Preventing and controlling sexually transmitted infections (STIs) in the United States, which have risen alarmingly over the past 2 decades, requires taking a holistic approach that addresses social and structural factors that drive STIs and implementing a range of strategic improvements, says a new report from the National Academies of Sciences, Engineering, and Medicine (NASEM).
In addition to tackling root causes of poor health and STI risk, the report recommends such steps as expanding options for people to access STI prevention and treatment at no cost, boosting support for the STI workforce, modernizing national STI surveillance and monitoring systems, and investing in the development of new vaccines and diagnostics.
Furthermore, taking steps to unify services for STIs (including HIV) and for COVID-19 “could cultivate a pluripotent public health workforce” better positioned to fight not only STIs and COVID-19 but also future infectious disease outbreaks, the report says.
The Centers for Disease Control and Prevention (CDC) estimates that 1 in 5 people in the United States has an STI in a given year, translating to approximately 68 million cases. According to the NASEM report, US case rates for the 3 most common reportable STIs (chlamydia, gonorrhea, and syphilis) have been increasing over the past 20 years. Since 2000, the overall case rate has doubled for chlamydia and risen nearly 1.4-fold for gonorrhea and 5-fold for primary and secondary syphilis.
Despite these concerning trends, the CDC’s funding for addressing STIs has remained flat. In addition, the report says, efforts to control STIs have been undercut by the COVID-19 pandemic, which led many people to delay routine STI screenings. It also caused health authorities to turn to already-underfunded STI programs and channel STI clinic staff and resources to the COVID-19 response, resulting in “less attention to STIs and fewer critical services being delivered.”
The report, from NASEM’s Committee on Prevention and Control of Sexually Transmitted Infections in the United States, champions an approach that emphasizes addressing interpersonal, community, institutional, and other societal factors that influence STI risk, prevention, health care access and delivery, and treatment.
Approaches to improve STI management “cannot be optimally effective without also addressing root causes of poor health and STI risk, namely, the structural and social determinants of health, such as poverty, unequal access to quality health care, stigma, racism, and discrimination,” the committee wrote. The group calls for the Department of Health and Human Services to lead a response that involves all federal government departments and agencies to develop a coordinated approach to promote sexual health and eliminate structural inequities that undermine STI prevention, testing, and treatment among marginalized groups who are disproportionately affected by STIs, including youth; LGBTQ+ populations; Black, Latino, and Indigenous communities; sex workers; incarcerated populations; and people living with mental health and substance use disorders.
With respect to access to STI services, the report urges the Department of Health and Human Services and state governments to make STI care more accessible through such options as comprehensive sexual health clinics, urgent care settings, pharmacies, and telehealth visits. It also calls for increasing options for free STI services and prioritizing people who face barriers to accessing such care, such as people who are ineligible for health coverage, those who cannot afford high out-of-pocket costs, and those who will not seek STI services without guarantees of confidentially, such as teens and young adults with coverage through their parents or guardians.
The committee also recommends strengthening existing systems and programs that are charged with responding to STIs (and thus have expertise in infectious diseases that require testing, treatment, and notification of contacts). The group says the CDC should identify federal and state policies that would most effectively draw on the existing health care workforce (an estimated 600 000 primary care physicians, 3.5 million nurses, 300 000 community pharmacists, and hundreds of thousands of behavioral health practitioners), promoting broader training in sexual health and STIs.
To help boost STI capabilities in the health care workforce, the committee advises, licensing bodies for primary care generalists and behavioral health specialists should formulate a minimum sexual-health skill set (such as taking a sexual history and familiarity with guidelines for STI screening and treatment) that is reflected in formal training programs and continuing medical education.
Other recommendations target improvements in technology. The committee said that the National Institutes of Health should prioritize the development of rapid point-of-care diagnostic tests and promote public-private partnerships to develop new antimicrobials effective against drug-resistant STIs and to speed development of vaccines for chlamydia, gonorrhea, syphilis, and herpes infections.
Other areas of technology that could be used to address STIs include artificial intelligence (AI) and apps and social media. The committee said the CDC should recruit data science professionals and experts in “digital behavior change” to harness the power of AI to improve STI surveillance and help tailor interventions. Artificial intelligence can sift through enormous amounts of data from electronic health records, insurance claims databases, search engines, and social media to help predict local STI rates and discover trends in risk factors.
In addition, social media platforms and dating apps can be leveraged to prevent STIs, speed diagnosis, and engage people to seek treatment. “For example, dating apps could host targeted ads for STI testing and include fields for testing status and timing,” the report notes. Digital contact tracing and exposure notification apps that have been used during the COVID-19 pandemic could similarly be used for STI prevention and control.
“The committee’s recommended changes may be challenging, but a substantial reduction in the societal impact of STIs is a realistic goal,” the group said.
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Stephenson J. JAMA Health Forum.
Corresponding Author: Joan Stephenson, PhD, Consulting Editor, JAMA Health Forum (Joan.Stephenson@jamanetwork.org).
Conflict of Interest Disclosures: None reported.
Identify all potential conflicts of interest that might be relevant to your comment.
Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.
Err on the side of full disclosure.
If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.
Not all submitted comments are published. Please see our commenting policy for details.
Stephenson J. National Academies Report Calls for Comprehensive Strategy to Tackle Sexually Transmitted Infections. JAMA Health Forum. 2021;2(3):e210633. doi:10.1001/jamahealthforum.2021.0633