After reviewing the current workforce landscape and identifying several gaps, the committee recognized the need for a clearly delineated plan to expand, develop, and sustain a strong and responsive sexually transmitted infection (STI) workforce to ensure effective implementation of this report. Most recently, the COVID-19 pandemic has drawn attention to the crucial role of the public health, clinical, laboratory, and community-based workforce in addressing national public health priorities (Krisberg, 2020; Nagendra et al., 2020; NCSD, 2020).
More than other issues of public health importance, STIs are subject to stigma, misconceptions, discrimination, and strongly held differences of opinion (Albright and Allen, 2018; Hilpert et al., 2010; Nsuami et al., 2010; ODPHP, 2020). As in the rest of this report, this chapter is guided by the principles of sexual health and wellness described in Chapter 1, including the ethical concepts of beneficence, nonmaleficence, autonomy, and justice. The committee also established the importance of countering the historically rooted tendency to regard sexual health as a mere byproduct of disease prevention and treatment. By focusing primarily on negative consequences and endorsing a risk-centered perspective, public health efforts have too often unwittingly fed health care–related stigma and public misunderstanding of STIs.
The workforce ought to conceive STI services as falling within the larger framework of sexual health promotion, with overall health and wellness as the ethos. This necessitates that the workforce adopt and promote a holistic and positive outlook to managing and preventing STIs that (1) upholds healthy expression of human sexuality (beneficence), (2) destigmatizes discussions around sex and removes the taboos and/or departs from the traditionally moralizing undertones of the current discourse (nonmaleficence), (3) encourages self-determination and bodily integrity (autonomy), and (4) champions individual sexual rights (justice).
The STI workforce can be broadly categorized as those providing services in a number of distinct domains, including clinical sexual health care, sex education and sexual health promotion, public health, pharmacy, and research. It includes roles for many types of professionals who provide primary care, sexual and reproductive health practitioners, and specialists. These professionals include those who directly provide focused STI testing, treatment, and clinical prevention services, those who offer nonclinical STI services, including counselors and disease intervention specialists (DIS), and those who advance research and technical aspects of public health and medicine relevant to STIs.
The committee identified three priority areas for strengthening the STI workforce: (1) refocusing and improving traditional service delivery paradigms within primary health care, STI specialty care, and supportive services in order to maximize the effectiveness, efficiency, and reach of the existing workforce; (2) leveraging health care systems and practitioners not traditionally involved in STI service delivery for novel prevention and treatment strategies; and (3) strengthening the national public health workforce for improved responses to public health emergencies and infectious disease outbreaks, including STIs, at the local, regional, and national levels. This chapter provides an overview of the current STI workforce and highlights important considerations for addressing each priority area.
Refocusing and Improving Traditional Service Delivery Paradigms in Clinical STI Prevention and Care
The clinical STI workforce includes both primary care generalists, whose work broadly relates to basic management and prevention, but who traditionally do not perceive STI services as a key focus area, and specialists in sexual health and STIs. Given the importance and complexity of the workforce involved in STI management and prevention, the purpose of the following section is to highlight the clinical STI workforce
in the context of traditional service delivery paradigms that may represent barriers to its optimal effectiveness, efficiency, and reach.
Clinical Health Care Services: Generalists
A broad array of health care generalists is well positioned to take on important roles in STI prevention and management, including primary care providers (i.e., primary care physicians, physician assistants [PAs], nurse practitioners [NPs]), nurses, and clinical behavioral health professionals [BHPs]). There are 200,000 primary care physicians (family and general practitioners, internists, pediatricians, obstetricians, and gynecologists), 120,000 PAs, and 200,000 NPs practicing in the United States (BLS, 2020) with prescriptive privileges, for whom STI vaccination and screening are recommended elements to primary care. This large workforce can carry out routine STI screening, initiate pharmaceutical treatment, and promote STI prevention, including offering evidence-based STI prevention counseling interventions recommended by the United States Preventive Services Task Force for all sexually active adolescents and for adults at increased risk for STIs (Krist et al., 2020). Notably, task-shifting and task-sharing approaches that broaden the workforce responsible for delivering important health care services relative to traditional paradigms represent an opportunity to leverage the entire array of qualified health care generalist for STI service delivery (NASEM, 2016b).
Nurses represent the largest segment of the U.S. health care workforce, with approximately 3 million registered nurses and 700,000 licensed practical and vocational nurses currently executing much of direct health care service delivery (BLS, 2020). As first-line providers, nurses are in frequent contact with patients and community members and often carry out important aspects of sexual health and behavior screenings (e.g., taking a sexual history), vaccinations, performing or ordering diagnostic testing, and medication administration (IOM, 2011; Santa Maria et al., 2017). In addition, advanced practice nurses initiate and prescribe biomedical STI treatment and prevention. Licensed clinical BHPs practicing in fields relevant to sexual health and STI prevention and treatment include professional counselors, licensed social workers, psychiatrists, psychologists, and psychiatric technicians. BHPs frequently work with vulnerable populations with behavioral and mental health challenges who are at elevated risk of STIs (O’Cleirigh et al., 2015). Specifically, misuse of alcohol or illicit substances is associated with increased STI risk and compulsive sexual behavior (Boden et al., 2011; Cook et al., 2006; Feaster et al., 2016; Garner et al., 2020). Therefore, BHPs are well placed to promote STI prevention and referral to testing and treatment (Brookmeyer et al., 2016). Conversely, screening for alcohol and substance use problems as part of STI service
delivery has been promising in identifying individuals in need of behavioral health services, warranting STI workforce development related to identifying and managing alcohol and substance use problems (Feaster et al., 2016; Patton et al., 2008). BHPs represent a sizable workforce of more than 500,000 U.S. practitioners (BLS, 2020).
STI-specific services tend to represent a small proportion of overall services delivered by health care generalists. As a result, generalists may view STI prevention, screening, and treatment as less salient and potentially overlook or ignore these issues in their day-to-day practice. National and international studies highlight barriers to routine STI testing in primary care and in general practice settings, including insufficient knowledge, lack of adequate training, and absence of explicit protocols (Cook et al., 2001; McNulty et al., 2004, 2010; Yeung et al., 2015). While most health care providers, including general practitioners, receive training on sexual health and STI services during their education (Ford et al., 2013), these skills may atrophy and become increasingly easily overlooked and set aside, unlike more regularly practiced skills that become more facile with experience (see Chapter 10). Notably, a significant number of practicing providers reports uncertainty about how or when testing should be performed, underestimates STI prevalence in the population, and expresses ambivalence about the benefits of routine screening and testing. This is exacerbated by the time constraints of the expansive recommendations for care provision in the clinical environment, their heavy workload, staff shortages, and inadequate financial resources (Cook et al., 2001; McNulty et al., 2004, 2010; Yeung et al., 2015). Some providers have raised general apprehensions about broaching sexual health and express discomfort in suggesting STI testing (McNulty et al., 2004, 2010). Many of these concerns can be addressed and are discussed later in the chapter.
