points for delivering sexual health education and health care services (including schools, athletics, military service, and fraternal organizations); and identify strategies for engaging men in promoting sexual health that include STI prevention, screening, and treatment.

Reorienting the popular conception of health to include sexual health may seem broad and perhaps intangible, but it offers the overarching framework for all of our subsequent recommendations and establishes the foundation for steps to better prevent and control STIs.

BROADEN OWNERSHIP AND ACCOUNTABILITY FOR RESPONDING TO STIs

I think improvements have been made in terms of overall societal stigma, but in the Black community especially, I think primarily due to religious and conservative ideals, there hasn’t been as great of a shift. This could be because the trusted messengers for Black people differ from that of other cultures.

Some examples of community leaders at the micro level include managers of local rec centers and church leaders and, at the macro level, would include people that are social media influencers, and something that I don’t think is tapped into enough are leaders in national Black sororities and fraternities.
—Participant, lived experience panel²

The Hidden Epidemic executive summary opens by acknowledging that STIs in the United States are epidemics of tremendous health and economic consequence that are hidden from view because many individuals are reluctant to openly address sexual health issues due to biological and social factors associated with these diseases (IOM, 1997). This committee’s review led it to conclude that STIs remain hidden because ownership, responsibility, and accountability for preventing and treating STIs is often unclear and is not broadly enough shared both within the health system and across society. To successfully reduce the nationwide burden and impact of STIs, there is a need for greater ownership of issues for which people and institutions are reluctant to take responsibility or where the potential power that various stakeholders could exert on better controlling STIs may not be readily apparent. The next section offers conclusions and recommendations for strengthening the existing STI services system, prevention, and care within the health sector. The committee provides conclusions and recommendations here for increasing engagement for preventing and controlling STIs across society by spotlighting parents and guardians and a range of other community stakeholders. See Box 12-2 for a summary of recommended actions to broaden ownership and accountability.

Better Support for Parents and Guardians to Model Sexual Health

Although maturing children learn information about sexual health in many ways, (including social media), parents and guardians (hereafter referred to as “parents,” but the term is inclusive of nonbiological primary caregivers or relatives who function in a parenting role) have critical roles in showing young people how to develop into sexually healthy adults, minimize exposure to STIs, and responsibly seek prevention and health care services (Guilamo-Ramos et al., 2019a; McKay and Fontenot, 2020; Widman et al., 2019). Yet, parents often lack knowledge and skills

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² The committee held virtual information-gathering meetings on September 9 and 14, 2020, to hear from individuals about their experiences with issues related to STIs. Quotes included throughout the report are from individuals who spoke to the committee during these meetings.

themselves, as well as the tools to fulfill their roles successfully (Ashcraft and Murray, 2017; Johnson-Motoyama et al., 2016). See Box 12-3 for relevant quotes from parents, and about parenting, from the committee’s September 2020 meeting. The committee recognizes that not all young people can rely on supportive parents to offer this guidance, and supporting parents in general does not negate the need to create additional sources to complement or substitute for supportive parents.

In 2011, Dr. Amy Schalet published Not Under My Roof, a comparative study of attitudes on teen sexuality among parents and their teenage children in the United States and the Netherlands (Schalet, 2011). One of her key findings was that in the Netherlands, sex among teens appeared to be more “normalized,” with parents allowing sleepovers with a child’s boyfriend or girlfriend under certain circumstances. By contrast, their American counterparts tended to “dramatize” teen sexuality and were less inclined to conceive of such circumstances: “Not under my roof” (Schalet, 2011).

During the past decade, sexuality norms, including sexual behaviors among adolescents, has been an important theme in the literature on sexual health in the United States (Espinosa-Hernández et al., 2020; Ksinan Jiskrova and Vazsonyi, 2019). An open and ongoing discussion of sex and sexuality between parents and their adolescent children has been recognized as an important component in this discourse (Guilamo-Ramos et al., 2016; Widman et al., 2016b). The roles of culture and ethnicity, religion, geography and rurality, family and social tradition, and peer influences all affect the dynamics around normalization, suppression, or neglect of issues around sexual activity by youth (Coyne et al., 2019; Widman et al., 2016a).

Parents want their children to grow into mature and healthy adults. Parents and communities strive to protect children and keep them safe as they experiment and learn from their successes and failures growing up (Foster et al., 2017; NASEM, 2019b; Sieving et al., 2017). Navigating complex social interactions necessarily involves trial and error (NASEM, 2019b). Just as children do not inherently possess the skills to maturely interact with adults, and just as young people with no experience with alcohol do not understand how to set limits and safely consume alcohol, intimate relationships involve experimenting with new behaviors, which may lead to unanticipated consequences and learning from mistakes (NASEM, 2019b). For example, individuals with high levels of romantic and sexual satisfaction in intimate relationships are often those with significant experience (Allen et al., 2020; Higgins et al., 2011).

Considerable evidence demonstrates the role of parents in shaping outcomes relevant to adolescent STI prevention, including delayed sexual debut, reduced frequency of sex, correct and consistent condom use, and enhanced use of sexual and reproductive health (SRH) services (Dittus et al., 2015; Guilamo-Ramos et al., 2019a; Henderson et al., 2020; Prado et al., 2012, 2019; Rojas et al., 2019; Widman et al., 2019). Less attention has been placed, however, on how parental influences directly rather than indirectly reduce STI incidence and morbidity.

Research has advanced the understanding of how to leverage parents to shape SRH decision making and behavior, including by engaging parents in adolescent health care settings (Guilamo-Ramos et al., 2020; Henderson et al., 2020). Confidentiality concerns are frequently cited as a primary barrier to STI testing among adolescents (Leichliter et al., 2017). Both parents and adolescents indicate that testing is acceptable as part of adolescent primary care (Cordova et al., 2018; Lane et al., 2020), but health care providers are less likely to take a sexual history or offer an STI test to an adolescent patient if parents are in the room during the entire visit (O’Sullivan et al., 2010), despite this parental acceptance. In fact, parental influences have been shown to promote such testing, as parent–adolescent communication about sex is associated with increased uptake of STI and HIV testing among adolescents (McKay and Fontenot, 2020).

In addition, parents’ role in adolescent uptake of the HPV vaccine has been extensively explored in recent years. Important parent-level factors, such as acceptance of vaccination costs, safety, and effectiveness, are associated with adolescent receipt of the HPV vaccine (Lack et al., 2020). The important role of provider–parent communication in achieving greater adolescent HPV vaccine coverage is particularly noteworthy, given that such communication is ongoing, is persistent, and addresses parental barriers associated with same-day HPV vaccination among adolescents (Clark et al., 2018; Shay et al., 2018). Among parents who decline HPV

vaccination at the initial visit, satisfaction with provider communication and increased HPV vaccine knowledge are associated with acceptance at a future visit (Kornides et al., 2018). Parents represent an important partner in the uptake of STI testing and prevention measures.

Parents have the primary responsibility for teaching an adolescent how to build and sustain healthy relationships and establish a moral and ethical framework (Bornstein and Putnick, 2018; NASEM, 2019b). This process includes not only education, through discussions and reading materials, but also methods designed to help facilitate healthy behavior, such as modeling (social norms), creating action plans (removing barriers), and rewarding healthy behavior (building intrinsic and extrinsic motivation). An essential component is modeling kind and loving relationships and teaching communication, negotiation and conflict resolution skills, and forgiveness (Jamison and Lo, 2020; Sommantico et al., 2019). Too frequently, parents do not have the tools to articulate what sexual health means for themselves and thus cannot communicate or model it for their children (Ashcraft and Murray, 2017; Johnson-Motoyama et al., 2016). Thus, a default approach may be to ignore sexuality and offer no guidance or to impose a rigid prohibition on sex and intimacy that can fail to produce the desired result and closes off a critical avenue of communication (Ashcraft and Murray, 2017).

Adolescents want to be able to turn to their parents for support and guidance as they seek to explore new kinds of intimate relationships (Pariera and Brody, 2018; Power to Decide, 2016), so a greater focus is needed on giving parents a broader perspective and skills to provide the necessary education and skills that their adolescent will need for healthy sexual health development. Thus, parents must be equipped with evidence-based educational resources, tools, and programs, such as Families Talking Together (Guilamo-Ramos et al., 2020) and Familias Unidas (Estrada et al., 2017; Prado et al., 2012) that are developmentally appropriate for their children (Guilamo-Ramos et al., 2019a; Johnson-Motoyama et al., 2016). An effective method to increase parental communication self-efficacy is national social marketing and media campaigns geared to improving parent–adolescent communication about sex (Davis et al., 2012). By promoting social norms regarding the appropriate age for sexual debut, expectations regarding parent–adolescent communication about sex, and guidance and tools on when and how to talk with their children, social marketing campaigns have evidence of efficacy in increasing the frequency of such communication (Davis et al., 2012).

Conclusion 12-3: Parents and guardians (parents) play a central role in supporting adolescent and young adult sexual and reproductive health and STI prevention. To fully leverage their role, parents need to have access to

evidence-based guidance regarding effective parenting strategies for sexual health promotion and STI prevention. Diverse channels and mechanisms to provide education and communication skills training are needed to maximize reach and impact.

Recommendation 12-2: Federal agencies and relevant professional organizations should equip parents with evidence-based guidance to engage in developmentally appropriate, comprehensive sexual health education and dialogue and to identify actionable steps for their children. Specifically, the committee recommends the following:

• The Department of Health and Human Services (HHS), through the Centers for Disease Control and Prevention (CDC) Division of STD Prevention, the CDC Division of Adolescent Health and School Health, the Indian Health Service, and other key public health service agencies, should develop a national, parent-focused communication campaign to promote and guide parental communication with adolescents regarding sexual health and sexually transmitted infection (STI) prevention.
• HHS, including CDC, the Health Resources and Services Administration, and the National Institutes of Health, should develop a compendium of existing evidence-based resources and programs for parental education and skills training on adolescent and young adult sexual health and STI prevention. In addition, there should be continued research investments to improve existing, and to develop new, evidence-based resources and programs.
• Guidelines should be developed for pediatric and adolescent health care to support skills training and educate parents in promoting adolescent and young adult sexual health, including the prevention of STIs. This would include the following:
  • Delivering evidence-based programs for parental education and skills training that are colocated as an extension of regular care, and
  • Providing training resources for providers that facilitate direct communication with parents regarding sexual health and STI prevention in their children.

Important constituencies that could collaborate in developing and implementing these practice guidelines include the American Academy of Pediatrics, the Society for Adolescent Health and Medicine, the American College of Obstetricians and Gynecologists, the American Nurses Association, and the American Counseling Association.

