STD Intersectionality
Uploaded by
Miraf MesfinSTD Intersectionality
Uploaded by
Miraf MesfinTHE NATIONAL ACADEMIES PRESS
This PDF is available at http://nap.edu/25955 SHARE
Sexually Transmitted Infections: Adopting a Sexual Health
Paradigm (2021)
DETAILS
750 pages | 6 x 9 | PAPERBACK
ISBN 978-0-309-68395-1 | DOI 10.17226/25955
CONTRIBUTORS
GET THIS BOOK Sten H. Vermund, Amy B. Geller, 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; National Academies of Sciences, Engineering, and Medicine
FIND RELATED TITLES
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.
Visit the National Academies Press at NAP.edu and login or register to get:
– Access to free PDF downloads of thousands of scientific reports
– 10% off the price of print titles
– Email or social media notifications of new titles related to your interests
– Special offers and discounts
Distribution, posting, or copying of this PDF is strictly prohibited without written permission of the National Academies Press.
(Request Permission) Unless otherwise indicated, all materials in this PDF are copyrighted by the National Academy of Sciences.
Copyright © National Academy of Sciences. All rights reserved.
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
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001
This activity was supported by a contract between the National Academy of
Sciences and the Centers for Disease Control and Prevention through the National
Association of County and City Health Officials (#2019-011503). Any opinions,
findings, conclusions, or recommendations expressed in this publication do not
necessarily reflect the views of any organization or agency that provided support
for the project.
International Standard Book Number-13: 978-0-309-68395-1
International Standard Book Number-10: 0-309-68395-5
Digital Object Identifier: https://doi.org/10.17226/25955
Library of Congress Control Number: 2021935093
Additional copies of this publication are available from the National Academies
Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or
(202) 334-3313; http://www.nap.edu.
Copyright 2021 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
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.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
The National Academy of Sciences was established in 1863 by an Act of
Congress, signed by President Lincoln, as a private, nongovernmental institution
to advise the nation on issues related to science and technology. Members are
elected by their peers for outstanding contributions to research. Dr. Marcia
McNutt is president.
The National Academy of Engineering was established in 1964 under the charter
of the National Academy of Sciences to bring the practices of engineering to
advising the nation. Members are elected by their peers for extraordinary
contributions to engineering. Dr. John L. Anderson is president.
The National Academy of Medicine (formerly the Institute of Medicine) was
established in 1970 under the charter of the National Academy of Sciences to
advise the nation on medical and health issues. Members are elected by their
peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau
is president.
The three Academies work together as the National Academies of Sciences,
Engineering, and Medicine to provide independent, objective analysis and
advice to the nation and conduct other activities to solve complex problems and
inform public policy decisions. The National Academies also encourage education
and research, recognize outstanding contributions to knowledge, and increase
public understanding in matters of science, engineering, and medicine.
Learn more about the National Academies of Sciences, Engineering, and Medicine
at www.nationalacademies.org.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Consensus Study Reports published by the National Academies of Sciences,
Engineering, and Medicine document the evidence-based consensus on the
study’s statement of task by an authoring committee of experts. Reports typically
include findings, conclusions, and recommendations based on information
gathered by the committee and the committee’s deliberations. Each report
has been subjected to a rigorous and independent peer-review process and it
represents the position of the National Academies on the statement of task.
Proceedings published by the National Academies of Sciences, Engineering, and
Medicine chronicle the presentations and discussions at a workshop, symposium,
or other event convened by the National Academies. The statements and opinions
contained in proceedings are those of the participants and are not endorsed by
other participants, the planning committee, or the National Academies.
For information about other products and activities of the National Academies,
please visit www.nationalacademies.org/about/whatwedo.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
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
v
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
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
vi
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Reviewers
This Consensus Study Report was reviewed in draft form by indi-
viduals chosen for their diverse perspectives and technical expertise. The
purpose of this independent review is to provide candid and critical com-
ments 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:
JAMILLE FIELDS ALLSBROOK, Center for American Progress
JOSÉ A. BAUERMEISTER, University of Pennsylvania
GINA M. BROWN, Gilead Sciences, Inc.
RALPH JOSEPH DICLEMENTE, New York University
TAMAR GINOSSAR, University of New Mexico
MATTHEW GOLDEN, University of Washington
CHAQUETTA T. JOHNSON, Louisiana Department of Health
ALLYSHA C. MARAGH-BASS, Duke University
JEANNE MARRAZZO, The University of Alabama at Birmingham
DAVID H. MARTIN, Louisiana State University Health Sciences
Center
INA PARK, University of California, San Francisco
vii
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
viii REVIEWERS
NAVEEN PATIL, Arkansas Department of Health
CUI TAO, The University of Texas Health Science Center
at Houston
JUDITH N. WASSERHEIT, University of Washington
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.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Contents
PREFACE xv
ACKNOWLEDGMENTS xix
ACRONYMS AND ABBREVIATIONS xxi
ABSTRACT xxv
SUMMARY 1
1 ADDRESSING STI EPIDEMICS: INTEGRATING SEXUAL
HEALTH, INTERSECTIONALITY, AND SOCIAL
DETERMINANTS 21
Introduction, 22
Urgency of Addressing STIs, 23
Committee’s Approach, 24
Changes in the STI Landscape in the Past 20 Years, 38
Study Process and Report Overview, 43
Concluding Observations, 47
References, 48
ix
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
x CONTENTS
2 PATTERNS AND DRIVERS OF STIs IN THE
UNITED STATES 53
Introduction, 54
Interpretation of Surveillance Data, 54
Patterns of STIs in the United States, 59
Drivers of STI Outcomes and Inequities, 79
Concluding Observations, 93
References, 94
3 PRIORITY POPULATIONS 113
Introduction, 114
STIs Across the Life Span, 115
Pregnancy and Infancy, 115
Children, 118
Adolescents, 119
Cisgender Heterosexual Adults, 133
Sexual and Gender Diverse Populations, 138
Men Who Have Sex with Men, 138
Transgender and Gender Diverse Adults, 141
Lesbian, Bisexual, and Other Sexual Minority Women, 147
LGBTQ+ Youth, 151
Other Populations That Require Focused Consideration, 157
American Indian/Alaska Native People, 157
People with Military Experience, 165
People with Disabilities, 173
People with Criminal Legal System Involvement, 175
Concluding Observations, 180
References, 181
4 STI ECONOMICS, PUBLIC-SECTOR FINANCING,
AND PROGRAM POLICY 219
Introduction, 219
Role of Government in Prevention and Control of STIs, 221
Overview of Federal Programs, 222
State and Local Efforts, 236
Economic Burden of STIs, 238
Conclusions, 240
References, 241
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
CONTENTS xi
5 INTERSECTION OF HIV AND STIs 247
Introduction, 248
History, 248
Consequences of STIs in People Living with HIV, 260
Important Lessons from the HIV Pandemic, 261
Conclusions, 263
References, 265
6 ROLE OF TECHNOLOGY AND NEW MEDIA IN
PREVENTING AND CONTROLLING STIs 283
Introduction, 284
Technologies, 290
Implementation Considerations: Costs and Feasibility, 317
Implementation Considerations: Ethics and the Rapidly
Changing Environment, 318
Conclusion and Recommendation, 319
Concluding Observations, 322
References, 324
7 BIOMEDICAL TOOLS FOR STI PREVENTION
AND MANAGEMENT 337
Introduction, 338
Tools for STI Diagnosis, 342
Antimicrobial Tools for STI Treatment, 353
Tools for STI Prevention, 365
Conclusions and Recommendation, 382
Concluding Observations, 384
References, 385
8 PSYCHOSOCIAL AND BEHAVIORAL INTERVENTIONS 399
Introduction, 400
Contributions of Psychosocial and Behavioral Interventions
on STI Prevention and Control, 402
Psychosocial and Behavioral Interventions, 405
Individual-Level Interventions, 405
Interpersonal-Level Interventions, 413
Community-Level Interventions, 421
Cost Effectiveness of Psychosocial and Behavioral
Interventions, 428
Technology-Based Interventions, 429
Dissemination of Evidence-Based Behavioral Interventions, 438
Implementation Science, 440
Conclusions and Recommendation, 444
References, 446
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
xii CONTENTS
9 STRUCTURAL INTERVENTIONS 463
Introduction, 464
Structural Interventions to Decrease STIs in Marginalized
U.S. Groups and Reduce STI Inequities, 466
Macro-Level Structural Interventions to Decrease STIs in the
U.S. Population Overall, 471
Meso-Level Structural Interventions to Decrease Overall
STI Rates and STI Inequities, 474
Community Mobilization for Structural Change Related
to STIs and HIV, 477
Conclusions and Recommendation, 487
References, 489
10 PAYING FOR AND STRUCTURING STI SERVICES 497
Introduction, 498
Paying for STI Prevention and Treatment Services, 498
Health Insurance Coverage Requirements, 505
Assessing Systems of Care and Accountability, 511
Clinical STI Services, 515
STI Systems of Care, 527
Conclusions and Recommendation, 535
Concluding Observations, 537
References, 538
11 SUPPORTING AND EXPANDING THE FUTURE
STI WORKFORCE 547
Introduction, 548
Sexual Health and Ethics as an Organizing Framework
for the STI Workforce, 548
Current STI Workforce in the United States, 549
Leveraging Health Care Systems and Practitioners Not
Traditionally Involved in STI Service Delivery, 555
Strengthening the National Public Health Workforce, 560
STI Workforce Gaps and Needs, 563
STI Workforce Education and Development, 564
Conclusion and Recommendation, 570
References, 573
12 PREPARING FOR THE FUTURE OF THE STI RESPONSE 581
Introduction, 582
Review of Recently Published Reports Addressing STI
Prevention in the United States, 583
National Academy of Public Administration STI Reports, 583
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
CONTENTS xiii
Treatment Action Group Gonorrhea, Chlamydia, and Syphilis
Pipeline Report 2019, 585
STI National Strategic Plan for the United States (2021–2025), 587
Charting a Path Forward, 592
Adopt a Sexual Health Paradigm, 593
Broaden Ownership and Accountability for Responding
to STIs, 597
Bolster Existing Systems and Programs for Responding
to STIs, 622
Embrace Innovation and Policy Change to Improve
Sexual Health, 633
Concluding Observations, 640
References, 641
APPENDIXES
A CHARACTERISTICS OF MAJOR STIs IN THE
UNITED STATES 655
B STI SCREENING AND TREATMENT GUIDELINES
ISSUED BY HEALTH PROFESSIONAL SOCIETIES 663
C MEASURING THE IMPACT OF WORRYING ABOUT
STIs ON QUALITY OF LIFE 687
D PUBLIC MEETING AGENDAS 701
E COMMITTEE MEMBER AND STAFF BIOGRAPHIES 711
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Preface
Sexually transmitted infections (STIs), although largely preventable,
are common in the United States, and their incidence rates have been ris-
ing 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 sub-
optimal due to low diagnosis rates and various barriers to care and treat-
ment. 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 question-
ing (LGBTQ+) individuals.
This committee report seeks to highlight and disentangle some of the
complexities of U.S. society, including its patchwork health care financ-
ing 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
xv
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
xvi PREFACE
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 diag-
nostics are not deployed widely. Focusing on sexual risk has proven a lim-
iting 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 ineq-
uities. Since 2006, the working definition of sexual health at the World
Health Organization1 has been
a state of physical, emotional, mental, and social well-being in relation
to sexuality; it is not merely the absence of disease, dysfunction, or
infirmity. Sexual health requires a positive and respectful approach to
sexuality and sexual relationships, as well as the possibility of having
pleasurable and safe sexual experiences, free of coercion, discrimination
and violence. For sexual health to be attained and maintained, the sexual
rights of all persons must be respected, protected and fulfilled.
“Sexual health” is a term referring to the salutary and positive view
of responsible and mutually consensual sex as a part of joy, desired pro-
creation, 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 Hid-
den 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).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PREFACE xvii
consequences of STDs in the United States.” This important report was
influential in mobilizing additional attention toward STIs in the govern-
ment 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 deploy-
ment 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 com-
mitments 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
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Acknowledgments
The committee wishes to thank and acknowledge the many individu-
als and organizations that contributed to the study process and devel-
opment 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 sup-
port 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
xix
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
xx ACKNOWLEDGMENTS
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 discus-
sions: 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, Engi-
neering, 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 mem-
bers’ 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.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Acronyms and Abbreviations
ACA Patient Protection and Affordable Care Act
ACIP Advisory Committee on Immunization Practices
AFAB assigned female at birth
AI/AN American Indian/Alaska Native
AIDS acquired immunodeficiency syndrome
AMAB assigned male at birth
AMR antimicrobial resistance
ART antiretroviral treatment
ASHA American Sexual Health Association
BRFSS Behavioral Risk Factor Surveillance System
C2P Connect to Protect
CDC Centers for Disease Control and Prevention
CHAC Advisory Committee on HIV, Viral Hepatitis, and STD
Prevention and Treatment
CLIA Clinical Laboratory Improvement Amendments
CMS Centers for Medicare & Medicaid Services
DIS disease intervention specialists
DOD Department of Defense
DOJ Department of Justice
DSTDP Division of STD Prevention (CDC)
xxi
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
xxii ACRONYMS AND ABBREVIATIONS
ECHO Evidence for Contraceptive Options and HIV Outcomes
EHE Ending the HIV Epidemic
EPT expedited partner treatment
FDA Food and Drug Administration
HBV hepatitis B virus
HEDIS Healthcare Effectiveness Data and Information Set
HHS Department of Health and Human Services
HIV human immunodeficiency virus
HPV human papillomavirus
HRSA Health Resources and Services Administration
HSV herpes simplex virus
HSV-1 herpes simplex virus type 1
HSV-2 herpes simplex virus type 2
IHS Indian Health Service
IOM Institute of Medicine
IUD intra-uterine contraceptive device
LGBT lesbian, gay, bisexual, and transgender
LGBTQ+ lesbian, gay, bisexual, transgender, and queer (or
questioning) and others
LGV lymphogranuloma venereum
MPT multipurpose prevention technology
MSM men who have sex with men
NAAT nucleic acid amplification test
NACCHO National Association of County and City Health Officials
NAPA National Academy of Public Administration
NCHHSTP National Center for HIV/AIDS, Viral Hepatitis, STD, and
TB Prevention (CDC)
NCSD National Coalition of STD Directors
NHANES National Health and Nutrition Examination Survey
NIAID National Institute of Allergy and Infectious Diseases
NIH National Institutes of Health
OASH Office of the Assistant Secretary for Health
OPA Office of Population Affairs
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ACRONYMS AND ABBREVIATIONS xxiii
PID pelvic inflammatory disease
POC point of care
PrEP pre-exposure prophylaxis
PSA prostate-specific antigen
RPR rapid plasma reagin
SAMHSA Substance Abuse and Mental Health Services
Administration
STD sexually transmitted disease
STI sexually transmitted infection
STI-NSP Sexually Transmitted Infections National Strategic Plan
USPSTF United States Preventive Services Task Force
VA Department of Veterans Affairs
VDRL Venereal Disease Research Laboratory
WASH World Association for Sexual Health
WHO World Health Organization
YRBSS Youth Risk Behavior Surveillance System
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
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):
I. 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)
xxv
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
xxvi ABSTRACT
II. 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)
III. Bolster Existing Systems and Programs for Responding to STIs
4. Modernize core CDC STI activities to strengthen timely monitor-
ing, ensure that treatment guidelines remain current as knowl-
edge evolves, and leverage federal support to increase consis-
tency 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 develop-
ment, 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 seg-
ments of the nonclinical public health and social services profes-
sions. (11-1)
8. Prioritize research in critical areas by developing point-of-care
diagnostic tests to reduce the interval between testing and treat-
ment, 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 vac-
cine 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, inter-
personal, and community levels. (8-1)
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ABSTRACT xxvii
IV. Embrace Innovation and Policy Change to Improve Sexual Health
10. Develop a whole-of-government interagency approach, in part-
nership 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 dif-
ferent 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.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Summary1
Sexual and reproductive health is of critical importance to overall health
and well-being. The prevention and control of sexually transmitted infec-
tions (STIs)—a major component of sexual and reproductive health—how-
ever, has been chronically underfunded, stigmatized, and too frequently
left out of national conversations around health. STIs are among the most
common infections affecting humans and cause significant morbidity and
mortality in the United States and globally. The Centers for Disease Control
and Prevention (CDC) estimates that one in five people in the United States
had an STI on any given day in 2018, totaling nearly 68 million estimated
infections. Furthermore, an estimated 26 million new STIs occurred in 2018,
representing an array of more than 30 viral, bacterial, and protozoal patho-
gens (see Box S-1 for key STI facts and statistics and Figure S-1 for STI rates
over time). Chlamydia, gonorrhea, and syphilis lead the list of reportable
U.S. STI infections; they are all preventable, easily diagnosed, and treatable
with antibiotics.
Although diagnosed STI rates have increased across all populations
in the United States, marginalized groups—youth; women; lesbian, gay,
bisexual, transgender, and queer (LGBTQ+) people; and Black, Latino/a,
American Indian/Alaska Native (AI/AN), and Native Hawaiian/other
Pacific Islander people—continue to experience a disproportionate share
of STI cases in the United States. Given the long-term sequelae, as well as
1 This Summary does not include references. Citations for the discussion presented in the
Summary appear in the subsequent report chapters.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
2 SEXUALLY TRANSMITTED INFECTIONS
BOX S-1
STI Facts and Statistics
• U.S. reported case rates of the three most common reportable STIs (chlamydia,
gonorrhea, and syphilis) have been increasing over the past two decades.
Since 2000, the overall case rate of chlamydia has doubled, gonorrhea has
increased nearly 1.4-fold, and primary and secondary syphilis is up 5-fold.
• Long-term effects of STIs include chronic pelvic pain, infertility, miscarriage or
newborn death, and increased risk of HIV infection, genital and oral cancers,
neurological and rheumatological consequences, and possible death in per-
sons not being screened or whose care is not well managed.
• The rise in reported STIs underestimates the full scope of the STI epidemic
in the United States, in part because many cases can be asymptomatic and
are therefore often undiagnosed and unreported. Asymptomatic individuals
may not know they are infected, yet they can still transmit an infection to their
sexual partners or offspring.
• Congenital syphilis is passed to a fetus with severe and often fatal conse-
quences for newborns. While it is fully preventable with prenatal care, the
number of cases in the United States has increased 2.6-fold from 2013 to 2018.
• Young people aged 15–24 years account for about 25 percent of the sexually
active population, yet they account for about half of all reported STIs annually.
• Gay, bisexual, and other men who have sex with men represent an estimated
2–3 percent of the adolescent/adult population, yet they account for 54 percent
of reported primary and secondary syphilis cases.
• STIs, including HIV, imposed an estimated nearly $16 billion in lifetime direct
medical costs in the United States in 2018.
the direct medical and economic costs resulting from STIs, these condi-
tions merit attention as a greater health priority, yet blame, embarrass-
ment, shame, and stigma mean that STI epidemics are too often hidden
or ignored. In 1997, the Institute of Medicine released a report, The Hidden
Epidemic: Confronting Sexually Transmitted Diseases. Although great scien-
tific advances have been made since then, demonstrating that efforts to
prevent and treat STIs are not futile, 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.
CDC, through the National Association of County and City Health
Officials (NACCHO), asked the National Academies to review the cur-
rent state of STIs in the United States, including the economic burden,
current public health strategies and programs (including STI diagnostics,
vaccines, monitoring and surveillance, and treatment), and barriers in the
health care system, to provide advice on future public health programs,
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Copyright National Academy of Sciences. All rights reserved.
FIGURE S-1 Notifiable sexually transmitted infections—rates of reported cases per 100,000 population (per 100,000 live births for
congenital syphilis), United States, 1999–2018.
3
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
4 SEXUALLY TRANSMITTED INFECTIONS
policy, and research in STI prevention and control. This report follows
three studies commissioned by the National Coalition of STD Directors
in 2018–2019, and the first STI National Strategic Plan that was developed
by the Department of Health and Human Services (HHS) and released
in December 2020. The release of these reports and the synergies among
them presents a timely opportunity to execute the recommendations pro-
vided in this National Academies report.
COMMITTEE’S APPROACH
The committee’s primary emphasis is on addressing the growing
epidemics of chlamydia, gonorrhea, and syphilis, but the framework and
recommendations presented in this report are intended to strengthen the
response to a broad range of STIs. Although HIV is an STI of significant
concern, the committee’s charge precludes it from providing HIV-specific
recommendations (the report sponsors—CDC and NACCHO—asked the
committee to focus its recommendations on STIs other than HIV, given
the alarming increases in rates of STIs). Thus, the committee’s consider-
ation of HIV focused on understanding the interplay between HIV and
other STIs and how current public health programs can integrate and
leverage separate HIV and STI prevention, care, and research programs.
The committee’s conceptual framework is depicted in Figure S-2.
The framework’s core elements emphasize the importance of interrelated
social ecological factors in the varied manifestations of STI pathogens,
social and structural determinants of health and health inequities, inter-
sectionality, and the recognition that sexual health is inextricably linked
to overall health and well-being across the life span. The committee views
human sexuality as a vital element of mutually consensual love and
pleasure, as well as the fundamental prerequisite for procreation. Pre-
vention and control efforts for STIs that are nested within a sexual health
paradigm are more likely to prevent and control STIs than efforts nested
within a risk framework, as the latter are steeped in and proliferate vic-
tim blaming, stigma, marginalization, and discrimination. Therefore, the
committee concludes that biomedical approaches to STI prevention and
control cannot be optimally effective without also addressing root causes
of poor health and STI risk, namely, the structural and social determi-
nants of health, such as poverty, unequal access to quality health care,
stigma, racism, and discrimination. Moreover, successful application of
this framework requires a shift in current siloed funding mechanisms to
an integrated and sustained funding approach that not only addresses
STIs as discrete health outcomes but also addresses interpersonal, com-
munity, institutional, and other societal factors that influence STI risk,
prevention, health care access, delivery, and treatment.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
SUMMARY 5
Structural
SocialCommunity
and Community-
Level Factors
Institutional
Interpersonal Factors
Interpersonal
Individual-
Individual
Level Factors Biological Effect Pathway
Systems and elements impact
across all stages of the life course
These intersecting factors have an impact across all stages of the life span
Pregnancy/In-utero
Preconception Pregnancy
Childhood Childhood
Adolescents/Young Adults Middle Adults
Middle Adults Older Adults/Seniors
Sexual Health and STIs Across the Life Span
FIGURE S-2 Modified Social Ecological Framework of sexual health and sexually
transmitted infection (STI) prevention, control, and treatment.
NOTE: This figure illustrates the multiple interrelated influences on STI risk, pre-
vention, health care access, delivery, and treatment across the life span.
The committee is concluding its work as the nation and the world
continue to grapple with the acute COVID-19 and chronic HIV/AIDS
pandemics. There is a growing challenge of misinformation that is exac-
erbating the decline of trust in public institutions in general, including
public health agencies. Adhering to public health guidance has life-or-
death implications, whether for prevention of COVID-19, HIV, congeni-
tal syphilis, or other STIs with potentially lifelong consequences. The
burden of responding to the COVID-19 pandemic has been felt heavily
by STI programs. Under-resourced STI programs have had to compete
for resources with a major new public health threat, and their staff have
been diverted to the COVID-19 response. This has translated into less
attention to STI services and fewer critical services being delivered. The
nation pays an increasing price for neglecting to fund public health and
thereby neglecting STIs or placing them in funding competition with
other urgent infectious diseases control priorities. The COVID-19 pan-
demic has exposed weaknesses in public health preparedness due to weak
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
6 SEXUALLY TRANSMITTED INFECTIONS
infrastructure, an under-capacitated and under-resourced workforce,
and limited surge capacity. Because STIs are infectious diseases that also
require testing, treatment, and partner notification, and the STI workforce
has deep expertise of relevance to pandemic responses, strengthening
STI infrastructure and expanding its workforce offers the dual benefits of
achieving stronger STI control and better positioning the nation for future
public health threats.
The largest federal source of funding to respond to STIs is appropri-
ated to CDC’s Division of STD Prevention (DSTDP). DSTDP’s funding
over the past two decades has remained flat (with a 40 percent reduction
in inflation-adjusted dollars). Although the committee’s charge did not
specifically ask it to make recommendations related to funding levels and
other necessary resource allocations for STIs, the committee notes that
some of the recommendations will require new or substantial realign-
ment of resources to implement and the authority and political support
to modify existing systems and policies. Furthermore, because the com-
mittee’s primary focus was on providing clear policy guidance and a
framework for action, it does not uniformly offer specific implementation
steps or metrics for each recommendation. The committee understands
that resources, policies, and stakeholders vary across the country and that
additional voices, including public stakeholders and STI program staff at
all levels of government, will be needed to guide implementation of the
committee’s recommendations.
The committee has organized its recommendations under four action
areas:
1. Adopt a sexual health paradigm.
2. Broaden ownership and accountability for responding to STIs.
3. Bolster existing systems and programs for responding to STIs.
4. Embrace innovation and policy changes to improve sexual health.
1. ADOPT A SEXUAL HEALTH PARADIGM2
Integrating Sexual Health as a Key Dimension of Healthy Living
The nation’s response to STIs has mostly focused on individual
risk factors and individual behavior change, and has failed to address
structural and social elements that foster infection and disease. Since the
beginning of the 20th century, approaches focusing on infectious disease
sequelae have tended to fuel stigma and shame and therefore have not
2 Note that recommendations are not presented in numerical order, as the Summary has
grouped them by topic; however, all report recommendations are presented.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
SUMMARY 7
been successful in fully addressing STI prevention and control. A holistic
approach that focuses on sexual health in the context of broader health
and well-being is needed. To carry out this change, significant work is
needed to eradicate stigma and educate the U.S. population on what it
means to be sexually healthy and where and how individuals can access
comprehensive sexual health services.
The committee acknowledges that the United States is a diverse coun-
try of almost 330 million people, and how one operationalizes a sexual
health paradigm will inevitably vary. This paradigm shift is needed, how-
ever, given the history of how marginalization has contributed to the
proliferation of STIs. Society is paying a cost for this marginalization, and
significantly shifting the cultural environment to be supportive of a sexual
health framework will take significant dedication and investment and the
strategic actions outlined in this report (for more on this topic, see Chapter
12). The committee does not view this as a political issue or one that needs
to be in conflict with religious beliefs or ethical standards. For example,
promoting sexual health in a manner that facilitates STI prevention, diag-
nosis, and treatment does not constrain faith communities from discuss-
ing sexual responsibility and sexual health in a way that is consistent with
their own faith traditions and ethical frameworks. The committee holds
an inclusive vision of respect and appreciation for diversity in religious
belief, culture, gender, and sexual orientation.
The clinical focus in the current health system emphasizes the harmful
effects of STIs on women and newborns without adequately addressing
the health of others, including sexual and gender minority and non-binary
or gender-expansive individuals. The committee notes, in particular, the
striking negligence toward promoting the health of men, including their
roles in transmitting STIs. Too often, public policies have failed to encour-
age men to consider their own health-seeking behaviors, in terms of both
shaping a conception of what sexual health means for them and offering
clear guidance for when and how men should access health services.
Recommendation 12-1: The Department of Health and Human Ser-
vices (HHS) should develop a vision and blueprint for sexual health
and well-being that can guide the incorporation of a sexual health
paradigm across all HHS programs, including the major public
insurance programs (Medicaid, Medicare, and the Children’s Health
Insurance Program), as well as the public health programs operated
throughout the department, including the Centers for Disease Con-
trol and Prevention, the Health Resources and Services Administra-
tion, the Indian Health Service, and the Substance Abuse and Men-
tal Health Services Administration. The plan should align sexual
health and well-being with other dimensions of health—physical,
mental, and emotional.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
8 SEXUALLY TRANSMITTED INFECTIONS
• A holistic approach to sexual health programs should include
new approaches and strategies for specifically engaging men
(including men who have sex with men) with readily available
male-centered sexual health specialty services and the imple-
mentation of sexual and reproductive health services in primary
care.
• The plan should include strategies for improving sexual health
services that address the needs of priority populations, such
as women, adolescents, and young adults, and expand atten-
tion and resources to underserved populations including Black,
Latino/a, and Indigenous populations; people who use drugs;
people who engage in sex work; transgender; and gender-
expansive populations.
HHS has an important role in catalyzing the shift the committee rec-
ommends, but it is imperative that other partners and leaders within the
federal government, health systems, and society help to adopt and imple-
ment these changes. The vision and action plan should include a course
of action for individuals, health care providers, and community members
to promote positive sexual health over the life span by giving individuals
more agency over their personal preferences and choices, acknowledging
the role of culture in influencing these choices, and highlighting structural
inequities and barriers to optimal health. Reorienting popular conceptions
of well-being to include sexual health is the overarching framework for
all recommendations in this report and establishes a new foundation for
successful STI prevention and control.
2. BROADEN OWNERSHIP AND
ACCOUNTABILITY FOR RESPONDING TO STIs
Better Support for Parents and Guardians to Model Sexual Health
Although maturing children learn information about sexual health in
many ways (including via social media), parents and guardians (hereafter
“parents”) play a central role in supporting adolescent and young adult
sexual and reproductive health and STI prevention. The committee recog-
nizes that not all young people can rely on understanding parents to offer
this guidance, and having supporting parents does not negate the need
to create additional sources to complement or substitute for supportive
parents. Nonetheless, to fully leverage their role, parents need evidence-
based guidance on effective parenting strategies for sexual health promo-
tion and STI prevention.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
SUMMARY 9
Recommendation 12-2: Federal agencies and relevant professional
organizations should equip parents with evidence-based guid-
ance to engage in developmentally appropriate, comprehensive
sexual health education and dialogue and to identify actionable
steps for their children. Specifically, the committee recommends
the following:
• The Department of Health and Human Services (HHS), through
the Centers for Disease Control and Prevention (CDC) Division
of STD Prevention, CDC Division of Adolescent Health and
School Health, the Indian Health Service, and other key pub-
lic health service agencies, should develop a national, parent-
focused communication campaign to promote and guide paren-
tal communication with adolescents regarding sexual health
and sexually transmitted infection (STI) prevention.
• HHS, including CDC, the Health Resources and Services
Administration, and the National Institutes of Health, should
develop a compendium of existing evidence-based resources
and programs for parental education and skills training on ado-
lescent and young adult sexual health and STI prevention. In
addition, there should be continued research investments to
improve existing, and to develop new, evidence-based resources
and programs.
• Guidelines should be developed for pediatric and adolescent
health care to support skills training and educate parents in
promoting adolescent and young adult sexual health, including
the prevention of STIs. This would include the following:
o Delivering evidence-based programs for parental educa-
tion and skills training that are colocated as an extension
of regular care, and
o Providing training resources for providers that facilitate
direct communication with parents regarding sexual health
and STI prevention in their children.
Engage Community Stakeholders to Create
Opportunities for Dialogue About Sexual Health
A limitation of the historical response to STI prevention and control
is that community stakeholders (e.g., families, schools and educators,
faith-based organizations, and workplaces) lack the resources and capac-
ity to engage in sexual health dialogue to improve STI outcomes. Thus,
the committee concludes that elevating the promotion of sexual health in
partnership with community stakeholders could create a fruitful avenue
for improving STI outcomes. Nonetheless, more direction and support
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
10 SEXUALLY TRANSMITTED INFECTIONS
are needed to empower communities to engage in such dialogue and to
provide resources for tailoring messages and information to be appropri-
ate for communities’ specific contexts, needs, and priorities.
Recommendation 12-3: The Centers for Disease Control and Pre-
vention Division of STD Prevention should take steps to expand
community knowledge of sexual health and promote actions that
lead to a greater understanding of healthy sexuality by encouraging
and supporting public dialogue and the adoption of evidence-based
interventions in various community settings (families, schools, faith
communities, community-based organizations, and workplaces).
3. BOLSTER EXISTING SYSTEMS AND
PROGRAMS FOR RESPONDING TO STIs
Enhance Federal Leadership and Support
DSTDP provides critical leadership in guiding the nation’s federal STI
response. The committee supports maintaining and enhancing this role,
including encouraging DSTDP to be more assertive and, in some cases,
more prescriptive in its grants to states and local jurisdictions to establish
minimum national standards of data reporting and STI care. Furthermore,
STI professionals, especially within state and local health departments,
have critical knowledge and expertise that need to be the foundation
of any efforts to improve the national response to STI prevention and
control. For CDC and states to effectively prevent and control STIs, accu-
rate STI surveillance is essential for understanding the epidemiology of
reportable STIs. The surveillance data, however, are difficult to interpret
because they rely on case reporting, which is ecologic, and periodic popu-
lation-based studies are too small for meaningful subpopulation analyses.
Recommendation 12-4: The Centers for Disease Control and Preven-
tion (CDC) should modernize its core sexually transmitted infection
(STI) activities to strengthen the timely monitoring of STIs with
less reliance on estimated rates based on case reports, to inform
proper treatment of persons with STIs, and to increase consistency
and accountability across jurisdictions. The committee recommends
a three-pronged approach:
1. Modernize surveillance activities to enable more rapid release
of data:
• Automate case reporting of reportable STIs.
• Release a preliminary STD Surveillance Report within 6 months
of the reporting period, with a revised report later in the year.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
SUMMARY 11
• Explore the use of new data sources to capture STI incidence (crit-
ically, both cases and numbers tested), such as electronic medi-
cal records, commercial databases, health information exchanges,
clinical and pharmacy data, social media/online searches, and
artificial intelligence, and invest in better data integration efforts
within the National Center for HIV/AIDS, Viral Hepatitis, STD,
and TB Prevention (NCHHSTP).
• Develop a publicly available STI dashboard to raise public aware-
ness and accountability.
2. Improve timeliness of the STI treatment guidelines:
• The CDC STI treatment guidelines should be updated and dis-
seminated annually, and more frequently if necessary, to bet-
ter address real-time changes to the STI epidemic and emerg-
ing treatments and technologies. The entirety of the guidelines
should undergo comprehensive reviews no less frequently than
every 5 years.
3. Increase accountability and establish new funding requirements:
• CDC should engage in a data standardization partnership across
NCHHSTP and with grantees to develop and publish a core set of
STI indicators with standardized definitions of terms. To promote
the use of these standardized data, CDC should set a condition
of awards for its funding programs to require that every grantee
report surveillance and other data to CDC consistent with these
new data standards.
• CDC should also make a condition of awards the requirement
that states engage in a broad and meaningful stakeholder engage-
ment process. This should include representatives of local health
departments, heavily affected communities, health insurance
programs and exchanges, federally qualified and other health
centers, Ryan White HIV/AIDS Program recipients, Substance
Abuse and Mental Health Services Administration recipients, and
others to develop a multi-year state or major municipalities STI
prevention and control plan that
o leverages disparate assets within the state or major munici-
palities for establishing STI prevention and care priorities,
aligning STI and HIV priorities;
o establishes benchmarks; and
o creates a process for monitoring and reporting on progress
toward achieving established benchmarks.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
12 SEXUALLY TRANSMITTED INFECTIONS
The committee recognizes the large differences in staff capacity across
health departments and other impediments to rapid integration of report-
ing standards. Therefore, the proposed partnership should consider the
current starting point and recommend phased implementation (if needed)
to account for current serious limitations in the capacity to carry out sur-
veillance and monitoring efforts at the state or local levels. Furthermore,
the committee is not recommending a specific model for stakeholder
engagement. HIV programs have long experience with HIV prevention
community planning, as well as Ryan White services planning. DSTDP
may consider ways to integrate STI consultation and resource allocation
processes within these existing mechanisms or may determine that such
an approach is inappropriate or not the best model, as critical STI stake-
holders not involved in HIV planning processes would be excluded (see
Chapter 12 for additional discussion).
Strengthen Local Efforts to Plan and Coordinate the STI Response
To ensure the delivery of comprehensive sexual health services, local
jurisdictions need to conduct, and be held accountable for, a broad and
meaningful stakeholder engagement process to identify the range of avail-
able community assets to support the STI response and establish preven-
tion and care priorities for their jurisdictions based on needs assessments.
Working in tandem with the preceding recommendation for CDC to require
statewide STI prevention and control plans, the committee recommends:
Recommendation 12-5: The Centers for Disease Control and Preven-
tion (CDC) should encourage local health departments to develop
and implement comprehensive plans for sexually transmitted infec-
tion (STI) prevention and control. This should be done by fund-
ing key partners, such as the National Association of County and
City Health Officials (NACCHO) and the National Coalition of
STD Directors (NCSD), to develop resources and provide technical
assistance to state and local health departments on how to conduct
a meaningful stakeholder consultation process, how to develop
a plan that offers strategic support for improving STI outcomes
leveraging all available community assets, and how to monitor
implementation and keep the public informed of progress toward
achieving the plan’s objectives. The plans should do the following:
• Include community-wide needs assessments, oversampling
high-priority populations, that determine the adequacy of avail-
able sexual health services in their jurisdictions and explore the
creation of new, improved, and easier access points for sexual
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
SUMMARY 13
health promotion in a stigma-free environment, including STI
screening and treatment services that take advantage of current
rapid and self-testing technologies.
• Identify mechanisms to meet the needs of underserved and
highly impacted populations.
• Establish formalized, funded relationships with trusted com-
munity-based organizations to deliver critical STI prevention
and care services.
CDC, in collaboration with the National Network of STD Preven-
tion Training Centers, NACCHO, and NCSD, should develop STI
Resource Centers (SRCs) for clinical consultation, workforce devel-
opment, and technical assistance to support the planning process
and provide consultation to individual clinical STI providers. At
a minimum, these SRCs should be operational at the level of state
and large municipal jurisdictions.
Establish New Payment and Coverage Options to
Close Gaps in Access to STI Coverage and Services
Effective public health efforts to control the transmission of infectious
diseases benefit the whole population, yet many people are not reached
by the current fragmented health care system. Many individuals experi-
ence financial barriers to STI screening and treatment services because of
their insurance status, immigration status, and/or ability to afford copay-
ments or coinsurance for treatment and services.
Recommendation 10-1: The Department of Health and Human Ser-
vices and state governments should identify and support innova-
tive programs to ensure that sexually transmitted infection (STI)
prevention and treatment services are available through multiple
venues and ensure that federal and state governments maximize
access opportunities for individuals who face health care access
barriers. Priority populations for these efforts should include per-
sons ineligible for coverage, persons who face affordability bar-
riers (including high out-of-pocket costs), and persons who will
not access STI services without confidentiality guarantees (such
as adolescents and young adults with insurance coverage through
parents or guardians).
Approaches to be explored include special Medicaid initiatives, such
as incentives to expand Medicaid or other options to fill coverage gaps,
state plan amendments and waivers, the establishment of a federally
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
14 SEXUALLY TRANSMITTED INFECTIONS
supported supplemental grant program to provide STI testing and treat-
ment at no cost through various safety net programs, promulgation of
new 340B Drug Pricing Program guidance to expand coverage for STI
services (including for population-based expedited partner therapy and
HIV PrEP services), and funding initiatives to support comprehensive
sexual health clinics and new access points for sexual health services.
Support and Expand the STI Workforce
The workforce for STI prevention and treatment has not been ade-
quately supported to meet the needs of the nation. Beyond STI special-
ists, the existing clinical health care workforce includes a large subset of
practitioners and stakeholders who are traditionally not involved directly
in sexual health service delivery.
Recommendation 11-1: Sexual health promotion should be opera-
tionalized and prioritized in practice guidelines and training cur-
ricula for U.S. health professionals. Sexually transmitted infection
(STI) prevention and management should be incentivized and facil-
itated 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 pri-
orities for implementing this recommendation:
1. Clinical practice guidelines and benchmarks developed by
health professional organizations should more heavily empha-
size 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 Associa-
tion, 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 Phy-
sicians, the American Academy of Family Physicians, the Amer-
ican College of Obstetrics and Gynecology, the Infectious Dis-
eases Society of America, and the HIV Medicine Association.
2. 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
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
SUMMARY 15
of guidelines for STI screening and treatment, and understand-
ing HIV prevention and care) to be reflected in formal training
programs and yearly continuing medical education, continuing
medical units, and continuing education requirements.
3. 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 pri-
mary care providers and nonclinical health and social services
professionals and paraprofessionals. This should be accom-
plished through consultation, technical assistance, and continu-
ing education (see also Recommendation 12-5).
4. 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.
5. The Centers for Medicare & Medicaid Services, the Health
Resources and Services Administration, CDC, and other agen-
cies 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.
Accelerate Research and Development for Biomedical Interventions
Recent scientific advances provide the means for improving STI diag-
nosis, but they are currently underused. Continuing evolution of antimi-
crobial resistance has threatened the continued efficacy and ease of STI
treatment, especially for Neisseria gonorrhoeae. In addition, the pipeline
for developing both new antimicrobials and vaccines for STI prevention
has been constrained by an unfavorable business case that suggests the
need for public engagement of the private sector, as has been done with
HIV/AIDS and COVID-19. In the absence of ready access to reliable diag-
nostic tests, syndromic diagnosis for persons with genitourinary symp-
toms remains common, but it is imprecise, fails to address the frequent
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
16 SEXUALLY TRANSMITTED INFECTIONS
occurrence of unrecognized infection, and is contrary to principles of
good antimicrobial stewardship.
Recommendation 7-1: To improve the efficacy and reach of tools for
sexually transmitted infection (STI) management and prevention,
the National Institutes of Health should prioritize development
of point-of-care (POC) diagnostic tests; development of diagnostic
tests for active syphilis; promotion of public–private partnerships
(PPPs) to develop new antimicrobials; and expedited development
of vaccines. Specifically:
• POC diagnostics: Prioritize development of POC diagnostic tests
to reduce the interval between testing and treatment. Use of these
POC tests should be promoted to reduce opportunities for trans-
mission. Optimally, POC tests should be inexpensive, rapid, and
receive a Clinical Laboratory Improvement Amendments waiver
to permit increased testing at sites providing health care or at
home.
• New diagnostics for syphilis: Promote development of new,
innovative diagnostic tests for active syphilis that distinguish
untreated, active syphilis from previously treated infection, which
is required to effectively control syphilis.
• Antimicrobials and vaccines for STI treatment and prevention:
Subsidize and encourage PPPs with the goals of developing new,
readily accessible antimicrobials for STI treatment and expediting
development of vaccines for prevention of high-priority STIs such
as chlamydia, gonorrhea, syphilis, and herpes.
Deploy Psychosocial and Behavioral
Interventions for Sexual Health
Psychosocial and behavioral interventions to promote sexual health
and prevent STIs are underused and have not been adopted and sustained
in clinical or community practice. These interventions, in conjunction
with biomedical, structural, informatics/technological, and health service
interventions, are integral to a comprehensive strategy for sexual health
and STI prevention and control. In addition, comprehensive sexual health
education taught in schools is effective in delaying the initiation of sexual
behavior, promoting sexual health, and reducing risk for STIs in students.
School-based sexual health education programs across the United States
are highly variable, with no nationwide policy on the subject. Community
intervention strategies also can promote sexual health and prevent STIs,
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
SUMMARY 17
including in racial and ethnic minorities and marginalized groups who
live and socialize in high-STI-prevalence, low-resourced communities.
Such approaches require sustained funding, however, and other support-
ive resources for them to be effective.
Recommendation 8-1: The Department of Health and Human Ser-
vices (HHS) should take steps to expand the reach of psychosocial
and behavioral interventions to prevent and control sexually trans-
mitted infections at the individual, interpersonal, and community
level. This can be accomplished by developing sustainable funding
mechanisms to deliver those interventions; establishing standard
guidelines for school-based comprehensive sexual health educa-
tion; and developing, evaluating, and disseminating community-
based approaches:
1. HHS should develop new mechanisms that provide sustain-
able funding for dissemination, adoption, and scale up of evi-
dence-based psychosocial and behavioral interventions by a
wide range of stakeholders, including community-based orga-
nizations, parent–teacher associations, workplaces, faith-based
organizations, and pediatric and primary care practices.
2. The Centers for Disease Control and Prevention (CDC) Divi-
sion of Adolescent and School Health should work in partner-
ship with parents and guardians, parent–teacher associations,
states, districts, and local school boards to establish standard
evidence-based guidelines for school-based comprehensive
sexual health education that is grounded in psychosocial and
behavioral theories and research. To ensure that each student
receives medically accurate, age-appropriate, and culturally
inclusive comprehensive sexual health education in elemen-
tary, middle, and high school, dedicated staff, including school-
based nurses and health educators, should be trained, provided
adequate time, and given necessary resources.
3. CDC, in collaboration with state and local departments of
health, should develop and evaluate the efficacy of promising
community-based approaches that are grounded in psychoso-
cial and behavioral research, extend reach into affected com-
munities, foster ongoing collaboration with community stake-
holders for capacity building and sustainability, and provide
allocation of sustained dedicated resources for formative work,
intervention implementation, evaluation, replication, and scale
up of evidence-based interventions.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
18 SEXUALLY TRANSMITTED INFECTIONS
4. EMBRACE INNOVATION AND POLICY
CHANGES TO IMPROVE SEXUAL HEALTH
Address Structural Inequities, Including Structural
Racism, That Hinder STI Prevention and Control
Structural inequities related to sexual orientation, gender identity,
race and ethnicity, and national origin, among others, are pervasive,
increase STI risk, perpetuate stigma, and undermine access to STI pre-
vention and treatment among marginalized populations. Very few struc-
tural interventions that address STIs, including the effect of intermediary
social determinants of health influenced by structural racism and other
health inequities, have been developed. Examining and addressing the
structural determinants of STIs and STI inequities will require bold vision.
This vision needs to be bolstered by a long-term commitment with multi-
disciplinary, intersectoral, and interagency collaboration and supported
through dedicated cross-agency funding from the National Institutes of
Health, CDC, Health Resources and Services Administration, and private
foundations and funders. This will demand steadfast political will at all
levels of government and sustained community engagement and mobi-
lization. Due to their focus on addressing the root causes of poor health
and their downstream social determinants, these efforts stand to have the
greatest impact on preventing STIs and STI inequities in the United States.
Recommendation 9-1: The Secretary of Health and Human Services
(HHS) should acknowledge structural racism and other forms of
structural inequities as root causes of sexually transmitted infec-
tion (STI) outcomes and inequities and as threats to sexual health.
HHS should lead a whole-of-government response that engages all
relevant federal departments and agencies to develop a coordinated
approach to reduce negative STI outcomes and address inequities
in the U.S. population by promoting sexual health and eliminating
structural inequities that are barriers to STI prevention, testing, and
treatment among marginalized groups.
In mounting this response, the Secretary should:
• consult broadly with affected communities and critical stake-
holders to conduct a national landscape analysis that assesses
social and structural barriers that prevent access to STI services.
The focus should be on identifying communities with high
morbidity and limited access to affordable and desirable STI
prevention and care services and resources in order to develop
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
SUMMARY 19
a national holistic plan for ongoing monitoring of the national
STI infrastructure and STI burden, including interrelated struc-
tural and social determinants of health inequities;
• establish a priority research agenda, including a data-collection
strategy that organizes data on STI outcomes and their struc-
tural and social determinants among marginalized populations;
• strengthen partnerships with, funding for, and technical assis-
tance to state and local health departments and community-
based organizations;
• foster greater collaboration across health and human services
agencies; and
• report regularly to the public on progress for addressing STI
outcomes and inequities.
Harness Technological Innovation to
Improve STI Prevention and Control
To keep pace with the rapid advancements in technology and its
effects on sexual health, it is essential that the field of public health imple-
ments policy based on three important considerations: (1) social media
and mobile-app-based technological innovations have been primarily
created by industry, and industry experts and companies needed to be
included in the public health response to STIs; (2) tools based on artificial
intelligence (AI) will become increasingly better at targeting individuals
and changing their behaviors; and (3) the ethical considerations around
technological tools are evolving faster than policies that can address issues
of concern. Public health agencies need to frequently and regularly evalu-
ate new tools and public views about them to determine the best course
of action for the changing ethical landscape.
The question of whether new technologies pose STI transmission risk
is no longer relevant, given that they are nearly ubiquitous and impos-
sible to prevent. Instead, the relevant questions are how, why, when, and
where these technologies increase risk; how, when, and where they can be
leveraged to promote sexual health; and how public health can integrate
this knowledge into daily STI prevention and control efforts to ensure safe
and ethical oversight (see Chapter 6 for a discussion of implementation,
cost, and feasibility considerations).
Recommendation 6-1: The Centers for Disease Control and Pre-
vention (CDC) should expand its capacity to use technology for
sexually transmitted infection (STI) prevention and control. To
accomplish this, CDC should recruit seasoned individuals from
the private and public sectors with experience in digital behavior
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
20 SEXUALLY TRANSMITTED INFECTIONS
change and team science to work collaboratively with agency public
health and marketing staff. It should develop timely and open data
systems and deploy artificial intelligence–based mass marketing
strategies to advance STI prevention.
Achieving this recommendation would entail that CDC undertake
regular dialogue with leading industry and nonprofit experts, along with
STI providers and community representatives; assess its STI data manage-
ment capacity; and partner with state and local health departments to use
highly targeted AI-based digital mass communication strategies to better
address STIs.
CONCLUSION
Despite the dedicated commitment of many individuals and agencies,
STI research, policy, and services continue to suffer from neglect. Rela-
tively flat federal investments and declining state and local investments
in the face of all-time high numbers of reported cases of STIs underscore
the failure of the STI crisis to capture the attention of the public and policy
makers. The committee’s exploration of the complexities of the challenge,
however, has instilled in its members a firm belief that it is possible to cre-
ate a different and better future where fewer people are infected, fewer
babies are born with STIs, and people entering adolescence and continu-
ing 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 are challenging, yet it is pos-
sible to reduce the impact of STIs on society and take the bold actions
recommended in this report to prevent and control STIs in the immediate
future and long term. In turn, this can create a positive and comprehen-
sive sexual health platform, so that the United States can return to the ulti-
mate task of planning for the elimination of these serious health threats.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Addressing STI Epidemics:
Integrating Sexual Health,
Intersectionality, and
Social Determinants
Chapter Contents
Introduction
Urgency of Addressing STIs
Committee’s Approach
• Ethical Principles Guiding This Report
• Sexual Health
• Evolution of Sexual Health Paradigms
• Report Conceptual Framework
• Moving from a Narrow View of STIs to a Broader Sexual
Health Approach
Changes in the STI Landscape in the Past 20 Years
• Recent STI-Related Reports
Study Process and Report Overview
• Report Terminology
• Methodology
• Report Overview
Concluding Observations
21
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
22 SEXUALLY TRANSMITTED INFECTIONS
INTRODUCTION
Sexually transmitted infections (STIs) cause significant morbidity
and mortality in the United States and around the world. The Centers for
Disease Control and Prevention (CDC) estimates that one in five people
in the United States had an STI on any given day in 2018, totaling nearly
68 million estimated infections. Furthermore, an estimated 26 million
new STIs occurred in 2018 in the United States (CDC, 2021). Such infec-
tions can range in seriousness from no symptoms and no long-lasting
harm to severe disability and death. These infections have burdened
humankind throughout recorded history and, as with other pathogens,
they will continue to evolve in their relationship with humankind. Mov-
ing beyond complacency to action for both long-standing and emerging
STIs is critically important to the nation. (See Box 1-1 for key STI facts
and statistics.)
BOX 1-1
STI Facts and Statistics
• U.S. reported case rates of the three most common reportable STIs (chlamydia,
gonorrhea, and syphilis) have been increasing over the past two decades.
Since 2000, the overall case rate of chlamydia has doubled, gonorrhea has
increased nearly 1.4-fold, and primary and secondary syphilis is up 5-fold.
• Long-term effects of STIs include chronic pelvic pain, infertility, miscarriage or
newborn death, and increased risk of HIV infection, genital and oral cancers,
neurological and rheumatological consequences, and possible death in per-
sons not being screened or whose care is not well managed.
• The rise in reported STIs underestimates the full scope of the STI epidemic in
the United States, in part because many cases can be asymptomatic (espe-
cially in women) and are therefore often undiagnosed and unreported. Asymp-
tomatic individuals may not know they are infected, yet they can still transmit
an infection to their sexual partners or offspring.
• Congenital syphilis is passed to a fetus with severe and often fatal conse-
quences for newborns. While it is fully preventable with prenatal care, the
number of cases in the United States has increased 2.6-fold from 2013 to 2018.
• Young people aged 15–24 account for about 25 percent of the sexually active
population, yet they account for about half of all reported STIs annually.
• Gay, bisexual, and other men who have sex with men represent an estimated
2–3 percent of the adolescent/adult population, yet they account for 54 percent
of reported primary and secondary syphilis cases.
• STIs, including HIV, imposed an estimated nearly $16.0 billion in lifetime direct
medical costs in the United States in 2018.
SOURCES: CDC, 2019a,c, n.d.; Chesson et al., 2021; Singh et al., 2017.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ADDRESSING STI EPIDEMICS 23
URGENCY OF ADDRESSING STIs
STIs representing an array of more than 30 viral, bacterial, and proto-
zoal pathogens are among the most common infections affecting humans,
with chlamydia, gonorrhea, and syphilis leading the list of notifiable
infections in the United States (CDC, 2019b). The long-term sequelae,
including infertility, chronic pain, miscarriage or newborn death, as well
as the increased risk of HIV infection and sometimes cancer and death
mean that these infections have long been identified as public health pri-
orities. Most famously, Surgeon General Dr. Thomas Parran did so in his
treatise on syphilis, Shadow on the Land (Parran, 1937). Given the blame,
embarrassment, shame, and stigma attached to STIs, compounded by a
general uneasiness in discussing sexuality and sexual health in the United
States, the STI epidemic has largely remained hidden (see Chapters 2, 3,
and 9 for in-depth discussions of stigma and structural factors related to
STIs). Nonetheless, over the decades, numerous public and private enti-
ties have endorsed the goal of controlling and ultimately eradicating STIs.
The United States has seen great scientific progress related to STIs in the
past 20 years that has resulted in important public health benefits. This
progress demonstrates that efforts to treat and prevent STIs are not futile.
Substantial problems remain, however, and progress combating bacte-
rial STIs has made little progress in the past two decades. For example,
marginalized groups—youth; women; members of the lesbian, gay, bisex-
ual, transgender, and queer (LGBTQ+) community; and Black, Latino/a,
American Indian/Alaska Native (AI/AN), and Native Hawaiian/Other
Pacific Island people—continue to experience a disproportionate share of
STI cases in the United States. Limitations of the current STI surveillance
system are also problematic (see Chapters 2 and 12). This report seeks to
address these persistent problems while addressing the issue of STIs in
the broader context of sexual health.
STI rates are increasing; in 2018, combined rates of reported chla-
mydia, gonorrhea, and syphilis were at an all-time high (see Figures 1-1
and 1-2). These rates underestimate the full scope of the U.S. STI epidem-
ics, in part because many cases can be asymptomatic and therefore go
undiagnosed and unreported. Asymptomatic individuals may not know
they are infected but can still pass infection to their sexual partners. Fur-
thermore, other STIs of public health significance, such as human papil-
lomavirus (HPV) and herpes simplex virus, are not nationally notifiable
conditions; thus, data on these infections are not routinely reported in
the same way. The Institute of Medicine released a report, The Hidden
Epidemic: Confronting Sexually Transmitted Diseases, more than 20 years ago
(in 1997), yet the problems and barriers described there persist today. Fur-
thermore, STIs remain an underfunded and neglected field of practice and
research (Unemo et al., 2017). For example, chlamydia, gonorrhea, and
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
24 SEXUALLY TRANSMITTED INFECTIONS
syphilis rates have been on the rise for the past 5 years, with a 44 percent
increase in congenital syphilis in 2017 (CDC, 2019d). CDC estimated that
incident STIs, including HIV, imposed an estimated $16.0 billion (25th–
75th percentile: $15.0–17.1 billion) in lifetime direct medical costs in the
United States in 2018 (Chesson et al., 2021) (see Chapter 4 for an in-depth
discussion of the U.S. economic burden of STIs).
Given the burden of STIs, CDC, through the National Association of
County and City Health Officials (NACCHO), requested the Health and
Medicine Division of the National Academies of Sciences, Engineering,
and Medicine to review the current state of STIs in the United States, the
economic burden, current public health strategies and programs (includ-
ing diagnostics, vaccines, monitoring and surveillance, and treatment),
and barriers in the health care system. Based on its review, the commit-
tee’s mandate was to provide direction for the future of public health
programs, policy, and research in STI prevention and control (see Box 1-2
for the full Statement of Task and Appendix E for the committee member
biographies).
COMMITTEE’S APPROACH
For purposes of this report, the committee’s review encompasses
all STIs; the report’s primary emphasis, however, is on addressing the
growing epidemics of chlamydia, gonorrhea, and syphilis. These three
conditions produce significant morbidity and are nationally reportable
conditions for which both diagnostic tools and therapeutics are cur-
rently available, and there are current national efforts to reduce the
FIGURE 1-1 Snapshot of reportable sexually transmitted infections in 2017.
SOURCE: Bolan, 2019.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Copyright National Academy of Sciences. All rights reserved.
FIGURE 1-2 Notifiable sexually transmitted infections—rates of reported cases per 100,000 population (per 100,000 live births for
congenital syphilis), United States, 1999–2018.
25
SOURCE: Data from CDC, n.d.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
26 SEXUALLY TRANSMITTED INFECTIONS
BOX 1-2
Committee on Prevention and Control of Sexually Transmitted
Infections in the United States Statement of Task
The Centers for Disease Control and Prevention, through the National Associa-
tion of County and City Health Officials, requests that the National Academies of
Sciences, Engineering, and Medicine convene an ad hoc committee to examine:
1. The epidemiological dimensions of sexually transmitted infections (STIs) in
the United States and factors that contribute to the epidemic (changes in
population demographics, sexual and other behaviors, social determinants),
as well as changes in the understanding of the agents that cause STIs;
2. To the extent possible, the economic burden associated with STIs;
3. Current public health strategies and programs to prevent and control STIs
(including STI diagnostics, STI vaccines, STI monitoring and surveillance,
treatment); and
4. Barriers in the health care system and insurance coverage associated with
the prevention and treatment of STIs.
The committee will provide direction for future public health programs, poli-
cy, and research in STI prevention and control and make recommendations* as
appropriate.
* The committee will not provide recommendations on HIV/AIDS or viral hepatitis preven-
tion, diagnosis, treatment, policy, or research, as that is not the focus of this study.
impact of them. The committee believes that the framework and recom-
mendations offered in this report will strengthen the response to a broad
range of STIs.
Although HIV is an STI, the committee’s charge prevented it from
making HIV-specific recommendations (the report sponsors—CDC and
NACCHO—asked the committee to focus its recommendations on STIs
other than HIV, given the alarming increasing rates of STIs). The impact
of the HIV epidemic on STIs in the United States, however, cannot be
overlooked. Without treatment, HIV is almost universally fatal, and it
continues to pose a serious threat to population health. An estimated 1.2
million U.S. individuals are living with HIV; after decades of concerted
effort, annual new infections have fallen from more than 130,000 per year
in the mid-1980s to approximately 38,000 in 2018 (CDC, 2016, 2020). Simi-
larly, the number of deaths has declined dramatically from a high of about
50,000 in 1995 to 15,820 deaths by any cause among those with diagnosed
HIV infection in 2018 (HIV.gov, 2020). Thus, the committee’s consider-
ation of HIV was focused on understanding the interplay between HIV
and the acquisition, transmission, and clinical manifestations of other STIs
(see Chapter 5 for more information), as well as considering how current
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ADDRESSING STI EPIDEMICS 27
public health programs at the federal, state, and local levels integrate HIV
and STI prevention, care, and research programs.
Furthermore, STIs cannot be addressed without also attending to the
root causes of poor health—racism, discrimination, poverty, and health
inequity for certain groups, including a lack of access to health care, edu-
cation, and transportation (Brown et al., 2019; NASEM, 2017). Centering
health inequities and structural factors is critical when approaching most
health concerns, and the committee discusses and assesses this through-
out this report.
The following sections describe the committee’s approach, including
the guiding principles and conceptual framework that steered this report.
Ethical Principles Guiding This Report
More than other issues of public health importance, STIs are subject
to stigma, misconceptions, discrimination, and differences in values and
beliefs about sex and sexuality. The committee therefore relied on sev-
eral core principles to guide the development of this report. Specifically,
the committee considered the ethical concepts of beneficence, nonmalefi-
cence, autonomy, and justice and endorses the concepts of sexual health
and overall wellness.
Beneficence: Promoting Sexual Health and Wellness
STIs are inherently linked to sexuality and to sexual behaviors funda-
mental to human existence and a critical source of well-being and plea-
sure. From that perspective, the committee finds that STIs often reflect the
untoward effects of otherwise normal, healthy, and desired behaviors in
the context of consensual relationships. Preventing and controlling STIs
cannot be considered outside of the larger realm of sexual health. The
committee therefore asserts that a framework based on sexual health and
well-being is a necessary starting point to guide this report.
Nonmaleficence: Fighting Stigma
STIs have been shrouded in shame, embarrassment, and discrimina-
tion, creating stigma with serious consequences at both the societal and
individual levels. STI stigma is directly related to a society that holds nega-
tive views of sexuality, particularly outside of monogamous, heterosexual
relationships. As a result, discussions about sexuality and sexual health
are avoided at multiple levels, including within families and schools and
even by some health care practitioners. At the individual level, societal
stigma shapes individuals’ willingness and knowledge about whether,
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
28 SEXUALLY TRANSMITTED INFECTIONS
how, and where to seek information about and screening for STIs. This
may lead to failure to seek recommended screening or vaccination and
delays in diagnosis and treatment, resulting in negative health outcomes
and the risk of ongoing STI transmission. The committee concludes that
unbiased and impartial discussions regarding sexuality, sexual health,
and STIs need to occur at all levels of society, including within families,
schools, faith communities, and other community settings, especially in
clinical encounters. Educational discussions between health care provid-
ers and their patients are imperative in the fight against STI-associated
stigma.
Autonomy: Respect for Individual Decision Making
The principles of beneficence and nonmaleficence imply the centrality
of individual autonomy (i.e., respect for individual sexual decision mak-
ing and sexual expression free of external coercion, whether by partners,
family, friends, figures of authority, or society at large). This principle
also requires us to respect the autonomy of a partner and to speak out
forcefully against sexual or gender-based violence in all of its aspects (see
Chapter 3 for more information on sexual and gender-based violence in
relation to STIs).
Justice: Addressing Disparities; Affirming Sexual Rights as Human Rights
The epidemiology of STIs in the United States reveals deep dispari-
ties by age, race and ethnicity, sexual orientation, and gender identity,
perpetuated by overarching social and economic inequities, racism, and
discrimination. These factors are associated with barriers to access to
education, health, and prevention services above and beyond the stigma
already discussed. Thus, effective interventions to prevent and control
STIs also need to address larger social and sexual health inequities. The
committee concludes that efforts to eliminate STIs need to be expanded
from interventions in the private and public health domains to encompass
a productive policy-making sexual health discourse at the local, state, and
federal levels that leads to legal protections and opportunities regardless
of socioeconomic status, race and ethnicity, gender, sexual orientation, or
ability to pay for care. Addressing sexual injustice requires the affirmation
of sexual rights as basic human rights that are enjoyed by all. Thus, the
committee endorses the 10 sexual rights formulated by the International
Planned Parenthood Federation in 2008 (see Table 1-1).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ADDRESSING STI EPIDEMICS 29
TABLE 1-1 Sexual Rights
1. Right to equality, All persons are born free and equal in dignity and rights
equal protection and must enjoy the equal protection of the law against
of the law, and discrimination based on their sexuality, sex, or gender.
freedom from
all forms of
discrimination
based on sex,
sexuality, or
gender.
2. Right to All persons are entitled to an environment that enables
participation for all active, free and meaningful participation in and
persons, regardless contribution to the civil, economic, social, cultural, and
of sex, sexuality, or political aspects of human life at local, national, regional
gender. and international levels, through the development of which
human rights and fundamental freedoms can be realized.
3. Rights to life, All persons have the right to life and liberty and to be free
liberty, security of torture and cruel, inhuman, and degrading treatment in
of the person, and all cases, and particularly on account of sex, age, gender,
bodily integrity. gender identity, sexual orientation, marital status, sexual
history or behavior, real or imputed, and HIV/AIDS status,
and shall have the right to exercise their sexuality free of
violence or coercion.
4. Right to privacy. All persons have the right not to be subjected to arbitrary
interference with their privacy, family, home, papers, or
correspondence and the right to privacy, which is essential
to the exercise of sexual autonomy.
5. Right to personal All persons have the right to be recognized before the law
autonomy and and to sexual freedom, which encompasses the opportunity
recognition before for individuals to have control and decide freely on matters
the law. related to sexuality, to choose their sexual partners, to
seek to experience their full sexual potential and pleasure,
within a framework of nondiscrimination and with due
regard to the rights of others and to the evolving capacity
of children.
6. Right to freedom of All persons have the right to exercise freedom of
thought, opinion, thought, opinion, and expression regarding ideas on
and expression; sexuality, sexual orientation, gender identity, and sexual
right to association. rights, without arbitrary intrusions or limitations based
on dominant cultural beliefs or political ideology, or
discriminatory notions of public order, public morality,
public health, or public security.
continued
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
30 SEXUALLY TRANSMITTED INFECTIONS
TABLE 1-1 Continued
7. Right to health and All persons have a right to the enjoyment of the highest
to the benefits of attainable standard of physical and mental health, which
scientific progress. includes the underlying determinants of health and
access to sexual health care for prevention, diagnosis, and
treatment of all sexual concerns, problems, and disorders.
8. Right to education All persons, without discrimination, have the right to
and information. education and information generally and to comprehensive
sexuality education and information necessary and useful
to exercise full citizenship and equality in the private,
public, and political domains.
9. Right to choose All persons have the right to choose whether or not
whether or not to to marry, whether or not to found and plan a family,
marry and when to have children and to decide the number and
to found and plan spacing of their children freely and responsibly, within
a family, and to an environment in which laws and policies recognize the
decide whether diversity of family forms as including those not defined by
or not, how and descent or marriage.
when, to have
children.
10. Right to All persons have the right to effective, adequate,
accountability accessible, and appropriate educative, legislative, judicial,
and redress. and other measures to ensure and demand that those
who are duty bound to uphold sexual rights are fully
accountable to them. This includes the ability to monitor
the implementation of sexual rights and to access remedies
for violations of sexual rights, including access to full
redress through restitution, compensation, rehabilitation,
satisfaction, guarantee of nonrepetition, and any other
means.
SOURCE: Adapted from IPPF, 2008.
Sexual Health
As described in the committee guiding principles and framework
(see below), sexual health is a critical frame when approaching STI pre-
vention and control. This section provides a brief historical overview of
sexual health in the United States and includes important considerations
for moving forward. In the first decade of the 20th century, organized
efforts to promote control of STIs were led by Prince Morrow, founder
of the American Society for Sanitary and Moral Prophylaxis, a “coalition
of … the settlement movement, charity groups, moral reformers, and
the church” who emphasized moral duty to remain chaste and healthy
(Brandt, 1985).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ADDRESSING STI EPIDEMICS 31
Over the remainder of the 20th century, sex education and efforts
to control STIs were led by similar organizations, such as the Amer-
ican Social Hygiene Association (predecessor of the American Sexual
Health Association). These organizations were joined by the U.S. Armed
Forces and Public Health Service in leading provision of sexual educa-
tion and guidance of efforts to prevent and manage STIs. These groups’
efforts tended to emphasize the deleterious consequences of STIs and link
them to stigmatized terms (e.g., “promiscuity,” “infidelity”) and adverse
health consequences (e.g., congenital infections, infertility). Such attitudes
appear to have dominated STI prevention messaging throughout the 20th
century as the role of the federal government and particularly CDC grew
to preeminence in guiding U.S. STI policies.
Evolution of Sexual Health Paradigms
In parallel, the scientific study of human sexuality and function devel-
oped as an interdisciplinary specialty, sexology, encompassing the medi-
cal, psychological, and cultural aspects of sexual development and rela-
tionships throughout the life span. From the outset, sexual health experts
focused their studies on healthy sexuality in the absence of disease and
dysfunction. In 1975, the World Health Organization (WHO) first pub-
lished a brief definition and discussion of sexual health (WHO, 1975).
Progress in the field was modest, catalyzed by the so-called sexual revo-
lution of the 1960s and 1970s, but began to grow with recognition of the
inextricable interaction of human sexuality and risk of HIV. In collabora-
tion with the Pan American Health Organization and, soon thereafter, the
larger WHO, a working group was convened and created an expanded
definition of sexual health (see Box 1-3), which began to impact public
health efforts in Europe and Australia (Coleman, 2011). In 2001, U.S. Sur-
geon General David Satcher issued his Call to Action, which provided the
foundation for U.S. public health interest in sexual health (Satcher, 2001).
U.S. attempts to incorporate sexual health into HIV and, subsequently,
STI control as part of efforts to address stigma, were further articulated
in the late 2000s. For example, Swartzendruber and Zenilman (2010)
discussed the need for a shift from a stigmatizing focus on STI morbidity
toward a strategy focused on health rather than disease. In 2010, CDC
held a consultation on sexual health; however, CDC did not formally
adopt a sexual health approach at that time (Douglas, 2011; Douglas and
Fenton, 2013). Satcher et al. (2015) suggested a hierarchical “pyramid”
sexual health framework with five elements (starting from the top): coun-
seling and education, clinical interventions, long-lasting protective inter-
ventions, changing the context to make individuals’ decisions healthy,
and socioeconomic factors. This framework could enhance disease control
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
32 SEXUALLY TRANSMITTED INFECTIONS
and prevention activities using four principles: emphasis on wellness,
focus on positive and respectful relationships, acknowledgment of sexual
health as an element of overall health, and an integrated approach to pre-
vention. CDC embraced these efforts (Douglas and Fenton, 2013) and the
CDC/Health Resources and Services Administration Advisory Commit-
tee on HIV, Viral Hepatitis, and STD Prevention and Treatment (CHAC)
culminated in a definition of sexual health that built on the 2002 revision
of the WHO definition (WHO, 2006) (see Box 1-3).
Importantly, the WHO definition includes “pleasure,” whereas the
CHAC definition does not. Pleasure is sufficiently central to many per-
spectives on sexual health, however, as to support its inclusion in a sexual
health definition. In its “Declaration on Sexual Pleasure,” the World Asso-
ciation for Sexual Health recognizes sexual pleasure as “the physical and/
or psychological satisfaction and enjoyment derived from shared or soli-
tary erotic experiences, including thoughts, fantasies, dreams, emotions,
and feelings” (WAS, 2019). Furthermore,“Self-determination, consent,
safety, privacy, confidence and the ability to communicate and negoti-
ate sexual relations are key enabling factors for pleasure to contribute to
sexual health and wellbeing.” Finally, “The experiences of human sexual
pleasure are diverse and sexual rights ensure that pleasure is a positive
experience for all concerned and not obtained by violating other people’s
human rights and well-being” (Ford et al., 2019; WAS, 2019). The latter
statement, however, also points to a potential negative corollary: trau-
matic experiences, especially in adolescence, may be linked to adverse
STI outcomes (London et al., 2017). Thus, trauma-responsive approaches
need to be considered that address interpersonal and structural violence
as part of a public health approach independent of technological advances
in diagnostics, vaccines, and pharmacotherapies.
Over the past decade, people working in the field have increasingly
incorporated the sexual health discourse into discussion of STI control
efforts. Information provided by CDC, although beginning to be less
negative, continues to first emphasize the negative consequences of STIs
(infertility, congenital infections, STI-related cancers, amplified HIV trans-
mission and acquisition) before celebrating the potential to identify and
address preventable causes of these sequelae. Furthermore, it seems that
the “sexual health perspective” has not yet been widely accepted by
providers working in settings other than those devoted to reproductive
health and STI management. While still limited in comparison to risk-
focused studies, the literature on sexual health–positive interventions is
growing. In a summary of data from 58 studies (1996–2011), mostly from
individual and group-based interventions addressing sexual behaviors
and attitudes/norms, Hogben et al. (2015) found that all but one study
reported positive outcomes in at least one domain, and half found null
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ADDRESSING STI EPIDEMICS 33
effects in at least one domain. Positive effects were seen particularly
in studies focused on sexual minorities, marginalized populations, and
parental communications (Hogben et al., 2015). Importantly, multi-dimen-
sional sexual health models have been empirically operationalized to
demonstrate that higher levels of sexual health awareness are associated
with preventive measures (i.e., sexual health is an important construct
for promoting positive sexual development), including abstinence, higher
proportion of condom-protected events, and absence of STIs (Hensel and
Fortenberry, 2013). In addition, while research into trauma-responsive
interventions for STI prevention is still in its infancy, studies linking
screening for sexual trauma and uptake of HIV testing (Cuca et al., 2019;
Reddy et al., 2019) support their potential.
In promoting a sexual health discourse to inform the STI prevention
agenda, it is important to ensure that the sexual health of all people is
addressed, especially marginalized populations that are often dispropor-
tionally affected by STIs, including LGBTQ+ populations; Black people;
Latino/a people; AI/AN people; sex workers; immigrants; incarcerated
populations; and people affected by mental health and substance use
BOX 1-3
Definitions of Sexual Health
World Health Organization definition: “Sexual health is a state of physical,
emotional, mental, and social well-being in relation to sexuality; it is not merely the
absence of disease, dysfunction, or infirmity. Sexual health requires a positive and
respectful approach to sexuality and sexual relationships, as well as the possibility
of having pleasurable and safe sexual experiences, free of coercion, discrimina-
tion, and violence. For sexual health to be attained and maintained, the sexual
rights of all persons must be respected, protected, and fulfilled” (WHO, 2006, p. 5).
Centers for Disease Control and Prevention/Health Resources and Services
Administration Advisory Committee on HIV, Viral Hepatitis, and STD Prevention
and Treatment definition: “Sexual health is a state of well-being in relation to
sexuality across the life span that involves physical, emotional, mental, social, and
spiritual dimensions. Sexual health is an intrinsic element of human health and is
based on a positive, equitable, and respectful approach to sexuality, relationships,
and reproduction, that is free of coercion, fear, discrimination, stigma, shame, and
violence. It includes: the ability to understand the benefits, risks, and responsi-
bilities of sexual behavior; the prevention and care of disease and other adverse
outcomes; and the possibility of fulfilling sexual relationships. Sexual health is
impacted by socioeconomic and cultural contexts—including policies, practices,
and services—that support healthy outcomes for individuals, families, and their
communities” (Douglas and Fenton, 2013, p. 1).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
34 SEXUALLY TRANSMITTED INFECTIONS
disorders. Thus, attention needs to be given to potential barriers that
these populations encounter at points of contact throughout the health
care system. In this context, service provision needs to be informed by
shared decision making among providers and patients, which requires
that the health care system sheds its image as a benevolent patriarchy
that is dominated by traditional privileged groups. The recent restructur-
ing of the STI clinic system in New York City to address delivery of care,
including renaming STD clinics into “Sexual Health Clinics,” carried out
by extensive community involvement, is an encouraging example (NYC
Health, 2017).
Report Conceptual Framework: A Modified Social
Ecological Framework of Sexual Health and STI
Prevention, Control, and Treatment
The conceptual framework that provides a unifying approach for
the committee’s report on the U.S. STI epidemic describes multiple and
interrelated influences on STI risk, prevention, health care access, deliv-
ery, and treatment, as depicted in Figure 1-3 and further detailed with
selected examples in Box 1-4. Specifically, this framework adapts the
Ecological model (Bronfenbrenner, 1979) and the succeeding Social Eco-
logical model (Baral et al., 2013; Brawner, 2014; McLeroy et al., 1988; Sal-
lis and Owen, 2015; Sallis et al., 2008), which integrates tenets of social
and structural determinants of health and health inequities (CDC, 2010;
Hogben and Leichliter, 2008; NASEM, 2017, 2019; WHO, 2010). The com-
mittee extended the Social Ecological model to include concepts from
the Intersectionality (Bowleg, 2012; Collins, 2015; Collins and Bilge, 2020;
López and Gadsden, 2016) and Sexual Health (Satcher et al., 2015; WHO,
2006) frameworks. Thus, the core elements of this report’s conceptual
framework emphasize the importance of the following.
Variation in STI Pathogens
Acquisition and transmission of STIs vary by pathogen type (e.g.,
viral, bacterial, protozoan) and species-to-species variation, that are deter-
mined by the confluence of many interconnected factors, including host
characteristics, the epidemiology of infection in the community, indi-
vidual behavior, sexual partner selection, and other sexual network influ-
ences within the broader social (institutional and community) and societal
(structural) domains (CDC, 2010; Hogben and Leichliter, 2008).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ADDRESSING STI EPIDEMICS 35
Interrelated Social Ecological Factors
Individual agency in sexual health decision making and behavior is
synergistically influenced by contextual factors that occur in interpersonal
relationships (e.g., family, peers, sexual partners, health providers) and
within the broader social and societal domains (Baral et al., 2013; McLeroy
et al., 1988).
Social and Structural Determinants of Health and Health Inequities
Societal conditions (e.g., health and social policies, social norms, gov-
ernance practices) shape the social context and determinants (e.g., socio-
economic resources, inequitable health care delivery) that facilitate STI
transmission and prevention beyond individual behavior (Brawner, 2014).
Intersectionality
Social identities, such as race and ethnicity, gender and gender iden-
tity, sexual orientation, and disability, are multi-dimensional, interdepen-
dent, and mutually intrinsic experiences operating at the individual level
that intersect with social inequalities (e.g., poverty, racism, heterosexism,
sexism, transphobia) operating at the societal level that provide the con-
text for vast STI disparities in resource-limited, marginalized, and minori-
tized communities (Bowleg, 2012; Brawner, 2014; Collins, 2015).
Sexual Health
Comprehensive STI surveillance, disease control, prevention, and
treatment require a holistic view that recognizes that sexual health is
inextricably linked to overall health and wellness. Because sexuality and
sexual expression occur across the life span, healthy, safe, and respectful
relationships are important and sexual rights for all need be protected
(Satcher, 2001; WHO, 2006) (see Table 1-1).
In sum, effective STI prevention, control, and treatment needs to move
beyond individual-level behavior and behavior-change models toward a
comprehensive framework that understands and addresses the inter-
connected and mutually reinforcing social and structural determinants
of health and health inequities. Successfully applying this framework
necessitates multi-pronged and multi-level evidence-based sustained
approaches that integrate individual, interpersonal, institutional, com-
munity, and structural facilitators to overcome barriers to sexual health
and STI prevention, control, and treatment in the United States. Moreover,
successful application of this framework requires a shift in current siloed
funding mechanisms to an integrated and sustained funding approach
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
36 SEXUALLY TRANSMITTED INFECTIONS
Structural
SocialCommunity
and Community-
Level Factors
Institutional
Interpersonal Factors
Interpersonal
Individual-
Individual
Level Factors Biological Effect Pathway
Systems and elements impact
across all stages of the life course
These intersecting factors have an impact across all stages of the life span
Pregnancy/In-utero
Preconception Pregnancy
Childhood Childhood
Adolescents/Young Adults Middle Adults
Middle Adults Older Adults/Seniors
Sexual Health and STIs Across the Life Span
FIGURE 1-3 Modified Social Ecological Framework of sexual health and sexually
transmitted infection (STI) prevention, control, and treatment.
NOTE: This figure illustrates the multiple interrelated influences on STI risk, pre-
vention, health care access, delivery, and treatment across the life span.
SOURCE: Adapted from NASEM, 2019.
that not only addresses STIs as discrete health outcomes but also addresses
the social and structural determinants that influence STI risk, prevention,
health care access, delivery, and treatment (see Chapter 2 for a detailed
description of the core elements in the conceptual framework).
Moving from a Narrow View of STIs
to a Broader Sexual Health Approach
As highlighted in this chapter and discussed throughout this report,
STI prevalence is determined by interrelated individual, social, com-
munity, and structural factors operating simultaneously in a person’s
environment (e.g., partners, family, community, society) that have led to
extensive disparities across groups in terms of socioeconomic status, eth-
nicity and race, sexual orientation, and gender identity. These disparities
limit access to and the availability of care and are perpetuated by stigma
that effectively blames marginalized individuals and communities while
ignoring overarching determinants of health. These disparities cannot be
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ADDRESSING STI EPIDEMICS 37
overcome by individual behavior change alone, but require an integrated
approach that acknowledges the importance of sexual health, structural
and social determinants of health, and intersectionality as key factors for
addressing STI inequities across the life span. The committee was guided
by such an approach in its ethical considerations and recognizes that
the ongoing STI epidemic in the United States is a societal problem that
demands a societal solution.
Conclusion 1-1: The committee concludes that the persistence and growth of
STIs pose a serious threat to the health of those residing in the United States.
Conclusion 1-2: The nation’s response to STIs since the beginning of the
20th century has mostly focused on individual risk factors and individual
behavior change and has neglected the social and structural determinants of
sexual behavior. This approach has tended to fuel stigma and shame, which
have hindered the successful prevention and control of STIs.
Conclusion 1-3: STI prevention and control efforts to date have centered
on treatment of infections and prevention. To successfully address STIs,
a holistic approach that focuses on sexual health in the context of broader
health and well-being is needed. To carry out this change, significant efforts
will be needed to eradicate stigma and to promote sexual health awareness.
The committee acknowledges that the United States is a diverse coun-
try of almost 330 million people, and how one operationalizes a sexual
health paradigm will inevitably vary. The sexual health component of STI
prevention and care, however, has not been adequately addressed, due
in part to STI stigma and long-standing cultural norms that hinder open
dialogue about sexuality. This paradigm shift is needed given the history
of how marginalization has contributed to the proliferation of STIs. There
is a cost that society is paying for this marginalization, and significantly
shifting the cultural environment to be supportive of this framework
will take dedication and investment, as well as strategic actions outlined
in this report (for more on this topic, see Chapter 12). The committee
does not view this as a political issue or one that needs to be in conflict
with religious beliefs or ethical standards. For example, promoting sexual
health in a manner that facilitates STI prevention, diagnosis, and treat-
ment does not constrain faith communities from teaching about sexual
responsibility and sexual health in a way that is consistent with their own
faith traditions and ethical frameworks. The committee holds an inclusive
vision of respect and appreciation for diversity in religious belief, culture,
gender, and sexual orientation.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
38 SEXUALLY TRANSMITTED INFECTIONS
BOX 1-4
Example Constructs Within the Modified Social Ecological
Framework of STI Prevention, Control, and Treatment
Individual Factors Associated with STI Risk, Prevention, and Acquisition
• Biological factors (e.g., penile circumcision, cervical ectopy, genital inflammation)
• Sociodemographic factors (e.g., age, race, ethnicity, gender identity, sexual
orientation)
• Physical and psychosocial development (e.g., puberty, communication skills)
• Sexual behaviors (e.g., condom use, partner concurrency)
• Mental health and co-occurring conditions (e.g., depression, trauma)
• Cognitive-behavioral influences (e.g., perceived behavioral risk)
• Substance misuse (e.g., binge alcohol use, club drug use)
• Personal interactions with media (e.g., Internet searches, media consumption,
consumption of sexually explicit media)
Interpersonal Factors That Increase STI Risk or Provide Social
Support or Reinforce STI-Protective Social Norms
• Parental, peer, and social network influences (e.g., perceived peer norms for
condom use)
• Sexual partner and sexual network influences (e.g., relationship structure, part-
ner concurrency, hookup culture)
• Social media and other interpersonal digital communications (e.g., dating apps)
• Patient–provider interactions and communication
Institutional Factors That Facilitate or Hinder STI Prevention,
Health Care Access, Delivery, and Treatment
• Health care practices that promote well-being or conversely reinforce stigma
and bias
CHANGES IN THE STI LANDSCAPE IN THE PAST 20 YEARS
The committee is completing its work as the nation and the world
continue to grapple with the COVID-19 pandemic and its associated dis-
ruptions in economic activity. A growing challenge of misinformation is
exacerbating declining trust in public institutions in general and public
health and public health agencies in particular at a time when the urgency
of following public health guidance (even if it changes and evolves with
new knowledge) has life-or-death implications. The burden of respond-
ing to the COVID-19 crisis has been felt heavily by local, state, and fed-
eral STI programs. Under-resourced STI programs have to compete for
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ADDRESSING STI EPIDEMICS 39
• Health system policies that promote gender equity in health care delivery (e.g.,
increase male access to sexual health services)
• Health system policies that foster inclusive health care delivery (e.g., safe and
competent health care for LGBTQ+ individuals and people with different abilities)
• School policies that facilitate or hinder school-based sexuality education
Community Factors That Influence Living Conditions That Affect STI
Prevention, Health Care Access, Health Care Delivery, and Treatment
• Poverty and other socioeconomic status–related factors (e.g., employment, in-
secure housing)
• Neighborhood resources (e.g., public transportation availability)
• Social climate (e.g., neighborhood safety)
• Mobility patterns (e.g., where and how people move within locations/space and
time)
• Community-level indicators of STI transmission (e.g., prevalence of STIs within
neighborhoods)
Structural Factors, Including Societal Values, Policies, and Practices
at Local, State, and Federal Levels That Determine STI Prevention,
Health Care Access, Health Care Delivery, and Treatment
• Social advocacy that promotes health equity and inclusion
• Social policies and laws that address structural inequities (e.g., structural sexism,
anti-LGBTQ+ structural stigma)
• Political priorities for increasing sexual health care services across the life span
• State policies that require parental consent for sexual and reproductive health
care
• Societal resources for provider training and workforce career development
• Societal sentiment, norms, and stigma regarding sexual health
• Surveillance infrastructure (e.g., data collection, analysis, interpretation)
funding and staff with this new public health threat as states are experi-
encing declining revenues at the same time that STI program staff have
been diverted as they were to the HIV response in prior decades; they
are professionals with the appropriate training and expertise to lead the
COVID-19 response, so this diversion was necessary and appropriate.
Nonetheless, it has meant less attention to STIs and fewer critical services
being delivered. A May 2020 survey of health department STI programs
found that 83 percent were deferring STI services or field visits, 62 per-
cent cannot maintain their HIV and syphilis caseloads, and 66 percent of
clinics reported a decrease in sexual health screening and testing (NCSD,
2020). Furthermore, the pandemic has led to a shortage of STI diagnostic
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
40 SEXUALLY TRANSMITTED INFECTIONS
test kits and laboratory supplies (Bolan, 2020). For example, it is estimated
that these STI health disruptions may lead to hundreds of new HIV cases
and thousands of STI cases in Atlanta alone (Jenness et al., 2020). (See
Chapter 12 for more information on the STI–COVID interface; examples
and lessons learned from COVID are used throughout the report, as
appropriate.)
This report also comes more than two decades after the release of the
foundational report The Hidden Epidemic: Confronting Sexually Transmit-
ted Disease (IOM, 1997). The committee believes that that report remains
relevant today and broadly endorses its recommendations. In particular,
the committee was guided by the report’s vision:
An effective system of services and information that supports individu-
als, families, and communities in preventing [STIs], including HIV in-
fection, and ensures comprehensive, high-quality [STI-related] health
services for all persons.
One of the committee’s goals for this report is to build on and extend the
work of The Hidden Epidemic by reflecting the changes in context of STIs
since 1997. At the time, the nation appeared on the verge of eliminating
syphilis, and chlamydia and gonorrhea rates also were declining. The
next year, CDC announced a detailed plan to eliminate sustained syphilis
transmission (Valentine and Bolan, 2018). CDC noted that annual cases
had declined by 86 percent from the last outbreak in 1990 and half the
reported cases arose in 28 counties, out of more than 3,000 U.S. counties
(CDC, 2007). Unfortunately, Congress cut funding for STI prevention and
control, and the plan’s objectives were not realized. In 2000, there were
5,979 cases of primary and secondary syphilis and 589 cases of congenital
syphilis (CDC, 2001). By 2018, the reported cases had risen to 35,063 (an
almost 6-fold increase), and they are growing rapidly. Congenital syphilis
cases had risen to 1,306 (more than doubling since 2000). Reported cases
of chlamydia and gonorrhea have followed a similar pattern of explosive
growth that continues today (CDC, 2019c).
Since The Hidden Epidemic, family structure has changed consider-
ably (Brown, 2020; Pew Research Center, 2019). For example, among
heterosexual people, increasing divorce rates, delayed marriage, and an
increase in those choosing to not marry, coupled with a longer life span,
have resulted in more single heterosexual adults (Brown, 2020; Karney
and Bradbury, 2020). More U.S. adults are single than ever before. In the
1960s, 72 percent of U.S. adults were married; in 2017, that declined to 54.8
percent (U.S. Census Bureau, 2017). Changing attitudes about extramari-
tal sex also may be influencing adults’ sexual behavior. Those who agree
that extramarital sex is not wrong at all have gone from 29 percent in the
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ADDRESSING STI EPIDEMICS 41
1970s to 58 percent in the 2012 (Twenge et al., 2015); however, a 2017 study
found that the number of Americans who report having extramarital sex
has remained relatively constant over the past 30 years at about 16 per-
cent (Wolfinger, 2017). The challenge of preventing and controlling STIs
is exacerbated by larger syndemics that include growing epidemics of
methamphetamine and opioid addiction (NASEM, 2020), which can also
indirectly lead to more STIs by practice of high-risk behavior.
A key factor affecting the challenges and opportunities for addressing
STIs is Internet usage. In 1997, fewer than one in four U.S. individuals
were estimated to use the Internet, whereas by 2020, this has risen to more
than 9 in 10. U.S. adults spend more than 11 hours per day interacting
with media (Nielsen, 2018). The iPhone was not introduced until 2007,
and the widespread adoption of this and other smart and mobile devices
has led to significant transformation in how people communicate and
interact through millions of readily accessible apps. While apps facilitate
activities from shopping to improving workplace productivity, the intro-
duction of apps that allow individuals to meet others for socialization
and sex has been revolutionary. The massive amount of “big data” from
apps and digital devices has facilitated development of artificial intelli-
gence–based machines that can influence sexual-health-related attitudes
and behaviors. While it is easy to denounce such technologies for poten-
tially facilitating greater STI transmission, a balanced assessment of them
may find both positive and negative effects. Technology and media also
may serve as a useful tool for sexual health behavior change. Millions of
people use these technologies and they continue to develop, so policies
and interventions to improve sexual health and wellness and to prevent
and control STIs also need to consider this reality. (See Chapter 6 for more
on the role of technology and media.)
Not all changes since 1997 have been negative. The broad adoption
of the Internet has allowed for wide-scale data collection that both pro-
duces new risks to privacy and personal safety and also facilitates greater
analysis of information that can dramatically improve our effectiveness
at identifying and responding to disease outbreaks. The increasing use
of machine learning and artificial intelligence means that this revolu-
tion is ongoing, so they will continue to pose both new threats and new
opportunities for preventing and controlling STIs. Clinical advances also
have continued over the past decade that have delivered more diagnostic
tools, such as telehealth, app-based interventions, home-based testing,
and rapid and point-of-care tests, and other innovations, such as the HPV
vaccine and hepatitis C curative treatment. Such advances will be signifi-
cant in fostering greater STI control.
It is also important to reflect on and learn from the very important
progress in responding to the HIV epidemic. The Hidden Epidemic was
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
42 SEXUALLY TRANSMITTED INFECTIONS
released 1 year after highly active antiretroviral therapy was introduced
in the United States, and the nation has become accustomed to the stun-
ning declines in deaths among people living with HIV. Moreover, scien-
tific innovation has continued to deliver more and better therapeutics,
and researchers appear to be on the cusp of transformative change, with
envisioned numerous long-acting agents for HIV treatment and preven-
tion that will not require daily dosing. Effective pre-exposure prophylaxis
(PrEP) for HIV, which has proven to be safe and highly effective, has been
available for less than a decade. More HIV PrEP options are anticipated,
including lower cost generic drugs that may increase access. Further-
more, starting in 2020, the United States Preventive Services Task Force
Recommendation for HIV PrEP began to require private health plans and
Medicaid expansion programs to provide PrEP when clinically indicated
without cost sharing, a move that is expected to greatly expand access.
Despite these promising developments, the growing STI crisis starkly
outlines what has not changed since 1997. The United States continues to
rely on long-standing and outdated medications for bacterial STIs. There
are too few vaccines and both a weak pipeline for new therapeutics and
growing concerns over drug resistance to existing therapies, especially for
gonorrhea. STI prevention, care, and research remain dramatically under-
funded at the federal level in relation to their public health burden, and
state and local funding is nonexistent or miniscule in most U.S. jurisdic-
tions. Unfortunately, this situation is but one component of the defund-
ing and underfunding of public health. As the nation and the world face
emerging pandemics, the nation will pay an increasing price for neglect-
ing to invest in public health and neglecting STIs or placing them in fund-
ing competition with other seemingly more urgent infectious diseases.
The committee considered whether the response to STIs should focus
on all individuals in the United States, as anyone can be at risk, or on
specific groups or communities. A disheartening reflection of what has not
changed in the past 20 years is how much the impact of STIs is not equally
distributed, but is rather highly concentrated, in terms of both place,
with the southern region bearing the heaviest burden, and people, with
racial and ethnic minorities, transgender people, and gay and bisexual
men and other sexual and gender minorities being highly disproportion-
ately impacted. This disproportionality cannot be neatly attributed to
individual behavior alone but is embedded in historical experience and
individuals’ social, cultural, and physical environments.
Young people also account for a very large share of STIs; people aged
15–24 comprise half of all annual diagnoses among sexually active indi-
viduals even though they make up only one-quarter of the population.
Moreover, whereas men may be at greater risk of acquiring certain STIs
than women, the consequences of untreated STIs are often more severe
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ADDRESSING STI EPIDEMICS 43
for women in terms of pelvic inflammatory disease, infertility, and in
transmitting infection to their offspring. Men are essential in transmitting
STIs to women, but historically have been underserved in STI prevention
and care programs.
The national response to the STI crisis needs to recognize that the
nation’s collective efforts will be most successful if funding and pro-
grams prioritize health equity and address broader factors that are asso-
ciated with an increased STI risk (such as racism, discrimination, unem-
ployment, income insecurity, poverty, and unstable housing) while also
increasing access to comprehensive STI health services. Nonetheless, the
committee believes that even as resource allocations are aligned with the
groups with the greatest needs and that bear the greatest consequences
of STIs, a successful national effort needs to engage individuals broadly.
Recent STI-Related Reports
Recently, several significant STI-focused reports and documents have
been published. The National Coalition of STD Directors engaged the
National Academy of Public Administration (NAPA) to undertake a two-
part study of the STD epidemic in the United States (NAPA, 2018, 2019).
The Treatment Action Group (TAG) analyzed ongoing research in the
pipeline for gonorrhea, chlamydia, and syphilis, and concluded that the
current toolbox for addressing them is inadequate (TAG, 2019). Finally,
the first-ever federal STI National Strategic Plan (STI-NSP): 2021–2025
was developed and released for public comment in 2020, and the final
plan was released in December 2020 (HHS, 2020). It builds on the NAPA
and TAG reports, as there are many synergies between them. A descrip-
tion of these reports and the STI-NSP is available in Chapter 12; in that
chapter and throughout this report, the committee identifies alignment
and variations in approach. Given the synergies between the STI-NSP and
this report, the implementation of the STI-NSP offers an important oppor-
tunity to execute many of the recommendations provided in this report.
STUDY PROCESS AND REPORT OVERVIEW
The committee gathered information through a variety of means. It
held seven information-gathering meetings or webinars between August
2019 and September 2020 (the agendas are available in Appendix D) on
a range of topics, including trends in sexual behavior and reproductive
health; opportunities and barriers at the state and local levels; structural,
behavioral, biomedical, and health system interventions and technologi-
cal tools; economic burden; and international perspectives. The commit-
tee held two webinars to hear individual and community perspectives
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
44 SEXUALLY TRANSMITTED INFECTIONS
on how to better respond to STIs—the comments and discussions were
very informative and added depth to the issues discussed in this report.
Quotes from these meetings are included throughout the report to illus-
trate the complex and intersecting barriers and opportunities related to
sexual health and STI prevention and control. The committee also held
deliberative meetings and received public submissions of materials for its
consideration throughout the course of the study.1 The committee’s online
activity page also provided information to the public about its work and
facilitated communication with the public.2
Report Terminology
Over time, terminology for sexual health (as discussed above) and
STIs has significantly evolved. Stigmatizing language used in the naming,
terms, and classification of STIs has contributed to blame and alienation of
the very persons who need to be engaged and assisted. Therefore, through-
out this report, the committee strived to use language that is respectful,
accurate, and maximally inclusive. This relies on attempting to reflect pref-
erences for how individuals and groups wish to be addressed, but there
is not always consensus on preferred terms, and these preferences may
evolve over time. As a general matter, this report uses Black people when
referencing African Americans and others that are part of the African dias-
pora, as the term is often understood to be broader and include persons
whose cultural history is not grounded in the United States. Similarly, the
committee has chosen “Latino/Latina” for consistency to refer to persons
with cultural connections to Latin America, recognizing that some people
may prefer “Hispanic,” “Latinx,” or another term.
Societal understanding of gender identity is rapidly evolving.
This report uses “transgender/non-binary” as an inclusive term that
is intended to encompass non-binary, gender fluid, and other persons.
Gender-related terms are also used, but when applicable, broader terms,
such as “pregnant people” in place of “pregnant women,” are intended to
acknowledge the diversity of gender identities and point to ways that our
common language can be updated to accord greater respect to all people.
“Gender expansive” is used to describe people that expand notions of
gender expression and identity beyond what is perceived as the expected
norms for their society or context. “LGBTQ+” refers to individuals who
are lesbian, gay, bisexual, transgender, and queer or questioning. Some-
times the terms, however, are determined by the terms or definitions in
data systems or a specific research study referred to or summarized. The
1 Public access materials can be requested from [email protected].
2 See nationalacademies.org/PreventSTIs (accessed July 14, 2020).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ADDRESSING STI EPIDEMICS 45
committee also recognizes the current discourse on the use of inclusive
and destigmatizing language when discussing sexual behaviors, such as
the preference for “condomless” rather than “unprotected” sex (Editors,
Sexually Transmitted Diseases, 2020). Finally, the committee uses “sexually
transmitted infections” instead of “sexually transmitted diseases” unless
referring to the actual diseases rather than to the infections. (See Box 1-5
for a comparison of these terms.)
Methodology
The committee undertook a comprehensive review of the peer-
reviewed and gray literature, including governmental and academic data-
bases and websites.3 Studies that evaluate the effectiveness and applica-
bility of interventions are important for assessing which interventions
are most effective and suitable for a general or more specific population.
Many interventions, however, have not been adequately evaluated for
their effectiveness. In addition, studies vary in their design and setting,
quality of execution, interactions with other interventions, and consider-
ation of economic consequences (NASEM, 2019). Therefore, in large part,
the committee relied on existing systematic reviews, meta-analyses, and
comprehensive reviews with strong methodologies. Certain populations
are frequently systematically excluded from or not the primary focus of
intervention studies or other STI research, including persons who are
transgender, AI/AN people, and persons with disabilities. In those cases,
the committee needed to rely on smaller or fewer studies. The commit-
tee notes throughout the report where this is the case and where more
BOX 1-5
Sexually Transmitted Diseases or
Sexually Transmitted Infections?
The term “sexually transmitted infection” (STI) refers to a virus, bacteria, fun-
gus, or parasite that has infected a person’s body via sexual contact, whereas
“sexually transmitted disease” (STD) refers to a recognizable disease state that
has developed from an STI. Some stakeholders commonly use “STI,” and some
commonly use “STD.” This report generally uses “STI” because the goal is to pre-
vent and treat infections before they develop into a disease state, although “STD”
appears when referring to data or information from sources that used it.
SOURCE: Adapted from HHS, 2020.
3 The date range for the search was October 2009 to May 2020.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
46 SEXUALLY TRANSMITTED INFECTIONS
research is needed. Research on HIV was included throughout the report
where lessons from that body of research could be applied or when
research on STIs was lacking. Regarding STI data, the committee used
the most recent data available—as of the writing of this report, the most
comprehensive was the 2019 CDC surveillance report containing data
from 2018 as the 2019 CDC STI surveillance report was delayed due to
the COVID-19 pandemic.
Report Overview
Throughout this report, the committee provides conclusions and rec-
ommendations for action, guided by the conceptual framework intro-
duced earlier in this chapter. To do so, the committee has organized its
recommendations under four key themes:
1. Adopt a Sexual Health Paradigm
2. Broaden Ownership and Accountability for Responding to STIs
3. Bolster Existing Systems and Programs for Responding to STIs
4. Embrace Innovation and Policy Change to Improve Sexual Health
These themes are explored in detail in the following chapters. Chap-
ters 1–5 provide background and address the first two components of
the committee’s charge, and Chapters 6–12 address the third component
of the charge—advice on future public health programs, policies, and
research in STI prevention and control (some of these chapters provide
conclusions, and others provide conclusions and recommendations for
action). Chapter 2 provides an overview of the status of STIs in the United
States and the contextual factors and drivers (such as the social and struc-
tural determinants of health) that need to be considered when working
to prevent and control STIs. Chapter 3 further explores these contex-
tual factors that drive STIs for priority populations. Chapter 4 discusses
the policy, financing, and economic factors that shape the STI landscape
today, including the economic burden. Chapter 5 highlights the impor-
tant interface between HIV and STIs and why they cannot be viewed in
silos. Chapter 6 explores the potential risks and benefits of technology
and media and how they can be used to improve the nation’s response.
Chapters 7, 8, and 9 examine biomedical, psychosocial and behavioral,
and structural interventions, respectively, and the need for these different
types of interventions to work together as part of multi-level interventions
to address STIs at every level. Chapter 10 examines the health care system
and the considerable gaps in addressing STIs. The report culminates with
Chapter 11 (which examines the current STI workforce and delineates
how to prepare and expand it to achieve the recommendations laid out
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ADDRESSING STI EPIDEMICS 47
in this report) and Chapter 12 (which offers a plan for actions to make
progress toward reducing STIs).
The committee provides a range of recommendations in Chapters 7–12
related to health care practice and access, policy, and research, including
some recommendations that will take time and sustained commitment
and funding to achieve. CDC’s STI funding over the past two decades
has remained flat (with a 40 percent reduction in inflation-adjusted dol-
lars). Although the committee’s charge did not specifically ask it to make
recommendations related to funding levels and other necessary resource
allocations for STIs, the committee notes that some of the recommenda-
tions will require new or substantial realignment of resources to imple-
ment, and the authority and political support to modify existing systems
at the local, state, and federal levels. Stronger leadership and coordination
of national STI prevention and control efforts are also needed to improve
STI prevention and control. Furthermore, because the committee’s pri-
mary focus was on providing clear policy guidance and a framework for
action, it does not uniformly offer specific implementation steps or metrics
for each recommendation. The committee acknowledges that to provide
more specific implementation steps would have required a more in-depth
understanding of STI resources, policies, and other circumstances at the
state, local, and federal levels and an understanding of the communities
and stakeholders who would have critical roles in operationalizing these
recommendations. The committee understands that resources, policies,
and stakeholders vary across the country and that flexibility in imple-
mentation of recommendations will need to adjust to those circumstances.
CONCLUDING OBSERVATIONS
Although much has changed since The Hidden Epidemic in 1997, many
conditions in the United States have not changed markedly. Despite the
dedicated commitment from many individuals and agencies committed
to reducing the burden of STIs and elevating sexual health, STI research,
policy, and services continue to suffer from neglect. Relatively flat federal
investments and declining state and local investments in the face of all-
time high numbers of reported cases of STIs underscores the failure of the
crisis to capture the attention of the public.
The committee’s exploration of the complexities of the challenge,
however, has instilled in its members a firm belief that it is possible to
create a different and better future where fewer adults are infected, fewer
babies are born with STIs, people, starting in adolescence but 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, and the nation
records progressive reductions in STIs, including the current epidemics
of chlamydia, gonorrhea, and syphilis.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
48 SEXUALLY TRANSMITTED INFECTIONS
The required changes will take concerted commitment and action, but
it is possible to reduce the impact of STIs on society and take bold actions
recommended in this report to control STIs in the immediate future. In
turn, this can create a platform where the nation can return to the ultimate
task of planning to eliminate these serious health threats.
REFERENCES
Baral, S., C. H. Logie, A. Grosso, A. L. Wirtz, and C. Beyrer. 2013. Modified Social Ecological
model: A tool to guide the assessment of the risks and risk contexts of HIV epidemics.
BMC Public Health 13:482.
Bolan, G. 2019. Division of STD prevention. Presentation to the Committee on Preven-
tion and Control of Sexually Transmitted Infections in the United States, Meet-
ing 1 (August 26). https://www.nationalacademies.org/event/08-26-2019/docs/
D3423E23A3A4A9B4447C205483C8F840EF1481A1EEE2 (accessed February 17, 2021).
Bolan, G. 2020. Dear colleague letter: Shortage of STI diagnotic test kits and laboratory supplies.
https://www.cdc.gov/std/general/DCL-Diagnostic-Test-Shortage.pdf (accessed Oc-
tober 25, 2020).
Bowleg, L. 2012. The problem with the phrase women and minorities: Intersectionality—an
important theoretical framework for public health. American Journal of Public Health
102(7):1267-1273.
Brandt, A. 1985. No magic bullet. A social history of venereal disease in the United States since
1880. New York: Oxford University Press.
Brawner, B. M. 2014. A multilevel understanding of HIV/AIDS disease burden among
African American women. Journal of Obstetric, Gynecologic, & Neonatal Nursing
43(5):E633-E650.
Bronfenbrenner, U. 1979. The ecology of human development. Cambridge, MA: Harvard Uni-
versity Press.
Brown, A. 2020. Nearly half of U.S. adults say dating has gotten harder for most people in
the last 10 years. Washington, DC: Pew Research Center.
Brown, A. F., G. X. Ma, J. Miranda, E. Eng, D. Castille, T. Brockie, P. Jones, C. O. Airhihen-
buwa, T. Farhat, L. Zhu, and C. Trinh-Shevrin. 2019. Structural interventions to reduce
and eliminate health disparities. American Journal of Public Health 109(Suppl 1):S72-S78.
CDC (Centers for Disease Control and Prevention). 2001. Syphilis elimination key facts.
https://www.cdc.gov/stopsyphilis/media/SyphElimKeyFacts.htm (accessed Febru-
ary 10, 2021).
CDC. 2007. The national plan to eliminate syphilis from the United States—executive summary.
https://www.cdc.gov/stopsyphilis/exec.htm (accessed February 10, 2021).
CDC. 2010. Establishing a holistic framework to reduce inequities in HIV, viral hepatitis, STDs, and
tuberculosis in the United States. Atlanta, GA: Centers for Disease Control and Preven-
tion, Department of Health and Human Services.
CDC. 2016. CDC fact sheet: Today’s HIV/AIDS epidemic. https://www.cdc.gov/nchhstp/
newsroom/docs/factsheets/todaysepidemic-508.pdf (accessed December 11, 2020).
CDC. 2019a. Congenital syphilis—CDC fact sheet. https://www.cdc.gov/std/syphilis/stdfact-
congenital-syphilis.htm (accessed February 19, 2021).
CDC. 2019b. National notifiable diseases surveillance system, 2018 annual tables of infec-
tious disease data. CDC Division of Health Informatics and Surveillance. https://wonder.
cdc.gov/nndss/static/2018/annual/2018-table1.html (accessed January 28, 2020).
CDC. 2019c. Sexually transmitted disease surveillance 2018. Atlanta, GA: Department of Health
and Human Services.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ADDRESSING STI EPIDEMICS 49
CDC. 2019d. Sexually transmitted disease surveillance 2019. https://www.cdc.gov/std/
stats18/STDSurveillance2018-full-report.pdf (accessed October 25, 2020).
CDC. 2020. Estimated HIV incidence and prevalence in the United States 2014-2018. https://www.
cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-supplemental-
report-vol-25-1.pdf (accessed December 11, 2020).
CDC. 2021. Sexually transmitted infections prevalence, incidence, and cost estimates in the United
States. https://www.cdc.gov/std/statistics/prevalence-2020-at-a-glance.htm (accessed
January 28, 2021).
CDC. n.d. CDC Atlas Plus: STD data. https://gis.cdc.gov/grasp/nchhstpatlas/charts.html
(accessed January 29, 2021).
Chesson, H. W., I. H. Spicknall, A. Bingham, M. Brisson, S. T. Eppink, P. G. Farnham,
K. M. Kreisel, S. Kumar, J.-F. Laprise, T. A. Peterman, H. Roberts, and T. L. Gift.
2021. The estimated direct lifetime medical costs of sexually transmitted infections
acquired in the United States in 2018. Sexually Transmitted Diseases. doi: 10.1097/
OLQ.0000000000001380.
Coleman, E. 2011. What is sexual health? Articulating a sexual health approach to HIV pre-
vention for men who have sex with men. AIDS and Behavior 15:S18-S24.
Collins, P. H. 2015. Intersectionality’s definitional dilemmas. Annual Review of Sociology
41(1):1-20.
Collins, P. H., and S. Bilge. 2020. Intersectionality. 2nd ed. Cambridge, UK: Polity Press.
Cuca, Y. P., M. Shumway, E. L. Machtinger, K. Davis, N. Khanna, J. Cocohoba, and C.
Dawson-Rose. 2019. The association of trauma with the physical, behavioral, and social
health of women living with HIV: Pathways to guide trauma-informed health care
interventions. Women’s Health Issues 29(5):376-384.
Douglas, J. M. 2011. Advancing a public health approach to improve sexual health in the United
States: A framework for national efforts. https://www.cdc.gov/sexualhealth/docs/
douglasnhpchivpx081611last.pdf (accessed January 28, 2021).
Douglas, J. M., Jr., and K. A. Fenton. 2013. Understanding sexual health and its role in more
effective prevention programs. Public Health Reports 128:1-4.
Editors, Sexually Transmitted Diseases. 2020. Making our words matter: Reflections on ter-
minology to describe behavioral risk factors in STD and HIV prevention. Sexually
Transmitted Diseases 47(1):4.
Ford, J. V., E. Corona Vargas, I. Finotelli, Jr, J. D. Fortenberry, E. Kismödi, A. Philpott, E.
Rubio-Aurioles, and E. Coleman. 2019. Why pleasure matters: Its global relevance
for sexual health, sexual rights and wellbeing. International Journal of Sexual Health
31(3):217-230.
Hensel, D. J., and J. D. Fortenberry. 2013. A multidimensional model of sexual health and
sexual and prevention behavior among adolescent women. Journal of Adolescent Health
52(2):219-227.
HHS (Department of Health and Human Services). 2020. Sexually Transmitted Infections
National Strategic Plan for the United States: 2021-2025. Washington, DC: Department of
Health and Human Services.
HIV.gov. 2020. Fast facts. https://www.hiv.gov/hiv-basics/overview/data-and-trends/
statistics (accessed October 23, 2020).
Hogben, M., and J. S. Leichliter. 2008. Social determinants and sexually transmitted disease
disparities. Sexually Transmitted Diseases 35(12 Suppl):S13-S18.
Hogben, M., J. Ford, J. S. Becasen, and K. F. Brown. 2015. A systematic review of sexual
health interventions for adults: Narrative evidence. Journal of Sex Research 52(4):444-469.
IOM (Institute of Medicine). 1997. The hidden epidemic: Confronting sexually transmitted dis-
eases. Washington, DC: National Academy Press.
IPPF (International Planned Parenthood Federation). 2008. Sexual rights: An IPPF declaration.
London, UK: International Planned Parenthood Federation.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
50 SEXUALLY TRANSMITTED INFECTIONS
Jenness, S. M., A. Le Guillou, C. Chandra, L. M. Mann, T. Sanchez, D. Westreich, and J. L.
Marcus. 2020. Projected HIV and bacterial STI incidence following COVID-related
sexual distancing and clinical service interruption. MedRXiv.
Karney, B. R., and T. N. Bradbury. 2020. Research on marital satisfaction and stability
in the 2010s: Challenging conventional wisdom. Journal of Marriage and the Family
82(1):100-116.
London, S., K. Quinn, J. D. Scheidell, B. C. Frueh, and M. R. Khan. 2017. Adverse experiences
in childhood and sexually transmitted infection risk from adolescence into adulthood.
Sexually Transmitted Diseases 44(9):524-532.
López, N., and V. L. Gadsden. 2016. Health inequities, social determinants, and intersectionality.
NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington,
DC.
McLeroy, K. R., D. Bibeau, A. Steckler, and K. Glanz. 1988. An ecological perspective on
health promotion programs. Health Education Quarterly 15(4):351-377.
NAPA (National Academy of Public Administration). 2018. The impact of sexually transmitted
diseases on the United States: Still hidden, getting worse, can be controlled. Washington, DC:
National Academy of Public Administration.
NAPA. 2019. The STD epidemic in America: The frontline struggle. Washington, DC: National
Academy of Public Administration.
NASEM (National Academies of Sciences, Engineering, and Medicine). 2017. Communities
in action: Pathways to health equity. Washington, DC: The National Academies Press.
NASEM. 2019. Vibrant and healthy kids: Aligning science, practice, and policy to advance health
equity. Washington, DC: The National Academies Press.
NASEM. 2020. Opportunities to improve opioid use disorder and infectious disease services: In-
tegrating responses to a dual epidemic. Washington, DC: The National Academies Press.
NCSD (National Coalition of STD Directors). 2020. COVID-19 & the state of the STD field.
https://www.ncsddc.org/wp-content/uploads/2020/05/STD-Field.Survey-Report.
Final_.5.13.20.pdf (accessed October 25, 2020).
Nielsen. 2018. Time flies: U.S. Adults now spend nearly half a day interacting with media. https://
www.nielsen.com/us/en/insights/article/2018/time-flies-us-adults-now-spend-
nearly-half-a-day-interacting-with-media (accessed July 7, 2020).
NYC Health. 2017. Health department announces historic expansion of HIV and STI services at
sexual health clinics. https://www1.nyc.gov/site/doh/about/press/pr2017/pr003-17.
page (accessed April 3, 2020).
Parran, T. 1937. Shadow on the land: Syphilis. New York: Reynal & Hitchcock.
Pew Research Center. 2019. Marriage and cohabitation in the U.S. https://www.pewresearch.
org/social-trends/2019/11/06/marriage-and-cohabitation-in-the-u-s (accessed Febru-
ary 19, 2021).
Reddy, S. M., G. A. Portnoy, H. Bathulapalli, J. Womack, S. G. Haskell, K. Mattocks, C. A.
Brandt, and J. L. Goulet. 2019. Screening for military sexual trauma is associated with
improved HIV screening in women veterans. Medical Care 57(7):536-543.
Sallis, J. F., and N. Owen. 2015. Ecological models of health behavior. In Health behavior:
Theory, research, and practice, 5th ed. Hoboken, NJ: Jossey-Bass/Wiley. Pp. 43-64.
Sallis, J. F., N. Owen, and E. Fisher. 2008. Ecological models of health behavior. In Health
behavior and health education: Theory, research, and practice. Hoboken, NJ: Jossey-Bass/
Wiley. Pp. 465-482.
Satcher, D. 2001. The surgeon general’s call to action to promote sexual health and responsible
sexual behavior. https://www.ncbi.nlm.nih.gov/books/NBK44216 (accessed February
10, 2021).
Satcher, D., E. W. Hook, 3rd, and E. Coleman. 2015. Sexual health in america: Improving
patient care and public health. JAMA 314(8):765-766.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ADDRESSING STI EPIDEMICS 51
Singh, S., A. Mitsch, and B. Wu. 2017. HIV care outcomes among men who have sex with
men with diagnosed HIV infection—United States, 2015. Morbidity and Mortality Weekly
Report 66(37):969-974.
Swartzendruber, A., and J. M. Zenilman. 2010. A national strategy to improve sexual health.
JAMA 304(9):1005-1006.
TAG (Treatment Action Group). 2019. Gonorrhea, chlamydia, and syphilis pipline report. https://
www.ncsddc.org/wp-content/uploads/2019/03/TAG_Pipeline_STI_2019_draft.pdf
(accessed October 25, 2020).
Twenge, J. M., R. A. Sherman, and B. E. Wells. 2015. Changes in American adults’ sexual
behavior and attitudes, 1972-2012. Archives of Sexual Behavior 44(8):2273-2285.
Unemo, M., C. S. Bradshaw, J. S. Hocking, H. J. C. de Vries, S. C. Francis, D. Mabey, J. M.
Marrazzo, G. J. B. Sonder, J. R. Schwebke, E. Hoornenborg, R. W. Peeling, S. S. Philip, N.
Low, and C. K. Fairley. 2017. Sexually transmitted infections: Challenges ahead. Lancet
Infectious Diseases 17(8):e235-e279.
U.S. Census Bureau. 2017. Unmarried and single Americans week: Sept. 17-23, 2017. https://
www.census.gov/content/dam/Census/newsroom/facts-for-features/2017/cb17-
ff16.pdf (accessed February 10, 2021).
Valentine, J. A., and G. A. Bolan. 2018. Syphilis elimination: Lessons learned again. Sexually
Transmitted Diseases 45(9S Suppl 1):S80-S85.
WAS (World Association for Sexual Health). 2019. Declaration on sexual pleasure. https://
worldsexualhealth.net/declaration-on-sexual-pleasure (accessed February 10, 2021).
WHO (World Health Organization). 1975. Education and treatment in human sexuality: The
training of health professionals, report of a WHO meeting (held in Geneva from 6 to 12 Febru-
ary 1974). Geneva, Switerzland: World Health Organization.
WHO. 2006. Defining sexual health. Report of a technical consultation on sexual health, 28-31 Janu-
ary 2002, Geneva. Geneva, Switzerland: World Health Organization.
WHO. 2010. A conceptual framework for action on the social determinants of health. Geneva: World
Health Organization.
Wolfinger, N. H. 2017. America’s generation gap in extramarital sex. Charlottesville, VA: Insti-
tute for Family Studies.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Patterns and Drivers of STIs
in the United States
Chapter Contents
Introduction
Interpretation of Surveillance Data
Patterns of STIs in the United States
• Chlamydia
• Gonorrhea
• Syphilis
• Other Notable STIs
• Coinfection and Reinfection
Drivers of STI Outcomes and Inequities
• Individual-Level Factors
• Interpersonal-Level Factors
• Social and Societal Level Factors
Concluding Observations
53
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
54 SEXUALLY TRANSMITTED INFECTIONS
INTRODUCTION
Sexually transmitted infections (STIs) are a major global public health
challenge that can lead to serious reproductive, physical, and mental
health issues with devastating sequelae. These can be especially deleteri-
ous for people who were assigned female at birth (AFAB) and children.
STIs also can amplify the risk for transmitting and acquiring HIV (see
Chapter 5 for more information). STI rates continue to increase globally,
with more than 1 million STIs acquired daily (Rowley et al., 2019). The
U.S. rates are among the highest in high-income economies (NCSD, 2018;
OECD/EU, 2016) and have continued to grow over several decades,
seemingly unabated by public health interventions, especially for the
most common and reportable STIs: chlamydia, gonorrhea, and syphilis.
Preventing future infections is critical to the nation’s health.
To protect the public from the harmful impacts of STIs, it is important
to understand the epidemiology of STIs, the strengths and limitations
of the Centers for Disease Control and Prevention (CDC) case reporting
surveillance system, and these infections’ root causes (including the indi-
vidual-, interpersonal-, institutional-, community-, and structural-level
factors). This chapter therefore includes three major sections: (1) inter-
pretation of surveillance data, (2) STI patterns in the United States, and
(3) drivers of those STI outcomes, patterns, and inequities, including the
multiple levels of risk and protective factors. The section on STI drivers
is particularly important because surveillance data in isolation can lead
to placing blame on the individual without taking into account the multi-
level societal factors that influence individual behaviors, circumstances,
and, ultimately, outcomes. As highlighted in the report’s modified social-
ecological model (see Chapter 1), a complex interplay among individual,
interpersonal, institutional, community, and structural factors shapes STI
prevention, control, and treatment. This chapter’s section on drivers of
STIs and STI inequities in the United States is expanded on further in
Chapter 3. Box 2-1 highlights key findings from the chapter.
INTERPRETATION OF SURVEILLANCE DATA
STI surveillance is key to understanding the magnitude of STIs in the
United States and in subpopulations that are most affected. The ability
of federal authorities to monitor STI trends and provide the public with
actionable national data depends on local health authorities providing
case reports and other information to states, pursuant to state law. States
aggregate these data, analyze them, and use them to guide state policy.
Furthermore, states voluntarily share such aggregated data, without indi-
vidual identifiers, with CDC. After quality assurance, nationwide surveil-
lance information is then disseminated via the CDC STD surveillance
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PATTERNS AND DRIVERS OF STIs IN THE UNITED STATES 55
BOX 2-1
Key Chapter Findings on STIs in the United States
• Centers for Disease Control and Prevention (CDC) modeling suggests ap-
proximately one in five people in the United States had an STI on any given
day in 2018 (Kreisel et al., 2021).
• The two most common reportable STIs, chlamydia and gonorrhea, are most
common in younger persons (CDC, 2019d).
• The rate of congenital syphilis in 2018 was 185 percent higher than in 2014;
this is in part due to gaps in prenatal testing and treatment (CDC, 2019d;
Kimball et al., 2020).
• Approximately 79 million people have human papillomavirus (HPV), making
it the most common STI (CDC, 2019b). Effective vaccines can prevent many
HPV-associated genital warts and cancers.
• The South and West are burdened with the highest rates of many STIs (CDC,
2019d).
• Many STIs have been shown to increase risk for both acquiring and transmit-
ting HIV (CDC, 2019d).
• There are serious limitations to the existing CDC STI surveillance system,
which may lead to erroneous conclusions about STI root causes, outcomes,
and inequities. The system does not provide a nuanced understanding of infec-
tion epidemiology because it relies on case rates.
• There are multiple risk and protective factors that affect STI outcomes and
inequities. These determinants range from individual- to structural-level condi-
tions that affect STI prevention, diagnosis, and treatment.
reports, which are published annually and describe the epidemiology of
four nationally notifiable infections (chlamydia, gonorrhea, syphilis, and
chancroid). A weakness of the current reporting system is the substantial
variation in STI monitoring capacity across states and local jurisdictions
(NAPA, 2018), which hinders the ability to make direct comparisons from
place to place in order to identify emerging issues in a timely manner
and respond. While states have primary responsibility for public health,
including data collection and reporting, this report recommends actions
to leverage federal financial support to states to achieve greater timeli-
ness, uniformity, and quality of data reported by all states to CDC. CDC
STD surveillance reports also compile information from published lit-
erature on human papillomavirus (HPV), herpes simplex virus (HSV),
and Trichomonas vaginalis. CDC’s number of reported cases is derived
from several sources: (1) notifiable disease reporting from state and local
STI programs; (2) projects that monitor STI positivity and prevalence in
various settings, such as the National Job Training Program, the STD
Surveillance Network, and the Gonococcal Isolate Surveillance Project;
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
56 SEXUALLY TRANSMITTED INFECTIONS
and (3) national surveys and other data-collection systems operated by
federal and private organizations (CDC, 2019d). Census data, rather than
overall numbers of people tested, determine the total size of the relevant
population. Case rates are derived by taking the number of cases reported
from these different sources and dividing by the population from the most
recent Census information.
CDC STI surveillance data give only a partial picture of unfolding
trends and need to be interpreted with caution for several reasons: (1)
they are ecological and highly influenced by screening rates, which are not
universal and are highly variable, so the case rates might not reflect the
true population-based prevalence rate; (2) only a few STIs are surveilled,
so less is known about those that are not nationally reportable; and (3) the
data are limited to a few sociodemographic variables, such as age, race,
sex, and geography, which often limit subgroup analyses. While the case
rates do provide a crude understanding of the epidemiology and trends
of these STIs, they are susceptible to variations and fluctuations in test-
ing rates, the absence of universal screening recommendations, lag time
in case reporting, underreporting, and repeat testing (see the section later
in this chapter on coinfection and reinfection). Furthermore, the Census
is performed only every 10 years and may underestimate certain popu-
lations. Finally, delays in publishing the CDC STD surveillance report
(generally 9 months after the end of the calendar year) render it ineffec-
tive for responding to outbreaks in real time. Currently, local jurisdictions
need to request CDC assistance during outbreaks, with no standardized
early warning system for outbreaks. Population-based surveys, such as
the National Health and Nutrition Examination Survey (NHANES), and
subpopulation-based surveys, such as the National HIV Behavioral Sur-
veillance, also provide essential data for tracking STI rates and behaviors.
See Appendix A of the CDC Sexually Transmitted Disease Surveillance,
2018 report for more information on nationally notifiable STI surveillance
and other sources of surveillance data (CDC, 2019d). See also Chapter 4
for information about funding of STI surveillance.
Increases in testing rates over time may increase STI case rates and
lead to spurious conclusions. Since 2001, chlamydia screening rates for
women who are privately insured have approximately doubled, while
the rate for those receiving Medicaid has increased 17 percent (NCQA,
n.d.). However, data from the Healthcare Effectiveness Data and Informa-
tion Set show that, in 2018, only about half of women recommended to
be screened for chlamydia were actually screened (NCQA, n.d.). While
overall chlamydia case reporting demonstrates an increase in case rates
over the past 20 years, prevalence estimates from NHANES actually show
a reduction. Data reported between 1999 and 2002 showed a chlamydia
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PATTERNS AND DRIVERS OF STIs IN THE UNITED STATES 57
prevalence of 2.2 percent (range 1.8–2.8 percent) (Datta et al., 2007); data
from 2007 to 2012 show it decreased to 1.7 percent (range 1.4–2.0 percent)
(Torrone et al., 2014). NHANES data also demonstrate that racial and
ethnic disparities have persisted over the years (Datta et al., 2012). These
data are susceptible to error, however, as the sample sizes are small (Miller
and Siripong, 2013). The conflict between these estimates creates confu-
sion; more accurate, nuanced, and timely surveillance data are needed.
Women are not screened as recommended for myriad reasons, includ-
ing lack of access to health care and, for women who do have access,
low uptake by providers. For men, the lack of general screening recom-
mendations leads to fewer cases detected. For all people, the asymp-
tomatic nature of many of the STIs contributes to fewer people being
screened and tested. Since the beginning of the COVID-19 pandemic,
many municipalities reported decreased numbers of STIs, presumably
due to decreased access to testing services and less health care–seeking
behavior (de Miguel Buckley et al., 2020; Hoffman, 2020; Latini et al., 2021;
Nagendra et al., 2020). Therefore, case rates of chlamydia, gonorrhea, and
syphilis, for example, illustrate only diagnosed and reported infections
and may distort or fail to reflect true infection rates. Other STIs of public
health significance, such as HPV and HSV, are not nationally notifiable,
so their data are not routinely reported. Understanding the significance of
other highly prevalent STIs, such as Trichomonas vaginalis and Mycoplasma
genitalium, is increasing, but has not resulted in screening recommenda-
tions or reporting requirements; yet, data are mounting regarding the
importance of these infections for reproductive health (Lis et al., 2015),
perinatal morbidity (Silver et al., 2014), and amplified HIV transmission
(Kissinger and Adamski, 2013).
Traditionally, surveillance systems have captured some demographic
information about cases to understand the population at risk for the
four most common reportable STIs (chlamydia, gonorrhea, syphilis, and
HIV), but this information has been limited to sex, race and ethnicity,
and age; quality surveillance data are missing for many sexual minority
groups and transgender and other gender diverse populations. For these
reasons and those explained above, case-based surveillance is not suf-
ficient for an effective response. To address some of these shortcomings,
CDC also uses prevalence data from NHANES and the STD Surveil-
lance Network (a sentinel surveillance project in 11 jurisdictions). More
detailed information is collected in other national initiatives, too, such as
the Youth Risk Behavior Surveillance System and Behavioral Risk Factor
Surveillance System. Other potential sources of relevant data include the
National Survey of Family Growth and the National Longitudinal Study
of Adolescent to Adult Health. As with the CDC surveillance data, each
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
58 SEXUALLY TRANSMITTED INFECTIONS
source has value and limitations. For example, the STD Surveillance Net-
work only examines factors related to gonorrhea and underrepresents the
South, where a large portion of STIs occur. NHANES no longer tests for
syphilis or gonorrhea,1 and NHANES data are more accurate when com-
bined for multi-year periods because prevalence estimates and sample
sizes for any given cycle are relatively small, especially for demographic
subgroup analysis (Torrone et al., 2013). NHANES data are not available
at the regional or state levels, which could obscure regional differences
of geographically clustered STIs (Torrone et al., 2013). Finally, the Youth
Risk Behavior Surveillance System does not include out-of-school youth
(e.g., homeless, incarcerated, dropped out); these subgroups could have
high STI rates. (For more detailed information about these data sources’
strengths and limitations, see Datta et al., 2012; Miller and Siripong, 2013;
NASEM, 2019a,b; Pierannunzi et al., 2013; Rietmeijer et al., 2009; Torrone
et al., 2013; Underwood et al., 2020.) Additionally, large databases, such
as hospital discharge databases, claims data, and Healthcare Cost and
Utilization Project databases, can help to provide insight into sequelae
for STIs, such as neonatal herpes and pelvic inflammatory disease (PID).
Other databases could also potentially be used for STI surveillance as
more electronic health record information becomes available. The frag-
mented efforts described in this section highlight the need to modernize
STI surveillance (NAPA, 2018, 2019). See Chapter 12 for conclusions and
recommendations on improving STI surveillance.
Detailed surveillance data are important for STI program staff, but are
often inaccessible to laypersons. Developing other information formats
is critically important for the public to understand important trends and
emerging issues, track progress toward achieving STI reduction goals, and
hold policy makers accountable for results. The federal Ending the HIV
Epidemic Initiative has generated important resources that enable the
public to understand key indicators and track progress toward achieving
HIV milestones.2 This type of effort offers a model for increasing public
commitment to improving STI outcomes by clearly communicating cru-
cial goals in a way that easily enables individuals to monitor progress.
Simple dashboards (a short, easy-to-understand visual tool for monitor-
ing progress) can establish standard measures that can be applied to
federal, state, local, or clinical outcomes.
1 Personal communication with Hillard Weinstock, Centers for Disease Control and Pre-
vention. Available by request from the National Academies of Sciences, Engineering, and
Medicine’s Public Access Records Office ([email protected]).
2 See https://ahead.hiv.gov (accessed November 15, 2020).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PATTERNS AND DRIVERS OF STIs IN THE UNITED STATES 59
PATTERNS OF STIs IN THE UNITED STATES
U.S.-reported case rates of the three most common reportable STIs
(chlamydia, gonorrhea, and syphilis) have been increasing over the past
decades. Since 2000, the overall case rate of chlamydia has doubled, gon-
orrhea has increased nearly 1.4-fold, and primary and secondary syphilis
is up 5-fold (CDC, 2019d). In 2021, CDC estimated the incidence and prev-
alence of eight STIs to understand more fully the U.S. STI burden (Kreisel
et al., 2021). This model showed an estimated 26.2 million incident and
67.6 million prevalent STI infections in 2018. Chlamydia, trichomoniasis,
genital herpes, and HPV accounted for approximately 93 and 98 percent
of all incident and prevalent infections, respectively. This analysis indi-
cates that more than 20 percent of the U.S. population had an STI at some
point in 2018. Young people aged 15–24 are disproportionately affected,
as more than 45 percent of estimated incident infections were in that age
group (Kreisel et al., 2021).
Furthermore, STIs cost U.S. taxpayers billions of dollars. According
to recent estimates, the total lifetime direct medical cost of incident STIs
is $15.9 billion (2019 dollars), with the majority due to HIV ($13.7 bil-
lion) (Chesson et al., 2021). Of the remainder, $1 billion is attributed to
gonorrhea and chlamydia combined; three-quarters of the remaining cost
burden is due to STIs in women. Among young people aged 15–24, the
total cost of incident STIs (including HIV) is $4.2 billion (Chesson et al.,
2021). The human costs of STIs (e.g., anxiety, infertility, relationship strife
or disruption, childhood disabilities) are far more difficult to quantify
(see Chapter 4).
The sections below describe the epidemiology of the three common,
reportable STIs and of other STIs, including HIV, HPV, HSV, hepatitis B
virus (HBV), T. vaginalis, M. genitalium, chancroid, Lymphogranuloma
venereum, and a related dysbiosis, bacterial vaginosis (BV). Although STI
rates have increased across all populations in the United States, marginal-
ized groups—youth; women; members of the lesbian, gay, bisexual, trans-
gender, and queer (LGBTQ+) community; and Black, Latino/a, Ameri-
can Indian/Alaska Native (AI/AN), and Native Hawaiian/Other Pacific
Islander people—continue to experience a disproportionate share of STI
cases in the United States.
Chlamydia
Increasing chlamydial infections are in large part fueling the U.S. STI
crisis. Chlamydia is the most common notifiable condition (CDC, 2019d).
This is not a new trend, as chlamydia has made up the largest propor-
tion of STIs reported to CDC at least since 1994. Complications of unde-
tected chlamydia infections, such as PID, can lead to devastating health
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
60 SEXUALLY TRANSMITTED INFECTIONS
consequences later in life. PID is a major preventable cause of chronic
pelvic pain and tubal scarring, leading to infertility and ectopic preg-
nancy. Untreated chlamydia in pregnancy can result in infant pneumonia
and ophthalmia neonatorum, leading to blindness. Undetected infec-
tions in people assigned male at birth (AMAB) generally have less severe
sequelae, but can lead to epididymitis and contribute to such people’s
role as a reservoir. In both sexes, chlamydia infections can amplify HIV
acquisition and transmission. See Appendix A for more information.
In 2018, there were 1.7 million chlamydia infections reported to CDC,
corresponding to 539.9 cases per 100,000; this is a 20 percent increase from
2014 (CDC, 2019d). From 2000 to 2018, reported rates increased in men
and women, in all racial and ethnic groups, and in all geographic regions
(CDC, 2019d). Reported cases are likely only a fraction of the actual num-
ber of infections. A CDC modeling study estimated 4.0 million incident
chlamydia infections in those aged 15–39 in 2018 (Kreisel et al., 2021),
suggesting that the true infection rate may be more than double.
Rates of reported chlamydia cases among men and women increased
from 2000 to 2018, with a slight unexplained dip from 2011 to 2013 (CDC,
2019d) (see Figure 2-1). Case rates in CDC surveillance reports are always
higher among women than men, due to both screening differences and
biological reasons. CDC recommends screening sexually active women
under the age of 25 but screening only older women at increased risk
of infection (e.g., new sex partner, more than one sex partner) or men in
FIGURE 2-1 Rates of reported chlamydia cases by sex in the United States,
2000–2018.
* Per 100,000.
SOURCE: CDC, 2019d.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PATTERNS AND DRIVERS OF STIs IN THE UNITED STATES 61
high-prevalence settings (CDC, 2015). The narrow age range was deter-
mined to maximize efficiency in detection but may result in undiagnosed
infections, which serve as a reservoir of infection and sustain the epi-
demic. Population-based 2007–2012 NHANES data show a significantly
higher prevalence in women compared to men in the 14–39 age group
(2.0 percent versus 1.4 percent, respectively) (Torrone et al., 2014). CDC
prevalence assessments support these NHANES data, estimating 1.3 mil-
lion prevalent infections in women and 1.1 million in men in 2018 (Kreisel
et al., 2021).
Chlamydia disproportionately affects youth (see Figure 2-2); two-
thirds of all reported cases and estimated incident and prevalent infec-
tions were among persons aged 15–24 (CDC, 2019d; Kreisel et al., 2021).
The precipitous drop in infection after age 24 may be the result of behav-
ioral and biological factors, including a tendency for older persons to
be more likely to be in longer-term relationships and cumulative partial
immunity to reinfection (Batteiger et al., 2010; Lantagne and Furman,
2017; Meier and Allen, 2009).
All racial and ethnic groups experienced increases in reported chla-
mydia cases from 2014 to 2018 (CDC, 2019d). Racial and ethnic minori-
ties, however, are disproportionately burdened; the highest rates in 2018
were among Black, AI/AN, and Native Hawaiian/Other Pacific Islander
individuals. Compared with white people, rates of reported cases were
5.6, 3.7, and 3.3 times higher in these groups, respectively. Similarly, the
FIGURE 2-2 Rates of reported chlamydia cases by age group and sex in the
United States, 2018.
* Per 100,000.
SOURCE: CDC, 2019d.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
62 SEXUALLY TRANSMITTED INFECTIONS
rate of reported cases among Hispanic or Latino/a people was 1.9 times
that of white people. In contrast, the rate among persons of Asian descent
was 0.6 times that among white people (CDC, 2019d).
While rates have been increasing in all areas, in 2018, they were high-
est in the South and West, with a remarkably high rate in Alaska (see
Figure 2-3). There are geographic clusters of chlamydia, as there are with
gonorrhea and syphilis. For example, 44 percent of the reported cases
came from just 70 of more than 3,000 counties; about two-thirds of those
counties and independent cities were in the South and West (CDC, 2019d).
Gonorrhea
Second only to chlamydia, gonorrhea is a common notifiable STI
(CDC, 2019d). Much like chlamydia, its sequelae are problematic: PID,
ectopic pregnancy, and infertility for people AFAB, blindness in children
delivered by people who are infected, epididymitis in people AMAB, and
increased risk of HIV infection in all people (see Appendix A for more
information).
FIGURE 2-3 Rates of reported cases of chlamydia by state and territory in the
United States, 2018.
* Per 100,000.
SOURCE: CDC, 2019d.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PATTERNS AND DRIVERS OF STIs IN THE UNITED STATES 63
There were 583,405 cases reported to CDC in 2018, corresponding
to a rate of 179.1 cases per 100,000 (CDC, 2019d). The rate in 2018 was a
63 percent increase from that in 2014, and an almost 83 percent increase
from 2009, when reported cases were at a historic low (CDC, 2019d). Fig-
ure 2-4 shows 2000–2018 rates per 100,000. As with chlamydia, reported
gonorrhea rates increased in men and women, in all racial and ethnic
groups, and in all geographic regions from 2017 to 2018. Furthermore, a
troublesome trend has emerged, as drug-resistant strains of gonorrhea are
spreading worldwide. More than half of all infections in the United States
in 2018 were estimated to be resistant to at least one antibiotic (CDC,
2019a,d). CDC estimated that there were 1.6 million incident and 209,000
prevalent gonorrhea infections in 2018 (Kreisel et al., 2021).
The age and sex distribution is somewhat different from that of
chlamydia, because gonorrhea tends to be more symptomatic in people
AMAB than chlamydia is. CDC also recommends screening all sexually
active women under the age of 25 but not general screening of asymptom-
atic men (CDC, 2015). Surveillance data demonstrate that the age range at
highest risk is 20–24 and that men have higher rates (CDC, 2019d). From
2014 to 2018, the male rate increased by almost 80 percent compared to
approximately 45 percent for women (CDC, 2019d). Surveillance data
demonstrate that the rapid increase since 2014 is likely due to increased
infection among gay and bisexual men compared to men who have sex
with women (MSW) and women (see Figure 2-5). Additional contribu-
tors may be improved case identification among gay, bisexual, and other
FIGURE 2-4 Gonorrhea rates per 100,000 people in the United States, 2000–2018.
SOURCE: Data from CDC, n.d.-a.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
64 SEXUALLY TRANSMITTED INFECTIONS
FIGURE 2-5 Estimated rates of reported gonorrhea cases by MSM, MSW, and
women, 2010–2018.
NOTES: MSM = gay, bisexual, and other men who have sex with men; MSW
= men who have sex with women only. Sites include Baltimore, Philadelphia,
New York City, San Francisco, Washington State, and California (excluding San
Francisco).
‡ Per 100,000.
* Estimates based on interviews among a random sample of reported cases of
gonorrhea (n = 21,417); cases weighted for analysis. Data not available for 2014;
2013–2015 trend interpolated; trend lines overlap for MSW and women in this
figure.
SOURCE: CDC, 2019d.
men who have sex with men (MSM) through more extragenital screening
(CDC, 2019d).
As with chlamydia, adolescents and young adults were the age groups
most burdened in 2018. As Figure 2-6 shows, women aged 20–24 had the
highest rates of reported cases, followed by those aged 15–19. The trend in
men shifted slightly older, with the highest rates of reported cases in those
aged 20–24 and the next highest in those 25–29 (CDC, 2019d). Likewise,
people aged 15–24 made up more than half of the estimated incident and
prevalent infections in 2018 (Kreisel et al., 2021).
Black, AI/AN, Native Hawaiian/Other Pacific Islander, and Hispanic
or Latino/a populations have experienced higher rates of gonorrhea than
white or Asian populations. Despite increases for all racial and ethnic
groups from 2014 to 2018, rates were highest among Black and AI/AN
people (CDC, 2019d) (see Figure 2-7). In 2018, rates among Black people
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PATTERNS AND DRIVERS OF STIs IN THE UNITED STATES 65
FIGURE 2-6 Rates of reported gonorrhea cases by age group and sex in the
United States, 2018.
* Per 100,000.
SOURCE: CDC, 2019d.
FIGURE 2-7 Rates of reported gonorrhea cases by race/Hispanic ethnicity in the
United States, 2014–2018.
* Per 100,000.
NOTE: AI/AN = American Indian/Alaska Native; NHOPI = Native Hawaiian/
Other Pacific Islander.
SOURCE: CDC, 2019d.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
66 SEXUALLY TRANSMITTED INFECTIONS
FIGURE 2-8 Rates of reported gonorrhea cases by state and territory in the United
States, 2018.
* Per 100,000.
SOURCE: CDC, 2019d.
were 7.7 times higher than in white people. AI/AN, Native Hawaiian/
Other Pacific Islander, and Hispanic or Latino/a people also had rates
4.6, 2.6, and 1.6 times, respectively, that of white people. The rate in Asian
individuals was half that in white individuals (CDC, 2019d).
All regions experienced increased rates from 2017 to 2018, but rates
were highest in the South and Midwest in 2018 (CDC, 2019d) (see Figure
2-8). As with chlamydia, 40 states reported higher rates in 2018 than in
2017 (CDC, 2019d). While more than 93 percent of counties reported at
least one case in 2018, just under half of these were from 70 counties and
independent cities3 (CDC, 2019d), suggesting that, like chlamydia, gonor-
rhea occurs in clusters.
Syphilis
Syphilis is a genital ulcerative disease. Left untreated, it can cause
significant complications in multiple stages of infection across decades.
Primary and secondary syphilis (the early stages) are often symptomatic
3A city that is not in the territory of any county.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PATTERNS AND DRIVERS OF STIs IN THE UNITED STATES 67
and indicate incident infection. Untreated syphilis at any stage can also
be transmitted from the pregnant person to the fetus (see Appendix A).
While syphilis is far less common than chlamydia and gonorrhea, the
rates of reported primary and secondary syphilis have increased 5-fold
over the past two decades (CDC, 2019d). CDC estimates 146,000 incident
and 156,000 prevalent infections (all stages) in 2018 (Kreisel et al., 2021).
There were 115,045 reported cases of all stages in 2018; this is the highest
case count since 1991 and a 13.3 percent increase from 2017 (CDC, 2019d).
Despite historic lows in 2000 and 2001, the rate of primary and secondary
syphilis has increased almost every year since (see Figure 2-9). There were
35,063 such cases in 2018: a rate of 10.8 cases per 100,000, a 14.9 percent
increase from 2017 and a 71.4 percent increase from 2014 (CDC, 2019d).
As observed with chlamydia and gonorrhea rates, rates of reported pri-
mary and secondary syphilis increased in men and women, in all racial
and ethnic groups, and in all U.S. geographic regions from 2017 to 2018.
As with chlamydia and gonorrhea, young individuals (20–29) are
disproportionately affected by primary and secondary syphilis. As Figure
2-10 shows, rates of reported cases were highest among men aged 25–29
and women aged 20–24 in 2018. All age groups over 15 experienced
increased rates from 2017 to 2018 (CDC, 2019d).
Although rates have been increasing since 2009 for all regions, the
West and South had the highest rates of reported primary and secondary
syphilis in 2018 (see Figure 2-11). Approximately 61 percent of these cases
FIGURE 2-9 Rates of primary and secondary syphilis per 100,000 people in the
United States, 2000–2018.
SOURCE: Data from CDC, n.d.-b.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
68 SEXUALLY TRANSMITTED INFECTIONS
FIGURE 2-10 Rates of reported primary and secondary syphilis cases by age
group and sex in the United States, 2018.
* Per 100,000.
SOURCE: CDC, 2019d.
FIGURE 2-11 Rates of reported primary and secondary syphilis cases by region
in the United States, 2009–2018.
* Per 100,000.
SOURCE: CDC, 2019d.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PATTERNS AND DRIVERS OF STIs IN THE UNITED STATES 69
FIGURE 2-12 Rates of reported primary and secondary syphilis cases by race and
Hispanic ethnicity in the United States, 2014–2018.
* Per 100,000.
NOTE: AI/AN = American Indian/Alaska Native; NHOPI = Native Hawaiian/
Other Pacific Islander.
SOURCE: CDC, 2019d.
in 2018 came from 70 counties and independent cities, underscoring the
need for contact tracing for syphilis (CDC, 2019d).
Primary and secondary syphilis rates increased in all racial and ethnic
groups from 2014 to 2018 (see Figure 2-12). As observed with chlamydia
and gonorrhea, Black, Native Hawaiian/Other Pacific Islander, AI/AN,
and Hispanic or Latino/a people had higher rates than white people
in 2018 (CDC, 2019d). The rate of primary and secondary syphilis in
these groups was 4.7, 2.7, 2.6, and 2.2 times, respectively, that of white
individuals. Asian people had a lower rate than white individuals (0.8
times). Although the rate was highest among Black individuals in 2018,
the largest rate increase from 2017 to 2018 was among AI/AN people (40.9
percent increase) (CDC, 2019d).
The rate of reported primary and secondary syphilis among men has
increased annually since 2000. Men comprised 85.7 percent of cases in
2018, yielding a rate of 18.7 cases per 100,000. Moreover, more than half
(53.5 percent) of the 35,063 cases in 2018 were among MSM (CDC, 2019d).
CDC estimates of incident and prevalent syphilis infection (all stages)
support this surveillance data, finding that men accounted for more than
71 and 82 percent of all prevalent and incident infections, respectively, in
2018 (Kreisel et al., 2021).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
70 SEXUALLY TRANSMITTED INFECTIONS
FIGURE 2-13 Reported primary and secondary syphilis cases by sex and sex of
sex partners in 36 states, 2014–2018.
NOTES: 36 states were able to classify ≥70 percent of reported cases of primary
and secondary syphilis as either MSM, MSW, or women for each year during
2014–2018. MSM = gay, bisexual, and other men who have sex with men; MSW =
men who have sex with women only.
SOURCE: CDC, 2019d.
Cases among MSW and women also have increased in the past 5
years (see Figure 2-13). For example, the rate of primary and second-
ary syphilis among women increased 30 percent from 2017 to 2018 and
more than 170 percent from 2014 to 2018 (CDC, 2019d). Increased cases
in these populations are associated with increased drug use; for instance,
their reported use of heroin, methamphetamine, and injection drugs more
than doubled from 2013 to 2017 (Kidd et al., 2019). A large proportion of
heterosexual syphilis transmission, then, is among men and women using
these drugs. Similar trends were not found for MSM (Kidd et al., 2019).
Congenital Syphilis
The rise in cases among women is reflected in rates of congenital
syphilis, which can cause miscarriage and stillbirth and myriad lifelong
and developmental health problems. Up to 80 percent of children deliv-
ered by people infected with syphilis are also infected, and stillbirth and
infant death occur among 40 percent of them (see the section on preg-
nancy in Chapter 3 for more information) (CDC, 2019d). There were 1,306
cases of congenital syphilis in 2018 (CDC, 2019d). This rate, 33.1 cases per
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PATTERNS AND DRIVERS OF STIs IN THE UNITED STATES 71
FIGURE 2-14 Reported congenital syphilis cases by year of birth and rates of
reported primary and secondary syphilis cases among females aged 15–44 years
in the United States, 2009–2018.
* Per 100,000.
NOTE: CS = congenital syphilis; P&S = primary and secondary syphilis.
SOURCE: CDC, 2019d.
100,000 live births, is almost 40 percent higher than that in 2017 and more
than 185 percent higher than that in 2014 (see Figure 2-14). These increases
were observed primarily in the West and South, where rates more than
doubled from 2014 to 2018 (278.9 percent and 190.3 percent increases,
respectively) (CDC, 2019d). These regions had the highest reported rates
in 2018; there were 48.5 and 44.7 cases per 100,000 live births in the West
and South, respectively (CDC, 2019d). Case rates per 100,000 live births
were highest among Black (86.6), AI/AN (79.2), and Hispanic or Latino/a
(44.7) individuals. Comparatively, there were 13.5 cases per 100,000 live
births among white people and 9.2 cases among Asian and Pacific Islander
individuals (CDC, 2019d).
A combination of factors contributes to the high congenital syphilis
rate, and screening based on behavioral risk factors alone misses many
pregnant people with syphilis (Trivedi et al., 2019). An analysis of national
syphilis case reports from 2012 to 2016 demonstrated that half of preg-
nant women with syphilis had no known risk behaviors for the infection
(Trivedi et al., 2019). The most commonly reported risk factors were a
history of an STI (43 percent) and more than one sex partner in the past
year (30 percent) (Trivedi et al., 2019). Furthermore, cases of syphilis dur-
ing pregnancy are more common among people who are impoverished,
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
72 SEXUALLY TRANSMITTED INFECTIONS
young (under 29 years of age), Black, and without health insurance and
prenatal care. Other risk factors include incarceration, illicit drugs, high
community syphilis prevalence, and sex work (Rac et al., 2017). Univer-
sal testing during the first prenatal visit and the third trimester could
identify asymptomatic infected individuals at high risk for transmitting
to the infant. However, congenital syphilis is also a failure of the health
care system; half of new cases in 2018 were due to gaps in prenatal test-
ing and treatment (Kimball et al., 2020). A CDC report identified the lack
of adequate maternal treatment, despite timely diagnosis, as the most
common prevention opportunity missed (30.7 percent) nationally; lack
of timely prenatal care (28.2 percent) was another important preven-
tion opportunity missed (Kimball et al., 2020). These missed opportuni-
ties varied across the United States and are important in understanding
increasing congenital syphilis rates and implementing effective, tailored
interventions.
Other Notable STIs
Other STIs include HIV, HPV, HSV types 1 and 2, HBV, Trichomonas
vaginalis, Mycoplasma genitalium, chancroid, and Lymphogranuloma vene-
reum. BV is a related dysbiosis, and more research is needed on whether
it is sexually transmitted. This section briefly describes these STIs; how-
ever, detailed data are not available for all of them because they are not
all nationally reportable.
HIV
While surveillance for HIV is rigorous and active, it also has limita-
tions, as less than 40 percent of U.S. individuals have ever been tested
(Pitasi et al., 2019). Approximately 1.2 million U.S. individuals were living
with HIV in 2018, and an estimated one in seven did not know they had
HIV (CDC, 2020e). New HIV diagnoses decreased 7 percent from 2014 to
2018; 37,968 people of all ages were diagnosed in 2018 (CDC, 2020d), 69
percent of which were among MSM, 24 percent were among heterosexu-
als, and 7 percent were among people who inject drugs (CDC, 2020d). As
Figure 2-15 shows, 42 percent of new HIV diagnoses were among Black
individuals (though they constitute about 13 percent of the population),
and 27 percent were among Hispanic or Latino/a individuals; Black MSM
were the most affected subgroup in 2018 (CDC, 2020d). Additionally, new
HIV diagnoses were highest among those aged 13–34 (see Figure 2-16).
HIV rates were highest in the South (15.6 cases per 100,000) in 2018 (CDC,
2020d). See Chapter 5 for a discussion of the interface of STIs and HIV.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PATTERNS AND DRIVERS OF STIs IN THE UNITED STATES 73
American Indian/
Alaska Native <1%
Native
Asian Hawaiian/
2% Other Pacific
Islander
Multiple Race
<1%
2%
White
Black/African
25%
American*
42%
Hispanic/LaƟno†
27%
FIGURE 2-15 New HIV diagnoses by race/ethnicity in the United States and
dependent areas, 2018.
* Black refers to people having origins in any of the Black racial groups of Africa.
African American is a term often used for Americans of African descent with
ancestry in North America.
† Hispanics/Latinos can be of any race.
SOURCE: CDC, 2020d.
FIGURE 2-16 New HIV diagnoses by age in the United States and dependent
areas, 2018.
SOURCE: CDC, 2020d.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
74 SEXUALLY TRANSMITTED INFECTIONS
Human Papillomavirus
There are more than 40 types of HPV that can infect the genital tract,
and while many infections are asymptomatic and most resolve on their
own within a few years, 13 types are associated with an increased risk
for anogenital and head and neck cancers (CDC, 2020b). An estimated
42.5 million people aged 15–59 had at least one disease-associated HPV
type in 2018, and 13.0 million people in the same age group acquired a
new infection in 2018 (Kreisel et al., 2021); 79 million people in the United
States have HPV (CDC, 2019b). See Appendix B for information on HPV
screening recommendations.
Persistent infections can cause genital warts and precancerous and
cancerous lesions of the cervix, vulva, vagina, penis, anus, and orophar-
ynx. HPV types 6 and 11 account for about 90 percent of U.S. cases of geni-
tal warts. HPV types 16 and 18 cause approximately two-thirds of cervical
cancer cases and one-quarter of low-grade and half of high-grade cervical
dysplasia. Three HPV vaccines are licensed for use in the United States
and target various oncogenic types: bivalent (types 16 and 18), quadri-
valent (types 6, 11, 16, and 18), and 9-valent (types 6, 11, 16, 18, 31, 33,
45, 52, and 58). Since 2016, however, the 9-valent vaccine is the only one
distributed in the United States. Vaccination is recommended for routine
use in everyone ages 11–12, with catch-up vaccination through age 26; the
9-valent vaccine is approved for people up to age 45 (Meites et al., 2019).
The vaccines have had a considerable, positive effect on sequelae of
HPV infection, including reduced genital HPV infections among adoles-
cent girls and young women, high-grade cervical lesions and invasive cer-
vical cancer among young women (Lei et al., 2020), and anogenital warts
among male and female adolescents and young people (CDC, 2019d).
Additionally, NHANES data show a substantial decline in the prevalence
of HPV types 6, 11, 16, and 18 among women aged 14–24 after vaccine
introduction (Oliver et al., 2017). NHANES data from 2013 to 2014 also
indicate a low prevalence of those four types in young men (Gargano et
al., 2017). Furthermore, health care claims data show a positive effect of
the vaccine on the prevalence of high-grade cervical intraepithelial neo-
plasia grades 2 and 3 among women aged 15–24 (Flagg et al., 2016).
Despite these effective vaccines, current vaccine uptake does not meet
the Healthy People 2030 goal of 80 percent coverage. In fact, approxi-
mately 70 percent of girls aged 13–17 had received at least one dose in
2018, but only 54 percent had received all doses. Fewer boys received the
vaccine in 2018; about two-thirds had received at least one dose, and less
than half had all doses (Walker et al., 2019).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PATTERNS AND DRIVERS OF STIs IN THE UNITED STATES 75
Herpes Simplex Virus
HSV is another prevalent viral STI. The majority of infections are
unrecognized; apparent infections manifest as painful and recurring geni-
tal and/or anal lesions. In the United States, HSV-2 is responsible for most
genital infections; HSV-1 usually causes orolabial infections that are typi-
cally acquired in childhood. However, genital infections with HSV-1 are
increasing in young adults (CDC, 2019d).
Genital HSV infections are not nationally notifiable like some other
STIs, and many patients remain undiagnosed. For instance, more than
87 percent of the HSV-2 seropositive NHANES population (2007–2010)
reported never being diagnosed by a health care professional (Fanfair et
al., 2013). NHANES data also reveal that age-adjusted HSV-2 seropreva-
lence decreased from 18 percent in 1999–2000 to about 12 percent in 2015–
2016 (McQuillan et al., 2018). All racial and ethnic groups experienced this
decline, but seroprevalence remained highest among Black individuals
(McQuillan et al., 2018). A CDC modeling paper estimated 18.6 million
prevalent HSV-2 infections in those aged 15–49 in 2018 (Kreisel et al.,
2021). Furthermore, there were an estimated 572,000 incident infections,
42.3 percent of which were among youth aged 15–24 (Kreisel et al., 2021).
NHANES data show decreasing HSV-1 prevalence and orolabial
infection among those aged 14–19; HSV-1 seroprevalence declined sig-
nificantly: 39 percent from 1999 to 2004 to about 30 percent from 2005
to 2010 (Bradley et al., 2014). Meanwhile, genital HSV-1 infections are
climbing among young adults, ascribed partly to the decrease in orola-
bial HSV-1 infections (Bernstein et al., 2013; Roberts et al., 2003). People
without HSV-1 antibodies at sexual debut are more prone to genital HSV-1
infection and symptomatic genital HSV-2 infection (Bradley et al., 2014).
This susceptibility has implications for people of childbearing age, as pri-
mary genital HSV infection during pregnancy raises the risk of neonatal
transmission.
Hepatitis B
HBV has no cure and can be transmitted through sexual activity,
contaminated blood, and childbirth. Acute infection can resolve, or the
condition can become chronic. The risk of infection becoming chronic
depends on age at infection: infants and young children have the greatest
risk (Fattovich et al., 2008). Long-term, untreated infection damages the
liver, potentially resulting in liver fibrosis, liver cancer, and ultimately,
liver failure or death (CDC, 2020g). Like HPV, there is an effective vaccine,
and it is part of the routine childhood vaccination schedule; universal
newborn vaccination in the United States began in 1991 (Kruszon-Moran
et al., 2020).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
76 SEXUALLY TRANSMITTED INFECTIONS
In 2018, there were 3,322 reported incident cases of acute HBV in the
United States; after adjusting the data for under-reporting and under-
ascertainment, there were an estimated 21,600 acute infections (CDC,
2020g). Including the vaccine in the childhood schedule has lowered
rates among children and young adults to age 29. More than half of the
reported acute cases, however, were among people aged 30–49 (CDC,
2020g). From 2003 to 2018, acute rates have been consistently higher
among men than women. In 2018, rates of acute infection were highest
among white and Black people (1.0 reported cases per 100,000), followed
by American Indian/Alaska Native, Hispanic or Latino/a, and Asian/
Pacific Islander (0.9, 0.4, and 0.3 reported cases per 100,000, respectively)
people (CDC, 2020g).
A CDC modeling paper estimated 103,000 prevalent sexually trans-
mitted HBV infections in those 15 and older in 2018 (Kreisel et al., 2021).
NHANES data from 2018 indicate prevalence of past or present HBV
infection is 4.3 percent (5.3 percent among men and 3.4 percent among
women); this decreased from 5.7 percent in 1999. Asian adults had the
highest prevalence of past or present infection (21.1 percent); Black (10.8
percent) and Hispanic or Latino/a (3.8 percent) adults also had higher
prevalence than white adults (2.1 percent). Past or present infection was
also greater among those born outside of the United States (Kruszon-
Moran et al., 2020).
Trichomonas vaginalis
Trichomoniasis is estimated to be the most common nonviral STI in
the world (Rowley et al., 2019). Among women, the global prevalence
is more common than chlamydia, gonorrhea, and syphilis combined
(Rowley et al., 2019). Trichomoniasis has been associated with poor birth
outcomes, such as premature rupture of membranes, preterm delivery,
and low birth weight, and with PID and increased risk of HIV infection
(Kissinger and Adamski, 2013; Silver et al., 2014; Van Gerwen et al., 2021).
General screening for trichomoniasis is not currently recommended,
and it is not a CDC-reportable disease. Modeling has estimated, however,
that there were approximately 156 million new cases worldwide in 2016
(Rowley et al., 2019). In the United States in 2018, there were an estimated
2.6 million prevalent infections and an astounding 6.9 million incident
infections among people aged 15–59 (Kreisel et al., 2021). Women are 6
times more likely than men to have a prevalent infection. Non-Hispanic
Black people are 8 times more likely to be infected than non-Hispanic
white people, constituting a dramatic health disparity (Patel et al., 2018).
Other risk factors include older age, two or more sex partners in the
past year, less than a high school education, life below the poverty level,
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PATTERNS AND DRIVERS OF STIs IN THE UNITED STATES 77
smoking, and history of incarceration (Patel et al., 2018; Satterwhite et al.,
2013). The prevalence in MSM is very low (Francis et al., 2008). It is cur-
rently unclear if extragenital (oral, rectal) infection occurs; a few studies
have detected it in these areas by nucleic acid amplification test (NAAT)
testing, but it is much less common (Carter-Wicker et al., 2016; Francis
et al., 2008). Oral and rectal testing or screening is not currently recom-
mended for women or men (CDC, 2015).
Mycoplasma genitalium
Mycoplasma genitalium (MG) is an emerging, recently identified bacte-
rial STI that causes persistent urethritis in people AMAB and is associated
with cervicitis, endometritis, PID, and tubal factor infertility in people
AFAB (Manhart et al., 2007). Its epidemiology, however, is not currently
well understood. In some studies, it is among the most prevalent STIs,
usually second only to chlamydia (CDC, 2015; Jensen, 2017; Manhart et
al., 2007; Sonnenberg et al., 2013, 2015). A study using data from Britain’s
third National Survey of Sexual Attitudes and Lifestyles found MG preva-
lence was 1.2 percent in men and 1.3 percent in women (Sonnenberg et
al., 2015). The highest prevalence among men was in those aged 25–34
(2.1 percent); the highest prevalence among women was in those aged
16–19 (2.4 percent). In the study sample overall, more than 90 percent of
in men and more than 66 percent of in women were in the 25–44-year-
old age group. About half of women and the majority of men reported
no symptoms, although MG was associated with postcoital bleeding in
women (Sonnenberg et al., 2015). A 2007 study using data from the U.S.
National Longitudinal Study of Adolescent Health found prevalence was
1.0 percent among those aged 18–27; prevalence was significantly higher
among Black adolescents and young adults (Manhart et al., 2007). More-
over, a 2020 study using data from a large, multi-center clinical valida-
tion study of a diagnostic test for MG found overall prevalence was 10.3
percent (Manhart et al., 2020). The prevalence among those aged 15–24
was significantly higher than those aged 35–39, and Black study partici-
pants were about twice as likely to have an infection as white participants
(Manhart et al., 2020).
Furthermore, antibiotic resistance is increasing. In some countries,
the proportion of MG cases with macrolide resistance is greater than
50 percent, with reports of dual or multi-drug resistance, especially in the
Asia-Pacific region (Jensen, 2017). CDC included MG in its 2019 antibiotic
threats report, indicating that while antibiotic-resistant MG has not yet
spread widely in the United States, it could become common without
vigilance (CDC, 2019a). Clearly, more research is needed into the natural
history of MG infection and its prevalence in the United States.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
78 SEXUALLY TRANSMITTED INFECTIONS
Chancroid
Chancroid is a reportable bacterial STI caused by Haemophilus ducreyi,
although, unlike chlamydia, gonorrhea, and syphilis, it is not a major
contributor to the U.S. epidemic of STIs. When infection occurs, it is usu-
ally associated with infrequent outbreaks. Chancroid cases peaked in the
mid-1940s and decreased after the expansion of effective antibiotics. There
have been fewer than 100 reported cases each year since 2000; 2018 had
three (CDC, 2019d).
Lymphogranuloma Venereum
Lymphogranuloma venereum is an STI caused by three serovars
of Chlamydia trachomatis (L1, L2, or L3). Although it is uncommon in
the United States, there are increasing reports of incident cases among
MSM (Ceovic and Gulin, 2015). Additionally, it may be more commonly
reported among people AMAB because early symptoms are more appar-
ent in them (Ceovic and Gulin, 2015). Clinical symptoms include a pain-
less genital ulcer, lymphadenopathy, and proctitis. Untreated, the later
stages of the infection can lead to systemic infection and anogenital fistu-
las (CDC, 2015; Ceovic and Gulin, 2015).
Bacterial Vaginosis
BV is a dysbiosis caused by a change in the vaginal microbiome,
characterized by the loss of hydrogen-peroxide-producing lactobacilli
and an increase in facultative and strict anaerobes (Bautista et al., 2016;
Muzny et al., 2019). It is the most common cause of symptomatic vagi-
nal discharge in women aged 15–44 (CDC, 2020a). Black and Hispanic
or Latina women in North America were found to have significantly
higher BV prevalence than white and Asian women (33.2, 30.7, 22.7, 11.1
percent, respectively) (Peebles et al., 2019). BV usually occurs in sexually
active people AFAB and is more common among women who have sex
with women (WSW) (Muzny et al., 2019). The syndrome is associated
with increased susceptibility to other STIs, including HIV, and with other
adverse health outcomes, such as PID (CDC, 2020a; Mirmonsef et al.,
2012; Peebles et al., 2019). BV can be asymptomatic, so people may be
unaware of it. BV may resolve without treatment but can be cured with
antibiotics. Recommended therapy results in resolution in only 70–80
percent of women; despite treatment, more than half of people experience
recurrent BV within 3–6 months of therapy (Joesoef et al., 1999; Muzny
and Kardas, 2020; Workowski and Bolan, 2015).
Understanding of BV pathogenesis and transmission remain complex
(CDC, 2020a; Muzny and Kardas, 2020). However, anything that affects
the vagina’s pH and the balance of vaginal bacterial growth, such as
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PATTERNS AND DRIVERS OF STIs IN THE UNITED STATES 79
vaginal douching, vaginal deodorant, and new or multiple sexual part-
ners, is associated with BV (Bautista et al., 2016; CDC, 2020a; Planned
Parenthood, n.d.). Data suggest BV may be sexually transmitted (Fethers
et al., 2008, 2012; Muzny and Kardas, 2020; Ratten et al., 2021). BV-associ-
ated bacteria may be sexually transmitted (Fethers et al., 2012; Muzny et
al., 2019), but more research is needed on whether it is a single keystone
pathogen or a combination of sexually transmitted bacteria that causes
BV (Muzny and Kardas, 2020).
Coinfection and Reinfection
Given the common route of transmission, an STI may occur as one of
several organisms transmitted. For example, gonorrhea and chlamydia,
syphilis and HIV, or trichomoniasis and HSV-2 could be transmitted in
the same sexual encounter between a coinfected person and a susceptible
partner. Reproductive tract perturbations can facilitate the ease of trans-
mission in several ways, including mucosal disruption and increasing
inflammatory dynamics (see, too, the above section in this chapter on BV)
(Galvin and Cohen, 2004; Nusbaum et al., 2004).
Long-term immunity is provided by prior infection for some STIs, but
not for most. For example, many adults are able to recover completely
from acute HBV infection; an antibody to the HBV surface antigen confers
immunity to subsequent infection (CDC, 2020c; Fattovich et al., 2008).
Type-specific HPV protection is thought to protect from subsequent infec-
tion for many years, but there are other, less closely related HPV types
that circulate in humans, so it is possible to reacquire HPV even after
resolution of an infection from a different HPV type (Wang and Roden,
2013). Sexually transmitted HSV results in chronic infections, as does HIV.
Curable and/or self-limiting bacterial STIs (e.g., chlamydia, gonorrhea,
syphilis) or parasites (e.g., Trichomonas vaginalis) generate limited (or no)
lasting immunity, so reinfection can occur (Cameron and Lukehart, 2014;
Hosenfeld et al., 2009; Malla et al., 2014; Menezes and Tasca, 2016). Lack of
sustained acquired immunity underscores the risk of lifelong susceptibil-
ity to many STIs (see Chapter 7 for information on STI vaccines).
DRIVERS OF STI OUTCOMES AND INEQUITIES
Knowledge does not always lead to better choices…. Barriers to health care
are universal, and some other barriers include fear, lack of education, stigma
against getting tested, and lack of access to discreet care.
—Participant, lived experience panel4
4 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.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
80 SEXUALLY TRANSMITTED INFECTIONS
Although CDC surveillance data can help public health profession-
als understand which populations are affected by STIs, these data do not
explain why some individuals acquire STIs while others do not and why
some groups have higher STI rates. Since The Hidden Epidemic was pub-
lished more than two decades ago, the rate of common STIs has grown, as
has the understanding of factors that increase transmission. In the 1980s,
May and Anderson (1987) described the basic reproductive rates of an STI
epidemic as Ro = β * c * D, where β is the transmissibility of the organ-
ism, c is the number of new partners per unit time, and D is the duration
of infection. It is now understood that each component of this model is
influenced by complex and ever-changing individual, interpersonal, insti-
tutional, community, and structural factors, as depicted in the conceptual
framework in Chapter 1 (see Figure 1-3).
Transmissibility (β) is influenced by many factors, including the
increase in drug-resistant STI infections and changing sexual behaviors,
such as an increase in extragenital sex and relaxation of or misuse of bar-
rier protection. Effective antibiotic treatment moderates transmissibility,
but drug resistance is fueled by the overuse of antibiotics and the lack
of new product development. Condoms also reduce transmissibility of
all STIs. The increasing use of pre-exposure prophylaxis (PrEP) for HIV
prevention may potentially lead to decreased condom use, leading to
high rates of STIs among PrEP users, although recommended quarterly
STI screening as part of the PrEP regimen also may potentially increase
diagnosis and treatment rates and ultimately reduced population-level
burden of STIs (Jenness et al., 2017). It remains difficult to observe secular
trends, given the increases in STIs prior to PrEP use and uncertain impacts
of treatment as prevention and life-saving antiretroviral medications for
those living with HIV. Transmission probability also depends on the con-
text within which sexual partnering occurs. Sexual exposure is a neces-
sary but not sufficient factor for STI transmission. For example, a person
could have multiple sexual exposures with multiple partners who are not
infected and so never become infected. Another person could have sexual
exposure to just one person who is infected and become infected. STI
prevalence in a sexual network is dependent on numerous scenarios. Net-
works that are more densely connected or have concurrency can increase
transmission across a network subgroup. Transmission is also influenced
by community prevalence.
Number of new partners per unit time (c) is an important attribute
because having additional partners increases the probability of coming
into contact with an infected person, and individuals with higher num-
bers of partners tend to be in contact with one another. This can amplify
transmission, particularly if the partners have higher rates of STIs (this
is a more important variable than partner number). Number of partners
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PATTERNS AND DRIVERS OF STIs IN THE UNITED STATES 81
has been increasing because of reduced age of sexual debut, delayed mar-
riage or long-term coupling, and access to more partners because of social
media/hookup apps and changing mores that may dissociate emotional
attachment and intimacy from sex (CDC, 2017; Heywood et al., 2015; Liu
et al., 2015). Duration of the infection (D) is elongated when asymptomatic
people do not get screened or symptomatic people are either not treated
or improperly treated. Screening policies, health care access, and vaccine
and therapeutic development rely on financial resources, public aware-
ness, and political will, none of which have been robust for STI treatment
and prevention (NAPA, 2018).
In Chapter 1, a social-ecological approach is proposed to guide under-
standing of the multi-level societal factors that may drive the observed
increase in STIs in the U.S. population in general and its unequal dis-
tribution across social groups. Understanding the epidemiology of STI
inequities and identifying the structural and social factors associated with
these inequities are key to developing effective interventions to prevent,
diagnose, and treat STIs. This section describes the common individual-,
interpersonal-, community-, institutional-, and structural-level social, eco-
nomic, political, cultural, and environmental factors that affect STI out-
comes and inequities in the U.S. population. The sections below highlight
drivers of STIs that range from factors such as sexual behaviors, substance
use, and sexual networks to health system policies, socioeconomic issues,
and societal values, laws, and policies. Technology is an important multi-
level driver associated with sexual health and STI acquisition, prevention,
and care at all levels of these factors (see Chapter 6 for more information
on the role of technology and media).
As this report’s conceptual model describes, intersectionality is an
important conceptual and analytic framework in considering the interre-
lated societal influences on STI risk, acquisition, prevention, testing, and
care across and within social groups. A growing body of public health
research and practice uses this framework, which has its roots in Black
feminist theory and praxis. Intersectionality focuses on how multiple
social identities and positions at the micro level (e.g., gender identity,
race, ethnicity, sexual orientation, socioeconomic status) and structural
inequities (e.g., sexism, cisgenderism, racism, heterosexism, poverty) at
the macro level simultaneously shape individuals’ and groups’ lived
experiences in social, economic, political, and historical context (Calabrese
et al., 2018; Collins and Bilge, 2020; Earnshaw et al., 2013; Gkiouleka et al.,
2018; Howard et al., 2019; Li et al., 2017; Rice et al., 2018).
Intersectionality indicates that the structural inequities outlined in this
chapter (e.g., sexism, racism, heterosexism, poverty) contribute to higher
rates of STIs for multiply marginalized populations, including Black and
Latino MSM; Black, Latina, and AI/AN women; and LGBTQ+ youth. Of
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
82 SEXUALLY TRANSMITTED INFECTIONS
note, these structural inequities influence individual and group access to
social, economic, and health care resources that mitigate the risk of STIs
(e.g., income, health insurance, usual source of health care, education), as
well as societal factors that increase STI exposure, including involvement
in sex work, substance use, violence, and judicial involvement and/or
incarceration. CDC only provides epidemiological data for some of the
aforementioned marginalized groups (e.g., Black MSM, Latina women).
However, research suggests that all the aforementioned social groups
have disproportionately higher STI rates. These groups face significant
discrimination and stigma that deter them from accessing testing and
treatment services as a result of the compounding effect of multiple forms
of structural inequities and social determinants of health, which need to
be addressed to mitigate observed STI disparities (Bowleg et al., 2014;
Brinkley-Rubinstein et al., 2016; Dyer et al., 2020; Glick et al., 2020; Kelly
et al., 2018; Leichliter et al., 2020; London et al., 2017) (see Chapter 3 for
more information). The STI National Strategic Plan (STI-NSP): 2021–2025
has embraced the importance of addressing the social determinants of
health (HHS, 2020), which aligns with this report.
Individual-Level Factors
This section provides an overview of the biological and social
individual-level factors that need to be taken into consideration for STI
prevention and control. Chapter 3 further describes these factors and their
impact on various priority populations.
Biological Factors
Research on biological modifiers to STI susceptibility is limited. While
rates of infection among Black, Latino/a, and AI/AN individuals are
higher for many STIs (CDC, 2019d), no data exist to indicate a biological
reason for this. Some indicators suggests that women, particularly young
women, are more susceptible to infection and that certain types of sex
behavior lead to a higher likelihood of infection. For example, vaginal and
anal exposure and lack of penile circumcision have well-demonstrated
impact on STI susceptibility (Critchlow et al., 1995; Jacobson et al., 2000;
Sharma et al., 2018), as do modifiable practices, such as contraceptive
methods, and the coexistence of other conditions, such as BV (see Chap-
ter 7 for more information on the effects of contraceptive measures). A
number of these variables are also associated with social determinants of
health that may also influence susceptibility, as described below.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PATTERNS AND DRIVERS OF STIs IN THE UNITED STATES 83
Sex, gender, sexual orientation, and sexual behavior Irrespective of
gender identity, for persons with a cervix who engage in vaginal sex,
the primary site of infection with common mucosal pathogens such as
Neisseria gonorrhoeae and Chlamydia trachomatis are the columnar cells of
the cervix and endocervix (Jacobson et al., 2000). In prepubertal sexually
active persons with a cervix, vaginal squamous epithelium is susceptible
to gonococcal or chlamydial vaginitis. During the hormonal shifts in
puberty, mediating changes make the vaginal epithelium less susceptible
to infection (Colvin and Abdullatif, 2013). A biological contributor to the
increased STI risk in adolescents may be a manifestation of the residual
columnar cervical epithelium (“ectopy”) present at the cervix as this
transition occurs (CDC, 2019d; Critchlow et al., 1995). Interestingly, some
hormonal contraceptives are also associated with increased ectopy (Bright
et al., 2011) and have been hypothesized to increase susceptibility to gon-
orrhea and chlamydial infections (Mohllajee et al., 2006; Morrison et al.,
2004), although data remain inconclusive (Berry and Hall, 2019).
Individuals with a vagina are relatively more susceptible to infec-
tion from penile-vaginal penetrative intercourse. This may be due to the
retention of genital secretions within the vaginal vault, thereby prolong-
ing exposure of the cervical epithelium to the infectious agent, whereas
the penis would be removed from the vagina and cervical exposure.
Susceptibility increases with increased trauma to the epithelium during
sex. While data are lacking, people who engage in receptive rectal inter-
course may be analogously susceptible to infection related to retaining
genital secretions and sustaining possible trauma to the anal mucosa.
The transmission efficiency of receptive or active oral sex is a topic of
ongoing debate. Additionally, kissing may be associated with oropharyn-
geal gonorrhea transmission (Chow et al., 2019). For people AFAB with
partners AFAB, the biological efficiency of STI transmission appears to
be somewhat lower (however, this depends on whether they also have
sex with partners AMAB and on other factors, such as sexual violence).
The biological susceptibility to STIs among trans and non-binary people
after medical gender affirmation procedures is unknown. Testosterone
hormone therapy to affirm gender identity, however, has been found to
reduce Lactobacillus dominance in the vaginal microbiome of trans men
(Winston McPherson et al., 2019); this altered microbial environment may
be correlated with BV, which could increase susceptibility to other STIs.
Circumcision Penile circumcision is a common elective procedure rooted
in cultural and religious practices. It is associated with reduced suscepti-
bility to HIV and some other STIs (Sharma et al., 2018; Yuan et al., 2019;
Zhang et al., 2019b). The difference in susceptibility may reflect changes to
the epithelial surface of the circumcised penis, with epithelial thickening
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
84 SEXUALLY TRANSMITTED INFECTIONS
and increased keratinization, though some scientists postulate alternative
mechanisms (Dinh et al., 2012; Kigozi et al., 2020). Inflammatory changes
in diverse populations of uncircumcised men are implicated in higher
HIV and STI risks (Anderson et al., 2011; Lemos et al., 2014; Morris and
Wamai, 2012).
A meta-analysis of 49 studies from around the world found an esti-
mated 42 percent reduction in circumcised men’s risk for HIV acquisi-
tion; heterosexual men had a greater risk ratio reduction (72 percent)
than MSM (20 percent) (Sharma et al., 2018). A subsequent systematic
review and meta-analysis found circumcision was associated with 23
percent reduced odds of HIV acquisition among MSM (Yuan et al., 2019).
This protection, however, was stronger among circumcised MSM in low-
and middle-income countries, with no significant benefit found in MSM
from high-income nations (Yuan et al., 2019). A third systematic review
and meta-analysis found a 7 percent protective benefit for circumcised
compared to uncircumcised MSM; it was higher among men from Africa
or Asia (38 percent) than among men from other regions (Zhang et al.,
2019b). The potential impact on the MSM HIV pandemic suggests that
circumcision could play a role in combination prevention efforts (Zhang
et al., 2019a, 2020). Methodological differences across studies may help
to explain the wide variations in protective efficacy (Qian et al., 2016;
Sharma et al., 2018; Yuan et al., 2019; Zhang et al., 2019b). Penile circum-
cision is now firmly grounded as an important HIV prevention effort in
sub-Saharan Africa, where incidence rates are high and circumcision rates
are low (Vermund et al., 2013). Universal neonatal circumcision in high
HIV incidence areas has been advocated but is far from being a global
standard (Joseph Davey et al., 2016; Morris et al., 2016). Debate continues
as to the utility of neonatal circumcision for high-income, lower HIV inci-
dence venues (Earp, 2015).
Epidemiological studies have demonstrated that circumcision is also
associated with reduced risk for acquiring HPV and ulcerative STI patho-
gens, such as HSV-2 and, theoretically, chancroid, among men and among
women who have sex with men (WSM) (Morris et al., 2019; Tobian et al.,
2009; Yuan et al., 2019). The effect on risk for syphilis and mucosal STIs,
such as gonorrhea and chlamydia, is less certain (Jameson et al., 2010;
Sharma et al., 2018; Tobian et al., 2009; Weiss et al., 2006). It may be con-
cluded that STI rates could be reduced with male circumcision to greater
or lesser extent, depending on context. In nations or populations with
higher HIV and STI rates, the risk–benefit ratio will favor circumcision;
in lower risk settings, it may not be cost effective.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PATTERNS AND DRIVERS OF STIs IN THE UNITED STATES 85
Vaginal and rectal microbiome and douching A healthy vaginal micro-
bial environment is composed of hydrogen-peroxide-producing lacto-
bacilli (Martino and Vermund, 2002), which likely protect against the
overgrowth of both endogenous flora and exogenous organisms. Vaginal
flora and lactobacilli can be diminished with douching, which will physi-
cally wash out protective lactobacilli, opening ecological niches for other
organisms, including STIs (Newton et al., 2001; Tsai et al., 2009). On bal-
ance, evidence suggests that repeated douching can diminish lactobacilli
dominance and increase the risk of reproductive tract infections (Martino
and Vermund, 2002).
Some individuals douche vaginally, particularly after sex or the
menstrual cycle. According to the 2015–2017 National Survey of Family
Growth, about 16 percent of women did so in the previous year (CDC,
2019c). Douching is more prevalent among Black adolescents and women
than among white adolescents and women, which could be due in part
to opinions from mothers, peers, and media that associate douching with
“hygiene and cleanliness,” particularly after menstrual cycles (Annang
et al., 2006; Brown et al., 2016; DiClemente et al., 2012; Funkhouser et al.,
2002a,b; Martino et al., 2004). For example, a study of Black young women
aged 14–20 in Atlanta, Georgia, found 43 percent reported ever douch-
ing, and 29 percent reported douching in the past 90 days (DiClemente et
al., 2012). Another study of a cohort of women in Los Angeles found 61
percent of Black women reported douching in the past year compared to
40 percent of white women (Brown et al., 2016). However, education can
reduce douching prevalence (Cottrell, 2010; Grimley et al., 2005). Reduc-
ing or eliminating vaginal douching may reduce STI acquisition.
People who engage in receptive anal intercourse may douche rectally
(Dangerfield et al., 2020; Hambrick et al., 2018). Recent rectal douching
among MSM (at least once within the past 12 months) before receptive
intercourse varied across studies in a 2018 literature review (43–64 per-
cent) (Carballo-Diéguez et al., 2018). The reasons included hygiene main-
tenance, request from a sexual partner, preparation for intercourse, and
advice from peers (Carballo-Diéguez et al., 2018). It is hypothesized that
HIV and other STIs could cross through or infect rectal mucosa more eas-
ily after douching than in the more natural state, because some douching
preparations may disrupt the protective epithelium or because of poten-
tial rectal trauma sustained during douching (Baggaley et al., 2010; Li et
al., 2019). Some studies have found an association between rectal douch-
ing and increased odds of infection with HIV and other STIs (Hassan et
al., 2018; Li et al., 2019); additional research into co-occurring behaviors
that increase the risk of infection is needed.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
86 SEXUALLY TRANSMITTED INFECTIONS
Alcohol, Substance Use, and Compulsive Sexual Behavior
Both alcohol and substance use are associated with increased sexual
risk behavior and STI risk (Boden et al., 2011; Cook et al., 2006; Feaster
et al., 2016; Strathdee et al., 2020). Results from a 30-year longitudinal
birth cohort study from New Zealand provide compelling evidence for
increasing risk of STI diagnoses as alcohol use increases (Boden et al.,
2011). Furthermore, binge drinking is associated with a 5 times higher
risk for gonorrhea among women (Hutton et al., 2008). Similarly, case–
control and longitudinal studies and surveys show elevated STI risk
among individuals who use illicit substances (Cook et al., 2006; Feaster et
al., 2016; Strathdee et al., 2020). Alcohol, and particularly substance use,
can increase the risk of STI acquisition through multiple mechanisms.
First, both are associated with increased sexual risk behavior, including
condomless intercourse and increased number and concurrency of sex
partners (Adimora et al., 2007, 2011; Berry and Johnson, 2018; Celentano
et al., 2008; Khan et al., 2013; Strathdee et al., 2020). Second, alcohol and
substance use, addiction, and dependence are associated with increased
participation in transactional sex (Gerassi et al., 2016; Patton et al., 2014;
Strathdee et al., 2020)—a primary risk factor for STIs. Third, direct blood
contact represents a possible STI transmission mechanism among people
who use injection drugs and other individuals who share needles (Celen-
tano et al., 2008; Khan et al., 2013).
Of note, the association of substance use pattern and STI risk has
been shown to differ across risk groups defined by gender and partner
gender (i.e., for MSW versus MSM versus WSM versus WSW) (Feaster et
al., 2016). For women (both WSM and WSW), severity of street drug use
(e.g., heroin, crack cocaine) was most strongly associated with STI risk,
while for MSM, severity of club drug use (e.g., powder cocaine, metham-
phetamine, ecstasy, hallucinogens) most predicted STI risk. Associations
between substance use patterns and STI risk were weakest for MSW
(Feaster et al., 2016). These findings linking club drug use to STI risk for
MSM are in line with evidence suggesting a high prevalence of sexualized
recreational drug use (chemsex) among MSM (although both systematic
reviews found wide variations in prevalence estimates) (Maxwell et al.,
2019; Tomkins et al., 2019). Sexualized drug use involves taking recre-
ational drugs to enhance sexual experiences (Tomkins et al., 2019). Of
concern, chemsex among MSM has been linked to increased sexual risk
behavior, including condomless sex, group sex, and transactional sex,
as well as increased risk of STI acquisition (González-Baeza et al., 2018;
Tomkins et al., 2019).
Research also indicates that compulsive sexual behavior (i.e., hyper-
sexuality, sex addiction) is often comorbid with alcohol or substance use
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PATTERNS AND DRIVERS OF STIs IN THE UNITED STATES 87
disorders (Ballester-Arnal et al., 2020; Garner et al., 2020; Moisson et al.,
2019). While compulsive sexual behavior continues to be inadequately
defined and controversy regarding its classification as a mental health
condition remains unresolved, a growing body of literature supports an
association with increased risk behavior (Derbyshire and Grant, 2015;
Yoon et al., 2016). Taken together, the well-established relationship of
alcohol and substance use with STI risk and the elevated prevalence of
compulsive sexual behavior among alcohol and substance users suggests
the utility of a greater integration of alcohol/substance use services and
STI services. For example, routine screening for sexual risk behavior and
STIs in alcohol and substance use treatment represents a promising strat-
egy to promote STI prevention and management among key populations
at increased risk. This integration of services is a major component of
the STI-NSP: 2021–2025, and the committee concurs with and supports
including coordinated efforts to address the syndemic of STIs (including
HIV and viral hepatitis) and substance use disorder as one of the plan’s
high-level goals (HHS, 2020). See Chapter 12 for more information on the
STI-NSP: 2021–2025. Box 2-2 lists additional important individual-level
factors associated with acquiring and preventing STIs.
Interpersonal-Level Factors
Interpersonal factors that drive STIs represent any unit that tran-
scends the individual. Dyadic (two individuals), triadic, and other net-
work levels are all interpersonal levels that require consideration. Over
the past century, U.S. STI epidemiology analyses have focused on indi-
viduals. Clearly, such approaches are limited, as they do not account for
the other important actor(s) that can confer a context of risk for trans-
mission or acquisition. Foundational work by Ed Laumann and others
clearly identified that individuals could have “lower-risk behavior” (i.e.,
more condom use) but be at higher risk of STIs due to the nature and
composition of their sexual networks (Laumann and Youm, 1999). Three
important interpersonal factors that drive STIs are dyadic (interpersonal
violence and discrimination) and network (sexual network composition;
see additional discussion on this topic in Chapters 3 and 8).
Interpersonal Violence
Interpersonal violence most commonly includes a dyad where the tie
between the two individuals is characterized by emotional, sexual, and/
or physical violence (Mercy et al., 2017). Violent victimization, such as
intimate partner or dating violence (Kaplan et al., 2013; Lowry et al., 2017;
Mercy et al., 2017), is an example of such ties. One type of intimate partner
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
88 SEXUALLY TRANSMITTED INFECTIONS
BOX 2-2
Other Key Individual-Level Factors That Impact STIs
Declining rates of condom use: Condom use is on the decline among adoles-
cents and men who have sex with men, likely for different reasons. Adolescent
girls may be less likely to use condoms because of an increase in using long-
acting reversible contraceptives; thus, they may be less worried about the risk
of pregnancy during condomless sex (Steiner et al., 2016). Similarly, increased
use of HIV pre-exposure prophylaxis (PrEP) may potentially lead to decreased
condom use, placing PrEP users at risk of acquiring other STIs (Ong et al., 2019;
Volk et al., 2015).
Mental health: One in five U.S. adults live with a mental illness (51.5 million in
2019) (SAMHSA, 2020). People with mental illness are at high risk of acquiring
STIs. Depression has been associated with behaviors that increase risk of STI
acquisition, and it may be associated with STI prevalence (Dembo et al., 2017;
Khan et al., 2009). A population-based study found that both Axis-I and Axis-II
disorders were also associated with STIs (Magidson et al., 2014). People with
serious mental illness are also at higher risk for HIV (Senn and Carey, 2008).
Factors contributing to increased risk of STIs among people with mental illness
include impaired autonomy and increased impulsivity and susceptibility to coerced
sex (Coverdale et al., 1995).
Adverse childhood experiences: Adverse childhood experiences are potentially
traumatic events that take place before age 18 (CDC, 2020f). Examples include
abuse or neglect and growing up in a household with stressors such as domestic
violence, parental substance misuse, mental illness, or incarceration, and parental
separation or divorce. Adverse childhood experiences are common; the 2017–
2018 National Survey of Children’s Health found that one-third of children had
experienced at least one in the lifetime (HRSA, 2020). Exposure to these experi-
ences have been linked to poor physical and mental health (NASEM, 2019c), as
well as increased behaviors that can lead to STIs (CDC, 2020f; Fang et al., 2016;
London et al., 2017; Tsuyuki et al., 2019). For example, sexual abuse during young
adulthood has been found to be associated with sex trade (London et al., 2017).
violence, reproductive coercion, involves partner pressure to become
pregnant and active attempts to prevent the use of contraceptive methods
(Rome and Miller, 2020). Reproductive coercion and intimate partner vio-
lence have been associated with STI acquisition, unintended pregnancy,
and low consistent and correct condom use (Rome and Miller, 2020).
Even within intimate partner violence at the population level, it varies
significantly by population and community. For example, trans women
experience violence at much higher rates and are likely even more vul-
nerable to these experiences than cisgender women. A significant burden
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PATTERNS AND DRIVERS OF STIs IN THE UNITED STATES 89
of the violent deaths among trans women originates from violence per-
petrated by sexual partners. Substance use, incarceration, posttraumatic
stress disorder, and police brutality all enhance, propagate, and intensify
interpersonal violence (Cohen et al., 2013; Krüsi et al., 2014; Mimiaga et
al., 2019; Poteat et al., 2014; Reback et al., 2018), which is associated with
increased STI transmission.
Interpersonal Discrimination
Interpersonal discrimination has been defined as the negative “non-
verbal, paraverbal, and even some of the verbal behaviors that occur
in social interactions” (Hebl et al., 2002, p. 816). Focused and repeated
actions, such as sexist, homophobic, transphobic, or racist behaviors, are
based on perceived membership in stigmatized groups. Interpersonal
discrimination can affect physical and mental health and health-seeking
behaviors (Pascoe and Smart Richman, 2009; Sellers et al., 2013). Provid-
ers’ bias, stigma, and discrimination can affect the delivery and quality of
STI care (Wiehe et al., 2011) and therefore further exacerbate disparities
in STI rates (see Chapter 11 for more information on the effects of bias in
STI health care systems).
Social Networks
Social network composition and structure can explain social con-
text, social norms, social capital, and interpersonal connections, and all
can drive STI transmission. Only in the past century have network ana-
lytic approaches, software, and data-collection tools become rigorous
enough to be at a level commensurate with traditional individual-level
epidemiology—a movement toward network epidemiology, which looks
beyond the individual actor (Valente, 2012). Sexual network analysis
is one of the foremost methodological tools used to investigate “risk-
potential networks” (Friedman and Aral, 2001) through which STIs are
spread (Friedman et al., 2009; Klovdahl, 1985; Valente and Fujimoto, 2010;
Valente et al., 2004). Various network characteristics have been identified
as contributing to individuals’ behaviors, risk perceptions, or infectious
outcomes related to STIs: occupying central, peripheral, or bridging5 posi-
tions within social networks, being a member of a network core group,6
varying personal network density, having multiple sex ties concurrently,
5 This is the structure where an individual may connect two groups that are otherwise not
connected. This structure has implications for STI transmission across groups.
6 Typically, this is the group at the center of the sexual network and where the majority of
STI transmission occurs.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
90 SEXUALLY TRANSMITTED INFECTIONS
and network distance between infected and susceptible persons (Auer-
bach et al., 1984; Bettinger et al., 2004; Fichtenberg et al., 2009; Friedman
et al., 1997; Klovdahl et al., 1994; Latkin et al., 1995). Sex network analysis
also has been used to model STI epidemics, and the contributions of social
scientists to understanding cultural and behavioral variations that chan-
nel infectious disease within dynamic systems have grown enormously
(Goodreau, 2010).
Most network-level forces that relate to STI transmission are focused
at the dyadic/partner level, such as main and casual partnerships and
measuring the most recent sex partner (Fichtenberg et al., 2009; Fried-
man and Aral, 2001; Schneider and Laumann, 2011). There are several
network-level factors that drive STI transmission and that have been
better illuminated with local and whole network analyses, including (1)
core-periphery network structures7 and sex network mixing and (2) con-
currency. Early conceptualizations of the core group identified the high
rates of partner exchange that concentrate STIs within groups (Brunham,
1997; Thomas and Tucker, 1996; Wasserheit and Aral, 1996). Key connec-
tions to noncore members, such as those adjacent to cores and the periph-
ery, however, are critical to ongoing STI epidemics. Understanding of
this work was extended to include core-group behaviors but with a focus
on the behavior of network members connected to the individual (Aral,
1999; Wasserheit and Aral, 1996). Laumann and Youm (1999) expanded
this work, with a focus on network mixing and particularly how differ-
ent core, periphery, and adjacent groups mix to drive onward STI trans-
mission; intragroup mixing within racial and ethnic groups was more
common for Black community members as a mechanism for describing
disparities in STI rates in the United States. Other network forces, such as
norms and personal influence, are important. These network forces oper-
ate through community norms, which are described below and are closely
related to network interventions described in Chapter 8.
Social and Societal Contextual Factors
Very often, folks who came in with an STI had many additional issues
that needed to be addressed, whether it be gender identity issues, high-risk
sexual behavior, depression, bipolar disorder, substance abuse, homelessness,
and the list goes on. So, despite a patient perhaps presenting with what might
seem like a pretty straightforward STI—I know the medication, I know how to
treat this—there were usually many other issues that needed to be addressed.
7Sex network ties are partitioned into two general groups: the core and the periphery,
where the core typically has high density and the periphery (fewer sex network connections
and less transmission) has connections to the core.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PATTERNS AND DRIVERS OF STIs IN THE UNITED STATES 91
And it’s hard to do that when you have a small amount of time. So when
we discuss with providers methodologies for treating and addressing
STIs, we must realize that these do not occur in a vacuum, and that
the STI is only one aspect of the person who is presenting that day—
in fact, the STI may be the least important thing that they need addressed.
—Participant (health care provider), lived experience panel
There is considerable overlap among the institutional-, community-,
and structural-level factors that shape STI outcomes and inequities;
therefore, this section collectively considers these interrelated contextual
factors.
Institutional elements that affect STI prevention, care, and treatment
include health care practices that either promote well-being or reinforce
stigma. For example, lack of health care resources in the form of youth-
and LGBTQ+-friendly services are a key barrier to delivering adequate
testing and treatment. Rural and underserved urban communities also
suffer from a lack of accessible sexual health services (Bonney et al., 2012;
Kolak et al., 2020; McKenney et al., 2018; Sarno et al., 2021). The relation-
ships between health insurance and health costs and STIs are mixed.
For example, data suggest that some adolescents fear STI testing costs
may appear on parental insurance claims and breach their confidentiality
(Loosier et al., 2018), especially because access to confidential care varies
by state (English et al., 2010). The impacts of Medicaid expansion and the
Patient Protection and Affordable Care Act also have been varied. One
study found increased uptake of sexual and reproductive health services,
including testing, while others have found minimal differences (Drainoni
et al., 2014; Gibbs et al., 2020; Montgomery et al., 2017; Pearson et al., 2016)
(see Chapter 10 for more information). To facilitate quality STI preven-
tion and health care delivery, health policies and health care practices
that are inclusive, accessible, competent, affordable, safe, and respectful
to all persons are crucial. For instance, sexual and gender minorities may
encounter a poor match between their health care needs and the available
services (NASEM, 2017), which would delay preventive STI services and
timely management of infection. Additionally, people are less likely to
receive STI screening, testing, and treatment in areas with limited and/or
underfunded medical and social services (ODPHP, 2020a,b).
Community-level factors include social, economic, and health care
resources (the social determinants of health), which are all shaped by
structural factors and contribute to disparities in STI rates across dif-
ferent populations (see below and Chapter 9 for an in-depth overview
of structural factors in relation to STIs). These elements influence living
conditions that affect health care access and delivery, including STI pre-
vention, testing, and treatment. Social resources are often conceptualized
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
92 SEXUALLY TRANSMITTED INFECTIONS
as social capital (Dean and Fenton, 2010; Holtgrave and Crosby, 2003). A
study found significant associations between social capital and STIs: areas
with higher levels of social capital had lower STI rates (Owusu-Edusei et
al., 2020).