Private primary care practitioners and health maintenance organizations (HMOs) represent the largest segment of U.S. clinical health care providers who diagnose and treat STIs. They diagnose and report only approximately 20–30 percent of all STI cases (CDC, 2019a), and compliance with the recommendation to screen sexually active women below the age of 25 for chlamydia annually, for example, was only 50 percent for commercial HMOs and 58 percent for Medicaid HMOs (NCQA, n.d.).
These findings suggest significant room for improvement in implementing routine STI screening for early detection. Insufficiently prioritizing prevention, testing, and management in primary settings represents a missed opportunity to leverage a large segment of the clinical health care workforce to address increasing STI prevalence nationally. Therefore, a shift in traditional paradigms of primary care delivery toward increased recognition of the important role of general practitioners in sexual health, STI prevention, and management is drastically needed.
Clinical Health Care Services: Sexual and Reproductive Health and STI Specialists
In contrast to primary care generalists, clinical sexual and reproductive health (SRH) specialists, such as gynecologists/obstetricians and women care–focused NPs, specialize in the clinical services for sexual health promotion and routinely provide STI prevention and treatment (Barrow et al., 2020). Accordingly, proportionately more women than men have access to and use sexual health services. Integrating STI services into women-specialized care provides greater opportunity for screening and contributes to higher rates of STI testing for these patients (Bertakis et al., 2000; Kalmuss and Tatum, 2007; KFF, 2015). The gender asymmetry in testing may contribute to gender differences in STI rates detected through screening. While routine STI screening is frequently implemented in gynecologic or obstetric care, failure to provide routine STI screening remains too prevalent, contributing to the persistently high prevalence of undiagnosed asymptomatic infections among women (Torrone et al., 2014).
Men remain inadequately engaged in SRH services (Fine et al., 2017; Kalmuss and Tatum, 2007; Santa Maria et al., 2018). More generally, women are introduced to the concept of periodic, ongoing, lifelong health care at puberty, while men are not. There is an absolute need to shift the paradigm to prioritize male SRH more than is currently the case (see Chapters 10 and 12). Attending to men’s sexual health needs will require more readily available male-centered sexual health specialty services and implementing gender-inclusive SRH services integrated into primary care (Santa Maria et al., 2018). For persons living with HIV and those at risk of HIV who are receiving pre-exposure prophylaxis (PrEP), current recommendations include periodic STI screening (Owens et al., 2019; Workowski and Bolan, 2015). While implementation has been incomplete, including STI screening in these HIV recommendations has expanded STI screening and management services for some, mostly men (Montaño et al., 2019).
Public health STI specialty clinics continue to be essential sources for prevention and management. Clinical STI specialists provide comprehensive treatment and prevention, sometimes practicing in specialty clinics (Barrow et al., 2020), which offer timely and confidential onsite testing and treatment as well as services for exposed partners. While such clinics frequently provide services at little or no cost and have become an important safety net for individuals without health insurance, budget cuts to state and local STI programs have resulted in a steadily declining availability (Barrow et al., 2020; Leichliter et al., 2017; NCSD, 2019).
Such budget cuts have resulted in reduced office hours and decreased access to care at these clinics. This particularly affects uninsured, undocumented, and impoverished individuals and others disenfranchised from primary health care environments who may rely disproportionately on
STI specialty clinics for sexual health and STI prevention and management services. In 2017, at least one-third of U.S. counties were estimated to have no STI clinic (defined as a publicly funded provider of STI services, including family planning clinics, community health centers, and school-based clinics) (Meyerson et al., 2019).
Because of the decreasing availability of STI specialty care, the proportion of STIs diagnosed in designated STI clinics has decreased substantially over the past decade (CDC, 2019a). An examination of the infrastructure of public STI clinics (defined in the study as those clinics specialized in or with hours and staff specifically devoted to STI services) showed more frequent availability of important specialty services, such as extragenital testing, stat rapid plasma reagin testing for active syphilis, and stat gonorrhea Gram stain testing for symptomatic men, compared to other public clinics (Leichliter et al., 2017). As visible components of the public health infrastructure, many STI clinics also serve an essential role for practitioner training and as a referral resource for community clinicians who encounter unusual or challenging problems in provision of STI management, such as multidrug-resistant gonorrhea. The availability of these specialty services highlights the continued importance of public STI clinics for comprehensive population-level STI management beyond the safety-net functioning for persons without health insurance (ASTDA Board of Directors, 2020).
Addressing the Important Role of Bias in the Delivery of STI Services
Institutionalized racism, especially in the clinical field, is definitely a barrier for me with the medical professionals not always listening to people of color, not always listening to queer people. And even if your provider is a person of color, just by the way that system portrays people of color is a barrier. I am willing to talk to my regular health care provider about my sexual health, and they are making moves toward being more trans friendly, but they don’t necessarily have all the language and noninvasive manners of asking questions, so I’m a little bit hesitant. My recommendation would be to be more personable, supportive, and nonjudgmental and to have spaces that are there for non-heteronormative spaces.
—Participant, lived experience panel1
1 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.
Bias in health care both reflects and reinforces pre-existing societal inequalities. While the validity of explicit bias estimates is questioned because of social desirability, evidence shows that health care providers exhibit levels of implicit bias comparable to the general population (FitzGerald and Hurst, 2017; Hall et al., 2015). A provider’s implicit expectations or assumptions can be negatively primed by trivial or otherwise care-irrelevant characteristics, such as race, ethnicity, gender identity, gender expression, sexual orientation, religious affiliation, socioeconomic status, nationality, immigration status, insurance, drug use, mental illness, age, weight, or perceived illness responsibility (FitzGerald and Hurst, 2017). Research conducted with STI service providers has primarily focused on race/ethnicity, sexual or gender minority status, and age as factors that affect STI testing. Unconscious stereotypes can override objective health assessments, as demonstrated in a study of STI testing among youth: all symptoms being equal, race and ethnicity was significantly associated with being tested for an STI, with Black adolescents being more likely to receive a test than the rest of the sample (Goyal et al., 2012). Paradoxically, despite strong evidence that youth represent a key population that is disproportionately impacted by STIs, testing of adolescents remains relatively scarce (Cuffe et al., 2016). Implicit bias among health care providers has also been linked to an unwitting attitude of discomfort with taking a sexual history for lesbian, gay, bisexual, transgender, and queer (LGBTQ) clients (Hayes et al., 2015; Mayfield et al., 2017).
