NATIONAL STRATEGIC PLAN TO ADDRESS STIs

To combat the considerable rise in STIs, the U.S. Department of Health and Human Services (HHS) developed a 5-year plan aimed at preventing and treating STIs in America. The purpose of the plan is to provide guidance at the national level to halt the increase in STIs. The plan also recognizes that certain demographics are overly affected by the upward trend in STIs. Although this is a national plan, it emphasizes the importance of individualizing the plan to stakeholder populations and resources (U.S. DHHS, 2019).

Part of the problem noted in several national reports is the lack of a coordinated approach in addressing the prevention and treatment of STIs. Many public health agencies at the local and state levels do not have sufficient resources to address the STI epidemic. The STI National Strategic Plan provides a coordinated framework to address the STI epidemic for government and nongovernment parties at national, state, and local levels (U.S. DHHS, 2020).

Strategic Plan Goals

The STI National Strategic Plan focuses on chlamydia, gonorrhea, syphilis, and HPV. Of the 30 or more STIs, these four carry the greatest rates of morbidity, have the most significant STI burden, and create the highest national health impact. The focus on HPV, gonorrhea, and syphilis also lines up with the World Health Organization’s focus in their 2016–2021 global strategy.

The plan has five main goals to provide all individuals with high-quality STI prevention, screening, and treatment free from stigma and discrimination:

Prevent new STIs
Improve the health of people by reducing adverse outcomes of STIs
Accelerate progress in STI research, technology, and innovation
Reduce STI-related health disparities and health inequities
Achieve integrated, coordinated efforts that address the STI epidemic
(U.S. DHHS, 2019)

The STI National Strategic Plan emphasizes that no one goal is more important or carries a higher priority than the others.

PREVENTING NEW STIs

One goal of the STI National Strategic Plan is to prevent the spread of STIs through primary prevention—that is, prevention of STIs from occurring in susceptible populations. To be effective in high-risk populations, prevention education programs should demonstrate cultural, linguistic, and age sensitivity. Moreover, education should be presented in a manner that reduces stigma associated with STIs and include information on the importance of STI testing in high-risk populations.

REDUCING ADVERSE OUTCOMES OF STIs

Another goal of the STI National Strategic Plan uses secondary and tertiary prevention to stop STIs from developing into STDs and to provide treatment when an STD develops. This goal involves better, earlier, and more widespread screening to identify and treat those with STIs to prevent progression to an STD and halt the potential spread to others. Moreover, having an STI places an individual at risk for HIV.

When individuals present for treatment of an STI, pregnancy testing, or birth control, a discussion of testing for other STIs should take place. Electronic health records with clinical decision support systems can help providers identify at-risk individuals who require further testing or care (U.S. DHHS, 2019).

This goal also calls for education of healthcare providers and the workforce in various settings about STI prevention, screening, diagnosis, and treatment.

ACCELERATING RESEARCH, TECHNOLOGY, AND INNOVATION

A third goal of the STI National Strategic Plan addresses the use of research, technology, and innovation to improve and develop rapid point-of-care diagnostic testing, self-specimen collection, vaccinations, and treatment of STIs as well as fighting antimicrobial resistance and promoting antimicrobial stewardship (HHS, 2019).

THE ADVANTAGE OF RAPID TESTS

To prevent the spread of STIs, it is ideal to diagnose and treat diseases during the patient’s same visit. This immediacy safeguards against patients not returning for a second visit and reduces the time during which patients are infectious, thus decreasing the spread of the infection.

Rapid tests that can be performed in less than 30 minutes are available for syphilis, gonorrhea, chlamydia, HIV, and genital herpes. There are also several syphilis rapid tests that can return results within 15 minutes and can be performed and interpreted by nonlaboratory personnel. One test involves obtaining whole blood via fingerstick and then applying it to the testing device (Fakile et al., 2019).

REDUCING HEALTH DISPARITIES AND INEQUITIES

A fourth goal addresses health disparities and inequities. Some populations do not have access to STI prevention resources, while others face discrimination or social stigmas related to STIs or are more prone to high-risk behaviors. Still other groups may have a mistrust of the medical system. Certain racial, ethnic, sexual, and gender populations also face higher rates of STIs. Other factors that are related to a higher rate of STIs include poverty, a lack of health insurance, and employment issues. Healthcare providers must work to ensure universal access to care in a welcoming, culturally sensitive, and trauma-informed manner.

