Sexually
Transmitted
Infections

Adopting a Sexual Health Paradigm

Sten H. Vermund, Amy B. Geller, and Jeffrey S. Crowley, Editors

Committee on Prevention and Control of Sexually
Transmitted Infections in the United States

Board on Population Health and Public Health Practice

Health and Medicine Division

A Consensus Study Report of

THE NATIONAL ACADEMIES PRESS
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International Standard Book Number-13: 978-0-309-68395-1
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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2021. Sexually transmitted infections: Adopting a sexual health paradigm. Washington, DC: The National Academies Press. https://doi.org/10.17226/25955.

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COMMITTEE ON PREVENTION AND CONTROL OF SEXUALLY TRANSMITTED INFECTIONS IN THE UNITED STATES

STEN H. VERMUND (Chair), Dean and Anna M.R. Lauder Professor of Public Health, Yale School of Public Health; Professor of Pediatrics, Yale School of Medicine, Yale University

MADINA AGÉNOR, Gerald R. Gill Assistant Professor of Race, Culture, and Society, Department of Community Health, Tufts University

CHERRIE B. BOYER, Professor and Associate Director for Research and Academic Affairs, Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco

MYRON S. COHEN, Yeargan-Bate Professor of Medicine, Microbiology, and Epidemiology; Associate Vice Chancellor for Medical Affairs and Global Health; Director, Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill

JEFFREY S. CROWLEY, Program Director, Infectious Disease Initiatives; Adjunct Professor of Law, O’Neill Institute for National and Global Health Law, Georgetown University

CHARLOTTE A. GAYDOS, Professor Emerita, Former Director, Johns Hopkins University Center for Development of Point-of-Care Tests for Sexually Transmitted Infections, Division of Infectious Diseases, School of Medicine, Johns Hopkins University

VINCENT GUILAMO-RAMOS, Professor and Associate Vice Provost of Mentoring and Outreach Programs, Director and Founder, Center for Latino Adolescent and Family Health, New York University

EDWARD W. HOOK III, Emeritus Professor of Infectious Disease, Department of Medicine, The University of Alabama at Birmingham

PATRICIA KISSINGER, Professor, School of Public Health and Tropical Medicine; Associate Dean for Faculty Affairs and Development, Tulane University

GUILLERMO (“WILLY”) J. PRADO, Vice Provost, Faculty Affairs; Dean, Graduate School; Professor, Nursing and Health Studies, University of Miami

CORNELIS (“KEES”) RIETMEIJER, President, Rietmeijer Consulting, LLC

ALINA SALGANICOFF, Senior Vice President and Director, Women’s Health Policy, Kaiser Family Foundation

JOHN SCHNEIDER, Professor, Medicine and Epidemiology, Departments of Medicine and Public Health Sciences, University of Chicago

NEERAJ SOOD, Professor, Vice Dean for Faculty Affairs and Research, Sol Price School of Public Policy, University of Southern California

JESSICA WILLOUGHBY, Associate Professor, The Edward R. Murrow College of Communication, Washington State University

SEAN D. YOUNG, Executive Director, University of California Institute for Prediction Technology; Associate Professor, Departments of Emergency Medicine and Informatics, University of California, Irvine

CARMEN D. ZORRILLA, Professor, Obstetrics and Gynecology, School of Medicine, University of Puerto Rico; Principal Investigator, Maternal-Infant Studies Center

Study Staff

AMY B. GELLER, Study Director

AIMEE MEAD, Associate Program Officer

SOPHIE YANG, Research Associate

HAYAT YUSUF, Senior Program Assistant (until March 2020)

HARIKA DYER, Research Assistant (from April 2020)

ANNA W. MARTIN, Administrative Assistant (until April 2020)

Y. CRYSTI PARK, Administrative Assistant (from April 2020)

MISRAK DABI, Finance Business Partner

ROSE MARIE MARTINEZ, Senior Board Director

TASHA BIGELOW, Editor

Consultants

ADAM S. BENZEKRI, Center for Latino Adolescent and Family Health, New York University