For a national, parent-focused communication campaign, the initiative should draw on campaign development best practices, including digital toolkits to support state and local health departments and public health workers in community-engaged tailoring and dissemination, particularly in areas with high prevalence of STIs among adolescents.

Engaging Community Stakeholders to Create Opportunities for Dialogue About Sexual Health

Education about sexual health needs to be delivered where the target audience is and in a form that they understand, whether that be social media, messaging in their living spaces, recreation, et cetera. I also think it needs to be available for all to see, so no one is singled out for looking at it; no one has to go off to any particular place away from the group to look at it. It needs to be normalized instead of set off to the side.
—Participant, lived experience panel

Sex and sexuality can influence daily interactions with others. Society needs new ways to engage the public in dialogues about healthy living. Various settings where individuals gather occupationally and socially can be important settings for normalizing dialogues about sexual health in a general sense. Of course, such environments are not necessarily appropriate venues to discuss and act on very personal goals for intimacy. Rather, as has been discussed, society suffers from inadequate attention to what it means to be sexually healthy. Because these settings are a step removed from an individual’s pursuit of their own goals, they may offer an environment where individuals can learn principles and ideas for linking familiar elements of empathy and respect to less familiar themes, such as communications about sex or seeking pleasure with sex. While not an exhaustive list, the following sectors of our communities should be enlisted to play their part in promoting sexual health.

Families

As discussed earlier, families, primarily parents, often represent an important influence in adolescent sexual decision making. Family members have both individual and collective roles to play in offering support for adolescent sexual health and STI reduction (Grossman et al., 2015). The extant literature has primarily sought to understand the role of maternal influence—including monitoring and supervision, communication, and relationship satisfaction—in shaping developmentally appropriate outcomes important for STI reduction, including delay of sexual initiation for younger adolescents and consistent and correct condom use for

older adolescents (Guilamo-Ramos et al., 2012, 2019a, 2020; Widman et al., 2019). Increasing attention focuses on the role of fathers in adolescent SRH. Emerging evidence indicates that fathers have independent effects on adolescent sexual decision making (Guilamo-Ramos et al., 2012, 2018, 2019b; Santa Maria et al., 2015). Not only do fathers and their sons endorse condom-specific, paternal monitoring and supervision, communication, and role modeling, they each indicate interest in father-based programs and fathers’ involvement beyond the traditional role of disciplinarian (Guilamo-Ramos et al., 2012, 2018, 2019b). Limited attention has been placed on the role of nonparental units in shaping adolescent sexual risk exposure (Guilamo-Ramos et al., 2019b; Santa Maria et al., 2015). In addition, a family focus can have multigenerational influence on STI reduction across the life span. For example, father–son interventions that seek to build capacity in fathers to shape correct and consistent condom use can impact their condom knowledge, skills, and use (Guilamo-Ramos et al., 2018, 2019b).

Family-based engagement around STI prevention also includes queer kinship or families of choice. Families of choice most relevant to STI prevention include the house/ballroom community and other gay family structures. House culture (or ballroom culture) is typically a community of Black and Latino/a sexual and gender minorities (Arnold and Bailey, 2009; Bailey, 2009) that is often organized around two interdependent features: (1) the anchoring family-like structures (i.e., fathers, mothers siblings, kids), called “houses,” and (2) the competitive performances of gender and sexuality, dance, and fashion that houses participate in (Arnold and Bailey, 2009). Independent gay families provide the same kind of familial support and relational structure as ballroom houses, but without the added pressures of competition (Dickson-Gomez et al., 2014; Horne et al., 2015). The structure of the community both nationally and in local jurisdictions is well organized and already has been engaged around HIV prevention (Young et al., 2017). Engagement in STI education and prevention could thus be facilitated through parental structures that organically exist in the house/ballroom and gay family communities.

Schools and Educators

Because of my adverse child experiences, it would have been really helpful if I had been screened in school when I was young. Even a school counselor just doing a basic screening on me or maybe a school program could have flagged me and maybe got me in front of someone when I was younger. I don’t remember ever really being evaluated by a school counselor, ever being evaluated by a school nurse, anybody ever having a discussion with me about what my behaviors were.
—Participant, lived experience panel

As children, adolescents, and young adults spend time within educational environments with important implications for the maturing brain (Lamblin et al., 2017; Morris et al., 2018), the parent–teacher nexus is a critical component in the evolving sexual health discourse as well. Whereas the parental role is especially important in conveying values and expectations (Guilamo-Ramos et al., 2019a), educators are needed to validate or offer objective and accurate information (Denford et al., 2017). This includes not only teaching about sexuality and health, with components that include STI awareness and prevention and when and where to seek screening and treatment, but also integrating such information into broader lessons about healthy living and maintaining healthy relationships (CDC, 2019c). Adolescents who participate in comprehensive sexual health education programs in school settings are more likely to delay initiation of sexual behavior, have increased knowledge of STI risks and consequences, and report enhanced contraceptive use (Chin et al., 2012; Denford et al., 2017; Kirby, 2007; Lopez et al., 2016; Santelli et al., 2017; Underhill et al., 2007).

Despite the important role of parents in shaping adolescent and young adult sexual decision making (Power to Decide, 2016), school-based programs primarily deliver sexual health education in the classroom setting directly to adolescents, often neglecting to include parents for any reason beyond obtaining consent for student participation (Denford et al., 2017). Comprehensive sexual health education programs in school-based settings, such as Families Talking Together, that include parent–adolescent sessions and homework assignments have been efficacious in shaping multiple adolescent outcomes, including delay of sexual initiation (Guilamo-Ramos et al., 2011). In addition, health care providers in school-based health clinics represent important partners for enhancing existing sexual education programs. For example, nurse-led interventions have been associated with increased uptake of STI testing and contraception in school-based health centers (Brigham et al., 2020; Ethier et al., 2011). Moreover, evidence suggests that both school- and parent-based approaches have the added benefit of addressing STI-related misinformation from peers and social media sources (Cameron et al., 2020; Guyer et al., 2015).

Universal access to comprehensive, age-appropriate, evidence-based, and medically accurate sexual health education is needed, as are greater opportunities outside of school settings for young people to receive this information (Chin et al., 2012; Denford et al., 2017; Santelli et al., 2017). One idea could be shifting focus toward giving young people life skills that includes teaching them what it means to be sexually healthy (Aggleton and Campbell, 2000; Lee and Lee, 2019). (See Chapter 8 for more information on sexual health education in school settings.)

In the public domain, ASHA has played an important role in promoting normalization of the sexual health discourse in the United States. It has articulated six evidence-based components of what it means to be sexually healthy (ASHA, 2020; Phillips, 2019), to assist educators, as well as parents, in the development of age-appropriate curricula:

• Understanding that sexuality is a natural part of life and involves more than sexual behavior;
• Recognizing and respecting the sexual rights shared by all;
• Having access to sexual health information, education, and care;
• Making an effort to prevent unintended pregnancies and STIs and seek care and treatment when needed;
• Being able to experience sexual pleasure, satisfaction, and intimacy when desired and appropriate; and
• Being able to communicate about sexual health with others, including sexual partners and health care providers.

Faith Communities

My church had been my foundation from a very young age. But when I started getting in trouble and started drinking and doing drugs, I thought, “Oh, I can’t turn to God anymore,” and that was a huge detriment for me because it was my safe place for such a long time. I think that the church has a lot of work to do on that message. They play a big role in the message that they give out to people on their lifestyles, that if you are not doing all the right things then you are rejected.
—Participant, lived experience panel

Promoting sexual health as a key dimension of human health and well-being does not have to be in conflict with religious beliefs. As the institutions and leaders that are often the most respected and trusted voices within a community (Nunn et al., 2019; Ransome et al., 2018; Vigliotti et al., 2020), faith-based organizations and clergy have an opportunity to be transformative in legitimizing attention to and consideration of sexual health as an important component of health. Within a broad spectrum of views, ranging from complete rejection of sex outside of male–female marriage to the acceptance of the widest range of sexual expression, faith communities have a critical role in translating their values and beliefs in ways that foster agency and individual decision making to promote sexual health. The existence of nearly 350,000 congregations in the United States illustrates their potential in contributing to improved sexual health as part of caring for their members (NASEM, 2019a).

Although people often turn to faith communities to address spiritual health, health involves more aspects of a person’s life, reflected in the World Health Organization’s (WHO’s) definition: a “state of complete physical, mental and social well-being.” Moreover, many churches and houses of worship have historically led the way (and continue to do so) in promoting health through ministries that foster healthier behaviors and address specific conditions, such as diabetes, smoking cessation, and HIV (DeHaven et al., 2004; Maynard, 2017; NASEM, 2017; Ochillo et al., 2017; Schoenberg et al., 2015).

Early in the HIV crisis, organizations such as The Balm in Gilead (The Balm in Gilead, 2020) were established that served to create entry points and resources for Black faith communities to address HIV. The organization has since broadened its focus to cover a range of other health issues impacting persons of African descent. Similarly, the National Black Leadership Commission on Health (NBLCH, 2020) (originally, the National Black Leadership Commission on AIDS) has historically worked to engage faith communities in responding to HIV and broadened its work to cover other health issues that affect Black people in the United States (Ransome et al., 2018).

At a time when the United States is divided in many respects, it is reassuring to look at the nation’s great legacy of religious freedom and respect for religious difference. The committee holds an inclusive vision of respect and appreciation for diversity in religious belief, culture, gender, and sexual orientation. The committee also asserts that promoting sexual health in a manner that facilitates STI prevention, diagnosis, and treatment does not constrain faith communities from teaching about sexual responsibility and sexual health in a way that is consistent with their own faith traditions and ethical frameworks. For example, some faith communities often instruct their members to be chaste and abstinent not only as an extension of faith, but also out of an impulse to be protective and promote health. Ideally, research-based insights could be integrated with such traditions or ethical frameworks. Research has shown that fear- and shame-based teachings are among the least effective and may preclude the openness needed for honest dialogue (Earl and Albarracín, 2007; Hutchinson and Dhairyawan, 2018; Morris et al., 2014). For children or adults, comprehensive, strengths-based approaches that seek to bolster self-esteem and teach people to make decisions about their own sexual health goals and how to act on them in real life are more likely to lead to delayed sexual initiation in young people and healthy outcomes (including STI prevention and more prompt screening and treatment) in all people (Downs et al., 2018; Mahat et al., 2016; Scull et al., 2018).

