Reaching a ‘New Sexual Health Paradigm’ Means Expanding STI Care


A key aspect of expanding access to and care for sexually transmitted infections (STIs) in the United States is expanding accountability for such care throughout the health system and other community resources, according to an article published online July 6 to Clinical infectious diseases. This expansion and decentralization of care is at the heart of the adoption of the “new paradigm of sexual health” advocated by a National academies report which was released in March.

“STIs represent a significant, long-standing and growing public health challenge,” write Vincent Guilamo-Ramos, PhD, MPH, dean and professor at Duke University School of Nursing and director of the Center for Latino Adolescent and Family Health (CLAFH ) at Duke University, Durham, North Carolina, and colleagues. Yet the limitations of the current STI workforce and limited federal funding and support for STI prevention and care means it will take clinicians of all types from all health care to meet the challenge. , they explain.

“For too long, prevention and treatment of STIs has been seen as the sole responsibility of a small workforce of STI specialists and HIV service providers, ”wrote Guilamo-Ramos and his co-author, Marco Thimm-Kaiser, MPH, research associate at Duke University and epidemiologist at CLAFH, in an email to Medscape Medical News.

“However, the resources allocated to this specialized STI workforce have declined over time, along with declining investment in the broader US public health infrastructure,” they continued. “At the same time, and in part because of this underinvestment, STI rates have skyrocketed, hitting a record high for the sixth consecutive year in 2019.”

These factors led to the National Academies’ report, which recommends moving away from “the traditional disease-focused perspective of STIs in favor of a holistic perspective of sexual health as an integral component of health and well-being. to be in general, ”Guilamo-Ramos and Thimm-Kaiser wrote to Medscape Medical News.

In their article, the authors review the limitations of the STI workforce, the implications of these limitations for the entire healthcare sector, and what STI and HIV specialists will need. as well as regulators to ensure that it is possible to achieve the paradigm shift recommended by the National Academies.

Currently, the biggest limitation is access to care, said Laura Mercer, MD, MBA, clerkship director in Obstetrics and Gynecology and Clinical Assistant Professor of Obstetrics and Gynecology at the College of Medicine at the University of Arizona, in Phoenix, Arizona. Mercer, who was not involved in the National Academies report or its analysis, said Medscape Medical News that it is essential to focus on “sexual health as a central part of routine primary and preventive care” to ensure that it becomes more accessible to patients without the need to seek specialist care.

Guilamo-Ramos and colleagues stress the importance of such a change noting that more than 200 million Americans live in counties without infectious disease physicians. Disparities are greatest in southern states, which account for 40% of all reported STIs. The labor shortage continued to worsen alongside the deterioration of the clinical infrastructure supporting specialist STI services, the authors write.

Hence the need to extend responsibility for care not only to primary care physicians, but also to nurses, pharmacists, physician assistants, nurse practitioners and behavioral health practitioners. This also requires standardizing sexual health services in all health professions.

“Prevention is a critical first step” for this, said Mercer. “This is especially important because we recall that almost half of new sexually transmitted infections occur in adolescents. De-stigmatizing sexual health and sexual health education will also help encourage patients of all ages to ask. and accept the test. “

Additionally, with primary care practitioners handling most STI testing and treatment, subspecialists may focus primarily on complex or refractory cases, she added. Ways to expand care include developing point-of-care STI testing and improving the accuracy of existing tests, she said.

“The aim is to make routine sexual health services accessible in a wide range of settings, such as primary care, pharmacies and community settings, and to draw on a larger workforce to providing sexual health services, ”Guilamo -Ramos and Thimm-Kaiser told Medscape.

Kevin Ault, MD, professor of obstetrics and gynecology 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 integrating sexual health into routine preventive care. He also noted that pharmacists have already become proactive in preventing STIs and may continue to do so.

“Vaccines for hepatitis and human papillomavirus are commonly available at drugstores, ”Ault told Medscape. He was not involved in the article by Guilamo-Ramos and colleagues nor in the original report. “Pharmacists could also fill a gap by administering injectable drugs such as penicillin. States should approve policy changes, but many states have already done so for accelerated partner therapy. “

Guilamo-Ramos and Thimm-Kaiser noted similar barriers that must be removed to expand the delivery of ITS services.

“Unfortunately, too many healthcare providers who are highly qualified and well positioned to deliver sexual health services face regulatory or administrative barriers to practice within 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 new models of decentralized health service delivery that rely on non-physician providers may hold the most promise. “

As more diverse health practitioners assume these roles, identification and HIV specialists can provide expertise in developing training and technical assistance to support generalists, wrote Guilamo-Ramos and Thimm. -Kaiser. They can also help align “clinical education programs, accreditation criteria and practice guidelines with routine sexual health service delivery”.

Guilamo-Ramos and his co-authors offer specific recommendations for professional training, licensing, and practice guidelines to help overcome the “insufficient knowledge, inadequate training, and lack of explicit protocols” that currently hamper delivery. STI services in general medicine establishments.

While the paradigm shift recommended by the national academies is ambitious, it is also necessary, and “none of the recommendations are out of reach,” Guilamo-Ramos and Thimm-Kaiser told Medscape. They highlighted how the COVID-19 pandemic has highlighted the lack of workforce resources and health infrastructure and the great disparities in health care.

“There is momentum towards rebuilding the country’s health and public health system in a more effective and efficient manner,” they said, and many recommendations in the STI report “overlap with priorities for the health system. and public health in the broad sense.

Mercer also thinks the recommendations are realistic, “but only the beginning,” she told Medscape. “Comprehensive sexuality education to expand knowledge on STI prevention and public health campaigns to help de-stigmatize sexual health care in general will remain crucial,” she said.

Sexuality education, expanding access and de-stigmatizing sexual care are particularly important in reaching populations who need it most, especially adolescents and young adults, as well as ethnic, racial, sexual youth. and from gender minorities.

“The importance of a priority population of adolescents and young adults cannot be overstated,” wrote Guilamo-Ramos and Thimm-Kaiser. They noted that people between the ages of 15 and 24 account for half of all STIs each year, but only make up a quarter of the sexually active population. “Targeted efforts for the prevention and treatment of STIs in adolescents and young adults are therefore essential for a successful comprehensive strategy to combat 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 did not disclose any relevant financial relationship. Guilamo-Ramos has received grants and personal honoraria from ViiV Healthcare.

Clin Infect Dis. Published online July 6, 2021. Abstract

Tara Haelle is a Texas-based freelance science journalist who writes on medical research. Find her at @tarahelle.

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