MARIE A. BRAULT, School of Public Health, Yale University

YANNINE ESTRADA, School of Nursing and Health Studies, University of Miami

ANIRUDDHA HAZRA, Pritzker School of Medicine, University of Chicago

LEANNE LOO, Tufts University

ALYSSA LOZANO, Miller School of Medicine, University of Miami

SHERINE A. POWERFUL, Harvard T.H. Chan School of Public Health

SARAH E. RUTSTEIN, School of Medicine, University of North Carolina

MARCO THIMM-KAISER, Center for Latino Adolescent and Family Health, New York University

LAUREN L. TINGEY, Johns Hopkins Center for American Indian Health

GABRIELA WEIGEL, School of Medicine, University of California, San Francisco

Reviewers

This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.

We thank the following individuals for their review of this report:

Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft before its release. The review of this report was overseen by CLAIRE D. BRINDIS, University of California, San Francisco, and ELAINE L. LARSON, Columbia University. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.

Contents

PREFACE

ACKNOWLEDGMENTS

ACRONYMS AND ABBREVIATIONS

ABSTRACT

SUMMARY

1 ADDRESSING STI EPIDEMICS: INTEGRATING SEXUAL HEALTH, INTERSECTIONALITY, AND SOCIAL DETERMINANTS

Introduction

Urgency of Addressing STIs

Committee’s Approach

Changes in the STI Landscape in the Past 20 Years

Study Process and Report Overview

Concluding Observations

References

2 PATTERNS AND DRIVERS OF STIs IN THE UNITED STATES

Introduction

Interpretation of Surveillance Data

Patterns of STIs in the United States

Drivers of STI Outcomes and Inequities

Concluding Observations

References

3 PRIORITY POPULATIONS

Introduction

STIs Across the Life Span

Pregnancy and Infancy

Children

Adolescents

Cisgender Heterosexual Adults

Sexual and Gender Diverse Populations

Men Who Have Sex with Men

Transgender and Gender Diverse Adults

Lesbian, Bisexual, and Other Sexual Minority Women

LGBTQ+ Youth

Other Populations That Require Focused Consideration

American Indian/Alaska Native People

People with Military Experience

People with Disabilities

People with Criminal Legal System Involvement

Concluding Observations

References

4 STI ECONOMICS, PUBLIC-SECTOR FINANCING, AND PROGRAM POLICY

Introduction

Role of Government in Prevention and Control of STIs

Overview of Federal Programs

State and Local Efforts

Economic Burden of STIs

Conclusions

References

5 INTERSECTION OF HIV AND STIs

Introduction

History

Consequences of STIs in People Living with HIV

Important Lessons from the HIV Pandemic

Conclusions

References

6 ROLE OF TECHNOLOGY AND NEW MEDIA IN PREVENTING AND CONTROLLING STIs

Introduction

Technologies

Implementation Considerations: Costs and Feasibility

Implementation Considerations: Ethics and the Rapidly Changing Environment

Conclusion and Recommendation

Concluding Observations

References

7 BIOMEDICAL TOOLS FOR STI PREVENTION AND MANAGEMENT

Introduction

Tools for STI Diagnosis

Antimicrobial Tools for STI Treatment

Tools for STI Prevention

Conclusions and Recommendation

Concluding Observations

References

8 PSYCHOSOCIAL AND BEHAVIORAL INTERVENTIONS

Introduction

Contributions of Psychosocial and Behavioral Interventions on STI Prevention and Control

Psychosocial and Behavioral Interventions

Individual-Level Interventions

Interpersonal-Level Interventions

Community-Level Interventions

Cost Effectiveness of Psychosocial and Behavioral Interventions

Technology-Based Interventions

Dissemination of Evidence-Based Behavioral Interventions

Implementation Science

Conclusions and Recommendation

References

9 STRUCTURAL INTERVENTIONS

Introduction

Structural Interventions to Decrease STIs in Marginalized U.S. Groups and Reduce STI Inequities