Consistent with this discourse, emerging research indicates that sexual health can be addressed in communities of faith and that theoretical

models (Wingood and DiClemente, 2008) can be used to adapt evidence-based sexual education and HIV prevention programs to such settings rather than developing faith-based interventions (Weeks et al., 2016). In a study from Baltimore, involving in-depth interviews and multiple focus groups of pastors, ministers, parents, and youth from nine participating Black churches, researchers found that certain youth felt that churches were the preferred place for sexual health education. Facilitators in the adaptation process included the positive influence of youth ministers and life lessons as teaching tools. Barriers were also identified, including perceived resistance from congregants, youth discomfort, lack of financial resources, and competing messages at home about sexual health (Powell et al., 2017). Wingood et al. (2011) found that an evidence-based HIV prevention intervention focused on young African American women could be successfully adapted to the church setting with high levels of fidelity to the original intervention, and with high attendance in this two-session program. (See Chapter 8 for more information on faith-based interventions.)

Community-Based Organizations with Roots in Activism and Advocacy

Rejection, labeling, and loss of self-esteem are really predominant in rural areas…. I was a sex worker, putting myself at risk because I didn’t care if I lived or died, because the place that I grew up in told me I was bad and I was disgusting. When you have been given that message all your life it does chip away at your psyche and your ability to live. What helped me was knowing that there was at least a group that didn’t treat me like my family did and my church did. Just to have that safety net of somebody, a group, or an organization or something to say you are not bad, you’re not wrong.
—Participant, lived experience panel

Trust is an essential component of health promotion. Culture and group identities shape how health is viewed and understood. Individuals and groups carry with them unique histories that shape how information is received and who is trusted to convey information. People who were raised in households with consistent access to affordable health coverage seek care in ways that are very different than persons who have never had such access, and these differences often remain even if access is equalized. African Americans and others remember the 1932–1972 U.S. Public Health Service Syphilis Study at the Tuskegee Institute (White, 2000), on the natural history of syphilis in Black men; it was conducted without informed consent, and diagnosed individuals were not offered treatment or told that they could disenroll from the study and seek treatment outside of it.

This is only one of many examples of racist disregard for the best interests of a group of people denied agency in optimizing their health.

The background and attributes of the individual or entity that initiates a dialogue about health is important, and just as no person fits neatly into a single group identity, it is the diversity of environments where people lead their lives that offer opportunities for differing and nuanced dialogues about healthy living, including sexual health, that can contribute to a healthier population. Intersectionality (see Chapters 1 and 2) is an important concept in this care engagement and in how community members position themselves and find comfort and acceptance in their lived experiences. An intersectional lens needs to be applied to the client–provider relationship, with important recognition of how shared decision making and subsequent positive health outcomes depend on multiple identities (Peek et al., 2009).

Community-based organizations have critical roles in promoting trust, advocating for service needs, holding health care providers and systems accountable, and delivering essential health care and/or supportive services. As explored in Chapter 8, social network interventions and community-level interventions can contribute to an improved STI response. Assessing effective advocacy, tools that assist in building community capacity for delivering interventions, and community mobilization models addressing related issues can offer new insights for bolstering the role of community partners in strengthening responses to STIs.

Starting in the 1980s and 1990s, women of color across the nation, often led by Black women but including Indigenous, Latina, and other women of color, established a framework and organized around the principles of reproductive justice (Silliman et al., 2004). This was in part a reaction to racism experienced by marginalized populations within feminist movements led by white women and the belief that a narrow focus on abortion rights neglected broader considerations facing women of color (Silliman et al., 2004). Thus, central tenets of the early reproductive justice movement were focused on the right to have a child, the right to not have a child, and the right to parent the child(ren) one has (Ross, 2017). The first national conference on Black women’s health issues was held at Spelman College in Atlanta in 1983 and has catalyzed sustained organizing, with diffuse actors across the country establishing organizations, leading community dialogues, engaging in the policy-making process, and broadening the numbers and the types of people who are engaged in policy conversations about reproductive rights and justice (Silliman et al., 2004).

Additionally, in the early 1970s, community activism raised awareness about health disparities in the LGBTQ+ community, particularly rising levels of STIs, which led to health centers with the specific purpose of serving the gay and lesbian community. For example, the Whitman

Walker clinic, now one of the largest providers of HIV care in Washington, DC, started as the Gay Men’s VD Clinic in 1973. Likewise, Howard Brown Health was founded in 1974 by gay medical students in response to rising rates of STIs, particularly hepatitis B, among gay men in Chicago, and Fenway Health in Boston had a similar genesis in 1971. When the first cases of AIDS were reported in 1981, these health centers quickly mobilized to provide health care and other services and have since grown into nationally and internationally renowned clinical care and research institutions. Many of them have led the field with developing innovative client-centered strategies that include extragenital sample collection, self-sampling, rapid test result notification (Cohen et al., 2017), and self-service, kiosk-based STI testing with Healthvana texts and results.³

Since the early 1980s, community-based organizations have been critical to the civic response to HIV/AIDS. Often initiated and supported by leaders in the LGBTQ+ community, AIDS service organizations emerged nationwide to assist with daily needs, including shelter, food, and psychological support. These organizations became involved with advocacy, education, and prevention, resulting in a strong force in the fight against HIV/AIDS stigma. The importance of these and other community-based organizations in the spectrum of HIV/AIDS-related services is reflected in their receipt of separate federal funding through Part C of the Ryan White Care Act to support ambulatory health services since 1990.

Over time, with the emergence of highly effective antiretroviral therapy to treat HIV and later PrEP to prevent it, these organizations became increasingly important in delivering health and prevention services, and many opened dedicated clinics to serve their clients. With rising rates of STI rates among persons living with HIV and those taking PrEP, these clinics have become important venues to offer STI services.

The Open Arms Clinic in Jackson, Mississippi, is a good example of this evolution.⁴ Its founding organization, My Brother’s Keeper, had been in existence as a 501(c)(3) community-based organization, providing services to persons living with HIV in the Jackson area since 1999.⁵ In 2013, the organization expanded HIV testing services to include STI screening, blood pressure and body mass index measurements, glucose, and cholesterol testing to create a more holistic health focus and reduce stigma around HIV and STI testing. In collaboration with the Division of Infectious Diseases at the University of Mississippi Medical Center,

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³ See, for example, Howard Brown Health (https://howardbrown.org/press/healthvana [accessed October 30, 2020]) and Fenway Health (https://fenwayhealth.org/care/medical/std-testing-services [accessed October 30, 2020]).

⁴ See https://oahcc.org (accessed January 26, 2021).

⁵ See https://mbkinc.org/about-us (accessed January 26, 2021).

which provided clinicians, and the Mississippi State Department of Health, which provided resources for HIV and STI testing to create the infrastructure and administrative leadership, the HIV testing and adjacent food pantry was transformed into the Open Arms Clinic in 2013. It has moved to a new standalone location that includes multiple exam rooms, an onsite laboratory and pharmacy, and research space.

In addition to influencing policies and politics, community activists and leaders have thus spawned health models for HIV prevention and care that have reduced stigma and enhanced access to the most vulnerable populations (Valdiserri and Holtgrave, 2019). Given the increases of STIs in these populations, these health care settings are increasingly testing for STIs, and their staff now includes STI clinical experts. Developing integrative models of HIV and STI care and prevention, embedded in community-based environments that increasingly embrace a general wellness approach, needs to be encouraged and supported; these models need support, however, to expand efforts to address STIs (see Chapter 8 for more information).

Workplaces

Workplaces offer an important opportunity to advance sexual health and STI prevention and control. They can give employees an understanding of what it means to be sexually healthy and of where, when, and how to access STI services. Workplaces also have a role in reducing stigma around STIs by normalizing these services as part of overall health. Businesses are uniquely situated because of their contacts with employees, communities, and the wider business community and their wealth of experience and skills (NASEM, 2016a). Businesses have a history of promoting health and health education for their employees, including policies and programs that ensure employee rights, such as access to health care and counseling (NASEM, 2016a). Furthermore, businesses have carried out programs aimed at improving health of their customers and the broader community and also acknowledged that factors beyond health care—the social determinants of health—are important to focus on, including by strengthening individual connections to the community (NASEM, 2016a, 2017, 2020b). Several businesses and organizations have addressed employee health, including the U.S. Chamber of Commerce and the National Business Group on Health, and shifted away from focusing on workplace wellness and health care to consider businesses’ broader role in addressing the social determinants of health and health inequities (NASEM, 2017). In 2015, the Vitality Institute (a South African health promotion research institution) published a report for business leaders to provide support for their interest in engaging with communities to

improve health beyond company walls (Oziransky et al., 2015). Corporations also have collaborated to address other social issues, as evidenced by the Corporate Alliance to End Partner Violence and workplace programs (often through Employee Assistance Programs) on topics such as parenting, caregiving, work/life balance, and addiction (GuideStar, n.d.; NIH, n.d.).

One example from the HIV field is Business and Labor Responds to AIDS, a PPP initiative of CDC established in 1992 as a resource to businesses to operate workplace programs to reduce HIV stigma and prevent discrimination against employees living with HIV (CDC, 2019e). It is both an educational platform and communication vehicle and focuses on the following:

• Prevention and Education—Provides resources and tools to implement HIV awareness, prevention, and testing efforts in the workplace.
• Policies—Implements peer-based technical assistance on human resources policies that address stigma and discrimination, the rights of people living with HIV, and inclusion of HIV-specific insurance coverage in the workplace.
• Treatment and Support Services—Provides information and facilitates linkage to treatment and support services.
• Philanthropy and Volunteerism—Facilitates opportunities and examples of how businesses can support national and community-based HIV organizations (CDC, 2019a).

Potential benefits for participating businesses include increased productivity, access to accurate, timely, and relevant HIV information, resources and peer-based technical assistance, and linkages to a network of businesses and stakeholders (CDC, 2019a). This example shows how workplaces can focus both on employee wellness and the broader community.

Chapter 8 discusses the role of businesses at the community level and outlines the promising role of barbershops to disseminate information about sexual health, wellness, and STI prevention (Brawner et al., 2013). It also explains how interventions that address social norms, such as fear and stigma associated with STIs, are likely to be effective in reducing STI risk (Adimora and Auerbach, 2010; Myer et al., 2001). Workplaces could adapt and adopt these interventions. Although the committee could not identify and recommend specific non-HIV STI or sexual health programs, it believes workplaces, where so much time is spent, provide an important opportunity for communication, education, and a platform to advance sexual health.