Health care providers’ implicit biases can translate into differences in service delivery and quality of care, to the detriment of already marginalized populations. Unconscious stereotypes and attitudes (1) distort perception of the patient, (2) influence patient–provider interactions, (3) affect clinical decision making (such as testing, diagnosis, and treatment), and (4) ultimately fuel health outcome disparities. For instance, in the STI workforce, the stereotype that Latino/a people, African American people, or men who have sex with men are more prone to sexual risk and less likely to adhere to medication results in delayed or lower likelihood of prescribing PrEP or antiretroviral treatment (Bean et al., 2013; Calabrese et al., 2014; Hall et al., 2015; Stone, 2005). An immediate consequence of these stereotypes is patient distrust of providers; ethnic, sexual, and gender minorities typically report that they experience microaggressions and provide lower ratings of satisfaction with health care interactions and lower levels of trust in their providers, which can affect treatment compliance and future care seeking (FitzGerald and Hurst, 2017; Hall et al., 2015). In addition, differential STI testing (e.g., overtesting members of racial minority groups) may exaggerate reported racial disparities in STI burden (Goyal et al., 2012).
Solutions to diminish the impact of unconscious biases require convergent efforts at the individual and institutional levels, including (1) greater inclusion of underrepresented minorities in the STI workforce itself and in positions of authority and leadership, in addition to support once hired to prevent departure and promote staff well-being and retention; (2) cultural appropriateness, diversity, and structural competency training for staff (Metzl and Hansen, 2014); (3) education about unconscious bias and intentional exposure to counterstereotypical experiences; and (4) broader testing of diverse populations at risk. Because of the nature of unconscious biases, STI workforce providers are encouraged to seek mentorship, acknowledge their stereotypes, actively self-reflect on how those biases might influence their practice, and engage in stereotype replacement using effective cognitive strategies (Marcelin et al., 2019).
A systematic approach to strengthening the U.S. STI workforce in response to alarming increases in STIs needs to include efforts for leveraging health care systems and practitioners not traditionally involved in STI service delivery for novel prevention and treatment strategies. In addition, dimensions of effective and comprehensive STI prevention and management outside of traditional clinical settings warrant consideration, given that populations disproportionately affected by STIs frequently face access barriers to traditional health care systems. Specifically, diversifying the settings in which prevention and management is routinely addressed represents an opportunity to build a more inclusive workforce for comprehensive sexual health promotion.
This section highlights three workforce domains that are not traditionally involved in direct STI service delivery but could be leveraged for expanded and comprehensive population-level STI prevention and management: diverse actors in sexual education and sexual health promotion, pharmacists, and researchers. This wide network of practitioners represents an invaluable resource for comprehensive national STI prevention and management. Specifically, the broad range of their distinct competencies provides multiple leverage points to improve the effectiveness, efficiency, and appropriateness of the STI response system as a whole.
Diverse Actors in Sexual Education and Sexual Health Promotion
Important aspects of comprehensive sexual education and sexual health promotion can be delivered outside of clinical settings. Diverse actors, including parents, health educators, and civic and religious leaders,
can be influential in family- and community-based efforts. For example, families represent an important social context and are influential in shaping a range of sexual reproductive health outcomes, particularly for adolescents and young adults. Specifically, parental communication about sex and contraception and parental monitoring behaviors are associated with reduced sexual risk behavior, including condom use (Dittus et al., 2015; Guilamo-Ramos et al., 2016, 2019) (see Chapter 8).
Similarly, health educators promote core principles of sexual health throughout adolescence in school-based settings (Mason-Jones et al., 2012; Salam et al., 2016). Religious leaders have been influential in promoting STI testing and treatment (Svanemyr et al., 2015), and civic leaders and employers have reached community members of differing ages with sexual health and education messaging and tools for STI prevention (CDC, 2019c; Salam et al., 2016).
A large pool of paraprofessionals in the human services, such as family support and case workers, social services specialists, youth workers, and community health workers (CHWs), represents an additional segment of the workforce relevant to sexual education and sexual health promotion. Through targeted allocation of resources, these paraprofessionals can be leveraged to build a pipeline that expands the STI workforce beyond the practitioners traditionally involved in STI service delivery, as they can be trained to take on an important role in various services that are essential to prevent, identify, and manage STIs, such as general and STI-specific health literacy education and patient navigation to testing services (Han et al., 2018; Harmon-Darrow et al., 2020). For example, CHWs have historically worked in communities underserved by mainstream health care systems and are effective in reaching populations who may otherwise lack access to health care services (CDC, 2014). Because CHWs are indigenous to the communities they serve, they are uniquely positioned to deliver health care information and services in a culturally relevant and linguistically appropriate fashion (Ingram et al., 2008). CHWs address some of the primary access barriers to health education and services that individuals in these communities encounter (Lehmann and Sanders, 2007), including for STIs, and have been found to improve health outcomes and increase access to health care (Rosenthal et al., 2010; Spencer et al., 2010). CHWs’ competencies and scope of practice allow for a unique approach to health promotion among diverse, socioeconomically disadvantaged, and structurally marginalized populations who are frequently disconnected from access to health and social services systems; the core of CHWs’ practice includes outreach and community organizing, home visitation, health education and coaching, health and social services navigation, and case management and care coordination (Findley et al., 2012).
State regulation of CHW reimbursement remains inconsistent, particularly with regard to Medicaid coverage (NASHP, n.d.), representing a primary barrier to national initiatives that seek to expand the role in efforts to reduce health disparities. The often inadequate reimbursement options for CHW-delivered STI education, sexual health promotion, and service referrals will limit the extent to which CHWs’ capacity to improve STI service access and outcomes in underserved communities can be used. Nevertheless, CHWs and other paraprofessionals in the human services are well positioned to deliver services that support preventing, identifying, and managing STIs and can be leveraged for the STI workforce.