Community-level factors also include economic resources, concen-
trated poverty, and other issues associated with socioeconomic status,
neighborhood resources and climate, and community-level indicators
of STI transmission and prevalence (Hogben and Leichliter, 2008). The
United States is experiencing increasing wealth and income inequality,
resulting in more residential segregation; this differentiation is often
based on race and ethnicity and socioeconomic status, and it affects sexual
networks (Hogben and Leichliter, 2008; NASEM, 2017). As a result of both
structural and interpersonal discrimination, racial, ethnic, sexual, and
gender minorities tend to have fewer economic resources, further contrib-
uting to STI inequities (Glick et al., 2019; Nagata et al., 2021; Palar et al.,
2016). Studies have specifically identified discriminatory economic poli-
cies (such as mortgage loan denial) that drive residential segregation and
mortgage discrimination as being associated with sexual behaviors and
STIs in Black residents (Lutfi et al., 2015) and among Black, Latino/a, and
white people who inject drugs (Linton et al., 2020). Place matters to indi-
vidual and community health outcomes; the schools, workplaces, places
of worship, and available resources within neighborhoods and communi-
ties affect economic and social opportunities. This includes, for example,
the quality of schools and educational opportunities, which, in turn, affect
later employment (and usually, health insurance), income, and health lit-
eracy and behaviors. Lower education levels, lower income, and higher
unemployment have been associated with higher STI rates (Hogben and
Leichliter, 2008). Another community factor that can affect STI prevention
and care is transportation. Accessible, affordable, timely, and safe mobility
helps ensure access to health care (ODPHP, 2020b). Furthermore, lack of
stable housing may also indicate lack of employment and income and is
associated with barriers to education and health care access and increased
rates of substance use and violence (NASEM, 2017). Homeless or margin-
ally housed persons have myriad factors that place them at higher risk for
STIs, such as substance use, mental health disorders, arrest history, history
of intimate partner violence, and childhood or adult physical or sexual
abuse (Caton et al., 2013; Williams and Bryant, 2018). Furthermore, home-
lessness has been associated with high STI prevalence rates (Williams
and Bryant, 2018). Housing instability, homelessness, and poverty rates
also contribute to poor sexual health across groups (Cooper et al., 2016;
Holtgrave and Crosby, 2003; Leichliter et al., 2019; Lim et al., 2017; Moen
et al., 2020; Williams and Bryant, 2018). Other community/neighborhood
factors, such as incarceration rates, crime/violence rates, and religiosity,
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PATTERNS AND DRIVERS OF STIs IN THE UNITED STATES 93
have also been associated with sexual risk and STI rates (Buttram, 2020;
Green et al., 2019; Haley et al., 2019; Holtgrave and Crosby, 2003; Tapp
and Hudson, 2020; Thomas et al., 2010).
Structural-level factors play a central role in shaping both STI out-
comes and inequities, by both influencing the social determinants of
health and perpetuating structural violence against marginalized groups
(e.g., though structural racism, which embeds racism in societal practice,
norms, and distribution of resources). “Structural discrimination” refers
to the macro-level conditions that differentially affect groups’ access to
and distribution of resources and opportunities (Freeman et al., 2017;
Sumartojo, 2000). Specifically, structural-level factors (e.g., laws, policies,
governance practices, and social norms, including those that discrimi-
nate against marginalized racial, ethnic, gender, and sexual orientation
groups) influence social factors at other levels, such as provider bias and
stigma, sexual networks, and access to high-quality sexuality education
and sexual health care. See Box 2-3 for other examples of structural and
interpersonal factors and the social factors they influence. The impacts
of structural-level factors are wide ranging; however, addressing them is
crucial to advance equitable outcomes in sexual health (see Chapter 9).
CONCLUDING OBSERVATIONS
Although STI rates have steadily increased across the United States
in recent years, certain subgroups experience much higher rates than
others. The populations disproportionately impacted include young
people; members of the LGBTQ+ community; Black, Latino/a, AI/AN,
and Native Hawaiian/Other Pacific Islander communities; and cisgender
women, along with people occupying multiple marginalized socioeco-
nomic positions. In addition to individual behaviors that can increase risk
for STIs, it is now clear that structural factors and the social determinants
of health drive much of these inequities in STI rates (see Chapters 1 and
3 for more information). Differential access to care (and quality of care),
often rooted in structural racism, drives much of the racial disparities.
Stigma, the availability of HIV PrEP and treatment as prevention medica-
tions that could reduce concerns about condomless sex, social media and
dating apps that increase the availability of partners, and alcohol and
substance use (such as meth use and the opioid epidemic) are associated
with increased STI rates. Additional epidemiological data are needed to
further elucidate these relationships. It is also critical that interventions
employ intersectional and syndemic lenses to fully address the needs of
historically marginalized groups. Interventions to address the intertwined
factors perpetuating STI inequities are described in Chapters 7 (biomedi-
cal interventions), 8 (psychosocial and behavioral interventions), and 9
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
94 SEXUALLY TRANSMITTED INFECTIONS
BOX 2-3
Structural and Interpersonal Discrimination and STI Inequities
Structural and interpersonal discrimination, stigma, and violence have been shown
to contribute to the inequities in STI rates observed in the United States (see Chapter
3 for more information). Structural discrimination has effects outside of the health care
system, through laws, policies, political practices, and social norms; this includes poli-
cies related to housing, education, and other social determinants of health (see Chapter
9 for more information).
Black, Latino/a, and AI/AN People
Structural and interpersonal racial discrimination play a significant role in perpetuat-
ing the high STI rates in Black and Latino/a communities. In particular, the long history
of anti-Black racism and unethical medical experimentation with Black and Latino/a
communities has contributed to medical mistrust that presents a barrier to initial health
care engagement and STI/HIV testing and care (Freeman et al., 2017; Prather et al.,
2016, 2018; Relf et al., 2019; Taylor et al., 2018). Fears and previous experiences of dis-
crimination are also barriers to quality care within clinical settings, as patients describe
health care providers and staff directing discriminatory language and judgment toward
them (Alarcon et al., 2020). Black, Latino/a, and AI/AN people and other marginalized
groups are less likely to receive patient-centered primary and sexual health care, which
has been linked with poorer sexual health outcomes (Dang et al., 2017; Grilo et al.,
2019; Mitchell et al., 2020; Williams and Mohammed, 2009). Evidence also exists that
previous experiences of “everyday” or routine discrimination and racism outside the
medical setting are associated with barriers to care, increased behaviors that heighten
the risk of STIs, and greater odds of STI diagnosis for Black and Latino/a people (Dale et
al., 2019; Kaplan et al., 2016; Rosenthal et al., 2014). Racial and ethnic discrimination,
when combined with other factors, such as depression, sexual risk taking, substance
use, incarceration, and abuse/violence, including intimate partner violence, can work as
a syndemic to increase STI risk for Black men and women (Dyer et al., 2020; Godley
and Adimora, 2020).
(structural interventions). Chapter 3 discusses the complex and intercon-
nected factors that place certain populations at greater risk.
REFERENCES
Adimora, A. A., V. J. Schoenbach, and I. A. Doherty. 2007. Concurrent sexual partnerships
among men in the United States. American Journal of Public Health 97(12):2230-2237.
Adimora, A. A., V. J. Schoenbach, E. M. Taylor, M. R. Khan, and R. J. Schwartz. 2011. Concur-
rent partnerships, nonmonogamous partners, and substance use among women in the
United States. American Journal of Public Health 101(1):128-136.
Ahmad, F. A., D. B. Jeffe, K. Plax, K. B. Schechtman, D. E. Doerhoff, J. M. Garbutt, and D. M.
Jaffe. 2018. Characteristics of youth agreeing to electronic sexually transmitted infection
risk assessment in the emergency department. Emergency Medicine Journal 35(1):46-51.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PATTERNS AND DRIVERS OF STIs IN THE UNITED STATES 95
Adolescents and Young Adults
Stigma, fear of provider bias and medical mistrust, and lack of competent care play
a critical role in the high STI rates among adolescents and young adults (Arrington-
Sanders et al., 2020; Hoopes et al., 2017; Morales-Alemán et al., 2020). Other well-
documented challenges in the accessibility and delivery of youth-friendly sexual and
reproductive health care include concerns about confidentiality, inadequate or mislead-
ing sex education, lack of awareness of available services, lack of transportation, and
limited implementation of youth-friendly treatment recommendations. These, in turn,
limit adolescent sexual health care access and contribute to higher STI rates among
youth (Bender and Fulbright, 2013; Brittain et al., 2020; Bryant-Comstock et al., 2016;
Cafferty et al., 2020; Chin et al., 2012; Cuffe et al., 2016). Recognizing the high burden
of STIs among youth and the challenges associated with testing and treatment, an in-
creasing number of interventions target the specific needs of adolescents and seek to
improve implementation of youth-friendly standards, including promotion of STI testing
and treatment (Ahmad et al., 2018; Aronson et al., 2020; Bernstein et al., 2017; Brittain
et al., 2020).
Sexual Minorities
Sexual minorities, or those in the LGBTQ+ community, are another population that
experiences stigma and discrimination in health care settings and everyday life. Fears
of or previous experiences with homophobic discrimination prevent many men who have
sex with men from accessing sexual health care (Mayer, 2018; Phillips et al., 2019;
Rucinski et al., 2020). Discrimination against gay men and pervasive homophobia in
some communities are associated with depression symptoms and risky sexual behav-
iors (Murray et al., 2018; Pines et al., 2014). Transgender people also face considerable
discrimination and violence, contributing to unmet sexual health needs and high rates of
substance use, sexual risk behaviors such as condomless sex, and STIs (Eisenberg et
al., 2020; Glick et al., 2020; Macapagal et al., 2016; Mimiaga et al., 2019; Perez-Brumer
et al., 2018; Reback et al., 2018). Stigma and discrimination with the health care system
can affect trans people’s ability and inclination to access care, as can some providers’
lack of expertise in transgender medicine (De Santis et al., 2020; Safer et al., 2016).
Alarcon, J., T. B. Loeb, A. B. Hamilton, N. J. Moss, C. M. Curley, M. Zhang, W. C. Jordan, G.
Lockett, C. Carey-Grant, and G. E. Wyatt. 2020. Barriers to testing for sexually trans-
mitted infections among HIV-serodiscordant couples: The influence of discrimination.
Ethnicity & Disease 30(2):261-268.
Anderson, D., J. A. Politch, and J. Pudney. 2011. HIV infection and immune defense of the
penis. American Journal of Reproductive Immunology 65(3):220-229.
Annang, L., D. M. Grimley, and E. W. Hook, 3rd. 2006. Vaginal douche practices among black
women at risk: Exploring douching prevalence, reasons for douching, and sexually
transmitted disease infection. Sexually Transmitted Diseases 33(4):215-219.
Aral, S. O. 1999. Sexual network patterns as determinants of STD rates: Paradigm shift
in the behavioral epidemiology of STDs made visible. Sexually Transmitted Diseases
26(5):262-264.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
96 SEXUALLY TRANSMITTED INFECTIONS
Aronson, I. D., R. Freeman, T. Taylor, and A. S. Bennett. 2020. Developing digital media to
destigmatize emergency department human immunodeficiency virus testing among
sexual and racial minority youth: A hyper-iterative methodology. Cureus Journal of
Medical Science 12(3):e7209.
Arrington-Sanders, R., K. Hailey-Fair, A. L. Wirtz, A. Morgan, D. Brooks, M. Castillo, C. Trex-
ler, J. Kwait, N. Dowshen, N. Galai, C. Beyrer, and D. Celentano. 2020. Role of structural
marginalization, HIV stigma, and mistrust on HIV prevention and treatment among
young Black Latinx men who have sex with men and transgender women: Perspectives
from youth service providers. AIDS Patient Care and STDs 34(1):7-15.
Auerbach, D. M., W. W. Darrow, H. W. Jaffe, and J. W. Curran. 1984. Cluster of cases of the
acquired immune deficiency syndrome. Patients linked by sexual contact. The American
Journal of Medicine 76(3):487-492.
Baggaley, R. F., R. G. White, and M. C. Boily. 2010. HIV transmission risk through anal
intercourse: Systematic review, meta-analysis and implications for HIV prevention.
International Journal of Epidemiology 39(4):1048-1063.
Ballester-Arnal, R., J. Castro-Calvo, C. Giménez-García, B. Gil-Juliá, and M. D. Gil-Llario.
2020. Psychiatric comorbidity in compulsive sexual behavior disorder (CSBD). Addictive
Behaviors 107:106384.
Batteiger, B. E., F. Xu, R. E. Johnson, and M. L. Rekart. 2010. Protective immunity to Chla-
mydia trachomatis genital infection: Evidence from human studies. The Journal of Infec-
tious Diseases 201(Suppl 2):S178-S189.
Bautista, C. T., E. Wurapa, W. B. Sateren, S. Morris, B. Hollingsworth, and J. L. Sanchez.
2016. Bacterial vaginosis: A synthesis of the literature on etiology, prevalence, risk
factors, and relationship with chlamydia and gonorrhea infections. Military Medical
Research 3(1):4.
Bender, S. S., and Y. K. Fulbright. 2013. Content analysis: A review of perceived barriers
to sexual and reproductive health services by young people. The European Journal of
Contraception & Reproductive Health Care 18(3):159-167.
Bernstein, D. I., A. R. Bellamy, E. W. Hook, 3rd, M. J. Levin, A. Wald, M. G. Ewell, P. A. Wolff,
C. D. Deal, T. C. Heineman, G. Dubin, and R. B. Belshe. 2013. Epidemiology, clinical
presentation, and antibody response to primary infection with herpes simplex virus
type 1 and type 2 in young women. Clinical Infectious Diseases 56(3):344-351.
Bernstein, J., D. Dorfman, J. Lunstead, D. Topp, H. Mamata, S. Jaffer, and E. Bernstein. 2017.
Reaching adolescents for prevention: The role of pediatric emergency department
health promotion advocates. Pediatric Emergency Care 33(4):223-229.
Berry, A., and J. V. Hall. 2019. The complexity of interactions between female sex hormones
and Chlamydia trachomatis infections. Current Clinical Microbiology Reports 6(2):67-75.
Berry, M. S., and M. W. Johnson. 2018. Does being drunk or high cause HIV sexual risk be-
havior? A systematic review of drug administration studies. Pharmacology Biochemistry
and Behavior 164:125-138.
Bettinger, J. A., N. E. Adler, F. C. Curriero, and J. M. Ellen. 2004. Risk perceptions, condom
use, and sexually transmitted diseases among adolescent females according to social
network position. Sexually Transmitted Diseases 31(9):575-579.
Boden, J. M., D. M. Fergusson, and L. J. Horwood. 2011. Alcohol and STI risk: Evidence from
a New Zealand longitudinal birth cohort. Drug and Alcohol Dependence 113(2-3):200-206.
Bonney, L. E., H. L. Cooper, A. M. Caliendo, C. Del Rio, J. Hunter-Jones, D. F. Swan, R.
Rothenberg, and B. Druss. 2012. Access to health services and sexually transmitted
infections in a cohort of relocating African American public housing residents: An as-
sociation between travel time and infection. Sexually Transmitted Diseases 39(2):116-121.
Bowleg, L., C. C. Fitz, G. J. Burkholder, J. S. Massie, R. Wahome, M. Teti, D. J. Malebranche,
and J. M. Tschann. 2014. Racial discrimination and posttraumatic stress symptoms as
pathways to sexual HIV risk behaviors among urban Black heterosexual men. AIDS
Care 26(8):1050-1057.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PATTERNS AND DRIVERS OF STIs IN THE UNITED STATES 97
Bradley, H., L. E. Markowitz, T. Gibson, and G. M. McQuillan. 2014. Seroprevalence of
herpes simplex virus types 1 and 2—United States, 1999-2010. The Journal of Infectious
Diseases 209(3):325-333.
Bright, P. L., A. Norris Turner, C. S. Morrison, E. L. Wong, C. Kwok, I. Yacobson, R. A. Royce,
H. O. Tucker, and P. D. Blumenthal. 2011. Hormonal contraception and area of cervical
ectopy: A longitudinal assessment. Contraception 84(5):512-519.
Brinkley-Rubinstein, L., S. Parker, A. Gjelsvik, L. Mena, P. A. Chan, J. Harvey, B. Marshall,
C. G. Beckwith, J. Rose, R. Riggins, T. Arnold, and A. Nunn. 2016. Condom use and in-
carceration among STI clinic attendees in the Deep South. BMC Public Health 16(1):971.
Brittain, A. W., H. D. Tevendale, T. Mueller, A. D. Kulkarni, D. Middleton, M. L. B. Garrison,
M. R. Read-Wahidi, and E. H. Koumans. 2020. The Teen Access and Quality Initiative:
Improving adolescent reproductive health best practices in publicly funded health
centers. Journal of Community Health 45(3):615-625.
Brown, J. M., E. Poirot, K. L. Hess, S. Brown, M. Vertucci, and M. Hezareh. 2016. Motiva-
tions for intravaginal product use among a cohort of women in Los Angeles. PLoS One
11(3):e0151378.
Brunham, R. 1997. Core group theory: A central concept in STD epidemiology. Venereology
10:34-35, 38-39.
Bryant-Comstock, K., A. G. Bryant, S. Narasimhan, and E. E. Levi. 2016. Information about
sexual health on crisis pregnancy center web sites: Accurate for adolescents? Journal of
Pediatric and Adolescent Gynecology 29(1):22-25.
Buttram, M. E. 2020. The social environmental context of resilience among substance-us-
ing African American/Black men who have sex with men. Journal of Homosexuality
67(6):816-832.
Cafferty, R., B. Desai, Z. Alfath, C. Davey, and K. Schneider. 2020. Adolescent Pride Festival
attendees—assessing their interactions with primary care physicians. Journal of Adoles-
cent Health 66(6):666-671.
Calabrese, S. K., V. A. Earnshaw, M. Magnus, N. B. Hansen, D. S. Krakower, K. Underhill,
K. H. Mayer, T. S. Kershaw, J. R. Betancourt, and J. F. Dovidio. 2018. Sexual stereotypes
ascribed to Black men who have sex with men: An intersectional analysis. Archives of
Sexual Behavior 47(1):143-156.
Cameron, C. E., and S. A. Lukehart. 2014. Current status of syphilis vaccine development:
Need, challenges, prospects. Vaccine 32(14):1602-1609.
Carballo-Diéguez, A., C. Lentz, R. Giguere, E. J. Fuchs, and C. W. Hendrix. 2018. Rectal
douching associated with receptive anal intercourse: A literature review. AIDS and
Behavior 22(4):1288-1294.
Carter-Wicker, K., O. Utuama, and F. Omole. 2016. Can trichomoniasis cause pharyngitis? A
case report. SAGE Open Medical Case Reports 4:1-3.
Caton, C. L., N. El-Bassel, A. Gelman, S. Barrow, D. Herman, E. Hsu, A. Z. Tochterman, K.
Johnson, and A. Felix. 2013. Rates and correlates of HIV and STI infection among home-
less women. AIDS and Behavior 17(3):856-864.
CDC (Centers for Disease Control and Prevention). 2015. 2015 sexually transmitted diseases
treatment guidelines. https://www.cdc.gov/std/tg2015/default.htm (accessed October
22, 2019).
CDC. 2017. Key statistics from the National Survey of Family Growth—N Listing: Number
of sexual partners in lifetime. https://www.cdc.gov/nchs/nsfg/key_statistics/n.
htm#numberlifetime (accessed January 21, 2021).
CDC. 2019a. Antibiotic resistance threats in the United States, 2019. Atlanta, GA: Centers for
Disease Control and Prevention.
CDC. 2019b. Genital HPV infection— fact sheet. https://www.cdc.gov/std/hpv/stdfact-hpv.
htm (accessed November 16, 2020).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
98 SEXUALLY TRANSMITTED INFECTIONS
CDC. 2019c. Key statistics from the National Survey of Family Growth—D listing: Douching,
vaginal. https://www.cdc.gov/nchs/nsfg/key_statistics/d_2015-2017.htm#douching
(accessed November 16, 2020).
CDC. 2019d. Sexually transmitted disease surveillance 2018. Atlanta, GA: Department of Health
and Human Services.
CDC. 2020a. Bacterial vaginosis—CDC fact sheet. https://www.cdc.gov/std/bv/stdfact-
bacterial-vaginosis.htm (accessed November 16, 2020).
CDC. 2020b. Basic information about HPV and cancer. https://www.cdc.gov/cancer/hpv/
basic_info/index.htm (accessed November 16, 2020).
CDC. 2020c. Hepatitis B questions and answers for health professionals. https://www.cdc.gov/
hepatitis/hbv/hbvfaq.htm (accessed February 3, 2021).
CDC. 2020d. HIV in the United States and dependent areas. https://www.cdc.gov/hiv/
statistics/overview/ataglance.html (accessed November 16, 2020).
CDC. 2020e. HIV: Basic statistics. https://www.cdc.gov/hiv/basics/statistics.html (accessed
November 16, 2020).
CDC. 2020f. Preventing adverse childhood experiences. https://www.cdc.gov/violenceprevention/
aces/fastfact.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fviolence
prevention%2Facestudy%2Ffastfact.html (accessed November 16, 2020).
CDC. 2020g. Viral hepatitis surveillance—United States, 2018. Atlanta, GA: Centers for Disease
Control and Prevention.
CDC. n.d.-a. CDC Atlas Plus: Gonorrhea 2000-2018. https://gis.cdc.gov/grasp/nchhstpatlas/
charts.html (accessed November 17, 2020).
CDC. n.d.-b. CDC Atlas Plus: Primary and secondary syphilis 2000-2018. https://gis.cdc.gov/
grasp/nchhstpatlas/charts.html (accessed November 17, 2020).
Celentano, D. D., A. D. Latimore, and S. H. Mehta. 2008. Variations in sexual risks in drug
users: Emerging themes in a behavioral context. Current HIV/AIDS Reports 5(4):212-218.
Ceovic, R., and S. J. Gulin. 2015. Lymphogranuloma venereum: Diagnostic and treatment
challenges. Infection and Drug Resistance 8:39-47.
Chesson, H. W., I. H. Spicknall, A. Bingham, M. Brisson, S. T. Eppink, P. G. Farnham,
K. M. Kreisel, S. Kumar, J.-F. Laprise, T. A. Peterman, H. Roberts, and T. L. Gift.
2021. The estimated direct lifetime medical costs of sexually transmitted infections
acquired in the United States in 2018. Sexually Transmitted Diseases. doi: 10.1097/
OLQ.0000000000001380.
Chin, H. B., T. A. Sipe, R. Elder, S. L. Mercer, S. K. Chattopadhyay, V. Jacob, H. R. Wethington,
D. Kirby, D. B. Elliston, M. Griffith, S. O. Chuke, S. C. Briss, I. Ericksen, J. S. Galbraith,
J. H. Herbst, R. L. Johnson, J. M. Kraft, S. M. Noar, L. M. Romero, and J. Santelli. 2012.
The effectiveness of group-based comprehensive risk-reduction and abstinence educa-
tion interventions to prevent or reduce the risk of adolescent pregnancy, human im-
munodeficiency virus, and sexually transmitted infections: Two systematic reviews for
the guide to community preventive services. American Journal of Preventative Medicine
42(3):272-294.
Chow, E. P. F., V. J. Cornelisse, D. A. Williamson, D. Priest, J. S. Hocking, C. S. Bradshaw,
T. R. H. Read, M. Y. Chen, B. P. Howden, and C. K. Fairley. 2019. Kissing may be an
important and neglected risk factor for oropharyngeal gonorrhoea: A cross-sectional
study in men who have sex with men. Sexually Transmitted Infections 95(7):516-521.
Cohen, L. R., C. Field, A. N. Campbell, and D. A. Hien. 2013. Intimate partner violence
outcomes in women with PTSD and substance use: A secondary analysis of NIDA
Clinical Trials Network “Women and Trauma” multi-site study. Addictive Behaviors
38(7):2325-2332.
Collins, P. H., and S. Bilge. 2020. Intersectionality. 2nd ed. Cambridge, UK: Polity Press.
Colvin, C. W., and H. Abdullatif. 2013. Anatomy of female puberty: The clinical relevance
of developmental changes in the reproductive system. Clinical Anatomy 26(1):115-129.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PATTERNS AND DRIVERS OF STIs IN THE UNITED STATES 99
Cook, R. L., D. M. Comer, H. C. Wiesenfeld, C. C. Chang, R. Tarter, J. R. Lave, and D. B. Clark.
2006. Alcohol and drug use and related disorders: An underrecognized health issue
among adolescents and young adults attending sexually transmitted disease clinics.
Sexually Transmitted Diseases 33(9):565-570.
Cooper, H. L., L. Bonney, R. Luo, D. F. Haley, S. Linton, J. Hunter-Jones, Z. Ross, G. M.
Wingood, A. A. Adimora, and R. Rothenberg. 2016. Public housing relocations and
partnership dynamics in areas with high prevalences of sexually transmitted infections.
Sexually Transmitted Diseases 43(4):222-230.
Cottrell, B. H. 2010. An updated review of evidence to discourage douching. The American
Journal of Maternal/Child Nursing 35(2):102-107; quiz 108-109.
Coverdale, J. H., T. L. Bayer, L. B. McCullough, and F. A. Chervenak. 1995. Sexually transmit-
ted disease prevention services for female chronically mentally ill patients. Community
Mental Health Journal 31(4):303-315.
Critchlow, C. W., P. Wölner-Hanssen, D. A. Eschenbach, N. B. Kiviat, L. A. Koutsky, C. E.
Stevens, and K. K. Holmes. 1995. Determinants of cervical ectopia and of cervicitis: Age,
oral contraception, specific cervical infection, smoking, and douching. American Journal
of Obstetrics and Gynecology 173(2):534-543.
Cuffe, K. M., A. Newton-Levinson, T. L. Gift, M. McFarlane, and J. S. Leichliter. 2016. Sexu-
ally transmitted infection testing among adolescents and young adults in the United
States. Journal of Adolescent Health 58(5):512-519.
Dale, S. K., T. Dean, R. Sharma, R. Reid, S. Saunders, and S. A. Safren. 2019. Microaggressions
and discrimination relate to barriers to care among Black women living with HIV. AIDS
Patient Care and STDs 33(4):175-183.
Dang, B. N., R. A. Westbrook, S. M. Njue, and T. P. Giordano. 2017. Building trust and rap-
port early in the new doctor-patient relationship: A longitudinal qualitative study. BMC
Medical Education 17(1):32.
Dangerfield, D. T., 2nd, D. Johnson, S. Hamlin-Palmer, D. C. Browne, K. H. Mayer, and D.
A. Hickson. 2020. Prevalence and correlates of rectal douching and enema use among
Black sexual minority men and Black transwomen in the Deep South. Archives of Sexual
Behavior 49(6):1915-1922.
Datta, S. D., M. Sternberg, R. E. Johnson, S. Berman, J. R. Papp, G. McQuillan, and H. Wein-
stock. 2007. Gonorrhea and chlamydia in the United States among persons 14 to 39
years of age, 1999 to 2002. Annals of Internal Medicine 147(2):89-96.
Datta, S. D., E. Torrone, D. Kruszon-Moran, S. Berman, R. Johnson, C. L. Satterwhite, J. Papp,
and H. Weinstock. 2012. Chlamydia trachomatis trends in the United States among per-
sons 14 to 39 years of age, 1999-2008. Sexually Transmitted Diseases 39(2):92-96.
de Miguel Buckley, R., E. Trigo, F. de la Calle-Prieto, M. Arsuaga, and M. Díaz-Menéndez.
2020. Social distancing to combat COVID-19 led to a marked decrease in food-borne
infections and sexually transmitted diseases in Spain. Journal of Travel Medicine 27(8):1-2.
De Santis, J. P., M. Cintulova, E. Provencio-Vasquez, A. E. Rodriguez, and E. C. Cicero. 2020.
Transgender women’s satisfaction with healthcare services: A mixed-methods pilot
study. Perspectives in Psychiatric Care 56(4):926-938.
Dean, H. D., and K. A. Fenton. 2010. Addressing social determinants of health in the pre-
vention and control of HIV/AIDS, viral hepatitis, sexually transmitted infections, and
tuberculosis. Public Health Reports 125(Suppl 4):1-5.
Dembo, R., J. Krupa, J. Wareham, J. Schmeidler, and R. J. DiClemente. 2017. A multigroup,
longitudinal study of truant youths, marijuana use, depression, and STD-associated
sexual risk behavior. Journal of Child & Adolescent Substance Abuse 26(3):192-204.
Derbyshire, K. L., and J. E. Grant. 2015. Compulsive sexual behavior: A review of the litera-
ture. Journal of Child & Adolescent Substance Abuse 4(2):37-43.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
100 SEXUALLY TRANSMITTED INFECTIONS
DiClemente, R. J., A. M. Young, J. L. Painter, G. M. Wingood, E. Rose, and J. M. Sales. 2012.
Prevalence and correlates of recent vaginal douching among African American adoles-
cent females. Journal of Pediatric and Adolescent Gynecology 25(1):48-53.
Dinh, M. H., T. Hirbod, G. Kigozi, E. A. Okocha, G. C. Cianci, X. Kong, J. L. Prodger, K.
Broliden, R. Kaul, D. Serwadda, M. J. Wawer, R. H. Gray, and T. J. Hope. 2012. No
difference in keratin thickness between inner and outer foreskins from elective male
circumcisions in Rakai, Uganda. PLoS One 7(7):e41271.
Drainoni, M. L., M. Sullivan, S. Sequeira, J. Bacic, and K. Hsu. 2014. Health reform and shifts
in funding for sexually transmitted infection services. Sexually Transmitted Diseases
41(7):455-460.
Dyer, T. V., R. E. Turpin, R. Stall, M. R. Khan, L. E. Nelson, R. Brewer, M. R. Friedman, M.
J. Mimiaga, R. L. Cook, C. OʼCleirigh, and K. H. Mayer. 2020. Latent profile analysis
of a syndemic of vulnerability factors on incident sexually transmitted infection in a
cohort of Black men who have sex with men only and Black men who have sex with
men and women in the HIV Prevention Trials Network 061 study. Sexually Transmitted
Diseases 47(9):571-579.
Earnshaw, V. A., L. M. Bogart, J. F. Dovidio, and D. R. Williams. 2013. Stigma and racial/
ethnic HIV disparities: Moving toward resilience. American Psychologist 68(4):225-236.
Earp, B. D. 2015. Do the benefits of male circumcision outweigh the risks? A critique of the
proposed CDC guidelines. Frontiers in Pediatrics 3:18.
Eisenberg, M. E., B. J. McMorris, G. N. Rider, A. L. Gower, and E. Coleman. 2020. “It’s kind
of hard to go to the doctor’s office if you’re hated there.” A call for gender-affirming
care from transgender and gender diverse adolescents in the United States. Health &
Social Care in the Community 28(3):1082-1089.
English, A., L. Bass, A. D. Boyle, and F. Eshragh. 2010. State minor consent laws: A summary.
Chapel Hill, NC: Center for Adolescent Health & the Law.
Fanfair, R. N., A. Zaidi, L. D. Taylor, F. Xu, S. Gottlieb, and L. Markowitz. 2013. Trends in
seroprevalence of herpes simplex virus type 2 among non-Hispanic blacks and non-
Hispanic whites aged 14 to 49 years—United States, 1988 to 2010. Sexually Transmitted
Diseases 40(11):860-864.
Fang, L., D. M. Chuang, and Y. Lee. 2016. Adverse childhood experiences, gender, and HIV
risk behaviors: Results from a population-based sample. Preventive Medicine Reports
4:113-120.
Fattovich, G., F. Bortolotti, and F. Donato. 2008. Natural history of chronic hepatitis B:
Special emphasis on disease progression and prognostic factors. Journal of Hepatology
48(2):335-352.
Feaster, D. J., C. L. Parish, L. Gooden, T. Matheson, P. C. Castellon, R. Duan, Y. Pan, L. F.
Haynes, B. R. Schackman, C. K. Malotte, R. N. Mandler, G. N. Colfax, and L. R. Metsch.
2016. Substance use and STI acquisition: Secondary analysis from the AWARE study.
Drug and Alcohol Dependence 169:171-179.
Fethers, K. A., C. K. Fairley, J. S. Hocking, L. C. Gurrin, and C. S. Bradshaw. 2008. Sexual
risk factors and bacterial vaginosis: A systematic review and meta-analysis. Clinical
Infectious Diseases 47(11):1426-1435.
Fethers, K., J. Twin, C. K. Fairley, F. J. I. Fowkes, S. M. Garland, G. Fehler, A. M. Morton,
J. S. Hocking, S. N. Tabrizi, and C. S. Bradshaw. 2012. Bacterial vaginosis (BV) candidate
bacteria: Associations with BV and behavioural practices in sexually-experienced and
inexperienced women. PLoS One 7(2):e30633.
Fichtenberg, C. M., S. Q. Muth, B. Brown, N. S. Padian, T. A. Glass, and J. M. Ellen. 2009.
Sexual network position and risk of sexually transmitted infections. Sexually Transmitted
Infections 85(7):493-498.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PATTERNS AND DRIVERS OF STIs IN THE UNITED STATES 101
Flagg, E. W., E. A. Torrone, and H. Weinstock. 2016. Ecological association of human papillo-
mavirus vaccination with cervical dysplasia prevalence in the United States, 2007-2014.
American Journal of Public Health 106(12):2211-2218.
Francis, S. C., C. K. Kent, J. D. Klausner, L. Rauch, R. Kohn, A. Hardick, and C. A. Gaydos.
2008. Prevalence of rectal Trichomonas vaginalis and Mycoplasma genitalium in male
patients at the San Francisco STD clinic, 2005-2006. Sexually Transmitted Diseases
35(9):797-800.
Freeman, R., M. V. Gwadz, E. Silverman, A. Kutnick, N. R. Leonard, A. S. Ritchie, J. Reed,
and B. Y. Martinez. 2017. Critical race theory as a tool for understanding poor engage-
ment along the HIV care continuum among African American/Black and Hispanic
persons living with HIV in the United States: A qualitative exploration. International
Journal for Equity in Health 16(1):54.
Friedman, S. R., and S. Aral. 2001. Social networks, risk-potential networks, health, and
disease. Journal of Urban Health 78(3):411-418.
Friedman, S. R., A. Neaigus, B. Jose, R. Curtis, M. Goldstein, G. Ildefonso, R. B. Rothenberg,
and D. C. Des Jarlais. 1997. Sociometric risk networks and risk for HIV infection. Ameri-
can Journal of Public Health 87(8):1289-1296.
Friedman, S. R., H. L. Cooper, and A. H. Osborne. 2009. Structural and social contexts of
HIV risk among African Americans. American Journal of Public Health 99(6):1002-1008.
Funkhouser, E., T. D. Hayes, and S. H. Vermund. 2002a. Vaginal douching practices among
women attending a university in the southern United States. Journal of American College
Health 50(4):177-182.
Funkhouser, E., L. Pulley, G. Lueschen, C. Costello, E. Hook, 3rd, and S. H. Vermund. 2002b.
Douching beliefs and practices among black and white women. Journal of Women’s
Health & Gender-Based Medicine 11(1):29-37.
Galvin, S. R., and M. S. Cohen. 2004. The role of sexually transmitted diseases in HIV trans-
mission. Nature Reviews Microbiology 2(1):33-42.
Gargano, J. W., E. R. Unger, G. Liu, M. Steinau, E. Meites, E. Dunne, and L. E. Markowitz.
2017. Prevalence of genital human papillomavirus in males, United States, 2013-2014.
The Journal of Infectious Diseases 215(7):1070-1079.
Garner, A. R., R. C. Shorey, S. Anderson, and G. L. Stuart. 2020. Risky sexual behaviors
among men in residential treatment for substance misuse: The role of compulsive
sexual behavior. Sexual Addiction & Compulsivity 27(1-2):135-148.
Gerassi, L. B., M. Jonson-Reid, K. Plax, and G. Kaushik. 2016. Trading sex for money or
compensation: Prevalence and associated characteristics from a sexually transmitted
infection (STI) clinic sample. Journal of Aggression, Maltreatment & Trauma 25(9):909-920.
Gibbs, S., S. M. Harvey, L. Bui, L. Oakley, J. Luck, and J. Yoon. 2020. Evaluating the effect of
Medicaid expansion on access to preventive reproductive care for women in Oregon.
Preventive Medicine 130:105899.
Gkiouleka, A., T. Huijts, J. Beckfield, and C. Bambra. 2018. Understanding the micro and
macro politics of health: Inequalities, intersectionality & institutions—a research agen-
da. Social Science & Medicine 200:92-98.
Glick, J. L., A. Lopez, M. Pollock, and K. P. Theall. 2019. “Housing insecurity seems to almost
go hand in hand with being trans”: Housing stress among transgender and gender
non-conforming individuals in New Orleans. Journal of Urban Health 96(5):751-759.
Glick, J. L., S. Lim, S. W. Beckham, C. Tomko, J. N. Park, and S. G. Sherman. 2020. Structural
vulnerabilities and HIV risk among sexual minority female sex workers (SM-FSW) by
identity and behavior in Baltimore, MD. Harm Reduction Journal 17(1):43.
Godley, B. A., and A. A. Adimora. 2020. Syndemic theory, structural violence and HIV
among African-Americans. Current Opinion in HIV and AIDS 15(4):250-255.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
102 SEXUALLY TRANSMITTED INFECTIONS
González-Baeza, A., H. Dolengevich-Segal, I. Pérez-Valero, A. Cabello, M. J. Téllez, J. Sanz,
L. Pérez-Latorre, J. I. Bernardino, J. Troya, S. De La Fuente, O. Bisbal, I. Santos, S. Ar-
ponen, V. Hontañon, J. L. Casado, and P. Ryan. 2018. Sexualized drug use (chemsex)
is associated with high-risk sexual behaviors and sexually transmitted infections in
HIV-positive men who have sex with men: Data from the U-SEX GESIDA 9416 study.
AIDS Patient Care and STDs 32(3):112-118.
Goodreau, S. M. 2010. Accounting for epidemics: Mathematical modeling and anthropology.
In Plagues and epidemics: Infected spaces past and present, edited by D. A. Herring and A.
C. Swedlund. London, UK: Bloomsbury Academic. Pp. 213-230.
Green, K. M., P. A. Matson, B. A. Reboussin, A. J. Milam, C. D. M. Furr-Holden, J. A. Rabi-
nowitz, T. W. Powell, and N. S. Ialongo. 2019. Individual and neighborhood factors
associated with sexual behavior classes in an urban longitudinal sample. Sexually
Transmitted Diseases 46(2):98-104.
Grilo, S. A., M. Catallozzi, J. S. Santelli, H. Yan, X. Song, J. Heitel, K. Kaseeska, J. Gorz-
kowski, A. E. Dereix, and J. D. Klein. 2019. Confidentiality discussions and private
time with a health-care provider for youth, United States, 2016. Journal of Adolescent
Health 64(3):311-318.
Grimley, D. M., M. K. Oh, R. A. Desmond, E. W. Hook, 3rd, and S. H. Vermund. 2005. An
intervention to reduce vaginal douching among adolescent and young adult women:
A randomized, controlled trial. Sexually Transmitted Diseases 32(12):752-758.
Haley, D. F., A. Edmonds, V. J. Schoenbach, C. Ramirez, D. A. Hickson, G. M. Wingood, H.
Bolivar, E. Golub, and A. A. Adimora. 2019. Associations between county-level voter
turnout, county-level felony voter disenfranchisement, and sexually transmitted infec-
tions among women in the southern United States. Annals of Epidemiology 29:67-73.
Hambrick, H. R., S. H. Park, W. C. Goedel, J. G. Morganstein, N. T. Kreski, O. Mgbako, and
D. T. Duncan. 2018. Rectal douching among men who have sex with men in Paris:
Implications for HIV/STI risk behaviors and rectal microbicide development. AIDS
and Behavior 22(2):379-387.
Hassan, A., J. S. Blumenthal, M. P. Dube, E. Ellorin, K. Corado, D. J. Moore, and S. R. Mor-
ris. 2018. Effect of rectal douching/enema on rectal gonorrhoea and chlamydia among
a cohort of men who have sex with men on HIV pre-exposure prophylaxis. Sexually
Transmitted Infections 94(7):508-514.
Hebl, M. R., J. B. Foster, L. M. Mannix, and J. F. Dovidio. 2002. Formal and interpersonal
discrimination: A field study of bias toward homosexual applicants. Personality and
Social Psychology Bulletin 28(6):815-825.
Heywood, W., K. Patrick, A. Smith, and M. Pitts. 2015. Associations between early first
sexual intercourse and later sexual and reproductive outcomes: A systematic review of
population-based data. Archives of Sexual Behavior 44:531-569.
HHS (Department of Health and Human Services). 2020. Sexually transmitted infections
National Strategic Plan for the United States: 2021-2025. Washington, DC: Department of
Health and Human Services.
Hoffman, J. 2020. People are still having sex. So why are S.T.D. rates dropping? https://www.nytimes.
com/2020/10/28/health/covid-std-testing.html?action=click&module=Top%20
Stories&pgtype=Homepage (accessed November 13, 2020).
Hogben, M., and J. S. Leichliter. 2008. Social determinants and sexually transmitted disease
disparities. Sexually Transmitted Diseases 35(12):S13-S18.
Holtgrave, D. R., and R. A. Crosby. 2003. Social capital, poverty, and income inequality as
predictors of gonorrhoea, syphilis, chlamydia and AIDS case rates in the United States.
Sexually Transmitted Infections 79(1):62-64.
Hoopes, A. J., S. K. Benson, H. B. Howard, D. M. Morrison, L. K. Ko, and T. Shafii. 2017.
Adolescent perspectives on patient-provider sexual health communication: A qualita-
tive study. Journal of Primary Care & Community Health 8(4):332-337.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PATTERNS AND DRIVERS OF STIs IN THE UNITED STATES 103
Hosenfeld, C. B., K. A. Workowski, S. Berman, A. Zaidi, J. Dyson, D. Mosure, G. Bolan, and
H. M. Bauer. 2009. Repeat infection with chlamydia and gonorrhea among females: A
systematic review of the literature. Sexually Transmitted Diseases 36(8):478-489.
Howard, S. D., K. L. Lee, A. G. Nathan, H. C. Wenger, M. H. Chin, and S. C. Cook. 2019.
Healthcare experiences of transgender people of color. Journal of General Internal Medi-
cine 34(10):2068-2074.
HRSA (Health Resources and Services Administration). 2020. NSCH data brief june 2020:
Adverse childhood experiences. https://mchb.hrsa.gov/sites/default/files/mchb/Data/
NSCH/nsch-ace-databrief.pdf (accessed November 16, 2020).
Hutton, H. E., M. E. McCaul, P. B. Santora, and E. J. Erbelding. 2008. The relationship
between recent alcohol use and sexual behaviors: Gender differences among sexu-
ally transmitted disease clinic patients. Alcoholism: Clinical and Experimental Research
32(11):2008-2015.
Jacobson, D. L., L. Peralta, N. M. H. Graham, and J. Zenilman. 2000. Histologic develop-
ment of cervical ectopy: Relationship to reproductive hormones. Sexually Transmitted
Diseases 27(5):252-258.
Jameson, D. R., C. L. Celum, L. Manhart, T. W. Menza, and M. R. Golden. 2010. The associa-
tion between lack of circumcision and HIV, HSV-2, and other sexually transmitted in-
fections among men who have sex with men. Sexually Transmitted Diseases 37(3):147-152.
Jenness, S. M., K. M. Weiss, S. M. Goodreau, T. Gift, H. Chesson, K. W. Hoover, D. K. Smith,
A. Y. Liu, P. S. Sullivan, and E. S. Rosenberg. 2017. Incidence of gonorrhea and chla-
mydia following human immunodeficiency virus preexposure prophylaxis among men
who have sex with men: A modeling study. Clinical Infectious Diseases 65(5):712-718.
Jensen, J. S. 2017. Mycoplasma genitalium: Yet another challenging STI. Lancet Infectious Dis-
eases 17(8):795-796.
Joesoef, M. R., G. P. Schmid, and S. L. Hillier. 1999. Bacterial vaginosis: Review of treat-
ment options and potential clinical indications for therapy. Clinical Infectious Diseases
28(Suppl 1):S57-S65.
Joseph Davey, D. L., S. H. Vermund, R. Wamai, R. Phili, J. D. Klausner, and for the Early
Infant Male Circumcision Expert Technical Group. 2016. Why wait? We need to scale-
up infant male circumcision for global HIV control. AIDS 30(11).
Kaplan, D. L., E. J. Jones, E. C. Olson, and C. B. Yunzal-Butler. 2013. Early age of first sex
and health risk in an urban adolescent population. Journal of School Health 83(5):350-356.
Kaplan, K. C., J. M. Hormes, M. Wallace, M. Rountree, and K. P. Theall. 2016. Racial dis-
crimination and HIV-related risk behaviors in southeast Louisiana. American Journal of
Health Behavior 40(1):132-143.
Kelly, M. A., E. Barnert, and E. Bath. 2018. Think, ask, act: The intersectionality of mental
and reproductive health for judicially involved girls. Journal of the American Academy of
Child and Adolescent Psychiatry 57(10):715-718.
Khan, M. R., J. S. Kaufman, B. W. Pence, B. N. Gaynes, A. A. Adimora, S. S. Weir, and W.
C. Miller. 2009. Depression, sexually transmitted infection, and sexual risk behavior
among young adults in the United States. Archives of Pediatrics & Adolescent Medicine
163(7):644-652.
Khan, M. R., A. Berger, J. Hemberg, A. O’Neill, T. P. Dyer, and K. Smyrk. 2013. Non-injection
and injection drug use and STI/HIV risk in the United States: The degree to which
sexual risk behaviors versus sex with an STI-infected partner account for infection
transmission among drug users. AIDS and Behavior 17(3):1185-1194.
Kidd, S. E., J. A. Grey, E. A. Torrone, and H. S. Weinstock. 2019. Increased methamphetamine,
injection drug, and heroin use among women and heterosexual men with primary and
secondary syphilis—United States, 2013-2017. Morbidity and Mortality Weekly Report
68(6):144-148.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
104 SEXUALLY TRANSMITTED INFECTIONS
Kigozi, G., C. M. Liu, D. Park, Z. R. Packman, R. H. Gray, R. Kaul, A. A. R. Tobian, A. G.
Abraham, J. Ssekasanvu, J. Kagaayi, and J. L. Prodger. 2020. Foreskin surface area is
not associated with sub-preputial microbiome composition or penile cytokines. PLoS
One 15(6):e0234256.
Kimball, A., E. Torrone, K. Miele, L. Bachmann, P. Thorpe, H. Weinstock, and V. Bowen.
2020. Missed opportunities for prevention of congenital syphilis—United States, 2018.
Morbidity and Mortality Weekly Report 69:661-665.
Kissinger, P., and A. Adamski. 2013. Trichomoniasis and HIV interactions: A review. Sexually
Transmitted Infections 89(6):426-433.
Klovdahl, A. S. 1985. Social networks and the spread of infectious diseases: The AIDS ex-
ample. Social Science & Medicine 21(11):1203-1216.
Klovdahl, A. S., J. J. Potterat, D. E. Woodhouse, J. B. Muth, S. Q. Muth, and W. W. Darrow.
1994. Social networks and infectious disease: The Colorado Springs study. Social Science
& Medicine 38(1):79-88.
Kolak, M. A., Y. T. Chen, S. Joyce, K. Ellis, K. Defever, C. McLuckie, S. Friedman, and M. T.
Pho. 2020. Rural risk environments, opioid-related overdose, and infectious diseases:
A multidimensional, spatial perspective. International Journal of Drug Policy 102727.
Kreisel, K. M., I. H. Spicknall, J. W. Gargano, F. M. Lewis, R. M. Lewis, L. E. Markowitz,
H. Roberts, A. S. Johnson, R. Song, S. B. St. Cyr, E. J. Weston, E. A. Torrone, and
H. S. Weinstock. 2021. Sexually transmitted infections among U.S. women and men:
Prevelance and incidence estimates, 2018. Sexually Transmitted Diseases. doi: 10.1097/
OLQ.0000000000001355.
Krüsi, A., K. Pacey, L. Bird, C. Taylor, J. Chettiar, S. Allan, D. Bennett, J. S. Montaner, T. Kerr,
and K. Shannon. 2014. Criminalisation of clients: Reproducing vulnerabilities for vio-
lence and poor health among street-based sex workers in Canada—a qualitative study.
BMJ Open 4(6):e005191.
Kruszon-Moran, D., R. Paulose-Ram, C. B. Martin, L. K. Barker, and G. McQuillan. 2020.
Prevalence and trends in hepatitis B virus infection in the United States, 2015-2018.
NCHS Data Brief (361):1-8.
Lantagne, A., and W. Furman. 2017. Romantic relationship development: The interplay be-
tween age and relationship length. Developmental Psychology 53(9):1738-1749.
Latini, A., F. Magri, M. G. Donà, M. Giuliani, A. Cristaudo, and M. Zaccarelli. 2021. Is
COVID-19 affecting the epidemiology of STIs? The experience of syphilis in Rome.
Sexually Transmitted Infections 97(1):78.
Latkin, C., W. Mandell, D. Vlahov, A. Knowlton, M. Oziemkowska, and D. Celentano. 1995.
Personal network characteristics as antecedents to needle-sharing and shooting gallery
attendance. Social Networks 17(3):219-228.
Laumann, E. O., and Y. Youm. 1999. Racial/ethnic group differences in the prevalence of
sexually transmitted diseases in the United States: A network explanation. Sexually
Transmitted Diseases 26(5):250-261.
Lei, J., A. Ploner, K. M. Elfström, J. Wang, A. Roth, F. Fang, K. Sundström, J. Dillner, and P.
Sparén. 2020. HPV vaccination and the risk of invasive cervical cancer. New England
Journal of Medicine 383(14):1340-1348.
Leichliter, J. S., J. A. Grey, K. M. Cuffe, A. de Voux, R. Cramer, S. Hexem, H. W. Chesson, and
K. T. Bernstein. 2019. Geographic correlates of primary and secondary syphilis among
men who have sex with men in the United States. Annals of Epidemiology 32:14-19.
Leichliter, J. S., P. J. Dittus, C. E. Copen, and S. O. Aral. 2020. Trends in factors indicating
increased risk for STI among key subpopulations in the United States, 2002-2015. Sexu-
ally Transmitted Infections 96(2):121-123.
Lemos, M. P., J. R. Lama, S. T. Karuna, Y. Fong, S. M. Montano, C. Ganoza, R. Gottardo, J.
Sanchez, and M. J. McElrath. 2014. The inner foreskin of healthy males at risk of HIV
infection harbors epithelial CD4+ CCR5+ cells and has features of an inflamed epider-
mal barrier. PLoS One 9(9):e108954.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PATTERNS AND DRIVERS OF STIs IN THE UNITED STATES 105
Li, M. J., J. P. Thing, F. H. Galvan, K. D. Gonzalez, and R. N. Bluthenthal. 2017. Contextualis-
ing family microaggressions and strategies of resilience among young gay and bisexual
men of Latino heritage. Culture, Health & Sexuality 19(1):107-120.
Li, P., T. Yuan, T. Fitzpatrick, K. Smith, J. Zhao, G. Wu, L. Ouyang, Y. Wang, K. Zhang, Y.
Zhou, M. Li, D. Chen, L. Li, W. Cai, Y. Cai, and H. Zou. 2019. Association between
rectal douching and HIV and other sexually transmitted infections among men who
have sex with men: A systematic review and meta-analysis. Sexually Transmitted Infec-
tions 95(6):428-436.
Lim, S., T. P. Singh, and R. C. Gwynn. 2017. Impact of a supportive housing program on
housing stability and sexually transmitted infections among young adults in New York
City who were aging out of foster care. American Journal of Epidemiology 186(3):297-304.
Linton, S. L., H. L. F. Cooper, Y. T. Chen, M. A. Khan, M. E. Wolfe, Z. Ross, D. C. Des Jarlais,
S. R. Friedman, B. Tempalski, D. Broz, S. Semaan, C. Wejnert, and G. Paz-Bailey. 2020.
Mortgage discrimination and racial/ethnic concentration are associated with same-
race/ethnicity partnering among people who inject drugs in 19 US cities. Journal of
Urban Health 97(1):88-104.
Lis, R., A. Rowhani-Rahbar, and L. E. Manhart. 2015. Mycoplasma genitalium infection
and female reproductive tract disease: A meta-analysis. Clinical Infectious Diseases
61(3):418-426.
Liu, G., S. Hariri, H. Bradley, S. L. Gottlieb, J. S. Leichliter, and L. E. Markowitz. 2015. Trends
and patterns of sexual behaviors among adolescents and adults aged 14 to 59 years,
United States. Sexually Transmitted Diseases 42(1):20-26.
London, S., K. Quinn, J. D. Scheidell, B. C. Frueh, and M. R. Khan. 2017. Adverse experiences
in childhood and sexually transmitted infection risk from adolescence into adulthood.
Sexually Transmitted Diseases 44(9):524-532.
Loosier, P. S., H. Hsieh, R. Cramer, and G. Tao. 2018. Young adults’ access to insurance
through parents: Relationship to receipt of reproductive health services and chlamydia
testing, 2007-2014. Journal of Adolescent Health 63(5):575-581.
Lowry, R., L. Robin, and L. Kann. 2017. Effect of forced sexual intercourse on associations
between early sexual debut and other health risk behaviors among U.S. high school
students. Journal of School Health 87(6):435-447.
Lutfi, K., M. J. Trepka, K. P. Fennie, G. Ibanez, and H. Gladwin. 2015. Racial residential
segregation and risky sexual behavior among non-Hispanic blacks, 2006-2010. Social
Science & Medicine 140:95-103.
Macapagal, K., R. Bhatia, and G. J. Greene. 2016. Differences in healthcare access, use, and
experiences within a community sample of racially diverse lesbian, gay, bisexual, trans-
gender, and questioning emerging adults. LGBT Health 3(6):434-442.
Magidson, J. F., A. J. Blashill, M. M. Wall, I. C. Balan, S. Wang, C. W. Lejuez, and C. Blanco.
2014. Relationship between psychiatric disorders and sexually transmitted diseases
in a nationally representative sample. Journal of Psychosomatic Research 76(4):322-328.
Malla, N., K. Goyal, R. S. Dhanda, and M. Yadav. 2014. Immunity in urogenital protozoa.
Parasite Immunology 36(9):400-408.
Manhart, L. E., K. K. Holmes, J. P. Hughes, L. S. Houston, and P. A. Totten. 2007. Mycoplasma
genitalium among young adults in the United States: An emerging sexually transmitted
infection. American Journal of Public Health 97(6):1118-1125.
Manhart, L. E., C. A. Gaydos, S. N. Taylor, R. A. Lillis, E. W. Hook, 3rd, J. D. Klausner, C. V.
Remillard, M. Love, B. McKinney, and D. K. Getman. 2020. Characteristics of Mycoplas-
ma genitalium urogenital infections in a diverse patient sample from the United States:
Results from the Aptima Mycoplasma genitalium Evaluation Study (AMES). Journal of
Clinical Microbiology 58(7):e00165-00120.
Martino, J. L., and S. H. Vermund. 2002. Vaginal douching: Evidence for risks or benefits to
women’s health. Epidemiologic Reviews 24(2):109-124.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
106 SEXUALLY TRANSMITTED INFECTIONS
Martino, J. L., S. Youngpairoj, and S. H. Vermund. 2004. Vaginal douching: Personal practices
and public policies. Journal of Women’s Health 13(9):1048-1065.
Maxwell, S., M. Shahmanesh, and M. Gafos. 2019. Chemsex behaviours among men who
have sex with men: A systematic review of the literature. International Journal of Drug
Policy 63:74-89.
May, R. M., and R. M. Anderson. 1987. Transmission dynamics of HIV infection. Nature
326(6109):137-142.
Mayer, K. H. 2018. Old pathogen, new challenges: A narrative review of the multilevel driv-
ers of syphilis increasing in American men who have sex with men. Sexually Transmitted
Diseases 45(9):S38-S41.
McKenney, J., P. S. Sullivan, K. E. Bowles, E. Oraka, T. H. Sanchez, and E. DiNenno. 2018.
HIV risk behaviors and utilization of prevention services, urban and rural men who
have sex with men in the United States: Results from a national online survey. AIDS
and Behavior 22(7):2127-2136.
McQuillan, G., D. Kruszon-Moran, E. W. Flagg, and R. Paulose-Ram. 2018. Prevalence of
herpes simplex virus type 1 and type 2 in persons aged 14-49: United States, 2015-2016.
NCHS Data Brief (304):1-8.
Meier, A., and G. Allen. 2009. Romantic relationships from adolescence to young adulthood:
Evidence from the National Longitudinal Study of Adolescent Health. The Sociological
Quarterly 50(2):308-335.
Meites, E., P. G. Szilagyi, H. W. Chesson, E. R. Unger, J. R. Romero, and L. E. Markowitz.
2019. Human papillomavirus vaccination for adults: Updated recommendations of the
Advisory Committee on Immunization Practices. Morbidity and Mortality Weekly Report
68(32):698-702.
Menezes, C. B., and T. Tasca. 2016. Trichomoniasis immunity and the involvement of the
purinergic signaling. Biomedical Journal 39(4):234-243.
Mercy, J. A., S. D. Hillis, A. Butchart, M. A. Bellis, C. L. Ward, X. Fang, and M. L. Rosenberg.
2017. Interpersonal violence: Global impact and paths to prevention. In Injury preven-
tion and environmental health. 3rd ed., edited by C. N. Mock, R. Nugent, O. Kobusingye,
and K. R. Smith. Washington, DC: World Bank.
Miller, W. C., and N. Siripong. 2013. Estimates of sexually transmitted infection prevalence
and incidence in the United States: Time to embrace uncertainty. Sexually Transmitted
Diseases 40(3).
Mimiaga, M. J., J. M. W. Hughto, K. B. Biello, C. M. Santostefano, L. M. Kuhns, S. L. Reis-
ner, and R. Garofalo. 2019. Longitudinal analysis of syndemic psychosocial problems
predicting HIV risk behavior among a multicity prospective cohort of sexually active
young transgender women in the United States. Journal of Acquired Immune Deficiency
Syndromes 81(2):184-192.
Mirmonsef, P., L. Krass, A. Landay, and G. T. Spear. 2012. The role of bacterial vaginosis and
trichomonas in HIV transmission across the female genital tract. Current HIV Research
10(3):202-210.
Mitchell, J. A., E. G. Williams, Y. Li, and W. Tarraf. 2020. Identifying disparities in patient-
centered care experiences between non-Latino white and black men: Results from the
2008-2016 Medical Expenditure Panel Survey. BMC Health Services Research 20(1):495.
Moen, M., D. German, C. Storr, E. Friedmann, C. Flynn, and M. Johantgen. 2020. Social
stability relates social conditions to the syndemic of sex, drugs, and violence. Journal
of Urban Health 97(3):395-405.
Mohllajee, A. P., K. M. Curtis, S. L. Martins, and H. B. Peterson. 2006. Hormonal contracep-
tive use and risk of sexually transmitted infections: A systematic review. Contraception
73(2):154-165.
Moisson, J., M. N. Potenza, S. D. Shirk, R. A. Hoff, C. L. Park, and S. W. Kraus. 2019. Psycho-
pathology and hypersexuality among veterans with and without histories of alcohol-
use disorders. The American Journal on Addictions 28(5):398-404.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PATTERNS AND DRIVERS OF STIs IN THE UNITED STATES 107
Montgomery, M. C., J. Raifman, A. S. Nunn, T. Bertrand, A. Z. Uvin, T. Marak, J. Comella,
A. Almonte, and P. A. Chan. 2017. Insurance coverage and utilization at a sexually
transmitted disease clinic in a Medicaid expansion state. Sexually Transmitted Diseases
44(5):313-317.
Morales-Alemán, M. M., G. Ferreti, and I. C. Scarinci. 2020. “I don’t like being stereotyped, I
decided I was never going back to the doctor”: Sexual healthcare access among young
Latina women in Alabama. Journal of Immigrant and Minority Health 22(4):645-652.
Morris, B. J., and R. G. Wamai. 2012. Biological basis for the protective effect conferred
by male circumcision against HIV infection. International Journal of STD & AIDS
23(3):153-159.
Morris, B. J., J. N. Krieger, and J. D. Klausner. 2016. Critical evaluation of unscientific argu-
ments disparaging affirmative infant male circumcision policy. World Journal of Clinical
Pediatrics 5(3):251-261.
Morris, B. J., C. A. Hankins, J. Banerjee, E. R. Lumbers, A. Mindel, J. D. Klausner, and J. N.
Krieger. 2019. Does male circumcision reduce women’s risk of sexually transmitted
infections, cervical cancer, and associated conditions? Frontiers in Public Health 7:4.
Morrison, C. S., P. Bright, E. L. Wong, C. Kwok, I. Yacobson, C. A. Gaydos, H. T. Tucker, and
P. D. Blumenthal. 2004. Hormonal contraceptive use, cervical ectopy, and the acquisi-
tion of cervical infections. Sexually Transmitted Diseases 31(9):561-567.
Murray, A., Z. Gaul, M. Y. Sutton, and J. Nanin. 2018. “We hide…”: Perceptions of HIV
risk among Black and Latino MSM in New York City. American Journal of Men’s Health
12(2):180-188.
Muzny, C. A., and P. Kardas. 2020. A narrative review of current challenges in the diagnosis
and management of bacterial vaginosis. Sexually Transmitted Diseases 47(7):441-446.
Muzny, C. A., S. Y. Lensing, K. J. Aaron, and J. R. Schwebke. 2019. Incubation period and
risk factors support sexual transmission of bacterial vaginosis in women who have sex
with women. Sexually Transmitted Infections 95(7):511-515.
Nagata, J. M., K. Palar, H. C. Gooding, A. K. Garber, J. L. Tabler, H. J. Whittle, K. Bibbins-
Domingo, and S. D. Weiser. 2021. Food insecurity, sexual risk, and substance use in
young adults. Journal of Adolescent Health 68(1):169-177.
Nagendra, G., C. Carnevale, N. Neu, A. Cohall, and J. Zucker. 2020. The potential impact
and availability of sexual health services during the COVID-19 pandemic. Sexually
Transmitted Diseases 47(7):434-436.
NAPA (National Academy of Public Administration). 2018. The impact of sexually transmitted
diseases on the United States: Still hidden, getting worse, can be controlled. Washington, DC:
National Academy of Public Administration.
NAPA. 2019. The STD epidemic in America: The frontline struggle. Washington, DC: National
Academy of Public Administration.
NASEM (National Academies of Sciences, Engineering, and Medicine). 2017. Communities
in action: Pathways to health equity. Washington, DC: The National Academies Press.
NASEM. 2019a. The promise of adolescence: Realizing opportunity for all youth. Washington, DC:
The National Academies Press.
NASEM. 2019b. Promoting positive adolescent health behavior and outcomes: Thriving in the 21st
century. Washington, DC: The National Academies Press.
NASEM. 2019c. Vibrant and healthy kids: Aligning science, practice, and policy to advance health
equity. Washington, DC: The National Academies Press.
NCQA (National Committee for Quality Assurance). n.d. Chlamydia screening in women.
https://www.ncqa.org/hedis/measures/chlamydia-screening-in-women (accessed
November 16, 2020).
NCSD (National Coalition of STD Directors). 2018. Press release: STDs hit record highs again,
threatening millions of American lives. https://www.ncsddc.org/stds-hit-record-highs-
again-threatening-millions-of-american-lives (accessed November 16, 2020).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
108 SEXUALLY TRANSMITTED INFECTIONS
Newton, E. R., J. M. Piper, R. N. Shain, S. T. Perdue, and W. Peairs. 2001. Predictors of the
vaginal microflora. American Journal of Obstetrics and Gynecology 184(5):845-853.
Nusbaum, M. R. H., R. R. Wallace, L. M. Slatt, and E. C. Kondrad. 2004. Sexually transmitted
infections and increased risk of co-infection with human immunodeficiency virus. The
Journal of the American Osteopathic Association 104(12):527-535.
ODPHP (Office of Disease Prevention and Health Promotion). 2020a. Healthy people 2020:
Sexually transmitted diseases. https://www.healthypeople.gov/2020/topics-objectives/
topic/sexually-transmitted-diseases (accessed September 4, 2020).
ODPHP. 2020b. Healthy people 2020: Social determinants of health. https://www.healthypeople.
gov/2020/topics-objectives/topic/social-determinants-of-health (accessed November
16, 2020).
OECD (Organisation for Economic Co-operation and Development)/EU (European Union).
2016. Health at a glance: Europe 2016—state of health in the EU cycle. Paris, France: OECD
Publishing.
Oliver, S. E., E. R. Unger, R. Lewis, D. McDaniel, J. W. Gargano, M. Steinau, and L. E.
Markowitz. 2017. Prevalence of human papillomavirus among females after vaccine
introduction—National Health and Nutrition Examination Survey, United States, 2003-
2014. The Journal of Infectious Diseases 216(5):594-603.
Ong, J. J., R. C. Baggaley, T. E. Wi, J. D. Tucker, H. Fu, M. K. Smith, S. Rafael, V. Anglade, J.
Falconer, R. Ofori-Asenso, F. Terris-Prestholt, I. Hodges-Mameletzis, and P. Mayaud.
2019. Global epidemiologic characteristics of sexually transmitted infections among
individuals using preexposure prophylaxis for the prevention of HIV infection: A sys-
tematic review and meta-analysis. JAMA Network Open 2(12):e1917134.
Owusu-Edusei, K., Jr., B. McClendon-Weary, L. Bull, T. L. Gift, and S. O. Aral. 2020. County-
level social capital and bacterial sexually transmitted infections in the United States.
Sexually Transmitted Diseases 47(3):165-170.
Palar, K., B. Laraia, A. C. Tsai, M. O. Johnson, and S. D. Weiser. 2016. Food insecurity is
associated with HIV, sexually transmitted infections and drug use among men in the
United States. AIDS 30(9):1457-1465.
Pascoe, E. A., and L. Smart Richman. 2009. Perceived discrimination and health: A meta-
analytic review. Psychological Bulletin 135(4):531-554.
Patel, E. U., C. A. Gaydos, Z. R. Packman, T. C. Quinn, and A. A. R. Tobian. 2018. Prevalence
and correlates of Trichomonas vaginalis infection among men and women in the United
States. Clinical Infectious Diseases 67(2):211-217.
Patton, R., F. C. Blow, A. S. Bohnert, E. E. Bonar, K. L. Barry, and M. A. Walton. 2014.
Prevalence and correlates of transactional sex among an urban emergency depart-
ment sample: Exploring substance use and HIV risk. Psychology of Addictive Behaviors
28(2):625-630.
Pearson, W. S., R. Cramer, G. Tao, J. S. Leichliter, T. L. Gift, and K. W. Hoover. 2016.
Willingness to use health insurance at a sexually transmitted disease clinic: A survey
of patients at 21 US clinics. American Journal of Public Health 106(8):1511-1513.
Peebles, K., J. Velloza, J. E. Balkus, R. S. McClelland, and R. V. Barnabas. 2019. High global
burden and costs of bacterial vaginosis: A systematic review and meta-analysis. Sexu-
ally Transmitted Diseases 46(5):304-311.
Perez-Brumer, A., A. Nunn, E. Hsiang, C. Oldenburg, M. Bender, L. Beauchamps, L. Mena,
and S. MacCarthy. 2018. “We don’t treat your kind”: Assessing HIV health needs ho-
listically among transgender people in Jackson, Mississippi. PLoS One 13(11):e0202389.
Phillips, G., 2nd, B. Neray, P. Janulis, D. Felt, B. Mustanski, and M. Birkett. 2019. Utilization
and avoidance of sexual health services and providers by YMSM and transgender
youth assigned male at birth in Chicago. AIDS Care 31(10):1282-1289.
Pierannunzi, C., S. S. Hu, and L. Balluz. 2013. A systematic review of publications assess-
ing reliability and validity of the Behavioral Risk Factor Surveillance System (BRFSS),
2004-2011. BMC Medical Research Methodology 13(1):49.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PATTERNS AND DRIVERS OF STIs IN THE UNITED STATES 109
Pines, H. A., P. M. Gorbach, R. E. Weiss, S. Shoptaw, R. J. Landovitz, M. Javanbakht, D. G.
Ostrow, R. D. Stall, and M. Plankey. 2014. Sexual risk trajectories among MSM in the
United States: Implications for pre-exposure prophylaxis delivery. Journal of Acquired
Immune Deficiency Syndromes 65(5):579-586.
Pitasi, M. A., K. P. Delaney, J. T. Brooks, E. A. DiNenno, S. D. Johnson, and J. Prejean. 2019.
HIV testing in 50 local jurisdictions accounting for the majority of new HIV diagnoses
and seven states with disproportionate occurrence of HIV in rural areas, 2016-2017.
Morbidity and Mortality Weekly Report 68(25):561-567.
Planned Parenthood. n.d. What is bacterial vaginosis? https://www.plannedparenthood.org/
learn/health-and-wellness/vaginitis/what-bacterial-vaginosis (accessed November 16,
2020).
Poteat, T., S. L. Reisner, and A. Radix. 2014. HIV epidemics among transgender women.
Current Opinion in HIV and AIDS 9(2):168-173.
Prather, C., T. R. Fuller, K. J. Marshall, and W. L. Jeffries IV. 2016. The impact of racism on
the sexual and reproductive health of African American women. Journal of Women’s
Health 25(7):664-671.
Prather, C., T. R. Fuller, W. L. t. Jeffries, K. J. Marshall, A. V. Howell, A. Belyue-Umole, and
W. King. 2018. Racism, African American women, and their sexual and reproductive
health: A review of historical and contemporary evidence and implications for health
equity. Health Equity 2(1):249-259.
Qian, H.-Z., Y. Ruan, Y. Liu, D. F. Milam, H. M. L. Spiegel, L. Yin, D. Li, B. E. Shepherd, Y.
Shao, and S. H. Vermund. 2016. Lower HIV risk among circumcised men who have sex
with men in China: Interaction with anal sex role in a cross-sectional study. Journal of
Acquired Immune Deficiency Syndromes 71(4):444-451.
Rac, M. W., P. A. Revell, and C. S. Eppes. 2017. Syphilis during pregnancy: A preventable
threat to maternal-fetal health. American Journal of Obstetrics & Gynecology 216(4):352-363.
Ratten, L. K., E. L. Plummer, G. L. Murray, J. Danielewski, C. K. Fairley, S. M. Garland, J.
S. Hocking, G. Tachedjian, E. Chow, C. S. Bradshaw, and L. A. Vodstrcil. 2021. Sex is
associated with the persistence of non-optimal vaginal microbiota following treatment
for bacterial vaginosis: A prospective cohort study. British Journal of Obstetrics and
Gynaecology 128:756-767.
Reback, C. J., K. Clark, I. W. Holloway, and J. B. Fletcher. 2018. Health disparities, risk be-
haviors and healthcare utilization among transgender women in Los Angeles county:
A comparison from 1998-1999 to 2015-2016. AIDS and Behavior 22(8):2524-2533.
Relf, M. V., W. Pan, A. Edmonds, C. Ramirez, S. Amarasekara, and A. A. Adimora. 2019.
Discrimination, medical distrust, stigma, depressive symptoms, antiretroviral medica-
tion adherence, engagement in care, and quality of life among women living with HIV
in North Carolina: A mediated structural equation model. Journal of Acquired Immune
Deficiency Syndromes 81(3):328-335.
Rice, W. S., C. H. Logie, T. M. Napoles, M. Walcott, A. W. Batchelder, M. C. Kempf, G. M.
Wingood, D. J. Konkle-Parker, B. Turan, T. E. Wilson, M. O. Johnson, S. D. Weiser, and
J. M. Turan. 2018. Perceptions of intersectional stigma among diverse women living
with HIV in the United States. Social Science & Medicine 208:9-17.
Rietmeijer, C. A., J. Donnelly, K. T. Bernstein, J. M. Bissette, S. Martins, P. Pathela, J. A. Schil-
linger, M. R. Stenger, H. Weinstock, and L. M. Newman. 2009. Here comes the SSuN:
Early experiences with the STD surveillance network. Public Health Reports 124(Suppl
2):72-77.
Roberts, C. M., J. R. Pfister, and S. J. Spear. 2003. Increasing proportion of herpes simplex
virus type 1 as a cause of genital herpes infection in college students. Sexually Transmit-
ted Diseases 30(10):797-800.
Rome, E. S., and E. Miller. 2020. Intimate partner violence in the adolescent. Pediatrics in
Review 41(2):73-80.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
110 SEXUALLY TRANSMITTED INFECTIONS
Rosenthal, L., V. A. Earnshaw, J. B. Lewis, T. T. Lewis, A. E. Reid, E. C. Stasko, J. N. Tobin,
and J. R. Ickovics. 2014. Discrimination and sexual risk among young urban pregnant
women of color. Health Psychology 33(1):3-10.
Rowley, J., S. Vander Hoorn, E. Korenromp, N. Low, M. Unemo, L. J. Abu-Raddad, R. M.
Chico, A. Smolak, L. Newman, S. Gottlieb, S. S. Thwin, N. Broutet, and M. M. Taylor.
2019. Chlamydia, gonorrhoea, trichomoniasis and syphilis: Global prevalence and inci-
dence estimates, 2016. Bulletin of the World Health Organization 97(8):548P-562P.
Rucinski, K. B., L. A. Eaton, E. R. Learner, R. J. Watson, J. L. Maksut, and V. A. Earnshaw.
2020. Transactional sex and incident chlamydia and gonorrhea among Black men who
have sex with men in Atlanta, Georgia. Sexually Transmitted Diseases 47(6):355-360.
Safer, J. D., E. Coleman, J. Feldman, R. Garofalo, W. Hembree, A. Radix, and J. Sevelius. 2016.
Barriers to healthcare for transgender individuals. Current Opinion in Endocrinology,
Diabetes, and Obesity 23(2):168-171.
SAMHSA (Substance Abuse and Mental Health Services Administration). 2020. Key substance
use and mental health indicators in the United States: Results from the 2019 National Survey
on Drug Use and Health. Rockville, MD: Substance Abuse and Mental Health Services
Administration.
Sarno, E. L., E. Bettin, K. Jozsa, and M. E. Newcomb. 2021. Sexual health of rural and urban
young male couples in the United States: Differences in HIV testing, pre-exposure
prophylaxis use, and condom use. AIDS and Behavior 25:191-202.
Satterwhite, C. L., E. Torrone, E. Meites, E. F. Dunne, R. Mahajan, M. Cheryl Bañez Oc-
femia, J. Su, F. Xu, and H. Weinstock. 2013. Sexually transmitted infections among
US women and men: Prevalence and incidence estimates, 2008. Sexually Transmitted
Diseases 40(3):187-193.
Schneider, J. A., and E. O. Laumann. 2011. Alternative explanations for negative findings in
the Community Popular Opinion Leader multisite trial and recommendations for im-
provements of health interventions through social network analysis. Journal of Acquired
Immune Deficiency Syndromes 56(4):e119-e120.
Sellers, S. L., D. Cherepanov, J. Hanmer, D. G. Fryback, and M. Palta. 2013. Erratum to: Inter-
personal discrimination and health-related quality of life among black and white men
and women in the United States. Quality of Life Research 22(6):1313-1318.
Senn, T. E., and M. P. Carey. 2008. HIV, STD, and sexual risk reduction for individuals with
a severe mental illness: Review of the intervention literature. Current Psychiatry Reviews
4(2):87-100.
Sharma, S. C., N. Raison, S. Khan, M. Shabbir, P. Dasgupta, and K. Ahmed. 2018. Male cir-
cumcision for the prevention of human immunodeficiency virus (HIV) acquisition: A
meta-analysis. BJU International 121(4):515-526.
Silver, B. J., R. J. Guy, J. M. Kaldor, M. S. Jamil, and A. R. Rumbold. 2014. Trichomonas vagi-
nalis as a cause of perinatal morbidity: A systematic review and meta-analysis. Sexually
Transmitted Diseases 41(6):369-376.
Sonnenberg, P., S. Clifton, S. Beddows, N. Field, K. Soldan, C. Tanton, C. H. Mercer, F. C. da
Silva, S. Alexander, A. J. Copas, A. Phelps, B. Erens, P. Prah, W. Macdowall, K. Wellings,
C. A. Ison, and A. M. Johnson. 2013. Prevalence, risk factors, and uptake of interven-
tions for sexually transmitted infections in Britain: Findings from the National Surveys
of Sexual Attitudes and Lifestyles (NATSAL). Lancet 382(9907):1795-1806.
Sonnenberg, P., C. A. Ison, S. Clifton, N. Field, C. Tanton, K. Soldan, S. Beddows, S. Alexan-
der, R. Khanom, P. Saunders, A. J. Copas, K. Wellings, C. H. Mercer, and A. M. Johnson.
2015. Epidemiology of Mycoplasma genitalium in British men and women aged 16-44
years: Evidence from the third National Survey of Sexual Attitudes and Lifestyles
(NATSAL-3). International Journal of Epidemiology 44(6):1982-1994.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PATTERNS AND DRIVERS OF STIs IN THE UNITED STATES 111
Steiner, R. J., N. Liddon, A. L. Swartzendruber, C. N. Rasberry, and J. M. Sales. 2016.
Long-acting reversible contraception and condom use among female U.S. high school
students: Implications for sexually transmitted infection prevention. JAMA Pediatrics
170(5):428-434.
Strathdee, S. A., C. C. Bristow, T. Gaines, and S. Shoptaw. 2020. Collateral damage: A narra-
tive review on epidemics of substance use disorders and their relationships to sexually
transmitted infections in the United States. Sexually Transmitted Diseases. doi: 10.1097/
OLQ.0000000000001341.
Sumartojo, E. 2000. Structural factors in HIV prevention: Concepts, examples, and implica-
tions for research. AIDS 14(Suppl 1):S3-S10.
Tapp, J., and T. Hudson. 2020. Sexually transmitted infections prevalence in the United States
and the relationship to social determinants of health. Nursing Clinics of North America
55(3):283-293.
Taylor, B. S., L. Fornos, J. Tarbutton, J. Muñoz, J. A. Saber, D. Bullock, R. Villarreal, and A.
E. Nijhawan. 2018. Improving HIV care engagement in the South from the patient and
provider perspective: The role of stigma, social support, and shared decision-making.
AIDS Patient Care and STDs 32(9):368-378.
Thomas, J. C., and M. J. Tucker. 1996. The development and use of the concept of a sexually
transmitted disease core. The Journal of Infectious Diseases 174(Suppl 2):S134-S143.
Thomas, J. C., E. A. Torrone, and C. R. Browning. 2010. Neighborhood factors affecting rates
of sexually transmitted diseases in Chicago. Journal of Urban Health 87(1):102-112.
Tobian, A. A. R., D. Serwadda, T. C. Quinn, G. Kigozi, P. E. Gravitt, O. Laeyendecker, B.
Charvat, V. Ssempijja, M. Riedesel, A. E. Oliver, R. G. Nowak, L. H. Moulton, M. Z.
Chen, S. J. Reynolds, M. J. Wawer, and R. H. Gray. 2009. Male circumcision for the
prevention of HSV-2 and HPV infections and syphilis. New England Journal of Medicine
360(13):1298-1309.
Tomkins, A., R. George, and M. Kliner. 2019. Sexualised drug taking among men who have
sex with men: A systematic review. Perspectives in Public Health 139(1):23-33.
Torrone, E. A., R. E. Johnson, L. H. Tian, J. R. Papp, S. D. Datta, and H. S. Weinstock. 2013.
Prevalence of Neisseria gonorrhoeae among persons 14 to 39 years of age, United States,
1999 to 2008. Sexually Transmitted Diseases 40(3):202-205.
Torrone, E., J. Papp, H. Weinstock, C. Centers for Disease, and Prevention. 2014. Prevalence
of Chlamydia trachomatis genital infection among persons aged 14-39 years—United
States, 2007-2012. Morbidity and Mortality Weekly Report 63(38):834-838.
Trivedi, S., C. Williams, E. Torrone, and S. Kidd. 2019. National trends and reported risk fac-
tors among pregnant women with syphilis in the United States, 2012-2016. Obstetrics
and Gynocology 133(1):27-32.
Tsai, C. S., B. E. Shepherd, and S. H. Vermund. 2009. Does douching increase risk for sexually
transmitted infections? A prospective study in high-risk adolescents. American Journal
of Obstetrics and Gynecology 200(1):e31-e38.
Tsuyuki, K., N. A. Al-Alusi, J. C. Campbell, D. Murry, A. N. Cimino, A. E. Servin, and J. K.
Stockman. 2019. Adverse childhood experiences (ACEs) are associated with forced and
very early sexual initiation among Black women accessing publicly funded STD clinics
in Baltimore, MD. PLoS One 14(5):e0216279.
Underwood, J. M., N. Brener, and B. Halpern-Felsher. 2020. Tracking adolescent health behav-
iors and outcomes: Strengths and weaknesses of the Youth Risk Behavior Surveillance System.
Washington, DC: National Academy of Medicine.
Valente, T. W. 2012. Network interventions. Science 337(6090):49-53.
Valente, T. W., and K. Fujimoto. 2010. Bridging: Locating critical connectors in a network.
Social Networks 32(3):212-220.
Valente, T. W., P. Gallaher, and M. Mouttapa. 2004. Using social networks to understand
and prevent substance use: A transdisciplinary perspective. Substance Use & Misuse
39(10-12):1685-1712.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
112 SEXUALLY TRANSMITTED INFECTIONS
Van Gerwen, O. T., M. C. Craig-Kuhn, A. T. Jone, J. A. Whetsel, J. Deaver, P. J. Kissinger,
P. Buekens, and C. A. Muzny. 2021. Trichomonas vaginalis and adverse birth outcomes: A
systematic review and meta-analysis. Paper presented at Centers for Disease Control and
Prevention STD Conference, virtual, September 23, 2020.
Vermund, S. H., J. A. Tique, H. M. Cassell, M. E. Pask, P. J. Ciampa, and C. M. Audet. 2013.
Translation of biomedical prevention strategies for HIV: Prospects and pitfalls. Journal
of Acquired Immune Deficiency Syndromes 63(Suppl 1):S12-S25.
Volk, J. E., J. L. Marcus, T. Phengrasamy, D. Blechinger, D. P. Nguyen, S. Follansbee, and C. B.
Hare. 2015. No new HIV infections with increasing use of HIV preexposure prophylaxis
in a clinical practice setting. Clinical Infectious Diseases 61(10):1601-1603.
Walker, T. Y., L. D. Elam-Evans, D. Yankey, L. E. Markowitz, C. L. Williams, B. Fredua, J. A.
Singleton, and S. Stokley. 2019. National, regional, state, and selected local area vac-
cination coverage among adolescents aged 13-17 years—United States, 2018. Morbidity
and Mortality Weekly Report 68(33):718-723.
Wang, J. W., and R. B. Roden. 2013. Virus-like particles for the prevention of human papillo-
mavirus-associated malignancies. Expert Review of Vaccines 12(2):129-141.
Wasserheit, J. N., and S. O. Aral. 1996. The dynamic topology of sexually transmitted dis-
ease epidemics: Implications for prevention strategies. The Journal of Infectious Diseases
174(Suppl 2):S201-S213.
Weiss, H. A., S. L. Thomas, S. K. Munabi, and R. J. Hayes. 2006. Male circumcision and risk of
syphilis, chancroid, and genital herpes: A systematic review and meta-analysis. Sexually
Transmitted Infections 82(2):101-109.
Wiehe, S. E., M. B. Rosenman, J. Wang, B. P. Katz, and J. D. Fortenberry. 2011. Chlamydia
screening among young women: Individual- and provider-level differences in testing.
Pediatrics 127(2):e336-e344.
Williams, D. R., and S. A. Mohammed. 2009. Discrimination and racial disparities in health:
Evidence and needed research. Journal of Behavioral Medicine 32(1):20-47.
Williams, S. P., and K. L. Bryant. 2018. Sexually transmitted infection prevalence among
homeless adults in the United States: A systematic literature review. Sexually Transmit-
ted Diseases 45(7):494-504.
Winston McPherson, G., T. Long, S. J. Salipante, J. A. Rongitsch, N. G. Hoffman, K. Stephens,
K. Penewit, and D. N. Greene. 2019. The vaginal microbiome of transgender men. Clini-
cal Chemistry 65(1):199-207.
Workowski, K. A., and G. A. Bolan. 2015. Sexually transmitted diseases treatment guidelines,
2015. MMWR Recommendations and Reports 64(RR-03):1-137.
Yoon, I. S., S. T. Houang, S. Hirshfield, and M. J. Downing. 2016. Compulsive sexual behavior
and HIV/STI risk: A review of current literature. Current Addiction Reports 3(4):387-399.
Yuan, T., T. Fitzpatrick, N.-Y. Ko, Y. Cai, Y. Chen, J. Zhao, L. Li, J. Xu, J. Gu, J. Li, C. Hao, Z.
Yang, W. Cai, C.-Y. Cheng, Z. Luo, K. Zhang, G. Wu, X. Meng, A. E. Grulich, Y. Hao, and
H. Zou. 2019. Circumcision to prevent HIV and other sexually transmitted infections
in men who have sex with men: A systematic review and meta-analysis of global data.
The Lancet Global Health 7(4):e436-e447.
Zhang, C., D. F. Penson, H. Z. Qian, G. F. Webb, J. Lou, B. E. Shephard, Y. Liu, and S. H.
Vermund. 2019a. Modeling economic and epidemiological impact of voluntary medical
male circumcision among men who have sex with men in Beijing, China. International
Journal of STD & AIDS 30(7):630-638.
Zhang, C., H. Z. Qian, Y. Liu, and S. H. Vermund. 2019b. Voluntary medical male circum-
cision and HIV infection among men who have sex with men: Implications from a
systematic review. SAGE Open Medicine 7:1-9.
Zhang, C., G. F. Webb, J. Lou, B. E. Shepherd, H. Z. Qian, Y. Liu, and S. H. Vermund. 2020.
Predicting the long-term impact of voluntary medical male circumcision on HIV inci-
dence among men who have sex with men in Beijing, China. AIDS Care 32(3):343-353.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Priority Populations
Chapter Contents
Introduction
STIs Across the Life Span
• Pregnancy and Infancy
• Children
• Adolescents
• Cisgender Heterosexual Adults
o Racial and Ethnic Minority Heterosexual People
o Women Who Engage in Sex Work
o Older Heterosexual Adults
• Sexual and Gender Diverse Populations
o Men Who Have Sex with Men
o Transgender and Gender Diverse Adults
o Lesbian, Bisexual, and Other Sexual Minority Women
o LGBTQ+ Youth
• Other Populations That Require Focused Consideration
o American Indian/Alaska Native People
o People with Military Experience
o People with Disabilities
o People with Criminal Legal System Involvement
Concluding Observations
113
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
114 SEXUALLY TRANSMITTED INFECTIONS
INTRODUCTION
When seeing if you are going to have the ability to go get tested, you have
to take into consideration the cost of living and if you can even spend that
money to get tested or if you have to put it elsewhere. And worrying about
personal safety in clinical environments, getting to clinical environments,
just worrying about personal safety as a social determinant that I am faced
with. And then recognizing institutionalized racism, especially in the clinical
field, is definitely important, with the medical professionals not always
listening to people of color, not always listening to queer people.… So,
definitely, having institutionalized racism being a thing is a barrier for me.
—Participant, lived experience panel1
While any person who has sex (genital, anal, or oral) without barrier
protection is at risk for a sexually transmitted infection (STI), risk varies
over the life span and is influenced by social and societal factors. In the
United States, STIs disproportionately affect individuals with intersect-
ing social identities (e.g., race, ethnicity, gender, gender identities) who
are often marginalized;2 in this chapter, these important intersections are
highlighted and discussed. Other groups with a disproportionately high
prevalence of STIs include men who have sex with men (gay, bisexual,
same gender loving, and other men who have sex with men [MSM]) and
other sexual and gender diverse people (e.g., transgender women), ado-
lescents and young adults, and people of color (Black, Latino/a, Ameri-
can Indian/Alaska Native [AI/AN], and Native Hawaiian/Other Pacific
Islander individuals). Pregnant people are important to consider because
STIs can cause poor birth outcomes and infections can be transmitted
in utero or via childbirth. Other groups with unique circumstances that
require tailored services and attention include children, people with crim-
inal legal system involvement, people with disabilities, and people with
military experience.
Chapter 2 presented the epidemiology of STIs and highlighted data
that demonstrate that young people and socially and economically mar-
ginalized populations experience the highest STI burden. Guided by the
idea that sexual health is important for persons of all ages, this chapter
begins with an overview of STIs across the life span, followed by sections
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.
2 “Marginalized” refers to those who have often suffered discrimination or have been
excluded or marginalized from society and the health-promoting resources it has to offer,
including inadequate access to key opportunities (such as health care) (Braveman, 2017).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 115
on other populations that require focused consideration. It also examines
specific needs and concerns of marginalized groups who experience a
disproportionately high percentage of STIs, due, in part, to multiple,
interrelated social and societal influences. Its organizational structure is
guided by the report’s conceptual model (see Chapter 1), with a focus on
social and structural drivers of STI inequities. Some groups have a rich
literature, but data are limited or missing for others (e.g., female sex work-
ers, older people, some sexual and gender diverse people, and people
with disabilities); shorter sections for these groups does not mean that the
committee sees them of lesser importance but rather that more research is
needed (see Chapter 2 for limitations of current STI surveillance systems).
The committee recognizes that this chapter is therefore not inclusive of
every population affected by STIs. In identifying common drivers, the
committee acknowledges that some social and structural determinants
might affect people differently among and within groups not included in
this chapter. For each population discussed in this chapter, factors at each
level of the committee framework are discussed (individual to structural
factors; see Figure 1-3), but the committee recognizes that these factors are
all interconnected, particularly that individual- and interpersonal-level
factors are shaped by community- and structural-level factors.
STIs ACROSS THE LIFE SPAN
PREGNANCY AND INFANCY
STIs in pregnancy can have dire health and social consequences. STIs
contribute to adverse outcomes and can cause serious neonatal and infant
disease. Maternal chlamydia and gonorrhea can cause sight-threatening
eye infections (Azari and Arabi, 2020) and pneumonias in infants (Xu et
al., 2018). Many STIs, including chlamydia, gonorrhea, and trichomonas,
cause premature rupture of membranes, preterm birth, and babies who
are small for their gestational age (He et al., 2020; Silver et al., 2014). See
Box 3-1 for key takeaway messages about STIs in pregnancy and infancy.
Comprehensive HIV screening and treatment has virtually elimi-
nated perinatal HIV transmission in the United States (Wortley et al.,
2001). Owing to comprehensive outreach, quality improvement strategies,
and specific funding from states and the federal government, the rate of
perinatal HIV transmission decreased from an initial 25 percent among
births to people living with HIV to less than 1 percent by 2012, with
subsequent decreasing trends (Taylor et al., 2017). In 2017, only 39 babies
were born with HIV out of more than 3.8 million live births (CDC, 2020a),
due primarily to universal prenatal HIV testing, perinatal prophylaxis
provided to pregnant people infected with HIV and their infants, and
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
116 SEXUALLY TRANSMITTED INFECTIONS
BOX 3-1
Key Takeaways: Pregnancy and Infancy
• Sexually transmitted infections (STIs) contribute to adverse outcomes and can
cause serious neonatal and infant disease.
• Untreated syphilis in pregnancy can be associated with miscarriage, preterm
birth, stillbirth, impaired fetal growth, congenital infection, and neonatal mor-
tality. These can have long-term morbidity and increased health care costs.
• Common missed opportunities to prevent congenital syphilis in the United
States include lack of adequate treatment during pregnancy, despite timely
diagnosis, and lack of timely prenatal care.
• Successful strategies used for HIV perinatal prevention can be applied to STIs
in pregnancy with the aim of eliminating them (congenital syphilis, chlamyd-
ia, gonorrhea, and herpes simplex virus). These strategies include universal
screening in pregnancy (first visit and third trimester), comprehensive care,
partner testing, and prompt treatment.
other strategies, including cesarean section (particularly when antiretro-
viral therapies were suboptimal) and providing infant formula to prevent
transmission through breast milk (Nesheim et al., 2017).
People at risk for HIV and who can become pregnant are also at
increased risk for other STIs. While HIV perinatal transmission has fallen,
congenital syphilis continues to rise. The successful strategies used for
HIV perinatal prevention can be applied to congenital syphilis, chla-
mydia, gonorrhea, and herpes simplex virus type 2 (HSV-2) (and some-
times HSV-1), which also can be transmitted in utero or during childbirth.
These strategies include screening and prompt treatment in persons of
childbearing age, especially when they are pregnant. In many jurisdic-
tions, HIV screening is performed early in the pregnancy and in the third
trimester, but may not include screening for other STIs.
Syphilis in Pregnancy
Untreated syphilis can be associated with miscarriage, preterm birth,
stillbirth, impaired fetal growth and congenital infection (leading to
infants born with bone deformities, jaundice, and neurological problems,
including blindness and deafness), and neonatal death (Cooper and San-
chez, 2018). The impact of congenital syphilis includes not only infant
mortality risks but long-term morbidity and increased health care costs.
Across the United States, lack of adequate syphilis treatment for the
pregnant person (despite timely diagnosis) was the most common missed
prevention opportunity in one analysis; lack of timely prenatal care was
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 117
another common missed prevention opportunity (Kimball et al., 2020).
Congenital syphilis is related to failures in screening because of struc-
tural, community, or individual issues, but it is nearly always grounded
in social determinants of health.
It is imperative that prenatal care strategies are renewed, redesigned,
and implemented with a comprehensive perspective so that pregnant
people can access quality prenatal care that includes early trimester STI
screening and treatment of curable (syphilis, gonorrhea, chlamydia) or
chronic (HSV, HIV, hepatitis B virus [HBV]) infections. In one study, one
in three women who transmitted syphilis to her baby was tested during
pregnancy and might have contracted it after the initial test (The Lan-
cet, 2018), emphasizing the potential need for multiple antenatal tests in
people at high risk of syphilis infection. The Centers for Disease Control
and Prevention (CDC) and the American College of Obstetricians and
Gynecologists recommend syphilis screening during pregnancy at the
first prenatal visit (which is ideally in the first trimester) and again in the
third trimester and at delivery for those at higher risk, as well as after
exposure to a partner with syphilis (AAP and ACOG, 2017; Workowski
and Bolan, 2015). Syphilis during pregnancy should be treated with peni-
cillin G to prevent transmission to the fetus (Workowski and Bolan, 2015).
See Chapter 10 and Appendix B for more information.
Individual- and Interpersonal-Level Factors
Individual factors that could contribute to STIs during pregnancy are
similar to those of people who are not pregnant and include young age,
multiple sex partners, history of an STI, fewer years of education, and low
income (Hogben and Leichliter, 2008; Wheeler et al., 2012). Additional fac-
tors include lack of uptake or adherence to treatment, and power inequality
in relationships. These issues may be magnified in pregnancy because of
the added stigma of the potential for transmission to the fetus or newborn.
From a biological perspective, pregnancy-related immunosuppression also
may contribute to excess risk. As described in Chapters 1 and 2, these
individual-level factors are shaped by interpersonal-, institutional-, com-
munity-, and structural-level factors that affect STI prevention and care.
Interpersonal influences include perceived and practiced beliefs and
values, parental attitudes, and the role of peers and sexual partners. For
example, STIs that are acquired during pregnancy are often due to a part-
ner’s behaviors. As stated in Chapter 2, an analysis of congenital syphilis
cases found that half of pregnant women with syphilis in the study had
no known risk factor; a history of an STI and more than one sexual part-
ner in the past year were the most common risk factors in the other half
(Trivedi et al., 2019).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
118 SEXUALLY TRANSMITTED INFECTIONS
Institutional-, Community-, and Structural-Level Factors
Missed opportunities of lack or delayed treatment and prenatal care
are often fueled by situations beyond the individual’s control. Lack of
timely, good-quality prenatal care can be related to structural barriers that
may accompany salient psychosocial and behavioral factors, including
lack of or late enrollment in prenatal care, lack of health insurance (such as
Medicaid), cost of insurance copayments or out-of-pocket charges, lack of
transportation or child care, unawareness of the pregnancy, unwanted or
unplanned pregnancy, and mental health and substance use issues (Hog-
ben and Leichliter, 2008; Mayer, 1997; Mazul et al., 2017; NASEM, 2019b).
Undocumented immigration status and heightened federal immigration
enforcement has discouraged pregnant people from accessing care if they
fear discrimination or deportation (Bowen et al., 2015; Braveman et al.,
2000; Daw and Sommers, 2017). Although emergency Medicaid covers the
costs of labor and delivery for low-income people regardless of immigra-
tion status, it does not cover prenatal or postpartum care (DuBard and
Massing, 2007; Swartz et al., 2017).
CHILDREN
STIs can be acquired at any stage of development—as a fetus in utero,
as a newborn emerging from the birth canal, as a small child through
sexual assault, or as a teenager, as discussed in the adolescent section.
Fetuses and Newborns
Intrapartum or peripartum, a fetus or newborn can acquire many
STIs, including chlamydia, gonorrhea, syphilis, HIV, HBV, HSV, human
papillomavirus (HPV), and, more rarely, hepatitis C virus (HCV), tricho-
moniasis, Mycoplasma genitalium, or human T-cell lymphotrophic virus
type 1 (HTLV-1) (Petca et al., 2020; Sethi et al., 2012; Workowski and
Bolan, 2015). Any of these can be devastating or even fatal. HIV, syphilis,
and HBV are the focus of World Health Organization efforts to combine
screening during pregnancy to ensure that HIV is suppressed, syphilis
is cured, and HBV is prevented with active immunization of the infant
and passive antibody therapy of the newborn (Aliyu et al., 2016; Cheung
et al., 2019; Hamilton et al., 2017; Heston and Arnold, 2018; Vrazo et al.,
2018; Wang et al., 2015). Chlamydia or gonorrhea can inoculate the eyes
of a newborn passing through an infected birth canal, causing ophthal-
mia neonatorum, which can be dangerous to the developing cornea and
lead to blindness (Hull et al., 2017). As discussed earlier, proper prena-
tal screening and treatment during antenatal and peripartum care can
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 119
immensely diminish STI risk to the fetus and infant. CDC recommends
screening all pregnant people for HIV, syphilis, and HBV. Additional
recommendations for chlamydia, gonorrhea, and HCV are based on age
and/or behavioral risk factors. No evidence supports routine pregnancy
screening for HSV-2, bacterial vaginosis (BV), or trichomoniasis in asymp-
tomatic patients (Workowski and Bolan, 2015).
Children
In the United States, a child is sexually abused every 9 minutes
(RAINN, 2020); 90 percent know their abuser, and 30 percent of abus-
ers are family members (Darkness to Light, 2015). Children acquire STIs
though sexual abuse perpetrated largely by men, or sometimes by older
children, though adults are responsible for most transmission of syphilis,
gonorrhea, chlamydia, HIV, HSV-2, and other STIs (Bechtel, 2010; Kawsar
et al., 2008). All possible sexual assaults in children require carefully
and sensitively conducted histories, physical exams with STI tests, and
psychological evaluation and counseling for victims, siblings, and other
affected family members (Gallion et al., 2016; Smith et al., 2018). Child-
hood sexual abuse is an adverse childhood experience that can affect
physical and mental health through adulthood; see Chapter 2 for more
information about how adverse childhood experiences are related to STIs.
Children of any age can be in situations that increase their risk of
STI exposure, particularly if their households contain predatory adults
or adolescents (Bechtel, 2010; Goldberg and Moore, 2018). Children who
were assaulted earlier in life are at higher risk of acquiring STIs as adoles-
cents for a variety of reasons, such as being at increased risk for engaging
in behaviors related to STIs, continuing to live in an abusive environment,
acquiring aberrant views of sex as a consequence of their earlier traumas,
with depression and loss of self-esteem, for example, or confusing affec-
tive with sexual contact (Lalor and McElvaney, 2010). Substance abuse
and addiction among parents or guardians or caretakers have been associ-
ated with childhood sexual abuse and STI risk (Levine et al., 2018; Lown
et al., 2011; Sutherland, 2011). Childhood sexual abuse is also a risk factor
for sexual revictimization in adulthood (Ports et al., 2016).
ADOLESCENTS
Adolescence spans several developmental stages as people transition
from childhood to adulthood. Starting with puberty (which, on aver-
age, begins between 8 and 10) and crossing into adulthood (up to age
25), adolescence is a formative period in which young people have the
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
120 SEXUALLY TRANSMITTED INFECTIONS
opportunity to positively develop, learn, grow, and mature when appro-
priately protected and supported (NASEM, 2019a). Puberty is a gradual
development influenced by biological and social processes. It involves
the development and maturation of primary and secondary sex charac-
teristics, leading to reproductive maturity. Genetic and environmental
factors both affect the timing of puberty. Puberty is also marked by neuro-
biological and psychosocial growth, including development of the brain,
cognitive, emotional, and social skills, and self-identity (NASEM, 2019a).
Adolescents experience “pubertal, neurobiological, cognitive, and psy-
chosocial changes” that can lead them to “form healthy relationships with
their peers and families, develop a sense of identity and self, and experi-
ence enriching and memorable engagements with the world” (NASEM,
2019a, p. 75). Adolescence is a time in which the sense of self evolves to
include awareness and development of sexuality and sexual and gender
identity. Although often viewed as a time in which young people engage
in high-risk behaviors, adolescence is in fact “a period of great oppor-
tunity for adolescents to flourish and thrive” (NASEM, 2019a, p. 75).
Nonetheless, STIs are common in this age group; for example, those aged
15–24 make up about 13 percent of the population, yet account for about
half of STIs reported in the United States (see Figure 3-1). The literature
on this group is vast, but is summarized below (see the section later in
the chapter, too, on STIs among lesbian, gay, bisexual, transgender, and
queer [LGBTQ+] youth). Box 3-2 summarizes important takeaway mes-
sages about adolescents and multi-level drivers of STIs in this population.
Individual-Level Factors
Sexual Initiation
Normative biological (e.g., hormones and physical growth) and social
(e.g., sexual attraction and dating) development during adolescence
FIGURE 3-1 Young people are disproportionately burdened by STIs.
SOURCE: Keller, 2020.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 121
BOX 3-2
Key Takeaways: Adolescents
• Normative biological and social development during adolescence influence the
onset of adolescent sexual behavior. This developmental milestone is important
for increasing adolescents’ knowledge and experience with their sexuality and
intimate relationships, but it also provides opportunities for risk, especially
when it occurs during early adolescence, when young people may lack skills
for healthy sexual decision making.
• Although a majority of adolescents remain sexually abstinent or engage in
safer sexual behaviors, a smaller, but sizable, proportion do engage in sexual
behaviors that increase their risk for sexually transmitted infections (STIs).
• Co-occurring health conditions (e.g., stress, anxiety, and depression, childhood
exposure to trauma, experiences with intimate partner violence or teen dating
violence) are prevalent among adolescents and significantly linked to factors
that increase risk of exposure to STIs (e.g., substance use and homelessness).
• Adolescents’ risk for and protection against STI exposure are dependent on in-
terpersonal, social, and contextual factors, including parental, peer, and sexual
network influences; sexual partner influences; community and other environ-
mental factors; media and other digital communications; and health care and
health care access.
• While confidentiality is an important concern for adolescents, approaches that
incorporate parents in adolescent sexual and reproductive health care delivery
are encouraged by adolescent-focused organizations and supported by current
national guidelines.
• Community-based STI screening and treatment in locations where adolescents
live and socialize, primarily in contexts of high STI prevalence, have been
identified as a promising approach for STI prevention and control.
influences the onset of sexual behavior. This developmental milestone
is important for increasing adolescents’ knowledge and experience with
their sexuality, intimate relationships, and pleasure (Tolman and McClel-
land, 2011; Vasilenko et al., 2016). It also provides opportunities for risk,
especially if it occurs during early adolescence, when young people may
lack skills for healthy sexual decision making (Dahl, 2001; Steinberg,
2005). Research indicates that an early age of sexual debut is associated
with STIs in adolescents (Epstein et al., 2014; Heywood et al., 2015; Kaestle
et al., 2005; Lara and Abdo, 2016; Upchurch et al., 2004; von Ranson et al.,
2000) and behaviors that increase risk for STIs, including a greater number
of recent, lifetime, multiple, and concurrent sexual partners (Adimora et
al., 2002; Epstein et al., 2014; Heywood et al., 2015; Kaplan et al., 2013;
Sandfort et al., 2008; Sneed, 2009), and violent victimization, such as inti-
mate partner or dating violence (Kaplan et al., 2013; Lowry et al., 2017;
Seth et al., 2013).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
122 SEXUALLY TRANSMITTED INFECTIONS
Sexual Partnerships
While most adolescents remain sexually abstinent (approximately 60
percent of high school students in 2019) or engage in safer sexual behav-
iors, a smaller but sizable proportion engage in sexual behaviors that
increase their risk for STIs (CDC, 2020e; Johnston et al., 2015; Kann et al.,
2018; Vasilenko et al., 2015). The prevalence and pattern of adolescents’
sexual behaviors, including their partner selections, determine their risk
for and exposure to STIs.
Multiple and concurrent sexual partners Multiple sexual partnerships
that occur within a short period (serial monogamy) and those that overlap
in time (concurrent relationships) are prevalent patterns during adoles-
cence and associated with increased risk for STIs (Ashenhurst et al., 2017;
Boyer et al., 2000; CDC, 2020e; Habel et al., 2018; Johnston et al., 2015;
Kann et al., 2018; Reed et al., 2012; Vasilenko and Lanza, 2014).
Nationally, among in-school adolescents, nearly one-tenth (8.6 per-
cent) have had four or more lifetime sexual partners in 2019, which occurs
more among boys (10.0 percent) than girls (7.2 percent), and more among
Black students (13.3 percent) compared with their white (7.7 percent)
and Latino/a (9.2 percent) peers (CDC, 2020e). Differences also occur by
sexual identity, with a significantly higher percentage of lesbian, gay, or
bisexual (11.1 percent) than heterosexual (8.2 percent) or unsure of their
sexual identity (8.0 percent) students (CDC, 2020e). More students whose
self-reported sexual partners were only same-sex or both sexes (23.6 per-
cent) had sex with four or more lifetime sexual partners than students
who had sexual contact with only the opposite sex (15.6 percent) (CDC,
2020e). Importantly, the proportion of students who had multiple lifetime
sexual partners has declined dramatically over the past decade, from 13.8
percent in 2009 to 8.6 percent in 2019 (CDC, 2020e).
Exchange of sex Adolescents’ exchange of sex for drugs, money, food, or
shelter (sex exchange) is associated with STIs (Boyer et al., 2018; Edwards
et al., 2006; Kaestle, 2012; Silverman, 2011), and STI-related risk factors,
including multiple sexual partners (Lavoie et al., 2010; Marshall et al.,
2010; Patton et al., 2014b; Raiford et al., 2014; Reilly et al., 2014), inconsis-
tent condom use (Kaestle, 2012; Marshall et al., 2010), injection drug use
(Edwards et al., 2006; Reilly et al., 2014) and use of other substances (Boyer
et al., 2018; Kaestle, 2012; Patton et al., 2014b; Raiford et al., 2014; Reilly
et al., 2014; Woods-Jaeger et al., 2013), and childhood trauma (London et
al., 2017). Data from the National Longitudinal Study of Adolescent to
Adult Health (referred to as Add Health) indicate that a relatively small
percentage of adolescents, overall, have ever experienced sex exchange (2.3
percent), and that it is most prevalent among young men (62.9 percent of
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 123
this total). Not surprisingly, sex exchange occurs most commonly among
groups of young people with difficult living conditions and social cir-
cumstances, including those who had recently run away from home or
experienced homelessness, sexual coercion, childhood abuse, depression,
cannabis3 use, or shoplifting (Edwards et al., 2006; Kaestle, 2012). Other
influences include factors such as homelessness, unemployment even after
participating in job training programs, housing instability, reliance on
others for income, crime victimization, and perceived community norms
indicating that sex exchange is common among peers (Boyer et al., 2017,
2018). Research on adolescent sex exchange calls for community resources
that reduce the need for young people to engage in transactional sex.
Condom Use
Despite condoms being relatively affordable and accessible to many
adolescents, condom use remains inconsistent among sexually active
adolescents (Bauermeister et al., 2011; CDC, 2020e; Harper et al., 2018;
Reece et al., 2010). Correct, consistent external condom use is particularly
challenging for young women who need to rely on the cooperation of
their sexual partners (Swan and O’Connell, 2012; Teitelman et al., 2008,
2011; Vasilenko et al., 2015). Key barriers that affect young women’s abil-
ity to negotiate with sexual partners about condoms include gendered
powerlessness that fosters conditions that limit their power in sexual
relationships (Chiaramonte et al., 2020; Lim et al., 2019; Wingood and
DiClemente, 1998) and intimate partner violence (Fair and Vanyur, 2011;
Rosenbaum et al., 2016; Seth et al., 2013). When sexual communication
specifically about condoms does occur within relationships, however,
adolescents are significantly more likely to use them (DePadilla et al.,
2011; Noar, 2006; Schmid et al., 2015; Widman et al., 2014).
Relationship dynamics and condom use Other relationship dynamics,
such as the length and quality of sexual partnerships, are also related to
adolescent condom use. Adolescents in new or casual relationships are
more likely to use condoms and to do so more consistently (Fortenberry
et al., 2002; Katz et al., 2000), whereas relationships that are characterized
as serious or committed (Kusunoki and Upchurch, 2011; Sayegh et al.,
2006) or having high levels of trust/love (Ewing and Bryan, 2015) and
mutually high intimacy (Wildsmith et al., 2015) are associated with incon-
sistent condom use. Unfortunately, too few studies examine adolescent
3 Theliterature uses the terms “cannabis” and “marijuana”; for consistency, the report uses
the genus name, “cannabis,” in part due to racist connotations associated with “marijuana”
(Solomon, 2020).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
124 SEXUALLY TRANSMITTED INFECTIONS
relationship dynamics over time. Matson et al. (2011) found that young
women who changed from multiple sexual partnerships during adoles-
cence to monogamous main partnerships decreased their condom use
over time, those who changed from monogamous main partnerships
to multiple sexual partnerships increased condom use, and those who
did not change partnership patterns did not change condom use. Thus,
young people may modify their condom use based on their perception of
risk associated with their partners. Therefore, STI prevention strategies
need to consider sexual relationship dynamics, such as their length and
quality, gendered power imbalances, adolescents’ cognitive development
(e.g., ability to plan ahead or project future consequences for behavior),
and interpersonal skills (e.g., ability to assertively articulate one’s sexual
and reproductive health [SRH] preferences), as well as salient gender and
cultural norms that discourage open sexual health communication within
sexual relationships.
Contraceptive use and condom use Inconsistent condom use in ado-
lescents is also related to young women’s contraceptive use, with recent
evidence and trends suggesting that young women who use long-acting
reversible contraceptives are less likely to consistently use condoms (Bas-
tow et al., 2014; Pazol et al., 2010; Steiner et al., 2016; Walsh-Buhi and
Helmy, 2018; Williams and Fortenberry, 2013). Research also suggests that
young women who use both oral contraceptives and condoms are primar-
ily motivated by preventing pregnancy rather than STIs (Crosby et al.,
2001; Lemoine et al., 2017). Nationally, while sexual activity has declined
among adolescents, condom use assessed at last sex among those who
partake has also declined between 2009 (61.1 percent) and 2019 (54.3 per-
cent) (CDC, 2020e). In 2019, more sexually active male (60.0 percent) than
female (49.6 percent) high school students used a condom during their
last sexual encounter. This was lower, however, among sexual minority
students, with 41.3 percent of gay, lesbian, and bisexual students and
47.3 percent of students who are not sure of their sexual identity using
condoms compared with 56.6 percent of heterosexual students. By race
and ethnicity, Black (48.2 percent), Latino/a (56.2 percent), and white (55.8
percent) students used condoms. Overall, high school students’ condom
use has declined dramatically over the past decade (CDC, 2020e). Some
barriers for adolescents are embarrassment about or lack of funds for
purchasing condoms, lack of knowledge in how to use them, and lack
of preplanning and negotiation skills during sex (McCool-Myers et al.,
2019). More nuanced studies are needed to examine adolescent condom
use within a holistic person-centered context that accounts for partnership
dynamics and change in use as adolescents mature and gain experience
(Tolman and McClelland, 2011). More psychosocial research can aid in
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 125
a better understanding of the motivating factors and barriers that limit
condom use related to or independent of young women’s contraceptive
use and in identifying key targets for STI prevention interventions and
risk-reduction counseling.
Co-occurring Health Conditions
Other coexisting influences on adolescents’ risk for and acquisition of
STIs include mental health conditions, such as stress, anxiety, and depres-
sion (Brown et al., 2010; Champion, 2011; Gerassi et al., 2016; Hulland et
al., 2015; Jackson et al., 2015; Khan et al., 2009); childhood exposure to
trauma, including physical, emotional, and sexual abuse (Aalsma et al.,
2011; Champion, 2011; Gavril et al., 2012; Gerassi et al., 2016; Girardet
et al., 2009; London et al., 2017; Oshri et al., 2012); and experiences with
intimate partner violence or teen dating violence (Seth et al., 2012, 2013;
Vagi et al., 2015). The onset of psychiatric disorders typically occurs dur-
ing adolescence and early adulthood. Specifically, one-half of all adult
psychiatric disorders start by the age of 14, but are often untreated for
6–23 years after onset of symptoms (ACOG Committee on Adolescent
Health Care, 2017a). Adolescents living with psychiatric disorders are
more likely to engage in sexual risk behaviors, including condomless sex
(Lee et al., 2016), yet are less likely to be screened for STIs (Lee et al., 2016;
Workowski and Bolan, 2015). These health outcomes are prevalent among
adolescents, significantly linked with other experiences related to STIs
(e.g., substance use and homelessness), and central to adolescent sexual
health decision making. These co-occurring health conditions dispropor-
tionately affect cisgender female adolescents, racial and ethnic minorities,
LGBTQ+ populations (see later sections in this chapter), homeless and
detained youth, and youthful substance users (Aalsma et al., 2011; Gerassi
et al., 2016; Jackson et al., 2015; Oshri et al., 2012; Sales et al., 2016; Seth
et al., 2012, 2013). Taken together, further research is clearly needed that
provides a greater understanding of proximal behaviors and distal con-
textual factors that contribute to STI risk. STI prevention strategies that
integrate a trauma-informed approach to prevention and risk-reduction
efforts are also sorely needed (Sales et al., 2016). Health providers who
screen adolescents for STIs need to also screen for trauma, mental health
conditions, and substance use (Gerassi et al., 2016).
Alcohol and Other Substance Use
Alcohol and other substance use, such as cannabis and products
delivered by electronic vapor devices (e.g., e-cigarettes and vaping pens),
are prevalent during adolescence, including with high school students
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
126 SEXUALLY TRANSMITTED INFECTIONS
(Cullen et al., 2019; Kann et al., 2018; McCabe et al., 2017), college students
(Adefuye et al., 2009; Brown and Vanable, 2007; Wu et al., 2009), STI clinic
patients (Carey et al., 2016; Senn et al., 2010), adolescents in the juvenile
justice system (Bryan et al., 2018; Hendershot et al., 2010), participants
in substance use treatment programs (Brooks et al., 2010; Hulland et al.,
2015), and individuals with co-occurring mental health conditions (Cun-
ningham et al., 2017).
Alcohol use Alcohol use and misuse (e.g., binge or heavy drinking)
during adolescence are associated with risky sexual behaviors, including
commencing sexual activity at a young age (Epstein et al., 2014; Lowry et
al., 2017), increased sexual activity (Brown et al., 2010), a higher number
of lifetime partners (Carey et al., 2016), multiple partners (Aicken et al.,
2011; Khan et al., 2012), casual or noncommitted partners (Claxton et al.,
2015; Owen and Fincham, 2011), inconsistent condom use (Khan et al.,
2012), condomless sex during the last sexual encounter and with casual
or nonsteady partners (Brown and Vanable, 2007; Brown et al., 2010;
Metrik et al., 2016), and sex with a partner infected with an STI (Khan
et al., 2012). Several studies have also identified variation in findings by
gender, including more sexual risk factors for young women than young
men (Carey et al., 2016; Hutton et al., 2013; Owen and Fincham, 2011).
Cannabis use Like alcohol use, cannabis use is associated with sexual
behaviors and STIs (Hendershot et al., 2010; Lee et al., 2014). Cannabis,
sometimes combined with other substances, such as alcohol, cocaine, opi-
ates, and ecstasy (Metrik et al., 2016; Ritchwood et al., 2015), is associated
with a number of STI-related risk indices (Bryan et al., 2012; Connell et
al., 2009; Guzmán and Dello Stritto, 2012; Madkour et al., 2010; Tucker
et al., 2012). It is also associated with higher STI incidence (Smith et al.,
2010; Wu et al., 2009); increasing levels of cannabis use are associated
with higher prevalence of STIs (De Genna et al., 2007; Smith et al., 2010).
A number of these sexual risk factors are moderated by sex, race, and
ethnicity (Kaestle, 2012; Ritchwood et al., 2015). Additionally, the land-
scape around the legality of cannabis has changed over the past 8 years.
As of this report, 15 states and the District of Columbia had legalized
recreational cannabis, with Washington and Colorado being the first to
do so in 2012 (Infobase, 2020). Research on U.S. adult cannabis use, sexual
behaviors, and STIs found that after including measured confounding
variables to the model, the association between cannabis use and STIs was
no longer significant (Patel et al., 2020), contrary to the evidence found
in adolescent populations. Additionally, in a cohort study of MSM with
2014–2017 data, fewer participants tested positive for STIs if they only
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 127
used cannabis in the 6 months prior in comparison to those with no drug
use or those with use of other drugs (Gorbach et al., 2019). This conflict-
ing work highlights the need for continued exploration of understanding
cannabis use in sexual relationships and its effect on STI transmission.4
Electronic cigarette use While not directly linked to STIs, cigarette usage
is a marker of high-risk behavior. Data indicate that e-cigarettes are now
the most widely used tobacco product among adolescents (Cullen et al.,
2019; King et al., 2018). Their use is associated with behaviors such as
multiple sexual partners and condomless sex and often co-occurs with
use of other substances (Chadi et al., 2019; Demissie et al., 2017; McCabe
et al., 2017). Specifically, adolescents who had frequent or daily e-cigarette
use were significantly more likely to also engage in binge drinking, can-
nabis use, and other illicit drug use (McCabe et al., 2017). A meta-analytic
review noted higher cannabis use among youth who used electronic
cigarettes (Chadi et al., 2019).
Substance use and co-occurring health conditions Adolescents’ use
of alcohol, cannabis, and e-cigarettes is associated with behaviors that
increase risk for STIs (Brown and Vanable, 2007; Bryan et al., 2012; Demis-
sie et al., 2017; Metrik et al., 2016). Cannabis, alcohol, and other substance
use is also associated with co-occurring mental health conditions, such as
stress, anxiety, depression, schizophrenia, and attention deficit disorders,
which are also correlated with sexual behaviors (Hulland et al., 2015;
Wilson and Cadet, 2009). Some studies focus on use as a single event
(e.g., during the last sexual encounter), however, a measurement frame
that often misses the broader interpersonal context of these behaviors.
Longitudinal research can assess the temporal order of behaviors and
the mechanisms that promote risk and prevention. Examining contextual
mediators can increase understanding of how individual, social, and
environmental factors interact to contribute to adolescent sexual and sub-
stance use behaviors. Thus, more successful STI prevention interventions
could be developed and tailored for defined subgroups (Swartzendruber
et al., 2013).
4 Cannabis arrests reflect significant racial bias; Black people are more than 3 times more
likely to be arrested, despite usage rates almost equal to those of white people. This is true
of states that have legalized cannabis, too (ACLU, 2020). Similarly, analysis of arrests in New
York City shows Black and Latino people, males, and people aged 16–29 disproportionately
affected by cannabis arrests (Golub et al., 2007). This unequal policing and enforcement
disproportionately puts young Black and Latino men in contact with the criminal legal
system; see the section later in this chapter on the association between that system and STIs.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
128 SEXUALLY TRANSMITTED INFECTIONS
Cognitive-Behavioral and Psychosocial Influences Related to STIs
Cognitive-behavioral and psychosocial influences on STI-related risk
and protective factors in adolescents are well described, yet there is no
single framework that fully captures the complex association of intersect-
ing factors (Vasilenko and Lanza, 2014; Zimmer-Gembeck and Helfand,
2008). Variation in findings across studies is hard to interpret when dif-
ferent constructs are measured (e.g., knowledge, perceived personal risk,
communication self-efficacy, attitudes toward condoms) and outcomes
are characterized differently (e.g., sexual debut, condom use, partner
concurrency, STI diagnosis). Many cognitive-behavioral and psychosocial
variables are highly correlated, and some may be both antecedents and
outcomes (McCree and Hogben, 2010). Nevertheless, strategies to prevent
STIs in adolescents are informed by those antecedent mechanisms con-
sistent across studies that underlie adolescents’ sexual health decisions
and subsequent sexual behaviors (see Chapter 8 for a review of cognitive-
behavioral and psychosocial theories of health and behavior change).
Summary of Individual-Level Factors and Future Considerations
Adolescents’ risk, prevention, and acquisition of STIs are the result
of interrelated SRH behaviors and substance use that are influenced by
antecedent cognitive-behavioral and psychosocial factors and intersecting
health conditions within their social and environmental context. Longi-
tudinal examination of these multi-dimensional and interrelated factors
may provide insights into the manner in which sexual behaviors change
with increasing age and experience and help to identify both health-moti-
vating and risk-promoting individual-level factors. Additionally, more
basic behavioral research and innovative STI prevention strategies that
use a theoretically guided, person-centered, holistic approach to adoles-
cent sexual health are needed (Hallfors et al., 2016; Tolman and McClel-
land, 2011), which must incorporate tenets of adolescent development,
gender-based dynamics, cultural norms, and other social determinants.
Interpersonal-, Institutional-, Community-,
and Structural-Level Factors
Adolescent sexual and contraceptive decision making and behavior
occur in a context that increases or reduces STI risk. Some of the most
important interpersonal, social, and contextual factors shaping the risk
for and protection against STIs include (1) parental, peer, and sexual net-
work influences; (2) sexual partner influences; (3) community and other
environmental factors; (4) media and other digital communications; and
(5) health care and health care access.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 129
Interpersonal Factors
Parental influences Parents provide an important social context for ado-
lescent sexual decision making (Power to Decide, 2016) and behavior.
Parents shape a wide range of adolescent sexual behaviors, including
timing of first intercourse, frequency of sex, contraception use, and STI
and HIV testing (Balaji et al., 2017; Gavin et al., 2015; Widman et al., 2016).
Parent-based interventions designed to reduce adolescent STI exposure
have shown efficacy in delaying sexual debut and promoting use of con-
doms and accessing of SRH services (Gavin et al., 2015; Guilamo-Ramos
et al., 2019a). Specific parental behaviors and influences associated with
reduced STI exposure include age-appropriate monitoring and supervi-
sion, parent–adolescent communication, and parent–adolescent relation-
ship satisfaction (Coakley et al., 2017; Dittus et al., 2015; Guilamo-Ramos
et al., 2016, 2019a). In particular, specific parental influences, such as STI-
specific communication, are more likely to shape adolescent STI exposure
than general parenting behaviors (Coakley et al., 2017; Guilamo-Ramos et
al., 2016). Additionally, parental willingness for adolescents to have time
alone with their health care providers encourages adolescents’ emerging
autonomy, allows adolescents to build skills to manage and advocate for
their own health, and enhances physician–adolescent trust and commu-
nication, including about topics such as sexual behaviors (Miller et al.,
2018). See Box 10-1 in Chapter 10 for information on confidentiality, and
Chapter 12 for more on the important role of parents in reducing STIs.
Peer influences Adolescence is a developmental period in which peers
play an increasingly critical role in shaping identity, social norms, and
sexual behavior. Adolescent identity is partially shaped by peer percep-
tions (NASEM, 2019a). For example, adolescent STI exposure is, in part,
affected by perceptions of peers’ behavior; they are more likely to engage
in condomless sex when there are higher levels of perceived peer endorse-
ment of it (NASEM, 2019a; van Hoorn et al., 2018). Compared to adults,
adolescents have reduced emotional and reward regulation and are gener-
ally more likely to engage in risk-taking behaviors in the presence of peers
(Hansen et al., 2019; NASEM, 2019a; van Hoorn et al., 2018). Peers also
can play a protective role in adolescent sexual and contraceptive decision
making. Specifically, adolescents with peers who (1) have positive social
prototypes of adolescents who engage in protective sexual behavior, such
as correct and consistent condom use and (2) are perceived to be engaging
in safe sexual behavior are more likely to practice protective behaviors
themselves (Hansen et al., 2019; NASEM, 2019a). Peer-based interventions
have shown efficacy in shaping behaviors that reduce STI exposure, such
as condom use (Patton et al., 2016).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
130 SEXUALLY TRANSMITTED INFECTIONS
Characteristics of social/sexual networks can predict adolescent neg-
ative SRH outcomes, including STIs (Fichtenberg et al., 2009). Adolescents
in sexual networks with high STI prevalence are more likely to acquire
STIs while engaging in the same sexual behaviors as those in sexual net-
works of low STI prevalence (Ellen et al., 2005; Macapagal et al., 2018).
Sexual partner influences Sexual and romantic partners are an impor-
tant social context that influences adolescent SRH outcomes (Staras et al.,
2009). Factors associated with STIs include older sexual partners (Begley
et al., 2003; Boyer et al., 1999; Ford and Lepkowski, 2004; Stein et al.,
2008; Swartzendruber et al., 2013), casual partners (Lyons, 2017; Lyons
et al., 2015), new sexual partnerships (Ott et al., 2011), and partners with
a prior history of STIs (Staras et al., 2009). In addition, adolescents often
misclassify a partner as monogamous, resulting in greater likelihood of
STI exposure (Copen et al., 2019; Lenoir et al., 2006; Matson et al., 2018;
Sanchez et al., 2016).
Couples’ communication is an important factor in adolescent STI
exposure (Widman et al., 2014). Adolescent couples who report less com-
munication regarding barrier methods and STI testing are more likely to
engage in condomless sex and acquire STIs (Widman et al., 2014). Addi-
tionally, partner communication can have a protective role. Increased
communication about barrier methods to prevent STIs, such as consistent
and correct condom use, has been associated with enhanced condom use
(Gause et al., 2018; Widman et al., 2014).
Ascribing to traditional gender norms regarding masculinity and
femininity and perpetuating unequal gender roles has been associated
with adolescent sexual behavior, including condomless sex (Rome and
Miller, 2020). Adolescents who report low power in their sexual relation-
ships are more likely to acquire STIs (Haberland, 2015; Rome and Miller,
2020). Interventions that address gender and power have been associ-
ated with decreased STI rates and reductions in unintended pregnancies
(Haberland, 2015).
Another important consideration is intimate partner violence and
reproductive coercion, which represent significant drivers of STI acquisi-
tion among adolescents. Intimate partner violence among adolescents is
defined as physical, emotional, or sexual violence that occurs in a relation-
ship where at least one partner is an adolescent or young adult (Rome and
Miller, 2020). See Chapter 2 for more information.
Media and Other Digital Communications
Digital tools, such as dating apps, play a role in romantic and sexual
relationships, especially among adolescents. Adolescents are most likely
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 131
to form romantic and sexual relationships through dating apps (Anderson
et al., 2020). Approximately half of adolescents report ever using a dat-
ing app or website (Anderson et al., 2020). Adolescents who seek sexual
partners online report higher rates of condomless sex and STI diagnoses
(Anderson et al., 2020; Sawyer et al., 2018). This enhanced STI exposure
has been attributed to the expanded sexual network size of adolescents on
dating apps (Macapagal et al., 2018; Sawyer et al., 2018). Increasing atten-
tion has been placed on providing STI prevention and treatment services
to adolescents using dating apps and websites (Cao et al., 2020; Maca-
pagal et al., 2018). Research has also found that adolescents’ exposure
to sexual media content in mainstream media influence sexual attitudes
and behaviors (Coyne et al., 2019; Young and Jordan, 2013). Additionally,
in a review and meta-analysis of adolescent exposure to sexually explicit
websites and sexting, sexually explicit website exposure correlated with
condomless sex, and sexting correlated with multiple recent sexual part-
ners and other outcomes (Smith et al., 2016). See Chapter 6 for more
discussion on the role of technology, including examples pertaining to
adolescents and STIs.
Health Care and Health Care Access
When I was 18, I started going to the doctor on my own, and I got
the question if I was sexually active. At first, I wasn’t. But by the time
I finally said I was, it was kind of too late. I had already contracted three STIs,
and one of them does not have a cure. If I had been able to open up to the
doctor back [when I first became sexually active], I don’t think this would
have happened. If we train doctors to build the trust of their patients,
the patients wouldn’t mind opening up about sex.
—Participant, lived experience panel
Current normative screening and treatment approaches National health
organization guidelines recommend STI screening for sexually active
adolescents based on behavioral, community, and population risk factors
(Lee et al., 2016; Workowski and Bolan, 2015). As part of the clinical visit,
CDC guidelines recommend that health care providers collect a complete
sexual history from their adolescent patients (ACOG Committee on Ado-
lescent Health Care, 2017b; Todd and Black, 2020; Workowski and Bolan,
2015). This may be accomplished more easily when adolescents talk with
their health care providers alone. Furthermore, data from the National
Survey of Family Growth shows that adolescents aged 15–17 who spent
time alone with a health care provider were more likely to seek sexual
and reproductive health care than adolescents who did not (Copen et
al., 2016). The United States Preventive Services Task Force recommends
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
132 SEXUALLY TRANSMITTED INFECTIONS
risk-reduction counseling for all sexually active adolescents, aimed at
preventing STIs (Lee et al., 2016). Pre-exposure vaccination is currently
available for HPV, HBV, and hepatitis A virus (HAV) (Workowski and
Bolan, 2015), yet adolescent vaccination rates remain too low (Abdullahi
et al., 2020). Barriers to vaccination uptake include lack of awareness and
communication and misinformation among adolescents, their parents,
and health care providers (Dibble et al., 2019).
For adolescents living with STIs, immediate onsite treatment, sexual
partner referral for STI testing, and repeat STI screening after treatment
are warranted (Lee et al., 2016; Workowski and Bolan, 2015). Clinical and
nonclinical organizations have considerable variability in their STI screen-
ing/treatment of adolescents, despite national guidelines. For example,
clinical guidelines recommend adolescents living in detention centers
receive routine STI screening and treatment due to high STI prevalence
(Workowski and Bolan, 2015). Short-term jail and juvenile detention facili-
ties, however, often do not provide screening and have suboptimal STI
treatment outcomes after diagnosis (Borschmann et al., 2020; Owusu-Edu-
sei et al., 2013; Workowski and Bolan, 2015). Similarly, adolescents in the
child welfare system have higher STI prevalence, yet are often overlooked
in STI screening (Harmon-Darrow et al., 2020).
Health care barriers Clinicians may experience barriers to initiating com-
munication with adolescents about their sexual history for a variety of
reasons, including (1) provider discomfort and lack of confidence; (2)
beliefs regarding adolescent sexual behavior based on age, gender, sex-
ual orientation, etc.; and (3) concern regarding parental permission and
confidentiality (Fuzzell et al., 2017) (see Chapters 2, 10 [see Box 10-1],
11, and 12 for more information). For example, while all 50 states allow
for minors to receive STI screening without parental permission, physi-
cians can inform parents about screening and/or treatment in 18 states
(Guttmacher Institute, 2019). Health care providers may recommend STI
screening to groups with high HIV prevalence, such as Black and Latino
adolescent MSM, who already experience racism, discrimination, gender
bias, homophobia, transphobia, and other forms of stigma (Cuffe et al.,
2016; NASEM, 2019a; Unemo et al., 2019).
Adolescent barriers to engagement and retention include costs associ-
ated with health care use and treatment, low health literacy, and organi-
zations’ hours (“9 to 5”) not matching adolescent availability (NASEM,
2019a). Perceived stigma represents a significant barrier to STI screening
and care; adolescents may be less likely to seek STI services if being clas-
sified as “high risk” conflicts with their desired identity (Cuffe et al., 2016;
NASEM, 2019a). Recurring, daily treatment regimens may be a barrier to
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 133
adherence if youth prioritize short-term reward over long-term conse-
quences (Unemo et al., 2019).
Need for new paradigms While confidentiality is an important concern
for youth, approaches that incorporate parents in adolescent sexual and
reproductive delivery (Dittus, 2016; Ford et al., 2011; Guilamo-Ramos et
al., 2019b) are encouraged by organizations and supported by profes-
sional guidelines (ACOG Committee on Adolescent Health Care, 2020;
CDC, 2018a; SAHM, 2014). Triadic interventions (parent–adolescent–
health care provider) have shown efficacy in reshaping negative SRH
outcomes in adolescents (Guilamo-Ramos et al., 2011, 2020). See Chapter
8 for more information. Time alone with a health care provider supports
adolescents’ autonomy; it can facilitate discussion of sexual behaviors
and collection of a full sexual history, and allows for receipt of sexual
and reproductive health services (Copen et al., 2016; Miller et al., 2018).
Promising approaches to STI prevention and treatment can incorporate
adolescent-specific considerations regarding confidentiality, perceived
stigma, community STI prevalence, and treatment regimens. Improved
framing of STI testing and treatment that moves beyond an emphasis on
risk to one that incorporates positive adolescent identity is needed (Keller,
2020). Furthermore, community-based STI screening and treatment in
locations where adolescents are present, primarily in contexts of high STI
prevalence, have been identified as a promising approach (Shannon et al.,
2019b). Finally, long-acting pre-exposure treatment or vaccination options
for adolescents are needed (Unemo et al., 2019).
CISGENDER HETEROSEXUAL ADULTS
While LGBTQ+, adolescent, AI/AN, and other populations are dis-
proportionately affected by STIs, certain groups of cisgender heterosex-
ual adults are also heavily affected (e.g., Black heterosexual women and
men and female sex workers). In moving from adolescence to adulthood,
the number of sex partners and frequency of sexual activity generally
decreases. For example, an analysis of data from the General Social Sur-
vey found that sexual activity decreased among women aged 25–34 and
men aged 18–34 from 2000 to 2018; this decrease in sexual activity among
men was observed mainly in unmarried men (Ueda et al., 2020). Individu-
als also may settle into more exclusive partnering, which typically leads
to lower rates of STIs (Meier and Allen, 2009). High STI prevalence rates
may manifest in subgroups that do not have this pattern of exclusive
partnering, as with women engaging in transactional sex, persons who
have mental illness, including substance use disorders, and the increasing
number of single, older adults. In the United States, female sex workers
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
134 SEXUALLY TRANSMITTED INFECTIONS
and those with mental illness experience high levels of marginalization
and current services delivery models often fail to meet their STI preven-
tion and care needs effectively. Population-based studies and good sur-
veillance data also are lacking. Box 3-3 provides summarizing information
for STIs among cisgender heterosexual adults.
Racial and Ethnic Minority Heterosexual People
Heterosexual people comprise a heterogeneous population. In par-
ticular, they come from diverse racial and ethnic backgrounds, and these
subgroups each have a specific and unique STI burden and differ in the
structural and social determinants of STIs differ. To ensure effective STI
prevention and care among all heterosexual people, including those from
marginalized racial and ethnic groups, services, programs, policies, and
practices need to account for and be tailored to the distinct burden and
structural and social determinants of racial, ethnic, and other subgroups.
Although research on racial and ethnic disparities in STIs and their
structural and social determinants among heterosexual people in particu-
lar is limited, investigators have identified pronounced STI disparities
across racial and ethnic groups in the U.S. population in general (see
Chapter 2). As a result of pervasive anti-Black structural and interpersonal
racism rooted in histories and legacies of slavery and medical experimen-
tation targeting Black women and men, which shapes access to social
and economic resources that influence STI risk, prevention, and care and
exposure to risk factors today, Black–white STI disparities are especially
BOX 3-3
Key Takeaways: Cisgender Heterosexual Adults
• Cisgender heterosexual adults who engage in condomless sex with multiple
partners are at risk for sexually transmitted infections (STIs).
• The structural and social determinants of STIs differ among heterosexual peo-
ple in relation to race and ethnicity.
• Disparities in STI rates experienced by Black and American Indian/Alaska
Native heterosexual women and men are largely due to community- and struc-
tural-level factors that shape STI risk and access to STI prevention and care.
• Certain subgroups, such as female sex workers, are difficult to identify and may
be marginalized from health care. Consequently, their STIs may go undetected.
• Some female sex workers have co-occurring health problems such as mental
health problems and substance use disorders that can amplify their STI risk.
• Older cisgender heterosexual adults are not often targeted for intervention
because of the misperception that they are unlikely to have sex.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 135
pronounced (CDC, 2019c) (see Chapter 2 for more information). More-
over, as a result of rampant structural and interpersonal discrimination
against AI/AN people rooted in histories and legacies of settler colonial-
ism and genocide, which affect access to social and economic resources
that influence STI risk, prevention, and care and exposure to risk factors
today, AI/AN men and women in general are also considerably more
likely than their white counterparts to have an STI (CDC, 2019c). See
the section later in this chapter on STIs among AI/AN people for more
information.
The few studies that have specifically focused on racial and ethnic
disparities in STIs among U.S. heterosexual people in particular have
identified pronounced Black–white disparities in STIs, which are largely
due to community- and structural-level factors that shape STI risk and
access to STI prevention and care among Black heterosexual women and
men. These factors include racial residential segregation and a dispro-
portionate burden of poverty, unemployment, and incarceration, which
influences the structure of sexual networks and exposure to STIs and
access to STI-related services (Adimora and Schoenbach, 2005; Adimora
et al., 2002; Bowleg and Raj, 2012; Hamilton and Morris, 2015). More-
over, racialized and gendered cultural norms, societal expectations, and
sexual stereotypes shape heterosexual sexual relationships and STI risk
among Black heterosexual women and men (Crooks et al., 2020), which
contributes to Black–white STI disparities among heterosexual people in
the United States.
Women Who Engage in Sex Work
While the true amount of transactional sex work among women in
the United States is not known, an estimated 1 million women identify
as sex workers (Lubin, 2012). An unknown additional number engage in
informal transactional sex, such as for gifts, services, or money. Among
unmarried women aged 20–45, Black women are more likely to report
transactional sex with someone who is not a main partner compared to
white women (13.1 percent versus 2.9 percent) (Dunkle et al., 2010). HIV
prevalence was 4.9 percent among cisgender women who exchanged sex
for money or drugs in four U.S. cities (Nerlander et al., 2020). There is
far less information on other STIs among cisgender female sex workers
in the United States, but one study in Baltimore found the incidence of
chlamydia, gonorrhea, and trichomonas was 14.3, 19.3, and 69.1 per 100
person-years, respectively, among 250 study participants (Park et al., 2019).
Sex work increases exposure to STIs by increasing the number of
often higher-risk sex partners. Women engaging in transactional sex often
do not use condoms consistently (Medina-Perucha et al., 2019), due to
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
136 SEXUALLY TRANSMITTED INFECTIONS
client preference, physical and sexual violence, or the monetary value of
condomless sex in this context (Decker et al., 2020). In a meta-analysis of
published studies of female sex workers, the average rate of inconsistent
condom use for vaginal intercourse was 19 percent, but it was far higher
(46 percent) for anal sex, despite high transmission risk for HIV and other
STIs (Owen et al., 2020).
People who engage in sex work are more likely to live in poverty, be
victims of sexual and physical abuse, be involved in the criminal legal
system, and have substance use disorders and/or mental illness, and they
more often access health care via emergency departments rather than pri-
mary care (Patton et al., 2014a). Transactional sex is associated with food
insecurity, housing instability, substance abuse, and partner incarceration
(Stoner et al., 2019). See Chapter 2 for more information on how alcohol
and substance use, mental health, and housing instability are related to
STIs. See, too, the section later in this chapter on STIs among people with
criminal legal system involvement.
Attitudes about sex work in the United States lead to stigmatization
and marginalization. While less than half (43 percent) of U.S. individu-
als think that sex work should be illegal (Moore, 2016), it is illegal in all
states (it is legal in 10 counties in Nevada). Harsh police pressures on
people who engage in sex work have been associated with increased
risk of sexual/physical violence from clients or other parties, HIV/STI,
and condomless sex (Platt et al., 2018). Some evidence indicates that pos-
sessing condoms may increase the chance that a woman is arrested for
prostitution (Human Rights Watch, 2012). Most states punish people who
engage in sex work and customers equally; however, nine states have
harsher penalties for the customer (Colorado, Kansas, Massachusetts,
Montana, Nebraska, New York, North Carolina, Tennessee, Utah) and two
have harsher penalties for the person who engages in sex work (Delaware,
Minnesota) (ProCon.org, n.d.)—see Chapter 9 for more information on the
potential effect of decriminalizing commercial sex on STIs.
While male sex workers are not discussed in this report, they also
have a high prevalence of STIs (see Bacon et al., 2006; Baral et al., 2015;
Biello et al., 2020; Verhaegh-Haasnoot et al., 2015, for more information).
Similarly, for information on cisgender heterosexual adults working in
the adult film industry, see Goldstein et al. (2011), Rodriguez-Hart et al.
(2012), and the section describing online pornography in Chapter 6.
Older Heterosexual Adults
There is a common notion that older people do not have sex and are
not at risk for STIs, but the data do not support this idea (Nusbaum et al.,
2004; Patel et al., 2003; Smith and Christakis, 2009). One study found 73
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 137
percent of respondents aged 57–64, 53 percent of those aged 65–74, and
26 percent of those aged 75–85 were sexually active (Lindau et al., 2007).
Furthermore, there has been an uptick in the rates of some STIs among
older people. For example, from 2017 to 2018, rates of reported syphilis
cases increased 21.1 percent among those aged 55–64 and 28.6 percent
among those aged 65 and older (CDC, 2019c). According to data from
athenahealth, diagnosis rates for HSV-2, HBV, and trichomoniasis also
increased from 2014 to 2017 for those aged 60 and older (Pereto, 2018). In
2018, more than half of people in the United States living with diagnosed
HIV were aged 50 and older; though new HIV diagnoses are declining in
this population, about one in six HIV diagnoses in 2018 were in this age
group (CDC, 2020c).
Biological susceptibility may predispose older persons to STI risk
through a weakened immune system, but there are other likely relevant
factors, such as decreased vaginal lubrication and resulting friable vaginal
tissue (Johnson, 2013). Relationship changes, such as divorce and partner
death, can lead to new sexual relationships and may increase the risk of
STIs (Sherman et al., 2005; Smith and Christakis, 2009). Older individuals
may use online dating, where they are unacquainted with their partners
and their sexual histories. Baby Boomers who matured during the sexual
revolution of the 1960s/1970s may continue or revert to sexual behaviors
that carry substantial risk for STI acquisition (Patel et al., 2003; Stall and
Catania, 1994; Tuddenham et al., 2017). Seniors who were already mar-
ried when sex education gained prominence may have missed “safer
sex” talks aimed at younger generations. Additionally, medications such
as sildenafil (Viagra) for men and hormonal replacement for women can
reduce age-related physical barriers to having sex. Low risk awareness
and embarrassment about sexuality among older persons, however, may
result in both condomless sex and sex with more than one partner (Syme
et al., 2017). Patients and health care providers alike also may overlook
STI screening (Bauer et al., 2016; Bergeron et al., 2017; Haesler et al., 2016;
Nusbaum et al., 2004; Thomason et al., 2015). For example, the majority
of participants (about 65 percent) in a study of women aged 57 and older
reported that sex is important, but less than one-quarter had talked about
it with a physician (Bergeron et al., 2017). Similarly, a survey of 3,005 U.S.
adults aged 57–85 found 38 percent of men and 22 percent of women had
discussed sex with their provider since turning 50 (Lindau et al., 2007).
Older adults may not consider oral or anal sex as ways of contracting or
transmitting STIs and may forgo condoms because they do not fear preg-
nancy (Harvard Health Letter, 2018). Older adults also may face issues in
accessing appropriate health care, reliable and accessible transportation,
and other social determinants of health (Pooler and Srinivasan, 2018).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
138 SEXUALLY TRANSMITTED INFECTIONS
SEXUAL AND GENDER DIVERSE POPULATIONS
MEN WHO HAVE SEX WITH MEN
MSM are a diverse and heterogeneous group with high community
connectivity and gender privilege, yet they have distinct and unique
vulnerabilities to STI transmission. This section highlights key elements
from a body of scholarship that can frame existing and forthcoming STI
interventions focused on this highly susceptible community. Particular
attention is paid to Black and Latino MSM, given their disproportionate
rates of STIs as a function of social and structural forces. Box 3-4 summa-
rizes key information about STIs among MSM.
Individual-Level Factors
Penetrative anal sex is a potential factor causing increased biological
susceptibility to STIs because of the thin lining of the rectum, which
is easily damaged (CDC, 2019a). The number of recent or lifetime sex
partners, rate of partnerships, and frequency of condomless intercourse
affect STI transmission (CDC, 2019c; Glick et al., 2012). Given the increased
rates of substance use, including use of drugs proximate to sexual activity
(chemsex and erectile dysfunction drugs), behavioral disinhibition and
greater frequency and duration of sex can create an environment where
BOX 3-4
Key Takeaways: Men Who Have Sex with Men (MSM)
• MSM are a diverse and heterogeneous group with high network connectivity
and gender privilege, yet they have distinct and unique vulnerabilities to sexu-
ally transmitted infection (STI) transmission.
• Within MSM, there are clear intersectional drivers of STIs, with Black and La-
tino MSM experiencing decades of oppression and disenfranchisement, which
reinforces concentrated STI epidemics and transmission with other cis- and
transgender women.
• Black MSM have increased within-group sexual mixing compared to other race
and ethnicity identities and are more likely to mix with others of different risk
statuses, again driven by segregation and other racialized policies that drive
housing instability, criminal legal system involvement, and limited employment
opportunities.
• While singular causes for increased STIs are debated, it is likely that multiple
factors are involved, potentially including antiretrovirals for HIV prevention,
increased access to sexual partners, growing methamphetamine use among
racial and ethnic minority MSM, and decreased AIDS morbidity/mortality.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 139
STI transmission is more likely. Many MSM, especially from highly
marginalized communities, may rely on substance use because it can
remove deeply rooted inhibitions to intimacy; networks of substance
users can create a sense of community (Benoit and Koken, 2012; Harawa
et al., 2008; McKirnan et al., 2001; Schneider et al., 2013).
Many of these behaviors may relate to societal forces of discrimina-
tion and stigma, which can lead to internalized stigma/homophobia.
In addition, MSM report higher rates of early experiences of childhood
abuse and victimization (see Chapter 2 for more information).
Interpersonal-Level Factors
As discussed in Chapter 2, various network characteristics have been
identified as contributing to individuals’ STI risk behaviors, risk percep-
tions, or infectious outcomes (see also Chapter 8). Specific assortative
and disassortative mixing5 factors concentrate STIs within specific com-
munities. These patterns, for example, undergird higher STI concentration
within MSM as compared to heterosexual populations and higher concen-
tration within Black MSM as a subgroup of all MSM. Overall population
size is an important factor to consider when describing relative risk of
STI infections in the context of such mixing, which tends to increase rates
within smaller populations and community subpopulations. In addition,
assortativity6 can be attributed to specific sex behaviors, including sex
drug use, group sex, and condomless sex, which, when disassortative, can
provide a network mechanism for onward STI transmission (Doherty et
al., 2009; Schneider et al., 2013). Both types of mixing have been acceler-
ated by dating apps (Beymer et al., 2014).
An additional network force is concurrency (overlapping partner-
ships). It provides opportunities for increased STI transmission at the
partner level; the network risk increases substantially. Group sex is a clear
case of concurrency; a potent mechanism for STI transmission exists, and
overlapping sex acts take place within a short time. Additionally, group
sex has the further accelerative effect of sharing infectious fluids between
individuals from other network(s) who may have had indirect sex with
someone else unknown to them (Friedman and Aral, 2001). Concurrency
can be conceptualized in current understandings as being in an open
relationship.
5 Displaying a preferential attachment to others with dissimilar attributes or behaviors.
6 Preferential attachment to others with similar attributes or behaviors.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
140 SEXUALLY TRANSMITTED INFECTIONS
Community-Level Factors
Community and other network norms are significant drivers of STIs
among MSM. People prefer to have condomless sex for a variety of rea-
sons. For MSM, the threat of HIV infection and its associated mortal-
ity earlier in the HIV epidemic served to instill an ethos and norm in
favor of consistent condom use. As described in Chapter 6, perceptions
of the declining severity of HIV and AIDS since the late 1990s have
likely contributed to behavior changes, such as increases in condomless
sex (Morgan et al., 2017) and condomless sex with casual partners, that
may increase personal satisfaction with one’s sex life while also fueling
increased rates of STIs among MSM (Schmidt et al., 2019b; Stenger et
al., 2017). These relationships are complex, and other community norms
could potentially contribute to STI transmission and increasing rates, such
as increasing use of hookup apps, group sex, sex drug use, and condom-
less sex with pre-exposure prophylaxis to prevent HIV.
Having dense and assortative networks offers several key benefits,
however, particularly with respect to health-seeking behavior, including
the normalization of testing for STIs, such as HIV. Many MSM recognize
the need for annual testing; others test more frequently, in line with CDC
guidelines of every 3–6 months. Combined STI/HIV screening can be
optimized based on sex behaviors and partnership patterns (Khanna et
al., 2015). In addition, despite the general lack of culturally competent
health systems with respect to sexual minority health, specialized sexual
health centers exist that MSM use and share with other community mem-
bers. Many health centers that specialize in LGBTQ+ health, for example,
add to existing options for STI testing. Several have models for decreas-
ing barriers, such as cost and time to obtain services (i.e., walk-in) and/
or results (i.e., express service). These are typically safe spaces for MSM
that complement other traditional STI clinics. Traditional STI clinics that
provide care to MSM may have less cultural competency, but there can
be anonymity factors in these spaces that some MSM prefer, particularly
if these are not located where they work, live, or play.
Structural-Level Factors
Several societal forces drive STI transmission among MSM. Fore-
most are the insidious stigma, discrimination, and cultural violence forces
directed toward sexual minorities in general and MSM in particular.
While some progress has been made recently with marriage equality, per-
sistent efforts continue to dehumanize MSM through unscientific policies
and programs, including “gay conversion,” prohibiting adoption among
same-sex couples, and barring school-based, same-sex sex education.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 141
Intersectional social identities and positions are important consid-
erations, as they may not allow for increased social capital among those
with multiple marginalized statuses because these statuses are often
stigmatized. This can result in additive and potentially multiplicative
negative impacts on MSM health and well-being. Racism also works to
marginalize MSM of color further, particularly in what should otherwise
be “safe spaces” for queer people. They experience long-standing contin-
ued racism and resulting bigotry (Crawley, 2012). This is a particularly
corrosive feature directed at people with multiple marginalized social
identities and positions and is unfortunately often evident in organiza-
tions that promote sexual and gender minority health (Crawley, 2012).
Racism clearly leads to un- and underemployment, housing instability,
and criminal legal system involvement, which directly increase STIs in
Black and Latino MSM (Newman and Berman, 2008).
Internalized homonegativity is a key factor that leads to increased
STIs, substance use, poor mental health, and increased suicidality (Berg
et al., 2016; Jeffries and Johnson, 2015; Newcomb and Mustanski, 2010).
Limited positive self-perception and self-worth and limited support from
kin can lead to acceptance-seeking behaviors, which can be associated
with increases in STIs, overexpressed sexuality through increased partner-
ships, and sexual nonconformity.
TRANSGENDER AND GENDER DIVERSE ADULTS
Being uninsured and not having access to funds to get tested is another bar-
rier. There’s the LGBTQ center where testing is free, but if I wanted to go to
my regular health care provider, although I would be insured once a year to
get testing, throughout the rest of the year, I would not be insured, so that is
definitely a barrier. Then there’s just cost of living in general. When seeing if
you have the ability to get tested, you have to take into consideration the cost of
living and if you can even spend that money to get tested or if you have to put
it elsewhere. And worrying about personal safety in clinical environments and
getting to clinical environments is a social determinant that I am faced with.
—Participant, lived experience panel
Transgender Women
STI rates among transgender (trans) women, and Black and Latina
trans women in particular, are some of the highest in the United States
(Becasen et al., 2019; Poteat et al., 2014). High rates of infection suggest
the importance of extragenital testing for STIs, with more than 80 percent
of women with an extragenital gonococcal or chlamydial infection hav-
ing a concurrent negative urogenital test. Black and Latina trans women
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
142 SEXUALLY TRANSMITTED INFECTIONS
experience discernable gendered and racialized dynamics. They possess
multiple marginalized statuses: the effects of their gender identity and
sexual orientation, which have variable expression and form, are exacer-
bated by the forces of racial discrimination (Bostwick et al., 2014; Frost et
al., 2015; Han et al., 2015). Box 3-5 includes key summarizing information
about STIs among trans and gender diverse adults.
Individual-Level Factors
There are notable behavioral susceptibilities that may increase vulner-
ability to STIs among trans women, including higher rates of oral sex and
receptive intercourse. Increased oral sex offers additional opportunities
for STI acquisition. In addition, while trans women are often the receptive
partner when engaging in sex, health care professionals and other health
educators often assume this and may not necessarily provide informa-
tion on topping or other insertive roles that can lead to STIs and may
not be routinely tested and treated appropriately. Among trans women
BOX 3-5
Key Takeaways: Transgender and Gender Diverse Adults
• Black and Latina transgender (trans) women experience discernable gendered
and racialized dynamics. They possess multiple marginalized statuses: the
effects of their gender identity and sexual orientation, which have variable
expression and form, are exacerbated by the forces of racial discrimination.
• While trans women are often the receptive sex partner, health care profes-
sionals and other health educators often assume this and may not necessarily
provide information on topping or other insertive roles that can lead to sexually
transmitted infections (STIs). Trans women may not be routinely tested and
treated.
• The house/ballroom and other gay family communities may provide increased
social support and opportunities for romantic partnership among trans women.
They are also spaces for STI prevention.
• Intense transphobia and extreme violence against Black trans women in par-
ticular directly drive STI transmission and low life expectancy and represent a
major public health emergency.
• Trans and gender diverse assigned female at birth (AFAB) people can acquire
STIs from assigned male at birth and AFAB sexual partners.
• Exposure to STIs and access to STI-related services in trans and gender di-
verse AFAB individuals is shaped by pervasive gender identity–related stigma
and discrimination in society.
• Black, Latino, and other transgender and gender diverse AFAB people of color,
who experience not only transphobia but also racism, may face a dispropor-
tionate STI burden.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 143
without vaginoplasty, 16 percent have engaged in insertive anal sex with
non-main, commercial partners in the past 30 days (Nemoto et al., 2014).
Some of the structural factors described below that affect trans
women can lead to increased use of substances, including alcohol and/
or sex drugs, that can result in concomitant decision-making impairment
and less agency (see Chapter 2 for more information on the association
between alcohol and substance use and STIs). Furthermore, the potential
for needle sharing for hormone therapy or group silicone pumping could
potentially lead to STI transmission. Research conducted with Black trans
women in Los Angeles has shown that they are more likely to engage in
hormone misuse (e.g., nonprescribed use) compared to trans women who
are not Black (Clark et al., 2018). Behavioral interventions to reduce sexual
risk for acquiring and transmitting STIs are urgently needed for young
trans women (Kuhns et al., 2017).
Interpersonal-Level Factors
Similar to MSM, smaller networks can lead to greater likelihood of
core groups overlapping with those at the periphery. Intersectional mar-
ginalization based on gender identity and race and ethnicity can foster
partnerships with heterosexual men and MSM. Networks that include
concurrent contacts driven by sex work and overlap between main and
casual partners can drive STI transmission. In addition, evidence indi-
cates that Black trans women’s sexual networks change significantly more
than Black MSM’s and are generally less stable (Ezell et al., 2018). These
dynamics are especially critical given the observed association between
belongingness, well-being, and sexual health for trans women (Austin
and Goodman, 2017; Barr et al., 2016; Katz-Wise et al., 2017).
Social spaces, including the house/ballroom community, gay families,
or other families of choice can lead to increased contact with networks
that engender higher STI rates. High rates of interpersonal violence also
result in STI transmission. There are social supportive structures that can
include other trans women, kin, and families of choice. Trans women
are in similar structural network positions within MSM networks, which
makes them as vulnerable to STIs as MSM; they may have additional
vulnerability, however, with CDC deeming sexual relations with het-
erosexual men high risk (Ezell et al., 2018). Interventions to reduce STIs
among trans women need to attend to risk behaviors within primary
partnerships and to sex with partners outside the primary partnership;
couples-based interventions that focus on trans women and their male
primary partners are promising (Operario et al., 2011).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
144 SEXUALLY TRANSMITTED INFECTIONS
Institutional- and Community-Level Factors
Black and Latina trans women experience high levels of economic
deprivation, substandard schooling, and violence in underserved commu-
nities; these community-level factors contribute to the disproportionate
STI morbidity in these women. Cascading impacts of societal discrimina-
tion and transphobia lead to unemployment, housing instability, limited
health insurance and gender-affirming care, and criminal legal system
involvement, all of which are associated with increased STI transmission
(Ezell et al., 2018). Trans people are twice as likely to experience homeless-
ness as other members of the general population; this is associated with
engagement in survival sex, which increases the risk of STIs. A study
using data from the National Transgender Discrimination Survey found
those assigned male at birth (AMAB) and Black, Latino/a, biracial, and
multi-racial trans people were more likely to engage in survival sex than
those assigned female at birth (AFAB) and white trans people (Kattari
and Begun, 2016). Furthermore, segregation results in community mem-
bers who often live, work, socialize, worship, and establish romantic and
sexual partnerships in the same spaces (Bowleg and Raj, 2012); little is
known about whether these interactional tendencies are comparable or
intensified among trans women of marginalized racial and ethnic groups.
Social and community stigma against sex assignment variance affect
gender identity, are associated with lower levels of education, and are
linked to limited access to health-promoting resources. Such factors typify
the comparable highly salient challenges trans women may face and share
(Arnold et al., 2018; Frye et al., 2015; Graham, 2014). As compared to
MSM, social norms around annual or frequent STI testing may not be part
of the cultural identity, particularly given that trans communities tend to
be smaller and more heterogeneous. Among trans women, for example,
HPV prevalence is very high compared to MSM and knowledge dispro-
portionately low; however, additional outreach could increase awareness
and uptake of HPV vaccination (Singh et al., 2019). While social norms
around STI prevention, such as HPV vaccination, may not be realized, any
benefit from receiving gender-affirming care can be offset by health care
systems that lack cultural competency. The few exceptions are typically
specialized sexual health centers, particularly those that serve sexual and
gender minority communities in urban STI epicenters; even there, how-
ever, trans women and people of color can be marginalized. Economic
security, especially as related to social support and gender transition,
need to be addressed by STI prevention programs (Nemoto et al., 2016).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 145
Structural-Level Factors
Much of the similar social and structural factors that affect MSM
impact trans women as well. MSM and trans women do not necessarily
share a monolith of similar experiences. Trans women often face similar
stigma and discrimination, however, as LGBTQ+ youth working through
sexuality and gender identity, this is particularly true for trans women of
marginalized racial and ethnic groups. While some improvements have
occurred in sexual minority policy, the health and well-being of trans
women have seen limited improvements, if any. There also has been open
discrimination, including state-sanctioned discrimination, such as bath-
room bills7 (Kralik, 2019) and conscientious objection laws8 (Dickens, 2009;
Eberl, 2019; Perez-Brumer et al., 2018). Racism and transphobia intersect
to further drive health inequities, as protections for health insurance for
trans women under Section 1557 of the Patient Protection and Affordable
Care Act were eliminated in June 2020 by the Trump administration. On
January 20, 2021, however, President Biden issued an Executive Order on
Preventing and Combating Discrimination on the Basis of Gender Identity
and Sexual Orientation that will likely lead to rule-making to reverse this
action (The White House, 2021).
Actions such as the Trump administration’s efforts to rescind protec-
tions for gender minorities are a form of structural violence that further
impacts Black trans women who already experience limited access due to
systematic racism that privileges specific insurance and ability to navigate
increasingly complex health care systems. Such systems can relegate Black
trans women to limited STI care options, including LGBTQ-focused clin-
ics, emergency care, and STI clinics.
One of the most profound health inequities driven by intersecting
gender identity (e.g., transphobia) and racial (i.e., racism) discrimination
manifests in the horrific epidemic of homicide experienced by, in par-
ticular, Black trans women. Pronounced violence against trans women
permeates all aspects of health and well-being and has led to the low-
est life expectancy overall and particularly among Black trans women.
This violence includes well-documented murders due to gender identity
perpetrated by community members, as well as police harassment and
brutality. Furthermore, criminalization and policing strategies that target
7 According to the National Conference of State Legislatures, bathroom bills are “legisla-
tion that would restrict access to multiuser restrooms, locker rooms, and other sex-segre-
gated facilities on the basis of a definition of sex or gender consistent with sex assigned at
birth or ‘biological sex’” (Kralik, 2019).
8 Within the health care field, conscientious objection laws allow health care providers to
object to providing care (e.g., medical procedures) that conflicts with their religious, moral,
or personal beliefs (Dickens, 2009; Eberl, 2019).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
146 SEXUALLY TRANSMITTED INFECTIONS
people who engage in sex work exacerbate the harms and increase vulner-
ability to violence and STIs (Krüsi et al., 2014). These factors may further
lead to internalized stigma and loss of self-worth, which affect STI trans-
mission and other health vulnerabilities.
Conceptualization of sexuality and sexual orientation among Black
trans women may change over time. Gender identity among Black trans
women may be affected by flexibility in binary distinction in sexual iden-
tity (Galupo et al., 2016). This might be ascribed, in part, to the distinct
racial disparities in gender transition programs and the current trajectory
of medicalization (e.g., puberty suppression); Black trans women may
transition later and identify early on as gay due to limited options for
other identification (Lopez et al., 2018; Olson-Kennedy et al., 2016). Com-
pared to both white trans women and to trans women with high income
and education levels, Black trans women may find it may be substantially
more difficult to access essential transition resources, such as puberty and
hormone treatments and psychosocial support, financially and geographi-
cally. Gender affirmation (social, psychological, medical, and legal) is
a social determinant of health uniquely affecting trans people’s health,
including factors related to STIs (Reisner et al., 2016).
Transgender and Gender Diverse
Assigned Female at Birth People
Although research on this topic is scarce, existing studies indicate
that trans and gender diverse AFAB people—that is, those who identify
as a man, trans man, transmasculine, another masculine gender identity,
and/or a combination of or neither male/masculine nor female/feminine
(Dutton et al., 2008), who are identified within HIV but not STI surveil-
lance statistics (CDC, 2019b), are at risk of acquiring STIs from a range of
sexual risk behaviors with partners of various genders and sexual orienta-
tions (Bauer et al., 2013; Kenagy, 2005; Kenagy and Hsieh, 2005; Reisner
and Murchison, 2016; Reisner et al., 2014; Sevelius, 2009; Stephenson et
al., 2017). Moreover, although research is limited, existing studies suggest
that trans and gender diverse AFAB people with cisgender male sexual
partners may be at particularly elevated risk of STIs, although those with
AFAB partners (e.g., cisgender women, trans men) are also at risk (Bauer
et al., 2013; Reisner et al., 2010; Sevelius, 2009; Stephenson et al., 2017).
Multi-Level Drivers
Trans and gender diverse AFAB people may be particularly suscep-
tible to STIs as a result of social factors at the individual, interpersonal,
community, and institutional levels that undermine their access to STI
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 147
prevention, testing, and care services and resources. These factors include
high levels of participation in sex work and exposure to sexual violence,
a lack of access to social, economic, political, and health care resources,
limited access to tailored and relevant sexual health information, a lack
of health care provider training and knowledge in trans health, and dis-
crimination from health care providers and staff in the health care system.
These factors are all shaped by structural factors (e.g., cultural norms,
societal expectations and practices, laws, and policies) that foster perva-
sive gender identity–related stigma and discrimination toward trans and
gender diverse individuals (e.g., transphobia) in various social systems
and society in general (James et al., 2016; Reisner et al., 2014; Stephenson
et al., 2017).
Intersectional Considerations
Studies also suggest that Black, Latino, and other trans and gender
diverse AFAB people of color, who are exposed to not only transphobia
but also racism and lack access to social, economic, and political resources
and tailored health care and social services, may be at higher risk of STIs
compared to their white counterparts (Kenagy, 2005; Xavier et al., 2005).
For example, in a sample of trans men in Philadelphia, Pennsylvania,
Black, Latino, bi/multi-racial, AI/AN, and Asian individuals were signifi-
cantly more likely than their white counterparts to have engaged in con-
domless sex in the past year (Kenagy, 2005). In a sample of trans people
in Ontario, Canada, those who experienced both racism and transphobia
had significantly higher odds of engaging in STI risk behaviors compared
to those who reported only one or no type of discrimination (Marcellin
et al., 2013).
LESBIAN, BISEXUAL, AND OTHER
SEXUAL MINORITY WOMEN
Overview
Sexual minority women (SMW; i.e., women who identify as lesbian,
bisexual, or queer and women with same-sex sexual partners and/or
sexual attractions) can acquire bacterial, viral, and parasitic STIs through
a range of sexual behaviors with both AFAB and AMAB sexual partners
(Gorgos and Marrazzo, 2011; Schick et al., 2015). Furthermore, the major-
ity (up to 87 percent) of women who report same-sex sexual behavior
have had male sexual partners at some point in their lives, and some con-
tinue to do so in the present (Gorgos and Marrazzo, 2011). STIs, includ-
ing chlamydia, gonorrhea, trichomoniasis, syphilis, herpes, and HPV,
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
148 SEXUALLY TRANSMITTED INFECTIONS
can be transmitted between AFAB sexual partners through oral-vaginal,
vaginal-vaginal, digital-vaginal, and digital-anal contact and via sex toys
for vaginal or anal penetration (Gorgos and Marrazzo, 2011; Marrazzo,
2004). Although chlamydia and gonorrhea transmission may be highest in
the context of penile-vaginal intercourse, herpes, syphilis, and HPV also
can be transmitted through skin-to-skin contact, further facilitating their
transmission between AFAB sexual partners (Marrazzo, 2004). (See Box
3-6 for key takeaways.)
Data on STIs among SMW are not routinely collected and are thus
very limited (Gorgos and Marrazzo, 2011). Existing data show that, on
average, however, the overall prevalence of STIs is higher among SMW
compared to non-SMW (i.e., women who identify as heterosexual and
those with only male sexual partners and different-sex sexual attrac-
tions) (Everett, 2013; Reiter and McRee, 2016; Xu et al., 2010). In par-
ticular, STI prevalence is considerably higher among bisexual-identified
women and those with both male and female sexual partners compared
to heterosexual-identified women and those with only male sexual part-
ners, respectively (Everett, 2013; Gorgos and Marrazzo, 2011; Reiter and
McRee, 2016). Using Add Health data among U.S. adolescents, Everett
found that STI prevalence was significantly higher among bisexual-iden-
tified women (those with only male sexual partners and both male and
female sexual partners—51.1 and 64.1 percent, respectively) and women
with both male and female sexual partners (both heterosexual- and
BOX 3-6
Key Takeaways: Lesbian, Bisexual, and
Other Sexual Minority Women (SMW)
• Lesbian, bisexual, and other SMW can acquire sexually transmitted infections
(STIs) from assigned female at birth and assigned male at birth sexual partners.
• In particular, bisexual women and women with male and female sexual partners
are more likely to acquire an STI compared to heterosexual women and women
with only male sexual partners, respectively.
• The disproportionate burden of STIs among SWM in general and bisexual
women and women with female and male sexual partners in particular may
be due to higher levels of sexual victimization, STI-related sexual behaviors,
limited access to social, economic, and health care resources, a lack of inclu-
sion in sexuality education, and poor patient–provider sexual health commu-
nication—all of which are shaped by sexual orientation–related stigma and
discrimination at the interpersonal and structural levels.
• SMW of color, who face not only sexual orientation–related discrimination but
also racism, may experience a higher burden of STIs compared to their white
counterparts.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 149
bisexual-identified—58.1 and 64.1 percent, respectively) compared to het-
erosexual-identified women with only male sexual partners (46.6 percent)
(Everett, 2013). By contrast, lesbian-identified women were significantly
less likely to report an STI compared to heterosexual women with only
male sexual partners (32.0 versus 46.6 percent) (Everett, 2013).
Using National Health and Nutrition Examination Survey (NHANES)
data among U.S. women aged 20–59, Reiter and McRee (2016, 2017) found
that HPV prevalence was higher among SMW relative to non-SMW: 49.7
percent among lesbian, bisexual, and other non-heterosexual women
(combined) versus 41.1 percent among heterosexual women and 55.9 per-
cent among women with only female sexual partners and those with both
male and female sexual partners (combined) compared to 41.0 percent
among those with only male sexual partners. Specifically, the researchers
observed higher levels of HPV among bisexual-identified women (57.7
percent), followed by heterosexual-identified (41.1 percent) and lesbian-
identified (35.5 percent) women (Reiter and McRee, 2016, 2017).
NHANES data on U.S. women aged 18–59 indicate that HSV-2 preva-
lence was significantly higher among SMW (30.3 percent among women
with only female or both male and female sexual partners in the past year
and 36.2 percent among those with only female or both male and female
sexual partners in their lifetime) compared to non-SMW (23.8 percent)
(Xu et al., 2010). Additionally, HSV-2 prevalence varied widely among
SMW—45.6 percent among those who self-identified as heterosexual and
35.9 percent and 8.2 percent among self-identified bisexual and lesbian
women, respectively (Xu et al., 2010). Lastly, in a sample of adolescent
and young adult U.S. women receiving care at family planning clinics in
the Pacific Northwest, Singh et al. found that the prevalence of chlamydia
was higher among those with only female sexual partners and those with
both male and female sexual partners (combined; 7.1 percent) compared
to those with only male sexual partners (5.3 percent) (Singh et al., 2011).
Individual-Level Factors
Research suggests that sexual orientation disparities in STI prevalence
among women may be due to higher levels of victimization, including
sexual abuse and violence, for bisexual women and those with both male
and female sexual partners compared to heterosexual women and women
with only male sexual partners, respectively (Austin et al., 2008; Everett,
2013; McNair, 2005). Other explanatory factors may include higher levels
of STI-related sexual behaviors (e.g., higher number of sexual partners
and anal sex acts), lack of social support, and limited access to social,
economic, and health care resources among bisexual women and women
with both male and female sexual partners, which is shaped by a broader
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
150 SEXUALLY TRANSMITTED INFECTIONS
social context of structural and interpersonal discrimination toward SMW
in general and bisexual women in particular (Dodge et al., 2016; Everett,
2013). Moreover, research suggests that SMW and health care providers
alike perceive women with female sexual partners to be at low risk of
acquiring STIs, which may in turn lead to a lack of engagement in STI
prevention practices and low testing (Agénor et al., 2019b; Marrazzo et
al., 2005; McNair, 2005; Muzny et al., 2013; Power et al., 2009; Schick et
al., 2012).
Interpersonal- and Institutional-Level Factors
Studies indicate that SMW, in general, are excluded from sexuality
education, lack access to accurate and relevant sexual health information
that addresses their unique and specific needs and concerns (including STI
transmission between partners AFAB), face notable barriers to patient–
provider STI communication (including erroneous assumptions among
health care providers that SMW are not at risk for STIs), and experience
interpersonal discrimination in society in general and the health care
system in particular—all of which may contribute to STI acquisition and
a lack of access to and use of STI-related services among SMW (Agénor et
al., 2019b; Jahn et al., 2019; McNair, 2005; Power et al., 2009).
Structural-Level Factors
Few studies have examined the association between structural stigma
and sexual health. Charlton et al. found, however, that sexual minority
adolescent women living in states with lower compared to higher levels of
structural stigma—as measured by the density of same-sex partner house-
holds, proportion of high schools with gay-straight alliances, a composite
variable of five state-level protective policies related to sexual orienta-
tion (e.g., employment non-discrimination policies), and public opinion
toward sexual minorities data—were significantly less likely to have an
STI diagnosis, adjusting for individual- and state-level covariates (Charl-
ton et al., 2019). This study suggests that changing state-level laws and
policies and social norms to be inclusive of sexual minorities may help
mitigate STIs among young SMW (Charlton et al., 2019). Additionally,
supportive social policy, such as civil union legislation, has been found
to have a positive effect on the health of SMW, as measured by levels of
stigma consciousness, perceived discrimination, depressive symptoms,
and one indicator of hazardous drinking (Everett et al., 2016). Moreover,
Agénor et al. (2019) found that the Patient Protection and Affordable
Care Act of 2010, which extended dependent coverage and included a no
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 151
cost-sharing provision for preventive health services, were significantly
associated with a higher prevalence of HPV vaccination among both les-
bian and bisexual women in 2015 compared to 2007–2010, adjusting for
temporal trends and demographic factors.
Intersectional Considerations
Investigators have found that STI prevalence may be higher among
SMW of color relative to white SMW (Gorgos and Marrazzo, 2011; Singh
et al., 2011). Intersectionality suggests that multiple forms of interpersonal
and structural discrimination (e.g., sexism, racism, heterosexism, classism,
xenophobia) may have a compounding and/or unique effect on the health
outcomes (including risk behaviors and STIs) of multiply marginalized
social groups (Ayala et al., 2012; Bowleg, 2008; Díaz et al., 2004; Mizuno
et al., 2012). Although few studies have investigated the STI prevalence of
racial and ethnic subgroups of SMW, Muzny et al. (2018) found that, in a
sample of Southern Black women with female sexual partners and with
low levels of socioeconomic resources, lifetime STI history was common,
at a prevalence of 67.3 percent. The researchers also found a positive asso-
ciation between lifetime incarceration and intimate partner violence and
lifetime STI history in this sample (Muzny et al., 2018). Singh et al. found
that AI/AN (14.3 percent) and Asian/Pacific Islander (7.3 percent) women
with only female sexual partners had a higher prevalence of chlamydia
than their white counterparts (6.4 percent). The researchers also found that,
among women with both female and male sexual partners, Latina women
(12.7 percent) had the highest prevalence of chlamydia and Asian/Pacific
Islander women (5.4 percent) had the lowest (Singh et al., 2011).
LGBTQ+ YOUTH
In queer youth, I would say … mistrust of the health care system
and the lack of access to care, and that lack of access can be due to cost,
fear of their family finding out through listing of things
through insurance, and lack of gender-affirming care.
—Participant, lived experience panel
LGBTQ+ youth, including those who self-identify as lesbian, gay,
bisexual, transgender, queer, or another sexual orientation or gender iden-
tity or have same-sex sexual partners, bear a disproportionate share of
STIs and poor quality of sexual-orientation- and gender identity–specific
sexual health care (Hafeez et al., 2017). Youth who engage in same-sex
sexual activity are especially at an elevated risk of STIs (Benson and Her-
genroeder, 2005). Box 3-7 provides key information about STI rates and
drivers of STIs among LGBTQ+ youth.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
152 SEXUALLY TRANSMITTED INFECTIONS
BOX 3-7
Key Takeaways: Lesbian, Gay, Bisexual, Transgender, and
Queer (or Questioning) and Others (LGBTQ+) Youth
• LGBTQ+ youth are disproportionately affected by sexually transmitted infec-
tions (STIs); they have unique structural and social determinants of STIs.
• LBGTQ+ youth are at risk of physical, emotional, and sexual abuse from peers
and adults. Family rejection can result in them experiencing homelessness,
which is associated with higher STI prevalence.
• LGBTQ+ youth may experience discrimination, nonaffirmation of sexual and/
or gender identity, and internalized homophobia or transphobia, which nega-
tively affect physical and mental health. Transgender youth in particular face
economic marginalization and social stigma.
• Multi-level drivers of STIs among LGBTQ+ youth include lack of access to
comprehensive sex education and some physicians’ lack of training in LGBTQ+
care, including gender-affirming care. Assumption of patient sexuality can affect
STI prevention care.
• Additional longitudinal studies with longer follow-up periods, larger represen-
tative studies with multi-dimensional measures of sexuality, and translational
research to eliminate disparities in STIs and reduce stigma are needed.
Multi-Level Drivers of STIs
High STI rates among LGBTQ+ youth are not necessarily the result
of an increased number of partners or frequency of sex; LGBTQ+ youth
are more likely than heterosexual and cisgender youth to experience far-
reaching health inequities that place them at a higher risk of STIs and
HIV (Mustanski et al., 2014). For example, a 3-year prospective cohort
study evaluating the presentation and persistence of syndemic conditions
among young MSM underscore how health challenges persist across time
as they emerge into adulthood (Halkitis et al., 2015). STI-related behav-
iors and mental health burdens that begin in youth are multi-faceted and
interconnected. They are not the sole catalyst for or driver of higher STI
burdens among LGBTQ+ youth, but rather need to be viewed as part of a
bigger picture that includes behavioral and structural inequities. LGBTQ+
youth are more likely to be involved in health risk behaviors due to peer
victimization. Other forms of victimization include childhood physical
and sexual abuse, substance use, and homelessness due to family rejection
(Friedman et al., 2011). LGBTQ+ youth experiencing unstable housing
or homelessness are at increased risk of engaging in survival sex; trans
youth and Black, Latino/a, and multi-racial LGBTQ+ youth who experi-
ence homelessness may be targeted for additional victimization as a result
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 153
of their multiple, intersecting marginalized social positions (Alessi et al.,
2020). Young MSM are more likely to report forced sex compared to het-
erosexual young men who have sex with women, which increases their
risk of acquiring an STI (Everett et al., 2014).
Structural barriers, such as lacking comprehensive sex health educa-
tion in schools, negatively impact LGBTQ+ health (see Chapter 8 for more
information on sex education). Structural barriers that align with racial
disparities act as barriers to health care themselves, increasing the risk of
HIV (Millett et al., 2012). A syndemic analysis highlights how behavioral
and health-related determinants influence each other to both contribute
to sexual health disparities (Halkitis et al., 2015).
Challenges within the health care provider education system are also
significant. More than half of physician education programs in the United
States lack training in LGBTQ+ health, and only 16 percent comprehen-
sively address it (Khalili et al., 2015). Yet, health care providers can make
a critical impact on the lives of LGBTQ+ youth by providing supportive,
evidence-based, comprehensive SRH care (Wood et al., 2016). LGBTQ+
youth subgroups are distinct and have unique structural and social deter-
minants of STIs and STI-related needs; these subgroups are discussed
below.
Young MSM
Young men with male sexual partners are more likely than their
counterparts with only female sexual partners to acquire STIs, including
chlamydia and gonorrhea (Mayer, 2011). Furthermore, younger sexual
minority men have greater odds of STIs in comparison to older sexual
minority men (Grov et al., 2016). Bisexual boys are more likely to acquire
STIs compared to their heterosexual peers (Everett et al., 2014). Pooled
data from the 2005 to 2007 Youth Risk Behavior Survey encompassing
more than 13,000 male respondents aged 12–18 years who reported at
least one sexual partner found that bisexual-identifying adolescents were
more likely to report multiple STI risk behaviors, such as a greater num-
ber of sex partners, concurrent sex partners, and younger age of first
sex, compared to heterosexual-identified young men who have sex with
women, heterosexual-identified young MSM, and gay-identified respon-
dents (Everett et al., 2014). Overall, young sexual minority men who have
sex with other men and those who identify as gay or bisexual are at an
increased risk of STIs relative to young heterosexual men (Brewer et al.,
2011; Mustanski et al., 2017).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
154 SEXUALLY TRANSMITTED INFECTIONS
Multi-Level Drivers of STIs
The multi-level drivers of STIs among young sexual minority men
are those described above among the multi-level drivers of STIs for the
broader sexual minority adolescents. Both network and behavioral factors
influence HIV-STI coinfection. Data collected from sexual minority boys
and young men in Houston and Chicago showed that syphilis-HIV coin-
fection was associated with having a sexual network with higher coin-
fection prevalence; syphilis monoinfection was associated with a higher
number of social venues attended, and HIV monoinfection was associated
with having more condomless top partners (Fujimoto et al., 2018).
Trans and Gender Diverse Youth
Trans and gender diverse (including non-binary, gender non-con-
forming, genderqueer, gender fluid, and agender) youth are dispropor-
tionately affected by STIs (Reisner, 2019; Reisner et al., 2015). In a sample
of U.S. gender minority youth aged 16–24, one-third had a history of
one or more STIs other than HIV; the most frequently diagnosed were
chlamydia (55 percent), syphilis (48 percent), and gonorrhea (47 percent)
(Reisner, 2019).
STIs affect subgroups of gender diverse youth differently. For exam-
ple, in a national sample of gender minority youth, investigators found
that the lifetime odds of being diagnosed with an STI were 4 times higher
among people AMAB compared to people AFAB participants (Reisner,
2019). Similarly, in a study of adolescents in New Orleans and Los Ange-
les, trans women and non-binary individuals AMAB had a higher STI
prevalence compared to other gender and sexual minority groups (Shan-
non et al., 2019a).
Multi-Level Drivers of STIs
Trans youth face multi-level barriers accessing and receiving health
care services, such as economic marginalization and social stigma, which
further contribute to both gender and age-related health disparities
(Edmiston et al., 2016). Trans youth experience gender minority and social
stressors, such as discrimination, rejection, nonaffirmation of gender
identity by others, internalized transphobia, and anticipated stigma with
age (Hatzenbuehler and Pachankis, 2016). In crossing the individual,
interpersonal, and the structural, stressors range from the proximal,
such as internalized transphobia and anticipated stigma, to the distal,
such as gender-related discrimination, gender-related rejection, and
nonaffirmation of identity (Hendricks and Testa, 2012; Rood et al., 2016).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 155
Trans youths’ lack of preventative screening and other such efforts,
for instance, are connected with the higher share of STIs observed in these
youth and do not stem from a single cause, but are rather multi-factorial
(Sharma, 2019). There are low levels of annual HIV (15.1 percent) and
other STI (22.6 percent) testing among predominantly sexually active
trans youth aged 15–24, with young trans women being less likely to
report such testing (Sharma, 2019). The limited availability of evidence-
based screening guidelines from expert organizations for trans people,
lack of provider awareness surrounding risk assessment protocols, and
lack of access to providers experienced in treating trans people all con-
tribute to low testing levels (Edmiston et al., 2016).
Other drivers include being more vulnerable to risk taking (e.g., con-
domless sex, sex work, needle sharing), which emphasizes the need for
preventative screenings for gender minority youth and more informed
health care practices (Stieglitz, 2010).
Anatomic diversity among trans youth is a key issue when assessing
gender minority youth risks for HIV and other STIs. Many trans youth
have not undergone reconstruction procedures to replace birth anatomy
with gender-affirming anatomy, even among those who sought gender-
affirming treatment (Sharma, 2019). Trans youth may not feel entirely
comfortable with their bodies and may be reluctant to undergo testing,
even more so when gender-affirming health care services are scarce—
especially in communities where gender-affirming health care services
are restricted (Bostwick and Hequembourg, 2014).
Overall, using a syndemic and multi-level framework when analyz-
ing key drivers of STIs among LGBTQ+ youth allows for a more accurate
and holistic picture of how different personal, behavioral, and systemic
factors affect sexual health outcomes.
Young Lesbian, Bisexual, and Other Sexual Minority Women
Young women with both male and female sexual partners are more
likely to acquire an STI compared to those with only male sexual partners.
In a study of approximately 30,000 sexually active college women aged
18–24, those who reported multiple female and male sexual partners in
the past year were more likely to have had an STI (16 percent) relative to
those with only male sexual partners (9 percent) (Lindley et al., 2008). In
contrast, sexually active college women with only female sexual partners
in the past year were less likely than those with only male sexual partners
(9 percent) to report having an STI (6 percent) (Lindley et al., 2008).
Bisexual girls are more likely to acquire STIs relative to their hetero-
sexual counterparts (Marrazzo and Gorgos, 2012; White Hughto et al.,
2016). Likewise, a cohort study of 4,224 adolescent girls and young adult
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
156 SEXUALLY TRANSMITTED INFECTIONS
women found that, after accounting for sociodemographic and sexual
history, respondents identifying as bisexual or “mostly heterosexual” had
significantly higher odds of being diagnosed with an STI in their lifetime
so far compared to the completely heterosexual group (Charlton et al.,
2011). In contrast, lesbian adolescents and young women had significantly
lower odds of being diagnosed with an STI in their lifetime relative to
completely heterosexual young women (Charlton et al., 2011).
Lesbian young women with an STI, however, had highly elevated
odds of considering themselves at a very low risk of having an STI in
comparison to heterosexual women (Kaestle and Waller, 2011). Research
suggests that lesbian-identifying young women across all age groups are
less likely to be tested for STIs and get regular pap smears (Aaron, 2001;
Cochran et al., 2001; Marrazzo et al., 2001).
Multi-Level Drivers of STIs
Physicians’ and educators’ judgmental attitudes and assumptions
of patient sexuality can severely jeopardize the health of young SMW
(Arbeit et al., 2016). Specifically, health care providers may believe that
lesbian women or women who only have sex with women do not need
sexual health screening or sexual health education (Fishman and Ander-
son, 2003; Marrazzo et al., 1998). Restricted youth openness with health
care providers was also associated with bisexual stigma within families,
suggesting fear of disclosure to parents or guardians (Arbeit et al., 2016).
In school settings, sexual health education was limited by a lack of STI
risk information relevant to sex between women (Arbeit et al., 2016). On
college campuses, sexual health education programs and providers need
to recognize STI risk among lesbian students and young women who
have sex with women by emphasizing that even women with only female
partners are at risk for STIs (Lindley et al., 2008).
Cultural bisexual invisibility also can underlie implicit and uncon-
scious inclinations to categorize people as either exclusive same- or other-
sex attracted (i.e., lesbian or gay); extreme cases include an explicit denial
of the existence of bisexuality itself (Bostwick and Hequembourg, 2014;
Flanders et al., 2015).
Research Needs
Much less research about LGBTQ+ youth exists relative to adults,
with few longitudinal follow-ups beyond 1 year (Mustanski et al., 2017).
For example, because many federal, state, and local agencies have incom-
plete data on trans individuals, it is difficult to obtain accurate popula-
tion-based estimates of their STI rates. Future studies need to include
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 157
adequate samples of trans youth and provide the option of indicating
trans and non-binary sexual partners (Flanders et al., 2015). Additionally,
representative samples with multi-dimensional measures of sexuality can
add depth to current understandings of sexual minority status and health
(Kaestle and Waller, 2011). More translational research is necessary not
only to speak to the existence of health disparities, but also understand
the mechanisms beyond the individual level and effective approaches
to eliminate health disparities among LGBTQ+ youth (Mustanski et al.,
2017). Research is also needed to determine the best strategies to decrease
stigma and health care access issues and increase routine screening and
care among LGBTQ+ youth (Shannon and Klausner, 2018).
OTHER POPULATIONS THAT REQUIRE
FOCUSED CONSIDERATION
AMERICAN INDIAN/ALASKA NATIVE PEOPLE
Culturally, AI/AN people have a holistic perspective of well-being
with corresponding values, traditions, and practices that ensure the physi-
cal, social, emotional, and spiritual health of individuals, families, and
communities. Since colonization of the United States, however, many of
these systems for promoting health have been disrupted or destroyed by
federal legislation. Native populations have experienced genocide, forced
relocation, violence, and widespread structural discrimination, resulting
in intergenerational cycles of historical trauma. These insults operate
across levels, ranging from the interpersonal to political, have been per-
petuated over the entire history of the country, and have led to an array
of health problems and inequities, including high rates of STIs, across
multiple generations (NASEM, 2019b). Because of the disproportionate
rates of STIs and the unique barriers faced by AI/AN people, they are
highlighted here. Box 3-8 highlights key information about STIs and the
multi-level drivers of STI disparities in AI/AN people.
Despite these impediments, Native people are actively working to
reinvigorate their own cultural assets and protective health practices to
promote individual and collective health and prosperity; multi-factorial,
systems-level barriers, however, challenge this. Similar to other marginal-
ized racial and ethnic groups, such as Black and Latino/a individuals, dis-
parities in STIs among AI/AN people have been attributed in the literature
to a variety of social conditions associated with lower socioeconomic sta-
tus, including poverty, abuse, mental health problems, and alcohol disor-
ders, as well as a lack of access to evidence-based sexual health education
and clinical services that address their needs (Athar et al., 2013; Beckles
and Truman, 2013; de Ravello et al., 2014; Ehlers et al., 2013; Hellerstedt et
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
158 SEXUALLY TRANSMITTED INFECTIONS
BOX 3-8
Key Takeaways: American Indian/Alaska Native (AI/AN) People
• AI/AN populations have been subjected to genocide, forced relocation, vio-
lence, and widespread structural discrimination, resulting in intergenerational
cycles of historical trauma. These insults have been perpetuated over the his-
tory of the country and have led to an array of health problems and inequities,
including in sexually transmitted infections (STIs), across multiple generations.
• Similar to other marginalized racial and ethnic minorities, the literature has
attributed disparities in STIs among AI/AN people to a variety of social condi-
tions associated with lower socioeconomic status, including poverty, abuse,
mental health problems, and alcohol disorders, as well as a lack of access to
evidence-based sexual health education and clinical services that address their
needs. AI/AN people, however, have unique barriers that need to be considered
to control health disparities, including STIs.
• A high rate of exposure to physical and sexual violence is documented in these
communities. Nationally, AI/AN women experience the highest rates of lifetime
sexual assault (27.5 percent) and physical violence from an intimate partner
(51.7 percent), compared with women of all other racial and ethnic groups.
• Approximately 40 percent of all AI/AN people rely on the Indian Health Service,
a historically underfunded system with limited capacity to provide high-quality,
culturally relevant care.
• Factors driving risk of and protection against STIs in these communities need
to be framed by the history and resulting policies undermining access to sexual
and reproductive health services, including STI prevention and treatment. Many
researchers have therefore urged culturally relevant sexual health education
programming (developed and delivered by AI/AN people themselves) and care
to alleviate mistrust of health care and concerns regarding discrimination.
al., 2006; Kaufman et al., 2007b; Rink et al., 2007). AI/AN people, however,
have unique barriers that need to be considered to control health dispari-
ties, including STIs (CDC, 2019c; Harling et al., 2013).
One example of a unique barrier is the surveillance practice of only
counting AI/AN people who declare that as their only race/ethnicity
category. This leads to misclassification and under-reporting in national
reporting systems. For example, per the 2010 U.S. Census, 5.2 million indi-
viduals reported their race as AI/AN, of whom 2.9 million self-identified
as AI/AN alone and 2.3 million identified as AI/AN in combination
with one or more other races (Norris et al., 2012). That latter would not
be classified as AI/AN, misclassifying nearly half of this population. See
Chapter 2 for more information about the limitations of STI surveillance
systems.
There is a tendency to lump all AI/AN groups together, though there
are 574 tribes in the federal registry, each with its own health promotion
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 159
practices and cultural factors that influence STI rates. Surveillance dem-
onstrates the diversity of AI/AN people and suggests that those who live
on reservations may have higher STI rates. Approximately 55.2 percent of
AI/AN people live in areas where Indian Health Service (IHS) adminis-
ters STI surveillance and care. IHS comprises 12 regional administrative
units (also referred to as “areas”) with 625 service counties that often cross
state lines and serve approximately 2.1 million AI/AN people through
direct care, tribal health systems, and urban health centers. A comparison
of STI rates for all races versus AI/AN people nationally versus AI/AN
people in the IHS found, in 2010, that for chlamydia, the U.S. rate for all
races was 397/100,000, whereas the all AI/AN rate was 585/100,000 and
the IHS rate was 896/100,000; 9 of the 12 area units had rates higher than
the U.S. all AI/AN rate. In 2010, for gonorrhea, the U.S. rate for all races
was 129/100,000, whereas the all AI/AN rate was 95/100,000 and the IHS
rate was 127/100,000; 5 of the 12 area units had rates higher than the all
AI/AN rate (Walker et al., 2015).
Additionally, a study shows the proportion of minority populations
residing in U.S. counties is positively associated with the odds of a county
being a multi-STI hotspot (Owusu-Edusei and Chang, 2019). More specifi-
cally, a one-point increase in the percentage of Native residents was asso-
ciated with a 3.3 percent increase in the odds of being a multi-STI hotspot;
this increase was greater than for Black (3.2 percent) and Latino/a (1.6
percent) individuals (Owusu-Edusei and Chang, 2019). In the same study,
lower population density, common in rural reservation locations, was
positively associated with the odds of being in a multi-STI hotspot. This
study shows marked differences in STI rates among Native people resid-
ing in urban versus rural locations.
Individual-Level Factors
Literature specific to the AI/AN population shows, as a whole, that
sexual debut typically begins at a younger age than the national popula-
tion (CDC, 2020e; de Ravello et al., 2014; Kaufman et al., 2004, 2007a). Early
sexual initiation increases the amount of potential time and exposure to
condomless sexual encounters. Other individual factors that increase the
risk of STIs have been identified as occurring among Native individuals
more frequently, including substance use, poor mental health, multiple
sexual partners, inconsistent/incorrect condom use, and exposure to risky
situations, including dating violence and parties where substance use is
occurring (Blum et al., 1992; Kaufman et al., 2007a,b).
Data on substance use and mental health among AI/AN populations
show differing trends. Some research identifies the highest rates of alcohol
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
160 SEXUALLY TRANSMITTED INFECTIONS
use disorder, while other research indicates most AI/AN adults abstain
from alcohol use and have the lowest rate of past month use of all U.S.
groups (Grant et al., 2015; SAMHSA, 2011). Historically, the rate of alcohol
use increased in parallel with colonization and the resulting historical and
intergenerational trauma endured by Native communities (Whitbeck and
Armenta, 2015). More Native adults report past-year mental health issues
than in the general population (21 percent versus 18 percent), and Native
youth have the highest rates of lifetime major depressive disorder and
self-reported depression rates than any other ethnic/racial group (APA,
2017). Yet, other research conducted with AI/AN people shows high rates
of positive mental health: in a sample of Native adults, 17.1 percent met
criteria for depression, but 51.5 percent met criteria for “flourishing” or
positive mental health (Kading et al., 2015). Therefore, additional research
exploring the unique intersection of substance use, trauma, and STIs is
needed in Native communities, considering the diversity within AI/AN
groups. See Chapter 2 for more information on how alcohol and substance
use and mental health are associated with STIs.
Several individual-level factors also have been demonstrated in
the literature specific to AI/AN people that protect against poor sexual
health outcomes, including higher academic performance, valuing school
achievement, self-efficacy to abstain from sex, and greater sexual health
knowledge (Griese et al., 2016; Henson et al., 2017; Kaufman et al., 2007a;
Palacios and Kennedy, 2010). In addition, positive Native ethnic identity
and connectedness to community and traditional cultural practices are
protective against risk for STIs (Kaufman et al., 2007a).
Risk perception, or an individual’s belief about the likelihood of an
adverse event occurring to them, is a well-known predictor of health
behavior among all racial-ethnic groups and a key component of several
theories of health behavior change. Not surprisingly, among Native com-
munities for whom few evidence-based sexual health programs exist, mis-
conceptions about STI prevention and transmission and the subsequent
lack of feeling vulnerable or susceptible to STIs is an established risk fac-
tor (Chambers et al., 2018; Hafner and Craig Rushing, 2019; Markham et
al., 2015). Lower perception of risk may be further exacerbated in Native
communities that endure higher rates of poverty and other socioeconomic
challenges and for whom STIs may not be an urgent threat. Alternatively,
intention, specifically the intention to engage or abstain from sex, has been
cited as an important factor in predicting protective sexual health prac-
tices (such as delayed sexual initiation and condom use) among both AI/
AN people and other ethnic groups (Buhi and Goodson, 2007; Markham
et al., 2015; Tingey et al., 2018).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 161
Interpersonal-Level Factors
Interpersonal factors impacting STI risk and exposure that also may
provide social support to reinforce protective sexual health norms can be
organized across intimate partner, peer, and family domains.
Intimate Partner
A high rate of exposure to physical and sexual violence are doc-
umented in Native communities (Burnette, 2016). Physical and sexual
violence create both direct and indirect pathways to increased STI trans-
mission through an immediate loss in the ability to protect oneself from
infection (direct) and impact of the experience on future emotional reac-
tions, risk perceptions, communication skills, and ability to negotiate use
of prevention methods with sexual partners (indirect) (Gesink et al., 2016;
Masters et al., 2014; Thompson et al., 2017). More specifically, individuals
who have experienced sexual and intimate partner violence may antici-
pate a negative reaction from a partner about a request to use a condom
or perceive condomless sex as a lower-risk consequence than the poten-
tial for repeated abuse (Quina et al., 2000). Nationally, AI/AN women
experience the highest rates of lifetime sexual assault (27.5 percent) and
physical violence from an intimate partner (51.7 percent), compared with
women of all other racial and ethnic groups (Rosay, 2016). In addition to
preventing and addressing the underlying factors that lead to perpetrator
violence, training in communication and partner negotiation skills may be
especially important for STI prevention for AI/AN women.