Celebrities and Prominent Individuals

Celebrities and other prominent individuals also can contribute to expanding knowledge and agency over sexual health. The explosion of social media platforms, continuous 24-hour cable news cycles, and popular culture that permeates U.S. society suggests the benefits of celebrity advocates for neglected and/or stigmatized diseases. STIs have not had the benefit of such popular advocates.

Previous reports (e.g., NAPA, 2018) have highlighted a need for popular advocates for STI research and funding. Respected celebrities and community leaders can assist with reducing stigma and promulgating prevention messages. In the committee’s information-gathering sessions, multiple speakers identified how celebrity advocates could help with STI prevention and control, creating a culture of sexual health to obtain better policy support and funding, and addressing stigma (Barclay, 2019; Sofaer, 2018). NAPA authors urged the designation of “a national STD champion to coordinate federal, state, and local efforts and to lead the development and implementation of a national strategy” (NAPA, 2018, p. vii). As was done with the Ryan White HIV/AIDS Program, the authors note the need to put a face to the STI epidemic, perhaps with a national champion who could personalize its impact on the health of pregnant people and children and focus efforts on preventing infant deaths (NAPA, 2018). Individuals who became well-known advocates for people living with HIV/AIDS include Magic Johnson, Elizabeth Taylor, Mary Fisher, and Dr. Mathilde Krim. Johnson and Taylor brought messages of hope and empathy to millions of U.S. individuals who might not otherwise have appreciated the importance of addressing the crisis. Fisher was instrumental in reaching across the political divide to frame HIV as a medical and humanitarian issue of concern to persons of any and all political persuasions. Krim helped mobilize private-sector resources for HIV research and raise consciousness in Hollywood about the dramatic potential inherent in the crisis. Other STIs also have received increased attention from the media and general public due to disclosure from celebrities and portrayal in pop culture. Michael Douglas’s disclosure of his throat cancer created significantly increased media attention for oral cancer and HPV (The Oral Cancer Foundation, n.d.; Throat Cancer Foundation, 2013). HBO’s critically acclaimed television show “Insecure” raised the issue of sexual health when one of its main characters was revealed to have chlamydia (Villarreal, 2018) after the show was previously criticized for not depicting safe sex practices, including condom use (Byrd, 2018; Mitchell, 2018; Moss, 2018). The importance of sexual education for teenagers is also the focus of the popular British television series “Sex Education” on Netflix (Nightingale, 2019).

The authors of the first NAPA report, however, suggest that rather than an individual from the entertainment or sports industries, the STI national champion could be a senior individual from the Office of the Assistant Secretary for Health or elsewhere in HHS who would have “the standing and clout [to] unify and harmonize policy across the disparate agencies that play a role in STD prevention and control” (NAPA, 2018, p. 69). Surgeon General Dr. C. Everett Koop in the 1980s or National Institute of Allergy and Infectious Diseases (NIAID) director Dr. Anthony Fauci in 2020 on the COVID-19 pandemic could serve as possible models for such medical celebrity advocacy.

Similarly, ASHA has developed campaigns that leverage individuals with large social networks and/or social media followings to educate and encourage individuals to seek STI testing services. ASHA recruits volunteers nationally and globally for its social media ambassador program⁶ to develop and disseminate positive sexual health messages within their networks. As of 2019, the program had 517 ambassadors who reached more than 832,000 people (Barclay, 2019). ASHA also runs a campaign, Yes Means Test,⁷ that uses social media influencers to create awareness, educate, and encourage 18–24-year-old women to be tested for chlamydia and gonorrhea. As of 2019, the campaign has generated more than 1.6 million video views, more than 270,000 website views, and 26,740 clicks on the website’s clinic locator (Barclay, 2019). In 2019, ASHA also launched a campaign directed at young members of the military that focuses on testing, contraception, PrEP, and HPV vaccination (Barclay, 2019).

Celebrity advocacy is seen in many other areas of health. Actress Angelina Jolie has helped to destigmatize breast cancer surgery and genetic screening with her personal testimonials. Musician Miley Cyrus and comedian Pete Davidson have brought mental health issues to the forefront of U.S. pop culture. Journalist Katie Couric has highlighted colon cancer and the need for screening. Journalist Maria Shriver has advocated for Alzheimer’s disease awareness, and actor Michael J. Fox has been an activist for Parkinson’s disease. Usually, either the celebrity or someone in their immediate family suffered from the condition. A celebrity, however, may be unlikely to announce that they have acquired syphilis, gonorrhea, or chlamydia, arguably more stigmatized than even HIV/AIDS or mental health. It may be more realistic to have a popular culture figure advocating for regular check-ups to stay healthy, as is done for diet and fitness health activities. Hence, the NAPA suggestion that a medical or government advocate fill this role may be a useful first step.

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⁶ See https://ashaambassadors.socialtoaster.com (accessed November 3, 2020).

⁷ See https://yesmeanstest.org (accessed November 3, 2020).

Relatedly, a public figure or celebrity can serve to help shed light on certain topics and even alter behaviors. For example, research has found that public figure health disclosures can impact information seeking and health behaviors, such as requests for cancer screenings (Noar et al., 2014). A recent meta-analysis found a small to medium effect size between audience involvement (e.g., identification) with celebrities following a disclosure and behavior intentions, with behaviors that did not require a medical procedure producing greater effects (Kresovich and Noar, 2020). In the HIV field, after actor Charlie Sheen publicly disclosed his HIV status, sales for an in-home HIV test kit were elevated for 4 weeks, with more than 8,000 more sales than expected for that time frame, surpassing sales around World AIDS Day (Allem et al., 2017). Web searches over that period mirrored the increase in sales (Allem et al., 2017).

Public figures have careers and income streams to protect. Admitting to having had an STI, having a family member with one, or even choosing to speak out on the issue may be viewed by agents as bad for business. Stigma is surely keeping public figures from disclosing or advocating. Still, advocates who do not have an STI could still bring awareness to the topic. Actress Mariska Hargitay learned about sexual assault issues in her role on Law & Order: Special Victims Unit and has been an activist ever since. Krim and Taylor both advocated for HIV/AIDS for decades without themselves or their immediate families having been affected, but rather because of their empathy for others. STI experts may consider efforts to recruit and train a small cadre of celebrity, scientific, and government advocates to capture the imagination of the media, policy makers, and community leaders toward sexual health and STI prevention as part of an effort to change the culture around STIs.

Artificial intelligence (AI) approaches hold promise in addressing the potential costs and difficulty in recruiting famous celebrities. Although it might be difficult to gain the support and commitment of famous people as spokespersons, artificial intelligence modeling on social media data (described in more detail in Chapter 6) may be a solution. For example, many individuals are respected and influential on social media and passionate about STI prevention. They may not have the status of a famous actor, but they can be a type of domain-specific (e.g., specific to sexual health) celebrity. In similar ways that the field of public health, including HIV, has leveraged peer role models and community popular opinion leaders to promote health behaviors, these online influencers may be helpful for promoting sexual health. Compared to a traditional well-known celebrity, these “domain-specific online influencers” might be more committed to assisting government and public health because they are already passionate about sexual health. They also are likely to receive fewer requests for promotional efforts compared to traditional celebrities, making them more excited about the opportunity.

The committee recognizes that identifying sexual health–related online influencers might still be challenging, especially as online influencers are constantly changing. One potential solution is to leverage AI modeling to identify current social media influencers related to sexual health. For example, in the HIV space, researchers have used AI methods to sort through millions of Twitter posts in real time to identify individuals who appear to be influential in HIV prevention (Zheng et al., 2020). Celebrities with more than 80 million Twitter followers each include singers Justin Bieber, Katy Perry, Rihanna, Taylor Swift, and Lady Gaga and soccer star Christiano Ronaldo (Brandwatch, 2020). Any one of these superstar influencers who might embrace a “please test to stay healthy” mantra for STIs might inspire young persons to do just that. This type of technology adapts over time, allowing the ability to keep up with current trends by flagging the current (daily, weekly, or as needed) online influencers. These methods could play an increasing role in the future of STI prevention by cost-effectively helping to identify online influencers around sexual health, increasing the likelihood of gaining a large number of highly committed, low-cost “celebrity” advocates.

PPPs for STI Prevention and Control

PPPs, in which private-sector entities, including corporations and philanthropies, either work directly with governmental agencies on collaborative projects or agree to work separately toward shared goals, can be an important avenue for broadening ownership for STIs. Both in the United States and globally, PPPs can bring private-sector expertise and resources to bear on topics of high public interest. These are especially salient when market forces are inadequate to drive enough private-sector innovation and product development to meet public needs. Two examples from global health help illustrate these principles: The Rotary Club International partnership with WHO and dozens of ministries of health and donor nations began global efforts to eradicate poliovirus from the planet. As the needs grew in the “end game,” this PPP was complemented by major involvement from the Bill & Melinda Gates Foundation and additional private-sector groups that subsidized these efforts, suggesting models for the future (Awale et al., 2019). Project Last Mile combined beverage industry leaders with vaccine and drug distributors in ministries of health to bring logistics expertise—notably, transportation, storage, and inventory management—from the private sector into the public sector (Linnander et al., 2017). In contrast to polio eradication, this project was clouded by previous criticisms of soft drink interests and engagement in scientific support (Hernandez-Aguado and Zaragoza, 2016; Jane and Gibson, 2018).

PPP-driven projects may not always be evaluated rigorously, casting doubt on their impact (Della Rocca, 2017; Holeywell, 2013). Conflict of interest may seem likely if the private-sector actor has a financial stake in the product or program being promoted (Hernandez-Aguado and Zaragoza, 2016; Omobowale et al., 2010). Some programs that are woefully underfunded or neglected within the government or the industrial spheres may have timely assistance or experience innovative inputs with PPPs (Albalate and Bel-Piñana, 2019; Brady and Potter, 2014; Granados Moreno et al., 2017; Saadeh et al., 2019). Hospitals or entire health systems may have PPP elements (NASEM, 2016c, 2020a; Vrangbaek, 2008). The circumstances of a given PPP need to be evaluated to judge its merits and winnow out potential conflicts of interest.

Women’s health has garnered STI-relevant investments, as with support from the private sector for Planned Parenthood. Medicines360 is a women’s health pharmaceutical nonprofit, working with a humanitarian aid group, Direct Relief; it has partnered since 2018 to provide Medicines360’s hormonal intrauterine device for free, often to uninsured individuals (Direct Relief, 2018). Other women’s health, maternal and child health, and nutritional initiatives have benefited within a variety of PPPs (Campos et al., 2019; Hoddinott et al., 2016; Kamugumya and Olivier, 2016).

