A vital aspect of expanding access and care for sexually transmitted infections (STIs) in the United States is broadening responsibility for this care across the healthcare system and other community resources, according to an article published online July 6 in Clinical Infectious Diseases. This expansion and decentralization of care are central to adopting the “new sexual health paradigm” recommended by a National Academies report that was published in March.
“STIs represent a sizable, longstanding, and growing public health challenge,” write Vincent Guilamo-Ramos, PhD, MPH, dean and professor at the Duke University School of Nursing and director of the Center for Latino Adolescent and Family Health (CLAFH) at Duke University, in Durham, North Carolina, and his colleagues. Yet the limitations on the current STI workforce and limited federal funding and support for STI prevention and care mean it will take clinicians of all types from across the healthcare spectrum to meet the challenge, they explain.
“For too long, STI prevention and treatment has been perceived as the sole responsibility of a narrow workforce of specialized STI and HIV service providers,” Guilamo-Ramos and his coauthor, Marco Thimm-Kaiser, MPH, associate in research at Duke University and epidemiologist at CLAFH, wrote in an email to Medscape Medical News.
“However, the resources allocated to this STI specialty workforce have diminished over time, along with decreasing investments in the broader U.S. public health infrastructure,” they continued. “At the same time — and in part due to this underinvestment — STI rates have soared, reaching a record-high for the sixth year in a row in 2019.”
Those factors led to the National Academies report, which recommends moving “away from the traditional, disease-focused perspective on STIs in favor of a holistic perspective of sexual health as an integral component of overall health and well-being,” Guilamo-Ramos and Thimm-Kaiser wrote to Medscape Medical News.
In their article, the authors review the limitations in the STI workforce, the implications of those limitations for the broader healthcare industry, and what it will take for STI and HIV specialists as well as regulators to ensure it’s possible to achieve the paradigm shift recommended by the National Academies.
Currently, the biggest limitation is access to care, said Laura Mercer, MD, MBA, the ob/gyn clerkship director and a clinical assistant professor of ob/gyn at the University of Arizona College of Medicine, Phoenix, Arizona. Mercer, who was not involved with the National Academies report or the analysis of it, told Medscape Medical News that it’s essential to emphasize “sexual health as a core element of routine primary and preventative care” to ensure it becomes more accessible to patients without the need to seek out specialty care.
Guilamo-Ramos and his colleagues drive home the importance of such a shift by noting that more than 200 million Americans live in counties with no practicing infectious disease physicians. The disparities are greatest in Southern states, which account for 40% of all reported STIs. The workforce shortage has continued to worsen alongside the deterioration of the clinical infrastructure supporting STI specialty services, the authors write.
Hence the need to expand accountability for care not only to primary-care physicians but also to nurses, pharmacists, physician assistants, nurse practitioners, and behavioral health practitioners. Doing so also requires normalizing sexual health services across healthcare professions.
“Prevention is a crucial first step” to this, Mercer said. “This is particularly important as we recall that almost half of new sexually transmitted infections occur in teenagers. Destigmatizing sexual health and sexual health education will also help encourage patients of all ages to request and accept testing.”
Further, with primary-care practitioners managing most STI testing and treatment, subspecialists can focus primarily on complex or refractory cases, she added. Ways to help broaden care include developing point-of-care testing for STIs and improving the accuracy of existing testing, she said.
“The goal is to make routine sexual health services accessible in a wide range of settings, such as in primary care, at pharmacies, and in community-based settings, and to draw on a broader workforce for delivery of sexual health services,” Guilamo-Ramos and Thimm-Kaiser told Medscape.
Kevin Ault, MD, a professor of ob/gyn and director of clinical and translational research at the University of Kansas Medical Center, in Kansas City, Kansas, said that many medical organizations, such as the American College of Obstetricians and Gynecologists, have long advocated incorporating sexual health into routine preventive care. He also noted that pharmacists have already become proactive in preventing STIs and could continue to do so.
“Vaccines for hepatitis and human papillomavirus are commonly available at pharmacies,” Ault told Medscape. He was not involved in the article by Guilamo-Ramos and colleagues or the original report. “Pharmacists could also fill a gap by administering injectable medications such as penicillin. States would have to approve changes in policy, but many states have already done this for expedited partner therapy.”
Guilamo-Ramos and Thimm-Kaiser noted similar barriers that must be removed to broaden delivery of STI services.
“Unfortunately, too many highly-trained healthcare providers who are well-positioned for the delivery of sexual health services face regulatory or administrative barriers to practice to the full scope of their training,” they wrote to Medscape. “These barriers can have a particularly negative impact in medically underserved communities, where physician-shortages are common and where novel, decentralized healthcare service delivery models that draw on non-physician providers may hold the greatest promise.”
As more diverse healthcare practitioners take on these roles, ID and HIV specialists can provide their expertise in developing training and technical assistance to support generalists, Guilamo-Ramos and Thimm-Kaiser wrote. They can also aid in aligning “clinical training curricula, licensing criteria, and practice guidelines with routine delivery of sexual health services.”
Guilamo-Ramos and his coauthors offer specific recommendations for professional training, licensing, and practice guidelines to help overcome the “insufficient knowledge, inadequate training, and absence of explicit protocols” that currently impede delivery of STI services in general practice settings.
Although the paradigm shift recommended by the National Academies is ambitious, it’s also necessary, and “none of the recommendations are out of reach,” Guilamo-Ramos and Thimm-Kaiser told Medscape. They pointed out how the COVID-19 pandemic has highlighted how underresourced the healthcare workforce and infrastructure are and how great healthcare disparities are.
“There is momentum toward rebuilding the nation’s health and public health system in a more effective and efficient way,” they said, and many of the STI report’s recommendations “overlap with priorities for the broader health and public health system moving forward.”
Mercer also believes the recommendations are realistic, “but only the beginning,” she told Medscape. “Comprehensive sexual education to expand knowledge about STI prevention and public health campaigns to help destigmatize sexual healthcare in general will remain crucial,” she said.
Sexual education, expanded access, and destigmatizing sexual care are particularly important for reaching the populations most in need of care, particularly adolescents and young adults, as well as ethnic, racial, sexual, and gender-minority youth.
“It cannot be overstated how important of a priority population adolescents and young adults are,” Guilamo-Ramos and Thimm-Kaiser wrote. They noted that those aged 15 to 24 account for half of all STIs each year but represent only a quarter of the sexually active population. “Targeted efforts for STI prevention and treatment among adolescents and young adults are therefore essential for an overall successful strategy to address STIs and sexual health in the United States.”
The National Academies report was supported by the Centers for Disease Control and Prevention and the National Association of County and City Health Officials. Mercer, Ault, and Thimm-Kaiser have disclosed no relevant financial relationships. Guilamo-Ramos has received grants and personal fees from ViiV Healthcare.
Clin Infect Dis. Published online July 6, 2021. Abstract
Tara Haelle is an independent science journalist based in Texas who writes about medical research. Find her at @tarahaelle.