Peer Influences
The literature documents the influence of peers in sexual health deci-
sion making among adolescents of all ethnicities, which is also true for
Native youth and their peer networks. Research shows for Native youth
and adolescents, more prosocial attitudes and the perception that their
friends are engaging in fewer risky health behaviors have been identified
as protective factors for abstaining from sex and using prevention meth-
ods (Dickens et al., 2012; Greene et al., 2018; Mitchell et al., 2007; Pu et al.,
2013). Qualitative research with Native youth also shows nuance in the
role of peer groups between girls and boys. More specifically, boys and
girls describe social pressure from peers and a desire for connectedness,
respectively, as a driving factor for engaging in condomless sex (Cham-
bers et al., 2018).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
162 SEXUALLY TRANSMITTED INFECTIONS
Family Influences
Research conducted across a myriad of ethnic groups documents the
impact of positive parent–child relationships and parent connectedness
on lower participation in risky behaviors, including early sexual initiation
and condomless sex. In Native communities, family is generally valued
as the nexus of strength for individuals and shown to yield great influ-
ence on adolescents’ behavioral choices (Dalla and Gamble, 1996; Henson
et al., 2017; MacPhee et al., 1996). For AI youth in particular, this also
may be true for the extended family, especially among rural reservation-
based youth who may be more likely than their urban counterparts to
have larger proximal family networks on whom they rely for caregiving
(LaFromboise and Dizon, 2003). Research specific to Native youth has
found several family-level factors associated with abstention from sex,
including parental warmth (e.g., responsiveness and communication)
(Griese et al., 2016), higher perceived parental support, higher perceived
parental knowledge, and monitoring of adolescent’s activities and friends
(BigFoot and Funderbunk, 2010; Chewning et al., 2001; Griese et al.,
2016; LaFromboise et al., 2006). As a result, additional research suggests
and promotes including trusted family members in STI prevention and
intervention efforts as a means to align with the collectivist nature of
Native families and communities that may be protective against STI risk
(Garwick et al., 2008; Tingey et al., 2017a).
Institutional-, Community-, and Structural-Level Factors
American Indian and Alaska Native, gay and bisexual men face a lot of
culturally based stigma and concerns about confidentiality when it comes to
seeking care for HIV services, for prevention services, especially in those tribal
communities that are very rural where they don’t have access to any other
health care except for their Native-sponsored or IHS-sponsored clinics where all
of their family members work there or go there or are the doctor there, and they
really don’t have a lot of options when it comes to preventive services.
—Participant, lived experience panel
School connectedness, or a sense of belonging to school, is an estab-
lished community-level protective factor for STI prevention among all
ethnic groups, including AI/AN people. More specifically, the opportu-
nity to receive sexual health education, have social support from teachers
and other caring adults, and engage in prosocial extracurricular activities
are identified in the literature as significant protective factors for the
sexual health behavior of Native youth (Catalano et al., 2004; Dickens et
al., 2012; Moilanen et al., 2014). These same factors similarly have been
established for preventing substance use among Native youth, which
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 163
is also a driving factor for engaging in condomless sex, suggesting pro-
grams targeting these issues may have dual prevention benefits (Tingey
et al., 2016, 2017c). Reflecting this literature, school-based sexual health
programming is a primary means for receiving medically accurate sexual
health education for most U.S. youth (Talashek et al., 2003). Yet, for many
Native youth, particularly those residing in rural reservation communities
in the Southwest, school-based sexual health education is not required,
and if available, parents may opt their children out of these classes. For
example, in Arizona, which has the third highest percentage of Native
Americans in any state (CDC, 2018b), just 31 percent of school districts
provide sexual health education at all, and of those, the majority use
abstinence-only curricula that focus exclusively on refraining from all
sexual behavior (AZDHS, 1989; Day et al., 2017) and that have been found
to be ineffective. See Chapter 8 for more information on sex education.
Other community-level factors central to STI prevention and treat-
ment are access to and use of health care for routine STI screening.
Research specific to AI/AN communities suggests that higher STI rates
may be in part due to health care access barriers (Eitle et al., 2015; Tay-
lor et al., 2011; Winscott et al., 2010). More specifically, approximately
40 percent of all AI/AN people rely on IHS for health care services, a
historically underfunded system with limited capacity to provide high-
quality, culturally relevant care (OIG, 2011; Warne and Frizzell, 2014). In
AI/AN communities that are rural and/or reservation based, challenges
to accessing health care are further exacerbated by geographic isolation
and poverty. Overall, AI/AN people are more likely than white people
to have transportation barriers to health care (Call et al., 2006; Richards
and Mousseau, 2012). Additionally, research shows more than two-thirds
of Native patients travel more than 120 miles round trip to access care at
IHS (GAO, 2005). Close-knit communities, including those common to
collectivist Native societies, may contribute to confidentiality concerns
and/or stigma with seeking care for sensitive issues such as STIs. More
specifically, Native patients obtaining care in communities with one or
few health centers, such as at an IHS facility, may be uncomfortable com-
pleting STI screening and treatment because they might encounter family
or friends at the facility (CDC, 2019c; Chambers et al., 2016a,b; Duran et
al., 2005; Leston et al., 2012; Tingey et al., 2015). In sum, these access bar-
riers can lead to missed appointments, delayed STI diagnosis, treatment,
and partner notification, and treatment noncompliance (Call et al., 2006;
Johnson et al., 2010; Syed et al., 2013).
In contrast, other research shows a protective effect of rural residency
and access to IHS facilities: one study shows AI/AN women residing
in rural areas and with public insurance were more likely to access STI
screening and birth control services (Cahn et al., 2019). This study agrees
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
164 SEXUALLY TRANSMITTED INFECTIONS
with older research showing that AI/AN people eligible for IHS health
care were more likely to report a past-year visit with a provider than
those not accessing IHS care (Zuckerman et al., 2004). Nevertheless, the
majority of the U.S. AI/AN population lives in urban areas, where facili-
ties and funding specific to Native health are more limited (Moss, 2010;
Urban Indian Health Institute, n.d.). Thus, limited access to sexual health
care in urban areas may also be fueling disparities in STIs among the AI/
AN population.
Cultural and Societal Values and Policies
Research specific to AI/AN people highlights the strength of encul-
turation, as measured by participation in traditional Native activities,
identification with AI/AN culture and ethnicity, and participation in
spiritual traditions, as cultural/societal factors that protect against sexual
health risk taking (Adams et al., 2006; LaFromboise et al., 2006). More spe-
cifically, engaging in cultural practices, such as visiting sacred sites, has
been discussed as a method for imparting cultural values and spiritual-
ity, both strengths to be drawn on in potentially preventing risky sexual
situations (Griese et al., 2016). This research suggests that programs that
seek to engage participants in cultural practices and internalize cultural
values can develop strengths and promote protective factors to bolster
positive sexual health outcomes and may be both desirable and impactful
in Native communities (McMahon et al., 2015).
Factors driving risk of and protection against STIs among Native peo-
ple need to be framed by the history and resulting policies undermining
access to sexual and reproductive health services, including STI preven-
tion and treatment in Native communities (Arnold, 2014; Lawrence, 2000).
For example, prohibitions on using federal funds for abortion (including
at IHS facilities) and state/federal policies enacted in the 1970s and 1980s
led to the sterilization of AI/AN women (Arnold, 2014; Lawrence, 2000).
In addition, health care providers’ prescribing longer-acting modes of
contraception (particularly Depo-Provera and Norplant) without ade-
quate consent, counseling on side effects, or standardized monitoring has
limited Native women’s control over their fertility (Smith, 2003, 2015).
Not surprisingly, the combined effects of these local, state, and federal
policies have produced skepticism and distrust of the medical system in
some AI/AN women, which may further deter their use of STI health care
services. Many researchers have therefore urged for culturally relevant
sexual health education programming to alleviate mistrust of health care
and concerns regarding discrimination (Craig Rushing et al., 2018; Gon-
zales et al., 2013; Kaufman et al., 2007a, 2009; Tingey et al., 2017b, 2019).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 165
Sexual health programs also need to address gender inequities and
the experience of stigma and structural discrimination to improve access
to STI prevention and treatment. Compared to men of other ethnicities
nationally, Native men have higher rates of STIs, likely driven by the fact
that they have more comorbid risks, including substance abuse, mental
health issues, unemployment, and low educational attainment (Rink et
al., 2017).
Another subgroup experiencing inequities in sexual health is Two-
Spirit individuals. “Two-Spirit” is an overarching term that describes
Native people who are diverse in terms of their sexual orientation and
gender identity. Native community-specific definitions and roles for gen-
der and sexual orientation and cultural values around sexual health are
more extensive and varied (Carrier et al., 2020; Kaufman et al., 2004).
While contemporary use of Two-Spirit has become more widespread,
Native conceptualizations of diverse gender identities, roles, and sexual
orientations have existed for generations (Carrier et al., 2020). Two-Spirit
people face numerous health disparities, including stigma, structural dis-
crimination, violence, poor mental health, and substance abuse (Chae and
Walters, 2009; Fieland et al., 2007; Nelson et al., 2011). These challenges
are associated with increased sexual risk taking (Nelson et al., 2011).
To be responsive to the unique needs of this group, interventions need
to be data driven, culturally responsive, and fluid to navigate multiply
oppressive forces among individuals in highly marginalized social posi-
tions (Argüello and Walters, 2018). In addition, service delivery systems
may benefit from focusing on racism in LGBTQ+-centric contexts and
heterosexism in more Native-centric ones and embracing the knowledge
that there is “diversity within diversity” with regard to multiple socially
located and marginalized individuals (Argüello and Walters, 2018).
PEOPLE WITH MILITARY EXPERIENCE
Stigma is still present, especially in the military. We have that interplay
between those who are more conservative, if you will—those who are
older, those who tend to be the leaders and be in charge—and those who
are younger, who may be more open to what we would consider nontraditional
sexuality and sexual behaviors. These are amplified by the very strict and
rigid system within the military of those who are in charge versus those
who are not in charge. I think understanding that this exists and putting
into place methodologies to help break down that barrier are important.
—Participant, lived experience panel
STIs are the most commonly diagnosed infectious disease among
U.S. military personnel (Stahlman and Oetting, 2017; Stahlman et al.,
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
166 SEXUALLY TRANSMITTED INFECTIONS
2019), which is mostly composed of young, healthy, unmarried, sexually
active, and highly mobile men and women (DOD, 2016). The prevalence
of diagnosed STIs in military recruits and active-duty service members
consistently exceeds that in civilian groups of comparable age, race, and
ethnicity (Boyer et al., 2008; Deiss et al., 2019; Goyal et al., 2012; Masel et
al., 2015; Stahlman et al., 2015). For example, in a large cohort study of
female Marine Corps recruits who were screened for chlamydia, gonor-
rhea, and trichomoniasis at entry, 14.1 percent tested positive compared
with 8.0 percent of women of a similar age in a national population-based
study during the same period (Boyer et al., 2008). Although STI preva-
lence varies within branches of the military (Bautista et al., 2019; Deiss et
al., 2016; Stahlman and Oetting, 2017), chlamydia (Stahlman and Oetting,
2017; Stahlman et al., 2019) and gonorrhea (Bautista et al., 2017, 2019) are
the most commonly diagnosed STIs across all branches. These are univer-
sally treated once identified, but partner treatment is not universal and
may lead to repeat infections (Stidham et al., 2015). Viral STIs, such as HIV
and chronic hepatitis, may additionally interfere with service members’
readiness to perform their daily duties and restrict their availability for
deployment (Armed Forces Surveillance Center, 2013; Gaydos et al., 2013).
Box 3-9 summarizes key messages about STIs among people with military
experience. Of note, for this report, the focus was primarily on recruits
and active-duty service members, and veterans are discussed specifically
in the context when describing the role that sexual trauma plays in the
risk for STIs and other SRH outcomes.
Sociodemographic Risk Markers
Sociodemographic markers of STI risk in military personnel are also
comparable to those identified in civilian populations. For example, STIs
are identified at higher rates among the youngest age groups, mainly
recruits and junior enlisted (early career) active-duty personnel (Bautista
et al., 2017; Deiss et al., 2016; Stahlman and Oetting, 2017; Stahlman et al.,
2019). Women, in particular, bear a disproportionately high share of STIs,
in part because they are more frequently screened for asymptomatic infec-
tions (Bautista et al., 2017, 2019; Deiss et al., 2019). This occurs primarily
within their first year of service (Gaydos et al., 2013) and annually during
reproductive health care visits (Deiss et al., 2016). With few exceptions
(Deiss et al., 2016; Harbertson et al., 2019; Hood et al., 2020; Stahlman and
Oetting, 2017; Stahlman et al., 2019), there is a dearth of STI screening and
surveillance data on male recruits and active-duty service members. Thus,
it is difficult to fully assess the extent to which they asymptomatically
acquire and transmit STIs.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 167
BOX 3-9
Key Takeaways: People with Military Experience
• Active-duty military personnel comprise mostly young, healthy, unmarried,
sexually active, and highly mobile men and women.
• The prevalence of diagnosed sexually transmitted infections (STIs) in military
recruits and active-duty service members consistently exceeds those identified
in civilian groups of comparable age, race, and ethnicity.
• STIs in military service members are universally treated once they are identi-
fied, but viral STIs, such as HIV infection and chronic hepatitis, may addition-
ally interfere with service members’ readiness to perform their daily duties and
restrict their availability for deployment.
• Women in the military are frequently screened, primarily within their first year
of service and annually during reproductive health care visits; however, there
is a dearth of STI screening and surveillance data on male recruits and active-
duty service members.
• There is limited information on service members’ sexual and reproductive
health decision making and behaviors and the role these factors may play in
their risk, acquisition, and transmission of STIs.
• The military has an unacceptably high prevalence of sexual assault, sexual
trauma, and unwanted sexual contact, which places service members at in-
creased risk for numerous health consequences, including STIs, HIV, and
unintended pregnancy.
• Excessive alcohol use, including binge drinking and heavy use, is prevalent
among military service members and associated with unintentional injuries
resulting in increased hospitalizations and health care cost and adversely affect
military readiness and work-related productivity.
• Although an association between alcohol use and STIs has been established
in the general population, recent military-specific data are noticeably absent.
Other sociodemographic markers of STI risk among military person-
nel include African American/non-Hispanic Black race (Bautista et al.,
2017; Boyer et al., 2008; Deiss et al., 2016; Stahlman and Oetting, 2017;
Stahlman et al., 2019) and other nonspecific references to race, such as
“non-white” or “minority” (Hakre et al., 2011; Hood et al., 2020; Jordan
et al., 2011). Furthermore, single marital status (Hakre et al., 2014; Har-
bertson et al., 2019; Stahlman et al., 2015), high school as the maximum
educational attainment (Deiss et al., 2016, 2019; Hakre et al., 2014), and
residence in rural locations (Boyer et al., 2006) or the South (Gaydos et
al., 2003) are other risk markers for STIs in the armed forces. Lastly, con-
sistent with civilian public health reports, having a history of STIs is an
indicator of increased risk for acquiring a new or repeat STI (Bautista et
al., 2017; Hakre et al., 2011; Hood et al., 2020). For example, a population-
based surveillance study of servicewomen found that the likelihood of a
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
168 SEXUALLY TRANSMITTED INFECTIONS
chlamydia diagnosis increased significantly with an increasing number of
prior gonorrhea diagnoses, and the median time to the chlamydia diag-
nosis decreased with an increasing number of gonorrhea diagnoses (Bau-
tista et al., 2019). These data on STI markers suggest the need for ongo-
ing comprehensive STI screening, surveillance, and sexual health care
for all recruits and junior enlisted service members; these are primarily
young and racial and ethnic minorities and include increasing numbers
of women in their peak reproductive years (DOD, 2016).
Sexual Behaviors
Sexual behaviors associated with STI risk in active-duty military per-
sonnel are highly prevalent and occur more frequently than the rates
identified in comparable civilian groups (Goyal et al., 2012; Stahlman et
al., 2015). Such behaviors include new (Stahlman et al., 2015; Thomas et
al., 2001), casual (Deiss et al., 2019; Harbertson et al., 2015), and multiple
sexual partnerships (O’Rourke et al., 2008; Stahlman et al., 2014, 2015). As
with their civilian counterparts, military personnel use condoms inconsis-
tently and infrequently (Deiss et al., 2019; Goyal et al., 2012; Harbertson
et al., 2019; von Sadovszky et al., 2008).
Research also indicates that women report less frequent condom use
than both their male military colleagues and their civilian female peers
(Hwang et al., 2007; O’Rourke et al., 2008; Stahlman et al., 2014). A small
qualitative study of active-duty young women (aged 18–25) in the U.S.
Navy found that one-quarter reported anal intercourse in their most recent
sexual encounter, most of which was condomless (86.7 percent). Women
who listed sex with a casual male partner (42.2 percent) reported rarely
or never using condoms (Deiss et al., 2019). Other research indicates that
condom use among U.S. Army enlisted women was infrequent, with the
most cited reasons for avoidance being irritation or inflammation, break-
age, improper fit, or ruining the moment (von Sadovszky et al., 2008).
Another qualitative study of women enlisted in the Navy documented
that barriers to condom use included perceptions of being stigmatized
as promiscuous after requesting condoms from sexual partners and fear
that seeking condoms during deployments would reveal a violation of
military policy, which prohibits sexual activity during deployments (Duke
and Ames, 2008). A study of shipboard U.S. Navy and Marine Corps men
and women found a higher prevalence of STIs and condom use primarily
during deployments, when casual and transactional sexual activity are
more likely. However, condomless sex was associated with hazardous
alcohol use and drug use to enhance sexual experiences (Harbertson et al.,
2019). As with other aspects of sexual health, military-based research has
focused primarily on women, which leads to a partial understanding of
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 169
male condom use and the contextual factors surrounding nonuse. This is
particularly problematic since men typically initiate and control condom
use communication with their female sexual partners (Teitelman et al.,
2011). Therefore, further research is needed regarding effective strategies
to increase consistent condom use among military men and women.
Contextual Factors Associated with Sexual Behaviors
To date, few studies have examined social contextual influences on
sexual behaviors in military personnel. However, a Department of Defense
(DOD) study of health behaviors among active-duty military found 25.2
percent of men and 9.3 percent of women reported five or more sexual
partners in the prior year. Among men and women in this study, binge
drinking and illicit substance use, as well as unwanted sexual contact,
were associated with higher numbers of sexual partners. High levels of
personal life stress among women and psychological distress among men
and women were also associated with multiple sexual partners (Stahlman
et al., 2014). While service members who had two or more partners in the
prior 12 months were significantly more likely to report a history of STIs,
this association was even stronger for those with five or more partners
(Stahlman et al., 2014). Other studies provide insights into the nature
of casual sexual partnerships in the military context. Contrary to prior
research findings, which assumed casual and transactional sex occurred
primarily during deployments (Harbertson et al., 2017, 2019), a study
of U.S. Navy and Marine Corps shipboard personnel conducted state-
side assessed sexual behaviors in a 12-month period before deployment
revealed that among those with a sexual partner outside of their primary
partnership, 24 percent reported using a condom the last time they had
sex, and 30 percent reported their outside partner was another service
member. More women than men (50 versus 26 percent) reported their
most recent STIs were acquired from another service member (Harbertson
et al., 2015). This research highlights the social context surrounding STIs
and sexual partnerships, including possible sexual networks that develop
among military personnel who live and work in close proximity (Gaydos
et al., 2015). Social and other contextual factors need to be examined fur-
ther to better understand the most efficacious strategies to prevent and
control STIs within the military, whether service members are stateside
or deployed overseas.
Contraceptive Use and Unintended Pregnancy
Other factors associated with STIs in the military include contracep-
tive use and unintended (i.e., mistimed, unwanted, unplanned) pregnancy.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
170 SEXUALLY TRANSMITTED INFECTIONS
Contraceptive use among female service members is an important aspect
of their personal reproductive care, but it is also inextricably linked to
their military service (Harrington et al., 2017), as servicewomen can-
not serve in combat while pregnant. Among servicewomen, unplanned
pregnancy has been found to be univariately associated with young age,
single marital status, inconsistent condom use, a new partner in the prior
6 months, and recent multiple partners. High STI rates have been found
among servicewomen, particularly those who became pregnant. Navy
enlisted women had a prevalence of chlamydial infection and pregnancy
of 4.7 percent and 9.7 percent, respectively, with 48.3 percent of the preg-
nancies unplanned (Thomas et al., 2001). Among pregnant servicewomen,
13.8 percent were infected with chlamydia (Thomas et al., 2001).
Military Sexual Assault
Veterans with a history of sexual trauma might be at greater risk
of having STIs, but they might actually have greater barriers to seeking
care. Some women veterans who have a history of sexual trauma in the
military may be somewhat reluctant to seek care in a VA facility
because it may remind them of their previous traumatic experiences.
—Participant, lived experience panel
Military sexual assault, defined as physical contact of a sexual nature
without voluntary consent that occurs while serving in the military
(DOD, 2012; Suris and Lind, 2008), has been a long-standing problem.
Among active-duty service members, military sexual assault is estimated
to have occurred to 1.0 percent of men and 4.9 percent of women, with
an average of approximately 2.5 incidents per 100 men and 9.6 incidents
per 100 women over a 1-year period. The highest rate was among the
most junior enlisted men and women and lower-ranked female officers
(Morral et al., 2015). Other research indicates that 14.3 percent of service
members reported unwanted sexual contact over the course of their life-
time (i.e., cumulative sexual abuse that occurs prior to and during mili-
tary service); 42 percent of women reported a history of lifetime abuse,
with 21.7 percent reporting unwanted sexual contact since joining the
military, compared with 9.2 percent of lifetime sexual abuse among men
(Barlas et al., 2013). Among veterans, military sexual assault occurred
to 3–54 percent of women and up to 3 percent of men (Schuyler et al.,
2017). The varying rates are partially explained by differences in the
method of assessment (e.g., general open-ended question versus specific
definitions), the type of sample (research versus clinical versus benefit
seeking), and the definition used (i.e., military sexual trauma, which
includes both harassment and assault, versus a focused definition of
sexual assault) (Suris and Lind, 2008).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 171
There is ample evidence demonstrating the impact that military sexual
assault has on mental (e.g., posttraumatic stress disorder, depression) and
physical (e.g., pelvic pain, headaches, chronic fatigue) health and health
behaviors (e.g., smoking, substance use, alcohol misuse) (Stahlman et al.,
2015; Suris and Lind, 2008). Less is known, however, about its impact on
sexual health (Schuyler et al., 2017). When lifetime sexual assault is exam-
ined among active-duty men and women and female veterans, research
indicates that unwanted sexual contact is associated with a greater fre-
quency of casual and multiple sexual partners, binge drinking, and illicit
substance use (Stahlman et al., 2014). Other research has also found an
association between military sexual trauma and STIs (Sadler et al., 2011;
Turchik et al., 2012), and sex exchange for goods or services (Strauss et
al., 2011). Despite limited reported data on sexual trauma and sexual
health among male veterans, one study found that men with a history
of military sexual trauma had nearly twice the odds of an STI diagnosis,
compared with those who did not experience such trauma (Turchik et al.,
2012). Other research has found significantly higher rates of HIV/AIDS
among male veterans with a history of military sexual assault, compared
with those without (Kimerling et al., 2007; Turchik et al., 2012). Together,
these data demonstrate an unacceptably high prevalence of sexual assault
and trauma and unwanted sexual contact in the U.S. military, which
places service members at increased risk for numerous health conse-
quences, including unintended pregnancy and STIs, such as HIV/AIDS.
More research is needed to critically examine the impact that any form of
sexual abuse has on the SRH of military personnel, including veterans.
Such information is essential for devising effective approaches to prevent
future occurrences and necessary for expanding support programs for
those who are vulnerable and most affected. A small but compelling body
of literature examines the military-specific social and cultural context in
which military sexual assault occurs (Morral et al., 2015; Schuyler et al.,
2017; Suris and Lind, 2008); despite its importance, this is beyond the
scope of this current report. Nonetheless, the military-specific context of
sexual assault needs to be a central factor in ongoing efforts that address
the SRH of all military personnel including recruits, active-duty members,
and veterans.
Alcohol Use
Alcohol use in the military is common (Barlas et al., 2013; Bray et
al., 2013; Goyal et al., 2012), has long been an acceptable behavior that
is interwoven in the military culture, rituals, and practices (Barry et al.,
2013), and is affordable and easily accessible on U.S. installations (Ames
et al., 2008). Excessive alcohol use, including binge drinking (at least
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
172 SEXUALLY TRANSMITTED INFECTIONS
one episode during 1 month of five or more drinks on a single occasion
for men or four or more drinks for women) and heavy use (a pattern of
multiple episodes of binge drinking during 1 month) are also prevalent
among U.S. personnel and associated with unintentional injuries, result-
ing in increased hospitalizations and health care costs and adversely
affecting military readiness and work-related productivity (Barlas et al.,
2013; Stahre et al., 2009).
A survey of 1,095 U.S. Army recruits found that 48.8 percent of
male and 33.2 percent of female respondents reported binge drinking
(O’Rourke et al., 2008), compared with about 14 percent in the general
population (Naimi et al., 2003). A 2011 DOD anonymous survey found
that 84.5 percent of service members were classified as current drinkers,
with approximately one-third (33.1 percent) reporting binge drinking in
the past 30 days (Barlas et al., 2013). Another study of a large shipboard
cohort of U.S. Navy and Marine Corps military personnel that were sur-
veyed just prior to deployment found that 39–54 percent screened posi-
tive for hazardous alcohol misuse, 27 percent for binge drinking, and 15
percent for dependent alcohol use, while 7 percent reported involuntary
drug consumption history, based on the Alcohol Use Disorders Identifica-
tion Test-Consumption (Harbertson et al., 2016).
Although an association between alcohol use and STIs has been
established in the general population (Cook and Clark, 2005) (see Chap-
ter 2), newer military-specific data are noticeably absent. The study of
Navy-enlisted women, however, found an association between alcohol
misuse (drinking until passing out or vomiting in the past 30 days) and
a chlamydia diagnosis (Thomas et al., 2001). Several other studies identi-
fied an association between alcohol consumption and sexual risk behav-
iors, including inconsistent condom use among Army active-duty men
(Jenkins et al., 2000), multiple sexual partnerships among Army female
recruits (Eitzen and Sawyer, 1997), and condomless sex in a cohort of
shipboard, male Marine Corps members (Shafer et al., 2002). Binge drink-
ing also has been associated with ineffective contraceptive use during the
last reported sexual encounter in Army recruits (O’Rourke et al., 2008)
and sex under the influence of alcohol or drugs in the 3 months prior to
recruit training entry in female Marine Corps recruits (Boyer et al., 2008).
Lastly, more frequent episodes of alcohol intoxication were associated
with multiple sexual partners in the past 12 months (Thompson et al.,
2005). Collectively, these data provide strong evidence for the problem
of alcohol use, including excessive use, in the U.S. military. In particular,
they underscore the urgent need for further research that assesses the
role that alcohol use and its concomitant behaviors and health outcomes
have on the sexual health of military personnel. These factors need to be
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 173
central to any efforts to prevent STIs in all military personnel, particularly
among those who are new recruits and in the early stages of their careers.
PEOPLE WITH DISABILITIES9
For me, the barriers to accessing screening and treatment would be navi-
gating the world as a person with disabilities, and that goes along with my
ability to work. And also navigating barriers like transportation, being able to
get to those testing sites…. I use the LGBTQ center at Durham to learn about
STI prevention. They go through Durham County services for providing STI
testing. But since it is free, it’s only accessible during certain days of the week.
—Participant, lived experience panel
Box 3-10 provides key information about STIs among people with dis-
abilities. People with disabilities include those with long-term physical,
mental, intellectual, or sensory impairment, and they represent about 26
percent of the population; 13.7 percent of people with a disability have
a mobility disability, and 10.8 percent of people with a disability have
an intellectual or developmental disability (I/DD) (CDC, 2020b). Until
recently, people with disabilities have not been included in population
health data collection, analysis, and reports (Krahn et al., 2015). Literature
on the association between disability and both STI and HIV risk is also
very limited. Although people with an I/DD face disparities relating to
SRH services (Powell et al., 2020), little is known about the prevalence
of STIs and STI testing in this population (Greenwood and Wilkinson,
2013; Schmidt et al., 2019a). Further investigations into the intersection
BOX 3-10
Key Takeaways: People with Disabilities
• There is limited information on sexually transmitted infections (STIs) among
people with disabilities, despite this group making up about 26 percent of the
population.
• People with intellectual or developmental disabilities face disparities related to
sexual and reproductive health services.
• Multi-level drivers of STIs among people with intellectual or developmental dis-
abilities include limited access to health information, such as knowledge about
safe sex practices, increased vulnerability to sexual assault, and barriers to
accessing comprehensive health care.
9 The World Health Organization’s International Classification of Functioning, Disability and
Health defines disability as an umbrella term for impairments, activity limitations, and par-
ticipation restrictions (WHO, 2002).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
174 SEXUALLY TRANSMITTED INFECTIONS
of disability and STI/HIV risk are needed (Doyle et al., 2020; Schmidt et
al., 2020).
A nationally representative sample of middle-school- and high-
school-age youth showed that 8 percent of male and 26 percent of girls
with low cognitive ability had been exposed to an STI, compared to 3 per-
cent of boys and 10 percent of girls with average cognitive ability (Cheng
and Udry, 2005). A cross-sectional study that used special education data
and Medicaid data from Philadelphia, Pennsylvania, for calendar year
2002 found that 3 percent of male and 5 percent of female participants
were treated for an STI; among the female participants, those with intel-
lectual disabilities (classified in this study as being in the “mental retarda-
tion [MR]” category) were at greatest risk (6.9 percent) and those in the
emotionally disturbed or “no special education” category at lowest risk
(4.9 percent each) (Mandell et al., 2008). An analysis of privately insured
individuals with I/DD that used multi-variable models found they were
significantly less likely to have an STI diagnosis, and no difference was
found between groups on the odds of STI testing overall (Schmidt et al.,
2019a). Based on this study, and evidence from prior studies, the authors
concluded, however, that this might be explained, in part, by fewer sexual
experiences, and protective factors such as increased supervision in social
settings, and delayed onset of sexual activity compared to the general
population (Schmidt et al., 2019a). Data on STI prevalence is not available
for individuals with other types of disabilities.
Multi-Level Drivers
A variety of factors place young adults with I/DD at greater risk
of an STI and sexual health disparities, including a lack of knowledge/
understanding about sexuality and safe sex strategies and trouble relat-
ing health information to their own life experiences. One of the most
pronounced disparities is a heightened vulnerability to sexual assault
and abuse (Murray, 2019). Research suggests the tendency to desexualize
or downplay the sexual needs of persons with I/DD has increased their
health risks by limiting their access to sexual health information, repro-
ductive health care, and counseling (Walters and Gray, 2018). Mosher
et al. (2017) found that women with I/DD received fewer family plan-
ning services compared to women without disabilities, and the difference
was larger for women of lower socioeconomic status. Further research is
needed on other factors that affect the ability of people with disabilities to
obtain the SRH services they need, including those related to STIs.
For specific subgroups of people with disabilities (both I/DD or
physical/mobility disabilities), certain factors can compound the effects
of having a disability, such as race and ethnicity, age, language, sex or
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 175
gender, poverty, and low education (Krahn et al., 2015). Having a dis-
ability is associated with an increased likelihood of lacking a high school
education, less likelihood of employment, inadequate access to transpor-
tation, less access to the Internet, and an increased likelihood of having
an annual income less than $15,000 (Krahn et al., 2015).
Living with a disability can present barriers to accessing health care
services and navigating the health care system (CDC, 2020b; WHO, 2018).
In the past year, one in three adults with disabilities did not have a regu-
lar health care provider and had an unmet health care need due to cost
(CDC, 2020b), and one in four has not had a routine check-up in the past
year (CDC, 2020b). People with disabilities are significantly less likely to
receive preventive care despite higher rates of chronic disease than the
general population (Krahn et al., 2015). Additional barriers include com-
mon misconceptions about disabilities, stigma, and providers’ attitudes
(Krahn et al., 2015). There is a striking gap in available data for this popu-
lation and in available services and supports to promote sexual health and
prevent sexual abuse (Murray, 2019). See Chapter 2 for more information
on how the social determinants of health are associated with STIs.
PEOPLE WITH CRIMINAL LEGAL SYSTEM INVOLVEMENT
The first time I got arrested I think I was 14. I feel like there were
several opportunities when I was young that someone could have
pulled me aside in the jails, especially in juvenile detention. A nurse,
a counselor or somebody in public health could have pulled me aside and
asked me “What are you doing?” “What are you participating in?”
“How are you protecting yourself?” “How often are you getting tested?”
and educated me on these things. I can’t tell you that I would necessarily
have listened, but I think there were definitely opportunities for testing.
—Participant, lived experience panel
Inmates in jails and prisons face a disproportionate share of STIs
(Krieger et al., 2019; Nowotny et al., 2020; Thomas et al., 2008; Wiehe et
al., 2015; Wise et al., 2017). While most STIs were acquired before incar-
ceration, some transmission does occur while imprisoned. The prevalence
of HIV among incarcerated individuals is 4–5 times that in the general
population (Wiehe et al., 2015). STI rates are also elevated in individuals
whose sexual partners have been incarcerated recently (Green et al., 2012;
Henderson, 2018; Khan et al., 2011a,b; Swartzendruber et al., 2012; Wiehe
et al., 2015; Wise et al., 2017). Sexual risk can contribute to encountering
the criminal legal system, such as through exchanging sex for money or
drugs. Black and Latino/a people or those who are of lower socioeco-
nomic status are more likely to be involved in the criminal legal system
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
176 SEXUALLY TRANSMITTED INFECTIONS
after an accusation of a crime, due to fewer criminal defense resources
and structural racism, and also to have less access to sexual health care
services, due to poverty or bias and discrimination. These issues are
examined in the context of services needed within the criminal legal sys-
tem. See Box 3-11 for summarizing information about STIs among people
with criminal legal system involvement.
Individual- and Interpersonal-Level Factors
Criminal legal system involvement shares some of the same risk
factors for STIs in general, including substance use and mental illness
(Alexander-Rodriguez and Vermund, 1987; Belenko et al., 2009; Hammett,
2009; Joesoef et al., 2006; Kouyoumdjian et al., 2012; Pelligrino et al., 2017;
Spaulding et al., 2013; Tohme and Holmberg, 2012). Incarceration has
been associated with concurrent sexual partnerships and transactional
sex, though many other behavioral, educational, community, health care
access, and socioeconomic attributes also contribute to the STI–incarcera-
tion syndemic (Khan et al., 2011b; Menza and Mayer, 2019; Muñoz-Laboy
et al., 2013; Workowski and Bolan, 2015). Individuals in juvenile detention
centers may have been accused of crimes or be deemed as “persons in
need of supervision” who may be runaway and truant youth suffering
sexual exploitation at home or after leaving home (Biglan et al., 1995;
Brown et al., 2014; Gates et al., 2015, 2016; Rawstron et al., 1993; Senn
et al., 2008; Vermund et al., 1990; Voisin et al., 2004). In addition, incar-
ceration increases high-risk sexual behaviors because it destabilizes social
and sexual networks in home communities, for both prisoners and their
BOX 3-11
Key Takeaways: People with Criminal
Legal System Involvement
• People with criminal legal system involvement have high rates of sexually
transmitted infections (STIs); STIs may be acquired in the community or while
in prison or jail.
• Incarceration may be associated with behaviors that increase risk of STIs, such
as transactional sex and having multiple sexual partners. Due to social and
societal factors and inequities, people with criminal legal system involvement
may have limited economic and health care resources prior to incarceration.
• Structural racism results in racial disparities among those who are arrested
and incarcerated.
• Incarceration destabilizes social and sexual networks in home communities.
• STI education, screening, and treatment within correctional facilities are public
health opportunities.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 177
spouses or partners left behind (Gates et al., 2015; Khan et al., 2011b).
Some neighborhoods have high population ratios of women to men,
when many men from that community are incarcerated. This may put
women at risk when the remaining men have multiple concurrent sexual
partners (Green et al., 2012; Pouget et al., 2010). Lower-income neighbor-
hoods rarely have optimized primary care and public health services for
STI recognition, treatment, follow-up, and partner notification. The lack
of supportive networks among incarcerated individuals also can contrib-
ute to mental health issues and substance use–seeking behaviors, which
elevate STI risks (Epperson et al., 2010; Knittel and Lorvick, 2019; Knittel
et al., 2019). Prisoners are a vulnerable population; it has been estimated
that approximately 3 percent of them experience sexual assault while in
prison from either another inmate or prison staff (Bozelko, 2015; Sawyer
and Wagner, 2020).
Institutional- and Community-Level Factors
The problem is not just the lack of resources; it’s the lack of thinking
about people in those places as people, not just part of the system. These
are systems designed to dehumanize the people held in them and also
the people who work in them, including doctors and nurses. Often, when
law enforcement is the hub of deciding whether you even have a health problem
or if your health problem qualifies for other options than being incarcerated,
it often still can dehumanize and fail to address your overall health.
—Participant, lived experience panel
The broader antecedents of STI risk among incarcerated adults and
youth are multi-factorial. Yet, correctional facilities themselves represent
a sort of a community with society norms that may emerge within the
lifestyle context of incarceration. Interventions can be facilitated, para-
doxically, by the immediate availability of the population and the com-
paratively high STI prevalence among inmates. Thus, STI education,
screening, and treatment represent a significant public health opportu-
nity within correctional facilities. Screening and treatment are feasible, as
demonstrated in diverse correctional settings: jails, prisons, and juvenile
detention facilities (Hammett, 2009; NCCHC, 2020; Owusu-Edusei et al.,
2013). STI services are easier to promulgate in prisons than in many other
settings. Jails and juvenile detention facilities are more challenged, how-
ever, due to high turnover rates for some entrants, who may be detained
for just hours or 1 day. The ability of correctional facilities to track people
and provide medical access to underserved and marginalized populations
can facilitate overall STI control, but this depends on screening at entry.
STI screenings are built into the intake procedure in some jails, prisons,
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
178 SEXUALLY TRANSMITTED INFECTIONS
and juvenile detention centers, but by no means is this standard practice
at all correctional facilities (Krieger et al., 2019). CDC and the Federal
Bureau of Prisons have established screening guidelines to maximize
the detection of STIs among high-risk and otherwise hard-to-reach indi-
viduals (Spaulding et al., 2018). Urine and blood samples can be taken to
assess STIs during intake, and medications can then be provided. Prison-
ers with longer incarceration terms can be followed-up in prison to ensure
cure or to evaluate incident infections from sexual engagement within the
prison itself.
Rapid turnaround rates for screening and treatment, along with
community follow-up, are essential in short-term stay facilities. In jails
and juvenile detention centers, approximately 50 percent of entrants are
released back into the community within 48 hours, making it challenging
to provide screening results (Poteat et al., 2018; Wiehe et al., 2015; Wirtz
et al., 2018). Nonetheless, given the prevalence of STIs among detain-
ees and subsequent community transmission, ensuring rapid screening
turnaround and community follow-up can make a significant impact in
ending transmission. Successful strategies include screening at or shortly
after intake, rapid receipt of screening results, same-day treatment when
possible, reporting to the local department of public health, ensuring
community follow-up for treatment and cure, and partner notification
through public health outreach.
The United States needs to consider a harm reduction approach for
incarcerated persons. While condoms are the mainstay of STI prevention,
current policies in the vast majority of U.S. prisons hold that sex in prison
is illegal and condoms are contraband (Tucker et al., 2007). In Europe,
many countries view condom distribution as a harm reduction approach
and have seen subsequent decreases in STIs (Sander et al., 2016).
Structural-Level Factors
Structural racism in society contributes insofar as persons of margin-
alized racial and ethnic groups are more likely to be arrested and incar-
cerated, are less likely to have ready access to preventive and therapeu-
tic health care services, and may have fewer educational and economic
advantages, due in large part to racism, discrimination, and underlying
structural inequities (Brewer et al., 2019; Dyer et al., 2020; Ibragimov et
al., 2020; NASEM, 2017). While providing STI screening and treatment in
correctional facilities is cost effective given the high yield from screening
in a high-prevalence population, use of this opportunity varies greatly
in different states and geographic areas (Hammett, 2009; Owusu-Edusei
et al., 2013). The United States spends far less per prisoner than other
higher-income nations, though health care spending is higher than most
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 179
countries (Sridhar et al., 2018). Health service commitments to incarcer-
ated persons vary by state and local jurisdiction. For example, health care
spending per inmate varied dramatically in fiscal year 2015—from $2,173
in Louisiana to $19,796 in California (Pew Charitable Trusts, 2017).
Many prisoners have received suboptimal sexual health care prior
to incarceration, such that screening by correctional facility health care
providers represents an excellent opportunity to identify STIs and treat
syphilis, gonorrhea, chlamydia, and trichomoniasis. Additional health care
services can screen for, and mitigate harm from, HPV, HSV-2, bacterial
vaginosis, and other reproductive tract infections (Hsu et al., 2011). Health
services that are provided by correctional facilities directly or outsourced
to for-profit or nonprofit organizations could mandate 2010 CDC-recom-
mended STI screening and treatment as part of their service provisions
(Senteio et al., 2010). A position statement of the National Commission on
Correctional Health Care generally aligns with CDC recommendations for
STI screening at intake (NCCHC, 2014). Given the recent rise in syphilis in
the United States, screening is recommended for all incarcerated individu-
als (Wolfe et al., 2001). Guidelines are available from other organizations,
including the American Public Health Association, the American Cor-
rectional Association, the Academy of Correctional Health Professionals,
the American Correctional Health Services Association, the American Jail
Association, the American Probation and Parole Association, the Ameri-
can College of Correctional Physicians, and the National Coalition of STD
Directors (NCCHC, 2014). As HIV is screened for routinely, syphilis, HBV,
HCV, and HSV-2 are easily added to this blood draw (Wang et al., 2015;
Wirtz et al., 2018). Urine nucleic acid amplification test (NAAT) is conve-
nient for gonorrhea and chlamydia. Adult and adolescent prisoners AFAB
benefit from a pelvic examination that can evaluate trichomoniasis, HPV
and cervical status, and bacterial vaginosis.
Intersectoral Considerations:
Incarcerated Undocumented Immigrants
As of September 2020, there were 133 immigration detention facili-
ties run by Immigration and Customs Enforcement (ICE, 2020). These
facilities do not screen for STIs routinely and are not readily accessible to
researchers. Studies of incarceration and STI prevalence are rare (Folch
et al., 2016; Lederman et al., 2020). Immigrants may have infections seen
rarely in the United States, such as human HTLV-I and HTLV-II that may
be transmitted sexually, parenterally, and especially perinatally (Ansaldi
et al., 2003). A subset of persons coming from countries with a loss of
social cohesion may be at especially high STI risk and/or have suffered
sexual violence (Bickell et al., 1991; Swartzendruber et al., 2012; Vermund
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
180 SEXUALLY TRANSMITTED INFECTIONS
et al., 1990). While some undocumented people may be at high STI risk,
as when exchanging sex for money, goods, or protection (Anderson et
al., 2016; Gaines et al., 2013; Sangaramoorthy and Kroeger, 2013), others
may be at lower risk because of mores from traditional societies that may
have lower-risk sexual behaviors (Castillo-Mancilla et al., 2012). At the
same time, traditional societies may have stigmas or taboos around sexual
behaviors that can jeopardize timely and appropriate STI testing and care.
Immigration detention centers can provide screening opportunities, but a
stronger detention health infrastructure would be needed, with attendant
positive client-centered attitudes that have not been dominant in recent
U.S. political narratives (Parmet, 2018).
Intervention and Research Needs
High STI prevalence among incarcerated individuals reflects individ-
ual risk and community and societal dynamics that disadvantage persons
with lower educational and socioeconomic status. Community-level STI
services in disadvantaged communities need to be improved, but a bridge
may be to optimize STI screening, education, and care among incarcerated
adults and adolescents. Programs targeting incarcerated and detained
persons can stop STI transmission cycles through diagnosis, treatment,
and education. Research needs to focus on best practices for optimizing
interventions, characterizing prevalence and risk, and improving service
transitions for persons reentering the community. STI prevalence and
feasibility of screening for understudied subpopulations, such as incarcer-
ated immigrants, require further investigation. A greater understanding is
needed as to why there are differences in screening/medical care between
the states and in different geographical jurisdictions and of the impact of
these differences. Correctional facilities, including juvenile detention and
immigration detention centers, represent a high-impact, cost-effective
opportunity to reduce STI rates with a highly vulnerable subgroup of
society (Bonney et al., 2008; Flanigan et al., 2010; Smith et al., 2017; Tede-
schi et al., 2007). The greatest impact will require collaboration between
public health, health care, and criminal legal systems to improve services
in vulnerable communities.
CONCLUDING OBSERVATIONS
As highlighted throughout this chapter, key STI data are missing
for many high-priority populations. This differential availability of data
further marginalizes people who are already disproportionally impacted
by STIs. As discussed in a 2017 National Academies report, significant
research and practical application challenges need to be addressed so that
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 181
knowledge can strategically and accurately inform interventions aimed at
reducing or eliminating health inequities (NASEM, 2017). More research
and specific attention is sorely needed to address data equity, including
ensuring that current data systems capture appropriate categories of race
and ethnicity consistently so that there are sufficiently large samples
of some racial and ethnic groups and sexual minorities in population-
level epidemiological studies. Furthermore, more and better metrics and
indicators to capture a broader definition of health are needed, among
other needs (see NASEM, 2017, 2020, for more discussion on this topic).
The committee endorses the inclusion of expanded data collection and
improved surveillance in populations underrepresented in current data
as an objective of the STI National Strategic Plan: 2021–2025 (HHS, 2020).
Nonetheless, the available data show that STIs are not evenly dis-
tributed throughout the population, but rather are concentrated heav-
ily among certain groups. Many of these groups, especially those with
multiple social identities, are stigmatized and often socioeconomically
disadvantaged. The underlying epidemiology and complex social and
structural determinants outlined in Chapters 2 and 3 are crucial to under-
standing the state of STIs in the United States. These factors need to be
taken into account when mounting any response to improving sexual
health and reducing the epidemics of STIs.
REFERENCES
Aalsma, M. C., S. E. Wiehe, M. J. Blythe, Y. Tong, J. Harezlak, and M. B. Rosenman. 2011.
Mental health screening and STI among detained youth. Journal of Community Health
36(2):300-306.
AAP (American Academy of Pediatrics) and ACOG (American College of Obstetricians
and Gynecologists). 2017. Guidelines for perinatal care. 8th ed. Elk Grove, IL: American
Academy of Pediatrics; American College of Obstetricians and Gynecologists.
Aaron, D. J., N. Markovic, M. E. Danielson, J. A. Honnold, J. E. Janosky, and N. J. Schmidt.
2001. Behavioral risk factors for disease and preventive health practices among lesbi-
ans. American Journal of Public Health 91(6):972-975.
Abdullahi, L. H., B. M. Kagina, V. N. Ndze, G. D. Hussey, and C. S. Wiysonge. 2020. Im-
proving vaccination uptake among adolescents. Cochrane Database of Systematic Reviews
1(1):CD011895.
ACLU (American Civil Liberties Union). 2020. A tale of two countries: Racially targeted arrests
in the era of marijuana reform. Washington, DC: American Civil Liberties Union.
ACOG (American College of Obstetricians and Gynecologists) Committee on Adolescent
Health Care. 2017a. Committee opinion no. 705: Mental health disorders in adolescents.
Obstetrics and Gynocology 130(1):e32-e41.
ACOG Committee on Adolescent Health Care. 2017b. Committee opinion no. 710: Counsel-
ing adolescents about contraception. Obstetrics and Gynocology 130(2):e74-e80.
ACOG Committee on Adolescent Health Care. 2020. Confidentiality in adolescent health
care: ACOG committee opinion, number 803. Obstetrics and Gynocology 135(4):e171-e177.
Adams, G., S. A. Fryberg, D. M. Garcia, and E. U. Delgado-Torres. 2006. The psychology of
engagement with indigenous identities: A cultural perspective. Cultural Diversity and
Ethnic Minority Psychology 12(3):493-508.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
182 SEXUALLY TRANSMITTED INFECTIONS
Adefuye, A. S., T. C. Abiona, J. A. Balogun, and M. Lukobo-Durrell. 2009. HIV sexual risk
behaviors and perception of risk among college students: Implications for planning
interventions. BMC Public Health 9:281.
Adimora, A. A., and V. J. Schoenbach. 2005. Social context, sexual networks, and racial dis-
parities in rates of sexually transmitted infections. Journal Infectious Diseases 191(Suppl
1):S115-S122.
Adimora, A. A., V. J. Schoenbach, D. M. Bonas, F. E. Martinson, K. H. Donaldson, and T.
R. Stancil. 2002. Concurrent sexual partnerships among women in the United States.
Epidemiology 13(3):320-327.
Agénor, M., J. L. Jahn, E. Kay, R. A. Bishop, S. M. Peitzmeier, J. Potter, and S. B. Austin. 2019a.
Human papillomavirus risk perceptions among young adult sexual minority cisgender
women and nonbinary individuals assigned female at birth. Perspectives on Sexual and
Reproductive Health 51(1):27-34.
Agénor, M., G. Murchison, J. Chen, D. Bowen, M. Rosenthal, S. Haneuse, and S. Austin.
2019b. Impact of the Affordable Care Act on human papillomavirus vaccination initia-
tion among lesbian, bisexual, and heterosexual U.S. women. Health Services Research
55(1):18-25.
Aicken, C. R., A. Nardone, and C. H. Mercer. 2011. Alcohol misuse, sexual risk behaviour and
adverse sexual health outcomes: Evidence from Britain’s National Probability Sexual
Behaviour surveys. Journal of Public Health 33(2):262-271.
Alessi, E. J., B. Greenfield, D. Manning, and M. Dank. 2020. Victimization and resilience
among sexual and gender minority homeless youth engaging in survival sex. Journal
of Interpersonal Violence 1-24.
Alexander-Rodriguez, T., and S. H. Vermund. 1987. Gonorrhea and syphilis in incarcerated
urban adolescents: Prevalence and physical signs. Pediatrics 80(4):561-564.
Aliyu, M. H., M. Blevins, C. M. Audet, M. Kalish, U. I. Gebi, O. Onwujekwe, M. L. Linde-
gren, B. E. Shepherd, C. W. Wester, and S. H. Vermund. 2016. Integrated prevention of
mother-to-child HIV transmission services, antiretroviral therapy initiation, and ma-
ternal and infant retention in care in rural north-central Nigeria: A cluster-randomised
controlled trial. Lancet HIV 3(5):e202-e211.
Ames, G. M., M. R. Duke, R. S. Moore, and C. B. Cunradi. 2008. The impact of occupational
culture on drinking behavior of young adults in the U.S. Navy. Journal of Mixed Methods
Research 3(2):129-150.
Anderson, L. E., G. A. Dingle, B. O’Gorman, and M. J. Gullo. 2020. Young adults’ sexual
health in the digital age: Perspectives of care providers. Sexual & Reproductive Health
Care 25:100534.
Anderson, S., K. Shannon, J. Li, Y. Lee, J. Chettiar, S. Goldenberg, and A. Krüsi. 2016. Con-
doms and sexual health education as evidence: Impact of criminalization of in-call ven-
ues and managers on migrant sex workers access to HIV/STI prevention in a Canadian
setting. BMC International Health and Human Rights 16(1):30.
Ansaldi, F., M. Comar, P. D’Agaro, S. Grainfenberghi, L. Caimi, F. Gargiulo, B. Bruzzone, R.
Gasparini, G. Icardi, F. Perandin, C. Campello, and N. Manca. 2003. Seroprevalence of
HTLV-I and HTLV-II infection among immigrants in northern Italy. European Journal of
Epidemiology 18(6):583-588.
APA (American Psychiatric Association). 2017. Mental health disparities: American Indians and
Alaska Natives. https://www.psychiatry.org/File%20Library/Psychiatrists/Cultural-
Competency/Mental-Health-Disparities/Mental-Health-Facts-for-American-Indian-
Alaska-Natives.pdf (accessed February 21, 2021).
Arbeit, M. R., C. B. Fisher, K. Macapagal, and B. Mustanski. 2016. Bisexual invisibility and
the sexual health needs of adolescent girls. LGBT Health 3(5):342-349.
Argüello, T. M., and K. Walters. 2018. They tell us “we don’t belong in the world and we
shouldn’t take up a place”: HIV discourse within two-spirit communities. Journal of
Ethnic & Cultural Diversity in Social Work 27(2):107-123.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 183
Armed Forces Surveillance Center. 2013. Sexually transmitted infections, active component,
U.S. Armed Forces, 2000-2012. Medical Surveillance Monthly Report 20(2):5-10.
Arnold, E. A., E. Sterrett-Hong, A. Jonas, and L. M. Pollack. 2018. Social networks and social
support among ball-attending African American men who have sex with men and
transgender women are associated with HIV-related outcomes. Global Public Health
13(2):144-158.
Arnold, S. B. 2014. Reproductive rights denied: The Hyde amendment and access to abortion
for Native American women using Indian Health Service facilities. American Journal of
Public Health 104(10):1892-1893.
Ashenhurst, J. R., E. R. Wilhite, K. P. Harden, and K. Fromme. 2017. Number of sexual
partners and relationship status are associated with unprotected sex across emerging
adulthood. Archives of Sexual Behavior 46(2):419-432.
Athar, H. M., M. H. Chang, R. A. Hahn, E. Walker, and P. Yoon. 2013. Unemployment—
United States, 2006 and 2010. MMWR Supplements 62(3):27-32.
Austin, A., and R. Goodman. 2017. The impact of social connectedness and internalized
transphobic stigma on self-esteem among transgender and gender non-conforming
adults. Journal of Homosexuality 64(6):825-841.
Austin, S. B., A. L. Roberts, H. L. Corliss, and B. E. Molnar. 2008. Sexual violence vic-
timization history and sexual risk indicators in a community-based urban cohort of
“mostly heterosexual” and heterosexual young women. American Journal of Public
Health 98(6):1015-1020.
Ayala, G., T. Bingham, J. Kim, D. P. Wheeler, and G. A. Millett. 2012. Modeling the impact
of social discrimination and financial hardship on the sexual risk of HIV among Latino
and Black men who have sex with men. American Journal of Public Health 102(Suppl
2):S242-S249.
Azari, A. A., and A. Arabi. 2020. Conjunctivitis: A systematic review. Journal of Ophthalmic
& Vision Research 15(3):372-395.
AZDHS (Arizona Department of Health Services). 1989. R7-2-303. Sex education. https://
azdhs.gov/documents/prevention/womens-childrens-health/rfga/prep-tribal/
policy-proceduer-manual/attachment-d-r7-2-303-sex-ed-in-schools-rule.pdf (accessed
November 19, 2020).
Bacon, O., P. Lum, J. Hahn, J. Evans, P. Davidson, A. Moss, and K. Page-Shafer. 2006. Com-
mercial sex work and risk of HIV infection among young drug-injecting men who have
sex with men in San Francisco. Sexually Transmitted Diseases 33(4):228-234.
Balaji, A. B., E. Oraka, A. M. Fasula, P. E. Jayne, M. G. Carry, and J. L. Raiford. 2017. As-
sociation between parent-adolescent communication about sex-related topics and HIV
testing, United States. 2006-2013. AIDS Care 29(3):344-349.
Baral, S. D., M. R. Friedman, S. Geibel, K. Rebe, B. Bozhinov, D. Diouf, K. Sabin, C. E. Hol-
land, R. Chan, and C. F. Cáceres. 2015. Male sex workers: Practices, contexts, and vul-
nerabilities for HIV acquisition and transmission. The Lancet 385(9964):260-273.
Barlas, F., W. Higgins, J. Pflieger, and K. Diecker. 2013. Department of Defense health related
behaviours survey of active duty military personnel. http://www.murray.senate.gov/
public/_cache/files/889efd07-2475-40ee-b3b0-508947957a0f/final-2011-hrb-active-
duty-survey-report.pdf (accessed February 15, 2021).
Barr, S. M., S. L. Budge, and J. L. Adelson. 2016. Transgender community belongingness as a
mediator between strength of transgender identity and well-being. Journal of Counseling
Psychology 63(1):87-97.
Barry, A. E., M. L. Stellefson, B. Hanik, B. L. Tennant, S. D. Whiteman, J. Varnes, and S. M.
Wadsworth. 2013. Examining the association between binge drinking and propensity
to join the military. Military Medicine 178(1):37-42.
Bastow, B., J. Sheeder, and S. Teal. 2014. Do adolescents who initiate LARC use condoms
with new partners? Contraception 90(3):296.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
184 SEXUALLY TRANSMITTED INFECTIONS
Bauer, G. R., N. Redman, K. Bradley, and A. I. Scheim. 2013. Sexual health of trans men who
are gay, bisexual, or who have sex with men: Results from Ontario, Canada. Interna-
tional Journal of Transgender Health 14(2):66-74.
Bauer, M., E. Haesler, and D. Fetherstonhaugh. 2016. Let’s talk about sex: Older people’s
views on the recognition of sexuality and sexual health in the health-care setting. Health
Expectations 19(6):1237-1250.
Bauermeister, J. A., M. A. Zimmerman, and C. H. Caldwell. 2011. Neighborhood disadvan-
tage and changes in condom use among African American adolescents. Journal of Urban
Health 88(1):66-83.
Bautista, C. T., E. K. Wurapa, W. B. Sateren, S. M. Morris, B. P. Hollingsworth, and J. L. San-
chez. 2017. Repeat infection with Neisseria gonorrhoeae among active duty U.S. Army
personnel: A population-based case-series study. International Journal of STD & AIDS
28(10):962-968.
Bautista, C. T., E. K. Wurapa, and J. L. Sanchez. 2019. Does the hazard of chlamydia increase
with the number of gonorrhea diagnoses? A large population-based study among U.S.
Army women. Journal of Women’s Health 28(2):220-224.
Becasen, J. S., C. L. Denard, M. M. Mullins, D. H. Higa, and T. A. Sipe. 2019. Estimating
the prevalence of HIV and sexual behaviors among the US transgender population:
A systematic review and meta-analysis, 2006-2017. American Journal of Public Health
109(1):e1-e8.
Bechtel, K. 2010. Sexual abuse and sexually transmitted infections in children and adoles-
cents. Current Opinion in Pediatrics 22(1):94-99.
Beckles, G. L., and B. I. Truman. 2013. Education and income—United States, 2009 and 2011.
MMWR Supplements 62(3):9-19.
Begley, E., R. A. Crosby, R. J. DiClemente, G. M. Wingood, and E. Rose. 2003. Older partners
and STD prevalence among pregnant African American teens. Sexually Transmitted
Diseases 30(3):211-213.
Belenko, S., R. Dembo, M. Rollie, K. Childs, and C. Salvatore. 2009. Detecting, preventing,
and treating sexually transmitted diseases among adolescent arrestees: An unmet pub-
lic health need. American Journal of Public Health 99(6):1032-1041.
Benoit, E., and J. A. Koken. 2012. Perspectives on substance use and disclosure among
behaviorally bisexual black men with female primary partners. Journal of Ethnicity in
Substance Abuse 11(4):294-317.
Benson, P. A., and A. C. Hergenroeder. 2005. Bacterial sexually transmitted infections in gay,
lesbian, and bisexual adolescents: Medical and public health perspectives. Seminars in
Pediatric Infections Diseases 16(3):181-191.
Berg, R. C., H. M. Munthe-Kaas, and M. W. Ross. 2016. Internalized homonegativity: A sys-
tematic mapping review of empirical research. Journal of Homosexuality 63(4):541-558.
Bergeron, C. D., H. H. Goltz, L. E. Szucs, J. V. Reyes, K. L. Wilson, M. G. Ory, and M. L. Smith.
2017. Exploring sexual behaviors and health communication among older women.
Health Care for Women International 38(12):1356-1372.
Beymer, M. R., R. E. Weiss, R. K. Bolan, E. T. Rudy, L. B. Bourque, J. P. Rodriguez, and D. E.
Morisky. 2014. Sex on demand: Geosocial networking phone apps and risk of sexually
transmitted infections among a cross-sectional sample of men who have sex with men
in Los Angeles county. Sexually Transmitted Infections 90(7):567-572.
Bickell, N. A., S. H. Vermund, M. Holmes, S. Safyer, and R. D. Burk. 1991. Human papillo-
mavirus, gonorrhea, syphilis, and cervical dysplasia in jailed women. American Journal
of Public Health 81(10):1318-1320.
Biello, K. B., W. C. Goedel, A. Edeza, S. A. Safren, K. H. Mayer, B. D. L. Marshall, C. Lat-
kin, and M. J. Mimiaga. 2020. Network-level correlates of sexual risk among male sex
workers in the United States: A dyadic analysis. Journal of Acquired Immune Deficiency
Syndromes 83(2):111-118.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 185
BigFoot, D. S., and B. W. Funderbunk. 2010. Communique: Honoring children, making relatives:
Indigenous traditional parenting practices compatible with evidence-based treatment. Wash-
ington, DC: American Psychological Association.
Biglan, A., J. Noell, L. Ochs, K. Smolkowski, and C. Metzler. 1995. Does sexual coercion play
a role in the high-risk sexual behavior of adolescent and young adult women? Journal
of Behavioral Medicine 18(6):549-568.
Blum, R. W., B. Harmon, L. Harris, L. Bergeisen, and M. D. Resnick. 1992. American Indian—
Alaska Native youth health. JAMA 267(12):1637-1644.
Bonney, L. E., J. G. Clarke, E. M. Simmons, J. S. Rose, and J. D. Rich. 2008. Racial/ethnic
sexual health disparities among incarcerated women. JAMA 100(5):553-558.
Borschmann, R., E. Janca, A. Carter, M. Willoughby, N. Hughes, K. Snow, E. Stockings, N.
T. M. Hill, J. Hocking, A. Love, G. C. Patton, S. M. Sawyer, S. Fazel, C. Puljević, J. Rob-
inson, and S. A. Kinner. 2020. The health of adolescents in detention: A global scoping
review. Lancet Public Health 5(2):e114-e126.
Bostwick, W., and A. Hequembourg. 2014. “Just a little hint”: Bisexual-specific microag-
gressions and their connection to epistemic injustices. Culture, Health & Sexuality
16(5):488-503.
Bostwick, W. B., C. J. Boyd, T. L. Hughes, B. T. West, and S. E. McCabe. 2014. Discrimination
and mental health among lesbian, gay, and bisexual adults in the United States. The
American Journal of Orthopsychiatry 84(1):35-45.
Bowen, V., J. Su, E. Torrone, S. Kidd, and H. Weinstock. 2015. Increase in incidence of
congenital syphilis—United States, 2012-2014. Morbidity and Mortality Weekly Report
64(44):1241-1245.
Bowleg, L. 2008. When Black + lesbian + woman ≠ Black lesbian woman: The method-
ological challenges of qualitative and quantitative intersectionality research. Sex Roles
59(5):312-325.
Bowleg, L., and A. Raj. 2012. Shared communities, structural contexts, and HIV risk: Priori-
tizing the HIV risk and prevention needs of Black heterosexual men. American Journal
of Public Health 102(Suppl 2):S173-S177.
Boyer, C. B., J. M. Tschann, and M.-A. Shafer. 1999. Predictors of risk for sexually transmit-
ted diseases in ninth grade urban high school students. Journal of Adolescent Research
14(4):448-465.
Boyer, C. B., M.-A. Shafer, C. J. Wibbelsman, D. Seeberg, E. Teitle, and N. Lovell. 2000. As-
sociations of sociodemographic, psychosocial, and behavioral factors with sexual risk
and sexually transmitted diseases in teen clinic patients. Journal of Adolescent Health
27(2):102-111.
Boyer, C. B., M. A. Shafer, L. M. Pollack, J. Canchola, J. Moncada, and J. Schachter. 2006.
Sociodemographic markers and behavioral correlates of sexually transmitted infections
in a nonclinical sample of adolescent and young adult women. The Journal of Infectious
Diseases 194(3):307-315.
Boyer, C. B., L. M. Pollack, J. Becnel, and M. A. Shafer. 2008. Relationships among sociode-
mographic markers, behavioral risk, and sexually transmitted infections in U.S. female
Marine Corps recruits. Military Medicine 173(11):1078-1084.
Boyer, C. B., L. Greenberg, K. Chutuape, B. Walker, D. Monte, J. Kirk, and J. M. Ellen. 2017.
Exchange of sex for drugs or money in adolescents and young adults: An examination
of sociodemographic factors, HIV-related risk, and community context. Journal of Com-
munity Health 42(1):90-100.
Boyer, C. B., O. J. Santiago Rivera, D. M. Chiaramonte, and J. M. Ellen. 2018. Examination
of behavioral, social, and environmental contextual influences on sexually transmitted
infections in at risk, urban, adolescents, and young adults. Sexually Transmitted Diseases
45(8):542-548.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
186 SEXUALLY TRANSMITTED INFECTIONS
Bozelko, C. 2015. Why we let prison rape go on. https://www.nytimes.com/2015/04/18/
opinion/why-we-let-prison-rape-go-on.html (accessed February 15, 2021).
Braveman, P., K. Marchi, S. Egerter, M. Pearl, and J. Neuhaus. 2000. Barriers to timely pre-
natal care among women with insurance: The importance of prepregnancy factors.
Obstetrics and Gynocology 95(6 Pt 1):874-880.
Braveman, P., E. Arkin, T. Orleans, D. Proctor, and A. Plough. 2017. What is health equity? And
what difference does a definition make? Princeton, NJ: Robert Wood Johnson Foundation.
Bray, R. M., J. M. Brown, and J. Williams. 2013. Trends in binge and heavy drinking, alcohol-
related problems, and combat exposure in the U.S. military. Substance Use & Misuse
48(10):799-810.
Brewer, R., C. Daunis, S. Ebaady, L. Wilton, S. Chrestman, S. Mukherjee, M. Moore, R. Corri-
gan, and J. Schneider. 2019. Implementation of a socio-structural demonstration project
to improve HIV outcomes among young Black men in the Deep South. Journal of Racial
and Ethnic Health Disparities 6(4):775-789.
Brewer, T. H., J. Schillinger, F. M. Lewis, S. Blank, P. Pathela, L. Jordahl, K. Schmitt, and T. A.
Peterman. 2011. Infectious syphilis among adolescent and young adult men: Implica-
tions for human immunodeficiency virus transmission and public health interventions.
Sexually Transmitted Diseases 38(5):367-371.
Brooks, A., C. S. Meade, J. S. Potter, Y. Lokhnygina, D. A. Calsyn, and S. F. Greenfield. 2010.
Gender differences in the rates and correlates of HIV risk behaviors among drug abus-
ers. Substance Use & Misuse 45(14):2444-2469.
Brown, J. L., and P. A. Vanable. 2007. Alcohol use, partner type, and risky sexual behav-
ior among college students: Findings from an event-level study. Addictive Behaviors
32(12):2940-2952.
Brown, J. L., A. M. Young, J. M. Sales, R. J. DiClemente, E. S. Rose, and G. M. Wingood.
2014. Impact of abuse history on adolescent African-American women’s current HIV/
STD-associated behaviors and psychosocial mediators of HIV/STD risk. Journal of Ag-
gression, Maltreatment & Trauma 23(2):151-167.
Brown, L. K., W. Hadley, A. Stewart, C. Lescano, L. Whiteley, G. Donenberg, and R. DiCle-
mente. 2010. Psychiatric disorders and sexual risk among adolescents in mental health
treatment. Journal of Consulting and Clinical Psychology 78(4):590-597.
Bryan, A. D., S. J. Schmiege, and R. E. Magnan. 2012. Marijuana use and risky sexual behav-
ior among high-risk adolescents: Trajectories, risk factors, and event-level relationships.
Developmental Psychology 48(5):1429-1442.
Bryan, A. D., R. E. Magnan, A. S. Gillman, E. A. Yeater, S. W. Feldstein Ewing, A. S. Kong,
and S. J. Schmiege. 2018. Effect of including alcohol and cannabis content in a sexual
risk-reduction intervention on the incidence of sexually transmitted infections in ado-
lescents: A cluster randomized clinical trial. JAMA Pediatrics 172(4):e175621.
Buhi, E. R., and P. Goodson. 2007. Predictors of adolescent sexual behavior and intention: A
theory-guided systematic review. Journal of Adolescent Health 40(1):4-21.
Burnette, C. E. 2016. Historical oppression and Indigenous families: Uncovering potential
risk factors for Indigenous families touched by violence. Family Relations 65(2):354-368.
Cahn, M. A., S. M. Harvey, and K. Gonzales. 2019. Use of sexual health services among
American Indian and Alaska Native women. Women & Health 59(9):953-966.
Call, K. T., D. D. McAlpine, P. J. Johnson, T. J. Beebe, J. A. McRae, and Y. Song. 2006. Bar-
riers to care among American Indians in public health care programs. Medical Care
44(6):595-600.
Cao, B., H. Bao, E. Oppong, S. Feng, K. M. Smith, J. D. Tucker, and W. Tang. 2020. Digital
health for sexually transmitted infection and HIV services: A global scoping review.
Current Opinion in Infectious Diseases 33(1):44-50.
Carey, K. B., T. E. Senn, J. L. Walsh, L. A. Scott-Sheldon, and M. P. Carey. 2016. Alcohol use
predicts number of sexual partners for female but not male STI clinic patients. AIDS
and Behavior 20(Suppl 1):S52-S59.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 187
Carrier, L., J. Dame, and J. Lane. 2020. Two-spirit identity and Indigenous conceptualization
of gender and sexuality: Implications for nursing practice. Creative Nursing 26(2):96-100.
Castillo-Mancilla, J., A. Allshouse, C. Collins, M. Hastings-Tolsma, T. B. Campbell, and
S. Mawhinney. 2012. Differences in sexual risk behavior and HIV/AIDS risk factors
among foreign-born and U.S.-born Hispanic women. Journal of Immigrant and Minority
Health 14(1):89-99.
Catalano, R. F., K. P. Haggerty, S. Oesterle, C. B. Fleming, and J. D. Hawkins. 2004. The
importance of bonding to school for healthy development: Findings from the social
development research group. Journal of School Health 74:252-261.
CDC (Centers for Disease Control and Prevention). 2018a. Health care providers and teen preg-
nancy prevention. https://www.cdc.gov/teenpregnancy/health-care-providers/index.
htm (accessed December 16, 2020).
CDC. 2018b. Tribal population. https://www.cdc.gov/tribal/tribes-organizations-health/
tribes/state-population.html (accessed February 9, 2021).
CDC. 2019a. Anal sex and HIV risk. https://www.cdc.gov/hiv/risk/analsex.html (accessed
November 19, 2020).
CDC. 2019b. Issue brief: HIV and transgender communities. https://www.cdc.gov/hiv/pdf/
policies/cdc-hiv-transgender-brief.pdf (accessed February 15, 2021).
CDC. 2019c. Sexually transmitted disease surveillance 2018. Atlanta, GA: Department of Health
and Human Services.
CDC. 2020a. Diagnoses of HIV infection in the United States and dependent areas, 2018: Children
aged <13 years. https://www.cdc.gov/hiv/library/reports/hiv-surveillance/vol-31/
content/children.html (accessed November 18, 2020).
CDC. 2020b. Disability impacts all of us. https://www.cdc.gov/ncbddd/disabilityandhealth/
infographic-disability-impacts-all.html#:~:text=61%20million%20adults%20in%20
the,is%20highest%20in%20the%20South (accessed November 19, 2020).
CDC. 2020c. HIV and older Americans. https://www.cdc.gov/hiv/group/age/older
americans/index.html (accessed November 19, 2020).
CDC. 2020d. HIV and youth. https://www.cdc.gov/hiv/group/age/youth/index.html (ac-
cessed November 19, 2020).
CDC. 2020e. Youth Risk Behavior Survey, data summary & trends report, 2009-2019. Atlanta, GA:
Centers for Disease Control and Prevention.
Chadi, N., R. Schroeder, J. W. Jensen, and S. Levy. 2019. Association between electronic ciga-
rette use and marijuana use among adolescents and young adults: A systematic review
and meta-analysis. JAMA Pediatrics 173(10):e192574.
Chae, D. H., and K. L. Walters. 2009. Racial discrimination and racial identity attitudes in
relation to self-rated health and physical pain and impairment among two-spirit Amer-
ican Indians/Alaska Natives. American Journal of Public Health 99(Suppl 1):S144-S151.
Chambers, R., L. Tingey, A. Beach, A. Barlow, and A. Rompalo. 2016a. Testing the efficacy
of a brief sexual risk reduction intervention among high-risk American Indian adults:
Study protocol for a randomized controlled trial. BMC Public Health 16:366.
Chambers, R., L. Tingey, B. Mullany, S. Parker, A. Lee, and A. Barlow. 2016b. Exploring
sexual risk taking among American Indian adolescents through protection motivation
theory. AIDS Care 28(9):1089-1096.
Chambers, R. S., S. Rosenstock, A. Lee, N. Goklish, F. Larzelere, and L. Tingey. 2018. Explor-
ing the role of sex and sexual experience in predicting American Indian adolescent con-
dom use intention using protection motivation theory. Frontiers in Public Health 6:318.
Champion, J. D. 2011. Context of sexual risk behaviour among abused ethnic minority ado-
lescent women. International Nursing Review 58(1):61-67.
Charlton, B. M., H. L. Corliss, S. A. Missmer, A. L. Frazier, M. Rosario, J. A. Kahn, and S.
B. Austin. 2011. Reproductive health screening disparities and sexual orientation in a
cohort study of U.S. adolescent and young adult females. Journal of Adolescent Health
49(5):505-510.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
188 SEXUALLY TRANSMITTED INFECTIONS
Charlton, B. M., M. L. Hatzenbuehler, H. J. Jun, V. Sarda, A. R. Gordon, J. R. G. Raifman, and
S. B. Austin. 2019. Structural stigma and sexual orientation-related reproductive health
disparities in a longitudinal cohort study of female adolescents. Journal of Adolescence
74:183-187.
Cheng, M. M., and J. R. Udry. 2005. Sexual experiences of adolescents with low cognitive
abilities in the U.S. Journal of Developmental and Physical Disabilities 17(2):155-172.
Cheung, K. W., M. T. Y. Seto, and T. T.-H. Lao. 2019. Prevention of perinatal hepatitis B virus
transmission. Archives of Gynecology and Obstetrics 300(2):251-259.
Chewning, B., J. Douglas, P. K. Kokotailo, J. LaCourt, D. S. Clair, and D. Wilson. 2001.
Protective factors associated with American Indian adolescents’ safer sexual patterns.
Maternal and Child Health Journal 5(4):273-280.
Chiaramonte, D., R. L. Miller, K. Lee, O. J. Santiago Rivera, I. D. Acevedo-Polakovich, S.
McGirr, J. L. Porter, J. M. Ellen, and C. B. Boyer. 2020. Gendered powerlessness in at-
risk adolescent and young women: An empirical model. AIDS Care 32(10):1333-1342.
Clark, K., J. B. Fletcher, I. W. Holloway, and C. J. Reback. 2018. Structural inequities and
social networks impact hormone use and misuse among transgender women in Los
Angeles county. Archives of Sexual Behavior 47(4):953-962.
Claxton, S. E., H. K. DeLuca, and M. H. van Dulmen. 2015. The association between alcohol
use and engagement in casual sexual relationships and experiences: A meta-analytic
review of non-experimental studies. Archives of Sexual Behavior 44(4):837-856.
Coakley, T. M., S. Randolph, J. Shears, E. R. Beamon, P. Collins, and T. Sides. 2017. Parent-
youth communication to reduce at-risk sexual behavior: A systematic literature review.
Journal of Human Behavior in the Social Environment 27(6):609-624.
Cochran, S., V. Mays, D. Bowen, S. Gage, D. Bybee, S. Roberts, R. Goldstein, A. Robison,
E. Rankow, and J. White. 2001. Cancer-related risk indicators and preventive screen-
ing behaviors among lesbians and bisexual women. American Journal of Public Health
91(4):591-597.
Connell, C. M., T. D. Gilreath, and N. B. Hansen. 2009. A multiprocess latent class analysis of
the co-occurrence of substance use and sexual risk behavior among adolescents. Journal
of Studies on Alcohol and Drugs 70(6):943-951.
Cook, R. L., and D. B. Clark. 2005. Is there an association between alcohol consumption
and sexually transmitted diseases? A systematic review. Sexually Transmitted Diseases
32(3):156-164.
Cooper, J. M., and P. J. Sanchez. 2018. Congenital syphilis. Seminars in Perinatology
42(3):176-184.
Copen, C. E., P. J. Dittus, and J. S. Leichliter. 2016. Confidentiality concerns and sexual and re-
productive health care among adolescents and young adults aged 15-25. NCHS data brief, No.
266. Hyattsville, MD: National Center for Health Statistics.
Copen, C. E., J. S. Leichliter, I. H. Spicknall, and S. O. Aral. 2019. Sexually transmitted
infection risk reduction strategies among U.S. adolescents and adults with multiple
opposite-sex sex partners or perceived partner nonmonogamy, 2011-2017. Sexually
Transmitted Diseases 46(11):722-727.
Coyne, S. M., L. M. Ward, S. L. Kroff, E. J. Davis, H. G. Holmgren, A. C. Jensen, S. E. Er-
ickson, and L. W. Essig. 2019. Contributions of mainstream sexual media exposure to
sexual attitudes, perceived peer norms, and sexual behavior: A meta-analysis. Journal
of Adolescent Health 64(4):430-436.
Craig Rushing, S., D. Stephens, R. Shegog, J. Torres, G. Gorman, C. Jessen, A. Gaston, J.
Williamson, L. Tingey, C. Lee, A. Apostolou, C. Kaufman, and C. M. Markham. 2018.
Healthy native youth: Improving access to effective, culturally-relevant sexual health
curricula. Frontiers in Public Health 6:225.
Crawley, A. T. 2012. Can you be BLACK and work here? Social justice activist organizing and
BLACK aurality. In Black genders and sexualities, edited by S. McGlotten and D. Davis.
New York: Palgrave Macmillan. Pp. 173-186.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 189
Crooks, N., A. Wise, and T. Frazier. 2020. Addressing sexually transmitted infections in the
sociocultural context of black heterosexual relationships in the United States. Social
Science & Medicine 263:113303.
Crosby, R. A., R. J. DiClemente, G. M. Wingood, C. Sionean, B. K. Cobb, K. Harrington, S. L.
Davies, E. W. Hook, 3rd, and M. K. Oh. 2001. Correlates of using dual methods for sexu-
ally transmitted diseases and pregnancy prevention among high-risk African-American
female teens. Journal of Adolescent Health 28(5):410-414.
Cuffe, K. M., A. Newton-Levinson, T. L. Gift, M. McFarlane, and J. S. Leichliter. 2016. Sexu-
ally transmitted infection testing among adolescents and young adults in the United
States. Journal of Adolescent Health 58(5):512-519.
Cullen, K. A., A. S. Gentzke, M. D. Sawdey, J. T. Chang, G. M. Anic, T. W. Wang, M. R.
Creamer, A. Jamal, B. K. Ambrose, and B. A. King. 2019. E-cigarette use among youth
in the United States, 2019. JAMA 322(21):2095-2103.
Cunningham, K., D. A. Martinez, L. A. J. Scott-Sheldon, K. B. Carey, M. P. Carey, and M. R.
Team. 2017. Alcohol use and sexual risk behaviors among adolescents with psychiatric
disorders: A systematic review and meta-analysis. Journal of Child & Adolescent Sub-
stance Abuse 26(5):353-366.
Dahl, R. E. 2001. Affect regulation, brain development, and behavioral/emotional health in
adolescence. CNS Spectrums 6(1):60-72.
Dalla, R. L., and W. C. Gamble. 1996. Native American Navajo teenage parenting women, cross-
generational support and implications for policy. Paper presented at National Council on
Family Relations, Kansas City, MO.
Darkness to Light. 2015. Child sexual abuse statistics: Perpetrators. https://www.childsafehouse.
org/wp-content/uploads/perpetrators.pdf (accessed November 16, 2020).
Daw, J. R., and B. D. Sommers. 2017. Immigration, pregnancy, and heath insurance: New
evidence and ongoing debate. Obstetrics and Gynocology 130(5):935-937.
Day, J. K., A. Tanaka, A. Cherian, Q. Morrow, R. Reeves, V. Hadd-Wissler, and S. T. Russell.
2017. “Comprehensive” sexuality education in Arizona schools: Searching for a clearer under-
standing of policies and practices regarding sexuality education. Tucson, AZ: The Frances
McClelland Institute for Children, Youth, and Familes, The University of Arizona.
De Genna, N. M., M. D. Cornelius, and R. L. Cook. 2007. Marijuana use and sexually trans-
mitted infections in young women who were teenage mothers. Women’s Health Issues
17(5):300-309.
de Ravello, L., S. Everett Jones, S. Tulloch, M. Taylor, and S. Doshi. 2014. Substance use and
sexual risk behaviors among American Indian and Alaska Native high school students.
Journal of School Health 84(1):25-32.
Decker, M. R., J. N. Park, S. T. Allen, B. Silberzahn, K. Footer, S. Huettner, N. Galai, and
S. G. Sherman. 2020. Inconsistent condom use among female sex workers: Partner-
specific influences of substance use, violence, and condom coercion. AIDS and Behavior
24(3):762-774.
Deiss, R., R. J. Bower, E. Co, O. Mesner, J. L. Sanchez, J. Masel, A. Ganesan, G. E. Macalino,
and B. K. Agan. 2016. The association between sexually transmitted infections, length
of service and other demographic factors in the U.S. military. PLoS One 11(12):e0167892.
Deiss, R., M. Byrne, S. M. Echols, S. M. Cammarata, L. Potswald, E. Gomez, J. A. Curry, E.
Garges, G. Macalino, B. K. Agan, and M. F. Bavaro. 2019. Extragenital chlamydia infec-
tion among active-duty women in the United States Navy. Military Medicine Research
6(1):3.
Demissie, Z., S. Everett Jones, H. B. Clayton, and B. A. King. 2017. Adolescent risk behaviors
and use of electronic vapor products and cigarettes. Pediatrics 139(2):e20162921.
DePadilla, L., M. Windle, G. Wingood, H. Cooper, and R. DiClemente. 2011. Condom use
among young women: Modeling the theory of gender and power. Health Psychology
30(3):310-319.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
190 SEXUALLY TRANSMITTED INFECTIONS
Díaz, R. M., G. Ayala, and E. Bein. 2004. Sexual risk as an outcome of social oppression: Data
from a probability sample of Latino gay men in three U.S. cities. Cultural Diversity and
Ethnic Minority Psychology 10(3):255-267.
Dibble, K. E., J. L. Maksut, E. J. Siembida, M. Hutchison, and K. M. Bellizzi. 2019. A system-
atic literature review of HPV vaccination barriers among adolescent and young adult
males. Journal of Adolescent and Young Adult Oncology 8(5):495-511.
Dickens, B. M. 2009. Legal protection and limits of conscientious objection: When conscien-
tious objection is unethical. Medicine and Law 28(2):337-347.
Dickens, D. D., S. E. Dieterich, K. L. Henry, and F. Beauvais. 2012. School bonding as a
moderator of the effect of peer influences on alcohol use among American Indian ado-
lescents. Journal of Studies on Alcohol and Drugs 73(4):597-603.
Dittus, P. J. 2016. Promoting adolescent health through triadic interventions. Journal of Ado-
lescent Health 59(2):133-134.
Dittus, P. J., S. L. Michael, J. S. Becasen, K. M. Gloppen, K. McCarthy, and V. Guilamo-Ramos.
2015. Parental monitoring and its associations with adolescent sexual risk behavior: A
meta-analysis. Pediatrics 136(6):e1587-e1599.
DOD (Department of Defense). 2012. Department of Defense annual report on sexual assault in
the military: Fiscal year 2011. https://apps.dtic.mil/dtic/tr/fulltext/u2/a564805.pdf
(accessed December 24, 2020).
DOD. 2016. 2016 demographics: Profile of the military community. Office of the deputy assistant
secretary of defense. http://download.militaryonesource.mil/12038 (accessed February
15, 2021).
Dodge, B., D. Herbenick, M. R. Friedman, V. Schick, T.-C. Fu, W. Bostwick, E. Bartelt, M.
Muñoz-Laboy, D. Pletta, M. Reece, and T. G. M. Sandfort. 2016. Attitudes toward bi-
sexual men and women among a nationally representative probability sample of adults
in the United States. PLoS One 11(10):e0164430.
Doherty, I. A., V. J. Schoenbach, and A. A. Adimora. 2009. Sexual mixing patterns and hetero-
sexual HIV transmission among African Americans in the southeastern United States.
Journal of Acquired Immune Deficiency Syndromes 52(1):114-120.
Doyle, K. E., C. Sionean, G. Paz-Bailey, N. D. Hollis, D. Kanny, C. Wejnert, and N. S. Group.
2020. High prevalence of disability and HIV risk among low socioeconomic status
urban adults, 17 U.S. Cities. Disability and Health Journal 13(1):100834.
DuBard, C. A., and M. W. Massing. 2007. Trends in emergency Medicaid expenditures for
recent and undocumented immigrants. JAMA 297(10):1085-1092.
Duke, M. R., and G. M. Ames. 2008. Challenges of contraceptive use and pregnancy preven-
tion among women in the U.S. Navy. Qualitative Health Research 18(2):244-253.
Dunkle, K. L., G. M. Wingood, C. M. Camp, and R. J. DiClemente. 2010. Economically
motivated relationships and transactional sex among unmarried African American
and white women: Results from a U.S. national telephone survey. Public Health Reports
125(Suppl 4):90-100.
Duran, B., J. Oetzel, J. Lucero, Y. Jiang, D. K. Novins, S. Manson, and J. Beals. 2005. Obstacles
for rural American Indians seeking alcohol, drug, or mental health treatment. Journal of
Consulting and Clinical Psychology 73(5):819-829.
Dutton, L., K. Koenig, and K. Fennie. 2008. Gynecologic care of the female-to-male transgen-
der man. Journal of Midwifery & Women’s Health 53(4):331-337.
Dyer, T. V., R. E. Turpin, R. Stall, M. R. Khan, L. E. Nelson, R. Brewer, M. R. Friedman, M.
J. Mimiaga, R. L. Cook, C. OʼCleirigh, and K. H. Mayer. 2020. Latent profile analysis
of a syndemic of vulnerability factors on incident sexually transmitted infection in a
cohort of Black men who have sex with men only and Black men who have sex with
men and women in the HIV Prevention Trials Network 061 study. Sexually Transmitted
Diseases 47(9):571-579.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 191
Eberl, J. T. 2019. Conscientious objection in health care. Theoretical Medicine and Bioethics
40(6):483-486.
Edmiston, E. K., C. A. Donald, A. R. Sattler, J. K. Peebles, J. M. Ehrenfeld, and K. L. Eck-
strand. 2016. Opportunities and gaps in primary care preventative health services for
transgender patients: A systematic review. Transgender Health 1(1):216-230.
Edwards, J. M., B. J. Iritani, and D. D. Hallfors. 2006. Prevalence and correlates of exchanging
sex for drugs or money among adolescents in the United States. Sexually Transmitted
Infections 82(5):354-358.
Ehlers, C. L., I. R. Gizer, D. A. Gilder, and R. Yehuda. 2013. Lifetime history of traumatic
events in an American Indian community sample: Heritability and relation to substance
dependence, affective disorder, conduct disorder and PTSD. Journal of Psychiatric Re-
search 47(2):155-161.
Eitle, D., K. Greene, and T. M. Eitle. 2015. American Indians, substance use, and sexual
behavior: Do predictors of sexually transmitted infections explain the race gap among
young adults? Sexually Transmitted Diseases 42(2):64-67.
Eitzen, J. P., and R. G. Sawyer. 1997. Sexually transmitted diseases: Risk behaviors of female
active duty U.S. Army recruits. Military Medicine 162(10):686-689.
Ellen, J. M., B. A. Brown, S. E. Chung, J. J. Potterat, S. Q. Muth, T. W. Valente, and N. S. Pa-
dian. 2005. Impact of sexual networks on risk for gonorrhea and chlamydia among low-
income urban African American adolescents. The Journal of Pediatrics 146(4):518-522.
Epperson, M. W., N. El-Bassel, M. Chang, and L. Gilbert. 2010. Examining the temporal
relationship between criminal justice involvement and sexual risk behaviors among
drug-involved men. Journal of Urban Health 87(2):324-336.
Epstein, M., J. A. Bailey, L. E. Manhart, K. G. Hill, J. D. Hawkins, K. P. Haggerty, and R. F.
Catalano. 2014. Understanding the link between early sexual initiation and later sexu-
ally transmitted infection: Test and replication in two longitudinal studies. Journal of
Adolescent Health 54(4):435-441.
Everett, B. G. 2013. Sexual orientation disparities in sexually transmitted infections: Exam-
ining the intersection between sexual identity and sexual behavior. Archives of Sexual
Behavior 42(2):225-236.
Everett, B. G., P. W. Schnarrs, M. Rosario, R. Garofalo, and B. Mustanski. 2014. Sexual orien-
tation disparities in sexually transmitted infection risk behaviors and risk determinants
among sexually active adolescent males: Results from a school-based sample. American
Journal of Public Health 104(6):1107-1112.
Everett, B. G., M. L. Hatzenbuehler, and T. L. Hughes. 2016. The impact of civil union legisla-
tion on minority stress, depression, and hazardous drinking in a diverse sample of sex-
ual-minority women: A quasi-natural experiment. Social Science & Medicine 169:180-190.
Ewing, S. W., and A. D. Bryan. 2015. A question of love and trust? The role of relationship
factors in adolescent sexual decision making. Journal of Developmental and Behavioral
Pediatrics 36(8):628-634.
Ezell, J. M., M. J. Ferreira, D. T. Duncan, and J. A. Schneider. 2018. The social and sexual
networks of Black transgender women and Black men who have sex with men: Results
from a representative sample. Transgender Health 3(1):201-209.
Fair, C. D., and J. Vanyur. 2011. Sexual coercion, verbal aggression, and condom use consis-
tency among college students. Journal of American College Health 59(4):273-280.
Fichtenberg, C. M., S. Q. Muth, B. Brown, N. S. Padian, T. A. Glass, and J. M. Ellen. 2009.
Sexual network position and risk of sexually transmitted infections. Sexually Transmitted
Infections 85(7):493-498.
Fieland, K. C., K. L. Walters, and J. M. Simoni. 2007. Determinants of health among two-spirit
American Indians and Alaska Natives. In The health of sexual minorities: Public health
perspectives on lesbian, gay, bisexual, and transgender populations, edited by I. H. Meyer
and M. E. Northridge. Springer Science+Business Media. Pp. 268-300.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
192 SEXUALLY TRANSMITTED INFECTIONS
Fishman, S. J., and E. H. Anderson. 2003. Perception of HIV and safer sexual behaviors
among lesbians. Journal of the Association of Nurses in AIDS Care 14(6):48-55.
Flanders, C. E., C. Dobinson, and C. Logie. 2015. “I’m never really my full self”: Young bi-
sexual women’s perceptions of their mental health. Journal of Bisexuality 15(4):454-480.
Flanigan, T. P., N. Zaller, C. G. Beckwith, L. B. Bazerman, A. Rana, A. Gardner, D. A. Wohl,
and F. L. Altice. 2010. Testing for HIV, sexually transmitted infections, and viral hepa-
titis in jails: Still a missed opportunity for public health and HIV prevention. Journal of
Acquired Immune Deficiency Syndromes 55(Suppl 2):S78-83.
Folch, C., J. Casabona, A. Espelt, X. Majó, M. Meroño, V. Gonzalez, L. Wiessing, J. Colom,
and M. T. Brugal. 2016. High prevalence and incidence of HIV and HCV among new
injecting drug users with a large proportion of migrants—is prevention failing? Sub-
stance Use & Misuse 51(2):250-260.
Ford, C. A., A. F. Davenport, A. Meier, and A. L. McRee. 2011. Partnerships between parents
and health care professionals to improve adolescent health. Journal of Adolescent Health
49(1):53-57.
Ford, K., and J. M. Lepkowski. 2004. Characteristics of sexual partners and STD infection
among American adolescents. International Journal of STD & AIDS 15(4):260-265.
Fortenberry, J. D., W. Tu, J. Harezlak, B. P. Katz, and D. P. Orr. 2002. Condom use as a func-
tion of time in new and established adolescent sexual relationships. American Journal
of Public Health 92(2):211-213.
Friedman, M. S., M. P. Marshal, T. E. Guadamuz, C. Wei, C. F. Wong, E. Saewyc, and R. Stall.
2011. A meta-analysis of disparities in childhood sexual abuse, parental physical abuse,
and peer victimization among sexual minority and sexual nonminority individuals.
American Journal of Public Health 101(8):1481-1494.
Friedman, S. R., and S. Aral. 2001. Social networks, risk-potential networks, health, and
disease. Journal of Urban Health 78(3):411-418.
Frost, D. M., K. Lehavot, and I. H. Meyer. 2015. Minority stress and physical health among
sexual minority individuals. Journal of Behavioral Medicine 38(1):1-8.
Frye, V., L. Wilton, S. Hirshfied, M. A. Chiasson, D. Usher, D. Lucy, J. McCrossin, E. Greene,
B. Koblin, and The All About Me Study. 2015. “Just because it’s out there, people aren’t
going to use it.” HIV self-testing among young, Black MSM, and transgender women.
AIDS Patient Care and STDs 29(11):617-624.
Fujimoto, K., C. A. Flash, L. M. Kuhns, J.-Y. Kim, and J. A. Schneider. 2018. Social networks
as drivers of syphilis and HIV infection among young men who have sex with men.
Sexually Transmitted Infections 94(5):365.
Fuzzell, L., C. G. Shields, S. C. Alexander, and J. D. Fortenberry. 2017. Physicians talk-
ing about sex, sexuality, and protection with adolescents. Journal of Adolescent Health
61(1):6-23.
Gaines, T. L., A. E. Rudolph, K. C. Brouwer, S. A. Strathdee, R. Lozada, G. Martinez, S. M.
Goldenberg, and M. L. Rusch. 2013. The longitudinal association of venue stability with
consistent condom use among female sex workers in two Mexico–USA border cities.
International Journal of STD & AIDS 24(7):523-529.
Gallion, H. R., L. J. Milam, and L. L. Littrell. 2016. Genital findings in cases of child sexual
abuse: Genital vs. vaginal penetration. Journal of Pediatric and Adolescent Gynecology
29(6):604-611.
Galupo, M. P., S. B. Henise, and N. L. Mercer. 2016. “The labels don’t work very well”:
Transgender individuals’ conceptualizations of sexual orientation and sexual identity.
International Journal of Transgenderism 17(2):93-104.
GAO (Government Accountability Office). 2005. Health care services are not always available to
Native Americans. Washington, DC: Government Accountability Office.
Garwick, A. W., K. L. Rhodes, M. Peterson-Hickey, and W. L. Hellerstedt. 2008. Native teen
voices: Adolescent pregnancy prevention recommendations. Journal of Adolescent Health
42(1):81-88.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 193
Gates, M. L., M. Staples-Horne, J. Cartier, C. Best, V. Walker, D. Schwartz, and W. Yoo. 2015.
Understanding psychosocial and high-risk sexual behaviors among detained juveniles:
A descriptive study protocol. JMIR Research Protocols 4(4):e144.
Gates, M. L., M. Staples-Horne, J. Cartier, C. Best, R. Stone, V. Walker, B. Hastings, W. Yoo, N.
C. Webb, and R. L. Braithwaite. 2016. A call to develop evidence-based interventions to
reduce sexually transmitted infections in juvenile justice populations. Journal of Health
Care for the Poor and Underserved 27(2A):34-44.
Gause, N. K., J. L. Brown, J. Welge, and N. Northern. 2018. Meta-analyses of HIV prevention
interventions targeting improved partner communication: Effects on partner communi-
cation and condom use frequency outcomes. Journal of Behavioral Medicine 41(4):423-440.
Gavin, L. E., J. R. Williams, M. I. Rivera, and C. R. Lachance. 2015. Programs to strengthen
parent-adolescent communication about reproductive health: A systematic review.
American Journal of Preventative Medicine 49(2 Suppl 1):S65-S72.
Gavril, A. R., N. D. Kellogg, and P. Nair. 2012. Value of follow-up examinations of children
and adolescents evaluated for sexual abuse and assault. Pediatrics 129(2):282-289.
Gaydos, C. A., M. R. Howell, T. C. Quinn, K. T. McKee, Jr., and J. C. Gaydos. 2003. Sustained
high prevalence of Chlamydia trachomatis infections in female Army recruits. Sexually
Transmitted Diseases 30(7):539-544.
Gaydos, J. C., K. T. McKee, Jr., and C. A. Gaydos. 2013. The changing landscape of control-
ling sexually transmitted infections in the U.S. military. Medical Surveillance Monthly
Report 20(2):2-4.
Gaydos, J. C., K. T. McKee, Jr., and D. J. Faix. 2015. Sexually transmitted infections in the mili-
tary: New challenges for an old problem. Sexually Transmitted Infections 91(8):536-537.
Gerassi, L., M. Jonson-Reid, and B. Drake. 2016. Sexually transmitted infections in a sample
of at-risk youth: Roles of mental health and trauma histories. Journal of Child & Adoles-
cent Trauma 9(3):209-216.
Gesink, D., L. Whiskeyjack, T. Suntjens, A. Mihic, and P. McGilvery. 2016. Abuse of power
in relationships and sexual health. Child Abuse & Neglect 58:12-23.
Girardet, R. G., S. Lahoti, L. A. Howard, N. N. Fajman, M. K. Sawyer, E. M. Driebe, F. Lee,
R. L. Sautter, E. Greenwald, C. M. Beck-Sagué, M. R. Hammerschlag, and C. M. Black.
2009. Epidemiology of sexually transmitted infections in suspected child victims of
sexual assault. Pediatrics 124(1):79-86.
Glick, S. N., M. Morris, B. Foxman, S. O. Aral, L. E. Manhart, K. K. Holmes, and M. R.
Golden. 2012. A comparison of sexual behavior patterns among men who have sex
with men and heterosexual men and women. Journal of Acquired Immune Deficiency
Syndromes 60(1):83-90.
Goldberg, A., and J. Moore. 2018. Domestic minor sex trafficking. Child and Adolescent Psy-
chiatric Clinics of North America 27(1):77-92.
Goldstein, B. Y., J. K. Steinberg, G. Aynalem, and P. R. Kerndt. 2011. High chlamydia and
gonorrhea incidence and reinfection among performers in the adult film industry. Sexu-
ally Transmitted Diseases 38(7):644-648.
Golub, A., B. D. Johnson, and E. Dunlap. 2007. The race/ethnicity disparity in misdemeanor
marijuana arrests in New York City. Criminology & Public Policy 6(1):131-164.
Gonzales, K. L., A. K. Harding, W. E. Lambert, R. Fu, and W. G. Henderson. 2013. Perceived
experiences of discrimination in health care: A barrier for cancer screening among
American Indian women with type 2 diabetes. Women’s Health Issues 23(1):e61-e67.
Gorbach, P. M., M. Javanbakht, C. L. Shover, R. K. Bolan, A. Ragsdale, and S. Shoptaw. 2019.
Associations between cannabis use, sexual behavior, and sexually transmitted infec-
tions/human immunodeficiency virus in a cohort of young men who have sex with
men. Sexually Transmitted Diseases 46(2):105-111.
Gorgos, L. M., and J. M. Marrazzo. 2011. Sexually transmitted infections among women who
have sex with women. Clinical Infectious Diseases 53(Suppl 3):S84-S91.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
194 SEXUALLY TRANSMITTED INFECTIONS
Goyal, V., K. M. Mattocks, and A. G. Sadler. 2012. High-risk behavior and sexually transmit-
ted infections among U.S. active duty servicewomen and veterans. Journal of Women’s
Health 21(11):1155-1169.
Graham, L. F. 2014. Navigating community institutions: Black transgender women’s experi-
ences in schools, the criminal justice system, and churches. Sexuality Research and Social
Policy 11:274-287.
Grant, B. F., R. B. Goldstein, T. D. Saha, S. P. Chou, J. Jung, H. Zhang, R. P. Pickering, W. J.
Ruan, S. M. Smith, B. Huang, and D. S. Hasin. 2015. Epidemiology of DSM-5 alcohol
use disorder: Results from the National Epidemiologic Survey on Alcohol and Related
Conditions III. JAMA Psychiatry 72(8):757-766.
Green, T. C., E. R. Pouget, M. Harrington, F. S. Taxman, A. G. Rhodes, D. OʼConnell, S. S.
Martin, M. Prendergast, and P. D. Friedmann. 2012. Limiting options: Sex ratios, incar-
ceration rates, and sexual risk behavior among people on probation and parole. Sexually
Transmitted Diseases 39(6):424-430.
Greene, K. M., D. Eitle, and T. M. Eitle. 2018. Developmental assets and risky sexual behav-
iors among American Indian youth. The Journal of Early Adolescence 38(1):50-73.
Greenwood, N. W., and J. Wilkinson. 2013. Sexual and reproductive health care for women
with intellectual disabilities: A primary care perspective. International Journal of Family
Medicine 2013:642472.
Griese, E. R., D. B. Kenyon, and T. R. McMahon. 2016. Identifying sexual health protective
factors among Northern Plains American Indian youth: An ecological approach utiliz-
ing multiple perspectives. American Indian and Alaska Native Mental Health Research
(Online) 23(4):16-43.
Grov, C., D. Cain, H. J. Rendina, A. Ventuneac, and J. T. Parsons. 2016. Characteristics as-
sociated with urethral and rectal gonorrhea and chlamydia diagnoses in a U.S. national
sample of gay and bisexual men: Results from the One Thousand Strong panel. Sexually
Transmitted Diseases 43(3):165-171.
Guilamo-Ramos, V., A. Bouris, J. Jaccard, B. Gonzalez, W. McCoy, and D. Aranda. 2011. A
parent-based intervention to reduce sexual risk behavior in early adolescence: Building
alliances between physicians, social workers, and parents. Journal of Adolescent Health
48(2):159-163.
Guilamo-Ramos, V., J. J. Lee, and J. Jaccard. 2016. Parent-adolescent communication about
contraception and condom use. JAMA Pediatrics 170(1):14-16.
Guilamo-Ramos, V., A. Benzekri, and M. Thimm-Kaiser. 2019a. Parent-based interventions
to affect adolescent sexual and reproductive health: Reconsidering the best evidence
vs all evidence. JAMA Pediatrics 173(9):821-823.
Guilamo-Ramos, V., M. Thimm-Kaiser, A. Benzekri, C. Rodriguez, T. Fuller, L. Warner, and
E. Koumans. 2019b. Father-son communication about consistent and correct condom
use. Pediatrics 143:e20181609.
Guilamo-Ramos, V., A. Benzekri, M. Thimm-Kaiser, P. Dittus, Y. Ruiz, C. M. Cleland, and W.
McCoy. 2020. A triadic intervention for adolescent sexual health: A randomized clinical
trial. Pediatrics 145(5):e20192808.
Guttmacher Institute. 2019. Minors’ access to STI services. https://www.guttmacher.org/
statepolicy/explore/minors-access-sti-services (accessed December 23, 2020).
Guzmán, B., and M. E. Dello Stritto. 2012. The role of socio-psychological determinants in
the sexual behaviors of Latina early adolescents. Sex Roles 66:776-789.
Habel, M. A., J. S. Leichliter, P. J. Dittus, I. H. Spicknall, and S. O. Aral. 2018. Heterosexual
anal and oral sex in adolescents and adults in the United States, 2011-2015. Sexually
Transmitted Diseases 45(12):775-782.
Haberland, N. A. 2015. The case for addressing gender and power in sexuality and HIV
education: A comprehensive review of evaluation studies. International Perspectives on
Sexual and Reproductive Health 41(1):31-42.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 195
Haesler, E., M. Bauer, and D. Fetherstonhaugh. 2016. Sexuality, sexual health and older
people: A systematic review of research on the knowledge and attitudes of health
professionals. Nurse Education Today 40:57-71.
Hafeez, H., M. Zeshan, M. A. Tahir, N. Jahan, and S. Naveed. 2017. Health care disparities
among lesbian, gay, bisexual, and transgender youth: A literature review. Cureus Journal
of Medical Science 9(4):e1184.
Hafner, S. P., and S. Craig Rushing. 2019. Sexual health, STI and HIV risk, and risk percep-
tions among American Indian and Alaska Native emerging adults. Prevention Science
20(3):331-341.
Hakre, S., D. M. Brett-Major, D. E. Singer, R. J. O’Connell, W. B. Sateren, J. L. Sanchez, B.
K. Agan, N. L. Michael, and P. T. Scott. 2011. Medical encounter characteristics of HIV
seroconverters in the U.S. Army and Air Force, 2000-2004. Journal of Acquired Immune
Deficiency Syndromes 56(4):372-380.
Hakre, S., R. J. Oyler, K. A. Ferrell, F. Li, N. L. Michael, P. T. Scott, and B. P. Petruccelli. 2014.
Chlamydia trachomatis infection rates among a cohort of mobile soldiers stationed at Fort
Bragg, North Carolina, 2005-2010. BMC Public Health 14:181.
Halkitis, P. N., F. Kapadia, K. L. Bub, S. Barton, A. D. Moreira, and C. B. Stults. 2015. A lon-
gitudinal investigation of syndemic conditions among young gay, bisexual, and other
MSM: The P18 Cohort Study. AIDS and Behavior 19(6):970-980.
Hallfors, D. D., A. A. Haydon, C. T. Halpern, and B. J. Iritani. 2016. Patterns of risk behavior
change from adolescence to emerging adulthood: Implications for HIV/STD racial
disparities. In Drug use trajectories among minority youth, edited by Y. F. Thomas and L.
N. Price (pp. 367-398). Dordrecht, The Netherlands: Springer Science+Business Media.
Hamilton, D. T., and M. Morris. 2015. The racial disparities in STI in the U.S.: Concurrency,
STI prevalence, and heterogeneity in partner selection. Epidemics 11:56-61.
Hamilton, E., B. Bossiky, J. Ditekemena, G. Esiru, F. Fwamba, A. E. Goga, M. P. Kieffer, L.
D. Tsague, R. van de Ven, R. Wafula, and L. Guay. 2017. Using the PMTCT cascade to
accelerate achievement of the global plan goals. Journal of Acquired Immune Deficiency
Syndromes 75(Suppl 1):S27-S35.
Hammett, T. M. 2009. Sexually transmitted diseases and incarceration. Current Opinion in
Infectious Diseases 22(1):77-81.
Han, C. S., G. Ayala, J. P. Paul, R. Boylan, S. E. Gregorich, and K. H. Choi. 2015. Stress and
coping with racism and their role in sexual risk for HIV among African American,
Asian/Pacific Islander, and Latino men who have sex with men. Archives of Sexual
Behavior 44(2):411-420.
Hansen, A., C. C. Turpyn, K. Mauro, J. C. Thompson, and T. M. Chaplin. 2019. Adolescent
brain response to reward is associated with a bias toward immediate reward. Develop-
mental Neuropsychology 44(5):417-428.
Harawa, N. T., J. K. Williams, H. C. Ramamurthi, C. Manago, S. Avina, and M. Jones. 2008.
Sexual behavior, sexual identity, and substance abuse among low-income bisexual and
non-gay-identifying African American men who have sex with men. Archives of Sexual
Behavior 37(5):748-762.
Harbertson, J., P. T. Scott, J. Moore, M. Wolf, J. Morris, S. Thrasher, M. D’Onofrio, M. P. Grillo,
M. B. Jacobs, B. R. Tran, J. Tian, S. I. Ito, J. McAnany, N. Michael, and B. R. Hale. 2015.
Sexually transmitted infections and sexual behaviour of deploying shipboard U.S. mili-
tary personnel: A cross-sectional analysis. Sexually Transmitted Infections 91(8):581-588.
Harbertson, J., B. R. Hale, E. Y. Watkins, N. L. Michael, and P. T. Scott. 2016. Pre-deployment
alcohol misuse among shipboard active-duty U.S. military personnel. American Journal
of Preventative Medicine 51(2):185-194.
Harbertson, J., K. De Vera, P. Scott, R. Shaffer, N. Michael, and B. Hale. 2017. Factors associ-
ated with not using a condom at last sex among sexually active U.S. Navy and Marine
Corps personnel across a shipboard deployment. Open Forum Infectious Diseases 4(Suppl
1):S102.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
196 SEXUALLY TRANSMITTED INFECTIONS
Harbertson, J., P. T. Scott, H. Lemus, N. L. Michael, and B. R. Hale. 2019. Cross-sectional
study of sexual behavior, alcohol use, and mental health conditions associated with
sexually transmitted infections among deploying shipboard U.S. military personnel.
Military Medicine 184(11-12):e693-e700.
Harling, G., S. Subramanian, T. Bärnighausen, and I. Kawachi. 2013. Socioeconomic dis-
parities in sexually transmitted infections among young adults in the United States:
Examining the interaction between income and race/ethnicity. Sexually Transmitted
Diseases 40(7):575-581.
Harmon-Darrow, C., K. Burruss, and N. Finigan-Carr. 2020. “We are kind of their parents”:
Child welfare workers’ perspective on sexuality education for foster youth. Children
and Youth Services Review 108:104565.
Harper, C. R., R. J. Steiner, R. Lowry, S. Hufstetler, and P. J. Dittus. 2018. Variability in con-
dom use trends by sexual risk behaviors: Findings from the 2003-2015 national Youth
Risk Behavior Surveys. Sexually Transmitted Diseases 45(6):400-405.
Harrington, L. A., K. A. Shaw, and J. G. Shaw. 2017. Contraception in U.S. servicewomen:
Emerging knowledge, considerations, and needs. Current Opinion in Obstetrics and
Gynecology 29(6):431-436.
Harvard Health Letter. 2018. Sexually transmitted disease? At my age? Harvard Health
Publishing, https://www.health.harvard.edu/diseases-and-conditions/sexually-
transmitted-disease-at-my-age (accessed February 15, 2021).
Hatzenbuehler, M. L., and J. E. Pachankis. 2016. Stigma and minority stress as social determi-
nants of health among lesbian, gay, bisexual, and transgender youth: Research evidence
and clinical implications. Pediatric Clinics of North America 63(6):985-997.
He, W., Y. Jin, H. Zhu, Y. Zheng, and J. Qian. 2020. Effect of Chlamydia trachomatis on
adverse pregnancy outcomes: A meta-analysis. Archives of Gynecology and Obstetrics
302(3):553-567.
Hellerstedt, W. L., M. Peterson-Hickey, K. L. Rhodes, and A. Garwick. 2006. Environmental,
social, and personal correlates of having ever had sexual intercourse among American
Indian youths. American Journal of Public Health 96(12):2228-2234.
Hendershot, C. S., R. E. Magnan, and A. D. Bryan. 2010. Associations of marijuana use and
sex-related marijuana expectancies with HIV/STD risk behavior in high-risk adoles-
cents. Psychology of Addictive Behaviors 24(3):404-414.
Henderson, L. 2018. The sexual health of African American and white men: Does former
incarceration status matter? In Inequality, crime, and health among African American males.
Research in Race and Ethnic Relations, Vol. 20: Emerald Publishing Limited. Pp. 53-71.
Hendricks, M., and R. Testa. 2012. A conceptual framework for clinical work with transgen-
der and gender nonconforming clients: An adaptation of the minority stress model.
Professional Psychology: Research and Practice 43:460.
Henson, M., S. Sabo, A. Trujillo, and N. Teufel-Shone. 2017. Identifying protective factors to
promote health in American Indian and Alaska Native adolescents: A literature review.
Journal of Primary Prevention 38(1-2):5-26.
Heston, S., and S. Arnold. 2018. Syphilis in children. Infectious Disease Clinics of North America
32(1):129-144.
Heywood, W., K. Patrick, A. Smith, and M. Pitts. 2015. Associations between early first
sexual intercourse and later sexual and reproductive outcomes: A systematic review of
population-based data. Archives of Sexual Behavior 44:531-569.
HHS (Department of Health and Human Services). 2020. Sexually Transmitted Infections
National Strategic Plan for the United States: 2021-2025. Washington, DC: Department of
Health and Human Services.
Hogben, M., and J. S. Leichliter. 2008. Social determinants and sexually transmitted disease
disparities. Sexually Transmitted Diseases 35(12 Suppl):S13-S18.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 197
Hood, K. B., L. M. Pollack, D. D. Jackson, and C. B. Boyer. 2020. Associations among behav-
ioral risk, sociodemographic identifiers, and sexually transmitted infections in male
and female Army enlisted personnel. Military Medicine. doi: 10.1093/milmed/usaa247.
Hsu, K., K. Jolin, J. Miller, T. Lincoln, R. Lubelczyk, and A. E. Nijhawan. 2011. Managing STDs
in the correctional setting: A guide for clinicians. Sylvie Ratelle and NCSD.
Hughes, G. D., C. Hoyo, and T. R. Puoane. 2006. Fear of sexually transmitted infections
among women with male migrant partners—relationship to oscillatory migration pat-
tern and risk-avoidance behaviour. South African Medical Journal 96(5):434-438.
Hull, S., S. Kelley, and J. L. Clarke. 2017. Sexually transmitted infections: Compelling case
for an improved screening strategy. Population Health Management 20(Suppl 1):S1-S11.
Hulland, E. N., J. L. Brown, A. L. Swartzendruber, J. M. Sales, E. S. Rose, and R. J. DiCle-
mente. 2015. The association between stress, coping, and sexual risk behaviors over
24 months among African-American female adolescents. Psychology, Health & Medicine
20(4):443-456.
Human Rights Watch. 2012. Sex workers at risk: Condoms as evidence of prostitution in
four US cities. https://www.hrw.org/report/2012/07/19/sex-workers-risk/condoms-
evidence-prostitution-four-us-cities# (accessed November 19, 2020).
Hutton, H. E., M. E. McCaul, G. Chander, M. W. Jenckes, C. Nollen, V. L. Sharp, and E. J.
Erbelding. 2013. Alcohol use, anal sex, and other risky sexual behaviors among HIV-
infected women and men. AIDS and Behavior 17(5):1694-1704.
Hwang, L. Y., M. A. Shafer, L. M. Pollack, Y. J. Chang, and C. B. Boyer. 2007. Sexual behaviors
after universal screening of sexually transmitted infections in healthy young women.
Obstetrics and Gynocology 109(1):105-113.
Ibragimov, U., S. Beane, S. R. Friedman, J. C. Smith, B. Tempalski, L. Williams, A. A. Adi-
mora, G. M. Wingood, S. McKetta, R. D. Stall, and H. L. Cooper. 2020. Police killings
of Black people and rates of sexually transmitted infections: A cross-sectional analysis
of 75 large U.S. metropolitan areas, 2016. Sexually Transmitted Infections 96(6):429-431.
ICE (Immigration and Customs Enforcement). 2020. Detention facility locator. https://www.
ice.gov/detention-facilities (accessed December 24, 2020).
Infobase. 2020. Marijuana: Should the United States legalize marijuana? Issues & Controver-
sies. http://icof.infobaselearning.com/icofprintarticle.aspx?articleID=1621aa&citation
=mla (accessed November 19, 2020).
Jackson, J. M., P. Seth, R. J. DiClemente, and A. Lin. 2015. Association of depressive symp-
toms and substance use with risky sexual behavior and sexually transmitted infections
among African American female adolescents seeking sexual health care. American
Journal of Public Health 105(10):2137-2142.
Jahn, J. L., R. A. Bishop, A. S. L. Tan, and M. Agénor. 2019. Patient-provider sexually
transmitted infection prevention communication among young adult sexual minority
cisgender women and nonbinary assigned female at birth individuals. Women’s Health
Issues 29(4):308-314.
James, S. E., J. L. Herman, S. Rankin, M. Keisling, L. Mottet, and M. Anafi. 2016. The report
of the 2015 U.S. Transgender survey. Washington, DC: National Center for Transgender
Equality.
Jeffries, W. L. t., and O. D. Johnson. 2015. Homonegative attitudes and risk behaviors for
HIV and other sexually transmitted infections among sexually active men in the United
States. American Journal of Public Health 105(12):2466-2472.
Jenkins, R. A., P. R. Jenkins, E. D. Nannis, K. T. McKee, Jr., and L. R. Temoshok. 2000. Cor-
relates of human immunodeficiency virus infection risk behavior in male attendees of
a clinic for sexually transmitted disease. Clinical Infectious Diseases 30(4):723-729.
Joesoef, M. R., R. H. Kahn, and H. S. Weinstock. 2006. Sexually transmitted diseases in incar-
cerated adolescents. Current Opinion in Infectious Diseases 19(1):44-48.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
198 SEXUALLY TRANSMITTED INFECTIONS
Johnson, B. K. 2013. Sexually transmitted infections and older adults. Journal of Gerontological
Nursing 39(11):53-60.
Johnson, P. J., K. F. Carlson, and M. O. Hearst. 2010. Healthcare disparities for American Indi-
an veterans in the United States: A population-based study. Medical Care 48(6):563-569.
Johnston, L. D., P. M. O’Malley, J. G. Bachman, J. E. Schulenberg, M. E. Patrick, and R. A.
Miech. 2015. Monitoring the Future national survey results: HIV/AIDS risk & protective
behaviors among adults ages 21 to 40 in the U.S., 2004-2014. Ann Arbor, MI: Institute for
Social Research, University of Michigan.
Jordan, N. N., S. E. Lee, G. Nowak, N. M. Johns, and J. C. Gaydos. 2011. Chlamydia tracho-
matis reported among U.S. active duty service members, 2000-2008. Military Medicine
176(3):312-319.
Kading, M. L., D. S. Hautala, L. C. Palombi, B. D. Aronson, R. C. Smith, and M. L. Walls.
2015. Flourishing: American Indian positive mental health. Society and Mental Health
5(3):203-217.
Kaestle, C. E. 2012. Selling and buying sex: A longitudinal study of risk and protective fac-
tors in adolescence. Prevention Science 13(3):314-322.
Kaestle, C. E., and M. W. Waller. 2011. Bacterial STDs and perceived risk among sexual mi-
nority young adults. Perspectives on Sexual and Reproductive Health 43(3):158-163.
Kaestle, C. E., C. T. Halpern, W. C. Miller, and C. A. Ford. 2005. Young age at first sexual
intercourse and sexually transmitted infections in adolescents and young adults. Ameri-
can Journal of Epidemiology 161(8):774-780.
Kann, L., T. McManus, W. A. Harris, S. L. Shanklin, K. H. Flint, B. Queen, R. Lowry, D.
Chyen, L. Whittle, J. Thornton, C. Lim, D. Bradford, Y. Yamakawa, M. Leon, N. Brener,
and K. A. Ethier. 2018. Youth risk behavior surveillance—United States, 2017. MMWR
Surveillance Summaries 67(8):1-114.
Kaplan, D. L., E. J. Jones, E. C. Olson, and C. B. Yunzal-Butler. 2013. Early age of first sex
and health risk in an urban adolescent population. Journal of School Health 83(5):350-356.
Kattari, S. K., and S. Begun. 2016. On the margins of marginalized: Transgender homeless-
ness and survival sex. Affilia 32(1):92-103.
Katz, B. P., J. D. Fortenberry, G. D. Zimet, M. J. Blythe, and D. P. Orr. 2000. Partner-specific
relationship characteristics and condom use among young people with sexually trans-
mitted diseases. The Journal of Sex Research 37(1):69-75.
Katz-Wise, S. L., S. L. Budge, E. Fugate, K. Flanagan, C. Touloumtzis, B. Rood, A. Perez-
Brumer, and S. Leibowitz. 2017. Transactional pathways of transgender identity de-
velopment in transgender and gender nonconforming youth and caregivers from the
Trans Youth Family Study. The International Journal of Transgenderism 18(3):243-263.
Kaufman, C. E., J. Beals, C. M. Mitchell, P. Lemaster, A. Fickenscher, and The Pathways
of Choice and Healthy Ways Project Teams. 2004. Stress, trauma, and risky sexual
behaviour among American Indians in young adulthood. Culture, Health & Sexuality
6(4):301-318.
Kaufman, C. E., J. Desserich, C. K. Big Crow, B. Holy Rock, E. Keane, and C. M. Mitchell.
2007a. Culture, context, and sexual risk among Northern Plains American Indian youth.
Social Science & Medicine (1982) 64(10):2152-2164.
Kaufman, C. E., L. Shelby, D. J. Mosure, J. Marrazzo, D. Wong, L. de Ravello, S. C. Rushing,
V. Warren-Mears, L. Neel, S. J. Eagle, S. Tulloch, F. Romero, S. Patrick, and J. E.
Cheek. 2007b. Within the hidden epidemic: Sexually transmitted diseases and HIV/
AIDS among American Indians and Alaska Natives. Sexually Transmitted Diseases
34(10):767-777.
Kaufman, C. E., C. M. Mitchell, J. Beals, J. A. Desserich, C. Wheeler, E. M. Keane, N. R. Whi-
tesell, A. Sam, and C. Sedey. 2009. Circle of life: Rationale, design, and baseline results
of an HIV prevention intervention among young American Indian adolescents of the
Northern Plains. Prevention Science 11(1):101-112.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 199
Kawsar, M., S. Long, and O. P. Srivastava. 2008. Child sexual abuse and sexually transmitted
infections: Review of joint genitourinary medicine and paediatric examination practice.
International Journal of STD & AIDS 19:349-350.
Keller, L. 2020. Reducing STI cases: Young people deserve better sexual health information
and services. Guttmacher Policy Review 23. https://www.guttmacher.org/gpr/2020/04/
reducing-sti-cases-young-people-deserve-better-sexual-health-information-and-
services (accessed November 16, 2020).
Kenagy, G. P. 2005. Transgender health: Findings from two needs assessment studies in
Philadelphia. Health & Social Work 30(1):19-26.
Kenagy, G. P., and C. M. Hsieh. 2005. The risk less known: Female-to-male transgender
persons’ vulnerability to HIV infection. AIDS Care 17(2):195-207.
Khalili, J., L. B. Leung, and A. L. Diamant. 2015. Finding the perfect doctor: Identifying les-
bian, gay, bisexual, and transgender-competent physicians. American Journal of Public
Health 105(6):1114-1119.
Khan, M. R., J. S. Kaufman, B. W. Pence, B. N. Gaynes, A. A. Adimora, S. S. Weir, and W.
C. Miller. 2009. Depression, sexually transmitted infection, and sexual risk behavior
among young adults in the United States. Archives of Pediatrics & Adolescent Medicine
163(7):644-652.
Khan, M. R., L. Behrend, A. A. Adimora, S. S. Weir, B. L. White, and D. A. Wohl. 2011a. Dis-
solution of primary intimate relationships during incarceration and implications for
post-release HIV transmission. Journal of Urban Health 88(2):365-375.
Khan, M. R., M. W. Epperson, P. Mateu-Gelabert, M. Bolyard, M. Sandoval, and S. R. Fried-
man. 2011b. Incarceration, sex with an STI- or HIV-infected partner, and infection with
an STI or HIV in Bushwick, Brooklyn, NY: A social network perspective. American
Journal of Public Health 101(6):1110-1117.
Khan, M. R., A. T. Berger, B. E. Wells, and C. M. Cleland. 2012. Longitudinal associations
between adolescent alcohol use and adulthood sexual risk behavior and sexually
transmitted infection in the United States: Assessment of differences by race. American
Journal of Public Health 102(5):867-876.
Khanna, A., S. M. Goodreau, D. Wohlfeiler, E. Daar, S. Little, and P. M. Gorbach. 2015. Indi-
vidualized diagnosis interventions can add significant effectiveness in reducing human
immunodeficiency virus incidence among men who have sex with men: Insights from
Southern California. Annals of Epidemiology 25(1):1-6.
Kimball, A., E. Torrone, K. Miele, L. Bachmann, P. Thorpe, H. Weinstock, and V. Bowen.
2020. Missed opportunities for prevention of congenital syphilis—United States, 2018.
Morbidity and Mortality Weekly Report 69:661-665.
Kimerling, R., K. Gima, M. W. Smith, A. Street, and S. Frayne. 2007. The Veterans Health
Administration and military sexual trauma. American Journal of Public Health
97(12):2160-2166.
King, B. A., D. G. Gammon, K. L. Marynak, and T. Rogers. 2018. Electronic cigarette sales in
the United States, 2013-2017. JAMA 320(13):1379-1380.
Kissinger, P., S. Kovacs, C. Anderson-Smits, N. Schmidt, O. Salinas, J. Hembling, A. Beau-
lieu, L. Longfellow, N. Liddon, J. Rice, and M. Shedlin. 2012. Patterns and predictors
of HIV/STI risk among Latino migrant men in a new receiving community. AIDS and
Behavior 16(1):199-213.
Knittel, A. K., and J. Lorvick. 2019. Self-reported sexually-transmitted infections and crimi-
nal justice involvement among women who use drugs. Addictive Behaviors Reports
10:100219.
Knittel, A. K., B. H. Lambdin, M. L. Comfort, A. H. Kral, and J. Lorvick. 2019. Sexual risk
and criminal justice involvement among women who use drugs. AIDS and Behavior
23(12):3366-3374.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
200 SEXUALLY TRANSMITTED INFECTIONS
Kouyoumdjian, F. G., D. Leto, S. John, H. Henein, and S. Bondy. 2012. A systematic review
and meta-analysis of the prevalence of chlamydia, gonorrhoea and syphilis in incarcer-
ated persons. International Journal of STD & AIDS 23(4):248-254.
Krahn, G. L., D. K. Walker, and R. Correa-De-Araujo. 2015. Persons with disabilities as an
unrecognized health disparity population. American Journal of Public Health 105(Suppl
2):S198-S206.
Kralik, J. 2019. “Bathroom bill” legislative tracking. https://www.ncsl.org/research/
education/-bathroom-bill-legislative-tracking635951130.aspx (accessed December 4,
2020).
Krieger, D., C. Abe, A. Pottorff, X. Li, J. Rich, and A. E. Nijhawan. 2019. Sexually transmitted
infections detected during and after incarceration among people with human immu-
nodeficiency virus: Prevalence and implications for screening and prevention. Sexually
Transmitted Diseases 46(9):602-607.
Krüsi, A., K. Pacey, L. Bird, C. Taylor, J. Chettiar, S. Allan, D. Bennett, J. S. Montaner, T. Kerr,
and K. Shannon. 2014. Criminalisation of clients: Reproducing vulnerabilities for vio-
lence and poor health among street-based sex workers in Canada—a qualitative study.
BMJ Open 4(6):e005191.
Kuhns, L. M., M. J. Mimiaga, S. L. Reisner, K. Biello, and R. Garofalo. 2017. Project Lifeskills—
a randomized controlled efficacy trial of a culturally tailored, empowerment-based, and
group-delivered HIV prevention intervention for young transgender women: Study
protocol. BMC Public Health 17(1):713.
Kusunoki, Y., and D. M. Upchurch. 2011. Contraceptive method choice among youth in the
United States: The importance of relationship context. Demography 48(4):1451-1472.
LaFromboise, T. D., and M. Dizon. 2003. American Indian children and adolescents. In
Children of Color: Psychological Interventions with Culturally Diverse Youth, edited by J. T.
Gibbs and L. N. Huang. San Francisco, CA: Jossey-Bass. Pp. 45-90.
LaFromboise, T. D., D. R. Hoyt, L. Oliver, and L. B. Whitbeck. 2006. Family, community,
and school influences on resilience among American Indian adolescents in the upper
midwest. Journal of Community Psychology 34(2):193-209.
Lalor, K., and R. McElvaney. 2010. Child sexual abuse, links to later sexual exploitation/
high-risk sexual behavior, and prevention/treatment programs. Trauma Violence Abuse
11(4):159-177.
Lara, L. A. S., and C. H. N. Abdo. 2016. Age at time of initial sexual intercourse and health
of adolescent girls. Journal of Pediatric and Adolescent Gynecology 29(5):417-423.
Lavoie, F., C. Thibodeau, M. H. Gagné, and M. Hébert. 2010. Buying and selling sex in
Québec adolescents: A study of risk and protective factors. Archives of Sexual Behavior
39(5):1147-1160.
Lawrence, J. 2000. The Indian Health Service and the sterilization of Native American
women. American Indian Quarterly 24(3):400-419.
Lederman, E., A. Blackwell, G. Tomkus, M. Rios, B. Stephen, A. Rivera, and P. Farabaugh.
2020. Opt-out testing pilot for sexually transmitted infections among immigrant detain-
ees at 2 Immigration and Customs Enforcement Health Service Corps–staffed detention
facilities, 2018. Public Health Reports 135(1 Suppl):82S-89S.
Lee, K. C., Q. Ngo-Metzger, T. Wolff, J. Chowdhury, M. L. LeFevre, and D. S. Meyers. 2016.
Sexually transmitted infections: Recommendations from the U.S. Preventive Services
Task Force. American Family Physician 94(11):907-915.
Lee, Y. M., A. Cintron, and S. Kocher. 2014. Factors related to risky sexual behaviors and
effective STI/HIV and pregnancy intervention programs for African American adoles-
cents. Public Health Nursing 31(5):414-427.
Lemoine, J., S. B. Teal, M. Peters, and M. Guiahi. 2017. Motivating factors for dual-method
contraceptive use among adolescents and young women: A qualitative investigation.
Contraception 96(5):352-356.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 201
Lenoir, C. D., N. E. Adler, D. L. Borzekowski, J. M. Tschann, and J. M. Ellen. 2006. What you
don’t know can hurt you: Perceptions of sex-partner concurrency and partner-reported
behavior. Journal of Adolescent Health 38(3):179-185.
Leston, J. D., C. M. Jessen, and B. C. Simons. 2012. Alaska Native and rural youth views
of sexual health: A focus group project on sexually transmitted diseases, HIV/AIDS,
and unplanned pregnancy. American Indian and Alaska Native Mental Health Research
(Online) 19(1):1-14.
Levine, E. C., O. Martinez, B. Mattera, E. Wu, S. Arreola, S. E. Rutledge, B. Newman, L.
Icard, M. Muñoz-Laboy, C. Hausmann-Stabile, S. Welles, S. D. Rhodes, B. M. Dodge, S.
Alfonso, M. I. Fernandez, and A. Carballo-Diéguez. 2018. Child sexual abuse and adult
mental health, sexual risk behaviors, and drinking patterns among Latino men who
have sex with men. Journal of Child Sexual Abuse 27(3):237-253.
Lim, S., T. W. Powell, Q.-L. Xue, V. L. Towe, R. B. Taylor, J. M. Ellen, and S. G. Sherman.
2019. The longitudinal association between perceived powerlessness and sexual risk
behaviors among urban youth: Mediating and moderating effects. Journal of Youth and
Adolescence 48(8):1532-1543.
Lindau, S. T., L. P. Schumm, E. O. Laumann, W. Levinson, C. A. O’Muircheartaigh, and L. J.
Waite. 2007. A study of sexuality and health among older adults in the United States.
New England Journal of Medicine 357(8):762-774.
Lindley, L. L., C. L. Barnett, H. M. Brandt, J. W. Hardin, and M. Burcin. 2008. STDs among
sexually active female college students: Does sexual orientation make a difference?
Perspectives on Sexual and Reproductive Health 40(4):212-217.
London, S., K. Quinn, J. D. Scheidell, B. C. Frueh, and M. R. Khan. 2017. Adverse experiences
in childhood and sexually transmitted infection risk from adolescence into adulthood.
Sexually Transmitted Diseases 44(9):524-532.
Lopez, C. M., D. Solomon, S. D. Boulware, and E. R. Christison-Lagay. 2018. Trends in the
use of puberty blockers among transgender children in the United States. Journal of
Pediatric Endocrinology and Metabolism 31(6):665-670.
Lown, E. A., M. B. Nayak, R. A. Korcha, and T. K. Greenfield. 2011. Child physical and
sexual abuse: A comprehensive look at alcohol consumption patterns, consequences,
and dependence from the National Alcohol Survey. Alcoholism, Clinical and Experimental
Research 35(2):317-325.
Lowry, R., L. Robin, and L. Kann. 2017. Effect of forced sexual intercourse on associations
between early sexual debut and other health risk behaviors among US high school
students. Journal of School Health 87(6):435-447.
Lubin, G. 2012. There are 42 million prostitutes in the world and here’s where they live. https://
www.businessinsider.com/there-are-42-million-prostitutes-in-the-world-and-heres-
where-they-live-2012-1 (accessed January 6, 2021).
Lyons, H. A. 2017. Heterosexual casual sex and STI diagnosis: A latent class analysis. Inter-
national Journal of Sexual Health 29(1):32-47.
Lyons, H. A., W. D. Manning, M. A. Longmore, and P. C. Giordano. 2015. Gender and casual
sexual activity from adolescence to emerging adulthood: Social and life course corre-
lates. Journal of Sex Research 52(5):543-557.
Macapagal, K., D. A. Moskowitz, D. H. Li, A. Carrión, E. Bettin, C. B. Fisher, and B. Mustan-
ski. 2018. Hookup app use, sexual behavior, and sexual health among adolescent men
who have sex with men in the United States. Journal of Adolescent Health 62(6):708-715.
MacPhee, D., J. Fritz, and J. Miller-Heyl. 1996. Ethnic variations in personal social networks
and parenting. Child Development 67(6):3278-3295.
Madkour, A. S., T. Farhat, C. T. Halpern, E. Godeau, and S. N. Gabhainn. 2010. Early ado-
lescent sexual initiation as a problem behavior: A comparative study of five nations.
Journal of Adolescent Health 47(4):389-398.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
202 SEXUALLY TRANSMITTED INFECTIONS
Mandell, D. S., C. C. Eleey, J. A. Cederbaum, E. Noll, M. K. Hutchinson, L. S. Jemmott, and
M. B. Blank. 2008. Sexually transmitted infection among adolescents receiving special
education services. The Journal of School Health 78(7):382-388.
Marcellin, R. L., G. R. Bauer, and A. I. Scheim. 2013. Intersecting impacts of transphobia and
racism on HIV risk among trans persons of colour in Ontario, Canada. Ethnicity and
Inequalities in Health and Social Care 6(4):97-107.
Markham, C. M., S. Craig Rushing, C. Jessen, T. L. Lane, G. Gorman, A. Gaston, T. K. Revels,
J. Torres, J. Williamson, E. R. Baumler, R. C. Addy, M. F. Peskin, and R. Shegog. 2015.
Factors associated with early sexual experience among American Indian and Alaska
Native youth. Journal of Adolescent Health 57(3):334-341.
Marrazzo, J. M. 2004. Barriers to infectious disease care among lesbians. Emerging Infectious
Diseases 10(11):1974-1978.
Marrazzo, J. M., and L. M. Gorgos. 2012. Emerging sexual health issues among women who
have sex with women. Current Infectious Disease Reports 14:204-211.
Marrazzo, J. M., L. A. Koutsky, K. L. Stine, J. M. Kuypers, T. A. Grubert, D. A. Galloway,
N. B. Kiviat, and H. H. Handsfield. 1998. Genital human papillomavirus infection in
women who have sex with women. The Journal of Infectious Diseases 178(6):1604-1609.
Marrazzo, J. M., L. A. Koutsky, N. B. Kiviat, J. M. Kuypers, and K. Stine. 2001. Papanicolaou
test screening and prevalence of genital human papillomavirus among women who
have sex with women. American Journal of Public Health 91(6):947-952.
Marrazzo, J. M., P. Coffey, and A. Bingham. 2005. Sexual practices, risk perception and
knowledge of sexually transmitted disease risk among lesbian and bisexual women.
Perspectives on Sexual Reproductive Health 37(1):6-12.
Marshall, B. D., K. Shannon, T. Kerr, R. Zhang, and E. Wood. 2010. Survival sex work and
increased HIV risk among sexual minority street-involved youth. Journal of Acquired
Immune Deficiency Syndromes 53(5):661-664.
Masel, J., R. G. Deiss, X. Wang, J. L. Sanchez, A. Ganesan, G. E. Macalino, J. C. Gaydos,
M. G. Kortepeter, and B. K. Agan. 2015. Seroprevalence and seroincidence of herpes
simplex virus (2006-2010), syphilis (2006-2010), and vaccine-preventable human papil-
lomavirus subtypes (2000-2010) among U.S. military personnel. Sexually Transmitted
Diseases 42(5):253-258.
Masters, N. T., W. H. George, K. C. Davis, J. Norris, J. R. Heiman, A. J. Jacques-Tiura, A.
K. Gilmore, H. V. Nguyen, K. F. Kajumulo, J. M. Otto, and C. A. Stappenbeck. 2014.
Women’s unprotected sex intentions: Roles of sexual victimization, intoxication, and
partner perception. Journal of Sex Research 51(5):586-598.
Matson, P. A., N. E. Adler, S. G. Millstein, J. M. Tschann, and J. M. Ellen. 2011. Developmental
changes in condom use among urban adolescent females: Influence of partner context.
Journal of Adolescent Health 48(4):386-390.
Matson, P. A., J. D. Fortenberry, S. E. Chung, C. A. Gaydos, and J. M. Ellen. 2018. Weekly
variations in feelings of trust predict incident STI within a prospective cohort of ado-
lescent women from a US city. Sexually Transmitted Infections 94(8):594-597.
Mayer, J. P. 1997. Unintended childbearing, maternal beliefs, and delay of prenatal care.
Birth 24(4):247-252.
Mayer, K. H. 2011. Sexually transmitted diseases in men who have sex with men. Clinical
Infectious Diseases 53(Suppl 3):S79-S83.
Mazul, M. C., T. C. Salm Ward, and E. M. Ngui. 2017. Anatomy of good prenatal care:
Perspectives of low income African-American women on barriers and facilitators to
prenatal care. Journal of Racial and Ethnic Health Disparities 4(1):79-86.
McCabe, S. E., B. T. West, P. Veliz, and C. J. Boyd. 2017. E-cigarette use, cigarette smoking,
dual use, and problem behaviors among U.S. adolescents: Results from a national
survey. Journal of Adolescent Health 61(2):155-162.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 203
McCool-Myers, M., A. Myo, and J. A. Carter. 2019. Barriers to purchasing condoms in a high
HIV/STI-risk urban area. Journal of Community Health 44(4):836-843.
McCree, D. H., and M. Hogben. 2010. The contribution to and context of other sexually trans-
mitted diseases and tuberculosis in the HIV/AIDS epidemic among African Americans.
In African Americans and HIV/AIDS: Understanding and addressing the epidemic, edited by
D. H. McCree, K. Jones, and A. O’Leary. New York: Springer.
McKirnan, D. J., P. A. Vanable, D. G. Ostrow, and B. Hope. 2001. Expectancies of sexual “es-
cape” and sexual risk among drug and alcohol-involved gay and bisexual men. Journal
of Substance Abuse Treatment 13(1-2):137-154.
McMahon, T. R., J. D. Hanson, E. R. Griese, and D. B. Kenyon. 2015. Teen pregnancy preven-
tion program recommendations from urban and reservation Northern Plains American
Indian community members. American Journal of Sexuality Education 10(3):218-241.
McNair, R. 2005. Risks and prevention of sexually transmissible infections among women
who have sex with women. Sexual Health 2(4):209-217.
Medina-Perucha, L., H. Family, J. Scott, S. Chapman, and C. Dack. 2019. Factors associ-
ated with sexual risks and risk of STIs, HIV and other blood-borne viruses among
women using heroin and other drugs: A systematic literature review. AIDS and Behavior
23(1):222-251.
Meier, A., and G. Allen. 2009. Romantic relationships from adolescence to young adulthood:
Evidence from the National Longitudinal Study of Adolescent Health. The Sociological
Quarterly 50(2):308-335.
Menza, T. W., and K. H. Mayer. 2019. HIV and sexually transmitted infection vulnerability
among heterosexual couples involved in the criminal justice system—the corrections
connection. JAMA Network Open 2(3):e191165.
Metrik, J., A. J. Caswell, M. Magill, P. M. Monti, and C. W. Kahler. 2016. Sexual risk behavior
and heavy drinking among weekly marijuana users. Journal of Studies on Alcohol and
Drugs 77(1):104-112.
Miller, V. A., E. Friedrich, J. F. García-España, J. H. Mirman, and C. A. Ford. 2018. Adoles-
cents spending time alone with pediatricians during routine visits: Perspectives of
parents in a primary care clinic. Journal of Adolescent Health 63(3):280-285.
Millett, G. A., J. L. Peterson, S. A. Flores, T. A. Hart, W. L. Jeffries, P. A. Wilson, S. B. Rourke,
C. M. Heilig, J. Elford, K. A. Fenton, and R. S. Remis. 2012. Comparisons of disparities
and risks of HIV infection in Black and other men who have sex with men in Canada,
UK, and USA: A meta-analysis. The Lancet 380(9839):341-348.
Mitchell, C. M., N. R. Whitesell, P. Spicer, J. Beals, C. E. Kaufman, and the Pathways of
Choice Healthy Ways Project Team. 2007. Cumulative risk for early sexual initiation
among American Indian youth: A discrete-time survival analysis. Journal of Research on
Adolescence 17(2):387-412.
Mizuno, Y., C. Borkowf, G. A. Millett, T. Bingham, G. Ayala, and A. Stueve. 2012. Homopho-
bia and racism experienced by Latino men who have sex with men in the United States:
Correlates of exposure and associations with HIV risk behaviors. AIDS and Behavior
16(3):724-735.
Moilanen, K. L., C. A. Markstrom, and E. Jones. 2014. Extracurricular activity availability and
participation and substance use among American Indian adolescents. Journal of Youth
and Adolescence 43(3):454-469.
Moore, P. 2016. Significant gender gap on legalizing prostitution. https://today.yougov.
com/topics/politics/articles-reports/2016/03/10/prostitution (accessed November
19, 2020).
Morgan, E., B. Skaathun, N. Lancki, A. D. Jimenez, J. Ramirez-Valles, R. Bhatia, S. Masiello-
Schuette, N. Benbow, N. Prachand, and J. A. Schneider. 2017. Trends in HIV risk, test-
ing, and treatment among MSM in Chicago 2004-2014: Implications for HIV elimination
planning. Journal of Urban Health 94(5):699-709.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
204 SEXUALLY TRANSMITTED INFECTIONS
Morral, A. R., K. L. Gore, T. L. Schell, B. Bicksler, C. Farris, B. Ghosh-Dastidar, L. H. Jaycox,
D. Kilpatrick, S. Kistler, A. Street, T. Tanielian, and K. M. Williams. 2015. Sexual assault
and sexual harassment in the U.S. military: Volume 2. Estimates for Department of Defense
service members from the 2014 rand military workplace study. Santa Monica, CA: RAND
Corporation.
Mosher, W., T. Bloom, R. Hughes, L. Horton, R. Mojtabai, and J. L. Alhusen. 2017. Dispari-
ties in receipt of family planning services by disability status: New estimates from the
National Survey of Family Growth. Disability and Health Journal 10(3):394-399.
Moss, M. 2010. American Indian health disparities: By the sufferance of Congress? Hamline
Journal of Public Law & Policy 32:59.
Muñoz-Laboy, M., J. Garcia, A. Perry, V. Guilamo-Ramos, J. Lee, and K. V. Lotz. 2013. Social
network factors associated with sexually transmitted infections among formerly incar-
cerated Latino men. International Journal of Sexual Health 25(2):163-168.
Murray, B. L. 2019. Sexual health education for adolescents with developmental disabilities.
Health Education Journal 78(8):1000-1011.
Mustanski, B., A. Van Wagenen, M. Birkett, S. Eyster, and H. L. Corliss. 2014. Identifying sex-
ual orientation health disparities in adolescents: Analysis of pooled data from the Youth
Risk Behavior Survey, 2005 and 2007. American Journal of Public Health 104(2):211-217.
Mustanski, B., B. A. Feinstein, K. Madkins, P. Sullivan, and G. Swann. 2017. Prevalence and
risk factors for rectal and urethral sexually transmitted infections from self-collected
samples among young men who have sex with men participating in the Keep It Up! 2.0
randomized controlled trial. Sexually Transmitted Diseases 44(8):483-488.
Muzny, C. A., C. A. Rivers, E. L. Austin, and J. R. Schwebke. 2013. Trichomonas vaginalis infec-
tion among women receiving gynaecological care at an Alabama HIV clinic. Sexually
Transmitted Infections 89(6):514-518.
Muzny, C. A., A. E. Perez, E. F. Eaton, and M. Agenor. 2018. Psychosocial stressors and sexual
health among southern African American women who have sex with women. LGBT
Health 5(4):234-241.
Naimi, T. S., R. D. Brewer, A. Mokdad, C. Denny, M. K. Serdula, and J. S. Marks. 2003. Binge
drinking among U.S. adults. JAMA 289(1):70-75.
NASEM (National Academies of Sciences, Engineering, and Medicine). 2017. Communities
in action: Pathways to health equity. Washington, DC: The National Academies Press.
NASEM. 2019a. The promise of adolescence: Realizing opportunity for all youth. Washington, DC:
The National Academies Press.
NASEM. 2019b. Vibrant and healthy kids: Aligning science, practice, and policy to advance health
equity. Washington, DC: The National Academies Press.
NASEM. 2020. Understanding the well-being of LGBTQI+ populations. Washington, DC: The
National Academies Press.
NCCHC (National Commission on Correctional Health Care). 2014. STI testing for adolescents
and adults upon admission to correctional facilities. https://www.ncchc.org/STI-testing-
upon-admission (accessed December 23, 2020).
NCCHC. 2020. STI testing for adolescents and adults upon admission to correctional facilities.
https://www.ncchc.org/STI-testing-upon-admission (accessed November 18, 2020).
Nelson, K. M., J. M. Simoni, C. R. Pearson, and K. L. Walters. 2011. “I’ve had unsafe sex so
many times why bother being safe now?”: The role of cognitions in sexual risk among
American Indian/Alaska Native men who have sex with men. Annals of Behavioral
Medicine 42(3):370-380.
Nemoto, T., B. Bödeker, M. Iwamoto, and M. Sakata. 2014. Practices of receptive and in-
sertive anal sex among transgender women in relation to partner types, sociocultural
factors, and background variables. AIDS Care 26(4):434-440.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 205
Nemoto, T., T. Cruz, M. Iwamoto, K. Trocki, U. Perngparn, C. Areesantichai, S. Suzuki, and
C. Roberts. 2016. Examining the sociocultural context of HIV-related risk behaviors
among kathoey (male-to-female transgender women) sex workers in Bangkok, Thai-
land. Journal of the Association of Nurses in AIDS Care 27(2):153-165.
Nerlander, L. M., S. Handanagic, K. L. Hess, A. Lutnick, C. B. Agnew-Brune, B. E. Hoots, S.
L. Braunstein, S. N. Glick, E. Higgins, P. Padgett, S. M. Schuette, D. Broz, W. Ivy, 3rd,
A. Smith, A. Thorson, and G. Paz-Bailey. 2020. HIV prevalence among women who
exchange sex for money or drugs—4 U.S. cities. Journal of Acquired Immune Deficiency
Syndromes 84(4):345-354.
Nesheim, S. R., J. Wiener, L. F. Fitz Harris, M. A. Lampe, and P. J. Weidle. 2017. Brief report:
Estimated incidence of perinatally acquired HIV infection in the United States, 1978-
2013. Journal of Acquired Immune Deficiency Syndromes 76(5):461-464.
Newcomb, M. E., and B. Mustanski. 2010. Internalized homophobia and internalizing mental
health problems: A meta-analytic review. Clinical Psychology Review 30(8):1019-1029.
Newman, L. M., and S. M. Berman. 2008. Epidemiology of STD disparities in African Ameri-
can communities. Sexually Transmitted Diseases 35(12 Suppl):S4-S12.
Noar, S. M. 2006. A 10-year retrospective of research in health mass media campaigns: Where
do we go from here? Journal of Health Communication 11(1):21-42.
Norris, T., P. L. Vines, and E. M. Hoeffell. 2012. 2010 census brief: The American Indian and
Alaska Native population: 2010. Washington, DC: U.S. Census Bureau.
Nowotny, K. M., M. Omori, M. McKenna, and J. Kleinman. 2020. Incarceration rates and in-
cidence of sexually transmitted infections in U.S. counties, 2011-2016. American Journal
of Public Health 110(Suppl 1):S130-S136.
Nusbaum, M. R. H., A. R. Singh, and A. A. Pyles. 2004. Sexual healthcare needs of women
aged 65 and older. Journal of the American Geriatrics Society 52(1):117-122.
OIG (Office of Inspector General). 2011. Access to mental health services at Indian Health Service
and tribal facilities. Washington, DC: Department of Health and Human Services.
Olson-Kennedy, J., P. T. Cohen-Kettenis, B. P. C. Kreukels, H. F. L. Meyer-Bahlburg, R.
Garofalo, W. Meyer, and S. M. Rosenthal. 2016. Research priorities for gender
nonconforming/transgender youth: Gender identity development and biopsychosocial
outcomes. Current Opinion in Endocrinology, Diabetes, and Obesity 23(2):172-179.
Operario, D., T. Nemoto, M. Iwamoto, and T. Moore. 2011. Unprotected sexual behavior
and HIV risk in the context of primary partnerships for transgender women. AIDS and
Behavior 15(3):674-682.
O’Rourke, K., A. Richman, M. Roddy, and M. Custer. 2008. Does pregnancy/paternity inten-
tion predict contraception use? A study among U.S. soldiers who have completed initial
entry training. The Journal of Family Planning and Reproductive Health Care 34(3):165-168.
Oshri, A., J. G. Tubman, and M. L. Burnette. 2012. Childhood maltreatment histories, alco-
hol and other drug use symptoms, and sexual risk behavior in a treatment sample of
adolescents. American Journal of Public Health 102(Suppl 2):S250-S257.
Ott, M. A., A. Katschke, W. Tu, and J. D. Fortenberry. 2011. Longitudinal associations among
relationship factors, partner change, and sexually transmitted infection acquisition in
adolescent women. Sexually Transmitted Diseases 38(3):153-157.
Owen, B. N., R. F. Baggaley, J. Elmes, A. Harvey, Z. Shubber, A. R. Butler, R. Silhol, P. Anton,
B. Shacklett, A. van der Straten, and M. C. Boily. 2020. What proportion of female sex
workers practise anal intercourse and how frequently? A systematic review and meta-
analysis. AIDS and Behavior 24(3):697-713.
Owen, J., and F. D. Fincham. 2011. Effects of gender and psychosocial factors on “friends with
benefits” relationships among young adults. Archives of Sexual Behavior 40(2):311-320.
Owusu-Edusei, K., Jr., and B. A. Chang. 2019. Investigating multiple-reported bacterial sexu-
ally transmitted infection hot spot counties in the United States: Ordered spatial logistic
regression. Sexually Transmitted Diseases 46(12):771-776.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
206 SEXUALLY TRANSMITTED INFECTIONS
Owusu-Edusei, K., Jr., T. L. Gift, H. W. Chesson, and C. K. Kent. 2013. Investigating the
potential public health benefit of jail-based screening and treatment programs for
chlamydia. American Journal of Epidemiology 177(5):463-473.
Palacios, J., and H. P. Kennedy. 2010. Reflections of Native American teen mothers. Journal
of Obstetric, Gynecologic, and Neonatal Nursing 39(4):425-434.
Park, J. N., C. A. Gaydos, R. H. White, M. R. Decker, K. H. A. Footer, N. Galai, B. E. Silber-
zahn, K. Riegger, M. Morris, S. S. Huettner, S. T. Allen, and S. G. Sherman. 2019. Inci-
dence and predictors of chlamydia, gonorrhea and trichomonas among a prospective
cohort of cisgender female sex workers in Baltimore, Maryland. Sexually Transmitted
Diseases 46(12):788-794.
Parmet, W. 2018. Immigration and health care under the Trump administration. In Health
Affairs Blog (January 18).
Patel, D., B. Gillespie, and B. Foxman. 2003. Sexual behavior of older women: Results of a
random-digit-dialing survey of 2,000 women in the United States. Sexually Transmitted
Diseases 30(3):216-220.
Patel, E. U., J. L. White, C. A. Gaydos, T. C. Quinn, S. H. Mehta, and A. A. R. Tobian.
2020. Marijuana use, sexual behaviors, and prevalent sexually transmitted infections
among sexually experienced males and females in the United States: Findings from
the National Health and Nutrition Examination Surveys. Sexually Transmitted Diseases
47(10):672-678.
Patton, G. C., S. M. Sawyer, J. S. Santelli, D. A. Ross, R. Afifi, N. B. Allen, M. Arora, P. Az-
zopardi, W. Baldwin, C. Bonell, R. Kakuma, E. Kennedy, J. Mahon, T. McGovern, A. H.
Mokdad, V. Patel, S. Petroni, N. Reavley, K. Taiwo, J. Waldfogel, D. Wickremarathne, C.
Barroso, Z. Bhutta, A. O. Fatusi, A. Mattoo, J. Diers, J. Fang, J. Ferguson, F. Ssewamala,
and R. M. Viner. 2016. Our future: A Lancet commission on adolescent health and
wellbeing. The Lancet 387(10036):2423-2478.
Patton, R., F. C. Blow, A. S. Bohnert, E. E. Bonar, K. L. Barry, and M. A. Walton. 2014a.
Prevalence and correlates of transactional sex among an urban emergency depart-
ment sample: Exploring substance use and HIV risk. Psychology of Addictive Behaviors
28(2):625-630.
Patton, R. A., R. M. Cunningham, F. C. Blow, M. A. Zimmerman, B. M. Booth, and M. A.
Walton. 2014b. Transactional sex involvement: Exploring risk and promotive factors
among substance-using youth in an urban emergency department. Journal of Studies on
Alcohol and Drugs 75(4):573-579.
Pazol, K., M. R. Kramer, and C. J. Hogue. 2010. Condoms for dual protection: Patterns of
use with highly effective contraceptive methods. Public Health Reports 125(2):208-217.
Pelligrino, N., B. H. Zaitzow, M. Sothern, R. Scribner, and S. Phillippi. 2017. Incarcerated
Black women in the southern USA: A narrative review of STI and HIV risk and implica-
tions for future public health research, practice, and policy. Journal of Racial and Ethnic
Health Disparities 4(1):9-18.
Pereto, A. 2018. Patients over 60? Screen for STIs. https://www.athenahealth.com/knowledge-
hub/clinical-trends/over-60-stis-may-not-be-done-you (accessed January 14, 2021).
Perez-Brumer, A., A. Nunn, E. Hsiang, C. Oldenburg, M. Bender, L. Beauchamps, L. Mena,
and S. MacCarthy. 2018. “We don’t treat your kind”: Assessing HIV health needs ho-
listically among transgender people in Jackson, Mississippi. PLoS One 13(11):e0202389.
Petca, A., A. Borislavschi, M. E. Zvanca, R. C. Petca, F. Sandru, and M. C. Dumitrascu. 2020.
Non-sexual HPV transmission and role of vaccination for a better future (review).
Experimental and Therapeutic Medicine 20(6):186.
Pew Charitable Trusts. 2017. Prison health care costs and quality. https://www.pewtrusts.
org/-/media/assets/2017/10/sfh_prison_health_care_costs_and_quality_final.pdf
(accessed February 15, 2021).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 207
Platt, L., P. Grenfell, R. Meiksin, J. Elmes, S. G. Sherman, T. Sanders, P. Mwangi, and A.-L.
Crago. 2018. Associations between sex work laws and sex workers’ health: A system-
atic review and meta-analysis of quantitative and qualitative studies. PLoS Medicine
15(12):e1002680.
Pooler, J., and M. Srinivasan. 2018. Issue brief: Social determinants of health and the aging
population. https://impaqint.com/sites/default/files/issue-briefs/Issue%20Brief_
SDOHandAgingPopulation_0.pdf (accessed November 19, 2020).
Ports, K. A., D. C. Ford, and M. T. Merrick. 2016. Adverse childhood experiences and sexual
victimization in adulthood. Child Abuse & Neglect 51:313-322.
Poteat, T., S. L. Reisner, and A. Radix. 2014. HIV epidemics among transgender women.
Current Opinion in HIV and AIDS 9(2):168-173.
Poteat, T. C., M. Malik, and C. Beyrer. 2018. Epidemiology of HIV, sexually transmitted
infections, viral hepatitis, and tuberculosis among incarcerated transgender people: A
case of limited data. Epidemiologic Reviews 40(1):27-39.
Pouget, E. R., T. S. Kershaw, L. M. Niccolai, J. R. Ickovics, and K. M. Blankenship. 2010.
Associations of sex ratios and male incarceration rates with multiple opposite-sex
partners: Potential social determinants of HIV/STI transmission. Public Health Reports
125(Suppl 4):70-80.
Powell, R. M., S. L. Parish, M. Mitra, and E. Rosenthal. 2020. Role of family caregivers regard-
ing sexual and reproductive health for women and girls with intellectual disability: A
scoping review. Journal of Intellectual Disability Research 64(2):131-157.
Power, J., R. McNair, and S. Carr. 2009. Absent sexual scripts: Lesbian and bisexual women’s
knowledge, attitudes and action regarding safer sex and sexual health information.
Culture, Health & Sexuality 11(1):67-81.
Power to Decide. 2016. Parent power (October 2016): Survey says. https://powertodecide.
org/what-we-do/information/resource-library/parent-power-october-2016-survey-
says (accessed December 23, 2020).
ProCon.org. n.d. U.S. federal and state prostitution laws and related punishments. https://
prostitution.procon.org/us-federal-and-state-prostitution-laws-and-related-
punishments (accessed December 3, 2020).
Pu, J., B. Chewning, I. D. St Clair, P. K. Kokotailo, J. Lacourt, and D. Wilson. 2013. Protective
factors in American Indian communities and adolescent violence. Maternal and Child
Health Journal 17(7):1199-1207.
Quina, K., L. Harlow, P. Morokoff, G. Burkholder, and P. J. Deiter. 2000. Sexual communi-
cation in relationships: When words speak louder than actions. Sex Roles 42:523-549.
Raiford, J. L., J. H. Herbst, M. Carry, F. A. Browne, I. Doherty, and W. M. Wechsberg. 2014.
Low prospects and high risk: Structural determinants of health associated with sexual
risk among young African American women residing in resource-poor communities in
the south. American Journal of Community Psychology 54(3-4):243-250.
RAINN (Rape, Abuse & Incest National Network). 2020. Children and teens: Statistics. https://
www.rainn.org/statistics/children-and-teens (accessed January 5, 2021).
Rawstron, S. A., K. Bromberg, and M. R. Hammerschlag. 1993. STD in children: Syphilis and
gonorrhoea. Genitourinary Medicine 69(1):66-75.
Reece, M., D. Herbenick, V. Schick, S. A. Sanders, B. Dodge, and J. D. Fortenberry. 2010.
Condom use rates in a national probability sample of males and females ages 14 to 94
in the United States. The Journal of Sexual Medicine 7(Suppl 5):266-276.
Reed, S. J., A. Bangi, N. Sheon, G. W. Harper, J. A. Catania, K. A. Richards, M. M. Dolcini,
and C. B. Boyer. 2012. Influences on sexual partnering among African American adoles-
cents with concurrent sexual relationships. Research in Human Development 9(1):78-101.
Reilly, K. H., A. Neaigus, T. Wendel, D. M. Marshall IV, and H. Hagan. 2014. Correlates
of selling sex among male injection drug users in New York City. Drug and Alcohol
Dependence 144:78-86.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
208 SEXUALLY TRANSMITTED INFECTIONS
Reisner, S. L., and G. R. Murchison. 2016. A global research synthesis of HIV and STI
biobehavioural risks in female-to-male transgender adults. Global Public Health
11(7-8):866-887.
Reisner, S. L., B. Perkovich, and M. J. Mimiaga. 2010. A mixed methods study of the sexual
health needs of New England transmen who have sex with nontransgender men. AIDS
Patient Care and STDs 24(8):501-513.
Reisner, S. L., J. M. White, J. B. Bradford, and M. J. Mimiaga. 2014. Transgender health dis-
parities: Comparing full cohort and nested matched-pair study designs in a community
health center. LGBT Health 1(3):177-184.
Reisner, S. L., R. Vetters, J. M. White, E. L. Cohen, M. LeClerc, S. Zaslow, S. Wolfrum, and
M. J. Mimiaga. 2015. Laboratory-confirmed HIV and sexually transmitted infection
seropositivity and risk behavior among sexually active transgender patients at an
adolescent and young adult urban community health center. AIDS Care 27(8):1031-1036.
Reisner, S. L., A. Radix, and M. B. Deutsch. 2016. Integrated and gender-affirming trans-
gender clinical care and research. Journal of Acquired Immune Deficiency Syndromes 72.
Reisner, S. L., L. Jadwin-Cakmak, L. Sava, S. Liu, and G. W. Harper. 2019. Situated vulner-
abilities, sexual risk, and sexually transmitted infections’ diagnoses in a sample of
transgender youth in the United States. AIDS Patient Care and STDs 33(3):120-130.
Reiter, P. L., and A. L. McRee. 2016. HPV infection among sexual minority women: Does
it matter how sexual orientation is measured? Cancer Epidemiology, Biomarkers, and
Prevention 25(3):559.
Reiter, P. L., and A. L. McRee. 2017. HPV infection among a population-based sample of
sexual minority women from USA. Sexually Transmitted Infections 93(1):25-31.
Richards, J., and A. Mousseau. 2012. Community-based participatory research to improve
preconception health among Northern Plains American Indian adolescent women.
American Indian and Alaska Native Mental Health Research 19(1):154-185.
Rink, E., R. Tricker, and S. M. Harvey. 2007. Onset of sexual intercourse among female
adolescents: The influence of perceptions, depression, and ecological factors. Journal of
Adolescent Health 41(4):398-406.
Rink, E., K. FourStar, and M. P. Anastario. 2017. The relationship between pregnancy preven-
tion and STI/HIV prevention and sexual risk behavior among American Indian men.
The Journal of Rural Health 33(1):50-61.
Ritchwood, T. D., H. Ford, J. DeCoster, M. Sutton, and J. E. Lochman. 2015. Risky sexual
behavior and substance use among adolescents: A meta-analysis. Children and Youth
Services Review 52:74-88.
Rodriguez-Hart, C., R. A. Chitale, R. Rigg, B. Y. Goldstein, P. R. Kerndt, and P. Tavrow. 2012.
Sexually transmitted infection testing of adult film performers: Is disease being missed?
Sexually Transmitted Diseases 39(12):989-994.
Rome, E. S., and E. Miller. 2020. Intimate partner violence in the adolescent. Pediatrics in
Review 41(2):73-80.
Rood, B. A., S. L. Reisner, F. I. Surace, J. A. Puckett, M. R. Maroney, and D. W. Pantalone.
2016. Expecting rejection: Understanding the minority stress experiences of transgender
and gender-nonconforming individuals. Transgender Health 1(1):151-164.
Rosay, A. B. 2016. National Institute of Justice research report: Violence against American Indian
and Alaska Native women and men: 2010 findings from the National Intimate Partner and
Sexual Violence Survey. Washington, DC: Department of Justice.
Rosenbaum, J. E., J. Zenilman, E. Rose, G. Wingood, and R. DiClemente. 2016. Predicting
unprotected sex and unplanned pregnancy among urban African-American adolescent
girls using the theory of gender and power. Journal of Urban Health 93(3):493-510.
Sadler, A. G., M. A. Mengeling, C. H. Syrop, J. C. Torner, and B. M. Booth. 2011. Lifetime
sexual assault and cervical cytologic abnormalities among military women. Journal of
Women’s Health 20(11):1693-1701.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 209
SAHM (Society for Adolescent Health and Medicine). 2014. Sexual and reproductive health
care: A position paper of the Society for Adolescent Health and Medicine. Journal of
Adolescent Health 54(4):491-496.
Sales, J. M., A. Swartzendruber, and A. L. Phillips. 2016. Trauma-informed HIV prevention
and treatment. Current HIV/AIDS Reports 13(6):374-382.
SAMHSA (Substance Abuse and Mental Health Services Administration). 2011. Results from
the 2009 National Survey on Drug Use and Health: Summary of national findings. Rockville,
MD: Substance Abuse and Mental Health Services Administration.
Sanchez, D. M., V. J. Schoenbach, S. M. Harvey, J. T. Warren, A. A. Adimora, C. Poole, P. A.
Leone, and C. R. Agnew. 2016. Association of perceived partner non-monogamy with
prevalent and incident sexual concurrency. Sexually Transmitted Infections 92(4):266-271.
Sander, G., A. Scandurra, A. Kamenska, C. MacNamara, C. Kalpaki, C. F. Bessa, G. N. Laso,
G. Parisi, L. Varley, M. Wolny, M. Moudatsou, N. H. Pontes, P. Mannix-McNamara,
S. Libianchi, and T. Antypas. 2016. Overview of harm reduction in prisons in seven
European countries. Harm Reduction Journal 13(1):28.
Sandfort, T. G., M. Orr, J. S. Hirsch, and J. Santelli. 2008. Long-term health correlates of
timing of sexual debut: Results from a national U.S. study. American Journal of Public
Health 98(1):155-161.
Sangaramoorthy, T., and K. Kroeger. 2013. Mobility, Latino migrants, and the geography
of sex work: Using ethnography in public health assessments. Human Organization
72(3):263-272.
Sawyer, A. N., E. R. Smith, and E. G. Benotsch. 2018. Dating application use and sexual risk
behavior among young adults. Sexuality Research & Social Policy 15(2):183-191.
Sawyer, W., and P. Wagner. 2020. Mass incarceration: The whole pie 2020. Northampton, MA:
Prison Policy Initiative.
Sayegh, M. A., J. D. Fortenberry, M. Shew, and D. P. Orr. 2006. The developmental associa-
tion of relationship quality, hormonal contraceptive choice and condom non-use among
adolescent women. Journal of Adolescent Health 39(3):388-395.
Scarinci, I. C., I. C. Garcés-Palacio, and E. E. Partridge. 2007. An examination of acceptability
of HPV vaccination among African American women and Latina immigrants. Journal
of Women’s Health 16(8):1224-1233.
Schick, V., J. G. Rosenberger, D. Herbenick, and M. Reece. 2012. Sexual behaviour and risk
reduction strategies among a multinational sample of women who have sex with
women. Sexually Transmitted Infections 88(6):407-412.
Schick, V., B. Van Der Pol, B. Dodge, A. Baldwin, and J. D. Fortenberry. 2015. A mixed meth-
ods approach to assess the likelihood of testing for STI using self-collected samples
among behaviourally bisexual women. Sexually Transmitted Infections 91(5):329-333.
Schmid, A., N. R. Leonard, A. S. Ritchie, and M. V. Gwadz. 2015. Assertive communication
in condom negotiation: Insights from late adolescent couples’ subjective ratings of self
and partner. Journal of Adolescent Health 57(1):94-99.
Schmidt, E. K., B. N. Hand, K. N. Simpson, and A. R. Darragh. 2019a. Sexually transmitted
infections in privately insured adults with intellectual and developmental disabilities.
Journal of Comparative Effectiveness Research 8(8):599-606.
Schmidt, R., P. J. Carson, and R. J. Jansen. 2019b. Resurgence of syphilis in the United States:
An assessment of contributing factors. Infectious Diseases 12:1178633719883282.
Schmidt, E. K., C. Brown, and A. Darragh. 2020. Scoping review of sexual health education
interventions for adolescents and young adults with intellectual or developmental dis-
abilities. Sexuality and Disability 38:439-453.
Schneider, J. A., B. Cornwell, D. Ostrow, S. Michaels, P. Schumm, E. O. Laumann, and S.
Friedman. 2013. Network mixing and network influences most linked to HIV infection
and risk behavior in the HIV epidemic among Black men who have sex with men.
American Journal of Public Health 103(1):e28-e36.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
210 SEXUALLY TRANSMITTED INFECTIONS
Schuyler, A., S. Kintzle, C. L. Lucas, H. Moore, and C. Castro. 2017. Military sexual assault
(MSA) among veterans in Southern California: Associations with physical health, psy-
chological health, and risk behaviors. Traumatology 23(3):223.
Senn, T. E., M. P. Carey, and P. A. Vanable. 2008. Childhood and adolescent sexual abuse
and subsequent sexual risk behavior: Evidence from controlled studies, methodological
critique, and suggestions for research. Clinical Psychology Review 28(5):711-735.
Senn, T. E., M. P. Carey, and P. A. Vanable. 2010. The intersection of violence, substance use,
depression, and STDs: Testing of a syndemic pattern among patients attending an ur-
ban STD clinic. Journal of the National Medical Association 102(7):614-620.
Senteio, C., S. W. Collins, R. Jackson, S. Welk, and S. Zhang. 2010. Effective resources sup-
porting healthy sexual behavior in formerly incarcerated persons. American Journal of
Sexuality Education 5(4):362-376.
Seth, P., D. L. Lang, R. J. Diclemente, N. D. Braxton, R. A. Crosby, L. K. Brown, W. Hadley,
and G. R. Donenberg. 2012. Gender differences in sexual risk behaviours and sexually
transmissible infections among adolescents in mental health treatment. Sexual Health
9(3):240-246.
Seth, P., R. J. DiClemente, and A. E. Lovvorn. 2013. State of the evidence: Intimate partner
violence and HIV/STI risk among adolescents. Current HIV Research 11(7):528-535.
Sethi, S., G. Singh, P. Samanta, and M. Sharma. 2012. Mycoplasma genitalium: An emerging
sexually transmitted pathogen. The Indian Journal of Medical Research 136(6):942-955.
Sevelius, J. 2009. “There’s no pamphlet for the kind of sex I have”: HIV-related risk factors
and protective behaviors among transgender men who have sex with nontransgender
men. Journal of the Association of Nurses in AIDS Care 20(5):398-410.
Shafer, M. A., C. B. Boyer, R. A. Shaffer, J. Schachter, S. I. Ito, and S. K. Brodine. 2002. Cor-
relates of sexually transmitted diseases in a young male deployed military population.
Military Medicine 167(6):496-500.
Shannon, C. L., and J. D. Klausner. 2018. The growing epidemic of sexually transmitted infec-
tions in adolescents: A neglected population. Current Opinion in Pediatrics 30(1):137-143.
Shannon, C. L., E. M. Keizur, A. Fehrenbacher, D. Wood-Palmer, W. Ramos, M. Koussa, J.
Fournier, S. J. Lee, D. Patel, W. N. Akabike, S. E. Abdalian, M. J. Rotheram-Borus, and
J. D. Klausner. 2019a. Sexually transmitted infection positivity among adolescents with
or at high-risk for human immunodeficiency virus infection in Los Angeles and New
Orleans. Sexually Transmitted Diseases 46(11):737-742.
Shannon, C. L., M. Koussa, S. J. Lee, J. Fournier, S. E. Abdalian, M. J. Rotheram, and J.
D. Klausner. 2019b. Community-based, point-of-care sexually transmitted infection
screening among high-risk adolescents in Los Angeles and New Orleans: Protocol for
a mixed-methods study. JMIR Research Protocols 8(3):e10795.
Sharma, A., E. Kahle, K. Todd, S. Peitzmeier, and R. Stephenson. 2019. Variations in testing
for HIV and other sexually transmitted infections across gender identity among trans-
gender youth. Transgender Health 4(1):46-57.
Sherman, C. A., S. M. Harvey, and J. Noell. 2005. “Are they still having sex?” STIs and
unintended pregnancy among mid-life women. Journal of Women & Aging 17(3):41-55.
Silver, B. J., R. J. Guy, J. M. Kaldor, M. S. Jamil, and A. R. Rumbold. 2014. Trichomonas vagi-
nalis as a cause of perinatal morbidity: A systematic review and meta-analysis. Sexually
Transmitted Diseases 41(6):369-376.
Silverman, J. G. 2011. Adolescent female sex workers: Invisibility, violence and HIV. Archives
of Disease in Childhood 96(5):478-481.
Singh, D., D. N. Fine, and J. M. Marrazzo. 2011. Chlamydia trachomatis infection among
women reporting sexual activity with women screened in family planning clinics in
the Pacific Northwest, 1997 to 2005. American Journal of Public Health 101(7):1284-1290.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 211
Singh, V., B. Gratzer, P. M. Gorbach, R. A. Crosby, G. Panicker, M. Steinau, R. Amiling, E. R.
Unger, L. E. Markowitz, and E. Meites. 2019. Transgender women have higher human
papillomavirus prevalence than men who have sex with men—two U.S. cities, 2012-
2014. Sexually Transmitted Diseases 46(10):657-662.
Smith, A. 2003. Not an Indian tradition: The sexual colonization of native peoples. Hypatia
18(2):70-85.
Smith, A. 2015. Conquest: Sexual violence and American Indian genocide. Durham, NC: Duke
University Press.
Smith, A. M., J. A. Ferris, J. M. Simpson, J. Shelley, M. K. Pitts, and J. Richters. 2010. Cannabis
use and sexual health. The Journal of Sexual Medicine 7(2 Pt 1):787-793.
Smith, J. M., A. Z. Uvin, A. Macmadu, and J. D. Rich. 2017. Epidemiology and treatment of
hepatitis B in prisoners. Current Hepatology Reports 16(3):178-183.
Smith, K. P., and N. A. Christakis. 2009. Association between widowhood and risk of diag-
nosis with a sexually transmitted infection in older adults. American Journal of Public
Health 99(11):2055-2062.
Smith, L. W., B. Liu, L. Degenhardt, J. Richters, G. Patton, H. Wand, D. Cross, J. S. Hocking,
S. R. Skinner, S. Cooper, C. Lumby, J. M. Kaldor, and R. Guy. 2016. Is sexual content in
new media linked to sexual risk behaviour in young people? A systematic review and
meta-analysis. Sexual Health 13(6):501-515.
Smith, T. D., S. R. Raman, S. Madigan, J. Waldman, and M. Shouldice. 2018. Anogenital
findings in 3569 pediatric examinations for sexual abuse/assault. Journal of Pediatric
and Adolescent Gynecology 31(2):79-83.
Sneed, C. D. 2009. Sexual risk behavior among early initiators of sexual intercourse. AIDS
Care 21(11):1395-1400.
Solomon, M. M., K. H. Mayer, D. V. Glidden, A. Y. Liu, V. M. McMahan, J. V. Guanira, S.
Chariyalertsak, T. Fernandez, and R. M. Grant. 2014. Syphilis predicts HIV incidence
among men and transgender women who have sex with men in a preexposure prophy-
laxis trial. Clinical Infectious Diseases 59(7):1020-1026.
Solomon, R. 2020. Racism and its effect on cannabis research. Cannabis and Cannabinoid
Research 5(1):2-5.
Spaulding, A. C., J. Miller, B. G. Trigg, P. Braverman, T. Lincoln, P. N. Reams, M. Staples-
Horne, A. Sumbry, D. Rice, and C. L. Satterwhite. 2013. Screening for sexually trans-
mitted diseases in short-term correctional institutions: Summary of evidence reviewed
for the 2010 Centers for Disease Control and Prevention sexually transmitted diseases
treatment guidelines. Sexually Transmitted Diseases 40(9):679-684.
Spaulding, A. C., T. L. Lemon, and M. So. 2018. Measuring correctional experience to inform
development of HIV, sexually transmitted infection, and substance use interventions
for incarcerated Black men who have sex with men. American Journal of Public Health
108(S4):S237-S239.
Sridhar, S., R. Cornish, and S. Fazel. 2018. The costs of healthcare in prison and custody:
Systematic review of current estimates and proposed guidelines for future reporting.
Frontiers in Psychiatry 9:716.
Stahlman, S., and A. A. Oetting. 2017. Sexually transmitted infections, active component,
U.S. armed forces, 2007-2016. Medical Surveillance Monthly Report 24(9):15-22.
Stahlman, S., M. Javanbakht, S. Cochran, A. B. Hamilton, S. Shoptaw, and P. M. Gorbach.
2014. Self-reported sexually transmitted infections and sexual risk behaviors in the U.S.
military: How sex influences risk. Sexually Transmitted Diseases 41(6):359-364.
Stahlman, S., M. Javanbakht, S. Cochran, A. B. Hamilton, S. Shoptaw, and P. M. Gorbach.
2015. Mental health and substance use factors associated with unwanted sexual contact
among U.S. active duty service women. Journal of Traumatic Stress 28(3):167-173.
Stahlman, S., N. Seliga, and A. A. Oetting. 2019. Sexually transmitted infections, active
component, US armed forces, 2010-2018. Medical Surveillance Monthly Report 26(3):2-10.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
212 SEXUALLY TRANSMITTED INFECTIONS
Stahre, M. A., R. D. Brewer, V. P. Fonseca, and T. S. Naimi. 2009. Binge drinking among U.S.
active-duty military personnel. American Journal of Preventative Medicine 36(3):208-217.
Stall, R., and J. Catania. 1994. AIDS risk behaviors among late middle-aged and elderly amer-
icans. The National AIDS Behavioral Surveys. Archives of Internal Medicine 154(1):57-63.
Staras, S. A., R. L. Cook, and D. B. Clark. 2009. Sexual partner characteristics and sexually
transmitted diseases among adolescents and young adults. Sexually Transmitted Diseases
36(4):232-238.
Stein, C. R., J. S. Kaufman, C. A. Ford, P. J. Feldblum, P. A. Leone, and W. C. Miller. 2008.
Partner age difference and prevalence of chlamydial infection among young adult
women. Sexually Transmitted Diseases 35(5):447-452.
Steinberg, L. 2005. Cognitive and affective development in adolescence. Trends in Cognitive
Sciences 9(2):69-74.
Steiner, R. J., N. Liddon, A. L. Swartzendruber, C. N. Rasberry, and J. M. Sales. 2016.
Long-acting reversible contraception and condom use among female U.S. high school
students: Implications for sexually transmitted infection prevention. JAMA Pediatrics
170(5):428-434.
Stenger, M. R., S. Baral, S. Stahlman, D. Wohlfeiler, J. E. Barton, and T. Peterman. 2017. As
through a glass, darkly: The future of sexually transmissible infections among gay,
bisexual and other men who have sex with men. Sexual Health 14(1):18-27.
Stephenson, R., E. Riley, E. Rogers, N. Suarez, N. Metheny, J. Senda, K. M. Saylor, and J. A.
Bauermeister. 2017. The sexual health of transgender men: A scoping review. Journal of
Sex Research 54(4-5):424-445.
Stidham, R. A., E. C. Garges, and S. A. Knapp. 2015. Expedited partner therapy to combat
Neisseria gonorrhoeae and Chlamydia trachomatis in military populations: Can we apply
this best practice? Military Medicine 180(8):876-881.
Stieglitz, K. A. 2010. Development, risk, and resilience of transgender youth. Journal of the
Association of Nurses in AIDS Care 21(3):192-206.
Stoner, M. C. D., D. F. Haley, C. E. Golin, A. A. Adimora, and A. Pettifor. 2019. The relation-
ship between economic deprivation, housing instability and transactional sex among
women in North Carolina (HPTN 064). AIDS and Behavior 23(11):2946-2955.
Strauss, J. L., C. E. Marx, J. C. Weitlauf, K. M. Stechuchak, K. Straits-Tröster, A. W. Worjoloh,
C. B. Sherrod, M. K. Olsen, M. I. Butterfield, and P. S. Calhoun. 2011. Is military sexual
trauma associated with trading sex among women veterans seeking outpatient mental
health care? Journal of Trauma & Dissociation 12(3):290-304.
Suris, A., and L. Lind. 2008. Military sexual trauma: A review of prevalence and associated
health consequences in veterans. Trauma Violence Abuse 9(4):250-269.
Sutherland, M. A. 2011. Examining mediators of child sexual abuse and sexually transmitted
infections. Nursing Research 60(2):139-147.
Swan, H., and D. J. O’Connell. 2012. The impact of intimate partner violence on women’s
condom negotiation efficacy. Journal of Interpersonal Violence 27(4):775-792.
Swartz, J. J., J. Hainmueller, D. Lawrence, and M. I. Rodriguez. 2017. Expanding prenatal
care to unauthorized immigrant women and the effects on infant health. Obstetrics and
Gynecology 130(5):938-945.
Swartzendruber, A., J. L. Brown, J. M. Sales, C. C. Murray, and R. J. DiClemente. 2012. Sexu-
ally transmitted infections, sexual risk behavior, and intimate partner violence among
African American adolescent females with a male sex partner recently released from
incarceration. Journal of Adolescent Health 51(2):156-163.
Swartzendruber, A., J. M. Zenilman, L. M. Niccolai, T. S. Kershaw, J. L. Brown, R. J. Dicle-
mente, and J. M. Sales. 2013. It takes 2: Partner attributes associated with sexually
transmitted infections among adolescents. Sexually Transmitted Diseases 40(5):372-378.
Syed, S. T., B. S. Gerber, and L. K. Sharp. 2013. Traveling towards disease: Transportation
barriers to health care access. Journal of Community Health 38(5):976-993.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 213
Syme, M. L., T. J. Cohn, and J. Barnack-Tavlaris. 2017. A comparison of actual and perceived
sexual risk among older adults. Journal of Sex Research 54(2):149-160.
Talashek, M., K. Norr, and B. Dancy. 2003. Building teen power for sexual health. Journal of
Transcultural Nursing 14:207-216.
Taylor, A. W., S. R. Nesheim, X. Zhang, R. Song, L. F. FitzHarris, M. A. Lampe, P. J. Weidle,
and P. Sweeney. 2017. Estimated perinatal HIV infection among infants born in the
United States, 2002-2013. JAMA Pediatrics 171(5):435-442.
Taylor, M. M., B. Reilley, S. Tulloch, M. Winscott, A. Dunnigan, M. Russell, and J. T. Redd.
2011. Identifying opportunities for chlamydia screening among American Indian wom-
en. Sexually Transmitted Diseases 38(10):947-948.
Tedeschi, S. K., L. E. Bonney, R. Manalo, K. H. Mayer, S. Shepardson, J. D. Rich, and M. A.
Lally. 2007. Vaccination in juvenile correctional facilities: State practices, hepatitis B,
and the impact on anticipated sexually transmitted infection vaccines. Public Health
Reports 122(1):44-48.
Teitelman, A. M., S. J. Ratcliffe, M. M. Morales-Aleman, and C. M. Sullivan. 2008. Sexual
relationship power, intimate partner violence, and condom use among minority urban
girls. Journal of Interpersonal Violence 23(12):1694-1712.
Teitelman, A. M., J. Tennille, J. M. Bohinski, L. S. Jemmott, and J. B. Jemmott, 3rd. 2011.
Unwanted unprotected sex: Condom coercion by male partners and self-silencing of
condom negotiation among adolescent girls. Advances in Nursing Science 34(3):243-259.
The Lancet. 2018. Congenital syphilis in the USA. The Lancet 392(10154):1168.
The White House. 2021. Executive order on preventing and combating discrimination on the
basis of gender identity or sexual orientation. https://www.whitehouse.gov/briefing-
room/presidential-actions/2021/01/20/executive-order-preventing-and-combating-
discrimination-on-basis-of-gender-identity-or-sexual-orientation (accessed February
4, 2021).
Thomas, A. G., S. K. Brodine, R. Shaffer, M. A. Shafer, C. B. Boyer, S. Putnam, and J.
Schachter. 2001. Chlamydial infection and unplanned pregnancy in women with ready
access to health care. Obstetrics and Gynocology 98(6):1117-1123.
Thomas, J. C., B. A. Levandowski, M. R. Isler, E. Torrone, and G. Wilson. 2008. Incarcera-
tion and sexually transmitted infections: A neighborhood perspective. Journal of Urban
Health 85(1):90-99.
Thomason, A., N. Capps, L. Lefler, and G. Richard-Davis. 2015. Factors affecting gynecologic
and sexual assessment in older women: A lesson for primary care providers. Healthcare
(Basel, Switzerland) 3(3):683-694.
Thompson, J. C., T. C. Kao, and R. J. Thomas. 2005. The relationship between alcohol
use and risk-taking sexual behaviors in a large behavioral study. Preventive Medicine
41(1):247-252.
Thompson, R., T. Lewis, E. C. Neilson, D. J. English, A. J. Litrownik, B. Margolis, L. Proctor,
and H. Dubowitz. 2017. Child maltreatment and risky sexual behavior. Child Maltreat-
ment 22(1):69-78.
Tingey, L., R. Strom, R. Hastings, A. Parker, A. Barlow, A. Rompalo, and C. Gaydos. 2015.
Self-administered sample collection for screening of sexually transmitted infection
among reservation-based American Indian youth. International Journal of STD & AIDS
26(9):661-666.
Tingey, L., M. F. Cwik, S. Rosenstock, N. Goklish, F. Larzelere-Hinton, A. Lee, R. Suttle, M.
Alchesay, K. Massey, and A. Barlow. 2016. Risk and protective factors for heavy binge
alcohol use among American Indian adolescents utilizing emergency health services.
American Journal of Drug and Alcohol Abuse 42(6):715-725.
Tingey, L., R. Chambers, N. Goklish, F. Larzelere, A. Lee, R. Suttle, S. Rosenstock, K. Lake,
and A. Barlow. 2017a. Rigorous evaluation of a pregnancy prevention program for
American Indian youth and adolescents: Study protocol for a randomized controlled
trial. Trials 18(1):89.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
214 SEXUALLY TRANSMITTED INFECTIONS
Tingey, L., R. Chambers, S. Rosenstock, A. Lee, N. Goklish, and F. Larzelere. 2017b. The im-
pact of a sexual and reproductive health intervention for American Indian adolescents
on predictors of condom use intention. Journal of Adolescent Health 60(3):284-291.
Tingey, L., M. Cwik, R. Chambers, N. Goklish, F. Larzelere-Hinton, R. Suttle, A. Lee, M. Al-
chesay, A. Parker, and A. Barlow. 2017c. Motivators and influences on American Indian
adolescent alcohol use and binge behavior: A qualitative exploration. Journal of Child &
Adolescent Substance Abuse 26(1):75-85.
Tingey, L., R. Chambers, S. Rosenstock, F. Larzelere, N. Goklish, A. Lee, and A. Rompalo.
2018. Risk and protective factors associated with lifetime sexual experience among rural,
reservation-based American Indian youth. Journal of Primary Prevention 39(4):401-420.
Tingey, L., C. Sutcliffe, R. Chambers, H. Patel, A. Lee, S. Lee, L. Melgar, A. Slimp, A. Rom-
palo, M. Craig, and C. Gaydos. 2019. Protecting our future generation: Study protocol
for a randomized controlled trial evaluating a sexual health self-care intervention with
Native American youth and young adults. BMC Public Health 19(1):1614.
Todd, N., and A. Black. 2020. Contraception for adolescents. Journal of Clinical Research in
Pediatric Endocrinology 12(Suppl 1):28-40.
Tohme, R. A., and S. D. Holmberg. 2012. Transmission of hepatitis C virus infection through
tattooing and piercing: A critical review. Clinical Infectious Diseases 54(8):1167-1178.
Tolman, D. L., and S. I. McClelland. 2011. Normative sexuality development in adolescence:
A decade in review, 2000-2009. Journal of Research on Adolescence 21(1):242-255.
Trivedi, S., C. Williams, E. Torrone, and S. Kidd. 2019. National trends and reported risk fac-
tors among pregnant women with syphilis in the United States, 2012-2016. Obstetrics
and Gynocology 133(1):27-32.
Tucker, J. D., S. W. Chang, and J. P. Tulsky. 2007. The catch 22 of condoms in U.S. correctional
facilities. BMC Public Health 7:296.
Tucker, J. S., G. W. Ryan, D. Golinelli, B. Ewing, S. L. Wenzel, D. P. Kennedy, H. D. Green,
Jr., and A. Zhou. 2012. Substance use and other risk factors for unprotected sex: Results
from an event-based study of homeless youth. AIDS and Behavior 16(6):1699-1707.
Tuddenham, S. A., K. R. Page, P. Chaulk, E. B. Lobe, and K. G. Ghanem. 2017. Patients fifty
years and older attending two sexually transmitted disease clinics in Baltimore, Mary-
land. International Journal of STD & AIDS 28(4):330-344.
Turchik, J. A., J. Pavao, D. Nazarian, S. Iqbal, C. McLean, and R. Kimerling. 2012. Sexually
transmitted infections and sexual dysfunctions among newly returned veterans with
and without military sexual trauma. International Journal of Sexual Health 24(1):45-59.
Ueda, P., C. H. Mercer, C. Ghaznavi, and D. Herbenick. 2020. Trends in frequency of sexual
activity and number of sexual partners among adults aged 18 to 44 years in the U.S.,
2000-2018. JAMA Network Open 3(6):e203833.
Unemo, M., H. S. Seifert, E. W. Hook, 3rd, S. Hawkes, F. Ndowa, and J. R. Dillon. 2019.
Gonorrhoea. Nature Reviews Disease Primers 5(1):79.
Upchurch, D. M., W. M. Mason, Y. Kusunoki, and M. J. Kriechbaum. 2004. Social and be-
havioral determinants of self-reported STD among adolescents. Perspectives on Sexual
Reproductive Health 36(6):276-287.
Urban Indian Health Institute. n.d. Urban Indian Health. https://www.uihi.org/urban-
indian-health (accessed November 19, 2020).
Vagi, K. J., E. O’Malley Olsen, K. C. Basile, and A. M. Vivolo-Kantor. 2015. Teen dating vio-
lence (physical and sexual) among U.S. high school students: Findings from the 2013
National Youth Risk Behavior Survey. JAMA Pediatrics 169(5):474-482.
Valverde, E. E., T. Painter, J. D. Heffelfinger, J. D. Schulden, P. Chavez, and E. A. DiNenno.
2015. Migration patterns and characteristics of sexual partners associated with unpro-
tected sexual intercourse among Hispanic immigrant and migrant women in the United
States. Journal of Immigrant and Minority Health 17(6):1826-1833.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 215
van Hoorn, J., E. M. McCormick, C. R. Rogers, S. L. Ivory, and E. H. Telzer. 2018. Differential
effects of parent and peer presence on neural correlates of risk taking in adolescence.
Social Cognitive and Affective Neuroscience 13(9):945-955.
Vasilenko, S. A., and S. T. Lanza. 2014. Predictors of multiple sexual partners from adoles-
cence through young adulthood. Journal of Adolescent Health 55(4):491-497.
Vasilenko, S. A., D. A. Kreager, and E. S. Lefkowitz. 2015. Gender, contraceptive attitudes,
and condom use in adolescent romantic relationships: A dyadic approach. Journal of
Research on Adolescence 25(1):51-62.
Vasilenko, S. A., K. C. Kugler, and S. T. Lanza. 2016. Latent classes of adolescent sexual and
romantic relationship experiences: Implications for adult sexual health and relationship
outcomes. Journal of Sex Research 53(7):742-753.
Verhaegh-Haasnoot, A., N. H. Dukers-Muijrers, and C. J. Hoebe. 2015. High burden of STI
and HIV in male sex workers working as Internet escorts for men in an observational
study: A hidden key population compared with female sex workers and other men who
have sex with men. BMC Infectious Diseases 15:291.
Vermund, S. H., T. Alexander-Rodriguez, S. Macleod, and K. F. Kelley. 1990. History of
sexual abuse in incarcerated adolescents with gonorrhea or syphilis. Journal of Adoles-
cent Health Care 11(5):449-452.
Voisin, D. R., L. F. Salazar, R. Crosby, R. J. DiClemente, W. L. Yarber, and M. Staples-Horne.
2004. The association between gang involvement and sexual behaviours among de-
tained adolescent males. Sexually Transmitted Infections 80(6):440-442.
von Ranson, K., S. Rosenthal, F. Biro, L. Lewis, and P. Succop. 2000. Longitudinal risk of STD
acquisition in adolescent girls using a generalized estimating equations model. Journal
of Pediatric and Adolescent Gynecology 13(2):87.
von Sadovszky, V., N. Ryan-Wenger, S. Germann, M. Evans, and C. Fortney. 2008. Army
women’s reasons for condom use and nonuse. Women’s Health Issues 18(3):174-180.
Vrazo, A. C., J. Firth, A. Amzel, R. Sedillo, J. Ryan, and B. R. Phelps. 2018. Interventions to
significantly improve service uptake and retention of HIV-positive pregnant women
and HIV-exposed infants along the prevention of mother-to-child transmission con-
tinuum of care: Systematic review. Tropical Medicine & International Health 23(2):136-148.
Walker, F. J., E. Llata, M. Doshani, M. M. Taylor, J. Bertolli, H. S. Weinstock, and H. I. Hall.
2015. HIV, chlamydia, gonorrhea, and primary and secondary syphilis among Ameri-
can Indians and Alaska Natives within Indian health service areas in the United States,
2007-2010. Journal of Community Health 40(3):484-492.
Walsh-Buhi, E. R., and H. L. Helmy. 2018. Trends in long-acting reversible contraceptive
(LARC) use, LARC use predictors, and dual-method use among a national sample of
college women. Journal of American College Health 66(4):225-236.
Walters, F. P., and S. H. Gray. 2018. Addressing sexual and reproductive health in adolescents
and young adults with intellectual and developmental disabilities. Current Opinion in
Pediatrics 30(4):451-458.
Wang, A.-L., Y.-P. Qiao, L.-H. Wang, L.-W. Fang, F. Wang, X. Jin, J. Qiu, X.-Y. Wang, Q. Wang,
J.-L. Wu, S. H. Vermund, and L. Song. 2015. Integrated prevention of mother-to-child
transmission for human immunodeficiency virus, syphilis and hepatitis B virus in
China. Bulletin of the World Health Organization 93(1):52-56.
Warne, D., and L. B. Frizzell. 2014. American Indian health policy: Historical trends and
contemporary issues. American Journal of Public Health 104(Suppl 3):S263-S267.
Wheeler, R., V. A. Earnshaw, T. Kershaw, and J. R. Ickovics. 2012. Postpartum sexually
transmitted disease: Refining our understanding of the population at risk. Sexually
Transmitted Diseases 39(7):509-513.
Whitbeck, L. B., and B. E. Armenta. 2015. Patterns of substance use initiation among Indig-
enous adolescents. Addictive Behaviors 45:172-179.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
216 SEXUALLY TRANSMITTED INFECTIONS
White Hughto, J. M., K. B. Biello, S. L. Reisner, A. Perez-Brumer, K. J. Heflin, and M. J.
Mimiaga. 2016. Health risk behaviors in a representative sample of bisexual and hetero-
sexual female high school students in Massachusetts. Journal of School Health 86(1):61-71.
WHO (World Health Organization). 2002. Towards a common language for functioning, disability
and health. Geneva, Switzerland: World Health Organization.
WHO. 2018. Disability and health. https://www.who.int/news-room/fact-sheets/detail/
disability-and-health (accessed November 19, 2020).
Widman, L., S. Choukas-Bradley, S. W. Helms, C. E. Golin, and M. J. Prinstein. 2014. Sexual
communication between early adolescents and their dating partners, parents, and best
friends. Journal of Sex Research 51(7):731-741.
Widman, L., S. Choukas-Bradley, S. M. Noar, J. Nesi, and K. Garrett. 2016. Parent-adolescent
sexual communication and adolescent safer sex behavior: A meta-analysis. JAMA Pe-
diatrics 170(1):52-61.
Wiehe, S. E., M. B. Rosenman, M. C. Aalsma, M. L. Scanlon, and J. D. Fortenberry. 2015.
Epidemiology of sexually transmitted infections among offenders following arrest or
incarceration. American Journal of Public Health 105(12):e26-e32.
Wildsmith, E., J. Manlove, and N. Steward-Streng. 2015. Relationship characteristics and
contraceptive use among dating and cohabiting young adult couples. Perspectives on
Sexual Reproductive Health 47(1):27-36.
Williams, R. L., and J. D. Fortenberry. 2013. Dual use of long-acting reversible contracep-
tives and condoms among adolescents. Journal of Adolescent Health 52(4 Suppl):S29-S34.
Wilson, N., and J. L. Cadet. 2009. Comorbid mood, psychosis, and marijuana abuse disor-
ders: A theoretical review. Journal of Addictive Diseases 28(4):309-319.
Wingood, G. M., and R. J. DiClemente. 1998. Partner influences and gender-related factors
associated with noncondom use among young adult African American women. Ameri-
can Journal of Community Psychology 26(1):29-51.
Winscott, M., M. Taylor, and K. Kenney. 2010. Sexually transmitted diseases among Ameri-
can Indians in Arizona: An important public health disparity. Public Health Reports
125(Suppl 4):51-60.
Wirtz, A. L., P. T. Yeh, N. L. Flath, C. Beyrer, and K. Dolan. 2018. HIV and viral hepatitis
among imprisoned key populations. Epidemiologic Reviews 40(1):12-26.
Wise, A., T. Finlayson, L. Nerlander, C. Sionean, G. Paz-Bailey, and for the NHBS Study
Group. 2017. Incarceration, sexual risk-related behaviors, and HIV infection among
women at increased risk of HIV infection, 20 United States cities. Journal of Acquired
Immune Deficiency Syndromes 75.
Wolfe, M. I., F. Xu, P. Patel, M. O’Cain, J. A. Schillinger, M. E. St Louis, and L. Finelli. 2001. An
outbreak of syphilis in Alabama prisons: Correctional health policy and communicable
disease control. American Journal of Public Health 91(8):1220-1225.