A dramatic recent example of a massive U.S. PPP is the 2020 Operation Warp Speed, which provided hundreds of billions of dollars to the private sector to produce and deliver 300 million doses of SARS-CoV-2 vaccines as soon as the Food and Drug Administration determines that they are proven safe and effective. Other elements focus on countermeasures, such as COVID-19 therapeutics and diagnostics (Slaoui and Hepburn, 2020). While the economic impact of the COVID-19 pandemic is far higher than the economic burden from STIs, PPPs are still appealing strategies if they can capture the imagination of enlightened business, foundation, and nonprofit partners. They could be built on many themes: adolescent health, women’s health, men’s health, LGBTQ+ health, perinatal and children’s health, POC diagnostics, and public health capacity building.

STI drug development

Substantive experiences with PPPs in the STI field are relatively recent and have shown great promise, with some early successes. An ongoing PPP with immense promise is testing the antibiotic zoliflodacin for gonorrhea, an endeavor of Entasis (a company created by AstraZeneca) and the Global Antibiotic Research and Development Project, a nongovernmental organization created by Doctors Without Borders (Alirol, 2019; Bradford et al., 2020; Cristillo et al., 2019; Foerster et al., 2019; Jacobsson et al., 2019). The Phase 3 trial is based on Entasis donating the rights to their drug for global (except for the United States) sales

and production and distribution to the Global Antibiotic Research and Development Project. The trial is being carried out with donated drugs, and the study is supported by donations from NIAID, WHO, the Bill & Melinda Gates Foundation, and others.

Another example of PPPs for antibiotic development that include STIs is CARB-X,⁸ a PPP that invests in new antibiotics, offering 56 small companies (as of 2020) substantial financial support. Similarly, the Antimicrobial Resistance Fund has taken a special interest in gonorrhea.⁹ These PPPs are in the spirit of prior infection control and pharmaceutical partnerships that have been supported by PPPs in diverse global and U.S. settings (Miles et al., 2014; NASEM, 2016b; Shrivastava et al., 2019). International experiences with PPPs to address STIs have been documented, sometimes with industries and their workers (Albis et al., 2019; Fobosi et al., 2017; Kokku et al., 2014).

Prevention, testing, and advocacy

New technologies are not the only vehicles for PPPs for STI prevention and control. A condom coalition led by ASHA that involves the Trojan brand has been supported by Church & Dwight, the makers of Trojan condoms.¹⁰ Similarly, the Kaiser Family Foundation (KFF) is spearheading a national condom campaign, Rap it Up, with support from Black Entertainment Television (KFF, n.d.). The Bill & Melinda Gates Foundation supported a “condom of the future” project in 2013 that stimulated research in a previously quiescent field.

Perhaps the most promising arena for PPPs is STI testing. MTV has partnered to support a CDC and KFF “Get Yourself Tested” campaign (CDC, 2019b). Diagnostics companies that stand to gain from expanded STI testing with more accessible and affordable POC strategies may support rolling their products out. Another partnership, Project Last Mile, supports hepatitis C therapy funding support built on a Netflix model (USC Schaeffer Center, 2019).

The most dramatic examples of success in PPPs are HIV/AIDS and COVID-19. KFF has worked with Walgreens and Orasure Technologies to aid HIV/AIDS diagnosis, care, and treatment efforts in their “Greater Than AIDS” project (KFF, 2020b). Public communications campaigns show promise in engaging professional advertisers with marketing expertise, as with CDC’s Community Approaches to Reducing Sexually Transmitted Diseases initiative (CDC, 2020) (see Chapter 8 for more information).

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⁸ See https://carb-x.org (accessed October 29, 2020).

⁹ See https://www.ifpma.org/partners-2/the-amr-action-fund (accessed October 29, 2020).

¹⁰ See https://www.ashasexualhealth.org/condomology (accessed October 29, 2020).

Many HIV campaigns have engaged expert marketers, both paid and pro bono, in partnerships motivated by public health concerns (HIV.gov, n.d.).

Issues related to health equity and race may be hard for a politicized public sector to address, even when societal and economic benefits are made obvious (ASTHO, 2012). Such issues may be tackled by private-sector actors in PPPs. A new national STI coalition of 17 nonprofit advocacy organizations¹¹ was established in early February 2020, just before the COVID-19 pandemic hit the United States (NCSD, 2020).

Conclusion 12-4: The committee concludes that an important limitation of the historical response to STI prevention and control is that community stakeholders (e.g., families, schools and educators, faith-based organizations, and workplaces) lack the resources and agency they need to help reduce STI outcomes and inequities in their communities. The committee further concludes that elevating the promotion of sexual health for all in partnership with community stakeholders is a promising strategy for improving STI outcomes and inequities, but more direction and support is needed to empower communities to engage in sexual health dialogue and promotion efforts tailored to their specific community contexts, needs, and priorities.

Recommendation 12-3: The Centers for Disease Control and Prevention Division of STD Prevention should take steps to expand community knowledge of sexual health and promote actions that lead to a greater understanding of healthy sexuality by encouraging and supporting public dialogue and the adoption of evidence-based interventions in various community settings (families, schools, faith communities, community-based organizations, and workplaces).

CDC should collaborate with other relevant federal, state, local, tribal, and territorial partners to generate new and enhanced partnerships to support the Division of STD Prevention’s (DSTDP’s) mission. As a first step, DSTDP may consider an internal consultation with other divisions within the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention that have a diversity of potential partners for DSTDP to foster collaboration and program integration. These divisions also may have

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¹¹ Advocates for Youth, AIDS Institute, American Sexual Health Association, American STD Association, Association of Maternal & Child Health Programs, Association of State and Territorial Health Officials, GLMA: Health Professionals Advancing LGBTQ Equality, HIV Medicine Association, Infectious Diseases Society of America, National Alliance of State and Territorial Aids Directors, National Association of County and City Health Officials, National Coalition of STD Directors, National Family Planning & Reproductive Health Association, NMAC, Planned Parenthood Federation of America, SIECUS: Sex Ed for Social Change, and Treatment Action Group.

additional experience in identifying models for effectively working with community partners. A follow-up action may be to convene an external consultation “summit” to bring together a range of community stakeholders, to both expand partnerships with a range of entities already engaged in health-related education, advocacy and services delivery and strategize on how to engage and sustain collaborations with a broader set of nongovernmental partners. This imperative also has been highlighted in the 2018 NAPA report (NAPA, 2018). Such a summit also may bring together experts in strategies for developing community and organizational capacity for delivering evidence-based interventions to prevent and control STIs (see Chapter 8). The added strength and influence of a phalanx of powerful private-sector allies and funders working to enhance the reach and influence of public health evidence-based STI control efforts is needed. Actions from community stakeholders could include the following:

• Families: Families play an essential role in normalizing health-seeking behavior and teaching values and expectations, not only for young people but across the life span. Families should discuss actions that promote sexual health.
• Schools and Educators: Just as parents have the central responsibility for guiding children’s healthy development, schools and educators also perform an essential reinforcing role. School districts, education associations, the national Parent–Teacher Association, and other education-affiliated institutions should develop or adopt existing evidence-based training guides and other resources for conveying information about healthy living, including health sexuality that is nonjudgmental, medically accurate, age appropriate, and inclusive of all persons.
• Faith Communities: Many faith communities have established ministries on other health topics and offer an important venue for conversations about how to integrate sexual health into one’s life. They should be encouraged—and provided the necessary tools and resources—to adapt evidence-based models for sexual health promotion for their congregations.
• Community-Based Businesses and Other Settings: Small businesses and other establishments in communities where people live and socialize are ideal settings for engaging individuals in meaningful dialogue about health and wellness, including messages about sexual health and STI prevention. With trainings and resources from CDC and state and local health departments, community stakeholders should be deployed to engage on these topics.
• Workplaces: Many people spend more time at work than at home. Employers, unions, and human resources associations should

• develop or adopt existing evidence-based educational tools and messages to normalize healthy living and dialogue about sexual health.

BOLSTER EXISTING SYSTEMS AND PROGRAMS FOR RESPONDING TO STIs

The challenge of preventing and controlling STIs in the United States is large. The committee’s analysis of these complex issues leads it to call for a new sexual health paradigm and broadened ownership and

accountability for contributing to the STI response. Despite highlighting certain deficiencies in the current response, the committee does not believe that the actors or agencies and systems in place, at all levels, to address STIs have failed. Rather, they have frequently performed commendably given the level of resources and political and public support that they have been given. This section draws on the barriers, opportunities, and evidence discussed throughout this report to highlight meaningful opportunities for action that will significantly enhance current efforts. See Box 12-4 for a summary of recommended actions to bolster the current system.

Enhancing Federal Leadership and Support

The center of the federal government’s response to STIs is the CDC DSTDP, which leads the national surveillance and monitoring effort and conducts workforce training and research. The majority of its funding, however, is passed through to state and local health departments (see Chapter 4). Both its intramural activities and its grant-making programs serve the dual purposes of supporting state and local efforts and synthesizing various data, other inputs, and best practices from these jurisdictions to capture a national picture of emerging trends and to intervene comprehensively and strategically.

Surveillance and Monitoring

CDC operates numerous essential disease surveillance systems that typically fund state and local health departments to collect and analyze information, including on nationally reportable infectious diseases (see Chapters 2 and 4). Frequently, however, resource limitations mean that CDC has to conduct sentinel surveillance and use sampling tools (such as funding a subset of states) to collect information that is used to model national incidence and prevalence estimates. CDC’s work in partnership with states, and secondarily with local health departments, is extremely valuable. Nonetheless, the capacity to collect, analyze, and use surveillance and other data varies dramatically between jurisdictions. Additionally, data are often collected separately for different infectious diseases; for example, someone with co-occurring syphilis and HIV may be interviewed by different people to contact trace the different infections, a duplication of effort. This means it is not always possible to rapidly identify clusters of disease transmission or spot other trends that would be visible if cases were monitored across infectious diseases. The committee observes that integrating data systems to improve interoperability at CDC and within health departments could improve population-level outcomes. The goal would not be to achieve uniform, single systems for all infectious diseases, but to upgrade public health capacity to respond effectively to STIs and other infectious diseases.

Population-based surveys and STI screening are the gold standard for measuring disease prevalence and risk factors. Current population-based surveys, such as the National Health and Nutrition Examination Survey and Behavioral Risk Factor Surveillance System, however, are infrequent and have small sample sizes. Disease prevalence for several STIs is modeled rather than observed and the nation does not have the ability to monitor it over time. Therefore, the nation does not know the true disease burden of STIs and how it has changed. This information is fundamental

to guiding national policy. Without this, it is difficult to know if national efforts to curtail disease burden are succeeding or failing.