Macro-Level Structural Interventions to Decrease STIs in the U.S. Population Overall

Meso-Level Structural Interventions to Decrease Overall STI Rates and STI Inequities

Community Mobilization for Structural Change Related to STIs and HIV

Conclusions and Recommendation

References

10 PAYING FOR AND STRUCTURING STI SERVICES

Introduction

Paying for STI Prevention and Treatment Services

Health Insurance Coverage Requirements

Assessing Systems of Care and Accountability

Clinical STI Services

STI Systems of Care

Conclusions and Recommendation

Concluding Observations

References

11 SUPPORTING AND EXPANDING THE FUTURE STI WORKFORCE

Introduction

Sexual Health and Ethics as an Organizing Framework for the STI Workforce

Current STI Workforce in the United States

Leveraging Health Care Systems and Practitioners Not Traditionally Involved in STI Service Delivery

Strengthening the National Public Health Workforce

STI Workforce Gaps and Needs

STI Workforce Education and Development

Conclusion and Recommendation

References

12 PREPARING FOR THE FUTURE OF THE STI RESPONSE

Introduction

Review of Recently Published Reports Addressing STI Prevention in the United States

National Academy of Public Administration STI Reports

Treatment Action Group Gonorrhea, Chlamydia, and Syphilis Pipeline Report 2019

STI National Strategic Plan for the United States (2021–2025)

Charting a Path Forward

Adopt a Sexual Health Paradigm

Broaden Ownership and Accountability for Responding to STIs

Bolster Existing Systems and Programs for Responding to STIs

Embrace Innovation and Policy Change to Improve Sexual Health

Concluding Observations

References

APPENDIXES

A CHARACTERISTICS OF MAJOR STIs IN THE UNITED STATES

B STI SCREENING AND TREATMENT GUIDELINES ISSUED BY HEALTH PROFESSIONAL SOCIETIES

C MEASURING THE IMPACT OF WORRYING ABOUT STIs ON QUALITY OF LIFE

D PUBLIC MEETING AGENDAS

E COMMITTEE MEMBER AND STAFF BIOGRAPHIES

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Preface

Sexually transmitted infections (STIs), although largely preventable, are common in the United States, and their incidence rates have been rising steadily for more than a decade. They can have serious negative health impacts in both the short and long terms, yet service uptake is often suboptimal due to low diagnosis rates and various barriers to care and treatment. For example, congenital syphilis is a grave and often lethal threat to newborns that provides a dramatic and tragic indicator of public health failure; while it is preventable with quality prenatal care, diagnoses have increased 2.6-fold from 2013 to 2018 in the United States. Although STIs can affect anyone who is sexually active, the heavy burden on persons of color, including Black, American Indian and Alaska Native, and Latino/a individuals, highlights structural inequities that pervade U.S. society and impede an effective STI response, as does the disproportionate impact of STIs on many lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ+) individuals.

This committee report seeks to highlight and disentangle some of the complexities of U.S. society, including its patchwork health care financing system, that result in some of the highest STI rates among higher-income nations. This report does not provide recommendations to prevent and control HIV because the report sponsors—the Centers for Disease Control and Prevention and the National Association of County and City Health Officials—asked the committee to focus its recommendations on STIs other than HIV, given the alarming increasing rates of non-HIV STIs. The committee concludes that the nation needs a new paradigm for

confronting STIs. Historically, STIs have focused on individual risks and interventions, with biomedical goals of screening, treatment, and clinical engagement of sexual partners and attention to individual risk factors and conduct. Biomedical approaches remain constrained. Except for human papillomavirus and hepatitis B virus, the nation lacks STI vaccines. STI therapies are suboptimal in too many instances, and point-of-care diagnostics are not deployed widely. Focusing on sexual risk has proven a limiting paradigm, given that sexual risk can be incurred without personal volition or awareness of risk.