The STI National Strategic Plan addresses the disproportionate increase in STIs that has affected certain “priority” populations, including adolescents and young adults, men having sex with men, pregnant women, and certain racial and ethnic minorities (U.S. DHHS, 2019).

Adolescents and Young Adults

Adolescents and young adults acquire STIs at disproportionately high rates. While they represent just over 25% of the sexually active, those ages 15–24 years account for half of the 26 million new STIs that occur in the United States each year. Approximately 25% of sexually active adolescent females has an STD (CDC, 2021b, 2020a).

Certain activities prevalent in the adolescent population put them at higher risk for exposure to STIs: new or multiple or anonymous sexual partners, concurrent illicit drug use (especially methamphetamines), MSM, and HIV-positive status (CDC, 2019). Rates of oral and anal sex are also rising among adolescents wishing to avoid pregnancy and the loss of virginity, and these practices may lead to oral, throat, and anorectal STIs/STDs.

Men Who Have Sex with Men

Men who have sex with men accounted for more than half the cases of primary and secondary syphilis in 2018. An elevated STI burden is of concern because it may indicate high risk for HIV infection. The high incidence of infection among MSM may be related to factors such as the number of sex partners, rate of partner exchange, and frequency of condomless sex. Furthermore, experiences of stigma are associated with increased sexual risk behavior among MSM.

PATIENTS WITH NONBINARY GENDER IDENTITIES

Transgender is an umbrella term for persons whose gender identity or expression (masculine, feminine, other) is different from their sex (male, female) at birth. Gender identity refers to one’s internal understanding of one’s own gender or the gender with which a person identifies. Gender expression is a term used to describe people’s outward presentation of their gender.

Gender identity and sexual orientation are different facets of identity. Everyone has a gender identity and a sexual orientation, but a person’s gender does not determine a person’s sexual orientation. Transgender people may identify as heterosexual, homosexual, bisexual, or none of the above.

With transgender patients, it is important to ask questions necessary to assess the pertinent issue but to avoid unrelated probing. For example: “To help assess your health risks, can you tell me about any history you have had with hormone use?”

When providing care to transgender patients, healthcare providers should communicate in a way that promotes respect and makes transgender individuals feel comfortable and welcome:

Avoid the use of gendered titles such as “Sir” or “Ma’am.” Instead of Mr. or Ms., patients may wish to be addressed as Mx. (pronounced with a “ks” or “x” sound at the end).
Ask patients for information such as pronouns, preferred name, and gender identity. Pronouns may include he/his/him, she/hers/her, or a range of options for nonbinary transgender patients, such as they/their/them, ze, sie, hir, co, and ey. Always respect the patient’s pronouns and apologize if the wrong pronouns are used by mistake.
Always ask for clarification about what a patient would like to be called or how the patient would like to be addressed. Apologize if referring to a patient in a way that inadvertently seemed offensive.
Ask patients what terms they use to refer to their anatomy and mirror those terms during the patient interaction. Transgender patients may experience gender dysphoria and may not be comfortable with traditional terms for body parts.
Do not make assumptions about patients’ sexual orientations, gender identities, beliefs, or concerns based on physical characteristics such as clothing, tone of voice, or perceived femininity/masculinity.
Do not ask patients questions about sexual orientation or gender identity that are not material to their care or treatment.

(CDC, 2021r; Ness, 2020)

Pregnant Women

From 2014 to 2108, there was a 185% rate increase in congenital syphilis in pregnant women, leading to stillbirths and infant deaths. When treating a woman for an STD/STI, it is important to know if she could be pregnant. Therefore, a pregnancy test is commonly added to other STD/STI tests for women in their reproductive years.

Racial and Ethnic Minorities

Racial and ethnic minorities may face barriers in accessing healthcare or be uninsured. STIs have a greater impact on certain subgroups of these priority populations, including Black, American Indian/Alaska Native, and Hispanic populations.

Moreover, higher rates of STIs can be seen in the southern and western parts of the United States. The rates of primary, secondary, and congenital syphilis are greatest in the western regions, while chlamydia is highest in the southern region. The rates of gonorrhea are highest in the southern and western regions, while HPV vaccination rates are lowest in the south (U.S. DHHS, 2020).

ACHIEVING COORDINATION OF CARE

A fifth goal of the STI National Strategic Plan relates to providing coordination among various levels of government and across programs to address the STI epidemic to improve quality of care and preventative services. This coordinated approach encourages a sharing of ideas and strategies and promotes collaboration to improve health outcomes. Coordinated care also involves the collection and use of data to monitor and evaluate progress (U.S. DHHS, 2019).