CDC primarily relies on case reporting to monitor STIs. That system, however, is too slow to allow the public health system to react, and reports are publicly released approximately 9 months after the end of the calendar year because of an antiquated data infrastructure that requires extensive effort to harmonize data from local jurisdictions. Automating and modernizing this infrastructure holds the potential to produce far more valuable and actionable information.

In addition to traditional surveillance data, big data from multiple sources, including Internet searches, social media, mobility data from phones, and health insurance claims has the potential to significantly improve the speed of identifying disease outbreaks (see Chapter 6). Therefore, supplementing traditional case reported data with these and other new data sources would produce better and more timely results.

STI Clinical Treatment Guidelines

The STI Treatment Guidelines are widely read and downloaded;¹² they are viewed nearly half a million times each month, and the guidelines mobile app is one of the top-ranked apps at CDC, with a rating of 4.3/5.0 (see Chapters 7 and 10 for more information on the treatment guidelines). Its recommendations have global impact and are helpful to other guideline processes from such organizations as WHO and the British Association for Sexual Health and HIV. As with surveillance, a critical shortcoming of these guidelines is the slow pace of revision. The committee believes there are real costs and harm from not keeping these essential practice guidelines up to date.

In the modern era of Internet connectivity, the committee believes that real-time updates are vital adjuncts to the original guidelines produced only twice per decade. Periodic reviews should be yearly, but this need not be laborious when guidelines are being continuously updated with state-of-the-art advisories. An effort to achieve more real-time updates of the CDC STI Treatment guidelines was made by posting the most current gonorrhea treatment recommendations within the online version of the still current 2015 CDC STD Treatment Guidelines, and an additional alert was also placed on the Guidelines website (St. Cyr et al., 2020). This is a somewhat awkward way to reconcile with the old guidelines process, however, in an era where rapid adjustments can be made and distributed

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¹² Personal communication with Nikki Mayes and Melissa Habel (CDC). Available by request from the National Academies of Sciences, Engineering, and Medicine’s Public Access Records Office (PARO@nas.edu).

online to respond to a quickly changing field that goes beyond gonorrhea treatment. For example, HIV guidelines are updated regularly on the Internet (clinicalinfo.hiv.gov, n.d.); this is a model for how STI guidelines could be continuously updated as treatments evolve. The goal is real-time accurate treatment advice with delays of just weeks, not months or years.

Achieving Greater Consistency in Response Across Jurisdictions

As discussed in Chapter 4, the federal–state partnership that conducts STI prevention and control efforts through a relationship known as “cooperative federalism” is under strain. Whereas federal funding has remained relatively flat in the face of growing STI epidemics, state and local funding has declined in significance. Beyond funding levels, however, this partnership could meet the needs of the nation, but it is not reaching its full potential. The committee observes that a rationale for federal engagement in STI control is to support state and local efforts to not only elevate standards and the quality of services in jurisdictions across the country, but also enable a coordinated national response and to achieve greater uniformity in adhering to best practices and greater comparability across jurisdictions. Differences in definitions of terms and in approach related to how health departments engage with relevant stakeholders, including—importantly—members of the community, lead to gaps in the collective ability to gain a national picture of the STI crisis. This also enables some jurisdictions and other partners to evade accountability for improving STI outcomes. The committee concludes that the federal investment in STI prevention and control through grants to states and local jurisdictions should be leveraged to achieve greater consistency of practice and comparability of results.

Additionally, CDC has a responsibility to ensure that its support is beneficial to the residents of the states it is funding and the return on the investment is maximized. Federal funding was never intended to be the sole source, and multiple stakeholders are critically necessary to achieve an effective and coordinated response, so it is appropriate to encourage and mandate that states take steps to consult broadly with not only affected communities that can benefit from a coordinated and strategic statewide STI control plan but also the broad range of stakeholders who need to be actively engaged for such a plan to be successful.

Conclusion 12-5: STI professionals at all levels of government have performed valiantly within the constraints of the resources provided and the policy attention that they have received. Furthermore, STI professionals, especially within state and local health departments, have critical knowledge and expertise that needs be the foundation of any efforts to improve the national response to STI prevention and control.

Conclusion 12-6: The CDC Division of STD Prevention provides critical leadership in guiding the federal STI response. The committee supports maintaining and enhancing this role, including in encouraging the division to be more assertive and in some cases, more prescriptive in its grants to states and local jurisdictions in order to establish minimum national STI standards of care.

Conclusion 12-7: Development and dissemination of improved clinical practices and standards is critically important. Both CDC and the National Institutes of Health (NIH) have made investments in regional centers with the goal of supporting state and local health departments to stay current with the latest science and to offer expert consultation for providers dealing with tough cases. However, existing structures are inadequate to meet the needs of local providers and health departments.

Conclusion 12-8: Accurate STI surveillance is essential to understand the epidemiology of reportable STIs. STI surveillance, however, is presently difficult to interpret because it reflects case reporting, which is ecologic in nature, and periodic population-based studies, which are too small for meaningful subpopulation analyses. Population-based surveys are highly desirable for surveillance of many STIs to secure representative prevalence and behavioral data; however, costs and burden on health departments can be prohibitive.

Recommendation 12-4: The Centers for Disease Control and Prevention (CDC) should modernize its core sexually transmitted infection (STI) activities to strengthen the timely monitoring of STIs with less reliance on estimated rates based on case reports, to inform proper treatment of persons with STIs, and to increase consistency and accountability across jurisdictions. The committee recommends a three-pronged approach:

1. Modernize surveillance activities to enable more rapid release of data:
   • Automate case reporting of reportable STIs.
   • Release a preliminary STD Surveillance Report within 6 months of the reporting period, with a revised report later in the year.
   • Explore the use of new data sources to capture STI incidence (critically, both cases and numbers tested), such as electronic medical records, commercial databases, health information exchanges, clinical and pharmacy data, social media/online searches, and artificial intelligence, and invest in better data

1. • integration efforts within the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP).
   • Develop a publicly available STI dashboard to raise public awareness and accountability.
2. Improve timeliness of the STI treatment guidelines:
   • The CDC STI treatment guidelines should be updated and disseminated annually, and more frequently if necessary, to better address real-time changes to the STI epidemic and emerging treatments and technologies. The entirety of the guidelines should undergo comprehensive reviews no less frequently than every 5 years.
3. Increase accountability and establish new funding requirements:
   • CDC should engage in a data standardization partnership across NCHHSTP and with grantees to develop and publish a core set of STI indicators with standardized definitions of terms. To promote the use of these standardized data, CDC should set a condition of awards for its funding programs to require that every grantee report surveillance and other data to CDC consistent with these new data standards.
   • CDC should also make a condition of awards the requirement that states engage in a broad and meaningful stakeholder engagement process. This should include representatives of local health departments, heavily affected communities, health insurance programs and exchanges, federally qualified and other health centers, Ryan White HIV/AIDS Program recipients, Substance Abuse and Mental Health Services Administration recipients, and others to develop a multi-year state or major municipalities STI prevention and control plan that
     • leverages disparate assets within the state or major municipalities for establishing STI prevention and care priorities, aligning STI and HIV priorities;
     • establishes benchmarks; and
     • creates a process for monitoring and reporting on progress toward achieving established benchmarks.

Regarding item 1 of Recommendation 12-4, the 2018 and 2019 NAPA reports also highlight the need for improved STI surveillance and list this as a recommended action. Implementing improved surveillance is also crucial to ensure better use of technologies to support STI prevention and control (see Chapter 6, Recommendation 6-1).

Regarding item 3 of Recommendation 12-4, DSTDP’s flagship STI prevention funding program, Strengthening STD Prevention and Control for Health Departments, is a 5-year cooperative agreement now running from January 2019 through December 2023.¹³ It funds all 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and 6 large cities (NAPA, 2018) and focuses on five strategy areas: conduct surveillance; conduct disease investigation and intervention; promote CDC-recommended screening, diagnosis, and treatment; promote prevention and policy; and analyze and use data for program improvement. Crosscutting strategies include STD-related HIV prevention and creating, maintaining, and leveraging partnerships. This program already contains numerous requirements that are conditions of award,¹⁴ and this report recommends further refining these requirements to produce greater comparability and actionability for the data collected. The time remaining before the next 5-year agreement offers CDC sufficient time to engage in necessary stakeholder consultations and conduct a data standardization process. The committee encourages that this recommendation be effectuated in full for the next 5-year agreement, and consideration should be given to what steps can be taken more immediately.

The committee recognizes the large differences in staff capacity across health departments and other impediments to rapid integration of reporting standards. Therefore, the proposed partnership should consider the current starting point and recommend phased implementation (if needed) to account for current serious limitations in the capacity to carry out surveillance and monitoring efforts at the state or local levels. Other interventions may be needed to enhance the STI monitoring capacity at the health department level through greater use of CDC assignees to health departments and greater support for health department–academic partnerships. Nonetheless, such a collaborative process should lead inexorably to the timely achievement of higher-quality, more uniform, and more timely data reporting, along with meaningful accountability measures to enforce compliance with these requirements.

Furthermore, the committee is not recommending a specific model for stakeholder engagement. Indeed, HIV programs have long experience with HIV prevention community planning, as well as Ryan White services planning. In recent years, significant federal efforts have been made to support the integration of HIV prevention and care planning. The committee recognizes that STI-specific community consultation and

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¹³ See https://www.cdc.gov/std/funding/pchd/default.htm (accessed November 16, 2020).

¹⁴ See https://www.cdc.gov/std/funding/pchd/guidance.htm#funding-tables (accessed November 16, 2020).

collaboration processes have been developed in several jurisdictions (see Chapter 10). DSTDP may consider ways to integrate STI consultation and resource allocation processes within these existing mechanisms or may determine that such an approach is inappropriate or not the best model, as critical STI stakeholders not involved with HIV planning processes would be excluded. The history of these planning processes is fraught with examples where the process itself became too cumbersome and resource intensive or was used to justify health department decisions without obtaining or truly reflecting the perspectives of external stakeholders. The thrust of this recommendation rests on the idea that governmental agencies often need to be nudged toward greater and more meaningful public consultation and that more responsive STI programs with high levels of community trust can only be achieved with meaningful engagement from intended clients and community leaders and buy-in from external stakeholders that have the capacity to contribute greatly to the success of such public health efforts.