Wood, S. M., C. Salas-Humara, and N. L. Dowshen. 2016. Human immunodeficiency virus,
other sexually transmitted infections, and sexual and reproductive health in lesbian,
gay, bisexual, transgender youth. Pediatric Clinics of North America 63(6):1027-1055.
Woods-Jaeger, B. A., A. Sparks, K. Turner, T. Griffith, M. Jackson, and A. F. Lightfoot. 2013.
Exploring the social and community context of African American adolescents’ HIV
vulnerability. Qualitative Health Research, 23(11):1541-1550.
Workowski, K. A., and G. A. Bolan. 2015. Sexually transmitted diseases treatment guidelines,
2015. MMWR Recommendations and Reports 64(RR-03):1-137.
Wortley, P. M., M. L. Lindegren, and P. L. Fleming. 2001. Successful implementation of
perinatal HIV prevention guidelines. A multistate surveillance evaluation. MMWR
Recommendations and Reports 50(RR-6):17-28.
Wu, L. T., C. L. Ringwalt, A. A. Patkar, R. L. Hubbard, and D. G. Blazer. 2009. Association
of MDMA/ecstasy and other substance use with self-reported sexually transmitted
diseases among college-aged adults: A national study. Public Health 123(8):557-564.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PRIORITY POPULATIONS 217
Xavier, J. M., M. Bobbin, B. Singer, and E. Budd. 2005. Needs assessment of transgen-
dered people of color living in Washington, DC. International Journal of Transgenderism
8(2-3):31-47.
Xu, F., M. Sternberg, and L. Markowitz. 2010. Women who have sex with women in the
United States: Prevalence, sexual behavior and prevalence of herpes simplex virus type
2 infection-results from National Health and Nutrition Examination Survey 2001-2006.
Sexually Transmitted Diseases 37:407-413.
Xu, J., L. Yu, B. Fu, D. Zhao, and F. Liu. 2018. Influence of different delivery modes on the
clinical characteristics of Chlamydia trachomatis pneumonia. European Journal of Pediatrics
177(8):1255-1260.
Young, S. D., and A. H. Jordan. 2013. The influence of social networking photos on social
norms and sexual health behaviors. Cyberpsychology, Behavior, and Social Networking
16(4):243-247.
Zimmer-Gembeck, M. J., and M. Helfand. 2008. Ten years of longitudinal research on U.S.
adolescent sexual behavior: Developmental correlates of sexual intercourse, and the
importance of age, gender and ethnic background. Developmental Review 28(2):153-224.
Zuckerman, S., J. Haley, Y. Roubideaux, and M. Lillie-Blanton. 2004. Health service access,
use, and insurance coverage among American Indians/Alaska Natives and whites:
What role does the Indian Health Service play? American Journal of Public Health
94(1):53-59.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
STI Economics, Public-Sector
Financing, and Program Policy
Chapter Contents
Introduction
Role of Government in Prevention and Control of STIs
• Cooperative Federalism and Public Health
Overview of Federal Programs
• Background
• Overview of Federally Funded Public Health Programs
State and Local Efforts
Economic Burden of STIs
Conclusions
INTRODUCTION
To offer recommendations for future public health programs, policy,
and research, it is important to understand the historical experience and
current status of public efforts to respond to sexually transmitted infec-
tions (STIs). Several findings emerged from the committee’s review of
219
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
220 SEXUALLY TRANSMITTED INFECTIONS
STI prevention and control efforts in the United States (see Box 4-1). First,
despite evidence that the burden of STIs has potentially increased, federal
funding to address STIs has remained stagnant. In addition, state funding
as a share of total funding has decreased, reflecting a decline in funding
at the state level in absolute terms. Finally, current methods and resources
for tracking progress in decreasing the rates of STIs are inadequate or
nonexistent.
These findings reflect a lack of programmatic coordination in how
the United States addresses STIs at the federal, state, and local levels and
within its health care and public health systems. A highly fragmented
patchwork of programs has resulted in a lack of timely and consistent
data on overall funding investments, creating difficulty in tracking prog-
ress of and investment in prevention and control efforts over time. In
addition, progress in other outcomes has also been difficult to measure.
For example, recent Centers for Disease Control and Prevention (CDC)
studies estimated the prevalence and incidence of many STIs and their
associated direct medical costs in 2018 (Chesson et al., 2017; Kreisel et
al., 2021). This was the first update to both estimates in the past 10 years.
Because of data limitations and changes in methodology, however, these
estimates cannot be compared over time. Thus, whether the investments
in STI programs and research are truly providing value and decreasing
the burden of STIs is difficult to ascertain.
Finally, the fragmentation of U.S. efforts has resulted in a lack of
information on how control and prevention efforts are prioritized and
measured within the federal government and by state and local pub-
lic health departments. If measuring and quantifying change signal the
importance of progress toward the intended outcomes, then the inability
BOX 4-1
Chapter Findings
• Despite evidence that the burden of sexually transmitted infections (STIs) has
increased, federal funding to address STIs has remained stagnant.
• State funding as a share of total funding has decreased, reflecting a decline in
funding at the state level in absolute terms.
• Current methods and resources for tracking progress in decreasing the rates
of STIs are inadequate or nonexistent.
• In addition to fragmented funding, the quality of local STI programs is further
dependent on local leadership and academic affiliations. As a result of this
patchwork of resources, the quality of local STI programs varies greatly.
• Current data on federal and state investments and public-sector use of STI
funds are not available for timely accountability and programmatic oversight.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
STI ECONOMICS, PUBLIC-SECTOR FINANCING, AND PROGRAM POLICY 221
or unwillingness to measure change reflects a lack of importance or pri-
oritization and will considerably hinder progress.
This chapter describes current federal and state programs that finance
and deliver STI screening, prevention, and treatment services and sup-
port STI research and provides an overview of the economic burden of
STIs in the United States. The committee does not offer specific funding
recommendations as it was beyond the scope of its work; however, the
chapter points to funding barriers and opportunities for STI prevention
and control.
ROLE OF GOVERNMENT IN PREVENTION
AND CONTROL OF STIs
An important starting point to understanding the legal and opera-
tional underpinnings of how the current system addresses STIs is to
examine which level of government is responsible for STIs and pub-
lic health and how the leadership and financing for STI programs has
evolved. In the United States, STI prevention activities fall into two are-
nas, with diagnosis and treatment mostly occurring at the local level and
surveillance activities and partner services mostly (with exceptions in
larger cities) funded and coordinated at the federal and state levels.
Cooperative Federalism and Public Health
The 10th Amendment to the Constitution helps to define federal
and state government powers and responsibilities under the U.S. system
of federalism. It reserves to state governments the power and primary
responsibility for protecting the public health of their respective popula-
tions (NCSL, 2014). The Constitution’s Commerce Clause, however, gives
the federal government certain authority to order quarantines or take
other measures in response to a public health threat, such as an infectious
disease transmitted across state borders. Nonetheless, most state–federal
relations in the public health context operate under what is called coopera-
tive federalism: federal policy makers may seek to achieve uniform national
policies and practices through funding state efforts. Instead of attempting
to compel states to take actions (for which the Constitution may not grant
the authority), they provide federal funding and condition these funds
on states’ taking specific actions, but states’ acceptance of such funding
remains voluntary.
Public health is nested within this cooperative federalism construct
as a state responsibility with federal input and partial funding through
CDC, the Health Resources and Services Administration (HRSA), the Sub-
stance Abuse and Mental Health Services Administration (SAMHSA), and
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
222 SEXUALLY TRANSMITTED INFECTIONS
others. In its most recent funding announcement for state STI programs,
for example, CDC states that as a condition of receiving federal funding,
“all applicants are required to implement a program of core STD preven-
tion and control strategies and activities across the public health functions
of assessment, assurance, and policy development,” with more specific
conditions articulated in the announcement (grants.gov, 2018).
While states retain responsibility for public health and state health
officials are essential leaders in responding to STIs, the current state–fed-
eral partnership has evolved away from the Founders’ intention expressed
by cooperative federalism. Given that the federal government is such a
dominant funder of STI and other public health programs, yet it is still
faced with large variations in the scope and quality of STI services across
the states, it is questionable whether cooperative federalism is working
in this context. Governors and other state officials could assert their con-
stitutional prerogatives for public health yet also excuse shortcomings by
blaming inadequate federal funding. While it is beyond the scope of this
committee to make recommendations on whether the current federal–
state funding dynamic is consistent with the ideals of the Constitution,
a broader evaluation of the role and relative contributions of states in
enhancing STI and other public health responses may be necessary.
OVERVIEW OF FEDERAL PROGRAMS
Background
STI control efforts are supported through a combination of private
and public funds, including private insurance payments, public cover-
age programs like Medicaid, and out-of-pocket expenditures for billed
clinical services. Similarly, numerous federal, state, and local funding
streams support STI prevention efforts, either as a standalone program
or as a part of other health services funding programs (e.g., Title X fund-
ing for family planning and Section 330 of the Public Health Service Act
[PHSA] for HRSA funding for qualifying health centers). Reports by the
National Academy of Public Administration (NAPA), commissioned by
the National Coalition of STD Directors (NCSD), provide a comprehen-
sive overview of these funding streams (NAPA, 2018, 2019).
The only federal categorical funding stream specifically dedicated to
STI prevention and control is authorized by Section 318 of the PHSA and
primarily administrated by the Division of STD Prevention (DSTDP) in
the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Preven-
tion at CDC. Current funding for CDC’s STI programs has been level
for many years at approximately $157 million (with the 2020 budget
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
STI ECONOMICS, PUBLIC-SECTOR FINANCING, AND PROGRAM POLICY 223
increasing slightly to $160.8 million); after adjustment for inflation, this is
a reduction of about 40 percent since 2003 (NAPA, 2018).
The vast majority of national and community-level programs to
address STIs are supported by components of the Department of Health
and Human Services (HHS) (see Figure 4-1). Its primary functions include
(1) data surveillance; (2) prevention and control programs, including
direct health care provision; (3) workforce development and capacity
building; and (4) research and evaluation. In addition, coverage programs
like Medicare and Medicaid, as well as private insurance, finance clinical
services and treatment for most U.S. residents. Many uninsured indi-
viduals have access to screening, testing, and treatment services through
a network of clinics and safety-net providers that are supported largely
through the government-funded programs discussed below. This frag-
mented system leaves many without affordable and accessible opportu-
nities for regular STI services and perpetuates the transmission of these
preventable conditions.
Overview of Federally Funded Public Health Programs
Most federal support for STI services is provided by HHS and under-
pins the operation of a wide range of programs funded and administered
by CDC, the HHS Office of Population Affairs (OPA), HRSA, SAMHSA,
the Indian Health Service (IHS), the National Institutes of Health, and
public coverage programs, including Medicaid and Medicare through the
Centers for Medicare & Medicaid Services (see Figure 4-1). This section
provides an overview of public programs (both within and outside of
HHS) that support STI surveillance, training, and research and discusses
public and private support of programs that finance services to prevent,
screen for, and treat STIs. A comprehensive review is also available in
the 2019 NAPA report The STD Epidemic in America: The Frontline Struggle
(NAPA, 2019).
Centers for Disease Control and Prevention
Despite the increase in STI rates, federal funding for CDC programs
that support STI services over the past 10 years has been level (as noted,
after adjustment for inflation, this reflects a 40 percent reduction since
2003) (see Figure 4-2). DSTDP oversees all STI programs operated by
CDC. The majority of funding goes toward state and local program grants
and staffing. A small share of the STI budget goes toward workforce train-
ing, data surveillance, and research and evaluation (see Figure 4-3). CDC’s
current STI goals include (1) eliminating congenital syphilis and prevent-
ing primary and secondary syphilis, (2) preventing antimicrobial-resistant
Copyright National Academy of Sciences. All rights reserved.
224
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Copyright National Academy of Sciences. All rights reserved.
FIGURE 4-1 Federal agencies that provide sexually transmitted infection funding.
SOURCE: Adapted from NAPA, 2019, to reflect organization as of December 2020.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Copyright National Academy of Sciences. All rights reserved.
FIGURE 4-2 Annual Centers for Disease Control and Prevention sexually transmitted infection prevention budget, inflation-
adjusted budget, and syphilis rates, fiscal years 2003–2019.
225
SOURCE: NCSD, 2019.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
226 SEXUALLY TRANSMITTED INFECTIONS
FIGURE 4-3 Division of STD Prevention fiscal year 2020 budget breakdown by
percent, funding.
NOTES: Developed by CDC for this report; supporting data are available by
request via the project Public Access File via email at [email protected]. CDC =
Centers for Disease Control and Prevention; DA = direct assistance; HHS = De-
partment of Health and Human Services.
gonorrhea, and (3) preventing STI-related pelvic inflammatory dis-
ease, ectopic pregnancy, and infertility (NAPA, 2018). Given its limited
resources, DSTDP has defined its primary responsibilities as encompass-
ing “assessment, assurance, policy development, and prevention strate-
gies” (CDC, 2017a). Primary responsibility for STI research and treatment
is viewed as outside of its purview, and while CDC is not primarily
responsible for directly providing clinical services, it does seek to ensure
that clinical services exist, along with local health departments.
CDC programming is primarily focused in the following areas:
• Evidence-based scientific information for providers, pub-
lic health professionals, and patients and communities: CDC
develops provider guidelines including Recommendations for
Providing Quality Sexually Transmitted Diseases Clinical Services
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
STI ECONOMICS, PUBLIC-SECTOR FINANCING, AND PROGRAM POLICY 227
(Barrow et al., 2020), Sexually Transmitted Diseases Treatment
Guidelines (Workowski and Bolan, 2015), and Provider Pocket
Guides (CDC, 2015). Patient education/community outreach
includes online/printable brochures (CDC, 2016b), fact sheets
(CDC, 2016a), infographics (CDC, 2020j), and STD Awareness
Week (CDC, 2020h).
• STI surveillance to assess the burden, outcomes, and costs of
STIs: CDC conducts annual surveillance of reportable STIs (CDC,
2019c). It provides the National Center for HIV/AIDS, Viral Hep-
atitis, STD, and TB Prevention AtlasPlus tool so users can build
custom reports from these surveillance files (CDC, 2019a). CDC
also tracks the antimicrobial-resistant bacterium Neisseria gon-
orrhoeae through the STD Surveillance Network (CDC, 2016d)
and the Gonococcal Isolate Surveillance Project (CDC, 2020e). In
addition, CDC helps publish action plans on antibiotic-resistant
bacteria, such as the National Action Plan for Combating Anti-
biotic-Resistant Bacteria report that sets goals to maintain the
prevalence of ceftriaxone-resistant gonorrhea below 2 percent,
maintain capacity for rapid response to antimicrobial resistance,
and support surveillance efforts (Federal Task Force on Combat-
ing Antibiotic-Resistant Bacteria, 2015, 2020).
• Funding for state and local prevention and control programs:
In addition to basic program support, CDC provides targeted
funding to address particular issues or public health priorities.
For example, the Strengthening STD Prevention and Control
for Health Departments program provides cooperative agree-
ments/grants to state, local, and territorial health departments to
address chlamydia, gonorrhea, and syphilis (CDC, 2018). Another
example is the Community Approaches to Reducing STDs initia-
tive, which funds recipients to address STI health equity (CDC,
2020a) (see Chapter 8 for more information). CDC also helps
providers implement Project Connect, an intervention that aims
to increase youth access to sexual and reproductive health care
(CDC, 2020g). CDC offers several tools for program manage-
ment and evaluation (CDC, 2019b), including program evaluation
training (NCSD, 2020), a gap assessment toolkit (CDC, 2016c),
and effective interventions guidelines (CDC, 2020b). Through
the National Center for Immunization and Respiratory Diseases’
Vaccines for Children Program, CDC also buys (at a discount)
and distributes vaccines, including for hepatitis B and human
papillomavirus (HPV), recommended by the Advisory Commit-
tee on Immunization Practices, to its grantees to provide free vac-
cination for children younger than 19 years of age and who are
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
228 SEXUALLY TRANSMITTED INFECTIONS
Medicaid eligible, uninsured, underinsured, and/or American
Indian/Alaska Native (AI/AN) (CDC, 2016f).
• Workforce development and capacity building: CDC funds
multiple training opportunities (CDC, 2013), including in-person
training for public and private providers at the STD Clinical Pre-
vention Training Centers (PTCs) (CDC, 2017b). Several online
learning tools are also available, including webinars for clinicians,
physicians, and public health practitioners (CDC, 2016e) and the
online National STD Curriculum, which offers continuing educa-
tion credits upon completion (CDC, 2020f). Through the PTCs,
CDC also funds the STD Clinical Consultation Network, which
provides expert consultation to providers who need assistance
with complex clinical cases (National STD Curriculum, n.d.). (See
Chapter 11 for more information on STI workforce development.)
• Research and evaluation: A small fraction of CDC’s budget sup-
ports STI research on the priority populations of adolescents and
young adults, men who have sex with men, transgender persons,
and pregnant persons and on STI vaccines, therapeutics, and point-
of-care diagnostics. CDC collaborates with professional associa-
tions, such as the National Association of County and City Health
Officials (NACCHO), to conduct surveys to assess the level of
publicly funded STI services offered at the state and local levels
(NAPA, 2018). Every 2 years, CDC hosts an STI prevention confer-
ence, bringing together scientific evidence in the field (CDC, 2020i).
Office of Population Affairs
HHS’s OPA plays an important role in supporting STI prevention and
treatment services for low-income individuals through grants for family
planning services at sites throughout the country and guidance on provid-
ing family planning services.
OPA’s primary responsibility has been to administer the Title X Fam-
ily Planning program, which supports clinical family planning services
(including STI and HIV prevention education, counseling, and testing)
at sites nationwide that serve low-income patients (OPA, 2020). The most
current Title X regulation defines family planning services to
include preconception counseling, education, and general reproductive
and fertility health care, in order to improve maternal and infant out-
comes, and the health of women, men, and adolescents who seek family
planning services, and the prevention, diagnosis, and treatment of infec-
tions and diseases which may threaten childbearing capability or the
health of the individual, sexual partners, and potential future children.
(GPO, 2019)
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
STI ECONOMICS, PUBLIC-SECTOR FINANCING, AND PROGRAM POLICY 229
The regulation also notes that programs are permitted, but not required,
to “diagnose, test for, and treat STDs” (Electronic Code of Federal Regula-
tions, 2020).
Clinics that have participated in the program include federally
qualified health centers (FQHCs), state and county health departments,
Planned Parenthood clinics, and specialized family planning providers.
Participating sites receive federal support and are eligible for the federal
340B drug pricing program (see the relevant later section in this chapter
for more details).
The Title X program underwent significant changes in 2019 as a result
of new regulations that block Title X support to clinics that provide abortion
services and referrals in addition to family planning and STI services. Partici-
pating sites fell from 4,515 in 2009 to approximately 3,825 in 2019 (OPA, 2020).
The new regulations have not only resulted in these sites losing funding
available to provide low-income individuals with contraceptive services but
also may have affected the availability of clinics that continue to offer free or
low-cost STI testing and treatment services in many communities. The new
regulations opened the door for organizations that do not provide contracep-
tion or even condoms to receive federal family planning funds, limiting their
services to abstinence or natural family planning. Patients who are tested and
treated for STIs at these new Title X-funded sites are not given condoms but
rather prescribed abstinence for prevention (Varney, 2019).
Family planning clinic users who obtained services from supported
providers fell by 21 percent from 2018 to 2019 (OPA, 2020). There was also
a reduction in both the number and share of users (both men and women)
who had chlamydia and gonorrhea tests (OPA, 2020). Information on STI
treatment and referral, however, is not available. In addition to losing
federal funding, some sites that have withdrawn from the program can
no longer qualify for 340B discounts, which enabled clinics to offset the
cost of medications.
In partnership with CDC, OPA published recommendations for Pro-
viding Quality Family Planning Services, which includes STI and HIV
testing and treatment guidelines. Family planning providers are recom-
mended to assess the patient’s reproductive life plan, screen patients for
STIs based on risk, provide HPV vaccines, treat patients with STIs and
their partner(s), and provide risk counseling for sexual behavior risk
reduction (CDC, 2014). OPA also oversees activities regarding adoles-
cents and sexual and reproductive health and funds the Teen Pregnancy
Prevention Program (TPP), which has about 65 grantees and a budget of
about $101 million (OPA, n.d.-b). The TPP provides up to 3-year grants to
implement interventions that aim to improve adolescent health, prevent
teen pregnancy, and reduce STIs. OPA also hosts resources and training
for providers working with adolescents and STIs (OPA, n.d.-a).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
230 SEXUALLY TRANSMITTED INFECTIONS
Despite its importance in financing publicly funded family planning
services for low-income populations, the Title X program is small, with
a budget of $286 million in 2019; over the past decade, the program has
shrunk in actual and constant dollars (OPA, 2021). To put this in context,
between 2008 and 2018, health care costs increased by 21.6 percent (Clax-
ton et al., 2018). The reduced Title X funding has also been associated
with reductions in the number of people who have been served by clinics
receiving support from the program (OPA, 2020). On January 28, 2021,
President Biden ordered a review of the 2019 Title X rule, but any changes
would require notice-and-comment rulemaking, meaning that they could
not be immediately put into effect (The White House, 2021).
Health Resources and Services Administration
HRSA is largely responsible for supporting services to medically
underserved and rural communities and oversees several divisions and
programs that work on STI prevention and treatment, including the Wom-
en’s Preventive Services Guidelines, which include recommendations for
behavioral counseling for all sexually active adolescents and adult women
at increased risk for STIs (HRSA, 2020e).
340B Drug Pricing Program This is a drug discount program adminis-
tered by HRSA’s Office of Pharmacy Affairs. Its purpose is “to stretch
scarce federal resources as far as possible, reaching more eligible patients
and providing more comprehensive services” (HRSA, 2020a). By design,
the 340B program helps to subsidize the operations of safety-net provid-
ers by permitting them to obtain discounted outpatient pharmaceuticals
and retain higher reimbursements, when available, from private insur-
ance, Medicare, and, in some states, Medicaid.
The 340B program is not a health coverage program, but it enables eli-
gible participants to generate revenue that can be used to extend coverage
to more people or enhance the scope of services offered. Only nonprofit
health care organizations that have a certain federal designation or receive
funding from specific federal programs can be considered “eligible enti-
ties.” Figure 4-4 shows the categories of covered entities and their 2014
participation rates.
STI clinics that receive funding from CDC under Section 318 of the
PHSA are eligible recipients, as are FQHCs, Ryan White HIV/AIDS pro-
gram grantees, and sites that receive Title X family planning funding
(HRSA, 2020c). They must apply to HRSA to participate, and once accepted,
these “covered entities” can purchase drugs at prices that are the same as or
lower (often significantly lower) than the Medicaid rebate price. Currently,
3,226 STI clinics participate in the 340B program (HRSA, n.d.).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
STI ECONOMICS, PUBLIC-SECTOR FINANCING, AND PROGRAM POLICY 231
FIGURE 4-4 340B participation rates by covered entity category, 2014.
NOTE: DSH = disproportionate share hospital; FQHC = federally qualified health
center; STD = sexually transmitted disease.
SOURCE: Mulcahy et al., 2014.
Covered entities cannot resell or transfer drugs to other entities.
Although the clinic or health provider is defined as 340B eligible, the out-
patient drug discount can only be secured for “eligible patients,” defined
by federal rules as those who meet the following criteria:
• Have an established relationship with the covered entity, as dem-
onstrated by the covered entity maintaining a medical record for
the patient;
• Receive services from a health care professional who is either
employed by the covered entity or provides health care under
contractual or other arrangements (e.g., referral for consultation)
such that responsibility for the care provided remains with the
covered entity; and
• Receive a service or a range of services from the covered entity,
which is consistent with the grant funding or the FQHC look-
alike status that has been provided to the entity (GPO, 1996).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
232 SEXUALLY TRANSMITTED INFECTIONS
While there is no formal guidance, if a patient meets the 340B patient
definition at a visit and tests positive for an STI, then 340B-acquired drugs
may be used for them and expedited partner therapy (EPT) (see Chapters
7 and 10 for more on expedited partner therapy). The rationale is that EPT
actually treats the eligible patient because it prevents reinfection (FPNTC,
2017; NFPRHA, 2019).
The required discount is either 13 percent (generic) or 23.1 percent
(brand name) from the average manufacturer price. Additional discounts
are also required if the manufacturer has chosen to increase the price
faster than the rate of inflation and/or offers a lower price to certain other
purchasers. Manufacturers also may voluntarily offer deeper discounts.
Manufacturers are prohibited from providing a discounted 340B price and
Medicaid drug rebate for the same drug.
In addition to the program providing the most deeply discounted
prices for medications, an important advantage has been allowing cov-
ered entities to bill payers (Medicare, private insurance, and decreas-
ingly Medicaid programs) the regular reimbursement rates for drugs
and receive reimbursement greater than their costs. For many clinics and
programs, the difference between the payment and reimbursement is a
significant revenue generator. This revenue must be used consistent with
the purpose of the 340B-qualifying program (for STI clinics, this is the
purpose of CDC funding), such as to serve more low-income people in
need of sexual health services or provide a broader range or higher level
of services (Schwartz, 2015). Some 340B entities have expressed concerns
that this policy has been interpreted overly restrictively, so the current
restrictions may merit reconsideration. For example, Ryan White HIV/
AIDS Program recipients have been precluded from using 340B income
for pre-exposure prophylaxis and other preventive services (HRSA,
2016). Furthermore, others have claimed that the lack of clear guidance
acknowledging that EPT is a permissible use of 340B income has limited
the effectiveness of the program in supporting this critical public health
purpose (FPNTC, 2017; Golden and Estcourt, 2011; NFPHRA, 2019). As
the distinctions between treatment and prevention blur, wherein effective
prevention reduces the need for HIV treatment services within a commu-
nity, these entities believe that the purpose of the grant in the context of
the 340B program could be interpreted more broadly to enable providers
to serve more individuals in need of services.
Bureau of Primary Health The bureau administers the Health Center
Program, which provides grants to support primary care and related ser-
vices through a network of more than 1,400 health centers that operate at
about 12,000 service delivery sites in every state, the District of Columbia,
and the U.S. territories (McDevitt, 2019). In addition to receiving federal
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
STI ECONOMICS, PUBLIC-SECTOR FINANCING, AND PROGRAM POLICY 233
grants, FQHCs also qualify for the 340B discount drug program, are reim-
bursed using an enhanced Medicare and Medicaid payment system, qual-
ify for Health Professional Shortage Area designation, and may obtain
clinicians through the National Health Service Corps. Certain health cen-
ters located in medically underserved communities are designated fed-
eral “look-alike” status; they do not receive federal grants, but they offer
the same range of services as FQHCs and qualify for the other benefits
granted to FQHCs discussed above (HRSA, 2018). According to HRSA,
more than 28 million people were seen at HRSA-funded health centers
in 2019 (McDevitt, 2019). Health centers serve individuals regardless of
ability to pay or immigration status. Participating clinics are required to
provide primary care services; it is assumed that STI services would be
included, but the terms of participation do not specify prevention, test-
ing, and treatment of STIs other than HIV, hepatitis B, and hepatitis C
(McDevitt, 2019). The Uniform Data System, the database that tracks the
number and types of services that health centers provide, reports 376,840
visits for STI services and 256,203 visits with an STI diagnosis in 2018.1
Maternal and Child Health Bureau The bureau administers the Title V
Maternal and Child Health Program, a block grant to improve maternal,
child, and family health. Title V goals include improving maternal and
child health (through improved access, quality, and prevention) for low-
income women (HRSA, 2020d). The program provides grants for Sexual
Risk Avoidance Education, whose regulations require that education
heavily focus on sexual risk avoidance rather than risk reduction strate-
gies (i.e., STI education) (FYSB, 2020; SSA, n.d.). For more information on
sexual education in schools, see Chapter 8.
CDC/HRSA Advisory Committee on HIV, Viral Hepatitis, and STD Pre-
vention and Treatment The committee is a collaboration between CDC
and HRSA, currently focusing on HIV and opioids.
HRSA HIV/AIDS Bureau The bureau administers the Ryan White HIV/
AIDS Program, which “provides a comprehensive system of HIV primary
medical care, essential support services, and medications for low-income
people living with HIV who are uninsured and underserved” (HRSA,
2020b). This program funds health care services for individuals living
with HIV and also supports other STI services for low-income people
with HIV or at risk. See Chapter 5 for information on the intersection of
HIV and STIs.
1 Data obtained from the HRSA National Health Center Data website. See https://data.
hrsa.gov/tools/data-reporting/program-data/national (accessed October 20, 2020).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
234 SEXUALLY TRANSMITTED INFECTIONS
Indian Health Service
IHS, an operating division of HHS, is responsible for providing direct
clinical services, including STI care, to AI/AN individuals. IHS partners
with CDC on STI prevention and control, outreach and educational pro-
gramming, and data surveillance (IHS and CDC, 2018). For information
on the challenges and opportunities related to STIs for AI/AN people,
see Chapter 3.
Substance Abuse and Mental Health Services Administration
SAMHSA collaborates with other governmental organizations
(including CDC and HRSA) on co-occurring mental illness and STIs. It
also publishes practice guidelines and data surveillance related to STIs
and mental health. Its STI-related resources include the following:
• Data Spotlight: a brief that highlights data on colocation of sub-
stance abuse treatment and STI screening (SAMHSA, 2013)
• SAMHSA-HRSA Center for Integrated Health Solutions: Support-
ing Clients in Sexual Health: a brief for providers on the overlap
among sexual, behavioral, and mental health (SAMHSA, 2017)
• Treatment Improvement Protocol (TIP) 37: Substance Abuse
Treatment for Persons with HIV/AIDS (SAMHSA, 2000)
• TIP 42: Substance Abuse Treatment for Persons with Co-Occur-
ring Disorders (SAMHSA, 2020)
• TIP 51: Substance Abuse Treatment: Addressing the Specific
Needs of Women (SAMHSA, 2009)
Department of Defense and Department of Veterans Affairs
The Department of Defense (DOD) and the Department of Veterans
Affairs (VA) run several programs that address STIs among service mem-
bers and their dependents and for veterans. Active-duty service members
and veterans receive health care, including STI care, through TRICARE
and the Veterans Health Administration (VHA). Additionally, DOD over-
sees the following two programs in data surveillance and clinical research
affecting active-duty members of the military.
Armed Forces Health Surveillance Center The center monitors and
evaluates surveillance data in the military, including STIs, using the
Defense Medical Surveillance System and produces a medical surveil-
lance monthly report based on trends in health-related conditions.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
STI ECONOMICS, PUBLIC-SECTOR FINANCING, AND PROGRAM POLICY 235
Infectious Disease Clinical Research Program The program supports
clinical research in the military health system, including STI-related stud-
ies, such as the GC Resistance Study and the GC Reference Laboratory
and Repository study (IDCRP, n.d.). One goal is to support STI preven-
tion, diagnosis, and treatment.
Veterans Health Administration The VHA served approximately 2.8
million working-age veterans in 2016; about one-quarter (732,000) did
not have any other health coverage and used the VA as their only source
of coverage. The remaining VA population has employer insurance, indi-
vidually purchased coverage, Medicaid, or other government coverage
(TRICARE or Medicare). Because eligibility is based on veteran status,
service-connected disability status, income level, and other factors, not all
veterans qualify for VA care (Holder and Day, 2017). The VA offers a wide
range of services, including STI screening and testing.
Department of Justice Federal Bureau of Prisons
The Federal Bureau of Prisons, an agency under the Department of
Justice, is responsible for providing direct clinical services, including STI
care, to individuals in the federal prison system. It also publishes clinical
guidelines for preventing and treating STIs in prison settings, such as the
following:
• The Infectious Disease Management Program Statement states
that (1) all inmates entering bureau facilities will receive edu-
cation on viral hepatitis and STIs, including general review of
current information on transmission, treatment, and prevention,
and (2) testing for viral hepatitis and STIs is performed based on
clinical indicators and guidance from the medical director (BOP,
2014).
• The Preventative Health Care Screening Clinical Guidance offers
screening and testing guidance for HIV, hepatitis C, syphilis,
gonorrhea, chlamydia, and HPV (BOP, 2018).
• The Clinical Practice Guidelines include guides available for hep-
atitis B, hepatitis C, HIV management, and medical management
of exposures (including sexual exposures) (BOP, n.d.).
• The Inmate Information Handbook has a section on STIs that
includes frequently asked questions (BOP, 2012).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
236 SEXUALLY TRANSMITTED INFECTIONS
STATE AND LOCAL EFFORTS
While much of the on-the-ground work to tackle STIs happens at
the state and local levels, the vast majority of funding comes from the
federal government and coverage programs, such as Medicaid and pri-
vate insurance. At the state level, formula funding from CDC is mostly
used to support STI surveillance and epidemiology and provide partner
services. Some states support local public health programs in their juris-
dictions, but Section 318 of the PHSA does not specifically authorize the
direct provision of STI diagnostic and treatment services. Recipients of
the Strengthening STD Prevention and Control for Health Departments
(PCHD) cooperative agreements, authorized by Section 318, can spend no
more than 10 percent of their funding on direct STI services, unless special
approval is obtained.
PCHD-funded programs are relatively well aligned and coordinated
with one another for three reasons. First, they all respond to the same
grant provisions and associated performance measures. Second, they
receive designated supports from expert staff in DSTDP’s program, sur-
veillance, and epidemiology branches. Finally, they are represented by
a very active and well-resourced nonprofit organization, NCSD, which
advocates for them with CDC and with Congress.
Such cohesiveness, however, is lacking at the local level, where most
of the frontline STI services occur. There are no categorical STI funding
streams that benefit local public health programs, other than flow-through
funding from PCHD grantees, especially in states where the state health
departments are directly in charge of local STI programs. In addition, local
STI programs and clinics depend on a number of other funding sources,
including city/county and state transfers (often bundled with other fund-
ing); Title X family planning grants; Ryan White HIV/AIDS Program
funding; HRSA’s Health Center Program (authorized by Section 330 of the
PHSA) that includes funding for FQHCs; and the 340B program. Besides
fragmented funding, the quality of local STI programs further depends on
local leadership and academic affiliations. As a result of this patchwork
of resources, program quality varies greatly. Some have evolved into STI
centers of excellence and been able to attract additional resources as train-
ing and research centers, whereas others have floundered and clinics have
closed. Public funding for STI services appears to be declining in the past
decade; in a study of local health departments from 2013 to 2014, 61.5
percent reported recent budget cuts. This means that clinics sometimes
needed to decrease hours (42.8 percent), decrease routine screening (40.2
percent) and partner services (42 percent), and increase fees or copays (25
percent) (Leichliter et al., 2017). Other data have shown similar conse-
quences of budget cuts; funding reductions have also caused decreasing
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
STI ECONOMICS, PUBLIC-SECTOR FINANCING, AND PROGRAM POLICY 237
numbers of staff and clinicians and STD clinic closures (NAPA, 2019).
Unfortunately, some of the areas with the highest morbidity have the
fewest resources.
Important support for local STI programs and clinics comes from
the CDC-funded National Network of STD Prevention Training Centers,
consisting of eight regional centers that provide STI workforce training
and technical assistance (Stoner et al., 2019). (See Chapter 11 for more
information.) In addition, NCSD has recently stepped up to develop an
STI clinic initiative, “Reimagining STD Clinics for the Future,” which
advocates for public and private STI clinics and envisions ultimately
developing a “community of practice” for STI clinics. These are important
resources; they are, however, insufficiently funded to cover current tech-
nical assistance and workforce development needs and do not directly
address funding levels for clinical operation (NAPA, 2019). Thus, much
more needs to be done to reverse the downward spiral many STI clinics
are experiencing and shore up the front lines in STI prevention.
Less commonly, nongovernmental organizations offer funding oppor-
tunities. For example, one of the focus areas for NACCHO, consisting of
nearly 3,000 local health departments, is to support local health depart-
ments in addressing STIs. NACCHO partners with CDC to offer Local
Innovations in Congenital Syphilis Prevention, which provides at least
five health departments with up to $25,000 to decrease congenital syphilis
in their areas (Horowitz, 2019). With funding from CDC, NACCHO also
conducts the Supporting the Delivery of Quality STD Services project to
support the use of CDC STI recommendations at local health departments
and the STI Express Initiative to assess evidence for “express STI visits” or
“fast-tracking” STI services (NACCHO, 2019; Rodgers, 2019). In addition,
the Association of State and Territorial Health Officials works to support
state and territorial health departments in preventing and responding
to STIs, in collaboration with CDC and other partners. It has published
resources, including National STD Trends (ASTHO, 2019), which outlines
key STI information for public health leadership; Investing in STD Pre-
vention (ASTHO, 2018), which helps local actors make the case for STI
funding; and other resources for how to integrate STI prevention into
public health and primary care models (ASTHO, n.d.).
Given the critical importance of providing STI care at the local level
for STI prevention nationally, action needs to be taken to reverse these
trends. Elsewhere in this report (see Chapter 12), specific suggestions are
made toward increasing local community planning for STI prevention,
strengthening the role of STI clinics in cities and selected nonurban areas,
and developing STI prevention and care resource centers in every state.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
238 SEXUALLY TRANSMITTED INFECTIONS
ECONOMIC BURDEN OF STIs
As part of its Statement of Task, the committee was asked to examine—
to the extent possible—the economic burden associated with STIs. While
the literature on this is not extensive, a CDC study (Chesson et al., 2021)
estimated the lifetime medical costs of incident cases of eight STIs in
2018 in the United States: Chlamydia trachomatis (chlamydia), Neisseria
gonorrhoeae (gonorrhea), Trichomonas vaginalis (trichomoniasis), Treponema
pallidum (syphilis), genital herpes (due to herpes simplex virus type 2),
HPV, and hepatitis B virus and HIV attributed to sexual transmission.
With the exception of HPV, the study estimated the direct medical cost
burden of each STI by multiplying the lifetime medical costs per infection
of treating each STI and its sequelae with the number of incident cases
of each STI in 2018. The estimates of cases and costs were obtained from
existing peer-reviewed studies.
The lifetime medical care costs per infection varied: from $5 for trichomo-
niasis to more than $420,000 for HIV for men and from $36 for trichomoniasis
to more than $420,000 for HIV for women (Chesson et al., 2021). The inci-
dence in 2018 also varied; fortunately, incidence was inversely related to
lifetime costs per infection. For example, there were more than 7 million
incident cases of trichomoniasis but fewer than 37,000 incident cases of
HIV (HIV.gov, 2020).
The study estimated that the total lifetime direct medical cost of inci-
dent STIs in the United States in 2018 was almost $16.0 billion (25th–75th
percentile: $14.9–$16.9 billion). HIV accounted for the vast majority of
this, at $13.7 billion, followed by $1 billion for chlamydia and gonorrhea
combined and $0.8 billion for HPV. Excluding HIV, the lifetime cost of
incident STIs was $2.2 billion. The majority of this burden was borne by
women, at about $1.6 billion excluding HIV. Youth also accounted for a
significant fraction of total lifetime costs: $4.2 billion (25th–75th percen-
tile: $3.9–$4.5 billion) for persons aged 15–24 years, of which about $3.0
billion was for HIV, $0.6 billion for chlamydia and gonorrhea combined,
and $0.4 billion for HPV (Chesson et al., 2021).
While the lifetime medical care costs of incident STIs in 2018 are high
in absolute terms, they are small relative to total health care spending
in the United States. In 2019, total health care spending was $3.8 trillion
(CMS, 2020), so incident STIs accounted for less than 1 percent. However,
the lifetime medical care costs of STIs might vastly underestimate the
true disease burden. STIs impose costs not only in terms of dollars spent
on health care but also by influencing the quality of life of people who
are infected or currently uninfected but might be at risk in the future. For
those who are infected, the costs include not only the lifetime medical
costs of treating STIs but also the loss in quality of life due to the health
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
STI ECONOMICS, PUBLIC-SECTOR FINANCING, AND PROGRAM POLICY 239
and social consequences of living with the STI. Measuring the long-term
impacts of STIs and their sequelae on quality of life might be challenging
(Weatherly et al., 2009). Some prior studies have addressed these chal-
lenges and suggest that the loss in quality of life from STI infection can
be significant (Chesson et al., 2017; Jackson et al., 2014; Ong et al., 2019;
Tran et al., 2015).
STIs also can impose significant costs on the uninfected. These costs
are often ignored because they are difficult to measure, but they could be
much higher than the direct medical costs of STIs. The committee com-
missioned a pilot study2 to explore methods that could be used to help
quantify the impact of STIs on the quality of life of the uninfected, which
could arise through multiple channels. For example, people might worry
about getting an STI due to present sexual activity. This worry or anxiety
might reduce quality of life in the present. Such concerns could also lead
people to change sexual behaviors, such as having fewer sexual partners
and being more likely to wear condoms, which might lead to less enjoy-
able sexual experiences.
The commissioned pilot study used an innovative application of a
well-established strategy called the “time trade-off” method to measure
the impact of STIs on quality of life (Muennig and Bounthavong, 2016;
Torrance and Feeny, 1989). The goal is to find out how many years of life
people are willing to give up to eliminate the risk of STIs. For example,
if people are indifferent, on average, about living 10 years of life with
their current STI risk and living 9 years with no STI risk, that implies that
people are willing to give up 1 out of 10 years to eliminate the risk of STIs.
This implies that the risk reduces quality of life by 0.1 quality-adjusted
life-years (QALYs).
The pilot study, while preliminary, shows that the time trade-off
method produces reasonable estimates of the loss of QALYs due to risk of
STIs. For example, the QALY loss was higher for people who worry more
about getting STIs; those that were very worried about getting an STI
suffered a QALY loss of 0.39 years, and the somewhat worried lost 0.21
years. Similarly, QALY loss from STIs was higher for those who practice
riskier sexual behavior and thus face a higher risk of STIs. The QALY loss
was robust to alternate techniques for measuring it.
A separate nationally representative survey also commissioned by
the committee and conducted by the Kaiser Family Foundation showed
that 3 percent of the U.S. population was very worried and 5 percent
somewhat worried about STIs (Kirzinger et al., 2020). Combining these
results with the QALY loss for each group suggests that the current risk
2 The pilot survey questions are available by request via the project Public Access File
email at [email protected].
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
240 SEXUALLY TRANSMITTED INFECTIONS
of STIs for those who are uninfected but worried about an STI results in
a loss of close to 6 million QALYs. Prior research suggests that 1 QALY is
at least worth $100,000 (Hirth et al., 2000; Ubel et al., 2003). This implies
that the risk of STIs among those worried or somewhat worried about it
imposes a quality of life loss valued at about $600 billion. These studies
are preliminary, and more refined methods might alter the results.
Overall, the review of studies on costs or burden of STIs shows that
eliminating STI risk can generate significant economic value through
reducing direct medical costs and improving quality of life for people
both with and without infections. Other chapters in this report and a
recent issue of Sexually Transmitted Diseases discuss several proven and
promising interventions for STI prevention (CDC, 2020c). Juxtaposing the
two facts suggests that implementing these interventions and scaling up
efforts to prevent STIs can generate tremendous economic value.
CONCLUSIONS
DSTDP has been basically flat-funded for years and, adjusting for
inflation, has lost approximately 40 percent of its purchasing power since
2003 (NAPA, 2019). Similarly, at the local level, many STI programs have
curtailed their services due to lack of funding or programmatic changes
in policy, as is the case for the Title X program, even though increased
health care coverage due to the Patient Protection and Affordable Care
Act may be increasing access to STI care. In a survey, the majority of local
health departments (61.5 percent) reported recent budget cuts. Of those
with decreased budgets, the most common impacts were reductions in
clinic hours (42.8 percent), routine screening (40.2 percent), and partner
services (42.1 percent) (Leichliter et al., 2017).
Conclusion 4-1: While the reasons for the increases in STI rates are multi-
factorial, experts have suggested that STI rises are in part a symptom of
insufficient public health infrastructure, particularly at the local level. The
countervailing trends between rising STI rates and stagnant public health
funding on STIs require a careful re-examination of the current STI preven-
tion infrastructure and levels of STI care.
Conclusion 4-2: Efforts to address and curb the growing threats posed by
STIs require an urgent response to reinforce the existing public health infra-
structure for providing sexual health and STI health services.
There are many opportunities to improve local and state capacity to
address STIs. For example, CDC could develop a new funding mechanism
to support dedicated sexual health clinics. These clinics would ideally
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
STI ECONOMICS, PUBLIC-SECTOR FINANCING, AND PROGRAM POLICY 241
exist in all cities and nonurban areas that are underserved and provide
walk-in comprehensive sexual health treatment and care to explicitly seek
to serve the highest morbidity and underserved populations to address
inequities. Grants provided by CDC in 2019 to strengthen the infrastruc-
ture of STD clinics serving a high volume of racial and sexual minorities
to enhance and scale up HIV prevention services in three local clinics
(Baltimore City, DeKalb County, and East Baton Rouge Parish) under the
Ending the HIV Epidemic program represent an example of this type of
funding (CDC, 2020d). Another example would be to expand funding for
state and local epidemiologic capacity related to STIs, which would fill
another important need, including funding for cities (not only states) to
monitor STI epidemiology and service provision at the local level. To do
so, the current relationship between CDC and states and cities may need
to be revised (see Chapter 12 for recommendations on STI surveillance).
To overcome barriers related to capacity in this area, CDC would need to
send trained epidemiologists to local health departments or foster new
collaborations to expand epidemiologic capacity in the long term. While
there are many financial barriers to overcome, doing so is necessary to
implement the needed changes outlined later in this report.
REFERENCES
ASTHO (Association of State and Territorial Health Officials). 2018. Investing in STD
prevention: Making the case for your jurisdiction. https://www.astho.org/generickey/
GenericKeyDetails.aspx?contentid=20314&folderid=5150&catid=7184 (accessed
December 31, 2020).
ASTHO. 2019. National STD trends: Key information on sexually transmitted diseases for public
health leadership. Arlington, VA: Association of State and Territorial Health Officials.
ASTHO. n.d. Public health and healthcare integration for STD prevention. https://www.astho.
org/Programs/Infectious-Disease/Hepatitis-HIV-STD-TB/Sexually-Transmitted-
Diseases/Integration-Webinar-Series (accessed December 9, 2020).
Barrow, R. Y., F. Ahmed, G. A. Bolan, and K. A. Workowski. 2020. Recommendations for
providing quality sexually transmitted diseases clinical services, 2020. MMWR Recom-
mendations and Reports 68(5):1-20.
BOP (Federal Bureau of Prisons). 2012. Inmate information handbook. https://www.bop.gov/
locations/institutions/spg/SPG_aohandbook.pdf (accessed November 19, 2020).
BOP. 2014. Infectious disease management. https://www.bop.gov/policy/progstat/6190_004.
pdf (accessed November 19, 2020).
BOP. 2018. Preventive health care screening. Clinical guidance. https://www.bop.gov/resources/
pdfs/phc.pdf (accessed November 19, 2020).
BOP. n.d. Health management resources. https://www.bop.gov/resources/health_care_
mngmt.jsp (accessed November 19, 2020).
CDC (Centers for Disease Control and Prevention). 2013. Sexually transmitted diseases: Train-
ing. https://www.cdc.gov/std/training/default.htm (accessed November 18, 2020).
CDC. 2014. Update: Providing quality family planning services—recommendations of
CDC and the U.S. Office of Population Affairs. Morbidity and Mortality Weekly Report
63(4):231-234.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
242 SEXUALLY TRANSMITTED INFECTIONS
CDC. 2015. STD treatment guidelines pocket guide. https://www.cdc.gov/std/products/
provider-pocket-guides.htm (accessed November 17, 2020).
CDC. 2016a. CDC fact sheets. https://www.cdc.gov/std/healthcomm/fact_sheets.htm (ac-
cessed November 18, 2020).
CDC. 2016b. The facts brochures. https://www.cdc.gov/std/healthcomm/the-facts.htm (ac-
cessed November 19, 2020).
CDC. 2016c. STD preventive services gap assessment toolkit. https://www.cdc.gov/std/
program/gap/default.htm (accessed November 18, 2020).
CDC. 2016d. STD surveillance network (SSuN). https://www.cdc.gov/std/ssun/default.htm
(accessed November 18, 2020).
CDC. 2016e. STD webinars. https://www.cdc.gov/std/training/webinars.htm (accessed
November 18, 2020).
CDC. 2016f. Vaccines for children program (VFC). https://www.cdc.gov/vaccines/programs/
vfc/index.html (accessed November 17, 2020).
CDC. 2017a. Sexually transmitted diseases (STDs). About the division of STD prevention. Strategic
summary. https://www.cdc.gov/std/dstdp/strategic-summary.html (accessed June
24, 2020).
CDC. 2017b. STD clinical prevention training centers. https://nnptc.org (accessed November
18, 2020).
CDC. 2018. NOFO: Ps19-1901 strengthening STD prevention and control for health departments
(STD PCHD). https://www.cdc.gov/std/funding/pchd/default.htm (accessed No-
vember 18, 2020).
CDC. 2019a. NCHHSTP AtlasPlus. https://www.cdc.gov/nchhstp/atlas/index.htm?s_
cid=bb-od-atlasplus_002 (accessed November 18, 2020).
CDC. 2019b. Program management & evaluation tools. https://www.cdc.gov/std/program/
default.htm (accessed November 18, 2020).
CDC. 2019c. Sexually transmitted disease surveillance 2018. Atlanta, GA: Department of Health
and Human Services.
CDC. 2020a. Community approaches to reducing sexually transmitted diseases. https://www.cdc.
gov/std/health-disparities/cars.htm (accessed October 25, 2020).
CDC. 2020b. Effective interventions. https://www.cdc.gov/hiv/effective-interventions/
index.html (accessed November 18, 2020).
CDC. 2020c. Effective interventions. https://www.cdc.gov/std/program/interventions.htm
(accessed January 26, 2021).
CDC. 2020d. Ending the HIV Epidemic (EHE): Scaling up HIV prevention services in STD spe-
cialty clinics. https://www.cdc.gov/std/projects/ehe/default.htm (accessed February
3, 2021).
CDC. 2020e. Gonococcal isolate surveillance project (GISP). https://www.cdc.gov/std/gisp/
default.htm (accessed November 18, 2020).
CDC. 2020f. National STD curriculum. https://www.std.uw.edu (accessed November 18,
2020).
CDC. 2020g. Project CONNECT. https://www.cdc.gov/std/projects/connect/default.htm
(accessed November 18, 2020).
CDC. 2020h. STD awareness week. https://www.cdc.gov/std/saw (accessed November 19,
2020).
CDC. 2020i. STD prevention conference. https://www.cdc.gov/stdconference/default.htm
(accessed November 18, 2020).
CDC. 2020j. STD prevention infographics. https://www.cdc.gov/std/products/infographics.
htm (accessed November 17, 2020).
Chesson, H. W., P. Mayaud, and S. O. Aral. 2017. Sexually transmitted infections: Impact and
cost-effectiveness of prevention. In Major infectious diseases, edited by K. K. Holmes, S.
Bertozzi, B. R. Bloom, and P. Jha. Washington, DC: International Bank for Reconstruc-
tion and Development/The World Bank. Pp. 203-232.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
STI ECONOMICS, PUBLIC-SECTOR FINANCING, AND PROGRAM POLICY 243
Chesson, H. W., I. H. Spicknall, A. Bingham, M. Brisson, S. T. Eppink, P. G. Farnham,
K. M. Kreisel, S. Kumar, J.-F. Laprise, T. A. Peterman, H. Roberts, and T. L. Gift.
2021. The estimated direct lifetime medical costs of sexually transmitted infections
acquired in the United States in 2018. Sexually Transmitted Diseases. doi: 10.1097/
OLQ.0000000000001380.
Claxton, G., M. Rae, L. Levitt, and C. Cox. 2018. How have healthcare prices grown in the U.S.
over time? https://www.healthsystemtracker.org/chart-collection/how-have-health-
care-prices-grown-in-the-u-s-over-time (accessed January 22, 2021).
CMS (Centers for Medicare & Medicaid Services). 2020. National health expenditure data.
https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-
Reports/NationalHealthExpendData/NationalHealthAccountsHistorical (accessed
February 11, 2021).
Electronic Code of Federal Regulations. 2020. Electronic code of federal regulations. Title 42:
Public health. Part 59—grants for family planning services. https://www.ecfr.gov/cgi-bin/
text-idx?SID=9e7d4b25c907ce15ad3499765fe34bd3&mc=true&node=pt42.1.59&rgn=d
iv5 (accessed October 20, 2020).
Federal Task Force on Combating Antibiotic-Resistant Bacteria. 2015. National action plan for
combating antibiotic-resistant bacteria. Washington, DC: Department of Health and Hu-
man Services, Department of Agriculture, and Department of Defense.
Federal Task Force on Combating Antibiotic-Resistant Bacteria. 2020. National action plan for
combating antibiotic-resistant bacteria, 2020-2025. Washington, DC: Department of Health
and Human Services, Department of Agriculture, and Department of Defense.
FPNTC (Family Planning National Training Center). 2017. 340B drug pricing program fre-
quently asked questions for Title X family planning agencies. https://www.fpntc.org/sites/
default/files/resources/340b_faq_2017-12-08.pdf (accessed June 10, 2020).
FYSB (Family and Youth Services Bureau). 2020. Title V competitive sexual risk avoidance edu-
cation grant program. https://www.acf.hhs.gov/fysb/title-v-competitive-sexual-risk-
avoidance-education-grant-program (accessed November 18, 2020).
Golden, M. R., and C. S. Estcourt. 2011. Barriers to the implementation of expedited partner
therapy. Sexually Transmitted Infections 87:ii37-ii38.
GPO (Government Publishing Office). 1996. Health Resources and Services Administration.
[0905-za92]. Notice regarding section 602 of the Veterans Health Care Act of 1992 pa-
tient and entity eligibility. Federal Register 61(207):55156-55158. http://www.hrsa.gov/
opa/programrequirements/federalregisternotices/patientandentityeligibility102496.
pdf (accessed June 23, 2020).
GPO. 2019. Department of Health and Human Services. 42 CFR Part 59. [HHS-OS-2018-0008].
Rin 0937-za00. Compliance with statutory program integrity requirements. Federal
Register 84(42):7714-7791. https://www.govinfo.gov/content/pkg/FR-2019-03-04/
pdf/2019-03461.pdf (accessed May 29, 2020).
grants.gov. 2018. CDC-rfa-ps19-1901. Strengthening STD prevention and control for health
departments (STD PCHD). Department of Health and Human Services. Centers for Dis-
ease Control—NCHHSTP. https://www.grants.gov/web/grants/view-opportunity.
html?oppId=304454 (accessed April 24, 2020).
Hirth, R. A., M. E. Chernew, E. Miller, A. M. Fendrick, and W. G. Weissert. 2000. Willingness
to pay for a quality-adjusted life year: In search of a standard. Medical Decision Making
20(3):332-342.
HIV.gov. 2020. Fast facts. https://www.hiv.gov/hiv-basics/overview/data-and-trends/
statistics (accessed October 23, 2020).
Holder, K. A., and J. C. Day. 2017. Health insurance coverage of veterans. U.S. Census Bureau.
https://www.census.gov/newsroom/blogs/random-samplings/2017/09/health_
insurancecov0.html (accessed October 15, 2020).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
244 SEXUALLY TRANSMITTED INFECTIONS
Horowitz, R. 2019. Request for applications: Local innovations in congenital syphilis prevention.
https://www.naccho.org/blog/articles/request-for-applications-local-innovations-in-
congenital-syphilis-prevention (accessed November 19, 2020).
HRSA (Health Resources and Services Administration). 2016. Frequently asked questions.
March 21, 2016. Policy clarification notices (PCNs) 15-03 and 15-04. https://hab.hrsa.gov/
sites/default/files/hab/Global/faq15031504.pdf (accessed October 23, 2020).
HRSA. 2018. Health center program look-alikes. https://bphc.hrsa.gov/programopportunities/
lookalike/index.html (accessed January 27, 2021).
HRSA. 2020a. 340B drug pricing program. https://www.hrsa.gov/opa/index.
html#:~:text=The%20340B%20Program%20enables%20covered,entities%20at%20sig-
nificantly%20reduced%20prices (accessed June 10, 2020).
HRSA. 2020b. About the Ryan White HIV/AIDS program. https://hab.hrsa.gov/about-ryan-
white-hivaids-program/about-ryan-white-hivaids-program (accessed June 23, 2020).
HRSA. 2020c. Sexually transmitted disease clinics. https://www.hrsa.gov/opa/eligibility-
and-registration/specialty-clinics/sexually-transmitted-disease/index.html (accessed
June 23, 2020).
HRSA. 2020d. Title V maternal and child health services block grant program. https://mchb.
hrsa.gov/maternal-child-health-initiatives/title-v-maternal-and-child-health-services-
block-grant-program (accessed November 18, 2020).
HRSA. 2020e. Women’s preventive services guidelines. https://www.hrsa.gov/womens-
guidelines-2019 (accessed November 8, 2020).
HRSA. n.d. Office of Pharmacy Affairs. 340B OPAIS. https://340bopais.hrsa.gov/CoveredEn-
titySearch/000032539 (accessed June 10, 2020).
IDCRP (Infectious Disease Clinical Research Program). n.d. Sexually transmitted infections.
https://www.idcrp.org/research-area/sexually-transmitted-infections (accessed No-
vember 17, 2020).
IHS (Indian Health Service) and CDC. 2018. Indian health surveillance report—sexually trans-
mitted diseases, 2015. Rockville, MD: Department of Health and Human Services.
Jackson, L. J., P. Auguste, N. Low, and T. E. Roberts. 2014. Valuing the health states associ-
ated with Chlamydia trachomatis infections and their sequelae: A systematic review of
economic evaluations and primary studies. Value in Health 17(1):116-130.
Kirzinger, A., C. Muñana, M. Brodie, B. Frederiksen, G. Weigel, U. Ranji, and A. Salganicoff.
2020. KFF polling and policy insights: Abortion and STIs. San Francisco, CA: The Henry J.
Kaiser Family Foundation.
Kreisel, K. M., I. H. Spicknall, J. W. Gargano, F. M. Lewis, R. M. Lewis, L. E. Markowitz,
H. Roberts, A. S. Johnson, R. Song, S. B. St. Cyr, E. J. Weston, E. A. Torrone, and
H. S. Weinstock. 2021. Sexually transmitted infections among US women and men:
Prevelance and incidence estimates, 2018. Sexually Transmitted Diseases. doi: 10.1097/
OLQ.0000000000001355.
Leichliter, J. S., K. Heyer, T. A. Peterman, M. A. Habel, K. A. Brookmeyer, S. S. Arnold Pang,
M. R. Stenger, G. Weiss, and T. L. Gift. 2017. US public sexually transmitted disease
clinical services in an era of declining public health funding: 2013-14. Sexually Transmit-
ted Diseases 44(8):505-509.
McDevitt, S. 2019. Powerpoint presentation to the Committee on Prevention and Control of
Sexually Transmitted Infections in the United States. Irvine, CA (presented remotely).
December 16, 2019. https://www.nationalacademies.org/event/12-16-2019/
prevention-and-control-of-sexually-transmitted-infections-in-the-united-states-
meeting-4 (accessed November 17, 2020).
Muennig, P., and M. Bounthavong. 2016. Cost-effectiveness analyses in health: A practical ap-
proach, 3rd edition. San Francisco, CA: Jossey-Bass.
Mulcahy, A. W., C. Armstrong, J. Lewis, and S. Mattke. 2014. The 340B prescription drug dis-
count program: Origins, implementation, and post-reform future. https://www.rand.org/
pubs/perspectives/PE121.html (accessed January 15, 2021).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
STI ECONOMICS, PUBLIC-SECTOR FINANCING, AND PROGRAM POLICY 245
NACCHO (National Association of County and City Health Officials). 2019. Supporting the
delivery of quality STD services: A NACCHO project to facilitate implementation of CDC’s
recommendations for providing quality STD clinical services. Washington, DC: National
Association of County and City Health Officials.
NAPA (National Academy of Public Administration). 2018. The impact of sexually transmitted
diseases on the United States: Still hidden, getting worse, can be controlled. Washington, DC:
National Academy of Public Administration.
NAPA. 2019. The STD epidemic in America: The frontline struggle. Washington, DC: National
Academy of Public Administration.
National STD Curriculum. n.d. STD clinical consultation network. https://www.std.uw.edu/
page/site/clinical-consultation (accessed February 11, 2021).
NCSD (National Coalition of STD Directors). 2019. Fifth-straight year of STD increases demands
urgent action. https://www.prnewswire.com/news-releases/fifth-straight-year-of-std-
increases-demands-urgent-action-300934045.html (accessed January 28, 2021).
NCSD. 2020. STD program evaluation trainings and tools. https://www.ncsddc.org/std-pett
(accessed November 18, 2020).
NCSL (National Conference of State Legislatures). 2014. Responsibilities in a public health
emergency. https://www.ncsl.org/research/health/public-health-chart.aspx (accessed
April 24, 2020).
NFPRHA (National Family Planning & Reproductive Health Association). 2019. 340 drug
pricing program for family planning providers. NFPRHA winter meeting 2019. https://
www.nationalfamilyplanning.org/file/2019-december-meeting-pdfs/12.9---340B-
Training.pdf (accessed June 10, 2020).
Ong, K. J., M. Checchi, L. Burns, C. Pavitt, M. J. Postma, and M. Jit. 2019. Systematic review
and evidence synthesis of non-cervical human papillomavirus-related disease health
system costs and quality of life estimates. Sexually Transmitted Infections 95(1):28-35.
OPA (Office of Population Affairs). 2020. Title X family planning annual report: 2019 national
summary. Rockville, MD: Office of Population Affairs.
OPA. 2021. Title X program funding history. https://opa.hhs.gov/grant-programs/archive/
title-x-program-funding-history (accessed January 22, 2021).
OPA. n.d.-a. Adolescent health. https://opa.hhs.gov/adolescent-health?adolescent-
development/reproductive-health-and-teen-pregnancy/stds/index.html (accessed
December 31, 2020).
OPA. n.d.-b. Teen pregnancy prevention (TPP) program. https://opa.hhs.gov/grant-programs/
teen-pregnancy-prevention-program-tpp (accessed February 10, 2021).
Rodgers, K. 2019. Executive summary: Supporting the establishment, scale up, and evaluation
of STI express services. https://www.naccho.org/blog/articles/executive-summary-
supporting-the-establishment-scale-up-and-evaluation-of-sti-express-services
(accessed November 19, 2020).
SAMHSA (Substance Abuse and Mental Health Services Administration). 2000. TIP 37: Sub-
stance abuse treatment for persons with HIV/AIDS. Rockville, MD: Substance Abuse and
Mental Health Services Administration.
SAMHSA. 2009. TIP 51: Substance abuse treatment: Addressing the specific needs of women. Rock-
ville, MD: Substance Abuse and Mental Health Services Administration.
SAMHSA. 2013. Forty-two percent of substance abuse treatment facilities offer on-site screening
for infectious diseases. https://www.samhsa.gov/data/sites/default/files/spot070-
infectious.pdf (accessed November 19, 2020).
SAMHSA. 2017. SAMHSA-HRSA Center for Integrated Health Solutions (CIHS). https://www.
samhsa.gov/integrated-health-solutions (accessed November 18, 2020).
SAMHSA. 2020. TIP 42: Substance abuse treatment for persons with cooccurring disorders. Rock-
ville, MD: Substance Abuse and Mental Health Services Administration.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
246 SEXUALLY TRANSMITTED INFECTIONS
Schwartz, K. 2015. New analysis: Who benefits from contract pharmacy arrangements
in 340B program? PhRMA. http://catalyst.phrma.org/who-benefits-from-contract-
pharmacy-arrangements-in-340b-program (accessed June 23, 2020).
SSA (Social Security Administration). n.d. Title V—maternal and child health services block
grant. https://www.ssa.gov/OP_Home/ssact/title05/0500.htm (accessed December
31, 2020).
Stoner, B. P., J. Fraze, C. A. Rietmeijer, J. Dyer, A. Gandelman, E. W. Hook, 3rd, C. Johnston,
N. M. Neu, A. M. Rompalo, G. Bolan, and National Network of STD Clinical Prevention
Training Centers. 2019. The national network of sexually transmitted disease clinical
prevention training centers turns 40—a look back, a look ahead. Sexually Transmitted
Diseases 46(8):487-492.
The White House. 2021. Fact sheet: President Biden to sign executive orders strengthening Amer-
icans’ access to quality, affordable health care. https://www.whitehouse.gov/briefing-
room/statements-releases/2021/01/28/fact-sheet-president-biden-to-sign-executive-
orders-strengthening-americans-access-to-quality-affordable-health-care (accessed
January 28, 2021).
Torrance, G. W., and D. Feeny. 1989. Utilities and quality-adjusted life years. International
Journal of Technology Assessment in Health Care 5(4):559-575.
Tran, B. X., L. H. Nguyen, A. Ohinmaa, R. M. Maher, V. M. Nong, and C. A. Latkin. 2015.
Longitudinal and cross sectional assessments of health utility in adults with HIV/
AIDS: A systematic review and meta-analysis. BMC Health Services Research 15(1):7.
Ubel, P. A., R. A. Hirth, M. E. Chernew, and A. M. Fendrick. 2003. What is the price of
life and why doesn’t it increase at the rate of inflation? Archives of Internal Medicine
163(14):1637-1641.
Varney, S. 2019. Federally funded Obria prescribes abstinence to stop the spread of STDs. https://
californiahealthline.org/news/federally-funded-obria-prescribes-abstinence-to-stop-
the-spread-of-stds/#:~:text=But%20Obria%20will%20not%20advocate,according%20
to%20the%20group’s%20application (accessed January 22, 2021).
Weatherly, H., M. Drummond, K. Claxton, R. Cookson, B. Ferguson, C. Godfrey, N. Rice, M.
Sculpher, and A. Sowden. 2009. Methods for assessing the cost-effectiveness of public
health interventions: Key challenges and recommendations. Health Policy 93(2-3):85-92.
Workowski, K. A., and G. A. Bolan. 2015. Sexually transmitted diseases treatment guidelines,
2015. MMWR Recommendations and Reports 64(RR-03):1-137.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Intersection of HIV and STIs
Chapter Contents
Introduction
History
• Treatment of STIs to Prevent HIV: Before Antiretroviral
Treatment
• Management of HIV, Antiretroviral Treatment, and STIs
• Antiretroviral Agents as Pre-Exposure Prophylaxis (PrEP)
for HIV
• Substance Use, Alcohol Use, and STI/HIV Risk
Consequences of STIs in People Living with HIV
Important Lessons from the HIV Pandemic
Conclusions
247
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
248 SEXUALLY TRANSMITTED INFECTIONS
Because I was HIV positive, I regularly tested my partners for HIV.
But I didn’t understand that testing them for STDs like chlamydia, gonorrhea,
and syphilis was just as important. I didn’t know that my partner was
stepping out on me and had contracted chlamydia. They exposed me to
chlamydia because I wasn’t testing for that, causing my viral load
to increase and my CD4 to go down. That happens when someone
who is living with HIV contracts an opportunistic infection.
—Participant, lived experience panel1
INTRODUCTION
In this chapter, the committee considers the interactions between
HIV, the world’s most important sexually transmitted infection (STI),
and “classical” STIs (especially the curable bacterial STIs) that lead to
mucosal inflammation and genital ulcers. There is a large literature that
examines the biological, epidemiological, and behavioral aspects of HIV–
STI interactions. This chapter highlights aspects of these interactions
that may affect the trajectory of the ongoing STI epidemics in the United
States. The chapter also examines how prevention and care programs to
control the distinct, yet intertwined HIV and “classical” STI epidemics
diverged, with profound adverse effects on the spread of STIs. Consid-
ering this history emphasizes opportunities to develop more efficient
programs going forward that recognize the “syndemic” relationship
between HIV, STIs, and viral hepatitis that can and should be addressed
in an integrated fashion.
HISTORY
HIV was first recognized in 1981, in Los Angeles and New York City
where reports of gay, bisexual, and other men who have sex with men
(MSM) who acquired pneumocystis pneumonia and/or Kaposi’s sarcoma
secondary to immunodeficiency foreshadowed the AIDS pandemic (CDC,
1981; Gottlieb et al., 1981, 1982; Masur et al., 1981). Given the initial clus-
tering of cases, this syndrome was initially termed “gay-related immune
deficiency,” and later renamed “acquired immunodeficiency syndrome”
(Marx, 1982). The appearance of the same disease in persons with hemo-
philia (CDC, 1983; Gottlieb et al., 1982; Marx, 1983), neonates (Marx,
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.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
INTERSECTION OF HIV AND STIs 249
1983), injection drug using women and women sex workers (Harris et al.,
1983; Masur et al., 1982), transfusion recipients (CDC, 1982), and children
(Oleske et al., 1983; Rosner and Giron, 1983; Rubinstein et al., 1983) clari-
fied the route(s) of transmission of the causal pathogen: sexual, blood-
borne, and mother-to-child transmission during pregnancy, delivery, and
breastfeeding (Royce et al., 1997).
In 1983 and 1984, the causative agent, a retrovirus named “human
immunodeficiency virus,” was discovered and described, and antibody
testing became available in 1985 (Gallo, 2002; Gallo and Montagnier,
2003). It was several years before it was accepted widely that HIV was
primarily a sexually transmitted disease, however, and delays in preven-
tion interventions contributed to the spread of the virus in both MSM and
heterosexuals.
While HIV spread rapidly worldwide it attracted attention due to
mounting morbidity and mortality in endemic regions and when it was
shown to be indiscriminate in its potential to infect (e.g., children, women,
blood product recipients, and celebrities). The aggressive and effective
advocacy of lesbian, gay, bisexual, transgender, and queer (LGBTQ+)
and other communities helped accelerate research, services, and policy
changes (Shilts, 1987). The importance of advocacy in efforts to control
the spread of HIV in the United States and worldwide is discussed later
in this chapter.
HIV tests rendered the blood supply much safer (Weiss et al., 1985).
Virus transmission remained an immense challenge nonetheless, through
sexual, parenteral, and perinatal routes (Coates and Schechter, 1988;
Royce et al., 1997; Vermund and Leigh-Brown, 2012). Although a world-
wide pandemic ensued, the transmission of HIV per sexual encounter was
recognized to be inefficient relative to other STIs. For example, gonorrhea
transmission is very efficient, as it has a 20–53 percent chance of transmis-
sion from a woman infected with gonorrhea to a male partner through a
single episode of vaginal intercourse (Hooper et al., 1978). By comparison,
HIV transmission may occur just once in 300–1,000 sexual encounters
involving someone with a chronic infection (Blower and Boe, 1993; Hol-
lingsworth et al., 2008; Pinkerton et al., 2011; Powers et al., 2008; Røttingen
and Garnett, 2002; Royce et al., 1997; Varghese et al., 2002).
As a consequence of transient very high viral loads, before the host
immune system can respond, acutely infected persons have far higher
transmission probabilities (Pilcher et al., 2004b; Pinkerton et al., 2011),
closer to those seen with bacterial STIs. Viral load (blood and genital
tract) in someone with HIV can predict sexual transmission risk to an
HIV-negative partner (Baeten et al., 2011; Chakraborty et al., 2001; Cohen
et al., 2011; Fideli et al., 2001; Quinn et al., 2000). While patients with acute
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
250 SEXUALLY TRANSMITTED INFECTIONS
HIV infection have the highest viral load observed during the course of
infection as the transmitted virus has rapid growth until restrained by
evolving host defenses (Pilcher et al., 2004b), even chronically infected
persons can be especially infectious if their viral loads are high, as with
genital inflammation that recruits infected T-cells into the genital tract
(Cohen et al., 2019; Passmore et al., 2016). Co-factors for the efficiency of
sexual transmission continue to be elucidated (Council et al., 2020; Noël-
Romas et al., 2020).
Blood-borne transmission among people who inject drugs is quite
efficient because of the volume of infectious blood that can be derived
from a person with untreated HIV (Degenhardt et al., 2010). The opioid
crisis has contributed to a new wave of HIV in some parts of the United
States, as illustrated by the Scott County, Indiana outbreak (Alpren et al.,
2020; Crowley and Millett, 2017; Des Jarlais et al., 2020; Gonsalves and
Crawford, 2018; Kishore et al., 2019; Peters et al., 2016).
While HIV spread is driven by the prevalence of unrecognized and
untreated HIV infections (Cohen, 2006), co-factors and especially concom-
itant STIs enhance the efficiency of sexual HIV transmission, by increasing
either the person’s infectiousness or the partner’s susceptibility (Baggaley
and Hollingsworth, 2015; Blaser et al., 2014) (see Figure 5-1).
Sexual behaviors per se can affect the probability of transmission.
For example, condomless anal intercourse leads to a transmission prob-
ability at least 10 times higher than penile-vaginal intercourse (Dosekun
and Fox, 2010; Harman et al., 2013; Vermund and Leigh-Brown, 2012). It
is generally believed that the density of lymphocytes and dendritic cells
“defending” anal tissue (yet susceptible to HIV), and possibly the fragility
of the anal and rectal mucosa and associated trauma, accounts for this risk
(Harman et al., 2013; Kaul et al., 2008; Schneider et al., 1996).
Early in the pandemic, it was recognized that STIs (e.g., syphilis,
herpes simplex virus type 2 [HSV-2], gonorrhea, and chlamydia) that
were detected in people with HIV infection, might have amplified viral
transmission through access provided by genital ulceration and mucosal
inflammation (see Figure 5-1). Piot and Laga (1989, p. 624) focused on this
idea in their early work in Zaire, stating that
Programs to control sexually transmitted diseases should be strength-
ened or initiated where they do not exist. Not only will this reduce the
incidence of severe complications and sequelae of sexually transmitted
disease, but it may also interfere with the spread of HIV. The two things
not to do are to take the resources for AIDS prevention away from the
general budget to control sexually transmitted diseases and to isolate
the programs to prevent AIDS from those to control sexually transmit-
ted diseases.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
INTERSECTION OF HIV AND STIs 251
Estimated distribution of viral load in semen
Theoretical viral load in semen with hypothetical intervention
5
------ Threshold viral load (VL) for HIV transmission
HIV RNA in semen
(log10 copies/ml)
4
With intercurrent infections that
increase HIV VL
3
FIGURE 5-1 Intercurrent infections and HIV viral load: A conceptual example
of someone who might be more infectious at different times in the course of
their HIV infection, depending on coinfections, notably sexually transmitted
infections.
NOTE: HSV-2 = herpes simplex virus type 2; TB = tuberculosis.
SOURCE: Informed by Cohen and Pilcher, 2005.
The relationship between well-known STIs and HIV was described
as “epidemiologic synergy” to emphasize how each might exacerbate the
transmission or pathogenicity of the other (Wasserheit, 1992). The synergy
concept highlighted key populations that might be affected by both HIV
and other STIs, including the challenges in treating STIs in persons with
advanced HIV who might be profoundly immunosuppressed. According
to this idea, STIs made people more susceptible to HIV and rendered
people with HIV more infectious as well.
Interest in the relationship between STIs and HIV led to an explo-
sion of research, including study of the biological basis for epidemio-
logic synergy (Galvin and Cohen, 2004). When the HIV pandemic began,
the virus only could be studied by growth in tissue culture, a laborious
procedure that required intensive safety precautions. Developing a poly-
merase chain reaction (PCR) assay that amplified viral RNA allowed HIV
to be quantitated as the number of copies in blood or a bodily secretion.
Using this technique, Mellors et al. (1996) were able to show that the HIV
concentration in blood was correlated with the rate of clinical decline in
the MultiCenter AIDS Cohort Study. In remarkably consistent landmark
articles from Uganda and Zambia, studies of serodiscordant heterosexual
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
252 SEXUALLY TRANSMITTED INFECTIONS
couples (i.e., one partner with HIV and the other without) were able to
correlate the blood concentration with the probability of heterosexual
transmission (Fideli et al., 2001; Quinn et al., 2000). Subsequent field
studies in Africa have helped define the concentration of HIV in mucosal
secretions required for transmission (Baeten et al., 2011; Lingappa et al.,
2010). Systematic reviews suggested the benefits of preventing coinfec-
tions, including STIs, in reducing HIV viral load and presumed HIV
transmission risks (Modjarrad et al., 2008).
Just as PCR was a game changer for monitoring disease progression
and treatment response, rapid, affordable, point-of-care (POC) diagnostics
were a key to expanded HIV treatment and prevention (Manoto et al.,
2018). The advent of these technologies for HIV diagnosis and manage-
ment starkly contrasts with modern-day approaches to classical STIs, in
which POC tests are only now emerging, and at a slow pace and high cost
compared to POC tests for HIV (see Chapter 7).
Using PCR, investigators were able to demonstrate that STIs revers-
ibly increased the concentration of HIV in genital secretions, supporting
the theory that the higher viral concentrations evoked by STIs increased
HIV transmission (Cohen et al., 1997; Johnson and Lewis, 2008). STIs
also lowered the viral threshold for HIV transmission, with STI-induced
denuded mucosa and epithelium (rich in inflammatory cells) increasing
HIV acquisition (Galvin and Cohen, 2004; Mayer and Venkatesh, 2011).
Furthermore, STIs increase the number of inflammatory cells available
and the expression of critical receptors on such cells, further facilitating
HIV infection (Galvin and Cohen, 2004; Sheffield et al., 2007). HIV vari-
ants less fit for growth were shown to persist as a cause of infection in
the presence of an STI coinfection (Carlson et al., 2014). The emerging
paradigm suggested that people with unrecognized or untreated STI–HIV
coinfection might first transmit the more efficient “classical” STIs, causing
enough inflammation in the sexual partner to set the stage for subsequent
HIV transmission. In an effort to stem the global HIV pandemic, thera-
peutic studies of treatment of STIs to reduce HIV transmission efficiency
were conducted.
Treatment of STIs to Prevent HIV: Before Antiretroviral Treatment
In the early days of the HIV epidemic, the principal tools to prevent
sexual transmission were the “ABCs”—abstain from sex, be faithful in
sexual partnerships, and use latex condoms consistently and correctly
(AIDS Epidemic Sparks Campaign to Encourage Condom Use, 1985).
While they are perhaps not always easy to use and are often not a popu-
lar option among prospective users, latex condoms are very effective at
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
INTERSECTION OF HIV AND STIs 253
preventing transmission of HIV and many other STIs (Fonner et al., 2014;
Purcell et al., 2017; Shahmanesh et al., 2008; Weller and Davis, 2002).
Given the emphasis on “epidemiological synergy” (Fleming and
Wasserheit, 1999) and data indicating STIs to be a risk factor for HIV
transmission, it was hoped that treating one or more STIs could reduce
the spread of HIV. Investigators attacked the STI/HIV problem in many
ways, including increasing effort(s) to determine the most important STI
coinfection (Abu-Raddad et al., 2008; Buchacz et al., 2004; Cohen, 1998;
Fleming and Wasserheit, 1999; Freeman et al., 2006; Laga et al., 1993;
Quinlivan et al., 2012; Sheffield et al., 2007; van de Wijgert et al., 2009) and
ramp up diagnostic and treatment efforts against STIs. The basic idea was
that the spread of HIV could be partially controlled through treatment of
STIs and, perhaps, other coinfections (Modjarrad and Vermund, 2010).
As treatment of gonococcal infections significantly reduced HIV con-
centrations in semen (Cohen, 1998; Cohen et al., 1997), it was presumed
that controlling gonorrhea, and perhaps chlamydia, would reduce HIV
transmission efficiency. Similarly, treating trichomonas led to reduced
HIV in vaginal secretions (Hobbs et al., 1999; Kissinger and Adamski,
2013; Price et al., 2003). HIV acquisition may have been reduced modestly
after bacterial vaginosis treatment (Taha et al., 1998). Indeed, there has
long been an interest in the effect of vaginal flora on HIV acquisition. The
general idea was that replacing lactobacilli (normal vaginal flora) with
anaerobic bacteria causes bacterial vaginosis, a disruption that facilitated
HIV infection (Taha et al., 1998). Vaginal douching may be harmful for
women by disturbing healthy vaginal microbiota (see Chapter 3 for more
information on douching). More recently, the vaginal flora have been
studied with molecular methods that carefully define bacterial species
responsible for vaginal “dysbiosis” and inflammation, and this work has
stimulated renewed interest in novel ways to prevent HIV (Masson et al.,
2019; McClelland et al., 2018; Sabo et al., 2020).
Given the high prevalence of genital HSV-2 (Weiss, 2004), Celum
and colleagues studied the ability of acyclovir (an antiviral drug that
suppresses herpes virus infection activity) to reduce HIV infectious-
ness (Celum et al., 2008, 2010) and acquisition in serodiscordant couples
(Celum et al., 2008). Acyclovir, however, was not able to prevent HIV
transmission; the authors and others have postulated that this inability
to reduce HIV infections may have been due to inadequate dosing and/
or to persistent inflammation that treating HSV-2 did not eliminate (Zhu
et al., 2009). Acyclovir for genital ulcers only modestly reduced the HIV
blood viral burden (Celum et al., 2010).
Looking back, a far more ambitious plan was mass treatment of
STIs to reduce HIV incidence. Nine STI/HIV prevention trials were con-
ducted between 1995 and 2010 (Celum et al., 2008, 2010; Ghys et al., 2001;
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
254 SEXUALLY TRANSMITTED INFECTIONS
Gregson et al., 2007; Grosskurth et al., 1995; Hayes et al., 2010; Kamali et
al., 2003; Kaul et al., 2004; Watson-Jones et al., 2008; Wawer et al., 1998,
1999; Wetmore et al., 2010). These trials were launched at a time when
HIV was spreading rapidly, and no other biological prevention strategies
were available in low-resource settings. STI mass treatment trials were
primarily conducted outside of the United States, where the intersecting
high prevalence of HIV and STIs allowed assessment of this hypothesis.
In a community-randomized trial conducted in the Mwanza district of
Tanzania, HIV incidence was reduced by 40 percent by prompt syndromic
treatment of STIs (Grosskurth et al., 1995). Other similar trials, however,
did not realize the same benefit, and the causes for this discrepancy have
been the subject of extensive consideration: issues relating to the stage of
the epidemic in which the intervention occurred, the exact nature of the
approach to STI control, populations affected, and other factors (Hayes
et al., 2010; White et al., 2008). The results of these studies were disap-
pointing and suggested that while STI control was important, it was not a
robust strategy, apart from other measures, for substantial HIV prevention
(Abuelezam et al., 2016; Vermund and Hayes, 2013). The STI outcomes in
many of these studies have defined innovative strategies to reduce STI
incidence, an outcome quite important to this report. Ultimately, develop-
ment of potent combinations of antiretroviral agents led the HIV research
community away from further and more intensive consideration of STI
control as a major pillar of HIV prevention (Heaton et al., 2015).
Management of HIV, Antiretroviral Treatment, and STIs
In 1988, azidothymidine (AZT or zidovudine [ZDV]) was recognized
to reduce replication of HIV and death from HIV/AIDS (Fischl et al.,
1987) and the transmission of HIV to the child during and after pregnancy
(Connor et al., 1994). By 1996, triple-drug, multi-class ZDV had become
the standard of HIV care (Carpenter et al., 1996), and by 2006, antiretro-
viral treatment (ART) treatment was typically reduced to one pill per day
for treatment-naïve individuals.
Observational studies of HIV serodiscordant couples (Fideli et al.,
2001; Quinn et al., 2000) found no sexual transmissions when the per-
son living with HIV had a low viral load. Similarly, antiretroviral drugs
prevented HIV transmission in pregnancy by reducing viral loads, par-
ticularly in parts of sub-Saharan Africa where young, reproductive-age
women bore a disproportionate burden of disease (Guay et al., 1999;
Stringer et al., 2003). In 2011, the HPTN 052 trial (Cohen et al., 2011)
proved that ART virtually eliminated HIV transmission in heterosexual
couples once viremia is suppressed, putting the “treatment as preven-
tion” (TasP) prospect at the forefront of HIV control policies (Cohen et
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
INTERSECTION OF HIV AND STIs 255
al., 2011, 2012, 2016). Newer studies in MSM engaged in condomless anal
intercourse confirmed the remarkable relationship between suppressing
HIV replication and eliminating transmission (Rodger et al., 2016).
These studies ultimately led to considering ART-based treatment as
a tool for prevention—TasP. This strategy seeks to maximize the propor-
tion of persons living with HIV who are successfully diagnosed, treated,
and virally suppressed, such that they are far less likely to transmit the
virus. Recognizing the potential of effective treatment to stop the spread
of HIV, the “Swiss Statement” (Vernazza and Bernard, 2016; Vernazza
et al., 2008) outlined the potential for unprotected intercourse in people
with HIV with effective and sustained suppression of viral replication.
The Swiss Statement presaged the very popular global U=U campaign
(undetectable viral load equals untransmittable) (Cohen et al., 2012; Hasse
et al., 2010; Persson, 2010; The Lancet HIV, 2017). U=U seeks to simplify
HIV prevention strategies, though there are challenges with this unitary
TasP message (Grace et al., 2020; Rendina et al., 2020). While not under-
mining its significance, TasP alone is not likely to be sufficient to end the
AIDS epidemic. Recent community-based trials of ART failed to show
the desired population-level reduction of HIV anticipated, suggesting the
need for more robust combination prevention strategies (Abdool Karim,
2019; Havlir et al., 2019; Hayes et al., 2019; Makhema et al., 2019). (See
Chapter 7 for a discussion of STI PrEP.) Advances in HIV treatment, and
efforts to increase HIV diagnosis, continue to transform the appreciation
of the relationship between STIs and HIV. Since HIV was recognized as a
sexually transmitted pathogen, several classical STIs were appropriately
identified as potential markers of higher HIV exposure risk and amplified
acquisition (Cohen et al., 2019; Kalichman et al., 2010; Melo et al., 2019)
(see Figure 5-1). HIV is frequently detected in STI clinic patients, so STI
clinics are important venues at which to screen and identify people with
highly infectious acute, early, and/or untreated HIV infection (Fiscus et
al., 2007; Kojima et al., 2009; Pilcher et al., 2004a; Powers et al., 2007; Rut-
stein et al., 2016; Wolpaw et al., 2011). Detecting STIs in this setting allows
for effective treatment. Since ART takes many weeks to reduce viral bur-
den, the immediate treatment of STIs in people with newly detected HIV
infection has an important public health benefit, as demonstrated for the
treatment of gonorrhea (Cohen et al., 1997).
Unfortunately, HIV testing is often overlooked when STIs are detected,
especially in MSM (Klein et al., 2014; Millett et al., 2011). Conversely, STI
screening is performed very inconsistently among persons infected with
HIV (Landovitz et al., 2018a; Li et al., 2019a). Smith et al. (2019) noted
that people newly diagnosed with HIV had frequently sought care in the
previous year prior to diagnosis, but did not receive an HIV test even
though STIs were often the presenting complaint. This represents a critical
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
256 SEXUALLY TRANSMITTED INFECTIONS
“missed opportunity” for HIV diagnosis when another STI is suspected
and/or screened for (Peterman et al., 2015). For example, an MSM with
an STI in New York City had a substantial chance to acquire HIV in the
subsequent year (Pathela et al., 2015). Models suggest that targeting per-
sons with gonorrhea or syphilis would substantially improve the impact
of pre-exposure prophylaxis (PrEP) programs for HIV (described later
in this chapter) (Kasaie et al., 2019). In 2019, researchers at the Centers
for Disease Control and Prevention (CDC) and the University of Albany
published a modeling study of U.S. MSM that found that 10.2 percent of
HIV infections were attributable to infection by chlamydia and/or gonor-
rhea in one or both of the partners (Jones et al., 2019). While the focus of
this report is preventing and treating STIs, the additional critical public
health benefits related to HIV and viral hepatitis cannot be overlooked.
And, in turn, screening for STIs among persons living with HIV or being
monitored for high HIV risk is vital to reduce STIs in the United States
(Dresser et al., 2020; Kennedy et al., 2017). Metrics and programmatic inte-
gration in the United Kingdom may serve as a model (see, e.g., Michael
et al., 2017; Molloy et al., 2017).
In a recent multi-jurisdictional study, Norkin et al. (2021) found that
previously diagnosed HIV infection was common among persons diag-
nosed with early syphilis, latent syphilis, and gonorrhea, yet that over
a quarter of these patients were out of care and/or had unsuppressed
HIV viral loads at the time of STI diagnosis. This result indicates that
a greater integration of HIV and STI control efforts would improve the
highly interrelated landscapes of HIV and STI care and transmission
(Norkin et al., 2021).
The management of HIV has critical lessons for STI prevention
and care. Missed opportunities for HIV detection and care have been
addressed with policy changes, including (1) removing barriers to broader
clinic-based screening by eliminating written consent for an HIV test and
adopting verbal consent with a chart notation (Wing, 2009); (2) increasing
resources for clinic and community testing, including expanded testing
tailored to specific high-prevalence communities (Chou et al., 2019); and
(3) following United States Preventive Services Task Force guidelines for
broad population-based screening designed to test more persons who do
not perceive themselves to be at risk or whose clinical providers do not
appreciate their risk. Strategies to provide convenient and routine testing
for persons at risk apply just as well to STIs as they do for HIV (Owens
et al., 2019).
By some estimates, HIV detection rates in the United States have
risen to 86 percent of all persons living with HIV; still, one in seven such
persons is unaware of their HIV status. This pool of individuals likely
represents a highly marginalized subset and may be disenfranchised in
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
INTERSECTION OF HIV AND STIs 257
a variety of ways from mainstream testing, public health, and medical
infrastructures. As recently as 2015, the median time from HIV infection
to diagnosis was estimated to be 3 years, and one in four people had
been living with the virus for 7 or more years before diagnosis. Delayed
detection of HIV is most notable in sexual and racial minorities, especially
MSM of color (CDC, 2010; Gamarel et al., 2018; Millett et al., 2011). Fur-
thermore, use of UNAIDS 90-90-90 (2020 goal) and 95-95-95 (2030 goal)
metrics may overestimate true coverage in the neediest communities
(Haber et al., 2020). Such a failure to test and link to care is mimicked
in the STI field, where treatment for STIs is often delayed or overlooked
altogether, typically in marginalized populations that do not receive opti-
mized health care screening or care.
HIV diagnosis and linkage to care through programs like the Ryan
White HIV/AIDS Program (discussed below) should facilitate targeted
and regular STI testing. Kalichman et al. (2011) reviewed STI incidence
and prevalence in persons living with HIV or AIDS, noting a 19 per-
cent point prevalence of one or more STIs. Accordingly, current CDC
(Workowski and Bolan, 2015) and World Health Organization (WHO,
2016) guidelines call for routinely testing for and treating STIs in people
living with HIV. About half of all U.S. people with HIV receive services
from the Ryan White HIV/AIDS Program (HRSA, 2020).
The rising incidence of STIs in persons living with HIV or AIDS after
the availability of ART launched a discussion of “risk compensation”
or “behavioral disinhibition.” This public health paradox theorizes that
reduced fear of transmitting or acquiring HIV due to ART may have led
to reduced use of condoms, more partners, and higher STI rates (DiCle-
mente et al., 2002; Eaton and Kalichman, 2007; Moskowitz and Roloff,
2010; Pinkerton, 2001). Reports on this topic in both heterosexual men
(Apondi et al., 2011; Crepaz et al., 2004; Westercamp et al., 2014) and MSM
have varying opinions and conclusions (Cassell et al., 2006; Delva and
Helleringer, 2016; Dukers et al., 2001; Katz et al., 2002; Rietmeijer et al.,
2003; Stolte et al., 2001; Venkatesh et al., 2011). Qualitative studies suggest
that MSM self-report less condom use with less fear of HIV lethality; it is
not as apparent that this loss of fear has affected the sexual behavior of
heterosexual people (Flagg et al., 2015; Harawa et al., 2008; Vanable et al.,
2012; Wade Taylor et al., 2013; Woods et al., 2013).
Another issue is the lack of perceived harm from the consequences
of STIs in persons living with HIV or AIDS. MSM may not see untreated
STIs and HIV as serious consequences within their communities, given
that the principal damage of STIs is to fertility in people assigned female
at birth or their neonates (Marston et al., 2017; Ross, 2001; Tsevat et al.,
2017; Wiesenfeld et al., 2012). It is not widely appreciated that without
effective ART, STIs can have more pathogenic consequences, as sometimes
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
258 SEXUALLY TRANSMITTED INFECTIONS
demonstrated by severe or unusual manifestations of syphilis, HSV-2, and
chancroid (Courjon et al., 2015; Hanson et al., 2014; Mena Lora et al., 2017;
Oette et al., 2005; Peeling and Hook, 2006; Rompalo et al., 2001a,b; Tran et
al., 2005; Wang et al., 2012).
Antiretroviral Agents as Pre-Exposure Prophylaxis (PrEP) for HIV
Beyond TasP, another biological solution for the prevention of an
infection is pre- and post-exposure prophylaxis (PrEP and PEP). PrEP,
used as designed, represents a theoretically powerful tool for disrupting
the trajectory of the HIV epidemic and has received great attention. Tri-
als of tenofovir/emtricitabine (TDF-FTC), and more recently tenofovir
alafenamide (TAF)-FTC, demonstrated remarkable HIV protection in men
(Grant et al., 2010; Mayer et al., 2020; McCormack et al., 2016; Molina et
al., 2017) and likely comparable effects in women (although not as well
documented) (Janes et al., 2018). Despite its efficacy, HIV PrEP effective-
ness has been limited by slow and incomplete uptake in populations most
at risk for HIV; mathematical modeling suggests high PrEP use rates are
needed to have an impact on the HIV epidemic (Buchanan et al., 2020;
Gomez et al., 2012; Marshall et al., 2018). Encouragingly, a report linked
PrEP prescriptions to reduced HIV incidence in some U.S. communities
(Jenness et al., 2019). Several important health care providers and industry
partners have assured support for the Ending the HIV Epidemic: A Plan
for America campaign (discussed below) (HHS, n.d.). This plan focuses
on HIV detection, TasP, and PrEP (Fauci et al., 2019).
In addition, a long-acting injectable agent, cabotegravir, prevented
HIV in MSM better than oral TDF-FTC (HPTN 083) (HPTN, 2020; Lando-
vitz et al., 2018b). A trial of this same agent in women (HPTN 084) demon-
strated that cabotegravir was safe and superior to daily oral FTC/TDF for
HIV prevention among cisgender women in sub-Saharan Africa (Delany-
Moretlwe et al., 2020). The antiretroviral agent dapivirine, embedded in
vaginal rings, led to modest reduction in HIV acquisition, depending
on reliable and proper use of the devices (Baeten et al., 2016; Rosenberg,
2017). Recently, the European Medicines Agency and WHO have looked
favorably on distribution of dapivirine antiretroviral microbicide rings
to help reduce acquisition of HIV (Baeten et al., 2016; Rosenberg, 2017;
WHO, 2020, 2021). All of these HIV PrEP strategies may lend themselves
to further consideration of STI PrEP (discussed in Chapter 7). In addition,
multi-purpose rings to prevent HIV or STIs or pregnancy concomitantly
are in development (Achilles et al., 2018; Dallal Bashi et al., 2019; Li et al.,
2019b; Young Holt et al., 2020).
Mirroring the debate regarding risk compensation or behavioral dis-
inhibition as contributing to high rates of STIs after scale-up of ART, PrEP
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
INTERSECTION OF HIV AND STIs 259
has also sparked intense scrutiny of sex behaviors leading to greater STI
acquisition (Blumenthal and Haubrich, 2014; Cassell et al., 2006; Grov et
al., 2015; Guest et al., 2008; Marcus et al., 2013, 2019; Milam et al., 2019;
Rojas Castro et al., 2019). While STI rates were clearly on the rise before
TDF-FTC as PrEP (Marrazzo et al., 2018), the increase has continued. Of
88 articles that examined STI prevalence at the time of PrEP initiation, a
systematic review found that in studies that enabled a composite outcome
of chlamydia, gonorrhea, and early syphilis, the pooled prevalence was
23.9 percent (95% confidence interval: 18.6%–29.6%) at baseline (Ong et
al., 2019).
There are multiple explanations for concurrent rise of STIs and PrEP.
These include increased detection due to more frequent testing and
improved diagnostics of STIs, as mandated by many PrEP implementa-
tion guidelines, and behavioral risk taking among PrEP users who eschew
condoms and are therefore de facto at greater risk for STIs (Ramchandani
and Golden, 2019; Scott and Klausner, 2016; Stenger et al., 2017). Despite
what is clearly a complex relationship of STI rates in the setting of PrEP,
one thing should not be ignored: in the context of a population with
a more generalized HIV epidemic, presenting with a new STI should
prompt a provider to discuss PrEP. These missed opportunities are just
one of the reasons that PrEP uptake has fallen short of the level needed
to make the greatest impact. (See Chapter 7 for a discussion of PrEP for
STIs apart from HIV.)
Substance Use, Alcohol Use, and STI/HIV Risk
The syndemic of STI and HIV risk is linked with substance use and/
or alcohol use in at least three contexts. First, persons using drugs such
as opioids, cocaine, or methamphetamines may support their cravings by
selling sex or exchanging sex for drugs. Second, sexual activity may be
linked to use of alcohol or party or club drugs/chemsex (to enhance or
facilitate greater pleasure or extended sexual activity), including MDMA
(3,4-methylenedioxy-methamphetamine, often known as “ecstasy”), GHB
(gamma hydroxybutyrate, also known as a “date rape” drug), Rohypnol
(flunitrazepam, also a “date rape” drug), ketamine, methamphetamine,
LSD (acid), and cocaine/crack cocaine, to name a few of the most popular
drugs. Third, some MSM have drugs that for decades have been used in
concert with sex, including alcohol, erectile dysfunction drugs, such as
sildenafil, volatile nitrates (poppers), and the aforementioned club drugs
(McCarty-Caplan et al., 2014). When persons who wish to have sex are
using alcohol and/or drugs, risk taking is more likely and condom use
is far less likely (Bonar et al., 2014; Pellowski et al., 2018; Reynolds and
Fisher, 2019; Santelli et al., 2001; Storholm et al., 2017).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
260 SEXUALLY TRANSMITTED INFECTIONS
CONSEQUENCES OF STIs IN PEOPLE LIVING WITH HIV
STIs among people living with HIV represent a significant risk for
reproductive tract sequelae for themselves and their sexual partners.
While STIs may cause fewer reproductive complications in MSM, bridg-
ing STIs to the heterosexual male population and to women has been
demonstrated (Williamson et al., 2019). Additionally, the rise in syphilis
among women has led to a dramatic rise in congenital syphilis, both in
the United States and worldwide (Liew et al., 2021; Schmidt et al., 2019).
Currently, CDC (Barrow et al., 2020) and WHO (2016) treatment and
prevention guidelines recommend frequent testing for and treatment of
STIs, but HIV—given its potential lethality, incurability, and high preva-
lence—remains a far greater funding and programmatic priority from
governments and foundations alike (Barrow et al., 2020).
STIs are used to represent markers of sexual behavior. A history of
an STI is often required to enroll in HIV prevention trials and to justify
PrEP. HIV prevention trials rarely target both HIV and STIs, focusing on
HIV as the most serious of all the STIs. While an STI may indicate higher-
than-average HIV risk, the trends of STIs and HIV may not be in sync.
For example, as ART and PrEP use expands, HIV incidence has declined,
perhaps a “treatment as prevention” effect. At the same time, STI rates
continue to rise.
Recently, the White House has launched Ending the HIV Epidemic: A
Plan for America, with four pillars (Fauci et al., 2019):
• Diagnose all individuals with HIV as early as possible after
infection;
• Treat HIV infection rapidly and effectively to achieve sustained
viral suppression;
• Prevent at-risk individuals from acquiring HIV, including the use
of PrEP and syringe exchange programs; and
• Rapidly detect and respond to emerging clusters of HIV infection
to reduce new transmissions.
While treatment of HIV/AIDS is a key pillar, STI control is not explic-
itly included in this strategy, which may represent a missed opportunity
for better integration of management of HIV, STIs, and viral hepatitis.
Importantly, before leaving office, the Trump administration’s Office of the
Assistant Secretary for Health at the Department of Health and Human
Services (HHS) published an HIV National Strategic Plan (HIV-NSP) in
January 2021 (HHS, 2020a). Additionally, President Biden, in Decem-
ber 2020, committed his administration to updating the National HIV/
AIDS Strategy for the United States (the most recent iteration covered
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
INTERSECTION OF HIV AND STIs 261
2015–2020) (KFF, 2020), which may presumably start with a review of
the HIV-NSP. The HIV-NSP, however, is focused on the 48 U.S. coun-
ties responsible for half of all HIV diagnoses, along with the District of
Columbia and San Juan, Puerto Rico, and 7 rural states with HIV risks
derived from the opioid epidemic and other concerns. The Office of the
Assistant Secretary for Health also updated the National Viral Hepatitis
Action Plan (HHS, 2020c) and recently released the first-ever federal STI
National Strategic Plan (STI-NSP, see Chapter 12 for more information)
(HHS, 2020b). The STI-NSP emphasizes coordination with Ending the
HIV Epidemic (EHE) (HHS, 2020b) (see Box 5-1 and additional discussion
later in this chapter).
IMPORTANT LESSONS FROM THE HIV PANDEMIC
The worsening spread of STIs motivated the request for this report
and is linked to the novel STI-NSP (HHS, 2020a). The committee believes
there are important lessons to be learned from historical and ongoing
attempts to control the spread of HIV. First, successes in treating and
preventing HIV reflect unique, sustained, and powerful advocacy by
BOX 5-1
Example of Synergies Between Ending the HIV Epidemic
(EHE) from the 2020 STI National Strategic Plan
EHE is a bold initiative by the U.S. government to end HIV in the nation by
2030. Efforts to control HIV have crosscutting effects on the control of other sexual
transmitted infections (STIs). For example, EHE’s funding and support of STI
clinics in three jumpstart jurisdictions—Baltimore City, Maryland; DeKalb County,
Georgia; and East Baton Rouge Parish, Louisiana—supports both missions.
Scaling Up HIV Prevention Services in Specialty STI Clinics
In 2019, each of the three jurisdictions was awarded $1.3 million to strengthen
the infrastructure of STI clinics serving a high proportion of racial/ethnic and sexual
minorities as part of the implementation phase of EHE. In just a few months, the
jurisdictions implemented innovative, evidence-based approaches to scale up
clinic capacity and HIV care services with self-registration kiosks, express visits,
virtual visits for PrEP follow-up, and a citywide health resource directory to connect
STI clinic patients with key resources.
This is one example of the STI Plan’s integrated approach to addressing the
critical and time-sensitive concurrent STI and HIV epidemics in some of the highest
burden, but lowest health-resource settings.
SOURCE: HHS, 2020b.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
262 SEXUALLY TRANSMITTED INFECTIONS
affected communities. The rise of the Gay Men’s Health Crisis and other
community-based organizations across the country, along with establish-
ment of local and national activist and advocacy organizations, including
the AIDS Coalition to Unleash Power, the National Association of People
with AIDS, NMAC (formerly the National Minority AIDS Council), the
Latino Commission on AIDS, the Black AIDS Institute, and the Treat-
ment Action Group in the 1980s and 1990s, books and dramatic works,
such as And the Band Played On (book and movie), The Normal Heart and
Angels in America (plays), Philadelphia (movie), and celebrity disclosure of
HIV infection (e.g., Rock Hudson, Liberace, Arthur Ashe, Magic Johnson,
Greg Louganis, Freddie Mercury, and Charlie Sheen) inspired massive
commitments to treating and preventing HIV. The late Surgeon General
C. Everett Koop’s ”Understanding AIDS” mailing to all U.S. households
by CDC in 1986 acknowledged HIV as a major public health problem
and urged Americans to seek testing (Koop, 1986). This was a remark-
able moment: the Surgeon General with CDC, independent of the White
House, acknowledged an STI, urged all Americans to get tested, and
advocated for healthier sexual behaviors to the entire U.S. population.
Effective advocacy ultimately led to resources for HIV treatment
and infection at a level that has been unavailable for STIs and many
other infectious diseases. In 1990, the Ryan White Comprehensive AIDS
Resources Emergency Act was enacted, named for a courageous young
boy with hemophilia who died from HIV and whose family was ostra-
cized; his family were tireless in their search to access government
resources and showed understanding and compassion for people with
HIV. This critical and remarkably successful legislation was the first
attempt to mount a nationwide response to the care and treatment
needs of people with HIV by expanding funding for high-prevalence
cities and metropolitan areas and providing funding to states and HIV
primary care clinics in areas with lower prevalence, which has allowed
for high-quality care for more than half of the people living with HIV
in the United States.
In 2003, President Bush developed the President’s Emergency Plan
for AIDS Relief with broad bipartisan support, providing resources to
address global HIV prevention and treatment. These substantial funding
commitments, nationally and globally, resulted in advances in diagnostics
and therapies that fundamentally shifted outcomes, notably in Africa.
Moreover, the rise in the number of persons living with HIV or AIDS
that accompanied breakthroughs in treatment has sustained a level of
advocacy and attention to HIV that is perhaps unparalleled relative to
other health conditions, at least before the COVID-19 pandemic. Public
health messaging centers on positive messages from diverse individuals
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
INTERSECTION OF HIV AND STIs 263
living with HIV, including celebrities and prominent people from all
walks of life and HIV-negative allies among civic leaders, faith leaders,
elected officials, athletes, and celebrities.
These observations need to be compared with historical efforts at
STI control; classical STIs have simply never received the same funding
or national awareness. There has been no parallel movement or aware-
ness, with rare literary exceptions like the 1882 Henrik Ibsen play Ghosts
(shocking and reviled at the time of its release) and the little-known 1993
play In the Clap Shack by well-known novelist William Styron. While an
Internet search will find many celebrities diagnosed with HSV-2, chla-
mydia, gonorrhea, syphilis, and other STIs, none speak out in advocacy
for prevention and control as is seen for HIV. Advocacy organizations
exist2 but are not anywhere near as successful in defining STIs as an
important cause worthy of public attention as HIV community-based
and policy-oriented groups have been. In fact, comedy routines discuss-
ing STIs may actually have an opposing effect: leading people to be less
concerned about STI severity and prevention. For example, Saturday Night
Live’s Weekend Update on October 12, 2019, parodied that STIs have a
relatively low negative impact on quality of life compared to other infec-
tious diseases, such as influenza (SNL, 2019). Although such content
is designed for entertainment, trivializing the harms of STIs likely also
influences viewers’ attitudes/beliefs and behaviors. The STI epidemic’s
growth reflects many social, biological, and behavioral forces; limited
resources for public awareness and risk reduction education, and limited
investments in surveillance, screening, and treatment, also contribute to
STI spread.
CONCLUSIONS
This chapter has sought to provide historical information about HIV
and emphasize the inextricable linkage between HIV, classical STIs, and
viral hepatitis. Ultimately, HIV and many types of viral hepatitis are most
importantly STIs. While the committee was not charged with providing
policy recommendations related to HIV, it offers a series of conclusions
(see Box 5-2 for examples of potential synergies between HIV and STI
prevention, treatment, and control):
Conclusion 5-1: STIs and HIV are inextricably linked. Over the past 40
years, however, they frequently have been addressed in silos by the U.S.
public health system even though they are very often detected concomitantly.
2 See https://www.ncsddc.org/national-sti-coaltion-members (accessed October 16, 2020).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
264 SEXUALLY TRANSMITTED INFECTIONS
Conclusion 5-2: There are opportunities for greater synergies for HIV and
STIs that would improve prevention, treatment, and linkage to care for both.
STI and HIV service integration at the client level and program integration
at the federal, state, and local levels will enhance the prevention and care of
both. Furthermore, increased education for HIV providers regarding treat-
ment and prevention of STIs is needed.
Conclusion 5-3: Significant federal investments have been made toward
screening individuals for HIV, yet when such screening is not integrated
with screening for bacterial STIs, it represents a missed opportunity. Con-
versely, it is equally important to assess HIV status among those diagnosed
with a bacterial STI; and for those with HIV infection, screening for other
STIs should be elevated as a priority within routine clinical management of
HIV.
Conclusion 5-4: Ending the HIV Epidemic (EHE) has the potential to drive
significant improvements in the health of communities affected by STIs;
therefore, targets for STI reduction could be added to the EHE Plan in
partnership with CDC. While this initiative is supporting STI clinics, the
absence of more central consideration of STIs in the EHE has the potential
to limit the achievements of EHE goals and sustain ongoing transmission
of these infections.
BOX 5-2
Examples of Potential Synergies Between HIV
and STI Prevention, Treatment, and Control
• HIV and sexually transmitted disease (STD) programs at the Centers for
Disease Control and Prevention could collaborate to identify areas for en-
hanced HIV/STD program integration at the state and local levels and
monitor and promote recommended activities. These could include activi-
ties such as integrating pre-exposure prophylaxis (PrEP) referrals and the
identification of out-of-care, HIV-positive persons into STI partner services,
enhancing the provision of PrEP in STI clinics, increasing STI testing in
Ryan White clinics, and using PrEP programs to develop new mechanisms
to promote nonclinical STI testing.
• Ending the HIV Epidemic planning and community engagement could inte-
grate efforts to develop and implement a broader STI control plan.
• Point-of-care diagnostics could be deployed for STIs in nearly all venues
where rapid HIV testing is available.
• Programs that reach out to persons living with HIV, or perceived to be at
higher risk to acquire HIV, could have STI screening and control components.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
INTERSECTION OF HIV AND STIs 265
In past decades, STIs and HIV have mostly been addressed by the U.S.
public health system in “silos” even though they are very often detected
in combination. Advances in HIV can be ascribed to funding and growth
of a massive community of researchers, clinical and community-based
services providers, and people living with HIV and their advocates. In
addition, the rapidity of scientific progress for new diagnostic, therapeu-
tic, and preventative tools contrasts to comparatively indolent progress
for other STIs, despite their clinical recognition for centuries and their
microbiological characterization for many decades. Progress with HIV
underscores what can be done if a problem is confronted and prioritized;
programmatic successes with HIV serve to emphasize the promise for
substantially improved STI control. Yet, public health support for STIs
has lagged the demands of the rising incidence in the United States,
contributing to the rise of STIs and a relative dearth of vaccine research,
innovative diagnostics, and improved treatments. Unfortunately, success
in preventing and treating HIV has likely contributed to STI spread in
some populations, as concern around HIV infection has diminished. STIs
cannot be seen as simply an annoyance or inevitability, given the serious-
ness of STI long-term sequelae, including infertility. STI and HIV service
integration will enhance the prevention and care of both.
REFERENCES
Abdool Karim, S. S. 2019. HIV-1 epidemic control—insights from test-and-treat trials. New
England Journal of Medicine 381(3):286-288.
Abu-Raddad, L. J., A. S. Magaret, C. Celum, A. Wald, I. M. Longini, Jr., S. G. Self, and L.
Corey. 2008. Genital herpes has played a more important role than any other sexually
transmitted infection in driving HIV prevalence in Africa. PLoS One 3(5):e2230.
Abuelezam, N. N., A. W. McCormick, T. Fussell, A. N. Afriyie, R. Wood, V. DeGruttola, K. A.
Freedberg, M. Lipsitch, and G. R. Seage, 3rd. 2016. Can the heterosexual HIV epidemic
be eliminated in South Africa using combination prevention? A modeling analysis.
American Journal of Epidemiology 184(3):239-248.
Achilles, S., C. W. Kelly, D. L. Blithe, J. Long, B. A. Richardson, B. Devlin, C. W. Hendrix,
S. M. Poloyac, M. A. Marzinke, D. Singh, J. M. Piper, J. Steytler, and B. A. Chen. 2018.
Safety and pharmacokinetics of dapivirine and levonorgestrel vaginal rings for multi-
purpose prevention of HIV and pregnancy (abstract OA12.02LB). Madrid, Spain: HIV
Research for Prevention (HIVR4P), October 21-25.
AIDS Epidemic Sparks Campaign to Encourage Condom Use. 1985. Contraceptive Technology
Update 6(12):161-163.
Alpren, C., E. L. Dawson, B. John, K. Cranston, N. Panneer, H. D. Fukuda, K. Roosevelt, R.
M. Klevens, J. Bryant, P. J. Peters, S. B. Lyss, W. M. Switzer, A. Burrage, A. Murray, C.
Agnew-Brune, T. Stiles, P. McClung, E. M. Campbell, C. Breen, L. M. Randall, S. Das-
gupta, S. Onofrey, D. Bixler, K. Hampton, J. L. Jaeger, K. K. Hsu, W. Adih, B. Callis, L.
R. Goldman, S. P. Danner, H. Jia, M. Tumpney, A. Board, C. Brown, A. DeMaria, Jr., and
K. Buchacz. 2020. Opioid use fueling HIV transmission in an urban setting: An outbreak
of HIV infection among people who inject drugs—Massachusetts, 2015-2018. American
Journal of Public Health 110(1):37-44.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
266 SEXUALLY TRANSMITTED INFECTIONS
Apondi, R., R. Bunnell, J. P. Ekwaru, D. Moore, S. Bechange, K. Khana, R. King, J. Campbell,
J. Tappero, and J. Mermin. 2011. Sexual behavior and HIV transmission risk of Ugandan
adults taking antiretroviral therapy: 3 year follow-up. AIDS 25(10):1317-1327.
Baeten, J. M., E. Kahle, J. R. Lingappa, R. W. Coombs, S. Delany-Moretlwe, E. Nakku-Joloba,
N. R. Mugo, A. Wald, L. Corey, D. Donnell, M. S. Campbell, J. I. Mullins, and C. Celum.
2011. Genital HIV-1 RNA predicts risk of heterosexual HIV-1 transmission. Science
Translational Medicine 3(77):77ra29.
Baeten, J. M., T. Palanee-Phillips, E. R. Brown, K. Schwartz, L. E. Soto-Torres, V. Govender,
N. M. Mgodi, F. Matovu Kiweewa, G. Nair, F. Mhlanga, S. Siva, L. G. Bekker, N.
Jeenarain, Z. Gaffoor, F. Martinson, B. Makanani, A. Pather, L. Naidoo, M. Husnik,
B. A. Richardson, U. M. Parikh, J. W. Mellors, M. A. Marzinke, C. W. Hendrix, A. van
der Straten, G. Ramjee, Z. M. Chirenje, C. Nakabiito, T. E. Taha, J. Jones, A. Mayo, R.
Scheckter, J. Berthiaume, E. Livant, C. Jacobson, P. Ndase, R. White, K. Patterson, D.
Germuga, B. Galaska, K. Bunge, D. Singh, D. W. Szydlo, E. T. Montgomery, B. S. Mensch,
K. Torjesen, C. I. Grossman, N. Chakhtoura, A. Nel, Z. Rosenberg, I. McGowan, and
S. Hillier. 2016. Use of a vaginal ring containing dapivirine for HIV-1 prevention in
women. New England Journal of Medicine 375(22):2121-2132.
Baggaley, R. F., and T. D. Hollingsworth. 2015. Brief report: HIV-1 transmissions during
asymptomatic infection: Exploring the impact of changes in HIV-1 viral load due to
coinfections. Journal of Acquired Immune Deficiency Syndromes 68(5):594-598.
Barrow, R. Y., F. Ahmed, G. A. Bolan, and K. A. Workowski. 2020. Recommendations for
providing quality sexually transmitted diseases clinical services, 2020. MMWR Recom-
mendations and Reports 68(5):1-20.
Blaser, N., C. Wettstein, J. Estill, L. S. Vizcaya, G. Wandeler, M. Egger, and O. Keiser. 2014.
Impact of viral load and the duration of primary infection on HIV transmission: Sys-
tematic review and meta-analysis. AIDS (London, England) 28(7):1021-1029.
Blower, S. M., and C. Boe. 1993. Sex acts, sex partners, and sex budgets: Implications for risk
factor analysis and estimation of HIV transmission probabilities. Journal of Acquired Im-
mune Deficiency Syndromes (1988) 6(12):1347-1352.
Blumenthal, J., and R. H. Haubrich. 2014. Will risk compensation accompany pre-exposure
prophylaxis for HIV? Virtual Mentor 16(11):909-915.
Bonar, E. E., R. M. Cunningham, S. T. Chermack, F. C. Blow, K. L. Barry, B. M. Booth, and M.
A. Walton. 2014. Prescription drug misuse and sexual risk behaviors among adolescents
and emerging adults. Journal of Studies on Alcohol and Drugs 75(2):259-268.
Buchacz, K., P. Patel, M. Taylor, P. R. Kerndt, R. H. Byers, S. D. Holmberg, and J. D. Klausner.
2004. Syphilis increases HIV viral load and decreases CD4 cell counts in HIV-infected
patients with new syphilis infections. AIDS 18(15):2075-2079.
Buchanan, A. L., S. Bessey, W. C. Goedel, M. King, E. J. Murray, S. Friedman, M. E. Halloran,
and B. D. L. Marshall. 2020. Disseminated effects in agent based models: A potential
outcomes framework and application to inform pre-exposure prophylaxis coverage
levels for HIV prevention. American Journal of Epidemiology. doi: 10.1093/aje/kwaa239.
Carlson, J. M., M. Schaefer, D. C. Monaco, R. Batorsky, D. T. Claiborne, J. Prince, M. J. Dey-
mier, Z. S. Ende, N. R. Klatt, C. E. DeZiel, T. H. Lin, J. Peng, A. M. Seese, R. Shapiro, J.
Frater, T. Ndung’u, J. Tang, P. Goepfert, J. Gilmour, M. A. Price, W. Kilembe, D. Hecker-
man, P. J. Goulder, T. M. Allen, S. Allen, and E. Hunter. 2014. HIV transmission. Selec-
tion bias at the heterosexual HIV-1 transmission bottleneck. Science 345(6193):1254031.
Carpenter, C. C., M. A. Fischl, S. M. Hammer, M. S. Hirsch, D. M. Jacobsen, D. A. Katzenstein,
J. S. Montaner, D. D. Richman, M. S. Saag, R. T. Schooley, M. A. Thompson, S. Vella, P.
G. Yeni, and P. A. Volberding. 1996. Antiretroviral therapy for HIV infection in 1996.
Recommendations of an international panel. International AIDS Society—USA. JAMA
276(2):146-154.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
INTERSECTION OF HIV AND STIs 267
Cassell, M. M., D. T. Halperin, J. D. Shelton, and D. Stanton. 2006. Risk compensation: The
Achilles’ heel of innovations in HIV prevention? BMJ 332(7541):605-607.
CDC (Centers for Disease Control and Prevention). 1981. Kaposi’s sarcoma and pneumo-
cystis pneumonia among homosexual men—New York City and California. Morbidity
and Mortality Weekly Report 30(25):305-308.
CDC. 1982. Possible transfusion-associated acquired immune deficiency syndrome (AIDS)—
California. Morbidity and Mortality Weekly Report 31(48):652-654.
CDC. 1983. Leads from the MMWR. Acquired immunodeficiency syndrome among patients
with hemophilia. JAMA 250(24):3277-3278.
CDC. 2010. Prevalence and awareness of HIV infection among men who have sex with men—
21 cities, United States, 2008. Morbidity and Mortality Weekly Report 59(37):1201-1207.
Celum, C., A. Wald, J. Hughes, J. Sanchez, S. Reid, S. Delany-Moretlwe, F. Cowan, M.
Casapia, A. Ortiz, J. Fuchs, S. Buchbinder, B. Koblin, S. Zwerski, S. Rose, J. Wang,
and L. Corey. 2008. Effect of aciclovir on HIV-1 acquisition in herpes simplex virus 2
seropositive women and men who have sex with men: A randomised, double-blind,
placebo-controlled trial. Lancet 371(9630):2109-2119.
Celum, C., A. Wald, J. R. Lingappa, A. S. Magaret, R. S. Wang, N. Mugo, A. Mujugira, J. M.
Baeten, J. I. Mullins, J. P. Hughes, E. A. Bukusi, C. R. Cohen, E. Katabira, A. Ronald,
J. Kiarie, C. Farquhar, G. J. Stewart, J. Makhema, M. Essex, E. Were, K. H. Fife, G. de
Bruyn, G. E. Gray, J. A. McIntyre, R. Manongi, S. Kapiga, D. Coetzee, S. Allen, M.
Inambao, K. Kayitenkore, E. Karita, W. Kanweka, S. Delany, H. Rees, B. Vwalika, W.
Stevens, M. S. Campbell, K. K. Thomas, R. W. Coombs, R. Morrow, W. L. Whittington,
M. J. McElrath, L. Barnes, R. Ridzon, and L. Corey. 2010. Acyclovir and transmission
of HIV-1 from persons infected with HIV-1 and HSV-2. New England Journal of Medicine
362(5):427-439.
Chakraborty, H., P. K. Sen, R. W. Helms, P. L. Vernazza, S. A. Fiscus, J. J. Eron, B. K. Patter-
son, R. W. Coombs, J. N. Krieger, and M. S. Cohen. 2001. Viral burden in genital secre-
tions determines male-to-female sexual transmission of HIV-1: A probabilistic empiric
model. AIDS 15(5):621-627.
Chou, R., T. Dana, S. Grusing, and C. Bougatsos. 2019. Screening for HIV infection in asymp-
tomatic, nonpregnant adolescents and adults: Updated evidence report and systematic
review for the US Preventive Services Task Force. JAMA 321(23):2337-2348.
Coates, R. A., and M. T. Schechter. 1988. Sexual modes of transmission of the human im-
munodeficiency virus (HIV). Annals of Sex Research 1:115-137.
Cohen, M. S. 1998. Sexually transmitted diseases enhance HIV transmission: No longer a
hypothesis. Lancet 351(Suppl 3):5-7.
Cohen, M. 2006. Amplified transmission of HIV-1: New clues to the AIDS pandemic. Transac-
tions of the American Clinical and Climatological Association (117):213-225.
Cohen, M. S., and C. D. Pilcher. 2005. Amplified HIV transmission and new approaches to
HIV prevention. The Journal of Infectious Diseases 191(9):1391-1393.
Cohen, M. S., I. F. Hoffman, R. A. Royce, P. Kazembe, J. R. Dyer, C. C. Daly, D. Zimba, P. L.
Vernazza, M. Maida, S. A. Fiscus, and J. J. Eron, Jr. 1997. Reduction of concentration
of HIV-1 in semen after treatment of urethritis: Implications for prevention of sexual
transmission of HIV-1. AIDSCAP Malawi research group. Lancet 349(9069):1868-1873.
Cohen, M. S., Y. Q. Chen, M. McCauley, T. Gamble, M. C. Hosseinipour, N. Kumarasamy,
J. G. Hakim, J. Kumwenda, B. Grinsztejn, J. H. Pilotto, S. V. Godbole, S. Mehendale, S.
Chariyalertsak, B. R. Santos, K. H. Mayer, I. F. Hoffman, S. H. Eshleman, E. Piwowar-
Manning, L. Wang, J. Makhema, L. A. Mills, G. de Bruyn, I. Sanne, J. Eron, J. Gallant, D.
Havlir, S. Swindells, H. Ribaudo, V. Elharrar, D. Burns, T. E. Taha, K. Nielsen-Saines, D.
Celentano, M. Essex, and T. R. Fleming. 2011. Prevention of HIV-1 infection with early
antiretroviral therapy. New England Journal of Medicine 365(6):493-505.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
268 SEXUALLY TRANSMITTED INFECTIONS
Cohen, M. S., C. Holmes, N. Padian, M. Wolf, G. Hirnschall, Y. R. Lo, and E. Goosby. 2012.
HIV treatment as prevention: How scientific discovery occurred and translated rapidly
into policy for the global response. Health Affairs 31(7):1439-1449.
Cohen, M. S., Y. Q. Chen, M. McCauley, T. Gamble, M. C. Hosseinipour, N. Kumarasamy, J. G.
Hakim, J. Kumwenda, B. Grinsztejn, J. H. S. Pilotto, S. V. Godbole, S. Chariyalertsak, B.
R. Santos, K. H. Mayer, I. F. Hoffman, S. H. Eshleman, E. Piwowar-Manning, L. Cottle,
X. C. Zhang, J. Makhema, L. A. Mills, R. Panchia, S. Faesen, J. Eron, J. Gallant, D. Havlir,
S. Swindells, V. Elharrar, D. Burns, T. E. Taha, K. Nielsen-Saines, D. D. Celentano, M.
Essex, S. E. Hudelson, A. D. Redd, and T. R. Fleming. 2016. Antiretroviral therapy for
the prevention of HIV-1 transmission. New England Journal of Medicine 375(9):830-839.
Cohen, M. S., O. D. Council, and J. S. Chen. 2019. Sexually transmitted infections and HIV in
the era of antiretroviral treatment and prevention: The biologic basis for epidemiologic
synergy. Journal of the International AIDS Society 22:e25355.
Connor, E. M., R. S. Sperling, R. Gelber, P. Kiselev, G. Scott, M. J. O’Sullivan, R. VanDyke,
M. Bey, W. Shearer, R. L. Jacobson, et al. 1994. Reduction of maternal-infant transmis-
sion of human immunodeficiency virus type 1 with zidovudine treatment. Pediatric
AIDS Clinical Trials Group Protocol 076 study group. New England Journal of Medicine
331(18):1173-1180.
Council, O. D., S. Zhou, C. D. McCann, I. Hoffman, G. Tegha, D. Kamwendo, M. Matoga, S.
L. Kosakovsky Pond, M. S. Cohen, and R. Swanstrom. 2020. Deep sequencing reveals
compartmentalized HIV-1 in the semen of men with and without sexually transmitted
infection-associated urethritis. Journal of Virology 94(12):e00151-20.
Courjon, J., T. Hubiche, N. Dupin, P. A. Grange, and P. Del Giudice. 2015. Clinical aspects of
syphilis reinfection in HIV-infected patients. Dermatology 230(4):302-307.
Crepaz, N., T. A. Hart, and G. Marks. 2004. Highly active antiretroviral therapy and sexual
risk behavior: A meta-analytic review. JAMA 292(2):224-236.
Crowley, J. S., and G. A. Millett. 2017. Preventing HIV and hepatitis infections among people
who inject drugs: Leveraging an Indiana outbreak response to break the impasse. AIDS
and Behavior 21(4):968-972.
Dallal Bashi, Y. H., C. F. McCoy, D. J. Murphy, P. Boyd, P. Spence, K. Kleinbeck, B. Devlin, and
R. K. Malcolm. 2019. Towards a dapivirine and levonorgestrel multipurpose vaginal
ring: Investigations into the reaction between levonorgestrel and addition-cure silicone
elastomers. International Journal of Pharmaceutics 569:118574.
Degenhardt, L., B. Mathers, P. Vickerman, T. Rhodes, C. Latkin, and M. Hickman. 2010.
Prevention of HIV infection for people who inject drugs: Why individual, structural,
and combination approaches are needed. Lancet 376(9737):285-301.
Delany-Moretlwe, S., J. P. Hughes, P. Bock, S. Gurrion, P. Hunidzarira, D. Kalonji, N. Kayange,
J. Makhema, P. Mandima, C. Mathew, M. Mokgoro, J. Mpendo, P. Mukwekwerere,
N. Mgodi, P. Nahirya Ntege, G. Nair, C. Nakabiito, H. Nuwagaba-Biribonwoha, R.
Panchia, N. Singh, B. Siziba, J. Farrior, S. Rose, R. Berhanu, P. Anderson, Y. Agyei,
S. H. Eshleman, M. Marzinke, E. Piwowar-Manning, A. Asmelash, F. Conradie, M.
Moorhouse, P. Richardson, S. Beigel-Orme, L. Emel, K. Bokoch, R. White, S. Hosek,
B. Tolley, N. Sista, K. Shin, A. Adeyeye, J. Rooney, A. Rinehart, K. Smith, B. Hanscom,
M. Cohen, and M. Hosseinipour. 2020. Long acting injectable cabotegravir is safe and
effective in preventing HIV infection in cisgender women: Interim results from HPTN
084. HIV Research for Prevention conference (virtual): LB1479.
Delva, W., and S. Helleringer. 2016. Beyond risk compensation: Clusters of antiretroviral
treatment (ART) users in sexual networks can modify the impact of ART on HIV inci-
dence. PLoS One 11(9):e0163159.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
INTERSECTION OF HIV AND STIs 269
Des Jarlais, D. C., V. Sypsa, J. Feelemyer, A. O. Abagiu, V. Arendt, D. Broz, D. Chemtob, C.
Seguin-Devaux, J. M. Duwve, M. Fitzgerald, D. J. Goldberg, A. Hatzakis, R. E. Jipa, E.
Katchman, E. Keenan, I. Khan, S. Konrad, A. McAuley, S. Skinner, and L. Wiessing.
2020. HIV outbreaks among people who inject drugs in Europe, North America, and
Israel. The Lancet HIV 7(6):e434-e442.
DiClemente, R. J., E. Funkhouser, G. Wingood, H. Fawal, S. D. Holmberg, and S. H. Vermund.
2002. Protease inhibitor combination therapy and decreased condom use among gay
men. Southern Medical Journal 95(4):421-425.
Dosekun, O., and J. Fox. 2010. An overview of the relative risks of different sexual behav-
iours on HIV transmission. Current Opinion in HIV and AIDS 5(4):291-297.
Dresser, M., J. Hussey, and N. Premchand. 2020. Kicking the habit—how can we improve the
routine care for patients who are well controlled living with HIV? International Journal
of STD & AIDS 31(13):1315-1319.
Dukers, N. H., J. Goudsmit, J. B. de Wit, M. Prins, G. J. Weverling, and R. A. Coutinho. 2001.
Sexual risk behaviour relates to the virological and immunological improvements dur-
ing highly active antiretroviral therapy in HIV-1 infection. AIDS 15(3):369-378.
Eaton, L. A., and S. Kalichman. 2007. Risk compensation in HIV prevention: Implications
for vaccines, microbicides, and other biomedical HIV prevention technologies. Current
HIV/AIDS Reports 4(4):165-172.
Fauci, A. S., R. R. Redfield, G. Sigounas, M. D. Weahkee, and B. P. Giroir. 2019. Ending the
HIV epidemic: A plan for the United States. JAMA 321(9):844-845.
Fideli, U. S., S. A. Allen, R. Musonda, S. Trask, B. H. Hahn, H. Weiss, J. Mulenga, F. Kasolo,
S. H. Vermund, and G. M. Aldrovandi. 2001. Virologic and immunologic determinants
of heterosexual transmission of human immunodeficiency virus type 1 in Africa. AIDS
Research and Human Retroviruses 17(10):901-910.
Fischl, M. A., D. D. Richman, M. H. Grieco, M. S. Gottlieb, P. A. Volberding, O. L. Laskin, J.
M. Leedom, J. E. Groopman, D. Mildvan, R. T. Schooley, et al. 1987. The efficacy of azi-
dothymidine (AZT) in the treatment of patients with AIDS and AIDS-related complex.
A double-blind, placebo-controlled trial. New England Journal of Medicine 317(4):185-191.
Fiscus, S. A., C. D. Pilcher, W. C. Miller, K. A. Powers, I. F. Hoffman, M. Price, D. A.
Chilongozi, C. Mapanje, R. Krysiak, S. Gama, F. E. Martinson, and M. S. Cohen. 2007.
Rapid, real-time detection of acute HIV infection in patients in Africa. The Journal of
Infectious Diseases 195(3):416-424.
Flagg, E. W., H. S. Weinstock, E. L. Frazier, E. E. Valverde, J. D. Heffelfinger, and J. Skar-
binski. 2015. Bacterial sexually transmitted infections among HIV-infected patients in
the United States: Estimates from the medical monitoring project. Sexually Transmitted
Diseases 42(4):171-179.
Fleming, D. T., and J. N. Wasserheit. 1999. From epidemiological synergy to public health
policy and practice: The contribution of other sexually transmitted diseases to sexual
transmission of HIV infection. Sexually Transmitted Infections 75(1):3-17.
Fonner, V. A., C. E. Kennedy, K. R. O’Reilly, and M. D. Sweat. 2014. Systematic assessment
of condom use measurement in evaluation of HIV prevention interventions: Need for
standardization of measures. AIDS and Behavior 18(12):2374-2386.
Freeman, E. E., H. A. Weiss, J. R. Glynn, P. L. Cross, J. A. Whitworth, and R. J. Hayes. 2006.
Herpes simplex virus 2 infection increases HIV acquisition in men and women: System-
atic review and meta-analysis of longitudinal studies. AIDS 20(1):73-83.
Gallo, R. C. 2002. Historical essay. The early years of HIV/AIDS. Science 298(5599):1728-1730.
Gallo, R. C., and L. Montagnier. 2003. The discovery of HIV as the cause of AIDS. New Eng-
land Journal of Medicine 349(24):2283-2285.
Galvin, S. R., and M. S. Cohen. 2004. The role of sexually transmitted diseases in HIV trans-
mission. Nature Reviews Microbiology 2(1):33-42.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
270 SEXUALLY TRANSMITTED INFECTIONS
Gamarel, K. E., K. M. Nelson, R. Stephenson, O. J. Santiago Rivera, D. Chiaramonte, and R.
L. Miller. 2018. Anticipated HIV stigma and delays in regular HIV testing behaviors
among sexually-active young gay, bisexual, and other men who have sex with men and
transgender women. AIDS and Behavior 22(2):522-530.
Ghys, P. D., M. O. Diallo, V. Ettiegne-Traore, G. A. Satten, C. K. Anoma, C. Maurice, J. C.
Kadjo, I. M. Coulibaly, S. Z. Wiktor, A. E. Greenberg, and M. Laga. 2001. Effect of inter-
ventions to control sexually transmitted disease on the incidence of HIV infection in
female sex workers. AIDS 15(11):1421-1431.
Gomez, G. B., A. Borquez, C. F. Caceres, E. R. Segura, R. M. Grant, G. P. Garnett, and T. B.
Hallett. 2012. The potential impact of pre-exposure prophylaxis for HIV prevention
among men who have sex with men and transwomen in Lima, Peru: A mathematical
modelling study. PLoS Medicine 9(10):e1001323.
Gonsalves, G. S., and F. W. Crawford. 2018. Dynamics of the HIV outbreak and response
in Scott County, IN, USA, 2011-15: A modelling study. The Lancet HIV 5(10):e569-e577.
Gottlieb, M. S., H. M. Schanker, P. T. Fan, A. Saxon, and J. D. Weisman. 1981. Centers for
Disease Control (CDC). Pneumocystis pneumonia—Los Angeles. Morbidity and Mortal-
ity Weekly Report 30(21):250-252.
Gottlieb, M. S., H. M. Schanker, P. T. Fan, A. Saxon, and J. D. Weisman. 1982. Pneumocystis
carinii pneumonia among persons with hemophilia A. Morbidity and Mortality Weekly
Report 31(27):365-367.
Grace, D., R. Nath, R. Parry, J. Connell, J. Wong, and T. Grennan. 2020. “… if U equals U what
does the second U mean?”: Sexual minority men’s accounts of HIV undetectability and
untransmittable scepticism. Culture, Health & Sexuality 1-17.
Grant, R. M., J. R. Lama, P. L. Anderson, V. McMahan, A. Y. Liu, L. Vargas, P. Goicochea,
M. Casapia, J. V. Guanira-Carranza, M. E. Ramirez-Cardich, O. Montoya-Herrera, T.
Fernandez, V. G. Veloso, S. P. Buchbinder, S. Chariyalertsak, M. Schechter, L. G. Bek-
ker, K. H. Mayer, E. G. Kallas, K. R. Amico, K. Mulligan, L. R. Bushman, R. J. Hance,
C. Ganoza, P. Defechereux, B. Postle, F. Wang, J. J. McConnell, J. H. Zheng, J. Lee, J. F.
Rooney, H. S. Jaffe, A. I. Martinez, D. N. Burns, and D. V. Glidden. 2010. Preexposure
chemoprophylaxis for HIV prevention in men who have sex with men. New England
Journal of Medicine 363(27):2587-2599.
Gregson, S., S. Adamson, S. Papaya, J. Mundondo, C. A. Nyamukapa, P. R. Mason, G.
P. Garnett, S. K. Chandiwana, G. Foster, and R. M. Anderson. 2007. Impact and
process evaluation of integrated community and clinic-based HIV-1 control: A cluster-
randomised trial in eastern Zimbabwe. PLoS Medicine 4(3):e102.
Grosskurth, H., F. Mosha, J. Todd, E. Mwijarubi, A. Klokke, K. Senkoro, P. Mayaud, J. Chan-
galucha, A. Nicoll, G. ka-Gina, et al. 1995. Impact of improved treatment of sexually
transmitted diseases on HIV infection in rural Tanzania: Randomised controlled trial.
Lancet 346(8974):530-536.
Grov, C., T. H. Whitfield, H. J. Rendina, A. Ventuneac, and J. T. Parsons. 2015. Willingness to
take PrEP and potential for risk compensation among highly sexually active gay and
bisexual men. AIDS and Behavior 19(12):2234-2244.
Guay, L. A., P. Musoke, T. Fleming, D. Bagenda, M. Allen, C. Nakabiito, J. Sherman, P.
Bakaki, C. Ducar, M. Deseyve, L. Emel, M. Mirochnick, M. G. Fowler, L. Mofenson,
P. Miotti, K. Dransfield, D. Bray, F. Mmiro, and J. B. Jackson. 1999. Intrapartum and
neonatal single-dose nevirapine compared with zidovudine for prevention of mother-
to-child transmission of HIV-1 in Kampala, Uganda: HIVNET 012 randomised trial.
Lancet 354(9181):795-802.
Guest, G., D. Shattuck, L. Johnson, B. Akumatey, E. E. Clarke, P. L. Chen, and K. M.
MacQueen. 2008. Changes in sexual risk behavior among participants in a PrEP HIV
prevention trial. Sexually Transmitted Diseases 35(12):1002-1008.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
INTERSECTION OF HIV AND STIs 271
Haber, N. A., C. R. Lesko, M. P. Fox, K. A. Powers, G. Harling, J. K. Edwards, J. A. Salomon, S.
A. Lippman, J. Bor, A. Y. Chang, A. Anglemyer, and A. Pettifor. 2020. Limitations of the
UNAIDS 90-90-90 metrics: A simulation-based comparison of cross-sectional and lon-
gitudinal metrics for the HIV care continuum. AIDS (London, England) 34(7):1047-1055.
Hanson, C., R. Fischer, G. Fraga, A. Rajpara, D. Hinthorn, D. Aires, and D. Liu. 2014. Lues
maligna praecox: An important consideration in HIV-positive patients with ulcero-
nodular skin lesions. Dermatology Online Journal 21(3).
Harawa, N. T., J. K. Williams, H. C. Ramamurthi, C. Manago, S. Avina, and M. Jones. 2008.
Sexual behavior, sexual identity, and substance abuse among low-income bisexual and
non-gay-identifying African American men who have sex with men. Archives of Sexual
Behavior 37(5):748-762.
Harman, A. N., M. Kim, N. Nasr, K. J. Sandgren, and P. U. Cameron. 2013. Tissue dendritic
cells as portals for HIV entry. Reviews in Medical Virology 23(5):319-333.
Harris, C., C. B. Small, R. S. Klein, G. H. Friedland, B. Moll, E. E. Emeson, I. Spigland, and
N. H. Steigbigel. 1983. Immunodeficiency in female sexual partners of men with the ac-
quired immunodeficiency syndrome. New England Journal of Medicine 308(20):1181-1184.
Hasse, B., B. Ledergerber, B. Hirschel, P. Vernazza, T. R. Glass, A. Jeannin, J. M. Evison, L.
Elzi, M. Cavassini, E. Bernasconi, D. Nicca, and R. Weber. 2010. Frequency and deter-
minants of unprotected sex among HIV-infected persons: The Swiss HIV cohort study.
Clinical Infectious Diseases 51(11):1314-1322.
Havlir, D. V., L. B. Balzer, E. D. Charlebois, T. D. Clark, D. Kwarisiima, J. Ayieko, J. Kabami,
N. Sang, T. Liegler, G. Chamie, C. S. Camlin, V. Jain, K. Kadede, M. Atukunda, T. Ruel,
S. B. Shade, E. Ssemmondo, D. M. Byonanebye, F. Mwangwa, A. Owaraganise, W. Olilo,
D. Black, K. Snyman, R. Burger, M. Getahun, J. Achando, B. Awuonda, H. Nakato, J.
Kironde, S. Okiror, H. Thirumurthy, C. Koss, L. Brown, C. Marquez, J. Schwab, G.
Lavoy, A. Plenty, E. Mugoma Wafula, P. Omanya, Y.-H. Chen, J. F. Rooney, M. Bacon,
M. van der Laan, C. R. Cohen, E. Bukusi, M. R. Kamya, and M. Petersen. 2019. HIV
testing and treatment with the use of a community health approach in rural Africa. New
England Journal of Medicine 381(3):219-229.
Hayes, R., D. Watson-Jones, C. Celum, J. van de Wijgert, and J. Wasserheit. 2010. Treatment
of sexually transmitted infections for HIV prevention: End of the road or new begin-
ning? AIDS 24(Suppl 4):S15-S26.
Hayes, R. J., D. Donnell, S. Floyd, N. Mandla, J. Bwalya, K. Sabapathy, B. Yang, M. Phiri,
A. Schaap, S. H. Eshleman, E. Piwowar-Manning, B. Kosloff, A. James, T. Skalland,
E. Wilson, L. Emel, D. Macleod, R. Dunbar, M. Simwinga, N. Makola, V. Bond, G.
Hoddinott, A. Moore, S. Griffith, N. Deshmane Sista, S. H. Vermund, W. El-Sadr, D. N.
Burns, J. R. Hargreaves, K. Hauck, C. Fraser, K. Shanaube, P. Bock, N. Beyers, H. Ayles,
and S. Fidler. 2019. Effect of universal testing and treatment on HIV incidence—HPTN
071 (POPART). New England Journal of Medicine 381(3):207-218.
Heaton, L. M., P. D. Bouey, J. Fu, J. Stover, T. B. Fowler, R. Lyerla, and M. Mahy. 2015. Estimat-
ing the impact of the US President’s Emergency Plan for AIDS Relief on HIV treatment
and prevention programmes in Africa. Sexually Transmitted Infections 91(8):615-620.
HHS (Department of Health and Human Services). 2020a. National Strategic Plan: A roadmap
to end the epidemic for the United States 2021-2025. Washington, DC: Department of
Health and Human Services.
HHS. 2020b. Sexually transmitted infections National Strategic Plan for the United States: 2021-
2025. Washington, DC: Department of Health and Human Services.
HHS. 2020c. Viral hepatitis National Strategic Plan for the United States: A roadmap to elimination
(2021-2025). Washington, DC: Department of Health and Human Services.
HHS. n.d. Ending the HIV Epidemic: A plan for America (overview). https://www.hiv.gov/
federal-response/ending-the-hiv-epidemic/overview (accessed October 12, 2020).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
272 SEXUALLY TRANSMITTED INFECTIONS
Hobbs, M. M., P. Kazembe, A. W. Reed, W. C. Miller, E. Nkata, D. Zimba, C. C. Daly, H.
Chakraborty, M. S. Cohen, and I. Hoffman. 1999. Trichomonas vaginalis as a cause of
urethritis in Malawian men. Sexually Transmitted Diseases 26(7):381-387.
Hollingsworth, T. D., R. M. Anderson, and C. Fraser. 2008. HIV-1 transmission, by stage of
infection. The Journal of Infectious Diseases 198(5):687-693.
Hooper, R. R., G. H. Reynolds, O. G. Jones, A. Zaidi, P. J. Wiesner, K. P. Latimer, A. Lester, A.
F. Campbell, W. O. Harrison, W. W. Karney, and K. K. Holmes. 1978. Cohort study of
venereal disease. I: The risk of gonorrhea transmission from infected women to men.
American Journal of Epidemiology 108(2):136-144.
HPTN (HIV Prevention Trials Network). 2020. HPTN 083. https://www.hptn.org/research/
studies/hptn083 (accessed January 30, 2021).
HRSA (Health Resources and Services Administration). 2020. About the Ryan White HIV/AIDS
program. https://hab.hrsa.gov/about-ryan-white-hivaids-program/about-ryan-white-
hivaids-program (accessed June 23, 2020).
Janes, H., L. Corey, G. Ramjee, L. N. Carpp, C. Lombard, M. S. Cohen, P. B. Gilbert, and G.
E. Gray. 2018. Weighing the evidence of efficacy of oral PrEP for HIV prevention in
women in southern Africa. AIDS Research and Human Retroviruses 34(8):645-656.
Jenness, S. M., K. M. Maloney, D. K. Smith, K. W. Hoover, S. M. Goodreau, E. S. Rosenberg,
K. M. Weiss, A. Y. Liu, D. W. Rao, and P. S. Sullivan. 2019. Addressing gaps in HIV pre-
exposure prophylaxis care to reduce racial disparities in HIV incidence in the United
States. American Journal of Epidemiology 188(4):743-752.
Johnson, L. F., and D. A. Lewis. 2008. The effect of genital tract infections on HIV-1 shed-
ding in the genital tract: A systematic review and meta-analysis. Sexually Transmitted
Diseases 35(11):946-959.
Jones, J., K. Weiss, J. Mermin, P. Dietz, E. S. Rosenberg, T. L. Gift, H. Chesson, P. S. Sullivan,
C. Lyles, K. T. Bernstein, and S. M. Jenness. 2019. Proportion of incident human immu-
nodeficiency virus cases among men who have sex with men attributable to gonorrhea
and chlamydia: A modeling analysis. Sexually Transmitted Diseases 46(6):357-363.
Kalichman, S. C., L. Eaton, and C. Cherry. 2010. Sexually transmitted infections and infec-
tiousness beliefs among people living with HIV/AIDS: Implications for HIV treatment
as prevention. HIV Medicine 11(8):502-509.
Kalichman, S. C., J. Pellowski, and C. Turner. 2011. Prevalence of sexually transmitted co-
infections in people living with HIV/AIDS: Systematic review with implications for
using HIV treatments for prevention. Sexually Transmitted Infections 87(3):183-190.
Kamali, A., M. Quigley, J. Nakiyingi, J. Kinsman, J. Kengeya-Kayondo, R. Gopal, A. Ojwiya,
P. Hughes, L. M. Carpenter, and J. Whitworth. 2003. Syndromic management of sexual-
ly-transmitted infections and behaviour change interventions on transmission of HIV-1
in rural Uganda: A community randomised trial. Lancet 361(9358):645-652.
Kasaie, P., C. M. Schumacher, J. M. Jennings, S. A. Berry, S. A. Tuddenham, M. S. Shah, E. S.
Rosenberg, K. W. Hoover, T. L. Gift, H. Chesson, D. German, and D. W. Dowdy. 2019.
Gonorrhoea and chlamydia diagnosis as an entry point for HIV pre-exposure prophy-
laxis: A modelling study. BMJ Open 9(3):e023453.
Katz, M. H., S. K. Schwarcz, T. A. Kellogg, J. D. Klausner, J. W. Dilley, S. Gibson, and W.
McFarland. 2002. Impact of highly active antiretroviral treatment on HIV seroincidence
among men who have sex with men: San Francisco. American Journal of Public Health
92(3):388-394.
Kaul, R., J. Kimani, N. J. Nagelkerke, K. Fonck, E. N. Ngugi, F. Keli, K. S. MacDonald, I. W.
Maclean, J. J. Bwayo, M. Temmerman, A. R. Ronald, and S. Moses. 2004. Monthly anti-
biotic chemoprophylaxis and incidence of sexually transmitted infections and HIV-1 in-
fection in Kenyan sex workers: A randomized controlled trial. JAMA 291(21):2555-2562.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
INTERSECTION OF HIV AND STIs 273
Kaul, R., C. Pettengell, P. M. Sheth, S. Sunderji, A. Biringer, K. MacDonald, S. Walmsley, and
A. Rebbapragada. 2008. The genital tract immune milieu: An important determinant
of HIV susceptibility and secondary transmission. Journal of Reproductive Immunology
77(1):32-40.
Kennedy, C. E., S. A. Haberlen, and M. Narasimhan. 2017. Integration of sexually transmit-
ted infection (STI) services into HIV care and treatment services for women living with
HIV: A systematic review. BMJ Open 7(6):e015310.
KFF (Kaiser Family Foundation). 2020. President-elect Biden releases statement on World
AIDS Day, calls for expanded support for PEPFAR, Global Fund. https://www.kff.org/
news-summary/president-elect-biden-releases-statement-on-world-aids-day-calls-for-
expanded-support-for-pepfar-global-fund (accessed February 2, 2021).
Kishore, S., M. Hayden, and J. Rich. 2019. Lessons from Scott County—progress or paralysis
on harm reduction? New England Journal of Medicine 380(21):1988-1990.
Kissinger, P., and A. Adamski. 2013. Trichomoniasis and HIV interactions: A review. Sexually
Transmitted Infections 89(6):426-433.
Klein, P. W., I. B. K. Martin, E. B. Quinlivan, C. L. Gay, and P. A. Leone. 2014. Missed oppor-
tunities for concurrent HIV-STD testing in an academic emergency department. Public
Health Reports 129(Suppl 1):12-20.
Kojima, Y., T. Kawahata, and H. Mori. 2009. Cases of HIV type 1 acute infection at STI-related
clinics in Osaka. AIDS Research and Human Retroviruses 25(7):717-719.
Koop, C. E. 1986. Surgeon general’s report on acquired deficiency syndrome. https://www.
nlm.nih.gov/exhibition/survivingandthriving/education/Activity-Surgeon-General/
Surgeon-Generals-Report-on-AIDS.pdf (accessed November 15, 2020).
Laga, M., A. Manoka, M. Kivuvu, B. Malele, M. Tuliza, N. Nzila, J. Goeman, F. Behets, V.
Batter, M. Alary, et al. 1993. Non-ulcerative sexually transmitted diseases as risk fac-
tors for HIV-1 transmission in women: Results from a cohort study. AIDS 7(1):95-102.
Landovitz, R. J., J. L. Gildner, and A. A. Leibowitz. 2018a. Sexually transmitted infection test-
ing of HIV-positive Medicare and Medicaid enrollees falls short of guidelines. Sexually
Transmitted Diseases 45(1):8-13.
Landovitz, R. J., S. Li, B. Grinsztejn, H. Dawood, A. Y. Liu, M. Magnus, M. C. Hosseinipour,
R. Panchia, L. Cottle, G. Chau, P. Richardson, M. A. Marzinke, C. W. Hendrix, S. H.
Eshleman, Y. Zhang, E. Tolley, J. Sugarman, R. Kofron, A. Adeyeye, D. Burns, A. R.
Rinehart, D. Margolis, W. R. Spreen, M. S. Cohen, M. McCauley, and J. J. Eron. 2018b.
Safety, tolerability, and pharmacokinetics of long-acting injectable cabotegravir in low-
risk HIV-uninfected individuals: HPTN 077, a phase 2a randomized controlled trial.
PLoS Medicine 15(11):e1002690.
Li, J., C. Armon, F. J. Palella, Jr., R. M. Novak, D. Ward, S. Purinton, M. Durham, and K.
Buchacz. 2019a. Chlamydia and gonorrhea incidence and testing among patients in
the Human Immunodeficiency Virus Outpatient Study (HOPS), 2007−2017. Clinical
Infectious Diseases 71(8):1824-1835.
Li, J., G. Regev, S. K. Patel, D. Patton, Y. Sweeney, P. Graebing, S. Grab, L. Wang, V. Sant,
and L. C. Rohan. 2019b. Rational design of a multipurpose bioadhesive vaginal film for
co-delivery of dapivirine and levonorgestrel. Pharmaceutics 12(1).
Liew, Z. Q., V. Ly, and C. Olson-Chen. 2021. An old disease on the rise: New approaches to
syphilis in pregnancy. Current Opinion in Obstetrics and Gynecology 33(2):78-85.
Lingappa, J. R., J. P. Hughes, R. S. Wang, J. M. Baeten, C. Celum, G. E. Gray, W. S. Stevens, D.
Donnell, M. S. Campbell, C. Farquhar, M. Essex, J. I. Mullins, R. W. Coombs, H. Rees,
L. Corey, and A. Wald. 2010. Estimating the impact of plasma HIV-1 RNA reductions
on heterosexual HIV-1 transmission risk. PLoS One 5(9):e12598.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
274 SEXUALLY TRANSMITTED INFECTIONS
Makhema, J., K. E. Wirth, M. Pretorius Holme, T. Gaolathe, M. Mmalane, E. Kadima, U.
Chakalisa, K. Bennett, J. Leidner, K. Manyake, A. M. Mbikiwa, S. V. Simon, R. Letlhogile,
K. Mukokomani, E. van Widenfelt, S. Moyo, R. Lebelonyane, M. G. Alwano, K. M.
Powis, S. L. Dryden-Peterson, C. Kgathi, V. Novitsky, J. Moore, P. Bachanas, W. Abrams,
L. Block, S. El-Halabi, T. Marukutira, L. A. Mills, C. Sexton, E. Raizes, S. Gaseitsiwe,
H. Bussmann, L. Okui, O. John, R. L. Shapiro, S. Pals, H. Michael, M. Roland, V.
DeGruttola, Q. Lei, R. Wang, E. Tchetgen Tchetgen, M. Essex, and S. Lockman. 2019.
Universal testing, expanded treatment, and incidence of HIV infection in Botswana.
New England Journal of Medicine 381(3):230-242.
Manoto, S. L., M. Lugongolo, U. Govender, and P. Mthunzi-Kufa. 2018. Point of care di-
agnostics for HIV in resource limited settings: An overview. Medicina (Kaunas) 54(1).
Marcus, J. L., D. V. Glidden, K. H. Mayer, A. Y. Liu, S. P. Buchbinder, K. R. Amico, V. McMa-
han, E. G. Kallas, O. Montoya-Herrera, J. Pilotto, and R. M. Grant. 2013. No evidence of
sexual risk compensation in the Iprex trial of daily oral HIV preexposure prophylaxis.
PLoS One 8(12):e81997.
Marcus, J. L., K. A. Katz, D. S. Krakower, and S. K. Calabrese. 2019. Risk compensation
and clinical decision making—the case of HIV preexposure prophylaxis. New England
Journal of Medicine 380(6):510-512.
Marrazzo, J. M., J. C. Dombrowski, and K. H. Mayer. 2018. Sexually transmitted infections
in the era of antiretroviral-based HIV prevention: Priorities for discovery research,
implementation science, and community involvement. PLoS Medicine 15(1):e1002485.
Marshall, B. D. L., W. C. Goedel, M. R. F. King, A. Singleton, D. P. Durham, P. A. Chan, J. P.
Townsend, and A. P. Galvani. 2018. Potential effectiveness of long-acting injectable pre-
exposure prophylaxis for HIV prevention in men who have sex with men: A modelling
study. The Lancet HIV 5(9):e498-e505.
Marston, M., J. Nakiyingi-Miiro, S. Kusemererwa, M. Urassa, D. Michael, C. Nyamukapa,
S. Gregson, B. Zaba, and J. W. Eaton. 2017. The effects of HIV on fertility by infection
duration: Evidence from African population cohorts before antiretroviral treatment
availability. AIDS 31(Suppl 1):S69-S76.
Marx, J. L. 1982. New disease baffles medical community. Science 217(4560):618-621.
Marx, J. L. 1983. Spread of AIDS sparks new health concern. Science 219(4580):42-43.
Masson, L., S. Barnabas, J. Deese, K. Lennard, S. Dabee, H. Gamieldien, S. Z. Jaumdally, A. L.
Williamson, F. Little, L. Van Damme, K. Ahmed, T. Crucitti, S. Abdellati, L. G. Bekker, G.
Gray, J. Dietrich, H. Jaspan, and J. S. Passmore. 2019. Inflammatory cytokine biomarkers
of asymptomatic sexually transmitted infections and vaginal dysbiosis: A multicentre
validation study. Sexually Transmitted Infections 95(1):5-12.
Masur, H., M. A. Michelis, J. B. Greene, I. Onorato, R. A. Stouwe, R. S. Holzman, G. Wormser,
L. Brettman, M. Lange, H. W. Murray, and S. Cunningham-Rundles. 1981. An outbreak
of community-acquired Pneumocystis carinii pneumonia: Initial manifestation of cellular
immune dysfunction. New England Journal of Medicine 305(24):1431-1438.
Masur, H., M. A. Michelis, G. P. Wormser, S. Lewin, J. Gold, M. L. Tapper, J. Giron, C. W.
Lerner, D. Armstrong, U. Setia, J. A. Sender, R. S. Siebken, P. Nicholas, Z. Arlen, S.
Maayan, J. A. Ernst, F. P. Siegal, and S. Cunningham-Rundles. 1982. Opportunistic
infection in previously healthy women. Initial manifestations of a community-acquired
cellular immunodeficiency. Annals of Internal Medicine 97(4):533-539.
Mayer, K. H., and K. K. Venkatesh. 2011. Interactions of HIV, other sexually transmitted
diseases, and genital tract inflammation facilitating local pathogen transmission and
acquisition. American Journal of Reproductive Immunology 65(3):308-316.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
INTERSECTION OF HIV AND STIs 275
Mayer, K. H., J.-M. Molina, M. A. Thompson, P. L. Anderson, K. C. Mounzer, J. J. De Wet, E.
DeJesus, H. Jessen, R. M. Grant, P. J. Ruane, P. Wong, R. Ebrahimi, L. Zhong, A. Mathias,
C. Callebaut, S. E. Collins, M. Das, S. McCallister, D. M. Brainard, C. Brinson, A. Clarke,
P. Coll, F. A. Post, and C. B. Hare. 2020. Emtricitabine and tenofovir alafenamide vs.
emtricitabine and tenofovir disoproxil fumarate for HIV pre-exposure prophylaxis
(DISCOVER): Primary results from a randomised, double-blind, multicentre, active-
controlled, phase 3, non-inferiority trial. The Lancet 396(10246):239-254.
McCarty-Caplan, D., I. Jantz, and J. Swartz. 2014. MSM and drug use: A latent class analysis
of drug use and related sexual risk behaviors. AIDS and Behavior 18(7):1339-1351.
McClelland, R. S., J. R. Lingappa, S. Srinivasan, J. Kinuthia, G. C. John-Stewart, W. Jaoko, B.
A. Richardson, K. Yuhas, T. L. Fiedler, K. N. Mandaliya, M. M. Munch, N. R. Mugo, C.
R. Cohen, J. M. Baeten, C. Celum, J. Overbaugh, and D. N. Fredricks. 2018. Evaluation
of the association between the concentrations of key vaginal bacteria and the increased
risk of HIV acquisition in African women from five cohorts: A nested case-control
study. Lancet Infectious Diseases 18(5):554-564.
McCormack, S., D. T. Dunn, M. Desai, D. I. Dolling, M. Gafos, R. Gilson, A. K. Sullivan, A.
Clarke, I. Reeves, G. Schembri, N. Mackie, C. Bowman, C. J. Lacey, V. Apea, M. Brady, J.
Fox, S. Taylor, S. Antonucci, S. H. Khoo, J. Rooney, A. Nardone, M. Fisher, A. McOwan,
A. N. Phillips, A. M. Johnson, B. Gazzard, and O. N. Gill. 2016. Pre-exposure prophy-
laxis to prevent the acquisition of HIV-1 infection (PROUD): Effectiveness results from
the pilot phase of a pragmatic open-label randomised trial. Lancet 387(10013):53-60.
Mellors, J. W., C. R. Rinaldo, Jr., P. Gupta, R. M. White, J. A. Todd, and L. A. Kingsley. 1996.
Prognosis in HIV-1 infection predicted by the quantity of virus in plasma. Science
272(5265):1167-1170.
Melo, M. G., E. Sprinz, P. M. Gorbach, B. Santos, T. M. Rocha, M. Simon, M. Almeida, R.
Lira, M. C. Chaves, T. Kerin, I. Varella, and K. Nielsen-Saines. 2019. HIV-1 heterosexual
transmission and association with sexually transmitted infections in the era of treat-
ment as prevention. International Journal of Infectious Diseases 87:128-134.
Mena Lora, A. J., M. Braniecki, A. Nasir, and M. Brito. 2017. The great impostor: Lues ma-
ligna in an HIV-infected male. SAGE Open Medical Case Reports 5:2050313x17731050.
Michael, S., M. Gompels, C. Sabin, H. Curtis, and M. T. May. 2017. Benchmarked perfor-
mance charts using principal components analysis to improve the effectiveness of
feedback for audit data in HIV care. BMC Health Services Research 17(1):506.
Milam, J., S. Jain, M. P. Dube, E. S. Daar, X. Sun, K. Corado, E. Ellorin, J. Blumenthal, R.
Haubrich, D. J. Moore, and S. R. Morris. 2019. Sexual risk compensation in a pre-
exposure prophylaxis demonstration study among individuals at risk of HIV. Journal
of Acquired Immune Deficiency Syndromes 80(1):e9-e13.
Millett, G. A., H. Ding, G. Marks, W. L. Jeffries 4th, T. Bingham, J. Lauby, C. Murrill, S. Flores,
and A. Stueve. 2011. Mistaken assumptions and missed opportunities: Correlates of
undiagnosed HIV infection among black and Latino men who have sex with men.
Journal of Acquired Immune Deficiency Syndromes 58(1):64-71.
Modjarrad, K., and S. H. Vermund. 2010. Effect of treating co-infections on HIV-1 viral load:
A systematic review. Lancet Infectious Diseases 10(7):455-463.
Modjarrad, K., E. Chamot, and S. H. Vermund. 2008. Impact of small reductions in plasma
HIV RNA levels on the risk of heterosexual transmission and disease progression. AIDS
22(16):2179-2185.
Molina, J. M., I. Charreau, B. Spire, L. Cotte, J. Chas, C. Capitant, C. Tremblay, D. Rojas-
Castro, E. Cua, A. Pasquet, C. Bernaud, C. Pintado, C. Delaugerre, L. Sagaon-Teyssier,
S. L. Mestre, C. Chidiac, G. Pialoux, D. Ponscarme, J. Fonsart, D. Thompson, M. A.
Wainberg, V. Dore, and L. Meyer. 2017. Efficacy, safety, and effect on sexual behaviour
of on-demand pre-exposure prophylaxis for HIV in men who have sex with men: An
observational cohort study. Lancet HIV 4(9):e402-e410.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
276 SEXUALLY TRANSMITTED INFECTIONS
Molloy, A., H. Curtis, F. Burns, and A. Freedman. 2017. Routine monitoring and assessment
of adults living with HIV: Results of the British HIV Association (BHIVA) national audit
2015. BMC Infectious Diseases 17(1):619.
Moskowitz, D. A., and M. E. Roloff. 2010. Moderators of sexual behavior in gay men. Ar-
chives of Sexual Behavior 39(4):950-958.
Noël-Romas, L., M. Perner, R. Molatlhegi, C. Farr Zuend, A. Mabhula, S. Hoger, A. Lamont,
K. Birse, A. Berard, S. McCorrister, G. Westmacott, A. Leslie, V. Poliquin, R. Heffron,
L. R. McKinnon, and A. D. Burgener. 2020. Vaginal microbiome-hormonal contraceptive
interactions associate with the mucosal proteome and HIV acquisition. PLOS Pathogens
16(12):e1009097.
Norkin, S. K., S. Benson, A. M. Civitarese, A. Reich, M. Chomsky Albright, A. Convery, I. M.
Kasarskis, H. Cassidy-Stewart, K. Howe, X. Wang, M. R. Golden, C. M. Khosropour,
S. N. Glick, and R. P. Kerani. 2021. Inadequate engagement in HIV care among people
with HIV newly diagnosed with an STD: A multi-jurisdictional analysis. Sexually Trans-
mitted Diseases. doi: 10.1097/OLQ.0000000000001381.
Oette, M., J. Hemker, T. Feldt, A. Sagir, J. Best, and D. Häussinger. 2005. Acute syphilitic
blindness in an HIV-positive patient. AIDS Patient Care and STDs 19(4):209-211.
Oleske, J., A. Minnefor, R. Cooper, Jr., K. Thomas, A. dela Cruz, H. Ahdieh, I. Guerrero,
V. V. Joshi, and F. Desposito. 1983. Immune deficiency syndrome in children. JAMA
249(17):2345-2349.
Ong, J. J., R. C. Baggaley, T. E. Wi, J. D. Tucker, H. Fu, M. K. Smith, S. Rafael, V. Anglade, J.
Falconer, R. Ofori-Asenso, F. Terris-Prestholt, I. Hodges-Mameletzis, and P. Mayaud.
2019. Global epidemiologic characteristics of sexually transmitted infections among
individuals using preexposure prophylaxis for the prevention of HIV infection: A sys-
tematic review and meta-analysis. JAMA Network Open 2(12):e1917134.
Owens, D. K., K. W. Davidson, A. H. Krist, M. J. Barry, M. Cabana, A. B. Caughey, S. J.
Curry, C. A. Doubeni, J. W. Epling, Jr., M. Kubik, C. S. Landefeld, C. M. Mangione, L.
Pbert, M. Silverstein, M. A. Simon, C. W. Tseng, and J. B. Wong. 2019. Screening for
HIV infection: U.S. Preventive Services Task Force recommendation statement. JAMA
321(23):2326-2336.
Passmore, J. A., H. B. Jaspan, and L. Masson. 2016. Genital inflammation, immune activa-
tion and risk of sexual HIV acquisition. Current Opinion in HIV and AIDS 11(2):156-162.
Pathela, P., S. L. Braunstein, S. Blank, C. Shepard, and J. A. Schillinger. 2015. The high risk
of an HIV diagnosis following a diagnosis of syphilis: A population-level analysis of
New York City men. Clinical Infectious Diseases 61(2):281-287.
Peeling, R. W., and E. W. Hook, 3rd. 2006. The pathogenesis of syphilis: The great mimicker,
revisited. Journal of Pathology 208(2):224-232.
Pellowski, J. A., T. B. Huedo-Medina, and S. C. Kalichman. 2018. Food insecurity, substance
use, and sexual transmission risk behavior among people living with HIV: A daily level
analysis. Archives of Sexual Behavior 47(7):1899-1907.
Persson, A. 2010. Reflections on the Swiss consensus statement in the context of qualitative
interviews with heterosexuals living with HIV. AIDS Care 22(12):1487-1492.
Peterman, T. A., D. R. Newman, L. Maddox, K. Schmitt, and S. Shiver. 2015. Risk for HIV
following a diagnosis of syphilis, gonorrhoea or chlamydia: 328,456 women in Florida,
2000-2011. International Journal of STD & AIDS 26(2):113-119.
Peters, P. J., P. Pontones, K. W. Hoover, M. R. Patel, R. R. Galang, J. Shields, S. J. Blosser, M. W.
Spiller, B. Combs, W. M. Switzer, C. Conrad, J. Gentry, Y. Khudyakov, D. Waterhouse, S.
M. Owen, E. Chapman, J. C. Roseberry, V. McCants, P. J. Weidle, D. Broz, T. Samandari,
J. Mermin, J. Walthall, J. T. Brooks, and J. M. Duwve. 2016. HIV infection linked to
injection use of oxymorphone in Indiana, 2014-2015. New England Journal of Medicine
375(3):229-239.
Pilcher, C. D., M. A. Price, I. F. Hoffman, S. Galvin, F. E. Martinson, P. N. Kazembe, J. J. Eron,
W. C. Miller, S. A. Fiscus, and M. S. Cohen. 2004a. Frequent detection of acute primary
HIV infection in men in Malawi. AIDS 18(3):517-524.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
INTERSECTION OF HIV AND STIs 277
Pilcher, C. D., H. C. Tien, J. J. Eron, Jr., P. L. Vernazza, S. Y. Leu, P. W. Stewart, L. E. Goh, and
M. S. Cohen. 2004b. Brief but efficient: Acute HIV infection and the sexual transmission
of HIV. The Journal of Infectious Diseases 189(10):1785-1792.
Pinkerton, S. D. 2001. Sexual risk compensation and HIV/STD transmission: Empirical
evidence and theoretical considerations. Risk Analysis 21(4):727-736.
Pinkerton, S. D., H. W. Chesson, R. A. Crosby, and P. M. Layde. 2011. Linearity and nonlin-
earity in HIV/STI transmission: Implications for the evaluation of sexual risk reduction
interventions. Evaluation Review 35(5):550-565.
Piot, P., and M. Laga. 1989. Genital ulcers, other sexually transmitted diseases, and the sexual
transmission of HIV. BMJ 298(6674):623-624.
Powers, K. A., W. C. Miller, C. D. Pilcher, C. Mapanje, F. E. Martinson, S. A. Fiscus, D. A.
Chilongozi, D. Namakhwa, M. A. Price, S. R. Galvin, I. F. Hoffman, and M. S. Cohen.
2007. Improved detection of acute HIV-1 infection in sub-Saharan Africa: Development
of a risk score algorithm. AIDS 21(16):2237-2242.
Powers, K. A., C. Poole, A. E. Pettifor, and M. S. Cohen. 2008. Rethinking the heterosexual
infectivity of HIV-1: A systematic review and meta-analysis. Lancet Infectious Diseases
8(9):553-563.
Price, M. A., D. Zimba, I. F. Hoffman, S. C. Kaydos-Daniels, W. C. Miller, F. Martinson, D.
Chilongozi, E. Kip, E. Msowoya, M. M. Hobbs, P. Kazembe, and M. S. Cohen. 2003.
Addition of treatment for trichomoniasis to syndromic management of urethritis in
malawi: A randomized clinical trial. Sexually Transmitted Diseases 30(6):516-522.
Purcell, D. W., D. Higa, Y. Mizuno, and C. Lyles. 2017. Quantifying the harms and benefits
from serosorting among HIV-negative gay and bisexual men: A systematic review and
meta-analysis. AIDS and Behavior 21(10):2835-2843.
Quinlivan, E. B., S. N. Patel, C. A. Grodensky, C. E. Golin, H. C. Tien, and M. M. Hobbs.
2012. Modeling the impact of Trichomonas vaginalis infection on HIV transmission in
HIV-infected individuals in medical care. Sexually Transmitted Diseases 39(9):671-677.
Quinn, T. C., M. J. Wawer, N. Sewankambo, D. Serwadda, C. Li, F. Wabwire-Mangen, M. O.
Meehan, T. Lutalo, and R. H. Gray. 2000. Viral load and heterosexual transmission of
human immunodeficiency virus type 1. Rakai Project Study Group. New England Journal
of Medicine 342(13):921-929.
Ramchandani, M. S., and M. R. Golden. 2019. Confronting rising STIs in the era of PrEP and
treatment as prevention. Current HIV/AIDS Reports 16(3):244-256.
Rendina, H. J., J. Cienfuegos-Szalay, A. Talan, S. S. Jones, and R. H. Jimenez. 2020. Growing
acceptability of undetectable = untransmittable but widespread misunderstanding of
transmission risk: Findings from a very large sample of sexual minority men in the
United States. Journal of Acquired Immune Deficiency Syndromes 83(3):215-222.
Reynolds, G. L., and D. G. Fisher. 2019. A latent class analysis of alcohol and drug use im-
mediately before or during sex among women. American Journal of Drug and Alcohol
Abuse 45(2):179-188.
Rietmeijer, C. A., J. L. Patnaik, F. N. Judson, and J. M. Douglas, Jr. 2003. Increases in gonor-
rhea and sexual risk behaviors among men who have sex with men: A 12-year trend
analysis at the Denver metro health clinic. Sexually Transmitted Diseases 30(7):562-567.
Rodger, A. J., V. Cambiano, T. Bruun, P. Vernazza, S. Collins, J. van Lunzen, G. M. Corbelli,
V. Estrada, A. M. Geretti, A. Beloukas, D. Asboe, P. Viciana, F. Gutiérrez, B. Clotet,
C. Pradier, J. Gerstoft, R. Weber, K. Westling, G. Wandeler, J. M. Prins, A. Rieger, M.
Stoeckle, T. Kümmerle, T. Bini, A. Ammassari, R. Gilson, I. Krznaric, M. Ristola, R.
Zangerle, P. Handberg, A. Antela, S. Allan, A. N. Phillips, J. Lundgren, and Partner
Study Group. 2016. Sexual activity without condoms and risk of HIV transmission in
serodifferent couples when the HIV-positive partner is using suppressive antiretroviral
therapy. JAMA 316(2):171-181.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
278 SEXUALLY TRANSMITTED INFECTIONS
Rojas Castro, D., R. M. Delabre, and J. M. Molina. 2019. Give PrEP a chance: Moving on
from the “risk compensation” concept. Journal of the International AIDS Society 22(Suppl
6):e25351.
Rompalo, A. M., M. R. Joesoef, J. A. O’Donnell, M. Augenbraun, W. Brady, J. D. Radolf,
R. Johnson, and R. T. Rolfs. 2001a. Clinical manifestations of early syphilis by HIV
status and gender: Results of the Syphilis and HIV study. Sexually Transmitted Diseases
28(3):158-165.
Rompalo, A. M., J. Lawlor, P. Seaman, T. C. Quinn, J. M. Zenilman, and E. W. I. Hook. 2001b.
Modification of syphilitic genital ulcer manifestations by coexistent HIV infection.
Sexually Transmitted Diseases 28(8):448-454.
Rosenberg, Z. 2017. Pooled efficacy analysis of two phase III trials of dapivirine vaginal ring (DVR)
for the reduction of HIV-1 infection risk in HIV uninfected women in sub-Saharan Africa.
http://programme.ias2017.org/Abstract/Abstract/5704 (accessed January 29, 2021).
Rosner, F., and J. A. Giron. 1983. Immune deficiency syndrome in children. JAMA 250(22):3046.
Ross, J. 2001. Pelvic inflammatory disease. BMJ 322(7287):658-659.
Røttingen, J.-A., and G. P. Garnett. 2002. The epidemiological and control implications
of HIV transmission probabilities within partnerships. Sexually Transmitted Diseases
29(12):818-827.
Royce, R. A., A. Sena, W. Cates, Jr., and M. S. Cohen. 1997. Sexual transmission of HIV. New
England Journal of Medicine 336(15):1072-1078.
Rubinstein, A., M. Sicklick, A. Gupta, L. Bernstein, N. Klein, E. Rubinstein, I. Spigland, L.
Fruchter, N. Litman, H. Lee, and M. Hollander. 1983. Acquired immunodeficiency with
reversed t4/t8 ratios in infants born to promiscuous and drug-addicted mothers. JAMA
249(17):2350-2356.
Rutstein, S. E., A. E. Pettifor, S. Phiri, G. Kamanga, I. F. Hoffman, M. C. Hosseinipour, N.
E. Rosenberg, D. Nsona, D. Pasquale, G. Tegha, K. A. Powers, M. Phiri, B. Tembo, W.
Chege, and W. C. Miller. 2016. Incorporating acute HIV screening into routine HIV
testing at sexually transmitted infection clinics, and HIV testing and counseling centers
in Lilongwe, Malawi. Journal of Acquired Immune Deficiency Syndromes 71(3):272-280.
Sabo, M. C., D. A. Lehman, B. Wang, B. A. Richardson, S. Srinivasan, L. Osborn, D. Matemo,
J. Kinuthia, T. L. Fiedler, M. M. Munch, A. L. Drake, D. N. Fredricks, J. Overbaugh, G.
John-Stewart, R. S. McClelland, and S. M. Graham. 2020. Associations between vaginal
bacteria implicated in HIV acquisition risk and proinflammatory cytokines and chemo-
kines. Sexually Transmitted Infections 96(1):3-9.
Santelli, J. S., L. Robin, N. D. Brener, and R. Lowry. 2001. Timing of alcohol and other drug
use and sexual risk behaviors among unmarried adolescents and young adults. Family
Planning Perspectives 33(5):200-205.
Schmidt, R., P. J. Carson, and R. J. Jansen. 2019. Resurgence of syphilis in the United States:
An assessment of contributing factors. Infectious Diseases 12:1178633719883282.
Schneider, T., R. Ullrich, and M. Zeitz. 1996. The immunologic aspects of human immu-
nodeficiency virus infection in the gastrointestinal tract. Seminars in Gastrointestinal
Disease 7(1):19-29.
Scott, H. M., and J. D. Klausner. 2016. Sexually transmitted infections and pre-exposure
prophylaxis: Challenges and opportunities among men who have sex with men in the
US. AIDS Research and Therapy 13:5.
Shahmanesh, M., V. Patel, D. Mabey, and F. Cowan. 2008. Effectiveness of interventions for
the prevention of HIV and other sexually transmitted infections in female sex workers
in resource poor setting: A systematic review. Tropical Medicine & International Health
13(5):659-679.
Sheffield, J. S., G. D. Wendel, Jr., D. D. McIntire, and M. V. Norgard. 2007. Effect of genital
ulcer disease on HIV-1 coreceptor expression in the female genital tract. The Journal of
Infectious Diseases 196(10):1509-1516.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
INTERSECTION OF HIV AND STIs 279
Shilts, R. 1987. And the band played on: Politics, people and the AIDS epidemic. New York: St.
Martin’s Press.
Smith, D. K., M. H. Chang, W. A. Duffus, S. Okoye, and S. Weissman. 2019. Missed oppor-
tunities to prescribe preexposure prophylaxis in South Carolina, 2013-2016. Clinical
Infectious Diseases 68(1):37-42.
SNL (Saturday Night Live). 2019. Weekend update: Pete Davidson on sexually transmitted diseases.
https://snltranscripts.jt.org/2019/weekend-update-pete-davidson-on-sexually-
transmitted-diseases.phtml#:~:text=Weekend%20Update%20Pete%20Davidson%20
on%20Sexually%20Transmitted%20Diseases,-0&text=Colin%20Jost%3A%20
According%20to%20the,highs%20because%20of%20dating%20apps.&text=Pete%20
Davidson%3A%20I%20don’t,can%20cure%20with%20a%20shot (accessed January 30,
2021).
Stenger, M. R., S. Baral, S. Stahlman, D. Wohlfeiler, J. E. Barton, and T. Peterman. 2017. As
through a glass, darkly: The future of sexually transmissible infections among gay,
bisexual and other men who have sex with men. Sexual Health 14(1):18-27.
Stolte, I. G., N. H. Dukers, J. B. de Wit, J. S. Fennema, and R. A. Coutinho. 2001. Increase in
sexually transmitted infections among homosexual men in Amsterdam in relation to
HAART. Sexually Transmitted Infections 77(3):184-186.
Storholm, E. D., J. E. Volk, J. L. Marcus, M. J. Silverberg, and D. D. Satre. 2017. Risk percep-
tion, sexual behaviors, and PrEP adherence among substance-using men who have sex
with men: A qualitative study. Prevention Science 18(6):737-747.
Stringer, E. M., M. Sinkala, J. S. Stringer, E. Mzyece, I. Makuka, R. L. Goldenberg, P. Kwape,
M. Chilufya, and S. H. Vermund. 2003. Prevention of mother-to-child transmission of
HIV in Africa: Successes and challenges in scaling-up a nevirapine-based program in
Lusaka, Zambia. AIDS 17(9):1377-1382.
Taha, T. E., D. R. Hoover, G. A. Dallabetta, N. I. Kumwenda, L. A. Mtimavalye, L. P. Yang,
G. N. Liomba, R. L. Broadhead, J. D. Chiphangwi, and P. G. Miotti. 1998. Bacterial
vaginosis and disturbances of vaginal flora: Association with increased acquisition of
HIV. AIDS 12(13):1699-1706.
The Lancet HIV. 2017. U=U taking off in 2017. The Lancet HIV 4(11):e475.
Tran, T. H., N. Cassoux, B. Bodaghi, C. Fardeau, E. Caumes, and P. Lehoang. 2005. Syphilitic
uveitis in patients infected with human immunodeficiency virus. Graefe’s Archive for
Clinical and Experimental Ophthalmology 243(9):863-869.
Tsevat, D. G., H. C. Wiesenfeld, C. Parks, and J. F. Peipert. 2017. Sexually transmitted dis-
eases and infertility. American Journal of Obstetrics and Gynecology 216(1):1-9.
van de Wijgert, J. H., C. S. Morrison, J. Brown, C. Kwok, B. Van Der Pol, T. Chipato, J. K.
Byamugisha, N. Padian, and R. A. Salata. 2009. Disentangling contributions of repro-
ductive tract infections to HIV acquisition in African women. Sexually Transmitted
Diseases 36(6):357-364.
Vanable, P. A., M. P. Carey, J. L. Brown, R. A. Littlewood, R. Bostwick, and D. Blair. 2012.
What HIV-positive MSM want from sexual risk reduction interventions: Findings from
a qualitative study. AIDS and Behavior 16(3):554-563.
Varghese, B., J. E. Maher, T. A. Peterman, B. M. Branson, and R. W. Steketee. 2002. Reducing
the risk of sexual HIV transmission: Quantifying the per-act risk for HIV on the basis
of choice of partner, sex act, and condom use. Sexually Transmitted Diseases 29(1):38-43.
Venkatesh, K. K., T. P. Flanigan, and K. H. Mayer. 2011. Is expanded HIV treatment prevent-
ing new infections? Impact of antiretroviral therapy on sexual risk behaviors in the
developing world. AIDS 25(16):1939-1949.
Vermund, S. H., and R. J. Hayes. 2013. Combination prevention: New hope for stopping the
epidemic. Current HIV/AIDS Reports 10(2):169-186.
Vermund, S. H., and A. J. Leigh-Brown. 2012. The HIV epidemic: High-income countries.
Cold Spring Harbor Perspectives in Medicine 2(5):a007195.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
280 SEXUALLY TRANSMITTED INFECTIONS
Vernazza, P., and E. J. Bernard. 2016. HIV is not transmitted under fully suppressive therapy:
The Swiss statement—eight years later. Swiss Medical Weekly 146:w14246.
Vernazza, P., B. Hirschel, E. Bernasconi, and M. Flepp, pour le Commission fédérale pour
les problèmes liés au sida (CFS) et le Commission d’experts clinique et thérapie VIH
et sida de l’Office fédéral de la santé publique (OFSP). 2008. Les personnes séroposi-
tives ne souffrant d’aucune autre mst et suivant un traitement antirétroviral efficace
ne transmettent pas le vih par voie sexuelle. Bulletin des Dédecins Suisses 89(5):165-169.
Wade Taylor, S., C. O’Cleirigh, K. H. Mayer, and S. A. Safren. 2013. HIV-infected men who
have sex with men who engage in very high levels of transmission risk behaviors: Es-
tablishing a context for novel prevention interventions. Psychology, Health & Medicine
18(5):576-587.
Wang, H., X. Wang, and S. Li. 2012. A case of lues maligna in an AIDS patient. International
Journal of STD & AIDS 23(8):599-600.
Wasserheit, J. N. 1992. Epidemiological synergy. Interrelationships between human immuno-
deficiency virus infection and other sexually transmitted diseases. Sexually Transmitted
Diseases 19(2):61-77.
Watson-Jones, D., H. A. Weiss, M. Rusizoka, J. Changalucha, K. Baisley, K. Mugeye, C.
Tanton, D. Ross, D. Everett, T. Clayton, R. Balira, L. Knight, I. Hambleton, J. Le Goff,
L. Belec, and R. Hayes. 2008. Effect of herpes simplex suppression on incidence of HIV
among women in Tanzania. New England Journal of Medicine 358(15):1560-1571.
Wawer, M. J., R. H. Gray, N. K. Sewankambo, D. Serwadda, L. Paxton, S. Berkley, D. McNairn,
F. Wabwire-Mangen, C. Li, F. Nalugoda, N. Kiwanuka, T. Lutalo, R. Brookmeyer, R.
Kelly, and T. C. Quinn. 1998. A randomized, community trial of intensive sexually
transmitted disease control for AIDS prevention, Rakai, Uganda. AIDS 12(10):1211-1225.
Wawer, M. J., N. K. Sewankambo, D. Serwadda, T. C. Quinn, L. A. Paxton, N. Kiwanuka,
F. Wabwire-Mangen, C. Li, T. Lutalo, F. Nalugoda, C. A. Gaydos, L. H. Moulton, M.
O. Meehan, S. Ahmed, and R. H. Gray. 1999. Control of sexually transmitted diseases
for AIDS prevention in Uganda: A randomised community trial. Rakai project study
group. Lancet 353(9152):525-535.
Weiss, H. 2004. Epidemiology of herpes simplex virus type 2 infection in the developing
world. Herpes 11(Suppl 1):24A-35A.
Weiss, S. H., J. J. Goedert, M. G. Sarngadharan, A. J. Bodner, R. C. Gallo, and W. A. Blattner.
1985. Screening test for HTLV-III (AIDS agent) antibodies. Specificity, sensitivity, and
applications. JAMA 253(2):221-225.
Weller, S., and K. Davis. 2002. Condom effectiveness in reducing heterosexual HIV transmis-
sion. Cochrane Database of Systematic Reviews (1):CD003255.
Westercamp, N., K. Agot, W. Jaoko, and R. C. Bailey. 2014. Risk compensation following male
circumcision: Results from a two-year prospective cohort study of recently circumcised
and uncircumcised men in Nyanza province, Kenya. AIDS and Behavior 18(9):1764-1775.
Wetmore, C. M., L. E. Manhart, and J. N. Wasserheit. 2010. Randomized controlled trials of
interventions to prevent sexually transmitted infections: Learning from the past to plan
for the future. Epidemiologic Reviews 32:121-136.
White, R. G., K. K. Orroth, J. R. Glynn, E. E. Freeman, R. Bakker, J. D. Habbema, F. Terris-
Prestholt, L. Kumaranayake, A. Buve, and R. J. Hayes. 2008. Treating curable sexually
transmitted infections to prevent HIV in Africa: Still an effective control strategy?
Journal of Acquired Immune Deficiency Syndromes 47(3):346-353.
WHO (World Health Organization). 2016. Consolidated guidelines on HIV prevention, diagnosis,
treatment and care for key populations. Geneva, Switzerland: World Health Organization.
WHO. 2020. European medicines agency (EMA) approval of the dapivirine ring for HIV prevention
for women in high HIV burden settings. https://www.who.int/news/item/24-07-2020-
european-medicines-agency-(ema)-approval-of-the-dapivirine-ring-for-hiv-prevention-
for-women-in-high-hiv-burden-settings (accessed January 25, 2021).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
INTERSECTION OF HIV AND STIs 281
WHO. 2021. WHO recommends the dapivirine vaginal ring as a new choice for HIV prevention for
women at substantial risk of HIV infection. https://www.who.int/news/item/26-01-2021-
who-recommends-the-dapivirine-vaginal-ring-as-a-new-choice-for-hiv-prevention-for-
women-at-substantial-risk-of-hiv-infection (accessed January 29, 2021).
Wiesenfeld, H. C., S. L. Hillier, L. A. Meyn, A. J. Amortegui, and R. L. Sweet. 2012. Subclini-
cal pelvic inflammatory disease and infertility. Obstetrics and Gynocology 120(1):37-43.
Williamson, D. A., E. P. F. Chow, C. L. Gorrie, T. Seemann, D. J. Ingle, N. Higgins, M. Easton,
G. Taiaroa, Y. H. Grad, J. C. Kwong, C. K. Fairley, M. Y. Chen, and B. P. Howden.
2019. Bridging of Neisseria gonorrhoeae lineages across sexual networks in the HIV pre-
exposure prophylaxis era. Nature Communications 10(1):3988.
Wing, C. 2009. Effects of written informed consent requirements on HIV testing rates:
Evidence from a natural experiment. American Journal of Public Health 99(6):1087-1092.
Wolpaw, B. J., C. Mathews, M. Chopra, D. Hardie, M. N. Lurie, and K. Jennings. 2011. Di-
agnosis and counselling of patients with acute HIV infection in South Africa. Sexually
Transmitted Infections 87(1):71-72.
Woods, W. J., N. Sheon, J. A. Morris, and D. Binson. 2013. Gay bathhouse HIV prevention:
The use of staff monitoring of patron sexual behavior. Sexuality Research and Social
Policy 10(2):77-86.
Workowski, K. A., and G. A. Bolan. 2015. Sexually transmitted diseases treatment guidelines,
2015. MMWR Recommendations and Reports 64(RR-03):1-137.
Young Holt, B., J. Kiarie, G. S. Kopf, K. Nanda, A. Hemmerling, and S. L. Achilles. 2020.
Bridging the gap: Advancing multipurpose prevention technologies from the lab into
the hands of women. Biology of Reproduction 103(2):286-288.
Zhu, J., F. Hladik, A. Woodward, A. Klock, T. Peng, C. Johnston, M. Remington, A. Magaret,
D. M. Koelle, A. Wald, and L. Corey. 2009. Persistence of HIV-1 receptor-positive cells
after HSV-2 reactivation is a potential mechanism for increased HIV-1 acquisition.
Nature Medicine 15(8):886-892.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Role of Technology and New Media
in Preventing and Controlling STIs
Chapter Contents
Introduction
• Critical Observations to Conceptualize the Role of
Technology in the STI Response
• Overview of Technology, Media Use, and Trends
Technologies
• Social Media
• Mobile Apps
• Dating Apps/Websites
• Online Pornography
• Virtual Reality/Augmented Reality
• Text Messaging
• Digital Contact Tracing and Digital Exposure Notification
• Wearable Devices/Biosensors
• Television, Radio, and Print
• Electronic Health Records
• Blockchain
• Cryptocurrency
• “Big Data” and Artificial Intelligence
283
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
284 SEXUALLY TRANSMITTED INFECTIONS
Chapter Contents Continued
Implementation Considerations: Costs and Feasibility
Implementation Considerations: Ethics and the Rapidly
Changing Environment
Conclusion and Recommendation
Concluding Observations
INTRODUCTION
Much has changed in the technology and media landscape in the
past two decades that has had an impact on sexually transmitted infec-
tion (STI) acquisition, prevention, screening, and treatment. Taking into
account these recent changes, this chapter provides a high-level overview
of the following:
1. Various technological innovations and their trends, including
social media, virtual reality (VR)/augmented reality (AR), artifi-
cial intelligence (AI), electronic health records (EHRs), and a his-
torical background on traditional media and television (see Box
6-1 for definitions of the technologies and relevant technological
terms included in this chapter);
2. The risks and benefits of these innovations (if applicable);
3. Considerations for implementation and ethical issues, including
the financial costs associated with implementation; and
4. The role that the COVID-19 pandemic is playing on potential
innovations relevant for sexual health.
Critical Observations to Conceptualize the Role
of Technology in the STI Response
The broad key takeaways from this chapter are the following:
• A large and growing number of technological innovations are
affecting sexual health and STI risk.
• Each innovation is only a tool that can (if designed properly) be
used to reach and engage masses quickly; it is not inherently
“risky” or “health promoting” by itself, as this depends on the use.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ROLE OF TECHNOLOGY AND NEW MEDIA 285
• Some of these innovations are ready for immediate implementa-
tion; others require more research.
• The technological innovations in this chapter have typically been
led by industry (e.g., media and technology companies). The
tools have become highly effective in improving identification,
targeting, and behavior change of individuals and groups. The
Centers for Disease Control and Prevention (CDC) and public
health departments would benefit greatly from working directly
with industry to learn about these tools, their risks and benefits,
and how to incorporate them into STI policy and practice. See
Chapter 12 for more information on the effects of COVID-19 on
STIs and sexual health.
• Research on this topic has often been designed for and/or in col-
laboration with health departments, in order to address potential
barriers and improve likelihood of implementation.
The chapter concludes with a recommendation to CDC regarding how to
leverage these technological innovations to improve STI prevention and
control efforts.
Due to the large and growing number of and constantly chang-
ing trends in innovations, this chapter does not provide an exhaus-
tive review of all possible innovations but seeks to offer a number of
diverse key examples and their associated risks and benefits. Addi-
tionally, eHealth and mHealth are both defined and referred to in this
chapter, but the focus is not specifically on prevention through the use
of technology overall but the associations between specific technologies
and their risks and benefits related to STIs. More information specific
to interventions, such as those used in eHealth and mHealth efforts, are
described in Chapter 8.
The chapter is structured with subsections for each innovation,
including (1) a description of and trends in its use, (2) an example of
research conducted with it, and (3) ways that it potentially increases STI
risk and/or promotes sexual health (if applicable). Due to the novelty and
recency of these technologies, this chapter sometimes references research
on technologies in other domains (e.g., HIV, influenza) if research within
the field of STIs is limited. Importantly, this chapter highlights that tech-
nology itself is just a platform/tool and therefore not problematic or beneficial
but how technologies are used is what affect STI acquisition, prevention,
and control. While some technologies may be associated with sexual
health outcomes, the mechanisms through which effects may occur are
unclear (see Chapter 8 for a discussion of possible mechanisms that may
influence effectiveness). Additionally, it is likely that technology can have
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
286 SEXUALLY TRANSMITTED INFECTIONS
BOX 6-1
Terminology
Artificial intelligence (AI): The field of AI can generally be defined as “the study of
ideas to bring into being machines that respond to stimulation consistent with traditional
responses from humans, given the human capacity for contemplation, judgment, and in-
tention” (Shubhendu and Vijay, 2013). More simply, AI is “the idea of building machines
[that] are capable of thinking like humans” (Marr, 2017a).
Augmented reality (AR): “Augmented reality is the integration of digital information
with the user’s environment in real time. Unlike virtual reality, which creates a totally
artificial environment, augmented reality uses the existing environment and overlays
new information on top of it” (Rouse, 2016). More simply, AR is a “way of viewing the
real world in which your view of the real world is ‘augmented’ by computer-generated
input, such as still images, audio, or video” (Mealy, n.d.).
Data science: “Data science is an umbrella term to describe the entire complex and
multistep processes used to extract value from data” (Irizarry, 2020).
Digital literacy: Digital literacy can be defined as “the ability to use digital technology,
communication tools or networks to locate, evaluate, use and create information”;
“the ability to understand and use information in multiple formats from a wide range of
sources when it is presented via computers”; and “a person’s ability to perform tasks
effectively in a digital environment” (U.S. Digital Literacy, n.d.).
eHealth (electronic health): “eHealth is the use of information and communication
technologies for health” (WHO, n.d.).
Machine learning: “Machine learning is a field of computer science that aims to teach
computers how to learn and act without being explicitly programmed. More specifically,
machine learning is an approach to data analysis that involves building and adapting
a variety of impacts that could influence STIs, including at the different
levels highlighted in the committee’s conceptual model (see Chapter 1).
The technologies discussed are associated with sexual health across
all levels identified in the committee’s conceptual model (see Chapter 1).
For example, dating apps may influence the interpersonal level, as they
allow for connections between individuals, but they also may have an
effect at the community level, affecting expectations more broadly. Immer-
sive pornography, viewed on VR devices, may influence the individual
level but may also have an impact at the community/institutional level by
affecting norms. (See Chapter 8 for additional examples of how technol-
ogy and media fit within the committee’s conceptual model.) Data from
technologies, such as from a mobility/global positioning system (GPS),
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ROLE OF TECHNOLOGY AND NEW MEDIA 287
models, which allow programs to ‘learn’ through experience. Machine learning involves
the construction of algorithms that adapt their models to improve their ability to make
predictions” (DeepAI, n.d.).
mHealth (mobile health): mHealth is a component of eHealth and can be defined
as “medical and public health practice supported by mobile devices, such as mobile
phones, patient monitoring devices, personal digital assistants (PDAs), and other wire-
less devices” (WHO Global Observatory for eHealth, 2011).
Social marketing: Social marketing is defined as “the application of proven concepts
and techniques drawn from the commercial sector to promote changes in diverse social-
ly important behaviors such as drug use, smoking, [and] sexual behavior” (Andreasen,
1995). A more recent definition of social marketing is the application of “commercial
marketing strategies to promote public health” (Evans, 2006).
Social media: Social media can be defined as “any digital tool that allows users to
quickly create and share content with the public. Social media encompasses a wide
range of websites and apps” (Hudson, 2020).
Virtual reality (VR): Virtual reality can be defined as “the use of computer technology
to create a simulated environment. Unlike traditional user interfaces, VR places the user
inside an experience. Instead of viewing a screen in front of them, users are immersed
and able to interact with 3D worlds” (Bardi, 2020). VR environments and/or tools typi-
cally consist of a headset and some sort of controller.
Wearable devices: Also known as “wearable technology” or “wearables,” wearable
devices are “any kind of electronic device designed to be worn on the user’s body”
(Rouse, 2019). They are often used for tracking a user’s vital signs or pieces of data
related to health and fitness, location, or even biofeedback indicating emotions (Tech-
nopedia, 2017). Some common examples of wearable devices are smart watches,
glasses, and rings.
which can be integrated into AI approaches, may influence all levels of
the model, depending on how the data are applied.
Technological innovation has advanced greatly in recent years, but
many opportunities and areas of study remain to be explored and further
studied. Areas related to each of the technologies described for which
evidence does not exist are noted throughout the chapter.
Overview of Technology, Media Use, and Trends
Digital technology and media use have seen shifts in the past 20
years. For example, nearly 60 percent of U.S. individuals use a stream-
ing digital service to view television content, with Netflix as a primary
platform (Liesman, 2018). Additionally, 20 percent of survey respondents
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
288 SEXUALLY TRANSMITTED INFECTIONS
used streaming only (Liesman, 2018). The digital divide, or the ability for
higher socioeconomic status groups to have greater Internet access, has
decreased (Anderson and Kumar, 2019), with most U.S. individuals now
having Internet access and some using smartphones for primary Internet
access (Anderson, 2019). According to a 2019 Pew Research Center sur-
vey, approximately 70 percent of adults who live in a household with an
income of less than $30,000 per year have a smartphone, 56 percent have
broadband, and 54 percent have a computer (Anderson and Kumar, 2019).