Pharmacists are highly trained health care professionals who not only dispense medication, but also help to prevent, manage, and treat diseases and conditions through the safe and effective use of medications (Chisholm-Burns et al., 2010; Schneider et al., 2015). Although medication distribution and counsel are essential functions, pharmacists’ scope of practice can be expanded. The integral role of pharmacists within public health, however, has not yet been broadly recognized, and they are not traditionally regarded as a core segment of the STI workforce. Adding pharmacists as recognized STI service providers is one promising way to improve STI prevention and control (APhA, 2006; Chisholm-Burns et al., 2010; Gronowski et al., 2016; Wood and Gudka, 2018).
Pharmacies are a convenient, widely available entry point for patients into the health care system (HRSA, 2008). There are about 68,000 pharmacies and roughly 311,000 pharmacists practicing in the community setting (BLS, 2020; Qato et al., 2017), and approximately 90 percent of the American population has a community pharmacy located within 2 miles (Qato et al., 2017). In addition to retail pharmacies, there are 1,900 retail clinics in pharmacies and stores2 (Iglehart, 2015). Pharmacies often offer convenient after-work hours with no appointments required (Gronowski et al., 2016; Herbin et al., 2020). Furthermore, almost all pharmacies accept private insurance and Medicare, and many accept Medicaid as well. Stigma and mistrust of the health care system can be limiting factors to patients seeking and receiving quality care; however, pharmacists are among the most trusted health care professionals (Gronowski et al., 2016; Herbin et al., 2020).
2 Examples include MinuteClinic (CVS), Healthcare Clinic (Walgreens), Little Clinic (Kroger Foods), Target Clinic (Target), and Redi-Clinic (Rite Aid).
Zhang et al., 2020), a broader pool of practitioners available to order and interpret tests and arrange treatment suggests the great potential utility of pharmacists for the STI workforce. An estimated 13 billion pharmacy visits occur per year, which is more than 10 times the annual number of patient contacts with all other primary care providers combined (Herbin et al., 2020). Pharmacies can therefore increase access to care, especially for underserved populations, help shift practitioners’ time to serve more critically ill patients, and improve overall health care delivery (Giberson et al., 2011).
Several studies have found that when pharmacists are able to provide direct patient care, health care costs are reduced, care is less fragmented, and patient health is improved. Improved outcomes include better control of hypertension, high cholesterol, and diabetes; more screenings and other preventive health measures; and fewer specialist visits, trips to the emergency room, and hospitalizations (APhA, 2006; CDC, 2013; Chisholm-Burns et al., 2010; Giberson et al., 2011). A 2010 systematic review and meta-analysis also found favorable effects of pharmacist-provided care on patient knowledge, medication adherence, and safety outcomes, such as adverse drug events and reactions and medication errors (Chisholm-Burns et al., 2010).
In recent years, innovative nonclinical point-of-care (POC) tests for a variety of infectious diseases, including some STIs, have become available through pharmacies (Herbin et al., 2020) (see Chapter 7). Pharmacists are highly trained and well suited to perform these tests (Habel et al., 2015), especially those that are Clinical Laboratory Improvement Amendments (CLIA) waived (see Chapter 7) and cleared for home use (CDC, 2020b). Licensed POC tests have a satisfactorily low risk of an inaccurate result and are simple to perform and acceptable to patients (Widdice et al., 2018). POC tests have many advantages for STIs, because immediate results allow patients to be connected to treatment in one visit to prevent further transmission of the infection.
The complete incorporation of pharmacists into health care delivery systems faces barriers, however, such as regulatory limitations on providing direct patient care (e.g., testing for and treating STIs). Collaborative practice agreements (CPAs)—formal relationships between pharmacists and prescribers that expand pharmacists’ scope of practice under specific conditions—are allowed in 48 states, but laws governing CPAs differ widely by state (CDC, 2017). State laws and regulations dictate variables within CPAs, such as participants (e.g., number and type of prescribers and number of pharmacists and patients), allowed pharmacist functions (e.g., initiating, modifying, and discontinuing medications and performing or ordering and interpreting tests), and additional requirements or restrictions (e.g., practice setting, requirement of liability insurance, and length of time the CPA is valid) (CDC, 2017).
Limited reimbursement options represent another barrier (Avalere Health, 2015; CDC, 2013; NGA, 2015), as current policies primarily compensate pharmacists for medications and the act of dispensing them rather than for direct care services (APhA, 2020; Avalere Health, 2015; NGA, 2015). Pharmacists are not formally recognized as providers under Medicare Part B and so are excluded from directly billing for patient care services to any state or private plans aligned with Medicare payment policies (APhA, 2020; Avalere Health, 2015; CDC, 2017; Goode et al., 2019; NGA, 2015). Therefore, reimbursement for services outside of pharmacists’ traditional scope of practice remains limited, varied, and unstandardized across practice settings and care systems (APhA, 2020; Avalere Health, 2015; NGA, 2015).
A change in the partnership of pharmacists with clinical care providers and public health professionals for STI control would leverage pharmacists’ expertise and access to the community, expand services to patients and increase their access to care, and improve the efficiency and cost effectiveness of that care (APhA, 2006; CDC, 2013; Chisholm-Burns et al., 2010; Giberson et al., 2011; Herbin et al., 2020).
Medical, pharmaceutical, and public health researchers represent an important part of the STI workforce. Specifically, generating new knowledge in four distinct fields of research is particularly relevant to prevent and manage STIs: (1) the development of novel prophylactic, diagnostic, and treatment tools; (2) the development of behavioral interventions that promote STI prevention and treatment outcomes; (3) research that improves the effectiveness and efficiency of service delivery models in STI prevention and treatment, including eHealth (electronic and mobile tools, respectively) and artificial intelligence/machine learning modeling research; and (4) implementation science that promotes the adoption of existing evidence-based practices and interventions. Research professionals in the STI workforce are most often employed in academia, the pharmaceutical industry, public health agencies, or specialty clinics.
Existing biomedical and behavioral research on STI prevention and management does not correspond to the scale of innovation needed to address STIs as a national and international public health priority. In response, leadership at the National Institutes of Health (NIH) has called for refocused and scaled research efforts, such as the National Institute of Allergy and Infectious Diseases–funded STI Cooperative Research Centers (NIH, 2019) and increased private-sector investments (Eisinger et al., 2020). In addition, mechanisms to incentivize more specialized operational and implementation STI research are needed, such as modeled after
the NIH Loan Repayment Programs, which provide financial incentives for entering careers in biomedical or biobehavioral research (NIH, 2020), as well as additional support for academic STI research centers.