Strengthening Local Efforts to Plan and Coordinate the STI Response

Just as the committee understands that it is critically important to reinforce the federal–state partnership, it also recognizes that policies and initiatives often succeed or fail at the local level. Therefore, innovative leaders and strong champions for the STI response are needed in health departments, academic institutions, public and private health care settings, and community-based organizations. As highlighted in Chapter 4, local health departments rely on a patchwork of funding sources, creating significant differences in resources by jurisdiction. The complex and uncoordinated U.S. health system results in large variation in how health care and public health services are organized at the local level, which further complicates the ability to achieve consistently healthy populations. Except in those local jurisdictions that CDC directly funds, it is difficult to conceive of how to achieve greater equity and comparability across jurisdictions without further investments. Nonetheless, a meaningful opportunity exists to improve planning and coordination of effort among the diversity of stakeholders within a community. While health department leadership is critical, the best outcomes will be achieved with strong partnerships and true collaboration between public health, the health system, community, and philanthropy.

Conclusion 12-9: To ensure comprehensive sexual health services and to improve STI prevention and control, local jurisdictions need to conduct, and be held accountable for, a broad and meaningful stakeholder engagement process to identify needs and assets and to establish prevention and care priorities for their jurisdictions.

Working in tandem with the preceding recommendation for CDC to require statewide STI prevention and control plans, the committee recommends the following:

Recommendation 12-5: The Centers for Disease Control and Prevention (CDC) should encourage local health departments to develop and implement comprehensive plans for sexually transmitted infection (STI) prevention and control. This should be done by funding key partners, such as the National Association of County and City Health Officials (NACCHO) and the National Coalition of STD Directors (NCSD), to develop resources and provide technical assistance to state and local health departments on how to conduct a meaningful stakeholder consultation process, how to develop a plan that offers strategic support for improving STI outcomes leveraging all available community assets, and how to monitor implementation and keep the public informed of progress toward achieving the plan’s objectives. The plans should do the following:

• Include community-wide needs assessments, oversampling high-priority populations, that determine the adequacy of available sexual health services in their jurisdictions and explore the creation of new, improved, and easier access points for sexual health promotion in a stigma-free environment, including STI screening and treatment services that take advantage of current rapid and self-testing technologies.
• Identify mechanisms to meet the needs of underserved and highly impacted populations.
• Establish formalized, funded relationships with trusted community-based organizations to deliver critical STI prevention and care services.

CDC, in collaboration with the National Network of STD Prevention Training Centers, NACCHO, and NCSD, should develop STI Resource Centers (SRCs) for clinical consultation, workforce development, and technical assistance to support the planning process and provide consultation to individual clinical STI providers. At a minimum, these SRCs should be operational at the level of state and large municipal jurisdictions.

While some overlap will occur between stakeholders in the community planning process and SRCs in certain jurisdictions, most states and local jurisdictions do not currently have the expert resources needed to support local planning or to provide consultation to providers. Dependent

on the availability of STI expertise and funding, SRCs may take different forms. At a minimum, they should involve a formal collaboration between STI clinical and prevention experts from different institutions, including local and state health departments, academia, the National Network of STD Clinical Prevention Training Centers, STI/sexual health centers, and other STI care providers (see Chapter 11 for additional discussion).

Establishing New Payment and Coverage Options to Close Gaps in Access to STI Coverage and Services

The current system for financing and delivering STI services in the United States leaves out too many people. To achieve population health and control infectious diseases, it is necessary to create accessible, affordable, nonstigmatizing, and nondiscriminatory options for prevention, screening, and treatment services that are available to all persons within a community. As discussed in Chapter 10, however, STI control efforts are too frequently limited because the complex and fragmented system leaves too many individuals with inadequate access to services. Recommendation 10-1 suggests that HHS and states develop innovative programs to ensure STI services are available to persons facing access barriers.

Supporting and Expanding the STI Workforce

As the nation looks to the future of the STI response, bolstering current efforts is critically important. The workforce of STI professionals is broad and encompasses clinical providers, educators, researchers, and public health officials. They are the essential underpinning of any capacity to mount a strengthened STI response. Chapter 11 examines the STI workforce in detail, highlights the need for it to refocus and improve the traditional service delivery paradigm, and identifies opportunities for leveraging health care systems and practitioners to improve STI services and strengthen the broader public health workforce to respond to public health emergencies, including STI outbreaks. Recommendation 11-1 is that sexual health promotion be operationalized and prioritized in practice guidelines and training curricula and that STI prevention and management be incentivized and prioritized as a focus area of practice.

Accelerate Biomedical Research and Development

Ensuring a strong investment in STI-focused research is critical to protecting public health. The U.S. biomedical research enterprise has scored many remarkable successes over the decades and remains a critical priority for ongoing support. While STI research takes place in the

private sector and is conducted by or funded through a variety of federal agencies, NIH is the flagship for U.S. biomedical research. The agency is burdened with a multitude of competing demands and a wide variety of long-standing pressing health and disease threats, as well as emerging novel threats, as exemplified by COVID-19. Chapter 7 offers a clear explication of the biomedical tools available for STI prevention and management. While the committee supports a broad and diverse approach to STI research and believes that many of NIH’s investments are both promising and necessary, it also concludes that there are specific areas where current opportunities demand greater prioritization and urgency.

Deploy Psychosocial and Behavioral Interventions for Sexual Health

An effective response demands a sophisticated strategy that aligns all intervention types to help society prevent and control STIs. The committee seeks to expand the investment and support for developing, adopting, and disseminating psychosocial and behavioral interventions. Too frequently, there has been a policy dialogue that has presented a binary choice between relying on biomedical strategies to attack specific pathogens or behavioral tools to guide individual behavior. With this understanding, the committee outlines a series of steps in Recommendation 8-1 to ensure sustained funding for psychosocial and behavioral interventions, establish more uniform national evidence-based standards for school-based sexual health education, and use psychosocial and behavioral research to support developing more effective community-based interventions.

EMBRACE INNOVATION AND POLICY CHANGE TO IMPROVE SEXUAL HEALTH

The Hidden Epidemic was premised on the idea that STIs have not been sufficiently addressed, in part, because too many members of the public would prefer to not think about and have to deal with them (IOM, 1997). An assessment of the current state of STI prevention and control indicates that investments have been too low, the response too fragmented, and attention on the growing challenge of STIs too fleeting. Because STIs remain in the shadows, some may think it will be difficult to garner a focused and strategic response, in addition to a tendency to interpret cultural and social changes with an innate pessimism that makes a growing STI threat appear to be foreordained. The committee rejects this view. Despite recognizing the potential for any number of factors to weaken the STI response, changes in law and policy, society, and technology create reasons for optimism that STI outcomes can be improved. Indeed, as the

nation grapples with an unfolding pandemic, even some of the biggest challenges caused by COVID-19 may, perhaps paradoxically, create new opportunities for policy action. See Box 12-5 for a summary of recommended actions.

COVID-19 and STIs

The COVID-19 pandemic has significantly disrupted STI management and the delivery of comprehensive sexual health care resulting from clinic closures, staffing diversions, and COVID-19-related resource constraints (Krakower et al., 2020; Nagendra et al., 2020; Napoleon et al., 2020). More challenges are expected as the pandemic continues to unfold on an uncertain course and spillover effects resulting from economic disruption and other factors expand.

Importantly, DIS, mostly trained and hired originally to investigate contacts for HIV, syphilis, and other STIs, have been deployed for COVID-19 contact tracing, thus leaving a large void for STI and HIV control. This exposes a fundamental weakness in public health capacity that should lead to significant investments in public health infrastructure in ways that, as a result, should strengthen STI prevention, care, and treatment. Conversely, through strengthening STI and other public health capacity at the local, state, and tribal levels, it is possible to better respond to

COVID-19 and be better prepared for a future novel infectious disease threat.

This crisis has underscored the importance of a well-prepared public health infrastructure and timely, coordinated action at the federal, state, and local levels. The federal government has a critical role to play in providing leadership, synthesizing data, and exposing trends unfolding across the country to inform and shape state-level surveillance and response that feeds into tailored local-level response and service delivery. It could be said that public health has failed STI prevention, but it would be better argued that society has failed public health. STIs are a societal problem that requires a societal solution.

Over the past decade, median per capita expenditures among local health departments have declined by 18 percent despite increased public health needs, including burgeoning STI rates (NACCHO, 2020). Since 2008, this funding reduction has translated into the loss of 38,000 state and local public health jobs (Weber et al., 2020). A 2018 report by leading national public health experts proposed a new mandatory federal financing source to fill an estimated $4.5 billion gap in annual funding for foundational public health activities, with additional increases in state and local public health investments (PHLF, 2018). Both the COVID-19 pandemic and ongoing STI epidemic spotlight the impact of the erosion of public health infrastructure and the urgent need to consider additional resource commitments.

COVID-19 Implications for Prevention and Control of STIs

The COVID-19 pandemic has significantly disrupted STI management and the delivery of comprehensive sexual health care, due to clinic closures, staffing diversions, and related resource constraints. Necessary social distancing measures also made it difficult to see patients (Krakower et al., 2020; Nagendra et al., 2020; Pampati et al., 2020). Those working in STI/HIV services are in a unique position to leverage their existing skill sets to integrate public health and medical services for STIs alongside COVID-19 and enhance preparedness for future public health threats. Reinvesting in public health, specifically sexual health, can be critical to controlling these health crises. Due to waning budgets, STI/HIV public health work has developed the means to meet rising demands while limiting costs. Express STI testing is one such innovation, where a triage-based, patient-centered model has led to increased clinic capacity, decreased costs, shortened visit times, and reduced time to treatment (Rukh et al., 2014; Shamos et al., 2008). Many municipal clinics and community health centers focused on traditional and express STI testing have successfully converted existing workflows for high-throughput COVID-19 testing

at minimal or no cost (Schneider and Pollack, 2020).¹⁵ Mobile STI/HIV screening is another creative initiative that can economically reach large at-risk communities, and these too have been transformed into COVID-19 testing venues (Schutz and Myers, 2020). DIS and partner services team members trained in STI/HIV reporting and notification are highly skilled contact tracers who may do the work themselves or oversee teams of more junior staff. Public health workers already have pioneered large-scale COVID-19 contact tracing efforts for major metropolitan cities (Chase and Schuba, 2020; Schorsch, 2020). Lastly, those working in sexual health are experienced in sustainable approaches to promote behavior modification through understanding personal susceptibility and dismantling stigma. These skills are essential in practical messaging around prevention for both STIs and COVID-19 and will be critical as the United States prepares for future crises.