While the efficiency and reach of STI services are vital elements of success, a more positive and holistic approach to prevent STI spread is needed. The committee adopted a Modified Social Ecological Framework of Sexual Health and STI Prevention, Control, and Treatment that moves beyond individual-level behavioral or biomedical constructs toward a comprehensive framework to address the interconnected and mutually reinforcing structural and social determinants of health and health inequities. Since 2006, the working definition of sexual health at the World Health Organization¹ has been

“Sexual health” is a term referring to the salutary and positive view of responsible and mutually consensual sex as a part of joy, desired procreation, love, and pleasure available to all humankind, the antithesis of disease and attendant suffering caused by STIs. STI control that is viewed within a healthy sexual life is likely to be more successful than the traditional medical and public health model that is steeped in blame, stigma, marginalization, and discrimination. In this report, the committee considers the interplay between biomedical, psychosocial and behavioral, and structural interventions and the need for them to be understood and addressed synergistically—not in silos—for greatest impact.

In 1997, the Institute of Medicine published a report titled The Hidden Epidemic: Confronting Sexually Transmitted Diseases to “educate health professionals, policy makers, and the public regarding the truths and

___________________

¹ See https://www.who.int/reproductivehealth/topics/sexual_health/sh_definitions/en (accessed November 10, 2020).

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

Sten H. Vermund, Chair
Committee on Prevention and Control of Sexually Transmitted Infections in the United States

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Acknowledgments

The committee wishes to thank and acknowledge the many individuals and organizations that contributed to the study process and development of this report. To begin, the committee would like to thank the Centers for Disease Control and Prevention and the National Association of County and City Health Officials—the study sponsors—for their support of this work.

The committee found the perspectives of many individuals and groups immensely helpful in informing its deliberations through presentations and discussions that took place at the committee’s public meetings. Speakers provided presentations on the state of sexually transmitted infection (STI) science and policy: Emilie Alirol, Kevin Ault, Lynn Barclay, Eliav Barr, José Bauermeister, Georges Benjamin, Kim Blankenship, Gail Bolan, Laura Cheever, Liz Chen, Harrell Chesson, Eli Coleman, Demetre Daskalakis, Henry de Vries, Carolyn Deal, Meg Doherty, Evgeniy Gabrilovich, Sami Gottlieb, David Harvey, Sean Howell, Carol S. Jimenez, Seth Kalichman, Jeffrey Klausner, Brenda Korte, Shannon McDevitt, Leandro Mena, John Pachankis, Ina Park, Naveen Patil, Emmett Patterson, Manos Perros, Raul Romaguera, Elizabeth Ruebush, Joanna Shaw-KaiKai, Susan Sherman, Shoshanna Sofaer, Melanie Taylor, Maria Trent, Krishna Upadhya, Barbara (Bobbie) Van Der Pol, George Walton, Kate Washburn, Gretchen Weiss, Janet Wilson, Dan Wohlfeiler, and Gail Wyatt. The committee also received important insights and information from Andria Apostolou, Judith Harbertson, Kenneth Mayer, and Sara Rosenbaum. The committee

received helpful and timely background information from many staff at the Department of Health and Human Services throughout the study process, including Sevgi Aral, Gail Bolan, Harrell Chesson, Thomas Gift, Melissa Habel, Carol S. Jimenez, Kristen Kreisel, Jennifer Ludovic, Raul Romaguera, Ian Spicknall, and Hillard Weinstock.

The committee’s work was enhanced by the technical expertise, writing contributions, data evaluation, and other support provided by Adam Benzekri, Marie Brault, Matthew Crane, Yannine Estrada, J. Dennis Fortenberry, Aniruddha Hazra, Andrew Hidalgo, Dan Li, Leanne Loo, Alyssa Lozano, Sherine Powerful, Sarah Rutstein, Marco Thimm-Kaiser, Lauren Tingey, Zachary Wagner, and Gabriela Weigel, who served as consultants.