Workforce development for STI prevention and control must be considered within a broad framework of national public health preparedness. The COVID-19 pandemic has once again profoundly highlighted that national public health preparedness must be strengthened, including the need for a well-trained and resourced public health workforce to respond to public health emergencies and infectious disease outbreaks at the local, regional, and national levels.
Public health practitioners whose scope of work includes preventing and managing STIs are diverse and include public health officials, laboratory technicians, DIS, and providers of clinical STI prevention and treatment. Epidemiologists and other public health officials at local and state health departments oversee and coordinate STI programming, disseminate prevention messaging, and implement surveillance for reporting to the Centers for Disease Control and Prevention (CDC, n.d.). Technicians at both public health and commercial laboratories are essential for STI diagnostics and reporting to surveillance systems (Davis and Gaynor, 2020).
The clinical STI workforce and DIS are particularly important for responding to localized outbreaks of elevated STI incidence. Specifically, clinicians treat and manage STIs to control transmission dynamics, and DIS may be deployed for contact tracing, follow-up, case finding, and surveillance (CDC, n.d.). The below section highlights in more detail the potential to leverage nurses and DIS to simultaneously address STI prevention and control and broader public health preparedness in the United States.
Leveraging Nurses for Population Health
The more than 3 million nurses in the United States comprise the largest segment of the clinical health care workforce and perform a large proportion of direct health care service delivery (Salmond and Echevarria, 2017). A 2011 Institute of Medicine (IOM) report highlighted their instrumental role in achieving universally accessible, equitable, and high-quality national health care delivery (IOM, 2011). The IOM emphasizes the importance of enabling nursing practice to the full extent of nursing education and training, which is particularly important for preparing and facilitating health care systems’ response to pressing public health
priorities (HRSA, 2016; IOM, 2011). For example, nurses are trained and also well situated, as first-line providers, to deliver most aspects of STI prevention and management, including taking sexual histories and administering vaccinations, tests, and medications (IOM, 2011; Santa Maria et al., 2017). Advanced practice nurses with prescriptive privileges can deliver pharmaceutical treatment and prevention, including for STIs, and a Cochrane review suggests that they deliver primary care services that result in similar or better health outcomes and higher patient satisfaction compared to those from physicians (Laurant et al., 2018).
Despite national calls to remove practice barriers for advanced practice nurses (Fauteux et al., 2017; IOM, 2011; NASEM, 2016a), only 26 states allow NPs to practice fully independently, including evaluating and diagnosing patients; ordering and interpreting diagnostic tests; and initiating and managing treatments, including prescribing medications and controlled substances (AANP, 2019). Support for efforts to remove these practice barriers represents an important step toward fully leveraging NPs for sexual health promotion and STI prevention and management nationally.
Federal-, state-, and local-level regulatory and programmatic support for a broader scope of nursing practice in STI prevention and control is particularly meaningful within the context of innovative service delivery models outside of traditional clinical settings. The Health Resources and Services Administration (HRSA) recognizes nurses as a key segment of the health care workforce to implement novel, decentralized, and patient- and community-centered approaches for health care service delivery (HRSA, 2016). Internationally, nurses have been shown to provide effective and high-quality health care services with locational flexibility, including in community settings (Martínez-González et al., 2014; Wood et al., 2018). Increased attention for the potential of similar approaches in the United States is warranted, given that improved effectiveness, efficiency, and reach of health care services in key geographies and communities experiencing access barriers to traditional health care systems is necessary to address long-standing health disparities, including for STIs.
DIS for Population Health
The approximately 2,200 highly trained, community-focused DIS currently work within health departments and community health centers, conduct contact tracing, and provide STI partner services, including in community settings (Bolan and Mermin, 2019; NCSD, n.d.; PHAB, 2017). These numbers may be changing due to the COVID-19 pandemic and the increased need for new DIS; many DIS have been redirected to COVID-19 responses, negatively affecting STI program capacities and services
(NCSD, 2020). Traditionally, DIS conduct ground-level investigations of reported and suspected cases of STIs, including HIV, and help decrease transmission and reinfection by tracking and identifying patients’ sexual partners. DIS typically interview diagnosed patients to determine sexual contacts, locate them, notify them of possible exposure, and refer them for screening and treatment. DIS are proficient in SRH service delivery. They identify emerging infection clusters and provide STI and HIV education, counseling, testing, and referral services to populations at elevated risk (MacDonald et al., 2007; PHAB, 2017). Their scope of work also includes surveillance data collection by tracking and documenting STI cases. These data help determine priority populations for targeted interventions and inform public health policy of state and local agencies (PHAB, 2017).
While DIS have proven effective in preventing the spread of STIs (Cope et al., 2019), a result that can conceivably be extrapolated to other communicable diseases (Cope et al., 2019; PHAB, 2017), the demand for DIS in public health programming has long been moderate, with the salaries and numbers hired remaining stagnant (Cope et al., 2019). In recent months, however, the pandemic has sparked an increase in demand for contact tracing to contain and mitigate future outbreaks. As additional DIS are hired to support these efforts, the current STI tracking model represents a basis on which a national public health force could be designed and offers a strong rationale to retain DIS.
Specifically, the existing framework could be extended to incorporate a range of infectious diseases and entail larger, broader responsibilities for DIS, including STI field testing and treatment, such as expedited partner treatment (Cope et al., 2019; Mase et al., 2018). Training initiatives designed to expand the DIS workforce could draw on the existing pool of clinical and nonclinical health and human service professionals and paraprofessionals and represent an opportunity to diversify the workforce with STI specialty training and expertise. Thus, an expanded public health DIS workforce could potentially benefit STI prevention, and they would also function as core participants in community-based STI prevention collaboratives.
In addition, due to the increasing growth in using technologies and digital data as tools for sexual health (see Chapter 6), experts in digital interventions, digital marketing, computer science and artificial intelligence, data visualization, and other areas of innovation may play key roles in helping to track and intervene in sexual health promotion and disease prevention.