These trends continue to rapidly change, as smartphones are becoming
nearly ubiquitous, with 96 percent of 18–29-year-olds owning or having
access to one (Anderson, 2019). Figure 6-1 shows the 2019 percentage of
U.S. millennials, Boomers, and Gen Xers who said that they own a smart-
phone, own a tablet computer, and use social media.
Traditionally, the digital divide has been defined as the gap between
people who do and do not have access to communication technology, with
a focus on being able to physically access such services (Van Dijk, 2017).
However, work later moved to also focus on skills and competencies
(Van Dijk, 2017), including media literacy (i.e., the ability to apply critical
thinking to media messages) and digital literacy (i.e., the cognitive and
technical ability to navigate online environments). In a Pew Research Cen-
ter survey, participants’ digital knowledge varied greatly based on edu-
cational attainment and age, with better educated and/or younger adults
(i.e., those with a bachelor’s or advanced degree or under the age of 50)
scoring higher (Vogels and Anderson, 2019). Research suggests that, as
mobile and digital health continue to increase, limited digital health liter-
acy may impact demographic groups that experience disparities related to
health and health care (Smith and Magnani, 2019). Coupled with limited
health literacy, limited digital literacy presents additional challenges in
digital health services. Additionally, some people who traditionally expe-
rience the digital divide (e.g., lower-income, racial and ethnic minorities)
are also populations that tend to suffer inequities related to sexual health
(see Chapter 3 for a discussion on priority populations). Out of more than
1,900 women who were part of an HIV study, researchers found that daily
Internet use was associated with higher quality of life, and women who
had an annual income of more than $12,000 and were non-Hispanic white
were more likely to have daily Internet access (Philbin et al., 2019). The
authors concluded that providing reliable Internet access could improve
access to health promotion and may lead to improved health outcomes.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
FIGURE 6-1 Percentage of U.S. millennials, Boomers, and Gen Xers who own a smartphone, own a tablet computer, and use
social media (2019).
NOTES: Those who did not give an answer are not shown. Survey conducted January 8–February 7, 2019.
Copyright National Academy of Sciences. All rights reserved.
SOURCE: Pew Research Center, 2019a.
289
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
290 SEXUALLY TRANSMITTED INFECTIONS
TECHNOLOGIES
Social Media
Social media is the first example technology we will explore in this
chapter. Social media has great potential to impact sexual health, includ-
ing STI prevention and care services. Social media are websites and apps
that allow users to create and share digital content; a variety of platforms
are currently available. This chapter covers certain platforms, recognizing
that they may be similar in some ways and different in others, depending
on affordances (i.e., the benefits generated by the use of technology where
behavior-oriented goals become concrete actions [Bobsin et al., 2019]).
Statistics on Use
Social media use by U.S. adults continues to increase, with 72 percent
on at least one platform by 2019 (Pew Research Center, 2019a). In 2019,
the most popular platforms were YouTube and Facebook, followed by
Instagram, Pinterest, LinkedIn, Snapchat, Twitter, WhatsApp, and Red-
dit (Perrin and Anderson, 2019). Facebook, founded in 2004, was used by
69 percent of U.S. adults in 2019 (Perrin and Anderson, 2019). Since its
advent, social media has continued to expand. YouTube, created in 2005,
has been used by 73 percent of U.S. adults (Pew Research Center, 2019c).
A similar trend occurs among teens and young adults (15–25 years old),
with YouTube, Instagram, and Facebook as the top three sites, followed
by Snapchat, Twitter, Pinterest, Reddit, Tumblr, LinkedIn, WhatsApp, and
Periscope (Clement, 2019b).
Certain social media platforms are more popular among different
demographic groups. For example, Facebook use has declined among
teenagers in recent years (Anderson and Jiang, 2018), but Instagram and
Snapchat are both used by more than 70 percent of 18–24-year-olds (Perrin
and Anderson, 2019). These platforms provide different user characteris-
tics, such as the ability to like and share content (Bucher and Helmond,
2018). People use platforms for different purposes (Kane et al., 2014),
including to connect with friends, find employment, share health informa-
tion, and other personal and professional activities.
More frequent use of social media has also led to changes in the
way people acquire information. Reading of traditional newspapers for
news has declined (Pew Research Center, 2019c). In 2017, only half of
U.S. adults reported getting news regularly from television (Shearer and
Matsa, 2018), which has also been in decline. In contrast, nearly two-thirds
(68 percent) get at least some news from social media (Shearer and Matsa,
2018); Reddit, Twitter, and Facebook are the primary social media plat-
forms, with 73 percent of Reddit users getting their news there.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ROLE OF TECHNOLOGY AND NEW MEDIA 291
BOX 6-2
Misinformation
A major difference between modern society and past decades is the
overwhelming volume of online communication and 24/7 cable news network
information materials compared to earlier eras. It is easy for a lay audience and
even policy makers to glean compelling arguments that seem plausible but are
untrue. For example, conspiracy theories about the origin of viruses—Ebola, HIV,
COVID-19—have been able to thrive without sufficient evidence to justify them
(Law, 2020; Lewis, 2020; Rauhala, 2020; Schaeffer, 2020; Yee, 2020).
In part, these positions may be exacerbated because people who hold minority
positions may be more likely to speak out. For example, a research study found
that mothers who oppose childhood vaccination were more likely to seek and
share information about it, which can create an appearance that more people feel
this way than is actually the case (McKeever et al., 2016). A systematic review
of 57 studies found that studies about health misinformation were mainly related
to vaccination and infectious diseases and that misinformation was prevalent on
social media (Wang et al., 2019).
People’s ability to share and disseminate information across social media
means that it may spread and affect attitudes and perceptions. Online misinforma-
tion may also have severe negative effects on individuals’ health, quality of life, and
risk of mortality (Swire-Thompson and Lazer, 2020). Some social media outlets
have attempted to create restrictions on sharing inaccurate content. For example,
Twitter recently stated (via their own platform) that they wanted to promote healthy
public conversations and reduce the potential for harm by providing context for
posts that may be misleading (Pham, 2020).
Some scholars have argued that such efforts may not be enough to combat
the spread of misinformation and disinformation (Ananny, 2020; Walter et al.,
2020). Interventions created to refute misinformation online may be effective, as
a meta-analysis found a small to medium effect size (d = .40) across efforts to
correct misinformation on social media. Efforts were more effective at correcting
misinformation if participants were involved in the health topic and if the misin-
formation was distributed by a news outlet as opposed to a peer and refuted by
an expert. However, such efforts may be difficult to implement, depending on the
source of the misinformation.
Ultimately, the question still remains as to whether and how active a role tech-
nology companies/providers should take in filtering and choosing what is valid
information versus allowing users or government to determine this information and
guide the public toward reputable sources.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
292 SEXUALLY TRANSMITTED INFECTIONS
Social media allows anyone to share and pass information on without
an effective method for filtering out invalid sources and information; thus,
misinformation1 and disinformation2 are common (Wang et al., 2019). See
Box 6-2 for a discussion on misinformation, which relates to social media.
Examples: Potential of Technology to Increase STI Risk
Social media has been associated with behavior that can elevate
users’ risk for STIs, causing claims that this technology increases STI
transmission. For example, a study of young, urban men who have sex
with men (MSM) and transgender women found that they used social
media (i.e., Facebook and Twitter) and sexual networking/dating apps
(i.e., Grindr, Adam4Adam; more information about dating apps appears
in a later section) to seek sexual partners (56.7 percent), exchange sex for
money or clothes (19.6 percent), or obtain drugs (9.8 percent) (Patel et al.,
2016). Carmack and Rodriguez (2020) examined the influence of Face-
book on sexual risk behaviors among college students. The results sug-
gested that Facebook usage was significantly associated with intercourse
without a condom and that those who used Facebook 3 or more hours
per day were 1.9 times more likely to not use a condom in the past 30
days (B = .71, p = 0 .04) (Carmack and Rodriguez, 2020). This association
does not necessarily indicate causality, however, and other research has
not found an association between using the Internet for sexual purposes
(e.g., having Internet partners) and increased STI prevalence (Al-Tayyib
et al., 2009). Overall, research on this topic has been shifting from whether
social media leads to increased risk to how different methods of using social
media might lead to increased risk.
Examples: Potential of Technology to Decrease STI Risk
Research also suggests that social media can serve as a tool to decrease
STI risk, illustrating that it might both facilitate (as above) and decrease
risk behaviors, depending on how it is used and by whom. A study by
Stevens et al. (2017) sought to examine the influence of sexual health
information sources on their subsequent sexual risk reduction behaviors
among Black and Latino/a youth. They found that exposure to health
messages on social media increased the likelihood of using contraception
during the last sexual encounter (odds ratio [OR] = 2.69, p < 0.05).
1 Misinformation is “false information that is spread, regardless of whether there is intent
to mislead” (University of Washington Bothell and Cascadia College, 2020).
2 Disinformation is “deliberately misleading or biased information; manipulated narra-
tive or facts; propaganda” (University of Washington Bothell and Cascadia College, 2020).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ROLE OF TECHNOLOGY AND NEW MEDIA 293
Intervention studies to increase STI testing have been successful on
Facebook for a variety of diseases. For example, a targeted advertise-
ment was created for a sexual health campaign aimed at young women
to promote home-based chlamydia testing, with a 277 percent increase in
visits to the chlamydia testing kit page and 41 percent increase in test kit
requests compared to the period before the advertisement ran (Nadar-
zynski et al., 2019). Other investigators have used YouTube as part of a
randomized controlled trial to test the efficacy of an Internet-based health
and sexual education intervention among youth. The intervention group
was provided links to publicly accessible educational content, such as
interactive websites and YouTube videos. Participants in the intervention
group had a significant reduction in condomless vaginal or anal sex com-
pared to the control group (12.5 versus 47.6 percent, adjusted odds ratio
= 7.77, p < 0.05) (Whiteley et al., 2018). Importantly, these results should
not be attributed to the technology itself but to the combination of the
appropriate technology and psychological intervention elements (Young,
2020) (see Chapter 8 for more information).
Mobile Apps
Mobile apps are software developed to run on smartphones and tab-
lets across many platforms. They range in purpose, functionality, features,
and activities, including games, fitness, travel, ride-sharing, entertain-
ment, and education (Clement, 2019a). Research indicates high general
interest in apps related to STIs, emphasizing their potential in supporting
awareness and prevention (Jakob et al., 2020). Mobile apps can include
conversational agents, such as Siri3 and Alexa,4 as well as chatbots (which
can be included on mobile apps or mobile websites). Mobile apps can
also include social media, dating, and other technologies listed in this
chapter but are primarily described here to include those that are focused
on sexual health and/or research. Therefore, this section does not men-
tion these technologies’ potential to increase STI transmission, as specific
types of apps (e.g., dating apps) related to STI transmission are discussed
separately.
Statistics on Use
The popularity of mobile apps continues to grow, with 204 billion
downloads worldwide in 2019 (Perez, 2020). In the Apple App Store, as
3 See https://www.apple.com/siri (accessed January 29, 2021).
4 See https://developer.amazon.com/en-US/alexa (accessed January 29, 2021).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
294 SEXUALLY TRANSMITTED INFECTIONS
of 2020, there were more than 48,000 health care apps available (Statista,
2021b), and Google Play had more than 47,000 (Statista, 2021a).
Examples: Potential of Technology to Increase STI Risk
See the section in this chapter on dating apps/websites for examples
of potential risks.
Examples: Potential of Technology to Decrease STI Risk
Mobile apps may be used to address sexual health in a variety of
ways. While apps that address sexual health education may exist, a
review of 2,693 apps found in a search with keywords related to sexual
health found that only 25 percent (n = 697) addressed sexual health (Kalke
et al., 2018). Additionally, the majority of those apps (99 percent) did not
provide comprehensive programs, with only a small subset providing
information on STIs and pregnancy prevention (Kalke et al., 2018). Such
findings emphasize the need for collaboration between researchers and
app designers to develop evidence-based apps. In terms of data collection,
mobile apps allow researchers to survey participants at multiple points
in time close to when an event might occur, such as through ecological
momentary assessment (EMA), using their smartphone. EMA has been
well received by participants in STI/HIV studies (Hensel et al., 2012;
Trang et al., 2020). For example, Santa Maria et al. (2018) relied on EMA
to examine the sexual behaviors of homeless youth. The study results
suggested that sexual urge and drug use are factors that increase sexual
activity among this population (Santa Maria et al., 2018).
A three-armed randomized control trial by Wright et al. (2018) applied
ecological momentary intervention (EMI), a technique similar to EMA
that instead uses participant information to tailor content provided to par-
ticipant responses, to decrease alcohol consumption among young adults.
The EMI group received a short text message as feedback from their
EMA survey during six drinking events. The other two arms included an
EMA group with no feedback and control group with no contact at all.
Although investigators did not see significant differences in the number
of drinks consumed by the three groups, EMI was well received by study
participants (Wright et al., 2018), who stated that the feedback was useful
(69 percent) and relevant (88 percent) and agreed that “receiving the mes-
sages helped me to keep track of my drinking and spending” (58 percent)
(Wright et al., 2018). STI investigators may take note of EMA’s acceptabil-
ity in this research field to develop a trial with feedback text messages
to encourage condom use or initiate a conversation with their partner
about recent STI testing. An additional component could be examining
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ROLE OF TECHNOLOGY AND NEW MEDIA 295
participant location and creating an algorithm (see the data section below
as an example) that provides behavioral suggestions based on the EMA
response and location (i.e., completing the EMA at a bar). Such interven-
tions may also have similarities to just-in-time, adaptive interventions,
which are a type of intervention that offers tailored support at specific
time points. Such interventions were found to have moderate to large
effect sizes in a meta-analysis that looked at studies addressing health
behaviors and outcomes but not focused on addressing STIs (Wang and
Miller, 2020).
A variety of intervention types use mobile apps and may be useful
for addressing STI prevention (see Chapter 8 additional information). For
example, research has found a media literacy mobile app may be help-
ful for addressing media literacy and sexual health (Scull et al., 2018).
Researchers examining a media literacy program delivered in an app to
community college students found that the intervention reduced self-
reported high-risk sexual behaviors and was associated with increased
media skepticism. Media literacy may be useful for interpreting the com-
plex social media environment in which people may encounter disinfor-
mation and misinformation. There are also many examples in the field
of HIV of how mobile apps and other technologies more broadly can
increase HIV testing and the importance of studying this work (Hightow-
Weidman et al., 2018; Horvath et al., 2020; Muessig et al., 2015), which can
be applied to STI prevention and control efforts. For example, researchers
have studied games to improve sexual health and HIV-related outcomes,
with preliminary evidence of positive effects. Increasingly, this research
has been expanding to develop and test mobile gaming apps to achieve
sexual health outcomes (Aung et al., 2020; Karim et al., 2020; Muessig et
al., 2015). There are also a growing number of chatbots being explored
for use in sexual-health-related fields (Brixey et al., 2017; Nadarzynski et
al., 2020).
Dating Apps/Websites
Dating apps (a type of mobile app) and websites, such as Tinder,
Ship, Match, Bumble, Happn, Grindr, and Hornet, have rapidly grown in
popularity. A dating app is designed to enable persons who do not know
one another to meet online, often facilitating face-to-face social interac-
tions. They often rely on GPS to locate current app users in close prox-
imity (Burrell et al., 2012). Many are freely available for both Apple and
Android devices, though some offer subscription services for extra fea-
tures. As shown in Figure 6-2, dating apps and websites can be related to
both risk and non-risk activities, which could include health promotion.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
296 SEXUALLY TRANSMITTED INFECTIONS
To find an exclusive romantic partner
To have something fun/interesting to do
To see what the app is like
To boost my self-esteem
To have casual sex
To find non-exclusive romantic partners
To make platonic, non-romantic connections
To cheat on my significant other
Don't know
Prefer not to say
Other
0% 10% 20% 30% 40% 50% 60%
Percent of Respondents
18-34 Years 35-54 Years 55 Years or Older
FIGURE 6-2 Top reasons online dating websites or apps were used in the United
States, by age group.
NOTES: Field work dates: January 29–30, 2019; 383 respondents; 18 years and
older; sample: U.S. adults who have used a dating website or app.
SOURCE: Created using data from YouGov (see https://today.yougov.com).
Statistics on Use
Approximately 30 percent of U.S. adults have used a dating site or
app, higher for 18–29-year-olds (48 percent) and 30–49-year-olds (38 per-
cent) and lower for those 50 and older (16 percent) (Hobbs et al., 2017).
Gay, lesbian, and bisexual adults have a higher reported rate (55 percent)
of ever using a dating site or app than heterosexual adults (28 percent)
(Brown, 2020; Vogels, 2020a).
As use of these apps varies by several demographic factors, so do
perceptions of them. Nearly half (46 percent) of U.S. adults said that
dating sites and apps were either “not at all safe” or “not too safe,” but
younger respondents, LGBTQ+ respondents, and those with higher edu-
cation were more likely to see them as “somewhat safe” (Anderson et al.,
2020). People may use dating apps for a variety of reasons, from finding
a long-term partner to a casual “hookup” (Hobbs et al., 2017). Although
26 percent of respondents thought dating sites and apps have a mostly
negative effect on dating and relationships (Vogels, 2020a), users may find
dating apps to be more efficient than other methods of searching for a
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ROLE OF TECHNOLOGY AND NEW MEDIA 297
partner, believe they can lead to an expanded social network, or see them
as an opportunity to highlight certain aspects of themselves to prospective
partners (Hobbs et al., 2017).
Example of Potential STI Risk Related to the Technology
A review of Tinder that included 34 articles found that, while casual
sex occurred, sexual activities outside of a committed relationship were
the main predictor of casual sex (Ciocca et al., 2020). Men also used Tinder
more for casual sex in comparison to women (Ciocca et al., 2020).
Chemsex, the use of drugs during sexual intercourse, which is sig-
nificantly associated with bacterial STIs, was studied among MSM in the
Netherlands who were recruited either from a dating app (Grindr) or an
STI clinic. Chemsex was found to occur at a higher rate among dating app
users (29.3 percent) compared to STI clinic visitors (17.6 percent) (Drück-
ler et al., 2018). Compared to those from the clinic, participants from the
dating app reported lower frequency of sober sex within the past month
(87.0 percent versus 76.8 percent; p < 0.001). A similar trend was seen by
Beymer et al. (2014) for those who used dating apps to find sexual part-
ners. App users had greater odds of testing positive for gonorrhea (OR:
1.25; 95% confidence interval [CI] 1.06–1.48) and for chlamydia (OR: 1.37;
95% CI 1.13–1.65) compared to those who met partners through in-person
methods only (Beymer et al., 2014). Apps like Tinder (Timmermans and
Courtois, 2018) and Grindr (Licoppe et al., 2016) may facilitate sexual
encounters for those who intend and are motivated to use that app to find
sexual partners, with frequent in-person meetings significantly associated
with the number of one-night stands and casual sexual encounters (Tim-
mermans and Courtois, 2018).
Examples: Potential of Technology to Decrease STI Risk
Research has also investigated dating apps as a platform for preven-
tion messaging. A study examined the effectiveness of advertising in
various forms of digital tools for prevention messages to MSM during a
hepatitis A outbreak. Investigators found that apps garnered 85 percent
of the impressions during the campaign. Click rates also differed across
dating apps and websites, with significantly more clicks on ads on Grindr
compared to websites, while clicks on PlanetRomeo and Scruff were sig-
nificantly lower than websites (Ruscher et al., 2019).
Sun et al. (2015) used four different dating apps targeting the MSM
community to determine their acceptability and feasibility in providing
sexual health messages: 63.8 percent of participants were receptive to
health information presented in dating apps and 26 percent of initiated
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
298 SEXUALLY TRANSMITTED INFECTIONS
chats resulted in requesting referrals to local HIV/STI testing sites (Sun
et al., 2015). Huang et al. (2016a) examined the effectiveness of targeted
advertisements with online requests of free HIV self-test kits among Black
and Latino Grindr users: the advertisement led to 284 unique visitors
to the study website per day during the campaign and resulted in 334
requests for kits (Huang et al., 2016a). This approach could be similarly
applied for STI prevention interventions.
In addition, some dating apps targeting MSM have brought increased
attention to HIV status, with information available on profiles related to
testing status and timing (Howell, 2019; Patterson, 2019). A review of
safe sex messages in dating apps (Huang et al., 2016b) found that, of 60
dating apps reviewed, only 9 included sexual health content; 7 of those
apps were targeted toward MSM. See Chapter 3 for a discussion of MSM
as a priority population and Chapter 2 for a discussion of disassortative
mixing and social networks (an important consideration for STI preven-
tion and control).
Online Pornography
With the increase in technology availability, online pornography has
also become more accessible. Much of this is free, making it highly acces-
sible to young persons and even children.
Statistics on Use
With the expansion of the Internet, audiences who view pornography
have increased, as cost and social stigma barriers are eliminated when
materials are accessible online. A cross-sectional convenience survey
found that 75 and 56 percent of men and women, respectively, watched
pornography videos (Solano et al., 2020), with such videos being easy to
access online. In their sample of 1,392 adults aged 18–73, the researchers
found that 92 percent of men and 60 percent of women had consumed
pornography in the past month across various platforms (Solano et al.,
2020). Videos, pictures, and written pornography were the most common
formats (Solano et al., 2020).
Even when people are not searching for sexually explicit content,
it may be displayed online. In a meta-analysis of youths’ exposure to
unwanted online sexual media, researchers found that approximately one
in five adolescents was exposed to unwanted sexually explicit materials
online, and one in nine received online sexual solicitations (Madigan et
al., 2018).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ROLE OF TECHNOLOGY AND NEW MEDIA 299
Examples: Potential of Technology to Increase STI Risk
In a review of 20 years of pornography research, Peter and Valken-
burg (2016) found that adolescents’ use of pornography was associated
with more permissive sexual attitudes, increased casual sex, and more
sexual aggression. Other reviews have also noted the association between
pornography and sexual risk behaviors, including decreased condom use
(Lim et al., 2016). However, such research often relies on correlation and
does not demonstrate a cause-and-effect relationship (Lim et al., 2016).
Similarly, in a meta-analysis of nonexperimental studies, researchers noted
a significant association between violent pornography use and attitudes
that support violence against women (Hald et al., 2010), but other factors
may explain the association, such as men with a violent disposition seek-
ing out that content (Lim et al., 2016). Lim et al. (2016) conclude that while
online pornography is “extremely common,” its impact on outcomes
such as sexual health and well-being are uncertain. Similarly, Peter and
Valkenburg (2016) noted a dearth of “consistent, robust, and cumulative
evidence” between pornography use and sexual risk behaviors (p. 523).
Examples: Potential of Technology to Decrease STI Risk
Peter and Valkenburg (2016) noted the bias of pornography research
in focusing on potential negative outcomes. Other reviews have also men-
tioned this tendency (Lim et al., 2016). As Lim et al. (2016) note, there are
advocates for the benefits of pornography, and the body of supporting lit-
erature is limited but growing. The research primarily relies on subjective
assessments (Lim et al., 2016). Research on Danish and Australian adults,
for example, found from self-reports that participants believe pornogra-
phy has more positive than negative effects, including feelings of comfort
and open-mindedness about sex, is associated with an improved sex life,
and is associated with more attentiveness to a partner’s sexual pleasure
(Hald and Malamuth, 2008; McKee, 2007).
Virtual Reality/Augmented Reality
VR is a computer-generated environment that allows users to expe-
rience immersive realistic or fictional situations with which they can
interact. Oftentimes, users require special equipment (such as Oculus
or Google Cardboard). VR apps have allowed individuals to experience
online pornography in a more realistic, immersive way, which has cur-
rently unknown effects on the field of STI research.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
300 SEXUALLY TRANSMITTED INFECTIONS
Statistics on Use
Industries that invest in VR/AR/mixed reality include gaming, health
care and medical devices, education, military and defense, manufacturing
and automotive, movies and television, live events, workforce develop-
ment, marketing and advertising, retail, and real estate (Tankovska, 2020).
Figure 6-3 shows the growth in millions of VR and AR users from 2017
through 2021 (estimated).
Examples: Potential of Technology to Increase STI Risk
VR and AR apps related to sexual experiences have rapidly gained in
popularity. In an unpublished study, Bychkov and Young (2017)5 found
that within 1 month in 2017, on YouTube and Pornhub alone, a search for
FIGURE 6-3 U.S. virtual reality and augmented reality users, 2017–2021 (millions).
NOTES: Virtual reality (VR) users are individuals of any age who experience VR
content at least once per month via any device; augmented reality (AR) users are
individuals of any age who experience AR content at least once per month via
any device.
SOURCE: eMarketer, 2019.
5 Unpublished manuscript by David Bychkov and Sean D. Young, provided to National
Academies staff on December 8, 2020, for the Committee on Prevention and Control of
Sexually Transmitted Infections in the United States. Available by request from the National
Academies Public Access Records Office via email at [email protected].
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ROLE OF TECHNOLOGY AND NEW MEDIA 301
videos of “sex” uncovered more than 300 VR-related titles that gained
more than 13 million views. Although limited research has been con-
ducted on this topic, the fast growth and potential of VR for immersive
sexual encounters may influence STI risk.
Examples: Potential of Technology to Decrease STI Risk
The immersive nature of VR opens many potential uses, depending
on how the devices are deployed. For example, VR provides an oppor-
tunity for people to engage in virtual (rather than real-world) high-risk
behavior, thus potentially reducing the risk for STI transmission through
physical sex. Researchers have used VR for health outreach (Khan et al.,
2012; Read et al., 2006), for example, by targeting efforts toward high-
risk individuals in engaging ways to promote testing, safe sex practices,
and condom use (Mustanski et al., 2017; Read et al., 2006). In addition,
VR might be an effective tool to mitigate STI-related stigma by enabling
individuals to talk about STIs to other 3-D virtual humans. VR has already
been used clinically to relieve symptoms of anxiety, phobias, and post-
traumatic stress disorder and the stigma around sharing health informa-
tion (Rizzo and Shilling, 2017).
VR games might be developed to help increase self-efficacy in dis-
cussing STI testing with sexual partners or a health care provider. The
games could provide role-play situations and environments offering con-
versations that allow users the opportunity to think, learn, and gain con-
fidence in how to safely and healthily respond to different scenarios that
might present a risk.
Read et al. (2006) studied the effect of a virtual environment on par-
ticipants’ behavior and engagement in safer sex practices through a ran-
domized controlled trial. The intervention group received peer counseling
and an interactive video, while the control group received only the peer
counseling. The intervention group had higher levels of protected anal sex
and lower levels of condomless anal sex compared to the control group
(Read et al., 2006).
Text Messaging
Text messaging, or texting, is sending electronic messages to one
or more mobile devices. There are now various options for messages,
depending on the platform, such as short message service (SMS) or multi-
media messaging. Although text messaging started in the 1990s (Erickson,
2012), it is now ubiquitous and has been used in different ways, including
those relevant to STIs.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
302 SEXUALLY TRANSMITTED INFECTIONS
Statistics on Use
Ninety-six percent of U.S. individuals own a cell phone as of 2019;
81 percent own a smartphone, a substantial increase from 35 percent in
2011 (Pew Research Center, 2019b). These numbers are even greater for
younger age groups: 99 percent of 18–29-year-olds own a cellphone, with
96 percent owning a smartphone. The majority of cell phone owners send
text messages (Pew Research Center, 2019b).
Examples: Potential of Technology to Increase STI Risk
According to a systematic review of 31 studies, sexting has been
defined by researchers as sending sexually suggestive texts and/or sexu-
ally explicit photos (Klettke et al., 2014). Among 13 studies with an adult
sample, with 9 of them on undergraduate university students, the esti-
mated mean prevalence of sexting was 53.5 percent. The review noted
that, based on the studies analyzed, 10.2 percent of adolescents reported
sexting, with 11.9 percent specifying photo content. More adolescents
reported receiving than sending sexts. Among studies that measured
sexual activity, all found that people who reported sexting were signifi-
cantly more likely to be sexually active. Among the two studies reviewed
that examined the presence of STIs, one study noted that people who
sexted were more likely to report being diagnosed with an STI and the
other found no association.
In a systematic review and meta-analysis on sexting behaviors among
youth, researchers concluded that sexting has increased in recent years
and as youth age, and that sexting without consent also occurred, through
either forwarding (12 percent) or receiving (8.4 percent) a sext (Madigan
et al., 2018). In a separate meta-analysis of sexting among youth, research-
ers found sexting associated with sexual activity, having multiple sexual
partners, and lack of contraception, as well as other health outcomes, and
such outcomes were stronger in younger adolescents (Mori et al., 2019).
The authors concluded that additional longitudinal work is needed to
assess directionality and further understand the mechanisms of such
correlations. Both Madigan et al. (2018) and Mori et al. (2019) identified a
need to raise awareness related to digital health and safety among youth
to navigate these issues.
Examples: Potential of Technology to Decrease STI Risk
A variety of text message–based interventions exists for sexual health
promotion (Lim et al., 2008; Willoughby and Muldrow, 2017). Lim et al.
(2008) concluded that while SMS has been used in many ways to improve
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ROLE OF TECHNOLOGY AND NEW MEDIA 303
sexual health, studies of the effectiveness of such efforts are limited. In
a meta-analysis of the efficacy of text message–based interventions for
health promotion more generally, researchers found a mean effect size
of d = .329, showing that such interventions can have moderate effects
(Head et al., 2013). Messages that were tailored and targeted were the
most efficacious. A newer meta-analysis again focused on text messages
to change health behavior more generally, which included four studies on
text messaging for sexual health promotion, found an overall effect of d
= .24 (Armanasco et al., 2017). Interventions of 6–12 months were found
to be most effective, with no differences based on tailoring or targeting
message content. In a randomized controlled trial that examined the
effect of e-mail and text messaging on the sexual health of young people
(ages 16–29), after the yearlong intervention, the intervention group had
higher STI knowledge and its female participants were more likely to have
received an STI test or discussed sexual health with a provider (Lim et al.,
2012) (see Chapter 8 for additional information on digital interventions).
Digital Contact Tracing and Digital Exposure Notification
Current STI contact tracing methods typically involve having the
patient inform partners or a health department inform people about a
positive test result (NCSD, 2017). The evolution of contact tracing from
paper to digital (Ha et al., 2016) to mobile app (Apple and Google, 2020)
is documented for airborne communicable diseases and has recently been
applied to COVID-19.
Statistics on Use
The most recent data on digital contact tracing apps relates to the
COVID-19 pandemic, with the largest country-wide adoption occurring
in Australia, Turkey, and Germany (Clement, 2020). The United States was
not included in this list due to lack of adoption of a national digital con-
tact tracing method (it was left up to states). Digital contact tracing and
exposure notification have been available for STIs for a number of years,
and the increasing use of these apps as a result of the pandemic will likely
lead to greater future use for STI prevention and control.
Examples: Potential of Technology to Increase STI Risk
There are not clear examples of how digital contact tracing and expo-
sure notification apps may be related to increased STI risk.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
304 SEXUALLY TRANSMITTED INFECTIONS
Examples: Potential of Technology to Decrease STI Risk
Partner notification apps for STIs already exist. As dating apps are a
popular method to meet potential sexual partners, a contact tracing app
that uses information from the user’s dating apps could be developed to
notify partners of seroconversion. Research has already found electronic
communication technology to notify partners about STIs as an acceptable
strategy (Pellowski et al., 2016). In a review of 23 studies of technology
(e.g., the Internet, text messaging, or phone calls) for STI partner notifica-
tion, researchers found high interest and acceptability of e-notifications.
Despite this, the researchers noted little evidence of use of e-notification
services and that such services may work best for more casual partner-
ships (Pellowski et al., 2016). This would support the example described
above as a possible scenario or use of technology for partner notification
and potentially alleviate some of the barriers previously noted for such
resources. Current studies evaluating the success of digital contact tracing
for COVID-19 will help to inform future needs and the potential role of
these technologies in STI prevention and control.
Wearable Devices/Biosensors
Sensors are increasingly being incorporated into public health research
and practice, as well as daily life for health monitoring. A large number
of sensors are available for detecting health-related outcomes, including
movement, sleep, and biochemical reactions. Many of these sensors are
packaged into convenient wearable devices, including Fitbits and Apple
watches, to provide a user-friendly way for individuals to monitor their
health. Data from sensors can therefore be included into mobile phone
apps, or they can be collected through standalone devices other than a
mobile phone. Although limited research has studied wearable sensors
in the context of STI prevention, a number of potential application areas
are available and will likely be implemented in the near future, especially
as a result of the rapid advancements in sensors for detecting infectious
diseases due to the COVID-19 pandemic, making it important to be aware
of this growing area.
Statistics on Use
There are many types of wearable devices and biosensors, and wear-
ables continue to gain popularity. For example, one in five people in the
United States uses a fitness tracker or smart watch (Vogels, 2020b). This
chapter does not go into detail on all possible types of wearables but dis-
cusses some specifically related to STIs.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ROLE OF TECHNOLOGY AND NEW MEDIA 305
Examples: Potential of Technology to Increase STI Risk
There are not clear examples of how wearable devices and biosensors
may be related to increased STI risk.
Examples: Potential of Technology to Decrease STI Risk
Wearable condoms are one example of a sensor that can collect physi-
ological data and function beyond prophylactic needs. For example, iCon
is a novel wearable device that tracks performance during sexual inter-
course, including calories burned and thrust (British Condoms, 2020). The
Smart Condom Ring uses nano-chip and Bluetooth technology to transmit
data to the user’s cell phone. The developers also claim to have a feature
that can detect STIs such as chlamydia and syphilis through built-in indi-
cators (PRWeb, 2017).
There has also been development in modern condoms, designed
to increase condom use. For example, two graduate students created a
condom prototype with electrodes that sends electrical impulses to the
penis to stimulate pleasure during sexual intercourse (Dodge, 2014). Such
innovative design, if successful in increasing pleasure, might increase
frequency of condom use and thereby decrease STI transmission.
Television, Radio, and Print
Television, radio, and print have been prominent channels of com-
munication for decades. However, we have seen and continue to see shifts
in how these technologies are used. Television, for example, has moved
from a communal form of entertainment in the 1950s, when it first became
available, to individual viewing opportunities on a variety of devices.
Although use of these devices is declining compared to use of newer
digital tools, making them less likely to be considered a “technology,”
they are worth describing in this chapter, as they are the oldest current
forms of media and continue to influence the ways in which more modern
technologies evolve.
Statistics on Use
Traditional television use peaked in 2010, with U.S. households
watching approximately 9 hours per day (Madrigal, 2018). This number
has declined over the past few years, possibly due to the other ways
people can obtain media content (e.g., YouTube, Facebook) (Madrigal,
2018); but, on average, adults are still watching more than 4 hours of tele-
vision content per day (Nielsen, 2019b), with older adults spending the
greatest amount of time watching television (Nielsen, 2019a). Although
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
306 SEXUALLY TRANSMITTED INFECTIONS
people spend less time with radio overall, it still accounts for nearly 2
hours of daily media time for U.S. adults (Nielsen, 2019b). Streaming has
also become a popular way to view television content and access music,
with COVID-19 stay-at-home orders further associated with increases in
streaming (Nielsen, 2020).
How consumers interact with print media also continues to shift. The
majority of U.S. adults report having read a print magazine in the last 30
days, but 42 percent of survey respondents had read a magazine distrib-
uted electronically (Nicholas and Mateus, 2018).
Figure 6-4 shows the percentage of total media advertisement spend-
ing by type of media in 2018 and 2020. As later sections address, advertis-
ing on mobile devices has already exceeded other types of communication
tools. This trend is expected to increase, making it important for public
health departments to invest in digital approaches.
FIGURE 6-4 U.S. total media advertisement spending share, by media, 2018 and
projected 2022.
NOTES: Percentage of total. Numbers may not add up to 100 percent due to
rounding; (1) excludes digital; (2) includes newspapers and magazines, excludes
digital; (3) excludes off-air radio and digital; (4) print only, excludes digital.
SOURCE: eMarketer, 2018.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ROLE OF TECHNOLOGY AND NEW MEDIA 307
Examples: Potential of Technology to Increase STI Risk
Rape myth acceptance (false assumptions that result in denying or
excusing sexual violence) is a troubling finding for researchers, as it may
portend increased risk for intimate partner violence (Yapp and Quayle,
2018) or increased STI risk behaviors. A meta-analysis of 59 studies found
that exposure to sexual media content had a significant effect on sexual
attitudes and behaviors (Coyne et al., 2019). Participants with greater
exposure had more permissive sexual attitudes and rape myth accep-
tance. Increased exposure was positively associated with general sexual
experience and higher-risk sexual behaviors (e.g., number of partners,
no contraception) and negatively associated with age of sexual initiation
(people exposed to more sexual media initiated sex younger). The over-
all effect size was small (r = .14); however, stronger effects were found
for adolescents than young adults, boys than girls, and white compared
to Black participants. Previous meta-analyses have also found effects,
although effect sizes and specific outcomes may differ (Ferguson et al.,
2017; Fischer et al., 2011).
Such effects have also been noted in specific media types. For exam-
ple, a meta-analysis of 26 studies of sexual content in music and its asso-
ciation with sexual attitudes and behaviors among adolescents and young
adults found significant if small effects (r = .25 for attitudes and r = .16 for
behaviors) (Wright and Centeno, 2018). Different types of music exhibited
different effects. Wright and Centeno’s (2018) meta-analysis supports the
findings in Coyne et al. (2019), finding again that effects were stronger for
adolescents than young adults.
Examples: Potential of Technology to Decrease STI Risk
Media, including television, radio, and print, may also serve as a use-
ful tool for promoting behavior change. In a meta-analysis of 63 studies
on the effects of health communication mass media campaigns on health
outcomes across a variety of health topics (not specific to STIs), campaigns
affected health attitudes and behaviors (Anker et al., 2016). On the topic
of sexual health, a number of campaigns have focused on HIV preven-
tion. In a meta-analysis of mass media interventions for HIV prevention,
campaigns were associated with increased condom use (d = .25) and
knowledge, including on HIV transmission (d = .30) and prevention
(d = .39). Longer campaigns were associated with increased condom use
(LaCroix et al., 2014). These findings highlight the applicability of mass
media campaigns to sexual health, more broadly. Additionally, campaigns
can be useful for prompting interpersonal discussion. A meta-analysis of
28 studies, though not specific to STIs, found that conversations generated
from campaigns had a positive effect on the targeted outcomes (Jeong
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
308 SEXUALLY TRANSMITTED INFECTIONS
and Bae, 2017). Relatedly, interpersonal discussion can affect outcomes
pertinent to sexual health. For example, in a study of adolescents who
viewed a television show featuring a pregnancy announcement by a main
character followed by a discussion of the effectiveness of condoms (i.e.,
Friends), youth who talked to an adult reported that they were more likely
to learn about condoms from the episode and perceive condom efficacy
as higher (Collins et al., 2003).
Although campaigns may positively affect sexual health, they can
be expensive to create and distribute. Health communication campaigns
may benefit from formative research, a grounding in theory, and audience
segmentation (Noar, 2006), which can contribute to creation costs. How-
ever, state and local health departments may lack resources to create, dis-
tribute, and evaluate campaign messages (Ruebush, 2019; Walton, 2019;
Weiss, 2019). Some campaigns have been made more widely available,
such as Get Yourself Tested (CDC, 2019). For this campaign, CDC made
available sample social media posts, customizable articles, graphics, and
a widget that allows users to locate an STI testing location as an option
for STD Awareness Month. Preliminary research found that the campaign
reached youth and, based on STI testing data pre- and post-campaign,
may have been associated with increased STI testing (Friedman et al.,
2014). In a survey of 4,017 adolescents and young adults, participants
aware of the campaign were more likely to report engaging in STI and
HIV testing and talking to partners and providers about it (McFarlane et
al., 2015). Research that has looked at versions of the campaign adapted
for a high school setting found promising results, with increased testing
in participants from a school that implemented the campaign compared
to one without it (Liddon et al., 2019).
Entertainment education, embedding educational content in enter-
taining formats (Singhal and Rogers, 2012), is another strategy that often
uses media formats, such as television and radio, to positively influence
health outcomes. Such work has been conducted in a variety of settings,
including television, radio, and print, and through digital media, includ-
ing social media and text messaging (Moyer-Gusé et al., 2011; Rideout,
2008; Smith et al., 2007; Willoughby et al., 2018). A meta-analysis of 10
studies found small but significant effects of entertainment education nar-
ratives on sexual behaviors, with an association with reduced number of
partners, reduced condomless sex, and increased STI testing and manage-
ment (Orozco-Olvera et al., 2019).
Electronic Health Records
In contrast to the communication methods described above that
are primarily focused on the general population/individual, EHRs are
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ROLE OF TECHNOLOGY AND NEW MEDIA 309
primarily designed for health providers and administrators. EHRs have
evolved from a billing and accounting system to also being a patient care
delivery and management system, patient educational tool and resource,
and a system for administrative support processes (Reza et al., 2020). The
benefits of EHRs include improved patient care, care coordination among
health providers, reduced unnecessary tests and procedures, direct access
to one’s own health records, improved patient participation, and reduced
paperwork (HealthIT.gov, 2018). In addition, EHRs can also be useful for
public health surveillance, reporting of notifiable conditions, and out-
break monitoring and response (Reza et al., 2020).
Statistics on Use
More than 85 percent of office-based physicians have reported using
any EHR (CDC, 2020). In 2017, hospitals with a certified EHR ranged
from 93 percent in small, rural, and critical access hospitals to 99 percent
in large hospitals (more than 300 beds) (HealthIT.gov, 2019).
Examples: Potential of Technology to Increase STI Risk
There are not clear examples of how EHRs may be related to increased
STI risk.
Examples: Potential of Technology to Decrease STI Risk
Marcus et al. (2019) developed a machine learning model designed
to identify patients at risk of HIV among adult members of a large health
care organization. Investigators used 81 EHR variables to predict incident
cases within 3 years of the study period. The full model, which retained 44
predictive variables, was able to discriminate between HIV cases and non-
cases (C-statistic of 0.86, 95% CI 0.85–0.87) (Marcus et al., 2019). In clinical
settings, the implications of this work are that patients identified as high
risk for HIV might be targeted and recommended prevention methods,
such as pre-exposure prophylaxis. Similar work could be applied in the
context of STIs.
Furthermore, clinical decision support (CDS) tools (e.g., guidance and
alerts delivered through an EHR to health care providers to remind them
of STI screening guidelines during a patient visit) might be integrated into
patient care (Chadwick et al., 2017; Goyal et al., 2017). However, given the
issue of “alert fatigue” (an increasing number of EHR alerts being ignored
by health providers) (Ancker et al., 2017), the benefits and risks of devel-
oping CDS tools for STI clinical settings needs to be thoroughly consid-
ered in advance. CDC is taking steps to make the STI treatment guidelines
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
310 SEXUALLY TRANSMITTED INFECTIONS
available electronically and in real time and make screening and treat-
ment guidelines readily accessible in EHRs to guide clinician treatment
(NAPA, 2018). In 2019, a pilot project began, to demonstrate the feasibility
of posting the treatment guidelines in the cloud and working with EHR
vendors to automatically update screening and treatment recommenda-
tions whenever CDC updates the guidelines to facilitate updating CDS
tools in electronic medical records. Findings from the pilot show that
further refinement of the guidelines is needed “to incorporate flexibility
to support clinician’s local workflows and tele-health considerations” and
emphasize the need for “more open Application Programming Interfaces
(APIs) to integrate with clinician workflow and additional study to under-
stand barriers for CDS adoption amongst clinician users.”6,7
In the community setting, researchers have examined the impact of
EHRs in facilitating a discussion about STI testing between college stu-
dents and their potential sexual partners. Survey respondents reported
that access to their EHRs would help lead them to discuss STI testing ear-
lier in the relationship (60 percent) and improve communications about
STI prevention (63.6 percent) (Jackman et al., 2018).
EHRs as an avenue to increase testing among youth was examined in
a hospital emergency department by Ahmad et al. (2014). Youth who vis-
ited the emergency department were asked to complete a self-interview
about their sexual history. Physicians were prompted by the EHR to view
these answers based on the audio-enhanced computer-assisted self-inter-
view and decision tree and offer recommended testing to at-risk youth.
STI testing increased during the study period, to 17.8 percent compared
to 3 months before (9.3 percent) and 3 months after (12.4 percent) (Ahmad
et al., 2014). Although the intervention mainly focused on implementa-
tion, this study highlights EHRs as a vehicle to potentially target at-risk
populations to increase desired preventive behaviors. Finally, EHRs can
also facilitate opt-out screening for STIs, such as chlamydia screening for
women under 25 (Tomcho et al., 2021).
6 Middleton, B., M. Burton, K. Simon, S. Farzeneh, N. Mohanty, R. Padilla, S. Pohl, J. Carr,
and N. V. Collins. 2020. Clinical decision support in the real world: Learnings from a scalable CDS
implementation and suggestions for accelerating adoption and ensuring future success. Apervita,
AllianceChicago, and the Public Health Informatics Institute. Report from CDC, provided
to National Academies staff on November 6, 2020, by Raul Romaguera for the Committee
on Prevention and Control of Sexually Transmitted Infections in the United States. Available
by request from the National Academies Public Access Records Office via email at PARO@
nas.edu.
7 Middleton, B., and N. Mishra. 2018. CDS in the cloud: Deploying a CDC guideline for national
use. Presented at HIMSS18, Las Vegas. Presentation from CDC, provided to National Acad-
emies staff on November 6, 2020, by Raul Romaguera for the Committee on Prevention and
Control of Sexually Transmitted Infections in the United States. Available by request from
the National Academies Public Access Records Office via email at [email protected].
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ROLE OF TECHNOLOGY AND NEW MEDIA 311
Blockchain
Blockchain technology is a relatively new and growing type of infra-
structure that may affect many areas of sexual health in the future. Block-
chain is a shared, immutable repository of linked data. The technology
has been suggested to benefit users by increasing security and transpar-
ency because all transactions are chronologically recorded and difficult
to manipulate, even by the data owner (IBM, 2020). It is increasingly
being discussed as a potential tool for biomedical and health care applica-
tions to improve medical records management, enhance insurance claim
management, accelerate clinical research, and incorporate an advanced
biomedical data ledger, or accounting system, for data management (Kuo
et al., 2017).
Statistics on Use
In a 2017 survey of nearly 3,000 global C-suite executives, about 33
percent reported considering or already engaging with blockchain tech-
nology (IBM, 2017), with health care fast becoming a growing industry in
blockchain adoption (Casino et al., 2019; Hogan et al., 2016).
Examples: Potential of Technology to Increase STI Risk
There are not clear examples of how blockchain may be related to
increased STI risk. As cryptocurrency uses blockchain, see the relevant
section in this chapter, which provides examples of bitcoin and potential
risk.
Examples: Potential of Technology to Decrease STI Risk
Although no known research studies exist on the utility of blockchain
in decreasing STI transmission, Hopper conceived an idea using a popu-
lar digital tool. To decrease STI transmission and improve transparency
about current infection status with a potential sexual partner, Hopper sug-
gested merging blockchain technology with a dating app. For example,
before using the dating app, there could be a two-step verification process
whereby a user would (1) register for an account and (2) get tested for a
full panel of STIs (Hopper, 2019). Because users own their testing results,
they could give permission for the testing facility to share this verified
information with the app.
Blockchain technology might also be applied to sex work/transac-
tional sex. Similar to Hopper’s idea, blockchain might be used to verify
clients and their STI status, creating a safer work environment for sex
workers. For example, Gingr is an end-to-end scheduling platform that
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
312 SEXUALLY TRANSMITTED INFECTIONS
uses blockchain technology and allows booking a meeting location and
accepting a payment method (van Rijt, 2019). Through Gingr, sex workers
might be able to reduce their STI risk and improve sexual health (oreo-
fekari, 2019).
Cryptocurrency
Cryptocurrency is virtual, does not exist outside of the digital world,
and uses blockchain technology to record and facilitate transactions on
distributed networks (FTC, 2018), making it one type of example of how
blockchain technology might influence sexual health. In 2009, Bitcoin,
the first established cryptocurrency, was made publicly available; by
2011, several alternatives began to emerge (Marr, 2017b). As people have
secretly purchased illicit items (e.g., drugs) through the “underground”
Internet with cryptocurrency, it is also relevant to sexual health because
it is likely being used for transactional sex.
Statistics on Use
Cryptocurrency’s popularity has grown exponentially. It is traded in
billions of dollars per day (Kharif, 2019). Many companies and industries,
such as Microsoft, Overstock, BMW, and AT&T, accept it as payment
(Paybis, 2019).
Examples: Potential of Technology to Increase STI Risk
Although limited research has been conducted on this topic due to the
recency of the technology, numerous popular press examples report on
cryptocurrency in transactional sex and illicit activities (Andrews, 2019;
Foley et al., 2018; Nguyen, 2015).
Examples: Potential of Technology to Decrease STI Risk
Similar to blockchain, there are no known academic studies on the
impact of cryptocurrency on STIs. It is an acceptable form of payment on
Gingr, however, and could be applied in the blockchain example above
(Flavour of Boom, 2019). Another idea might be to partner with Safely, a
mobile app focused on sexual health, or a similar app to allow margin-
alized communities to pay for STI self-tests using cryptocurrency. This
would obviate the need for a bank account or credit card to access testing
and would provide privacy and confidentiality for the user. Additionally,
the Safely app does not require a physician’s order (The Safe Group, n.d.),
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ROLE OF TECHNOLOGY AND NEW MEDIA 313
which could be convenient for those without a primary care physician
or who might feel uncomfortable getting tested at a clinic due to stigma.
“Big Data” and Artificial Intelligence
It is estimated that 2.5 quintillion (i.e., 1 million times 1 million) bytes
of data are being created by technologies every day, with 90 percent
of the world’s data created within the past 2 years (Domo, 2020). This
includes a large amount of “social data,” such as from social media, wear-
able devices, and Internet search, which can provide information about
people’s attitudes, behaviors, locations, mobile apps and websites used,
searches for health information, and other digital behavioral outcomes
(Evans and Chi, 2008; Olshannikova et al., 2017; Olteanu et al., 2019). It
was previously not possible to aggregate and analyze such a large amount
of data due to technology infrastructure limitations. Recent advances
in “big data” infrastructure tools and AI modeling methods, however,
have made it possible to collect, aggregate, and analyze massive amounts
of data. These newer modeling methods—often interchangeably called
“AI,” “data science,” “machine learning,” and “big data statistical mod-
eling” (these terms and approaches do differ, but that is not essential to
this chapter)—enable the ability to find patterns and associations within
data at a faster pace than ever before. Although big data is not a stand-
alone tool like the other technologies described above (e.g., social media,
mobile apps), it has been included in this chapter because the technolo-
gies described above often lead to massive amounts of data that can be
analyzed using “big data” modeling methods.
Although these data are being analyzed to gain insights about indi-
viduals, their behaviors, health outcomes, and other factors, they can also
help generate insights and approaches into new methods of identifying
and engaging people to do things.
Companies such as Google, Amazon, and Facebook have led the
way in applying these new modeling methods to understand and predict
human behaviors, often with a goal of identifying people who will be
most likely to purchase specific products or click on advertisements. Com-
panies have used massive amounts of data from their users to send them
advertisements, improve features, and otherwise analyze user behavior.
For example, in the domain of sexual risk, hookup/sexual encounter
mobile apps use large amounts of data on their users’ locations, sexual
identities, HIV status, and other data to tailor information for their users
to make it easier for them to find sex partners.
These data have paved the way for new ways to conduct health out-
reach by identifying patients most in need and most likely to be responsive
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
314 SEXUALLY TRANSMITTED INFECTIONS
to outreach and to expand the use of AI methods and tools in health set-
tings outside the hospital and clinic (Aggarwal et al., 2020). Health-related
companies, such as pharmaceutical companies, are already beginning to
purchase and incorporate these types of data and digital communication
outreach approaches. For example, a pharmaceutical company interested
in recruiting STI patients for a clinical trial or to advertise a medication can
target mobile devices based on statistical datasets, including mobility pat-
terns. The company can access data on STI patients via a Health Insurance
Portability and Accountability Act–compliant dataset, use AI/statistical
approaches to identify millions of mobile devices that fit the (statistical)
profile of individuals likely to have contracted an STI, and serve mass
advertisements to these devices. Compared to typical methods of online
outreach, such as Facebook or Grindr advertisements, device ID outreach
methods can more accurately identify and engage a substantially larger
group of participants. The implication is that CDC and health departments
could apply these methods to scale their outreach efforts quickly.
These AI-based digital outreach methods are increasingly being used
during the COVID-19 pandemic due to the need to identify and engage
patients online so as to adhere to social distancing policies. In fact, these
methods are already being applied by health departments, including
CDC, to COVID-19 prevention (Ad Council, 2020). In the next 10 years,
they may become a mainstream part of public health outreach and engage-
ment, including for sexual health.
However, a number of potential implementation-related issues exist,
including ethical issues in the way these data are collected, analyzed, and
used, making it important to continually explore these changing ethical
questions and consider the rapid changes in technologies during imple-
mentation, as many of the dominant approaches in digital advertising
just 2–4 years ago are being phased out due to new methods designed to
improve privacy and effectiveness of outreach.
Examples: Potential of Technology to Increase STI Risk
Data from AI and related technologies could be used in ways that
might increase risk for STIs. For example, data/hookup apps could pur-
chase and/or use their own online data collected on users to identify indi-
viduals most interested in purchasing sex in order to serve ads to these
individuals (and the app owners are likely already doing so). Individuals
may be able to use data themselves to search through thousands of recent
classified advertisements to find other individuals wanting to have or
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ROLE OF TECHNOLOGY AND NEW MEDIA 315
exchange sex with them, potentially putting them and others at risk for
STIs (Wang and Young, 2021).8
Examples: Potential of Technology to Decrease STI Risk
Similar to private-sector companies and corporations, researchers
and public health departments can also analyze large amounts of data
to inform their surveillance and intervention efforts, and many have
already begun to study and implement these approaches. For example,
Internet search data from Google and social media data from Twitter have
been used to predict future syphilis cases (Young et al., 2018a,b). Mobile
phone app data can be analyzed to identify individuals’ locations and
map potential areas of risk (Duncan et al., 2018); social network and text
data from social media sites can be used to monitor STI- and HIV-related
trends in discussion topics and predict future testing rates (Ireland et al.,
2016; Schneider et al., 2013; Young and Jaganath, 2013; Young et al., 2014).
Furthermore, website analytics data (e.g., Google Analytics) can inform
surveillance and intervention efforts by identifying whether, when, and
how people are visiting websites (Johnson et al., 2016; Young et al., 2018b).
All of these types of analyses can be integrated into mapping and other
surveillance software to provide near-real-time data on individuals’ HIV-
and STI-related perceptions of risks, behaviors, and outcomes (Benbow
et al., 2020). Finally, integrating these data and models into interventions
has great potential. For example, public health departments may be able
to send advertisements to individuals identified by AI models as at risk
for STIs and incorporate other intervention methods described above.
There are two primary methods of research with technology data:
population-level and individual-level analyses. The former typically
involve publicly available, naturally occurring data (e.g., tweets that are
viewable by anyone). Studies using these data have rapidly collected
data from many users (e.g., hundreds of millions of users within a few
months). Population-level data, however, typically lack personal identi-
fiers and personally linked health information, making them appropriate
for surveillance efforts and/or models designed to predict trends at the
population or regional levels rather than to inform prevention or treat-
ment at an individual level.
In contrast, individual-level analyses involve data that are typi-
cally private, from individuals, and require user consent. Because
8 Unpublished manuscript by Jason Wang and Sean D. Young, provided to National Acad-
emies staff on February 2, 2021, for the Committee on Prevention and Control of Sexually
Transmitted Infections in the United States. Available by request from the National Acad-
emies Public Access Records Office via email at [email protected].
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
316 SEXUALLY TRANSMITTED INFECTIONS
individual-level analyses require recruiting individuals to provide their
data (e.g., by consenting to download an app or share their social media
usernames or other online activity), individual-level analyses and models
typically have a much smaller number of individuals and data points
compared to population-level analyses. Individual-level data analyses,
however, can have higher validity and address many of the limitations of
population-level analyses.
One primary benefit of digital data for surveillance is the ability to
address limitations in current surveillance methods. For example, tra-
ditional surveillance methods typically rely on case reporting, surveys,
interviews, and other direct patient data collection and so often suffer
from long time lags in reporting, aggregating, and releasing data, often
when it is urgent to access these data to prevent transmission. Similarly,
these methods are costly, are time consuming, require tremendous finan-
cial and personnel resources to scale and reach a large number of people
(e.g., large-scale campaigns to promote testing and treatment), and can
contain confidential patient information, decreasing the likelihood that all
local health departments would have the resources to use them frequently.
In contrast, technology data are often available in near or perfect
real time, free, publicly available, and, of course, massive compared to
traditional surveillance data, helping to address limitations in current
surveillance methods and enabling these data to be used as an additional
surveillance tool. Some limitations of technology data include lack of
resources and access to personnel/skills needed to analyze the data, dif-
ficulty in achieving access/partnerships with companies/technologies
who would be willing to share data, and lack of direct/valid data (as
technology data are typically used as proxies/predictors of STI cases but
are not verifiable compared to providing patients with an actual STI test
and measuring their results).
Researchers may also be able to collect data on individuals’ social
media posts and Internet searches for sexual encounter opportunities.
These near-real-time data can be combined with traditional surveillance
approaches to better understand regional differences in STI risk in order
to inform intervention efforts (Young et al., 2018a,b; Zhang et al., 2019).
Importantly, all of the digital technologies described in this chapter
also provide “big data footprints” that researchers and others can use to
infer information about people’s attitudes and behaviors. For example,
STI and HIV intervention studies occurring on social media sites, such
as Facebook, leave digital footprints of information, such as network ties,
people’s conversations, and data on topics that are engaging (Pagkas-
Bather et al., 2020; Young et al., 2014, 2020). Researchers can analyze
this information to better understand people’s STI-related behaviors and
improve delivery of future digital outreach and interventions.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ROLE OF TECHNOLOGY AND NEW MEDIA 317
IMPLEMENTATION CONSIDERATIONS:
COSTS AND FEASIBILITY
The AI-based approaches described in this chapter are included
because of the existing support for their ability to be feasible to imple-
ment and design, while keeping in mind the resource constraints of state
and local health departments. For example, as described above, CDC has
already partnered with researchers to use Internet search and social media
data to monitor STIs (Young et al., 2018a,b). Similarly, directors of state
and local health departments have worked with researchers to develop
visualization and mapping tools that leverage AI to identify, map the
location, and detect trends in social media posts related to HIV, including
perceptions of stigma and views about pre-exposure prophylaxis (Ben-
bow et al., 2020). Publicly available AI-based maps and tools such as this
are increasingly being developed, enabling health departments to use AI
in their work for little to no cost.
AI approaches also may be cost effective in their ability to inex-
pensively scale outreach to highly targeted groups. For example, the AI
methods being used for highly targeted consumer outreach by advertising
companies such as Google could be applied to STI prevention and care. AI
methods that leverage people’s data from the technologies described in
this chapter can be used to help identify groups in need of STI services. If
health departments were to use traditional (non-AI-based) methods, they
would typically need to collect resource-intensive data, such as surveys
and interviews, each time they target a new population (e.g., young men
who have sex with men). A traditional method of outreach (print advertis-
ing and venue-based recruitment) also would require extensive resources.
AI-based methods could reduce these costs, however, as the same model
for outreach can be slightly tweaked after “learning” the differences
between the new population attempting to be targeted. This could lead
to potentially dramatically reduced costs and also more targeted outreach.
Although AI-based approaches are being designed to be cost effec-
tive and feasible for implementation by health departments, as with any
approach, costs are still a potential issue. As work on the application of AI
to health outreach is still in its infancy, health departments that can afford
to hire an individual or team with technical expertise in this area (or col-
laborate with relevant researchers) will have an advantage in applying
these new approaches to their unique needs before tools become more
widely accessible for general public health use. More information about
potential costs of various approaches is provided in Recommendation 6-1.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
318 SEXUALLY TRANSMITTED INFECTIONS
IMPLEMENTATION CONSIDERATIONS: ETHICS AND
THE RAPIDLY CHANGING ENVIRONMENT
Although a full review of ethical considerations is beyond the scope
of this report, ethical considerations need to be addressed when imple-
menting tools and approaches that rely on technologies and their data.
A growing amount of research has been conducted around ethical issues
relating to technologies in public health research and practice. The gen-
eral public has been found to be generally supportive of public health
researchers and officials using their digital information to improve public
health outcomes (Romero and Young, 2021).
Determining the most ethical way to implement the technologies and
research approaches described in this chapter, however, is not an easy
task. Many questions first need to be addressed, including the following:
• Do companies, individuals, and/or public health departments
and researchers bear the ethical responsibility of using technolo-
gies in STI prevention and care?
• What role, if any, should public health and safety organizations,
including law enforcement, play in using these technologies and
gaining access to their data?
• Should policy decisions around implementation of technolo-
gies be based on data (which are often outdated) versus future
projections?
For example, one challenge in conducting ethical research on technologies
relates to the time lag between research and implementation. Because
technologies are rapidly changing and their use affects people’s ethical
views about them, by the time a study is finished and a policy imple-
mented, public views have often already changed. One possible question
is whether it makes sense to determine policy based on research studies if
these data are no longer applicable. Another possibility is for policy to be
informed by prior data and trends but also based on predictions of what
people’s beliefs will be. Yet another possibility is a policy that allows for
flexibility and rapid updates to keep up with the changing times and ethi-
cal perspectives. Regardless, it remains extremely important to accelerate
the rate of ethics and acceptability research on technologies to ensure
that health departments are investing in and applying tools that are still
relevant and impactful.
The COVID-19 pandemic might serve as a case study. For example,
one study surveyed approximately 150 individuals on their preferences
and willingness to share digital data (e.g., social media, wearable device/
GPS tracking, Internet search, and EHR data) to improve public health just
before COVID-19 cases were identified in the United States and related
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ROLE OF TECHNOLOGY AND NEW MEDIA 319
policies implemented. The team then went back in April 2020, at the
peak of the stay-at-home policies, and interviewed 25 participants, half of
whom had originally reported being willing and half unwilling to share
their data. Not surprisingly, the majority who had originally expressed
willingness remained willing. However, surprisingly, approximately 70
percent of participants who had reported being unwilling to share data
were now willing if it were used to address the pandemic. All participants
generally reported being more willing to share their data if researchers
and health officials rather than companies led the work (Romero and
Young, 2021). This example illustrates how quickly ethical views can
change as a result of external factors, making it essential that researchers
and policy makers develop and implement approaches that can account
for changing ethical views on technologies to keep up to date with cur-
rent perspectives.
Therefore, despite the possible appearance of privacy invasion and
other ethical concerns with various technologies described in this chapter,
the tools also offer many potential benefits, making it important to study
whether the benefits outweigh the risks. For example, related to data and
AI, STI and HIV officials are already keenly aware of the need for location
data (e.g., the Ending the HIV initiative focuses on counties most in need
of HIV interventions). The large amount of location-based data collected
from devices might allow for much more granular understanding and
use, not only by corporations to serve advertisements but also by public
health departments to identify and retain individuals and populations
who have been the most difficult to reach for STI and sexual health inter-
ventions and engagement and provide them with digital health outreach.
Collaborations between the industry owners and technology developers,
along with key stakeholders from the community and public sector, will
help to ensure that the tools can maximize the benefits as intended by
the developers while remaining aware of and minimizing potential risks.
CONCLUSION AND RECOMMENDATION
There are numerous opportunities to harness technological innova-
tion to improve STI prevention and control. Technological tools, including
AI, highly immersive media, and cryptographic data transfer methods/
blockchain apps, are rapidly changing STI epidemiology and intervention
efforts. Innovations from almost 20 years ago, such as Internet chat rooms,
pornographic online videos, and dating websites, were widely feared to
cause new STI epidemics. Those technologies quickly became outdated
as new innovations, such as social media, mobile hookup apps, and VR
apps, have caused even greater fears of increased STI transmission risk.
Those recent technologies are quickly being replaced again.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
320 SEXUALLY TRANSMITTED INFECTIONS
The question of whether new technologies pose STI transmission risk
is no longer relevant, given that they are nearly ubiquitous and impos-
sible to prevent. Instead, the relevant questions are how, why, when, and
where these technologies increase risk; how, when, and where they can be
leveraged to promote sexual health; and how public health can integrate
this knowledge into daily STI prevention and control efforts to ensure safe
and ethical oversight.
Conclusion 6-1: To keep pace with the rapid advancements in technology
and their effects on sexual health, it is essential that the field of public health
implements policy based on three important considerations:
1. Social media and mobile app-based technological innovations have been
primarily created by industry. Technology companies and individual
technologists and start-up companies have developed technologies to
address the public’s interests, such as a desire of some persons to quickly
and easily find relationships and/or sexual partners. It is imperative that
the same types of experts and companies who created these influential
tools be included in the public health response to STIs to provide insights
into individual decision-making processes related to sexual behaviors.
2. Artificial intelligence–based tools will become increasingly better at tar-
geting individuals and changing their behaviors. However, these tech-
nologies are merely platforms for engaging people in behavior change.
The same tools originally feared to increase STI transmission also hold
promise for altering individual and group behaviors and promoting
sexual health.
3. The ethical considerations around technological tools are evolving faster
than policies can address issues of concern. It typically takes years for
researchers to investigate users’ ethical concerns (e.g., beliefs about
a technology’s privacy, confidentiality, and risks versus benefits) and
translate these findings into policy. However, people’s ethical perspec-
tives about technologies change much faster than policy—sometimes,
literally overnight. Public health agencies need to frequently and regu-
larly evaluate new tools and public views about them to determine the
best course of action for the changing ethical landscape.
Recommendation 6-1: The Centers for Disease Control and Pre-
vention (CDC) should expand its capacity to use technology for
sexually transmitted infection (STI) prevention and control. To
accomplish this, CDC should recruit seasoned individuals from
the private and public sectors with experience in digital behavior
change and team science to work collaboratively with agency public
health and marketing staff. It should develop timely and open data
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ROLE OF TECHNOLOGY AND NEW MEDIA 321
systems and deploy artificial intelligence–based mass marketing
strategies to advance STI prevention.
Achieving this recommendation would entail that CDC undertake
the following activities:
1. CDC should establish a process for regular dialogue on ethi-
cal, technological, and health equity issues associated with novel
technologies with leading industry and nonprofit experts in digi-
tal technology and social communication along with STI provid-
ers and representatives of affected communities.
2. CDC should assess its STI data management capacity and that
of its grantees and make recommendations for strengthening
interoperability and security of such systems, safeguarding the
privacy and confidentiality of individually identifiable informa-
tion, and increasing the timeliness, openness, and accuracy of
aggregated data. The assessment should also include recommen-
dations for future investments in new epidemiologic data sources
and approaches, such as models incorporating STI-related social
media and Internet search data, data analytics, and data visual-
ization to effectively convey emerging STI trends to public health
stakeholders and the general public. These actions will require
state and local public health departments to assess and update
their efforts accordingly as well.
3. CDC should partner with state and local health departments to
develop and implement highly targeted AI-based digital mass
communication outreach strategies to identify and intervene to
address inequities among populations heavily impacted by STIs.
Such strategies could disseminate interventions and campaigns
to audiences at heightened risk of STI acquisition, leveraging
technology to improve the effectiveness of such efforts.
For example, action 1 in Recommendation 6-1 would be the least
expensive component of the recommendation, as the primary cost
involves meetings among key stakeholders. No payment, except for a
small honorarium, would be needed for the time of the researchers and
industry and/or nonprofit-sector individuals. Identifying highly engaged
experts within industry often takes time, as it requires finding the correct
contacts within an appropriate division. For example, an outreach attempt
to an AI group at Google or Amazon might seem logical to locate a key
stakeholder to advise on AI approaches but might lead to no response or
an unengaged partner. Requesting a stakeholder from a group at Google
or Amazon related to corporate social responsibility, marketing, or public
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
322 SEXUALLY TRANSMITTED INFECTIONS
partnerships might better identify someone who is more knowledgeable
and invested in the cause of public health. Although it can be difficult to
find the right industry partner, it is important not to “check the box” by
choosing anyone with industry experience involved in public–private
collaborations. Taking the time to find the right person—an expert who
is highly experienced with the technology, passionate about its use, and
excited about the chance to make a public service impact—will greatly
improve the success and safety of these technologies in public health.
Similarly, action 3 under Recommendation 6-1 would have relatively
low financial costs associated with its implementation. The primary costs
include purchasing advertisements.
The second action under Recommendation 6-1 would likely incur
the greatest financial costs of the three suggested actions, as it involves
changes to the surveillance software infrastructure and additional report-
ing activities from local health departments. These costs are unknown but
estimated to be large. One approach, if feasible, that could be used to keep
costs lower would be to outsource the software development to a vendor
experienced in data support systems and have short-term payment-based
milestones to evaluate the progress and specifications of this work (e.g.,
a series of small milestone-based payments contingent on successfully
delivering plans for software infrastructure before building any actual
software or spending significant money).
CONCLUDING OBSERVATIONS
It is important to understand the costs associated with implementing
technologies and AI approaches. Similar to the cost saving of prevent-
ing versus controlling an epidemic, investments in this infrastructure
are designed to lead to significant cost savings compared to waiting for
future problems. Overall, the costs associated with implementing these
recommendations are expected to be low but will differ based on multiple
factors.
Although both positive and negative outcomes associated with tech-
nology have been described in this chapter, technologies are not inher-
ently “good” or “bad” but rather need to be studied as to their potential
utility or harm for public health. Technology will only continue to evolve
and proliferate, as in the past. Therefore, based on the previous informa-
tion, the committee recognizes that technology needs to be acknowledged
as a tool that is changing the landscape in which information, interven-
tions, and research related to STI prevention, control, and treatment are
being conducted. More broadly, digital health funding has increased sig-
nificantly in recent years and will likely continue to grow rapidly (see Fig-
ure 6-5). This funding will likely lead to new technologies and approaches
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
323
NOTE: Only includes U.S. deals greater than $2 million.
FIGURE 6-5 Digital health funding, 2013–2020.
SOURCE: Rock Health, 2021.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
324 SEXUALLY TRANSMITTED INFECTIONS
that can be incorporated into public health activities. Work is needed
in the areas previously mentioned to determine what actions can have
beneficial effects on how to overcome and address some of the negative
effects. Box 6-3 provides examples of specific research needs in this space.
BOX 6-3
Future Research Needs
• What are the best practices for using social media, mobile apps, virtual
reality/augmented reality, and other technologies to reduce sexually trans-
mitted infection (STI) risk and maximize the linkage of at-risk persons with
screening, treatment, and prevention efforts?
• How can social harms inherent in facilitating larger sexual networks, often
with drug and alcohol use and without condom use, be mitigated?
• What are the current best practices (to be updated with changes in time)
in using artificial intelligence to improve public health/STI prevention/treat-
ment, as well as the ethical issues around privacy and data security inherent
in doing this?
• How can government public health agencies engage private-sector sexual
hookup apps to enable education and risk reduction within the context of
sexual partner seeking?
• How can technologies and technology research be implemented quickly
enough to remain consistent with current trends and findings?
• How can service providers, health educators, and relevant stakeholders
stay up to date with technological innovations that can benefit the field of
STI prevention and treatment?
• How can people working in STI prevention and treatment stay current on
perceptions related to privacy and keep privacy as a top-of-mind consid-
eration when developing technologies for STI prevention and treatment
efforts?
REFERENCES
Ad Council. 2020. Leading digital and tech platforms join Ad Council, White House, HHS and
CDC to address COVID-19 crisis. https://www.prnewswire.com/news-releases/lead-
ing-digital-and-tech-platforms-join-ad-council-white-house-hhs-and-cdc-to-address-
covid-19-crisis-301029731.html (accessed October 26, 2020).
Aggarwal, N., M. Ahmed, S. Basu, J. J. Curtin, B. J. Evans, M. E. Matheny, S. Nundy, M.
P. Sendak, C. Shachar, R. U. Shah, and S. Thadaney-Israni. 2020. Advancing artifi-
cial intelligence in health settings outside the hospital and clinic. NAM Perspectives.
Discussion Paper, National Academy of Medicine, Washington, DC. https://nam.edu/
advancing-artificial-intelligence-in-health-settings-outside-the-hospital-and-clinic (ac-
cessed December 1, 2020).
Ahmad, F. A., D. B. Jeffe, K. Plax, K. K. Collins, K. B. Schechtman, D. E. Doerhoff, J. Garbutt,
and D. M. Jaffe. 2014. Computerized self-interviews improve chlamydia and gonor-
rhea testing among youth in the emergency department. Annals of Emergency Medicine
64(4):376-384.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ROLE OF TECHNOLOGY AND NEW MEDIA 325
Al-Tayyib, A. A., M. McFarlane, R. Kachur, and C. A. Rietmeijer. 2009. Finding sex partners
on the Internet: What is the risk for sexually transmitted infections? Sexually Transmitted
Infections 85(3):216-220.
Ananny, M. 2020. Put Trump’s tweets on a time delay. https://www.wired.com/story/opinion-
put-trumps-tweets-on-a-time-delay (accessed October 15, 2020).
Ancker, J. S., A. Edwards, S. Nosal, D. Hauser, E. Mauer, and R. Kaushal. 2017. Effects of
workload, work complexity, and repeated alerts on alert fatigue in a clinical decision
support system. BMC Medical Informatics and Decision Making 17(1):36.
Anderson, M. 2019. Mobile technology and home broadband 2019. Pew Research Center.
https://www.pewresearch.org/internet/2019/06/13/mobile-technology-and-home-
broadband-2019 (accessed July 7, 2020).
Anderson, M., and J. Jiang. 2018. Teens, social media & technology 2018. https://www.pe-
wresearch.org/internet/2018/05/31/teens-social-media-technology-2018 (accessed
November 18, 2020).
Anderson, M., and M. Kumar. 2019. Digital divide persists even as lower-income Americans
make gains in tech adoption. Pew Research Center. https://www.pewresearch.org/fact-
tank/2019/05/07/digital-divide-persists-even-as-lower-income-americans-make-
gains-in-tech-adoption (accessed July 7, 2020).
Anderson, M., E. A. Vogels, and E. Turner. 2020. The virtues and downsides of online dating.
Washington, DC: Pew Research Center.
Andreasen, A. R. 1995. Marketing social change: Changing behavior to promote health, social
development, and the environment. San Francisco, CA: Jossey-Bass.
Andrews, I. 2019. Cryptocurrency for sex workers and their clients. https://medium.com/
@lafemmeisobel/cryptocurrency-for-sex-workers-and-their-clients-bee59466eb46 (ac-
cessed August 12, 2020).
Anker, A. E., T. H. Feeley, B. McCracken, and C. A. Lagoe. 2016. Measuring the effectiveness
of mass-mediated health campaigns through meta-analysis. Journal of Health Commu-
nication 21(4):439-456.
Apple and Google. 2020. Exposure notification. Cryptography specification. April 2020. v1.2.
https://covid19-static.cdn-apple.com/applications/covid19/current/static/contact-
tracing/pdf/ExposureNotification-CryptographySpecificationv1.2.pdf?1 (accessed
November 18, 2020).
Armanasco, A. A., Y. D. Miller, B. S. Fjeldsoe, and A. L. Marshall. 2017. Preventive health
behavior change text message interventions: A meta-analysis. American Journal of Pre-
ventive Medicine 52(3):391-402.
Aung, B., J. W. Mitchell, and K. L. Braun. 2020. Effectiveness of mHealth interventions for
improving contraceptive use in low- and middle-income countries: A systematic re-
view. Global Health: Science and Practice 8(4):813-826.
Bardi, J. 2020. What is virtual reality? [Definition and examples]. https://www.marxentlabs.
com/what-is-virtual-reality (accessed October 23, 2020).
Benbow, N., C. Kirkpatrick, A. Gupta, J. Villamar, K. Chernyshov, N. Cramer, L. Mena, R.
Mayer, and S. Young. 2020. An iterative process of integrating and developing big data mod-
eling and visualization tools in collaboration with public health officials. London, UK: SAGE
Publications Ltd. https://methods.sagepub.com/case/developing-data-modeling-
visualization-collaboration-health-officials (accessed October 2, 2020).
Beymer, M. R., R. E. Weiss, R. K. Bolan, E. T. Rudy, L. B. Bourque, J. P. Rodriguez, and D. E.
Morisky. 2014. Sex on demand: Geosocial networking phone apps and risk of sexually
transmitted infections among a cross-sectional sample of men who have sex with men
in Los Angeles County. Sexually Transmitted Infections 90(7):567-572.
Bobsin, D., M. Petrini, and M. Pozzebon. 2019. The value of technology affordances to
improve the management of nonprofit organizations. RAUSP Management Journal
54(1):14-37.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
326 SEXUALLY TRANSMITTED INFECTIONS
British Condoms. 2020. i.Con smart condom. https://britishcondoms.uk/the-icon-smart-
condoms.html (accessed November 20, 2020).
Brixey, J., R. Hoegen, W. Lan, J. Rusow, K. Singla, X. Yin, R. Artstein, and A. Leuski. 2017.
SHIHbot: A Facebook chatbot for sexual health information on HIV/AIDS. Proceedings
of the SIGDIAL 2017 Conference, August 15-17, 2017, Saarbrucken, Germany.
Brown, A. 2020. Lesbian, gay and bisexual online daters report positive experiences—but also ha-
rassment. Pew Research Center. https://www.pewresearch.org/fact-tank/2020/04/09/
lesbian-gay-and-bisexual-online-daters-report-positive-experiences-but-also-harass-
ment (accessed November 5, 2020).
Bucher, T., and A. Helmond. 2018. The affordances of social media platforms. In The SAGE
handbook of social media. London, UK: Sage Publications. Pp. 233-253.
Burrell, E. R., H. A. Pines, E. Robbie, L. Coleman, R. D. Murphy, K. L. Hess, P. Anton, and
P. M. Gorbach. 2012. Use of the location-based social networking application GRINDR
as a recruitment tool in rectal microbicide development research. AIDS and Behavior
16(7):1816-1820.
Carmack, C., and L. Rodriguez. 2020. Social media usage as a correlate of STI risk-related
sexual behavior on the college campus: Moderating effects of gender. Current Psychol-
ogy 39(5):1696-1704.
Casino, F., T. K. Dasaklis, and C. Patsakis. 2019. A systematic literature review of blockchain-
based applications: Current status, classification and open issues. Telematics and Infor-
matics 36:55-81.
CDC (Centers for Disease Control and Prevention). 2019. GYT: Get Yourself Tested campaign
materials. https://www.cdc.gov/std/sam/gyt/materials.htm (accessed September 24,
2020).
CDC. 2020. Electronic medical records/electronic health records (EMRs/EHRs). https://www.
cdc.gov/nchs/fastats/electronic-medical-records.htm (accessed November 18, 2020).
Chadwick, D. R., C. Hall, C. Rae, M. Rayment, M. Branch, J. Littlewood, and A. Sullivan.
2017. A feasibility study for a clinical decision support system prompting HIV testing.
HIV Medicine 18(6):435-439.
Ciocca, G., A. Robilotta, L. Fontanesi, A. Sansone, L. D’Antuono, E. Limoncin, F. Nimbi, C.
Simonelli, G. Di Lorenzo, A. Siracusano, and E. A. Jannini. 2020. Sexological aspects
related to Tinder use: A comprehensive review of the literature. Sexual Medicine Reviews
8(3):367-378.
Clement, J. 2019a. Mobile app usage—statistics & facts. Statista, https://www.statista.com/
topics/1002/mobile-app-usage (accessed October 10, 2020).
Clement, J. 2019b. Reach of leading social networking sites used by teenage and young adult online
users in the United States as of 3rd quarter 2020. Statista. https://www.statista.com/
statistics/199242/social-media-and-networking-sites-used-by-us-teenagers (accessed
October 10, 2020).
Clement, J. 2020. Adoption of government endorsed COVID-19 contact tracing apps in selected
countries as of July 2020. https://www.statista.com/statistics/1134669/share-
populations-adopted-covid-contact-tracing-apps-countries (accessed October 26, 2020).
Collins, R. L., M. N. Elliott, S. H. Berry, D. E. Kanouse, and S. B. Hunter. 2003. Entertainment
television as a healthy sex educator: The impact of condom-efficacy information in an
episode of Friends. Pediatrics 112(5):1115-1121.
Coyne, S. M., L. M. Ward, S. L. Kroff, E. J. Davis, H. G. Holmgren, A. C. Jensen, S. E. Er-
ickson, and L. W. Essig. 2019. Contributions of mainstream sexual media exposure to
sexual attitudes, perceived peer norms, and sexual behavior: A meta-analysis. Journal
of Adolescent Health 64(4):430-436.
DeepAI. n.d. Machine learning. https://deepai.org/machine-learning-glossary-and-terms/
machine-learning (accessed October 23, 2020).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ROLE OF TECHNOLOGY AND NEW MEDIA 327
Dodge, J. 2014. E condom: New device delivers electrical impulse during sex. CBS Chicago.
https://chicago.cbslocal.com/2014/02/26/e-condom-new-device-delivers-electrical-
impulse-during-sex (accessed November 18, 2020).
Domo. 2020. Data never sleeps 5.0. https://www.domo.com/learn/data-never-sleeps-5?aid=
ogsm072517_1&sf100871281=1 (accessed September 11, 2020).
Drückler, S., M. S. van Rooijen, and H. J. C. de Vries. 2018. Chemsex among men who have
sex with men: A sexualized drug use survey among clients of the sexually transmitted
infection outpatient clinic and users of a gay dating app in Amsterdam, the Nether-
lands. Sexually Transmitted Diseases 45(5):325-331.
Duncan, D. T., B. Chaix, S. D. Regan, S. H. Park, C. Draper, W. C. Goedel, J. A. Gipson, V.
Guilamo-Ramos, P. N. Halkitis, R. Brewer, and D. A. Hickson. 2018. Collecting mobility
data with GPS methods to understand the HIV environmental riskscape among young
Black men who have sex with men: A multi-city feasibility study in the Deep South.
AIDS and Behavior 22(9):3057-3070.
eMarketer. 2018. US total media ad spending share, by media, 2018 & 2022. https://www.emar-
keter.com/chart/217030/us-total-media-ad-spending-share-by-media-2018-2022-of-
total (accessed October 2, 2020).
eMarketer. 2019. US virtual reality and augmented reality users, 2017-2021. https://www.
emarketer.com/chart/226913/us-virtual-reality-augmented-reality-users-2017-2021-
millions (accessed October 2, 2020).
Erickson, C. 2012. A brief history of text messaging. https://mashable.com/2012/09/21/text-
messaging-history (accessed September 25, 2020).
Evans, B. M., and E. H. Chi. 2008. Towards a model of understanding social search. Paper pre-
sented at Proceedings of the 2008 ACM Conference on Computer Supported Coopera-
tive Work, San Diego, CA.
Evans, W. D. 2006. How social marketing works in health care. BMJ 332(7551):1207-1210.
Ferguson, C. J., R. K. L. Nielsen, and P. M. Markey. 2017. Does sexy media promote teen
sex? A meta-analytic and methodological review. Psychiatric Quarterly 88(2):349-358.
Fischer, P., T. Greitemeyer, A. Kastenmüller, C. Vogrincic, and A. Sauer. 2011. The effects of
risk-glorifying media exposure on risk-positive cognitions, emotions, and behaviors:
A meta-analytic review. Psychological Bulletin 137(3):367-390.
Flavour of Boom. 2019. Gingr—The blockchain backed solution for sexworkers. https://medium.
com/gingr/gingr-the-blockchain-backed-solution-for-sexworkers-ef6c41be5d36
(accessed November 18, 2020).
Foley, S., J. R. Karlsen, and T. J. Putniņš. 2018. Sex, drugs, and bitcoin: How much illegal
activity is financed through cryptocurrencies? Review of Financial Studies (forthcoming).
https://ssrn.com/abstract=3102645 (accessed August 12, 2020).
Friedman, A. L., K. A. Brookmeyer, R. E. Kachur, J. Ford, M. Hogben, M. A. Habel, L. M.
Kantor, E. Clark, J. Sabatini, and M. McFarlane. 2014. An assessment of the GYT: Get
Yourself Tested campaign: An integrated approach to sexually transmitted disease
prevention communication. Sexually Transmitted Diseases 41(3):151-157.
FTC (Federal Trade Commission). 2018. What to know about cryptocurrency. https://www.
consumer.ftc.gov/articles/what-know-about-cryptocurrency (accessed November 18,
2020).
Goyal, M. K., J. A. Fein, G. M. Badolato, J. A. Shea, M. E. Trent, S. J. Teach, T. E. Zaoutis,
and J. M. Chamberlain. 2017. A computerized sexual health survey improves testing
for sexually transmitted infection in a pediatric emergency department. The Journal of
Pediatrics 183:147-152.
Ha, Y. P., M. A. Tesfalul, R. Littman-Quinn, C. Antwi, R. S. Green, T. O. Mapila, S. L. Bellamy,
R. T. Ncube, K. Mugisha, A. R. Ho-Foster, A. A. Luberti, J. H. Holmes, A. P. Steenhoff,
and C. L. Kovarik. 2016. Evaluation of a mobile health approach to tuberculosis contact
tracing in Botswana. Journal of Health Communication 21(10):1115-1121.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
328 SEXUALLY TRANSMITTED INFECTIONS
Hald, G. M., and N. M. Malamuth. 2008. Self-perceived effects of pornography consumption.
Archives of Sexual Behavior 37(4):614-625.
Hald, G. M., N. M. Malamuth, and C. Yuen. 2010. Pornography and attitudes supporting
violence against women: Revisiting the relationship in nonexperimental studies. Ag-
gressive Behavior 36(1):14-20.
Head, K. J., S. M. Noar, N. T. Iannarino, and N. Grant Harrington. 2013. Efficacy of text
messaging-based interventions for health promotion: A meta-analysis. Social Science
& Medicine 97:41-48.
HealthIT.gov. 2018. What are electronic health records (EHRs)? https://www.healthit.gov/
topic/health-it-and-health-information-exchange-basics/what-are-electronic-health-
records-ehrs (accessed November 18, 2020).
HealthIT.gov. 2019. Quick stats. https://dashboard.healthit.gov/quickstats/quickstats.php
(accessed November 18, 2020).
Hensel, D. J., J. D. Fortenberry, J. Harezlak, and D. Craig. 2012. The feasibility of cell
phone based electronic diaries for STI/HIV research. BMC Medical Research Methodol-
ogy 12(1):75.
Hightow-Weidman, L. B., K. Muessig, E. Rosenberg, T. Sanchez, S. LeGrand, L. Gravens,
and P. S. Sullivan. 2018. University of North Carolina/Emory Center for Innovative
Technology (iTech) for addressing the HIV epidemic among adolescents and young
adults in the United States: Protocol and rationale for center development. JMIR Re-
search Protocols 7(8):e10365.
Hobbs, M., S. Owen, and L. Gerber. 2017. Liquid love?: Dating apps, sex, relationships and
the digital transformation of intimacy. Journal of Sociology 53(2):271-284.
Hogan, S., H. Fraser, P. Korsten, V. Pureswaran, and R. Gopinath. 2016. Healthcare rallies for
blockchains: Keeping patients at the center. Somers, NY: IBM Institute for Business Value.
Hopper, H. 2019. A blockchain solution to sexually transmitted infections in online dating. https://
medium.com/@huckhopper/a-blockchain-solution-to-sexually-transmitted-infections-
in-online-dating-c4ea784bd41 (accessed February 9, 2020).
Horvath, K. J., T. Walker, L. Mireles, J. A. Bauermeister, L. Hightow-Weidman, and R.
Stephenson. 2020. A systematic review of technology-assisted HIV testing interventions.
Current HIV/AIDS Reports 17(4):269-280.
Howell, S. 2019. PowerPoint presentation to the Committee on Prevention and Control of
Sexually Transmitted Infections in the United States. Irvine, CA. December 16, 2019.
https://www.nationalacademies.org/event/12-16-2019/prevention-and-control-of-
sexually-transmitted-infections-in-the-united-states-meeting-4 (accessed January 21,
2021).
Huang, E., R. W. Marlin, S. D. Young, A. Medline, and J. D. Klausner. 2016a. Using Grindr,
a smartphone social-networking application, to increase HIV self-testing among Black
and Latino men who have sex with men in Los Angeles, 2014. AIDS Education and
Prevention 28(4):341-350.
Huang, E. T., H. Williams, J. S. Hocking, and M. S. Lim. 2016b. Safe sex messages within dat-
ing and entertainment smartphone apps: A review. JMIR mHealth and uHealth 4(4):e124.
Hudson, M. 2020. What is social media? Definition and examples of social media. https://www.
thebalancesmb.com/what-is-social-media-2890301#what-is-social-media (accessed Oc-
tober 23, 2020).
IBM. 2017. Forward together: Three ways blockchain explorers chart a new direction. IBM Institute
for Business Value.
IBM. 2020. What is blockchain technology? https://www.ibm.com/blockchain/what-is-
blockchain (accessed July 24, 2020).
Ireland, M. E., Q. Chen, H. A. Schwartz, L. H. Ungar, and D. Albarracin. 2016. Action tweets
linked to reduced county-level HIV prevalence in the United States: Online messages
and structural determinants. AIDS and Behavior 20(6):1256-1264.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ROLE OF TECHNOLOGY AND NEW MEDIA 329
Irizarry, R. A. 2020. The role of academia in data science education. Harvard Data Science
Review 2(1).
Jackman, K.-M., S. D. Baral, L. Hightow-Weidman, and T. Poteat. 2018. Uncovering a role
for electronic personal health records in reducing disparities in sexually transmit-
ted infection rates among students at a predominantly African American university:
Mixed-methods study. JMIR Medical Informatics 6(3):e41.
Jakob, L., T. Steeb, Z. Fiocco, T. Pumnea, S. N. Jakob, A. Wessely, C. C. Rothenberger, T. J.
Brinker, L. E. French, C. Berking, and M. V. Heppt. 2020. Patient perception of mobile
phone apps for the care and prevention of sexually transmitted diseases: Cross-section-
al study. JMIR mHealth and uHealth 8(11):e16517.
Jeong, M., and R. E. Bae. 2017. The effect of campaign-generated interpersonal communica-
tion on campaign-targeted health outcomes: A meta-analysis. Health Communication
33(8):988-1003.
Johnson, A. K., T. Mikati, and S. D. Mehta. 2016. Examining the themes of STD-related In-
ternet searches to increase specificity of disease forecasting using Internet search terms.
Scientific Reports 6:36503.
Kalke, K. M., T. Ginossar, S. F. A. Shah, and A. J. West. 2018. Sex ed to go: A content analysis
of comprehensive sexual education apps. Health Education & Behavior 45(4):581-590.
Kane, G. C., M. Alavi, G. Labianca, and S. P. Borgatti. 2014. What’s different about social
media networks? A framework and research agenda. Management Information Systems
Quarterly 38(1):275-304.
Karim, H., H. Choobineh, N. Kheradbin, M. H. Ravandi, A. Naserpor, and R. Safdari. 2020.
Mobile health applications for improving the sexual health outcomes among adults
with chronic diseases: A systematic review. Digital Health 6:2055207620906956.
Khan, M. R., M. W. Epperson, L. Gilbert, D. Goddard, T. Hunt, B. Sarfo, and N. El-Bassel.
2012. The promise of multimedia technology for STI/HIV prevention: Frameworks
for understanding improved facilitator delivery and participant learning. AIDS and
Behavior 16(7):1949-1960.
Kharif, O. 2019. The world’s most-used cryptocurrency isn’t bitcoin. Bloomberg. https://
www.bloomberg.com/news/articles/2019-10-01/tether-not-bitcoin-likely-the-world-
s-most-used-cryptocurrency (accessed November 18, 2020).
Klettke, B., D. J. Hallford, and D. J. Mellor. 2014. Sexting prevalence and correlates: A sys-
tematic literature review. Clinical Psychology Review 34(1):44-53.
Kuo, T.-T., H.-E. Kim, and L. Ohno-Machado. 2017. Blockchain distributed ledger technolo-
gies for biomedical and health care applications. Journal of the American Medical Infor-
matics Association 24(6):1211-1220.
LaCroix, J. M., L. B. Snyder, T. B. Huedo-Medina, and B. T. Johnson. 2014. Effectiveness of
mass media interventions for HIV prevention, 1986-2013: A meta-analysis. Journal of
Acquired Immune Deficiency Syndrome 66:S329-S340.
Law, T. 2020. COVID-19 conspiracy theories are spreading rapidly—and they’re a public
health risk all their own. Time. https://time.com/5891333/covid-19-conspiracy-
theories (accessed October 27, 2020).
Lewis, T. 2020. Nine COVID-19 myths that just won’t go away. Scientific American. https://
www.scientificamerican.com/article/nine-covid-19-myths-that-just-wont-go-away (ac-
cessed October 27, 2020).
Licoppe, C., C. A. Rivière, and J. Morel. 2016. Grindr casual hook-ups as interactional
achievements. New Media & Society 18(11):2540-2558.
Liddon, N., L. H. Carver, L. Robin, C. R. Harper, C. C. Murray, M. A. Habel, and C. A.
Lesesne. 2019. Get Yourself Tested goes to high school: Adapted sexually transmitted
disease prevention campaign and associated student use of clinic sexually transmit-
ted disease testing services. Sexually Transmitted Diseases 46(6):383-388.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
330 SEXUALLY TRANSMITTED INFECTIONS
Liesman, S. 2018. Nearly 60% of Americans are streaming and most with Netflix: CNBC survey.
https://www.cnbc.com/2018/03/29/nearly-60-percent-of-americans-are-streaming-
and-most-with-netflix-cnbc-survey.html (accessed October 15, 2020).
Lim, M. S. C., J. S. Hocking, M. E. Hellard, and C. K. Aitken. 2008. SMS STI: A review of the
uses of mobile phone text messaging in sexual health. International Journal of STD &
AIDS 19(5):287-290.
Lim, M. S. C., J. S. Hocking, C. K. Aitken, C. K. Fairley, L. Jordan, J. A. Lewis, and M. E.
Hellard. 2012. Impact of text and email messaging on the sexual health of young
people: A randomised controlled trial. Journal of Epidemiology and Community Health
66(1):69-74.
Lim, M. S. C., E. R. Carrotte, and M. E. Hellard. 2016. The impact of pornography on gender-
based violence, sexual health and well-being: What do we know? Journal of Epidemiology
and Community Health 70(1):3-5.
Madigan, S., A. Ly, C. L. Rash, J. Van Ouytsel, and J. R. Temple. 2018. Prevalence of multiple
forms of sexting behavior among youth: A systematic review and meta-analysis. JAMA
Pediatrics 172(4):327-335.
Madrigal, A. C. 2018. When did TV watching peak? It’s probably later than you think, and
long after the Internet became widespread. https://www.theatlantic.com/technology/
archive/2018/05/when-did-tv-watching-peak/561464 (accessed September 23, 2020).
Marcus, J. L., L. B. Hurley, D. S. Krakower, S. Alexeeff, M. J. Silverberg, and J. E. Volk. 2019.
Use of electronic health record data and machine learning to identify candidates for
HIV pre-exposure prophylaxis: A modelling study. The Lancet HIV 6(10):e688-e695.
Marr, B. 2017a. The complete beginners’ guide to artificial intelligence. Forbes. https://
www.forbes.com/sites/bernardmarr/2017/04/25/the-complete-beginners-guide-to-
artificial-intelligence/?sh=7ce8a3c4a835 (accessed November 2, 2020).
Marr, B. 2017b. A short history of bitcoin and crypto currency everyone should read. Forbes.
https://www.forbes.com/sites/bernardmarr/2017/12/06/a-short-history-of-bitcoin-
and-crypto-currency-everyone-should-read/?sh=177bbcb83f27 (accessed November
5, 2020).
McFarlane, M., K. Brookmeyer, A. Friedman, M. Habel, R. Kachur, and M. Hogben. 2015.
GYT: Get Yourself Tested campaign awareness: Associations with sexually transmitted
disease/HIV testing and communication behaviors among youth. Sexually Transmitted
Diseases 42(11):619-624.
McKee, A. 2007. The relationship between attitudes towards women, consumption of por-
nography, and other demographic variables in a survey of 1,023 consumers of pornog-
raphy. International Journal of Sexual Health 19(1):31-45.
McKeever, B. W., R. McKeever, A. E. Holton, and J.-Y. Li. 2016. Silent majority: Childhood
vaccinations and antecedents to communicative action. Mass Communication and Society
19(4):476-498.
Mealy, P. n.d. Virtual & augmented reality for dummies cheat sheet. https://www.dummies.
com/software/virtual-augmented-reality-dummies-cheat-sheet (accessed November
2, 2020).
Mori, C., J. R. Temple, D. Browne, and S. Madigan. 2019. Association of sexting with sexual
behaviors and mental health among adolescents: A systematic review and meta-
analysis. JAMA Pediatrics 173(8):770-779.
Moyer-Gusé, E., C. Mahood, and S. Brookes. 2011. Entertainment-education in the context
of humor: Effects on safer sex intentions and risk perceptions. Health Communication
26(8):765-774.
Muessig, K. E., M. Nekkanti, J. Bauermeister, S. Bull, and L. B. Hightow-Weidman. 2015. A
systematic review of recent smartphone, Internet and Web 2.0 interventions to address
the HIV continuum of care. Current HIV/AIDS Reports 12(1):173-190.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ROLE OF TECHNOLOGY AND NEW MEDIA 331
Mustanski, B., K. Madkins, G. J. Greene, J. T. Parsons, B. A. Johnson, P. Sullivan, M. Bass,
and R. Abel. 2017. Internet-based HIV prevention with at-home sexually transmitted
infection testing for young men having sex with men: Study protocol of a randomized
controlled trial of Keep It Up! 2.0. JMIR Research Protocols 6(1):e1.
Nadarzynski, T., J. Burton, K. Henderson, D. Zimmerman, O. Hill, and C. Graham. 2019.
Targeted advertisement of chlamydia screening on social media: A mixed-methods
analysis. Digital Health 5:2055207619827193.
Nadarzynski, T., J. Bayley, C. Llewellyn, S. Kidsley, and C. A. Graham. 2020. Acceptabil-
ity of artificial intelligence (AI)-enabled chatbots, video consultations and live web-
chats as online platforms for sexual health advice. BMJ Sexual & Reproductive Health
46(3):210-217.
NAPA (National Academy of Public Administration). 2018. The impact of sexually transmitted
diseases on the United States: Still hidden, getting worse, can be controlled. Washington, DC:
National Academy of Public Administration.
NCSD (National Coalition of STD Directors). 2017. Sexually transmitted disease (STD) contact
tracing. https://www.ncsddc.org/wp-content/uploads/2017/08/infographic_5-26-16.
pdf (accessed July 24, 2020).
Nguyen, C. 2015. The sex workers’ guide to bitcoin. Vice. https://www.vice.com/en/
article/bmjegv/sex-workers-guide-to-bitcoin (accessed August 12, 2020).
Nicholas, D., and K. Mateus. 2018. Mequoda magazine consumer study: Analyzing multiplatform
magazine consumer habits. Boston, MA: Mequoda Group, LLC.
Nielsen. 2019a. The Nielsen total audience report. Q3 2018. New York: The Nielsen Company.
Nielsen. 2019b. U.S. consumers are shifting the time they spend with media. https://www.
nielsen.com/us/en/insights/article/2019/us-consumers-are-shifting-the-time-they-
spend-with-media (accessed January 26, 2021).
Nielsen. 2020. Going swimmingly: Streaming continues to grow among consumers. https://
www.nielsen.com/us/en/insights/article/2020/streaming-video-aug-2020-milestone
(accessed September 23, 2020).
Noar, S. M. 2006. A 10-year retrospective of research in health mass media campaigns: Where
do we go from here? Journal of Health Communication 11(1):21-42.
Olshannikova, E., T. Olsson, J. Huhtamäki, and H. Kärkkäinen. 2017. Conceptualizing big
social data. Journal of Big Data 4(1):3.
Olteanu, A., C. Castillo, F. Diaz, and E. Kıcıman. 2019. Social data: Biases, methodological
pitfalls, and ethical boundaries. Frontiers in Big Data 2(13).
oreofekari. 2019. GINGR, the first blockchain paid sex industry. https://steemit.com/
prostitution/@oreofekari/gingr-the-first-blockchain-paid-sex-industry (accessed
November 18, 2020).
Orozco-Olvera, V., F. Shen, and L. Cluver. 2019. The effectiveness of using entertainment
education narratives to promote safer sexual behaviors of youth: A meta-analysis,
1985-2017. PLoS One 14(2):e0209969.
Pagkas-Bather, J., L. E. Young, Y.-T. Chen, and J. A. Schneider. 2020. Social network interven-
tions for HIV transmission elimination. Current HIV/AIDS Reports 17(5):450-457.
Patel, V. V., M. Masyukova, D. Sutton, and K. J. Horvath. 2016. Social media use and HIV-
related risk behaviors in young Black and Latino gay and bi men and transgender
individuals in New York City: Implications for online interventions. Journal of Urban
Health 93(2):388-399.
Patterson, E. 2019. PowerPoint presentation to the Committee on Prevention and Control of
Sexually Transmitted Infections in the United States. Irvine, CA (presented remotely).
December 16, 2019. https://www.nationalacademies.org/event/12-16-2019/preven-
tion-and-control-of-sexually-transmitted-infections-in-the-united-states-meeting-4 (ac-
cessed January 21, 2021).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
332 SEXUALLY TRANSMITTED INFECTIONS
Paybis. 2019. 160 companies that accept Bitcoin (updated June 2020). https://paybis.com/blog/
companies-that-accept-bitcoin (accessed November 18, 2020).
Pellowski, J., C. Mathews, M. O. Kalichman, S. Dewing, M. N. Lurie, and S. C. Kalichman.
2016. Advancing partner notification through electronic communication technology:
A review of acceptability and utilization research. Journal of Health Communication
21(6):629-637.
Perez, S. 2020. App stores saw record 204 billion app downloads in 2019, consumer spend of $120
billion. https://techcrunch.com/2020/01/15/app-stores-saw-record-204-billion-app-
downloads-in-2019-consumer-spend-of-120-billion (accessed November 15, 2020).
Perrin, A., and M. Anderson. 2019. Share of U.S. adults using social media, including Facebook,
is mostly unchanged since 2018. https://www.pewresearch.org/fact-tank/2019/04/10/
share-of-u-s-adults-using-social-media-including-facebook-is-mostly-unchanged-
since-2018 (accessed November 18, 2020).
Peter, J., and P. M. Valkenburg. 2016. Adolescents and pornography: A review of 20 years of
research. The Journal of Sex Research 53(4-5):509-531.
Pew Research Center. 2019a. Millenials lead on some technology adoption measures, but Boom-
ers and Gen Xers are also heavy adopters. https://www.pewresearch.org/wp-content/
uploads/2019/09/FT_19.09.03_DigitalDivideGenerations_1.png (accessed October 2,
2020).
Pew Research Center. 2019b. Mobile fact sheet. https://www.pewresearch.org/internet/fact-
sheet/mobile (accessed September 25, 2020).
Pew Research Center. 2019c. Newspapers fact sheet. https://www.journalism.org/fact-sheet/
newspapers (accessed July 7, 2020).
Pham, S. 2020. Twitter says it labels tweets to provide “context, not fact-checking.” https://www.
cnn.com/2020/06/03/tech/twitter-enforcement-policy/index.html (accessed October
15, 2020).
Philbin, M. M., C. Parish, M. Pereyra, D. J. Feaster, M. Cohen, G. Wingood, D. Konkle-Parker,
A. Adedimeji, T. E. Wilson, J. Cohen, L. Goparaju, A. A. Adimora, E. T. Golub, and L. R.
Metsch. 2019. Health disparities and the digital divide: The relationship between com-
munication inequalities and quality of life among women in a nationwide prospective
cohort study in the United States. Journal of Health Communication 24(4):405-412.
PRWeb. 2017. The British condoms i.Con smart condom ring will be able to detect STIs—and
send the data straight to your smartphone. https://www.prweb.com/releases/2017/03/
prweb14102643.htm (accessed November 18, 2020).
Rauhala, E. 2020. The pandemic is amplifying the U.S. anti-vaccine movement—and global-
izing it. The Washington Post. https://www.washingtonpost.com/world/coronaviurs-
antivax-conspiracies/2020/10/06/96ddd2c2-028e-11eb-b92e-029676f9ebec_story.html
(accessed October 27, 2020).
Read, S. J., L. C. Miller, P. R. Appleby, M. E. Nwosu, S. Reynaldo, A. Lauren, and A. Putcha.
2006. Socially optimized learning in a virtual environment: Reducing risky sexual be-
havior among men who have sex with men. Human Communication Research 32(1):1-34.
Reza, F., J. T. Prieto, and S. P. Julien. 2020. Electronic health records: Origination, adoption,
and progression. In Public health informatics and information systems, edited by J. A.
Magnuson and B. E. Dixon. Cham: Springer International Publishing. Pp. 183-201.
Rideout, V. 2008. Television as a health educator: A case study of Grey’s Anatomy. Menlo Park,
CA: Kaiser Family Foundation.
Rizzo, A., and R. Shilling. 2017. Clinical Virtual Reality tools to advance the prevention,
assessment, and treatment of PTSD. European Journal of Psychotraumatology 8:1414560.
Rock Health. 2021. 2020 market insights report: Chasing a new equilibrium. https://rockhealth.
com/reports/2020-market-insights-report-chasing-a-new-equilibrium (accessed Febru-
ary 17, 2021).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ROLE OF TECHNOLOGY AND NEW MEDIA 333
Romero, R., and S. D. Young. 2021. Ethical perspectives in sharing digital data for public
health surveillance before and shortly after. Ethics & Behavior.
Rouse, M. 2016. Augmented reality (AR). https://whatis.techtarget.com/definition/
augmented-reality-AR (accessed October 23, 2020).
Rouse, M. 2019. Wearable technology. https://searchmobilecomputing.techtarget.com/
definition/wearable-technology (accessed October 23, 2020).
Ruebush, E. 2019. STI prevention and control: Opportunities and barriers at the state level. Pow-
erPoint presentation to the Committee on Prevention and Control of Sexually Trans-
mitted Infections in the United States. Washington, DC. September 9, 2019. https://
www.nationalacademies.org/event/09-09-2019/prevention-and-control-of-sexually-
transmitted-infections-in-the-united-states-meeting-2#sectionEventMaterials (accessed
November 17, 2020).
Ruscher, C., D. Werber, J. Thoulass, R. Zimmermann, M. Eckardt, C. Winter, and D. Sagebiel.
2019. Dating apps and websites as tools to reach anonymous sexual contacts during an
outbreak of hepatitis A among men who have sex with men, Berlin, 2017. Eurosurveil-
lance 24(21):1800460.
Santa Maria, D., N. Padhye, Y. Yang, K. Gallardo, and M. Businelle. 2018. Predicting sexual
behaviors among homeless young adults: Ecological momentary assessment study.
JMIR Public Health Surveillance 4(2):e39.
Schaeffer, K. 2020. A look at the Americans who believe there is some truth to the conspiracy
theory that COVID-19 was planned. Pew Research Center. https://www.pewresearch.
org/fact-tank/2020/07/24/a-look-at-the-americans-who-believe-there-is-some-truth-
to-the-conspiracy-theory-that-covid-19-was-planned (accessed October 27, 2020).
Schneider, J. A., B. Cornwell, D. Ostrow, S. Michaels, P. Schumm, E. O. Laumann, and S.
Friedman. 2013. Network mixing and network influences most linked to HIV infection
and risk behavior in the HIV epidemic among Black men who have sex with men.
American Journal of Public Health 103(1):e28-e36.
Scull, T. M., J. B. Kupersmidt, C. V. Malik, and E. M. Keefe. 2018. Examining the efficacy of an
mHealth media literacy education program for sexual health promotion in older ado-
lescents attending community college. Journal of American College Health 66(3):165-177.
Shearer, E., and K. E. Matsa. 2018. News use across social media platforms 2018. Pew
Research Center. https://www.journalism.org/2018/09/10/news-use-across-social-
media-platforms-2018 (accessed July 7, 2020).
Shubhendu, S., and J. Vijay. 2013. Applicability of artificial intelligence in different fields of
life. International Journal of Scientific Engineering and Research 1(1):28-35. https://www.
ijser.in/archives/v1i1/MDExMzA5MTU=.pdf (accessed October 23, 2020).
Singhal, A., and E. Rogers. 2012. Entertainment-education: A communication strategy for social
change. New York: Routledge.
Smith, B., and J. W. Magnani. 2019. New technologies, new disparities: The intersec-
tion of electronic health and digital health literacy. International Journal of Cardiology
292:280-282.
Smith, R. A., E. Downs, and K. Witte. 2007. Drama theory and entertainment education: Ex-
ploring the effects of a radio drama on behavioral intentions to limit HIV transmission
in Ethiopia. Communication Monographs 74(2):133-153.
Solano, I., N. R. Eaton, and K. D. O’Leary. 2020. Pornography consumption, modality and
function in a large Internet sample. Journal of Sex Research 57(1):92-103.
Statista. 2021a. Number of mHealth apps available at Google Play from 1st quarter 2015 to 3rd quar-
ter 2020. https://www.statista.com/statistics/779919/health-apps-available-google-
play-worldwide (accessed February 9, 2021).
Statista. 2021b. Number of mHealth apps available in the Apple App Store from 1st quarter 2015 to
3rd quarter 2020. https://www.statista.com/statistics/779910/health-apps-available-
ios-worldwide (accessed February 9, 2021).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
334 SEXUALLY TRANSMITTED INFECTIONS
Stevens, R., S. Gilliard-Matthews, J. Dunaev, A. Todhunter-Reid, B. Brawner, and J. Stewart.
2017. Social media use and sexual risk reduction behavior among minority youth: Seek-
ing safe sex information. Nursing Research 66(5):368-377.
Sun, C. J., J. Stowers, C. Miller, L. H. Bachmann, and S. D. Rhodes. 2015. Acceptability and
feasibility of using established geosocial and sexual networking mobile applications to
promote HIV and STD testing among men who have sex with men. AIDS and Behavior
19(3):543-552.
Swire-Thompson, B., and D. Lazer. 2020. Public health and online misinformation: Chal-
lenges and recommendations. Annual Review of Public Health 41(1):433-451.
Tankovska, H. 2020. VR/AR/MR/XR technology investment directions worldwide 2016-2019.
https://www.statista.com/statistics/829729/investments-focus-vr-augmented-reality-
worldwide (accessed October 10, 2020).
Technopedia. 2017. Wearable device. https://www.techopedia.com/definition/31206/
wearable-device (accessed November 2, 2020).
The Safe Group. n.d. SAFE: The safe sex app. https://safeapp.me (accessed July 24, 2020).
Timmermans, E., and C. Courtois. 2018. From swiping to casual sex and/or committed rela-
tionships: Exploring the experiences of Tinder users. The Information Society 34(2):59-70.
Tomcho, M. M., Y. Lou, S. C. O’Leary, D. J. Rinehart, T. Thomas-Gale, C. M. Douglas, F. J. Wu,
L. Penny, S. G. Federico, and H. M. Frost. 2021. Effectiveness of a universal chlamydia
and gonorrhea screening program to improve adolescent screening rates in pediatric
and family medicine primary care settings. Pediatrics.
Trang, K., P. S. Sullivan, D. E. Hinton, C. M. Worthman, M. G. Le, and T. Jovanovic. 2020.
Feasibility, acceptability, and design of a mobile health application for high-risk men
who have sex with men in Hanoi, Vietnam. The Lancet Global Health 8:S14.
University of Washington Bothell and Cascadia College. 2020. News: Fake news, misinforma-
tion & disinformation. https://guides.lib.uw.edu/c.php?g=345925&p=7772376 (accessed
December 16, 2020).
U.S. Digital Literacy. n.d. U.S. Digital Literacy. http://digitalliteracy.us (accessed October
23, 2020).
Van Dijk, J. A. G. M. 2017. Digital divide: Impact of access. In The international encyclope-
dia of media effects, edited by P. Rössler, C. A. Hoffner, and L. Zoonen. Hoboken, NJ:
Wiley-Blackwell.
van Rijt, T. 2019. Gingr aims to bring cryptocurrency to the prostitution industry. https://
www.datadriveninvestor.com/2019/01/28/gingr-aims-to-bring-cryptocurrency-to-
the-prostitution-industry (accessed November 18. 2020).
Vogels, E. A. 2020a. 10 facts about Americans and online dating. Pew Research Center. https://
www.pewresearch.org/fact-tank/2020/02/06/10-facts-about-americans-and-online-
dating (accessed July 7, 2020).
Vogels, E. A. 2020b. About one-in-five Americans use a smart watch or fitness tracker. Pew
Research Center. https://www.pewresearch.org/fact-tank/2020/01/09/about-one-
in-five-americans-use-a-smart-watch-or-fitness-tracker (accessed November 18, 2020).
Vogels, E. A., and M. Anderson. 2019. Americans and digital knowledge. Pew Research Center.
https://www.pewresearch.org/internet/2019/10/09/americans-and-digital-knowl-
edge (accessed July 8, 2020).
Walter, N., J. J. Brooks, C. J. Saucier, and S. Suresh. 2020. Evaluating the impact of attempts
to correct health misinformation on social media: A meta-analysis. Health Communica-
tion 1-9.
Walton, G. 2019. Panel—Opportunities and barriers at the state and local levels. PowerPoint
presentation to the Committee on Prevention and Control of Sexually Transmitted
Infections in the United States. Washington, DC. September 9, 2019. https://www.
nationalacademies.org/event/09-09-2019/prevention-and-control-of-sexually-
transmitted-infections-in-the-united-states-meeting-2#sectionEventMaterials (accessed
January 29, 2021).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ROLE OF TECHNOLOGY AND NEW MEDIA 335
Wang, L., and L. C. Miller. 2020. Just-in-the-moment adaptive interventions (JITAI): A meta-
analytical review. Health Communication 35(12):1531-1544.
Wang, Y., M. McKee, A. Torbica, and D. Stuckler. 2019. Systematic literature review on the
spread of health-related misinformation on social media. Social Science & Medicine
240:112552.
Weiss, G. 2019. STI prevention and control: Opportunities and barriers at the state and local level.
The local health department perspective. PowerPoint presentation to the Committee on Pre-
vention and Control of Sexually Transmitted Infections in the United States. Washing-
ton, DC. September 9, 2019. https://www.nationalacademies.org/event/09-09-2019/
prevention-and-control-of-sexually-transmitted-infections-in-the-united-states-meet-
ing-2#sectionEventMaterials (accessed November 17, 2020).
Whiteley, L. B., L. K. Brown, V. Curtis, H. J. Ryoo, and N. Beausoleil. 2018. Publicly available
Internet content as a HIV/STI prevention intervention for urban youth. The Journal of
Primary Prevention 39(4):361-370.
WHO (World Health Organization). n.d. eHealth. https://www.who.int/ehealth/about/en
(accessed October 23, 2020).
WHO Global Observatory for eHealth. 2011. mHealth: New horizons for health through mo-
bile technologies: Second global survey on eHealth. Geneva, Switzerland: World Health
Organization.
Willoughby, J. F., and A. Muldrow. 2017. SMS for sexual health: A comparison of service
types and recommendations for sexual health text message service providers. Health
Education Journal 76(2):231-243.
Willoughby, J. F., Z. Niu, and S. Liu. 2018. Assessing the potential use of narrative and the
entertainment education strategy in an mHealth text-message intervention. Journal of
Health Communication 23(1):20-27.
Wright, C. L., and B. Centeno. 2018. Sexual content in music and its relation to sexual
attitudes and behaviors among consumers: A meta-analytic review. Communication
Quarterly 66(4):423-443.
Wright, C., P. M. Dietze, P. A. Agius, E. Kuntsche, M. Livingston, O. C. Black, R. Room, M.
Hellard, and M. S. Lim. 2018. Mobile phone-based ecological momentary intervention
to reduce young adults’ alcohol use in the event: A three-armed randomized controlled
trial. JMIR mHealth and uHealth 6(7):e149.
Yapp, E. J., and E. Quayle. 2018. A systematic review of the association between rape myth
acceptance and male-on-female sexual violence. Aggression and Violent Behavior 41:1-19.
Yee, A. 2020. Recognize misinformation on the Internet. The New York Times. https://www.
nytimes.com/2020/08/22/at-home/recognize-misinformation-internet.html (accessed
October 27, 2020).
Young, L. E., S. Soliz, J. J. Xu, and S. D. Young. 2020. A review of social media analytic tools
and their applications to evaluate activity and engagement in online sexual health
interventions. Preventive Medicine Reports 19:101158.
Young, S. D. 2020. The Adaptive Behavioral Components (ABC) model for planning lon-
gitudinal behavioral technology-based health interventions: A theoretical framework.
Journal of Medical Internet Research 22(6):e15563.
Young, S. D., and D. Jaganath. 2013. Online social networking for HIV education and preven-
tion: A mixed-methods analysis. Sexually Transmitted Diseases 40(2):162-167.
Young, S. D., I. Holloway, D. Jaganath, E. Rice, D. Westmoreland, and T. Coates. 2014. Project
HOPE: Online social network changes in an HIV prevention randomized controlled
trial for African American and Latino men who have sex with men. American Journal of
Public Health 104(9):1707-1712.
Young, S. D., N. Mercer, R. E. Weiss, E. A. Torrone, and S. O. Aral. 2018a. Using social media
as a tool to predict syphilis. Preventive Medicine 109:58-61.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
336 SEXUALLY TRANSMITTED INFECTIONS
Young, S. D., E. A. Torrone, J. Urata, and S. O. Aral. 2018b. Using search engine data as a tool
to predict syphilis. Epidemiology 29(4):574-578.
Zhang, H., C. Wheldon, A. G. Dunn, C. Tao, J. Huo, R. Zhang, M. Prosperi, Y. Guo, and J.
Bian. 2019. Mining Twitter to assess the determinants of health behavior toward hu-
man papillomavirus vaccination in the United States. Journal of the American Medical
Informatics Association 27(2):225-235.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Biomedical Tools for STI
Prevention and Management
Chapter Contents
Introduction
Tools for STI Diagnosis
• Introduction
• Approaches to STI Screening and Diagnosis
• Gaps and Opportunities in STI Diagnosis
Antimicrobial Tools for STI Treatment
• Barriers to Therapeutic Innovation
• Antimicrobial Therapy for Bacterial STIs
• Antimicrobial Therapy for Viral STIs
• Antimicrobial Therapy for Protozoan STIs
• Gaps and Opportunities in STI Treatment
Tools for STI Prevention
• Condoms and Barrier Method Contraceptives
• Other Contraceptive Measures
• Multipurpose Prevention Technologies
• Antibiotics for STI Prevention
• Vaccines
• Gaps and Opportunities in STI Prevention
Conclusions and Recommendation
Concluding Observations
337
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
338 SEXUALLY TRANSMITTED INFECTIONS
INTRODUCTION
Throughout the 20th and 21st centuries, biomedical scientific advances
have provided numerous powerful tools to diagnose, prevent, and man-
age sexually transmitted infections (STIs). Even before modern antimi-
crobials became available, diagnostic testing (microscopy, early culture
methods) was possible, and more recently, it has evolved at an accelerat-
ing pace. Over the past 40 years, technical advances in molecular biology
and chemistry have led to newer tests and additional antibiotics and
provided tools that can be applied to vaccine development.
Translating these advances into widely available products is often
impacted by a time-consuming preclinical and clinical regulatory process,
which may take years and require millions of dollars. Corporate decision
making regarding developing new biomedical tools for STI management
also may be impacted by cost-related factors, such as the potential for
STI-related stigma to hinder vaccine acceptance, relatively less costly
single- rather than multiple-dose therapy for many STIs, and the desire
for low-cost, public health pricing. These factors have affected develop-
ment of new antibiotics and vaccines more than diagnostic tests.
As the modern age of antimicrobial therapy dawned in the mid-
1930s, the widespread availability of sulfonamide antibiotics made one
of two widely recognized STIs (gonorrhea) treatable, fueling increased
emphasis on accurate diagnosis as well. By the 1940s, when the “wonder
drug” penicillin became available, effective treatment of the second major
STI of concern, syphilis, became a reality and catalyzed expanded public
health efforts to control both diseases (Hook and Kirkcaldy, 2018). These
efforts became a governmental priority in the 1950s and 1960s and con-
tributed to the ascendance of the Venereal Disease Research Laboratory1
(VDRL), a predecessor, in part, to today’s Centers for Disease Control and
Prevention (CDC) as a leading public health agency. As recognized STIs
have increased since the 1960s, VDRL/CDC expanded monitoring of STI
prevalence, surveillance, and control efforts has been extended in vary-
ing degrees. Preferences for STI therapy in the United States have been
1 The Venereal Disease Research Laboratory was established in the 1920s as part of the U.S.
Public Health Service’s efforts to study the etiology, prevention, and treatment of diseases
such as syphilis and gonorrhea, especially in the military (Parascandola, 2001). Venereal
diseases were mainly thought to be syphilis, gonorrhea, lymphogranuloma venereum, and
chancroid. Since the 1970s, the field’s awareness of additional sexually transmitted patho-
gens has expanded, as has its understanding that the term “venereal” is stigmatizing and
disparaging (Handsfield, 2015). Language has evolved again, from sexually transmitted
“disease” to “infection” (Handsfield, 2015; Rietmeijer, 2015). Compared to “disease,” “in-
fection” is a more medically accurate and holistic and less stigmatizing term (Bolan, 2019;
Handsfield, 2015; Rietmeijer, 2015). See Chapter 1 for more information on stigma and
language.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
BIOMEDICAL TOOLS FOR STI PREVENTION AND MANAGEMENT 339
guided by CDC’s Sexually Transmitted Diseases Treatment Guidelines2
(Workowski and Bolan, 2015), a highly influential document with global
impact. The guidelines also help shape areas of STI research emphasis.
CDC also provides recommendations for STI testing and preferred test
methods.
In the 1980s, the field of STIs experienced major changes. First, the
HIV/AIDS pandemic led to increased interest in STIs, discussed in more
detail in Chapter 5. Rising STI incidence, coupled with the substantial
reproductive health morbidity associated with chlamydia infections,
added additional urgency to CDC’s ongoing STI control efforts. Currently,
CDC highlights three curable STIs (gonorrhea, chlamydia, and syphi-
lis) for high-priority non-HIV STI surveillance and control. Surveillance
for other common STIs, including trichomoniasis, herpes simplex virus
(HSV), human papillomavirus (HPV), and HIV, and for less common
infections, such as chancroid, ectoparasite infections, enteric infections,
and reproductive tract syndromes whose pathogenesis is not yet entirely
clear (e.g., nongonococcal urethritis [NGU]) and bacterial vaginosis [BV]),
are carried out variably and inconsistently using various surveillance
methods and elements of the public health agencies, as described in
Chapter 2.
Emerging and reemerging conditions are also more difficult to detect,
given a lack of screening and reporting consistency for many STIs, such
as occurred with the recent reemergence of lymphogranuloma venereum
among gay, bisexual, and other men who have sex with men (MSM) in
the United States. Similarly, emerging global public health threats are now
appreciated to be sexually transmissible, such as meningococcal, Ebola,
and Zika infections (CDC, 2019c, 2021; Ladhani et al., 2020), but the mag-
nitude of infections due to sexual transmission remains unknown.
In parallel to the evolution of STI control efforts at CDC, in the
late 1970s, STI research grew as an academic discipline. Academic STI
research, often in partnership with local public health agencies, is con-
ducted with support from the National Institutes of Health (NIH), CDC,
the pharmaceutical industry, and nonprofit agencies and foundations.
Over the past 50 years, investigators have expanded the list of pathogens
transmitted frequently through sexual contact to more than 30 bacterial,
viral, and protozoan pathogens (see Appendix A for a partial list). The
increased pathogen numbers, their biological variability, their ability to
infect nongenital mucosal sites, and frequent coinfection with multiple
2 The next iteration (expected in 2021) will be the “Sexually Transmitted Infections Treat-
ment Guidelines.” This report uses that language when referring to the guidelines antici-
pated in 2021 and the guidelines in general but the original “Sexually Transmitted Diseases
Treatment Guidelines” title for the guidelines published in 2015 or earlier.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
340 SEXUALLY TRANSMITTED INFECTIONS
pathogens have added complexity to the challenge of STI control over and
above the “traditional” challenges related to control of highly stigmatized
medical conditions.
Further adding to this complexity is that STIs regularly and dispro-
portionately burden marginalized groups (e.g., members of the lesbian,
gay, bisexual, transgender, and queer [LGBTQ+] community and Black,
Latino/a, American Indian/Alaska Native, and Native Hawaiian and
Other Pacific Islander individuals) whose risk for infection is significantly
impacted by access to health care and other social determinants of health
(see Chapters 2, 3, and 9 for more information). Biomedical tools also do
not exist in a vacuum—simply creating them will not ensure their uptake
or proper use, so it is critical to think of them in the larger context—that
is, successful STI prevention strategies require effectively integrating evi-
dence-based biomedical, behavioral, and structural interventions across
the life span (see Figure 1-3 in Chapter 1).
Since the 1980s, the “toolbox” of biomedical interventions for STI
control has broadened beyond diagnosis, therapy, and barrier methods
with the introduction of hepatitis B virus (HBV) vaccine, the first vaccine
ever developed for an STI. In 2006, a second STI vaccine became available,
first targeting HPV types 6, 11, 16, and 18, the causative agent of most
cervical, anal, and oral mucosal cancers. An available nonavalent vaccine
now expands coverage to HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58.
Similarly, in the 1990s, there was a diagnostic revolution as better, noncul-
ture nucleic acid amplification tests (NAATs) became available, improving
both test performance and ease of specimen collection (see below section
on diagnostics). Box 7-1 describes advanced molecular technologies that
have been applied to the STI field and are a promising area of research for
future STI prevention and control.
Some biomedical tools for STIs, such as condoms, have generalizable
benefits, including reducing risk for unplanned pregnancy, while others,
such as vaccines, target specific pathogens. Other contraception methods
also may modify STI risk, including intrauterine devices (IUDs), long-act-
ing injectable hormonal contraceptives, oral contraceptives, and spermi-
cides (Deese et al., 2018; McCarthy et al., 2019; Wilkinson et al., 2002). Fur-
thermore, the potential role of antimicrobial agents has been expanded,
and these now may be used for both treatment and prevention in exposed
or at-risk persons. STIs such as gonorrhea have become increasingly resis-
tant to standard antibiotic treatment; awareness of changing susceptibil-
ity and epidemiological surveillance are key to current control elements.
All such biomedical tools need to be used in combination with positive
sexual health messaging and behavioral and structural interventions (see
Chapters 8, 9, and 12). This chapter is not intended to take the place of
comprehensive texts or the vast literature on the topic but instead briefly
summarizes the strengths, vulnerabilities, and potential opportunities
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
BIOMEDICAL TOOLS FOR STI PREVENTION AND MANAGEMENT 341
BOX 7-1
Advanced Molecular Technology and Genetics
for STIs: The Present and the Future
Advanced molecular tools are having a profound effect on the study of STIs
and include the following:
• Sequencing and the subsequent development of molecular probes that
allow rapid detection of genes that express resistance of gonococci to qui-
nolones has opened the possibility of selective use of quinolone treatment
for sensitive organisms (Melendez et al., 2019). Antimicrobial resistance as-
sessments for azithromycin through genetic sequencing also can be used
to detect susceptible gonorrhea, enabling antibiotics that might otherwise
be overlooked (Melendez et al., 2018). This precision medicine approach
to molecular characterization of treatment options can prevent overuse of
selected antibiotics, preserving their utility in the face of evolving microbial
resistance.
• A variety of molecular techniques have been applied as an alternative to
culture to better dissect the complex microflora of bacterial vaginosis (Srini-
vasan et al., 2015; van den Munckhof et al., 2019). As a result of microflora
sequencing information of uncultivable organisms, several assays have
been commercialized into polymerase chain reaction assays. Study of the
sequencing of the associated microbiome is a flourishing area of research
(Ma et al., 2020).
• The sequencing and next-generation sequencing of some microorganisms
has been used to assess network transmission dynamics for STIs, including
microbial transmission clusters (Buckley et al., 2018). For example, by far
the most progress has been made in the molecular epidemiology of HIV. It
is now possible to use sequence information and advanced bioinformatics
methods to understand HIV evolution and diversity, identify transmission
clusters, and estimate the time of incident infection (Zhang et al., 2021).
Understanding high-risk behaviors and practices responsible for transmis-
sion can help target intervention strategies (e.g., risk reduction counseling
and immediate antiretroviral therapy) to priority groups and networks (Den-
nis et al., 2014). Identifying microbial transmission events, however, has
important legal, social, and ethical implications that must be considered
as such events are characterized (Coltart et al., 2018). The limits of the
application of some of these methods are yet to be determined, seeking to
benefit society through public health insights while not harming vulnerable
populations by criminalizing transmission events.
New molecular technologies hold the promise of helping better characterize
and control STIs in the future. For example, the CRISPR-Cas9 technology was
highlighted in the 2020 Nobel Prize in Chemistry to Charpentier and Doudna; its
application to STI research is foreshadowed with new discoveries for SARS-CoV-2
diagnosis, among other applications (Doudna, 2020). Further scientific investment
can accelerate the application of these molecular tools in preventing and control-
ling STIs to advance diagnostics, provide more precise use of antibiotics and
antivirals, and even advise targeted vaccine designs. This area of investigation is
expected to be a vibrant one in the next decades.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
342 SEXUALLY TRANSMITTED INFECTIONS
of biomedical tools to prevent, diagnose, and manage STIs to enhance
sexual health.
TOOLS FOR STI DIAGNOSIS
Introduction
The large number of STIs, which vary in prevalence and associated
morbidity, typically leads to the need to prioritize control efforts. Tests for
STI pathogens are used in several different ways. Screening is routine test-
ing as part of recommended health care in the absence of specific signs or
symptoms; it is recommended for selected groups in whom asymptomatic
STIs are relatively common (such as women under age 25 for chlamydia)
or in whom infections may have particularly untoward effect (such as
pregnant people and syphilis). As opposed to screening, “diagnostic” is
the term characteristically used for testing patients who have symptoms
to clarify the cause. Acceptable screening methods, such as self-collected
specimens, and more highly reliable confirmatory diagnostic tests facili-
tate patient care and surveillance to more accurately delineate the preva-
lence, incidence, and morbidity associated with STIs.
Excellent diagnostic tests that offer the ability to help describe current
STI epidemiology in the United States are the basis for reporting currently
prioritized non-HIV STIs (gonorrhea, chlamydial infections, and syphilis)
to CDC and are used to identify infections and guide treatment. Since
1997, highly reliable NAATs, which biochemically amplify microbial DNA
for pathogens such as chlamydia, gonorrhea, trichomonas, Mycoplasma
genitalium, HPV, and herpes simplex virus type 2 (HSV-2), have become
widely available and, in general, become the preferred tests for STI detec-
tion in most settings. These tests provide improved accuracy (sensitivity/
specificity), ease of specimen collection (noninvasive and self-collected),
and easy, room-temperature transport requirements.
In contrast to other prioritized pathogens, the Food and Drug Admin-
istration (FDA) has not cleared a commercially available NAAT for syphi-
lis, and its diagnosis has changed little in the past 80–100 years. The caus-
ative agent, Treponema pallidum, is cultured only in research laboratories.
Serologic tests are most often used for syphilis screening and diagnosis.
Specific screening and diagnostic recommendations for other STIs, such
as trichomoniasis or Mycoplasma genitalium, are not prioritized as highly
as surveillance and screening for HIV, gonorrhea, chlamydia, and syphilis.
These diagnostic tools are all described below.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
BIOMEDICAL TOOLS FOR STI PREVENTION AND MANAGEMENT 343
Approaches to STI Screening and Diagnosis
A variety of testing approaches exists for patient management; they
reflect, in large part, the acuity of the problem. For persons seeking care
for possible STI symptoms, rapid diagnosis and therapy initiation are
important. As virtually all STIs may be asymptomatic or have symptoms
that could be due to other causes, screening for asymptomatic infection
also is a critical element for effective STI control. Thus, many settings
have complementary roles for rapid diagnosis of symptomatic STIs and
testing to screen for unsuspected STIs or clarify the causes of symptoms
that may be due to STIs.
Syndromic STI Diagnosis
Syndromic management is often used to address genitourinary3
symptoms potentially due to STIs. It may be carried out with little or no
laboratory support (e.g., Gram stain, saline, or KOH4 slide preparation
and microscopy). By assessing patient symptoms on clinical evaluation,
treatment may be initiated based on a World Health Organization or
other algorithm (WHO, 2007). The advantages are that evaluations can
be carried out rapidly and only modest resources are required to quickly
alleviate symptoms, cure possible infections, and prevent spread.
Syndromic approaches, however, fail to detect asymptomatic STIs and
require that symptoms are bothersome enough to drive someone to seek
care. In addition, multiple STI pathogens may underlie the most common
STI syndromes (genital ulceration, vaginal discharge in women, and ure-
thral discharge in men). Even in carefully conducted research studies, a
substantial minority (20–40 percent) of symptomatic patients do not have
a demonstrable pathogen (Hylton-Kong et al., 2004). Despite these limi-
tations, syndromic diagnosis is widely practiced in a number of settings
(such as in emergency departments, urgent care clinics, and primary care
settings). When resources and screening tests are unavailable, as with
restricted health care access during the COVID-19 pandemic, syndromic
management may be better than nothing.
Use of Tests for Screening and Diagnostic Testing for
Chlamydia and Gonorrhea
NAATs are now preferred for gonorrhea and chlamydia screening,
clarifying diagnosis in symptomatic persons, and guiding treatment to
3 Relating to the genital and urinary organs.
4 Potassium hydroxide.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
344 SEXUALLY TRANSMITTED INFECTIONS
prevent complications and transmission of those infections (Papp et al.,
2014). Numerous commercially available assays are now FDA cleared
for chlamydia and gonorrhea diagnosis. Many of these tests also may be
performed using specimens collected by patients themselves. Recently,
following recognition of the relatively high prevalence of rectal and oro-
pharyngeal infections, FDA approved NAAT assays to detect chlamydia
and gonorrhea in rectal and oropharyngeal samples (FDA, 2019). How-
ever, self-collection of rectal or oropharyngeal specimens for testing and
sending of specimens to laboratories through the mail are not approved
by FDA.
NAATs have completely replaced older types of diagnostic tests, such
as cultures and enzyme immunoassays, except for specialized surveil-
lance programs that use cultures to determine gonococcal antimicrobial
susceptibility, such as CDC’s Gonococcal Isolate Surveillance Program
(Kirkcaldy et al., 2016). Many cost-effectiveness studies and modeling
studies have been published attesting to NAATs’ effectiveness in men
and women for various types of screening programs and demonstrating
them as an important and effective tool to prevent sequelae of STIs (Ronn
et al., 2019). Some research and commercial NAAT assays are in develop-
ment that simultaneously detect gonorrhea and validate its susceptibility
to ciprofloxacin; in the context of progressive antimicrobial resistance,
this would allow tailoring treatment options toward specific antibiotics
(Allan-Blitz et al., 2017; Melendez et al., 2019).
Much laboratory testing is currently regulated under the Clinical
Laboratory Improvement Amendments (CLIA); see Box 7-2 below for
more information. Currently, most testing for STI pathogens is performed
in licensed laboratories. Following careful evaluation, CLIA regulations
for testing may be waived, allowing it to be performed in non-laboratory
health care settings or even at home. Examples now include point-of-care
(POC) tests for influenza and tests for noninfectious variables, such as
blood glucose levels or pregnancy. Until the achievement of FDA-cleared,
sensitive, and specific POC NAATs that achieve CLIA waiver, these often
need to be performed in a laboratory as moderately or highly complex
tests. For tests under development, a CLIA waiver would allow the test to
be performed and interpreted outside of a laboratory by a “non-laborato-
rian,” such as a nurse or health care worker, thereby reducing the time to
results and treatment and helping to reduce transmission.
Point-of-Care Tests
POC tests are diagnostic tests that are completed at or near the time
and place of patient care. Multiple new, accurate POC or near-patient
rapid tests for chlamydia and gonorrhea with performance characteristics
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
BIOMEDICAL TOOLS FOR STI PREVENTION AND MANAGEMENT 345
BOX 7-2
Clinical Laboratory Improvement Amendments (CLIA) of 1988
As described below, diagnostic testing enables health care providers to screen,
detect, monitor diseases, and make treatment decisions. The CLIA ensure quality
laboratory testing. The regulations cover about 260,000 laboratory entities (CMS,
2020).
Three federal agencies share responsibility for CLIA: the Centers for Medicare
& Medicaid Services (CMS), the Food and Drug Administration (FDA), and the
Centers for Disease Control and Prevention (CDC). CMS uses CLIA to regulate
laboratory testing on humans (excluding research); CLIA requires clinical labo-
ratories to be certified by CMS before they can complete diagnostic testing on
human samples. The certificate type depends on the complexity of the diagnostic
tests performed. In addition to issuing laboratory certificates, CMS conducts in-
spections, collects user fees, publishes CLIA rules, and enforces compliance with
regulations.
FDA categorizes diagnostic tests into three levels based their complexity:
waived, moderate, and high. The categorization is determined for clinical labora-
tory devices under premarket review by FDA and devices that are exempt from
premarket notification. FDA is responsible for clinical laboratory devices that are
legally marketed and for which the sponsor seeks a waiver categorization (FDA,
2017). Waived tests are those that are waived by regulationa or are cleared or
approved for home use. Otherwise, FDA reviews test instructions and uses a cri-
teria scorecardb to classify diagnostic tests as moderate or high complexity (FDA,
2020a). If a diagnostic test is categorized as moderately complex, the manufac-
turer can submit a CLIA Waiver by Application to request that it be categorized as
waived from regulatory oversight. The manufacturer must then provide evidence
that the test is simple and accurate, with low risk of erroneous results and no
unreasonable risk of patient harm if performed incorrectly (FDA, 2020b). A waived
test can be performed by laboratories with a Certificate of Waiver; these sites must
have a CLIA certificate, but other CLIA requirements do not apply if the sites are
only performing waived tests (CDC, 2018). Laboratories performing moderately
and highly complex tests must have a CLIA certificate and meet regulatory quality
standards (CDC, 2018).
Finally, CDC provides research and technical assistance, develops practice
guidelines and standards, performs laboratory quality improvement studies, and de-
velops educational resources. There are CLIA-waived tests for some STIs, includ-
ing assays for Treponema pallidum antibodies, Trichomonas vaginalis antigens,
and HIV antigens and antibodies (see Table 7-1 for more information) (CMS, n.d.).
a Under 42 CFR 493.15(c). See https://www.law.cornell.edu/cfr/text/42/493.15 (accessed
February 22, 2021).
b The seven criteria can be found at https://www.fda.gov/node/365445#scorecard (ac-
cessed November 18, 2020). Scores for the seven criteria are added together. Diagnostic
tests with scores of 12 or less are classified as moderate complexity, and tests with a score
above 12 are high complexity.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
346 SEXUALLY TRANSMITTED INFECTIONS
similar to those of laboratory-based NAATs (Gaydos and Melendez, 2020)
are currently available or in late stages of development. For example, a
30-minute test to simultaneously detect chlamydia and gonorrhea recently
received FDA clearance and is available for use (Van Der Pol et al., 2020).
See Table 7-1 for more information on this test and others.
There are many advantages to POC tests. They allow for treating
patients at the time of testing, thus shortening infection duration, pre-
venting transmission, and simplifying follow-up testing to confirm a cure
(Ronn et al., 2019). These tests also may lower the risk of complications
and improve the patient experience (Tucker et al., 2013). For example,
POC tests have already changed the course of the HIV epidemic because
the immediate results allow providers to implement rapid antiretroviral
therapy or pre-exposure prophylaxis (PrEP). Furthermore, it has been
possible to nearly eliminate HIV transmission to newborns partially due
to the availability of HIV-POC during pregnancy, labor, and delivery
(Vrazo et al., 2018). POC allows for partner testing and couple testing in
some settings (Boeras et al., 2011). The increasing availability of POC tests
also can permit screening via the Internet or pharmacy recruitment (Gay-
dos et al., 2020) or even over-the-counter tests performed at home (see Box
7-3 for more information). Self-administered sample collection to screen-
ing for chlamydia and gonorrhea through at-home or at other non-clinic-
based settings is particularly relevant for some American Indian/Alaska
Native and rural communities, based on health care access and service
use challenges (see Chapter 3 for more information). Modeling evidence
shows that POC tests could reduce the prevalence of STI epidemics in the
United States (Gaydos and Melendez, 2020; Ronn et al., 2019).
Implementing POC tests also faces barriers. For example, the time
that patients are willing to wait is an important consideration for imme-
diate treatment, although many POC tests for STIs produce results in 30
minutes or less (Gettinger et al., 2020; Widdice et al., 2018) (see Table 7-1).
Additionally, single-use, individual POC test cartridges are substantially
more costly than laboratory-based, large robotic platform assays (Drain
et al., 2019). Often, test complexity and logistical issues can prevent the
adoption of POC tests for routine use in or outside a clinic. These issues
include the financial resources necessary for instruments and consum-
ables, the need to obtain a CLIA certificate (if the assay is CLIA waived),
validation of the new test, policies and staff training procedures, operator
training, operator recertification and proficiency, getting results into the
electronic medical records interface, space, clinic work flow disruption,
and billing and reimbursement challenges (Gaydos and Melendez, 2020).
Acceptability and decision making by all stakeholders in a clinical
situation will be important for POC tests for STIs to be widely adopted
(Garfield et al., 2016). A strong movement has recently begun toward
Copyright National Academy of Sciences. All rights reserved.
TABLE 7-1 Point-of-Care Tests Available and in Development for STIs
DPP POC
Medical Test for HIV
GeneXpert Sexual Health ResistancePlus Syphilis Antibody and Syphilis OSOM Rapid POC
Assay Io CT/NG CT/NG Test GC Rapid Test Serology TV Antigen Test
Company Binx Health Cepheid Visby SpeeDx Syphilis Health Chembio Sekisui
Check
Platform Table Top Table Top None required Table Top Lateral flow Lateral flow Immunochroma-
Integrated Integrated Integrated PCR machine immunochromagraphic graphic
Technology NAAT Real-time Real-time PlexPCR Antigen-antibody Antigen- Trichomonas vagi-
Small PCR PCR serology antibody nalis membrane
molecule serology proteins
chemistry Mouse antibodies
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Sample Self- and Swabs Self- and Swabs (cervical, Blood, plasma, Blood, plasma, Vaginal swabs
Type clinician- (cervical, clinician- vaginal, serum serum
collected self-collected collected pharyngeal, and
vaginal swabs; vaginal); vaginal swabs ocular); male
male urine male and and female
female urine urine
Procedure ~4 steps ~4 steps ~2 steps ~4 steps ~2 steps ~3 steps ~3 steps
Copyright National Academy of Sciences. All rights reserved.
347
continued
TABLE 7-1 Continued
348
DPP POC
Medical Test for HIV
GeneXpert Sexual Health ResistancePlus Syphilis Antibody and Syphilis OSOM Rapid POC
Assay Io CT/NG CT/NG Test GC Rapid Test Serology TV Antigen Test
Result 30 min. 90 min. 20 min. 50 min. 10 min. 15 min. 10 min.
Time
Regulatory FDA, CE-IVD FDA, CE-IVD FDA pending CE-IVD FDA, FDA approved FDA,
FDA pending CLIA waived CLIA waived
NOTE: CE-IVD = European conformity investigational device; CLIA = Clinical Laboratory Improvement Amendments; CT = Chlamydia trachoma-
tis; DPP = Dual Path Platform; FDA = Food and Drug Administration; NAAT = nucleic acid amplification test; NG = Neisseria gonorrhoeae; PCR =
polymerase chain reaction; POC = point of care; TV = Trichomonas vaginalis.
SOURCE: Table adapted from Gaydos and Melendez, 2020.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
349
BOX 7-3
Example of Approach to Increase STI Testing for
Individuals Reluctant or Unable to Attend Clinics
Internet-based digital technology has been used to promote and increase ac-
cess to STI testing by allowing individuals to order STI kits for home testing, like for
HIV, and obtain kits to self-sample urogenital or extragenital specimens at home,
which can then be mailed or dropped off for testing. Such digital access has the
ability to provide convenience, privacy, and confidentiality.
Oral fluid tests for HIV self-testing have been in use for nearly 10 years, espe-
cially in emergency departments (Gaydos et al., 2011; Nour et al., 2012). Surveys
have shown accuracy and satisfaction, for the most part. More recently, since the
oral fluid HIV test was Food and Drug Administration (FDA) cleared for home use,
it has been available to purchase in pharmacies, but uptake has been variable
(Walensky and Bassett, 2011).
In addition to self-testing for HIV, Internet-based demonstration projects have
been used for at-home self-collection of confidential specimens for STIs (chlamyd-
ia, gonorrhea, and trichomonas). These projects have found widespread accep-
tance and steady increases in requests for kits, especially during the COVID-19
epidemic, when traditional STI clinics were closed or STI services unavailable
(Carnevale et al., 2021; Melendez et al., 2020).
I Want the Kit is an example of a program that allows individuals to order test
kits online for home STI and HIV testing (Gaydos et al., 2006, 2009). The program
began in 2004 as a research study to promote self-testing for chlamydia in women.
Over ensuing years, additional testing was successfully provided for gonorrhea
and trichomoniasis. Men were added in 2006 for urine and penile-meatal swabs,
rectal swabs were added in 2009, and throat swabs were added in 2019. Valida-
tion studies were performed for self- and home-collected specimens. Acceptability
has been high (Hogenson et al., 2019). Additionally, a self-risk quiz was instituted
with six simple questions, which tallied a weighted risk score from 0 (low risk) to
10 (high risk), with subsequent analyses demonstrating that higher risk scores
statistically predicted an STI, which could potentially decrease future risk for us-
ers. Another report of an Internet-requested point-of-care test kit for trichomoniasis
performed at home using self-collected vaginal swabs demonstrated high accept-
ability and confidence that test results were correct (Gaydos et al., 2016; Patel et
al., 2018). Future use of self-performed tests and self-collected specimens awaits
formal FDA approval and could further expand access to STI testing.
broad stakeholder input, value propositions, and comprehensive evalua-
tion of devices beyond clinical performance and cost (Korte et al., 2020).
Given the growth of STI rates in the United States, especially among
underserved and/or marginalized populations, reliable and affordable
POC testing could be a higher programmatic priority of the federal gov-
ernment, in both expanding its availability substantially and educating
health care providers about the indications for screening or diagnosis. The
STI National Strategic Plan: 2021–2025 highlights POC tests as innovative
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
350 SEXUALLY TRANSMITTED INFECTIONS
tools for preventing and controlling STIs (HHS, 2020). The committee con-
curs with the plan’s assessment that the development and implementa-
tion of accessible, effective, and affordable POC tests promise to enhance
rapid STI diagnosis and treatment (see Chapter 12 for more information).
Syphilis Diagnosis
Syphilis is primarily diagnosed by serological methods initially devel-
oped more than a century ago. The current algorithm requires positive
results from two tests, performed sequentially: treponemal and nontrepo-
nemal tests. Treponemal tests are qualitative and detect antibodies to syn-
thetic treponemal proteins; if positive, the person usually remains positive
for life, despite treatment. Nontreponemal tests, such as the rapid plasma
reagin (RPR) and VDRL tests, detect nonspecific antibodies to cardiolipin-
lecithin-cholesterol antigens. When the nontreponemal test is positive,
it requires performing a titer, which can be used to confirm treatment
success if follow-up titers decrease over time. The nontreponemal tests
are important to confirm and manage positive treponemal tests, but they
are labor intensive, subjective, and affected by environmental conditions
(Hamill et al., 2018). Both types of test may have false-positive results,
may not be positive in persons at the earliest stages of infection, and can-
not readily distinguish treated from untreated infections.
Better assays for syphilis diagnosis are urgently needed. NAATs are
only available in research settings, for genital ulcer specimens, and have
been multiplexed to differentiate syphilis from HSV, chancroid, and lym-
phogranuloma venereum chlamydia. Their further development and
deployment would be a concrete step toward reducing syphilis in the
United States by making diagnosis more reliable and accessible (Theel et
al., 2020).
Automated and even new POC tests have been developed for the
treponemal antibody, which can be performed outside of the laboratory
with CLIA waiver using finger-stick blood. POC syphilis serological tests
appear to be performing well in patients with RPR-positive (more likely to
be active) syphilis and show promise for the United States in outreach and
antenatal care settings (Obafemi et al., 2019), where they are sorely needed
to help reduce congenital syphilis rates (Rogozińska et al., 2017; Tinajeros
et al., 2006). Dried blood spots also can be collected at home and mailed
in to a laboratory for treponemal syphilis testing, if laboratory validation
studies are performed. No test, however, is currently able to replace the
RPR assay. Developing a highly sensitive and specific serological syphilis
test that reflects disease activity but avoids the pitfalls of the current non-
treponemal tests would be of great benefit to the field.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
BIOMEDICAL TOOLS FOR STI PREVENTION AND MANAGEMENT 351
Diagnostics for Other STIs of Public Health Importance
Trichomoniasis, HPV, HSV, and Mycoplasma genitalium are among
the additional STIs of concern. Each infection, in addition to vaginitis/
vaginosis syndromes, can now be diagnosed using NAAT assays and
even POC tests (Gaydos et al., 2017a,b; Schwebke et al., 2019). Combina-
tion vaginal discharge/vaginitis assays include diagnostic targets for BV,
trichomonas, and yeast. Older, nonmolecular assays/algorithms for BV,
such as the Amsel and Nugent methods, are widely used but have been
demonstrated to be highly subjective and less sensitive and less specific
than molecular amplification NAAT assays that actually detect and quan-
tify the presence of contributing organisms (Marrazzo et al., 2010).
As explained in Chapter 2, however, none of these infections are
currently reportable to CDC. Several are highly prevalent, but no good
surveillance data or recommendations for screening of asymptomatic
persons are available. HPV infection has been previously inferred with
an abnormal Pap smear or anal scrape/swab to find squamous intraepi-
thelial lesions, but this is now augmented by HPV molecular screening.
Additionally, antibody tests exist for or HSV-1 and -2 diagnosis, but they
have substantial problems with the timeliness of the serological response
to infection, sensitivity, and specificity; routine screening for HSV is not
currently recommended. Mycoplasma genitalium has garnered much inter-
est recently. Few antibiotics are available to treat it, and increasing resis-
tance to azithromycin is a concern (CDC, 2019a; van der Schalk et al.,
2020). Some NAAT assays in development include assays to evaluate
antimicrobial susceptibility to azithromycin; this would allow precision
treatment decisions regarding specific antibiotics (Gaydos and Melendez,
2020; Gaydos et al., 2019). More data are needed regarding the importance
of M. genitalium as a major STI causing public health problems and its
appropriate management (see Chapter 2).
Multiplex Diagnostic Opportunities
The large number of STI pathogens and their potential to cause coin-
fections remain challenges to clinicians and those prioritizing which
pathogens are most pressing. A multiplex assay tests for multiple organ-
isms at one time. As explained above, current commercial NAATs detect
both chlamydia and gonorrhea, which came about as a market response
to the recommendation of major professional organizations to screen for
both of these curable infections. A multiplex assay for the differential diag-
nosis of genital ulcer disease outside of the research setting also would be
useful, especially to differentiate syphilitic from herpetic lesions. As tests
improve, it may be increasingly possible to detect additional STI organ-
isms in one assay. Less common STIs might not be amenable to screening
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
352 SEXUALLY TRANSMITTED INFECTIONS
if insurance will not pay (see Chapters 4 and 10 for more information
on insurance coverage). To multiplex or not requires careful thought
from developers and clinicians, as well as patients, who may not need or
desire screening for more than chlamydia and gonorrhea. As screening
requirements for new or different STIs change over time, considerations
for optimal strategies for development of multiplex tests for multiple STIs,
notably syphilis, HIV, and hepatitis B, need to be considered.
Gaps and Opportunities in STI Diagnosis
In summary, NAATs are now commercially available for diagnostic
and screening tests for most STIs, except syphilis. Multiple organizations
have recommended expanded screening with NAATs, including CDC
(Workowski and Bolan, 2015), the United States Preventive Services Task
Force (Bibbins-Domingo et al., 2016; LeFevre, 2014; USPSTF, 2016), Infec-
tious Diseases Society of America’s HIV Medical Association (Aberg et al.,
2014), and others (Committee on Adolescence and Society for Adolescent
Health and Medicine, 2014). Barriers to adopting highly accurate POC
rapid tests are that too few clinics, practitioners, or insurance companies
promulgate them because of perceived financial and logistical barriers
(Gaydos and Melendez, 2020). These barriers can be overcome, however,
and these tests show promise as STI control strategies as they become
more widely available (Gaydos and Melendez, 2020). For highly sensitive
and specific NAAT assays and new POC tests to have an impact on the
STI epidemic, they must be prioritized for development (Eisinger et al.,
2020) and used far more widely. Therefore, several questions that call for
expanded research remain, including
• Can test usage be increased substantially, targeting highest zip
code venues and selected subpopulations at highest risk?
• Can health care providers be engaged to include STI screening as
a fundamental part of their clinical practice?
• Can multiplex testing be optimized so that multiple infections are
detected in one assay?
• Can implementation studies help expand the development and
clinical use of POC tests?
• Can self-testing kits that could be used for home testing or via
online distribution systems be established?
• Can a better assay for syphilis diagnosis be developed?
• How can these diagnostics be used most judiciously in confront-
ing progressive antimicrobial resistance?
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
BIOMEDICAL TOOLS FOR STI PREVENTION AND MANAGEMENT 353
ANTIMICROBIAL TOOLS FOR STI TREATMENT
Desired characteristics for antimicrobial therapies for STI manage-
ment include high degrees of efficacy, safety, and tolerability; ease of
administration; and widespread availability at a low cost (Unemo et al.,
2017). When possible, single-dose, oral therapy is preferred in order to
ensure adherence and enhance therapeutic efficacy. In addition, unlike
other infections commonly encountered in clinical practice in which bac-
teria are isolated and tested for antimicrobial susceptibility to guide thera-
peutic decision making, current practice assumes that recommended STI
therapy will be highly effective when used without such testing.
Barriers to Therapeutic Innovation
Unfortunately, while most STIs are treatable, no individual antimicro-
bial agents are effective for more than a few STIs, and the “pipeline” for
new drug development has slowed. Overall, only 12 companies won FDA
approval for new antibiotics over the past decade; 2 of those have gone out
of business. Other pharmaceutical companies have filed for bankruptcy
in 2019 and 2020 or are being sold for a fraction of their previous market
value (Perros, 2019; Solman, 2020). This trend is partly related to the com-
mercial disadvantages of short-course medications for public health use
compared to the market advantages of drugs that patients may take for
years (e.g., antihypertensives, lipid-lowering medications) or have the
appeal of “lifestyle” enhancements (i.e., erectile dysfunction treatments,
antidepressants) (Solman, 2020). The pharmaceutical industry has gener-
ally disengaged from antibiotic development because of the poor return
on investment and challenges in funding for-profit research of antibiot-
ics (Solman, 2020). The antibiotic pipeline has contracted at a time when
development of antimicrobial resistance by Neisseria gonorrhoeae, one of the
most common multiple drug-resistant pathogens, is threatening the con-
tinued reliability of therapy for this prioritized and widespread infection.
Development of new antimicrobials for other STIs has also slowed and is
limited; Table 7-2 lists examples of current clinical trials for STI antibiotics.
Decisions related to STI treatment are profoundly impacted by treat-
ment guidelines issued by public health agencies. These guidelines vary
from nation to nation. In the United States, the CDC STI Treatment Guide-
lines are among the organization’s most widely accessed publications and
the primary source of guidance for STI treatment (Barrow et al., 2020).
Clinicians use these guidelines and expect that once an infection has been
diagnosed, the recommended treatment will be more than 95 percent
effective. The CDC STI Treatment Guidelines are updated at approxi-
mately 5-year intervals through a relatively complex process of literature
review and expert consultation to generate treatment recommendations
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
354 SEXUALLY TRANSMITTED INFECTIONS
that clinicians can be confident of. The Guidelines published in 2015 are
under revision with an anticipated publication date of 2021; treatment
recommendations are also updated occasionally in Morbidity and Mortal-
ity Weekly Report publications. Each revision contains numerous changes,
reflecting in part the accrual of information in the interval since the
last revision. Given the rapidly changing field, however, more frequent
reviews and revisions are highly desirable. Given the state of technology,
particularly the possibility of rapid online publication, disseminating
updated guidelines could be a continuous rather than an episodic process.
Antimicrobial Therapy for Bacterial STIs
In the United States, STI control surveillance and public health man-
agement strategies have focused on the three most common and widely
recognized STIs (gonorrhea, chlamydia, and syphilis) and their complica-
tions. Other STIs and related syndromes (e.g., trichomoniasis and STI syn-
dromes, such as NGU, BV, genital ulcer disease, and pelvic inflammatory
disease [PID]) are common and present different therapeutic challenges.
Gonorrhea
Since antimicrobial therapy was introduced for gonorrhea in the
1930s, it has progressively developed resistance to each drug (CDC, 2019a;
Młynarczyk-Bonikowska et al., 2020), as shown in Figure 7-1. In recent
years, this tendency and the slow development of new antimicrobials
have become a recognized public health challenge, as highlighted in
the 2020–2025 National Action Plan for Combating Antibiotic-Resistant
Bacteria, and CDC’s including it as an urgent threat in the 2019 report on
antibiotic resistance in the United States (CDC, 2019a; Federal Task Force
on Combating Antibiotic-Resistant Bacteria, 2020).
Currently, only injectable ceftriaxone is recommended globally as
first-line therapy for gonorrhea, and development of newer drugs has
been limited (St. Cyr et al., 2020). In the past two decades, only four new
medications have been evaluated in the United States. Two evaluations of
newer antimicrobials (delafloxacin and solithromycin) have been stopped
due to less than predicted efficacy (see Hook et al., 2019, for example),
and evaluation of just two additional new antimicrobials (zoliflodacin
and gepotidacin) has only recently begun. Both of the newer antimicrobi-
als currently entering Phase III trials have been developed with partial
Copyright National Academy of Sciences. All rights reserved.
TABLE 7-2 Examples of Clinical Trials of STI Antibiotics
Estimated
Study Title Recruit- Intervention Primary Study
[ClinicalTrials. ment Status/ Model Outcome Trial Sponsor and Trial Completion
gov Identifier] Status Phase Intervention(s) Description Participants Measure(s) Location(s) Date
Gonorrhea Trials
A Phase III, Recruiting Phase Gepotidacin Random- Esti- 1. Number Sponsor: September
Randomized, 3 and ceftri- ized, paral- mated 600 of sub- United Kingdom: GlaxoSmith- 8, 2023
Multi-Center, axone plus lel assign- 12+-year- jects with Kline
Open-Label azithromycin ment old men culture-
Study in and women confirmed Locations:
Adolescent and with uro- bacterial USA: California (4 sites); Flor-
Adult Partici- genital eradication ida (2 sites); Georgia (2 sites);
pants Compar- gonococcal of Neisseria Indiana; Louisiana; Massachu-
ing the Efficacy infection gonorrhoeae setts; North Carolina (4 sites);
and Safety of from the Ohio; Tennessee; Texas (2 sites)
Gepotidacin urogenital Australia: Sydney (5 sites);
to Ceftriaxone site at the Queensland (2 sites); Victoria (4
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Plus Azithro- test-of-cure sites); Western Australia
mycin in the Germany: Berlin (2 sites);
Treatment of Frankfurt (2 sites); Hamburg;
Uncomplicated Munich (2 sites)
Urogenital Gon- Mexico: Guadalajara (2 sites)
orrhea Caused Spain: Alicante; Barcelona (4
by Neisse- sites); Madrid (3 sites); Seville
ria gonorrhoeae United Kingdom: Birmingham;
[NCT04010539] Brighton; Leeds; London (5
sites); Manchester; St. Helens
Copyright National Academy of Sciences. All rights reserved.
355
continued
TABLE 7-2 Continued
356
Estimated
Study Title Recruit- Intervention Primary Study
[ClinicalTrials. ment Status/ Model Outcome Trial Sponsor and Trial Completion
gov Identifier] Status Phase Intervention(s) Description Participants Measure(s) Location(s) Date
A Multi-Center, Recruiting Phase Zoliflodacin 3 Random- Estimated 1. Efficacy Sponsor: August
Randomized, 3 g PO and cef- ized, paral- 1,092 of a single Switzerland: Global Antibiot- 2021
Open-Label, triaxone 500 lel assign- 12+-year- dose of zo- ics Research and Development
Non Inferiority mg IM plus ment; single old men liflodacin Partnership
Trial to Evalu- azithromycin dose of zo- and women assessed
ate the Efficacy 1 g PO liflodacin or with un- compared Locations:
and Safety of comparators complicat- to a combi- USA: Alabama; California;
a Single, combination ed gonor- nation of a Indiana; Louisiana; Ohio; Wash-
Oral Dose of in single rhea single dose ington
Zoliflodacin dose: ceftri- of ceftri- Netherlands: Amsterdam
Compared to a axone and axone and South Africa: Bothas Hill; Jo-
Combination of azithromy- azithromy- hannesburg; Tongaat
a Single Intra- cin cin Thailand: Bangkok (4 sites)
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
muscular Dose
of Ceftriaxone
and a Single
Oral Dose
of Azithro-
mycin in the
Treatment of
Patients with
Uncomplicat-
ed Gonorrhoea
Copyright National Academy of Sciences. All rights reserved.
[NCT03959527]
Chlamydia Trial
Randomized, Unknown Phase Azithromycin Randomized, Esti- 1. C. Sponsor: December
Open-Label, 4 and parallel mated 460 trachomatis- France: University Hospital, 1, 2019
Multi-Center doxycycline assignment 18+-year- positive Bordeaux
Study of old women NAAT
Azithromycin with C. result in Locations:
Compared With trachomatis- anorectal France: Marseille; Bordeaux (2
Doxycycline positive specimens sites); Nantes; Paris; Roubaix;
for Treating test after Tours
Anorectal Chla- treatment
mydia tracho-
matis Infection
Concomitant to
a Vaginal Infec-
tion
[NCT03532464]
Syphilis Trials
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Trial Evaluating Recruiting Phase Cefixime 400 Randomized, Esti- 1. Sponsor: September
the Clinical 1/2 mg PO and parallel mated 180 Quantitative Switzerland: World Health 30, 2021
Efficacy of benzathine assignment 18+-year- RPR titer Organization
Cefixime for penicillin (2:1) old women change
Treatment of 2.4 MU with posi- Location:
Early Syphilis in tive syphi- Brazil: Fortaleza
Non-Pregnant lis test
Women
[NCT03752112]
Copyright National Academy of Sciences. All rights reserved.
357
continued
TABLE 7-2 Continued
358
Estimated
Study Title Recruit- Intervention Primary Study
[ClinicalTrials. ment Status/ Model Outcome Trial Sponsor and Trial Completion
gov Identifier] Status Phase Intervention(s) Description Participants Measure(s) Location(s) Date
Clinical Trial Recruiting Phase Cefixime Randomized, Esti- 1. Sponsor: October
Evaluating the 2 400 mg oral parallel mated 100 Treatment USA: University of California, 2021
Clinical Efficacy capsule assignment 18+-year- response Los Angeles
of Cefixime for [Suprax] and old men
Treatment of benzathine and women Locations:
Early Syphilis penicillin G with pri- USA: California (9 sites);
[NCT03660488] mary, sec- Nevada
ondary, or
early latent
syphilis
One Dose Unknown Phase Benzathine Randomized, Estimated 1. RPR Sponsor: August
Versus Three 4 penicillin G parallel 150 titers China: Peking Union Medical 2020
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Weekly Doses assignment 18–60-year- College Hospital (Estimated)
of Benzathine old men
Penicillin G for and women Location:
Patients with with China: Beijing
Early Syphilis confirmed
[NCT02857959] early
symptomatic
syphilis
(primary or
secondary)
Copyright National Academy of Sciences. All rights reserved.
or high-
titer latent
syphilis
A Phase 4 Recruiting Phase Benzathine Randomized, Estimated 1. The Sponsor: March 1,
Comparative 4 penicillin G parallel 560 proportion USA: National Institute of Al- 2022
Trial of 2.4 MU IM assignment 18+-year- of subjects lergy and Infectious Diseases
Benzathine old men with a
Penicillin G 2.4 and women serological Locations:
Million Units with response USA: Alabama; Georgia; In-
Administered untreated (defined diana; Louisiana; Maryland;
as a Single Dose primary, as either Massachusetts; North Carolina;
Versus Three secondary, a fourfold Pennsylvania; Washington
Successive or early or greater
Weekly Doses latent decline in
for Treatment of syphilis RPR titer
Early Syphilis in compared
Subjects with to baseline
or Without HIV or being
Infection RPR-nega-
[NCT03637660] tive [seror-
eversion])
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Copyright National Academy of Sciences. All rights reserved.
359
continued
TABLE 7-2 Continued
360
Estimated
Study Title Recruit- Intervention Primary Study
[ClinicalTrials. ment Status/ Model Outcome Trial Sponsor and Trial Completion
gov Identifier] Status Phase Intervention(s) Description Participants Measure(s) Location(s) Date
Randomized, Unknown Phase Benzathine Randomized, Estimated 1. RPR titer Sponsor and Location: China: September
Clinical Trial 4 penicillin parallel 150 Peking Union Medical College 2020
to Compare assignment 18–60-year- Hospital (Estimated)
the Serological old men
Response Rates and
of Serofast women;
Early Syphi- early
lis Cases Re- syphilis
treated with cases
Three Doses determined
Benzathine to be
Penicillin and serofast at
Absence of Any 6 months
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Retreatment after initial
[NCT02884115] treatment
NOTES: ClinicalTrials.gov search and study recruitment status are as of September 4, 2020. DSMB = Data and Safety Monitoring Board; IM = in-
tramuscular; mg = milligram; MSM = men who have sex with men; MU = million units; NAAT = nucleic acid amplification test; PO = per os; RPR
= rapid plasma regain; USA = United States of America.
Copyright National Academy of Sciences. All rights reserved.
Neisseria gonorrhoeae – Indications of Resistance and
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Emerging Resistance to Antibiotics,* Gonococcal Isolate
Surveillance
BIOMEDICAL TOOLS Project AND
FOR STI PREVENTION (GISP), 2000-2017
MANAGEMENT 361
1980s 2007 2012
35 Penicillin and tetracycline no Ciprofloxacin no Cefixime no longer
longer recommended longer recommended recommended as a first-
30 line regimen Ciprofloxacin
25
Tetracycline
Percentage
20
15 Penicillin
10
5 Azithromycin
Cefixime
0 Ceftriaxone
2000 2002 2004 2006 2008 2010 2012 2014 2016
Year
FIGURE 7-1 Neisseria gonorrhoeae: Indications of resistance and emerging resis-
tance to antibiotics, Gonococcal Isolate Surveillance Project (GISP), 2000–2017.
SOURCE: Bolan, 2019.
support from the federal government (BARDA5 and National Institute
of Allergy and Infectious Diseases [NIAID]), nongovernmental agencies,
and pharmaceutical companies (see Table 7-2). Oral cefixime, penicillin,
ciprofloxacin, and azithromycin all have clinically unacceptable levels of
resistance, and the need for effective oral drugs is acute. Even with ceftri-
axone, different doses and recommendations to use it in combination with
other antibiotics vary from region to region (Fifer et al., 2020; WHO, 2016;
Workowski and Bolan, 2015). Increasing appreciation of the relatively
high frequency of infection at nongenital sites (i.e., the oropharynx and
rectum) and that therapy effective for genital infection may not be effec-
tive at other sites has further complicated recommendations for gonorrhea
therapy. With these challenges in mind, expanded research in antibiotic
development and evaluation for gonorrhea treatment is urgently needed,
especially given the limited number of new antimicrobials in the pipeline
and that the results of the few ongoing studies are not anticipated for
several years.
5 “Biomedical Advanced
Research and Development Authority (BARDA), part of the HHS
Office of the Assistant Secretary for Preparedness and Response, was established to aid in
securing our nation from chemical, biological, radiological, and nuclear (CBRN) threats, as
well as from pandemic influenza (PI) and emerging infectious diseases (EID).” For more
information, see phe.gov/about/barda/Pages/default.aspx (accessed June 11, 2020).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
362 SEXUALLY TRANSMITTED INFECTIONS
Chlamydia
The current treatment recommendation for chlamydia infections is a
single dose of azithromycin or multi-day course of doxycycline (Workowski
and Bolan, 2015). Doxycycline is not recommended for use in pregnancy,
however, and may be less effective in persons with poor medication
adherence (Marrazzo and Suchland, 2014). Declining cure rates may
change treatment recommendations. Unlike gonorrhea, antimicrobial
resistance remains rare for chlamydia, but like gonorrhea, the efficacy
of recommended therapy varies when genital infections are compared
to other sites (see Table 7-2). Furthermore, the heavy reliance on noncul-
ture methods to detect chlamydia and possible persistence of chlamydial
nucleic acids for weeks following effective therapy have complicated
assessing therapies (both established and emerging) and cures.
Syphilis
Although substantially less common than either gonococcal or chla-
mydial infections, syphilis is closely linked to increased risk for HIV
acquisition, is an important preventable cause of serious congenital infec-
tions, and is increasing, both in the United States and globally. Benzathine
penicillin G, whose precursor is available from a single non-U.S. source,
remains the globally recommended first-line therapy; its use is compli-
cated by approximately 10 percent of the U.S. population reporting a
penicillin allergy (although the true prevalence is likely to be much lower)
(Blumenthal et al., 2019) and repeated instances of global shortage of it.
The continuing rise in congenital syphilis is not from penicillin failure or
allergy, but rather is associated with inadequate screening and treatment
during pregnancy due to health system failures, which is indicative of the
effect of social determinants on STI health outcomes (Trivedi et al., 2019).
Few alternatives to penicillin are available. Azithromycin, a macrolide
antibiotic, was considered promising for single-dose therapy; however, a
substantial prevalence of macrolide antibiotic resistance mutations and
reports of treatment failure have tempered enthusiasm. Multiple-dose
therapy with doxycycline remains the sole accepted alternative. Given
its oral administration, it may be used more frequently, while parenteral
administration becomes more complicated with limitations in nonurgent
clinical services in the COVID-19 era. Finally, as described earlier, syphilis
diagnosis to guide therapy continues to rely primarily on serological tests
based on methods from more than 50 years ago, which are still compro-
mised by false-positive results and slow and difficult-to-interpret therapy
response. Newer, well-tolerated alternatives to penicillin are badly needed
for improved syphilis control (TAG, 2019).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
BIOMEDICAL TOOLS FOR STI PREVENTION AND MANAGEMENT 363
STI Syndromes
Managing STI syndromes presents yet another set of challenges for
control. As discussed in the diagnostics section above, syndromic man-
agement can be time efficient and cost effective for the most common
syndromes, while preventing transmission. For example, BV is the most
common cause of vaginal discharge. Current research suggests that this
syndrome is a polymicrobial dysbiosis for which sexual partners play an
important contributing role in pathogenesis, response to treatment, and
risk for recurrence (see Chapter 2 and Appendix A). Several new thera-
peutic agents have recently been or are under investigation for therapy
and prevention; however, current treatment response is unsatisfactory
(20–30 percent failure rate) and recurrences are common (Workowski and
Bolan, 2015). Genital ulcer disease is not always diagnosed properly and
may represent Haemophilus ducreyi, syphilis, or HSV-1 or HSV-2. Treat-
ment for chancroid and syphilis differ, and antiviral suppression of HSV
requires yet a third approach. The limitations of syndromic management,
however, may result in all-too-common mistreatment and unnecessary
exposure to antibiotics.
Antimicrobial Therapy for Viral STIs
Chronic, non-HIV viral infections, such as due to HSV and HPV,
require a different array of antimicrobial agents. Though antimicrobial
therapy does not cure these infections, it may hasten resolution of acute
signs and symptoms and reduce the probability of sexual transmission.
Behavioral and structural interventions, then, become even more impor-
tant in preventing and controlling viral STIs (see Chapters 8 and 9).
Antimicrobials that halt herpes virus replication have been available
for over three decades but are underused because approximately 80 per-
cent of persons with genital herpes are not diagnosed. After success with
acyclovir and valacyclovir to suppress HSV-2 viral shedding, new com-
pounds have been explored, many of natural origin (Akram et al., 2018;
Shiraki, 2018; Vere Hodge and Field, 2013). After decades of use of these
drugs, emerging resistance is an increasing concern. Research priorities
for future HSV management might include evaluation of new medicinal
therapies and pharmacologic modification of existing drug classes (pri-
marily viral thymidine kinase inhibitors) to provide easier-to-take, long-
acting antiviral activity. Finding a drug to cure HSV-2 has been elusive,
as is also true of other herpes viruses that are so well adapted to living
actively or quiescently in a human host for a lifetime.
HPV, too, has been a difficult target for antiviral drug development,
though far less investment has been made, given successes in vaccine
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
364 SEXUALLY TRANSMITTED INFECTIONS
development (Archambault and Melendy, 2013; Cherry et al., 2013; Kan-
war et al., 2011). HPV is treated with cellular ablation, as by freezing or
heating cells (cold coagulation or thermal ablation). For smaller lesions,
a variety of techniques are used. More extensive (and traumatic) laser
ablations and loop electrosurgical excision are deployed for larger or more
serious lesions; cancers are treated surgically.
Antimicrobial Therapy for Protozoan STIs
Trichomoniasis, while not reportable, is among the most prevalent
vaginal STIs. It infects more women than gonorrhea or chlamydia, and,
despite clearly being an STI, is rarely tested for in men. The 5-nitroimid-
azole drugs are the only available treatments, by oral and less often par-
enteral routes (Bouchemal et al., 2017). Only metronidazole and tinidazole
are available and FDA approved for trichomoniasis. The 5-nitrothiazolyl
derivative nitazonxanide is also effective to varying degrees, as are drugs
that can be used when a patient has a hypersensitivity to 5-nitroimid-
azoles: disulfiram and nithiamide. More research is needed for therapeu-
tics in the face of growing drug resistance (O’Donoghue et al., 2019).
Gaps and Opportunities in STI Treatment
Currently, no single or even two or three antimicrobials are sufficient
to control bacterial and protozoan STIs. Rather, the substantial menu
of pathogens requires an equally large variety of antimicrobial agents.
Management of common STIs has been variously challenged by, among
other things, progressive antimicrobial resistance (gonorrhea, trichomo-
niasis), limited screening despite widely accepted recommendations and
clinical guidelines (chlamydia), and underdiagnosis (especially among
marginalized populations with suboptimal access to health care and/
or health insurance) and therapeutic challenges associated with chronic,
incurable viral infections (e.g., HSV, HPV). The long timelines and high
costs to develop new STI antimicrobials further reduce the incentives for
pharmaceutical companies to prioritize developing new drugs (CDC,
2019a; Perros, 2019; Solman, 2020).
Antimicrobial agents are also now used to address goals other than
curing a specific, recognized pathogen, such as syndromic diagnosis being
widely used to accelerate the time to treatment and as a cost-saving mea-
sure. For bacterial and protozoan STIs, therapy is also frequently recom-
mended for persons exposed to infected sex partners (STI “contacts”)
before or even without proven infection.
For viral STIs, therapy is not curative and is largely directed at con-
trolling acute manifestations and possibly reducing transmission risk.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
BIOMEDICAL TOOLS FOR STI PREVENTION AND MANAGEMENT 365
In recent years, community-wide antibacterial therapy has been used to
intervene in or halt widespread STI outbreaks.
TOOLS FOR STI PREVENTION
Condoms and Barrier Method Contraceptives
Condoms have played a major role as part of both STI and pregnancy
prevention efforts for thousands of years, predating modern antimicrobial
therapy. They are in widespread use (more than 450 million sold annually
in the United States) (Planned Parenthood, 2018) by more than 33 million
Americans in 2020 (Statista, 2020), though a majority of coital episodes
are condomless (Copen, 2017). Among tools for STI prevention, condoms
(when used correctly and consistently) have the distinct advantage of
reducing risk for both acquiring and transmitting virtually all STIs and
preventing unintended pregnancy.
Condoms, however, also have limitations (D’Anna et al., 2012). Per-
sons may use them incorrectly by failing to put them on before sex, and
they break about 1–2 percent of the time and may slip off during inter-
course (Macaluso et al., 1999). Condoms may vary greatly in quality glob-
ally, though in the United States, manufacturing standards ensure quality
in approved products. In addition, decisions regarding condom use also
must occur with each sexual encounter, and they may be perceived to
reduce sensation of the penis and sometimes their partners. Usually,
promotion and use has focused on the latex or polyurethane external con-
dom, although limited research indicates that the internal condom is also
effective for STIs and pregnancy. Condom promotion and interventions
to encourage correct and consistent use have been the specified outcome
of many STI- and HIV-risk reduction interventions, and distribution has
been a prominent component of many public health measures to reduce
STIs.
It is difficult, if not impossible, to determine the magnitude of ben-
efit of condom use on preventing the spread of STIs; it is clear, however,
that condom promotion alone has not been sufficient. Furthermore, con-
dom use has been declining more recently in a key demographic (MSM)
(DiClemente et al., 2002; Hess et al., 2017; Paz-Bailey et al., 2016), possibly
related to expanded antiretroviral therapy for HIV and post-exposure
prophylaxis, reducing anxieties about HIV, and strong preferences for
condomless sex. Behavioral and marketing research to enhance condoms’
attractiveness, uptake, and successful use has suggested that increasing
use is possible in a wide variety of settings and among specific groups
(i.e., adolescents, see Chapter 8 for more information) (Malekinejad et al.,
2017; Pérez et al., 2018; Wang et al., 2018).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
366 SEXUALLY TRANSMITTED INFECTIONS
Data are more limited regarding diaphragm use; the data available
suggest reduced risk for STI acquisition, though concurrent spermicide
use makes it difficult to assess their relative contributions (de Bruyn et al.,
2011; Padian et al., 2007).
Other Contraceptive Measures
Another available contraceptive measure is spermicidal preparations
(short-action foams, creams, jellies, film, and suppositories applied at each
instance of intercourse and currently designed mainly to prevent preg-
nancy). Detergent-based spermicides are toxic for some STI pathogens.
Clinical trials in which high-risk populations used nonoxynol-9 detergent
spermicides, however, demonstrate no clear, significant protective effect
for bacterial STIs (Roddy et al., 1998, 2002; Wilkinson et al., 2002) and
were associated with an increased risk of HIV in one trial (Van Damme et
al., 2002), perhaps due to irritation and inflammation from the chemicals.
The opportunity to use reversible contraceptives has greatly ben-
efited women’s health; at the same time, the interplay between STIs and
contraceptives is complex and has been reviewed in detail (Deese et al.,
2018; McCarthy et al., 2019). Research on hormonal contraceptives (i.e.,
to prevent pregnancy) and related risk for STI acquisition is the subject
of ongoing research. Hormonal contraceptives (most specifically pro-
gestins) may increase the risk of exposed cisgender women to acquiring
chlamydial and gonococcal infections (Pettifor et al., 2009); these changes,
however, may be modified by which hormones are used and their dos-
age. Hormonal contraceptives’ role in the risk for viral STIs, such as HSV
and HPV, and trichomoniasis is unclear (Deese et al., 2018; McCarthy et
al., 2019). Epidemiologic studies in the 1980s suggested that IUDs were
associated with risk for pelvic inflammatory disease (PID) in cisgender
women with an infection, such as gonorrhea or chlamydia, but not for
acquisition of infection. IUDs have evolved substantially, and modern
IUDs no longer have this association (Deese et al., 2018; Jatlaoui et al.,
2016), although insertion may carry a risk for upper genital tract infection.
A high-profile clinical trial in Africa, the Evidence for Contraceptive
Options and HIV Outcomes (ECHO) Trial, found no difference in risk of
HIV acquisition with three different contraceptives: intramuscular depot
medroxyprogesterone acetate, a copper IUD, or a levonorgestrel implant
(ECHO Trial Consortium, 2019); additional research on the effect of these
contraception approaches on non-HIV STIs is ongoing.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
BIOMEDICAL TOOLS FOR STI PREVENTION AND MANAGEMENT 367
Multipurpose Prevention Technologies
Interventions can be combined to prevent several unwanted conse-
quences of sex. A single biomedical tool to prevent any combination of
STI infections, HIV, and/or pregnancy is highly desirable, as consumer
demand will be considerable for multipurpose prevention technologies
(MPTs) (Anderson et al., 2020; Li et al., 2019; Smith et al., 2017). Of course,
internal and external condoms are precisely such a technology (Beksinska
et al., 2020). Microbicides used intravaginally were thought to be highly
promising, as when the CAPRISA 004 trials showed modest topical teno-
fovir effects to prevent both HIV and HSV infection in South African
women (Abdool Karim et al., 2015; Karim et al., 2014). A number of antibi-
otics are effective against multiple STI pathogens and may be considered
MPTs. Vaginal rings may offer reliable contraception and some degree
of HIV prevention (Dallal Bashi et al., 2019; Derby et al., 2017). Other
than condoms, no products are designed to prevent one or more classi-
cal STIs and pregnancy. While studies of the acceptability and desirable
characteristics of MPTs have outlined their theoretical promise, proven
and acceptable products lag, and no MPTs are yet available with public
health impact (Guilamo-Ramos et al., 2018; Hunter et al., 2018; Hynes et
al., 2018, 2019; Vargas et al., 2019).
Antibiotics for STI Prevention
Effective STI treatment prevents transmission. Initially recommended
by Surgeon General Thomas Parran in 1938, testing and preventative
treatment of persons sexually exposed to partners with STIs has been an
essential element of control efforts (Hook, 2013). Partners may be treated
through expedited partner therapy, in which infected persons are given
sufficient medication to treat themselves and their sexual partners, with-
out clinically assessing the partners. Clinicians or public health workers,
such as disease intervention specialists, can offer expedited partner ther-
apy. It therefore provides timely treatment for recent partners, especially
for male partners of women with chlamydia or gonorrhea. See Chapter
10 for more information.
STI PrEP
An alternative strategy to reduce STIs is PrEP, perhaps first explored
in the U.S. Navy on a large scale (Rasnake et al., 2005). In one experi-
ment, Harrison et al. (1979) attempted to reduce gonorrhea infections
with minocycline, which proved effective only against highly suscep-
tible organisms; the trial demonstrated the hazards of selecting resistant
mutant bacteria with antibiotic prophylaxis.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
368 SEXUALLY TRANSMITTED INFECTIONS
The relatively high incidence of STIs in MSM has led to particular
interest in doxycycline PrEP (Bolan et al., 2015; Molina et al., 2018). In a
small trial conducted in MSM in France, doxycycline reduced syphilis
and chlamydia acquisition by 73 and 70 percent, respectively (Molina et
al., 2018). Gonorrhea acquisition was not affected, given that it is now
generally resistant to doxycycline. Enthusiasm over this potential inter-
vention has led to a number of ongoing investigations to determine both
the benefits and challenges (e.g., cost, durability, side effects, promo-
tion of antimicrobial resistance, vulnerability to other STIs, and potential
undesirable changes in the microbiome) of antibiotic PrEP. An analogous
concept is the chronic use of acyclovir or valacyclovir to reduce transmis-
sion of HSV-2 to sexual partners.
Mass antimicrobial therapy for STI control has been attempted on sev-
eral occasions. Yaws, a nonvenereal treponemal disease, was controlled
with mass administration of penicillin, and a side effect in parts of Africa
and China was reduced syphilis infection (Marks et al., 2014; Mitjà et al.,
2013). In fact, it reduced syphilis rates in China to close to zero, until the
liberalization of international travel and sexual mores led to reintroduc-
tion and spread. More recent efforts of mass therapy as part of efforts to
curtail large, sustained syphilis outbreaks in Vancouver, Canada, have not
been successful. Currently, the utility of this method for STI treatment and
prophylaxis remains a research question rather than an evidence-based
public health tool. Effects of STI mass treatment campaigns to control HIV
are discussed in Chapter 5.
Vaccines
Optimal prevention of most infectious diseases requires vaccines with
exceptional efficacy and safety (Doherty et al., 2016). Notable global suc-
cesses related to vaccine development include the eradication of small-
pox, the near-eradication of polio, and control of respiratory infections,
such as measles (Minor, 2015; Plotkin, 2014). The magnitude and gravity
of the STI epidemic has garnered considerable interest in vaccine strate-
gies. However, STIs represent a highly diverse group of viral, bacterial,
and protozoal organisms that have little in common except the mode
of transmission and, in some but not all cases, the mucosal or epithelial
tissues infected. Accordingly, each potential vaccine requires substantial
individual investment in knowledge related to the biology of transmis-
sion, infection pathogenesis, and credible ideas about protective immune
responses (“correlates of protection”). The “lumping” of STIs in discus-
sion of vaccine development leads to unrealistic expectations. In addition,
if STI vaccine development is successful, strategies required for optimal
deployment will be complicated, recognizing the uneven distribution of
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
BIOMEDICAL TOOLS FOR STI PREVENTION AND MANAGEMENT 369
certain diseases and general vaccine challenges in the current health care
system. However, mRNA-based technology is a potential new tool in the
development of prophylactic vaccines; this promising field is progressing
rapidly, with potential application to STI vaccines, such as HIV and HSV
(Abbasi, 2020; Egan et al., 2020; Maruggi et al., 2019; Pardi et al., 2018).
Two STI vaccines (hepatitis B and HPV) exist and have led to substan-
tial reductions in prevalence. Several other STIs have received substantial
research and investment, including HIV, gonorrhea, and genital herpes.
The NIAID recently created and funded six new STI vaccine cooperative
research centers, whose efforts target syphilis, chlamydia, and gonor-
rhea (Eisinger et al., 2020; NIAID, 2019). A classical vaccine development
approach was successful for hepatitis B: identify the correlate of protec-
tive immunity (hepatitis B surface antibody) and engineer a vaccine to
mount this precise response to a vaccine-induced antigenic challenge (Das
et al., 2019; Gerlich, 2013). In developing the HPV vaccine, an empirical
approach using type-specific, virus-like particles was highly successful,
even in the absence of a clear correlate of immunity (Wang and Roden,
2013). In contrast, despite decades of intensive investigation, the cor-
relates of protective immunity to strive for in vaccine development and
response still are not fully elucidated for HIV, gonorrhea, and herpes
(Haynes et al., 2012).
Developing STI vaccines requires consideration of target populations
at risk, including adolescents and young adults. Vaccines have been char-
acterized as either essential to achieve global control or merely helpful for
public health interventions (Hawkes et al., 2014). Many childhood vac-
cines, including hepatitis B, are termed essential to protect public health
and legally mandated for school attendance throughout the United States.
The hepatitis B vaccine was introduced in acknowledgment that adult
coverage rates were abysmal and that integrating this long-acting vaccine
into the childhood series would be programmatically more successful.
Unfortunately, HPV vaccines are more often seen as optional and
voluntary, limiting full coverage and their ultimate impact on prevention
of genital and oral cancers and genital warts (Baezconde-Garbanati et al.,
2017; Holman et al., 2014). Opt-in (not mandated) vaccines have lower
coverage rates than opt-out (mandated) vaccines. The HPV vaccines pro-
tect against genital HPV infection, high-grade cervical lesions, invasive
cervical cancer, anogenital warts, and some head and neck cancers (Her-
per, 2020; Kobayashi et al., 2018; Lei et al., 2020). Broader HPV vaccine
coverage, however, is essential for full public health benefits (Baezconde-
Garbanati et al., 2017; Holman et al., 2014). When practitioners see the
vaccine as optional or guess who might need it, coverage levels can be
compromised (Kashani et al., 2019; North and Niccolai, 2016).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
370 SEXUALLY TRANSMITTED INFECTIONS
A Brief Summary of STI Vaccine Progress
Different vaccines work in a variety of ways, but among the most
common is stimulating an anamnestic response to a challenge antigen
(i.e., the body has seen the antigen before [in the vaccine] and therefore
mounts a rapid, protective, usually antibody response to the challenge
[the infectious agent]). Vaccines may prevent infection, blunt infection
such that no illness is noted after exposure, reduce the severity of illness,
or prevent mortality, even if incidence is not affected. Some vaccines
produce lifelong immunity after a single dose, while others require peri-
odic boosters. For the hepatitis B vaccine, three doses produce lifelong
immunity in 95 percent of recipients. Possible lifelong immunity to the
viral types in the vaccine is expected in most recipients of just two doses
of HPV vaccine.
The diversity of organisms that cause STIs will involve a more com-
plex and elusive immune response that may require the vaccine to induce
both humoral and cellular immunity. The field to date has been unsuc-
cessful with HSV-2 viral vaccines. Bacterial and parasitic STI vaccines
against syphilis, gonorrhea, chlamydia, or trichomoniasis, to name a few,
have been similarly unsuccessful, but clinical trials continue. Table 7-3
lists examples of current STI vaccine trials (this does not include trials
studying the existing HPV vaccines).
Neisseria gonorrhoeae Gonococcal infections evoke an intense granulo-
cytic inflammatory response but virtually no protection from recurrent
infection(s) (Lovett and Duncan, 2018). Using a mouse model of vaginal
infection, Liu et al. (2017) demonstrated some protection with a prototype
outer membrane vesicle vaccine. This observation may be particularly
relevant because of cross-immunity between Neisseria meningitides and N.
gonorrhoeae, noted with the use of commercially available meningococ-
cal vaccine (Bexsero) (TAG, 2019). The N. meningitides vaccine contains
outer membrane vesicles; meningococcal and gonococcal vesicles share
considerable homology. In a retrospective cohort study, the effectiveness
of a unique New Zealand meningococcal B vaccine (MeNZB, similar to
Bexsero) against gonorrhea-associated hospitalization was assessed in
935,496 individuals born from 1984 to 1999 and eligible for meningococ-
cal B vaccination from 2004 to 2008 (Paynter et al., 2019). After adjust-
ment (sex, ethnicity, and economic deprivation), vaccine effectiveness
against hospitalization caused by gonorrhea was estimated to be 24 per-
cent (95% confidence interval: 1–42%) (Paynter et al., 2019). In follow-up
to this observation, several randomized clinical trials in various phases
have been initiated to evaluate Bexsero for gonorrhea prevention (see
Table 7-3); however, results are unlikely to be available for several years
(Petousis-Harris and Radcliff, 2019; Russell et al., 2019). A successful
Copyright National Academy of Sciences. All rights reserved.
TABLE 7-3 Examples of Clinical Trials of STI Vaccines
Estimated
Study Title Recruit- Intervention Trial Sponsor Study
[ClinicalTrials.gov ment Status/ Model Primary Outcome and Trial Completion
Identifier] Status Phase Intervention(s) Description Participants Measure(s) Location(s) Date
Gonorrhea Trials
Immunisation for Not yet Obser- 4CMenB vac- Prospective All con- 1. Notifications of Sponsor: December
Adolescents Against recruiting vational cine (Bexsero) cohort senting gonorrhea Australia: Univer- 31, 2024
Serious Communicable study 14–19-year- 2. Effect of sity of Adelaide
Diseases olds resid- 4CMenB vaccine on
[NCT04398849] ing in the carriage of all N. Locations: not
Northern meningitidis listed
Territory,
Australia in
2020–2021
(Estimated
7,100)
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Copyright National Academy of Sciences. All rights reserved.
371
continued
TABLE 7-3 Continued
372
Estimated
Study Title Recruit- Intervention Trial Sponsor Study
[ClinicalTrials.gov ment Status/ Model Primary Outcome and Trial Completion
Identifier] Status Phase Intervention(s) Description Participants Measure(s) Location(s) Date
Use of Bexsero Immuni- Not yet N/A 4CMenB vac- To assess Esti- 1. Humoral and T Sponsor: April 30,
sation to Detect Cross recruiting cine (Bexsero) if immuni- mated 50 cell cross-reactive United Kingdom: 2022
Reactive Antigens and sation of 18–25-year- responses against University of
Anti-Gonococcal Anti- individuals old men or Neisseria gonorrhoeae Oxford
bodies in Key Popula- at risk for women
tions in Kenya gonococcal Location:
[NCT04297436] infec- Kenya: Kilifi
tion with
4CMenB
(Bexsero)
elicits hu-
moral and
T cell cross-
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
reactive
responses
against
Neisseria
gonorrhoeae
Copyright National Academy of Sciences. All rights reserved.
A Phase II Randomized, Recruiting Phase 2 4CMenB vac- Random- Estimated 1. Number of par- Sponsor: August 1,
Observer-Blind, Placebo- cine (Bexsero) ized, 2,200 ticipants diagnosed USA: National In- 2023
Controlled Study, to and placebo parallel as- 18–50-year- with urogenital or stitute of Allergy
Assess the Efficacy of signment old men anorectal gonococ- and Infectious
Meningococcal Group and women cal infection post Diseases
B Vaccine rMenB+OMV second vaccination
NZ (Bexsero) in Prevent- Locations:
ing Gonococcal Infection USA: Alabama;
[NCT04350138] Georgia (2 sites);
Louisiana; Mary-
land
Thailand: Bang-
kok (2 sites)
A Multi-Centre Ran- Not yet Phase 3 4CMenB Random- Esti- 1. To measure wheth- Sponsor: February
domised Controlled Trial recruiting (Bexsero) and ized, mated 730 er the 4CMenB vac- Australia: Kirby 2024
Evaluating the Efficacy of placebo parallel 18–40-year- cine, when adminis- Institute
the Four-Component Me- assignment old high- tered in a two-dose
ningococcal B Vaccine, (1:1) risk men regimen at 0 and 3 Locations:
4CMenB (Bexsero), in the (cis and months, changes the Australia:
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Prevention of Neisse- trans), trans incidence of the first Sydney (2 sites);
ria Gonorrhoeae Infection women, episode of N. gonor- Queensland;
in Gay and Bisexual Men and non- rhoeae Melbourne
[NCT04415424] binary 2. To compare the
people who overall incidence of
have sex all episodes of N.
with men gonorrhoeae infection
diagnosed during
the study period
between the vac-
Copyright National Academy of Sciences. All rights reserved.
cine and placebo
arms
373
continued
TABLE 7-3 Continued
374
Estimated
Study Title Recruit- Intervention Trial Sponsor Study
[ClinicalTrials.gov ment Status/ Model Primary Outcome and Trial Completion
Identifier] Status Phase Intervention(s) Description Participants Measure(s) Location(s) Date
Institute for Global Recruiting Phase 4 4CMenB vac- Single Esti- 1. The change in Sponsor: February
Health and Infectious cine (Bexsero) group as- mated 15 anti-N. gonorrhoeae USA: University 2021
Diseases 11911 - Cross- signment 18–25-year- outer-membrane of North Carolina
Reactive N. gonorrhoeae old men or vesicle-specific IgG at Chapel Hill
Immune Responses women concentrations after
Induced by a N. immunization Location:
meningitidis Vaccine 2. The change in USA: North
[NCT04094883] anti-N. gonorrhoeae Carolina
outer-membrane
vesicle-specific IgM
concentrations after
immunization
3. The change in
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
anti-N. gonorrhoeae
outer-membrane
vesicle-specific IgA
concentrations after
immunization
4. The change in
frequency of CD4+
T cells expressing at
least two different
activation markers
Copyright National Academy of Sciences. All rights reserved.
after immunization
Chlamydia Trial
A Phase I First in Hu- Com- Phase 1 CTH522- Random- 35 1. Evaluation of Sponsor: Completed
man, Double-Blind, pleteda CAF01, ized assign- 18–45-year- adverse events/reac- Denmark: Statens July 31,
Parallel, Randomised CTH522- ment (3:3:1) old women tions and laboratory Serum Institut 2017
and Placebo Controlled Al(OH)3, and safety of adjuvanted
Clinical Trial of the placebo chlamydia vaccine Location:
Safety of SSI’s Adjuvant- United Kingdom:
ed Chlamydia Vaccine London
CTH522 in Healthy
Women Aged 18 to 45
Years
[NCT02787109]
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Copyright National Academy of Sciences. All rights reserved.
375
continued
TABLE 7-3 Continued
376
Estimated
Study Title Recruit- Intervention Trial Sponsor Study
[ClinicalTrials.gov ment Status/ Model Primary Outcome and Trial Completion
Identifier] Status Phase Intervention(s) Description Participants Measure(s) Location(s) Date
Herpes Simplex Virus Trials
Safety and Efficacy of Active, not Phase 1 Six HSV 2 Random- Esti- 1. Number of partici- Sponsor: May 2021
4 Investigational HSV recruiting and 2 formulations ized, mated 381 pants with immedi- France: Sanofi
2 Vaccines Administered sequential 18–55-year- ate adverse events Pasteur
by Intramuscular Route assignment old, HSV-2 2. Number of partici-
in Adults With Recurrent seropositive pants with solicited Locations:
Genital Herpes Caused men and injection site and USA: Florida;
by HSV 2 [NCT04222985] women systemic reactions Massachusetts;
3. Number of partici- North Carolina;
pants with unsolic- Washington
ited adverse events
4. Number of partici-
pants with MAAEs
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
5. Number of partici-
pants with AESIs
6. Number of partici-
pants with SAEs
7. Number of par-
ticipants with out-of-
range biological test
results
8. Viral genital shed-
Copyright National Academy of Sciences. All rights reserved.
ding rate
9. Genital HSV
recurrence
A Randomized, Placebo- Terminat- Phase 2 GEN-003 with Random- Estimated 1. Percentage of days Sponsor: N/A
Controlled, Double-Blind edb Matrix-M2 ized, 33 partici- with genital herpes USA: Genocea
Study to Assess the adjuvant and parallel pants who lesions Biosciences, Inc.