Health care workers at the front lines of the COVID-19 pandemic include critical care specialists and hospital staff, but also health care workers assigned to outpatient services, including HIV and STI care. This segment of the workforce is at higher risk of COVID-19 infection and mental health symptoms, including anxiety and depression. In addition, essential workers, laboratory staff, and other biomedical and support personnel have been shifted to respond to the pandemic. Preparedness might allow for continuous HIV and STI care while responding to emerging epidemics. This alone supports the need to strengthen the STI workforce. The United States is expected to need to continue to manage emerging infectious disease epidemics, such as COVID-19 and pandemic influenza, with some frequency in the future. National and statewide preparedness plans and workforce development will fail to maintain or improve STI services if pandemic preparedness plans do not consider needed mitigation for the rise in STIs and allow for workforce development and logistical planning (Nguyen et al., 2020; Rivara et al., 2020).

Management of STIs and Delivery of Sexual Health Care During an Ongoing Pandemic

As the burden of COVID-19 in the United States continues to shift, sexual health providers need to remain nimble to engage, protect, and advocate for patients. When in-person patient–clinician contact is limited, specific strategies can help meet these care delivery challenges (Napoleon et al., 2020). Due to the need for physical examination and laboratory

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¹⁵ See also, for example, Chicago: https://howardbrown.org/service/covid-19-services; Fort Lauderdale: https://careresource.org/testing-hours-locations; New York City: https://callen-lorde.org/covid-test (all accessed November 13, 2020).

diagnosis, sexual health clinics need to prioritize in-person encounters for patients with STI symptoms or populations at risk for STI-related complications (such as persons presenting with vaginal discharge and abdominal pain, pregnancy, or symptoms that may indicate neurosyphilis) (Bachmann et al., 2020). Telemedicine or other telehealth services can be used for syndromic management of urethritis, suspected primary or secondary syphilis, vaginal discharge, and proctitis (Barbee et al., 2020) (see Chapter 7 for more information on syndromic management). In most states, EPT for gonorrhea and chlamydia could be used more broadly to help reduce reinfections within sexual networks (CDC, 2015) (see Chapter 10 for more on EPT). Novel STI care delivery models need to be explored when facility-based services are limited by withdrawn elective medical services during COVID-19 outbreaks or concern about transmission and exposure for patients and clinical staff. This is especially important because the pandemic has caused decreased STI testing rates (Hoffman, 2020; Tao et al., 2021).

With or without the stress of COVID-19, STI services need to innovate in the face of rising STI rates. One example is the mobile STI/HIV clinic that has been shown to be an effective means to reach target populations not served by municipal sexual health clinics (Ellen et al., 2003). While successful in engaging marginalized populations and providing cost-savings benefits, mobile health care has faced challenges integrating into different health care systems (Yu et al., 2017). Notably, home-based STI/HIV testing and PrEP services have shown high feasibility and acceptability in younger populations, particularly MSM and others with sexual HIV transmission risk (CDC, 2019d; John et al., 2017). Many private-sector initiatives already offer home-based STI testing (Frederiksen et al., 2020); many of these were the first to try to develop and implement a home-based testing model in the early days of the COVID-19 pandemic (FDA, 2020; KFF, 2020a). Investment in mobile health and home-based services for STIs while in-person clinical encounters remain limited may be an effective way to not only retain patients, but potentially engage new populations when combined with COVID-19 screening, especially when using rapid testing technologies.

Sexual Transmission of SARS-CoV-2

As with other respiratory infections, in-person contact, such as kissing, is considered high risk for SARS-CoV-2 transmission due to sharing saliva and respiratory droplets. While studies have isolated SARS-CoV-2 in urine, stool, and human semen, transmission by these means has not been established (Chen et al., 2020b; Li et al., 2020). Notably, SARS-CoV-2 has not been detected in vaginal secretions and is inconsistently identified

in semen (Aitken, 2020; Delfino et al., 2020; Li et al., 2020; Qiu et al., 2020). As with STIs, it is supposed that the infection risk increases with the number of simultaneous partners; thus, group sex and other similar gatherings pose a greater threat. Lower-risk sexual activities would include those that limit exposure to respiratory droplets, such as mutual/self-masturbation, sex through a physical barrier, and cuddling with a mask (BCCDC, n.d.; NYC Health, 2020; Turban et al., 2020). The potential for SARS-CoV-2 to survive on surfaces for hours, and even on skin for 9 hours, presents an additional risk for transmission, although this is not yet reported or confirmed (Hirose et al., 2020).

People already perform multiple, often simultaneous, risk calculations to make decisions around intimacy and sex; the COVID-19 pandemic adds another variable to these equations. By approaching this with a harm reduction perspective, persons affected by COVID-19 will be better able to advocate for their sexual health and participate in intimacy while protecting themselves and those around them. A strategy commonly used in STI/HIV prevention efforts is to tighten a sexual network by limiting activity to those people know. Similarly, reevaluating and constricting one’s sexual network will also reduce the risk for COVID-19. As people begin to engage and reengage in sexual activity, mitigating SARS-CoV-2 infections resembles STIs in that testing may be advisable before a sexual relationship. If affected persons routinely meet partners outside their sexual network, such as through mobile applications, SARSCoV-2 screening at regular intervals (monthly or within 5–7 days of an encounter) may be advisable (BCCDC, n.d.; NYC Health, 2020).

Social Determinants of Health Driving STI/HIV Epidemics and COVID-19 Pandemic

The impacts of the ongoing STI/HIV epidemics and COVID-19 pandemic are not disparate health crises, but rather the result of the same long-standing health inequities contributing to similar disparities in outcomes (Millett et al., 2020a). As discussed in Chapters 2 and 3, there are racial and ethnic disparities across all STIs, with higher rates of infections in Black and Latino/a persons relative to their white counterparts (Yancy, 2020). Similarly, the most pervasive disparities in COVID-19 cases and deaths are observed among Black, Latino/a, and Indigenous individuals (Millett et al., 2020b; Rodriguez-Diaz et al., 2020).

The reasons behind these differences are more complex and nuanced than race and ethnicity alone. The social determinants of health are the overlapping social structures and economic systems that are responsible for most health inequities (NASEM, 2017). Lack of access to health care, inadequate housing, food insecurity, lack of employment, obesity, poverty,

and other socioeconomic disadvantages are characteristics commonly shared by patients facing COVID-19 in the context of rising rates of STI/HIVs (Golestaneh et al., 2020; Holmes et al., 2020; Rentsch et al., 2020). Addressing these factors, specifically as they pertain to racism, poverty, and structural inequities, is critical to design and implement programs that aim to reduce the burden of disease. The rapid emergence of clear disparities by race and ethnicity for COVID-19 cases and deaths that align with deep and persistent disparities in prevalence and access to STI prevention and care show that not only does medical care need be rooted in antiracism but it also needs to provide community-driven social and structural support in order to begin addressing these disparities in health outcomes (Webb Hooper et al., 2020; Yehia et al., 2020).

The nation would likely have been far better positioned to aggressively mitigate COVID-19 from the start had it not reduced public health investments for STI control, tuberculosis control, and other key infectious disease control functions (Interlandi, 2020; Weber et al., 2020). Instead, the disintegration of basic public health infrastructure at all levels has provided an environment for COVID-19 and other emergent infectious diseases to flourish. Unifying STI/HIV and COVID services through sustained policy and funding support, however, could cultivate a pluripotent public health workforce that could not only address these current crises, but be poised to pivot toward future pandemic needs as well.

Conclusion 12-10: The COVID-19 pandemic has exposed weaknesses in public health preparedness due to weak infrastructure, under-capacitated workforce, and limited surge capacity. STIs are infectious diseases that require testing, treatment, and partner notification, and the STI workforce has deep expertise. Therefore, strengthening the STI infrastructure and expanding its workforce offers the dual benefits of achieving better STI control and better positioning the nation for future public health threats.

Address Structural Racism and Other Structural Inequities That Hinder STI Control

For the nation to strengthen STI prevention, screening, and treatment to effectively reduce the risk for and harms from STIs, it is necessary to not only deal with individual factors and behaviors, but look broadly at the aspects of society that generate and perpetuate inequity. As stated in Recommendation 9-1, the Secretary of HHS should lead a whole-of-government, interagency response to counter structural racism and other structural inequities (such as societal-level policies, practices, and norms) by developing a coordinated approach, in collaboration with affected communities, to reduce STI outcomes and inequities.

Harnessing Technological Innovation to Improve STI Prevention and Control

Technology and media have fundamentally changed since the release of The Hidden Epidemic (IOM, 1997), but the angst over whether their use will cause changes in behaviors in ways that enhance risk for STI acquisition remains frequently expressed. As discussed in Chapter 6, this is largely irrelevant because these tools are broadly used by the population and the role they play in people’s lives can be expected to increase rather than decrease. Recommendation 6-1 seeks to accept these technologies and identify strategies to apply them for digital behavior change and in other ways to strengthen STI prevention and control.

CONCLUDING OBSERVATIONS

As noted in Chapter 1, the committee’s primary focus was on providing clear policy guidance and a framework for action; it does not uniformly provide specific implementation steps or metrics for each recommendation, as this requires a more in-depth understanding of STI resources, policies, and other circumstances at the state, local, and federal levels. As stakeholders address the recommendations in this report, however, implementation strategies that address barriers that impede the adoption and scale-up of evidence-based behavioral, biomedical, and structural interventions need to be developed and evaluated. This includes study designs, such as hybrid designs, that simultaneously address the effectiveness of interventions and important implementation science questions (Curran et al., 2012; see Chapter 8 for more information). Furthermore, the successful implementation of effective STI interventions requires an understanding of stigma, discrimination, and lack of access to health care, among other macrosystemic factors (Eisinger et al., 2019). Implementation strategies need to address these important factors. Finally, the implementation plan for HHS’s STI-NSP provides a valuable opportunity to highlight the importance of implementation science in the prevention and control of STIs, much like the Ending the Epidemic Initiative does for HIV (Eisinger et al., 2019).

People have a universal desire for health for themselves and their families, and hopefully for their communities and society at large. Sexual health is an essential component of overall health. Health is often defined as being free from illness or injury, so this also needs to include being free from STIs and other forms of disease. Therefore, expanding tools and knowledge to better prevent, screen for, and treat STIs is a critical endeavor. The framework adopted by the committee for conducting its examination, however, is much more expansive than such a narrow vision of health. Indeed, protecting the public from STIs is simply a critical first

step toward a future that embraces a broad definition of wellness and well-being that considers being sexually healthy, being able to experience pleasure, and maintaining varied and meaningful relationships of one’s own choosing as the essence of being human.

REFERENCES