As discussed in the previous sections, the United States has a large and varied clinical and nonclinical workforce qualified to provide comprehensive STI services (Barrow et al., 2020). However, only a small proportion of it has specialized in STI management and prevention. To adequately address the challenges associated with increasing STI incidence and prevalence, mechanisms to attract and train clinical and nonclinical health professionals to STI specialty professions are warranted, including programs comparable to HRSA’s NHSC Loan Repayment Program, which provides financial incentives for health care providers in selected disciplines to provide services in medically underserved communities (HRSA, n.d.).
Furthermore, too few qualified primary care providers deliver important STI services as part of routine care (Barrow et al., 2020). Many practitioners do not report any cases, given their populations, specialties, awareness of STIs, or availability of convenient diagnostic services. Discomfort with addressing STIs or sexual health are also barriers that must be overcome. Given the many competing priorities most providers face, STI diagnosis and treatment remains a low priority for skills development or time allocation (CDC, 2019a). Increasing the routine administration of sexual history questionnaires, regular STI screening, and vaccination administration are priority actions for enhancing STI-specific health care services within the context of routine primary care.
Recent advances, such as clinical audio computer-assisted self-interview questionnaires, self-collected specimens for recommended screening, and administration of vaccines at pharmacies, make realizing these efforts possible with a minimal impact on clinician workload.
The structure and distribution of clinical and nonclinical staff within the STI specialty workforce lead to additional gaps. First, individuals in rural areas, including American Indian and Alaska Native peoples, continue to experience geographic disparities in health care access and use, with fewer resources and providers available to them (Cromer et al., 2019; Hempel et al., 2015; Henning-Smith et al., 2019). In many rural areas where access to primary health care is limited, specialized STI health care is particularly scarce and the limited STI specialty workforce size may threaten the capacity to ensure confidentiality in treatment (Paschal et al., 2011). Second, the age distribution of the health care workforce, including that specializing in STI service delivery, skews older (Merritt Hawkins, 2017; Smiley and Bienemy, 2018), despite increases in demands for treatment and prevention services (Keehan et al., 2017). As increasing numbers of the STI specialty workforce retire or change careers due to aging, a shortage is expected, particularly among the clinical workforce, including
Finally, innovative nonclinical testing opportunities through pharmacies and self-test kits that can be implemented in medically underserved areas and community settings, including clinics, schools, jails, juvenile detention centers, and homeless shelters, provide new, effective, and efficient means for diagnosing previously unrecognized STIs. These promising strategies, however, have been used primarily to respond to geographically constrained STI outbreaks, when what is needed is the broad uptake and consistent implementation of STI screening, diagnosis, and therapy nationally (Bernstein et al., 2016). The gaps and needs outlined in this section warrant consideration as priorities in educating and developing the future STI workforce.
As outlined above, the STI workforce comprises many disciplines and also includes actors that have traditionally not been recognized as having an important role in STI prevention, such as community and faith leaders, parents, and educators. This section, however, focuses on professionals who directly interact with patients and clients as care or prevention providers and discusses existing and needed resources for STI workforce education and development.
Medical and Nursing School Curricula
Training for health care professionals starts in dedicated institutions, including schools for medicine, nursing, and PAs. While some schools include sexual health curricula, the presence and extent of these curricula are uneven. Given the importance of sexual health promotion and STI/HIV prevention for the general well-being of the populace and the frequency with which primary care practitioners interact with adolescents, young adults, and their parents and other individuals at increased risk of STI acquisition, a greater emphasis on sexual health is imperative, even though it is understood that curriculum development has many competing priorities. At a minimum, program graduates need to have a basic understanding of the premises of sexual health as laid out in this report, which would include a general understanding of STI/HIV epidemiology and surveillance in the United States.
In addition, these graduates need to have the skills to perform a basic sexual health assessment (sexual histories based on the “Five Ps;”3 see Chapter 10 for more information), provide STI prevention counseling, perform appropriate screening, including standard chlamydia/gonorrhea screening for sexually active women under the age of 25, and provide treatment as indicated based on the CDC guidelines. They also need to be aware of additional STI prevention resources, including STI specialty clinics and training programs.
Given that including pharmacists as collaborative partners in the health care workforce is one promising way to improve STI prevention and control, expanding their scope of practice warrants consideration in training curricula. Colleges and schools of pharmacy are required by their accrediting bodies to provide doctoral students with the knowledge and instruction necessary to perform and interpret various clinical laboratory tests (Gronowski et al., 2016). A certificate program trains on the appropriate use of CLIA-waived tests, including for STIs, and specimen collection, test performance, and interpretation for managing a CLIA-waived laboratory (Herbin et al., 2020).
Defining a set of competencies for schools of medical education and a corresponding minimum sexual health curriculum for primary care providers, including physicians, nurses, and PAs, that goes beyond the current status quo, as well as developing mechanisms for implementation and quality control, represent missing pieces of the current national STI strategy (STI-NSP). To this end, a comprehensive review of the current state of sexual health education in schools of medicine and nursing can inform curriculum revisions that reflect modern sexual health principles and strengthen the role of primary care providers as agents in STI prevention and sources of sexual health information.
STI Specialty Clinical Training and Basic Research
Certain medical specialties, including infectious diseases, obstetrics/gynecology, and adolescent medicine, have traditionally had a greater focus on sexual health and STI prevention, given their clinical focus on populations more likely to be encountered with or at risk for STIs. Some academic institutions have developed specific STI clinical specialty and research programs with funding from federal and private sources, such as the University of Washington, Johns Hopkins University, The University
of Alabama at Birmingham, Indiana University, the University of North Carolina, Louisiana State University, Washington University, and the University of California, Los Angeles. Over the years, these institutions have trained numerous STI clinical specialists and researchers. These programs have typically partnered with local STI specialty clinics and developed them into clinical centers of excellence for STI specialty training and research. In addition, some STI clinics have undergone a similar development through strong health department leadership, with or without substantial academic support.
These clinics have also played an important role in training the STI workforce, such as those collaborating in the National Network of STD Clinical Prevention Training Centers (NNPTCs), discussed in detail below. In recent years, the NNPTCs have been funded by CDC to support STI fellowship programs for medical doctors in addition to those supported by academic programs mentioned above. Academic development for STI clinicians and researchers is further supported by an annual 3-week intensive course, Principles of STI/HIV Research and Public Health Practice, at the University of Washington (University of Washington Department of Global Health, n.d.).