Efficacy and Safety of placebo assignment completed
a Maintenance Dose of (1:1) the GEN- Locations:
GEN-003 in Subjects with 003-003 USA: Alabama;
Genital Herpes Infection study California (2
[NCT03146403] sites); North
Carolina; Ohio;
Oregon; Texas;
Washington
a Resultspublished. See Abraham et al., 2019.
bTerminated in 2017 because of a business decision to cease spending on the GEN-003 vaccine project (https://clinicaltrials.gov/ct2/show/
NCT03146403 [accessed September 15, 2020]).
NOTES: ClinicalTrials.gov search and study recruitment status are as of September 2, 2020. AESI = adverse events of special interest; HSV-2 = herpes
simplex virus type 2; IgA = Immunoglobulin A; IgG = Immunoglobulin G; IgM = Immunoglobulin M; MAAE = medically attended adverse event;
SAE = serious adverse event; USA = United States of America.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Copyright National Academy of Sciences. All rights reserved.
377
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
378 SEXUALLY TRANSMITTED INFECTIONS
N. meningitides vaccine for N. gonorrhoeae has obvious design implications
for a more specific and effective gonorrhea vaccine. In addition to these
clinical trials, researchers have identified nine new potential proteins as
vaccine candidates (TAG, 2019).
Chlamydia trachomatis The feasibility of vaccines to prevent chlamydia
is supported by limited data indicating that persons with recent infections
are at somewhat reduced risk for reinfection (Brunham and Rey-Ladino,
2005; Phillips et al., 2019; Poston and Darville, 2018), although reinfections
certainly do occur (Geisler et al., 2013). A vaccine might prevent infec-
tion or sequelae of infection, including PID and female factor infertility
(Phillips et al., 2019). However, PID is difficult to diagnose with accuracy,
complicating assessment of vaccine benefits (Workowski and Bolan, 2015).
A vaccine that takes advantage of the immunogenicity of the chla-
mydial major outer membrane protein has been tested in a human Phase
1 clinical trial (Abraham et al., 2019; Tifrea et al., 2020). The genital C.
trachomatis vaccine candidate, CTH522, contains engineered heterolo-
gous immunorepeats from segments of the chlamydial major outer mem-
brane protein. Vaccines manufactured with either liposomal CAF01 or
aluminum hydroxide were administered three times via intramuscular
injection, followed by two intranasal inoculations (without adjuvant).
This historic trial indicated that both vaccines (with different adjuvants)
were well tolerated and immunogenic (Abraham et al., 2019) (see Table
7-3). CTH522:CAF01 induced more consistent cell-mediated interferon-γ
responses and higher serum antibody titers, so it is preferred. Phase 2
trials will follow, and a marketable vaccine could be available in several
years, if results and market forces are favorable. Research into other
potential vaccine candidates continues as well (Bulir et al., 2016; TAG,
2019).
Herpes simplex virus type 2 (HSV-2) HSV-2 infection is incurable and
recurrent (CDC, 2017). Recurrences can be painful and correlate with
increased probability of infecting sexual partners (Corey, 1982; Schiffer
and Corey, 2009) but can be suppressed or shortened with antiviral treat-
ment, which also reduces transmission (Workowski and Bolan, 2015).
Much current vaccine research is focused on “therapeutic vaccination”:
enhancing host immunity to better manage existing infections (Hofstetter
et al., 2014). These vaccines appear to reduce recurrences and genital tract
shedding of the virus. T cell and antibody responses have been demon-
strated to last up to 12 months (Dropulic and Cohen, 2012). However,
the commercial development of a suppressive HSV-2 vaccine remains
uncertain (WHO, 2019). Despite several encouraging phase 2 trials, only
a single HSV-2 vaccine is in clinical trials (see Table 7-3).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
BIOMEDICAL TOOLS FOR STI PREVENTION AND MANAGEMENT 379
Little progress has been made on a vaccine to prevent HSV-2 infection
(Kim and Lee, 2020). Several previous large NIH-led trials of preventa-
tive vaccines have failed (Belshe et al., 2012). Most recently, a live-atten-
uated vaccine candidate has harnessed antibody-mediated cell toxicity,
a promising approach; safety is ensured by the deletion of amino acid
sequences in key HSV proteins such that sustainable infection cannot
occur (Görander et al., 2014).
Treponema pallidum This microorganism is a spirochete, a spiral bacte-
rium that causes syphilis. It theoretically could be controlled with a vigor-
ous immune response (Lithgow and Cameron, 2017). Ideally, a syphilis
vaccine would prevent infection, the primary manifestation (primary
infection) represented by the cutaneous chancre (ulcer). Failing this, sub-
stantially reducing the dissemination of spirochetes, persistence (latency
and sequelae), and reinfection would all be helpful (McIntosh, 2020). The
biology and pathogenesis of syphilis infection, however, make vaccine
development challenging for many reasons (Duan et al., 2020). The T.
pallidum surface has a very limited array of outer membrane proteins and
an atypical lipid content; this bacterial surface seems to contribute to the
inability of the immune system to protect against infection.
While the exact correlates of protective immunity are unknown, a
rabbit experiment with irradiated T. pallidum published in 1973 has been
touted as a test of concept, suggesting the feasibility of a human vaccine
targeting treponemal surface antigens on the outer membranes (Miller,
1973). A reduction or delay in chancre formation was noted, along with
reduced recovery of spirochetes from other tissues. No active clinical trials
for syphilis vaccines exist; however, current research on vaccine develop-
ment focuses on a better understanding of surface-exposed treponemal
proteins and a better determination of the best correlates of immunity
(NIAID, 2019). For example, Lithgow et al. (2017) have focused on trepo-
nemal proteins Tp0751 and TPrK. There remains, however, some debate
about the physical location of these proteins. A paper by Luthra et al.
(2020) found no protection against local or disseminated infection fol-
lowing challenge with T. pallidum in rabbits immunized with Tp0751,
suggesting Tp0751 is in fact a subsurface protein. Results such as these
challenge the probability that these proteins can credibly serve as reliable
immunogens (Luthra et al., 2020; Radolf et al., 2016).
Preventing “vertical transmission” to the fetus during pregnancy is
an especially important goal, given the number of people who do not
get tested and/or treated and the severity of congenital syphilis in the
newborn (Kimball et al., 2020) (see Chapters 2 and 3). Congenital syphilis
during pregnancy is a leading, preventable cause of adverse pregnancy
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
380 SEXUALLY TRANSMITTED INFECTIONS
outcomes (miscarriage, spontaneous abortion, congenital infections caus-
ing lifelong sequelae) and is increasing in the United States (CDC, 2019b),
a true failure of public health and health care.
Stakeholders in STI Vaccine Development
NIH and CDC NIH has the most visible U.S. investment in STI vaccine
development. As mentioned above, the 2019 cooperative research pro-
grams launched by NIAID fund vaccine development for chlamydia,
syphilis, and gonorrhea (Eisinger et al., 2020; NIAID, 2019), with the
grants totaling many millions of dollars over 5 years. This is focused
largely on immunology, animal models, and early clinical trials (NIAID,
2019; TAG, 2019).
CDC plays a critical and unique policy and scientific advisory role
in deployment once vaccines are available. The Advisory Committee on
Immunization Practices comprises medical and public health experts who
develop recommendations on the use of proven vaccines in the civilian
population of the United States (CDC, 2020). The recommendations stand
as public health guidance for safe use of vaccines and related biological
products (CDC, 2020). In addition, the committee is charged to undertake
economic analysis of vaccine policy decisions and whether the right vac-
cines are deployed for the right populations (CDC, 2020).
CDC also plays a critical role in vaccine education and messaging.
Accordingly, the success of any STI vaccine will depend to a great extent
on CDC activities and successful collaboration between CDC and vaccine
developers. A good example of this relationship can be seen with the HPV
vaccine. Use grew exponentially since its introduction, but uptake has
plateaued in recent years; only about half of adolescents aged 13–17 had
completed the vaccine series in 2018 (Walker et al., 2019). The vaccine has
been “marketed,” however, more as preventing cancer rather than STIs,
to evade community sensitivities related to STI-associated stigma (Klein
and Luedtke, 2008). The economic potential for preventive STI vaccine(s)
remains uncertain, compromising investment and development strategies
from the private sector.
Industry and other partners Industry involvement is crucial for suc-
cessful vaccine development and bringing products to market. Vaccines
are not nearly as profitable compared to pharmaceuticals and biologics
for therapy. Hence, companies will critically assess the market forces
before they decide to partner for moving promising candidates forward
in the developmental pathway. Whether consumers (community mem-
bers), health care providers, and governments engage productively will
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
BIOMEDICAL TOOLS FOR STI PREVENTION AND MANAGEMENT 381
depend on conservative considerations of safety, cost, and benefit. Will
consumers and health care workers flock to an STI vaccine? HPV and
HBV vaccines prevent cancer, so there is less stigma for them, but a vac-
cine clearly focused on an STI may be shunned by consumers afraid of
social and familial opprobrium.
The role of the Bill & Melinda Gates Foundation; Gavi, The Vaccine
Alliance; WHO; governments; and perhaps other foundations may be
critical here. Industry may embrace a product if it can mitigate risk and
maximize income. As was done to bring relatively expensive vaccines—
Haemophilus influenzae type b and pneumococcus—to children in low-
income nations, bulk purchase guarantees in exchange for more afford-
able pricing may work to promulgate STI vaccines, too. See the section in
Chapter 12 on Public–Private Partnerships for STI Prevention and Control
for more information.
STI Vaccines and Risk Compensation
Increasing access to antiretroviral therapy for people living with HIV
and to HIV PrEP for vulnerable, HIV-seronegative populations has been
associated with rising STI incidence in MSM in some studies (Ramchan-
dani and Golden, 2019). Other research has not found a relationship with
antiretroviral therapy and rising STI rates (Freeborn and Portillo, 2018;
Liu and Buchbinder, 2017). Many experts believe that increasing rates of
STIs reflect, in part, “risk compensation” that result from reduced fear of
HIV infection, especially in MSM (Rojas Castro et al., 2019). It seems likely
that an STI vaccine might inspire similar changes in behavior, influencing
persons at risk to see themselves as protected from STI risk. Nonetheless,
such developments do not negate the benefits from reduced HIV risk
in the context of personal choices about which risk reduction strategies
individuals select for themselves.
On the other hand, the HPV vaccine has not been associated with
increased sexual risk taking (Hansen, 2016; Wu et al., 2019). No mat-
ter the efficacy of any novel STI vaccine, incident infections with other
organisms could well compromise its deployment and relative benefits,
potentially more serious if the vaccine were not particularly efficacious.
The HIV PrEP field may prove helpful here, as assertive counseling has
helped mitigate risk compensation in a number of populations (i.e., some
or most consumers can be educated not to overvalue STI vaccines and to
appreciate the need for continued risk reduction).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
382 SEXUALLY TRANSMITTED INFECTIONS
Gaps and Opportunities in STI Prevention
Human sexual behavior is a fundamental and powerful biological
and social drive and often also motivated by the wish to have children.
Given broad nonadherence with or unavailability of condoms, STIs are
unlikely to be properly controlled without a vaccine (Ortayli et al., 2014)
and other biological interventions (Eisinger et al., 2020). This section has
highlighted, however, the daunting biological challenges of mucosally
mediated infections, the social stigmas of biomedical interventions, and
investment obstacles for the private sector, which may make more money
from other products. STI vaccine development remains insecure, but the
committee applauds funding cooperative research centers for this goal.
Likewise, research continues into doxycycline to prevent bacterial STIs.
Although this is a promising approach to controlling STIs, better data are
needed on aspects such as target populations, doses and regimens, and
the overall risk–benefit analysis of this strategy (Grant et al., 2020).
Critical policy and deployment strategies present additional substan-
tial challenges, as discussed above. Deploying the hepatitis B and HPV
vaccines has not been without challenges and lessons learned (Hsieh et
al., 2015). The challenges have included misinformation related to safety,
reduced acceptance related to the stigma of STIs and misperceptions of
risk, and a limited infrastructure for adolescent and adult vaccine deploy-
ment and costs. For example, in the United States, major advances in
population-wide hepatitis B vaccine coverage beyond health care work-
ers did not occur until vaccination was recommended beginning at birth.
Additionally, the relatively high cost of HPV vaccines is also a barrier
that may apply to new STI vaccines as they emerge. Adolescents below
18 years of age may require parental consent in some venues, which
introduces yet another barrier that will likely require further consider-
ation by policy makers and public health officials (Hawkes et al., 2014).
The challenges in developing, implementing, and ensuring widespread
use of STI prevention tools highlights the need for accurate and avail-
able diagnostic and treatment tools, as well as concurrent behavioral and
structural interventions.
CONCLUSIONS AND RECOMMENDATION
Infections from a large number of bacteria, viruses, and protozoans,
each with its own biological characteristics, are classified as STIs. These
organisms share sexual and often perinatal transmission as fundamental
characteristics, but they require different therapies and ancillary control
measures. Accurate and timely diagnosis is crucial, yet many of these
infections are commonly asymptomatic and so may go unrecognized,
creating a long window for transmission and causing a variety of serious
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
BIOMEDICAL TOOLS FOR STI PREVENTION AND MANAGEMENT 383
complications. The consequences of many STIs may become apparent
only years later. Additional progress needs to be made in developing and
implementing biomedical tools to successfully combat the STI epidemic
(Eisinger et al., 2020).
Conclusion 7-1: Recent scientific advances provide the means for improving
STI diagnosis, but existing tools are currently underused and results may
not be available in a timely fashion, permitting further transmission. Increas-
ing antimicrobial resistance has threatened the continued efficacy and ease of
STI treatment and the pipeline for development of both new antimicrobials
and vaccines for STI prevention and treatment has been constrained by an
unfavorable business case that includes an expensive and time-consuming
regulatory pathway to approval and widespread availability.
Conclusion 7-2: Syndromic diagnosis and treatment for persons with genito-
urinary symptoms remain common. The efficacy of this approach to prevent
STI transmission to others is limited because it fails to address the frequent
occurrence of asymptomatic or otherwise unrecognized infections and is
contrary to principles of antimicrobial stewardship to slow the evolution of
antimicrobial resistance.
Therefore, the committee recommends:
Recommendation 7-1: To improve the efficacy and reach of tools for
STI management and prevention, the National Institutes of Health
should prioritize development of point-of-care (POC) diagnostic
tests; development of diagnostic tests for active syphilis; promotion
of public–private partnerships (PPPs) to develop new antimicrobi-
als; and expedited development of vaccines.
• POC diagnostics: Prioritize development of POC diagnostic tests
to reduce the interval between testing and treatment. Use of these
POC tests should be promoted to reduce opportunities for trans-
mission. Optimally, POC tests should be inexpensive, rapid, and
receive a Clinical Laboratory Improvement Amendments waiver
to permit increased testing at sites providing health care or at
home.
• New diagnostics for syphilis: Promote development of new,
innovative diagnostic tests for active syphilis that distinguish
untreated, active syphilis from previously treated infection, which
is required to effectively control syphilis.
• Antimicrobials and vaccines for STI treatment and prevention:
Subsidize and encourage PPPs with the goals of developing new,
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
384 SEXUALLY TRANSMITTED INFECTIONS
readily accessible antimicrobials for STI treatment and expedit-
ing development of vaccines for prevention of high-priority STIs,
such as chlamydia, gonorrhea, syphilis, and herpes.
Much needs to be accomplished to expand and improve the tools used
for prevention and management of STIs (Eisinger et al., 2020). Federally
initiated public–private partnerships (PPPs) will help to address a pace of
development of new tools often hindered by a business case that makes
investment in development less attractive than for medications taken
more often and already promoted as contributing to health maintenance
(see Chapter 12 for more information on PPPs). Ultimately, however, the
goal of STI prevention will be most effectively accomplished by develop-
ment and widespread use of safe and effective vaccines (Eisinger et al.,
2020). Ongoing trials of vaccines for gonorrhea promise to provide tools
for one of the world’s most common STIs. A recent initiative (Operation
Warp Speed) to rapidly develop and test vaccines for SARS COVID-19
provides a model to be emulated for other prioritized STI pathogens,
such as C. trachomatis (chlamydia), Treponema pallidum (syphilis), and HSV.
CONCLUDING OBSERVATIONS
In the interval since The Hidden Epidemic, technological advances have
expanded the tools available to contribute to control of STIs and provided
new methods with enormous potential for further additions to the inter-
vention “toolbox.” NAATs have supplanted less sensitive, less specific,
and more cumbersome diagnostic tests and are now the tests of choice for
chlamydia, gonorrhea, and trichomoniasis. POC NAATs and additional
molecular tests for emerging STIs, such as BV and Mycoplasma genitalium,
are becoming available as well and promise to expand the availability and
timeliness of STI testing for both diagnosis and screening.
In contrast, despite the technical advances with the potential to facil-
itate development, relatively few new antimicrobials have been stud-
ied for STI treatment in the past 20 years. Losing the antibiotic pipeline
infrastructure means losing the ability to innovate (Solman, 2020). More
recently, stimulated in part by the threat posed by progressive antimicro-
bial resistance, several newer antimicrobials for gonorrhea have entered
clinical trials (delafloxacin, solithromycin, zoliflodacin, gepotidacin), but
after unacceptable failure rates, delafloxacin and solithromycin are no
longer being evaluated. Similarly, other than the noteworthy exception
of vaccines for HPV, which have been marketed for cancer rather than
STI prevention, STI vaccine research and other prevention tools (e.g.,
antibiotic PrEP, expedited partner therapy), have moved forward in lim-
ited fashion, also due to the difficult development process and significant
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
BIOMEDICAL TOOLS FOR STI PREVENTION AND MANAGEMENT 385
time and resources needed. Research on potential gonococcal vaccines
has been recently stimulated by the observed benefit of type B meningo-
coccal vaccines on gonorrhea incidence and NIAID investment in basic
research aimed at developing prototype vaccines for syphilis, gonorrhea,
and chlamydia. Developing these drugs and vaccines for STI management
and prevention has been, in part, constrained by the impact of perceived
STI-related stigma on assessment of potential markets and a costly and
time-consuming regulatory pathway. New and existing biomedical tools
will need to be integrated with behavioral and structural interventions
across the life span to have the greatest effect on the STI epidemic.
REFERENCES
Abbasi, J. 2020. COVID-19 and mRNA vaccines—first large test for a new approach. JAMA
324(12):1125-1127.
Abdool Karim, S. S., Q. Abdool Karim, A. B. Kharsany, C. Baxter, A. C. Grobler, L. Werner, A.
Kashuba, L. E. Mansoor, N. Samsunder, A. Mindel, and T. N. Gengiah. 2015. Tenofovir
gel for the prevention of herpes simplex virus type 2 infection. New England Journal of
Medicine 373(6):530-539.
Aberg, J. A., J. E. Gallant, K. G. Ghanem, P. Emmanuel, B. S. Zingman, and M. A. Horberg.
2014. Primary care guidelines for the management of persons infected with HIV: 2013
update by the HIV Medicine Association of the Infectious Diseases Society of America.
Clinical Infectious Diseases 58(1):e1-e34.
Abraham, S., H. B. Juel, P. Bang, H. M. Cheeseman, R. B. Dohn, T. Cole, M. P. Kristiansen,
K. S. Korsholm, D. Lewis, A. W. Olsen, L. R. McFarlane, S. Day, S. Knudsen, K. Moen,
M. Ruhwald, I. Kromann, P. Andersen, R. J. Shattock, and F. Follmann. 2019. Safety
and immunogenicity of the chlamydia vaccine candidate CTH522 adjuvanted with
CAF01 liposomes or aluminium hydroxide: A first-in-human, randomised, double-
blind, placebo-controlled, phase 1 trial. The Lancet Infectious Diseases 19(10):1091-1100.
Akram, M., I. M. Tahir, S. M. A. Shah, Z. Mahmood, A. Altaf, K. Ahmad, N. Munir, M. Dani-
yal, S. Nasir, and H. Mehboob. 2018. Antiviral potential of medicinal plants against
HIV, HSV, influenza, hepatitis, and coxsackievirus: A systematic review. Phytotherapy
Research 32(5):811-822.
Allan-Blitz, L. T., R. M. Humphries, P. Hemarajata, A. Bhatti, M. W. Pandori, M. J. Siedner,
and J. D. Klausner. 2017. Implementation of a rapid genotypic assay to promote tar-
geted ciprofloxacin therapy of Neisseria gonorrhoeae in a large health system. Clinical
Infectious Diseases 64(9):1268-1270.
Anderson, D. J., J. A. Politch, R. A. Cone, L. Zeitlin, S. K. Lai, P. J. Santangelo, T. R. Moench,
and K. J. Whaley. 2020. Engineering monoclonal antibody-based contraception and
multipurpose prevention technologies. Biology of Reproduction 103(2):275-285.
Archambault, J., and T. Melendy. 2013. Targeting human papillomavirus genome replication
for antiviral drug discovery. Antiviral Therapy 18(3):271-283.
Baezconde-Garbanati, L., B. A. Lienemann, M. Robles, E. Johnson, K. Sanchez, R. Singhal, J.
Steinberg, J. M. Jaque, M. A. Pentz, and S. Gruber. 2017. Implementation of HPV vac-
cination guidelines in a diverse population in Los Angeles: Results from an environ-
mental scan of local HPV resources and needs. Vaccine 35(37):4930-4935.
Barrow, R. Y., F. Ahmed, G. A. Bolan, and K. A. Workowski. 2020. Recommendations for
providing quality sexually transmitted diseases clinical services, 2020. MMWR Recom-
mendations and Reports 68(5):1-20.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
386 SEXUALLY TRANSMITTED INFECTIONS
Beksinska, M., R. Wong, and J. Smit. 2020. Male and female condoms: Their key role in
pregnancy and STI/HIV prevention. Best Practice & Research Clinical Obstetrics & Gyn-
aecology 66:55-67.
Belshe, R. B., P. A. Leone, D. I. Bernstein, A. Wald, M. J. Levin, J. T. Stapleton, I. Gorfinkel, R.
L. A. Morrow, M. G. Ewell, A. Stokes-Riner, G. Dubin, T. C. Heineman, J. M. Schulte,
and C. D. Deal. 2012. Efficacy results of a trial of a herpes simplex vaccine. New England
Journal of Medicine 366(1):34-43.
Bibbins-Domingo, K., D. C. Grossman, S. J. Curry, K. W. Davidson, J. W. Epling, Jr., F. A.
García, A. R. Kemper, A. H. Krist, A. E. Kurth, C. S. Landefeld, C. M. Mangione, W. R.
Phillips, M. G. Phipps, M. P. Pignone, M. Silverstein, and C. W. Tseng. 2016. Serologic
screening for genital herpes infection: U.S. Preventive Services Task Force recommen-
dation statement. JAMA 316(23):2525-2530.
Blumenthal, K. G., J. G. Peter, J. A. Trubiano, and E. J. Phillips. 2019. Antibiotic allergy. Lancet
393(10167):183-198.
Boeras, D. I., N. Luisi, E. Karita, S. McKinney, T. Sharkey, M. Keeling, E. Chomba, C. Kraft,
K. Wall, J. Bizimana, W. Kilembe, A. Tichacek, A. M. Caliendo, E. Hunter, and S. Allen.
2011. Indeterminate and discrepant rapid HIV test results in couples’ HIV testing and
counselling centres in Africa. Journal of the International AIDS Society 14:18.
Bolan, G. 2019. Division of STD prevention. Presentation to the Committee on Sexually Transmitted
Infections in the United States, Meeting 1 (August 26). https://www.nationalacademies.
org/event/08-26-2019/docs/D3423E23A3A4A9B4447C205483C8F840EF1481A1EEE2
(accessed February 17, 2021).
Bolan, R. K., M. R. Beymer, R. E. Weiss, R. P. Flynn, A. A. Leibowitz, and J. D. Klausner. 2015.
Doxycycline prophylaxis to reduce incident syphilis among HIV-infected men who
have sex with men who continue to engage in high-risk sex: A randomized, controlled
pilot study. Sexually Transmitted Diseases 42(2):98-103.
Bouchemal, K., C. Bories, and P. M. Loiseau. 2017. Strategies for prevention and treatment of
Trichomonas vaginalis infections. Clinical Microbiology Reviews 30(3):811-825.
Brunham, R. C., and J. Rey-Ladino. 2005. Immunology of chlamydia infection: Implications
for a Chlamydia trachomatis vaccine. Nature Reviews Immunology 5(2):149-161.
Buckley, C., B. M. Forde, E. Trembizki, M. M. Lahra, S. A. Beatson, and D. M. Whiley. 2018.
Use of whole genome sequencing to investigate an increase in Neisseria gonorrhoeae
infection among women in urban areas of Australia. Scientific Reports 8(1):1503.
Bulir, D. C., S. Liang, A. Lee, S. Chong, E. Simms, C. Stone, C. Kaushic, A. Ashkar, and J.
B. Mahony. 2016. Immunization with chlamydial type III secretion antigens reduces
vaginal shedding and prevents fallopian tube pathology following live C. muridarum
challenge. Vaccine 34(34):3979-3985.
Carnevale, C., P. Richards, R. Cohall, J. Choe, J. Zitaner, N. Hall, A. Cohall, S. Whittier, D. A.
Green, M. E. Sobieszczyk, P. Gordon, and J. Zucker. 2021. At home testing for sexually
transmitted infections during the COVID-19 pandemic. Sexually Transmitted Diseases
48(1):e11-e14.
CDC (Centers for Disease Control and Prevention). 2017. Genital herpes—CDC fact sheet
(detailed). https://www.cdc.gov/std/herpes/stdfact-herpes-detailed.htm (accessed
November 9, 2020).
CDC. 2018. Test complexity categorization. https://www.cdc.gov/clia/test-complexities.html
(accessed November 2, 2020).
CDC. 2019a. Antibiotic resistance threats in the United States, 2019. Atlanta, GA: Centers for
Disease Control and Prevention.
CDC. 2019b. Sexually transmitted disease surveillance 2018. Atlanta, GA: Department of Health
and Human Services.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
BIOMEDICAL TOOLS FOR STI PREVENTION AND MANAGEMENT 387
CDC. 2019c. Zika virus: Sexual transmission and prevention. https://www.cdc.gov/zika/
prevention/sexual-transmission-prevention.html (accessed January 19, 2021).
CDC. 2020. Advisory Committee on Immunization Practices (ACIP): General committee-related
information. https://www.cdc.gov/vaccines/acip/committee/index.html (accessed
November 18, 2020).
CDC. 2021. Ebola (Ebola virus disease): Transmission. https://www.cdc.gov/vhf/ebola/
transmission/index.html (accessed January 19, 2021).
Cherry, J. J., A. Rietz, A. Malinkevich, Y. Liu, M. Xie, M. Bartolowits, V. J. Davisson, J. D.
Baleja, and E. J. Androphy. 2013. Structure based identification and characterization of
flavonoids that disrupt human papillomavirus-16 E6 function. PLoS One 8(12):e84506.
CMS (Centers for Medicare & Medicaid Services). 2020. Clinical laboratory improvement
amendments (CLIA). https://www.cms.gov/Regulations-and-Guidance/Legislation/
CLIA (accessed November 18, 2020).
CMS. n.d. Tests granted waived status under CLIA. https://www.cms.gov/Regulations-and-
Guidance/Legislation/CLIA/Downloads/waivetbl.pdf (accessed November 18, 2020).
Coltart, C. E. M., A. Hoppe, M. Parker, L. Dawson, J. J. Amon, M. Simwinga, G. Geller, G.
Henderson, O. Laeyendecker, J. D. Tucker, P. Eba, V. Novitsky, A. M. Vandamme, J.
Seeley, G. Dallabetta, G. Harling, M. K. Grabowski, P. Godfrey-Faussett, C. Fraser, M. S.
Cohen, and D. Pillay. 2018. Ethical considerations in global HIV phylogenetic research.
The Lancet HIV 5(11):e656-e666.
Committee on Adolescence and Society for Adolescent Health and Medicine. 2014. Screening
for nonviral sexually transmitted infections in adolescents and young adults. Pediatrics
134(1):e302-e311.
Copen, C. E. 2017. Condom use during sexual intercourse among women and men aged 15-
44 in the United States: 2011-2015 National Survey of Family Growth. National Health
Statistics Reports (105):1-18.
Corey, L. 1982. The diagnosis and treatment of genital herpes. JAMA 248(9):1041-1049.
Dallal Bashi, Y. H., C. F. McCoy, D. J. Murphy, P. Boyd, P. Spence, K. Kleinbeck, B. Devlin, and
R. K. Malcolm. 2019. Towards a dapivirine and levonorgestrel multipurpose vaginal
ring: Investigations into the reaction between levonorgestrel and addition-cure silicone
elastomers. International Journal of Pharmaceutics 569:118574.
D’Anna, L. H., A. D. Margolis, L. Warner, O. A. Korosteleva, L. O’Donnell, C. A. Rietmeijer,
J. D. Klausner, W. Nomura, and C. K. Malotte. 2012. Condom use problems during anal
sex among men who have sex with men (MSM): Findings from the Safe in the City
study. AIDS Care 24(8):1028-1038.
Das, S., K. Ramakrishnan, S. K. Behera, M. Ganesapandian, A. S. Xavier, and S. Selvarajan.
2019. Hepatitis B vaccine and immunoglobulin: Key concepts. Journal of Clinical and
Translational Hepatology 7(2):165-171.
de Bruyn, G., S. Shiboski, A. van der Straten, K. Blanchard, T. Chipato, G. Ramjee, E. Mont-
gomery, and N. Padian. 2011. The effect of the vaginal diaphragm and lubricant gel on
acquisition of HSV-2. Sexually Transmitted Infections 87(4):301-305.
Deese, J., S. Pradhan, H. Goetz, and C. Morrison. 2018. Contraceptive use and the risk of
sexually transmitted infection: Systematic review and current perspectives. Open Access
Journal of Contraception 9:91-112.
Dennis, A. M., J. T. Herbeck, A. L. Brown, P. Kellam, T. de Oliveira, D. Pillay, C. Fraser, and
M. S. Cohen. 2014. Phylogenetic studies of transmission dynamics in generalized HIV
epidemics: An essential tool where the burden is greatest? Journal of Acquired Immune
Deficiency Syndromes 67(2):181-195.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
388 SEXUALLY TRANSMITTED INFECTIONS
Derby, N., M. Aravantinou, J. Kenney, S. R. Ugaonkar, A. Wesenberg, J. Wilk, L. Kizima, A.
Rodriguez, S. Zhang, O. Mizenina, K. Levendosky, M. L. Cooney, S. Seidor, A. Get-
tie, B. Grasperge, J. Blanchard, M. Piatak, Jr., J. D. Lifson, J. Fernández-Romero, T. M.
Zydowsky, and M. Robbiani. 2017. An intravaginal ring that releases three antiviral
agents and a contraceptive blocks SHIV-RT infection, reduces HSV-2 shedding, and
suppresses hormonal cycling in rhesus macaques. Drug Delivery and Translational Re-
search 7(6):840-858.
DiClemente, R. J., E. Funkhouser, G. Wingood, H. Fawal, S. D. Holmberg, and S. H. Vermund.
2002. Protease inhibitor combination therapy and decreased condom use among gay
men. Southern Medical Journal 95(4):421-425.
Doherty, M., P. Buchy, B. Standaert, C. Giaquinto, and D. Prado-Cohrs. 2016. Vaccine impact:
Benefits for human health. Vaccine 34(52):6707-6714.
Doudna, J. A. 2020. The promise and challenge of therapeutic genome editing. Nature
578(7794):229-236.
Drain, P. K., J. Dorward, A. Bender, L. Lillis, F. Marinucci, J. Sacks, A. Bershteyn, D. S. Boyle,
J. D. Posner, and N. Garrett. 2019. Point-of-care HIV viral load testing: An essential
tool for a sustainable global HIV/AIDS response. Clinical Microbiology Reviews 32(3).
Dropulic, L. K., and J. I. Cohen. 2012. The challenge of developing a herpes simplex virus 2
vaccine. Expert Review Vaccines 11(12):1429-1440.
Duan, J., Y. Zhao, X. Zhang, H. Jiang, B. Xie, T. Zhao, and F. Zhao. 2020. Research status
and perspectives for pathogenic spirochete vaccines. Clinica Chemica Acta 507:117-124.
ECHO (Evidence for Contraceptive Options and HIV Outcomes) Trial Consortium. 2019.
HIV incidence among women using intramuscular depot medroxyprogesterone ac-
etate, a copper intrauterine device, or a levonorgestrel implant for contraception: A
randomised, multicentre, open-label trial. The Lancet 394(10195):303-313.
Egan, K. P., L. M. Hook, A. Naughton, N. Pardi, S. Awasthi, G. H. Cohen, D. Weissman, and
H. M. Friedman. 2020. An HSV-2 nucleoside-modified mRNA genital herpes vaccine
containing glycoproteins GC, GD, and GE protects mice against HSV-1 genital lesions
and latent infection. PLoS Pathogens 16(7):e1008795.
Eisinger, R. W., E. Erbelding, and A. S. Fauci. 2020. Refocusing research on sexually transmit-
ted infections. Journal of Infectious Diseases 222(9):1432-1434.
FDA (Food and Drug Administration). 2017. Administrative procedures for CLIA categoriza-
tion. https://www.fda.gov/regulatory-information/search-fda-guidance-documents/
administrative-procedures-clia-categorization (accessed February 17, 2021).
FDA. 2019. FDA clears first diagnostic tests for extragenital testing for chlamydia and gonorrhea.
https://www.fda.gov/news-events/press-announcements/fda-clears-first-diagnostic-
tests-extragenital-testing-chlamydia-and-gonorrhea (accessed November 2, 2020).
FDA. 2020a. CLIA categorizations. https://www.fda.gov/node/365445#scorecard (accessed
November 18, 2020).
FDA. 2020b. CLIA waiver by application. https://www.fda.gov/medical-devices/ivd-
regulatory-assistance/clia-waiver-application (accessed November 2, 2020).
Federal Task Force on Combating Antibiotic-Resistant Bacteria. 2020. National action plan for
combating antibiotic-resistant bacteria, 2020-2025. Washington, DC: Department of Health
and Human Services, Department of Agriculture, and Department of Defense.
Fifer, H., J. Saunders, S. Soni, S. T. Sadiq, and M. FitzGerald. 2020. 2018 UK national guide-
line for the management of infection with Neisseria gonorrhoeae. International Journal of
STD & AIDS 31(1):4-15.
Freeborn, K., and C. J. Portillo. 2018. Does pre-exposure prophylaxis for HIV prevention in
men who have sex with men change risk behaviour? A systematic review. Journal of
Clinical Nursing 27(17-18):3254-3265.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
BIOMEDICAL TOOLS FOR STI PREVENTION AND MANAGEMENT 389
Garfield, S., J. Polisena, S. S. D, A. Postulka, Y. L. C, S. K. Tiwana, E. Faulkner, N. Poulios, V.
Zah, and M. Longacre. 2016. Health technology assessment for molecular diagnostics:
Practices, challenges, and recommendations from the medical devices and diagnostics
special interest group. Value Health 19(5):577-587.
Gaydos, C. A., and J. H. Melendez. 2020. Point-by-point progress: Gonorrhea point of care
tests. Expert Review of Molecular Diagnostics 1-11.
Gaydos, C. A., K. Dwyer, M. Barnes, P. A. Rizzo-Price, B. J. Wood, T. Flemming, and M. T.
Hogan. 2006. Internet-based screening for Chlamydia trachomatis to reach non-clinic
populations with mailed self-administered vaginal swabs. Sexually Transmitted Diseases
33(7):451-457.
Gaydos, C. A., M. Barnes, B. Aumakhan, N. Quinn, P. Agreda, P. Whittle, and T. Hogan.
2009. Can e-technology through the Internet be used as a new tool to address the Chla-
mydia trachomatis epidemic by home sampling and vaginal swabs? Sexually Transmitted
Diseases 36(9):577-580.
Gaydos, C. A., Y. H. Hsieh, L. Harvey, A. Burah, H. Won, M. Jett-Goheen, M. Barnes, P.
Agreda, N. Arora, and R. E. Rothman. 2011. Will patients “opt in” to perform their
own rapid HIV test in the emergency department? Annals of Emergency Medicine
58(1):S74-S78.
Gaydos, C. A., M. Jett-Goheen, M. Barnes, L. Dize, P. Barnes, and Y. H. Hsieh. 2016. Use of a
risk quiz to predict infection for sexually transmitted infections: A retrospective analy-
sis of acceptability and positivity. Sexually Transmitted Infections 92(1):44-48.
Gaydos, C. A., S. Beqaj, J. R. Schwebke, J. Lebed, B. Smith, T. E. Davis, K. H. Fife, P. Nyirjesy,
T. Spurrell, D. Furgerson, J. Coleman, S. Paradis, and C. K. Cooper. 2017a. Clinical vali-
dation of a test for the diagnosis of vaginitis. Obstetrics and Gynecology 130(1):181-189.
Gaydos, C. A., J. D. Klausner, N. P. Pai, H. Kelly, C. Coltart, and R. W. Peeling. 2017b. Rapid
and point-of-care tests for the diagnosis of Trichomonas vaginalis in women and men.
Sexually Transmitted Infections 93(S4):S31-S35.
Gaydos, C. A., L. E. Manhart, S. N. Taylor, R. A. Lillis, E. W. Hook, 3rd, J. D. Klausner, C. V.
Remillard, M. Love, B. McKinney, and D. K. Getman. 2019. Molecular testing for Myco-
plasma genitalium in the United States: Results from the AMES prospective multicenter
clinical study. Journal of Clinical Microbiology 57(11).
Gaydos, C. A., M. Barnes, J. Holden, B. Silver, R. Smith, J. Hardick, and T. C. Quinn. 2020.
Acceptability and feasibility of recruiting women to collect a self-administered vaginal
swab at a pharmacy clinic for sexually transmissible infection screening. Sex Health
17(4):392-394.
Geisler, W. M., S. Y. Lensing, C. G. Press, and E. W. Hook, 3rd. 2013. Spontaneous resolution
of genital Chlamydia trachomatis infection in women and protection from reinfection.
Journal of Infectious Diseases 207(12):1850-1856.
Gerlich, W. H. 2013. Medical virology of hepatitis B: How it began and where we are now.
Virology Journal 10:239.
Gettinger, J., N. Van Wagoner, B. Daniels, A. Boutwell, and B. Van Der Pol. 2020. Patients are
willing to wait for rapid sexually transmitted infection results in a university student
health clinic. Sexually Transmitted Diseases 47(1):67-69.
Görander, S., M. Ekblad, T. Bergström, and J. Liljeqvist. 2014. Anti-glycoprotein G antibod-
ies of herpes simplex virus 2 contribute to complete protection after vaccination in
mice and induce antibody-dependent cellular cytotoxicity and complement-mediated
cytolysis. Viruses 6(11):4358-4372.
Grant, J. S., C. Stafylis, C. Celum, T. Grennan, B. Haire, J. Kaldor, A. F. Luetkemeyer, J. M.
Saunders, J. M. Molina, and J. D. Klausner. 2020. Doxycycline prophylaxis for bacterial
sexually transmitted infections. Clinical Infectious Diseases 70(6):1247-1253.
Guilamo-Ramos, V., M. Reading, A. S. Bowman, D. C. Perlman, and S. Barrett. 2018. Multi-
purpose prevention technologies: A global sexual and reproductive health priority. The
Journal of the Association of Nurses in AIDS Care 29(1):6-9.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
390 SEXUALLY TRANSMITTED INFECTIONS
Hamill, M. M., K. J. Mbazira, A. N. Kiragga, C. A. Gaydos, M. Jett-Goheen, R. Parkes-
Ratanshi, Y. C. Manabe, E. Nakku-Joloba, and A. Rompalo. 2018. Challenges of rapid
plasma reagin interpretation in syphilis screening in Uganda: Variability in nontrepone-
mal results between different laboratories. Sexually Transmitted Diseases 45(12):829-833.
Handsfield, H. H. 2015. Sexually transmitted diseases, infections, and disorders: What’s in
a name? Sexually Transmitted Diseases 42(4).
Hansen, B. T. 2016. No evidence that HPV vaccination leads to sexual risk compensation.
Human Vaccines & Immunotherapeutics 12(6):1451-1453.
Harrison, W. O., R. R. Hooper, P. J. Wiesner, A. F. Campbell, W. W. Karney, G. H. Reynolds, O.
G. Jones, and K. K. Holmes. 1979. A trial of minocycline given after exposure to prevent
gonorrhea. New England Journal of Medicine 300(19):1074-1078.
Hawkes, S., E. Kismodi, H. Larson, and K. Buse. 2014. Vaccines to promote and protect
sexual health: Policy challenges and opportunities. Vaccine 32(14):1610-1615.
Haynes, B. F., P. B. Gilbert, M. J. McElrath, S. Zolla-Pazner, G. D. Tomaras, S. M. Alam, D. T.
Evans, D. C. Montefiori, C. Karnasuta, R. Sutthent, H.-X. Liao, A. L. DeVico, G. K. Lewis,
C. Williams, A. Pinter, Y. Fong, H. Janes, A. DeCamp, Y. Huang, M. Rao, E. Billings, N.
Karasavvas, M. L. Robb, V. Ngauy, M. S. de Souza, R. Paris, G. Ferrari, R. T. Bailer, K.
A. Soderberg, C. Andrews, P. W. Berman, N. Frahm, S. C. De Rosa, M. D. Alpert, N. L.
Yates, X. Shen, R. A. Koup, P. Pitisuttithum, J. Kaewkungwal, S. Nitayaphan, S. Rerks-
Ngarm, N. L. Michael, and J. H. Kim. 2012. Immune-correlates analysis of an HIV-1
vaccine efficacy trial. New England Journal of Medicine 366(14):1275-1286.
Herper, M. 2020. FDA approves Gardasil 9, the HPV vaccine, to prevent head-and-neck cancer.
https://www.statnews.com/2020/06/12/fda-approves-gardasil-9-the-hpv-vaccine-to-
prevent-head-and-neck-cancer (accessed January 21, 2021).
Hess, K. L., N. Crepaz, C. Rose, D. Purcell, and G. Paz-Bailey. 2017. Trends in sexual behavior
among men who have sex with men (MSM) in high-income countries, 1990-2013: A
systematic review. AIDS and Behavior 21(10):2811-2834.
HHS (Department of Health and Human Services). 2020. Sexually Transmitted Infections
National Strategic Plan for the United States: 2021-2025. Washington, DC: Department of
Health and Human Services.
Hofstetter, A. M., S. L. Rosenthal, and L. R. Stanberry. 2014. Current thinking on genital
herpes. Current Opinion in Infectious Diseases 27(1):75-83.
Hogenson, E., M. Jett-Goheen, and C. A. Gaydos. 2019. An analysis of user survey data for
an Internet program for testing for sexually transmitted infections, I Want the Kit, in
Maryland and Washington, DC. Sexually Transmitted Diseases 46(12):768-770.
Holman, D. M., V. Benard, K. B. Roland, M. Watson, N. Liddon, and S. Stokley. 2014. Barriers
to human papillomavirus vaccination among U.S. adolescents: A systematic review of
the literature. JAMA Pediatrics 168(1):76-82.
Hook, E. W., 3rd. 2013. Remembering Thomas Parran, his contributions and missteps going
forward: History informs us. Sexually Transmitted Diseases 40(4):281-282.
Hook, E. W., 3rd, and R. D. Kirkcaldy. 2018. A brief history of evolving diagnostics and
therapy for gonorrhea: Lessons learned. Clinical Infectious Diseases 67(8):1294-1299.
Hook, E. W., 3rd, M. R. Golden, S. N. Taylor, E. Henry, C. Tseng, K. A. Workowski, J. Swerd-
low, A. Nenninger, and S. Cammarata. 2019. Efficacy and safety of single-dose oral
delafloxacin compared with intramuscular ceftriaxone for uncomplicated gonorrhea
treatment: An open-label, noninferiority, phase 3, multicenter, randomized study. Sexu-
ally Transmitted Diseases 46(5):279-286.
Hsieh, M. H., J. M. Brotherton, and A. A. Siddiqui. 2015. Hepatitis B vaccines and HPV
vaccines have been hailed as major public health achievements in preventing can-
cer—could a schistosomiasis vaccine be the third? PLoS Neglected Tropical Diseases
9(5):e0003598.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
BIOMEDICAL TOOLS FOR STI PREVENTION AND MANAGEMENT 391
Hunter, L. A., L. Nelson, J. M. Chow, B. Y. Holt, and H. M. Bauer. 2018. Contraceptive
method use and chlamydia positivity among California family planning clients: The
case for new multipurpose prevention technologies. Journal of Women’s Health (2002)
27(6):768-774.
Hylton-Kong, T., A. R. Brathwaite, G. R. Del Rosario, S. Kristensen, P. Kamara, P. E. Jolly, E.
W. Hook, 3rd, J. P. Figueroa, and S. H. Vermund. 2004. Marginal validity of syndromic
management for reproductive tract infections among pregnant women in Jamaica.
International Journal of STD & AIDS 15(6):371-375.
Hynes, J. S., J. M. Sales, A. N. Sheth, E. Lathrop, and L. B. Haddad. 2018. Interest in multipur-
pose prevention technologies to prevent HIV/STIs and unintended pregnancy among
young women in the United States. Contraception 97(3):277-284.
Hynes, J. S., A. N. Sheth, E. Lathrop, J. M. Sales, and L. B. Haddad. 2019. Preferred product
attributes of potential multipurpose prevention technologies for unintended pregnancy
and sexually transmitted infections or HIV among U.S. women. Journal of Women’s
Health (2002) 28(5):665-672.
Jatlaoui, T. C., K. B. Simmons, and K. M. Curtis. 2016. The safety of intrauterine contracep-
tion initiation among women with current asymptomatic cervical infections or at
increased risk of sexually transmitted infections. Contraception 94(6):701-712.
Kanwar, R. K., N. Singh, S. Gurudevan, and J. R. Kanwar. 2011. Targeting hepatitis B virus
and human papillomavirus induced carcinogenesis: Novel patented therapeutics. Re-
cent Patents on Anti-Infective Drug Discovery 6(2):158-174.
Karim, Q. A., C. Baxter, and S. A. Karim. 2014. Microbicides and their potential as a cata-
lyst for multipurpose sexual and reproductive health technologies. BJOG 121(Suppl
5):53-61.
Kashani, B. M., M. Tibbits, R. C. Potter, R. Gofin, L. Westman, and S. Watanabe-Galloway.
2019. Human papillomavirus vaccination trends, barriers, and promotion methods
among American Indian/Alaska Native and non-Hispanic white adolescents in Michi-
gan 2006-2015. Journal of Community Health 44(3):436-443.
Kim, H. C., and H. K. Lee. 2020. Vaccines against genital herpes: Where are we? Vaccines
(Basel) 8(3).
Kimball, A., E. Torrone, K. Miele, L. Bachmann, P. Thorpe, H. Weinstock, and V. Bowen.
2020. Missed opportunities for prevention of congenital syphilis—United States, 2018.
Morbity and Mortality Weekly Report 69:661-665.
Kirkcaldy, R. D., A. Harvey, J. R. Papp, C. Del Rio, O. O. Soge, K. K. Holmes, E. W. Hook, 3rd,
G. Kubin, S. Riedel, J. Zenilman, K. Pettus, T. Sanders, S. Sharpe, and E. Torrone. 2016.
Neisseria gonorrhoeae antimicrobial susceptibility—the Gonococcal Isolate Surveillance
Project, 27 sites, United States, 2014. MMWR Surveillance Summary 65(7):1-19.
Klein, K., and S. Luedtke. 2008. Human papillomavirus vaccination: A case for mandatory
immunization? The Journal of Pediatric Pharmacology and Therapeutics 13(1):47-50.
Kobayashi, K., K. Hisamatsu, N. Suzui, A. Hara, H. Tomita, and T. Miyazaki. 2018. A review
of HPV-related head and neck cancer. Journal of Clinical Medicine 7(9).
Korte, B. J., A. Rompalo, Y. C. Manabe, and C. A. Gaydos. 2020. Overcoming challenges with
the adoption of point-of-care testing: From technology push and clinical needs to value
propositions. Point of Care 19(3):77-83.
Ladhani, S. N., J. Lucidarme, S. R. Parikh, H. Campbell, R. Borrow, and M. E. Ramsay. 2020.
Meningococcal disease and sexual transmission: Urogenital and anorectal infections
and invasive disease due to Neisseria meningitidis. Lancet 395(10240):1865-1877.
LeFevre, M. L. 2014. Screening for chlamydia and gonorrhea: U.S. Preventive Services Task
Force recommendation statement. Annals of Internal Medicine 161(12):902-910.
Lei, J., A. Ploner, K. M. Elfström, J. Wang, A. Roth, F. Fang, K. Sundström, J. Dillner, and P.
Sparén. 2020. HPV vaccination and the risk of invasive cervical cancer. New England
Journal of Medicine 383(14):1340-1348.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
392 SEXUALLY TRANSMITTED INFECTIONS
Li, J., G. Regev, S. K. Patel, D. Patton, Y. Sweeney, P. Graebing, S. Grab, L. Wang, V. Sant,
and L. C. Rohan. 2019. Rational design of a multipurpose bioadhesive vaginal film for
co-delivery of dapivirine and levonorgestrel. Pharmaceutics 12(1).
Lithgow, K. V., and C. E. Cameron. 2017. Vaccine development for syphilis. Expert Review
of Vaccines 16(1):37-44.
Lithgow, K. V., R. Hof, C. Wetherell, D. Phillips, S. Houston, and C. E. Cameron. 2017. A
defined syphilis vaccine candidate inhibits dissemination of Treponema pallidum subspe-
cies pallidum. Nature Communications 8:14273.
Liu, A. Y., and S. P. Buchbinder. 2017. CROI 2017: HIV epidemic trends and advances in
prevention. Topics in Antiviral Medicine 25(2):35-50.
Liu, Y., L. A. Hammer, W. Liu, M. M. Hobbs, R. A. Zielke, A. E. Sikora, A. E. Jerse, N. K.
Egilmez, and M. W. Russell. 2017. Experimental vaccine induces TH1-driven immune
responses and resistance to Neisseria gonorrhoeae infection in a murine model. Mucosal
Immunology 10(6):1594-1608.
Lovett, A., and J. A. Duncan. 2018. Human immune responses and the natural history of
Neisseria gonorrhoeae infection. Frontiers in Immunology 9:3187.
Luthra, A., J. M. Montezuma-Rusca, C. J. La Vake, M. LeDoyt, K. N. Delgado, T. C. Dav-
enport, M. Fiel-Gan, M. J. Caimano, J. D. Radolf, and K. L. Hawley. 2020. Evidence
that immunization with TP0751, a bipartite Treponema pallidum lipoprotein with an
intrinsically disordered region and lipocalin fold, fails to protect in the rabbit model of
experimental syphilis. PLoS Pathogens 16(9):e1008871.
Ma, B., M. T. France, J. Crabtree, J. B. Holm, M. S. Humphrys, R. M. Brotman, and J.
Ravel. 2020. A comprehensive non-redundant gene catalog reveals extensive within-
community intraspecies diversity in the human vagina. Nature Communications
11(1):940.
Macaluso, M., J. Kelaghan, L. Artz, H. Austin, M. Fleenor, E. W. Hook, 3rd, and T. Valappil.
1999. Mechanical failure of the latex condom in a cohort of women at high STD risk.
Sexually Transmitted Diseases 26(8):450-458.
Malekinejad, M., A. Parriott, J. C. Blodgett, H. Horvath, R. K. Shrestha, A. B. Hutchinson, P.
Volberding, and J. G. Kahn. 2017. Effectiveness of community-based condom distribu-
tion interventions to prevent HIV in the United States: A systematic review and meta-
analysis. PLoS One 12(8):e0180718.
Marks, M., A. W. Solomon, and D. C. Mabey. 2014. Endemic treponemal diseases. Transac-
tions of the Royal Society of Tropical Medicine and Hygiene 108(10):601-607.
Marrazzo, J., and R. Suchland. 2014. Recent advances in understanding and managing Chla-
mydia trachomatis infections. F1000Prime Reports 6:120.
Marrazzo, J. M., D. H. Martin, D. H. Watts, J. Schulte, J. D. Sobel, S. L. Hillier, C. Deal,
and D. N. Fredricks. 2010. Bacterial vaginosis: Identifying research gaps proceed-
ings of a workshop sponsored by DHHS/NIH/NIAID. Sexually Transmitted Diseases
37(12):732-744.
Maruggi, G., C. Zhang, J. Li, J. B. Ulmer, and D. Yu. 2019. mRNA as a transformative
technology for vaccine development to control infectious diseases. Molecular Therapy
27(4):757-772.
McCarthy, K. J., E. L. Gollub, L. Ralph, J. van de Wijgert, and H. E. Jones. 2019. Hormonal
contraceptives and the acquisition of sexually transmitted infections: An updated sys-
tematic review. Sexually Transmitted Diseases 46(5):290-296.
McIntosh, E. D. G. 2020. Development of vaccines against the sexually transmitted infections
gonorrhoea, syphilis, chlamydia, herpes simplex virus, human immunodeficiency virus
and Zika virus. Therapeutic Advances in Vaccines and Immunotherapy 8:2515135520923887.
Melendez, J. H., J. Hardick, M. Barnes, K. R. Page, and C. A. Gaydos. 2018. Antimicrobial
susceptibility of Neisseria gonorrhoeae isolates in Baltimore, Maryland, 2016: The impor-
tance of sentinel surveillance in the era of multi-drug-resistant gonorrhea. Antibiotics
(Basel) 7(3).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
BIOMEDICAL TOOLS FOR STI PREVENTION AND MANAGEMENT 393
Melendez, J. H., Y. H. Hsieh, M. Barnes, J. Hardick, E. A. Gilliams, and C. A. Gaydos. 2019.
Can ciprofloxacin be used for precision treatment of gonorrhea in public STD clinics?
Assessment of ciprofloxacin susceptibility and an opportunity for point-of-care testing.
Pathogens 8(4).
Melendez, J. H., M. M. Hamill, G. Armington, C. A. Gaydos, and Y. C. Manabe. 2020. Home-
based testing for sexually transmitted infections: Leveraging online resources during
the COVID-19 pandemic. Sexually Transmitted Diseases 48(1):e11-e14.
Miller, J. N. 1973. Immunity in experimental syphilis. VI. Successful vaccination of rabbits
with Treponema pallidum, Nichols strain, attenuated by γ-irradiation. Journal of Immunol-
ogy 110(5):1206-1215.
Minor, P. D. 2015. Live attenuated vaccines: Historical successes and current challenges.
Virology 479-480:379-392.
Mitjà, O., K. Asiedu, and D. Mabey. 2013. Yaws. Lancet 381(9868):763-773.
Młynarczyk-Bonikowska, B., A. Majewska, M. Malejczyk, G. Młynarczyk, and S. Majewski.
2020. Multiresistant Neisseria gonorrhoeae: A new threat in second decade of the XXI
century. Medical Microbiolgy and Immunology 209(2):95-108.
Molina, J. M., I. Charreau, C. Chidiac, G. Pialoux, E. Cua, C. Delaugerre, C. Capitant, D.
Rojas-Castro, J. Fonsart, B. Bercot, C. Bebear, L. Cotte, O. Robineau, F. Raffi, P. Char-
bonneau, A. Aslan, J. Chas, L. Niedbalski, B. Spire, L. Sagaon-Teyssier, D. Carette, S.
L. Mestre, V. Dore, and L. Meyer. 2018. Post-exposure prophylaxis with doxycycline
to prevent sexually transmitted infections in men who have sex with men: An open-
label randomised substudy of the ANRS IPERGAY trial. The Lancet Infectious Diseases
18(3):308-317.
NIAID (National Institute of Allergy and Infectious Diseases). 2019. NIH awards will advance
development of vaccines for sexually transmitted infections. https://www.niaid.nih.gov/
news-events/nih-awards-will-advance-development-vaccines-sexually-transmitted-
infections (accessed November 2, 2020).
North, A. L., and L. M. Niccolai. 2016. Human papillomavirus vaccination requirements in
U.S. schools: Recommendations for moving forward. American Journal of Public Health
106(10):1765-1770.
Nour, S., Y. H. Hsieh, R. E. Rothman, M. Jett-Goheen, O. Langhorne, L. Wu, S. Peterson, and
C. A. Gaydos. 2012. Patients can accurately perform their own rapid HIV point-of-care
test in the emergency department. Point of Care 11(4):176-179.
Obafemi, O. A., K. A. Wendel, T. S. Anderson, T. E. Scott, S. E. Rowan, E. A. Travanty, and C.
A. Rietmeijer. 2019. Rapid syphilis testing for men who have sex with men in outreach
settings: Evaluation of test performance and impact on time to treatment. Sexually
Transmitted Diseases 46(3):191-195.
O’Donoghue, A. J., B. Bibo-Verdugo, Y. Miyamoto, S. C. Wang, J. Z. Yang, D. E. Zuill, S.
Matsuka, Z. Jiang, J. Almaliti, C. R. Caffrey, W. H. Gerwick, and L. Eckmann. 2019. 20S
proteasome as a drug target in Trichomonas vaginalis. Antimicrobial Agents and Chemo-
therapy 63(11).
Ortayli, N., K. Ringheim, L. Collins, and T. Sladden. 2014. Sexually transmitted infections:
Progress and challenges since the 1994 International Conference on Population and
Development (ICPD). Contraception 90(6 Suppl):S22-S31.
Padian, N. S., A. van der Straten, G. Ramjee, T. Chipato, G. de Bruyn, K. Blanchard, S.
Shiboski, E. T. Montgomery, H. Fancher, H. Cheng, M. Rosenblum, M. van der Laan,
N. Jewell, and J. McIntyre. 2007. Diaphragm and lubricant gel for prevention of HIV
acquisition in Southern African women: A randomised controlled trial. The Lancet
370(9583):251-261.
Papp, J. R., J. Schachter, C. A. Gaydos, and B. Van Der Pol. 2014. Recommendations for the
laboratory-based detection of Chlamydia trachomatis and Neisseria gonorrhoeae—2014.
MMWR Recommendations and Reports 63(RR-02):1-19.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
394 SEXUALLY TRANSMITTED INFECTIONS
Parascandola, J. 2001. John Mahoney and the introduction of penicillin to treat syphilis.
Pharmacy in History 43(1):3-13.
Pardi, N., M. J. Hogan, F. W. Porter, and D. Weissman. 2018. mRNA vaccines—a new era in
vaccinology. Nature Reviews Drug Discovery 17(4):261-279.
Patel, A. V., C. A. Gaydos, M. Jett-Goheen, M. Barnes, L. Dize, P. Barnes, and Y. H. Hsieh.
2018. Assessing association between I Want the Kit risk quiz tool and sexually trans-
mitted infection positivity in male users for sexually transmitted infection screening.
International Journal of STD & AIDS 29(2):122-127.
Paynter, J., F. Goodyear-Smith, J. Morgan, P. Saxton, S. Black, and H. Petousis-Harris. 2019.
Effectiveness of a group B outer membrane vesicle meningococcal vaccine in prevent-
ing hospitalization from gonorrhea in New Zealand: A retrospective cohort study.
Vaccines 7(1):5.
Paz-Bailey, G., M. Noble, K. Salo, and S. J. Tregear. 2016. Prevalence of HIV among U.S. female
sex workers: Systematic review and meta-analysis. AIDS and Behavior 20(10):2318-2331.
Pérez, A., E. K. Santamaria, and D. Operario. 2018. A systematic review of behavioral inter-
ventions to reduce condomless sex and increase HIV testing for Latino MSM. Journal
of Immigrant and Minority Health 20(5):1261-1276.
Perros, M. 2019. Spoken remarks: Presented at Meeting 3 of the Committee on Preven-
tion and Control of Sexually Transmitted Infections in the United States. Recording
available at https://www.nationalacademies.org/event/10-27-2019/prevention-and-
control-of-sexually-transmitted-infections-in-the-united-states (accessed February 17,
2021).
Petousis-Harris, H., and F. J. Radcliff. 2019. Exploitation of Neisseria meningitidis group B
OMV vaccines against N. gonorrhoeae to inform the development and deployment of
effective gonorrhea vaccines. Frontiers in Immunology 10:683.
Pettifor, A., S. Delany, I. Kleinschmidt, W. C. Miller, J. Atashili, and H. Rees. 2009. Use of
injectable progestin contraception and risk of STI among South African women. Con-
traception 80(6):555-560.
Phillips, S., B. L. Quigley, and P. Timms. 2019. Seventy years of chlamydia vaccine research—
limitations of the past and directions for the future. Frontiers in Microbiology 10:70.
Planned Parenthood. 2018. Fun facts about condoms!, edited by Planned Parenthood of the
Pacific Southwest.
Plotkin, S. 2014. History of vaccination. Proceedings of the National Academy of Sciences
111(34):12283-12287.
Poston, T. B., and T. Darville. 2018. Chlamydia trachomatis: Protective adaptive responses
and prospects for a vaccine. Current Topics in Microbiology and Immunology 412:217-237.
Radolf, J. D., R. K. Deka, A. Anand, D. Smajs, M. V. Norgard, and X. F. Yang. 2016. Treponema
pallidum, the syphilis spirochete: Making a living as a stealth pathogen. Nature Reviews
Microbiology 14(12):744-759.
Ramchandani, M. S., and M. R. Golden. 2019. Confronting rising STIs in the era of PrEP and
treatment as prevention. Current HIV/AIDS Reports 16(3):244-256.
Rasnake, M. S., N. G. Conger, K. McAllister, K. K. Holmes, and E. C. Tramont. 2005. History
of U.S. military contributions to the study of sexually transmitted diseases. Military
Medicine 170(4 Suppl):61-65.
Rietmeijer, C. A. 2015. You say STD…. Sexually Transmitted Diseases 42(9).
Roddy, R. E., L. Zekeng, K. A. Ryan, U. Tamoufé, S. S. Weir, and E. L. Wong. 1998. A con-
trolled trial of nonoxynol 9 film to reduce male-to-female transmission of sexually
transmitted diseases. New England Journal of Medicine 339(8):504-510.
Roddy, R. E., L. Zekeng, K. A. Ryan, U. Tamoufé, and K. G. Tweedy. 2002. Effect of non-
oxynol-9 gel on urogenital gonorrhea and chlamydial infection: A randomized con-
trolled trial. JAMA 287(9):1117-1122.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
BIOMEDICAL TOOLS FOR STI PREVENTION AND MANAGEMENT 395
Rogozińska, E., L. Kara-Newton, J. R. Zamora, and K. S. Khan. 2017. On-site test to detect
syphilis in pregnancy: A systematic review of test accuracy studies. BJOG 124(5):734-741.
Rojas Castro, D., R. M. Delabre, and J. M. Molina. 2019. Give PrEP a chance: Moving on
from the “risk compensation” concept. Journal of the International AIDS Society 22(Suppl
6):e25351.
Ronn, M. M., N. A. Menzies, T. L. Gift, H. W. Chesson, T. A. Trikalinos, M. Bellerose, Y.
Malyuta, A. Berruti, C. A. Gaydos, K. K. Hsu, and J. A. Salomon. 2019. Potential for
point-of-care tests to reduce chlamydia-associated burden in the United States: A math-
ematical modeling analysis. Clinical Infectious Diseases 70(9):1816-1823.
Russell, M. W., A. E. Jerse, and S. D. Gray-Owen. 2019. Progress toward a gonococcal vac-
cine: The way forward. Frontiers in Immunology 10:2417.
Schiffer, J. T., and L. Corey. 2009. New concepts in understanding genital herpes. Current
Infectious Disease Reports 11(6):457-464.
Schwebke, J., S. Taylor, R. Ackerman, R. Schlaberg, N. Quigley, C. Gaydos, S. Chavoustie,
P. Nyirjesy, C. Remillard, P. Estes, B. McKinney, D. Getman, and C. Clark. 2019. Clini-
cal validation of the Aptima bacterial vaginosis and Aptima candida/trichomonas
vaginitis assays: Results from a prospective multicenter clinical study. Journal of Clinical
Microbiology 58.
Shiraki, K. 2018. Antiviral drugs against alphaherpesvirus. Advances in Experimental Medicine
and Biology 1045:103-122.
Smith, J. M., J. A. Moss, P. Srinivasan, I. Butkyavichene, M. Gunawardana, R. Fanter, C. S.
Miller, D. Sanchez, F. Yang, S. Ellis, J. Zhang, M. A. Marzinke, C. W. Hendrix, A. Kapoor,
and M. M. Baum. 2017. Novel multipurpose pod-intravaginal ring for the prevention
of HIV, HSV, and unintended pregnancy: Pharmacokinetic evaluation in a macaque
model. PLoS One 12(10):e0185946.
Solman, P. 2020. How a crumbling antibiotics infrastructure could yield “catastrophe.”
PBS NewsHour. https://www.pbs.org/newshour/show/how-a-crumbling-antibiotics-
infrastructure-could-yield-catastrophe (accessed November 16, 2020).
Srinivasan, S., M. T. Morgan, T. L. Fiedler, D. Djukovic, N. G. Hoffman, D. Raftery, J. M.
Marrazzo, and D. N. Fredricks. 2015. Metabolic signatures of bacterial vaginosis. mBio
6(2):e00204-00215.
St. Cyr, S., L. Barbee, K. A. Workowski, L. H. Bachmann, C. Pham, K. Schlanger, E. Torrone,
H. Weinstock, E. N. Kersh, and P. Thorpe. 2020. Update to CDC’s treatment guidelines
for gonococcal infection, 2020. Morbidity and Mortality Weekly Report 69(50):1911-1916.
Statista. 2020. Usage of condoms in housholds in the U.S. 2020. https://www.statista.com/
statistics/275455/us-households-usage-of-condoms (accessed November 18, 2020).
TAG (Treatment Action Group). 2019. Gonorrhea, chlamydia, and syphilis pipline report. https://
www.ncsddc.org/wp-content/uploads/2019/03/TAG_Pipeline_STI_2019_draft.pdf
(accessed October 25, 2020).
Theel, E. S., S. S. Katz, and A. Pillay. 2020. Molecular and direct detection tests for Treponema
pallidum subspecies pallidum: A review of the literature, 1964-2017. Clinical Infectious
Diseases 71(Suppl 1):S4-S12.
Tifrea, D. F., S. Pal, J. Fairman, P. Massari, and L. M. de la Maza. 2020. Protection against a
chlamydial respiratory challenge by a chimeric vaccine formulated with the Chlamydia
muridarum major outer membrane protein variable domains using the Neisseria lac-
tamica porin B as a scaffold. NPJ Vaccines 5(1):37.
Tinajeros, F., D. Grossman, K. Richmond, M. Steele, S. G. Garcia, L. Zegarra, and R. Revollo.
2006. Diagnostic accuracy of a point-of-care syphilis test when used among pregnant
women in Bolivia. Sexually Transmitted Infections 82(Suppl 5):v17-v21.
Trivedi, S., C. Williams, E. Torrone, and S. Kidd. 2019. National trends and reported risk fac-
tors among pregnant women with syphilis in the United States, 2012-2016. Obstetrics
and Gynecology 133(1):27-32.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
396 SEXUALLY TRANSMITTED INFECTIONS
Tucker, J. D., C. H. Bien, and R. W. Peeling. 2013. Point-of-care testing for sexually transmit-
ted infections: Recent advances and implications for disease control. Current Opinion
in Infectious Diseases 26(1):73-79.
Unemo, M., C. S. Bradshaw, J. S. Hocking, H. J. C. de Vries, S. C. Francis, D. Mabey, J. M.
Marrazzo, G. J. B. Sonder, J. R. Schwebke, E. Hoornenborg, R. W. Peeling, S. S. Philip,
N. Low, and C. K. Fairley. 2017. Sexually transmitted infections: Challenges ahead. The
Lancet Infectious Diseases 17(8):e235-e279.
USPSTF (United States Preventive Services Task Force). 2016. Final recommendation state-
ment: Syphilis infection in nonpregnant adults and adolescents: Screening. JAMA
315(21):2321-2327.
Van Damme, L., G. Ramjee, M. Alary, B. Vuylsteke, V. Chandeying, H. Rees, P. Sirivongrang-
son, L. M. Tshibaka, V. Ettiègne-Traoré, C. Uaheowitchai, S. S. A. Karim, B. Mâsse, J.
Perriëns, and M. Laga. 2002. Effectiveness of COL-1492, a nonoxynol-9 vaginal gel, on
HIV-1 transmission in female sex workers: A randomised controlled trial. The Lancet
360(9338):971-977.
van den Munckhof, E. H. A., R. L. van Sitter, K. E. Boers, R. F. Lamont, R. Te Witt, S. le
Cessie, C. W. Knetsch, L. J. van Doorn, W. G. V. Quint, A. Molijn, and M. A. Leverstein-
van Hall. 2019. Comparison of Amsel criteria, Nugent score, culture and two CE-
IVD marked quantitative real-time PCRs with microbiota analysis for the diagnosis
of bacterial vaginosis. European Journal of Clinical Microbiology & Infectious Diseases
38(5):959-966.
Van Der Pol, B., S. N. Taylor, L. Mena, J. Lebed, C. J. McNeil, L. Crane, A. Ermel, A. Sukhija-
Cohen, and C. A. Gaydos. 2020. Evaluation of the performance of a point-of-care test
for chlamydia and gonorrhea. JAMA Network Open 3(5):e204819.
van der Schalk, T. E., J. F. Braam, and J. G. Kusters. 2020. Molecular basis of antimicro-
bial resistance in Mycoplasma genitalium. International Journal of Antimicrobial Agents
55(4):105911.
Vargas, S. E., M. M. Midoun, M. Guillen, M. L. Getz, K. Underhill, C. Kuo, and K. M. Guth-
rie. 2019. A qualitative systematic review of women’s experiences using contraceptive
vaginal rings: Implications for new technologies. Perspectives on Sexual and Reproductive
Health 51(2):71-80.
Vere Hodge, R. A., and H. J. Field. 2013. Antiviral agents for herpes simplex virus. Advances
in Pharmacology 67:1-38.
Vrazo, A. C., D. Sullivan, and B. Ryan Phelps. 2018. Eliminating mother-to-child transmis-
sion of HIV by 2030: 5 strategies to ensure continued progress. Global Health, Science
and Practice 6(2):249-256.
Walensky, R. P., and I. V. Bassett. 2011. HIV self-testing and the missing linkage. PLoS Medi-
cine 8(10):e1001101.
Walker, T. Y., L. D. Elam-Evans, D. Yankey, L. E. Markowitz, C. L. Williams, B. Fredua, J. A.
Singleton, and S. Stokley. 2019. National, regional, state, and selected local area vac-
cination coverage among adolescents aged 13-17 years—United States, 2018. Morbidity
and Mortality Weekly Report 68(33):718-723.
Wang, J. W., and R. B. Roden. 2013. Virus-like particles for the prevention of human papillo-
mavirus-associated malignancies. Expert Review of Vaccines 12(2):129-141.
Wang, T., M. Lurie, D. Govindasamy, and C. Mathews. 2018. The effects of school-based
condom availability programs (CAPs) on condom acquisition, use and sexual behavior:
A systematic review. AIDS and Behavior 22(1):308-320.
WHO (World Health Organization). 2007. Training modules for the syndromic management of
sexually transmitted infections. 2nd ed. Geneva, Switzerland: WHO Press.
WHO. 2016. WHO guidelines for the treatment of Neisseria gonorrhoeae. Geneva, Switzerland:
World Health Organization.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
BIOMEDICAL TOOLS FOR STI PREVENTION AND MANAGEMENT 397
WHO. 2019. WHO preferred product characteristics for herpes simplex virus vaccines. Geneva,
Switzerland: World Health Organization.
Widdice, L. E., Y. H. Hsieh, B. Silver, M. Barnes, P. Barnes, and C. A. Gaydos. 2018. Perfor-
mance of the Atlas Genetics rapid test for Chlamydia trachomatis and women’s attitudes
toward point-of-care testing. Sexually Transmitted Diseases 45(11):723-727.
Wilkinson, D., M. Tholandi, G. Ramjee, and G. W. Rutherford. 2002. Nonoxynol-9 spermicide
for prevention of vaginally acquired HIV and other sexually transmitted infections:
Systematic review and meta-analysis of randomised controlled trials including more
than 5000 women. The Lancet Infectious Diseases 2(10):613-617.
Workowski, K. A., and G. A. Bolan. 2015. Sexually transmitted diseases treatment guidelines,
2015. MMWR Recommendations and Reports 64(RR-03):1-137.
Wu, T., S. Qu, Y. Fang, M. Ip, and Z. Wang. 2019. Behavioral intention to perform risk com-
pensation behaviors after receiving HPV vaccination among men who have sex with
men in China. Human Vaccines & Immunotherapeutics 15(7-8):1737-1744.
Zhang, Y., C. Wymant, O. Laeyendecker, M. K. Grabowski, M. Hall, S. Hudelson, E. Pi-
wowar-Manning, M. McCauley, T. Gamble, M. C. Hosseinipour, N. Kumarasamy, J.
G. Hakim, J. Kumwenda, L. A. Mills, B. R. Santos, B. Grinsztejn, J. H. Pilotto, S. Chari-
yalertsak, J. Makhema, Y. Q. Chen, M. S. Cohen, C. Fraser, and S. H. Eshleman. 2021.
Evaluation of phylogenetic methods for inferring the direction of HIV transmission:
HPTN 052. Clinical Infectious Diseases 72(1):30-37.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Psychosocial and Behavioral
Interventions
Chapter Contents
Introduction
Contributions of Psychosocial and Behavioral Interventions on
STI Prevention and Control
• Psychosocial and Behavioral Theories and Conceptual Models
Psychosocial and Behavioral Interventions
Individual-Level Interventions
• Theoretical Basis and Content
• Intervention Delivery Mechanisms
• Population and Context-Specific Tailoring
• Sexual Education
Interpersonal-Level Interventions
• Family-Level Interventions
• Social Network Interventions
Community-Level Interventions
• Meta-Analytic and Systematic Reviews of Community
Interventions for HIV/STIs
• Promising Community-Based Strategies
399
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
400 SEXUALLY TRANSMITTED INFECTIONS
Chapter Contents Continued
Cost Effectiveness of Psychosocial and Behavioral Interventions
Technology-Based Interventions
• Technology-Based Intervention Benefits
• Reviews and Meta-Analyses of Technology-Based Sexual
Health Behavior Interventions
• Theoretical Frameworks for Technology-Based
Interventions
• Technology as a Dissemination Strategy
• Technology-Based Interventions Research and Future
Directions
Dissemination of Evidence-Based Behavioral Interventions
Implementation Science
Conclusions and Recommendation
INTRODUCTION
Psychosocial and behavioral interventions represent a fundamental
component of a comprehensive and effective national strategy to promote
sexual health and prevent and control sexually transmitted infections
(STIs). Such interventions aim to change individual behavior (e.g., pro-
mote condom use) or group interactions (e.g., parent–adolescent com-
munication about STI prevention) to reduce morbidity and mortality (e.g.,
STI incidence). These interventions’ important contributions to promote
sexual health and prevent and control STIs can be categorized as having
three distinct types of influence: (1) direct effects on reductions in STI
incidence (Globerman et al., 2017; Long et al., 2016); (2) direct effects on
behavioral outcomes associated with STI risk (e.g., reduced condomless
sex) (De Vasconcelos et al., 2018; Globerman et al., 2017); and (3) syn-
ergistic effects between these interventions and structural, biomedical,
or health service interventions that improve STI prevention or control
(e.g., improved uptake of human papillomavirus vaccines; improved STI
testing) (Long et al., 2016; Walling et al., 2016) (see the report conceptual
framework in Chapter 1).
Considerable empirical research demonstrates that psychosocial
and behavioral interventions are efficacious and effective in preventing
and reducing STIs and/or sexual risk behaviors associated with greater
likelihood of STI acquisition (e.g., condomless sex). Evidence-based
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PSYCHOSOCIAL AND BEHAVIORAL INTERVENTIONS 401
interventions have targeted diverse populations, including ethnic, racial,
and sexual minorities, across the life span (De Vasconcelos et al., 2018).
Additionally, such interventions’ effects on STI and sexual risk behavior
outcomes have been reported across intervention levels (e.g., individual,
family, social and sexual networks, community), delivery settings (e.g.,
schools, primary care), and delivery modalities (e.g., individual face-
to-face, group, telephone, online). These interventions also impact STI
outcomes and associated risk factors across varying levels of dosage (e.g.,
single versus multiple sessions) and interventions.
Because of the synergistic effects with biomedical interventions (Wall-
ing et al., 2016), psychosocial and behavioral interventions are necessary
to optimize the effectiveness of biomedical strategies for STI prevention
and control and vice versa (Padian et al., 2008). For example, interventions
that target social and behavioral factors associated with sexual health
decision making and behaviors can improve the uptake and sustainment
or adherence of biomedical strategies for STI prevention and control
(Brown et al., 2017). With respect to HIV, although pre-exposure pro-
phylaxis has been found to be effective in prevention (Pinto et al., 2018),
adherence rates are less than optimal when not coupled with psychosocial
and behavioral intervention strategies. Despite strong evidence for the
utility of psychosocial and behavioral interventions, scale-up and wide-
spread dissemination is absent (Hanley et al., 2010). Thus, evidence-based
interventions need to be scaled up and new interventions developed to
address the increasing rates of STIs in the United States.
This chapter discusses the extant literature on psychosocial and
behavioral STI interventions using five organizing themes. First, the
chapter provides an overview of psychosocial and behavioral theories
and conceptual models that commonly inform the development of these
interventions. Second, the chapter offers an overview of interventions at
the individual, interpersonal, and community levels, with attention to
various key groups. Consistent with the report’s social ecological frame-
work for sexual health promotion and STI prevention, the highlighted
interventions target factors across all levels of the social ecology—from
individual to community and across the life span. See Chapter 9 for
interventions targeting structural factors. Given the significant number of
meta-analyses and systematic reviews and of registries listing evidence-
based psychosocial and behavioral interventions (e.g., the Centers for Dis-
ease Control and Prevention’s [CDC’s] Compendium of Evidence-Based
Interventions) (CDC, 2020a), this chapter does not include a compre-
hensive review of them. Instead, it provides an overview of individual-,
interpersonal-, and community-level interventions, including successes,
gaps, lessons learned, and future directions. A summary lists key find-
ings from meta-analyses for priority populations. The third section offers
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
402 SEXUALLY TRANSMITTED INFECTIONS
an overview of technological interventions and considerations for how
and why technology has become an essential part of all STI intervention
campaigns. Fourth, the chapter raises programmatic considerations for
promoting, accelerating, and sustaining the scale-up of existing and new
psychosocial and behavioral STI interventions in practice settings. Fifth,
implementation science is discussed in terms of outcomes, strategies, and
study designs to consider in sexual health and promotion interventions.
Finally, the chapter offers conclusions and recommendations for future
directions.
CONTRIBUTIONS OF PSYCHOSOCIAL AND BEHAVIORAL
INTERVENTIONS ON STI PREVENTION AND CONTROL
Psychosocial and Behavioral Theories and Conceptual Models
Psychosocial and behavioral theories and conceptual models of health
and behavior change have guided the development of interventions to
prevent STIs and reduce associated health risk behaviors. Below is a sum-
mary of commonly used theories and conceptual models.
Health Belief Model
The Health Belief Model postulates that individuals will take action to
prevent illness if they believe they are susceptible, if the consequences are
severe, and if the benefits of action outweigh the costs (Janz and Becker,
1984). As it pertains to preventing health conditions, such as STIs, this
model is useful for predicting why people will take action to prevent,
screen, or seek treatment for symptoms (Champion and Skinner, 2008).
Theory of Reasoned Action
The Theory of Reasoned Action (Ajzen and Fishbein, 1980; Fishbein
and Ajzen, 1975) and its later evolution the Theory of Planned Behavior
(Ajzen, 1991) focus on motivational factors that determine the likelihood
of engaging in a particular behavior, such as condomless sex. The Theory
of Reasoned Action assumes that the most important determinant of a
behavior is a person’s intention to enact it. Behavioral intention includes
attitudes toward performing the behavior and subjective norms associ-
ated with it. The attitudinal component consists of a set of beliefs regard-
ing the behavior’s value and its consequences. For example, condom
use attitude is more favorable when the consequences of using them are
valued (e.g., preventing STIs) and the benefits of their use are viewed
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PSYCHOSOCIAL AND BEHAVIORAL INTERVENTIONS 403
as a positive aspect of the sexual encounter (Conner and Norman, 2005;
Espada et al., 2016). The Theory of Planned Behavior added the construct
of perceived control over the behavior, which takes into account situations
where a person may not have complete volitional control, such as through
a gender power imbalance that prevents condom use negotiations (Mon-
tano and Kasprzyk, 2015).
Social Cognitive Theory
Social cognitive theory asserts that information alone about a particu-
lar outcome or behavior does not necessarily influence or change a behav-
ior; instead, people need to be provided not only reasons for adopting or
changing a behavior, but also the requisite means, resources and social
supports, and skills to do so (Bandura, 1986). It posits that behavior is
determined by reciprocal and continuous interactions of cognitive, behav-
ioral, and environmental influences and emphasizes people’s potential
abilities to alter and construct their environment to fit their desired goals
(Bandura, 1986, 1994; Espada et al., 2016; McAlister et al., 2008). Specifi-
cally, the cognitive influences reflect confidence in the ability to perform
a task or accomplish a particular goal (e.g., perceived self-efficacy to cor-
rectly use condoms); behavioral influences include consequences of a par-
ticular behavior and the likelihood of correctly performing the behavior
by developing new skills (e.g., communication skills to effectively negoti-
ate condom use), and environmental influences involve opportunities for
learning or enacting a behavior through interpersonal or social modeling
(e.g., adolescents are more likely to use condoms if they perceive that their
friends do so) (Bandura, 2011; Espada et al., 2016; McAlister et al., 2008).
Social Ecological Theory
The social ecological theory describes the multiple and interrelated
influences on STIs and associated behaviors (Bronfenbrenner, 1979, 1986).
It is organized by multiple influences (e.g., structural, environmental,
social) according to proximity, from furthest to closest to the individual:
macrosystems (the broad social and philosophical ideals that define a par-
ticular society or culture); exosystems (contexts in which the individual
does not participate directly but that impact important members of the
individual’s life); mesosystems (contexts that comprise the interactions
between important members of the different contexts in which the indi-
vidual participates directly); and microsystems (contexts in which the
individual participates directly).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
404 SEXUALLY TRANSMITTED INFECTIONS
Cognitive-Affective Dual Process Models
Cognitive-affective dual process models have been proposed as an
alternative to traditional theories of behavior change (Bauermeister et
al., 2019; Gerrard et al., 2008). These models take into account affective
motivations (e.g., emotions), in addition to the cognitive factors usually
considered in behavioral theories, that may impact decision making and
behavior change (Bauermeister et al., 2019; Gerrard et al., 2008). Affective
motivators can function as both risk and protective factors.
Integrative Theoretical Models
Building on these frameworks, a number of integrative theoretical
models that were primarily developed to examine constructs associated
with HIV have been adapted to STIs and related risk and protective fac-
tors in adolescents (e.g., Bangi et al., 2013; Boyer et al., 1999, 2000; Cham-
pion et al., 2013; Dolcini et al., 2010; Fisher et al., 1999; Johnson, 2011),
including the AIDS Risk Reduction Model (ARRM) and the Information
Motivation Behavior (IMB) model.
The ARRM is a conceptual framework for organizing factors known to
influence behavior change into classification categories for people (Cata-
nia et al., 1990). The ARRM integrates elements of the Health Belief Model
(Janz and Becker, 1984), efficacy theory (Bandura, 1977), emotional influ-
ences (Leventhal, 1973), and interpersonal processes (Rogers, 1983). The
ARRM involves three stages: (1) recognizing and labeling one’s behavior
as high risk for infection, (2) making a commitment to change one’s
behavior to reduce risk and adopt safer practices, and (3) enacting change
by seeking solutions and adopting behaviors that decrease STI risk. Indi-
viduals may progress through certain stages, regress to a previous stage,
and move back and forth between stages before behavior change is sus-
tained (Catania et al., 1990). Specifically, in the labeling stage, knowledge
of STI risk and transmission and beliefs that one is vulnerable to acquiring
STIs are proposed determinants for labeling a behavior as risky (Boyer et
al., 1999). Factors involved in making a commitment to change behaviors
associated with risk for STIs include perceived self-efficacy, perceived
peer norms, and adverse emotional states, such as anxiety (Zimmerman et
al., 2007). Finally, behavior change (e.g., condom use or other risk preven-
tion strategies) is determined by individual characteristics (e.g., previous
behaviors) and perceived social support for engaging in health-promoting
behaviors (Logan et al., 2002).
The IMB model is another framework that has been widely used to
characterize STI risk and prevention (Fisher and Fisher, 1992; Fisher et al.,
1994). Specifically, it integrates constructs from the Theory of Reasoned
Action (Ajzen and Fishbein, 1980; Fishbein and Ajzen, 1975), efficacy
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PSYCHOSOCIAL AND BEHAVIORAL INTERVENTIONS 405
theory (Bandura, 1977), and the Health Belief Model (Janz and Becker,
1984). It posits that information, motivation, and behavioral skills are the
primary determinants of STI-preventive behavior. Specifically, the model
asserts that information regarding STI transmission and prevention is
a necessary prerequisite of risk-reduction behavior (Rotheram-Borus et
al., 2009). Motivation (psychosocial factors) to change risk behaviors is
a determinant of prevention and affects whether a person acts on such
knowledge. The IMB also asserts that motivation to engage in preven-
tive behaviors is a function of a person’s attitudes toward and perceived
peer norms about them. Other critical factors hypothesized to influence
motivation to engage in STI-preventive behaviors are perceived vulner-
ability to STIs and intention to enact the behaviors. The necessary skills
for specific preventive behaviors are the third determinant and affect
whether even a knowledgeable, highly motivated person will be able to
do so (Rotheram-Borus et al., 2009). These skills include the abilities to
communicate effectively with sexual partners about safer sex, competence
to engage in condomless sexual practices, and the ability to properly use
condoms. Individuals who practice preventive skills are also presumed
to have a strong self-belief (self-efficacy) in their ability to do so. Limits of
IMB include its relative lower emphasis on environmental- or structural-
level barriers to behavior change, social and community support, and
maintenance across time (Rotheram-Borus et al., 2009).
The following sections provide an overview of psychosocial and
behavioral interventions at the individual, interpersonal, and community
levels that use these theories and models (see Box 8-1 for definitions of
key terms used in the remainder of the chapter).
PSYCHOSOCIAL AND BEHAVIORAL INTERVENTIONS
As described previously in the committee’s conceptual framework
(see Figure 1-3), STI risks are influenced by individual, interpersonal,
and community-level factors. Interventions that target factors across mul-
tiple levels and delivery systems (e.g., schools, clinics, places of worship)
increase their impact on preventing and reducing STIs and related out-
comes, including condomless sex (DiClemente et al., 2008; Estrada et al.,
2017; Guilamo-Ramos et al., 2020). This section provides a brief overview
of STI behavioral multi-level interventions, followed by a summary of
meta-analyses highlighting key findings for priority populations.
INDIVIDUAL-LEVEL INTERVENTIONS
Research seeking to understand and shape the determinants of sexual
decision making and behavior emerged as a growing discipline during
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
406 SEXUALLY TRANSMITTED INFECTIONS
BOX 8-1
Key Chapter Terms
Adoption: The decision of consumers of an intervention to implement an evidence-
based intervention within a particular setting (Rabin and Brownson, 2017).
Community-based participatory research: An approach to research that is collabora-
tive and partnership oriented within the community and for the community. The goal is to
address social, health, physical, or environmental inequities with equitable involvement
of community representatives. Community members are engaged on multiple levels of
the planning and research process, from identifying the problem, to conceptualizing
the research question, to disseminating results. A crucial aspect is acknowledging and
applying the unique knowledge and skills that a community provides in the research
process to enhance an intervention’s delivery, efficacy, effectiveness, evaluation, and
sustainability.
Dissemination: The distribution of information and intervention materials to a specific
audience so an intervention can be successfully introduced, executed, and brought
to scale after it is deemed efficacious and effective. Dissemination is regarded as an
active process wherein information about evidence-based practices or the practices
themselves are strategically spread to target audiences.
Effectiveness study: Evaluates the effects of an intervention when delivered under
more real-world conditions (Flay et al., 2005). For example, a health care professional
may deliver an individual counseling session in an effectiveness study.
Efficacy study: Evaluates the effects of an intervention when delivered under optimal
and highly controlled conditions (Flay et al., 2005). In contrast to an effectiveness study,
a highly trained member of the research team (rather than a real-world health care
professional) may deliver an individual counseling session in an efficacy study.
Fidelity: Measures the degree to which the original intervention is implemented and/
or delivered as originally designed. Fidelity allows researchers and implementers to
understand if intervention outcomes are related to the quality or extent of implementa-
tion versus unrelated factors (Allen et al., 2012). Fidelity may be measured by assess-
ing (1) adherence (i.e., consistency of core components with the program design), (2)
dosage (i.e., consistency of the number, duration, and frequency of sessions/lessons
with the program design), (3) quality of program delivery (i.e., the enthusiasm, skill,
and preparation of those delivering the intervention), and (4) participant reaction and
the 1970s, as federal and private funders identified developing programs
to reduce teen pregnancy as a national public health and social welfare
priority (NRC, 1987). While these early sexual and reproductive health
intervention programs were designed to promote behaviors associated
with reduced STI risk among adolescents, such as delay of sexual debut,
preventing sexual transmission of infection was not a primary target
outcome. This focus shifted during the early years of the HIV pandemic
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PSYCHOSOCIAL AND BEHAVIORAL INTERVENTIONS 407
acceptance (i.e., reactions by participants about intervention outcomes and relevance)
(Rabin and Brownson, 2017).
Implementation science: The study of introducing and integrating evidence-based
interventions in specific settings, addressing what happens before and after integra-
tion, particularly in organizational settings, and understanding the extent to which an
evidence-based program or practice will be effective in real-world settings (Dearing
and Kee, 2012; Rabin et al., 2008). Implementation science focuses on the research
methods that facilitate the adoption and integration of evidence-based practices or
interventions into settings (NCI, n.d.).
Mediator: A variable that is intermediary in the causal pathway linking independent
(e.g., intervention) and dependent (e.g., sexually transmitted infection incidence) vari-
ables to further refine an understanding of the causal relationship. A mediator explains
the “why” and “how” interventions work.
Moderator: A variable in a causal model that affects the magnitude or direction of a
causal relationship. It explains the “when,” “for whom,” and “under what circumstances”
an intervention works.
Psychosocial and behavioral interventions: An intervention is a strategy used to
change or alter a currently ongoing process and specifically to modify human behavior.
These strategies are directed toward reducing risky behavior and encouraging protec-
tive factors and aim to result in positive behavior change for well-being. Psychosocial
and behavioral interventions typically use an interdisciplinary, multi-level, and multi-
modal approach that takes into account the observable actions of an individual’s own
personal behaviors and inherent phenomena (attitudes, motivations, and emotions) as
well as the larger social context (families, schools, communities, and policy) with which
they interact (adapted from OBSSR, 2019; Sundell and Olsson, 2017).
Scaling out: The use of strategies to implement, evaluate, improve, and sustain an
evidence-based intervention when it is delivered to new populations and/or through
new delivery systems not originally used in effectiveness studies (Aarons et al., 2017b).
Scaling up: “The ability of a health intervention shown to be efficacious and effective
on a small scale and or under controlled conditions to be expanded or scaled up under
real-world conditions to reach a greater proportion of the eligible population, while re-
taining effectiveness” (Milat et al., 2013).
in the 1980s, with increasing recognition of the need for psychosocial and
behavioral prevention interventions to target additional key populations
at increased risk of STI and HIV infection (Rietmeijer and Scahill, 2012). A
growing number of evidence-based individual-level behavioral counsel-
ing interventions grounded in rigorous decision and behavioral science
began to emerge in the 1990s, and individual-level interventions became
a cornerstone of national STI prevention efforts (Rietmeijer and Scahill,
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
408 SEXUALLY TRANSMITTED INFECTIONS
2012). Today, the efficacy/effectiveness of individual-level psychosocial
and behavioral interventions for STI prevention is well supported by
empirical evidence (Covey et al., 2016; Crepaz et al., 2009; De Vasconcelos
et al., 2018; Eaton et al., 2012; Morales et al., 2018). Most recently, in an
updated evidence report and systematic review, the United States Pre-
ventive Services Task Force concluded that behavioral counseling inter-
ventions were effective in reducing both STI incidence and behavioral
outcomes associated with STI risk, including condomless sex (Hender-
son et al., 2020). This review, which included 39 studies, showed that
most interventions were conducted in STI clinics, general primary care,
obstetrics and gynecology, women’s health clinics, adolescent medicine,
and family planning clinics. Of these studies, 9 consisted of interventions
with less than 30 minutes (low contact), 13 studies had interventions
of 30–120 minutes (moderate contact), and about 50 percent of studies
offered more than 2 hours of intervention (high contact). Motivational
interviewing was the most commonly used approach, followed by cogni-
tive behavioral therapy. Group counseling was the most frequently used
intervention component, often in tandem with other components, such as
individual counseling videos or phone calls. Of the studies that reported
on effectiveness for STI prevention, the findings indicated a statistically
significant effect, with most reports occurring between 6 and 12 months.
Greater effect sizes were found for studies with adolescents, high-contact
interventions, or group counseling sessions. Studies with adolescent boys,
men (including gay, bisexual, same gender loving, and other men who
have sex with men [MSM]), and populations with average risk levels
were not well represented. Studies reporting behavioral outcomes (34
studies [e.g., condom use, condomless sex, number of sexual partners]),
consisting of individuals at high risk for STIs, had effects on behavioral
outcomes, although the effects diminished in studies with follow-ups
greater than 1 year (Henderson et al., 2020).
Incorporating important shared principles and characteristics of these
effective existing interventions into the development of future STI preven-
tion programs represents a meaningful step toward strengthening sexual
health promotion in the United States. The following section discusses
three lessons learned from existing effective individual-level behavioral
STI prevention interventions: the importance of (1) a strong theoreti-
cal basis to the content, (2) delivery mechanisms that are aligned with
theoretically identified mediators of intervention effects, and (3) popula-
tion- and context-specific tailoring (Guilamo-Ramos et al., 2019). Finally,
a review of the extant literature on individual-level sexual education pro-
grams delivered in school-based settings in the United States is provided.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PSYCHOSOCIAL AND BEHAVIORAL INTERVENTIONS 409
Theoretical Basis and Content
Most individual-level STI prevention interventions are based on psy-
chosocial and behavioral theories (Crepaz et al., 2007, 2009), and meta-
analytic reviews found that applying theories of behavior in content
development enhanced the efficacy/effectiveness of the interventions
(Covey et al., 2016). Specifically, using a psychosocial and behavioral
theory in intervention development has been identified as one of the
most important moderators of efficacy/effectiveness (Covey et al., 2016).
Beyond using theory to inform intervention development in general,
formative research that explores the relative importance of theoretically
identified mediators for predicting target behaviors has utility to inform
intervention content that specifically addresses the individual-level deter-
minants of behavior (Covey et al., 2016).
Intervention Delivery Mechanisms
Individual-level STI psychosocial and behavioral interventions are
heterogeneous in modes of content delivery, delivery setting, and session
format (Henderson et al., 2020). In general, strong evidence is absent to
support specific delivery mechanisms as increasing efficacy/effective-
ness (Covey et al., 2016; Henderson et al., 2020). Yet, the importance of
aligning intervention delivery mechanisms with theoretically identified
mediators of intervention effects has been discussed (Guilamo-Ramos et
al., 2019). Selecting delivery mechanisms that are best suited to address
the hypothesized pathways through which the intervention shapes the
target outcome can amplify the effect of theoretically informed interven-
tion content (Guilamo-Ramos et al., 2019). Therefore, empirical formative
research that increases the understanding of hypothesized mediators of
intervention effects also represents an opportunity to inform the selection
of intervention delivery mechanisms (Guilamo-Ramos et al., 2019).
Population and Context-Specific Tailoring
Tailoring STI psychosocial and behavioral interventions is associated
with efficacy/effectiveness (Covey et al., 2016; Crepaz et al., 2009). It
involves specifically designing or adapting interventions for a particular
key population at increased risk of STIs, such as racial and ethnic minor-
ity adolescents and women or STI clinic patients, by considering and
addressing population- and context-specific facilitators and barriers of
intervention effectiveness in both content and delivery. For example, in
a review of meta-analytic evidence, psychosocial and behavioral inter-
ventions delivered by a facilitator who matched the target population
in race/ethnicity and gender showed better efficacy/effectiveness than
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
410 SEXUALLY TRANSMITTED INFECTIONS
interventions that did not (Covey et al., 2016). Another meta-analysis
found improved efficacy/effectiveness for interventions that included
content addressing cultural factors specific to the target population (Cre-
paz et al., 2009). Furthermore, interventions had increased efficacy when
they targeted developmentally appropriate outcomes, such as condom
use among older adolescents who are more likely to be sexually active,
as compared to young adolescents (Henderson et al., 2020). In addition,
tailoring can address important aspects of cultural and linguistic appro-
priateness of individual-level psychosocial and behavioral interventions
(Escoffery et al., 2018) and considering contextual feasibility constraints
during development or adaptation facilitates adoption at scale (Guilamo-
Ramos et al., 2004).
Incorporating lessons learned from decades of successful intervention
science into the development of future STI prevention programs repre-
sents a meaningful step toward strengthening sexual health promotion
in the United States and also can be leveraged to improve school-based
sexual education (Rankin et al., 2016).
Sexual Education
Existing evidence evaluating the efficacy and/or effectiveness of
sexual education programs in preventing STIs among adolescents have
focused on two distinct approaches: abstinence-only education and com-
prehensive sexual education (Chin et al., 2012; Lugo-Gil et al., 2016; San-
telli et al., 2017). This section reviews the evidence regarding (1) absti-
nence-only and comprehensive sexual education programs, (2) gaps in the
literature, and (3) the state of sexual education in the United States today.
Abstinence-only education, also referred to as AOUM or sexual risk
avoidance programs (see Table 8-1), instructs students that the only mor-
ally acceptable option for youth, and the only safe and effective way to
prevent unintended pregnancies and STIs, is abstinence from sexual activ-
ity (KFF, 2018; Santelli et al., 2017). It does not educate youth about effec-
tive use of contraception or condoms and only discusses these to highlight
their failure rates (Santelli et al., 2017). In contrast, comprehensive sexual
education programs typically include medically accurate, evidence-based
information about both contraception and abstinence to prevent preg-
nancy and promote condom use to forestall STI transmission (KFF, 2018;
Miedema et al., 2020; Santelli et al., 2017). Abstinence-only programs have
not been found to be effective in reducing adolescent sexual risk behav-
iors or STI rates (Chin et al., 2012; Hogben et al., 2010; Trenholm et al.,
2008); adolescents who participate in them are more likely than those who
received comprehensive sex education to be unaware of their STI status
and engage in condomless sex (Brückner and Bearman, 2005; Shepherd
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PSYCHOSOCIAL AND BEHAVIORAL INTERVENTIONS 411
TABLE 8-1 Types of Sexual Health Education Programs
Types of Sexual Education Programs
Abstinence-Only Education that emphasizes the importance of delaying sex and
Education excludes content regarding contraception and barrier methods
in preventing sexually transmitted infections (STIs) and/or
unplanned pregnancies. This has also been referred to as “sexual
risk avoidance” education.
Abstinence-Only Content that strictly defines sexual intercourse in the context of
Until Marriage marriage, stressing the importance of abstaining from sex until
Education after marriage for moral and/or religious reasons.
Abstinence “Plus” Education on the importance of abstinence in tandem with
Education information on barrier and contraceptive methods in preventing
STIs and unplanned pregnancies. This has also been referred to
as “sexual risk reduction” education.
Comprehensive The provision of medically accurate, developmentally
Sex Education appropriate information on abstinence and safe sex practices,
including barrier and contraceptive methods, in preventing
STIs and unplanned pregnancies. Such programs also offer
information regarding the importance of healthy relationships,
communication skills, and developmental considerations, as well
as other topics.
SOURCE: Adapted from KFF, 2018.
et al., 2017). Furthermore, analyses have indicated that states with man-
dates for abstinence-only education had among the highest gonorrhea
and chlamydia rates (Carr and Packham, 2017; Hogben et al., 2010). These
programs’ lack of effectiveness has been tied to including content that is
medically inaccurate, developmentally inappropriate, heteronormative,
and stigmatizing (Santelli et al., 2017).
Comprehensive sexual education, also referred to as “abstinence
plus” or “sexual risk reduction,” promotes abstinence as the primary
approach to prevent STIs but also encourages sexually active adolescents
to use available barrier and contraceptive methods (Denford et al., 2017;
Santelli et al., 2017). Adolescents who participate in such programs delay
initiating sexual behavior, have increased knowledge of STI risks and
consequences, and report enhanced contraceptive use (Chin et al., 2012;
Denford et al., 2017; Kirby, 2007; Lopez et al., 2016; Santelli et al., 2017;
Underhill et al., 2007). In addition, evidence suggests that comprehensive
sexual education programs and medically accurate programs are effec-
tive in reducing STI prevalence among adolescents (Chin et al., 2012) and
have been efficacious in delaying sexual debut among young adolescents
(Guilamo-Ramos et al., 2011).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
412 SEXUALLY TRANSMITTED INFECTIONS
Having school nurses deliver comprehensive sexual education to
parents represents a novel approach in school-based settings that war-
rants additional attention. The vast majority of U.S. individuals, including
parents, supports comprehensive sexual education delivery in school set-
tings (Cameron et al., 2020; Santelli et al., 2017). Parents are cited as hav-
ing the most significant influence in shaping adolescent sexual decision
making (Power to Decide, 2016), yet they frequently identify their lack of
sexual health expertise as the primary reason that schools need to provide
comprehensive content and resources (Johnson-Motoyama et al., 2016).
Despite parents’ important role, schools primarily deliver sexual educa-
tion in the classroom directly to adolescents, often neglecting to include
parents for reasons unrelated to parental consent (Denford et al., 2017).
Successfully including parents in designing and delivering sexual educa-
tion programs takes into account the perspectives and specific needs of
families, including consideration of time limitations, tailoring of program
content to local epidemiological context, and flexibility in program deliv-
ery (Smokowski et al., 2018). Furthermore, comprehensive sexual educa-
tion programs, such as Families Talking Together, delivered to parents
in school settings have been efficacious in shaping multiple adolescent
outcomes, including delay of sexual debut (Guilamo-Ramos et al., 2011).
Nurses in school-based health clinics represent an important oppor-
tunity for enhancing existing sexual education programs. They have been
rated consistently as a trusted source of information (Reinhart, 2020) and
have training that enables them to provide STI testing, treatment, con-
traception, including condoms, and specific guidance to adolescents in
such clinics. Nurse-led psychosocial and behavioral interventions have
been associated with increased uptake of STI testing and contracep-
tion in school-based health centers (Brigham et al., 2020; Ethier et al.,
2011). Despite significant progress in expanding these centers in the past
decade, only 1 in 10 (10.4 percent) of U.S. schools has one (Love et al.,
2018, 2019).
Research with school staff, parents, and adolescents has explored
facilitators of and barriers to implementation of sexual education in U.S.
schools (Eisenberg et al., 2013; Kocsis, 2020; Peskin et al., 2011; Thompson,
2020), including sexual education delivered by school nurses (Brewin
et al., 2014). Important barriers to sexual education that emerged from
the literature include restrictions imposed by state legislature, school
boards, or administrators; educator concerns regarding criticism from
parents and administrators; inadequate funding, resources, and lack of
sexual education curricula; inadequate self-efficacy for delivery of sexual
education among educators (i.e., inadequate preparation and training);
and religiosity (Brewin et al., 2014; Eisenberg et al., 2013; Peskin et al.,
2011). In contrast, training, experience, and comfort in delivery of sexual
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PSYCHOSOCIAL AND BEHAVIORAL INTERVENTIONS 413
education among educators; adequate prioritization and time allocation
to sexual education in curricula; parent advocates; community engage-
ment; perceived support from administrators and outside stakeholders,
such as parents and community leaders; and parental and public health
professional involvement in sex education content development have
been identified as facilitators of implementing sexual education (Brewin
et al., 2014; Kocsis, 2020; Peskin et al., 2011). These facilitators can be lever-
aged to improve sexual education in U.S. schools.
According to the Guttmacher Institute, sexual health education across
the United States is variable (Guttmacher Institute, 2020) (see Table 8-2).
While 39 states and Washington, DC, require sexual and/or HIV educa-
tion in the classroom, less than half of all states (17 states) require medical
accuracy of sexual health education content or content on contracep-
tion (Guttmacher Institute, 2020). Furthermore, no consistent nationwide
policy exists for teaching sexual education in schools, resulting in wide
variation by state (Hall et al., 2016; Santelli et al., 2017). States typically
pass laws that offer broad guidelines but do not require that sex education
be taught or offered (Hall et al., 2016). While state, districts, and school
boards set standards and requirements for sexual health education, the
adopted approach varies by school district and often even by school (Hall
et al., 2016). According to CDC’s School Health Profiles 2018, only about
half of U.S. middle and high schools teach all 20 CDC-recommended
sexual health topics (CDC, 2019b). Moreover, approximately one-third
of federal funding for sexual education programs each year is for absti-
nence-only education (KFF, 2018). Allocated federal funding to schools
from the Title V AOUM program cannot be used to educate adolescents
regarding barrier or contraceptive methods (Santelli et al., 2017). In sum,
school-based comprehensive sexual health education programs that seek
to meaningfully involve parents are sorely needed. Funding for their
ongoing development, implementation, and broad uptake represent an
overlooked opportunity to reduce STIs among youth in the United States.
INTERPERSONAL-LEVEL INTERVENTIONS
Family-Level Interventions
Family-level psychosocial and behavioral interventions are designed
to address challenges affecting the functioning and well-being of indi-
viduals and the family system. Specifically, they target risk factors, such
as poor family communication, and protective factors, such as family
support related to sexual health, STIs, and associated behaviors, includ-
ing condom use (Guilamo-Ramos et al., 2020; Prado et al., 2007). These
interventions may also modify maladaptive interaction patterns (e.g.,
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
414 SEXUALLY TRANSMITTED INFECTIONS
TABLE 8-2 Sex and HIV Education in Schools
Sex and HIV Education
Require Sex and When Provided, When Provided,
Mandate Sex HIV Programs Sex Education HIV Education
and/or HIV to Be Medically Must Include Must Include
State Education Accurate Contraception Condoms
U.S. Total 39 states and 17 states and 20 states and 19 states
Washington, Washington, DC Washington, DC
DC
Alabama HIV X X
Alaska
Arizona HIV
Arkansas HIV
California Sex and HIV X X X
Colorado X X
Connecticut HIV X
Delaware Sex and HIV X X
DC Sex and HIV X
Florida Sex and HIV
Georgia Sex and HIV
Hawaii Sex and HIV X X X
Idaho
Illinois HIV X X X
Indiana HIV
Iowa Sex and HIV X
Kansas Sex
Kentucky Sex and HIV
Louisiana X
Maine Sex and HIV X X X
Maryland Sex and HIV X X
Massachusetts
Michigan HIV
Minnesota Sex and HIV
Mississippi a Sex
Missouri HIV X
Montana Sex and HIV
Nebraska
Nevada Sex and HIV
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PSYCHOSOCIAL AND BEHAVIORAL INTERVENTIONS 415
TABLE 8-2 Continued
Sex and HIV Education
Require Sex and When Provided, When Provided,
Mandate Sex HIV Programs Sex Education HIV Education
and/or HIV to Be Medically Must Include Must Include
State Education Accurate Contraception Condoms
New Sex and HIV
Hampshire
New Jersey Sex and HIV X X X
New Mexico Sex and HIV X X
New York HIV
North Sex and HIV X X X
Carolina
North Dakota Sex and HIV
Ohio Sex and HIV
Oklahoma HIV HIV X
Oregon Sex and HIV X X X
Pennsylvania HIV
Rhode Island Sex and HIV X X X
South Sex and HIV X
Carolina
South Dakota
Tennessee b Sex and HIV X
Texas Sex and HIV X X
Utahc Sex and HIV
Vermont Sex and HIV X X
Virginia Sex and HIV X X
Washington HIV X X
West Virginia Sex and HIV X X
Wisconsin HIV
Wyoming
NOTE: Sex education typically includes discussion of sexually transmitted infections (STIs).
a Localities may include topics such as contraception or STIs only with permission from
the state Department of Education.
b Sex education is required in a county if pregnancy rate is at least 19.5 or higher per 1,000
young women aged 15–17.
c State also prohibits teachers from responding to students’ spontaneous questions in ways
that conflict with law’s requirements, State Laws and Policies, Sex and HIV Education, as
of June 1, 2020.
SOURCE: Guttmacher Institute, 2020.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
416 SEXUALLY TRANSMITTED INFECTIONS
misaligned family hierarchy) within the family system. Family-level inter-
ventions are informed by several models, including family systems theory
and social ecological theory. For sexual health and preventing STIs, these
interventions typically occur during adolescence, generally incorporate
the adolescent and parent(s), guardian(s), and, potentially, other extended
and nonbiological family members, and commonly use the parent as the
agent of change for modifying adolescent behavior.
Researchers and clinicians have recognized the importance of social
ecological factors in developing family-level interventions to promote
well-being and prevent risk behaviors, including condomless sex (DiCle-
mente et al., 2007; Prado et al., 2009). These factors include not only famil-
ial influences, which directly impact the adolescent, but also different
levels of the social ecology, such as parental stress. Techniques can include
psychoeducation, restructuring of family subsystems, and behavior modi-
fication components that are implemented depending on the intervention
modality and the needs of the family. Family-level interventions may
include various components, such as individual youth and/or parent
sessions, parent group sessions, youth group sessions, or a combination.
For example, in parent group sessions, parents learn and acquire skills
(e.g., effective communication on sexual health, condom use) that are then
practiced with youth in individual youth and parent sessions.
Family-level interventions to prevent STIs and behaviors associated
with STIs emerged in the late 1990s after the National Institute of Men-
tal Health, the National Institute on Drug Abuse, the National Institute
on Alcohol Abuse and Alcoholism, and the National Institute on Aging
requested research applications in 1995 for investigators to evaluate “fam-
ily process interventions to enhance the ability of families to prevent the
spread of HIV/AIDS and/or its consequences” (NIH, 1995). Although
the funding was aimed at evaluating the efficacy of family interventions
in preventing HIV and its consequences in adolescents and adults (across
racial and ethnic minority groups), many of these interventions exam-
ined and reported on sexual risk behavior outcomes associated with STIs
(Pequegnat and Szapocznik, 2000). The literature on family-level interven-
tion has grown considerably since. The resulting body of research, which
requires some level of parental or family participation, has documented
that preventive interventions targeting the family context have been suc-
cessful in preventing STIs (DiClemente et al., 2014; Prado et al., 2007),
preventing decreases in condom use (Estrada et al., 2017), and increasing
condom use (Guilamo-Ramos et al., 2020; Jemmott et al., 1999; Pantin et
al., 2009).
Family-level preventive interventions have demonstrated efficacy
and effectiveness (Sandler et al., 2014) in a number of populations, includ-
ing African American adolescents (Jemmott et al., 2020; Sutton et al.,
2014), Latino/a people (Estrada et al., 2017; Guilamo-Ramos et al., 2020),
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PSYCHOSOCIAL AND BEHAVIORAL INTERVENTIONS 417
criminally involved populations (Prado et al., 2012; Tolou-Shams et al.,
2017), and homeless youth (Rotheram-Borus et al., 1991a,b). One popula-
tion with little to no attention in the literature is sexual and gender minor-
ity youth. Because parental participation is key in family-level interven-
tions and some such youth may not disclose their identity to at least one
parent, they may not be able to participate in these interventions.
Family interventions, particularly those where the parent is the agent
of change, have long-term sustained effects. For example, interventions
delivered in childhood and adolescence affect condom use and STIs in
adulthood (Spoth et al., 2015). Family interventions with core components
focused on improving parent–child communication, teaching parents the
importance of effective and consistent parenting, and requiring parents to
practice acquired skills with their youth have the largest effects (Estrada
et al., 2017). In fact, in many of the trials demonstrating intervention
effects on condom use and STIs, the mechanism of change or media-
tor has been improvements in parent–adolescent communication, family
support, or positive parenting practices (McDade et al., 2019; Prado et
al., 2007). Specifically, the literature has demonstrated that immediate
improvements in family functioning indicators, such as parent–adolescent
communication, impact later outcomes, including condomless sex and
STIs. These mediators are the same factors that drive the effects of family
interventions developed to address outcomes (e.g., internalizing symp-
toms) other than STIs or condom use (Jensen et al., 2014). Therefore, it is
not surprising that family-level interventions often have crossover effects
on several outcomes. Research has shown that family-level interventions
that target conduct problems and mental health outcomes have affected
sexual health outcomes (Caruthers et al., 2014). Specifically, a brief family-
level intervention designed to target adolescent adjustment problems
influenced five high-risk sexual behaviors (e.g., condom use and sex with
people who were engaging in sex with others) at age 22 (Caruthers et al.,
2014). Similarly, Spoth et al. (2014), who delivered a family-centered inter-
vention to reduce early substance use initiation among youth in the sixth
grade, showed long-term reductions in high-risk sexual behaviors and
STIs at age 21. In both studies, the intervention effects on the sexual health
outcomes and/or STIs were mediated by improvements in parent–youth
interactions (Caruthers et al., 2014; Spoth et al., 2014). These findings are
important and consistent with Syndemic Theory, which posits that social
and environmental factors (e.g., effective parent–youth interactions) are
not associated with just one health condition but are related to multiple
intertwined health outcomes (González-Guarda et al., 2011; Singer et al.,
2006). Therefore, psychosocial interventions that have an effect on STIs
may also affect substance use and mental health (and vice versa). Addi-
tionally, the crossover effects of these family interventions increase their
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
418 SEXUALLY TRANSMITTED INFECTIONS
public health benefits (Reider et al., 2014) and may also substitute for
sexual education in communities where implementing it in schools may
be challenging or not feasible (Jenkins, 2014). Thus, family interventions
that can address multiple risk behaviors or health outcomes may be an
effective and cost-efficient strategy to prevent STIs and other adverse
health outcomes.
Family interventions have also been found to be efficacious in pro-
moting condom use and preventing STIs among ethnic minority samples
at increased risk (Jemmott et al., 2020; Sutton et al., 2014). Interventions
that are culturally syntonic to the target population (e.g., for a specific
ethnic group) are most efficacious, and the most efficacious family-level
interventions have a cultural component (Szapocznik et al., 2007). For
example, the Strong African American Families Program, which was spe-
cifically developed for African American families, has been efficacious in
reducing condomless sex (e.g., Brody et al., 2004). For Hispanic people,
family interventions such as Familias Unidas, which focuses on accultura-
tion, acculturative stress, and familismo (central Latino/a cultural value
involving dedication, commitment, and loyalty to family), have also pre-
vented decreases in condom use (Estrada et al., 2017) and prevent STIs
over time (Prado et al., 2007).
Family-level interventions have been delivered in a variety of set-
tings, including schools (Estrada et al., 2017), places of worship (Jemmott
et al., 2020), and primary care (Guilamo-Ramos et al., 2020; Prado et al.,
2019). They have recently been tested more often in primary care and
pediatric care (IOM, 2014) because these are routinely used by youth and
families and often offer a nonstigmatizing setting (Leslie et al., 2016),
where they have been found to be efficacious and effective for a wide
array of behavioral and health outcomes (Perrin et al., 2014; Reedtz et al.,
2011), including sexual health outcomes (Guilamo-Ramos et al., 2020) and
STI outcomes (Prado et al., 2007). Despite their efficacy and cost effective-
ness (e.g., Spoth et al., 2002), family-level interventions have not been sus-
tained in primary and pediatric care because physicians and other clinic
staff do not have the time or resources. Moving in-person interventions
online may be one mechanism to sustain them in primary care (Estrada
et al., 2019). Future research is needed on how to effectively integrate and
sustain family-level interventions in primary care.
Although the efficacy of family-level interventions is well docu-
mented, they face several challenges to implementation, including that
parental participation is difficult to sustain (Perrino et al., 2000; Spoth
et al., 1999). Families with social needs face many barriers to participa-
tion (e.g., low income, lack of transportation, child care) (Fernandez and
Eyberg, 2009; Spoth et al., 1996). Parent engagement and participation
in intervention sessions is as important as adherence to a medication
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PSYCHOSOCIAL AND BEHAVIORAL INTERVENTIONS 419
regimen: lack of either one reduces the benefits (Prado et al., 2006). An
important future direction is to refine and evaluate strategies to engage
and retain parents. Another challenge is that these interventions often
have delayed effects (Estrada et al., 2017). That is, they often do not pro-
duce changes in outcomes, such as condomless sex or STIs, for several
years. Given that the maximum funding cycle of the National Institutes
of Health (NIH), the primary funder for evaluating psychosocial and
behavioral interventions, is 5 years and that such evaluation studies need
ample preparation time and a dissemination phase, it may be challenging
to evaluate the efficacy and effectiveness of family interventions on STI
outcomes in a single NIH funding cycle.
Other important gaps in the family intervention literature are a lack of
interventions for sexual minority, American Indian, or Alaska Native ado-
lescents to promote sexual health and prevent STIs. Interventions must
be developed for these populations. This gap is noteworthy given that
Indigenous youth and young adults are at greatest risk for STIs (and cur-
rently the highest rate of STIs). Despite these challenges and gaps, family
interventions have significant potential to curb the epidemic of STIs and
improve sexual health in children, adolescents, and young adults. Future
research to address current gaps in family interventions to promote sexual
health and to prevent STIs is sorely needed, with adequate resources for
development, implementation, and long-term follow-up.
Social Network Interventions
Social networks have been demonstrated to be important in STI
transmission (Ellen et al., 2006; Klovdahl et al., 1994; Wylie and Jolly,
2001); therefore, addressing social networks is an important intervention
strategy (see Chapter 2 for more on social networks). Network mobiliza-
tion is an intervention strategy that stimulates peer-to-peer interaction to
create and promote peer influence along existing network pathways to
impact the members (Valente, 2012). Research has shown that individu-
als in the same social network are more likely to have similar STI risk
potential (Amirkhanian, 2014). As a result, recruiting social contacts in
addition to risk contacts, known as the Social Network Strategy (SNS)
(Lightfoot et al., 2018; McGoy et al., 2018), has been used with modest
results for identifying new HIV infection (Boyer et al., 2013, 2014), and
CDC recently promoted it as an effective HIV testing intervention (Light-
foot et al., 2018; McGoy et al., 2018). This strategy identifies individuals
with STIs and individuals at risk and asks them to recruit persons from
their social network for testing in exchange for an incentive. Some data
have indicated SNS to be effective in identifying new HIV infections
(Boyer et al., 2013, 2014), showing that a proportion of those tested were
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
420 SEXUALLY TRANSMITTED INFECTIONS
newly diagnosed with HIV or STIs; this is routinely higher than the
prevalence found via publicly funded counseling, testing, and referral
(Kimbrough et al., 2009).
Building on classical partner services and SNS, the Transmission
Reduction Intervention Project conducted network-based recruiting,
counseling, and testing in Odessa, Ukraine; Athens, Greece; and Chicago,
Illinois. The primary goal was to increase early detection of individuals
with recent HIV infections (Schueler et al., 2019). A secondary goal, at
the Chicago site only, was to identify additional active syphilis infections
(Friedman et al., 2014). A two-step approach (a person who recently sero-
converted was followed for two rounds of the study to capture additional
contacts who were positive for HIV) was used; network chain recruit-
ment started with “seeds”—people who were recently or long-term HIV
positive—and continued no further than two steps from a person living
with HIV, repeating the process if another person living with HIV was
identified at either the first or second step (Nikolopoulos et al., 2016). The
two-step approach was used in order to remain within each individual’s
immediate risk network environment; anything beyond this was consid-
ered to be too far removed. The project was effective at yielding individu-
als with active syphilis infection (Morgan et al., 2019; Nikolopoulos et al.,
2016). Variations on chain length can be considered, such as three-step
partner services (or SNS). Future work to determine the optimal network
mobilization strategy following STI outbreaks is a growing area of interest
and investigation that follows HIV molecular cluster analyses (Grabowski
et al., 2018; Smith et al., 2011).
SNS extends beyond testing and partner notification. Interventions
can be used to deliver a curriculum to an individual’s social network.
These interventions extend beyond the individual-level interventions
because, much like family interventions, social network interventions
consider interpersonal factors that contribute to STI risk. In a systematic
review and meta-analysis (Hunter et al., 2019), social network interven-
tions showed a significant effect on sexual health outcomes that was
consistent across a myriad of populations (e.g., ethnic minorities, MSM).
Other reviews (e.g., Wang et al., 2011) have drawn similar conclusions on
the efficacy of social network interventions on sexual health outcomes and
STI incidence. Such interventions have also been applied online to suc-
cessfully change sexual health and HIV-related behaviors (Bull et al., 2012;
Young et al., 2014). Because of the large and growing impact that online
tools have on people’s behaviors, interventions that leverage online social
influencers will be increasingly important for promoting sexual health.
Challenges in implementing and evaluating social network inter-
ventions include the potential contamination in social network interven-
tion studies (particularly in networks that are highly connected), where
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PSYCHOSOCIAL AND BEHAVIORAL INTERVENTIONS 421
participants randomized to the experimental intervention may also receive
the control condition (and vice versa) (see, e.g., Schneider et al., 2021).
Additionally, social network intervention studies require the index par-
ticipant to recruit a network of their peers and disseminate the interven-
tion to their network. Notwithstanding these challenges, social network
interventions are efficacious and may also facilitate the diffusion of other
efficacious and effective interventions (Kanamori et al., 2019).
COMMUNITY-LEVEL INTERVENTIONS
Community interventions are effective public health tools for reduc-
ing health disparities in large geographic locations, such as entire cities or
neighborhoods, or smaller entities within communities, such as schools,
faith institutions, or workplaces (Merzel and D’Afflitti, 2003; Trickett
et al., 2011). This approach to health promotion and illness prevention
reflects a shift from individual-level influences to a focus on social and
environmental influences, as suggested by social ecological models of
health (McLeroy et al., 1988, 2003; Merzel and D’Afflitti, 2003). In contrast
to prevention interventions that seek to change behaviors solely within
individuals, community interventions focus on behavior change within
entire communities or a subset of them. In addition to changing knowl-
edge, attitudes, and intentions among community participants, commu-
nity interventions emphasize changing community (social) norms to sup-
port individuals’ effort to reduce their risk and adopt health-promoting
practices (Merzel and D’Afflitti, 2003; Nababan et al., 2011; Ross and
Williams, 2002). Factors that community interventions target also influ-
ence and are influenced by upstream social and structural determinants
of health (Adimora and Auerbach, 2010; Charania et al., 2011; Israel et al.,
2005; Nababan et al., 2011). For example, community interventions that
address social norms, such as fear and stigma associated with STIs, or,
in contrast, empower communities to normalize STI screening, are likely
to be effective in reducing risk (Adimora and Auerbach, 2010; Naba-
ban et al., 2011). These social ecological principles rooted in community
interventions are consistent with the committee’s conceptual framework,
described in Chapter 1.
Beyond the central social ecological perspective, there is no singular
definition of community interventions related to STI prevention and con-
trol. Of more than three decades of interventions focused on sexual health,
most were designed for HIV prevention, leading to a dearth of evidence-
based interventions to reduce STI incidence. Moreover, definitions vary
widely in terms of level or reach (community level, community-wide,
community base), strategy (e.g., community outreach, community engage-
ment, community empowerment, community driven), unit of focus (e.g.,
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
422 SEXUALLY TRANSMITTED INFECTIONS
groups within specified community organizations or particular locations),
target group (e.g., heterosexual male adolescents, adult MSM, Latino/a
people, homeless individuals, commercial sex workers), and outcome(s)
of interest (e.g., STI incidence, STI testing, condom use, change in com-
munity norms, community capacity). These disparate views demonstrate
the inherent complexities of the field and also underscore the difficulty
in summarizing community interventions’ impact on STI prevention and
control.
Meta-Analytic and Systematic Reviews of
Community Interventions for HIV/STIs
Many reviews of community interventions examined effects in stud-
ies including the individual, group, community, and structural levels,
some focus on specific populations, and others have focused on a par-
ticular type of community intervention. Below is a brief review of several
systematic and meta-analytic reviews that highlight some such variation.
Community-Level Interventions for MSM
HIV/STI behavioral and social interventions determined by CDC to
be effective behavioral interventions (CDC, 2020a) include three inter-
ventions designed for the community level: the Popular Opinion Leader
program (Kelly et al., 1991), the MPowerment program (Kegeles et al.,
1996), and the AIDS Community Demonstration Projects, later known as
“Community Promise” (CDC AIDS Community Demonstration Projects
Research Group, 1999). While these three interventions differ in level
and details, they have a number of important commonalities. They aim
to affect behavior change through community mobilization; they target
specific communities disproportionally affected by HIV/STIs, includ-
ing MSM; they are based on established behavior change theories; and,
importantly, they use peer models as change agents in the community to
affect behavioral outcomes. Furthermore, the initial studies that evalu-
ated the interventions were controlled trials with intervention and control
groups and, while they did not include HIV or STI incidence outcomes,
they all showed efficacy in changing behaviors, including decreases in
condomless sex.
Other systematic reviews that focused on adult MSM indicate that
community-level HIV behavioral interventions have demonstrated effec-
tiveness in reducing the odds of condomless anal sex. Moreover, economic
evaluation indicates that community-level HIV behavioral interventions
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PSYCHOSOCIAL AND BEHAVIORAL INTERVENTIONS 423
for adult MSM are not only cost effective but also provide cost savings
(Community Preventive Services Task Force, 2015; Herbst et al., 2007).
Community-Based, Skills-Building Interventions for Adolescents
A systematic review of interventions for adolescents implemented in
schools, clinics, community-based settings, and specialized locations for
particular populations (e.g., juvenile detention facilities for incarcerated
youth) indicates that all the interventions identified changes in behaviors
among participants, including a decline in the frequency of condom-
less sex, fewer sexual partners, and less sexual activity. The authors
concluded that the most successful interventions included several key
elements: (1) a theoretical foundation, (2) tailoring to the target groups
of focus and implementation by trained facilitators, (3) comprehensive
content, and (4) various implementation methodologies (Sales et al.,
2006). Another systematic review of interventions, including but not lim-
ited to community-level interventions, that target adolescents identified
factors associated with effective programs, including a focus on sexual
communication, decision making, and problem-solving skills building.
Moreover, programs that included a variety of content delivery strate-
gies, such as arts and crafts, school councils, and community service
learning, had a longer duration, and had trained facilitators were more
likely to be effective in increasing condom use and other risk prevention
outcomes (Robin et al., 2004).
Condom Distribution Interventions Targeting Diverse Groups
An extensive systematic review that focused on community-based
interventions that made condoms widely available or accessible in com-
munity settings with outcomes for HIV infection, STIs, condom use, and
multiple sexual partnerships identified nine such studies from 10 U.S.
states between 1989 and 2011. Across all studies, three types of condom
distributions were identified: unlimited access to condoms, unlimited
access to condoms and other intervention activities, and coupons-based
condom distribution. The findings indicated that no studies reported
incident HIV, but community-based unlimited condom distributions
modestly reduced condomless sex, while the condom distribution inter-
ventions along with other intervention activities significantly reduced
multiple sexual partnerships. One coupon-based study, which was a not
a randomized controlled trial (RCT), showed reduction in condomless sex
in female participants; the second such study (an RCT) showed no effect
on STI incidence. The authors conclude that community-level condom
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
424 SEXUALLY TRANSMITTED INFECTIONS
distribution interventions may reduce some sexual risk behaviors (Male-
kinejad et al., 2017).
Another systematic review examined the overall efficacy of U.S. and
international community-level structural condom distribution interven-
tions on HIV risk behaviors and STIs (Charania et al., 2011). Twenty-one
such studies were identified, covering January 1988 through September
2007. Significant intervention effects were identified for condom use,
obtaining and carrying condoms, delayed sexual initiation among youth,
and reduced incident STIs. Community condom distribution interven-
tions targeting structural factors were efficacious for several groups,
including youth, adults, men, commercial sex workers, clinic popula-
tions, and populations in areas with high STI incidence. Interventions
that increased the availability and/or accessibility to condoms or includ-
ing additional individual, small-group, or community-level components
along with condom distribution were efficacious in increasing condom
use behaviors (Charania et al., 2011). A study of a campus-based HIV pre-
vention condom distribution intervention for African American women
attending a historically Black college in North Carolina showed promise
for this low-cost method for increasing condom use (Francis et al., 2018).
Community Empowerment Interventions for Sex Workers
Research has focused on community empowerment to activate par-
ticipation and mobilization in marginalized settings, such as in the sex
work industry (Abad et al., 2015; Evans and Lambert, 2008; Kerrigan et
al., 2013). Kerrigan et al.’s (2013) systematic review and meta-analysis of
community empowerment interventions for HIV prevention among sex
workers in low- and middle-income countries from 1990 to 2010 revealed
a reduction in gonorrhea and chlamydia in a longitudinal study and a
reduction gonorrhea in an observational study. For this group, commu-
nity empowerment included the traditional core elements of peer educa-
tion, condom distribution, and periodic STI screening, but also empha-
sized principles that support the perspective that “sex work is work and
should be respected as such, that sex workers know best how to identify
their priorities and areas of concern, and that meaningful and sustainable
responses to these challenges should be led by sex workers” to reduce
their risk for HIV and to improve their overall health and well-being
(Kerrigan et al., 2013, p. 1927). Another systematic review of U.S. com-
munity-based interventions for sex workers, without an empowerment
framework, found that while most interventions included information on
HIV and substance use prevention, few provided tailored content specific
to commercial sex work (Abad et al., 2015). These findings highlight the
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PSYCHOSOCIAL AND BEHAVIORAL INTERVENTIONS 425
significance of using a community empowerment framework to guide
interventions for this marginalized group.
Community Engagement Interventions for Latinas
Although few HIV prevention interventions have focused exclusively
on Latinas, one meta-analysis of seven interventions that specifically tar-
geted Latinas found that interventions that include content on relation-
ships and negotiation skills were effective at reducing HIV risk. Commu-
nity engagement with Latinas was important to recruit study participants,
maintain the cohort, and ensure the cultural appropriateness of the inter-
ventions’ design and implementation (Daniel-Ulloa et al., 2016). Given
the paucity of these community interventions, additional such research is
needed. Community stakeholders should be enlisted to serve in partner-
ship to ensure that interventions are culturally tailored and community
situated to build on strengths and address unique needs.
Promising Community-Based Strategies
Partnering with Faith Institutions to Build Capacity and Sustainability
To address cultural and structural influences on HIV awareness, test-
ing, risk-reduction behaviors, and stigma, community interventions have
focused on forming collaborations with African American churches and
other faith-based institutions (Abad et al., 2015; Derose et al., 2016; Griffith
et al., 2010; Lightfoot et al., 2014). Project Fostering AIDS Initiatives That
Heal (Project FAITH) is a faith-based model for developing, implement-
ing, and sustaining locally developed HIV/AIDS prevention interven-
tions in African American churches in South Carolina (Abara et al., 2015).
The following are key steps and lessons learned that contributed to the
success of this effort: (1) identify, educate, and build skills in existing
community assets and resources to ensure that the interventions will be
independently managed and sustained; (2) engage local and sometimes
national faith leaders about the high burden of HIV/AIDS within their
local communities and the role of places of worship in mitigating its
effects; (3) provide ongoing technical assistance via information, advice,
or assistance with managing the administrative affairs during implemen-
tation; (4) allocate funding specifically to support implementation; (5)
cultivate and promote HIV messages that are acceptable to faith-based
settings; and (6) have faith leadership explicitly demonstrate compassion
toward and acceptance of people living with HIV, which was critical to
dispelling HIV-related myths. Collectively, these activities and steps to
address challenges provided a foundation for successful partnerships
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
426 SEXUALLY TRANSMITTED INFECTIONS
with faith institutions to build capacity for developing, implementing,
and sustaining efforts to prevent HIV in African American communities.
Future consideration should be given to how faith communities can be
leveraged to partner with local health departments and public health
researchers to educate and provide resources and technical assistance to
diverse communities (e.g., urban, rural, low resourced, high STI preva-
lence) to promote sexual health, wellness, and STI prevention.
Engaging Local Businesses Through Community-Based
Participatory Research (CBPR)
Barbershops in African American communities have a long-standing
tradition of serving as a central location where Black men gather, not
only for haircuts, but to engage in lively “discussions and debates about
local happenings, racial and electoral politics, sports, news, and sexual
encounters” (Brawner et al., 2013, p. 2). Given barbershops’ prominence
in African American communities and the trust and rapport between
barbers and their clients, “barbershops are potentially one venue that is
culturally situated and contextually appropriate” to reach diverse groups
of African American men to disseminate information about sexual health,
wellness, and STI prevention (Brawner et al., 2013, p. 2). A number of
studies have examined the feasibility and acceptability of using this non-
traditional community venue for prevention education, STI/HIV screen-
ing, and referral to other services (Brawner et al., 2013; Jemmott et al.,
2017; Wilson et al., 2014). For example, Jemmott et al. (2017) developed
and implemented a randomized controlled cluster intervention trial in
48 barbershops in Philadelphia, Pennsylvania, neighborhoods with high
HIV/STI prevalence. Shape Up: Barbers Building Better Brothers is a
theory-based, culturally and contextually competent, and gender-specific
behavioral intervention to reduce the risk of clinically diagnosed STI/
HIV infections among African American men aged 18–24 years. Barbers
delivered the intervention, with the goals of increasing consistent and
proper condom use and reducing multiple sex partnerships. The trial is
still ongoing. Based on CBPR principles, steps for developing the inter-
vention included (1) assembling a community advisory board (CAB) of
barbers and barbershop owners, (2) identifying a theoretical framework
to guide development, (3) conducting formative research to assess the
feasibility of implementation, (4) developing the intervention in partner-
ship with the CAB and manualizing all educational materials for stan-
dardization, and (5) assessing intervention acceptability. Although this is
a culturally acceptable approach for this hard-to-reach group, few studies
have been evaluated for their short- and long-term efficacy or brought
to scale. Given the high burden of STIs in young, African American men
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PSYCHOSOCIAL AND BEHAVIORAL INTERVENTIONS 427
and their low use of health care services, such novel community-engaged
approaches are worthy of future consideration as a means for preventing
and controlling STIs.
Training and Supporting Lay Health Advisers to Extend Community Reach
Local sports leagues provide an opportunity to reach adolescents
and adult men who may not readily access sexual health services for
education and STI/HIV screening. To address this gap, lay health advis-
ers (LHAs) were enlisted to facilitate an intervention to increase condom
use and HIV testing among Latino men in a soccer league. The interven-
tion was developed in partnership with community members, relied on
male-centered intrapersonal networks, and was culturally tailored. Fifteen
LHAs from 15 Latino soccer teams were trained and worked with their
teammates for 18 months, with another 15 teams serving the control
group. Thirty days after, participants (N = 222) were more likely to report
condom use and HIV testing than controls were, indicating that LHA
interventions for Latino men could be a viable option for both outcomes
(Rhodes et al., 2009). Consideration should be given to how groups of
LHAs could be trained and provided resources so this approach could be
extended to other sports leagues (e.g., football, baseball, and basketball),
tailored to reach other groups of racial and ethnic men, and adapted to
focus on sexual health, including STI prevention. Clearly, more rigorously
designed trials using LHAs are needed to determine the long-term effi-
cacy of this promising approach.
Reaching Minoritized and Marginalized Groups Using Street-Based
and Alternative Venue Outreach
Community intervention approaches that use street-intercept and
venue-based outreach strategies are designed to reach groups of individu-
als who do not typically access health care services in clinics or medical
centers and, often, do not frequent mainstream community-based organi-
zations. Thus, nontraditional approaches for these stigmatized and hard-
to-reach individuals are needed to engage them in risk reduction educa-
tion, STI screening, and treatment. Both street- and venue-based outreach
approaches have been shown to be feasible and acceptable means for
successfully reducing sexual risk behavior, improving STI testing and
treatment, and increasing use of health resources in gay men (Kegeles
and Hart, 1998), sex workers (Pitpitan et al., 2013), homeless individuals
(Auerswald et al., 2006; Rotheram-Borus et al., 1991b), and individuals
residing in neighborhoods with high STI prevalence (Boyer et al., 2007;
Chutuape et al., 2009; Johnson et al., 2001; Ott et al., 2018; Rothenberg et
al., 2007; Wendell et al., 2003). Both strategies rely on effectively recruit-
ing and training peer educators and outreach workers and require strong
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
428 SEXUALLY TRANSMITTED INFECTIONS
public health research and community collaborations and deliberate
and systematic steps for community engagement, such as venue map-
ping, focus groups, street observations, and key informant interviews
in advance (Chutuape et al., 2009; Johnson et al., 2001; Ott et al., 2018;
Sieverding et al., 2005).
Building on and sustaining gains made in prior community street-
and venue-based outreach efforts warrant continued capacity building
and targeted community engagement and prevention efforts. The sustain-
ability of evidence-based efforts will require ongoing technical assistance
and building a well-trained and resourced cadre of community peer edu-
cators and outreach workers to provide prevention education, screening,
and referral to local services for further health care needs and follow-up.
Taken together, these community intervention strategies have shown
promising results, including community feasibility and acceptability.
However, a great deal more research is needed to further develop and
evaluate the efficacy of the interventions and resources to replicate them
in other settings to actualize their full potential in reducing community
transmission. Despite the current limitations, novel and creative inter-
vention approaches, such as those highlighted here, may be worthy of
future consideration to address the current STI epidemic. More than ever,
strategies need to be explored for reaching deeper within communities
most affected by the epidemic, including racial and ethnic minorities and
marginalized groups who live and socialize in low-resourced communi-
ties with high STI prevalence. The demonstrated feasibility and accept-
ability of these approaches should not be undervalued. Moreover, these
lesser-known community approaches to sexual health promotion and STI
prevention have shown the importance of community engagement and
capacity building through deliberate and ongoing partnership with key
community stakeholders, collaboration between public health research-
ers and key community members, and allocation of dedicated resources
for formative work, intervention implementation, evaluation, replication,
and scale-up.
COST EFFECTIVENESS OF PSYCHOSOCIAL
AND BEHAVIORAL INTERVENTIONS
In addition to STI-preventive interventions being efficacious and
effective, evidence indicates that they are cost effective. For example, a
systematic review on the effectiveness and economic efficiency of indi-
vidual-, group-, and community-level behavioral interventions to pre-
vent HIV in MSM found that group- and community-level interventions
were not only cost effective but resulted in actual cost savings (Herbst
et al., 2007). Furthermore, individual-level STI behavioral prevention
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PSYCHOSOCIAL AND BEHAVIORAL INTERVENTIONS 429
interventions have been found to be cost effective across a vast majority
of reviewed studies (Herbst et al., 2007) even after excluding associated
benefits, such as STI prevention, decreases in lost productivity, intangible
benefits (such as reduced pain and suffering), HIV incidence, and the
effects on STI outcomes other than those measured (Barham et al., 2007).
For example, Blandford and Gift (2006) estimated productivity losses to
untreated chlamydia to be $130 among reproductive-aged women. Other
studies exclude intervention effects on quality of life, which is often dif-
ficult to assign a dollar value to (see Chapter 4 for more information on
STI cost estimates, burden, and quality of life measures).
Psychosocial and behavioral interventions aimed at increasing con-
dom use among youth are also cost effective. Nonpartisan groups, such
as the Washington State Institute for Public Policy (WSIPP),1 conduct
research to determine the benefit–cost analyses of prevention programs
and provide a percentage on the chance that a program’s benefit will
exceed its costs, information that is used to make policy determinations.
WSIPP’s work has included a number of different areas, including crimi-
nal justice, education, child welfare, behavioral health, workforce devel-
opment, public health, and prevention and thus interventions that target
risk factors (e.g., alcohol use) for sexual health promotion and STI pre-
vention and management. Unfortunately, WSIPP has not addressed inter-
ventions that only target condom use and STIs, but it has included those
with condom use or STIs as outcomes combined with other outcomes.
For example, Familias Unidas, an evidence-based, family-centered inter-
vention found to be efficacious and effective in reducing condomless sex,
substance use, and preventing STIs in Hispanic adolescents, produced
benefits greater than the costs 68 percent of the time.2 Interventions such
as the Nurse Family Partnership that have had an impact on risk factors
for STIs and condomless sex (e.g., early alcohol use initiation, substance
use) are also included. The program has a 64 percent chance that benefits
will exceed costs and a benefit–cost ratio of $1.38.3
TECHNOLOGY-BASED INTERVENTIONS
Chapter 6 provides an overview of different types of technologies
that can be applied to prevent and control STIs. This section builds on
Chapter 6 and focuses on how to apply these technologies. In the context
of STI research and prevention, technologies are typically viewed as a
tool to deliver interventions, similar to word-of-mouth methods, radio
1 See www.wsipp.wa.gov (accessed January 27, 2021).
2 See http://www.wsipp.wa.gov/BenefitCost/Program/644 (accessed January 27, 2021).
3 See http://www.wsipp.wa.gov/BenefitCost/Program/35 (accessed January 27, 2021).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
430 SEXUALLY TRANSMITTED INFECTIONS
broadcasts, newspaper advertisements, or any other method that can be
used to deliver interventions. Technologies also play a more nuanced role
in sexual health, however, including affecting people’s attitudes and social
norms. This requires extensive consideration of when, how, and why they
should be incorporated into interventions. For example, in addition to
acting as a delivery tool, technologies such as social media can influence
people’s perceptions of sexual health and related STI risk, moral and
sexual-related judgments about themselves and their peer groups, and
social normative behaviors around sex (Young and Jaganath, 2013; Young
and Jordan, 2013). The relationship between people and technologies is
complicated and dialectical: technologies not only affect people’s sexual
health–related attitudes and behaviors, but people’s sexual health–related
attitudes and behaviors also affect technologies (e.g., people’s desire to
find new sex and dating partners influences the development of new dat-
ing/hookup apps, and their growing use affects people’s attitudes and
ability to find sex and dating partners). It therefore becomes important
to recognize the large and ever-changing role that technologies play in
sexual health and intervention delivery.
As discussed in Chapter 6, the committee sees technology as a tool
that can be helpful to control, prevent, and treat STIs but may also con-
tribute to STIs. The term “tool” is emphasized, as these are platforms
that allow for rapidly delivering a theory or intervention to a large group
of people, rather than stand-alone products that can change behavior
without incorporating the correct psychology/psychosocial-behavioral
approach. This distinction is important so that researchers and policy
makers are aware of the benefits and limitations of social technologies in
STI interventions.
Technology as a delivery platform is more than an option for dissemi-
nating traditional content, as it may have certain characteristics that assist
in promoting health behavior change. Technology-based interventions
come in a variety of forms, across platforms, and with differing names
and definitions. Electronic health (eHealth)4 and mobile health (mHealth)5
are umbrella concepts that may encompass a variety of intervention types.
Some reviews focus on digital health, others on social media. This report
primarily addresses technology-based interventions and is specific when
discussing different programs and the platforms through which they were
administered, as affordances may vary by technology.
4 eHealth is health care practice supported by electronic processes (e.g., electronic health
records, patient administration systems, and lab systems).
5 mHealth is the use of mobile devices, such as a mobile phone or a tablet, to support the
practice of health care.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PSYCHOSOCIAL AND BEHAVIORAL INTERVENTIONS 431
Technology-Based Intervention Benefits
eHealth interventions have been found to appeal to individuals and
offer convenience, privacy, anonymity, flexibility, and the ability to tailor
(Noar and Harrington, 2012). A meta-analysis not focused specifically on
STIs found tailored health communication efforts to be more efficacious
than non-tailored materials in Web-based settings (Lustria et al., 2013).
Similarly, a meta-analysis of text message–based health promotion inter-
ventions found tailored interventions to be more efficacious (Head et al.,
2013). Tailoring can be built into the system offerings, and it may be more
practical in certain technology-based programs. Research that has specifi-
cally assessed tailoring in technology-based sexual health interventions,
however, is limited, with one meta-analysis not finding an effect in influ-
encing the interventions’ effect on abstinence and condom use (Widman
et al., 2018). This could in part be due to the wide variety of variables on
which one may tailor. Previous research into tailoring through technol-
ogy not focused specifically on STIs has found that it is common to tailor
health interventions on more than one construct and to use a combina-
tion of theory-based and non-theory-based constructs (Krebs et al., 2010;
Lustria et al., 2009; Noar et al., 2007).
In addition to the affordances listed previously, research has found
that features of technology may influence program liking and, therefore,
possibly impact further downstream effects. For example, participants
who perceived a sexual health text message intervention as more inter-
active, regardless of actual differences in technological affordances, self-
reported an increased likelihood to recommend the service to a friend and
showed increased levels of repeat use (Willoughby and L’Engle, 2015).
Similarly, finding an eHealth intervention interactive and engaging may
lead to high rates of participation (Perrino et al., 2018). These outcomes
highlight program factors that may affect attention, which may be a nec-
essary first step in influencing behavior change. In one meta-analysis, the
interactivity level of technology-based interventions was not found to
impact outcomes associated with STIs and unintended pregnancies (Wid-
man et al., 2018), but a previous meta-analysis found that interactivity
influenced condom use, with interventions that included more interactive
components yielding significant effects (Swanton et al., 2015). Part of this
difference could be based on definitions used to conceptualize certain
features of technology, as the definition of interactivity may vary (Kiousis,
2002; Sundar et al., 2003). The impact may also be based not on the techni-
cal affordances, but on user perceptions of such affordances.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
432 SEXUALLY TRANSMITTED INFECTIONS
Reviews and Meta-Analyses of Technology-Based
Sexual Health Behavior Interventions
Reviews and meta-analyses have found technology-based interven-
tions for sexual health to be promising, including for addressing behav-
iors associated with STIs, such as increased condom use and STI testing.
In a meta-analysis, Swanton et al. (2015) found that new media interven-
tions (defined by the authors as including social networking sites, text
messaging, chat rooms, websites, e-mail, and smartphone apps) led to
significant changes in both condom use and STI testing but that not all
interventions had such outcomes. Interactivity (increased interactivity),
target audience (young adults), and study design (RCTs) moderated the
effects on condom use, with intervention duration influencing the impact
on STI testing (more than a single session had increased effects) (Swanton
et al., 2015). Therefore, more substantial interventions may have greater
effects. The authors also found differences among interventions targeted
to specific populations. Interventions targeting condom use were more
effective with women and less effective with MSM and young people,
and interventions that targeted STI testing were more effective for young
people than for MSM.
A newer meta-analysis found that technology-based interventions
positively influenced condom use and abstinence, but that interactivity
and other factors did not moderate the outcomes (Widman et al., 2018).
The duration from intervention to assessment, however, did influence
outcomes, with stronger effects in the short term (assessed between 1 and
5 months) compared to the long term (more than 6 months). This supports
the idea that the effects may dissipate, in both technology-based interven-
tions and face-to-face ones.
Specific to text messaging and sexual health, a meta-analysis of 35
studies examined intervention effects on prevention, detection, treatment,
and knowledge of STIs and HIV (Taylor et al., 2019). Most studies (N =
8) focused on the effectiveness of text messages for STI clinic appoint-
ments. Studies were conducted across 14 countries, the majority of which
included the United States (13 studies). Participant age was 16–84, follow-
up occurred on a range of 7 days to 24 months, and text messages were
delivered daily, weekly, monthly, or as one-off reminders; 83 percent
of studies consisted of one-way texting. The main outcomes examined
included prevention, HIV drug adherence, and HIV treatment outcomes.
Overall results point to mixed evidence regarding effectiveness for STI/
HIV outcomes. Part of this ambiguity is due to the great degree of vari-
ance in methods and a high percentage of studies (75 percent) with risk
of selection bias and performance bias caused by an inability to con-
ceal randomization allocation, blind study participants, and blind study
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PSYCHOSOCIAL AND BEHAVIORAL INTERVENTIONS 433
personnel (Taylor et al., 2019). The authors noted that the lack of certainty
around effects may have been due to the variations in the program types
(e.g., one-way versus two-way versus frequency of messaging). Differ-
ences in text message delivery (e.g., Willoughby and Muldrow, 2017)
may influence program features, experiences with the interventions, and
perceptions of the content to which individuals are exposed, and work
has yet to parse out which specific components lead to the greatest chance
of success. Work in text messaging health interventions more generally,
however, has provided some guidance on content timing and delivery
(see Head et al., 2013).
Theoretical Frameworks for Technology-Based Interventions
The effect of technology-based interventions is likely not from the
technology itself (i.e., simply putting the intervention online or on social
media), but from identifying and applying the correct theoretical basis
for behavior change (i.e., the specific way these technologies were used
to deliver the intervention).
For example, individuals in the Keep It Up! 2.0 intervention—rooted
in the IMB Skills model of HIV risk behavior change—compared to those
in a matched eHealth control group (with static text and content not tai-
lored to young MSM), had improved STI-related outcomes. Specifically,
compared to control group participants, STIs (urethral or rectal chlamydia
or gonorrhea) were significantly less likely (40 percent) at 12-month fol-
low-up. Although there are a variety of theories that could guide interven-
tion development (e.g., IMB model), it is important that the intervention
is delivered with an understanding and tailoring of the psychosocial and
behavioral needs of the population, rather than just assuming the technol-
ogy will work by itself. For Keep It Up! 2.0, it likely was the psychological
elements, such as engaging content, videos, and information tailored for
young MSM, that led to the study results, as the equivalent technology
without these factors did not perform as well.
The specific choice of technology for delivery is also important in
digital STI interventions, as characteristics of the technology affect how
it is used, by whom, and where. For example, the social media video
site YouTube might be a good tool for delivering STI prevention-related
videos, but only if the channel being promoted already has a large fol-
lowing (i.e., leveraging already engaging technologies and websites will
likely work better than trying to develop one from scratch and expecting
people to visit it).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
434 SEXUALLY TRANSMITTED INFECTIONS
An Example Framework for Technology-Based Interventions
A growing body of research on theoretical frameworks can be used
to improve delivery of digital behavioral interventions (Hekler et al.,
2016; Simoni et al., 2018). One recent option that might be applied for
integrating technologies into STI interventions is the Adaptive Behavioral
Components (ABC) model (Young, 2020) (see Figure 8-1). ABC applies
research from the fields of social and behavioral psychology, informatics,
and marketing that can be used to develop a model tailored to the needs
of various digital technology interventionists. The model is based on five
overarching factors that are needed to develop sustainable technology-
based interventions: (1) basic behavior change components; (2) inter-
vention and problem-focused characteristics; (3) population, social, and
behavioral characteristics; (4) individual-level and personality character-
istics; and (5) technology characteristics (Young, 2020).
As this chapter already provides the science on the elements needed
to deliver effective STI interventions, the ABC model can be used to
integrate these elements and potentially scale their reach and impact by
using social technologies. Importantly, the ABC model helps to address
the planning for potential changing technological trends and features,
which is important, especially for long-term sustainment (see Chapter 6
for more information on types of technologies and important consider-
ations for the future).
Technology characteristics can impact intervention engagement and
therefore may have a large impact on efficacy. For example, the success of
an intervention delivered using technologies can be impacted by trends
in popular communication styles (e.g., it is better to choose the preferred
communication medium), changes in ethical considerations (e.g., a breach
of security could decrease trust in a particular platform), or changes
in the features of a technology (e.g., adding an online community fea-
ture to a software app may change user engagement rates) (Garett and
Young, 2019; Young, 2020). Therefore, to deliver effective longitudinal
technology-based interventions, it is important to be aware of the current
technology landscape, understand the implications of such changes, and
be prepared with adaptations.
The most recent Harnessing Online Peer Education (HOPE) HIV
intervention serves as an example of how technology-related changes
can impact delivery and require adaptation. This second HOPE HIV
intervention is a multi-wave, 5-year HIV testing intervention funded in
2014 based on earlier methods and results from HOPE interventions in
2010 and 2012 that showed success in using Facebook groups as a delivery
platform (Young et al., 2013, 2015). From 2010 to 2014, and throughout
the next 5 years, however, a large number of changes occurred on social
media, including Facebook no longer being the dominant technology
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
435
FIGURE 8-1 Adaptive Behavioral Components (ABC) model for technology-based interventions.
SOURCE: Young, 2020.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
436 SEXUALLY TRANSMITTED INFECTIONS
among all age groups and populations. With the introduction of other
platforms, such as Snapchat and Instagram, Facebook use waned, espe-
cially among youth (Fox, n.d.), which might reduce the engagement and
potential efficacy of interventions delivered on it that rely on previous
rates of engagement.
Similarly, throughout the 5-year period, Facebook made a number of
changes to its interface, affecting HOPE’s engagement. For example, Face-
book announced that it was planning to change the way its algorithm dis-
played content, potentially affecting the advertising and outreach meth-
ods being used by businesses and researchers, possibly leading these
methods to cease working (Facebook, 2018). The HOPE intervention (and
other interventions leveraging Facebook groups) was impacted by these
changes; analysis of the HOPE study found that intervention participants
received fewer notifications about HIV prevention and testing compared
with control (Facebook) group participants (Young, 2020).
Although the intervention group remained significantly more engaged in
posting compared with the control group (as intended by the interven-
tion), the large number of posts within the intervention group combined
with the changes to the way Facebook groups and the Facebook algo-
rithm were used initially resulted in fewer testing-related posts being
viewed by the intervention group compared with the control group.
(Young, 2020)
HOPE illustrates the importance of not relying on a single technology
as a delivery platform for longitudinal interventions but instead using
multiple platforms that are dominant at that point in time and being able
to adapt to changing platforms and trends.
Technology as a Dissemination Strategy
Given the increasing popularity of technologies among populations
most affected by STIs and more broadly (see Chapter 6 on technology
for more detail), offline/face-to-face interventions need to be able to be
adapted online. This has become urgent during the COVID-19 pandemic;
related policies have required socially distanced interventions, as can be
done with remote technologies. It is therefore important to understand
the challenges in moving or adapting offline interventions. The Famil-
ias Unidas intervention is an example of this concept. It was originally
developed for face-to-face delivery, and one of the challenges in moving
to online delivery was recreating its participatory nature (Estrada et al.,
2017). A central tenet of Familias Unidas is that, with facilitator guidance,
parents are empowered to become the agents of change for their families
and youth. This means that through skills building and parent group
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PSYCHOSOCIAL AND BEHAVIORAL INTERVENTIONS 437
discussions focused on problem solving and effective communication,
parents can work on and achieve their goals. For the online adaptation,
the study team (Estrada et al., 2017) made it participatory in three ways.
First, parent video group discussions were developed, keeping in mind
the viewer at home. Videos were recorded so as to foster a sense of inclu-
siveness and interaction via pointed questions, such as “you watching
at home, please think about what goals you have for your adolescent”
and “for viewers at home, what do you think about what was just said?”
Second, interactive exercises were incorporated to adapt the participa-
tory learning strategy used in the face-to-face version; these varied from
session to session and included multiple-choice questions, true or false,
fill in the blank, and point-and-click responses, with instant feedback for
all responses. Third, the four facilitator-led family sessions were moved
to a live online delivery format. This highlights some of the necessary
considerations to adapt interventions for technology-based delivery. One
option to help with technology as a dissemination strategy is social mar-
keting, which has been applied more broadly, but could be leveraged for
technologies. A review of how social marketing principles were applied
in sexual health campaigns found that some elements were limited in
campaign creation (Akbar et al., 2020). Even with the understanding that
campaigns will likely focus on different elements, in a review of 26 articles
that covered 16 health communication and social marketing campaigns
specific to STD testing or prevention, nearly all campaigns reported differ-
ences in behavioral outcomes between people exposed to their messages
and those who were not (Friedman et al., 2016). The researchers con-
cluded that campaigns can be useful for targeting STD-related behaviors.
Technology-Based Interventions Research and Future Directions
Despite multiple technology-based interventions, the efficacy may not
be clear for many. Reviews and meta-analyses are limited by the specific
technology types and affordances examined. While such reviews can
provide guidance on possible effectiveness, interventions developed with
such differing characteristics (e.g., peer-to-peer interaction, one-way mes-
saging, differences in frequency) make it important to consider evaluation
and research strategies that may help to parse out the effects to determine
which characteristics and affordances of the technology may develop the
strongest interventions possible. One option is the Multiphase Optimiza-
tion Strategy (Collins, 2018; Collins et al., 2016), in which randomized
experimentation is conducted to evaluate the efficacy or effectiveness
of each component and whether its presence/absence affects the perfor-
mance of other components (Collins, 2018).
Additionally, technology-based interventions offer the benefit of scal-
ability, but they may not be done to scale, even if efficacious, because
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
438 SEXUALLY TRANSMITTED INFECTIONS
funding, resources, and/or a lack of partnerships with organizations (e.g.,
those serving adolescents and young adults) may prevent this.
Technology-based interventions can play an important role in psy-
chosocial and behavioral interventions, perhaps more so than ever due
to the rapidly changing environment and increased access to technol-
ogy (the COVID-19 pandemic is a current example). Understanding the
varied characteristics of different tools and how users interact with them
and grounding the intervention in theories and psychology, however, are
essential. Box 8-2 outlines important considerations when developing
interventions that use technology or adapting an offline intervention to
be online.
DISSEMINATION OF EVIDENCE-BASED
BEHAVIORAL INTERVENTIONS
Psychosocial and behavioral interventions with documented efficacy
in preventing STIs have generally not been widely disseminated. For
example, adoption of an intervention into a specific delivery setting (e.g.,
schools, health care, community agencies) may not occur for a number of
reasons, including (1) an organization’s structure, (2) available resources,
(3) costs, (4) number of providers available or willing to deliver the inter-
vention, or (5) competing demands within the organization. This lack of
dissemination is not unique to the STI field. A systemic review by Hanley
BOX 8-2
Considerations When Developing a New Technology-Based
Intervention or Adapting an Existing Intervention to Be Online
• Is the intervention leveraging an already popular/engaging technology or re-
quiring the target population to download/use a new one? Ideally, use technolo-
gies that are already popular.
• This technology/these technologies should be uniquely suited for the needs of
the target population.
• Does the technology-based intervention leverage a psychosocial-behavioral
framework and/or intuitive psychology, or does it only rely on the technology it-
self to intervene? The intervention should not rely on the technology, but should
incorporate effective psychosocial-behavioral/psychological components.
• What milestones (and metrics for measuring interim success of the milestones)
within the technology are being monitored to evaluate its ongoing success/
changing needs (e.g., Google analytics to assess the characteristics and fre-
quency of users)?
• What is the plan for how to adapt the intervention/technologies if the technol-
ogy changes, it becomes less popular among the target population, or the
milestones and metrics are not being met? There should be a backup plan.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PSYCHOSOCIAL AND BEHAVIORAL INTERVENTIONS 439
et al. (2010), for example, estimated that only 35 percent of evidence-
based substance abuse preventive interventions used in U.S. elementary
schools were evidence based. Despite this lack of wide-scale adoption
and sustainment of behavioral interventions, registries of evidence-based
interventions have facilitated the wide-scale dissemination of some. For
example, CDC’s compendium of evidence-based interventions and best
practices for HIV (and other STIs) disseminated dozens of behavioral
interventions to health departments and community organizations across
communities in the United States. Although these were not always imple-
mented with high fidelity (Rotheram-Borus et al., 2009), largely because
community organizations adapted them for local use, CDC’s effort was
successful in reducing sexual risk behaviors and STIs (Dworkin et al.,
2008). Unfortunately, with a few exceptions, the wide-scale dissemina-
tion of evidence-based, behavioral interventions to prevent STIs is not
common practice, and it is critical to find solutions to overcome barriers.
One solution to facilitating the adoption, integration, and sustainment
of evidence-based interventions to prevent and manage STIs into service
delivery systems is to involve key stakeholders, defined as “individual,
organizations or communities that have a direct interest in the process and
outcomes of a project, research or policy endeavor” (Deverka et al., 2012).
Their role in the entire process cannot be overstated. Key stakeholders are
vital individuals who act as gatekeepers in bridging research to practice.
For example, implementing an evidence-based intervention within pedi-
atric primary care settings to prevent STIs involves strategically forming
alliances with key administrative staff and winning support from physi-
cians (Molleda et al., 2017). Without stakeholder buy-in, evidence-based
interventions likely will not make the transition from research to practice.
Key stakeholders also include intervention recipients, such as adolescents
and families. Including them in developing and/or adapting existing
interventions can help address challenges with engagement, inform inter-
vention content, and give a voice to the needs of those who will ultimately
use the intervention in community practice.
Historically, key stakeholders have played a minimal role in the
research process. With the increased use of qualitative research and inclu-
sive methods, such as community-based participatory research, however,
the psychosocial and behavioral intervention field is increasingly includ-
ing them earlier on. Doing so as early as possible, even as early as in the
study design, has important implications for adopting and sustaining
behavioral interventions. For example, stakeholders can inform whether
an intervention is sustainable, culturally syntonic, or a good contextual
fit within a community or practice setting. Participatory approaches in
research are gradually increasing (Ewan et al., 2016; Vaughn et al., 2013)
and particularly important among minority populations (Ewan et al.,
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
440 SEXUALLY TRANSMITTED INFECTIONS
2016; Israel et al., 2005). Frameworks such as Communities That Care
(CTC) can identify community needs and provide guidance in selecting
behavioral interventions that align well with those needs and context, all
through harnessing the voices of community stakeholders (Hawkins et
al., 2009).
Another potential solution to overcoming barriers to adoption of STI
evidence-based intervention is developing mHealth or eHealth interven-
tions or adapting existing interventions for online delivery. As discussed,
some literature documents the efficacy or effectiveness of eHealth inter-
ventions in reducing rates of condomless sex, increasing STI testing, and
reducing STI incidence (Bauermeister et al., 2015; Mevissen et al., 2011;
Swanton et al., 2015). Unfortunately, despite this evidence, the number of
scientifically proven online STI preventive interventions remains low, and
even fewer are integrated into practice. This is surprising given that these
interventions are less resource intensive and provide greater flexibility as
to where, how, and when they can be disseminated (Prado et al., 2019).
Furthermore, they have greater potential to reach populations (e.g., youth,
ethnic minorities) disproportionately affected by STIs. Therefore, develop-
ing and evaluating evidence-based interventions and adapting them for
online are important priorities for STI prevention. Such adaptations, if
successful (Li et al., 2020; Prado et al., 2019), could lead to greater rates of
adoption and sustainment. Models such as the ABC described earlier can
also be used to sustain technology-based interventions.
IMPLEMENTATION SCIENCE
It is also important to turn to the field of implementation science for
methods to facilitate the adoption and sustainment of evidence-based
interventions to promote sexual health and STI prevention. The field is
not novel, but NIH and other federal agencies have paid it significant
attention over the past 10 years. In 2013, NIH issued the first funding
opportunity announcement specific to dissemination and implementation
research to “support innovative approaches to identifying, understand-
ing, and overcoming barriers to the adoption, adaptation, integration,
scale-up and sustainability of evidence-based interventions.”6 Since then,
the emphasis has shifted from developing behavioral interventions to
prevent and control STIs to disseminating existing evidence-based inter-
ventions. Research on how to accelerate the implementation process,
however, remains very limited.
6 See https://grants.nih.gov/grants/guide/pa-files/par-13-054.html (accessed November
16, 2020).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PSYCHOSOCIAL AND BEHAVIORAL INTERVENTIONS 441
Few studies have clearly measured implementation outcomes—most
still only focus on individual behavioral (e.g., condomless sex) or disease
(e.g., STI incidence) endpoints. Important implementation outcomes to
measure include intervention sustainability, perceived fit in the target
setting, fidelity, number of providers delivering or participants receiving
the intervention in a given practice, and financial feasibility (Proctor et al.,
2011). Furthermore, even fewer trials exist with an implementation-level
outcome, and none specifically involve an STI behavioral intervention.
Implementation trials may not take the form of a traditional randomized
clinical trial, which may not be feasible for many reasons. For example,
they are not appropriate in all settings, especially at the community level,
and randomization can be considered ethically objectionable if it denies
an intervention known to be beneficial. Such circumstances may require
alternative study designs, such as a step-wedged (Brown and Lilford,
2006) or rollout (Brown et al., 2017) design, where the intervention is
sequentially rolled out to participants so that all participants receive it by
the end of a study. That is, the randomization unit is the time when par-
ticipants receive the intervention. This type of design may be appropriate
to evaluate implementation-related outcomes (e.g., sustainment) when
the intervention is already known to be effective and no one should be
denied it. That is, a step-wedge design may be used to evaluate whether
an evidence-based intervention can be sustained (i.e., the implementation
outcome) in primary care or pediatric care clinics over time. In such a
study, clinics would be randomized to when they receive the interven-
tion. For clinics or communities, there may be advantages to receiving the
intervention either first or last. Clinics going first may have immediate
access to an evidence-based intervention, whereas if they are later, they
may be better prepared to adopt and sustain the intervention.
It is also important to evaluate implementation strategies that facili-
tate the adoption, integration, and/or sustainment of evidence-based
interventions in practice. To date, no intervention strategies have been
evaluated to examine the adoption of evidence-based sexual health and
STI behavioral interventions. The following section briefly reviews some
implementation strategies and systems that have been found to be effec-
tive in integrating behavioral interventions, although not specific to sex-
ual health and STIs.
Getting to Outcomes (GTO) was developed as a tailored tool and
guide to assist communities and organizations build performance and
individual capacity for delivering effective prevention interventions
(Chinman et al., 2001, 2008; Wandersman et al., 2000). The main goals are
to help organizations run an effective prevention program well so that it
can obtain its desired outcomes and facilitate the implementation process,
including sustaining the intervention. GTO consists of an intervention and
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
442 SEXUALLY TRANSMITTED INFECTIONS
a process component. The intervention component comprises the GTO
Manual, face-to-face training, and onsite technical assistance. The process
component includes ten steps, which should be properly addressed to
achieve positive results, tied into a step-by-step GTO process that includes
topics such as assisting the organization in choosing an evidence-based
intervention that is a good fit, ensuring the organization has the capacity
needed to run the program, and ensuring the organization is thinking
about and planning for sustainment. In a cluster RCT evaluating sexual
health outcomes, 32 Boys and Girls Clubs were randomized to either
Making Proud Choices, an evidence-based teen pregnancy preventive
intervention, or GTO + Making Proud Choices. Youth in GTO + Mak-
ing Proud Choices reported improvements in condom use attitudes and
intentions (Chinman et al., 2018).
CTC is an implementation system to strategically guide communities,
or coalitions, in planning and implementing evidence-based prevention
programming (Hawkins et al., 2008). The CTC system is designed to help
communities define the outcomes, prioritize factors to be targeted, offer
a menu of programs, and guide the community selecting, implement-
ing, and evaluating the selected program in their organization system.
Research demonstrates that CTC has positive outcomes (e.g., alcohol use,
cigarette use) for youth. For example, in an RCT with 24 communities
across 7 states, communities randomized to CTC had students who were
32 percent less likely to initiate drugs and 33 percent less likely to initiate
cigarette use, compared to the control communities (Rhew et al., 2016).
Furthermore, CTC has long-term effects, with reductions in lifetime inci-
dence of health-risk behaviors extending into young adulthood (Oesterle
et al., 2018). CTC has been implemented in hundreds of communities in
the United States.
CDC’s Community Approaches to Reducing Sexually Transmitted
Diseases (CARS) program began in 2011 (CDC, 2020b). CARS seeks to
support planning, implementing, and evaluating projects to reduce STI
disparities, promote individual sexual health, and support overall com-
munity wellness and health equity. A toolkit is offered to support com-
munities in implementing the CARS framework (CDC, 2019a). CARS
emphasizes community engagement and attention to the social deter-
minants of health throughout the process of intervention development,
implementation, evaluation, and dissemination. The specific steps of the
CARS process are laid out in the toolkit: (1) conduct a community health
needs assessment; (2) establish a CAB and develop initial community
partnerships; (3) train CAB members; (4) support CAB STI interven-
tion design and engage implementation partners; (5) engage the CAB
in social determinants of health prioritization; (6) facilitate CAB review
of additional community health assessment components; (7) implement
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PSYCHOSOCIAL AND BEHAVIORAL INTERVENTIONS 443
interventions; (8) evaluate community engagement, partnerships, and
interventions; (9) build and ensure sustainability through partnerships;
and (10) celebrate successes with the CAB and partners. The toolkit
emphasizes that this process may not always be linear, and certain steps
may entail multiple iterations and or need to occur throughout the pro-
gram period (CDC, 2019a).
The Leadership and Organizational Change for Implementation
(LOCI) strategy addresses leadership and organizational development in
implementing evidence-based practice (Aarons et al., 2015). LOCI aims
to achieve positive changes in implementation leadership, and quality
in service delivery systems, thus increasing the adoption and sustain-
ment of evidence-based interventions with fidelity (Aarons et al., 2015,
2017a). LOCI targets leadership at multiple levels, including first-level
leaders, such as supervisors of direct service providers, and high-level
administrative leaders (Aarons et al., 2014; Egeland et al., 2019). LOCI has
well-established feasibility, acceptability, and perceived utility and dem-
onstrated positive changes in leadership and climate (Aarons et al., 2015,
2017a). LOCI has also been found to adapt and respond to changes (e.g.,
staff and/or leader turnover) commonly faced by service delivery systems
implementing effective behavioral interventions (Aaron et al., 2015).
Implementation strategies, such those reviewed above (except CARS),
have been rigorously evaluated and shown to affect outcomes such as
adoption, reach, penetration, fidelity, and sustainment. Specifically, these
strategies (e.g., LOCI) have been found to change leadership and climate,
which, in turn, may likely impact intervention adoption and sustainment.
Unfortunately, the evaluation of implementation strategies is virtually
nonexistent in the field of STI prevention. Other disciplines, such as drug
abuse prevention and treatment, have benefited from rigorously evaluat-
ing these strategies. For example, CTC has led to incorporating evidence-
based interventions in hundreds of U.S. cities/communities. The chal-
lenge with evaluating both behavioral interventions and implementation
strategies are the costs and time required. One strategy to reduce both is
to evaluate psychosocial and behavioral interventions for effectiveness
(e.g., individual-level outcomes), as well as implementation outcomes.
For example, Hybrid II effectiveness-implementation trials (Brown et
al., 2009) that evaluate individual-level outcomes (e.g., STI incidence,
condomless sex) for STI prevention and implementation outcomes (e.g.,
sustainment) will reduce the costs of having to perform multiple stud-
ies and the time associated with conducting them. As with other health
research, the time lag between basic science (intervention development)
and practice (dissemination and implementation) is 17 years (Morris et
al., 2011). Acceleration is critical for the field to integrate evidence-based
STI behavioral interventions into practice. Moreover, these types of trials
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
444 SEXUALLY TRANSMITTED INFECTIONS
in combination with other innovative study designs may provide an
opportunity to uniquely evaluate behavioral interventions on individual-
level STI-related outcomes and implementation strategies/systems-level
interventions on implementation-related outcomes. For example, a hybrid
type II head-to-head randomized rollout trial with two different random
assignments may be used to evaluate an evidence-based intervention and
an implementation strategy. Specifically, randomization occurs at two
levels: during development of the implementation strategy and when
implementation begins (Brown and Lilford, 2006; Brown et al., 2009). Such
study designs can accelerate the translation of knowledge into practice,
improve the sexual health outcomes, and reduce STIs in the United States.
CONCLUSIONS AND RECOMMENDATION
Based on its review of the evidence, the committee provides the fol-
lowing conclusions, and Recommendation 8-1:
Conclusion 8-1: Psychosocial and behavioral interventions, in conjunction
with biomedical, structural, informatics/technological, and health service
interventions, are integral to a comprehensive strategy for sexual health and
STI prevention and control. Therefore, multidisciplinary investigative teams
are needed when developing psychosocial and behavioral interventions.
Conclusion 8-2: Psychosocial and behavioral interventions to promote sexual
health and prevent and control STIs are efficacious and effective for diverse
populations, but are underused and have not been adopted and sustained in
clinical or community practice. Future considerations for research for inter-
vention development include the following:
• Development and evaluation of effective implementation strategies of
these interventions;
• Use of varied scientific methodological designs (e.g., effectiveness–
implementation hybrid designs, step-wedge designs) to provide outcome
measures and inputs for implementation science analyses.
Conclusion 8-3: Evidence-based family interventions have demonstrated
effects on mental health and behavioral outcomes (e.g., drug use, suicide
behavior) with crossover effects on condom use and STIs. Funding for psy-
chosocial and behavioral interventions, however, historically has been siloed
by disease outcomes, which has not allowed studying multiple and inter-
related health outcomes, such as STIs, substance use, and mental health
conditions. As such, funding opportunities that cut across multiple health
conditions and behavioral outcomes are sorely needed in addition to funding
for outcome-specific interventions. Identifying these crossover effects could
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PSYCHOSOCIAL AND BEHAVIORAL INTERVENTIONS 445
lead to greater cost effectiveness and more sustainable impacts on health
outcomes, such as STIs.
Conclusion 8-4: Comprehensive sexual health education taught in schools
is effective in delaying the initiation of sexual behavior, promoting sexual
health, and reducing risk for STIs in students. In the 1990s, federal policy
adopted the promotion of abstinence-only until marriage as the singular
approach to school-based sexual health education. Rigorous research has
demonstrated the ineffectiveness of this approach, yet federal funds still
support such instruction even as comprehensive models also now receive
federal funding. Political conflict over abstinence-only education, combined
with pronounced conflict over addressing sexual orientation and gender
identity diversity in schools, has meant that many young people do not
receive sufficient instruction of guidance in these areas. School-based sexual
health education programs across the United States are highly variable, with
no nationwide policy regarding how sexual education is taught in schools.
Nonetheless, research indicates that parents broadly support comprehensive
school-based sexual health education for elementary, middle, and high school
students even when stratified by political party.
Conclusion 8-5: Community intervention strategies to promote sexual health
and prevent STIs have demonstrated feasibility and acceptability in com-
munities most affected by STIs, including racial and ethnic minorities and
marginalized groups who live and socialize in high–STI prevalence, low-
resourced communities. Additional research is needed, however, to evaluate
the efficacy and effectiveness of community-level interventions on reducing
community transmission of STIs. Community interventions that specifically
address social and structural determinants of health are needed.
Conclusion 8-6: Technologies, when combined with appropriate psychosocial
and behavioral interventions, have successfully changed STI-related atti-
tudes and behaviors. It is critical to consider incorporating these technologies
when developing or adapting psychosocial and behavioral interventions.
These technological tools can be used to deliver and/or scale up evidence-
based sexual health and STI prevention. Interventions that use technology
should be developed leveraging psychosocial, digital behavioral and informat-
ics intervention frameworks, including taking into account the affordances
of the specific technology for prevention efforts as well as intervention-
development best practices.
Recommendation 8-1: The Department of Health and Human Ser-
vices (HHS) should take steps to expand the reach of psychoso-
cial and behavioral interventions to prevent and control sexually
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
446 SEXUALLY TRANSMITTED INFECTIONS
transmitted infections at the individual, interpersonal, and commu-
nity level. This can be accomplished by developing sustainable
funding mechanisms to deliver those interventions; establish-
ing standard guidelines for school-based comprehensive sexual
health education; and developing, evaluating, and disseminating
community-based approaches:
1. HHS should develop new mechanisms that provide sustain-
able funding for dissemination, adoption, and scale-up of evi-
dence-based psychosocial and behavioral interventions by a
wide range of stakeholders, including community-based orga-
nizations, parent–teacher associations, workplaces, faith-based
organizations, and pediatric and primary care practices.
2. The Centers for Disease Control and Prevention (CDC) Divi-
sion of Adolescent and School Health should work in partner-
ship with parents and guardians, parent–teacher associations,
states, districts, and local school boards to establish standard
evidence-based guidelines for school-based comprehensive
sexual health education that is grounded in psychosocial and
behavioral theories and research. To ensure that each student
receives medically accurate, age-appropriate, and culturally
inclusive comprehensive sexual health education in elemen-
tary, middle, and high school, dedicated staff, including school-
based nurses and health educators, should be trained, provided
adequate time, and given necessary resources.
3. CDC, in collaboration with state and local departments of
health, should develop and evaluate the efficacy of promising
community-based approaches that are grounded in psychoso-
cial and behavioral research, extend reach into affected com-
munities, foster ongoing collaboration with community stake-
holders for capacity building and sustainability, and provide
allocation of sustained dedicated resources for formative work,
intervention implementation, evaluation, replication, and scale-
up of evidence-based interventions.
REFERENCES
Aarons, G. A., M. G. Ehrhart, L. R. Farahnak, and M. Sklar. 2014. Aligning leadership across
systems and organizations to develop a strategic climate for evidence-based practice
implementation. Annual Review of Public Health 35:255-274.
Aarons, G. A., M. G. Ehrhart, L. R. Farahnak, and M. S. Hurlburt. 2015. Leadership and
Organizational Change for Implementation (LOCI): A randomized mixed method pilot
study of a leadership and organization development intervention for evidence-based
practice implementation. Implementation Science 10:11.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PSYCHOSOCIAL AND BEHAVIORAL INTERVENTIONS 447
Aarons, G. A., M. G. Ehrhart, J. C. Moullin, E. M. Torres, and A. E. Green. 2017a. Testing
the Leadership and Organizational Change for Implementation (LOCI) intervention in
substance abuse treatment: A cluster randomized trial study protocol. Implementation
Science 12(1):29.
Aarons, G. A., M. Sklar, B. Mustanski, N. Benbow, and C. H. Brown. 2017b. “Scaling-out”
evidence-based interventions to new populations or new health care delivery systems.
Implementation Science 12(1):111.
Abad, N., B. N. Baack, A. O’Leary, Y. Mizuno, J. H. Herbst, and C. M. Lyles. 2015. A system-
atic review of HIV and STI behavior change interventions for female sex workers in
the United States. AIDS and Behavior 19(9):1701-1719.
Abara, W., J. D. Coleman, A. Fairchild, B. Gaddist, and J. White. 2015. A faith-based commu-
nity partnership to address HIV/AIDS in the southern United States: Implementation,
challenges, and lessons learned. Journal of Religion and Health 54(1):122-133.
Adimora, A. A., and J. D. Auerbach. 2010. Structural interventions for HIV prevention in the
United States. Journal of Acquired Immune Deficiency Syndromes 55:S132-S135.
Ajzen, I. 1991. The theory of planned behavior. Organizational Behavior and Human Decision
Processes 50(2):179-211.
Ajzen, I., and M. Fishbein. 1980. Understanding attitudes and predicting social behavior. Engle-
wood Cliffs, NJ: Prentice-Hall.
Akbar, M. B., J. French, and A. Lawson. 2020. Use of social marketing principles in sexual
health: An exploratory review. Social Business. 1-25.
Allen, J. D., L. A. Linnan, K. M. Emmons, R. Brownson, G. Colditz, and E. Proctor. 2012. Fi-
delity and its relationship to implementation effectiveness, adaptation, and dissemina-
tion. In Dissemination and implementation research in health: Translating science to practice.
Oxford, England: Oxford University Press. Pp. 281-304.
Amirkhanian, Y. A. 2014. Social networks, sexual networks and HIV risk in men who have
sex with men. Current HIV/AIDS Reports 11(1):81-92.
Auerswald, C. L., E. Sugano, J. M. Ellen, and J. D. Klausner. 2006. Street-based STD testing
and treatment of homeless youth are feasible, acceptable and effective. Journal of Ado-
lescent Health 38(3):208-212.
Bandura, A. 1977. Self-efficacy: Toward a unifying theory of behavioral change. Psychological
Review 84(2):191-215.
Bandura, A. 1986. Social foundations of thought and action: A social cognitive theory. Englewood
Cliffs, NJ: Prentice-Hall.
Bandura, A. 1994. Social cognitive theory of mass communication. In Media effects: Advances
in theory and research, LEA communication series. Hillsdale, NJ: Lawrence Erlbaum
Associates. Pp. 61-90.
Bandura, A. 2011. The social and policy impact of social cognitive theory. In Social psychology
and evaluation, edited by M. M. Mark, S. I. Donaldson, and B. Campbell. New York: The
Guilford Press. Pp. 31-71.
Bangi, A., M. M. Dolcini, G. W. Harper, C. B. Boyer, and L. M. Pollack. 2013. Psychosocial
outcomes of sexual risk reduction in a brief intervention for urban African American
female adolescents. Journal of HIV/AIDS & Social Services 12(2):146-159.
Barham, L., D. Lewis, and N. Latimer. 2007. One to one interventions to reduce sexually
transmitted infections and under the age of 18 conceptions: A systematic review of the
economic evaluations. Sexually Transmitted Infections 83(6):441.
Bauermeister, J. A., E. S. Pingel, L. Jadwin-Cakmak, G. W. Harper, K. Horvath, G. Weiss,
and P. Dittus. 2015. Acceptability and preliminary efficacy of a tailored online HIV/
STI testing intervention for young men who have sex with men: The Get Connected!
Program. AIDS and Behavior 19(10):1860-1874.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
448 SEXUALLY TRANSMITTED INFECTIONS
Bauermeister, J. A., R. C. Tingler, M. Demers, D. Connochie, G. Gillard, J. Shaver, T. Chavan-
duka, and G. W. Harper. 2019. Acceptability and preliminary efficacy of an online HIV
prevention intervention for single young men who have sex with men seeking partners
online: The Mydex project. AIDS and Behavior 23(11):3064-3077.
Blandford, J. M., and T. L. Gift. 2006. Productivity losses attributable to untreated chlamydial
infection and associated pelvic inflammatory disease in reproductive-aged women.
Sexually Transmitted Diseases 33(10 Suppl):S117-S121.
Boyer, C. B., J. M. Tschann, and M.-A. Shafer. 1999. Predictors of risk for sexually transmit-
ted diseases in ninth grade urban high school students. Journal of Adolescent Research
14(4):448-465.
Boyer, C. B., M.-A. Shafer, C. J. Wibbelsman, D. Seeberg, E. Teitle, and N. Lovell. 2000. As-
sociations of sociodemographic, psychosocial, and behavioral factors with sexual risk
and sexually transmitted diseases in teen clinic patients. Journal of Adolescent Health
27(2):102-111.
Boyer, C. B., J. Sieverding, J. Siller, A. Gallaread, and Y. J. Chang. 2007. Youth united through
health education: Community-level, peer-led outreach to increase awareness and im-
prove noninvasive sexually transmitted infection screening in urban African American
youth. Journal of Adolescent Health 40(6):499-505.
Boyer, C. B., L. Hightow-Weidman, J. Bethel, S. X. Li, L. Henry-Reid, D. Futterman, D. Ma-
turo, D. M. Straub, K. Howell, S. Reid, J. Lowe, B. G. Kapogiannis, and J. M. Ellen. 2013.
An assessment of the feasibility and acceptability of a friendship-based social network
recruitment strategy to screen at-risk African American and Hispanic/Latina young
women for HIV infection. JAMA Pediatrics 167(3):289-296.
Boyer, C. B., G. M. Robles-Schrader, S. X. Li, R. L. Miller, J. Korelitz, G. N. Price, C. M. Rivera
Torres, K. S. Chutuape, S. J. Stines, D. M. Straub, L. Peralta, I. Febo, L. Hightow-Wei-
dman, R. Gonin, B. G. Kapogiannis, and J. M. Ellen. 2014. A comparison of network-
based strategies for screening at-risk Hispanic/Latino adolescents and young adults
for undiagnosed asymptomatic HIV infection. Journal of Adolescent Health 55(6):765-773.
Brawner, B. M., J. L. Baker, J. Stewart, Z. M. Davis, J. Cederbaum, and L. S. Jemmott. 2013.
“The black man’s country club”: Assessing the feasibility of an HIV risk-reduction
program for young heterosexual African American men in barbershops. Family & Com-
munity Health 36(2):109-118.
Brewin, D., A. Koren, B. Morgan, S. Shipley, and R. L. Hardy. 2014. Behind closed doors:
School nurses and sexual education. Journal of School Nursing 30(1):31-41.
Brigham, K. S., M. J. Peer, B. B. Ghoshhajra, and J. P. T. Co. 2020. Increasing vaginal chla-
mydia trachomatis testing in adolescent and young adults. Pediatrics 146(2).
Brody, G. H., V. M. Murry, M. Gerrard, F. X. Gibbons, V. Molgaard, L. McNair, A. C. Brown,
T. A. Wills, R. L. Spoth, Z. Luo, Y. F. Chen, and E. Neubaum-Carlan. 2004. The strong
African American families program: Translating research into prevention program-
ming. Child Development 75(3):900-917.
Bronfenbrenner, U. 1979. The ecology of human development. Cambridge, MA: Harvard Uni-
versity Press.
Bronfenbrenner, U. 1986. Ecology of the family as a context for human development: Re-
search perspectives. Developmental Psychology 22(6):723-742.
Brown, C. A., and R. J. Lilford. 2006. The stepped wedge trial design: A systematic review.
BMC Medical Research Methodology 6(1):54.
Brown, C. H., T. R. Ten Have, B. Jo, G. Dagne, P. A. Wyman, B. Muthén, and R. D. Gibbons.
2009. Adaptive designs for randomized trials in public health. Annual Review of Public
Health 30:1-25.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PSYCHOSOCIAL AND BEHAVIORAL INTERVENTIONS 449
Brown, C. H., G. Curran, L. A. Palinkas, G. A. Aarons, K. B. Wells, L. Jones, L. M. Collins, N.
Duan, B. S. Mittman, A. Wallace, R. G. Tabak, L. Ducharme, D. A. Chambers, G. Neta,
T. Wiley, J. Landsverk, K. Cheung, and G. Cruden. 2017. An overview of research and
evaluation designs for dissemination and implementation. Annual Review of Public
Health 38:1-22.
Brückner, H., and P. Bearman. 2005. After the promise: The STD consequences of adolescent
virginity pledges. Journal of Adolescent Health 36(4):271-278.
Bull, S. S., D. K. Levine, S. R. Black, S. J. Schmiege, and J. Santelli. 2012. Social media-deliv-
ered sexual health intervention: A cluster randomized controlled trial. American Journal
of Preventive Medicine 43(5):467-474.
Cameron, A., E. Smith, N. Mercer, and B. Sundstrom. 2020. “It is our duty”: Understanding
parents’ perspectives on reproductive and sexual health education. Sexual Education
20(5):535-551.
Carr, J. B., and A. Packham. 2017. The effects of state-mandated abstinence-based sex educa-
tion on teen health outcomes. Health Economics 26(4):403-420.
Caruthers, A. S., M. J. Van Ryzin, and T. J. Dishion. 2014. Preventing high-risk sexual be-
havior in early adulthood with family interventions in adolescence: Outcomes and
developmental processes. Prevention Science (15 Suppl 1):S59-S69.
Catania, J. A., S. M. Kegeles, and T. J. Coates. 1990. Towards an understanding of risk be-
havior: An AIDS Risk Reduction Model (ARRM). Health Education Quarterly 17(1):53-72.
CDC (Centers for Disease Control and Prevention). 2019a. Community approaches to reducing
STDs: Community engagement toolkit. Atlanta, GA: Department of Health and Human
Services, Centers for Disease Control and Prevention, National Center for HIV/AIDS,
Viral Hepatitis, STD, and TB Prevention, Division of STD Prevention, Office of Health
Equity.
CDC. 2019b. School health profiles 2018: Characteristics of health programs among secondary
schools. Atlanta, GA: Centers for Disease Control and Prevention.
CDC. 2020a. Compendium of evidence-based interventions and best practices for HIV prevention.
https://www.cdc.gov/hiv/research/interventionresearch/compendium/index.html
(accessed November 12, 2020).
CDC. 2020b. Community approaches to reducing sexually transmitted diseases. Atlanta, GA: De-
partment of Health and Human Services, Centers for Disease Control and Prevention,
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of
STD Prevention, Office of Health Equity.
CDC AIDS Community Demonstration Projects Research Group. 1999. Community-level
HIV intervention in 5 cities: Final outcome data from the CDC AIDS community dem-
onstration projects. American Journal of Public Health 89(3):336-345.
Champion, J. D., B. Harlin, and J. L. Collins. 2013. Sexual risk behavior and STI health lit-
eracy among ethnic minority adolescent women. Applied Nursing Research 26(4):204-209.
Champion, V. L., and C. S. Skinner. 2008. The health belief model. In Health behavior and health
education: Theory, research, and practice, 4th ed., edited by K. Glanz, B. K. Rimer, and K.
Viswanath. San Francisco, CA: Jossey-Bass. Pp. 45-65.
Charania, M. R., N. Crepaz, C. Guenther-Gray, K. Henny, A. Liau, L. A. Willis, and C. M.
Lyles. 2011. Efficacy of structural-level condom distribution interventions: A meta-
analysis of U.S. and international studies, 1998-2007. AIDS and Behavior 15(7):1283-1297.
Chin, H. B., T. A. Sipe, R. Elder, S. L. Mercer, S. K. Chattopadhyay, V. Jacob, H. R. Wethington,
D. Kirby, D. B. Elliston, M. Griffith, S. O. Chuke, S. C. Briss, I. Ericksen, J. S. Galbraith,
J. H. Herbst, R. L. Johnson, J. M. Kraft, S. M. Noar, L. M. Romero, and J. Santelli. 2012.
The effectiveness of group-based comprehensive risk-reduction and abstinence educa-
tion interventions to prevent or reduce the risk of adolescent pregnancy, human im-
munodeficiency virus, and sexually transmitted infections: Two systematic reviews for
the guide to community preventive services. American Journal of Preventative Medicine
42(3):272-294.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
450 SEXUALLY TRANSMITTED INFECTIONS
Chinman, M., P. Imm, A. Wandersman, S. Kaftarian, J. Neal, K. T. Pendleton, and C. Ring-
walt. 2001. Using the Getting to Outcomes (GTO) model in a statewide prevention
initiative. Health Promotion Practice 2(4):302-309.
Chinman, M., S. B. Hunter, P. Ebener, S. M. Paddock, L. Stillman, P. Imm, and A. Wandersman.
2008. The Getting to Outcomes demonstration and evaluation: An illustration of the
prevention support system. American Journal of Community Psychology 41(3-4):206-224.
Chinman, M., J. Acosta, P. Ebener, P. S. Malone, and M. E. Slaughter. 2018. A cluster-random-
ized trial of Getting to Outcomes’ impact on sexual health outcomes in community-
based settings. Prevention Science 19(4):437-448.
Chutuape, K. S., M. Ziff, C. Auerswald, M. Castillo, A. McFadden, and J. Ellen. 2009. Ex-
amining differences in types and location of recruitment venues for young males and
females from urban neighborhoods: Findings from a multi-site HIV prevention study.
Journal of Urban Health 86(1):31-42.
Collins, L. M. 2018. Optimization of behavioral, biobehavioral, and biomedical interventions: The
multiphase optimization strategy (MOST). Cham, Switzerland: Springer International
Publishing AG.
Collins, L. M., K. C. Kugler, and M. V. Gwadz. 2016. Optimization of multicomponent behav-
ioral and biobehavioral interventions for the prevention and treatment of HIV/AIDS.
AIDS and Behavior (20 Suppl 1):S197-S214.
Community Preventive Services Task Force. 2015. 2014-2015 annual report to Congress, federal
agencies and prevention stakeholders, including a special update on recommendations to pre-
vent cancers. https://www.thecommunityguide.org/sites/default/files/assets/2015-
congress-report-full_0.pdf (accessed February 22, 2021).
Conner, M., and P. Norman. 2005. Predicting health behaviour: A social cognition approach.
Predicting Health Behaviour:1-27.
Covey, J., H. E. Rosenthal-Stott, and S. J. Howell. 2016. A synthesis of meta-analytic evi-
dence of behavioral interventions to reduce HIV/STIs. Journal of Behavioral Medicine
39(3):371-385.
Crepaz, N., A. K. Horn, S. M. Rama, T. Griffin, J. B. Deluca, M. M. Mullins, and S. O. Aral.
2007. The efficacy of behavioral interventions in reducing HIV risk sex behaviors and
incident sexually transmitted disease in black and Hispanic sexually transmitted dis-
ease clinic patients in the United States: A meta-analytic review. Sexually Transmitted
Diseases 34(6):319-332.
Crepaz, N., K. J. Marshall, L. W. Aupont, E. D. Jacobs, Y. Mizuno, L. S. Kay, P. Jones, D. H.
McCree, and A. O’Leary. 2009. The efficacy of HIV/STI behavioral interventions for
African American females in the United States: A meta-analysis. American Journal of
Public Health 99(11):2069-2078.
Daniel-Ulloa, J., M. Ulibarri, B. Baquero, C. Sleeth, H. Harig, and S. D. Rhodes. 2016. Behav-
ioral HIV prevention interventions among Latinas in the U.S.: A systematic review of
the evidence. Journal of Immigrant and Minority Health 18(6):1498-1521.
De Vasconcelos, S., I. Toskin, B. Cooper, M. Chollier, R. Stephenson, K. Blondeel, T. Trous-
sier, and J. Kiarie. 2018. Behaviour change techniques in brief interventions to prevent
HIV, STI and unintended pregnancies: A systematic review. PLoS One 13(9):e0204088.
Dearing, J. W., and K. F. Kee. 2012. Historical roots of dissemination and implementation
science. Dissemination and Implementation Research in Health: Translating Science to Practice
55:71.
Denford, S., C. Abraham, R. Campbell, and H. Busse. 2017. A comprehensive review of re-
views of school-based interventions to improve sexual-health. Health Psychology Review
11(1):33-52.
Derose, K. P., B. A. Griffin, D. E. Kanouse, L. M. Bogart, M. V. Williams, A. C. Haas, K. R.
Flórez, D. O. Collins, J. Hawes-Dawson, M. A. Mata, C. W. Oden, and B. D. Stucky.
2016. Effects of a pilot church-based intervention to reduce HIV stigma and promote
HIV testing among African Americans and Latinos. AIDS and Behavior 20(8):1692-1705.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PSYCHOSOCIAL AND BEHAVIORAL INTERVENTIONS 451
Deverka, P. A., D. C. Lavallee, P. J. Desai, L. C. Esmail, S. D. Ramsey, D. L. Veenstra, and S.
R. Tunis. 2012. Stakeholder participation in comparative effectiveness research: Defin-
ing a framework for effective engagement. Journal of Comparative Effectiveness Research
1(2):181-194.
DiClemente, R. J., L. F. Salazar, and R. A. Crosby. 2007. A review of STD/HIV preventive
interventions for adolescents: Sustaining effects using an ecological approach. Journal
of Pediatric Psychology 32(8):888-906.
DiClemente, R. J., C. P. Crittenden, E. Rose, J. M. Sales, G. M. Wingood, R. A. Crosby, and
L. F. Salazar. 2008. Psychosocial predictors of HIV-associated sexual behaviors and
the efficacy of prevention interventions in adolescents at-risk for HIV infection: What
works and what doesn’t work? Psychosomatic Medicine 70(5):598-605.
DiClemente, R. J., G. M. Wingood, J. M. Sales, J. L. Brown, E. S. Rose, T. L. Davis, D. L. Lang,
A. Caliendo, and J. W. Hardin. 2014. Efficacy of a telephone-delivered sexually trans-
mitted infection/human immunodeficiency virus prevention maintenance intervention
for adolescents: A randomized clinical trial. JAMA Pediatrics 168(10):938-946.
Dolcini, M. M., G. W. Harper, C. B. Boyer, and L. M. Pollack. 2010. Project ORE: A friendship-
based intervention to prevent HIV/STI in urban African American adolescent females.
Health Education & Behavior 37(1):115-132.
Dworkin, S. L., R. M. Pinto, J. Hunter, B. Rapkin, and R. H. Remien. 2008. Keeping the spirit
of community partnerships alive in the scale up of HIV/AIDS prevention: Critical
reflections on the roll out of DEBI (diffusion of effective behavioral interventions).
American Journal of Community Psychology 42(1-2):51-59.
Eaton, L. A., T. B. Huedo-Medina, S. C. Kalichman, J. A. Pellowski, M. J. Sagherian, M. War-
ren, A. R. Popat, and B. T. Johnson. 2012. Meta-analysis of single-session behavioral
interventions to prevent sexually transmitted infections: Implications for bundling
prevention packages. American Journal of Public Health 102(11):e34-e44.