Importantly, the committee heard from a number of individuals who shared their personal stories and experiences about STIs and sexual health with the committee. These discussions helped ground the committee in the lived experiences of the complex issues that needed to be tackled in this report, and the committee is incredibly grateful for their courage in sharing their experiences in a public forum. The committee is thankful to the organizations that helped to identify individuals for these discussions: CCF College and Community Fellowship, Cherokee Nation Health Services, FHI 360, HIPS, My Brother’s Keeper, Nationz Foundation, Real Talk Promising Futures, SisterLove, and University of Chicago.

The committee thanks the National Academies of Sciences, Engineering, and Medicine staff who contributed to producing this report, especially the extraordinary, creative, and tireless study staff Amy Geller, Aimee Mead, Sophie Yang, Harika Dyer, Hayat Yusuf, Anna Martin, Crysti Park, and Rose Marie Martinez. Thanks go to other staff in the Health and Medicine Division (HMD) who provided additional support, including Kat Anderson, Alina Baciu, Zaria Fyffe, and Justin Jones. The committee thanks the HMD communications staff, including Sadaf Faraz, Andrew Grafton, and Devona Overton. This project received valuable assistance from Stephanie Miceli (Office of News and Public Information); Misrak Dabi (Office of Financial Administration); and Clyde Behney, Tina Seliber, Lauren Shern, and Taryn Young (HMD Executive Office). The committee received valuable research assistance from Rebecca Morgan, Senior Research Librarian (National Academies Research Center), as well as Christopher Lao-Scott and Maya Thomas.

Finally, the National Academies staff offers thanks to committee members’ executive assistants and support staff, without whom scheduling the multiple committee meetings and conference calls would have been nearly impossible: Jacqueline Campoli, Robin Criffield, Ivette Gomez, Alexis Goodly, Jacqueline Lopez, Martha Pagan, Clovis Sarmiento, and Rashonda Winters.

Acronyms and Abbreviations

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Abstract

The Centers for Disease Control and Prevention (CDC) estimates that one in five people in the United States had a sexually transmitted infection (STI) on any given day in 2018, totaling nearly 68 million estimated infections. Although STI rates have increased across all U.S. populations, marginalized groups—youth, women, members of the lesbian, gay, bisexual, transgender, and queer community, and Black, Latino/a, American Indian/Alaska Native, and Native Hawaiian/other Pacific Islander people—continue to experience a disproportionate share of cases. In 1997, the Institute of Medicine released a report, The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Although significant scientific advances have been made since that time, many of the problems and barriers described in that report persist today; STIs remain an underfunded and comparatively neglected field of public health practice and research.

The committee reviewed the current state of STIs in the United States to provide advice on future public health programs, policy, and research. It organized its work under four action areas and makes the following 11 recommendations (see the Summary or the report for a full exposition of each recommendation):

1. Adopt a Holistic Sexual Health Paradigm
   1. Develop a vision and action plan for sexual health and well-being that aligns sexual health and well-being with other dimensions of health—physical, mental, and emotional. (12-1)

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

4. Embrace Innovation and Policy Change to Improve Sexual Health
   10. Develop a whole-of-government interagency approach, in partnership with affected communities, to promote sexual health and eliminate structural racism and inequities that are barriers to STI prevention, testing, and treatment. (9-1)
   11. Expand the capacity to use technology for STI prevention and control, including by developing timely, novel, and open data systems and using artificial-intelligence-based mass marketing. (6-1)

The committee’s exploration of the complexities of the STI epidemic has instilled in its members a firm belief that it is possible to create a different and better future where fewer people are infected, fewer babies are born with STIs, and people entering adolescence and continuing across the life span are taught the language and skills to conceptualize and enact their own vision for what it means to be sexually healthy. The committee’s recommended changes may be challenging, but a substantial reduction in the societal impact of STIs is a realistic goal.

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