Fellowship-based STI specialty training programs, particularly in the form of post-graduate fellowships, represent an important strategy to develop a cadre of future STI leaders committed to long-term careers in sexual health promotion and STI prevention and management. Such programs can develop a pipeline for STI experts who combine clinical and epidemiological STI expertise with programmatic and policy STI expertise by supporting applied experiences at sites such as CDC, STI programs at state and local health departments, and STI resource centers.
Schools of Public Health
Schools of public health are crucial to training the nonclinical STI workforce, particularly those who will be working in surveillance and epidemiology. While DIS often receive specific training through their training centers and learn on the job, many have public health degrees or pursue them later. Traditionally, the cadre of STI administrators in local, state, and federal public health agencies have come up through the DIS and STI field staff ranks, and schools of public health have been an important academic resource for these professionals. Despite STIs representing a leading cause of morbidity in the United States (Johnson et al., 2014), however, public health training tends to place little emphasis on STIs.
STI Programs at State and Local Health Departments
All state and a selected group of high-morbidity local health departments and selected territories receive federal STI block grants administered from the CDC STD Division. These funds are largely earmarked for surveillance and epidemiology and to support disease intervention specialist staff that offer partner services to persons with reportable STIs. In addition, the STI programs in these health departments may be involved to a varying degree in workforce development activities, such as coordinating and implementing periodic STI 101 and 201 courses for nurses and other health personnel who work in STI and family planning clinics, federally qualified health centers, corrections, and other clinical sites with high STI morbidity. STI programs also may receive special funding, mostly through CDC, to build capacity for STI specialty care or congenital syphilis prevention in high-morbidity states. Most health departments have developed strong collaborations with their regional STD Clinical PTC to coordinate and help deliver technical assistance and training.
STI Resource Centers
As described in Chapter 12, the committee envisions a community engagement process that involves an interdisciplinary collaboration of public and private stakeholders, including care providers and community leaders, to develop a comprehensive plan for STI prevention and control at the local and community levels. To provide technical support for these endeavors, the committee also envisions forming STI Resource Centers at the state or large jurisdictional levels, composed of STI experts, including epidemiologists, DIS, clinical and behavioral STI specialists with additional support from the regional STD Prevention Training Centers (discussed below). These Centers would combine, expand, and formalize many aspects of current teaching, research, and consultation on STI management and contribute to detailed surveillance. Core funding for these centers would be provided by federal agencies and could be supplemented by other agencies, industry, and other sources. These centers would serve as an important source of guidance for clinicians and public health policy, have strong, CDC-encouraged and -facilitated formal relationships with local health departments, and be expected to carry out teaching and research in dedicated sexual health/STI clinics. They would be a highly visible, readily accessible source of reliable consultation for challenging cases, provide quality uniform teaching of sexual health management skills, and be an important source to generate new knowledge. To encourage developing new expertise and serve regional needs, centers would periodically be competitively funded with explicit requirements for partnerships with local health departments.
STD Clinical Prevention Training Centers
The eight regional PTCs (the NNPTCs) comprise the only program categorically devoted to training the clinical workforce. Funded by CDC since 1979, the PTCs were based on model STI clinics and originally focused on practice-based, hands-on training (Stoner et al., 2019). Especially during the past decade, much of the training has moved from in-person to online delivery, recognizing that many providers lack the time and resources to attend in-person training and that capacity for it was also limited by curtailed funding (Stoner et al., 2019).
The PTCs’ philosophy also changed from a more or less passive approach, accepting anyone who desired training, to a more strategic one, where regional PTCs are reaching out to and collaborating with state STI programs and other stakeholders in developing regional leadership forums that collectively determine priorities for STI capacity building activities (Stoner et al., 2019). This includes quality improvement projects, technical assistance, and local or regional conferences. They have become much more selective in whom to offer hands-on, clinic-based training, focusing on those who are more likely to continue working in STI clinical programs and can be groomed to become local leaders in delivering quality STI clinical services and ongoing STI workforce development. The PTCs remain primary hubs of training resources and expertise that can be leveraged for the national plan on STI prevention and management. They are also uniquely positioned to partner in the STI Resource Centers, especially to assist in developing training curricula for local STI capacity building.
DIS Training Centers
CDC supports the training and work of DIS in a number of major ways. First, block grants to the states from the Division of STD Prevention support hiring and training DIS at the state and local levels (MacDonald et al., 2007). Second, since 1948, CDC has hired and trained public health advisors who have been deployed to state and local health departments to assist STI prevention programs, including DIS field services. In addition, CDC created the Public Health Associate Program in 2007 to train and provide experiential education, including DIS skills, to early career professionals contributing to the public health workforce, who upon graduation may qualify for entry-level positions as public health advisors or be directly hired by state or local health departments (CDC, 2020a). Third, CDC has funded four regional partner services training centers since 1995 (Stoner et al., 2019); these offer a variety of in-person and online courses to the DIS workforce. As of the April 2020 grant cycle, these centers are in California, Colorado, Indiana, and New York. Fourth, in collaboration
with the regional training centers, CDC has supported developing a core training curriculum: Passport to Partner Services. In addition to on-the-job training, new DIS staff is strongly encouraged and often required to complete this curriculum. Launched in 2013, it is a national curriculum composed of a number of online modules supplemented by a traditional classroom component delivered by one of the four regional centers. It is based on the Recommendations for Partner Services Programs for HIV Infection, Syphilis, Gonorrhea and Chlamydial Infection (CDC, 2008).
Despite this array of resources, budget cuts are severely limiting the availability of DIS. For example, public health advisors assigned to health departments decreased by 60 percent from 1993 to 2005 (Meyer et al., 2015), in line with the overall reduction in CDC’s purchasing power (NAPA, 2018, 2019). At the same time, the resurgence of syphilis since the early 2000s has necessitated refocusing DIS attention and limited resources to early syphilis and HIV and shifting away from gonorrhea and chlamydia, with the potential exception of people who are pregnant or living with HIV (MacDonald et al., 2007). The COVID-19 crisis has compounded this problem; DIS, given their broad skills, have been shifted to COVID-19 contact tracing. A silver lining is that current efforts to expand the DIS workforce in the context of the COVID-19 response may be sustained in anticipation of potential future waves of this infection or other infectious disease outbreaks.