Egeland, K. M., A. S. Skar, M. Endsjø, E. H. Laukvik, H. Bækkelund, A. Babaii, L. B. Granly,
G. K. Husebø, R. H. Borge, M. G. Ehrhart, M. Sklar, C. H. Brown, and G. A. Aarons.
2019. Testing the Leadership and Organizational Change for Implementation (LOCI)
intervention in Norwegian mental health clinics: A stepped-wedge cluster randomized
design study protocol. Implementation Science 14(1):28.
Eisenberg, M. E., N. Madsen, J. A. Oliphant, and R. E. Sieving. 2013. Barriers to providing
the sexuality education that teachers believe students need. Journal of School Health
83(5):335-342.
Ellen, J. M., C. Gaydos, S. E. Chung, N. Willard, L. V. Lloyd, and C. A. Rietmeijer. 2006. Sex
partner selection, social networks, and repeat sexually transmitted infections in young
men: A preliminary report. Sexually Transmitted Diseases 33(1):18-21.
Escoffery, C., E. Lebow-Skelley, R. Haardoerfer, E. Boing, H. Udelson, R. Wood, M. Hartman,
M. E. Fernandez, and P. D. Mullen. 2018. A systematic review of adaptations of
evidence-based public health interventions globally. Implementation Science 13(1):125.
Espada, J. P., A. Morales, A. Guillén-Riquelme, R. Ballester, and M. Orgilés. 2016. Predicting
condom use in adolescents: A test of three socio-cognitive models using a structural
equation modeling approach. BMC Public Health 16:35.
Estrada, Y., T. K. Lee, S. Huang, M. I. Tapia, M. R. Velázquez, M. J. Martinez, H. Pantin, M.
A. Ocasio, D. C. Vidot, L. Molleda, J. Villamar, B. A. Stepanenko, C. H. Brown, and G.
Prado. 2017. Parent-centered prevention of risky behaviors among Hispanic youths in
Florida. American Journal of Public Health 107(4):607-613.
Estrada, Y., T. K. Lee, R. Wagstaff, M. R. L, M. I. Tapia, M. R. Velázquez, K. Sardinas, H.
Pantin, M. Y. Sutton, and G. Prado. 2019. eHealth Familias Unidas: Efficacy trial of an
evidence-based intervention adapted for use on the Internet with Hispanic families.
Prevention Science 20(1):68-77.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
452 SEXUALLY TRANSMITTED INFECTIONS
Ethier, K. A., P. J. Dittus, C. J. DeRosa, E. Q. Chung, E. Martinez, and P. R. Kerndt. 2011.
School-based health center access, reproductive health care, and contraceptive
use among sexually experienced high school students. Journal of Adolescent Health
48(6):562-565.
Evans, C., and H. Lambert. 2008. Implementing community interventions for HIV preven-
tion: Insights from project ethnography. Social Science & Medicine 66(2):467-478.
Ewan, L. A., D. McLinden, F. Biro, M. DeJonckheere, and L. M. Vaughn. 2016. Mapping the
views of adolescent health stakeholders. Journal of Adolescent Health 58(1):24-32.
Facebook. 2018. Mark Zuckerberg facebook post. https://www.facebook.com/zuck/
posts/10104413015393571 (accessed November 16, 2020).
Fernandez, M. A., and S. M. Eyberg. 2009. Predicting treatment and follow-up attrition in
parent-child interaction therapy. Journal of Abnormal Child Psychology 37(3):431-441.
Fishbein, M., and I. Ajzen. 1975. Belief, attitude, intention and behaviour: An introduction to
theory and research. Reading, MA: Addison-Wesley.
Fisher, J. D., and W. A. Fisher. 1992. Changing AIDS-risk behavior. Psychological Bulletin
111(3):455-474.
Fisher, J., W. Fisher, S. Williams, and T. Malloy. 1994. Empirical tests of an information-
motivation-behavioral skills model of AIDS-preventive behavior with gay men and
heterosexual university students. Health Psychology 13:238-250.
Fisher, W. A., S. S. Williams, J. D. Fisher, and T. E. Malloy. 1999. Understanding AIDS risk
behavior among sexually active urban adolescents: An empirical test of the informa-
tion–motivation–behavioral skills model. AIDS and Behavior 3(1):13-23.
Flay, B. R., A. Biglan, R. F. Boruch, F. G. Castro, D. Gottfredson, S. Kellam, E. K. Mościcki,
S. Schinke, J. C. Valentine, and P. Ji. 2005. Standards of evidence: Criteria for efficacy,
effectiveness and dissemination. Prevention Science 6(3):151-175.
Fox, S. n.d. Key data points on U.S. teens and adults. https://susannahfox.com/research (ac-
cessed November 17, 2020).
Francis, D. B., S. M. Noar, D. A. Fortune, and A. A. Adimora. 2018. “Be straight up and so
will he”: Evaluation of a novel HIV prevention condom distribution and health com-
munication intervention targeting young African American females. AIDS Education
and Prevention 30(2):137-151.
Friedman, A. L., R. E. Kachur, S. M. Noar, and M. McFarlane. 2016. Health communi-
cation and social marketing campaigns for sexually transmitted disease prevention
and control: What is the evidence of their effectiveness? Sexually Transmitted Diseases
43(2):S83-S101.
Friedman, S. R., M. J. Downing, Jr., P. Smyrnov, G. Nikolopoulos, J. A. Schneider, B. Livak, G.
Magiorkinis, L. Slobodianyk, T. I. Vasylyeva, D. Paraskevis, M. Psichogiou, V. Sypsa, M.
M. Malliori, and A. Hatzakis. 2014. Socially-integrated transdisciplinary HIV preven-
tion. AIDS and Behavior 18(10):1821-1834.
Garett, R., and S. D. Young. 2019. Health care gamification: A study of game mechanics and
elements. Technology, Knowledge and Learning 24(3):341-353.
Gerrard, M., F. X. Gibbons, A. E. Houlihan, M. L. Stock, and E. A. Pomery. 2008. A dual-
process approach to health risk decision making: The prototype willingness model.
Developmental Review 28(1):29-61.
Globerman, J., S. Mitra, D. Gogolishvili, S. Rueda, L. Schoffel, K. Gangbar, Q. Shi, and
S. B. Rourke. 2017. HIV/STI prevention interventions: A systematic review and meta-
analysis. Open Medicine 12:450-467.
González-Guarda, R. M., B. E. McCabe, A. Florom-Smith, R. Cianelli, and N. Peragallo. 2011.
Substance abuse, violence, HIV, and depression: An underlying syndemic factor among
latinas. Nursing Research 60(3):182-189.
Grabowski, M. K., J. T. Herbeck, and A. F. Y. Poon. 2018. Genetic cluster analysis for HIV
prevention. Current HIV/AIDS Reports 15(2):182-189.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PSYCHOSOCIAL AND BEHAVIORAL INTERVENTIONS 453
Griffith, D. M., L. C. Pichon, B. Campbell, and J. O. Allen. 2010. Your blessed health: A
faith-based CBPR approach to addressing HIV/AIDS among African Americans. AIDS
Education and Prevention 22(3):203-217.
Guilamo-Ramos, V., J. Jaccard, and E. Casillas. 2004. The Parents Matter! Program: Practi-
cal, theoretical and methodological perspectives. Journal of Child and Family Studies
13(1):113-123.
Guilamo-Ramos, V., J. Jaccard, P. Dittus, A. Bouris, B. Gonzalez, E. Casillas, and S. Banspach.
2011. A comparative study of interventions for delaying the initiation of sexual
intercourse among Latino and black youth. Perspectives on Sexual Reproductive Health
43(4):247-254.
Guilamo-Ramos, V., A. Benzekri, and M. Thimm-Kaiser. 2019. Parent-based interventions to
affect adolescent sexual and reproductive health: Reconsidering the best evidence vs
all evidence. JAMA Pediatrics 173(9):821-823.
Guilamo-Ramos, V., A. Benzekri, M. Thimm-Kaiser, P. Dittus, Y. Ruiz, C. M. Cleland, and W.
McCoy. 2020. A triadic intervention for adolescent sexual health: A randomized clinical
trial. Pediatrics 145(5):e20192808.
Guttmacher Institute. 2020. Sex and HIV education. https://www.guttmacher.org/state-
policy/explore/sex-and-hiv-education (accessed November 12, 2020).
Hall, K. S., J. McDermott Sales, K. A. Komro, and J. Santelli. 2016. The state of sex education
in the United States. Journal of Adolescent Health 58(6):595-597.
Hanley, S. M., C. Ringwalt, S. T. Ennett, A. A. Vincus, J. M. Bowling, S. W. Haws, and L. A.
Rohrbach. 2010. The prevalence of evidence-based substance use prevention curricula
in the nation’s elementary schools. Journal of Drug Education 40(1):51-60.
Hawkins, J. D., R. F. Catalano, M. W. Arthur, E. Egan, E. C. Brown, R. D. Abbott, and D. M.
Murray. 2008. Testing Communities That Care: The rationale, design and behavioral
baseline equivalence of the community youth development study. Prevention Science
9(3):178-190.
Hawkins, J. D., S. Oesterle, E. C. Brown, M. W. Arthur, R. D. Abbott, A. A. Fagan, and R.
F. Catalano. 2009. Results of a type 2 translational research trial to prevent adolescent
drug use and delinquency: A test of Communities That Care. Archives of Pediatrics &
Adolescent Medicine 163(9):789-798.
Head, K. J., S. M. Noar, N. T. Iannarino, and N. Grant Harrington. 2013. Efficacy of text
messaging-based interventions for health promotion: A meta-analysis. Social Science
& Medicine 97:41-48.
Hekler, E. B., S. Michie, M. Pavel, D. E. Rivera, L. M. Collins, H. B. Jimison, C. Garnett, S.
Parral, and D. Spruijt-Metz. 2016. Advancing models and theories for digital behavior
change interventions. American Journal of Preventive Medicine 51(5):825-832.
Henderson, J. T., C. A. Senger, M. Henninger, S. I. Bean, N. Redmond, and E. A. O’Connor.
2020. Behavioral counseling interventions to prevent sexually transmitted infections:
Updated evidence report and systematic review for the U.S. Preventive Services Task
Force. JAMA 324(7):682-699.
Herbst, J. H., C. Beeker, A. Mathew, T. McNally, W. F. Passin, L. S. Kay, N. Crepaz, C. M.
Lyles, P. Briss, S. Chattopadhyay, and R. L. Johnson. 2007. The effectiveness of indi-
vidual-, group-, and community-level HIV behavioral risk-reduction interventions for
adult men who have sex with men: A systematic review. American Journal of Preventative
Medicine 32(4 Suppl):S38-S67.
Hogben, M., H. Chesson, and S. O. Aral. 2010. Sexuality education policies and sexually
transmitted disease rates in the United States of America. International Journal of STD
& AIDS 21(4):293-297.
Hunter, R. F., K. de la Haye, J. M. Murray, J. Badham, T. W. Valente, M. Clarke, and F. Kee.
2019. Social network interventions for health behaviours and outcomes: A systematic
review and meta-analysis. PLoS Medicine 16(9):e1002890.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
454 SEXUALLY TRANSMITTED INFECTIONS
IOM (Institute of Medicine). 2014. Strategies for scaling effective family-focused preventive inter-
ventions to promote children’s cognitive, affective, and behavioral health: Workshop summary.
Washington, DC: The National Academies Press.
Israel, B. A., E. A. Parker, Z. Rowe, A. Salvatore, M. Minkler, J. López, A. Butz, A. Mosley,
L. Coates, G. Lambert, P. A. Potito, B. Brenner, M. Rivera, H. Romero, B. Thompson, G.
Coronado, and S. Halstead. 2005. Community-based participatory research: Lessons
learned from the Centers for Children’s Environmental Health and Disease Prevention
Research. Environmental Health Perspectives 113(10):1463-1471.
Janz, N. K., and M. H. Becker. 1984. The health belief model: A decade later. Health Education
Quarterly 11(1):1-47.
Jemmott, J. B., 3rd, L. S. Jemmott, G. T. Fong, and K. McCaffree. 1999. Reducing HIV risk-
associated sexual behavior among African American adolescents: Testing the generality
of intervention effects. American Journal of Community Psychology 27(2):161-187.
Jemmott, L. S., J. B. Jemmott, Y. Lanier, C. Thompson, and J. L. Baker. 2017. Development of a
barbershop-based HIV/STI risk reduction intervention for young heterosexual African
American men. Health Promotion Practice 18(1):110-118.
Jemmott, L. S., J. B. Jemmott, 3rd, L. D. Icard, and J. Hsu. 2020. Effects of church-based
parent-child abstinence-only interventions on adolescents’ sexual behaviors. Journal of
Adolescent Health 66(1):107-114.
Jenkins, R. A. 2014. Supplemental issue on does early intervention prevent health-risking
sexual behaviors related to HIV/AIDS: Commentary on effects. Prevention Science
15(1):84-86.
Jensen, M. R., J. J. Wong, N. A. Gonzales, L. E. Dumka, R. Millsap, and S. Coxe. 2014. Long-
term effects of a universal family intervention: Mediation through parent-adolescent
conflict. Journal of Clinical Child & Adolescent Psychology 43(3):415-427.
Johnson, M. O. 2011. The shifting landscape of health care: Toward a model of health care
empowerment. American Journal of Public Health 101(2):265-270.
Johnson, R. L., P. D. Stanford, W. Douglas, Jr., G. Botwinick, and E. Marino. 2001. High-
risk sexual behaviors among adolescents engaged through a street-based peer out-
reach program—(the Adolescent HIV Project). Journal of the National Medical Association
93(5):170-177.
Johnson-Motoyama, M., M. Moses, T. K. Kann, E. S. Mariscal, M. Levy, C. Navarro, and
P. J. Fite. 2016. Parent, teacher, and school stakeholder perspectives on adolescent
pregnancy prevention programming for Latino youth. Journal of Primary Prevention
37(6):513-525.
Kanamori, M., M. Rosa, C. H. Shrader, C. Munayco, S. Doblecki-Lewis, G. Prado, S. Safren,
M. J. Trepka, and K. Fujimoto. 2019. Progreso en salud: Findings from two adapted so-
cial network HIV risk reduction interventions for Latina seasonal workers. International
Journal of Environmental Research and Public Health 16(22).
Kegeles, S. M., and G. J. Hart. 1998. Recent HIV-prevention interventions for gay men:
Individual, small-group and community-based studies. AIDS (12 Suppl A):S209-S215.
Kegeles, S. M., R. B. Hays, and T. J. Coates. 1996. The Mpowerment Project: A community-
level HIV prevention intervention for young gay men. American Journal of Public Health
86(8):1129-1136.
Kelly, J. A., J. S. St Lawrence, Y. E. Diaz, L. Y. Stevenson, A. C. Hauth, T. L. Brasfield, S. C.
Kalichman, J. E. Smith, and M. E. Andrew. 1991. HIV risk behavior reduction follow-
ing intervention with key opinion leaders of population: An experimental analysis.
American Journal of Public Health 81(2):168-171.
Kerrigan, D. L., V. A. Fonner, S. Stromdahl, and C. E. Kennedy. 2013. Community empow-
erment among female sex workers is an effective HIV prevention intervention: A sys-
tematic review of the peer-reviewed evidence from low- and middle-income countries.
AIDS and Behavior 17(6):1926-1940.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PSYCHOSOCIAL AND BEHAVIORAL INTERVENTIONS 455
KFF (Kaiser Family Foundation). 2018. Abstinence education programs: Definition, funding,
and impact on teen sexual behavior. https://www.kff.org/womens-health-policy/fact-
sheet/abstinence-education-programs-definition-funding-and-impact-on-teen-sexual-
behavior (accessed November 12, 2020).
Kimbrough, L. W., H. E. Fisher, K. T. Jones, W. Johnson, S. Thadiparthi, and S. Dooley. 2009.
Accessing social networks with high rates of undiagnosed HIV infection: The Social
Networks demonstration project. American Journal of Public Health 99(6):1093-1099.
Kiousis, S. 2002. Interactivity: A concept explication. New Media and Society 4(3):355-384.
Kirby, D. 2007. Emerging answers: Research findings on programs to reduce teen pregnancy and
sexually transmitted diseases. https://powertodecide.org/sites/default/files/resources/
primary-download/emerging-answers.pdf (accessed November 12, 2020).
Klovdahl, A. S., J. J. Potterat, D. E. Woodhouse, J. B. Muth, S. Q. Muth, and W. W. Darrow.
1994. Social networks and infectious disease: The Colorado Springs study. Social Science
& Medicine 38(1):79-88.
Kocsis, T. 2020. A critical analysis of sexuality education in the United States: Toward an inclusive
curriculum for social justice. New York: Routledge.
Krebs, P., J. O. Prochaska, and J. S. Rossi. 2010. A meta-analysis of computer-tailored inter-
ventions for health behavior change. Preventive Medicine 51(3-4):214-221.
Leslie, L. K., C. J. Mehus, J. D. Hawkins, T. Boat, M. A. McCabe, S. Barkin, E. C. Perrin,
C. W. Metzler, G. Prado, V. F. Tait, R. Brown, and W. Beardslee. 2016. Primary health
care: Potential home for family-focused preventive interventions. American Journal of
Preventative Medicine 51(4 Suppl 2):S106-S118.
Leventhal, H. 1973. Changing attitudes and habits to reduce risk factors in chronic disease.
American Journal of Cardiology 31(5):571-580.
Li, D. H., D. A. Moskowitz, K. Macapagal, R. Saber, and B. Mustanski. 2020. Using inter-
vention mapping to developmentally adapt an online HIV risk reduction program for
adolescent men who have sex with men. Prevention Science 21(7):885-897.
Lightfoot, A. F., T. Taggart, B. A. Woods-Jaeger, L. Riggins, M. R. Jackson, and E. Eng. 2014.
Where is the faith? Using a CBPR approach to propose adaptations to an evidence-
based HIV prevention intervention for adolescents in African American faith settings.
Journal of Religion and Health 53(4):1223-1235.
Lightfoot, M. A., C. K. Campbell, N. Moss, S. Treves-Kagan, E. Agnew, M. S. Kang Dufour,
H. Scott, A. M. Sa’id, and S. A. Lippman. 2018. Using a social network strategy to
distribute HIV self-test kits to African American and Latino MSM. Journal of Acquired
Immune Deficiency Syndromes 79(1):38-45.
Logan, T. K., J. Cole, and C. Leukefeld. 2002. Women, sex, and HIV: Social and contextual
factors, meta-analysis of published interventions, and implications for practice and
research. Psychological Bulletin 128(6):851-885.
Long, L., C. Abraham, R. Paquette, M. Shahmanesh, C. Llewellyn, A. Townsend, and R.
Gilson. 2016. Brief interventions to prevent sexually transmitted infections suitable for
in-service use: A systematic review. Preventive Medicine 91:364-382.
Lopez, L. M., T. W. Grey, M. Chen, E. E. Tolley, and L. L. Stockton. 2016. Theory-based in-
terventions for contraception. Cochrane Database of Systematic Reviews 11(11):CD007249.
Love, H., S. Soleimanpour, N. Panchal, J. Schlitt, C. Behr, and M. Even. 2018. 2016-17 national
school-based health care census report. Washington, DC: School-Based Health Alliance.
Love, H. E., J. Schlitt, S. Soleimanpour, N. Panchal, and C. Behr. 2019. Twenty years of
school-based health care growth and expansion. Health Affairs (Millwood) 38(5):755-764.
Lugo-Gil, J., A. Lee, D. Vohra, K. Adamek, J. Lacoe, and B. Goesling. 2016. Updated findings
from the HHS teen pregnancy prevention evidence review: July 2014 through August 2015.
Washington, DC: Department of Health and Human Services.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
456 SEXUALLY TRANSMITTED INFECTIONS
Lustria, M. L. A., J. Cortese, S. M. Noar, and R. L. Glueckauf. 2009. Computer-tailored health
interventions delivered over the web: Review and analysis of key components. Patient
Education and Counseling 74(2):156-173.
Lustria, M. L. A., S. M. Noar, J. Cortese, S. K. Van Stee, R. L. Glueckauf, and J. Lee. 2013. A
meta-analysis of web-delivered tailored health behavior change interventions. Journal
of Health Communication 18(9):1039-1069.
Malekinejad, M., A. Parriott, J. C. Blodgett, H. Horvath, R. K. Shrestha, A. B. Hutchinson, P.
Volberding, and J. G. Kahn. 2017. Effectiveness of community-based condom distribu-
tion interventions to prevent HIV in the United States: A systematic review and meta-
analysis. PLoS One 12(8):e0180718.
McAlister, A. L., C. L. Perry, and G. S. Parcel. 2008. How individuals, environments, and
health behaviors interact: Social cognitive theory. In Health behavior and health education:
Theory, research, and practice, 4th ed., edited by K. Glanz, B. K. Rimer, and K. Viswanath.
San Francisco, CA: Jossey-Bass. Pp. 169-188.
McDade, R. S., R. A. Vidourek, K. S. Biradar, K. A. King, and A. A. Merianos. 2019. Impact
of parental communication on African American adolescent sexual behavior: A mini
literature review. Sexuality and Culture 24(5):1579-1593.
McGoy, S. L., A. C. Pettit, M. Morrison, L. R. Alexander, P. Johnson, B. Williams, D. Ban-
ister, M. K. Young, C. Wester, and P. F. Rebeiro. 2018. Use of social network strategy
among young Black men who have sex with men for HIV testing, linkage to care, and
reengagement in care, Tennessee, 2013-2016. Public Health Reports 133(2 Suppl):43s-51s.
McLeroy, K., D. Bibeau, A. Steckler, and K. D. Glanz. 1988. An ecology perspective on health
promotion programs. Health Education Quarterly 15:351-377.
McLeroy, K. R., B. L. Norton, M. C. Kegler, J. N. Burdine, and C. V. Sumaya. 2003. Commu-
nity-based interventions. American Journal of Public Health 93(4):529-533.
Merzel, C., and J. D’Afflitti. 2003. Reconsidering community-based health promotion: Prom-
ise, performance, and potential. American Journal of Public Health 93(4):557-574.
Mevissen, F. E., R. A. Ruiter, R. M. Meertens, F. Zimbile, and H. P. Schaalma. 2011. Justify
your love: Testing an online STI-risk communication intervention designed to promote
condom use and STI-testing. Psychology and Health 26(2):205-221.
Miedema, E., M. L. J. Le Mat, and F. Hague. 2020. But is it comprehensive? Unpacking
the “comprehensive” in comprehensive sexuality education. Health Education Journal
79(7):747-762.
Milat, A. J., L. King, A. E. Bauman, and S. Redman. 2013. The concept of scalability: Increas-
ing the scale and potential adoption of health promotion interventions into policy and
practice. Health Promotion International 28(3):285-298.
Molleda, L., M. Bahamon, S. M. St George, T. Perrino, Y. Estrada, D. Correa Herrera, H.
Pantin, and G. Prado. 2017. Clinic personnel, facilitator, and parent perspectives of
ehealth Familias Unidas in primary care. Journal of Pediatric Health Care 31(3):350-361.
Montano, D., and D. Kasprzyk. 2015. Theory of reasoned action, theory of planned behavior,
and the integrated behavioral model. In Health behavior: Theory, research, and practice.
Vol. 4, edited by K. Glanz, B. K. Rimer, and K. V. Viswanath. San Francisco, CA: Jossey-
Bass. Pp. 95-124.
Morales, A., J. P. Espada, M. Orgilés, S. Escribano, B. T. Johnson, and M. Lightfoot. 2018.
Interventions to reduce risk for sexually transmitted infections in adolescents: A meta-
analysis of trials, 2008-2016. PLoS One 13(6).
Morgan, E., B. Skaathun, G. K. Nikolopoulos, D. Paraskevis, L. D. Williams, P. Smyrnov, S.
R. Friedman, and J. A. Schneider. 2019. A network intervention to locate newly HIV
infected persons within MSM networks in Chicago. AIDS and Behavior 23(1):15-20.
Morris, Z. S., S. Wooding, and J. Grant. 2011. The answer is 17 years, what is the question:
Understanding time lags in translational research. Journal of the Royal Society of Medicine
104(12):510-520.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PSYCHOSOCIAL AND BEHAVIORAL INTERVENTIONS 457
Nababan, H., E. Ota, W. Wariki, A. Koyanagi, S. Ezoe, K. Shibuya, and R. Tobe-Gai. 2011.
Structural and community-level interventions for increasing condom use to prevent
HIV and other sexually transmitted infections. (Protocol). Cochrane Database of System-
atic Reviews 11:CD003363.
NCI (National Cancer Institute). n.d. About implementation science. https://cancercontrol.
cancer.gov/is (accessed January 25, 2021).
NIH (National Institutes of Health). 1995. Family interventions and HIV/AIDS. https://grants.
nih.gov/grants/guide/rfa-files/RFA-MH-95-002.html (accessed November 12, 2020).
Nikolopoulos, G. K., E. Pavlitina, S. Q. Muth, J. Schneider, M. Psichogiou, L. D. Williams,
D. Paraskevis, V. Sypsa, G. Magiorkinis, P. Smyrnov, A. Korobchuk, T. I. Vasylyeva,
B. Skaathun, M. Malliori, E. Kafetzopoulos, A. Hatzakis, and S. R. Friedman. 2016. A
network intervention that locates and intervenes with recently HIV-infected persons:
The Transmission Reduction Intervention Project (TRIP). Scientific Reports 6:38100.
Noar, S. M., and N. G. Harrington. 2012. eHealth applications: An introduction and over-
view. In eHealth applications: Promising strategies for behavior change, edited by S. M. Noar
and N. G. Harrington. New York: Routledge.
Noar, S. M., C. N. Benac, and M. S. Harris. 2007. Does tailoring matter? Meta-analytic review
of tailored print health behavior change interventions. Psychological Bulletin 133(4):673.
NRC (National Research Council). 1987. Risking the future: Adolescent sexuality, pregnancy, and
childbearing, volume II: Working papers and statistical appendices, edited by S. L. Hofferth
and C. D. Hayes. Washington, DC: National Academy Press.
OBSSR (Office of Behavioral and Social Sciences Research). 2019. BSSR definition. https://
obssr.od.nih.gov/about/bssr-definition/#ref1 (accessed December 31, 2020).
Oesterle, S., M. R. Kuklinski, J. D. Hawkins, M. L. Skinner, K. Guttmannova, and I. C.
Rhew. 2018. Long-term effects of the Communities That Care trial on substance use,
antisocial behavior, and violence through age 21 years. American Journal of Public Health
108(5):659-665.
Ott, M. A., J. Campbell, T. M. Imburgia, Z. Yang, W. Tu, and C. L. Auerswald. 2018. Commu-
nity engagement and venue-based sampling in adolescent male sexually transmitted
infection prevention research. Journal of Adolescent Health 62(3 Suppl):S58-S64.
Padian, N. S., A. Buvé, J. Balkus, D. Serwadda, and W. Cates. 2008. Biomedical inter-
ventions to prevent HIV infection: Evidence, challenges, and way forward. Lancet
372(9638):585-599.
Pantin, H., G. Prado, B. Lopez, S. Huang, M. I. Tapia, S. J. Schwartz, E. Sabillon, C. H. Brown,
and J. Branchini. 2009. A randomized controlled trial of Familias Unidas for Hispanic
adolescents with behavior problems. Psychosomatic Medicine 71(9):987-995.
Pequegnat, W., and J. Szapocznik. 2000. Working with families in the era of HIV/AIDS. London,
UK: Sage Publications.
Perrin, E. C., R. C. Sheldrick, J. M. McMenamy, B. S. Henson, and A. S. Carter. 2014. Improv-
ing parenting skills for families of young children in pediatric settings: A randomized
clinical trial. JAMA Pediatrics 168(1):16-24.
Perrino, T., A. Gonzalez-Soldevilla, H. Pantin, and J. Szapocznik. 2000. The role of families
in adolescent HIV prevention: A review. Clinical Child and Family Psychology Review
3(2):81-96.
Perrino, T., Y. Estrada, S. Huang, S. S. George, H. Pantin, M. Á. Cano, T. K. Lee, and G. Prado.
2018. Predictors of participation in an ehealth, family-based preventive intervention for
Hispanic youth. Prevention Science 19(5):630-641.
Peskin, M., B. Hernandez, C. Markham, K. Baker, S. Tyrrell, R. Addy, R. Shegog, P. Cuccaro,
P. DeRoulet, and S. Tortolero. 2011. Sexual health education from the perspective of
school staff: Implications for adoption and implementation of effective programs in
middle school. Journal of Applied Research on Children 2(2):Article 9.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
458 SEXUALLY TRANSMITTED INFECTIONS
Pinto, R. M., K. R. Berringer, R. Melendez, and O. Mmeje. 2018. Improving PrEP implemen-
tation through multilevel interventions: A synthesis of the literature. AIDS Behavior
22(11):3681-3691.
Pitpitan, E. V., S. C. Kalichman, L. A. Eaton, S. A. Strathdee, and T. L. Patterson. 2013. HIV/
STI risk among venue-based female sex workers across the globe: A look back and the
way forward. Current HIV/AIDS Reports 10(1):65-78.
Power to Decide. 2016. Survey says: Parent power. https://powertodecide.org/system/files/
resources/primary-download/Talking%20is%20Power_Survey%20Says_002.pdf (ac-
cessed November 4, 2020).
Prado, G., H. Pantin, S. J. Schwartz, N. S. Lupei, and J. Szapocznik. 2006. Predictors of
engagement and retention into a parent-centered, ecodevelopmental HIV preventive
intervention for Hispanic adolescents and their families. Journal of Pediatric Psychology
31(9):874-890.
Prado, G., H. Pantin, E. Briones, S. J. Schwartz, D. Feaster, S. Huang, S. Sullivan, M. I. Tapia,
E. Sabillon, B. Lopez, and J. Szapocznik. 2007. A randomized controlled trial of a parent-
centered intervention in preventing substance use and HIV risk behaviors in Hispanic
adolescents. Journal of Consulting and Clinical Psychology 75(6):914-926.
Prado, G. J., S. J. Schwartz, M. Maldonado-Molina, S. Huang, H. M. Pantin, B. Lopez, and
J. Szapocznik. 2009. Ecodevelopmental × intrapersonal risk: Substance use and sexual
behavior in Hispanic adolescents. Health Education & Behavior 36(1):45-61.
Prado, G., D. Cordova, S. Huang, Y. Estrada, A. Rosen, G. A. Bacio, G. Leon Jimenez, H.
Pantin, C. H. Brown, M. R. Velazquez, J. Villamar, D. Freitas, M. I. Tapia, and K. McCol-
lister. 2012. The efficacy of Familias Unidas on drug and alcohol outcomes for Hispanic
delinquent youth: Main effects and interaction effects by parental stress and social
support. Drug and Alcohol Dependence 125(Suppl 1):S18-S25.
Prado, G., Y. Estrada, L. M. Rojas, M. Bahamon, H. Pantin, M. Nagarsheth, L. Gwynn, A. Y.
Ofir, L. Q. Forster, N. Torres, and C. H. Brown. 2019. Rationale and design for ehealth
Familias Unidas primary care: A drug use, sexual risk behavior, and STI preventive
intervention for Hispanic youth in pediatric primary care clinics. Contemporary Clinical
Trials 76:64-71.
Proctor, E., H. Silmere, R. Raghavan, P. Hovmand, G. Aarons, A. Bunger, R. Griffey, and M.
Hensley. 2011. Outcomes for implementation research: Conceptual distinctions, mea-
surement challenges, and research agenda. Administration and Policy in Mental Health
38(2):65-76.
Rabin, B. A., and R. C. Brownson. 2017. Terminology for dissemination and implementa-
tion research. Dissemination and Implementation Research in Health: Translating Science to
Practice 2:19-45.
Rabin, B. A., R. C. Brownson, D. Haire-Joshu, M. W. Kreuter, and N. L. Weaver. 2008. A glos-
sary for dissemination and implementation research in health. Journal of Public Health
Management and Practice 14(2):117-123.
Rankin, K., J. Jarvis-Thiébault, N. Pfeifer, M. Englebert, J. Perng, S. Yoon, and A. Heard. 2016.
Adolescent sexual and reproductive health: An evidence gap map (report 5). Washington, DC:
International Initiative for Impact Evaluation (3ie).
Reedtz, C., B. H. Handegård, and W. T. Mørch. 2011. Promoting positive parenting practices
in primary pare: Outcomes and mechanisms of change in a randomized controlled risk
reduction trial. Scandinavian Journal of Psychology 52(2):131-137.
Reider, E. E., E. B. Robertson, and B. E. Sims. 2014. Does early intervention prevent health-
risking sexual behaviors related to HIV/AIDS? Prevention Science (15 Suppl 1):S1-S5.
Reinhart, R. J. 2020. Nurses continue to rate highest in honesty, ethics. https://news.gallup.com/
poll/274673/nurses-continue-rate-highest-honesty-ethics.aspx (accessed November 12,
2020).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PSYCHOSOCIAL AND BEHAVIORAL INTERVENTIONS 459
Rhew, I. C., J. D. Hawkins, D. M. Murray, A. A. Fagan, S. Oesterle, R. D. Abbott, and R. F.
Catalano. 2016. Evaluation of community-level effects of Communities That Care on
adolescent drug use and delinquency using a repeated cross-sectional design. Preven-
tion Science 17(2):177-187.
Rhodes, S. D., K. C. Hergenrather, F. R. Bloom, J. S. Leichliter, and J. Montaño. 2009. Out-
comes from a community-based, participatory lay health adviser HIV/STD prevention
intervention for recently arrived immigrant Latino men in rural North Carolina. AIDS
Education and Prevention 21(5 Suppl):103-108.
Rietmeijer, K., and M. Scahill. 2012. Behavioral interventions for STD/HIV prevention. https://
www.cdc.gov/std/training/std101/presentations-2012/behavioral-interventions.pdf
(accessed February 22, 2021).
Robin, L., P. Dittus, D. Whitaker, R. Crosby, K. Ethier, J. Mezoff, K. Miller, and K. Pappas-
Deluca. 2004. Behavioral interventions to reduce incidence of HIV, STD, and pregnancy
among adolescents: A decade in review. Journal of Adolescent Health 34(1):3-26.
Rogers, R. W. 1983. Cognitive and physiological processes in fear appeals and attitude
change: A revised theory of protection motivation. In Social psychophysiology: A source-
book, edited by J. T. Cacioppo and R. E. Petty. New York: Guilford Press. Pp. 153-176.
Ross, M. W., and M. L. Williams. 2002. Effective targeted and community HIV/STD preven-
tion programs. Journal of Sex Research 39(1):58-62.
Rothenberg, R., T. D. M. Hoang, S. Q. Muth, and R. Crosby. 2007. The Atlanta Urban Adoles-
cent Network study: A network view of STD prevalence. Sexually Transmitted Diseases
34(8):525-531.
Rotheram-Borus, M. J., C. Koopman, and A. A. Ehrhardt. 1991a. Homeless youths and HIV
infection. American Psychologist 46(11):1188.
Rotheram-Borus, M. J., C. Koopman, C. Haignere, and M. Davies. 1991b. Reducing HIV
sexual risk behaviors among runaway adolescents. JAMA 266(9):1237-1241.
Rotheram-Borus, M. J., D. Swendeman, D. Flannery, E. Rice, D. M. Adamson, and B. In-
gram. 2009. Common factors in effective HIV prevention programs. AIDS and Behavior
13(3):399-408.
Sales, J. M., R. R. Milhausen, and R. J. Diclemente. 2006. A decade in review: Building on
the experiences of past adolescent STI/HIV interventions to optimise future prevention
efforts. Sexually Transmitted Infections 82(6):431-436.
Sandler, I., S. A. Wolchik, G. Cruden, N. E. Mahrer, S. Ahn, A. Brincks, and C. H. Brown.
2014. Overview of meta-analyses of the prevention of mental health, substance use, and
conduct problems. Annual Review of Clinical Psychology 10:243-273.
Santelli, J. S., L. M. Kantor, S. A. Grilo, I. S. Speizer, L. D. Lindberg, J. Heitel, A. T. Schalet,
M. E. Lyon, A. J. Mason-Jones, T. McGovern, C. J. Heck, J. Rogers, and M. A. Ott. 2017.
Abstinence-only-until-marriage: An updated review of U.S. policies and programs and
their impact. Journal of Adolescent Health 61(3):273-280.
Schneider, J. A., L. Young, A. Ramachandran, S. Michaels, H. Cohen, I. Robinson, L. Alon,
B. Hill, S. Nakasone, M. Balenciaga, D. Motley, A. Bouris, A. Khanna, M. Ferreira, T.
Valente, P. Schumm, and PrEP Chicago Network Intervention Team. 2021. A prag-
matic randomized controlled trial to increase pre-exposure prophylaxis uptake for HIV
prevention: 55-week results from PrEPChicago. Journal of Acquired Immune Deficiency
Syndromes 86(1):31-37.
Schueler, K., M. Ferreira, G. Nikolopoulos, B. Skaathun, D. Paraskevis, A. Hatzakis, S. R.
Friedman, and J. A. Schneider. 2019. Pre-exposure prophylaxis (PrEP) awareness and
use within high HIV transmission networks. AIDS and Behavior 23(7):1893-1903.
Shepherd, L. M., K. F. Sly, and J. M. Girard. 2017. Comparison of comprehensive and
abstinence-only sexuality education in young African American adolescents. Journal
of Adolescence 61:50-63.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
460 SEXUALLY TRANSMITTED INFECTIONS
Sieverding, J., C. B. Boyer, J. Siller, A. Gallaread, M. Krone, and Y. J. Chang. 2005. Youth
united through health education: Building capacity through a community collabora-
tive intervention to prevent HIV/STD in adolescents residing in a high STD prevalent
neighborhood. AIDS Education and Prevention 17(4):375-385.
Simoni, J. M., K. Ronen, and F. M. Aunon. 2018. Health behavior theory to enhance
ehealth intervention research in HIV: Rationale and review. Current HIV/AIDS Reports
15(6):423-430.
Singer, M. C., P. I. Erickson, L. Badiane, R. Diaz, D. Ortiz, T. Abraham, and A. M. Nicolay-
sen. 2006. Syndemics, sex and the city: Understanding sexually transmitted diseases in
social and cultural context. Social Science & Medicine 63(8):2010-2021.
Smith, B. D., E. Teshale, A. Jewett, C. M. Weinbaum, A. Neaigus, H. Hagan, S. M. Jenness, S.
K. Melville, R. Burt, H. Thiede, A. Al-Tayyib, P. R. Pannala, I. W. Miles, A. M. Oster, A.
Smith, T. Finlayson, K. E. Bowles, and E. A. Dinenno. 2011. Performance of premarket
rapid hepatitis C virus antibody assays in 4 national human immunodeficiency virus
behavioral surveillance system sites. Clinical Infectious Diseases 53(8):780-786.
Smokowski, P., R. Corona, M. Bacallao, B. L. Fortson, K. J. Marshall, and A. Yaros. 2018.
Addressing barriers to recruitment and retention in the implementation of parenting
programs: Lessons learned for effective program delivery in rural and urban areas.
Journal of Child and Family Studies 27(9):2925-2942.
Spoth, R., C. Redmond, C. Hockaday, and C. Y. Shin. 1996. Barriers to participation in fam-
ily skills preventive interventions and their evaluations: A replication and extension.
Family Relations 45(3):247-254.
Spoth, R., C. Goldberg, and C. Redmond. 1999. Engaging families in longitudinal preventive
intervention research: Discrete-time survival analysis of socioeconomic and social–
emotional risk factors. Journal of Consulting and Clinical Psychology 67(1):157-163.
Spoth, R. L., M. Guyll, and S. X. Day. 2002. Universal family-focused interventions in
alcohol-use disorder prevention: Cost-effectiveness and cost-benefit analyses of two
interventions. Journal of Studies on Alcohol and Drugs 63(2):219-228.
Spoth, R., S. Clair, and L. Trudeau. 2014. Universal family-focused intervention with young
adolescents: Effects on health-risking sexual behaviors and STDs among young adults.
Prevention Science (15 Suppl 1):S47-S58.
Spoth, R. L., L. S. Trudeau, C. Redmond, C. Shin, M. T. Greenberg, M. E. Feinberg, and G. H.
Hyun. 2015. Prosper Partnership delivery system: Effects on adolescent conduct prob-
lem behavior outcomes through 6.5 years past baseline. Journal of Adolescence 45:44-55.
Sundar, S. S., S. Kalyanaraman, and J. Brown. 2003. Explicating web site interactivity: Impres-
sion formation effects in political campaign sites. Communication Research 30(1):30-59.
Sundell, K., and T. Olsson. 2017. Social intervention research. https://www.oxfordbibliog-
raphies.com/view/document/obo-9780195389678/obo-9780195389678-0254.xml (ac-
cessed December 31, 2020).
Sutton, M. Y., S. M. Lasswell, Y. Lanier, and K. S. Miller. 2014. Impact of parent–child
communication interventions on sex behaviors and cognitive outcomes for Black/
African-American and Hispanic/Latino youth: A systematic review, 1988-2012. Journal
of Adolescent Health 54(4):369-384.
Swanton, R., V. Allom, and B. Mullan. 2015. A meta-analysis of the effect of new-media
interventions on sexual-health behaviours. Sexually Transmitted Infections 91(1):14-20.
Szapocznik, J., G. Prado, A. K. Burlew, R. A. Williams, and D. A. Santisteban. 2007. Drug
abuse in African American and Hispanic adolescents: Culture, development, and be-
havior. Annual Review of Clinical Psychology 3:77-105.
Taylor, D., C. Lunny, P. Lolic, O. Warje, J. Geldman, T. Wong, M. Gilbert, R. Lester, and G.
Ogilvie. 2019. Effectiveness of text messaging interventions on prevention, detection,
treatment, and knowledge outcomes for sexually transmitted infections (STIs)/HIV: A
systematic review and meta-analysis. Systematic Reviews 8(1):12.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PSYCHOSOCIAL AND BEHAVIORAL INTERVENTIONS 461
Thompson, C. T. 2020. Tiffani Kocsis: Critical analysis of sexuality education in the United
States: Toward an inclusive curriculum for social justice. Journal of Youth and Adolescence
49(8):1751-1753.
Tolou-Shams, M., E. Dauria, S. M. Conrad, K. Kemp, S. Johnson, and L. K. Brown. 2017.
Outcomes of a family-based HIV prevention intervention for substance using juvenile
offenders. Journal of Substance Abuse Treatment 77:115-125.
Trenholm, C., B. Devaney, K. Fortson, M. Clark, L. Q. Bridgespan, and J. Wheeler. 2008.
Impacts of abstinence education on teen sexual activity, risk of pregnancy, and risk of
sexually transmitted diseases. Journal of Policy Analysis and Management 27(2):255-276.
Trickett, E. J., S. Beehler, C. Deutsch, L. W. Green, P. Hawe, K. McLeroy, R. L. Miller, B. D.
Rapkin, J. J. Schensul, A. J. Schulz, and J. E. Trimble. 2011. Advancing the science of
community-level interventions. American Journal of Public Health 101(8):1410-1419.
Underhill, K., D. Operario, and P. Montgomery. 2007. Abstinence-only programs for HIV
infection prevention in high-income countries. Cochrane Database of Systematic Reviews
(4):CD005421.
Valente, T. W. 2012. Network interventions. Science 337(6090):49-53.
Vaughn, L. M., E. Wagner, and F. Jacquez. 2013. A review of community-based participatory
research in child health. American Journal of Maternal/Child Nursing 38(1):48-53.
Walling, E. B., N. Benzoni, J. Dornfeld, R. Bhandari, B. A. Sisk, J. Garbutt, and G. Colditz.
2016. Interventions to improve HPV vaccine uptake: A systematic review. Pediatrics
138(1).
Wandersman, A., P. Imm, M. Chinman, and S. Kaftarian. 2000. Getting to Outcomes: A
results-based approach to accountability. Evaluation and Program Planning 23(3):389-395.
Wang, K., K. Brown, S. Y. Shen, and J. Tucker. 2011. Social network-based interventions to
promote condom use: A systematic review. AIDS and Behavior 15(7):1298-1308.
Wendell, D. A., D. A. Cohen, D. LeSage, and T. A. Farley. 2003. Street outreach for HIV
prevention: Effectiveness of a state-wide programme. International Journal of STD &
AIDS 14(5):334-340.
Widman, L., J. Nesi, K. Kamke, S. Choukas-Bradley, and J. L. Stewart. 2018. Technology-
based interventions to reduce sexually transmitted infections and unintended preg-
nancy among youth. Journal of Adolescent Health 62(6):651-660.
Willoughby, J. F., and K. L. L’Engle. 2015. Influence of perceived interactivity of a sexual
health text message service on young people’s attitudes, satisfaction and repeat use.
Health Education Research 30(6):996-1003.
Willoughby, J. F., and A. Muldrow. 2017. SMS for sexual health: A comparison of service
types and recommendations for sexual health text message service providers. Health
Education Journal 76(2):231-243.
Wilson, T. E., M. Fraser-White, K. M. Williams, A. Pinto, F. Agbetor, B. Camilien, K. Henny,
R. C. Browne, Y. Gousse, T. Taylor, H. Brown, R. Taylor, and M. A. Joseph. 2014. Barber-
shop talk with brothers: Using community-based participatory research to develop and
pilot test a program to reduce HIV risk among Black heterosexual men. AIDS Education
and Prevention 26(5):383-397.
Wylie, J. L., and A. N. N. Jolly. 2001. Patterns of chlamydia and gonorrhea infection in sexual
networks in Manitoba, Canada. Sexually Transmitted Diseases 28(1).
Young, S. D. 2020. The Adaptive Behavioral Components (ABC) model for planning lon-
gitudinal behavioral technology-based health interventions: A theoretical framework.
Journal of Medical Internet Research 22(6):e15563.
Young, S. D., and D. Jaganath. 2013. Online social networking for HIV education and preven-
tion: A mixed-methods analysis. Sexually Transmitted Diseases 40(2):162-167.
Young, S. D., and A. H. Jordan. 2013. The influence of social networking photos on social
norms and sexual health behaviors. Cyberpsychology, Behavior, and Social Networking
16(4):243-247.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
462 SEXUALLY TRANSMITTED INFECTIONS
Young, S. D., W. G. Cumberland, S. J. Lee, D. Jaganath, G. Szekeres, and T. Coates. 2013. So-
cial networking technologies as an emerging tool for HIV prevention. Annals of Internal
Medicine 159(5):318-324.
Young, S. D., I. Holloway, D. Jaganath, E. Rice, D. Westmoreland, and T. Coates. 2014. Project
Hope: Online social network changes in an HIV prevention randomized controlled
trial for African American and Latino men who have sex with men. American Journal of
Public Health 104(9):1707-1712.
Young, S. D., W. G. Cumberland, R. Nianogo, L. A. Menacho, J. T. Galea, and T. Coates.
2015. The HOPE social media intervention for global HIV prevention in Peru: A cluster
randomised controlled trial. Lancet HIV 2(1):27-32.
Zimmerman, R. S., S. M. Noar, S. Feist-Price, O. Dekthar, P. K. Cupp, E. Anderman, and S.
Lock. 2007. Longitudinal test of a multiple domain model of adolescent condom use.
Journal of Sex Research 44(4):380-394.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Structural Interventions
Chapter Contents
Introduction
Structural Interventions to Decrease STIs in Marginalized U.S.
Groups and Reduce STI Inequities
• Root Causes of STI Inequities
• Looking to the Future
Macro-Level Structural Interventions to Decrease STIs in the
U.S. Population Overall
• Health Policies
• Social Policies
Meso-Level Structural Interventions to Decrease Overall STI
Rates and STI Inequities
• Structural Interventions in the:
o Health Care System
o Education System
o Criminal Legal System
o Congregate Care Systems
463
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
464 SEXUALLY TRANSMITTED INFECTIONS
Chapter Contents Continued
Community Mobilization for Structural Change Related to STIs
and HIV
• Approaches and Strategies
• Domains, Indicators, and Structural Change Objectives
• Assessing the Impact of Community Mobilization Efforts
• Gaps in Community Mobilization Research Around STIs
• Community Mobilization Research Limitations
• Implications of HIV Literature for STIs
Conclusions and Recommendation
INTRODUCTION
Structural interventions in public health are interventions that pro-
mote population health and/or health equity by altering the structural
context within which health is produced (Blankenship et al., 2006). Struc-
tural interventions hold great promise for advancing both population
health and health equity because they change or influence social, eco-
nomic, or political environments (the root causes of health and health
inequities) in ways that help many people collectively, often even without
their knowledge or relying on individual behavior change (CSDH, 2008;
Miller et al., 2018b; NASEM, 2017). Structural interventions may promote
population health overall or address health inequities in particular (Blan-
kenship et al., 2006; Brown et al., 2019).
While both are important, there is a difference between addressing
individuals’ social needs (e.g., providing relief for an immediate housing
need) and using structural interventions to address the underlying struc-
tural-level social, economic, and political factors that drive these individual
social needs, which is the focus of this chapter (Brown et al., 2019; Castrucci
and Auerbach, 2019; Green and Zook, 2019; WHO, 2010).
Structural interventions for sexually transmitted infection (STI) pre-
vention include policies, programs, practices, and norms that address
the structural-level social, economic, and political drivers of STIs and
STI inequities. They target social contextual factors at both the macro
(e.g., policies, social norms, societal distribution of power and resources)
and meso (e.g., social networks, community resources, local health care
system) levels (see Figure 9-1). Macro-level structural interventions target
factors such as federal and state health and social policies and structural
discrimination related to race and ethnicity, sexual orientation, and gen-
der identity, among other dimensions of social inequality. Meso-level
Copyright National Academy of Sciences. All rights reserved.
STI Macro-Level Structural Interventions:
• Address policies, social norms, distribution of power and resources with
broad reach
• Interventions target federal/state health and social policies, structural
discrimination
STI Meso-Level Structural Interventions:
• Address community/local norms, resources, and systems with more
immediate institutions in which individuals or groups are involved
• Interventions target local educational, health care, and legal systems
and institutions, community norms/resources, social networks
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
FIGURE 9-1 Macro- and meso-level structural interventions.
Copyright National Academy of Sciences. All rights reserved.
465
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
466 SEXUALLY TRANSMITTED INFECTIONS
interventions target factors such as local educational, health care, and
legal systems and institutions, community norms and resources, and
social networks. As noted, structural interventions can be implemented
at multiple levels—including the national, state, local, and institutional
levels (Bonell et al., 2006; Rhodes et al., 2005; Sumartojo, 2000). Structural
and social behavioral interventions should work together as part of multi-
level interventions to address the societal determinants of STIs.
This chapter covers structural interventions that address the high
rates of STIs among marginalized social groups in particular and the U.S.
population in general at both the macro level—including health and social
policies addressing structural inequities—and the meso level—including
structural interventions in health and social systems and community
mobilization strategies to advance structural change.
STRUCTURAL INTERVENTIONS TO DECREASE STIs IN
MARGINALIZED U.S. GROUPS AND REDUCE STI INEQUITIES
The federal government, at least for many Black people, is not widely
trusted due to years of racism at all levels, medical and research
misconduct like the Tuskegee syphilis cases, and just general lack of trust.
To get information out there, it has to come from more trusted sources.
—Participant, lived experience panel1
Root Causes of STI Inequities
As noted earlier in this report, STI incidence and prevalence show
pronounced inequities across a number of dimensions of social inequality
(e.g., gender, race, ethnicity, socioeconomic position, sexual orientation).
Scholars and researchers have observed that health inequities ultimately
stem from social, economic, and political contexts and mechanisms (also
referred to as social and structural determinants of health [e.g., laws, policies,
political practices, social norms]). These inequities are shaped by histori-
cal factors and organize the unequal distribution of power, prestige, and
other resources among social groups defined in relation to race, ethnicity,
gender identity, socioeconomic position, sexual orientation, and immi-
grant status, among other axes (NASEM, 2017; WHO, 2010).
These structural determinants of health in turn cause and operate
through the social determinants of health: housing, education, income,
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.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
STRUCTURAL INTERVENTIONS 467
wealth, social cohesion and support, psychosocial stressors (including
interpersonal discrimination), built environment, and health care, among
others. Due to their inequitable distribution and access for social groups,
these determinants shape not only population health but also health
equity (CSDH, 2008; Hatzenbuehler et al., 2010; NASEM, 2017).
In particular, research suggests that structural inequities—societal-
level policies, practices, norms, and conditions that undermine the social
position of marginalized populations and their access to health-promoting
social, economic, political, and health care resources—influence the dis-
proportionate burden of STIs among marginalized racial, ethnic, gen-
der identity, and sexual orientation groups, among others (CSDH, 2008).
Although promising, research examining the effect on STI inequities of
structural interventions that target structural inequities, however, remains
scarce (Brown et al., 2019). This section discusses the small but grow-
ing literature that has addressed how structural inequities—structural
racism and structural stigma against lesbian, gay, bisexual, transgen-
der, and queer (LGBTQ+) individuals—shape STI inequities, including
in the distribution of STIs across sexual orientation identity and racial
and ethnic groups, respectively. It also offers insights into the types of
structural interventions that might help decrease STI rates in marginal-
ized communities.
Structural Anti-LGBTQ+ Stigma and Sexual Orientation Inequities in STIs
Research indicates that the health of sexual minority (e.g., LGBTQ+)
groups can be negatively impacted by structural stigma, defined as
“societal-level conditions, cultural norms, and institutional policies and
practices that constrain the lives of the stigmatized” (Hatzenbuehler and
Link, 2014, p. 2). Structural stigma is often operationalized as discrimina-
tory state-level policies that undermine the health and rights of sexual
minorities.
To date, most studies examining structural stigma and health among
sexual minorities have focused on mental health outcomes—including
psychiatric morbidity (Hatzenbuehler et al., 2010), substance use (Hatzen-
buehler et al., 2015), and suicide attempts (Hatzenbuehler, 2011; Raifman
et al., 2017)—and have shown that sexual minorities living in states with
high levels of structural stigma have worse mental health outcomes than
their counterparts living in states with low levels of structural stigma.
Few studies have examined the association between structural stigma and
sexual health. Charlton et al. (2019) found, however, that sexual minority
adolescent women living in states with lower compared to higher levels
of structural stigma were significantly less likely to have an STI diagnosis,
adjusting for individual- and state-level covariates. Stigma was measured
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
468 SEXUALLY TRANSMITTED INFECTIONS
by the density of same-sex partner households, proportion of high schools
with gay–straight alliances, a composite variable of five state-level protec-
tive policies related to sexual orientation (e.g., employment nondiscrimina-
tion policies), and public opinion toward sexual minorities data. This study
suggests that changing state-level laws and policies and social norms to be
inclusive of sexual minorities may be a structural intervention to mitigate
the STI burden of young sexual minority women (Charlton et al., 2019).
Additionally, Oldenburg et al. (2015) found that state-level structural
stigma toward sexual minorities (as measured by state-level density of
same-sex households, proportion of gay–straight alliances, state laws
protecting sexual minorities, and public opinion toward sexual minori-
ties) was associated with lower odds of condomless anal sex and higher
odds of post- and pre-exposure prophylaxis awareness and use and of
comfort discussing male–male sexual behavior with health care providers
among U.S. gay, bisexual, same-gender-loving, and other men who have
sex with men (MSM), adjusting for individual- and state-level covariates.
Additional research is needed to better ascertain the role of structural
stigma in shaping STI inequities related to sexual orientation among both
women and men in the United States. This study suggests, however, that
structural interventions such as changing state-level laws and policies to
prevent discrimination and stigma against sexual minorities and norms to
be more favorable toward sexual minorities may help decrease STI rates
among MSM (Oldenburg et al., 2015). Along with community-based inter-
ventions that seek to decrease anti-LGBTQ+ discrimination and stigma
at the institutional/organizational, community, and interpersonal levels,
these state-level structural interventions could contribute to a decrease in
STIs in LGBTQ+ communities.
In a global context, Pachankis et al. (2015) found that MSM living
in European countries with high levels of structural stigma related to
sexual orientation (as measured by national laws, policies, and attitudes
regarding LGBTQ+ individuals) had higher odds of sexual risk behaviors,
unmet HIV prevention needs, HIV testing nonuse, and sexual orienta-
tion nondisclosure compared to their counterparts in countries with low
levels of structural stigma. The authors also found that MSM migrants in
European countries with high levels of anti-LGBTQ+ and anti-immigrant
structural stigma (as measured by national laws and policies toward
LGBTQ+ populations and national attitudes toward immigrants) had
lower levels of human papillomavirus (HPV)-related prevention knowl-
edge, behaviors, and service coverage compared to those in countries with
low levels of structural stigma (Pachankis and Bränström, 2018). Similar
research could be conducted in the U.S. context by comparing individuals
living in states with high versus low levels of structural stigma related to
both sexual minorities and immigrants.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
STRUCTURAL INTERVENTIONS 469
Structural Racism and Racial and Ethnic Inequities in STIs
Structural racism refers to “the totality of ways in which societies
foster racial discrimination, through mutually reinforcing inequitable
systems (in housing, education, employment, earnings, benefits, credit,
media, health care, criminal justice, and so on) that in turn reinforce dis-
criminatory beliefs, values, and distribution of resources, which together
affect the risk of adverse health outcomes” among populations of color
(Bailey et al., 2017). One example is Black individuals living in system-
atically under-resourced neighborhoods that have high levels of unem-
ployment, homelessness, and incarceration (Bailey et al., 2017). While
structural racism has broad population health impacts, historical and
contemporary practices and patterns of pervasive discrimination toward
Black, Latino/a, and Indigenous people and other individuals of color
in health care and social systems both directly and indirectly shape STI
outcomes in marginalized racial and ethnic groups. Of note, historical and
contemporary factors related to the health care system that shape access
to and use of STI testing and treatment services among marginalized
populations have historically included coercive experimental gynecologi-
cal surgery on enslaved Black women, the infamous Tuskegee Syphilis
Study on Black men, unethical medical research on the bodies of Black
people, such as Henrietta Lacks (whose biopsied cells were used without
consent to create the HeLa cell line, which has been used in research for
more than 50 years and remains the oldest and most commonly used cell
line in existence), and forced and coerced sterilization of Black, Latina,
and Indigenous women throughout the 20th and 21st centuries (Roberts,
2016)—all of which promote medical mistrust and the delay and avoid-
ance of STI-related care (IOM, 2003).
Moreover, discrimination in other social systems, including housing,
education, employment, criminal justice, and media, indirectly shape
racial and ethnic STI inequities in the United States by undermining
the access of marginalized groups to health-promoting resources (e.g.,
income), increasing exposure to STIs (e.g., mass incarceration, racial resi-
dential segregation), and promoting negative stereotypes (e.g., media rep-
resentations) about their behavior, including sexual behavior, that under-
mine equitable treatment in society in general and the health care system
in particular (Adimora and Schoenbach, 2005; Bailey et al., 2017; Fried-
man et al., 2009; Krieger, 2003). For example, in a 2019 ecological study,
researchers found a statistically significant positive association between
the median number of Black individuals killed by police (racialized police
brutality, a form of structural racism) and syphilis and gonorrhea rates
among Black residents across 75 large U.S. metropolitan statistical areas
(MSAs) (Ibragimov et al., 2019c). Furthermore, scientists found a statisti-
cally significant positive association between residential segregation of
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
470 SEXUALLY TRANSMITTED INFECTIONS
Black individuals, a dimension of structural racism, and gonorrhea rates
across 277 U.S. MSAs (Pugsley et al., 2013).
Similarly, one study found a statistically significant positive asso-
ciation between racial residential segregation and newly diagnosed HIV
cases among Black heterosexual individuals across 95 large U.S. MSAs
and evidence that this association may be mediated by Black/white
socioeconomic inequality (Ibragimov et al., 2019a). This research sug-
gests that developing, testing, and implementing structural interventions
that address the effect of structural racism (e.g., mass incarceration, racial
residential segregation, racialized policing) may decrease STIs among
communities of color and reduce racial and ethnic inequities in STIs
(Adimora and Auerbach, 2010; Blankenship et al., 2000, 2006; Ibragimov
et al., 2019a).
Additionally, very few interventions addressing the effect of interme-
diary social determinants of health influenced by structural racism (e.g.,
housing, employment, access to health care, incarceration) on racial and
ethnic STI inequities have been developed and tested or evaluated using
experimental or quasi-experimental research methods. One example is a
randomized controlled trial Towe et al. (2019) focused on homeless indi-
viduals living with HIV/AIDS to see if rapid rehousing would improve
housing and HIV viral suppression more than standard housing assis-
tance. Those in the rapid rehousing group were placed faster, more likely
to be placed, and twice as likely to achieve or maintain suppression.
Another recent example is the Adolescent Trials Network study (Work to
Prevent—ATN 151), which aims to test whether an employment interven-
tion, including working with employers, can reduce HIV/STI transmis-
sion behaviors among sexual and gender minority adolescents of color
(Hill et al., 2020). In 2020, the Community Preventive Services Task Force
concluded that that economic evidence shows that benefits exceed the
intervention cost for Housing First programs in the United States and
that these programs showed health benefits and reduced health services
use (Peng et al., 2020). For clients living with HIV infection, Housing First
programs reduced homelessness by 37 percent, viral load by 22 percent,
and mortality by 37 percent (Peng et al., 2020). Clinical trial networks,
however, rarely support interventions such as these.
Looking to the Future
Public health researchers and research funders need to conduct and
support the development, evaluation, implementation, and dissemination
of new or existing interventions that address both the upstream structural
and intermediary social determinants of racial and ethnic inequities in
STIs at the federal, state, county, city, or neighborhood level by engaging
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
STRUCTURAL INTERVENTIONS 471
government agencies, advocates, community-based organizations, com-
munity organizers, activists, and members, and other key stakeholders
(Adimora and Auerbach, 2010; Blankenship et al., 2000, 2006; Boyer et al.,
2016; Valdiserri and Holtgrave, 2019). For example, Los Angeles County
health officials recently attributed the rise in STI rates to structural racism
and vowed to evaluate and address its effects in partnership with commu-
nities (Karlamangla, 2018). Public health researchers could help to evalu-
ate such efforts in partnership with government officials and community
organizations and, in turn, contribute to the evidence base on structural
interventions and racial and ethnic inequities in STIs.
Furthermore, in a recent editorial, Fullilove (2020) urged STI research-
ers to stop focusing on race and instead move toward examining the
“proxy factors” that shape racial and ethnic inequities in STIs and design-
ing programs, policies, and other interventions to address them. This
recommendation is aligned with the committee’s call to examine and
address how structural racism, as a root cause, shapes racial and ethnic
STI inequities (see Recommendation 9-1).
Several public health and health care organizations (e.g., American
Public Health Association, American Medical Association), states, cities,
and counties, academic institutions, and scholars have declared racism a
public health crisis (AMA, 2020; APHA, 2020, n.d.; ASTHO, 2020; Dirr,
2019; Jones, 2018; Thulin, 2020; Vestal, 2020; Walters, 2020; Yearby et al.,
2020). Such declarations should seek to raise public awareness and dis-
course about how structural racism affects population health outcomes
and health inequities, including STI rates and inequities. These declara-
tions also need to determine key societal actions, inform the allocation of
public funds, and lead to committing other social, economic, and political
resources to address structural racism and other social inequities and their
effect on the health of marginalized racial and ethnic groups and the U.S.
population as a whole.
MACRO-LEVEL STRUCTURAL INTERVENTIONS TO
DECREASE STIs IN THE U.S. POPULATION OVERALL
Health Policies
Research suggests that federal and state health policies, such as the
Patient Protection and Affordable Care Act (ACA) (including federal and
state provisions, such as the optional Medicaid expansion, summarized
in Chapters 4 and 10) and state HPV vaccination policies, sexuality edu-
cation policies, and minor STI testing consent laws, may influence the
distribution of STIs across and within U.S. social groups—by increasing
access to prevention education and information and testing and treatment
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
472 SEXUALLY TRANSMITTED INFECTIONS
services. Moreover, several states have implemented HIV exposure crimi-
nalization laws, with the stated purpose of preventing further HIV infec-
tions by requiring that people living with HIV disclose their status to
sexual partners (Harsono et al., 2017). In addition to the harm caused to
individuals with HIV who are charged or prosecuted under these laws,
they also increase stigma toward people living with HIV and populations
with a high burden of HIV (e.g., MSM). Research examining the effect of
such laws on HIV/STI-related sexual behaviors provides little evidence
that they deter persons from engaging in sex without disclosing HIV
status or of any reduction in HIV transmission or increase in HIV/STI
prevention behaviors (Harsono et al., 2017).
The ACA did much to expand access to comprehensive and more
affordable coverage for health services, including STI testing and treat-
ment. The Medicaid expansion, subsidies for lower-income individuals to
purchase individual policies, and a requirement that all employer plans
offer coverage for dependent adult children up to age 26 resulted in an
important structural change for those most affected by STIs, particularly
young adults and low-income individuals.
Another aspect of the ACA that could produce structural change are
provisions that require coverage of preventive services that have been given
a high rating by the United States Preventive Services Task Force and those
that are recommended for children by Bright Futures and for women by the
Health Resources and Services Administration (HRSA) and the Advisory
Committee on Immunization Practices (discussed in Chapter 10). Elimi-
nating cost sharing can remove a financial barrier to access, and the broad
reach of the requirement across essentially all private health plans can
create a standard of access to critical preventive services. A review of the
research on the impact of the ACA preventive services coverage (Chait and
Glied, 2018) identified studies that have documented increases in preven-
tive visits, diabetes screening, glucose testing, and HIV screening among
low-income adults who were newly eligible for Medicaid (Simon et al.,
2017). One study analyzed the impact of the dependent coverage expan-
sion for adults aged 18–25 and found a 3–5 percent increase in the share
receiving preventive services, although the study did not focus specifically
on sexual and reproductive health care services.
The committee could not, however, identify any empirical study that
directly examined the association among the ACA, state HPV vaccination
policies, state minor STI testing consent laws, and STIs in the U.S. popula-
tion overall or in disproportionately affected social groups in particular,
at the individual or societal levels. Nonetheless, one study found that
federal and state ACA provisions would result in greater HIV testing,
which could decrease HIV cases and also suggests that the ACA may have
resulted in higher levels of STI testing and lower STI rates (Wagner et al.,
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
STRUCTURAL INTERVENTIONS 473
2014). Furthermore, several studies found a positive association between
ACA provisions that went into effect soon after enactment, but before the
law’s major coverage expansions in 2014 (coverage for extended depen-
dency and of preventive services with no cost sharing) and HPV vaccina-
tion among young U.S. women overall (Corriero et al., 2018; Lipton and
Decker, 2015) and lesbian and bisexual women in particular (Agénor et
al., 2019).
Several studies examined the association between state HPV vac-
cination policies and HPV vaccine uptake. Many of these studies found
no association among U.S. adolescents, potentially because of the lenient
opt-out provisions (Cuff et al., 2016; Perkins et al., 2016; Pierre-Victor et
al., 2017). One study found that the Rhode Island HPV vaccination school
entry mandate, however, was associated with an increase in vaccination
initiation among adolescent boys but not girls (Thompson et al., 2018).
Another study identified a set of state health policies that was consistently
associated with vaccine uptake among U.S. adolescents: Medicaid expan-
sion, policies permitting HPV vaccination in pharmacies, school entry
requirements, and classroom sex education (Roberts et al., 2018).
Additionally, one study examined the association between state sexu-
ality education policies for high school students and STIs (Hogben et al.,
2010), finding that states with no mandates for abstinence had the lowest
mean STI (gonorrhea and chlamydia) rates in the overall U.S. population
and among U.S. adolescents in particular, whereas states with sexuality
education policies emphasizing abstinence had the highest mean STI
rates; the burden of STIs in states with mandates to cover but not empha-
size abstinence fell in between (Hogben et al., 2010).
More research is urgently needed on the role of health policies in
STI rates and prevention, especially among groups who are dispropor-
tionately affected by STIs. Empirically guided research is limited on the
relationship between federal and state health policies (federal and state
ACA coverage and benefit provisions, state HPV vaccination policies,
state sexuality education policies, and state minor STI testing consent
laws), alone and in combination, and STIs in the U.S. population overall
and in disproportionately affected social groups. Additionally, health
policy research should strive to identify the potential mechanisms that
drive the association between health policies and STI impact such that
interventions could also target these mechanisms to decrease the overall
effect of STIs and STI inequities.
Social Policies
Federal and state social policies shape individuals’ and communities’
access to health care, social, and economic resources, which influence
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
474 SEXUALLY TRANSMITTED INFECTIONS
population health and health inequities (McLeroy et al., 1988; NASEM,
2017; WHO, 2010). Research that focuses on the effects of social policies
on STIs in the U.S. population overall is scarce (CSDH, 2008). Nonethe-
less, Ibragimov et al. (2019b) found that MSAs in states with a $1 higher
minimum wage had lower rates of syphilis (19.7 percent) and gonorrhea
(8.5 percent) compared to MSAs in states with a $1 lower minimum wage
among U.S. women, suggesting that state-level policies that increase the
minimum wage may help decrease STIs among women overall.
Moreover, federal and state policies and laws that decriminalize com-
mercial sex work may help decrease STIs for both commercial sex work-
ers and the U.S. population overall. For example, Cameron et al. found
that criminalizing sex work in a district in East Java, Indonesia, increased
STIs among female sex workers and potentially their clients, especially
by decreasing condom access and use, and decriminalization had the
potential to improve population STI outcomes (Cameron et al., 2020).
In a systematic review and meta-analysis of 1900–2018 quantitative and
qualitative research from around the world, Platt et al. (2018) found that
criminalizing sex work with aggressive policing of sex workers was asso-
ciated with higher levels of HIV and STI risk and condomless sex with cli-
ents (Platt et al., 2018). Additionally, Cunningham and Shah (2014) found
that, when Rhode Island decriminalized indoor commercial sex work in
2003, rape and gonorrhea among women decreased by 31 and 39 percent,
respectively, from 2004 to 2009. However, given the observational nature
of these studies, more research is needed.
MESO-LEVEL STRUCTURAL INTERVENTIONS TO
DECREASE OVERALL STI RATES AND STI INEQUITIES
Structural Interventions in the Health Care System
Several studies have examined STI-related structural interventions in
health care settings (Taylor et al., 2016) and identified several clinic-based
interventions that effectively promote STI screening and thus may help
decrease STIs in the U.S. population, including the strategic placement of
specimen collection materials within clinics, automatic screening as part
of routine health care visits, modifying electronic health records (EHRs) to
remind health care providers to screen all patients, patient testing remind-
ers, providing testing services at no or low cost, rapid express clinic
functionality, and hiring staff positions dedicated to screening activities
(Taylor et al., 2016). Automatic STI screening, EHR reminders, and patient
reminders led to the highest improvement at the lowest cost. Noninvasive
specimen collection methods, such as self-collection or even home test-
ing, likewise might facilitate recommended STI screening (see Chapter
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
STRUCTURAL INTERVENTIONS 475
7). Dedicated STI staff was associated with the highest improvement
in screening at the highest cost (Taylor et al., 2016). Further research is
needed to identify whether, in addition to facilitating STI screening in
the U.S. population overall, these clinic-based structural interventions
also help mitigate STI inequities related to race, ethnicity, socioeconomic
position, and sexual orientation among other social factors.
Across multiple health care financing and delivery models, various
stakeholders have sought innovative approaches to incentivize wellness
and maintenance of health rather than solely focusing on remedying
illness or providing treatment. These include Medicaid managed care,
health maintenance organizations, sexual health clinics that focus on self-
efficacy for prevention, and targeted services for key populations, such as
adolescents and LGBTQ+ communities. All are suitable for persons living
in households and alone, but health care services for institutionalized
populations cannot be neglected. These populations include residents of
correctional and penal institutions, persons living on military bases or
camps, school or college dormitories, and health care facilities, both short
and long term, including hospitals. Such institutions are theoretically
even more easily influenced toward sexual health interventions, given the
accessibility of the target populations.
Structural Interventions in the Education System
Although the committee could not identify any study that explicitly
examined STI-related structural interventions in educational settings, lim-
ited research has investigated such interventions in the context of HIV
prevention in schools (Rotheram-Borus, 2000) and showed that school-
based health centers and making condoms available are the types of inter-
ventions that facilitate access to HIV prevention and testing services and
decrease HIV risk behaviors among youth, including increasing condom
use during sexual encounters (Rotheram-Borus, 2000). (See Chapter 8 for
an overview of school-based sexual education interventions.)
Structural Interventions in the Criminal Legal System
In the United States, we have about 12 million incarcerations a year.
About 11 million of them happen in county jails, so these are places where
people come in and go out very quickly. Unless you are part of a big public
health agency like we were in New York City, it can be difficult to implement
some types of screening. Chlamydia screening is one where you absolutely need
[it] if you care about the public health. The impediment is almost exclusively
cost because it is quick now, and it’s easy to do. When I go around the country
looking at correctional health settings, I rarely find a county jail that’s doing
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
476 SEXUALLY TRANSMITTED INFECTIONS
this, but they could be. Certainly, if they wanted to address all of the morbidity
and mortality that is related to this, they could expand, as we did in New York
City, to include a systematic test coming into the correctional facility.
—Participant, lived experience panel
No studies that explicitly examine STI-related structural interven-
tions in relation to the criminal legal system were identified; several chal-
lenges and opportunities were noted (see Chapter 3 for background on
individuals who are criminal legal system involved and STIs, including
STI screening). Challenges for prevention and treatment in these institu-
tions are many, including financing, short stays in many jails and juve-
nile detention centers, lack of sexual health training among some health
providers, suboptimal diagnostic capacities, and stigma that may influ-
ence policy makers to direct health resources elsewhere (NCCHC, 2020).
Nonetheless, incarceration or detention represents an important window
of opportunity for intervention. For example, though the Federal Bureau
of Prisons guidelines are explicit as to screening strategies for incarcerated
persons, considerable variability can be seen in the degree of success for
state prisons, local jails, and juvenile detention programs to mount com-
parable programs. Furthermore, solicitations for contractors to provide
health care services in prisons, jails, immigration detention, or juvenile
detention entities rarely mandate routine STI screening and treatment
as a core requirement. Modern trends of privatizing prisons and health
services may work against deploying STI screening programs.
Although correctional policies often do not permit specific struc-
tural interventions in carceral settings, such as condom provision and
needle-exchange initiatives, this does not mean that such programs are
ineffective. In fact, previous empirical research suggests that these inter-
ventions are feasible, do not threaten security, and lead to greater use of
condoms and sterile injection equipment in prison settings (Belenko et
al., 2009; Donaldson et al., 2013; Underhill et al., 2014). Policy changes
that integrate structural interventions, psychosocial programs, and drug
treatment could reduce the impact of incarceration and criminal justice
involvement on individuals and communities at risk for HIV and other
STIs (Underhill et al., 2014).
Structural Interventions in Congregate Care Systems
Individuals living in congregate care systems may have varying
degrees of freedom of movement, depending on the living arrangements
and their independence and capacities. Such persons include adolescents
and children in transient foster care or in group homes (St Lawrence et
al., 1994). Too often, the congregate care or detention settings themselves
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
STRUCTURAL INTERVENTIONS 477
may increase STI risk due to child sexual abuse (Beal et al., 2018). Adults
may live in supervised halfway houses, nursing homes, intermediate care
facilities for people with intellectual disabilities, assisted living facilities,
homeless shelters, or residential treatment settings. Persons of all ages
may live in communities that may focus on mental health or substance
use and provide opportunities for sexual health interventions. There are
also “safe homes” and shelters for persons experiencing abuse for whom
a return to the home could be dangerous due to intimate partner violence
or other abuse.
Programs built as alternatives to prison or for formerly trafficked
youth and adults may have clients in a variety of housing arrangements
but typically can serve as an effective conduit to prevention and care
opportunities (Marshall et al., 2009). Parolees or prisoners reentering
society also may find themselves in some of these congregate care settings
(Levanon Seligson et al., 2017).
Structural interventions for congregate care and STI prevention and
control have rarely been examined. Because former foster youth are at
increased risk of housing instability and STIs during the transitional
period following foster care, Lim et al. (2017) used administrative records
in New York City, New York, to assess whether a supportive housing
program was effective at improving their housing stability and STI rates.
The program was positively associated with a pattern of stable housing
and negatively associated with diagnosed STI rates. The authors note
that these positive impacts highlight the program’s importance for this
population. Other opportunities for youth in foster care or transitioning
out include offering testing at intake, altering the consent process to allow
them to consent to confidential testing, and mandating that foster care
parents receive sexual health education (Willard et al., 2015). Congregate
care settings have too infrequently taken the opportunity to intervene in
sexual health and STI prevention.
COMMUNITY MOBILIZATION FOR STRUCTURAL
CHANGE RELATED TO STIs AND HIV
As described earlier in this chapter, achieving structural change
related to STIs is critical to support and sustain extant and forthcoming
interventions (Chutuape et al., 2014), and community mobilization and
community coalitions are an important mechanism through which to
enable this change (Chutuape et al., 2010). Community mobilization inter-
ventions require getting community members together for programs that
address defined issues and include collaboration between and empower-
ment of community members and grassroots organizations with shared
interests (Ziff et al., 2006). This was seen in the earliest responses to HIV,
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
478 SEXUALLY TRANSMITTED INFECTIONS
led by gay activists and community-based organizations that educated
people, raised awareness, and advocated for funds and better govern-
ment responses, as well as in the People with AIDS self-empowerment
movement, which used the Denver Principles (People with AIDS Advi-
sory Committee, 1983) to highlight that those affected by HIV need to be
respected as people and be actively involved in shaping responses to the
HIV epidemic. Such community participation underscores the importance
of empowering communities to advance their own health and aligns with
the principles of health equity (Valdiserri and Holtgrave, 2019).
This section summarizes the current knowledge on community mobi-
lization for structural change for prevention and risk reduction leveraging
literature on HIV, notes the gaps of this kind of research and substan-
tive findings on STIs, and discusses the implications of the existing HIV
research that can be applied to STIs.
Approaches and Strategies
A recent STI-focused example is the STI Regional Response Coalition
(STIRR), which aims to promote healthy sexual behaviors and reduce STI
incidence in the St. Louis community through education, collaboration,
and evidence-based practice. The faculty at the Division of Infectious
Disease and the Institute for Public Health at Washington University and
key stakeholders organized STIRR in early 2015. STIRR is largely a pro-
vider-led coalition, with participants from state, city, and county health
departments; academic medical centers; hospital emergency departments;
urgent care centers; community health centers (i.e., federally qualified
health centers); community-based organizations; and private providers. A
provisional goal of STIRR is to work toward a regional management plan
for STIs in the St. Louis area by using evidence-based medicine, expert
opinion, and national guidelines (STIRR, n.d.).
The majority of publications on community mobilization for struc-
tural change related to the HIV continuum of care in the United States,
however, are focused on Connect to Protect (C2P). C2P is a national multi-
site intervention located in 14 cities across the United States (inclusive of
Puerto Rico) that focuses on working with diverse community coalitions
to alter policies, practices, programs, and environmental influences asso-
ciated with HIV among youth (Ziff et al., 2006). Its specific communities
reflect a diverse array of urban populations and include youth subpopu-
lations at highest risk for HIV infection, such as Black and Latina hetero-
sexual adolescent and young adult women and young MSM. C2P was cre-
ated and implemented by the National Institutes of Health (NIH)-funded
Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN)
in 2001, and coalition sites were initially located in urban areas with high
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
STRUCTURAL INTERVENTIONS 479
rates of youth STIs and of youth at risk for HIV transmission and infec-
tion (Ellen et al., 2015). The C2P coalitions are based on the community
empowerment framework, build on “AIDS-competent communities” as
a concept (collaborative support for achieving objectives across the com-
munity) (Boyer et al., 2016), and focus on intermediate, or meso-level,
structural determinants (Ziff et al., 2006). Coalition members include
decision makers, local volunteer stakeholders, and content experts who
effectively worked together to identify HIV-related structural changes
(Boyer et al., 2016). They were involved with entities that served Black
and Latino/a youth, LGBTQ+ youth of color, and youth with additional
needs and concerns (e.g., sexual abuse, homelessness, etc.), and some
were youth themselves (Miller et al., 2018a).
Approaches for community mobilization for structural change
around HIV include initiatives that adjust the intricate networks of ser-
vices and organizations connected to the HIV continuum of care (Boyer et
al., 2016). The most promising strategies capitalize on community mobi-
lization efforts that create synergy between various community actors
(Wagner et al., 2014). Overall success documented at the C2P sites was
partially due to their ability to form meaningful, collaborative relation-
ships (Ziff et al., 2006). In this vein, multiple studies highlight the need
for multi-sectoral support and inclusion of community members and
organizations for community mobilization to heighten the import of HIV
prevention. A multi-sectoral, multi-partnered approach is appropriate,
given that various determinants contribute to health outcomes and health
inequities and increase success in achieving structural change objectives
(Chutuape et al., 2010, 2014; NASEM, 2017; Valdiserri and Holtgrave,
2019). Researchers also note that structural changes need engagement
from multiple stakeholders to reach the decision makers who hold the
power to enact structural change (Chutuape et al., 2014). Other coalitions
formed a linkage-to-care subcommittee that included members repre-
senting various health-related fields, sectors, and systems (e.g., health
care agencies, criminal justice system, school-based health centers, health
departments, crisis centers, AIDS education and training centers, public
schools, Planned Parenthood, etc.) (Boyer et al., 2016).
Additional approaches and strategies the C2P coalitions employed
include the following:
• developing stakeholder relationships and building partnerships,
particularly with those most impacted, and publicly honoring key
stakeholders (Chutuape et al., 2010; Harper et al., 2012);
• empowering the community through improved relationships
with those in power (e.g., law enforcement) (Pachankis and Brän-
ström, 2018);
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
480 SEXUALLY TRANSMITTED INFECTIONS
• gaining community buy-in through meetings, surveys, public
awareness building, education, and community events (Chutu-
ape et al., 2010; Harper et al., 2012);
• using a systematic planning process from the Community Tool-
box with a logic model and strategic planning materials to help
them develop localized structural changes to maximize relevance
and community acceptance (Chutuape et al., 2010; Ellen et al.,
2015);
• implementing a root cause analysis process and embedding it
within the C2P strategic planning framework in order to think
structurally (Boyer et al., 2016; Reed et al., 2014);
• building coalition members’ capacity (Chutuape et al., 2010;
Harper et al., 2012);
• gathering diverse supporters and identifying change agents
(Chutuape et al., 2010);
• employing flexibility and patience;
• cross-sharing information (Boyer et al., 2016) and offering techni-
cal assistance (Chutuape et al., 2010);
• using the Anderson and May model for HIV infection transmis-
sion dynamics (Ziff et al., 2006);
• collecting data from youth about HIV risk behaviors (Harper et
al., 2012); and
• employing social network data collection and intervention (Pag-
kas-Bather et al., 2020).
Another community mobilization example is the HIV Prevention
Community Planning effort: since 1994, the Centers for Disease Control
and Prevention (CDC) has required that 65 health department grantees
that receive funding for HIV prevention interventions engage in a com-
munity planning process to involve affected communities in local preven-
tion decision making, among other goals (CDC, 2012; Johnson-Masotti et
al., 2000). Local community planning groups are charged with identifying
and prioritizing unmet HIV prevention needs in their communities. They
also prioritize prevention interventions designed to address those needs.
Their recommendations form the basis for the local health department’s
request for HIV prevention funding from CDC (Johnson-Masotti et al.,
2000). Some lessons learned from this effort include the following:
• Rules and bylaws are needed to insure inclusion and proper
deliberation about data, and community planning groups need to
be organized to carry out their tasks and decide how to delegate
work within the group (Jenkins et al., 2005).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
STRUCTURAL INTERVENTIONS 481
• A coherent organization is essential to group members’ being able
to use data to adequately understand local needs (Jenkins et al.,
2005).
• A basic tenet of HIV planning is parity, inclusion, and represen-
tation. “Parity is the ability of HIV planning group members to
equally participate and carry out planning tasks or duties in the
planning process” (CDC, 2012, p. 11). CDC notes that to achieve
parity, opportunities for orientation and skills building should be
made available to representatives to participate in the planning
process and have an equal voice in voting and other decision-
making activities. “Inclusion is the meaningful involvement of
members in the process with an active role in making decisions”
(CDC, 2012, p. 11).
• The planning process should ensure that interagency services are
considered and linked to HIV planning, as appropriate (CDC,
2012).
Finally, another example from the HIV field is the Ryan White HIV/
AIDS Program Planning Councils and Planning Bodies funded through
HRSA (Planning CHATT, 2018). These councils determine the needs of
those who are identified as high risk for HIV and those already infected,
establish priorities for prevention and treatment services, and make rec-
ommendations to best meet the prioritized needs in their state. No other
federal health or human services program has a legislatively required
planning body that is the decision maker about how funds will be used,
has such defined membership composition, and requires such a high level
of consumer participation (at least 33 percent) (Planning CHATT, 2018).
Domains, Indicators, and Structural Change Objectives
There are several important components of community mobilization
to lead to structural change. Lippman et al. (2013) searched Western the-
ory to identify six elements that are needed to improve health outcomes or
behaviors (community consciousness, leadership, social cohesion, shared
concern, collective actions, and organizational networks/structures) and
concluded that to be successful, HIV intervention designs should focus on
addressing these elements, in addition to their designated content-specific
outcomes. This work contributes to community mobilization approaches,
particularly those for structural change, by establishing domains that can
guide and bolster intentional planning, strategy, and evaluation.
Chutuape et al. (2014) identified community mobilization indicators,
including (1) action steps, (2) key actors, (3) number of new key actors,
(4) sectors represented by key actors, and (5) time taken for objective
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
482 SEXUALLY TRANSMITTED INFECTIONS
completion, that facilitated assessing how successful the C2P coalitions
were in achieving structural change objectives (e.g., amending a law
allowing health professionals or representatives to offer HIV preventive
counseling or perform HIV/STD testing in the clinic and community to
youth under 21 without parental consent). These objectives can be used
to classify the coalitions as more or less successful. It took coalitions a
median of 3 action steps, 12 key actors, 6 new key actors, and 7 months
to complete objectives. The research indicates that structural change
objectives do not necessarily take more time to complete than individual
change objectives and that it is beneficial for coalitions to bundle related
objectives or have multiple objectives that target the same goal for their
processes (Chutuape et al., 2014; Willard et al., 2015).
C2P achieved multiple structural change objectives, including the
following:
• organizational policies to improve understanding of LGBTQ+
culture and youth (Chutuape et al., 2014);
• policies on HIV resource allocation and data collection (Chutuape
et al., 2014);
• linkages between organizations to expand youth access to HIV
services (CDC, 2012), such as referrals, mental health services,
voluntary counseling and testing, increased HIV/STIs diagnoses
(Ziff et al., 2006), and extended health facility hours (Ellen et al.,
2015);
• novel or improved youth development programs and youth-
friendly primary care (Ziff et al., 2006);
• adaptation and implementation of the CDC community-level pro-
gram from the Compendium of HIV Prevention Interventions
(Ziff et al., 2006);
• adoption of the Ryan White Program income eligibility policy
change (Boyer et al., 2016);
• alteration of physical structures to discourage risky behavior
(Ellen et al., 2015) and better social venues to promote more
healthful lifestyles (Ziff et al., 2006); and
• removal of mandatory parental/guardian consent (Ellen et al.,
2015).
Assessing the Impact of Community Mobilization Efforts
The C2P studies all stem from a single longitudinal intervention.
There are, however, varying analyses or subquestions related to their
development, implementation, and evaluation. For example, Reed et al.
(2014) discussed the usefulness of community coalition action theory
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
STRUCTURAL INTERVENTIONS 483
(CCAT), which is one of the primary frameworks demonstrating the
factors and processes contributing to the formation, maintenance, and
institutionalization of coalitions, as well as their outcomes. The research-
ers used CCAT in the analysis to assess how community context impacted
the development of objectives. Knowing the relationship between context
and coalitions’ achievements can be useful when trying to make structural
change in order to get a sense of feasibility and the difficulty of enacting it
and determine which types of change will be successful (Reed et al., 2014).
Building on this, any structural-level interventions, especially at a large
scale, need to be grounded in strong theory in community mobilization,
have a central administrative infrastructure, and support and encourage
the expertise of and collaboration between sites and communities (Ziff et
al., 2006).
Ellen et al. (2015) surveyed the coalitions’ target populations, includ-
ing 2,392 participants in their analysis, and found some suggested associa-
tions between an individual’s exposure to structural change interventions
in their community and the individual’s self-reported HIV risk–related
behaviors, but these were not statistically significant. This reflects the
difficulty in evaluating structural change interventions that span com-
munity sectors and target different social ecological levels (Ellen et al.,
2015). Miller et al. (2018a) surveyed 2,284 adolescents to assess the impact
of the C2P community mobilization efforts and the plausibility of the C2P
logic model by identifying the effects and links of expected HIV stigma,
risk and protective behaviors, and community support. They found that
adolescents reported few HIV-risky sexual encounters during their life-
time if they felt they lived in caring communities and that community
satisfaction improved over time, which aligns with how structural change
increases a community’s capability. The coalitions were not successful,
however, in lowering anticipated HIV stigma or upsetting the relationship
between risk behavior and HIV stigma, indicating a need to intervene on
stigma over long periods (Miller et al., 2018a).
Reed et al. (2014) suggested that C2P coalitions that were catego-
rized as “above average” increased community resources, built on cur-
rent efforts for quick wins, and prevented effort duplication. They also
partnered with other organizations working on upstream issues, such as
homelessness, adolescent parenthood, and impoverishment. The findings
suggest benefits in aligning coalition objectives with community priorities
that might seem more pressing than HIV prevention and aligning with
political priorities as a part of relationship building. Researchers also
observed that coalition groups that described their political environments
as conservative and mistrustful of collaboration or had communities with
strong faith-based traditions achieved fewer objectives and were not
ranked as “above average” (Reed et al., 2014). Paradoxically, many of the
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
484 SEXUALLY TRANSMITTED INFECTIONS
best-practice approaches in the literature for achieving structural change
are apt to receive community pushback (e.g., comprehensive sex educa-
tion) and political resistance (e.g., syringe services programs) and may
require many resources, which reduces feasibility and requires coalition
members to spend a disproportionate amount of time on them compared
to other objectives.
Gaps in Community Mobilization Research Around STIs
The committee did not identify research that specifically focuses on
community mobilization for structural change around non-HIV STIs spe-
cifically. In the global context, Cornish et al. (2014) performed a systematic
review and noted that a 2014 substudy of the Avahan program by Ramesh
et al. (2010) showed decreased prevalence of syphilis, gonorrhea, and
chlamydia among female sex workers, although not significantly. The
Frontiers Prevention Projects in Ecuador and Andhra Pradesh, India,
showed lower likelihoods of herpes simplex virus 2 and syphilis among
MSM and female sex workers (Gutiérrez et al., 2010, 2013). In addition,
Lippman et al. (2012) on the Encontros project in Brazil found nonsignifi-
cantly reduced odds of gonorrhea or chlamydia for sex workers exposed
to the intervention compared with those who were not. Overall, existing
data suggest that community mobilization efforts are associated with
reduced STI rates among sex workers. Cornish et al. (2014) indicate that
among youth and the general community, evidence is limited that com-
munity mobilization successfully reduces STIs, with success only among
Project Accept in Thailand and the Stepping Stones Program in South
Africa.
Accordingly, inferences will have to be made when considering how
to enable structural change for STIs. Studies that mention both HIV and
STIs offer little to no discussion about how community mobilization for
structural change might impact HIV risk and STI risk differently. While
STIs can increase a person’s risk of acquiring or transmitting HIV, studies
on the impact of community mobilization for structural change around
STIs alone are critical given the varying levels of stigma, discrimination,
care access, etc. and that some STIs are more easily treatable with medica-
tion (e.g., syphilis, chlamydia, and some strains of gonorrhea), whereas
others are lifelong conditions to be managed (e.g., herpes simplex virus).
Community Mobilization Research Limitations
No current standardized definition of community mobilization exists,
with a wide range of interventions considered to fall under that umbrella,
from structural interventions led by the community to community
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
STRUCTURAL INTERVENTIONS 485
sensitization and education (Kuhlmann et al., 2014). Additionally, in many
efforts and studies, community mobilization itself is also thought of as a
structural intervention, when it is actually a way to empower communi-
ties and change power dynamics (Cornish et al., 2014). This makes it chal-
lenging to compare findings across studies that use different definitions
and indicators, which can impact how efforts plan their processes based
on existing research.
Most U.S.-based research on community mobilization for structural
change centers on the C2P coalitions, which focused on adolescents and
young adults. The global research explored by Cornish et al. (2014) indi-
cates that for youth populations, the research is mostly inconclusive,
due to many nonsignificant findings, on how community mobilization
impacts HIV and STI risk. This indicates the need for more community
mobilization efforts and evaluation of those efforts around structural
change for HIV and other STIs. It follows that evidence-based examples
of structural interventions around HIV prevention are limited and, by
extension, so are those for STIs (Willard et al., 2015).
Beyond this, few existing studies show coalitions’ ability to bring
about structural change around HIV (Chutuape et al., 2010). If structural
changes are created, studies remain lacking that assess how this affects
individual-level behavioral changes (Ellen et al., 2015; Miller et al., 2018a).
For studies that have been able to measure structural- and individual-
level variables, researchers have noted that these measurements may not
be precise enough to detect change and that they do not assess change in
risk behavior over time. Many structural interventions target root causes
that take a long time to modify given their more distal locations on the
causal pathway (Ellen et al., 2015). Additionally, little attention has been
paid to structural barriers and the social determinants that constitute the
underlying root causes of barriers to the HIV continuum of care, such as
transportation access, unemployment, health insurance policies, impover-
ishment and food insecurity, and homelessness (Boyer et al., 2016).
Many of the prior reviews of HIV prevention programs focus on
heterosexual youth (Harper et al., 2012), leaving out LGTBQ+ youth and
queer communities of all ages. Structural prevention interventions as a
whole are underused in the United States, particularly for reducing HIV
in adolescents (Ziff et al., 2006), and are rarely evaluated for interventions
focused on adolescents and young adults (Boyer et al., 2016). Overall,
youth are understudied in research exploring how structural community
features promote HIV risk and exposure, even though they are quite
dependent on their community surroundings (Miller et al., 2018b). Exist-
ing community mobilization efforts for adolescent health have been lim-
ited because of the focus on access to substances, implementation of stan-
dardized programs, and low number of rigorous evaluations. They have
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
486 SEXUALLY TRANSMITTED INFECTIONS
not been widely used to help reduce the rates of HIV infection among
youth given that sexual activity is regulated differently from alcohol and
other substances (Ziff et al., 2006).
Implications of HIV Literature for STIs
Future considerations for future community mobilization from this
review around HIV and STIs include the following:
• HIV risk–related factors that serve as analysis outcomes include
areas that overlap with STI considerations, such as the number of
sexual partners in the previous 3 months, partner characteristics,
frequency of condom use and use at last encounter, current and
past-year STI status and health care and treatment, and past-year
HIV testing (Ellen et al., 2015).
• Evaluation of interventions may be difficult given the need to
enable structural change by targeting various levels of the Social
Ecological model, and it requires multi-sectoral partnerships and
approaches.
• There are age, gender, sexuality, race, and ethnicity differences
and an STI prevalence that is different from HIV.
• The tool referenced in Willard et al. (2015) could be adapted to
assist communities in identifying the necessary structural changes
for combating STIs at the local level.
• Stigma is still a major driving factor when it comes to accessing
HIV services, but stigma factors for STIs may differ.
• CCAT can be effective for grounding community mobilization for
structural change related to STIs.
• Ecological assessments can be used to create objectives that take
into account the demographic trends, features, and shifts of their
local context (Reed et al., 2014).
• The six community mobilization domains defined by Lippman
et al. (2013) for HIV prevention could be applied to structural
interventions for HIV and STIs, in the United States and globally.
However, the time it takes for structural change objectives to be
put in place and impact upstream structural-level changes needs
to be a consideration when choosing which structural change
objectives to focus on.
• Communities are dynamic and ever changing and adapting, so
any mobilization needs frequent checks on what is the commu-
nity and how is it evolving.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
STRUCTURAL INTERVENTIONS 487
CONCLUSIONS AND RECOMMENDATION
Although empirical research in the area of STI-specific structural
interventions is limited, studies indicate that macro-level structural inter-
ventions (e.g., federal and state health and social policies) and the factors
they target (e.g., access to health insurance and health care, anti-LGBTQ+
structural stigma, structural racism, other structural inequities), meso-
level structural interventions in health care and social systems and insti-
tutions, and community mobilization efforts seeking structural change
influence STI rates in both the U.S. population in general and margin-
alized U.S. groups in particular. First, to continue building this small
but growing body of work, additional research is needed that examines
how various structural factors and their downstream social determinants
influence STI rates and prevention in the U.S. population overall and in
marginalized groups. In particular, given that most existing studies have
focused on the role of structural discrimination related to sexual orienta-
tion identity in shaping STI outcomes, additional research is urgently
needed that examines how structural racism, transphobia, and xeno-
phobia singly and jointly shape STI rates and prevention in the U.S.
population overall and among marginalized groups using rigorous study
designs that address both broad population patterns (e.g., difference-in-
difference analysis) and the lived experiences of underserved populations
(e.g., mixed-methods study designs). Additionally, efforts are needed to
develop, test, implement, disseminate, and scale up policies, programs,
and other interventions that target upstream structural factors and their
social determinants at multiple levels of influence to prevent STIs overall
and STI inequities.
Based on its review of the evidence on structural interventions, the
committee provides the following conclusions and recommendation to
address structural racism and other structural inequities that hinder STI
prevention and control:
Conclusion 9-1: Observational, policy evaluation, and intervention research
on the structural (e.g., equitable/discriminatory federal and state health and
social policies) and social (e.g., housing, income, health care) determinants
of STI inequities related to race/ethnicity, sexual orientation, and gender/
gender identity are lacking, and need to be a focus moving forward for public
health researchers and funders.
Conclusion 9-2: Examining and addressing the structural determinants of
STIs and STI inequities will require bold vision, long-term commitment,
multidisciplinary, intersectoral, and interagency collaboration, dedicated
funding from NIH, CDC, HRSA, and private foundations and funders,
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
488 SEXUALLY TRANSMITTED INFECTIONS
steadfast political will at all levels of government, and sustained commu-
nity engagement and mobilization. Due to their focus on addressing root
causes and their downstream social determinants, these efforts stand to have
the greatest impact on preventing STIs and STI inequities in the United
States. Although achieving this goal will take time, it is imperative to start
now in order to prevent STIs and STI inequities for future generations.
Conclusion 9-3: Structural inequities related to sexual orientation, gender
identity, race and ethnicity, and national origin, among others, are pervasive,
increasing STI risk, perpetuating stigma, and undermining access to STI pre-
vention and treatment among marginalized populations. These inequities need
to be addressed in order for efficacious biomedical and social behavioral inter-
ventions to more effectively mitigate risk and disease for these populations.
Recommendation 9-1: The Secretary of Health and Human Services
(HHS) should acknowledge structural racism and other forms of
structural inequities as root causes of sexually transmitted infec-
tion (STI) outcomes and inequities and as threats to sexual health.
HHS should lead a whole-of-government response that engages all
relevant federal departments and agencies to develop a coordinated
approach to reduce negative STI outcomes and address inequities
in the U.S. population by promoting sexual health and eliminating
structural inequities that are barriers to STI prevention, testing, and
treatment among marginalized groups.
In mounting this response, the Secretary should:
• consult broadly with affected communities and critical stake-
holders to conduct a national landscape analysis that assesses
social and structural barriers that prevent access to STI services.
The focus should be on identifying communities with high
morbidity and limited access to affordable and desirable STI
prevention and care services and resources in order to develop
a national holistic plan for ongoing monitoring of the national
STI infrastructure and STI burden, including interrelated struc-
tural and social determinants of health inequities;
• establish a priority research agenda, including a data-collection
strategy that organizes data on STI outcomes and their struc-
tural and social determinants among marginalized populations;
• strengthen partnerships with, funding for, and technical assis-
tance to state and local health departments and community-
based organizations;
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
STRUCTURAL INTERVENTIONS 489
• foster greater collaboration across health and human services
agencies; and
• report regularly to the public on progress for addressing STI
outcomes and inequities.
This effort needs to be inclusive of community and clinical services
and educational efforts and should seek to bolster integration with rel-
evant other initiatives and programs, such as Title X, Health Centers,
and HIV prevention and care programs. Realizing this recommendation
will require political will and dedicated funding for delivering afford-
able, accessible, and acceptable STI services to affected communities and
addressing the structural and social determinants of STIs and STI inequi-
ties. This recommendation should be responsive to and implemented in
collaboration with local communities based on their needs, perspectives,
and priorities.
REFERENCES
Adimora, A. A., and J. D. Auerbach. 2010. Structural interventions for HIV prevention in the
United States. Journal of Acquired Immune Deficiency Syndromes 55:S132-S135.
Adimora, A. A., and V. J. Schoenbach. 2005. Social context, sexual networks, and racial
disparities in rates of sexually transmitted infections. Journal of Infectious Diseases
191(Suppl 1):S115-S122.
Agénor, M., G. Murchison, J. Chen, D. Bowen, M. Rosenthal, S. Haneuse, and S. Austin.
2019. Impact of the Affordable Care Act on human papillomavirus vaccination initia-
tion among lesbian, bisexual, and heterosexual U.S. women. Health Services Research 55.
AMA (American Medical Association). 2020. AMA: Racism is a threat to public health. https://
www.ama-assn.org/delivering-care/health-equity/ama-racism-threat-public-health
(accessed November 19, 2020).
APHA (American Public Health Association). 2020. Racism is an ongoing public health crisis
that needs our attention now. https://www.apha.org/news-and-media/news-releases/
apha-news-releases/2020/racism-is-a-public-health-crisis (accessed November 1, 2020).
APHA. n.d. Declarations of racism as a public health issue. https://www.apha.org/topics-
and-issues/health-equity/racism-and-health/racism-declarations (accessed October
30, 2020).
ASTHO (Association of State and Territorial Health Officials). 2020. State legislation to declare
racism a public health crisis and address institutional racism. https://www.astho.org/
StatePublicHealth/State-Legislation-to-Declare-Racism-a-Public-Health-Crisis-and-
Address-Institutional-Racism/08-12-20 (accessed November 1, 2020).
Bailey, Z. D., N. Krieger, M. Agenor, J. Graves, N. Linos, and M. T. Bassett. 2017. Struc-
tural racism and health inequities in the USA: Evidence and interventions. Lancet
389(10077):1453-1463.
Beal, S. J., K. Nause, I. Crosby, and M. V. Greiner. 2018. Understanding health risks for ado-
lescents in protective custody. Journal of Applied Research on Children 9(1).
Belenko, S., R. Dembo, M. Rollie, K. Childs, and C. Salvatore. 2009. Detecting, preventing,
and treating sexually transmitted diseases among adolescent arrestees: An unmet pub-
lic health need. American Journal of Public Health 99(6):1032-1041.
Blankenship, K. M., S. J. Bray, and M. H. Merson. 2000. Structural interventions in public
health. AIDS 14:S11-S21.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
490 SEXUALLY TRANSMITTED INFECTIONS
Blankenship, K. M., S. R. Friedman, S. Dworkin, and J. E. Mantell. 2006. Structural inter-
ventions: Concepts, challenges and opportunities for research. Journal of Urban Health
83(1):59-72.
Bonell, C., J. Hargreaves, V. Strange, P. Pronyk, and J. Porter. 2006. Should structural in-
terventions be evaluated using RCTs? The case of HIV prevention. Social Science &
Medicine 63(5):1135-1142.
Boyer, C. B., B. C. Walker, K. S. Chutuape, J. Roy, J. D. Fortenberry, and the Adolescent Medi-
cine Trials Network for HIV/AIDS Interventions. 2016. Creating systems of change to
support goals for HIV continuum of care: The role of community coalitions to reduce
structural barriers for adolescents and young adults. Journal of HIV/AIDS and Social
Services 15(2):158-179.
Brown, A. F., G. X. Ma, J. Miranda, E. Eng, D. Castille, T. Brockie, P. Jones, C. O. Airhihen-
buwa, T. Farhat, L. Zhu, and C. Trinh-Shevrin. 2019. Structural interventions to reduce
and eliminate health disparities. American Journal of Public Health 109(Suppl 1):S72-S78.
Cameron, L., J. Seager, and M. Shah. 2020. Crimes against morality: Unintended consequences of
criminalizing sex work (working paper). Cambridge, MA: National Bureau of Economic
Research.
Castrucci, B., and J. Auerbach. 2019. Meeting individual social needs falls short of address-
ing social determinants of health. https://www.healthaffairs.org/do/10.1377/
hblog20190115.234942/full (accessed November 7, 2019).
CDC (Centers for Disease Control and Prevention). 2012. HIV planning guidance. https://
www.cdc.gov/hiv/pdf/p/cdc-hiv-planning-guidance.pdf (accessed February 18,
2021).
Chait, N., and S. Glied. 2018. Promoting prevention under the Affordable Care Act. Annual
Review of Public Health 39:507-524.
Charlton, B. M., M. L. Hatzenbuehler, H. J. Jun, V. Sarda, A. R. Gordon, J. R. G. Raifman, and
S. B. Austin. 2019. Structural stigma and sexual orientation-related reproductive health
disparities in a longitudinal cohort study of female adolescents. Journal of Adolescence
74:183-187.
Chutuape, K. S., N. Willard, K. Sanchez, D. M. Straub, T. N. Ochoa, K. Howell, C. Rivera,
I. Ramos, and J. M. Ellen. 2010. Mobilizing communities around HIV prevention for
youth: How three coalitions applied key strategies to bring about structural changes.
AIDS Education Prevention 22(1):15-27.
Chutuape, K. S., A. Z. Muyeed, N. Willard, L. Greenberg, and J. M. Ellen. 2014. Adding to
the HIV prevention portfolio—the achievement of structural changes by 13 Connect to
Protect coalitions. Global Journal of Community Psychology Practice 5(2):1-8.
Cornish, F., J. Priego-Hernandez, C. Campbell, G. Mburu, and S. McLean. 2014. The impact
of community mobilisation on HIV prevention in middle and low income countries: A
systematic review and critique. AIDS and Behavior 18(11):2110-2134.
Corriero, R., J. L. Gay, S. W. Robb, and E. W. Stowe. 2018. Human papillomavirus vaccina-
tion uptake before and after the Affordable Care Act: Variation according to insurance
status, race, and education (NHANES 2006-2014). Journal of Pediatric Adolescent Gyne-
cology 31(1):23-27.
CSDH (Commission on Social Determinants of Health). 2008. Closing the gap in a generation:
Health equity through action on the social determinants of health: Final report of the commis-
sion on social determinants of health. Geneva, Switzerland: World Health Organization.
Cuff, R. D., T. Buchanan, E. Pelkofski, J. Korte, S. P. Modesitt, and J. Y. Pierce. 2016. Rates of
human papillomavirus vaccine uptake amongst girls five years after introduction of
statewide mandate in Virginia. American Journal of Obstetrics and Gynecology 214(6):752.
e751-752.e756.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
STRUCTURAL INTERVENTIONS 491
Cunningham, S., and M. Shah. 2014. Decriminalizing indoor prostitution: Implications for sexual
violence and public health. NBER working paper no. 20281. Cambridge, MA: National
Bureau of Economic Research.
Dirr, A. 2019. Milwaukee county executive signs resolution declaring racism a public health crisis.
https://www.jsonline.com/story/news/local/milwaukee/2019/05/20/abele-signs-
resolution-declaring-racism-public-health-crisis/3741809002 (accessed November 1,
2020).
Donaldson, A. A., J. Burns, C. P. Bradshaw, J. M. Ellen, and J. Maehr. 2013. Screening juvenile
justice-involved females for sexually transmitted infection: A pilot intervention for ur-
ban females in community supervision. Journal of Correctional Health Care 19(4):258-268.
Ellen, J. M., L. Greenberg, N. Willard, J. Korelitz, B. G. Kapogiannis, D. Monte, C. B. Boyer,
G. W. Harper, L. M. Henry-Reid, L. B. Friedman, and R. Gonin. 2015. Evaluation of the
effect of human immunodeficiency virus–related structural interventions: The Connect
to Protect project. JAMA Pediatrics 169(3):256-263.
Friedman, S. R., H. L. Cooper, and A. H. Osborne. 2009. Structural and social contexts of
HIV risk among African Americans. American Journal of Public Health 99(6):1002-1008.
Fullilove, R. E. I. 2020. Race and sexually transmitted diseases… again? Sexually Transmitted
Diseases 47(11):724-725.
Green, K., and M. Zook. 2019. When talking about social determinants, precision matters.
Health Affairs Blog. https://www.healthaffairs.org/do/10.1377/hblog20191025.776011/
full (accessed November 7, 2019).
Gutiérrez, J. P., S. McPherson, A. Fakoya, A. Matheou, and S. M. Bertozzi. 2010. Community-
based prevention leads to an increase in condom use and a reduction in sexually
transmitted infections (STIs) among men who have sex with men (MSM) and female
sex workers (FSW): The Frontiers Prevention Project (FPP) evaluation results. BMC
Public Health 10:497.
Gutiérrez, J. P., E. E. Atienzo, S. M. Bertozzi, and S. McPherson. 2013. Effects of the Frontiers
Prevention Project in Ecuador on sexual behaviours and sexually transmitted infections
amongst men who have sex with men and female sex workers: Challenges on evaluat-
ing complex interventions. Journal of Development Effectiveness 5(2):158-177.
Harper, G. W., N. Willard, J. M. Ellen, and the Adolescent Medicine Trials Network for HIV/
AIDS Interventions. 2012. Connect to Protect®: Utilizing community mobilization and
structural change to prevent HIV infection among youth. Journal of Prevention & Inter-
vention in the Community 40(2):81-86.
Harsono, D., C. L. Galletly, E. O’Keefe, and Z. Lazzarini. 2017. Criminalization of HIV expo-
sure: A review of empirical studies in the United States. AIDS and Behavior 21(1):27-50.
Hatzenbuehler, M. L. 2011. The social environment and suicide attempts in lesbian, gay, and
bisexual youth. Pediatrics 127(5):896-903.
Hatzenbuehler, M. L., and B. G. Link. 2014. Introduction to the special issue on structural
stigma and health. Social Science & Medicine 103:1-6.
Hatzenbuehler, M. L., K. A. McLaughlin, K. M. Keyes, and D. S. Hasin. 2010. The impact
of institutional discrimination on psychiatric disorders in lesbian, gay, and bisexual
populations: A prospective study. American Journal of Public Health 100(3):452-459.
Hatzenbuehler, M. L., H. J. Jun, H. L. Corliss, and S. Bryn Austin. 2015. Structural stigma
and sexual orientation disparities in adolescent drug use. Addictive Behaviors 46:14-18.
Hill, B. J., D. N. Motley, K. Rosentel, A. VandeVusse, R. Garofalo, L. M. Kuhns, M. D. Kipke,
S. Reisner, B. Rupp, R. West Goolsby, M. McCumber, L. Renshaw, and J. A. Schneider.
2020. Work2prevent, an employment intervention program as HIV prevention for
young men who have sex with men and transgender youth of color (Phase 3): Protocol
for a single-arm community-based trial to assess feasibility and acceptability in a real-
world setting. JMIR Research Protocols 9(9):e18051.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
492 SEXUALLY TRANSMITTED INFECTIONS
Hogben, M., H. Chesson, and S. O. Aral. 2010. Sexuality education policies and sexually
transmitted disease rates in the United States of America. International Journal of STD
& AIDS 21(4):293-297.
Ibragimov, U., S. Beane, A. A. Adimora, S. R. Friedman, L. Williams, B. Tempalski, R. Stall,
G. Wingood, H. I. Hall, A. S. Johnson, and H. L. F. Cooper. 2019a. Relationship of racial
residential segregation to newly diagnosed cases of HIV among Black heterosexuals in
U.S. metropolitan areas, 2008-2015. Journal of Urban Health 96(6):856-867.
Ibragimov, U., S. Beane, S. R. Friedman, K. Komro, A. A. Adimora, J. K. Edwards, L. D.
Williams, B. Tempalski, M. D. Livingston, R. D. Stall, G. M. Wingood, and H. L. F. Coo-
per. 2019b. States with higher minimum wages have lower STI rates among women:
Results of an ecological study of 66 U.S. metropolitan areas, 2003-2015. PLoS One
14(10):e0223579.
Ibragimov, U., S. Beane, S. R. Friedman, J. C. Smith, B. Tempalski, L. Williams, A. A. Adi-
mora, G. M. Wingood, S. McKetta, R. D. Stall, and H. L. Cooper. 2019c. Police killings
of Black people and rates of sexually transmitted infections: A cross-sectional analysis
of 75 large U.S. metropolitan areas, 2016. Sexually Transmitted Infections 96(6):429-431.
IOM (Institute of Medicine). 2003. Unequal treatment: Confronting racial and ethnic disparities
in health care. Washington, DC: The National Academies Press.
Jenkins, R. A., A. R. Averbach, A. Robbins, K. Cranston, H. Amaro, A. C. Morrill, S. M. Blake,
J. A. Logan, K. Batchelor, A. C. Freeman, and J. W. Carey. 2005. Improving the use of
data for HIV prevention decision making: Lessons learned. AIDS and Behavior 9(Suppl
2):S87-S99.
Johnson-Masotti, A. P., S. D. Pinkerton, D. R. Holtgrave, R. O. Valdiserri, and M. Willingham.
2000. Decision-making in HIV prevention community planning: An integrative review.
Journal of Community Health 25(2):95-112.
Jones, C. P. 2018. Toward the science and practice of anti-racism: Launching a national cam-
paign against racism. Ethnicity & Disease 28(Suppl 1):231-234.
Karlamangla, S. 2018. STDs in L.A. County are skyrocketing. Officials think racism and stigma
may be to blame. https://www.latimes.com/local/california/la-me-ln-std-stigma-
20180507-htmlstory.html (accessed November 2, 2020).
Krieger, N. 2003. Does racism harm health? Did child abuse exist before 1962? On explicit
questions, critical science, and current controversies: An ecosocial perspective. Ameri-
can Journal of Public Health 93(2):194-199.
Kuhlmann, A. S., C. Galavotti, P. Hastings, P. Narayanan, and N. Saggurti. 2014. Investing in
communities: Evaluating the added value of community mobilization on HIV preven-
tion outcomes among FSWS in India. AIDS and Behavior 18(4):752-766.
Levanon Seligson, A., F. M. Parvez, S. Lim, T. Singh, M. Mavinkurve, T. G. Harris, and B.
D. Kerker. 2017. Public health and vulnerable populations: Morbidity and mortality
among people ever incarcerated in New York City jails, 2001 to 2005. Journal of Cor-
rectional Health Care 23(4):421-436.
Lim, S., T. P. Singh, and R. C. Gwynn. 2017. Impact of a supportive housing program on
housing stability and sexually transmitted infections among young adults in New York
City who were aging out of foster care. American Journal of Epidemiology 186(3):297-304.
Lippman, S. A., M. Chinaglia, A. A. Donini, J. Diaz, A. Reingold, and D. L. Kerrigan. 2012.
Findings from Encontros: A multilevel STI/HIV intervention to increase condom use,
reduce STI, and change the social environment among sex workers in Brazil. Sexually
Transmitted Diseases 39(3):209-216.
Lippman, S. A., S. Maman, C. MacPhail, R. Twine, D. Peacock, K. Kahn, and A. Pettifor. 2013.
Conceptualizing community mobilization for HIV prevention: Implications for HIV
prevention programming in the African context. PLoS One 8(10):e78208.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
STRUCTURAL INTERVENTIONS 493
Lipton, B. J., and S. L. Decker. 2015. ACA provisions associated with increase in percent-
age of young adult women initiating and completing the HPV vaccine. Health Affairs
(Millwood) 34(5):757-764.
Marshall, B. D. L., T. Kerr, J. A. Shoveller, T. L. Patterson, J. A. Buxton, and E. Wood. 2009.
Homelessness and unstable housing associated with an increased risk of HIV and STI
transmission among street-involved youth. Health Place 15(3):753-760.
McLeroy, K., D. Bibeau, A. Steckler, and K. D. Glanz. 1988. An ecology perspective on health
promotion programs. Health Education Quarterly 15:351-377.
Miller, R. L., K. S. Lee, D. Chiaramonte, O. J. Santiago-Rivera, I. Acevedo-Polakovich, C.
B. Boyer, J. M. Ellen, and the Adolescent Medicine Trials Network for HIV/AIDS
Interventions. 2018a. Youth health outcomes from the Connect-to-Protect coalitions to
prevent adolescent HIV infections. Vulnerable Children and Youth Studies 13(2):142-157.
Miller, R. L., T. Strzyzykowski, K. S. Lee, D. Chiaramonte, I. Acevedo-Polakovich, H. Spring,
O. Santiago-Rivera, C. B. Boyer, and J. M. Ellen. 2018b. Structural effects on HIV risk
among youth: A multi-level analysis. AIDS and Behavior 22(11):3451-3467.
NASEM (National Academies of Sciences, Engineering, and Medicine). 2017. Communities
in action: Pathways to health equity. Washington, DC: The National Academies Press.
NCCHC (National Commission on Correctional Health Care). 2020. STI testing for adolescents
and adults upon admission to correctional facilities. https://www.ncchc.org/STI-testing-
upon-admission (accessed November 18, 2020).
Oldenburg, C. E., A. G. Perez-Brumer, M. L. Hatzenbuehler, D. Krakower, D. S. Novak,
M. J. Mimiaga, and K. H. Mayer. 2015. State-level structural sexual stigma and HIV
prevention in a national online sample of HIV-uninfected MSM in the United States.
AIDS 29(7):837-845.
Pachankis, J. E., and R. Bränström. 2018. Hidden from happiness: Structural stigma, sexual
orientation concealment, and life satisfaction across 28 countries. Journal of Consulting
and Clinical Psychology 86(5):403-415.
Pachankis, J. E., M. L. Hatzenbuehler, F. Hickson, P. Weatherburn, R. C. Berg, U. Marcus,
and A. J. Schmidt. 2015. Hidden from health: Structural stigma, sexual orientation
concealment, and HIV across 38 countries in the European MSM Internet survey. AIDS
29(10):1239-1246.
Pagkas-Bather, J., L. E. Young, Y.-T. Chen, and J. A. Schneider. 2020. Social network interven-
tions for HIV transmission elimination. Current HIV/AIDS Reports 17(5):450-457.
Peng, Y., R. A. Hahn, R. K. C. Finnie, J. Cobb, S. P. Williams, J. E. Fielding, R. L. Johnson,
A. E. Montgomery, A. F. Schwartz, C. Muntaner, V. H. Garrison, B. Jean-Francois, B. I.
Truman, and M. T. Fullilove. 2020. Permanent supportive housing with housing first
to reduce homelessness and promote health among homeless populations with dis-
ability: A community guide systematic review. Journal of Public Health Management and
Practice 26(5):404-411.
People with AIDS Advisory Committee. 1983. The Denver principles. https://www.sero-
project.com/wp-content/uploads/2016/11/denver_principles-FINAL.pdf (accessed
November 1, 2020).
Perkins, R. B., M. Lin, S. F. Wallington, and A. D. Hanchate. 2016. Impact of school-entry
and education mandates by states on HPV vaccination coverage: Analysis of the 2009-
2013 National Immunization Survey—Teen. Human Vaccines & Immunotherapeutics
12(6):1615-1622.
Pierre-Victor, D., T. F. Page, M. J. Trepka, D. P. Stephens, T. Li, and P. Madhivanan. 2017. Im-
pact of Virginia’s school-entry vaccine mandate on human papillomavirus vaccination
among 13–17-year-old females. Journal of Women’s Health 26(3):266-275.
Planning CHATT. 2018. The Ryan White HIV/AIDS program Part A: Planning council prim-
er. https://targethiv.org/sites/default/files/file-upload/resources/Primer_June2018.
pdf (accessed November 18, 2020).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
494 SEXUALLY TRANSMITTED INFECTIONS
Platt, L., P. Grenfell, R. Meiksin, J. Elmes, S. G. Sherman, T. Sanders, P. Mwangi, and A.-L.
Crago. 2018. Associations between sex work laws and sex workers’ health: A system-
atic review and meta-analysis of quantitative and qualitative studies. PLoS Medicine
15(12):e1002680.
Pugsley, R. A., D. A. Chapman, M. G. Kennedy, H. Liu, and K. L. Lapane. 2013. Residential
segregation and gonorrhea rates in U.S. metropolitan statistical areas, 2005-2009. Sexu-
ally Transmitted Diseases 40(6):439-443.
Raifman, J., E. Moscoe, S. B. Austin, and M. McConnell. 2017. Difference-in-differences
analysis of the association between state same-sex marriage policies and adolescent
suicide attempts. JAMA Pediatrics 171(4):350-356.
Ramesh, B. M., T. S. Beattie, I. Shajy, R. Washington, L. Jagannathan, S. Reza-Paul, J. F.
Blanchard, and S. Moses. 2010. Changes in risk behaviours and prevalence of sexu-
ally transmitted infections following HIV preventive interventions among female sex
workers in five districts in Karnataka State, South India. Sexually Transmitted Infections
86(Suppl 1):i17-i24.
Reed, S. J., R. L. Miller, V. T. Francisco, and the Adolescent Medical Trials Network for
HIV/AIDS Interventions. 2014. The influence of community context on how coalitions
achieve HIV-preventive structural change. Health Education & Behavior 41(1):100-107.
Rhodes, T., M. Singer, P. Bourgois, S. R. Friedman, and S. A. Strathdee. 2005. The social
structural production of HIV risk among injecting drug users. Social Science & Medicine
61(5):1026-1044.
Roberts, D. 2016. Killing the Black body: Race, reproduction, and the meaning of liberty. New
York: Vintage Books.
Roberts, M. C., T. Murphy, J. L. Moss, C. W. Wheldon, and W. Psek. 2018. A qualitative com-
parative analysis of combined state health policies related to human papillomavirus
vaccine uptake in the United States. American Journal of Public Health 108(4):493-499.
Rotheram-Borus, M. J. 2000. Expanding the range of interventions to reduce HIV among
adolescents. AIDS 14:S33-S40.
Simon, K., A. Soni, and J. Cawley. 2017. The impact of health insurance on preventive care
and health behaviors: Evidence from the first two years of the ACA Medicaid expan-
sions. Journal of Policy Analysis and Management 36(2):390-417.
St Lawrence, J. S., K. W. Jefferson, P. G. Banks, T. R. Cline, E. Alleyne, and T. L. Brasfield.
1994. Cognitive-behavioral group intervention to assist substance-dependent adoles-
cents in lowering HIV infection risk. AIDS Education and Prevention 6(5):425-435.
STIRR (STI Regional Response Coalition). n.d. STIRR home page. http://www.stlstirr.org
(accessed November 4, 2020).
Sumartojo, E. 2000. Structural factors in HIV prevention: Concepts, examples, and implica-
tions for research. AIDS 14(Suppl 1):S3-S10.
Taylor, M. M., J. Frasure-Williams, P. Burnett, and I. U. Park. 2016. Interventions to improve
sexually transmitted disease screening in clinic-based settings. Sexually Transmitted
Diseases 43(2S):S28-S41.
Thompson, E. L., M. D. Livingston, E. M. Daley, and G. D. Zimet. 2018. Human papilloma-
virus vaccine initiation for adolescents following Rhode Island’s school-entry require-
ment, 2010-2016. American Journal of Public Health 108(10):1421-1423.
Thulin, L. 2020. What “racism is a public health issue” means. Smithsonian Magazine.
https://www.smithsonianmag.com/science-nature/what-racism-public-health-issue-
means-180975326 (accessed October 30, 2020).
Towe, V. L., E. W. Wiewel, Y. Zhong, S. Linnemayr, R. Johnson, and J. Rojas. 2019. A random-
ized controlled trial of a rapid re-housing intervention for homeless persons living
with HIV/AIDS: Impact on housing and HIV medical outcomes. AIDS and Behavior
23(9):2315-2325.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
STRUCTURAL INTERVENTIONS 495
Underhill, K., D. Dumont, and D. Operario. 2014. HIV prevention for adults with criminal
justice involvement: A systematic review of HIV risk-reduction interventions in in-
carceration and community settings. American Journal of Public Health 104(11):e27-e53.
Valdiserri, R. O., and D. R. Holtgrave. 2019. Ending HIV in America: Not without the power
of community. AIDS and Behavior 23(11):2899-2903.
Vestal, C. 2020. Racism is a public health crisis, say cities and counties. Pew Charitable Trusts
(October 30). https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/
2020/06/15/racism-is-a-public-health-crisis-say-cities-and-counties (accessed October
30, 2020).
Wagner, Z., Y. Yanyu Wu, and N. Sood. 2014. The Affordable Care Act may increase the
number of people getting tested for HIV by nearly 500,000 by 2017. Health Affairs
33(3):378-385.
Walters, Q. 2020. Boston mayor declares racism a public health crisis. NPR (October 30).
https://www.npr.org/sections/live-updates-protests-for-racial-justice/2020/06/12/
876327158/boston-mayor-declares-racism-a-public-health-crisis (accessed October
30, 2020).
WHO (World Health Organization). 2010. A conceptual framework for action on the social deter-
minants of health. Geneva, Switzerland: World Health Organization.
Willard, N., K. Chutuape, R. Stewart-Campbell, C. B. Boyer, and J. Ellen. 2015. Targeting
structural change for HIV prevention: A process and tool for community application.
Health Promotion Practice 16(6):837-848.
Yearby, R., C. N. Lewis, K. L. Gilbert, and K. Banks. 2020. Racism is a public health crisis.
Here’s how to respond. TJC Institute. https://tjcinstitute.com/research/racism-is-a-pub-
lic-health-crisis (accessed October 30, 2020).
Ziff, M. A., G. W. Harper, K. S. Chutuape, B. G. Deeds, D. Futterman, V. T. Francisco, L. R.
Muenz, J. M. Ellen, and the Adolescent Medicine Trials Network for HIV/AIDS Inter-
ventions. 2006. Laying the foundation for Connect to Protect: A multi-site community
mobilization intervention to reduce HIV/AIDS incidence and prevalence among urban
youth. Journal of Urban Health 83(3):506-522.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
10
Paying for and Structuring
STI Services
Chapter Contents
Introduction
Paying for STI Prevention and Treatment Services
Health Insurance Coverage Requirements
• Federal Requirements for Coverage of STIs and Related
Services
• STI Testing and Treatment Guidelines Issued by Health
Professional Organizations
Assessing Systems of Care and Accountability
• Performance Measures on STIs
Clinical STI Services
• Sexual Health Assessment
• Behavioral Interventions
• Immunizations
• Testing and Screening
• Treatment
• Partner Services and Expedited Partner Therapy
• Telehealth
497
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
498 SEXUALLY TRANSMITTED INFECTIONS
Chapter Contents Continued
STI Systems of Care
• Primary Care
• STI Specialty Care
• Family Planning
• Emergency Departments
• HIV Care and Treatment
• Resources for On-Demand Testing
• School-/College-/University-Based Health
• Correctional Facilities
• Military Personnel Health Care Facilities
• Integration of STI Services: The Role of Public Health
Conclusions and Recommendation
Concluding Observations
INTRODUCTION
The committee calls for a new and broader focus on sexual health
and new and expanded ownership and accountability for confronting
sexually transmitted infections (STIs) across society. At the same time,
the committee recognizes and supports the health system as having pri-
macy in improving STI outcomes. Nonetheless, within the health system
(including public health, public and private health insurance programs,
and other health care safety-net programs), with its decentralized regula-
tion and complex organization and financing, it is unclear which entities
or professions are accountable for improving STI outcomes. It is the com-
mittee’s view that the answer is not to centralize responsibility into one or
more types of specialists or institutions. Rather, as with the recommenda-
tions for community stakeholders (see Chapter 12), the committee finds
that it is necessary to broaden responsibility for STI screening, prevention,
and treatment within the health system and increase accountability across
payers and programs.
PAYING FOR STI PREVENTION AND TREATMENT SERVICES
Health care and clinical preventive care in the United States are paid
for by a patchwork of private insurance plans and government-supported
programs, which finance STI services for the vast majority of, but not all,
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PAYING FOR AND STRUCTURING STI SERVICES 499
U.S. residents. About half the U.S. population relies on employer-spon-
sored health insurance to pay for STI screening, testing, and treatment
services (see Figure 10-1). One in five individuals, nearly all of whom
are low income, are covered by Medicaid, a program that is operated by
states under broad federal guidelines but jointly funded by state and fed-
eral governments. Both Medicare and Medicaid offer their beneficiaries
a defined set of benefits and guarantee coverage of medically necessary
services to those who qualify, which differs from other discretionary
programmatic funding discussed in Chapter 4 that is constrained by the
amount of funding appropriated by Congress. Despite the broad reach
of employment-based coverage, the availability of subsidized individual
plans to purchase coverage through Patient Protection and Affordable
Care Act (ACA) marketplaces, and the important role of Medicare and
Medicaid, a sizable fraction (about 9 percent) of U.S. residents are unin-
sured and do not have a direct payment source for their care (see Figure
10-1). Those who lack coverage rely on public health services and other
discretionary programs (see Chapter 4). The following sections discuss
the role of publicly and privately funded coverage programs in providing
access to and coverage of STI services for U.S. residents.
While sexually active individuals of all ages are at risk for acquiring
STIs, teens and reproductive-aged adults are disproportionately affected
(see Box 10-1 for information about confidentiality and its importance in
adolescent care).
Furthermore, as Figure 10-2 shows, 6 in 10 individuals aged 15–49
receive coverage through the workplace, either through their own
employer or as a dependent (typically as a dependent child up to age 26
FIGURE 10-1 Health insurance coverage of the U.S. population, 2019.
NOTE: Total excludes Puerto Rico.
SOURCE: Data from KFF, 2019a.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
500 SEXUALLY TRANSMITTED INFECTIONS
BOX 10-1
Confidentiality of Care in Adolescents and Young Adults
Providers should take the initiative to talk to teens alone, maybe even
talking to the parents by themselves before the child comes in and saying,
“Hey, your child may be sexually active; I can have a [more open]
conversation with them if you are not there.”
—Parent participant, lived experience panela
I used to dread going to the doctor as a teen because I would get asked
over and over if I was sexually active in front of my mom. They would try
to gain my trust, and instead of gaining my trust they would try to pry it out
of me. They told me stuff like, “we can tell if you’re sexually active,” and I would
always stick to my original response, even though they would scare me.
—Adolescent participant, lived experience panel
The Promise of Adolescence: Realizing Opportunity for All Youth (NASEM, 2019)
describes confidential care as a core principle of adolescent-friendly health services.
The report emphasizes that providers can enable adolescents’ growth by facilitating
meaningful participation in their own health care decisions in a confidential setting, as
appropriate. Adolescents, in particular those aged 15–17, may express confidentiality
concerns, especially because many remain on their parents’ health insurance plans
(Sedlander et al., 2015). According to data from the National Survey of Family Growth,
more than 12 percent of sexually experienced adolescents aged 15–25 who were on
a parent’s health insurance plan reported that they would not seek reproductive and
sexual health services because of concerns that a parent would find out (Leichliter et
al., 2017).
Confidential care is not guaranteed for adolescents (SAHM, 2016; Tylee et al.,
2007), and access to it varies greatly by state and medical condition (AAP, 2016; SAHM,
or a spouse). Nearly 8 percent obtain individually purchased insurance,
many securing subsidies based on their household income to purchase
coverage through federal or state marketplaces established by the ACA.
Under the ACA, nearly all of these plans cover a wide range of preven-
tive services, including for STIs, such as chlamydia screening for sexually
active women younger than age 25, and are not permitted to charge the
policyholder any cost sharing for those services (see later in this chapter
for a discussion of these programs).
Medicaid plays a particularly important role in providing coverage
for low-income individuals and Black and Hispanic populations, who dis-
proportionately have low incomes. In addition, a higher share of women
than men relies on the program, which stems from eligibility policy origi-
nating in categorical programs, including cash assistance and pregnancy-
related care. State-established Medicaid eligibility levels must fall within
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PAYING FOR AND STRUCTURING STI SERVICES 501
2016). While all states currently allow minors to consent to STI diagnosis and treatment,
some states have age restrictions ranging from ages 12 to 16, and other states allow
physicians to inform parents (Guttmacher Institute, 2019b). Furthermore, confidentiality
is not necessarily guaranteed when a state allows minors to consent to services without
parental consent. For example, although the care an adolescent/dependent child re-
ceives may be confidential, that confidentiality may be breached if they are covered by
their parents’ health insurance and parents are able to review the services through the
electronic health record (EHR) or an Explanation of Benefits (EOB) is sent to parents
(Sedlander et al., 2015; Tebb et al., 2015).
Other barriers to confidential care for adolescents include health care providers and
institutions’ lack of knowledge of practices and policies regarding adolescents’ rights to
confidential health services, including providers not allowing opportunities for adoles-
cents to have a private health care visit without parents being present (McKee et al.,
2011), and providers not informing adolescents about confidentiality policies, such as
the type of care services that can and cannot be kept confidential, which may result in
poor communication and mistrust in providers (Gleeson et al., 2002).
Finally, federal laws and implementing regulations that address patient communica-
tions through EOBs or EHRs, such as the Patient Protection and Affordable Care Act
and the Cures Act, could have unintended consequences of violating confidentiality for
adolescents and young adults who are either minors or covered as child dependents
(SAHM, 2020). There are protocols, however, that plans and providers can implement
to protect their confidentiality. These include policies that suppress mailing EOBs when
there is no cost sharing or by using a special Current Procedural Terminology code that
can denote that a sensitive service has been provided when submitting a claim or mask
the reason for the visit (Sedlander et al., 2015).
a 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 through-
out the report are from individuals who spoke to the committee during these meetings.
broad federal guidelines, meaning that states must cover parents but can
set their income standards and must extend eligibility to all pregnant
people with incomes below 135 percent of the federal poverty level (FPL).
The ACA included a Medicaid expansion that allows states to enroll
all eligible individuals with income up to 138 percent of the FPL; before
that, only individuals who fell into federally established categories,
including pregnant women, parents of dependent children, individuals
65 and older, and those with disabilities, could qualify. The ACA origi-
nally required all states to make this expansion, but a legal challenge that
reached the Supreme Court in 2012 (National Federation of Independent Busi-
ness v. Sebelius) resulted in a ruling that allowed states to be able to choose
whether to expand Medicaid to other populations and higher income
categories. This state choice has resulted in inconsistent coverage policies
across the country. As of September 2020, 38 states and the District of
Columbia have adopted a Medicaid expansion.
Copyright National Academy of Sciences. All rights reserved.
502
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
FIGURE 10-2 Health insurance coverage among individuals aged 15–49, by selected characteristics, 2019.
NOTES: The Census Bureau federal poverty level (FPL) was $13,300 for a nonelderly individual. “Other” includes those covered
under the military or Veterans Health Administration and nonelderly Medicare enrollees. AI/AN = American Indian/Alaska
Native.
SOURCE: Kaiser Family Foundation, unpublished analysis of 2019 Census Bureau’s American Community Survey; data file avail-
Copyright National Academy of Sciences. All rights reserved.
able upon request from [email protected].
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PAYING FOR AND STRUCTURING STI SERVICES 503
Twelve states1 have not expanded Medicaid and still limit eligibility
to low-income individuals in the categorical groups (pregnant women,
parents, individuals 65 and older, and those with disabilities) and often
those with incomes far below the FPL (KFF, 2020e). In all of these states,
adults aged 19–49 are not eligible, no matter their income level, if they
are not pregnant, parents, and/or living with a disability. Eligibility for
parents in these states ranges from a low of 17 percent of the FPL in Texas
to 100 percent of the FPL in Wisconsin. This policy results in many in these
states losing pregnancy-related Medicaid eligibility (which ends 60 days
postpartum). In non-expansion states, those who have Medicaid coverage
for pregnancy do not have a pathway to affordable coverage 2 months
after delivery, and half become uninsured (Daw et al., 2019). This also has
been documented to a lesser degree in expansion states, where coverage
churn affects one-third of those who were covered by Medicaid during
their pregnancy (Daw et al., 2019). This state inaction has prompted advo-
cates and policy leaders to call for federal and state responses to address
this coverage gap (Eckert, 2020; Ranji et al., 2020).
State refusal to adopt the ACA Medicaid expansion, in particular, has
contributed to the considerable variation in uninsured rates (see Figure
10-3), from 4 percent to 26 percent of adults under age 65. A county-level
analysis of STI rates across the United States found that 64.3 percent of
counties without current Medicaid expansion were in the highest two STI
quartiles compared to 42.2 percent of counties with Medicaid expansion
(p < 0.0001) (Rietmeijer et al., 2021).2 Thus, across quartiles, higher combined
STI rates were significantly associated with a lack of Medicaid expansion.
Medicaid also plays an outsize role in financing family planning
services, including STI screening, testing, and treatment for individuals.
Family planning services are mandatory under Medicaid, although the
phrase is not specifically defined in regulation or statute. Many states
have used a waiver mechanism to establish a Medicaid financed limited-
scope family planning program that typically includes STI services along
with contraceptive services and supplies (Ranji et al., 2019). The ACA has
enabled states to establish these programs using a state plan amendment
1 Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, Tennes-
see, Texas, Wisconsin, and Wyoming.
2 Rates of reportable STI (chlamydia, gonorrhea, and primary and secondary syphilis) were
examined at the county level (3,218 counties) for counties located in states with (2,177) or
without (1,041) Medicaid expansion using data from the Census Bureau’s American Com-
munity Survey. For simplicity, data for the three STIs were combined. County data were
grouped by quartile of combined STI rates, and a simple chi-square analysis was used to
test for statistical significance across quartiles. Odds ratios were calculated comparing the
highest quartile with a combination of the lowest three.
Copyright National Academy of Sciences. All rights reserved.
504
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
FIGURE 10-3 Share of uninsured adults aged 15–49, by state, 2019.
SOURCE: Kaiser Family Foundation, unpublished analysis of 2019 Census Bureau’s American Community Survey; data file avail-
Copyright National Academy of Sciences. All rights reserved.
able upon request from [email protected].
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PAYING FOR AND STRUCTURING STI SERVICES 505
(Ranji et al., 2016). There are currently 26 states operating these limited-
scope programs, and many, but not all, also include men (KFF, 2020d).
Eligibility for these programs is based on income, loss of Medicaid due
to the end of pregnancy-based eligibility (ends 60 days postpartum in
non-expansion states), or loss of Medicaid eligibility for other reasons.
A notable gap in Medicaid has been a ban on coverage of immigrants
lawfully present in the United States, who are generally ineligible for
Medicaid (unless they are asylees or refugees) for the first 5 years of legal
residency unless their state of residency has chosen to expand coverage
to those who are children or pregnant, which half of the states have done
(KFF, 2020a). Undocumented individuals, however, lack a pathway to
any type of publicly supported insurance coverage, including Medicaid,
Medicare, and subsidized ACA marketplace coverage, and are dispropor-
tionately uninsured unless they obtain coverage through an employer.
Uninsured individuals, particularly those who are low income, have
fewer STI screening and treatment options and typically depend on a
network of safety net providers, including STI clinics and health depart-
ments, federally qualified health centers (FQHCs), and family planning
providers, for free or low-cost screening and treatment services. These
providers typically rely on a patchwork of federal, state, and local fund-
ing to sustain these services (see Chapter 4). The decrease in funding to
support STI services and federal family planning funding has been well
documented (Gift et al., 2018). Clinic closures and reduced staffing and
hours of care have directly impacted the ability of uninsured individuals,
particularly those that are lowest income and more likely to be medically
underserved, to obtain care.
HEALTH INSURANCE COVERAGE REQUIREMENTS
Federal Requirements for Coverage of STI and Related Services
Coverage programs also have a large role in establishing payment,
performance, and service delivery standards. While the ACA was primar-
ily focused on providing more coverage to the uninsured, it also contains
several provisions that shape the scope of coverage for STI services for
individuals with commercial or employer plans, Medicare, or Medicaid.
Section 2713 of the ACA (KFF, 2015) includes a requirement that
health insurance plans cover preventive services, without any patient cost
sharing, that receive an A or a B rating from the United States Preventive
Services Task Force (USPSTF), are endorsed by the Advisory Committee
on Immunization Practices (ACIP), or are recommended for women by
the Health Resources and Services Administration (HRSA) (KFF, 2020b).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
506 SEXUALLY TRANSMITTED INFECTIONS
The law stipulates that all private plans cover these services—self-funded
and fully insured employer plans, as well as individual policies. Only
plans that have “grandfathered” status (i.e., have been in effect without
substantive changes since before the ACA was enacted) are exempt.
Medicaid expansion coverage must offer the same preventive services
that are required of private health plans. For those who would have quali-
fied under the pre-ACA income eligibility levels (i.e., traditional Medic-
aid), however, preventive services are considered “optional” (states can
decide not to cover them). Nevertheless, many states have aligned this
coverage and do not differ between the services they cover for expansion
populations and those who qualify under traditional pathways. Impor-
tantly, children have extra protections under Medicaid’s Early and Peri-
odic Screening, Diagnostic and Treatment (EPSDT) benefit, which requires
states to periodically screen people under age 21 for certain conditions; in
addition, any coverable service under Medicaid must be provided when
medically necessary to children, even if it is optional for adults.
Table 10-1 shows a breakdown of which recommended preventive
STI services must be covered by most private insurance plans, Medi-
care, ACA Medicaid expansion programs, and traditional Medicaid plans.
Only preventive services recommended by USPSTF, ACIP, HRSA’s Bright
Futures Project, and HRSA’s Women’s Preventive Services Guidelines are
covered without cost sharing (KFF, 2020b). While the ACA’s provisions set
a floor for coverage, they do not cover all aspects of STI preventive care
and treatment. For example, STI treatment is typically covered by most
public and private plans but may be subject to cost sharing for follow-up
visits and prescriptions. In addition, private plans or Medicaid programs
are not required to pay for partner evaluation and management, includ-
ing expedited partner therapy (EPT), which provides the patient with
medication or a prescription for an affected sexual partner (see below
and Chapter 7 for more on EPT). That risk assessment alone, however, is
insufficient for prevention and control, as persons may deny risk due to
stigma or be unaware of the risk that their partners create for them, which
is a shortcoming in general for STI screening guidelines.
The ACA preventive services coverage provision sets a standard for
coverage, and the recommendations in its requirements are all issued
by independent committees (USPSTF, ACIP, Bright Futures, and Wom-
en’s Preventive Services Guidelines) that make their recommendations
based on evidence-based reviews of findings from peer-reviewed studies.
Screening and testing recommendations for young adult men, however,
are generally lacking. While Bright Futures recommends screening for all
adolescents, many men under 25 are diagnosed with STIs, and no recom-
mendation suggests routine screening for them. Indeed, a shortcoming of
current recommendations is that they are focused on large average risk
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PAYING FOR AND STRUCTURING STI SERVICES 507
TABLE 10-1 Preventive Services Required to Be Covered by
Different Payers Without Cost Sharing
Medicaid
Private Expan-
Recommending Insurers* sion
Authority: Eligible (federally (federally Traditional
Service Populations Medicare required) required) Medicaid
Chlamydia USPSTF: Screen Women ≤24 √ √ Required
screening all sexually active annually; for
women age 24 women >24 if children
and younger, all at increased under
sexually active risk; up to 2 EPSDT
women (aged screenings in
25+) who are at pregnancy Covered
increased risk at state
option for
adults
Bright Futures: Χ √ √ Required
Screen all sexually for
active adolescents children
for STIs (11–21 under
years old) EPSDT
Covered
at state
option for
adults
Gonorrhea USPSTF: Screen Women ≤24 √ √ Covered
screening all sexually active annually; at state
women age 24 women >24 if option for
and younger, all at increased adults
sexually active risk; up to 2
women (aged screenings in
25+) who are at pregnancy
increased risk
Bright Futures: Χ √ √ Required
Screen all sexually for
active adolescents children
for STIs (11–21 under
years old) EPSDT
Covered
at state
option for
adults
continued
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
508 SEXUALLY TRANSMITTED INFECTIONS
TABLE 10-1 Continued
Medicaid
Private Expan-
Recommending Insurers* sion
Authority: Eligible (federally (federally Traditional
Service Populations Medicare required) required) Medicaid
Syphilis USPSTF: Screen all Pregnant women √ √ Covered
screening pregnant women at start of at state
and persons at risk pregnancy and option for
third trimester, adults
at delivery if
high risk; all
men and other
women annually
if at risk
Bright Futures: Χ √ √ Required
Screen all sexually for
active adolescents children
for STIs (11–21 under
years old) EPSDT
PPX for USPSTF: Provide Χ √ √ Covered
ocular prophylactic ocular at state
gonorrhea topical medication option for
to all newborns to adults
prevent gonococcal
ophthalmia
neonatorum
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PAYING FOR AND STRUCTURING STI SERVICES 509
TABLE 10-1 Continued
Medicaid
Private Expan-
Recommending Insurers* sion
Authority: Eligible (federally (federally Traditional
Service Populations Medicare required) required) Medicaid
HPV testing Women’s Covers screening √ √ Covered
Preventive Services once every at state
Guidelines: For 5 years if option for
women aged asymptomatic adults
21–29, screen with for ages 30–65
cytology every
3 years; for women
aged 30–65, screen
with cytology and
HPV testing every
5 years or cytology
alone every 3 years
USPSTF: Screen √ √ Covered
women aged 21–65 at state
with cytology option for
every 3 years or, adults
for women aged
30–65 who want to
lengthen screening
interval, screen
with cytology and
HPV testing every
5 years
HPV ACIP: Routine vac- Χ √ √ Required
vaccine cination for men for
and women aged children
11–12; also vacci- under
nate the following EPSDT
groups if they have
not been vacci- Covered
nated previously at state
or have not com- option for
pleted the three- adults
dose series: women
aged 13–26, men
aged 13–21, and
men who have sex
with men and im-
munocompromised
persons through
age 26
continued
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
510 SEXUALLY TRANSMITTED INFECTIONS
TABLE 10-1 Continued
Medicaid
Private Expan-
Recommending Insurers* sion
Authority: Eligible (federally (federally Traditional
Service Populations Medicare required) required) Medicaid
STI and USPSTF: Provide Up to two √ √ Required
HIV intensive 20–30-minute for
prevention behavioral behavioral children
counseling counseling to counseling under
prevent STIs to sessions annually EPSDT
all sexually active for those at high
adolescents and for risk Covered
adults at increased at state
risk for STIs option for
adults
Women’s Χ √ √ Covered
Preventive Services at state
Guidelines: Annual option for
counseling on STIs, adults
including HIV, for
all sexually active
women
NOTE: ACIP = Advisory Committee on Immunization Practices; EPSDT = Early and Period-
ic Screening, Diagnostic and Treatment; HPV = human papillomavirus; PPX = prophylaxis;
USPSTF = United States Preventive Services Task Force.
* Applies to non-grandfathered plans.
SOURCES: CDC, 2020d; CMS, n.d.; KFF, 2020b; Medicare.gov, n.d.-c.
populations by design and so neglect subpopulations such as adolescent
males, racial and ethnic minorities, men who have sex with men (MSM),
and others that are at greater risk for acquiring STIs. Without guidance
from USPSTF or clinical professional organizations, pathways to provide
these services to men and avenues for reimbursement and out-of-pocket
payment protections are both limited.
STI Testing and Treatment Guidelines Issued
by Health Professional Organizations
The Centers for Disease Control and Prevention (CDC) and USPSTF
provide national standards and guidance for the prevention, screening/
testing, and treatment of STIs. Health professional organizations, how-
ever, sometimes adapt these recommendations for their own members
or have their own recommendations. Appendix B presents the different
recommendations issued by leading health professional organizations
and highlights how they compare to the CDC/USPSTF recommenda-
tions. These organizations include the American Academy of Family
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PAYING FOR AND STRUCTURING STI SERVICES 511
Physicians, the American Academy of Pediatrics, the American College
of Obstetricians and Gynecologists, the American College of Physicians,
the American Academy of Physician Assistants, the American Public
Health Association, and various nursing organizations (e.g., American
Nurses Association).
For the most part, recommendations published by professional orga-
nizations are consistent or mostly consistent with CDC and USPSTF
guidelines. These organizations are more likely to publish guidance when
there is a paucity of information, however, than to publish inconsistent
information. Many organizations direct readers to CDC or USPSTF for
more detailed guidelines and focus more on the guidelines that pertain
only to their population of specialization (e.g., women for the American
College of Obstetricians and Gynecologists, pediatrics for the American
Academy of Pediatrics). Medical societies are also more likely to publish
specific screening/treatment recommendations than organizations repre-
senting nurses, physician assistants, and public health practitioners are,
as the latter tend to rely on existing policy recommendations.
ASSESSING SYSTEMS OF CARE AND ACCOUNTABILITY
Performance Measures on STIs
Despite broad recognition that the United States falls short in obtain-
ing health care value and quality for its outsized investment, the nation
still lacks a uniformly accepted and widely adopted method for measur-
ing quality. This is an especially notable gap for sexual and reproductive
health services, including STI prevention and treatment for sexual minor-
ity groups, such as LGBTQ populations, particularly MSM, bisexual, and
transgender individuals who are at higher risk of exposure to STIs.
The measures most commonly used by providers and plans are those
promulgated by the Healthcare Effectiveness Data and Information Set
(HEDIS), the National Quality Forum (NQF), and the Medicaid Core Set.
The measures that have been approved and adopted largely focus on
services for women, teens, and infants, including chlamydia screening for
women, human papillomavirus (HPV) vaccination, and cervical cancer
screening. NQF also collects data on the share of persons with HIV being
screened for STIs and vaccination rates for hepatitis A and B, although
these are not typically the focus of STI prevention efforts. Screening and
treatment completion indicators for gonorrhea are absent in the HEDIS
and Medicaid Core Set, as are targeted screening and treatment comple-
tion services for men. Because these performance measures are designed
to capture recommended services that pertain to a large population rather
than targeted at a population at risk, plans and payors are not able to
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
512 SEXUALLY TRANSMITTED INFECTIONS
provide information about the effectiveness of these systems in serving
these often marginalized and high-risk populations.
In contrast, the CDC performance measures for state health depart-
ments track the performance of STI clinics, family planning sites, and adult
jails along with measures to track partner services and data reporting.
These STI measures are considerably more robust than those that are used
by payors and plans with HEDIS and Medicaid. In addition, CDC mea-
sures include timelines of treatment and counseling, which are critical in
terms of tracking the recommended responses to identified cases yet are
not addressed by the HEDIS, NQF, or Medicaid measures. These measures,
however, have not been updated since 2011 (CDC, 2011). Table 10-2 lists the
performance measures on STIs for health plans, Medicaid, and CDC.
Overall, completion rates for the few STI-relevant measures tracked by
HEDIS are quite low. For example, according to 2018 HEDIS data on teens
who had a health care visit in the past year, only 30 percent enrolled in a
health maintenance organization (HMO), 25 percent enrolled in a preferred
provider organization (PPO), and 38 percent enrolled in a Medicaid HMO
had completed the HPV vaccine series by their 13th birthday. Similarly,
HEDIS reports that only half of sexually active women aged 16–24 who
were enrolled in an HMO or PPO and had a health care encounter had a
chlamydia screening during the measurement year; the rates were slightly
higher for those in a Medicaid HMO (58 percent). STI screening under
NQF is limited to persons with HIV. No STI-related measures for men are
represented in HEDIS, NQF, or the Medicaid core measures promulgated
by the Centers for Medicare & Medicaid Services. It also should be noted
that HEDIS measures are calculated based on health plan enrollees who
received a service within a given year. Enrollees who did not have a claim
or health care visit are not included in the denominator, so HEDIS mea-
sures likely overestimate the true screening rates among enrollees.
Given the number of enrollees who are now eligible for Medicaid
or individual policies through the ACA exchanges, the absence of mea-
sures for men represents a major gap for a population that is served by
these programs. With the growth and interest in developing value-based
payment strategies to incentivize the provision of recommended care,
the absence of measures that track a broader range of STI screening,
testing, and treatment for men and other populations that are at high
risk of exposure and also experience poor access to care represents a sig-
nificant gap. In addition to improving the completion rates for services
that affect women and teens, there is an urgent need to develop tools to
track whether providers and plans are meeting the standards of care for
often marginalized populations that are at higher risk for contracting
STIs, including MSM, transgender men and women, and other gender
nonconforming individuals discussed in Chapter 3. Finally, the lack of
STI performance measures for services needed by these populations will
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PAYING FOR AND STRUCTURING STI SERVICES 513
TABLE 10-2 Health Plan, Medicaid, and CDC Performance
Measures for Sexually Transmitted Infections
HEDIS Measures
HPV immunizations (NCQA, • Assess the share of adolescents who have
n.d.-c) completed the HPV vaccine series by their
13th birthday (2018: HMO 30%, PPO 25%,
Medicaid HMO 38%)
Chlamydia screening in women • Assess the share of sexually active women
(NCQA, n.d.-b) aged 16–24 who had at least one test for
chlamydia during the measurement year
(2018: HMO 51%, PPO 48%, Medicaid HMO
58%)
Cervical cancer screening • Assess the share of women aged 21–64 who
(NCQA, n.d.-a) were screened for cervical cancer using
cervical cytology every 3 years (if ages 21–64)
or using cervical cytology/HPV testing every
5 years (if ages 30–64) (2018: HMO 75%, PPO
74%, Medicaid HMO 59%)
• Assess the share of adolescent women aged
16–20 who were screened unnecessarily for
cervical cancer (2018: HMO 1%, PPO 1%,
Medicaid HMO 1%)
NQF-Endorsed Measures
Chlamydia screening in women • Percentage of women aged 16–24 who were
(NQF, n.d.) identified as sexually active and who had
at least one test for chlamydia during the
measurement year
STI screening for persons with • Percentage of patients aged 13 and older with
HIV (NQF, n.d.) a diagnosis of HIV/AIDS, who have received
chlamydia, gonorrhea, and syphilis screenings
at least once since the diagnosis of HIV
infection
Hepatitis B/hepatitis A vaccines • Percentage of children 2 years of age who had
(NQF, n.d.) three hepatitis B vaccines and one hepatitis A
vaccine (among other vaccines) by the second
birthday
Medicaid Performance Measures (data collected by state)
Cervical cancer screening (adult • Percentage of women aged 21–64 who were
core) (Medicaid.gov, n.d.-a) screened for cervical cancer using (1) cervical
cytology performed every 3 years (if ages
21–64) or (2) cervical cytology/HPV co-testing
performed every 5 years (if ages 30–64)
continued
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
514 SEXUALLY TRANSMITTED INFECTIONS
TABLE 10-2 Continued
Chlamydia screening in women • Percentage of women aged 21–24 who were
(adult core and child core) sexually active and had at least one test for
(Medicaid.gov, n.d.-a, n.d.-b) chlamydia during the measurement year
• Percentage of women aged 16–20
Immunizations for adolescents • Percentage of adolescents who had completed
(child core) (Medicaid.gov, the HPV vaccine series by their 13th birthday
n.d.-b)
CDC Performance Measures for Public Health Departments (CDC, 2011)
MLS
Chlamydia testing in • Proportion of female admittees to large juvenile
juvenile detention facilities who were tested for chlamydia
detention facilities
Chlamydia positivity in • (CSPS MLS1b): Proportion of female admittees
juvenile detention facilities tested in large juvenile detention facilities
diagnosed with chlamydia
Timely treatment of women • Among clients of IPP family planning clinics,
with chlamydia at family proportion of women with positive CT tests who
planning sites are treated within 14 and 30 days of the date of
specimen collection
Timely treatment of women • Among clients of IPP family planning clinics,
with gonorrhea at family proportion of women with positive GC tests who
planning sites are treated within 14 and 30 days of the date of
specimen collection
Timely treatment of women • Among clients of STD clinics, proportion of
with chlamydia at STD women with positive CT tests who are treated
clinics within 14 and 30 days of the date of specimen
collection
Timely treatment of women • Among clients of STD clinics, proportion of
with gonorrhea at STD women with positive GC tests who are treated
clinics within 14 and 30 days of the date of specimen
collection
Timely treatment of P&S • Proportion of P&S syphilis cases treated within 14
syphilis cases and 30 days of the date of specimen collection
Syphilis testing of women at • Proportion of female admittees entering selected
select adult jails project area adult city and county jails who were
tested for syphilis
New syphilis cases • Proportion of women tested who are newly
diagnosed in select adult diagnosed with syphilis (any stage) in select adult
jails jails
Timely syphilis treatment in • Proportion of women newly diagnosed with
select adult jails syphilis (any stage) treated within 14 and 30 days
of the date of specimen collection
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PAYING FOR AND STRUCTURING STI SERVICES 515
TABLE 10-2 Continued
CDC Partner Services
Timeliness of P&S syphilis • Proportion of P&S syphilis cases interviewed
interviews within 7, 14, and 30 calendar days from date of
specimen collection
Timeliness of prophylactic • Number of contacts prophylactically treated within
treatment for contacts to P&S 7, 14, and 30 calendar days from day of interview
syphilis cases (CSPS PS2a) of the index case, per case of P&S syphilis
Timeliness of treating • Number of contacts newly diagnosed and treated
contacts of P&S syphilis within 7, 14, and 30 calendar days from day
cases who are themselves of interview of the index case, per case of P&S
infected (CSPS PS2b) syphilis
Timeliness of gonorrhea • Proportion of ALL gonorrhea cases interviewed
interviews (CSPS PS3) within 7, 14, and 30 days of the date of specimen
(required for non-high- collection
morbidity areas only)
CDC Statistics and Data Management for Health Departments
Completeness of data • Proportion of reported cases of gonorrhea,
chlamydia, P&S syphilis, early latent syphilis, and
congenital syphilis sent to CDC via NETSS that
have complete data for age, race, sex, county, and
date of specimen collection
Timeliness of data • Proportion of reported cases of gonorrhea,
chlamydia, P&S syphilis, early latent syphilis, and
congenital syphilis sent to CDC via NETSS within
30 and 60 days from the date of specimen collection
Completeness of data • Proportion of reported cases of P&S syphilis and
early latent syphilis sent to CDC via NETSS where
sex of the sex partner(s) is known
NOTE: CDC = Centers for Disease Control and Prevention; CT = Chlamydia trachomatis; GC
= Neisseria gonorrhoeae; HEDIS = Healthcare Effectiveness Data and Information Set; HMO =
health maintenance organization; HPV = human papillomavirus; IPP = Infertility Prevention
Program; MLS = Medical and Laboratory Services; NETSS = National Electronic Telecom-
munications System for Surveillance; NQF = National Quality Forum; P&S = primary and
secondary; PPO = preferred provider organization; STD = sexually transmitted disease; STI
= sexually transmitted infection.
also pose a barrier to the future development of a sexual and reproductive
health reimbursement bundle that could potentially include payment for
the recommended screening and treatment services for STIs, counseling,
and other services.
CLINICAL STI SERVICES
In 2020, CDC released recommendations on improving quality of
STI clinical services, including sexual history and physical examination,
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
516 SEXUALLY TRANSMITTED INFECTIONS
prevention, screening, partner services, evaluation of STI-related con-
ditions, laboratory, treatment, and referral to a specialist for complex
STI or STI-related conditions. The recommendations distinguish between
basic services that should be available in primary care settings and more
extensive services in STI specialty settings (Barrow et al., 2020). These
guidelines represent an aspirational standard of STI care, but there are
many settings where STI care is delivered differently depending on the
population served, with the priority being that STI care and prevention
account for and address the medical needs of these populations and the
logistical and resource constraints in each setting. From a pragmatic and
strategic point of view, it is important to examine each of these settings in
detail to determine their optimal role in STI care and prevention.
The next sections discuss different components of STI clinical care,
followed by a detailed review of STI services in the spectrum of care set-
tings that identifies the relative strengths and weaknesses and how they
may fit together in a continuum of services rather than a fragmented
system.
Sexual Health Assessment
The more we focus on teaching doctors how to take a really
good sexual history, the better. A lot of doctors don’t feel comfortable
taking a sexual history and asking questions about sex—and maybe
when they do, they may make assumptions and moral judgments.
Patients sense this, and that adds to the discomfort they already feel.
—Participant, lived experience panel
Assessing sexual health is the force driving subsequent interven-
tions for STI prevention and control and can normalize sexual health as
a component of overall health. A basic sexual health assessment needs to
be an integral part of a “review of systems” as a standard in most health
care settings—both offered routinely by the provider and expected by
the patient/client. At a minimum, this assessment includes questions on
sexual orientation and gender identification (SOGI) and a review of the
“Five Ps”: partners (gender, number), (sexual) practices (receptive and
insertive vaginal, anal, oral sex), prevention (condom use, contraception),
previous history of STIs, and pregnancy (CDC, 2015a). Besides being good
clinical practice, the consistent collection and review of SOGI data at the
health systems level allows for sexual health policy development and
funding allocation.
While the fundamentals of sexual health assessments are routinely
taught as part of health care professional training, their use in the context
of routine care typically atrophies over time, particularly when training
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PAYING FOR AND STRUCTURING STI SERVICES 517
is carried out in acute care and inpatient settings. CDC recommends rou-
tine sexual health assessments in U.S. care settings, but a review showed
generally low adherence to these guidelines (Brookmeyer et al., 2020).
Thus, these sexual health assessments need to be further routinized and
automated and protocols developed that will reduce provider reliance to
determine who is at risk for STIs. Technological advances may provide
opportunities, such as clinical prompts in an electronic health record
(EHR; see Chapter 6 for more on EHRs). Information gathering, such as
tablet-based self-reporting of recent sexual activity, would allow data col-
lection in clinicians’ waiting rooms, with little impact on visit time. Such
assessments could be age and gender specific.
Following the principles laid out in Chapter 1, a sexual health assess-
ment needs to be free of prejudice and stigmatizing language. When
conducted appropriately, it provides a window into the patient’s sexual
well-being and suggests potential intervention steps. Conducting such
an assessment needs to be a basic competency addressed in medical and
nursing school curricula, and health systems could consider accommoda-
tions, such as EHRs, to facilitate recording the details. This information
could lead to action prompts, such as recommended chlamydia screening
for sexually active women under the age of 25 (see Chapter 6 for more
on this topic).
While a regular sexual health assessment is critical in sexual health
promotion and STI prevention, it also has limitations. For example,
given the continued stigma surrounding sexuality, sexual activity may
be under-reported, especially among adolescents and young adults and
people with multiple partners. Furthermore, STI acquisition depends
on partners’ sexual behavior, which may include exposures unknown
to the individual seeking care, and STIs may be missed when testing
is limited to those who verbalize potential exposure. Thus, STI screen-
ing programs, such as opt-out chlamydia screening for high-prevalence
groups (e.g., those under 25) regardless of sexual health assessment and
even bypassing the provider, could be developed. Evidence from cost-
effectiveness modeling studies suggests that such approaches may be cost
saving (Owusu-Edusei et al., 2016).
Behavioral Interventions
Health promotion and risk reduction counseling is the most com-
monly used behavioral intervention in the health care setting and serves
a variety of health objectives, including quitting smoking, promoting
healthy eating and drinking, addressing substance use, and enhanc-
ing physical activity. When performed correctly, counseling can have
positive impacts on health behavior. Effective counseling models have
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
518 SEXUALLY TRANSMITTED INFECTIONS
been developed and implemented in care settings, including the widely
adopted motivational interviewing (Miller and Rollnick, 1991). A simi-
lar technique called “client-centered counseling” has been proven to be
effective for STI prevention (Kamb et al., 1998), but a follow-up study
conducted 15 years later could not confirm its effectiveness (Metsch et al.,
2013), possibly related to overall changes in attitudes following the intro-
duction of highly active antiretroviral therapy that dramatically changed
the perception of HIV as an invariably deadly infection. Nonetheless, the
principles of motivational interviewing, including those applied in cli-
ent-centered counseling, and shared medical decision making have been
widely adopted and influenced the provider–client interaction (Elwyn et
al., 2014).
The following steps can be achieved in a single brief counseling ses-
sion (Dreisbach et al., 2014):
• Discuss how various sexual behaviors can expose a person to
STIs.
• Assess the patient’s understanding and beliefs about STI
transmission.
• Assess the circumstances that affect the patient’s sexual behavior.
• Assess the patient’s readiness to change.
• Negotiate a behavioral goal.
• Identify a concrete and realistic first step toward the goal.
One common critique of counseling is that it is time intensive; even
when providers can bill for it, it is often not implemented. The Safe in
the City waiting room video intervention was shown to be effective in
reducing incident STIs in a large, controlled study involving more than
40,000 patients in three STI clinics (Warner et al., 2008) and was highly
cost effective and even cost saving in many settings (Williams et al.,
2020). Follow-up studies demonstrated widespread adoption in STI clin-
ics (Harshbarger et al., 2012). Health care settings, including clinics and
doctors’ offices, could incorporate more of these brief behavioral interven-
tions and other types of behavioral interventions (e.g., family interven-
tions; see Chapter 8) to increase behavioral assessment, improve patient
education, and establish behavior change goals to increase positive sexual
health practices and decrease STI risk. To stay relevant and fresh, how-
ever, these interventions need regular updates. Unfortunately, despite its
cost effectiveness, no additional funding has been available to develop
follow-up videos for Safe in the City.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PAYING FOR AND STRUCTURING STI SERVICES 519
Immunizations
An inventory of recommended immunizations is obtained routinely
in many practices and needs to include approved and recommended
immunizations for sexually transmitted pathogens, including hepatitis B
virus and HPV. As discussed in Chapter 7, hepatitis B vaccination is now
widely recommended as part of the routine childhood series, so coverage
is increasing. In 2017, 73.6 percent of infants received it within 3 days of
birth (Hill et al., 2018). As the cohort that received standard childhood
immunization ages, overall coverage will also increase. HPV immuniza-
tion coverage has lagged behind; only 51.1 percent of adolescents aged
13–17 were fully immunized in 2018 and 48.6 percent in 2017 (Walker et
al., 2019), although the vaccine has had large positive effect on HPV infec-
tion (McClung et al., 2019) (see Chapter 7 for a discussion of barriers).
Uptake has been hampered in part by the cost of the three-dose schedule.
Thus, the recent shift in recommendations toward a two-dose schedule
(at baseline and 6–12 months later) for 9–14-year-olds will likely improve
coverage (CDC, 2019a). Unlike other routine childhood immunizations,
however, HPV vaccination is often presented as optional. This linkage to
(future) sexual activity creates a barrier for providers to offer and for par-
ents to accept it. Emphasizing its importance as a cancer prevention tool
and de-emphasizing the link with sexual activity has been suggested as a
more effective way in routinizing this intervention (Offit, 2014).
Testing and Screening
The reality is that we are all sexual creatures,
so we are all at risk, and we should all be screened.
—Participant, lived experience panel
Chapter 7 extensively discusses the technical details of diagnostics.
From an implementation perspective, STI testing can be considered to fall
into four not entirely mutually exclusive groups: screening, opportunistic
testing, on-demand testing, and diagnostic testing. Screening is universal
or age-based testing for populations considered to be at specific risk for
a certain pathogen and may include opportunistic testing (i.e., offering a
test, typically in a health care setting, to a person who makes a visit unre-
lated to the test, such as chlamydia testing for a sexually active woman
visiting her primary care provider for an upper respiratory tract infection
and who has no STI symptoms or concerns). On-demand testing typically
occurs for a specific concern (i.e., exposure to an STI but otherwise asymp-
tomatic). Finally, diagnostic testing is conducted for symptomatic STIs to
determine etiology and select appropriate treatment.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
520 SEXUALLY TRANSMITTED INFECTIONS
While many providers will offer testing in different categories, some
types are more appropriate for certain venues than others. For example,
online testing services may be very appropriate for on-demand testing but
not for diagnostic testing, as symptomatic patients should be encouraged
to seek out a health care provider. Making these distinctions will prove
useful for recommendations to enhance interventions for STI prevention,
as detailed below.
As discussed in Chapter 7, the widespread implementation of nucleic
acid amplification tests (NAATs) for gonorrhea and chlamydia since the
mid-1990s has revolutionized the armamentarium of STI diagnostics.
These tests are highly sensitive and specific and, most importantly, can
be performed on specimens, including urine specimens and self-obtained
vaginal, throat, or anal swabs, that no longer require invasive procedures.
As a result, STI testing is now conducted in a variety of settings, which
has effectively broadened the available venues beyond the traditional STI
specialty clinic, and extragenital (i.e., pharyngeal and anal) testing should
now be the standard of care for all providers of basic STI services per CDC
guidelines (Barrow et al., 2020).
Availability of point-of-care (POC) testing promises to further enhance
diagnostic capability. Some POC testing (Gram-stained smear to differen-
tiate gonococcal from nongonococcal urethritis and wet preps of vaginal
discharge to differentiate trichomoniasis, bacterial vaginosis, and yeast
infection) and rapid treponemal (Syphilis Health Check) and nontrepo-
nemal (such as rapid plasma reagin test) testing for syphilis, however,
have long been available but are not widely used outside the STI specialty
clinic setting due to regulatory and logistical issues. Studies, including
demonstration projects, need to be conducted to elucidate barriers and
facilitators to implementing POC testing in all venues that provide STI
care, as it is likely that tests on the horizon may face the same hurdles as
those now available.
Prenatal Screening for Syphilis and Other STIs
All cases of congenital syphilis are failures of the health care system.
To eliminate the disease, prenatal services need to be universally avail-
able without cost or access barriers (as many cases are missed due to lack
of prenatal care), and screening needs to be universal to treat infection
in the pregnant person and prevent neonatal infection (see Chapter 3 for
more information). Universal antepartum screening for syphilis (as well as
chlamydia and gonorrhea) is recommended because treatment provided
appropriately during pregnancy will prevent adverse outcomes for the
pregnant person and the infant in nearly all cases (Cheng et al., 2007;
Newman et al., 2013). The U.S. Public Health Service, CDC, the American
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PAYING FOR AND STRUCTURING STI SERVICES 521
College of Obstetricians and Gynecologists, and other medical, nursing,
and public health organizations recommend STI screening during the first
prenatal visit. Many states require syphilis testing during prenatal care, as
of 2018: 42 states have laws requiring syphilis screening in the first visit,
only 15 states require a second screening in the third trimester, and 5 require
screening only if high risk. Only six states require testing at delivery (and
six others do for those at high risk), in addition to prenatal care screening.
State policies regarding prenatal syphilis screening are diverse but may
be an alternative to address screening policies (CDC, 2020e; Warren et al.,
2018). Ideally, HIV screening would always be accompanied by other STI
screening and vice versa (Rac et al., 2017; Taylor et al., 2017). Guidelines
also typically recommend that women at higher risk be rescreened at the
beginning of their third trimester and again at delivery or after exposure to
a partner who may be infected. Universal screening for syphilis and other
STIs can reduce stigma because testing is offered to all pregnant people
irrespective of symptoms or risk behavior. Compared to single testing,
repeat testing for HIV and syphilis during pregnancy is cost effective and
improves outcomes for the pregnant person and the infant for both congen-
ital syphilis and HIV during pregnancy and at birth in higher-prevalence
priority populations (Albright et al., 2015; Hersh et al., 2018). There-
fore, offering unrestricted access to prenatal care and effectively deploying
screening services to key marginalized persons are essential in decreasing
rates of congenital syphilis. This will require improving access to prenatal
care and more widespread testing (including easier access points for care)
in populations of those most impacted and their sex partners.
STI Testing and Pre-/Post-Exposure Prophylaxis for HIV Prevention
As discussed in other parts of this report, the use of antiretrovirals in
pre- and post-exposure prophylaxis (PrEP and PEP, respectively) is a highly
recommended intervention for HIV prevention yet may lead to increases
in condomless sex and associated incidence of non-HIV STIs (Jenness et
al., 2017; Volk et al., 2015). As this intervention is being implemented in a
variety of settings, guidelines for PrEP and PEP stress regularly screening
for STIs, including serological syphilis testing and testing for chlamydia
and gonorrhea at all exposed anatomical sites (CDC, 2018). (See Chapter 5
for additional discussion on the intersection of STIs and HIV.)
“Express” Visits for STI Testing
NAATs have obviated the need for invasive anogenital sampling, so
some STI clinics have explored the possibility of testing-only visits (i.e.,
not including physical examination of asymptomatic patients) with the
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
522 SEXUALLY TRANSMITTED INFECTIONS
main objective of increasing the efficiency of clinic operations in times of
dwindling resources. These are known as “express” or “fast-track” vis-
its, and early proof-of-concept studies have shown their feasibility, with
up to 25 percent of visits qualifying for the express option, resulting in
decreased clinic time compared to traditional, full-exam visits (Heijman et
al., 2007; NACCHO, 2019; NAPA, 2018; Shamos et al., 2008). Subsequent
studies have confirmed that this approach is safe, efficient, and accept-
able to patients (Chambers et al., 2017, 2018), and many clinics have since
adopted some form of it. Taking this approach a step further, the Dean
Street EXPRESS clinic3 in London is the first and best-known example
of a clinic that only offers the express option, but it is organizationally
linked to a full-service HIV/STI clinic across the street that allows for
easy referral for treatment or clinical follow-up (Whitlock et al., 2018).
In the United States, CDC supports a project overseen by the National
Association of County and City Health Officials to develop demonstration
projects exploring feasibility and acceptability of express visit options in
different clinical environments. Challenges include insurance reimburse-
ment for services not involving medical providers. In addition, challenges
for standalone STI express clinics include lack of funding and the need
for expeditious referral to full-service clinics for additional follow-up and
care. Nonetheless, the evolving landscape of express STI clinical services
is an excellent example of how technological advancements, such as POC
tests, can leverage innovative approaches and new options in clinical care
and prevention (Gaydos et al., 2020). Further developments include offer-
ing testing-only options in nonclinical settings, including mobile outreach
units, pharmacies, community organizations, and other venues where
people disproportionally affected by STIs may congregate. Future avail-
ability and implementation of POC testing will be particularly important
in the evolution of the express visit option to decrease the time to treatment
for clients who otherwise do not present with an immediate reason to treat.
Treatment
At the provider level, STI treatment either follows a positive STI
test (etiologic treatment) or is implemented presumptively based on
patient symptoms (syndromic treatment) or partner infection (epidemio-
logic treatment). Syndromic treatment has been used for patients with
urethral discharge, vaginal discharge, genital ulcer disease, and pelvic
inflammatory disease. It has some obvious advantages (no need for onsite
laboratory tests) but also many disadvantages, including both overtreat-
ment with unnecessary antibiotics and under-treatment for those without
3 See https://dean.st (accessed January 26, 2021).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PAYING FOR AND STRUCTURING STI SERVICES 523
symptoms. The CDC Treatment Guidelines (CDC, 2015b) (discussed in
Chapter 7) cover both etiologic and syndromic STI management. As a
result of the COVID-19 pandemic and its restrictions on in-clinic patient
visits, CDC has issued interim guidelines that include expanding syn-
dromic management in certain cases (Bachmann et al., 2020).
Delays between diagnosis and treatment mean a patient may transmit
the infection; treatment needs to follow diagnosis as quickly as possible
(hence the need for POC testing), would ideally be delivered at the point
of care, and would preferably be a single dose to maximize adherence. For
example, studies show that 15–20 percent of persons seen in emergency
departments (EDs) and STI clinics with positive screening tests for chla-
mydia do not receive treatment within 30 days of testing, and of those
who return for treatment, approximately 4 percent develop complications,
such as pelvic inflammatory disease or epididymitis (Hook et al., 1994;
Schwebke et al., 1997). Unfortunately, neither POC testing nor treatment
are available in many clinic settings, and implementation studies are nec-
essary to better understand how and with what means the quality of STI
care in these settings may be improved (Gaydos et al., 2019).
Partner Services and Expedited Partner Therapy (EPT)
A challenge that I personally face in my practice is contradictory guidance
on EPT. In our Oklahoma laws, it’s very hazy. If I have a patient who tests
positive for chlamydia, and I want to send partner treatment home with my
patient, it’s a bit hazy whether or not I am covered by Oklahoma law according
to the CDC references. Now, I do it, but it is hazy. For some of my colleagues
who are maybe not as public health oriented, I think it keeps them from treating
partners, and I think that should be changed across the board in some way.
—Participant, lived experience panel
After diagnosis and treatment, prompt evaluation and treatment of
identifiable recent sex partners is the second pillar of effective STI con-
trol and prevention. Partner notification (PN) and referral for STI care,
however, often has been carried out irregularly. Historically, PN has been
conducted in differing ways: initiated by the patient/client after encour-
agement from the provider (client referral), sometimes aided by issu-
ing referral cards, or performed directly by the provider if clients feel
uncomfortable communicating with their partners (provider referral). A
third type of notification is a hybrid of the first two, where the client is
given a certain period to notify and the provider will take over if the cli-
ent has not done so, also known as “contract referral.” In the real world,
partner services exist along a continuum that includes these three options.
For example, one can think about assisted and unassisted client referral
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
524 SEXUALLY TRANSMITTED INFECTIONS
based on the level of counseling and follow-up and whether the patient
receives a referral card. State and local health departments often provide
PN and referral through disease intervention specialists (DIS). DIS can
be effective in case finding, but they are time consuming and costly. As a
result, DIS-initiated partner services are prioritized for STIs with the high-
est morbidity, including HIV and early syphilis, while some PN may be
initiated for chlamydia or gonorrhea in the context of co-occurring HIV
infection and/or pregnancy. Thus, partner services for most chlamydial
and gonococcal infections rely almost exclusively on patient/client refer-
ral (Hogben et al., 2016).
EPT (partner treatment without an intervening professional evalu-
ation) has been promoted and is becoming more common. CDC has
concluded that EPT is a “useful option” for partner treatment, especially
for male partners of women with chlamydia or gonorrhea (CDC, 2020b).
EPT can be implemented by providing patients with additional medica-
tion or a prescription for their partner(s). EPT has been demonstrated to
be effective in preventing reinfection in the index patient in a number of
randomized clinical trials (Golden et al., 2005, 2015), and CDC has recom-
mended it since 2005 for heterosexual men and women with chlamydial
or gonococcal infections (Douglas, 2015; Kissinger et al., 2005; Schillinger
et al., 2003). EPT has been demonstrated to be particularly effective for
gonococcal infections (Golden et al., 2005), even though it is given as oral
medications, which are not recommended as a first-line treatment for gon-
orrhea, given concerns of emerging resistance. In certain jurisdictions this
has hampered widespread adoption. Thus, developing new effective oral
antibiotics for the treatment of gonorrhea (see Chapter 7) may positively
affect more widespread EPT implementation. EPT is not recommended by
CDC for use among MSM, in large part because of missed opportunities
to diagnose HIV infection and syphilis when MSM present as contacts in
the clinical setting (Stekler et al., 2005). This issue requires further study.
EPT implementation varies by jurisdiction. According to CDC, it was
legally available in 45 states and the District of Columbia (as of May
2020) and is potentially available in 4 states4 as well as Guam and Puerto
Rico. Only South Carolina explicitly prohibits it (CDC, 2020c). EPT has
become more common among publicly funded family planning clinics;
a study found that 79 percent provided EPT at the same visit (Zola and
Frost, 2016).
Not all states, even those where there are no legal barriers, permit the
patient’s insurance plan to be billed for EPT (KFF, 2020c). This practice
limits access to EPT and can serve as an obstacle to it. A community-level
trial demonstrated that it is feasible to implement EPT at the population
4 Alabama, Kansas, Oklahoma, and South Dakota.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PAYING FOR AND STRUCTURING STI SERVICES 525
level if the medication is made widely available through public fund-
ing (Golden et al., 2015), suggesting that EPT effectiveness may increase
when it is considered as a public health rather than individual health
intervention. This also implies that 340B funding should be available for
EPT drugs, as has been successfully implemented in a number of juris-
dictions (FPNTC, 2017). Finally, safety issues (such as allergic reactions),
perceived legal obstacles, potential for intimate partner violence, and pos-
sible contributions to progressive antimicrobial resistance are important
consequences that impede EPT. Extensive experience in the past decade,
however, has allayed these concerns (Hogben et al., 2016; Jamison et al.,
2018, 2019), and the committee supports continued evaluation of the best
use of EPT for controlling STIs.
Telehealth
Telehealth services use electronic information and telecommunication
technologies to support primary, behavioral, and specialty health care.
Telemedicine is a subcategory that involves two-way, real-time commu-
nication for clinical care. Telemedicine coverage policies are complex,
dynamic, and often geographically specific. Telemedicine is playing an
increasingly important role due to the growth of new technologies and
the effects of the COVID-19 pandemic on the need for technologies to
facilitate physical distancing and replace in-person visits to health settings
(Hartnett et al., 2020; Koonin et al., 2020).
Many states only permit physicians licensed in those particular states
to provide telemedicine services. Some pre-COVID-19 policies have lim-
ited the extent to which patients can have an STI visit remotely through
strict requirements as to the type of provider and sometimes patient loca-
tion and communication medium. The COVID-19 pandemic, however,
has transformed the role of telemedicine in the future of health care,
including STI care (Nagendra et al., 2020). Illinois serves as a case example
(Young and Schneider, 2020). Both academic medical centers, such as
the University of Chicago, and FQHCs, such as Howard Brown Health,
transitioned scheduled patients to telemedicine beginning in March 2020,
developing telemedicine protocols, billing algorithms, and Health Insur-
ance Portability and Accountability Act–compliant communication video-
conferencing platforms. This occurred rapidly (within a few days), with
patient acceptability examined and clinical flow modified with experi-
ence. STI and HIV care was provided remotely, and patient engagement
was substantial (Young and Schneider, 2020). Furthermore, studies have
shown that individuals can successfully collect their own samples for
HIV and STI screening (Carnevale et al., 2020; Melendez et al., 2020). As
telemedicine increases as a result of COVID-19, using home-collected
samples for mail-in STI testing to a laboratory has also been shown to be
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
526 SEXUALLY TRANSMITTED INFECTIONS
efficient (Carnevale et al., 2020; Melendez et al., 2020; Ogale et al., 2019;
Patel et al., 2019).
From an implementation science perspective, several important ques-
tions remain regarding telemedicine’s effectiveness, feasibility, acceptabil-
ity, and contextual variation (Tuckson et al., 2017). For example:
• To what degree should sustainability of telehealth be pursued for
sexual health/wellness, and what hybrid models (telehealth/in
person) models are useful at the clinic and client levels?
• How can community-based testing approaches (i.e., mobile unit
care, home visits) become next generation through telehealth that
allows for busy providers to join remotely and potentially man-
age multiple programs simultaneously?
• How does acceptability vary by population subtype, and what
models can be optimized for care of those without or with limited
technology access?
• What strategies and interventions are needed to bridge the digital
divide experienced by individuals and clinics and community-
based organizations in underserved communities?
While COVID-19 has positioned telehealth as an important solution
for physical distancing, how it will evolve once better therapies and vac-
cines for COVID-19 exist and how STI client visits will be affected for
counseling, diagnosis, treatment, and PN remain unclear.
Furthermore, telemedicine for STI care has its downsides, especially
for symptomatic patients, which has led to temporary expansion of
syndromic management guidelines (Bachmann et al., 2020). It remains
to be seen how telemedicine will change the STI care landscape in the
post-COVID-19 era. Studies are necessary to evaluate the extent of tele-
health provision for STI care during the epidemic and to elucidate lessons
learned for future applications.
Given the dearth of U.S. clinical specialists who are experts in sexual
health and STI care and treatment, telemedicine will likely hold appeal
beyond the COVID-19 era. Rural areas may benefit the most, as these have
many fewer specialized providers available (AIDS United and MAO of
Alabama, 2017). Even urban clients may prefer telemedicine after their
COVID-19-related experiences because of the potential convenience and
privacy. Telemedicine will also benefit from new dermatological probes
and pathological diagnostic aids, often as simple as using a cell phone
camera with a special attachment. The future of telemedicine can bring
convenient and affordable services for positive sexual health and stigma-
tized conditions among clients reluctant to seek such services otherwise.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PAYING FOR AND STRUCTURING STI SERVICES 527
STI SYSTEMS OF CARE
STI diagnostic and treatment services are available from many clinical
providers, each with specific client/patient populations, opportunities,
and challenges. The following sections map national STI care and high-
light ways for a fragmented system to become better integrated.
Primary Care
The majority of reportable STIs (gonorrhea, chlamydia, and syphilis)
are diagnosed outside STI specialty clinics; a large proportion originate
from primary care providers and others, including those associated with
HMOs and other practice systems (CDC, 2019b). With more than 200,000
primary care physicians in the United States, however, and many more
nurses, nurse practitioners, physician assistants, and others in primary
care, the average primary care provider diagnoses only a few STIs annu-
ally. Thus, STIs do not constitute a high priority in a setting where more
prevalent conditions, including cardiovascular disease, pulmonary dis-
ease, and diabetes, require the most attention. On the other hand, the
“secret weapon” of primary care providers is continuity of care, as care
in these settings is built on a continuous patient–provider relationship
that allows issues that are not immediately top priorities to be addressed
in future visits, effectively breaking up the ongoing conversation, inter-
ventions, and follow-through over time. These are advantages not easily
replicated in other settings, such as STI clinics.
Given time and resource constraints, the greatest contribution that
primary care can provide in STI control lies in opportunistic testing, includ-
ing offering annual chlamydia screening to all sexually active women
under the age of 25, as recommended by CDC, USPSTF, and other orga-
nizations (USPSTF, 2014) (see Table 10-1). According to data from HEDIS,
however, recommendation adherence is less than 50 percent in most set-
tings (NCQA, n.d.-b), leaving substantial room for improvement that may
be accomplished by educating the general public to expect their primary
care provider to offer a basic set of sexual health services.
As discussed in Chapter 6, the widespread implementation of EHRs
in primary care settings is a promising tool in completing sexual health
assessments and expanding STI screening, including opt-out testing for
selected persons. For example, research at Phoenix Indian Medical Cen-
ter (the largest urban health care provider for American Indians in Ari-
zona, which is also an Indian Health Service [IHS] facility) demonstrated
increases in gonorrhea case finding and positivity after increasing pro-
vider training, EHR reminder prompts, and bundled laboratory orders
(Patton et al., 2016). The latter two are scalable interventions, particularly
in IHS facilities that use a common information technology platform, but
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
528 SEXUALLY TRANSMITTED INFECTIONS
need to be combined with other interventions in order to be sustainable
and combat alert fatigue (Patton et al., 2016). Research at Phoenix Indian
Medical Center also indicates the potential effectiveness of other possible
interventions, including incorporating STI screening into routine clinical
testing (Taylor et al., 2011) and conducting EPT (Taylor et al., 2013), to
increase STI screening rates. Systems-level interventions, including com-
puterized test reminders to enhance chlamydia screening, however, have
not been successful across the board (Hocking et al., 2018; Scholes et al.,
2006). Therefore, while some projects have demonstrated proof of concept
(Taylor et al., 2016), well-designed demonstration projects are needed to
develop best practices in the appropriate use of EHRs for STI prevention
and examine the challenges with lack of interoperability of data systems.
In this context, opt-out testing (e.g., routine chlamydia screening for cer-
tain age categories, regardless of risk) should also be considered, as dis-
cussed previously.
Primary care providers can also provide on-demand testing for patients
who have a specific concern about STIs even though they may not be
symptomatic. A request for on-demand testing is an important cue for
a detailed sexual health assessment. Some primary care providers may
offer diagnostic POC testing for those with symptoms (e.g., microscopy of
vaginal discharge samples that may indicate etiologic treatment for yeast
infections, trichomoniasis, and bacterial vaginosis). Where such diagnos-
tics are not available, women with vaginal discharge would be treated
syndromically. Unfortunately, Gram-stained smears of urethral discharge
specimens in men with urethritis are typically unavailable in primary care
settings. The future availability of easy-to-use and affordable POC tests
(as discussed in Chapter 7) holds great promise for the improvement of
etiologic treatment in primary care settings.
Finally, primary care providers need to have easy access to resources
that offer technical assistance in implementing appropriate STI services,
clinical consultation, and referral. Ideally, such resources would be avail-
able locally or regionally (see Chapter 11). Meanwhile, the online STD
Clinical Consultation Network, developed by the National Network of
Clinical STD Prevention Training Centers, is available to all U.S. clinical
providers (Caragol et al., 2017).
STI Specialty Care
As outlined in this chapter, a wide and growing array of clinics,
venues, and other resources exist for STI testing. However, STI specialty
clinics will continue to play a critical and central role in the STI prevention
and control infrastructure (ASTDA Board of Directors, 2020). First, while
access to care has increased in certain jurisdictions, many people continue
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PAYING FOR AND STRUCTURING STI SERVICES 529
to seek care at STI clinics for reasons that include clinical expertise, confi-
dentiality, easy walk-in access, and cost. Second, due to increasing patient
volume and greater focus on STIs, many STI clinics have developed into
specialty clinics that offer consultation to and referral from providers in
the region. Third, STI specialty clinics are important to sentinel surveil-
lance (Rietmeijer et al., 2009), STI research, and workforce development
(Stoner et al., 2019). Finally, in contrast to other STI service providers, pub-
licly funded STI specialty clinics have a primary STI control mission and
could thus play a central role in regional control and prevention efforts. A
number of examples in various U.S. geographic regions are doing so and
could serve as models to expand such clinics across the nation (e.g., see
Barrow et al., 2020). Unfortunately, existing levels of financial support will
not be sufficient to address these needs, and alternative funding streams
must be developed to expand the provision of STI specialty care to all cit-
ies and high-morbidity nonurban regions of the United States.
Family Planning
Women accessing family planning services are typically young and
sexually active and are therefore an important target for opportunistic STI
screening, especially for chlamydia, gonorrhea, and syphilis. Nearly all
publicly supported family planning clinics offered testing for chlamydia
and gonorrhea (98 percent) and STI treatment (97 percent) in 2015 (Gutt-
macher Institute, 2019a), but only 52 percent of users were actually tested
for chlamydia in 2018, including 61 percent of women under the age of 25
(OPA, 2019). In addition, more than 90 percent of publicly funded family
planning clinics offer HPV vaccination, but data on actual coverage are
lacking. Family planning clinics are encouraged to expand their services
to male clients; however, men only accounted for about 13 percent of
visitors in 2018 (OPA, 2019). An important consideration, however, is
how to implement such an expansion in light of new Title X restrictions
(discussed in Chapter 4), as facilities receiving these funds can no longer
provide counseling on pregnancy termination, which has led a number
of grantees and clinics, including Planned Parenthood clinics, to decline
Title X funding altogether, limiting the services that they can provide
(KFF, 2019b).
The committee finds that family planning clinics play an important
role in diagnosing, treating, and preventing STIs among their clients.
As is discussed in Chapter 4, funding for these programs has not kept
up with inflation, and, despite their critical role serving their communi-
ties, the number of clients they have served has fallen in the past decade
(OPA, 2020). In other parts of this report, the paucity of STI services for
men has been described as an important deficit in current U.S. STI control
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
530 SEXUALLY TRANSMITTED INFECTIONS
programs. While their focus on women is vital and not to be undermined,
family planning clinics need to be encouraged to further expand their
services to male clients and train their staff accordingly. The large network
of clinics employs a sizable cadre of providers who are well trained in
providing confidential and sensitive services, including STI care, which
could be an important foundation to expand the availability of STI ser-
vices to not only traditional family planning populations but also broader
communities who are disproportionately affected by STIs. Many of these
clinics are already invested in serving socially and financially marginal-
ized communities and could be used to address the current dearth of
services available to individuals who are at high risk for exposure to STIs
but lack access and coverage.
Emergency Departments
ED patients are disproportionally affected by STIs. Consequently,
people are increasingly visiting EDs for STI care and treatment, especially
if other STI services, such as STI clinics, are not easily accessible (Batteiger
et al., 2019). Ease of access and perceptions of clinical expertise may be
additional reasons to visit EDs for nonurgent purposes (Moskop, 2010).
Interventions have sought to capitalize on these developments. For exam-
ple, building on an existing opt-out HIV testing program, researchers at
the University of Chicago developed an ED-based routine syphilis test-
ing intervention in a region of the city with high syphilis incidence. With
automatic order sets and close collaborations with local sexual health/STI
clinics and the health department, large numbers of tests are performed
with high rates of newly diagnosed cases unrelated to the reason for the
visit (Stanford et al., 2020). Eckman et al. (2021) recently found that tar-
geted screening and universally offered screening are both cost-effective
strategies for identifying chlamydial and gonococcal infections in adoles-
cents and young adults who access acute care at EDs. Thus, some see EDs
as an important and promising access point for STI care and advocate for
expanding such services and improving STI skills among ED staff. On the
other hand, providing nonurgent care in the ED is controversial, as such
services may be unnecessarily costly and undermine the primary mission
of the ED (Moskop, 2010). Further studies are needed to investigate the
risks and benefits of the expansion of ED-based STI services and associ-
ated costs.
HIV Care and Treatment
Providers of HIV care and treatment have seen a dramatic increase in
STIs, specifically gonorrhea and syphilis, among their clientele. While a
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PAYING FOR AND STRUCTURING STI SERVICES 531
large proportion of these infections are detected due to screening guide-
lines, a rise in symptomatic infections means that HIV care providers are
becoming increasingly knowledgeable about non-HIV STIs. As a result,
historically HIV-focused care providers have become STI clinical experts,
effectively forming the rationale for further development of STI specialty
clinics in traditional HIV clinics, as discussed in a previous section of this
chapter. In addition, these clinics are increasingly branded as “sexual
health” clinics that are fully integrated to address not only STIs and HIV
treatment but also family planning, sexual dysfunction, and other related
services, such as gender-affirming care for transgender and non-binary
community members. Such clinics tend to be early adopters of newer
approaches to testing, results notification, and wrap-around services that
are key to enabling them to be as client centered as possible. This develop-
ment needs to be encouraged, and clinics moving in this direction need to
enhance their STI services, as stated in the Recommendations for Provid-
ing Quality Clinical STD Services (Barrow et al., 2020).
Resources for On-Demand Testing
Asymptomatic persons who feel at risk of an STI can access tradi-
tional, clinic-based services to request testing. In addition, the availability
of noninvasive NAATs and the proliferation of Internet resources have
spawned numerous for-profit and not-for-profit resources for on-demand
testing. Some of these services are quite costly, are of dubious quality,
and may test for pathogens otherwise not recommended (e.g., Ureaplasma
urealyticum or Mycoplasma hominis). An additional challenge is that home
collection of STI samples has not been cleared by the Food and Drug
Administration for a commercial assay and often may not be accurate, as
there is no regulatory oversight or guidance for such venues (Owens et
al., 2010).
On the other end of the spectrum, online services, including home
testing, have been developed and quality controlled by academic insti-
tutions and offered for free as part of public health campaigns (Gaydos
et al., 2006). Some STI specialty clinics are developing online portals
for home collection and mailing specimens to reduce the clinic burden
from asymptomatic patients (Hogenson et al., 2019; Jordan et al., 2020).
Restricted clinical access due to COVID-19 has further encouraged the use
of mail-in testing programs (Melendez et al., 2020). To the extent that these
services provide additional options for persons who would otherwise not
receive testing, these developments need to be encouraged, especially if
they are integrated into a full spectrum of STI prevention and care. Per-
sons with STI symptoms, however, need to be discouraged from using
these services and instead encouraged to seek clinical care.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
532 SEXUALLY TRANSMITTED INFECTIONS
School-/College-/University-Based Health
Gonorrhea and chlamydia prevalence are highest among adolescents
and young adults aged 15–25 (CDC, 2019b). According to the 2017 Youth
Risk Behavioral Survey, 41.4 percent of male and 37.7 percent of female
high school students report ever having had sexual intercourse (Kann et
al., 2018). These data provide a rationale for opportunistic testing among
sexually active high school and college/university students. A 2016 lit-
erature review on STI screening guidance concludes that school-based
programs are a feasible and cost-effective way to test large numbers of
adolescents for chlamydia and gonorrhea and provide counseling and
treatment to almost everyone with an infection (Lewis et al., 2016). STI
testing coverage in educational venues varies and depends on the poli-
cies of individual school districts and other educational organizations.
As detailed in Chapters 8 and 12, parents’ and educators’ involvement is
critical to develop a comprehensive sexual health discourse in educational
settings and create and implement school-based STI prevention programs,
including regular STI screening and HPV vaccination.
Correctional Facilities
Based on the evidence that chlamydia and gonorrhea rates are gener-
ally higher among persons in correctional facilities, especially juvenile
detention centers, than among demographically similar individuals in
the general community, CDC recommends that women and men up to
ages 35 or 30, respectively, in correctional facilities be screened for both
diseases at entry, if symptomatic/following exposure, and at discharge
(CDC, 2015b). The National Commission on Correctional Health Care
issued a similar position statement, recommending chlamydia/gonor-
rhea testing for women up to age 25 and, when possible, age 35, pregnant
women regardless of age, and men up to age 30 (NCCHC, 2014). Stud-
ies indicate that correctional screening programs may have a positive
impact on the community (Barry et al., 2009). Actual coverage (i.e., the
number of persons tested across detention centers), however, is not well
known. A study by CDC published in 2014 covering 126 geographically
diverse juvenile detention centers indicated an overall screening rate
of 55.2 percent and an overall chlamydia positivity rate of 14.7 percent
among 149,923 women tested (Satterwhite et al., 2014).