Other Training Resources
While not categorically targeting STI clinical or DIS training, a number of training organizations support clinical providers who are strongly allied to STI prevention, including HIV care providers (supported by the AIDS Education and Training Centers, funded by HRSA) and family planning providers (supported by the National Clinical Training Center for Family Planning at the University of Missouri, Kansas City, and the Family Planning National Training Center at the JSI Research and Training Institute—both funded by the Office of Population Affairs). Over the past two decades, the NNPTCs have developed strong ties with these other training centers and collectively formed collaborative platforms, the “3TCs,” and more recently the Federal Training Centers Collaborative, that also includes the 17 organizations intended to provide Capacity Building Assistance for High Impact HIV Prevention, funded by the Division of HIV Prevention at CDC (AIDS Education and Training Center, n.d.; CDC, 2019b).
In combining limited resources from multiple directions, these collaborations are a promising development. They have been mostly informal, however, and relied on local leadership, so they have developed
unevenly, with some regions further along than others. Importantly, their leadership should recognize that the STI workforce is much larger than those working in categorical STI, HIV, or family planning clinics and spans the wide array of primary care providers who, collectively, report a large proportion of STI cases. Some of these providers work in federally qualified health centers or other public clinics that see large numbers of STIs, and they may be receiving STI training services already. A large number of providers, however, is not being reached, and the challenge is to support them in ways that acknowledge that STI care may not be their highest priority and that they have limited time and means to attend specific STI training programs. Formulating a minimum STI skill set for these providers (e.g., taking a sexual history, understanding the basics of prevention, including guidelines for screening and treatment) and developing additional resources created for and marketed to primary care providers are needed to develop these competencies. One such resource, the CME-accredited online National STD Curriculum, developed by the University of Washington STD Prevention Training Center, has proven to be an effective tool in accomplishing these goals (National STD Curriculum, n.d.).
The workforce needs to be a primary pillar of reinforced national efforts to address increasing STI rates in the United States. The existing U.S. STI workforce characterized in this chapter has notable strengths, which can be leveraged for the national response to the increasing STI incidence. Notably, the existing health care infrastructure could draw on roughly 600,000 prescribers in primary care, more than 3.5 million nurses, and hundreds of thousands of BHPs to deliver STI testing, treatment, and clinical prevention services (BLS, 2020). The broad range of distinct competencies in the diverse network of nonclinical actors in STI workforce domains provides multiple leverage points to improve the effectiveness, efficiency, and appropriateness of the STI response system as a whole. This diverse workforce with distinctive competencies is well positioned to deliver comprehensive and effective STI services, given the availability of state-of-the-art biomedical and behavioral interventions for prevention and treatment (Barrow et al., 2020). The committee therefore provides the following conclusion and recommendation.
Conclusion 11-1: The workforce for the prevention and treatment of STIs has not been adequately supported to meet the needs of the nation. Therefore, ownership and accountability for the attainment of national sexual health milestones, including recommended assessment, vaccination, and screening,
needs to be expanded. Beyond STI specialists, inclusion of a variety of practitioners and stakeholders who are traditionally not directly involved in sexual health service delivery is a critical need for addressing the problem of STIs. This includes primary care generalists, behavioral health specialists, nonclinical health and human services professionals and paraprofessionals, sexual health educators, and private-sector innovators, such as pharmacy, urgent care, and telemedicine settings. Nonclinical community settings can also be mobilized for testing, including home-based testing, with referral for treatment and care.
Recommendation 11-1: Sexual health promotion should be operationalized and prioritized in practice guidelines and training curricula for U.S. health professionals. Sexually transmitted infection (STI) prevention and management should be incentivized and facilitated as a focus area of practice for both the clinical workforce and important segments of nonclinical public health and social services professionals. The committee recommends five programmatic priorities for implementing this recommendation:
- Clinical practice guidelines and benchmarks developed by health professional organizations should more heavily emphasize the importance of consistent delivery of recommended sexual health services (e.g., sexual histories, vaccinations, and routine STI screening). Relevant professional organizations include but are not limited to the American Medical Association, the National Medical Association, the American Nurses Association, the National League for Nursing, the Association of Nurse Practitioners, the American Academy of Physician Assistants, the American Academy of Pediatrics, the Society for Adolescent Health and Medicine, the American College of Physicians, the American Academy of Family Physicians, the American College of Obstetrics and Gynecology, the Infectious Diseases Society of America, and the HIV Medicine Association.
- Licensing bodies for primary care generalists (i.e., primary care physicians, nurse practitioners, physician assistants, and nurses) and behavioral health specialists should formulate a minimum sexual health skill set (e.g., taking a sexual history and understanding the basics of STI prevention, being aware of guidelines for STI screening and treatment, and understanding HIV prevention and care) to be reflected in formal training programs and yearly continuing medical education, continuing medical units, and continuing education requirements.
- The Centers for Disease Control and Prevention (CDC) and state and local health departments, in collaboration with STI/HIV expert providers and the regional STI prevention training centers, should serve as a resource of clinical expertise for primary care providers and nonclinical health and social services professionals and paraprofessionals. This should be accomplished through consultation, technical assistance, and continuing education (see also Recommendation 12-5).
- CDC should identify federal and state policy actions that would most effectively expand the available workforce to address STI prevention, screening, and treatment. Policies that identify new reimbursement models and promote the ability of advance practice clinicians, pharmacists, community health workers, and other health care workers to provide STI services should be identified and communicated to state policy makers and to encourage state legislatures to reduce or eliminate the scope of practice barriers.
- The Centers for Medicare & Medicaid Services, the Health Resources and Services Administration, CDC, and other agencies should explore public–private partnerships to address logistical and regulatory barriers to workforce expansion. The use of emerging technologies (e.g., point-of-care STI testing and treatment referrals) and delivery models (e.g., telehealth services, pharmacy-based health care) for sexual health services are two innovative examples that can extend the reach of the STI workforce.
Regarding item 4, eliminating such barriers may also allow for task shifting to ancillary staff for important activities, such as prevention counseling, that are often underused because they do not fit with the time constraints of a busy clinical provider. Regarding item number 5, regulatory barriers may restrict solutions for workforce expansion. These include residual prohibitions in some states in prescribing antibiotics by nonphysician primary care providers, such as PAs and NPs, and restrictions in prescribing for partners who are not actually seen by a clinician. Telemedicine also is restricted by the lack of interstate cross-credentialing for medical providers. See Chapter 12 for more details on public–private partnerships. Meeting the needs of the U.S. STI workforce, as highlighted in this chapter and recommendation, is essential to successfully implement the recommendations in this report.
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