An important challenge of STI testing and treatment in correctional
settings, especially jails and, to some extent, juvenile detention centers, is
the rapid turnover of detained persons, as many will have left the facil-
ity when their test results become available. The future availability and
implementation of POC testing will thus be particularly meaningful in
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PAYING FOR AND STRUCTURING STI SERVICES 533
these settings. (See Chapters 3 and 9 for more information on STIs within
criminal justice–involved populations.)
Military Personnel Health Care Facilities
The demographic composition of military personnel, including age,
race and ethnicity, and social background, as well as intensive social inter-
action and housing, disproportionally favors STI transmission (Deiss et
al., 2016; Gaydos and Gaydos, 2008) (see Chapter 3 for more information
on STI rates and drivers). Sexuality in the military is a taboo subject, as
it is seen as undermining morale and cohesion in the ranks even though
the military is becoming increasingly diverse with regard to gender iden-
tity and sexual orientation. The high prevalence of STIs among military
personnel, and the many reports of sexual coercion and violence, has
prompted an ongoing discourse on sexual health in the military (Deiss et
al., 2016; Schuyler et al., 2017). The military does offer universal health
services, including STI care and prevention, through military health care
facilities and the Veterans Health Administration system for active and
discharged personnel. These care systems, as discussed in greater detail
in Chapter 3, present an important opportunity for screening and periodic
sexual health assessment, including of sexual safety. Thus, while continu-
ing sexual health discourse is a priority for the entire military community,
military health care providers need to be a driving force in initiating and
supporting this discourse and, through proactive STI screening, can sig-
nificantly impact personnel’s STI epidemiology.
Integration of STI Services: The Role of Public Health
A positive perspective on the wide array of STI care services out-
lined above would be described as a mosaic composed of complementary
pieces. A more critical eye might see a fragmented system that, without
an integrating framework, produces duplication of efforts, inefficiencies,
and, most importantly, gaps in coverage and services for those popula-
tions with the greatest needs. The overarching challenge is that most
STI care providers do not have STI prevention as their primary mission;
for many, it is overtaken by more pressing health issues and behaviors,
including nutrition, substance abuse, physical activity, and now COVID-
19. Ideally, public health would serve as the indispensable glue that holds
all the pieces together. Unfortunately, public health is fragmented as well;
federal public funding for STI prevention through block grants to states
and some local jurisdictions is primarily devoted to surveillance, epide-
miology, and disease intervention, while STI diagnosis and treatment has
traditionally been seen as a responsibility of local health jurisdictions.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
534 SEXUALLY TRANSMITTED INFECTIONS
A holistic approach that incorporates structural, societal, and com-
munity perspectives, as espoused throughout this report, needs to be
applied to organize STI care and prevention. Decision-making collabora-
tives could be developed on the basis of a number of principles. First, they
need to have a local or regional focus to address local epidemiological
patterns and priority populations. Second, they need to be led by organi-
zations that have a primary STI-focused mission and can be held account-
able for the collaborative’s implementation and outcomes. Such leading
partners include state and local public health departments, specialty clin-
ics, and STI prevention training centers. Third, these collaboratives need
to engage a wide array of stakeholders, including care providers, public
health representatives, community leaders, and activists. Their center of
gravity will vary depending on local resources and STI leadership. Col-
laboratives could form around an STI specialty clinic with strong ties to
the community or evolve from HIV care centers, family planning clinics,
or community clinics that have expanded into STI specialty care. The
collaborative’s functions could include assessment (epidemiological and
availability of and gaps in services); policy development and advocacy;
and assurance of services, including developing new service arrange-
ments if deemed necessary.
This idea of STI collaboratives is not new. A number of them have
formed in recent years (e.g., St. Louis STI Regional Response Team),
and CDC has experience with a similar concept through the Community
Approaches to Reduce STDs projects. Since 2011, 3 grant cycles have
funded 12 sites, including Los Angeles, Baltimore, and Chicago (CDC,
2020a). Published experiences from the first two funding cycles suggest
a number of key elements in developing community engagement for STI
prevention: commitment to engagement, partner flexibility, talented and
trusted leadership, participation from diverse sectors, establishing a clear
vision and mission, open communication, minimizing power differen-
tials, working through conflict, identifying and leveraging resources, and
building a shared history (Rhodes et al., 2020). Experiences from these
projects, whether grassroots or CDC funded, need to be further evaluated
and leveraged as a guideline for further rollout. Specific community- and
structural-level interventions discussed in Chapter 9 can be deployed to
build and support critical community engagement in the development of
such collaboratives.
In this context, it is important to point out that community planning
has been a long-standing feature of national HIV care and prevention
efforts, through the Ryan White HIV/AIDS Program, HIV Prevention
Community Planning, and, more recently, the Ending the HIV Epidemic
Initiative. These efforts are much more heavily resourced than commu-
nity-based STI initiatives, and integrating both STI and HIV prevention
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PAYING FOR AND STRUCTURING STI SERVICES 535
in a combined community planning initiative may make good sense from
a fiscal perspective and avoid duplicating efforts.
As described in Chapter 11, the committee envisions creating STI
Resource Centers to provide technical assistance to such community col-
laboratives and easily accessible clinical consultation to STI care provid-
ers. These centers would operate on the level of states or large jurisdic-
tions and include an array of STI experts, including epidemiologists,
DIS, and clinical providers, with support from the regional STI Clinical
Prevention Training Centers.
CONCLUSIONS AND RECOMMENDATION
Conclusion 10-1: Effective public health efforts to control the transmission
of infectious diseases should benefit the whole population, yet many people
are not reached by the current fragmented health care system. Many indi-
viduals experience financial barriers to STI screening and treatment services
because of their insurance status, immigration status, or ability to afford
copayments and/or coinsurance for treatment and services. The committee
supports ongoing efforts to broaden no-cost care options for STI prevention
and treatment to all individuals.
Conclusion 10-2: As recommended in the 2015 STD Treatment Guide-
lines, expedited EPT is an important evidence-based tool in the treatment
of contacts of individuals with chlamydia, trichomonas, and, to a lesser
extent, gonorrhea. The barriers to implementation of EPT, such as finan-
cial obstacles (lack of insurance coverage) and ambiguity about the legal
status of state policies regarding EPT, however, have limited the use of this
tool. In addition, further research is needed to develop approaches to bet-
ter use EPT in certain populations, such as men who have sex with men.
Conclusion 10-3: There are notable gaps in measures that assess program
and plan performance in addressing STIs in populations and subpopulations
at risk. In particular, measures that track performance in screening, testing,
and treatment services for men are needed, as well as for MSM and other
gender expansive populations. The addition of these new measures could pro-
vide incentives for the development of payment bundles that could improve
the scope and quality of sexual health services offered by plans and programs.
Conclusion 10-4: The ongoing transition of local STI clinics to comprehen-
sive sexual health clinics taking place in some jurisdictions in the United
States is an important trend that needs to be supported and accelerated.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
536 SEXUALLY TRANSMITTED INFECTIONS
Conclusion 10-5: The Title X family planning program provides an impor-
tant foundation for STI services to low-income women. Its current structure
could be built on to expand access to sexual health more broadly and spe-
cifically to improve the availability of STI services to men, including het-
erosexual as well as LGBTQ and other gender nonconforming individuals.
The current program, however, is not adequately resourced or structured to
serve this function. While the focus on women and contraception is critical,
a broader lens on sexual health in Title X and among the providers who
participate could open up the pathway for care to populations who are dis-
proportionately affected by STIs and have limited care options.
Conclusion 10-6: Targeted initiatives for creating new, improved, and easier
care access points for sexual health care are needed. Promising initiatives
include readily accessed STI screening and treatment services venues, such
as urgent care centers and pharmacies. Access points could also include rapid
and on-demand testing sites, sexual and gender diverse clinics, and emergency
departments. Title X sites, family planning clinics, and FQHCs could provide
the foundation for these expanded and specialized services. Long-term sustain-
ability plans and new financing models to support these services are also needed.
Recommendation 10-1: The Department of Health and Human Ser-
vices and state governments should identify and support innova-
tive programs to ensure that sexually transmitted infection (STI)
prevention and treatment services are available through multiple
venues and ensure that federal and state governments maximize
access opportunities for individuals who face health care access
barriers. Priority populations for these efforts should include per-
sons ineligible for coverage, persons who face affordability bar-
riers (including high out-of-pocket costs), and persons who will
not access STI services without confidentiality guarantees (such
as adolescents and young adults with insurance coverage through
parents or guardians).
While some changes may require greater consideration, prompt explora-
tion of new initiatives could include the following:
• Incentives to expand full scope Medicaid or other well-subsidized
options to fill gaps in coverage, particularly in states that have
not opted to expand Medicaid or not fully enrolled eligible
populations.
• Special Medicaid-funded programs, such as developing guidance
to permit the expansion of Section 1115 Medicaid family planning
waivers or state plan amendments to include those who do not
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PAYING FOR AND STRUCTURING STI SERVICES 537
otherwise qualify for Medicaid because of their state of residence,
immigration status, and/or other factors.
• Establishment of a federally supported supplemental grant pro-
gram to provide funds to FQHCs, family planning providers,
state health departments, Title X providers, and STI providers
to offer STI testing and treatment services (including EPT) at no
cost for those who are uninsured or underinsured; to support
outreach, for the services that they offer; and to facilitate the
expansion of a broader range of sexual health services at those
sites.
• Promulgation of new 340B drug pricing program guidance that
deems the provision of STI prevention and treatment medications
(including population-based EPT services and HIV PrEP services)
to be allowable uses of program income.
• New funding initiatives to support and expand access to com-
prehensive sexual health clinics and create new access points for
sexual health services in a variety of settings and venues.
CONCLUDING OBSERVATIONS
STI clinical services are available from a large array of clinical special-
ties, with the level of services varying by specialty, from basic testing and
treatment in primary care settings to in-depth evaluation, diagnosis, and
management of complicated cases in STI specialty clinics. The committee
recognizes the unique contribution that each of these specialties brings
to STI diagnosis, treatment, and prevention. Emerging opportunities,
including online testing and increased involvement of nontraditional pro-
viders, hold promise in further strengthening the STI care system. There
are many missed opportunities for sexual health assessment and STI
evaluation in many settings, however, and better coordination of private
and public STI services at the local level would move the field from frag-
mentation to integration, with better overall outcomes for STI prevention
and control. Public and private insurance coverage options are important
sources of payments for STI prevention, screening, and treatment ser-
vices, but gaps in access to coverage and coverage of STI services persist.
Many people in the United States are uninsured or underinsured, have
no pathways to affordable coverage, and therefore rely on a patchwork
of providers to obtain care. The committee finds that the scope of cover-
age for preventive STI services established under the ACA is extensive,
but there are few recommendations for screening, testing, and treatment
services for men. In light of these coverage gaps, the committee recognizes
that policy changes addressing both who is eligible for coverage and the
scope of that coverage could reduce barriers to STI services that are acces-
sible and affordable.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
538 SEXUALLY TRANSMITTED INFECTIONS
REFERENCES
AAP (American Academy of Pediatrics). 2016. Confidentiality protections for adolescents
and young adults in the health care billing and insurance claims process (statement of
endorsement). Pediatrics 137(5):e20160593.
AIDS United and (Medical Advocacy and Outreach) of Alabama. 2017. Making connections:
A guide to starting a rural HIV care telemedicine program. Washington, DC: AIDS United
and Medical Advocacy and Outreach.
Albright, C. M., J. B. Emerson, E. F. Werner, and B. L. Hughes. 2015. Third-trimester prenatal
syphilis screening: A cost-effectiveness analysis. Obstetrics & Gynecology 126(3).
ASTDA (American Sexually Transmitted Diseases Association) Board of Directors. 2020.
ASTDA position statement: In support of the publicly-funded sexually transmitted
infections specialty clinic. Sexually Transmitted Diseases 47(8):503-505.
Bachmann, L., P. Thorpe, G. Bolan, and J. Mermin. 2020. Dear colleague letter STD treatment
options. https://www.cdc.gov/std/dstdp/DCL-STDTreatment-COVID19-04062020.
pdf (accessed November 4, 2020).
Barrow, R. Y., F. Ahmed, G. A. Bolan, and K. A. Workowski. 2020. Recommendations for
providing quality sexually transmitted diseases clinical services, 2020. MMWR Recom-
mendations and Reports 68(5):1-20.
Barry, P. M., C. K. Kent, K. C. Scott, J. Goldenson, and J. D. Klausner. 2009. Is jail screen-
ing associated with a decrease in chlamydia positivity among females seeking health
services at community clinics?—San Francisco, 1997-2004. Sexually Transmitted Diseases
36(Suppl 2):S22-S28.
Batteiger, T. A., B. E. Dixon, J. Wang, Z. Zhang, G. Tao, Y. Tong, W. Tu, S. A. Hoover, and
J. N. Arno. 2019. Where do people go for gonorrhea and chlamydia tests: A cross-sec-
tional view of the Central Indiana population, 2003-2014. Sexually Transmitted Diseases
46(2):132-136.
Brookmeyer, K. A., A. Coor, R. E. Kachur, O. Beltran, H. E. Reno, and P. J. Dittus. 2020. Sexual
history taking in clinical settings: A narrative review. Sexually Transmitted Diseases. doi:
10.1097/OLQ.0000000000001319.
Caragol, L. A., K. A. Wendel, T. S. Anderson, H. C. Burnside, A. Finkenbinder, J. D. Fitch, D.
H. Kelley, T. W. Stewart, M. Thrun, and C. A. Rietmeijer. 2017. A new resource for STD
clinical providers: The Sexually Transmitted Diseases Clinical Consultation Network.
Sexually Transmitted Diseases 44(8):510-512.
Carnevale, C., P. Richards, R. Cohall, J. Choe, J. Zitaner, N. Hall, A. Cohall, S. Whittier, D. A.
Green, M. E. Sobieszczyk, P. Gordon, and J. Zucker. 2020. At home testing for sexually
transmitted infections during the COVID-19 pandemic. Sexually Transmitted Diseases
48(1):e11-e14.
CDC (Centers for Disease Control and Prevention). 2011. 2011 performance measures: Quick
reference guide. https://www.cdc.gov/std/program/2011PerformanceMeasuresQuick
Guidel.pdf (accessed January 25, 2021).
CDC. 2015a. 2015 sexually transmitted diseases treatment guidelines. https://www.cdc.gov/
std/tg2015/default.htm (accessed October 22, 2019).
CDC. 2015b. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recommenda-
tions and Reports 64(3).
CDC. 2018. U.S. public health service: Preexposure prophylaxis for the prevention of HIV infection
in the United States—2017 update: A clinical practice guideline. Atlanta, GA: Centers for
Disease Control and Prevention.
CDC. 2019a. HPV vaccine schedule and dosing. https://www.cdc.gov/hpv/hcp/schedules-
recommendations.html (accessed June 15, 2020).
CDC. 2019b. Sexually transmitted disease surveillance 2018. Atlanta, GA: Department of Health
and Human Services.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PAYING FOR AND STRUCTURING STI SERVICES 539
CDC. 2020a. Community approaches to reducing sexually transmitted diseases. https://www.cdc.
gov/std/health-disparities/cars.htm (accessed February 21, 2021).
CDC. 2020b. Expedited partner therapy. https://www.cdc.gov/std/ept/default.htm#:~:
text=The%20usual%20alternative%20is%20to,refer%20their%20partners%20for%20
treatment.&text=CDC%20has%20concluded%20that%20EPT,with%20chlamydial%20
infection%20or%20gonorrhea (accessed December 8, 2020).
CDC. 2020c. Legal status of expedited partner therapy (EPT). https://www.cdc.gov/std/ept/
legal/default.htm (accessed February 10, 2021).
CDC. 2020d. Sexually transmitted disease preventive services coverage. https://www.cdc.gov/
nchhstp/highqualitycare/preventiveservices/std.html (accessed May 5, 2020).
CDC. 2020e. State statutory and regulatory language regarding prenatal syphilis screenings in the
United States, 2018. https://www.cdc.gov/std/treatment/prenatal-syphilis-screening-
laws-web-document-cleared-01-24-2020.pdf (accessed February 1, 2021).
Chambers, L. C., L. E. Manhart, D. A. Katz, M. R. Golden, L. A. Barbee, and J. C. Dombrows-
ki. 2017. Evaluation of an automated express care triage model to identify clinically rel-
evant cases in a sexually transmitted disease clinic. Sexually Transmitted Diseases 44(9).
Chambers, L. C., L. E. Manhart, D. A. Katz, M. R. Golden, L. A. Barbee, and J. C. Dombrowski.
2018. Comparison of algorithms to triage patients to express care in a sexually
transmitted disease clinic. Sexually Transmitted Diseases 45(10):696-702.
Cheng, J. Q., H. Zhou, F. C. Hong, D. Zhang, Y. J. Zhang, P. Pan, and Y. M. Cai. 2007. Syphi-
lis screening and intervention in 500,000 pregnant women in Shenzhen, the People’s
Republic of China. Sexually Transmitted Infections 83(5):347-350.
CMS (Centers for Medicare & Medicaid Services). n.d. Screening for sexually transmitted
infections (STIs) & high intensity behavioral counseling (HIBC) to prevent STIs (NCD
210.10). https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-
preventive-services/MPS-QuickReferenceChart-1.html#STI (accessed December 8,
2020).
Daw, J. R., K. B. Kozhimannil, and L. K. Admon. 2019. High rates of perinatal insurance churn
persist after the ACA. Health Affairs Blog (September 16). https://www.healthaffairs.
org/do/10.1377/hblog20190913.387157/full (accessed February 22, 2021).
Deiss, R., R. J. Bower, E. Co, O. Mesner, J. L. Sanchez, J. Masel, A. Ganesan, G. E. Macalino,
and B. K. Agan. 2016. The association between sexually transmitted infections, length
of service and other demographic factors in the U.S. military. PLoS One 11(12):e0167892.
Douglas, J. 2015. Dear colleague letter—regarding the use of expedited partner therapy. https://
www.cdc.gov/std/dearcolleagueept5-10-05.pdf (accessed February 10, 2021).
Dreisbach, S., H. Burnside, K. Hsu, L. Smock, P. Coury-Doniger, C. Hall, J. Marrazzo, G.
Nagendra, C. Rietmeijer, A. Rompalo, and M. Thrun. 2014. Improving HIV/STD pre-
vention in the care of persons living with HIV through a national training program.
AIDS Patient Care and STDS 28(1):15-21.
Eckert, E. 2020. It’s past time to provide continuous Medicaid coverage for one year post-
partum. Health Affairs Blog (February 6). https://www.healthaffairs.org/do/10.1377/
hblog20200203.639479/full (accessed February 22, 2021).
Eckman, M. H., J. L. Reed, M. Trent, and M. K. Goyal. 2021. Cost-effectiveness of sexually
transmitted infection screening for adolescents and young adults in the pediatric emer-
gency department. JAMA Pediatrics 175(1):81-89.
Elwyn, G., C. Dehlendorf, R. Epstein, K. Marrin, J. White, and D. Frosch. 2014. Shared deci-
sion making and motivational interviewing: Achieving patient-centered care across the
spectrum of health care problems. Annals of Family Medicine 12:270-275.
FPNTC (Family Planning National Training Center). 2017. 340B drug pricing program fre-
quently asked questions for Title X family planning agencies. https://www.fpntc.org/sites/
default/files/resources/340b_faq_2017-12-08.pdf (accessed June 10, 2020).
Gaydos, C. A., and J. C. Gaydos. 2008. Chlamydia in the United States military: Can we win
this war? Sexually Transmitted Diseases 35(3):260-262.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
540 SEXUALLY TRANSMITTED INFECTIONS
Gaydos, C. A., K. Dwyer, M. Barnes, P. A. Rizzo-Price, B. J. Wood, T. Flemming, and M. T.
Hogan. 2006. Internet-based screening for Chlamydia trachomatis to reach non-clinic
populations with mailed self-administered vaginal swabs. Sexually Transmitted Diseases
33(7):451-457.
Gaydos, C. A., M. C. Ako, M. Lewis, Y. H. Hsieh, R. E. Rothman, and A. F. Dugas. 2019. Use
of a rapid diagnostic for Chlamydia trachomatis and Neisseria gonorrhoeae for women in
the emergency department can improve clinical management: Report of a randomized
clinical trial. Annals of Emergency Medicine 74(1):36-44.
Gaydos, C. A., M. Barnes, J. Holden, B. Silver, R. Smith, J. Hardick, and T. C. Quinn. 2020.
Acceptability and feasibility of recruiting women to collect a self-administered vaginal
swab at a pharmacy clinic for sexually transmissible infection screening. Sexual Health
17(4):392-394.
Gift, T. L., K. M. Cuffe, and J. S. Leichliter. 2018. The impact of budget cuts on sexually
transmitted disease programmatic activities in state and local health departments
with staffing reductions in fiscal year 2012. Sexually Transmitted Diseases 45(11):e87-e89.
Gleeson, C., M. Robinson, and R. Neal. 2002. A review of teenagers’ perceived needs and
access to primary health care: Implications for health services. Primary Health Care
Research & Development 3:184-193.
Golden, M. R., W. L. Whittington, H. H. Handsfield, J. P. Hughes, W. E. Stamm, M. Hogben,
A. Clark, C. Malinski, J. R. Helmers, K. K. Thomas, and K. K. Holmes. 2005. Effect of
expedited treatment of sex partners on recurrent or persistent gonorrhea or chlamydial
infection. New England Journal of Medicine 352(7):676-685.
Golden, M. R., R. P. Kerani, M. Stenger, J. P. Hughes, M. Aubin, C. Malinski, and K. K.
Holmes. 2015. Uptake and population-level impact of expedited partner therapy (EPT)
on Chlamydia trachomatis and Neisseria gonorrhoeae: The Washington State community-
level randomized trial of EPT. PLoS Medicine 12(1):e1001777.
Guttmacher Institute. 2019a. Fact sheet: Publicly supported family planning services in the United
States. https://www.guttmacher.org/fact-sheet/publicly-supported-FP-services-US
(accessed November 17, 2019).
Guttmacher Institute. 2019b. Minors’ access to STI services. https://www.guttmacher.org/
state-policy/explore/minors-access-sti-services (accessed December 23, 2020).
Harshbarger, C. L., L. N. O’Donnell, L. Warner, A. D. Margolis, D. B. Richardson, S. R. Novey,
L. C. Glover, J. D. Klausner, C. K. Malotte, and C. A. Rietmeijer. 2012. Safe in the city:
Effective prevention interventions for human immunodeficiency virus and sexually
transmitted infections. American Journal of Preventative Medicine 42(5):468-472.
Hartnett, K. P., A. Kite-Powell, J. DeVies, M. A. Coletta, T. K. Boehmer, J. Adjemian, A. V.
Gundlapalli, and National Syndromic Surveillance Program Community of Practice.
2020. Impact of the COVID-19 pandemic on emergency department visits—United
States, January 1, 2019-May 30, 2020. Morbidity and Mortality Weekly Report 69:699-704.
Heijman, T. L., A. K. Van der Bij, H. J. De Vries, E. J. Van Leent, H. F. Thiesbrummel, and H.
S. Fennema. 2007. Effectiveness of a risk-based visitor-prioritizing system at a sexually
transmitted infection outpatient clinic. Sexually Transmitted Diseases 34(7):508-512.
Hersh, A. R., C. J. Megli, and A. B. Caughey. 2018. Repeat screening for syphilis in the
third trimester of pregnancy: A cost-effectiveness analysis. Obstetrics and Gynocology
132(3):699-707.
Hill, H. A., L. D. Elam-Evans, D. Yankey, J. A. Singleton, and Y. Kang. 2018. Vaccination cov-
erage among children aged 19-35 months—United States, 2017. Morbidity and Mortality
Weekly Report (67):1123-1128.
Hocking, J. S., M. Temple-Smith, R. Guy, B. Donovan, S. Braat, M. Law, J. Gunn, D. Regan, A.
Vaisey, L. Bulfone, J. Kaldor, C. K. Fairley, and N. Low. 2018. Population effectiveness
of opportunistic chlamydia testing in primary care in Australia: A cluster-randomised
controlled trial. Lancet 392(10156):1413-1422.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PAYING FOR AND STRUCTURING STI SERVICES 541
Hogben, M., D. Collins, B. Hoots, and K. O’Connor. 2016. Partner services in sexually
transmitted disease prevention programs: A review. Sexually Transmitted Diseases 43(2
Suppl 1):S53-S62.
Hogenson, E., M. Jett-Goheen, and C. A. Gaydos. 2019. An analysis of user survey data for
an Internet program for testing for sexually transmitted infections, I Want the Kit, in
Maryland and Washington, DC. Sexually Transmitted Diseases 46(12):768-770.
Hook, E. W., 3rd, C. Spitters, C. A. Reichart, T. M. Neumann, and T. C. Quinn. 1994. Use
of cell culture and a rapid diagnostic assay for Chlamydia trachomatis screening. JAMA
272(11):867-870.
Jamison, C. D., T. Chang, and O. Mmeje. 2018. Expedited partner therapy: Combating
record high sexually transmitted infection rates. American Journal of Public Health
108(10):1325-1327.
Jamison, C. D., J. S. Coleman, and O. Mmeje. 2019. Improving women’s health and combat-
ting sexually transmitted infections through expedited partner therapy. Obstetrics &
Gynecology 133(3):416-422.
Jenness, S. M., K. M. Weiss, S. M. Goodreau, T. Gift, H. Chesson, K. W. Hoover, D. K. Smith,
A. Y. Liu, P. S. Sullivan, and E. S. Rosenberg. 2017. Incidence of gonorrhea and chla-
mydia following human immunodeficiency virus preexposure prophylaxis among men
who have sex with men: A modeling study. Clinical Infectious Diseases 65(5):712-718.
Jordan, N. N., M. Jett-Goheen, Y. H. Hsieh, J. C. Gaydos, and C. A. Gaydos. 2020. Detection of
three sexually transmitted infections by anatomic site: Evidence from an Internet-based
screening program. Sexually Transmitted Diseases 47(4):243-245.
Kamb, M. L., M. Fishbein, J. M. Douglas, F. Rhodes, J. Rogers, G. Bolan, J. Zenilman, T.
Hoxworth, C. K. Malotte, M. Iatesta, C. Kent, A. Lentz, S. Graziano, R. H. Byers, and
T. A. Peterman. 1998. Efficacy of risk-reduction counseling to prevent human immu-
nodeficiency virus and sexually transmitted diseases: A randomized controlled trial.
Project respect study group. JAMA 280(13):1161-1167.
Kann, L., T. McManus, W. A. Harris, S. L. Shanklin, K. H. Flint, B. Queen, R. Lowry, D.
Chyen, L. Whittle, J. Thornton, C. Lim, D. Bradford, Y. Yamakawa, M. Leon, N. Brener,
and K. A. Ethier. 2018. Youth risk behavior surveillance—United States, 2017. Morbidity
and Mortality Weekly Report: Surveillance Summaries 67(8):1-114.
KFF (Kaiser Family Foundation). 2015. Preventive services covered by private health plans under
the Affordable Care Act. https://www.kff.org/health-reform/fact-sheet/preventive-
services-covered-by-private-health-plans (accessed December 23, 2020).
KFF. 2019a. Health insurance coverage of the total population. https://www.kff.org/other/
state-indicator/total-population/?activeTab=map¤tTimeframe=0&selected
Distributions=uninsured&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:
%22asc%22%7D (accessed February 22, 2021).
KFF. 2019b. The status of participation in the Title X federal family planning program. https://
www.kff.org/interactive/the-status-of-participation-in-the-title-x-federal-family-
planning-program (accessed July 9, 2020).
KFF. 2020a. Health coverage of immigrants. https://www.kff.org/racial-equity-and-health-
policy/fact-sheet/health-coverage-of-immigrants (accessed December 23, 2020).
KFF. 2020b. Preventive services tracker. https://www.kff.org/report-section/preventive-
service-tracker-sexual-health (accessed February 22, 2021).
KFF. 2020c. Sexually transmitted infections (STIs): An overview, payment, and coverage. https://
www.kff.org/womens-health-policy/fact-sheet/sexually-transmitted-infections-stis-
an-overview-payment-and-coverage (accessed December 23, 2020).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
542 SEXUALLY TRANSMITTED INFECTIONS
KFF. 2020d. States that have expanded eligibility for coverage of family planning services under
Medicaid. https://www.kff.org/medicaid/state-indicator/family-planning-services-
waivers/?currentTimeframe=0&sortModel=%7B%22colId%22:%22State%20Has%20
Secured%20a%20Waiver%20or%20State%20Plan%20Amendment%20(SPA)%20
from%20CMS%20to%20Cover%20Services%22,%22sort%22:%22asc%22%7D (accessed
January 25, 2021).
KFF. 2020e. Status of state Medicaid expansion decisions: Interactive map. https://www.kff.
org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-
map/#:~:text=To%20date%2C%2039%20states%20(including,available%20in%20a%20
table%20format (accessed November 18, 2020).
Kissinger, P., H. Mohammed, G. Richardson-Alston, J. S. Leichliter, S. N. Taylor, D. H. Mar-
tin, and T. A. Farley. 2005. Patient-delivered partner treatment for male urethritis: A
randomized, controlled trial. Clinical Infectious Diseases 41(5):623-629.
Koonin, L. M., B. Hoots, C. A. Tsang, Z. Leroy, K. Farris, T. Jolly, P. Antall, B. McCabe, C.
B. R. Zelis, I. Tong, and A. M. Harris. 2020. Trends in the use of telehealth during the
emergence of the COVID-19 pandemic—United States, January-March 2020. Morbidity
and Mortality Weekly Report (69):1595-1599.
Leichliter, J. S., C. Copen, and P. J. Dittus. 2017. Confidentiality issues and use of sexually
transmitted disease services among sexually experienced persons aged 15-25 years—
United States, 2013-2015. Morbidity and Mortality Weekly Report 66(9):237-241.
Lewis, F. M., P. Dittus, M. E. Salmon, and M. J. Nsuami. 2016. School-based sexually trans-
mitted disease screening: Review and programmatic guidance. Sexually Transmitted
Diseases 43(2 Suppl 1):S18-S27.
McClung, N. M., R. M. Lewis, J. W. Gargano, T. Querec, E. R. Unger, and L. E. Mar-
kowitz. 2019. Declines in vaccine-type human papillomavirus prevalence in females
across racial/ethnic groups: Data from a national survey. Journal of Adolescent Health
65(6):715-722.
McKee, M. D., S. E. Rubin, G. Campos, and L. F. O’Sullivan. 2011. Challenges of providing
confidential care to adolescents in urban primary care: Clinician perspectives. Annals
of Family Medicine 9(1):37.
Medicaid.gov. n.d.-a. Adult health care quality measures. https://www.medicaid.gov/
medicaid/quality-of-care/performance-measurement/adult-and-child-health-care-
quality-measures/adult-health-care-quality-measures/index.html (accessed November
19, 2020).
Medicaid.gov. n.d.-b. Children’s health care quality measures. https://www.medicaid.gov/
medicaid/quality-of-care/performance-measurement/adult-and-child-health-care-
quality-measures/childrens-health-care-quality-measures/index.html (accessed
November 19, 2020).
Medicare.gov. n.d.-c. Preventive & screening services. https://www.medicare.gov/coverage/
preventive-screening-services (accessed December 8, 2020).
Melendez, J. H., M. M. Hamill, G. Armington, C. A. Gaydos, and Y. C. Manabe. 2020. Home-
based testing for sexually transmitted infections: Leveraging online resources during
the COVID-19 pandemic. Sexually Transmitted Diseases 48(1):e11-e14.
Metsch, L. R., D. J. Feaster, L. Gooden, B. R. Schackman, T. Matheson, M. Das, M. R. Golden,
S. Huffaker, L. F. Haynes, S. Tross, C. K. Malotte, A. Douaihy, P. T. Korthuis, W. A. Duf-
fus, S. Henn, R. Bolan, S. S. Philip, J. G. Castro, P. C. Castellon, G. McLaughlin, R. N.
Mandler, B. Branson, and G. N. Colfax. 2013. Effect of risk-reduction counseling with
rapid HIV testing on risk of acquiring sexually transmitted infections: The AWARE
randomized clinical trial. JAMA 310(16):1701-1710.
Miller, W., and S. Rollnick. 1991. Motivational interviewing: Preparing people to change addictive
behavior. New York: Guilford Press.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PAYING FOR AND STRUCTURING STI SERVICES 543
Moskop, J. C. 2010. Nonurgent care in the emergency department—bane or boon? Virtual
Mentor 12(6):476-482.
NACCHO (National Association of County and City Health Officials). 2019. STI express
services: Increasing access and testing while maximizing resources. https://www.naccho.
org/uploads/downloadable-resources/issue-brief_STI-Express-Services.pdf (accessed
January 25, 2021).
Nagendra, G., C. Carnevale, N. Neu, A. Cohall, and J. Zucker. 2020. The potential impact
and availability of sexual health services during the COVID-19 pandemic. Sexually
Transmitted Diseases 47(7):434-436.
NAPA (National Academy of Public Administration). 2018. The impact of sexually transmitted
diseases on the United States: Still hidden, getting worse, can be controlled. Washington, DC:
National Academy of Public Administration.
NASEM (National Academies of Sciences, Engineering, and Medicine). 2019. Promoting posi-
tive adolescent health behavior and outcomes: Thriving in the 21st century. Washington, DC:
The National Academies Press.
NCCHC (National Commission on Correctional Health Care). 2014. STD testing for adoles-
cents and adults upon admission to correctional facilities. https://www.ncchc.org/std-
testing-upon-admission (accessed November 17, 2019).
NCQA (National Committee for Quality Assurance). n.d.-a. Cervical cancer screening (CCS).
https://www.ncqa.org/hedis/measures/cervical-cancer-screening (accessed Novem-
ber 19, 2020).
NCQA. n.d.-b. Chlamydia screening in women. https://www.ncqa.org/hedis/measures/
chlamydia-screening-in-women (accessed January 2, 2019).
NCQA. n.d.-c. Immunizations for adolescents (IMA). https://www.ncqa.org/hedis/measures/
immunizations-for-adolescents (accessed November 19, 2020).
Newman, L., M. Kamb, S. Hawkes, G. Gomez, L. Say, A. Seuc, and N. Broutet. 2013. Global
estimates of syphilis in pregnancy and associated adverse outcomes: Analysis of mul-
tinational antenatal surveillance data. PLoS Medicine 10(2):e1001396.
NQF (National Quality Forum). n.d. Measures, Reports & Tools. http://www.qualityforum.
org/measures_reports_tools.aspx (accessed November 19, 2020).
Offit, P. A. 2014. Let’s not talk about sex. The New York Times. https://www.nytimes.
com/2014/08/20/opinion/lets-not-talk-about-sex-HPV-vaccine.html (accessed No-
vember 13, 2020).
Ogale, Y., P. T. Yeh, C. E. Kennedy, I. Toskin, and M. Narasimhan. 2019. Self-collection of
samples as an additional approach to deliver testing services for sexually transmitted
infections: A systematic review and meta-analysis. BMJ Global Health 4(2):e001349.
OPA (Office of Population Affairs). 2019. Title X family planning annual report—2018 national
summary. https://www.hhs.gov/opa/sites/default/files/title-x-fpar-2018-national-
summary.pdf (accessed November 17, 2019).
OPA. 2020. Title X family planning annual report: 2019 national summary. Rockville, MD: Office
of Population Affairs.
Owens, S. L., N. Arora, N. Quinn, R. W. Peeling, K. K. Holmes, and C. A. Gaydos. 2010.
Utilising the Internet to test for sexually transmitted infections: Results of a survey and
accuracy testing. Sexually Transmitted Infections 86(2):112-116.
Owusu-Edusei, K., Jr., K. W. Hoover, and T. L. Gift. 2016. Cost-effectiveness of opt-out
chlamydia testing for high-risk young women in the U.S. American Journal of Preventive
Medicine 51(2):216-224.
Patel, A. V., S. M. Abrams, C. A. Gaydos, M. Jett-Goheen, C. A. Latkin, R. E. Rothman, and
Y.-H. Hsieh. 2019. Increasing HIV testing engagement through provision of home HIV
self-testing kits for patients who decline testing in the emergency department: A pilot
randomisation study. Sexually Transmitted Infections 95(5):358-360.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
544 SEXUALLY TRANSMITTED INFECTIONS
Patton, M. E., R. D. Kirkcaldy, D. C. Chang, S. Markman, M. Yellowman, E. Petrosky, L.
Adams, C. Robinson, A. Gupta, and M. M. Taylor. 2016. Increased gonorrhea screening
and case finding after implementation of expanded screening criteria—urban Indian
Health Service facility in Phoenix, Arizona, 2011-2013. Sexually Transmitted Diseases
43(6):396-401.
Rac, M. W., P. A. Revell, and C. S. Eppes. 2017. Syphilis during pregnancy: A preventable
threat to maternal-fetal health. American Journal of Obstetrics & Gynecology 216(4):352-363.
Ranji, U., Y. Bair, and A. Salganicoff. 2016. Medicaid and family planning: Background and
implications of the ACA. https://www.kff.org/report-section/medicaid-and-family-
planning-medicaid-family-planning-policy (accessed January 25, 2021).
Ranji, U., A. Salganicoff, L. Sobel, and I. Gomez. 2019. Financing family planning services for
low-income women: The role of public programs. https://www.kff.org/womens-health-
policy/issue-brief/financing-family-planning-services-for-low-income-women-the-
role-of-public-programs (accessed January 25, 2021).
Ranji, U., I. Gomez, and A. Salganicoff. 2020. Expanding postpartum Medicaid coverage. https://
www.kff.org/womens-health-policy/issue-brief/expanding-postpartum-medicaid-
coverage (accessed January 25, 2021).
Rhodes, S. D., J. Daniel-Ulloa, S. S. Wright, L. Mann-Jackson, D. Johnson, N. Hayes, and J.
Valentine. 2020. Critical elements of community engagement to address disparities and
related social determinants of health: The CDC community approaches to reducing
STDs (CARS) initiative. Sexually Transmitted Diseases 48(1):49-55.
Rietmeijer, C. A., J. Donnelly, K. T. Bernstein, J. M. Bissette, S. Martins, P. Pathela, J. A. Schil-
linger, M. R. Stenger, H. Weinstock, and L. M. Newman. 2009. Here comes the SSuN:
Early experiences with the STD Surveillance Network. Public Health Reports 124(Suppl
2):72-77.
Rietmeijer, C. A., B. C. Hauschild, H. C. Burnside, and K. A. Wendel. 2021. Medicaid ex-
pansion and rates of reportable sexually transmitted infections in the United States—
A county-level analysis. Sexually Transmitted Diseases. E-pub ahead of print.
SAHM (Society for Adolescent Health and Medicine). 2016. Confidentiality protections for
adolescents and young adults in the health care billing and insurance claims process.
Journal of Adolescent Health 58(3):374-377.
SAHM. 2020. The 21st Century Cures Act & adolescent confidentiality. https://www.
adolescenthealth.org/Advocacy/Advocacy-Activities/2019-(1)/NASPAG-SAHM-
Statement.aspx (accessed January 26, 2021).
Satterwhite, C. L., D. Newman, D. Collins, and E. Torrone. 2014. Chlamydia screening
and positivity in juvenile detention centers, United States, 2009-2011. Women Health
54(8):712-725.
Schillinger, J. A., P. Kissinger, H. Calvet, W. L. Whittington, R. L. Ransom, M. R. Sternberg,
S. M. Berman, C. K. Kent, D. H. Martin, M. K. Oh, H. H. Handsfield, G. Bolan, L.
E. Markowitz, and J. D. Fortenberry. 2003. Patient-delivered partner treatment with
azithromycin to prevent repeated Chlamydia trachomatis infection among women: A
randomized, controlled trial. Sexually Transmitted Diseases 30(1):49-56.
Scholes, D., L. Grothaus, J. McClure, R. Reid, P. Fishman, C. Sisk, J. E. Lindenbaum, B. Green,
J. Grafton, and R. S. Thompson. 2006. A randomized trial of strategies to increase chla-
mydia screening in young women. Preventative Medicine 43(4):343-350.
Schuyler, A., S. Kintzle, C. L. Lucas, H. Moore, and C. Castro. 2017. Military sexual assault
(MSA) among veterans in Southern California: Associations with physical health, psy-
chological health, and risk behaviors. Traumatology 23(3):223.
Schwebke, J. R., R. Sadler, J. M. Sutton, and E. W. Hook, 3rd. 1997. Positive screening tests for
gonorrhea and chlamydial infection fail to lead consistently to treatment of patients at-
tending a sexually transmitted disease clinic. Sexually Transmitted Diseases 24(4):181-184.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PAYING FOR AND STRUCTURING STI SERVICES 545
Sedlander, E., C. D. Brindis, S. H. Bausch, and K. P. Tebb. 2015. Options for assuring access
to confidential care for adolescents and young adults in an explanation of benefits
environment. Journal of Adolescent Health 56(1):7-9.
Shamos, S. J., C. J. Mettenbrink, J. A. Subiadur, B. L. Mitchell, and C. A. Rietmeijer. 2008.
Evaluation of a testing-only “express” visit option to enhance efficiency in a busy STI
clinic. Sexually Transmitted Diseases 35(4):336-340.
Stanford, K. A., A. Hazra, and J. Schneider. 2020. Routine opt-out syphilis screening in
the emergency department: A public health imperative. Academic Emergency Medicine
27(5):437-438.
Stekler, J., L. Bachmann, R. M. Brotman, E. J. Erbelding, L. V. Lloyd, C. A. Rietmeijer, H. H.
Handsfield, K. K. Holmes, and M. R. Golden. 2005. Concurrent sexually transmitted
infections (STIs) in sex partners of patients with selected STIs: Implications for patient-
delivered partner therapy. Clinical Infectious Diseases 40(6):787-793.
Stoner, B. P., J. Fraze, C. A. Rietmeijer, J. Dyer, A. Gandelman, E. W. Hook, 3rd, C. Johnston,
N. M. Neu, A. M. Rompalo, G. Bolan, and National Network of STD Clinical Prevention
Training Centers. 2019. The national network of sexually transmitted disease clinical
prevention training centers turns 40—a look back, a look ahead. Sexually Transmitted
Diseases 46(8):487-492.
Taylor, M. M., B. Reilley, S. Tulloch, M. Winscott, A. Dunnigan, M. Russell, and J. T. Redd.
2011. Identifying opportunities for chlamydia screening among American Indian wom-
en. Sexually Transmitted Diseases 38(10):947-948.
Taylor, M. M., B. Reilley, M. Yellowman, L. Anderson, L. de Ravello, and S. Tulloch. 2013.
Use of expedited partner therapy among chlamydia cases diagnosed at an urban Indian
Health Centre, Arizona. International Journal of STD & AIDS 24(5):371-374.
Taylor, M. M., J. Frasure-Williams, P. Burnett, and I. U. Park. 2016. Interventions to improve
sexually transmitted disease screening in clinic-based settings. Sexually Transmitted
Diseases 43(2 Suppl):S28-S41.
Taylor, M. M., M. Kamb, D. Wu, and S. Hawkes. 2017. Syphilis screening and treatment:
Integration with HIV services. Bulletin of the World Health Organization 95(9):610.
Tebb, K. P., E. Sedlander, S. Bausch, and C. D. Brindis. 2015. Opportunities and challenges
for adolescent health under the Affordable Care Act. Maternal and Child Health Journal
19(10):2089-2093.
Tuckson, R. V., M. Edmunds, and M. L. Hodgkins. 2017. Telehealth. New England Journal of
Medicine 377(16):1585-1592.
Tylee, A., D. M. Haller, T. Graham, R. Churchill, and L. A. Sanci. 2007. Youth-friendly
primary-care services: How are we doing and what more needs to be done? Lancet
369(9572):1565-1573.
USPSTF (United States Preventive Services Task Force). 2014. Final recommendation state-
ment chlamydia and gonorrhea: Screening. https://www.uspreventiveservicestaskforce.
org/uspstf/document/RecommendationStatementFinal/chlamydia-and-gonorrhea-
screening (accessed June 2, 2020).
Volk, J. E., J. L. Marcus, T. Phengrasamy, D. Blechinger, D. P. Nguyen, S. Follansbee, and C. B.
Hare. 2015. No new HIV infections with increasing use of HIV preexposure prophylaxis
in a clinical practice setting. Clinical Infectious Diseases 61(10):1601-1603.
Walker, T. Y., L. D. Elam-Evans, D. Yankey, L. E. Markowitz, C. L. Williams, B. Fredua, J. A.
Singleton, and S. Stokley. 2019. National, regional, state, and selected local area vac-
cination coverage among adolescents aged 13-17 years—United States, 2018. Morbidity
and Mortality Weekly Report 68(33):718-723.
Warner, L., J. D. Klausner, C. A. Rietmeijer, C. K. Malotte, L. O’Donnell, A. D. Margolis, G.
L. Greenwood, D. Richardson, S. Vrungos, C. R. O’Donnell, C. B. Borkowf, for the Safe
in the City Study Group. 2008. Effect of a brief video intervention on incident infection
among patients attending sexually transmitted disease clinics. PLoS Medicine 5(6):e135.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
546 SEXUALLY TRANSMITTED INFECTIONS
Warren, H. P., R. Cramer, S. Kidd, and J. S. Leichliter. 2018. State requirements for pre-
natal syphilis screening in the United States, 2016. Maternal and Child Health Journal
22(9):1227-1232.
Whitlock, G. G., D. C. Gibbons, N. Longford, M. J. Harvey, A. McOwan, and E. J. Adams.
2018. Rapid testing and treatment for sexually transmitted infections improve patient
care and yield public health benefits. International Journal of STD & AIDS 29(5):474-482.
Williams, A. M., T. L. Gift, L. N. OʼDonnell, C. A. Rietmeijer, C. K. Malotte, A. D. Margolis,
and L. Warner. 2020. Assessment of the cost-effectiveness of a brief video intervention
for sexually transmitted disease prevention. Sexually Transmitted Diseases 47(2):130-135.
Young, S. D., and J. Schneider. 2020. Clinical care, research, and telehealth services in the era
of social distancing to mitigate COVID-19. AIDS and Behavior 24(7):2000-2002.
Zola, M., and J. Frost. 2016. Publicly funded family planning clinics in 2015: Patterns and trends
in service delivery practices and protocol. New York: Guttmacher Institute.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
11
Supporting and Expanding
the Future STI Workforce
Chapter Contents
Introduction
Sexual Health and Ethics as an Organizing Framework for the
STI Workforce
Current STI Workforce in the United States
• Refocusing and Improving Traditional Service Delivery
Paradigms in Clinical STI Prevention and Care
Leveraging Health Care Systems and Practitioners Not
Traditionally Involved in STI Service Delivery
• Diverse Actors in Sexual Education and Sexual Health
Promotion
• Pharmacists
• Research
Strengthening the National Public Health Workforce
• Leveraging Nurses for Population Health
• DIS for Population Health
547
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
548 SEXUALLY TRANSMITTED INFECTIONS
Chapter Contents Continued
STI Workforce Gaps and Needs
STI Workforce Education and Development
• Medical and Nursing School Curricula
• STI Specialty Clinical Training and Basic Research
• Schools of Public Health
• STI Programs at State and Local Health Departments
• STI Resource Centers
• STD Clinical Prevention Training Centers
• DIS Training Centers
• Other Training Resources
Conclusion and Recommendation
INTRODUCTION
After reviewing the current workforce landscape and identifying sev-
eral gaps, the committee recognized the need for a clearly delineated plan
to expand, develop, and sustain a strong and responsive sexually trans-
mitted 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).
SEXUAL HEALTH AND ETHICS AS AN ORGANIZING
FRAMEWORK FOR THE STI WORKFORCE
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 by-
product 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.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
SUPPORTING AND EXPANDING THE FUTURE STI WORKFORCE 549
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).
CURRENT STI WORKFORCE IN THE UNITED STATES
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 pro-
vide primary care, sexual and reproductive health practitioners, and spe-
cialists. 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 infec-
tious 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 complex-
ity of the workforce involved in STI management and prevention, the
purpose of the following section is to highlight the clinical STI workforce
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
550 SEXUALLY TRANSMITTED INFECTIONS
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 profes-
sionals [BHPs]). There are 200,000 primary care physicians (family and
general practitioners, internists, pediatricians, obstetricians, and gyne-
cologists), 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 work-
force can carry out routine STI screening, initiate pharmaceutical treat-
ment, 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 work-
force, 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 fre-
quent 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 test-
ing, 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 pro-
fessional counselors, licensed social workers, psychiatrists, psychologists,
and psychiatric technicians. BHPs frequently work with vulnerable popu-
lations 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
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
SUPPORTING AND EXPANDING THE FUTURE STI WORKFORCE 551
delivery has been promising in identifying individuals in need of behav-
ioral 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 over-
all 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 test-
ing 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 train-
ing 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 rec-
ommendations 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 organiza-
tions (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 compli-
ance 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 imple-
menting routine STI screening for early detection. Insufficiently prioritiz-
ing 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.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
552 SEXUALLY TRANSMITTED INFECTIONS
Clinical Health Care Services: Sexual and Reproductive Health
and STI Specialists
In contrast to primary care generalists, clinical sexual and reproduc-
tive 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 gyne-
cologic or obstetric care, failure to provide routine STI screening remains
too prevalent, contributing to the persistently high prevalence of undi-
agnosed 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 manage-
ment 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 comprehen-
sive 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 clin-
ics 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, undocu-
mented, and impoverished individuals and others disenfranchised from
primary health care environments who may rely disproportionately on
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
SUPPORTING AND EXPANDING THE FUTURE STI WORKFORCE 553
STI specialty clinics for sexual health and STI prevention and manage-
ment 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 pro-
portion of STIs diagnosed in designated STI clinics has decreased sub-
stantially 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.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
554 SEXUALLY TRANSMITTED INFECTIONS
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 provid-
ers exhibit levels of implicit bias comparable to the general population
(FitzGerald and Hurst, 2017; Hall et al., 2015). A provider’s implicit expec-
tations 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 ill-
ness, age, weight, or perceived illness responsibility (FitzGerald and
Hurst, 2017). Research conducted with STI service providers has primar-
ily focused on race/ethnicity, sexual or gender minority status, and age as
factors that affect STI testing. Unconscious stereotypes can override objec-
tive 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 popula-
tion 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 mar-
ginalized 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).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
SUPPORTING AND EXPANDING THE FUTURE STI WORKFORCE 555
Solutions to diminish the impact of unconscious biases require con-
vergent 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 reten-
tion; (2) cultural appropriateness, diversity, and structural competency
training for staff (Metzl and Hansen, 2014); (3) education about uncon-
scious 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).
LEVERAGING HEALTH CARE SYSTEMS AND PRACTITIONERS
NOT TRADITIONALLY INVOLVED IN STI SERVICE DELIVERY
A systematic approach to strengthening the U.S. STI workforce in
response to alarming increases in STIs needs to include efforts for lever-
aging 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 com-
prehensive sexual health promotion.
This section highlights three workforce domains that are not tradi-
tionally 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 pro-
motion, pharmacists, and researchers. This wide network of practitioners
represents an invaluable resource for comprehensive national STI preven-
tion and management. Specifically, the broad range of their distinct com-
petencies 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,
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
556 SEXUALLY TRANSMITTED INFECTIONS
can be influential in family- and community-based efforts. For example,
families represent an important social context and are influential in shap-
ing a range of sexual reproductive health outcomes, particularly for ado-
lescents 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 sex-
ual 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 his-
torically 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 linguisti-
cally 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 struc-
turally 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).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
SUPPORTING AND EXPANDING THE FUTURE STI WORKFORCE 557
State regulation of CHW reimbursement remains inconsistent, par-
ticularly 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 ser-
vices are well positioned to deliver services that support preventing, iden-
tifying, and managing STIs and can be leveraged for the STI workforce.
Pharmacists
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 pharma-
cies and roughly 311,000 pharmacists practicing in the community setting
(BLS, 2020; Qato et al., 2017), and approximately 90 percent of the Ameri-
can 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 conve-
nient after-work hours with no appointments required (Gronowski et al.,
2016; Herbin et al., 2020). Furthermore, almost all pharmacies accept pri-
vate 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).
In the face of forecasted nationwide practitioner shortages and mis-
distribution of health care providers (AAMC, 2020; Giberson et al., 2011;
2 Examples include MinuteClinic (CVS), Healthcare Clinic (Walgreens), Little Clinic
(Kroger Foods), Target Clinic (Target), and Redi-Clinic (Rite Aid).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
558 SEXUALLY TRANSMITTED INFECTIONS
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 emer-
gency 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 provid-
ing 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 perform-
ing 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).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
SUPPORTING AND EXPANDING THE FUTURE STI WORKFORCE 559
Limited reimbursement options represent another barrier (Avalere
Health, 2015; CDC, 2013; NGA, 2015), as current policies primarily com-
pensate 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 pay-
ment 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 pro-
viders 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).
Research
Medical, pharmaceutical, and public health researchers represent an
important part of the STI workforce. Specifically, generating new knowl-
edge in four distinct fields of research is particularly relevant to prevent
and manage STIs: (1) the development of novel prophylactic, diagnos-
tic, 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 profession-
als in the STI workforce are most often employed in academia, the phar-
maceutical 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 Cen-
ters (NIH, 2019) and increased private-sector investments (Eisinger et al.,
2020). In addition, mechanisms to incentivize more specialized opera-
tional and implementation STI research are needed, such as modeled after
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
560 SEXUALLY TRANSMITTED INFECTIONS
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.
STRENGTHENING THE NATIONAL
PUBLIC HEALTH WORKFORCE
Workforce development for STI prevention and control must be con-
sidered 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, labora-
tory technicians, DIS, and providers of clinical STI prevention and treat-
ment. Epidemiologists and other public health officials at local and state
health departments oversee and coordinate STI programming, dissemi-
nate 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 diag-
nostics 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 Echevar-
ria, 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
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
SUPPORTING AND EXPANDING THE FUTURE STI WORKFORCE 561
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 satisfac-
tion compared to those from physicians (Laurant et al., 2018).
Despite national calls to remove practice barriers for advanced prac-
tice 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 leverag-
ing 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 expe-
riencing 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 cur-
rently 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
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
562 SEXUALLY TRANSMITTED INFECTIONS
(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 sala-
ries 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 rep-
resents 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 intel-
ligence, data visualization, and other areas of innovation may play key
roles in helping to track and intervene in sexual health promotion and
disease prevention.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
SUPPORTING AND EXPANDING THE FUTURE STI WORKFORCE 563
STI WORKFORCE GAPS AND NEEDS
As discussed in the previous sections, the United States has a large
and varied clinical and nonclinical workforce qualified to provide com-
prehensive STI services (Barrow et al., 2020). However, only a small pro-
portion of it has specialized in STI management and prevention. To ade-
quately 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, includ-
ing 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 impor-
tant STI services as part of routine care (Barrow et al., 2020). Many prac-
titioners do not report any cases, given their populations, specialties,
awareness of STIs, or availability of convenient diagnostic services. Dis-
comfort 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-inter-
view questionnaires, self-collected specimens for recommended screen-
ing, 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 treat-
ment 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
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
564 SEXUALLY TRANSMITTED INFECTIONS
physicians and nurses (AACN, 2020; Dall et al., 2020). An emphasis on
attracting new professionals is needed to counteract a possible shortage.
Finally, innovative nonclinical testing opportunities through phar-
macies and self-test kits that can be implemented in medically under-
served 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 out-
lined in this section warrant consideration as priorities in educating and
developing the future STI workforce.
STI WORKFORCE EDUCATION AND DEVELOPMENT
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 lead-
ers, parents, and educators. This section, however, focuses on profession-
als 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 fre-
quency 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 compet-
ing 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.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
SUPPORTING AND EXPANDING THE FUTURE STI WORKFORCE 565
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 appropri-
ate use of CLIA-waived tests, including for STIs, and specimen collection,
test performance, and interpretation for managing a CLIA-waived labora-
tory (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 preven-
tion 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
3Partners, (sexual) practices, prevention, previous history of STIs, and pregnancy (CDC,
2015).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
566 SEXUALLY TRANSMITTED INFECTIONS
of Alabama at Birmingham, Indiana University, the University of North
Carolina, Louisiana State University, Washington University, and the Uni-
versity 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 devel-
opment 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 inten-
sive 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 pro-
grams 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 impor-
tant 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.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
SUPPORTING AND EXPANDING THE FUTURE STI WORKFORCE 567
STI Programs at State and Local Health Departments
All state and a selected group of high-morbidity local health depart-
ments and selected territories receive federal STI block grants adminis-
tered from the CDC STD Division. These funds are largely earmarked for
surveillance and epidemiology and to support disease intervention spe-
cialist 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 coor-
dinating and implementing periodic STI 101 and 201 courses for nurses
and other health personnel who work in STI and family planning clin-
ics, 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 commu-
nity 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 Cen-
ters (discussed below). These Centers would combine, expand, and for-
malize 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 cen-
ters 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 man-
agement 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.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
568 SEXUALLY TRANSMITTED INFECTIONS
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). Espe-
cially 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 clini-
cal 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 pro-
fessionals contributing to the public health workforce, who upon gradu-
ation 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
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
SUPPORTING AND EXPANDING THE FUTURE STI WORKFORCE 569
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 num-
ber 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 Train-
ing 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 Collabora-
tive, that also includes the 17 organizations intended to provide Capac-
ity 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 col-
laborations are a promising development. They have been mostly infor-
mal, however, and relied on local leadership, so they have developed
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
570 SEXUALLY TRANSMITTED INFECTIONS
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 feder-
ally 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 Cur-
riculum, n.d.).
CONCLUSION AND RECOMMENDATION
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 com-
petencies 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,
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
SUPPORTING AND EXPANDING THE FUTURE STI WORKFORCE 571
needs to be expanded. Beyond STI specialists, inclusion of a variety of prac-
titioners 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 opera-
tionalized and prioritized in practice guidelines and training cur-
ricula for U.S. health professionals. Sexually transmitted infection
(STI) prevention and management should be incentivized and facil-
itated 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 pri-
orities for implementing this recommendation:
1. Clinical practice guidelines and benchmarks developed by
health professional organizations should more heavily empha-
size 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 Associa-
tion, 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 Phy-
sicians, the American Academy of Family Physicians, the Amer-
ican College of Obstetrics and Gynecology, the Infectious Dis-
eases Society of America, and the HIV Medicine Association.
2. 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 understand-
ing HIV prevention and care) to be reflected in formal training
programs and yearly continuing medical education, continuing
medical units, and continuing education requirements.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
572 SEXUALLY TRANSMITTED INFECTIONS
3. 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 pri-
mary care providers and nonclinical health and social services
professionals and paraprofessionals. This should be accom-
plished through consultation, technical assistance, and continu-
ing education (see also Recommendation 12-5).
4. 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.
5. The Centers for Medicare & Medicaid Services, the Health
Resources and Services Administration, CDC, and other agen-
cies 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.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
SUPPORTING AND EXPANDING THE FUTURE STI WORKFORCE 573
REFERENCES
AACN (American Association of Colleges of Nursing). 2020. Fact sheet: Nursing shortage.
https://www.aacnnursing.org/Portals/42/News/Factsheets/Nursing-Shortage-
Factsheet.pdf (accessed February 26, 2020).
AAMC (Association of American Medical Colleges). 2020. The complexities of physician supply
and demand: Projections from 2018 to 2033. Washington, DC: Association of American
Medical Colleges.
AANP (American Association of Nurse Practitioners). 2019. State practice environment.
https://www.aanp.org/advocacy/state/state-practice-environment (accessed Sep-
tember 24, 2020).
AIDS Education and Training Center. n.d. Partner training center networks. https://aidsetc.
org/directory/federal-training-centers (accessed February 8, 2021).
Albright, A. E., and R. S. Allen. 2018. HPV misconceptions among college students: The role
of health literacy. Journal of Community Health 43(6):1192-1200.
APhA (American Pharmacists Association). 2006. The role of the pharmacist in public health.
https://www.apha.org/policies-and-advocacy/public-health-policy-statements/
policy-database/2014/07/07/13/05/the-role-of-the-pharmacist-in-public-
health#Anchor%201 (accessed November 5, 2020).
APhA. 2020. Billing & payment. https://www.pharmacist.com/billing-payment (accessed
November 5, 2020).
ASTDA (American Sexually Transmitted Diseases Association) Board of Directors. 2020.
ASTDA position statement: In support of the publicly-funded sexually transmitted
infections specialty clinic. Sexually Transmitted Diseases 47(8):503-505.
Avalere Health. 2015. Developing trends in delivery and reimbursement of pharmacist services.
Washington, DC: Avalere Health LLC.
Barrow, R. Y., F. Ahmed, G. A. Bolan, and K. A. Workowski. 2020. Recommendations for
providing quality sexually transmitted diseases clinical services, 2020. MMWR Recom-
mendations and Reports 68(5):1-20.
Bean, M. G., J. Stone, G. B. Moskowitz, T. A. Badger, and E. S. Focella. 2013. Evidence of
nonconscious stereotyping of Hispanic patients by nursing and medical students. Nurs-
ing Research 62(5):362-367.
Bernstein, K. T., J. M. Chow, P. Pathela, and T. L. Gift. 2016. Bacterial sexually transmitted
disease screening outside the clinic—implications for the modern sexually transmitted
disease program. Sexually Transmitted Diseases 43(2):S42-S52.
Bertakis, K. D., R. Azari, L. J. Helms, E. J. Callahan, and J. A. Robbins. 2000. Gender differ-
ences in the utilization of health care services. Journal of Family Practice 49(2):147-152.
BLS (Bureau of Labor Statistics). 2020. May 2019 national occupational employment and wage
estimates: United States. https://www.bls.gov/oes/current/oes_nat.htm#29-0000 (ac-
cessed July 1, 2020).
Boden, J. M., D. M. Fergusson, and L. J. Horwood. 2011. Alcohol and STI risk: Evidence from
a New Zealand longitudinal birth cohort. Drug and Alcohol Dependence 113(2-3):200-206.
Bolan, G., and J. H. Mermin. 2019. A message to DIS from CDC. https://www.cdc.gov/std/
dstdp/DIS-Day-DCL-2019.pdf (accessed November 5, 2020).
Brookmeyer, K. A., M. Hogben, and J. Kinsey. 2016. The role of behavioral counseling in
sexually transmitted disease prevention program settings. Sexually Transmitted Diseases
43(2):S102-S112.
Calabrese, S. K., V. A. Earnshaw, K. Underhill, N. B. Hansen, and J. F. Dovidio. 2014. The
impact of patient race on clinical decisions related to prescribing HIV pre-exposure
prophylaxis (PrEP): Assumptions about sexual risk compensation and implications for
access. AIDS and Behavior 18(2):226-240.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
574 SEXUALLY TRANSMITTED INFECTIONS
CDC (Centers for Disease Control and Prevention). 2008. Recommendations for partner
services programs for HIV infection, syphilis, gonorrhea, and chlamydial infection.
MMWR Recommendations and Reports 57(RR-9):1-83; quiz CE81-CE84.
CDC. 2013. Collaborative practice agreements and pharmacists’ patient care services: A resource for
pharmacists. Atlanta, GA: Centers for Disease Control and Prevention.
CDC. 2014. Collaborating with community health workers to enhance the coordination of care and
advance health equity. https://www.cdc.gov/nccdphp/dch/pdfs/dch-chw-issue-brief.
pdf (accessed July 1, 2020).
CDC. 2015. 2015 sexually transmitted diseases treatment guidelines. https://www.cdc.gov/std/
tg2015/default.htm (accessed October 22, 2019).
CDC. 2017. Advancing team-based care through collaborative practice agreements: A resource and
implementation guide for adding pharmacists to the care team. Atlanta, GA: Centers for
Disease Control and Prevention.
CDC. 2019a. Sexually transmitted disease surveillance 2018. Atlanta, GA: Department of Health
and Human Services.
CDC. 2019b. Strengthening the nation’s HIV prevention workforce: Capacity building assistance
for high-impact HIV prevention. https://www.cdc.gov/hiv/funding/announcements/
ps19-1904/executive-summary.html (accessed February 8, 2021).
CDC. 2019c. What is BRTA? https://www.cdc.gov/hiv/workplace/index.html (accessed
November 4, 2020).
CDC. 2020a. About PHAP. https://www.cdc.gov/phap/about/index.html (accessed Febru-
ary 8, 2021).
CDC. 2020b. Clinical Laboratory Improvement Amendments (CLIA). https://www.cdc.gov/
clia/index.html (accessed July 1, 2020).
CDC. n.d. CDC: Protecting Americans from sexually transmitted diseases. https://www.cdc.
gov/nchhstp/budget/infographics/protecting-sti.html (accessed April 7, 2020).
Chisholm-Burns, M. A., J. Kim Lee, C. A. Spivey, M. Slack, R. N. Herrier, E. Hall-Lipsy, J.
Graff Zivin, I. Abraham, J. Palmer, J. R. Martin, S. S. Kramer, and T. Wunz. 2010. US
pharmacists’ effect as team members on patient care: Systematic review and meta-
analyses. Medical Care 48(10):923-933.
Cook, R. L., H. C. Wiesenfeld, M. R. Ashton, M. A. Krohn, T. Zamborsky, and S. H. Scholle.
2001. Barriers to screening sexually active adolescent women for chlamydia: A survey
of primary care physicians. Journal of Adolescent Health 28(3):204-210.
Cook, R. L., D. M. Comer, H. C. Wiesenfeld, C. C. Chang, R. Tarter, J. R. Lave, and D. B. Clark.
2006. Alcohol and drug use and related disorders: An underrecognized health issue
among adolescents and young adults attending sexually transmitted disease clinics.
Sexually Transmitted Diseases 33(9):565-570.
Cope, A. B., V. L. Mobley, E. Samoff, K. O’Connor, and T. A. Peterman. 2019. The changing
role of disease intervention specialists in modern public health programs. Public Health
Reports 134(1):11-16.
Cromer, K. J., L. Wofford, and D. K. Wyant. 2019. Barriers to healthcare access facing
American Indian and Alaska Natives in rural America. Community Health Nursing
36(4):165-187.
Cuffe, K. M., A. Newton-Levinson, T. L. Gift, M. McFarlane, and J. S. Leichliter. 2016. Sexu-
ally transmitted infection testing among adolescents and young adults in the United
States. Journal of Adolescent Health 58(5):512-519.
Dall, T., T. West, R. Chakrabarti, R. Reynolds, and W. Iacobucci. 2020. The complexities of
physician supply and demand: Projections from 2017 to 2032. Association of American
Medical Colleges. https://www.aamc.org/system/files/c/2/31-2019_update_-_the_
complexities_of_physician_supply_and_demand_-_projections_from_2017-2032.pdf
(accessed November 5, 2020).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
SUPPORTING AND EXPANDING THE FUTURE STI WORKFORCE 575
Davis, A., and A. Gaynor. 2020. Testing for sexually transmitted diseases in US public health
laboratories, 2016. Sexually Transmitted Diseases 47(2):122-127.
Dittus, P. J., S. L. Michael, J. S. Becasen, K. M. Gloppen, K. McCarthy, and V. Guilamo-Ramos.
2015. Parental monitoring and its associations with adolescent sexual risk behavior: A
meta-analysis. Pediatrics 136(6):e1587-e1599.
Eisinger, R. W., E. Erbelding, and A. S. Fauci. 2020. Refocusing research on sexually transmit-
ted infections. Journal of Infectious Diseases 222(9):1432-1434.
Fauteux, N., R. Brand, J. L. W. Fink, M. Frelick, and D. Werrlein. 2017. The case for remov-
ing barriers to APRN practice. Charting Nursing’s Future. https://www.rwjf.org/en/
library/research/2017/03/the-case-for-removing-barriers-to-aprn-practice.html (ac-
cessed November 5, 2020).
Feaster, D. J., C. L. Parish, L. Gooden, T. Matheson, P. C. Castellon, R. Duan, Y. Pan, L. F.
Haynes, B. R. Schackman, C. K. Malotte, R. N. Mandler, G. N. Colfax, and L. R. Metsch.
2016. Substance use and STI acquisition: Secondary analysis from the AWARE study.
Drug and Alcohol Dependence 169:171-179.
Findley, S. E., S. Matos, A. L. Hicks, A. Campbell, A. Moore, and D. Diaz. 2012. Building a
consensus on community health workers’ scope of practice: Lessons from New York.
American Journal of Public Health 102(10):1981-1987.
Fine, D., L. Warner, S. Salomon, and D. M. Johnson. 2017. Interventions to increase male
attendance and testing for sexually transmitted infections at publicly-funded family
planning clinics. Journal of Adolescent Health 61(1):32-39.
FitzGerald, C., and S. Hurst. 2017. Implicit bias in healthcare professionals: A systematic
review. BMC Medical Ethics 18(1):19.
Ford, J. V., R. Barnes, A. Rompalo, and E. W. Hook, 3rd. 2013. Sexual health training and
education in the U.S. Public Health Reports 128(Suppl 1):96-101.
Garner, A. R., R. C. Shorey, S. Anderson, and G. L. Stuart. 2020. Risky sexual behaviors
among men in residential treatment for substance misuse: The role of compulsive
sexual behavior. Sexual Addiction & Compulsivity 27(1-2):135-148.
Giberson, S., S. Yoder, and M. P. Lee. 2011. Improving patient and health system outcomes through
advanced pharmacy practice. A report to the U.S. Surgeon General. Office of the Chief Phar-
macist. U.S. Public Health Service.
Goode, J. V., J. Owen, A. Page, and S. Gatewood. 2019. Community-based pharmacy practice
innovation and the role of the community-based pharmacist practitioner in the United
States. Pharmacy 7(3).
Goyal, M. K., K. L. Hayes, and C. J. Mollen. 2012. Racial disparities in testing for sexually
transmitted infections in the emergency department. Academic Emergency Medicine
19(5):604-607.
Gronowski, A. M., A. Adams, C. Ball, C. A. Gaydos, and M. Klepser. 2016. Pharmacists in
the laboratory space: Friends or foes? Clinical Chemistry 62(5):679-683.
Guilamo-Ramos, V., J. J. Lee, and J. Jaccard. 2016. Parent–adolescent communication about
contraception and condom use. JAMA Pediatrics 170(1):14-16.
Guilamo-Ramos, V., A. Benzekri, and M. Thimm-Kaiser. 2019. Parent-based interventions to
affect adolescent sexual and reproductive health: Reconsidering the best evidence vs.
all evidence. JAMA Pediatrics 173(9):821-823.
Habel, M. A., R. Scheinmann, E. Verdesoto, C. Gaydos, M. Bertisch, and M. A. Chiasson.
2015. Exploring pharmacy and home-based sexually transmissible infection testing.
Sexual Health 12(6):472-479.
Hall, W. J., M. V. Chapman, K. M. Lee, Y. M. Merino, T. W. Thomas, B. K. Payne, E. Eng,
S. H. Day, and T. Coyne-Beasley. 2015. Implicit racial/ethnic bias among health care
professionals and its influence on health care outcomes: A systematic review. American
Journal of Public Health 105(12):e60-e76.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
576 SEXUALLY TRANSMITTED INFECTIONS
Han, H. R., K. Kim, J. Murphy, J. Cudjoe, P. Wilson, P. Sharps, and J. E. Farley. 2018. Com-
munity health worker interventions to promote psychosocial outcomes among people
living with HIV—a systematic review. PLoS One 13(4):e0194928.
Harmon-Darrow, C., K. Burruss, and N. Finigan-Carr. 2020. “We are kind of their parents”:
Child welfare workers’ perspective on sexuality education for foster youth. Children
and Youth Services Review 108:104565.
Hayes, V., W. Blondeau, and R. G. Bing-You. 2015. Assessment of medical student and resi-
dent/fellow knowledge, comfort, and training with sexual history taking in LGBTQ
patients. Family Medicine 47(5):383-387.
Hempel, S., M. M. Gibbons, J. G. Ulloa, I. T. Macqueen, I. M. Miake-Lye, J. M. Beroes, and P.
Shekelle. 2015. VA evidence-based synthesis program reports. In Rural healthcare work-
force: A systematic review. Washington, DC: Department of Veterans Affairs.
Henning-Smith, C., A. M. Hernandez, H. Neprash, and M. Lahr. 2019. Measuring access to care
in national surveys: Implications for rural health. Policy brief. Minneapolis, MN.
Herbin, S. R., D. G. Klepser, and M. E. Klepser. 2020. Pharmacy-based infectious disease
management programs incorporating CLIA-waived point-of-care tests. Journal of Clini-
cal Microbiology 58(5):e00726-00719.
Hilpert, J., M. Carrion, S. Ma, M. Brem, Ciani, and K. Ba. 2010. Young adult learning about
human papillomavirus on the Internet: What are the common misconceptions? Ameri-
can Journal of Health Studies 25.
HRSA (Health Resources and Services Administration). 2008. The adequacy of pharmacist sup-
ply: 2004-2030. Washington, DC: Department of Health and Human Services.
HRSA. 2016. Preparing nurses for new roles in population health management. https://www.
hrsa.gov/sites/default/files/hrsa/advisory-committees/nursing/reports/2016-
fourteenthreport.pdf (accessed February 17, 2021).
HRSA. n.d. NHSC loan repayment program. https://nhsc.hrsa.gov/loan-repayment/nhsc-
loan-repayment-program.html (accessed November 6, 2020).
Iglehart, J. K. 2015. The expansion of retail clinics—corporate titans vs. organized medicine.
New England Journal of Medicine 373(4):301-303.
Ingram, M., S. Sabo, J. Rothers, A. Wennerstrom, and J. G. de Zapien. 2008. Community
health workers and community advocacy: Addressing health disparities. Journal of
Community Health 33(6):417-424.
IOM (Institute of Medicine). 2011. The future of nursing: Leading change, advancing health.
Washington, DC: The National Academies Press.
Johnson, N. B., L. D. Hayes, K. Brown, E. C. Hoo, and K. A. Ethier. 2014. CDC national health
report: Leading causes of morbidity and mortality and associated behavioral risk and
protective factors—United States, 2005-2013. MMWR Supplements 63(4):3-27.
Kalmuss, D., and C. Tatum. 2007. Patterns of men’s use of sexual and reproductive health
services. Perspectives on Sexual and Reproductive Health 39(2):74-81.
Keehan, S. P., D. A. Stone, J. A. Poisal, G. A. Cuckler, A. M. Sisko, S. D. Smith, A. J. Madison,
C. J. Wolfe, and J. M. Lizonitz. 2017. National health expenditure projections, 2016-25:
Price increases, aging push sector to 20 percent of economy. Health Affairs 36(3):553-563.
KFF (Kaiser Family Foundation). 2015. Gender differences in health care, status, and use: Spot-
light on men’s health. https://www.kff.org/womens-health-policy/fact-sheet/gender-
differences-in-health-care-status-and-use-spotlight-on-mens-health (accessed June 5,
2020).
Krisberg, K. 2020. Already-strained US public health workforce grapples with COVID-19:
Despite resource gaps, workers fight on. The Nation’s Health 50(4):1-12.
Krist, A. H., K. W. Davidson, C. M. Mangione, M. J. Barry, M. Cabana, A. B. Caughey, K. Do-
nahue, C. A. Doubeni, J. W. Epling, Jr., M. Kubik, G. Ogedegbe, L. Pbert, M. Silverstein,
M. A. Simon, C. W. Tseng, and J. B. Wong. 2020. Behavioral counseling interventions
to prevent sexually transmitted infections: U.S. Preventive Services Task Force recom-
mendation statement. JAMA 324(7):674-681.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
SUPPORTING AND EXPANDING THE FUTURE STI WORKFORCE 577
Laurant, M., M. van der Biezen, N. Wijers, K. Watananirun, E. Kontopantelis, and A. van
Vught. 2018. Nurses as substitutes for doctors in primary care. Cochrane Database of
Systematic Reviews (7).
Lehmann, U., and D. Sanders. 2007. Community health workers: What do we know about them?
The state of the evidence on programmes, activities, costs and impact on health outcomes of us-
ing community health workers. Geneva, Switzerland: World Health Organization.
Leichliter, J. S., K. Heyer, T. A. Peterman, M. A. Habel, K. A. Brookmeyer, S. S. Arnold Pang,
M. R. Stenger, G. Weiss, and T. L. Gift. 2017. U.S. public sexually transmitted disease
clinical services in an era of declining public health funding: 2013-14. Sexually Transmit-
ted Diseases 44(8):505-509.
MacDonald, P. D., A. L. Nelson, L. Hightow-Weidman, and P. A. Leone. 2007. Disease inter-
vention specialists as a resource in a public health emergency. Biosecurity and Bioterror-
ism: Biodefense Strategy, Practice, and Science 5(3):239-248.
Marcelin, J. R., D. S. Siraj, R. Victor, S. Kotadia, and Y. A. Maldonado. 2019. The impact of
unconscious bias in healthcare: How to recognize and mitigate it. Journal of Infectious
Diseases 220(220):S62-S73.
Martínez-González, N. A., S. Djalali, R. Tandjung, F. Huber-Geismann, S. Markun, M. Wens-
ing, and T. Rosemann. 2014. Substitution of physicians by nurses in primary care: A
systematic review and meta-analysis. BMC Health Services Research 14:214.
Mase, W. A., A. R. Hansen, S. W. Smallwood, G. Shah, A. H. Peden, T. Mulherin, and K.
Bender. 2018. Disease intervention specialist education for the future: An analysis of
public health curricula. Public Health Reports 133(6):738-748.
Mason-Jones, A. J., C. Crisp, M. Momberg, J. Koech, P. De Koker, and C. Mathews. 2012. A
systematic review of the role of school-based healthcare in adolescent sexual, reproduc-
tive, and mental health. Systematic Reviews 1:49.
Mayfield, J. J., E. M. Ball, K. A. Tillery, C. Crandall, J. Dexter, J. M. Winer, Z. M. Bosshardt, J.
H. Welch, E. Dolan, E. R. Fancovic, A. I. Nañez, H. De May, E. Finlay, S. M. Lee, C. G.
Streed, and K. Ashraf. 2017. Beyond men, women, or both: A comprehensive, LGBTQ-
inclusive, implicit-bias-aware, standardized-patient-based sexual history taking cur-
riculum. MedEdPORTAL 13:10634.
McNulty, C. A., E. Freeman, J. Bowen, J. Shefras, and K. A. Fenton. 2004. Barriers to op-
portunistic chlamydia testing in primary care. British Journal of General Practice
54(504):508-514.
McNulty, C. A., E. Freeman, R. Howell-Jones, A. Hogan, S. Randall, W. Ford-Young, P. Beck-
with, and I. Oliver. 2010. Overcoming the barriers to chlamydia screening in general
practice—a qualitative study. Family Practice 27(3):291-302.
Merritt Hawkins. 2017. Physician supply considerations: The emerging shortage of medical special-
ists. https://www.merritthawkins.com/uploadedFiles/mhawhitepaperspecialties2017.
pdf (accessed November 5, 2020).
Metzl, J. M., and H. Hansen. 2014. Structural competency: Theorizing a new medical engage-
ment with stigma and inequality. Social Science & Medicine 103:126-133.
Meyer, P. A., K. M. Brusuelas, D. J. Baden, and H. L. Duncan. 2015. Training public health
advisors. Journal of Public Health Management & Practice 21(6):E19-E22.
Meyerson, B. E., A. Davis, H. Reno, L. T. Haderxhanaj, M. A. Sayegh, M. K. Simmons,
G. Multani, L. Naeyaert, A. Meador, and B. P. Stoner. 2019. Existence, distribution,
and characteristics of STD clinics in the United States, 2017. Public Health Reports
134(4):371-378.
Montaño, M. A., J. C. Dombrowski, S. Dasgupta, M. R. Golden, A. Duerr, L. E. Manhart, L.
A. Barbee, and C. M. Khosropour. 2019. Changes in sexual behavior and STI diagnoses
among MSM initiating PrEP in a clinic setting. AIDS and Behavior 23(2):548-555.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
578 SEXUALLY TRANSMITTED INFECTIONS
Nagendra, G., C. Carnevale, N. Neu, A. Cohall, and J. Zucker. 2020. The potential impact
and availability of sexual health services during the COVID-19 pandemic. Sexually
Transmitted Diseases 47(7):434-436.
NAPA (National Academy of Public Administration). 2018. The impact of sexually transmitted
diseases on the United States: Still hidden, getting worse, can be controlled. Washington, DC:
National Academy of Public Administration.
NAPA. 2019. The STD epidemic in America: The frontline struggle. Washington, DC: National
Academy of Public Administration.
NASEM (National Academies of Sciences, Engineering, and Medicine). 2016a. Assessing
progress on the Institute of Medicine report The Future of Nursing. Washington, DC: The
National Academies Press.
NASEM. 2016b. Envisioning the future of health professional education: Workshop summary.
Washington, DC: The National Academies Press.
NASHP (National Academy for State Health Policy). n.d. State community health worker
models. https://www.nashp.org/state-community-health-worker-models (accessed
November 5, 2020).
National STD Curriculum. n.d. National STD curriculum. A free educational website from the
University of Washington STD prevention training center. https://www.std.uw.edu (ac-
cessed November 5, 2020).
NCQA (National Committee for Quality Assurance). n.d. Chlamydia screening in women.
https://www.ncqa.org/hedis/measures/chlamydia-screening-in-women (accessed
January 2, 2019).
NCSD (National Coalition of STD Directors). 2019. Fact sheet: STD program capacity and
preparedness in the United States: Results of a national survey, 2009. https://www.
ncsddc.org/wp-content/uploads/2019/10/Fact-Sheet-STD-Program-Capacity-and-
Preparedness-in-the-United-States-Re....pdf (accessed June 5, 2020).
NCSD. 2020. COVID-19 & the state of the STD field. https://www.ncsddc.org/wp-content/
uploads/2020/05/STD-Field.Survey-Report.Final_.5.13.20.pdf (accessed October 25,
2020.
NCSD. n.d. Disease intervention specialists (DIS). https://www.ncsddc.org/our-work/
disease-intervention-specialists-dis (accessed February 26, 2020).
NGA (National Governors Association). 2015. The expanding role of pharmacists in a trans-
formed health care system. Washington, DC: National Governors Association.
NIH (National Institutes of Health). 2019. NIH awards will advance development of vaccines for
sexually transmitted infections. https://www.niaid.nih.gov/news-events/nih-awards-
will-advance-development-vaccines-sexually-transmitted-infections (accessed July 1,
2020).
NIH. 2020. NIH loan repayment programs. https://www.lrp.nih.gov (accessed November 6,
2020).
Nsuami, J. M., L. S. Sanders, and S. N. Taylor. 2010. Knowledge of sexually transmitted infec-
tions among high school students. American Journal of Health Education 41(4):206-217.
O’Cleirigh, C., J. F. Magidson, M. R. Skeer, K. H. Mayer, and S. A. Safren. 2015. Prevalence
of psychiatric and substance abuse symptomatology among HIV-infected gay and
bisexual men in HIV primary care. Psychosomatics 56(5):470-478.
ODPHP (Office of Disease Prevention and Health Promotion). 2020. Healthy people 2020:
Sexually transmitted diseases. https://www.healthypeople.gov/2020/topics-objectives/
topic/sexually-transmitted-diseases (accessed September 4, 2020).
Owens, D. K., K. W. Davidson, A. H. Krist, M. J. Barry, M. Cabana, A. B. Caughey, S. J. Curry,
C. A. Doubeni, J. W. Epling, Jr., M. Kubik, C. S. Landefeld, C. M. Mangione, L. Pbert, M.
Silverstein, M. A. Simon, C. W. Tseng, and J. B. Wong. 2019. Preexposure prophylaxis
for the prevention of HIV infection: U.S. Preventive Services Task Force recommenda-
tion statement. JAMA 321(22):2203-2213.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
SUPPORTING AND EXPANDING THE FUTURE STI WORKFORCE 579
Paschal, A. M., J. Oler-Manske, and T. Hsiao. 2011. The role of local health departments in
providing sexually transmitted disease services and surveillance in rural communities.
Journal of Community Health 36(2):204-210.
Patton, R., F. Keaney, and M. Brady. 2008. Drugs, alcohol and sexual health: Opportunities
to influence risk behaviour. BMC Research Notes 1:27.
PHAB (Public Health Accreditation Board). 2017. Disease intervention specialist certification
project: Final report to the Centers for Disease Control and Prevention. Executive summary.
Alexandria, VA: Public Health Accreditation Board.
Qato, D. M., S. Zenk, J. Wilder, R. Harrington, D. Gaskin, and G. C. Alexander. 2017. The
availability of pharmacies in the United States: 2007-2015. PLoS One 12(8):e0183172.
Rosenthal, E. L., J. N. Brownstein, C. H. Rush, G. R. Hirsch, A. M. Willaert, J. R. Scott, L. R.
Holderby, and D. J. Fox. 2010. Community health workers: Part of the solution. Health
Affairs (Millwood) 29(7):1338-1342.
Salam, R. A., A. Faqqah, N. Sajjad, Z. S. Lassi, J. K. Das, M. Kaufman, and Z. A. Bhutta. 2016.
Improving adolescent sexual and reproductive health: A systematic review of potential
interventions. Journal of Adolescent Health 59:S11-S28.
Salmond, S. W., and M. Echevarria. 2017. Healthcare transformation and changing roles for
nursing. Orthopaedic Nursing 36(1):12-25.
Santa Maria, D., V. Guilamo-Ramos, L. S. Jemmott, A. Derouin, and A. Villarruel. 2017.
Nurses on the front lines: Improving adolescent sexual and reproductive health across
health care settings. American Journal of Nursing 117(1):42-51.
Santa Maria, D., J. Rafferty, M. Lau, V. Guilamo-Ramos, K. Tebb, N. Chadi, A.-E. Ambresin, E.
Vyver, and A. V. Marcell. 2018. Advocating for adolescent and young adult male sexual
and reproductive health: A position statement from the Society for Adolescent Health
and Medicine. Journal of Adolescent Health 63(5):657-661.
Schneider, K., T. Byczkowski, and J. Reed. 2015. Treatment compliance among asymptomatic
adolescents with sexually transmitted infections. JAMA Pediatrics 169(11):1065-1066.
Smiley, R. A., and C. Bienemy. 2018. Results from the 2017 National Nursing Workforce Survey.
https://www.ncsbn.org/2018SciSymp_Smiley-Bienemy.pdf (accessed July 1, 2020).
Spencer, M. S., K. E. Gunter, and G. Palmisano. 2010. Community health workers and their
value to social work. The Social Worker 55(2):169-180.
Stone, V. E. 2005. Physician contributions to disparities in HIV/AIDS care: The role of pro-
vider perceptions regarding adherence. Current HIV/AIDS Reports 2(4):189-193.
Stoner, B. P., J. Fraze, C. A. Rietmeijer, J. Dyer, A. Gandelman, E. W. Hook, 3rd, C. Johnston,
N. M. Neu, A. M. Rompalo, G. Bolan, and National Network of STD Clinical Prevention
Training Centers. 2019. The national network of sexually transmitted disease clinical
prevention training centers turns 40—a look back, a look ahead. Sexually Transmitted
Diseases 46(8):487-492.
Svanemyr, J., A. Amin, O. J. Robles, and M. E. Greene. 2015. Creating an enabling environ-
ment for adolescent sexual and reproductive health: A framework and promising ap-
proaches. Journal of Adolescent Health 56:S7-S14.
Torrone, E., J. Papp, and H. Weinstock. 2014. Prevalence of Chlamydia trachomatis genital
infection among persons aged 14-39 years—United States, 2007-2012. Morbidity and
Mortality Weekly Report 63(38):834-838.
University of Washington Department of Global Health. n.d. Principles of STI/HIV research
and public health practice course. https://depts.washington.edu/pshr (accessed Febru-
ary 8, 2021).
Widdice, L. E., Y. H. Hsieh, B. Silver, M. Barnes, P. Barnes, and C. A. Gaydos. 2018. Perfor-
mance of the Atlas Genetics rapid test for Chlamydia trachomatis and women’s attitudes
toward point-of-care testing. Sexually Transmitted Diseases 45(11):723-727.
Wood, E. M., B. Zani, T. M. Esterhuizen, and T. Young. 2018. Nurse led home-based care for
people with HIV/AIDS. BMC Health Services Research 18(1):219.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
580 SEXUALLY TRANSMITTED INFECTIONS
Wood, H., and S. Gudka. 2018. Pharmacist-led screening in sexually transmitted infections:
Current perspectives. Integrated Pharmacy Research and Practice 7:67-82.
Workowski, K. A., and G. A. Bolan. 2015. Sexually transmitted diseases treatment guidelines,
2015. MMWR Recommendations and Reports 64(RR-03):1-137.
Yeung, A., M. Temple-Smith, C. Fairley, and J. Hocking. 2015. Narrative review of the barri-
ers and facilitators to chlamydia testing in general practice. Australian Journal of Primary
Health 21(2):139-147.
Zhang, X., D. Lin, H. Pforsich, and V. W. Lin. 2020. Physician workforce in the United States
of America: Forecasting nationwide shortages. Human Resources for Health 18(1):8.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
12
Preparing for the Future
of the STI Response
Chapter Contents
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
• Better Support for Parents and Guardians to Model Sexual
Health
• Engaging Community Stakeholders to Create
Opportunities for Dialogue About Sexual Health
581
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
582 SEXUALLY TRANSMITTED INFECTIONS
Chapter Contents Continued
Bolster Existing Systems and Programs for Responding to STIs
• Enhancing Federal Leadership and Support
• Strengthening Local Efforts to Plan and Coordinate the STI
Response
• Establishing New Payment and Coverage Options to Close
Gaps in Access to STI Coverage and Services
• Supporting and Expanding the STI Workforce
• Accelerate Biomedical Research and Development
• Deploy Psychosocial and Behavioral Interventions for
Sexual Health
Embrace Innovation and Policy Change to Improve Sexual
Health
• COVID-19 and STIs
• Address Structural Racism and Other Structural Inequities
That Hinder STI Control
• Harnessing Technological Innovation to Improve STI
Prevention and Control
Concluding Observations
INTRODUCTION
Overcoming the biological, social, economic, financial, and other bar-
riers that impede an effective national response to sexually transmit-
ted infection (STI) prevention and control is daunting. With so many
STIs of concern and new ones emerging, the scope of the challenge can
appear insurmountable. In the 1960s, the meteorologist Edward Lorenz
described the Butterfly Effect, wherein small changes can produce big
impacts within complex systems (a butterfly flapping its wings could
eventually produce a typhoon). The committee believes that similar sub-
tle, concerted, but significant changes in policy and outlook can lead
over time to transformative results. Effective STI prevention and control
emerges from a holistic, sexual health perspective involving many levels
of society and a variety of approaches. An integrated approach is needed
that acknowledges the centrality of biological pathogens, yet also involves
taking action throughout the entire population and at all levels of the
prevention and care continua. Ultimately, these actions can lead to better
prevention, screening, and treatment.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PREPARING FOR THE FUTURE OF THE STI RESPONSE 583
REVIEW OF RECENTLY PUBLISHED REPORTS ADDRESSING
STI PREVENTION IN THE UNITED STATES
Implied by its title and expanded on in Chapter 1, the committee was
guided in its deliberations by the idea that an effective approach to STI
prevention and control should be grounded in a holistic view of sexual
health as a component of overall health and a positive construct of sexual
activity as a normal and even essential component of humanity. The com-
mittee’s perspective is that this view can achieve greater success than a
traditional disease model. Furthermore, the committee views the STI epi-
demic as a societal problem requiring a societal solution. The committee
embraced a social ecological approach to develop a set of comprehensive
recommendations targeting all levels of society, including public and pri-
vate agencies, providers, parents, educators, faith and community leaders,
and priority populations disproportionally affected by STIs.
It is through this expansive lens that the committee has reviewed four
recently published reports that also specifically address the STI epidemic
in the United States, including two expert panel reports from the National
Academy of Public Administration (NAPA), and a report on the STI
research pipeline by the Treatment Action Group (TAG), all three of which
were commissioned by the National Coalition of STD Directors (NCSD).
Perhaps most significantly, the committee reviewed the STI National Stra-
tegic Plan from the Department of Health and Human Services (HHS)
that was formally released in December 2020 and that will guide federal
efforts to improve STI outcomes (HHS, 2020). In the following section, the
committee identifies and builds on the specific conclusions and recom-
mendations in each report and in the STI National Strategic Plan (STI-
NSP). The committee believes that rather than being duplicative, its report
complements and builds on these reports and can serve to both expand
on and go further than the STI-NSP, which is focused on efforts within
HHS, as well as highlight opportunities to bolster its implementation.
The release of these reports in a relatively short time frame encourages
a broad-based discussion on the future of STI prevention and control in
the United States.
NATIONAL ACADEMY OF PUBLIC
ADMINISTRATION STI REPORTS
The two reports NAPA commissioned by NCSD were developed and
released in 2018 (Phase 1) and 2019 (Phase 2), respectively (NAPA, 2018,
2019). An overview, including where they align with this report, follows.
The 2018 report The Impact of Sexually Transmitted Diseases on the United
States: Still Hidden, Getting Worse, Can Be Controlled recommended the fol-
lowing six “Actions for Consideration” (NAPA, 2018):
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
584 SEXUALLY TRANSMITTED INFECTIONS
1. Designate a national STD champion to coordinate federal, state,
and local efforts and to lead the development and implementa-
tion of a national STD strategy.
2. Change the STD narrative.
3. Unify the field as a necessary step.
4. Develop better data and more evaluation to learn about what
works—and what does not work—and to foster implementation
of best practices, which is essential.
5. Education and awareness.
6. Expanded funding and resources are necessary, given the scale of
the STD epidemic.
The committee is largely in agreement with the NAPA-recommended
actions. It recognizes the desire for a national champion and the appeal of
successful models in other areas, such as the “policy czars” at the White
House or within the federal government in other areas. The committee
also recognizes, however, the political and administrative challenges with
such models. This committee’s report emphasizes the need for enhanced
leadership and accountability for STIs within the health system and out-
side of the health sector, including at the community level, which is not
inconsistent with a national champion, and also seeks to elevate and
demand more from existing STI champions, including at the Centers
for Disease Control and Prevention (CDC). The 2018 NAPA report’s rec-
ommendation to destigmatize STIs and emphasize sexual health as “an
important dimension of overall health and wellness” also provides a
central emphasis of this report. The NAPA report argues for better inte-
gration between existing STI and HIV programs at the federal level and
within state and local health departments. It makes a compelling case
for the costs associated with not maintaining a more holistic approach,
such as the tunnel vision of responding aggressively to HIV prevention
in pregnancy without attention to syphilis or herpes simplex virus type 2.
The committee also concurs with the call to action for modernizing
both data collection and evaluation of best practices. Internet sources,
such as social media, and expanding electronic medical record systems
can help with both aims. The committee’s report includes recommenda-
tions on both. The emphasis on “tailored awareness campaigns, focused
on groups at higher risk” to improve “screening, testing, and treatment”
is also consistent with this report, as is the recommendation that “medi-
cal professionals must be encouraged to screen for STDs as a routine
practice.”
The 2019 NAPA Phase 2 report The STD Epidemic in America: The
Frontline Struggle recommended four more “Actions for Consideration”
(NAPA, 2019):
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PREPARING FOR THE FUTURE OF THE STI RESPONSE 585
1. Reform federal funding to enhance program agility across STD
programs.
2. Expand access to care, with a focus on delivering community-
sensitive and patient-centered care.
3. Enable more rapid data release and results of research.
4. Implement science-based, health-centric education and awareness
campaigns to reduce stigma and encourage healthy behaviors.
The committee observes that the 2019 NAPA report was prescient, as
the public health and medical care system failed to coordinate adequately
in the early days of the COVID-19 response. As with that acute pandemic,
a mounting STI toll reinforces the need for the nation to enable far bet-
ter interagency coordination and give local jurisdictions greater ability
to respond to outbreaks and unfavorable trends. The 2019 NAPA report
highlighted health-system-level limitations that inhibit priority popula-
tions and communities from receiving needed interventions. Eliminat-
ing insurance and payment obstacles, implementing expedited partner
therapy (EPT), expanding “telemedicine, in combination with mail-in
testing kits, remote diagnosis and prescription of medication,” enhancing
privacy, expanding clinic hours, and providing better transportation are
all logical elements of an STI reduction plan. This report offers its own
recommendations that run parallel to the NAPA recommendations.
The committee also concurs with NAPA in its emphasis on the unac-
ceptably slow collection, processing, and release of STI data, both ser-
vice process variables and surveillance reports, including drug resistance
information. This report cites and builds on NAPA’s recommendations in
this regard. Furthermore, the 2019 NAPA report supports school-based,
out-of-school, Internet, and other forms of educational outreach, stating
that “[t]his education must be community-sensitive and address at-risk
groups directly, with LGBTQIA+ considerations included” (NAPA, 2019,
p. 24). New community partnerships are essential to break down decades
of mistrust; to address public health issues, such as human sexuality,
human-centered design approaches incorporated into community-based
participatory research partnerships and projects hold the best promise
(Chen et al., 2020a). Including religious, educational, political, and par-
ent and youth perspectives has the best promise of breaking down the
suspicions of past decades that have stigmatized not only persons with
STIs but sexual health education itself.
TREATMENT ACTION GROUP GONORRHEA,
CHLAMYDIA, AND SYPHILIS PIPELINE REPORT 2019
NCSD commissioned a report from TAG concentrating on docu-
menting and addressing the “sparse research pipeline of new treatment,
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
586 SEXUALLY TRANSMITTED INFECTIONS
prevention, and diagnostic options” (TAG, 2019), and TAG made seven
recommendations focused on rising gonorrhea, chlamydia, and syphilis
rates. The committee abbreviates them here and refers readers to the full
TAG report for details.
1. Advocacy to fight STIs must be more than repackaging condoms
and behavioral interventions.
2. HIV pre-exposure prophylaxis (PrEP) and Undetectable =
Untransmittable (U=U) activists must understand that their suc-
cess is integrally linked to STI advocacy.
3. Substantially more investment in new prevention modalities—
particularly vaccine research—will be necessary.
4. Doxycycline should be seriously considered for scale-up as a PrEP
and/or post-exposure prophylaxis for syphilis and chlamydia.
5. Discussions on accessing zoliflodacin for treatment of multidrug-
resistant and extensively drug-resistant gonorrhea should begin
now.
6. Reliable, easy-to-use, change to Clinical Laboratory Improvement
Amendments (CLIA)-waived rapid tests for chlamydia, gonorrhea,
and syphilis should be developed and made widely available.
7. Infrastructure for the delivery of sexual health services remains
highly underfunded in the United States, and declining funding
for sexual health clinics must be addressed.
The TAG report takes a strong stand to “focus much more aggres-
sively on the structural, social, financial, and research barriers that under-
mine our ability to successfully use existing tools and develop essential
new tools.” It demonstrates how rising STI rates can undermine support
for scale-up of HIV PrEP programs, as well as U=U campaigns to expand
“treatment as prevention” programs for HIV control. It highlights the
need for new investments for STI vaccines and other biomedical primary
prevention approaches. Public–private partnerships (PPPs) in the form
of government-guaranteed market demand are encouraged to incentiv-
ize industry to bring safe and effective products to the public. The TAG
report also cites the widespread use of doxycycline for acne suppression
as a rationale for its more aggressive use for STI prevention.1 Specific
mention of STI suppression (syphilis and chlamydia) accompanying HIV
PrEP and post-exposure prophylaxis suggests synergies for the many
persons at dual risk of HIV and STIs. Based on the Phase 2 trial (Taylor et
1 In regard to doxycycline use for acne, the American Academy of Dermatology states the
need for antibiotic stewardship to minimize resistance; see https://www.aad.org/member/
clinical-quality/guidelines/acne (accessed January 26, 2021).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PREPARING FOR THE FUTURE OF THE STI RESPONSE 587
al., 2018), the TAG report is optimistic about the promise of zoliflodacin
and highlights the preparatory work needed to efficiently roll out this
new oral, single-dose alternative to intramuscular ceftriaxone for gonor-
rhea. The TAG authors assert that zoliflodacin “must be priced in a way
that ensures rapid and broad access while also providing a reasonable
return on investment for Entasis Therapeutics” (TAG, 2019, p. 25). Near
the time the TAG report was published, a number of other agents were
investigated (Barbee and Golden, 2020; Chen et al., 2019; Hook et al.,
2019; Ross et al., 2019). The TAG report joins the decades-long chorus
urging further development and widespread deployment of point-of-care
(POC), simple diagnostics to transform STI screening, diagnosis, and care.
The TAG report advocates for “sexual health clinics in the United States,
provider education, and appropriate curricula for providers-in-training.”
This sexual health paradigm is distinct from the classic STI clinic model
of care. While TAG’s contribution is more narrowly focused on the thera-
peutics pipeline than this report, the committee welcomes it and finds that
it is broadly consistent with this report.
STI NATIONAL STRATEGIC PLAN FOR
THE UNITED STATES (2021–2025)
In 2019, HHS announced that it was developing the first-ever STI-
NSP (HHS, 2020). The committee reviewed a draft toward the end of its
deliberations that was released for public comment in September 2020,
and it was able to update this discussion based on the final STI-NSP that
was released in December 2020. There are strong synergies between the
issues that the STI-NSP (an internal governmental report) cites as high
priorities for the next 5 years and what the committee’s report highlights
as necessary for an effective national response. This committee’s composi-
tion of nonfederal staff and its broader charge means that, unsurprisingly,
this report diverges in some respects from the focus of the STI-NSP. Per-
haps the principal difference is that the committee’s report highlights the
importance of responding to STIs through a sexual health lens, seeking to
incorporate positive messages of love, pleasure, and life-affirming aims
as a way to enhance STI risk-reducing actions by all parties engaging in
consensual sexual activity. In addition, the committee recognizes that STI
control falls at not only the individual level, but also the interpersonal,
institutional, community, and structural levels, as described in the com-
mittee’s conceptual framework and that these factors intersect in dynamic
and important ways (see Chapter 1). Five central “high-level” goals are
highlighted in the draft STI-NSP (with 16 subgoals):
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
588 SEXUALLY TRANSMITTED INFECTIONS
Goal 1: Prevent New STIs
Goal 2: Improve the Health of People by Reducing Adverse Outcomes
of STIs
Goal 3: Accelerate Progress in STI Research, Technology, and
Innovation
Goal 4: Reduce STI-Related Health Disparities and Health Inequities
Goal 5: Achieve Integrated, Coordinated Efforts That Address the STI
Epidemic
The STI-NSP makes clear why revitalized federal, state, and local
efforts are essential to decrease the increasing rates of human papilloma-
virus (HPV), primary and secondary syphilis, congenital syphilis, gonor-
rhea, and chlamydia.
Similar to this report, the STI-NSP discusses the need to address indi-
vidual, community, and structural factors that contribute to STIs, includ-
ing stigma and health disparities. Specific actions are undefined, although
it is hoped that a promised forthcoming STI-NSP implementation plan
will provide greater details, especially actions identified in this report
tailored to address the diversity of the U.S. population in terms of gender,
gender identity, and sexual orientation. The development of the STI-NSP
implementation plan also provides a timely opportunity to incorporate
the sexual health approach and recommendations provided in this report
to increase impact of the STI-NSP (using principles of implementation
science). The committee also notes the influence of the Internet (with its
virtual and social media platforms) and technology (including telemedi-
cine and artificial intelligence) on STI risk and risk mitigation. Thus, the
committee’s report offers insights into using modern technology and
media as a tool, alongside other types of interventions (see Chapter 6).
The lack of adequate integration between public health STI programs and
the health care system, including private insurance, Medicaid, Medicare,
and other safety net programs, represents both a challenge and opportu-
nity for better STI control. The committee’s report provides information
about these programs’ importance and may be useful for informing the
STI-NSP implementation plan.
Emphasis on the need for risk reduction through individual-level
changes, as captured in the STI-NSP, is a vital part of the STI control
narrative. Based on the committee’s review of the evidence, however,
individual-level changes are insufficient without addressing interper-
sonal, institutional, community, and structural opportunities to better
prevent, recognize, and/or mitigate STI harms. In particular, this report
reflects the committee’s view that forthrightly addressing structural rac-
ism and other social and structural inequities is an essential component
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PREPARING FOR THE FUTURE OF THE STI RESPONSE 589
for strengthening STI prevention and control. This is consistent with the
STI-NSP discussion on the importance of addressing the social determi-
nants of health to improve health outcomes for racial, ethnic, and sexual
minority groups and its objective to improve data collection and surveil-
lance of STIs in populations that are underrepresented in current data
(strategy 4.3.3).
In emphasizing the challenges and opportunities facing the United
States, the STI-NSP highlights five elements that include both existing chal-
lenges and new opportunities for deploying new tools and approaches:
1. Health disparities, stigma, and the role of social determinants of
health;
2. Provider education, awareness, and training;
3. Program capacity and access to prevention and care services;
4. The need to accelerate progress in STI research, technology, and
innovation; and
5. STIs, HIV, viral hepatitis, and substance use disorders—a holistic
approach to the syndemic.
The committee shares the STI-NSP’s view that these five elements
are fundamental for success in efforts to control STIs in the United States.
The committee was pleased by the federal emphasis of potential return
on investment from vaccines while cautioning about the potential for
low consumer demand. Demand is a vital topic that the committee has
addressed—namely, financing options for future STI vaccines and public
awareness campaigns to increase uptake.
The STI-NSP recognizes syndemic elements of the STI crisis. The
committee agrees that it is desirable to highlight that intersecting epi-
demics may reinforce and exacerbate each other. For example, advances
in HIV treatments and prevention modalities, increases in mental health
problems, including substance use, and stress heightened by a period of
extreme racial divisiveness may concurrently lead to changes in sexual
behaviors that may alter and potentially enhance STI risk.
The STI-NSP gives 5- and 10-year targets for identified indicators to
track progress toward the five goals and is aligned with the Ending the
HIV Epidemic: A Plan for America presidential initiative, which seeks
to reduce new HIV infections by 90 percent by 2030. Annual reports are
planned to document progress toward meeting these goals, with transpar-
ent accounting of all monitored indicators. The following section high-
lights where the committee’s report may offer additional insights that
complement the STI-NSP’s five “high-level” goals.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
590 SEXUALLY TRANSMITTED INFECTIONS
Goal 1: Prevent New STIs
The STI-NSP proposes STI prevention based on a traditional, indi-
vidual risk-based approach, with the committee endorsing a more holistic
perspective, in part because risk is often hard to ascertain. The importance
of engaging families and communities in prevention efforts is discussed
in the STI-NSP and is well aligned with this report, which describes the
opportunities to leverage parents, families, institutions, and communities.
The committee is intrigued by the idea of a “whole-of-nation” response,
which is consistent with its report’s recommendations to broaden own-
ership and accountability for responding to STIs. The STI-NSP imple-
mentation plan would be an excellent opportunity to further explore the
whole-of-nation concept.
Goal 2: Improve the Health of People by
Reducing Adverse Outcomes of STIs
The committee acknowledges the excellent elements in the STI-NSP,
such as highlighting the importance of self-collection options and POC
tests (see, for example, strategy 2.1.3 in the STI-NSP). In the forthcom-
ing implementation plans, the committee urges pursuing self-collection
options as a potential solution for STI prevention and control. The STI-
NSP also cites the need for an expanded, and perhaps changing, role for
disease intervention specialists (DIS) that incorporates greater use of tech-
nology. As discussed in Chapter 11, the committee suggests expanding
DIS roles, including in the areas of field-based diagnosis and treatment.
The STI-NSP implementation plan also would benefit from discussing
how STI specialists within the National Network of STD Clinical Pre-
vention Training Centers can be most effectively deployed to fill gaps in
STI clinical care, a topic addressed in this report (Stoner et al., 2019) (see
Chapter 11). The expressed objectives about expanding secondary preven-
tion align with the committee’s commitment to the important role of STI
specialty clinics.
Goal 3: Accelerate Progress in STI Research,
Technology, and Innovation
The committee supports the focus on research and innovation and
also seeks greater specificity in defining research priorities. The com-
mittee’s report discusses the need for partner services, including an EPT
expansion and evaluation (e.g., see Chapters 7 and 10 of this report, and
strategy 3.4.1 in the STI-NSP). A comprehensive assessment of gaps and
needs in STI research, technology, and innovation can be found in Chapter
7 of this report and in the TAG report (2019).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PREPARING FOR THE FUTURE OF THE STI RESPONSE 591
Goal 4: Reduce STI-Related Health Disparities and Health Inequities
The STI-NSP reviews individual-level factors (e.g., behaviors, socio-
economic status indicators, and widespread distrust of the health care
system) that impact STI spread. The committee concludes that a deeper
analysis of antecedent causes of individuals’ behaviors is needed and that
institutional, community, and structural contributors to these behaviors
need to be clarified (see Chapters 3 and 9 of this report for more informa-
tion). Also needed is a broader discussion of specific groups or priority
populations in society who have an acute need for enhanced STI preven-
tion, testing, and treatment interventions, including women and men
of color, men who have sex with men (MSM) and other sexual minority
populations, transgender and gender-diverse persons, persons reentering
society from carceral settings, adolescents and young adults, and undocu-
mented immigrants. The STI-NSP plan to integrate STI care into social ser-
vices is a potential game-changer for an implementation plan that could
decrease U.S. STI rates (see Goal 4 of the STI-NSP), as noted throughout
this report. Ideally, the federal implementation plan will address social
determinants of health and co-occurring conditions with specific policies
and linkages to STIs.
Goal 5: Achieve Integrated, Coordinated Efforts
That Address the STI Epidemic
The discussion in the STI-NSP on integration and coordination of
efforts would benefit from a broad discussion of deficits in the overall
health system. The goal will not be met if, for example, the public health
system is not integrated with Medicaid, Medicare, and private insurance.
The emphasis on expanding surveillance to identify antimicrobial
resistance is important. Moreover, the committee notes that the entire
STI surveillance system is too slow, is difficult to interpret because of its
case-based approach, and needs to be improved via modern technology
strategies and data sciences (see Recommendation 12-4 and several
related strategies in the STI-NSP, including 5.2.1 and 5.2.6). In the
committee’s view, strategies for tracking progress that are highlighted
by the STI-NSP need to be expanded by new data sources and both
clinic- and social services–based performance measures. This report
offers recommendations for better aligning public health with the health
care delivery system and strengthening monitoring of STI epidemics,
including through modernizing STI surveillance and placing a greater
emphasis on the potential for implementation science to point toward
more effective control strategies and interventions.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
592 SEXUALLY TRANSMITTED INFECTIONS
Indicators
Introducing concrete indicators and time-limited goals is an impor-
tant aspect of the STI-NSP. Core indicators that address population and
group disparities (e.g., region, race, sexual orientation, and gender iden-
tity) can be a next step. In some cases, the committee would encourage
the STI-NSP implementation plan to set more ambitious goals; the com-
mittee believes that a broader sexual health approach can accelerate rates
of change for the STI-NSP indicators. The committee does not have the
forecasting models to make “best estimates” of what might be feasible for
Core Indicator goals to reduce STI incidence in the STI-NSP. The indica-
tors need to be more aspirational, however, to truly make a public health
difference over the next 5–10 years. More ambitious goals could help to
motivate policy makers and practitioners to improve the STI prevention
and control landscape.
The STI-NSP is an important contribution to government efforts to
turn the tide on rising STI rates and, given the synergies between the
STI-NSP and this report, an important opportunity to implement the
recommendations provided in this report to drastically reduce STIs in the
United States. The committee commends the federal agency staff mem-
bers who conceived, researched, and presented this historic plan.
CHARTING A PATH FORWARD
As discussed throughout this report, to enhance STI prevention and
control, the committee concludes it is necessary to achieve the following:
1. Adopt a Sexual Health Paradigm
2. Broaden Ownership and Accountability for Responding to STIs
3. Bolster Existing Systems and Programs for Responding to STIs
4. Embrace Innovation and Policy Change to Improve Sexual Health
The remainder of this chapter is organized around these four actions,
summarizes the recommendations presented in earlier chapters, and
provides new, crosscutting recommendations to offer a comprehensive
and strategic approach to increasing the effectiveness of the nation’s STI
response.
For the sake of clarity, different types of interventions, including bio-
medical, psychosocial and behavioral, and structural interventions, have
been discussed separately (see Chapters 7, 8, and 9, respectively). The
aim of this chapter is to combine these complementary approaches into
an integrated STI strategy that is most practical in each of its domains.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PREPARING FOR THE FUTURE OF THE STI RESPONSE 593
ADOPT A SEXUAL HEALTH PARADIGM
As concluded in Chapter 1, the nation’s response to STIs since the
beginning of the 20th century has mostly focused on individual risk fac-
tors and individual behavior change, largely neglecting the structural and
social determinants impacting sexual behavior. This approach, because it
has typically blamed the individuals with STIs, has tended to fuel stigma
and shame and therefore has not led to successful STI prevention and
control (see Conclusion 1-2). Furthermore, STI efforts to date have cen-
tered on treating infections and prevention. To successfully address STIs,
a holistic approach that focuses on sexual health in the context broader
health and well-being is needed. To carry out this change, meaningful
efforts will be needed to eradicate stigma and to promote sexual health
awareness (see Conclusion 1-3). See Box 12-1 for a summary of recom-
mended actions to advance a sexual health paradigm.
The committee observes that men remain inadequately engaged in
sexual and reproductive health services (Fine et al., 2017; Kalmuss and
Tatum, 2007; Santa Maria et al., 2018; Vaidya et al., 2012), which creates
a deficit in the ability to achieve population-level control of many STIs.
More generally, women are introduced to the concept of periodic, ongo-
ing, lifelong health care at puberty, which men are not. Attending to men’s
sexual health needs will require more readily available male-centered
BOX 12-1
Adopting a Sexual Health Paradigm:
Recommendations in Brief
Integrating Sexual Health as a Key Dimension of Healthy Living:
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.
• Include new approaches and strategies for specifically engaging men (in-
cluding men who have sex with men) with readily available male-centered
sexual health specialty services, implementing gender-inclusive sexual and
reproductive health services in primary care.
• Include strategies for improving tailored sexual health services for prior-
ity populations, such as women and adolescents and young adults, and
expand attention and resources to underserved populations, including
Black, Latino/a, and Indigenous people, people who use drugs, people
who engage in sex work, and transgender and gender-expansive people.
(Chapter 12).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
594 SEXUALLY TRANSMITTED INFECTIONS
sexual health specialty services and integrating gender-inclusive sexual
and reproductive health services into primary care (Santa Maria et al.,
2018). This finding should not suggest that the committee proposes to pri-
oritize men over women, adolescents, or other important priority popula-
tions. Rather, it seeks to spotlight a glaring shortcoming in a comprehen-
sive and inclusive response to STI prevention and control.
While stigma and inattention to sexual health are widespread, mem-
bers of sexual minorities are disproportionately impacted. For example,
MSM are estimated to make up less than 3 percent of the population but
account for the majority of cases of primary and secondary syphilis and
are disproportionately impacted by gonorrhea (see Chapter 2). Notably,
for persons living with HIV or at risk of HIV and receiving PrEP, current
recommendations include periodic STI screening (Owens et al., 2019;
Workowski and Bolan, 2015). While implementation has been incomplete,
including STI screening in HIV treatment and prevention recommenda-
tions has demonstrably expanded STI screening and management services
for some, mostly men (Montaño et al., 2019). This includes many MSM,
as well as transgender women and men, who are at greatly elevated risk
for many STIs, yet who represent a small subset of the overall population.
Societal discourse on sexuality, sexual health, and sexual rights has
evolved over past decades (see the sexual health section of Chapter 1),
notably leading to fundamental changes in law and policy. Examples
include the legal recognition of same-sex marriage, upheld by the U.S.
Supreme Court in 2015, and the related 2020 Bostock v. Clayton County
decision that the Civil Rights Act of 1964 includes protection for work-
ers regardless of sexual orientation or gender identity, further enforced
through an executive order (Executive Order 13988) signed by President
Biden in January 2021 (U.S. Supreme Court, 2020). The full implications of
this decision on transgender rights and sexual orientation discrimination
likely await policy changes to comport with this precedent and court deci-
sions that will define the scope of protection beyond workplace settings.
Still, these potentially wide-ranging decisions reflect important societal
changes toward recognizing same-sex relationships and the civil rights of
lesbian, gay, bisexual, transgender, and queer (LGBTQ+) persons. These
and other legislative changes did not happen serendipitously, but were
the results of long-standing, grassroots advocacy and hard-fought battles
by diverse activists and LGBTQ+ community members, legal scholars,
health care professionals, and others.
The committee looks to these as instructive examples for how leg-
islation and social change can impact policy and seeks to glean lessons
that can inform ways for society to embrace a fuller conception of sexual
health to strengthen public policy responses to STI prevention and con-
trol. People living with HIV/AIDS have long been an essential part of the
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PREPARING FOR THE FUTURE OF THE STI RESPONSE 595
advocacy coalition for both expanded civil rights protections for LGBTQ+
people and civil rights protections and critical investments in programs
and services for communities heavily affected by HIV. For many, the
acceptance of living with HIV, a life-threatening and highly stigmatized
condition, has been transformative. Lessons learned from HIV/AIDS are
now being applied in such fields as breast cancer and Alzheimer’s disease,
where voices are more demanding than heretofore. Unfortunately, the STI
field lacks such recognition and vigorous advocacy, partly because many
STIs are episodic and most are treatable. Thus, admitting to an STI can be
avoided and STI stigma evaded by not publicly acknowledging a current
or past infection. People do not typically identify as “living with an STI.”
There are several public health organizations in the United States
that advocate for STI treatment and prevention, specifically the American
Sexual Health Association (ASHA), focusing on the general public; NCSD,
focusing on STI public health programs; the American STD Association,
focusing on STI care providers and researchers; and several others, includ-
ing the American Public Health Laboratories, the National Association of
County and City Health Officials, and the American Public Health Asso-
ciation, all of which include a sexual health focus. Some of these have had
a long-standing history of advocacy, especially at the federal level; their
reach has been limited, however, and expansion and new partnerships
could grow their influence with policy makers. Furthermore, while many
of these groups make laudable efforts to engage with and elevate the
voices of people with STIs, such efforts have not yet had the same moral
force or impact on the public as have people living with HIV/AIDS.
Where the power of local-level activism and advocacy is mobilized,
however, results can be impressive, as with the restructuring, improve-
ment, and rebranding of the New York City Sexual Health Clinics (NYC
Health, 2017). In some local U.S. jurisdictions, sexual health alliances are
forming, composed of different medical and nonmedical disciplines from
a variety of service areas, including STI clinics, family planning, ado-
lescent medicine, and state and local health department staff to discuss
issues of mutual interest and develop a common agenda (STI Regional
Response Coalition, 2020). Mutual outreach between these alliances and
national organizations, including ASHA, NCSD, and the American STD
Association, could foster local-level support and higher-level state and
national advocacy. These alliances could develop policy agendas and
engage with elected officials and with organizations that address the
rights and health of marginalized communities to further these agendas to
strengthen flagging STI prevention, treatment, and education programs.
Despite local and noteworthy successes, these generally are not scaled
or duplicated and do not happen in all jurisdictions. More coordinated
national guidance, metrics, and expectations are needed.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
596 SEXUALLY TRANSMITTED INFECTIONS
Conclusion 12-1: Current approaches to address sexual health and to control
the spread of STIs have not met the needs of the nation. This is most notable
in the lack of tailored clinical services to meet the needs of diverse popula-
tions and in the lack of evidence-based practices integrated within existing
delivery systems.
Conclusion 12-2: The clinical focus in current STI control efforts is pri-
marily on the harmful impacts of STIs on women and children, with little
focus on men and their role in transmitting STI infections. There is a need
for public policies in STI control to also address men’s sexual health needs,
which will not only improve men’s sexual health, but may have protective
effects on the health of women and children.
Recommendation 12-1: The Department of Health and Human Ser-
vices (HHS) should develop a vision and blueprint for sexual health
and well-being that can guide the incorporation of a sexual health
paradigm across all HHS programs, including the major public
insurance programs (Medicaid, Medicare, and the Children’s Health
Insurance Program), as well as the public health programs operated
throughout the department, including the Centers for Disease Con-
trol and Prevention, the Health Resources and Services Administra-
tion, the Indian Health Service, and the Substance Abuse and Men-
tal Health Services Administration. The plan should align sexual
health and well-being with other dimensions of health—physical,
mental, and emotional.
• A holistic approach to sexual health programs should include
new approaches and strategies for specifically engaging men
(including men who have sex with men) with readily available
male-centered sexual health specialty services and the imple-
mentation of sexual and reproductive health services in primary
care.
• The plan should include strategies for improving sexual health
services that address the needs of priority populations, such
as women, adolescents, and young adults, and expand atten-
tion and resources to underserved populations including Black,
Latino/a, and Indigenous populations; people who use drugs;
people who engage in sex work; transgender; and gender-
expansive populations.
HHS has an important role in catalyzing the shift the committee rec-
ommends, but it is imperative that other partners and leaders within the
federal government, health systems, and society adopt and implement it.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PREPARING FOR THE FUTURE OF THE STI RESPONSE 597
This includes critical actions by health professional organizations, health
regulators and accreditation bodies, and other entities, such as the Ameri-
can Medical Association, the National Medical Association, the American
College of Physicians, the American College of Obstetricians and Gyne-
cologists, the American Academy of Pediatrics, the American Nurses
Association, the National League for Nursing, the American Academy of
Emergency Medicine, the Society for Adolescent Health and Medicine,
the American Public Health Association, the American Osteopathic Asso-
ciation, the American Academy of Physician Assistants, and other key
professional organizations in such disciplines as pharmacy, laboratory
medicine, and social work. While HHS should provide leadership and
guidance, this vision and action plan needs to include local action and
engagement. In developing this vision, HHS should consult broadly with
agencies within and outside of its department, including tribal, state, and
local governments, and a diversity of other external stakeholders. It will
be essential to develop and effectively communicate what is meant by
sexual health embedded in a broader conceptualization of healthy living.
The vision and action plan should include discussion of actions for
individuals, health care providers, and other stakeholders to promote pos-
itive sexual health over the life span by giving individuals more agency
over their personal preferences and choices, acknowledging the role of
culture in influencing these choices, and highlighting structural inequities
and barriers to optimal health.
To address the gap in sexual health care for men, this action plan also
should examine and make recommendations for essential sexual-health-
related vaccinations and diagnostic and screening services across the life
span for cisgender and transgender men; identify underused intervention
points for delivering sexual health education and health care services
(including schools, athletics, military service, and fraternal organizations);
and identify strategies for engaging men in promoting sexual health that
include STI prevention, screening, and treatment.
Reorienting the popular conception of health to include sexual health
may seem broad and perhaps intangible, but it offers the overarching
framework for all of our subsequent recommendations and establishes
the foundation for steps to better prevent and control STIs.
BROADEN OWNERSHIP AND ACCOUNTABILITY
FOR RESPONDING TO STIs
I think improvements have been made in terms of overall societal stigma,
but in the Black community especially, I think primarily due to religious and
conservative ideals, there hasn’t been as great of a shift. This could be because
the trusted messengers for Black people differ from that of other cultures.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
598 SEXUALLY TRANSMITTED INFECTIONS
Some examples of community leaders at the micro level include managers of
local rec centers and church leaders and, at the macro level, would include
people that are social media influencers, and something that I don’t think is
tapped into enough are leaders in national Black sororities and fraternities.
—Participant, lived experience panel2
The Hidden Epidemic executive summary opens by acknowledging that
STIs in the United States are epidemics of tremendous health and eco-
nomic consequence that are hidden from view because many individuals
are reluctant to openly address sexual health issues due to biological and
social factors associated with these diseases (IOM, 1997). This committee’s
review led it to conclude that STIs remain hidden because ownership,
responsibility, and accountability for preventing and treating STIs is often
unclear and is not broadly enough shared both within the health system
and across society. To successfully reduce the nationwide burden and
impact of STIs, there is a need for greater ownership of issues for which
people and institutions are reluctant to take responsibility or where the
potential power that various stakeholders could exert on better control-
ling STIs may not be readily apparent. The next section offers conclusions
and recommendations for strengthening the existing STI services system,
prevention, and care within the health sector. The committee provides
conclusions and recommendations here for increasing engagement for
preventing and controlling STIs across society by spotlighting parents
and guardians and a range of other community stakeholders. See Box
12-2 for a summary of recommended actions to broaden ownership and
accountability.
Better Support for Parents and Guardians to Model Sexual Health
Although maturing children learn information about sexual health in
many ways, (including social media), parents and guardians (hereafter
referred to as “parents,” but the term is inclusive of nonbiological pri-
mary caregivers or relatives who function in a parenting role) have criti-
cal roles in showing young people how to develop into sexually healthy
adults, minimize exposure to STIs, and responsibly seek prevention and
health care services (Guilamo-Ramos et al., 2019a; McKay and Fontenot,
2020; Widman et al., 2019). Yet, parents often lack knowledge and skills
2 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.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PREPARING FOR THE FUTURE OF THE STI RESPONSE 599
BOX 12-2
Broadening Ownership and Accountability for
Responding to STIs: Recommendations in Brief
Better Support for Parents and Guardians to Model Sexual Health:
Equip parents and guardians with evidence-based guidance to engage in de-
velopmentally appropriate, comprehensive sexual health education and dialogue
with their children:
• Develop a new national, parent-focused communication campaign.
• Commission a compendium of existing evidence-based resources and pro-
grams, and continue research investments to improve existing and develop
new ones.
• Develop guidelines for pediatric and adolescent health care to support skills
training and educate parents in promoting adolescent and young adult
sexual health, including STI prevention. (Chapters 8 and 12)
Engage Community Stakeholders to Create
Opportunities for Dialogue About Sexual Health:
Encourage public dialogue in various community settings (such as with fami-
lies, 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. (Chapter 12)
themselves, as well as the tools to fulfill their roles successfully (Ashcraft
and Murray, 2017; Johnson-Motoyama et al., 2016). See Box 12-3 for rel-
evant quotes from parents, and about parenting, from the committee’s
September 2020 meeting. The committee recognizes that not all young
people can rely on supportive parents to offer this guidance, and sup-
porting parents in general does not negate the need to create additional
sources to complement or substitute for supportive parents.
In 2011, Dr. Amy Schalet published Not Under My Roof, a compara-
tive study of attitudes on teen sexuality among parents and their teenage
children in the United States and the Netherlands (Schalet, 2011). One of
her key findings was that in the Netherlands, sex among teens appeared
to be more “normalized,” with parents allowing sleepovers with a child’s
boyfriend or girlfriend under certain circumstances. By contrast, their
American counterparts tended to “dramatize” teen sexuality and were
less inclined to conceive of such circumstances: “Not under my roof”
(Schalet, 2011).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
600 SEXUALLY TRANSMITTED INFECTIONS
BOX 12-3
Opportunities for Parents and Guardians:
Excerpts from Lived Experience Panels
“When I was informed that my daughter was going to have her sex education class,
the school asked for permission from the parents. I think that would have been
a good opportunity to not just say, ‘Hey! Our curriculum this year includes Sex
Ed’ but also, ‘Do you want to learn how to talk to your child about this?’ Schools
could offer a forum, or seminar, or counselors. They could help prepare parents
for questions their child might ask.”
“I have a 17-year old, a 16-year old, and an 11-year old, so I have to talk to each
one a little bit differently, especially since one is a boy and two are girls. I have to
make sure that I choose my words correctly, which sometimes is not easy. The
more information you can give us so we can help them, the better. We need to
be able to give our teenagers the right information according to their age as well
as their risk.”
“Parents need to be more engaged and more comfortable with the idea of talking
with their children and their teenagers about sexual behavior. Usually teenagers
turn to their friends, who may not know any more than they do. But if parents ac-
cept sexual behavior as part of their nature, then maybe the teenagers will have
someone to talk to who has more experience, more knowledge, more information.”
“As a parent of three teenagers, it is not easy talking to them, but we have to. We
can’t take a hands-off approach because, unfortunately, they will make mistakes.
As a parent, we need to help them not make mistakes that could hurt them for the
rest of their lives if they are not careful. My parents never felt comfortable talking
about sex, so I have trouble talking about it too. But it has to be done.”
“We invite parents to attend our Healthy Love Parties as well. Parents often don’t
feel comfortable talking about their bodies and sex at all. Their parents didn’t talk
to them and they cannot have these conversations with their children.”
During the past decade, sexuality norms, including sexual behav-
iors among adolescents, has been an important theme in the literature
on sexual health in the United States (Espinosa-Hernández et al., 2020;
Ksinan Jiskrova and Vazsonyi, 2019). An open and ongoing discussion
of sex and sexuality between parents and their adolescent children has
been recognized as an important component in this discourse (Guilamo-
Ramos et al., 2016; Widman et al., 2016b). The roles of culture and ethnic-
ity, religion, geography and rurality, family and social tradition, and peer
influences all affect the dynamics around normalization, suppression,
or neglect of issues around sexual activity by youth (Coyne et al., 2019;
Widman et al., 2016a).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PREPARING FOR THE FUTURE OF THE STI RESPONSE 601
Parents want their children to grow into mature and healthy adults.
Parents and communities strive to protect children and keep them safe
as they experiment and learn from their successes and failures growing
up (Foster et al., 2017; NASEM, 2019b; Sieving et al., 2017). Navigating
complex social interactions necessarily involves trial and error (NASEM,
2019b). Just as children do not inherently possess the skills to maturely
interact with adults, and just as young people with no experience with
alcohol do not understand how to set limits and safely consume alcohol,
intimate relationships involve experimenting with new behaviors, which
may lead to unanticipated consequences and learning from mistakes
(NASEM, 2019b). For example, individuals with high levels of romantic
and sexual satisfaction in intimate relationships are often those with sig-
nificant experience (Allen et al., 2020; Higgins et al., 2011).
Considerable evidence demonstrates the role of parents in shaping
outcomes relevant to adolescent STI prevention, including delayed sexual
debut, reduced frequency of sex, correct and consistent condom use, and
enhanced use of sexual and reproductive health (SRH) services (Dittus et
al., 2015; Guilamo-Ramos et al., 2019a; Henderson et al., 2020; Prado et
al., 2012, 2019; Rojas et al., 2019; Widman et al., 2019). Less attention has
been placed, however, on how parental influences directly rather than
indirectly reduce STI incidence and morbidity.
Research has advanced the understanding of how to leverage par-
ents to shape SRH decision making and behavior, including by engaging
parents in adolescent health care settings (Guilamo-Ramos et al., 2020;
Henderson et al., 2020). Confidentiality concerns are frequently cited as a
primary barrier to STI testing among adolescents (Leichliter et al., 2017).
Both parents and adolescents indicate that testing is acceptable as part of
adolescent primary care (Cordova et al., 2018; Lane et al., 2020), but health
care providers are less likely to take a sexual history or offer an STI test
to an adolescent patient if parents are in the room during the entire visit
(O’Sullivan et al., 2010), despite this parental acceptance. In fact, parental
influences have been shown to promote such testing, as parent–adolescent
communication about sex is associated with increased uptake of STI and
HIV testing among adolescents (McKay and Fontenot, 2020).
In addition, parents’ role in adolescent uptake of the HPV vaccine has
been extensively explored in recent years. Important parent-level factors,
such as acceptance of vaccination costs, safety, and effectiveness, are asso-
ciated with adolescent receipt of the HPV vaccine (Lack et al., 2020). The
important role of provider–parent communication in achieving greater
adolescent HPV vaccine coverage is particularly noteworthy, given that
such communication is ongoing, is persistent, and addresses parental
barriers associated with same-day HPV vaccination among adolescents
(Clark et al., 2018; Shay et al., 2018). Among parents who decline HPV
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
602 SEXUALLY TRANSMITTED INFECTIONS
vaccination at the initial visit, satisfaction with provider communication
and increased HPV vaccine knowledge are associated with acceptance at a
future visit (Kornides et al., 2018). Parents represent an important partner
in the uptake of STI testing and prevention measures.
Parents have the primary responsibility for teaching an adolescent
how to build and sustain healthy relationships and establish a moral and
ethical framework (Bornstein and Putnick, 2018; NASEM, 2019b). This
process includes not only education, through discussions and reading
materials, but also methods designed to help facilitate healthy behavior,
such as modeling (social norms), creating action plans (removing bar-
riers), and rewarding healthy behavior (building intrinsic and extrinsic
motivation). An essential component is modeling kind and loving rela-
tionships and teaching communication, negotiation and conflict resolution
skills, and forgiveness (Jamison and Lo, 2020; Sommantico et al., 2019).
Too frequently, parents do not have the tools to articulate what sexual
health means for themselves and thus cannot communicate or model it
for their children (Ashcraft and Murray, 2017; Johnson-Motoyama et al.,
2016). Thus, a default approach may be to ignore sexuality and offer no
guidance or to impose a rigid prohibition on sex and intimacy that can
fail to produce the desired result and closes off a critical avenue of com-
munication (Ashcraft and Murray, 2017).
Adolescents want to be able to turn to their parents for support and
guidance as they seek to explore new kinds of intimate relationships
(Pariera and Brody, 2018; Power to Decide, 2016), so a greater focus is
needed on giving parents a broader perspective and skills to provide
the necessary education and skills that their adolescent will need for
healthy sexual health development. Thus, parents must be equipped with
evidence-based educational resources, tools, and programs, such as Fami-
lies Talking Together (Guilamo-Ramos et al., 2020) and Familias Unidas
(Estrada et al., 2017; Prado et al., 2012) that are developmentally appropri-
ate for their children (Guilamo-Ramos et al., 2019a; Johnson-Motoyama
et al., 2016). An effective method to increase parental communication
self-efficacy is national social marketing and media campaigns geared
to improving parent–adolescent communication about sex (Davis et al.,
2012). By promoting social norms regarding the appropriate age for sexual
debut, expectations regarding parent–adolescent communication about
sex, and guidance and tools on when and how to talk with their children,
social marketing campaigns have evidence of efficacy in increasing the
frequency of such communication (Davis et al., 2012).
Conclusion 12-3: Parents and guardians (parents) play a central role in
supporting adolescent and young adult sexual and reproductive health and
STI prevention. To fully leverage their role, parents need to have access to
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PREPARING FOR THE FUTURE OF THE STI RESPONSE 603
evidence-based guidance regarding effective parenting strategies for sexual
health promotion and STI prevention. Diverse channels and mechanisms to
provide education and communication skills training are needed to maximize
reach and impact.
Recommendation 12-2: Federal agencies and relevant professional
organizations should equip parents with evidence-based guid-
ance to engage in developmentally appropriate, comprehensive
sexual health education and dialogue and to identify actionable
steps for their children. Specifically, the committee recommends
the following:
• The Department of Health and Human Services (HHS), through
the Centers for Disease Control and Prevention (CDC) Division
of STD Prevention, the CDC Division of Adolescent Health and
School Health, the Indian Health Service, and other key pub-
lic health service agencies, should develop a national, parent-
focused communication campaign to promote and guide paren-
tal communication with adolescents regarding sexual health
and sexually transmitted infection (STI) prevention.
• HHS, including CDC, the Health Resources and Services
Administration, and the National Institutes of Health, should
develop a compendium of existing evidence-based resources
and programs for parental education and skills training on ado-
lescent and young adult sexual health and STI prevention. In
addition, there should be continued research investments to
improve existing, and to develop new, evidence-based resources
and programs.
• Guidelines should be developed for pediatric and adolescent
health care to support skills training and educate parents in
promoting adolescent and young adult sexual health, including
the prevention of STIs. This would include the following:
o Delivering evidence-based programs for parental educa-
tion and skills training that are colocated as an extension
of regular care, and
o Providing training resources for providers that facilitate
direct communication with parents regarding sexual health
and STI prevention in their children.
Important constituencies that could collaborate in developing and
implementing these practice guidelines include the American Academy of
Pediatrics, the Society for Adolescent Health and Medicine, the American
College of Obstetricians and Gynecologists, the American Nurses Associa-
tion, and the American Counseling Association.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
604 SEXUALLY TRANSMITTED INFECTIONS
For a national, parent-focused communication campaign, the initia-
tive should draw on campaign development best practices, including
digital toolkits to support state and local health departments and public
health workers in community-engaged tailoring and dissemination, par-
ticularly in areas with high prevalence of STIs among adolescents.
Engaging Community Stakeholders to Create
Opportunities for Dialogue About Sexual Health
Education about sexual health needs to be delivered where
the target audience is and in a form that they understand, whether
that be social media, messaging in their living spaces, recreation, et cetera.
I also think it needs to be available for all to see, so no one is singled out
for looking at it; no one has to go off to any particular place away from the
group to look at it. It needs to be normalized instead of set off to the side.
—Participant, lived experience panel
Sex and sexuality can influence daily interactions with others. Society
needs new ways to engage the public in dialogues about healthy living.
Various settings where individuals gather occupationally and socially can
be important settings for normalizing dialogues about sexual health in a
general sense. Of course, such environments are not necessarily appro-
priate venues to discuss and act on very personal goals for intimacy.
Rather, as has been discussed, society suffers from inadequate attention
to what it means to be sexually healthy. Because these settings are a step
removed from an individual’s pursuit of their own goals, they may offer
an environment where individuals can learn principles and ideas for
linking familiar elements of empathy and respect to less familiar themes,
such as communications about sex or seeking pleasure with sex. While
not an exhaustive list, the following sectors of our communities should
be enlisted to play their part in promoting sexual health.
Families
As discussed earlier, families, primarily parents, often represent an
important influence in adolescent sexual decision making. Family mem-
bers have both individual and collective roles to play in offering support
for adolescent sexual health and STI reduction (Grossman et al., 2015).
The extant literature has primarily sought to understand the role of mater-
nal influence—including monitoring and supervision, communication,
and relationship satisfaction—in shaping developmentally appropriate
outcomes important for STI reduction, including delay of sexual initia-
tion for younger adolescents and consistent and correct condom use for
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PREPARING FOR THE FUTURE OF THE STI RESPONSE 605
older adolescents (Guilamo-Ramos et al., 2012, 2019a, 2020; Widman et
al., 2019). Increasing attention focuses on the role of fathers in adolescent
SRH. Emerging evidence indicates that fathers have independent effects
on adolescent sexual decision making (Guilamo-Ramos et al., 2012, 2018,
2019b; Santa Maria et al., 2015). Not only do fathers and their sons endorse
condom-specific, paternal monitoring and supervision, communication,
and role modeling, they each indicate interest in father-based programs
and fathers’ involvement beyond the traditional role of disciplinarian
(Guilamo-Ramos et al., 2012, 2018, 2019b). Limited attention has been
placed on the role of nonparental units in shaping adolescent sexual risk
exposure (Guilamo-Ramos et al., 2019b; Santa Maria et al., 2015). In addi-
tion, a family focus can have multigenerational influence on STI reduction
across the life span. For example, father–son interventions that seek to
build capacity in fathers to shape correct and consistent condom use can
impact their condom knowledge, skills, and use (Guilamo-Ramos et al.,
2018, 2019b).
Family-based engagement around STI prevention also includes queer
kinship or families of choice. Families of choice most relevant to STI pre-
vention include the house/ballroom community and other gay family
structures. House culture (or ballroom culture) is typically a community
of Black and Latino/a sexual and gender minorities (Arnold and Bailey,
2009; Bailey, 2009) that is often organized around two interdependent
features: (1) the anchoring family-like structures (i.e., fathers, mothers
siblings, kids), called “houses,” and (2) the competitive performances
of gender and sexuality, dance, and fashion that houses participate in
(Arnold and Bailey, 2009). Independent gay families provide the same
kind of familial support and relational structure as ballroom houses, but
without the added pressures of competition (Dickson-Gomez et al., 2014;
Horne et al., 2015). The structure of the community both nationally and
in local jurisdictions is well organized and already has been engaged
around HIV prevention (Young et al., 2017). Engagement in STI educa-
tion and prevention could thus be facilitated through parental structures
that organically exist in the house/ballroom and gay family communities.
Schools and Educators
Because of my adverse child experiences, it would have been really helpful
if I had been screened in school when I was young. Even a school counselor just
doing a basic screening on me or maybe a school program could have flagged me
and maybe got me in front of someone when I was younger. I don’t remember
ever really being evaluated by a school counselor, ever being evaluated by a school
nurse, anybody ever having a discussion with me about what my behaviors were.
—Participant, lived experience panel
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
606 SEXUALLY TRANSMITTED INFECTIONS
As children, adolescents, and young adults spend time within educa-
tional environments with important implications for the maturing brain
(Lamblin et al., 2017; Morris et al., 2018), the parent–teacher nexus is
a critical component in the evolving sexual health discourse as well.
Whereas the parental role is especially important in conveying values
and expectations (Guilamo-Ramos et al., 2019a), educators are needed to
validate or offer objective and accurate information (Denford et al., 2017).
This includes not only teaching about sexuality and health, with compo-
nents that include STI awareness and prevention and when and where to
seek screening and treatment, but also integrating such information into
broader lessons about healthy living and maintaining healthy relation-
ships (CDC, 2019c). Adolescents who participate in comprehensive sexual
health education programs in school settings are more likely to delay
initiation of sexual behavior, have increased knowledge of STI risks and
consequences, and report enhanced contraceptive use (Chin et al., 2012;
Denford et al., 2017; Kirby, 2007; Lopez et al., 2016; Santelli et al., 2017;
Underhill et al., 2007).
Despite the important role of parents in shaping adolescent and young
adult sexual decision making (Power to Decide, 2016), school-based pro-
grams primarily deliver sexual health education in the classroom setting
directly to adolescents, often neglecting to include parents for any rea-
son beyond obtaining consent for student participation (Denford et al.,
2017). Comprehensive sexual health education programs in school-based
settings, such as Families Talking Together, that include parent–adoles-
cent sessions and homework assignments have been efficacious in shap-
ing multiple adolescent outcomes, including delay of sexual initiation
(Guilamo-Ramos et al., 2011). In addition, health care providers in school-
based health clinics represent important partners for enhancing existing
sexual education programs. For example, nurse-led interventions have
been associated with increased uptake of STI testing and contraception in
school-based health centers (Brigham et al., 2020; Ethier et al., 2011). More-
over, evidence suggests that both school- and parent-based approaches
have the added benefit of addressing STI-related misinformation from
peers and social media sources (Cameron et al., 2020; Guyer et al., 2015).
Universal access to comprehensive, age-appropriate, evidence-based,
and medically accurate sexual health education is needed, as are greater
opportunities outside of school settings for young people to receive this
information (Chin et al., 2012; Denford et al., 2017; Santelli et al., 2017).
One idea could be shifting focus toward giving young people life skills
that includes teaching them what it means to be sexually healthy (Aggle-
ton and Campbell, 2000; Lee and Lee, 2019). (See Chapter 8 for more
information on sexual health education in school settings.)
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PREPARING FOR THE FUTURE OF THE STI RESPONSE 607
In the public domain, ASHA has played an important role in promot-
ing normalization of the sexual health discourse in the United States. It
has articulated six evidence-based components of what it means to be
sexually healthy (ASHA, 2020; Phillips, 2019), to assist educators, as well
as parents, in the development of age-appropriate curricula:
• Understanding that sexuality is a natural part of life and involves
more than sexual behavior;
• Recognizing and respecting the sexual rights shared by all;
• Having access to sexual health information, education, and care;
• Making an effort to prevent unintended pregnancies and STIs and
seek care and treatment when needed;
• Being able to experience sexual pleasure, satisfaction, and inti-
macy when desired and appropriate; and
• Being able to communicate about sexual health with others,
including sexual partners and health care providers.
Faith Communities
My church had been my foundation from a very young age. But when I
started getting in trouble and started drinking and doing drugs, I thought,
“Oh, I can’t turn to God anymore,” and that was a huge detriment for me
because it was my safe place for such a long time. I think that the church has
a lot of work to do on that message. They play a big role in the message that
they give out to people on their lifestyles, that if you are not doing all the right
things then you are rejected.
—Participant, lived experience panel
Promoting sexual health as a key dimension of human health and
well-being does not have to be in conflict with religious beliefs. As the
institutions and leaders that are often the most respected and trusted
voices within a community (Nunn et al., 2019; Ransome et al., 2018;
Vigliotti et al., 2020), faith-based organizations and clergy have an oppor-
tunity to be transformative in legitimizing attention to and consideration
of sexual health as an important component of health. Within a broad
spectrum of views, ranging from complete rejection of sex outside of
male–female marriage to the acceptance of the widest range of sexual
expression, faith communities have a critical role in translating their val-
ues and beliefs in ways that foster agency and individual decision making
to promote sexual health. The existence of nearly 350,000 congregations
in the United States illustrates their potential in contributing to improved
sexual health as part of caring for their members (NASEM, 2019a).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
608 SEXUALLY TRANSMITTED INFECTIONS
Although people often turn to faith communities to address spiritual
health, health involves more aspects of a person’s life, reflected in the
World Health Organization’s (WHO’s) definition: a “state of complete
physical, mental and social well-being.” Moreover, many churches and
houses of worship have historically led the way (and continue to do so)
in promoting health through ministries that foster healthier behaviors and
address specific conditions, such as diabetes, smoking cessation, and HIV
(DeHaven et al., 2004; Maynard, 2017; NASEM, 2017; Ochillo et al., 2017;
Schoenberg et al., 2015).
Early in the HIV crisis, organizations such as The Balm in Gilead
(The Balm in Gilead, 2020) were established that served to create entry
points and resources for Black faith communities to address HIV. The
organization has since broadened its focus to cover a range of other
health issues impacting persons of African descent. Similarly, the National
Black Leadership Commission on Health (NBLCH, 2020) (originally, the
National Black Leadership Commission on AIDS) has historically worked
to engage faith communities in responding to HIV and broadened its
work to cover other health issues that affect Black people in the United
States (Ransome et al., 2018).
At a time when the United States is divided in many respects, it is
reassuring to look at the nation’s great legacy of religious freedom and
respect for religious difference. The committee holds an inclusive vision of
respect and appreciation for diversity in religious belief, culture, gender,
and sexual orientation. The committee also asserts that promoting sexual
health in a manner that facilitates STI prevention, diagnosis, and treat-
ment does not constrain faith communities from teaching about sexual
responsibility and sexual health in a way that is consistent with their
own faith traditions and ethical frameworks. For example, some faith
communities often instruct their members to be chaste and abstinent not
only as an extension of faith, but also out of an impulse to be protective
and promote health. Ideally, research-based insights could be integrated
with such traditions or ethical frameworks. Research has shown that
fear- and shame-based teachings are among the least effective and may
preclude the openness needed for honest dialogue (Earl and Albarracín,
2007; Hutchinson and Dhairyawan, 2018; Morris et al., 2014). For chil-
dren or adults, comprehensive, strengths-based approaches that seek to
bolster self-esteem and teach people to make decisions about their own
sexual health goals and how to act on them in real life are more likely to
lead to delayed sexual initiation in young people and healthy outcomes
(including STI prevention and more prompt screening and treatment) in
all people (Downs et al., 2018; Mahat et al., 2016; Scull et al., 2018).
Consistent with this discourse, emerging research indicates that sex-
ual health can be addressed in communities of faith and that theoretical
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PREPARING FOR THE FUTURE OF THE STI RESPONSE 609
models (Wingood and DiClemente, 2008) can be used to adapt evidence-
based sexual education and HIV prevention programs to such settings
rather than developing faith-based interventions (Weeks et al., 2016). In a
study from Baltimore, involving in-depth interviews and multiple focus
groups of pastors, ministers, parents, and youth from nine participating
Black churches, researchers found that certain youth felt that churches
were the preferred place for sexual health education. Facilitators in the
adaptation process included the positive influence of youth ministers
and life lessons as teaching tools. Barriers were also identified, including
perceived resistance from congregants, youth discomfort, lack of finan-
cial resources, and competing messages at home about sexual health
(Powell et al., 2017). Wingood et al. (2011) found that an evidence-based
HIV prevention intervention focused on young African American women
could be successfully adapted to the church setting with high levels of
fidelity to the original intervention, and with high attendance in this
two-session program. (See Chapter 8 for more information on faith-based
interventions.)
Community-Based Organizations with Roots in Activism and Advocacy
Rejection, labeling, and loss of self-esteem are really predominant
in rural areas…. I was a sex worker, putting myself at risk because I didn’t
care if I lived or died, because the place that I grew up in told me I was
bad and I was disgusting. When you have been given that message all your
life it does chip away at your psyche and your ability to live. What helped me
was knowing that there was at least a group that didn’t treat me like my family
did and my church did. Just to have that safety net of somebody, a group,
or an organization or something to say you are not bad, you’re not wrong.
—Participant, lived experience panel
Trust is an essential component of health promotion. Culture and
group identities shape how health is viewed and understood. Individuals
and groups carry with them unique histories that shape how information
is received and who is trusted to convey information. People who were
raised in households with consistent access to affordable health coverage
seek care in ways that are very different than persons who have never had
such access, and these differences often remain even if access is equalized.
African Americans and others remember the 1932–1972 U.S. Public Health
Service Syphilis Study at the Tuskegee Institute (White, 2000), on the natu-
ral history of syphilis in Black men; it was conducted without informed
consent, and diagnosed individuals were not offered treatment or told
that they could disenroll from the study and seek treatment outside of it.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
610 SEXUALLY TRANSMITTED INFECTIONS
This is only one of many examples of racist disregard for the best interests
of a group of people denied agency in optimizing their health.
The background and attributes of the individual or entity that initi-
ates a dialogue about health is important, and just as no person fits neatly
into a single group identity, it is the diversity of environments where
people lead their lives that offer opportunities for differing and nuanced
dialogues about healthy living, including sexual health, that can contrib-
ute to a healthier population. Intersectionality (see Chapters 1 and 2) is
an important concept in this care engagement and in how community
members position themselves and find comfort and acceptance in their
lived experiences. An intersectional lens needs to be applied to the client–
provider relationship, with important recognition of how shared decision
making and subsequent positive health outcomes depend on multiple
identities (Peek et al., 2009).
Community-based organizations have critical roles in promoting
trust, advocating for service needs, holding health care providers and
systems accountable, and delivering essential health care and/or sup-
portive services. As explored in Chapter 8, social network interventions
and community-level interventions can contribute to an improved STI
response. Assessing effective advocacy, tools that assist in building com-
munity capacity for delivering interventions, and community mobiliza-
tion models addressing related issues can offer new insights for bolstering
the role of community partners in strengthening responses to STIs.
Starting in the 1980s and 1990s, women of color across the nation,
often led by Black women but including Indigenous, Latina, and other
women of color, established a framework and organized around the prin-
ciples of reproductive justice (Silliman et al., 2004). This was in part a reac-
tion to racism experienced by marginalized populations within feminist
movements led by white women and the belief that a narrow focus on
abortion rights neglected broader considerations facing women of color
(Silliman et al., 2004). Thus, central tenets of the early reproductive justice
movement were focused on the right to have a child, the right to not have
a child, and the right to parent the child(ren) one has (Ross, 2017). The
first national conference on Black women’s health issues was held at Spel-
man College in Atlanta in 1983 and has catalyzed sustained organizing,
with diffuse actors across the country establishing organizations, leading
community dialogues, engaging in the policy-making process, and broad-
ening the numbers and the types of people who are engaged in policy
conversations about reproductive rights and justice (Silliman et al., 2004).
Additionally, in the early 1970s, community activism raised aware-
ness about health disparities in the LGBTQ+ community, particularly
rising levels of STIs, which led to health centers with the specific purpose
of serving the gay and lesbian community. For example, the Whitman
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PREPARING FOR THE FUTURE OF THE STI RESPONSE 611
Walker clinic, now one of the largest providers of HIV care in Washing-
ton, DC, started as the Gay Men’s VD Clinic in 1973. Likewise, Howard
Brown Health was founded in 1974 by gay medical students in response
to rising rates of STIs, particularly hepatitis B, among gay men in Chi-
cago, and Fenway Health in Boston had a similar genesis in 1971. When
the first cases of AIDS were reported in 1981, these health centers quickly
mobilized to provide health care and other services and have since grown
into nationally and internationally renowned clinical care and research
institutions. Many of them have led the field with developing innova-
tive client-centered strategies that include extragenital sample collection,
self-sampling, rapid test result notification (Cohen et al., 2017), and self-
service, kiosk-based STI testing with Healthvana texts and results.3
Since the early 1980s, community-based organizations have been criti-
cal to the civic response to HIV/AIDS. Often initiated and supported by
leaders in the LGBTQ+ community, AIDS service organizations emerged
nationwide to assist with daily needs, including shelter, food, and psy-
chological support. These organizations became involved with advocacy,
education, and prevention, resulting in a strong force in the fight against
HIV/AIDS stigma. The importance of these and other community-based
organizations in the spectrum of HIV/AIDS-related services is reflected in
their receipt of separate federal funding through Part C of the Ryan White
Care Act to support ambulatory health services since 1990.
Over time, with the emergence of highly effective antiretroviral ther-
apy to treat HIV and later PrEP to prevent it, these organizations became
increasingly important in delivering health and prevention services, and
many opened dedicated clinics to serve their clients. With rising rates of
STI rates among persons living with HIV and those taking PrEP, these
clinics have become important venues to offer STI services.
The Open Arms Clinic in Jackson, Mississippi, is a good example
of this evolution.4 Its founding organization, My Brother’s Keeper, had
been in existence as a 501(c)(3) community-based organization, provid-
ing services to persons living with HIV in the Jackson area since 1999.5
In 2013, the organization expanded HIV testing services to include STI
screening, blood pressure and body mass index measurements, glucose,
and cholesterol testing to create a more holistic health focus and reduce
stigma around HIV and STI testing. In collaboration with the Division
of Infectious Diseases at the University of Mississippi Medical Center,
3 See, for example, Howard Brown Health (https://howardbrown.org/press/healthvana
[accessed October 30, 2020]) and Fenway Health (https://fenwayhealth.org/care/medical/
std-testing-services [accessed October 30, 2020]).
4 See https://oahcc.org (accessed January 26, 2021).
5 See https://mbkinc.org/about-us (accessed January 26, 2021).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
612 SEXUALLY TRANSMITTED INFECTIONS
which provided clinicians, and the Mississippi State Department of
Health, which provided resources for HIV and STI testing to create the
infrastructure and administrative leadership, the HIV testing and adjacent
food pantry was transformed into the Open Arms Clinic in 2013. It has
moved to a new standalone location that includes multiple exam rooms,
an onsite laboratory and pharmacy, and research space.
In addition to influencing policies and politics, community activists
and leaders have thus spawned health models for HIV prevention and
care that have reduced stigma and enhanced access to the most vulner-
able populations (Valdiserri and Holtgrave, 2019). Given the increases
of STIs in these populations, these health care settings are increasingly
testing for STIs, and their staff now includes STI clinical experts. Devel-
oping integrative models of HIV and STI care and prevention, embedded
in community-based environments that increasingly embrace a general
wellness approach, needs to be encouraged and supported; these models
need support, however, to expand efforts to address STIs (see Chapter 8
for more information).
Workplaces
Workplaces offer an important opportunity to advance sexual health
and STI prevention and control. They can give employees an under-
standing of what it means to be sexually healthy and of where, when,
and how to access STI services. Workplaces also have a role in reducing
stigma around STIs by normalizing these services as part of overall health.
Businesses are uniquely situated because of their contacts with employ-
ees, communities, and the wider business community and their wealth
of experience and skills (NASEM, 2016a). Businesses have a history of
promoting health and health education for their employees, including
policies and programs that ensure employee rights, such as access to
health care and counseling (NASEM, 2016a). Furthermore, businesses
have carried out programs aimed at improving health of their customers
and the broader community and also acknowledged that factors beyond
health care—the social determinants of health—are important to focus
on, including by strengthening individual connections to the community
(NASEM, 2016a, 2017, 2020b). Several businesses and organizations have
addressed employee health, including the U.S. Chamber of Commerce
and the National Business Group on Health, and shifted away from focus-
ing on workplace wellness and health care to consider businesses’ broader
role in addressing the social determinants of health and health inequities
(NASEM, 2017). In 2015, the Vitality Institute (a South African health
promotion research institution) published a report for business leaders
to provide support for their interest in engaging with communities to
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PREPARING FOR THE FUTURE OF THE STI RESPONSE 613
improve health beyond company walls (Oziransky et al., 2015). Corpora-
tions also have collaborated to address other social issues, as evidenced
by the Corporate Alliance to End Partner Violence and workplace pro-
grams (often through Employee Assistance Programs) on topics such as
parenting, caregiving, work/life balance, and addiction (GuideStar, n.d.;
NIH, n.d.).
One example from the HIV field is Business and Labor Responds to
AIDS, a PPP initiative of CDC established in 1992 as a resource to busi-
nesses to operate workplace programs to reduce HIV stigma and prevent
discrimination against employees living with HIV (CDC, 2019e). It is both
an educational platform and communication vehicle and focuses on the
following:
• Prevention and Education—Provides resources and tools to
implement HIV awareness, prevention, and testing efforts in the
workplace.
• Policies—Implements peer-based technical assistance on human
resources policies that address stigma and discrimination, the
rights of people living with HIV, and inclusion of HIV-specific
insurance coverage in the workplace.
• Treatment and Support Services—Provides information and facil-
itates linkage to treatment and support services.
• Philanthropy and Volunteerism—Facilitates opportunities and
examples of how businesses can support national and commu-
nity-based HIV organizations (CDC, 2019a).
Potential benefits for participating businesses include increased produc-
tivity, access to accurate, timely, and relevant HIV information, resources
and peer-based technical assistance, and linkages to a network of busi-
nesses and stakeholders (CDC, 2019a). This example shows how work-
places can focus both on employee wellness and the broader community.
Chapter 8 discusses the role of businesses at the community level and
outlines the promising role of barbershops to disseminate information
about sexual health, wellness, and STI prevention (Brawner et al., 2013).
It also explains how interventions that address social norms, such as fear
and stigma associated with STIs, are likely to be effective in reducing STI
risk (Adimora and Auerbach, 2010; Myer et al., 2001). Workplaces could
adapt and adopt these interventions. Although the committee could not
identify and recommend specific non-HIV STI or sexual health programs,
it believes workplaces, where so much time is spent, provide an important
opportunity for communication, education, and a platform to advance
sexual health.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
614 SEXUALLY TRANSMITTED INFECTIONS
Celebrities and Prominent Individuals
Celebrities and other prominent individuals also can contribute to
expanding knowledge and agency over sexual health. The explosion of
social media platforms, continuous 24-hour cable news cycles, and popu-
lar culture that permeates U.S. society suggests the benefits of celebrity
advocates for neglected and/or stigmatized diseases. STIs have not had
the benefit of such popular advocates.
Previous reports (e.g., NAPA, 2018) have highlighted a need for popu-
lar advocates for STI research and funding. Respected celebrities and
community leaders can assist with reducing stigma and promulgating
prevention messages. In the committee’s information-gathering sessions,
multiple speakers identified how celebrity advocates could help with STI
prevention and control, creating a culture of sexual health to obtain better
policy support and funding, and addressing stigma (Barclay, 2019; Sofaer,
2018). NAPA authors urged the designation of “a national STD champion
to coordinate federal, state, and local efforts and to lead the development
and implementation of a national strategy” (NAPA, 2018, p. vii). As was
done with the Ryan White HIV/AIDS Program, the authors note the
need to put a face to the STI epidemic, perhaps with a national champion
who could personalize its impact on the health of pregnant people and
children and focus efforts on preventing infant deaths (NAPA, 2018).
Individuals who became well-known advocates for people living with
HIV/AIDS include Magic Johnson, Elizabeth Taylor, Mary Fisher, and Dr.
Mathilde Krim. Johnson and Taylor brought messages of hope and empa-
thy to millions of U.S. individuals who might not otherwise have appre-
ciated the importance of addressing the crisis. Fisher was instrumental
in reaching across the political divide to frame HIV as a medical and
humanitarian issue of concern to persons of any and all political persua-
sions. Krim helped mobilize private-sector resources for HIV research and
raise consciousness in Hollywood about the dramatic potential inherent
in the crisis. Other STIs also have received increased attention from the
media and general public due to disclosure from celebrities and portrayal
in pop culture. Michael Douglas’s disclosure of his throat cancer created
significantly increased media attention for oral cancer and HPV (The
Oral Cancer Foundation, n.d.; Throat Cancer Foundation, 2013). HBO’s
critically acclaimed television show “Insecure” raised the issue of sexual
health when one of its main characters was revealed to have chlamydia
(Villarreal, 2018) after the show was previously criticized for not depict-
ing safe sex practices, including condom use (Byrd, 2018; Mitchell, 2018;
Moss, 2018). The importance of sexual education for teenagers is also the
focus of the popular British television series “Sex Education” on Netflix
(Nightingale, 2019).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PREPARING FOR THE FUTURE OF THE STI RESPONSE 615
The authors of the first NAPA report, however, suggest that rather
than an individual from the entertainment or sports industries, the STI
national champion could be a senior individual from the Office of the
Assistant Secretary for Health or elsewhere in HHS who would have “the
standing and clout [to] unify and harmonize policy across the disparate
agencies that play a role in STD prevention and control” (NAPA, 2018, p.
69). Surgeon General Dr. C. Everett Koop in the 1980s or National Institute
of Allergy and Infectious Diseases (NIAID) director Dr. Anthony Fauci in
2020 on the COVID-19 pandemic could serve as possible models for such
medical celebrity advocacy.
Similarly, ASHA has developed campaigns that leverage individuals
with large social networks and/or social media followings to educate and
encourage individuals to seek STI testing services. ASHA recruits volun-
teers nationally and globally for its social media ambassador program6
to develop and disseminate positive sexual health messages within their
networks. As of 2019, the program had 517 ambassadors who reached
more than 832,000 people (Barclay, 2019). ASHA also runs a campaign,
Yes Means Test,7 that uses social media influencers to create awareness,
educate, and encourage 18–24-year-old women to be tested for chlamydia
and gonorrhea. As of 2019, the campaign has generated more than 1.6 mil-
lion video views, more than 270,000 website views, and 26,740 clicks on
the website’s clinic locator (Barclay, 2019). In 2019, ASHA also launched a
campaign directed at young members of the military that focuses on test-
ing, contraception, PrEP, and HPV vaccination (Barclay, 2019).
Celebrity advocacy is seen in many other areas of health. Actress
Angelina Jolie has helped to destigmatize breast cancer surgery and
genetic screening with her personal testimonials. Musician Miley Cyrus
and comedian Pete Davidson have brought mental health issues to the
forefront of U.S. pop culture. Journalist Katie Couric has highlighted
colon cancer and the need for screening. Journalist Maria Shriver has
advocated for Alzheimer’s disease awareness, and actor Michael J. Fox
has been an activist for Parkinson’s disease. Usually, either the celebrity
or someone in their immediate family suffered from the condition. A
celebrity, however, may be unlikely to announce that they have acquired
syphilis, gonorrhea, or chlamydia, arguably more stigmatized than even
HIV/AIDS or mental health. It may be more realistic to have a popular
culture figure advocating for regular check-ups to stay healthy, as is done
for diet and fitness health activities. Hence, the NAPA suggestion that a
medical or government advocate fill this role may be a useful first step.
6 See https://ashaambassadors.socialtoaster.com (accessed November 3, 2020).
7 See https://yesmeanstest.org (accessed November 3, 2020).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
616 SEXUALLY TRANSMITTED INFECTIONS
Relatedly, a public figure or celebrity can serve to help shed light on
certain topics and even alter behaviors. For example, research has found
that public figure health disclosures can impact information seeking and
health behaviors, such as requests for cancer screenings (Noar et al., 2014).
A recent meta-analysis found a small to medium effect size between
audience involvement (e.g., identification) with celebrities following a
disclosure and behavior intentions, with behaviors that did not require a
medical procedure producing greater effects (Kresovich and Noar, 2020).
In the HIV field, after actor Charlie Sheen publicly disclosed his HIV
status, sales for an in-home HIV test kit were elevated for 4 weeks, with
more than 8,000 more sales than expected for that time frame, surpassing
sales around World AIDS Day (Allem et al., 2017). Web searches over that
period mirrored the increase in sales (Allem et al., 2017).
Public figures have careers and income streams to protect. Admitting
to having had an STI, having a family member with one, or even choosing
to speak out on the issue may be viewed by agents as bad for business.
Stigma is surely keeping public figures from disclosing or advocating.
Still, advocates who do not have an STI could still bring awareness to the
topic. Actress Mariska Hargitay learned about sexual assault issues in
her role on Law & Order: Special Victims Unit and has been an activist ever
since. Krim and Taylor both advocated for HIV/AIDS for decades without
themselves or their immediate families having been affected, but rather
because of their empathy for others. STI experts may consider efforts to
recruit and train a small cadre of celebrity, scientific, and government
advocates to capture the imagination of the media, policy makers, and
community leaders toward sexual health and STI prevention as part of
an effort to change the culture around STIs.
Artificial intelligence (AI) approaches hold promise in addressing the
potential costs and difficulty in recruiting famous celebrities. Although it
might be difficult to gain the support and commitment of famous people
as spokespersons, artificial intelligence modeling on social media data
(described in more detail in Chapter 6) may be a solution. For example,
many individuals are respected and influential on social media and pas-
sionate about STI prevention. They may not have the status of a famous
actor, but they can be a type of domain-specific (e.g., specific to sexual
health) celebrity. In similar ways that the field of public health, including
HIV, has leveraged peer role models and community popular opinion
leaders to promote health behaviors, these online influencers may be
helpful for promoting sexual health. Compared to a traditional well-
known celebrity, these “domain-specific online influencers” might be
more committed to assisting government and public health because they
are already passionate about sexual health. They also are likely to receive
fewer requests for promotional efforts compared to traditional celebrities,
making them more excited about the opportunity.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PREPARING FOR THE FUTURE OF THE STI RESPONSE 617
The committee recognizes that identifying sexual health–related
online influencers might still be challenging, especially as online influ-
encers are constantly changing. One potential solution is to leverage AI
modeling to identify current social media influencers related to sexual
health. For example, in the HIV space, researchers have used AI methods
to sort through millions of Twitter posts in real time to identify individu-
als who appear to be influential in HIV prevention (Zheng et al., 2020).
Celebrities with more than 80 million Twitter followers each include
singers Justin Bieber, Katy Perry, Rihanna, Taylor Swift, and Lady Gaga
and soccer star Christiano Ronaldo (Brandwatch, 2020). Any one of these
superstar influencers who might embrace a “please test to stay healthy”
mantra for STIs might inspire young persons to do just that. This type of
technology adapts over time, allowing the ability to keep up with cur-
rent trends by flagging the current (daily, weekly, or as needed) online
influencers. These methods could play an increasing role in the future of
STI prevention by cost-effectively helping to identify online influencers
around sexual health, increasing the likelihood of gaining a large number
of highly committed, low-cost “celebrity” advocates.
PPPs for STI Prevention and Control
PPPs, in which private-sector entities, including corporations and
philanthropies, either work directly with governmental agencies on col-
laborative projects or agree to work separately toward shared goals, can
be an important avenue for broadening ownership for STIs. Both in the
United States and globally, PPPs can bring private-sector expertise and
resources to bear on topics of high public interest. These are especially
salient when market forces are inadequate to drive enough private-sector
innovation and product development to meet public needs. Two exam-
ples from global health help illustrate these principles: The Rotary Club
International partnership with WHO and dozens of ministries of health
and donor nations began global efforts to eradicate poliovirus from the
planet. As the needs grew in the “end game,” this PPP was complemented
by major involvement from the Bill & Melinda Gates Foundation and
additional private-sector groups that subsidized these efforts, suggesting
models for the future (Awale et al., 2019). Project Last Mile combined bev-
erage industry leaders with vaccine and drug distributors in ministries of
health to bring logistics expertise—notably, transportation, storage, and
inventory management—from the private sector into the public sector
(Linnander et al., 2017). In contrast to polio eradication, this project was
clouded by previous criticisms of soft drink interests and engagement
in scientific support (Hernandez-Aguado and Zaragoza, 2016; Jane and
Gibson, 2018).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
618 SEXUALLY TRANSMITTED INFECTIONS
PPP-driven projects may not always be evaluated rigorously, casting
doubt on their impact (Della Rocca, 2017; Holeywell, 2013). Conflict of
interest may seem likely if the private-sector actor has a financial stake
in the product or program being promoted (Hernandez-Aguado and
Zaragoza, 2016; Omobowale et al., 2010). Some programs that are woe-
fully underfunded or neglected within the government or the industrial
spheres may have timely assistance or experience innovative inputs with
PPPs (Albalate and Bel-Piñana, 2019; Brady and Potter, 2014; Granados
Moreno et al., 2017; Saadeh et al., 2019). Hospitals or entire health systems
may have PPP elements (NASEM, 2016c, 2020a; Vrangbaek, 2008). The
circumstances of a given PPP need to be evaluated to judge its merits and
winnow out potential conflicts of interest.
Women’s health has garnered STI-relevant investments, as with sup-
port from the private sector for Planned Parenthood. Medicines360 is
a women’s health pharmaceutical nonprofit, working with a humani-
tarian aid group, Direct Relief; it has partnered since 2018 to provide
Medicines360’s hormonal intrauterine device for free, often to uninsured
individuals (Direct Relief, 2018). Other women’s health, maternal and
child health, and nutritional initiatives have benefited within a variety
of PPPs (Campos et al., 2019; Hoddinott et al., 2016; Kamugumya and
Olivier, 2016).
A dramatic recent example of a massive U.S. PPP is the 2020 Operation
Warp Speed, which provided hundreds of billions of dollars to the private
sector to produce and deliver 300 million doses of SARS-CoV-2 vaccines
as soon as the Food and Drug Administration determines that they are
proven safe and effective. Other elements focus on countermeasures, such
as COVID-19 therapeutics and diagnostics (Slaoui and Hepburn, 2020).
While the economic impact of the COVID-19 pandemic is far higher than
the economic burden from STIs, PPPs are still appealing strategies if they
can capture the imagination of enlightened business, foundation, and
nonprofit partners. They could be built on many themes: adolescent health,
women’s health, men’s health, LGBTQ+ health, perinatal and children’s
health, POC diagnostics, and public health capacity building.
STI drug development Substantive experiences with PPPs in the STI
field are relatively recent and have shown great promise, with some early
successes. An ongoing PPP with immense promise is testing the antibiotic
zoliflodacin for gonorrhea, an endeavor of Entasis (a company created by
AstraZeneca) and the Global Antibiotic Research and Development Proj-
ect, a nongovernmental organization created by Doctors Without Borders
(Alirol, 2019; Bradford et al., 2020; Cristillo et al., 2019; Foerster et al.,
2019; Jacobsson et al., 2019). The Phase 3 trial is based on Entasis donat-
ing the rights to their drug for global (except for the United States) sales
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PREPARING FOR THE FUTURE OF THE STI RESPONSE 619
and production and distribution to the Global Antibiotic Research and
Development Project. The trial is being carried out with donated drugs,
and the study is supported by donations from NIAID, WHO, the Bill &
Melinda Gates Foundation, and others.
Another example of PPPs for antibiotic development that include
STIs is CARB-X,8 a PPP that invests in new antibiotics, offering 56 small
companies (as of 2020) substantial financial support. Similarly, the Anti-
microbial Resistance Fund has taken a special interest in gonorrhea.9
These PPPs are in the spirit of prior infection control and pharmaceutical
partnerships that have been supported by PPPs in diverse global and U.S.
settings (Miles et al., 2014; NASEM, 2016b; Shrivastava et al., 2019). Inter-
national experiences with PPPs to address STIs have been documented,
sometimes with industries and their workers (Albis et al., 2019; Fobosi et
al., 2017; Kokku et al., 2014).
Prevention, testing, and advocacy New technologies are not the only
vehicles for PPPs for STI prevention and control. A condom coalition led
by ASHA that involves the Trojan brand has been supported by Church
& Dwight, the makers of Trojan condoms.10 Similarly, the Kaiser Family
Foundation (KFF) is spearheading a national condom campaign, Rap it
Up, with support from Black Entertainment Television (KFF, n.d.). The Bill
& Melinda Gates Foundation supported a “condom of the future” project
in 2013 that stimulated research in a previously quiescent field.
Perhaps the most promising arena for PPPs is STI testing. MTV has
partnered to support a CDC and KFF “Get Yourself Tested” campaign
(CDC, 2019b). Diagnostics companies that stand to gain from expanded
STI testing with more accessible and affordable POC strategies may sup-
port rolling their products out. Another partnership, Project Last Mile,
supports hepatitis C therapy funding support built on a Netflix model
(USC Schaeffer Center, 2019).
The most dramatic examples of success in PPPs are HIV/AIDS and
COVID-19. KFF has worked with Walgreens and Orasure Technologies
to aid HIV/AIDS diagnosis, care, and treatment efforts in their “Greater
Than AIDS” project (KFF, 2020b). Public communications campaigns show
promise in engaging professional advertisers with marketing expertise, as
with CDC’s Community Approaches to Reducing Sexually Transmitted
Diseases initiative (CDC, 2020) (see Chapter 8 for more information).
8 See https://carb-x.org (accessed October 29, 2020).
9 See https://www.ifpma.org/partners-2/the-amr-action-fund (accessed October 29,
2020).
10 See https://www.ashasexualhealth.org/condomology (accessed October 29, 2020).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
620 SEXUALLY TRANSMITTED INFECTIONS
Many HIV campaigns have engaged expert marketers, both paid and pro
bono, in partnerships motivated by public health concerns (HIV.gov, n.d.).
Issues related to health equity and race may be hard for a politicized
public sector to address, even when societal and economic benefits are
made obvious (ASTHO, 2012). Such issues may be tackled by private-
sector actors in PPPs. A new national STI coalition of 17 nonprofit advo-
cacy organizations11 was established in early February 2020, just before
the COVID-19 pandemic hit the United States (NCSD, 2020).
Conclusion 12-4: The committee concludes that an important limitation
of the historical response to STI prevention and control is that community
stakeholders (e.g., families, schools and educators, faith-based organizations,
and workplaces) lack the resources and agency they need to help reduce
STI outcomes and inequities in their communities. The committee further
concludes that elevating the promotion of sexual health for all in partner-
ship with community stakeholders is a promising strategy for improving
STI outcomes and inequities, but more direction and support is needed to
empower communities to engage in sexual health dialogue and promotion
efforts tailored to their specific community contexts, needs, and priorities.
Recommendation 12-3: The Centers for Disease Control and Pre-
vention Division of STD Prevention should take steps to expand
community knowledge of sexual health and promote actions that
lead to a greater understanding of healthy sexuality by encouraging
and supporting public dialogue and the adoption of evidence-based
interventions in various community settings (families, schools, faith
communities, community-based organizations, and workplaces).
CDC should collaborate with other relevant federal, state, local, tribal,
and territorial partners to generate new and enhanced partnerships to
support the Division of STD Prevention’s (DSTDP’s) mission. As a first
step, DSTDP may consider an internal consultation with other divisions
within the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB
Prevention that have a diversity of potential partners for DSTDP to foster
collaboration and program integration. These divisions also may have
11 Advocates for Youth, AIDS Institute, American Sexual Health Association, American
STD Association, Association of Maternal & Child Health Programs, Association of State
and Territorial Health Officials, GLMA: Health Professionals Advancing LGBTQ Equality,
HIV Medicine Association, Infectious Diseases Society of America, National Alliance of State
and Territorial Aids Directors, National Association of County and City Health Officials,
National Coalition of STD Directors, National Family Planning & Reproductive Health As-
sociation, NMAC, Planned Parenthood Federation of America, SIECUS: Sex Ed for Social
Change, and Treatment Action Group.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PREPARING FOR THE FUTURE OF THE STI RESPONSE 621
additional experience in identifying models for effectively working with
community partners. A follow-up action may be to convene an external
consultation “summit” to bring together a range of community stakehold-
ers, to both expand partnerships with a range of entities already engaged
in health-related education, advocacy and services delivery and strategize
on how to engage and sustain collaborations with a broader set of non-
governmental partners. This imperative also has been highlighted in the
2018 NAPA report (NAPA, 2018). Such a summit also may bring together
experts in strategies for developing community and organizational capac-
ity for delivering evidence-based interventions to prevent and control STIs
(see Chapter 8). The added strength and influence of a phalanx of powerful
private-sector allies and funders working to enhance the reach and influ-
ence of public health evidence-based STI control efforts is needed. Actions
from community stakeholders could include the following:
• Families: Families play an essential role in normalizing health-
seeking behavior and teaching values and expectations, not only
for young people but across the life span. Families should discuss
actions that promote sexual health.
• Schools and Educators: Just as parents have the central respon-
sibility for guiding children’s healthy development, schools
and educators also perform an essential reinforcing role. School
districts, education associations, the national Parent–Teacher
Association, and other education-affiliated institutions should
develop or adopt existing evidence-based training guides and
other resources for conveying information about healthy living,
including health sexuality that is nonjudgmental, medically accu-
rate, age appropriate, and inclusive of all persons.
• Faith Communities: Many faith communities have established
ministries on other health topics and offer an important venue
for conversations about how to integrate sexual health into one’s
life. They should be encouraged—and provided the necessary
tools and resources—to adapt evidence-based models for sexual
health promotion for their congregations.
• Community-Based Businesses and Other Settings: Small busi-
nesses and other establishments in communities where people
live and socialize are ideal settings for engaging individuals in
meaningful dialogue about health and wellness, including mes-
sages about sexual health and STI prevention. With trainings and
resources from CDC and state and local health departments, com-
munity stakeholders should be deployed to engage on these topics.
• Workplaces: Many people spend more time at work than at home.
Employers, unions, and human resources associations should
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
622 SEXUALLY TRANSMITTED INFECTIONS
develop or adopt existing evidence-based educational tools and
messages to normalize healthy living and dialogue about sexual
health.
BOLSTER EXISTING SYSTEMS AND PROGRAMS
FOR RESPONDING TO STIs
The challenge of preventing and controlling STIs in the United States
is large. The committee’s analysis of these complex issues leads it to
call for a new sexual health paradigm and broadened ownership and
BOX 12-4
Bolster Existing Systems and Programs for
Responding to STIs: Recommendations in Brief
Enhance Federal Leadership and Support:
Modernize core Centers for Disease Control and Prevention STI activities to
strengthen timely monitoring, ensure that treatment guidelines remain current as knowl-
edge evolves, and leverage federal support to increase consistency and accountability
across jurisdictions. (Chapter 12)
Strengthen Local Efforts to Plan and Coordinate the STI Response:
• Improve coordination and strengthen population outcomes by supporting local
stakeholder engagement processes involving the breadth of public and private
stakeholders to develop and implement comprehensive multi-year local plans for
STI control and prevention.
• Develop STI Resource Centers for clinical consultation, workforce development,
and technical assistance to assist in the planning process and provide consulta-
tion to individual clinical STI providers. (Chapters 11 and 12)
Establish New Initiatives to Close Gaps in
Access to STI Coverage and Services:
Develop innovative programs to ensure that STI prevention and treatment services
are available to individuals who face access barriers, including persons who are ineli-
gible for coverage, have affordability barriers, including high out-of-pocket costs, or will
not access STI services without confidentiality guarantees. (Chapter 10)
Support and Expand the STI Workforce:
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.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PREPARING FOR THE FUTURE OF THE STI RESPONSE 623
accountability for contributing to the STI response. Despite highlight-
ing certain deficiencies in the current response, the committee does not
believe that the actors or agencies and systems in place, at all levels, to
address STIs have failed. Rather, they have frequently performed com-
mendably given the level of resources and political and public support
that they have been given. This section draws on the barriers, opportuni-
ties, and evidence discussed throughout this report to highlight meaning-
ful opportunities for action that will significantly enhance current efforts.
See Box 12-4 for a summary of recommended actions to bolster the current
system.
• Emphasize the importance of consistently delivering recommended sexual
health services (e.g., vaccinations and routine STI screening) in clinical practice
guidelines.
• Have licensing bodies formulate a minimum sexual health skill set to be reflected
in formal training programs.
• Expand STI workforce capacity-building infrastructure to share clinical and pre-
vention expertise through continuing education, consultation, and technical as-
sistance with primary care providers, as well as nonclinical health and human
services professionals and paraprofessionals.
• Identify policy barriers, and how to remove them, to expand the ability of advance
practice clinicians to deliver sexual health services.
• Explore public–private partnerships to overcome regulatory and logistical barriers
to implementing innovative technologies and delivery models for sexual health
services. (Chapter 11)
Prioritize Research In Critical Areas to Improve
STI Management and Prevention:
• Prioritize developing point-of-care diagnostic tests to reduce the interval between
testing and treatment.
• Promote developing diagnostic tests that distinguish untreated, active syphilis
from previously treated infection.
• Subsidizing and encouraging public–private partnerships to develop new, read-
ily accessible antimicrobials and expedite vaccine development for high-priority
STIs. (Chapter 7)
Deploy Psychosocial and Behavioral Interventions for Sexual Health:
Take steps to expand the reach of psychosocial and behavioral interventions to
prevent and control STIs at the individual, interpersonal, and community levels:
• Develop new mechanisms that provide sustainable funding for adoption, scale-
up, and dissemination.
• Establish standard guidelines for school-based comprehensive sexual health
education.
• Develop, evaluate, and disseminate community-based approaches. (Chapter 8)
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
624 SEXUALLY TRANSMITTED INFECTIONS
Enhancing Federal Leadership and Support
The center of the federal government’s response to STIs is the CDC
DSTDP, which leads the national surveillance and monitoring effort and
conducts workforce training and research. The majority of its funding,
however, is passed through to state and local health departments (see
Chapter 4). Both its intramural activities and its grant-making programs
serve the dual purposes of supporting state and local efforts and synthe-
sizing various data, other inputs, and best practices from these jurisdic-
tions to capture a national picture of emerging trends and to intervene
comprehensively and strategically.
Surveillance and Monitoring
CDC operates numerous essential disease surveillance systems that
typically fund state and local health departments to collect and ana-
lyze information, including on nationally reportable infectious diseases
(see Chapters 2 and 4). Frequently, however, resource limitations mean
that CDC has to conduct sentinel surveillance and use sampling tools
(such as funding a subset of states) to collect information that is used
to model national incidence and prevalence estimates. CDC’s work in
partnership with states, and secondarily with local health departments,
is extremely valuable. Nonetheless, the capacity to collect, analyze, and
use surveillance and other data varies dramatically between jurisdictions.
Additionally, data are often collected separately for different infectious
diseases; for example, someone with co-occurring syphilis and HIV may
be interviewed by different people to contact trace the different infections,
a duplication of effort. This means it is not always possible to rapidly
identify clusters of disease transmission or spot other trends that would
be visible if cases were monitored across infectious diseases. The com-
mittee observes that integrating data systems to improve interoperability
at CDC and within health departments could improve population-level
outcomes. The goal would not be to achieve uniform, single systems for
all infectious diseases, but to upgrade public health capacity to respond
effectively to STIs and other infectious diseases.
Population-based surveys and STI screening are the gold standard for
measuring disease prevalence and risk factors. Current population-based
surveys, such as the National Health and Nutrition Examination Survey
and Behavioral Risk Factor Surveillance System, however, are infrequent
and have small sample sizes. Disease prevalence for several STIs is mod-
eled rather than observed and the nation does not have the ability to
monitor it over time. Therefore, the nation does not know the true disease
burden of STIs and how it has changed. This information is fundamental
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PREPARING FOR THE FUTURE OF THE STI RESPONSE 625
to guiding national policy. Without this, it is difficult to know if national
efforts to curtail disease burden are succeeding or failing.
CDC primarily relies on case reporting to monitor STIs. That sys-
tem, however, is too slow to allow the public health system to react, and
reports are publicly released approximately 9 months after the end of the
calendar year because of an antiquated data infrastructure that requires
extensive effort to harmonize data from local jurisdictions. Automating
and modernizing this infrastructure holds the potential to produce far
more valuable and actionable information.
In addition to traditional surveillance data, big data from multiple
sources, including Internet searches, social media, mobility data from
phones, and health insurance claims has the potential to significantly
improve the speed of identifying disease outbreaks (see Chapter 6). There-
fore, supplementing traditional case reported data with these and other
new data sources would produce better and more timely results.
STI Clinical Treatment Guidelines
The STI Treatment Guidelines are widely read and downloaded;12
they are viewed nearly half a million times each month, and the guide-
lines mobile app is one of the top-ranked apps at CDC, with a rating of
4.3/5.0 (see Chapters 7 and 10 for more information on the treatment
guidelines). Its recommendations have global impact and are helpful to
other guideline processes from such organizations as WHO and the Brit-
ish Association for Sexual Health and HIV. As with surveillance, a critical
shortcoming of these guidelines is the slow pace of revision. The commit-
tee believes there are real costs and harm from not keeping these essential
practice guidelines up to date.
In the modern era of Internet connectivity, the committee believes that
real-time updates are vital adjuncts to the original guidelines produced
only twice per decade. Periodic reviews should be yearly, but this need
not be laborious when guidelines are being continuously updated with
state-of-the-art advisories. An effort to achieve more real-time updates of
the CDC STI Treatment guidelines was made by posting the most current
gonorrhea treatment recommendations within the online version of the
still current 2015 CDC STD Treatment Guidelines, and an additional alert
was also placed on the Guidelines website (St. Cyr et al., 2020). This is
a somewhat awkward way to reconcile with the old guidelines process,
however, in an era where rapid adjustments can be made and distributed
12 Personalcommunication with Nikki Mayes and Melissa Habel (CDC). Available by re-
quest from the National Academies of Sciences, Engineering, and Medicine’s Public Access
Records Office ([email protected]).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
626 SEXUALLY TRANSMITTED INFECTIONS
online to respond to a quickly changing field that goes beyond gonorrhea
treatment. For example, HIV guidelines are updated regularly on the
Internet (clinicalinfo.hiv.gov, n.d.); this is a model for how STI guidelines
could be continuously updated as treatments evolve. The goal is real-time
accurate treatment advice with delays of just weeks, not months or years.
Achieving Greater Consistency in Response Across Jurisdictions
As discussed in Chapter 4, the federal–state partnership that con-
ducts STI prevention and control efforts through a relationship known
as “cooperative federalism” is under strain. Whereas federal funding
has remained relatively flat in the face of growing STI epidemics, state
and local funding has declined in significance. Beyond funding levels,
however, this partnership could meet the needs of the nation, but it is
not reaching its full potential. The committee observes that a rationale
for federal engagement in STI control is to support state and local efforts
to not only elevate standards and the quality of services in jurisdictions
across the country, but also enable a coordinated national response and
to achieve greater uniformity in adhering to best practices and greater
comparability across jurisdictions. Differences in definitions of terms and
in approach related to how health departments engage with relevant
stakeholders, including—importantly—members of the community, lead
to gaps in the collective ability to gain a national picture of the STI crisis.
This also enables some jurisdictions and other partners to evade account-
ability for improving STI outcomes. The committee concludes that the
federal investment in STI prevention and control through grants to states
and local jurisdictions should be leveraged to achieve greater consistency
of practice and comparability of results.
Additionally, CDC has a responsibility to ensure that its support is
beneficial to the residents of the states it is funding and the return on the
investment is maximized. Federal funding was never intended to be the
sole source, and multiple stakeholders are critically necessary to achieve
an effective and coordinated response, so it is appropriate to encour-
age and mandate that states take steps to consult broadly with not only
affected communities that can benefit from a coordinated and strategic
statewide STI control plan but also the broad range of stakeholders who
need to be actively engaged for such a plan to be successful.
Conclusion 12-5: STI professionals at all levels of government have per-
formed valiantly within the constraints of the resources provided and the
policy attention that they have received. Furthermore, STI professionals,
especially within state and local health departments, have critical knowl-
edge and expertise that needs be the foundation of any efforts to improve the
national response to STI prevention and control.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PREPARING FOR THE FUTURE OF THE STI RESPONSE 627
Conclusion 12-6: The CDC Division of STD Prevention provides critical
leadership in guiding the federal STI response. The committee supports
maintaining and enhancing this role, including in encouraging the division
to be more assertive and in some cases, more prescriptive in its grants to
states and local jurisdictions in order to establish minimum national STI
standards of care.
Conclusion 12-7: Development and dissemination of improved clinical prac-
tices and standards is critically important. Both CDC and the National
Institutes of Health (NIH) have made investments in regional centers with
the goal of supporting state and local health departments to stay current with
the latest science and to offer expert consultation for providers dealing with
tough cases. However, existing structures are inadequate to meet the needs
of local providers and health departments.
Conclusion 12-8: Accurate STI surveillance is essential to understand the
epidemiology of reportable STIs. STI surveillance, however, is presently diffi-
cult to interpret because it reflects case reporting, which is ecologic in nature,
and periodic population-based studies, which are too small for meaningful
subpopulation analyses. Population-based surveys are highly desirable for
surveillance of many STIs to secure representative prevalence and behavioral
data; however, costs and burden on health departments can be prohibitive.
Recommendation 12-4: The Centers for Disease Control and Preven-
tion (CDC) should modernize its core sexually transmitted infection
(STI) activities to strengthen the timely monitoring of STIs with
less reliance on estimated rates based on case reports, to inform
proper treatment of persons with STIs, and to increase consistency
and accountability across jurisdictions. The committee recommends
a three-pronged approach:
1. Modernize surveillance activities to enable more rapid
release of data:
• Automate case reporting of reportable STIs.
• Release a preliminary STD Surveillance Report within 6
months of the reporting period, with a revised report later in
the year.
• Explore the use of new data sources to capture STI incidence
(critically, both cases and numbers tested), such as electronic
medical records, commercial databases, health information
exchanges, clinical and pharmacy data, social media/online
searches, and artificial intelligence, and invest in better data
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
628 SEXUALLY TRANSMITTED INFECTIONS
integration efforts within the National Center for HIV/AIDS,
Viral Hepatitis, STD, and TB Prevention (NCHHSTP).
• Develop a publicly available STI dashboard to raise public
awareness and accountability.
2. Improve timeliness of the STI treatment guidelines:
• The CDC STI treatment guidelines should be updated and
disseminated annually, and more frequently if necessary, to
better address real-time changes to the STI epidemic and
emerging treatments and technologies. The entirety of the
guidelines should undergo comprehensive reviews no less
frequently than every 5 years.
3. Increase accountability and establish new funding
requirements:
• CDC should engage in a data standardization partnership
across NCHHSTP and with grantees to develop and publish
a core set of STI indicators with standardized definitions of
terms. To promote the use of these standardized data, CDC
should set a condition of awards for its funding programs to
require that every grantee report surveillance and other data
to CDC consistent with these new data standards.
• CDC should also make a condition of awards the requirement
that states engage in a broad and meaningful stakeholder
engagement process. This should include representatives
of local health departments, heavily affected communities,
health insurance programs and exchanges, federally quali-
fied and other health centers, Ryan White HIV/AIDS Pro-
gram recipients, Substance Abuse and Mental Health Services
Administration recipients, and others to develop a multi-year
state or major municipalities STI prevention and control plan
that
o leverages disparate assets within the state or major
municipalities for establishing STI prevention and care
priorities, aligning STI and HIV priorities;
o establishes benchmarks; and
o creates a process for monitoring and reporting on prog-
ress toward achieving established benchmarks.
Regarding item 1 of Recommendation 12-4, the 2018 and 2019 NAPA
reports also highlight the need for improved STI surveillance and list this
as a recommended action. Implementing improved surveillance is also
crucial to ensure better use of technologies to support STI prevention and
control (see Chapter 6, Recommendation 6-1).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PREPARING FOR THE FUTURE OF THE STI RESPONSE 629
Regarding item 3 of Recommendation 12-4, DSTDP’s flagship STI
prevention funding program, Strengthening STD Prevention and Control
for Health Departments, is a 5-year cooperative agreement now running
from January 2019 through December 2023.13 It funds all 50 states, the
District of Columbia, Puerto Rico, the U.S. Virgin Islands, and 6 large
cities (NAPA, 2018) and focuses on five strategy areas: conduct surveil-
lance; conduct disease investigation and intervention; promote CDC-rec-
ommended screening, diagnosis, and treatment; promote prevention and
policy; and analyze and use data for program improvement. Crosscutting
strategies include STD-related HIV prevention and creating, maintaining,
and leveraging partnerships. This program already contains numerous
requirements that are conditions of award,14 and this report recommends
further refining these requirements to produce greater comparability and
actionability for the data collected. The time remaining before the next
5-year agreement offers CDC sufficient time to engage in necessary stake-
holder consultations and conduct a data standardization process. The
committee encourages that this recommendation be effectuated in full
for the next 5-year agreement, and consideration should be given to what
steps can be taken more immediately.
The committee recognizes the large differences in staff capacity across
health departments and other impediments to rapid integration of report-
ing standards. Therefore, the proposed partnership should consider the
current starting point and recommend phased implementation (if needed)
to account for current serious limitations in the capacity to carry out sur-
veillance and monitoring efforts at the state or local levels. Other interven-
tions may be needed to enhance the STI monitoring capacity at the health
department level through greater use of CDC assignees to health depart-
ments and greater support for health department–academic partnerships.
Nonetheless, such a collaborative process should lead inexorably to the
timely achievement of higher-quality, more uniform, and more timely
data reporting, along with meaningful accountability measures to enforce
compliance with these requirements.
Furthermore, the committee is not recommending a specific model
for stakeholder engagement. Indeed, HIV programs have long experi-
ence with HIV prevention community planning, as well as Ryan White
services planning. In recent years, significant federal efforts have been
made to support the integration of HIV prevention and care planning.
The committee recognizes that STI-specific community consultation and
13 See https://www.cdc.gov/std/funding/pchd/default.htm (accessed November 16,
2020).
14 See https://www.cdc.gov/std/funding/pchd/guidance.htm#funding-tables (accessed
November 16, 2020).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
630 SEXUALLY TRANSMITTED INFECTIONS
collaboration processes have been developed in several jurisdictions (see
Chapter 10). DSTDP may consider ways to integrate STI consultation and
resource allocation processes within these existing mechanisms or may
determine that such an approach is inappropriate or not the best model, as
critical STI stakeholders not involved with HIV planning processes would
be excluded. The history of these planning processes is fraught with
examples where the process itself became too cumbersome and resource
intensive or was used to justify health department decisions without
obtaining or truly reflecting the perspectives of external stakeholders. The
thrust of this recommendation rests on the idea that governmental agen-
cies often need to be nudged toward greater and more meaningful public
consultation and that more responsive STI programs with high levels
of community trust can only be achieved with meaningful engagement
from intended clients and community leaders and buy-in from external
stakeholders that have the capacity to contribute greatly to the success of
such public health efforts.
Strengthening Local Efforts to Plan and Coordinate the STI Response
Just as the committee understands that it is critically important to
reinforce the federal–state partnership, it also recognizes that policies and
initiatives often succeed or fail at the local level. Therefore, innovative
leaders and strong champions for the STI response are needed in health
departments, academic institutions, public and private health care set-
tings, and community-based organizations. As highlighted in Chapter 4,
local health departments rely on a patchwork of funding sources, creat-
ing significant differences in resources by jurisdiction. The complex and
uncoordinated U.S. health system results in large variation in how health
care and public health services are organized at the local level, which fur-
ther complicates the ability to achieve consistently healthy populations.
Except in those local jurisdictions that CDC directly funds, it is difficult to
conceive of how to achieve greater equity and comparability across juris-
dictions without further investments. Nonetheless, a meaningful oppor-
tunity exists to improve planning and coordination of effort among the
diversity of stakeholders within a community. While health department
leadership is critical, the best outcomes will be achieved with strong part-
nerships and true collaboration between public health, the health system,
community, and philanthropy.
Conclusion 12-9: To ensure comprehensive sexual health services and to
improve STI prevention and control, local jurisdictions need to conduct,
and be held accountable for, a broad and meaningful stakeholder engagement
process to identify needs and assets and to establish prevention and care
priorities for their jurisdictions.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PREPARING FOR THE FUTURE OF THE STI RESPONSE 631
Working in tandem with the preceding recommendation for CDC to
require statewide STI prevention and control plans, the committee rec-
ommends the following:
Recommendation 12-5: The Centers for Disease Control and Preven-
tion (CDC) should encourage local health departments to develop
and implement comprehensive plans for sexually transmitted infec-
tion (STI) prevention and control. This should be done by fund-
ing key partners, such as the National Association of County and
City Health Officials (NACCHO) and the National Coalition of
STD Directors (NCSD), to develop resources and provide technical
assistance to state and local health departments on how to conduct
a meaningful stakeholder consultation process, how to develop
a plan that offers strategic support for improving STI outcomes
leveraging all available community assets, and how to monitor
implementation and keep the public informed of progress toward
achieving the plan’s objectives. The plans should do the following:
• Include community-wide needs assessments, oversampling
high-priority populations, that determine the adequacy of avail-
able sexual health services in their jurisdictions and explore the
creation of new, improved, and easier access points for sexual
health promotion in a stigma-free environment, including STI
screening and treatment services that take advantage of current
rapid and self-testing technologies.
• Identify mechanisms to meet the needs of underserved and
highly impacted populations.
• Establish formalized, funded relationships with trusted com-
munity-based organizations to deliver critical STI prevention
and care services.
CDC, in collaboration with the National Network of STD Preven-
tion Training Centers, NACCHO, and NCSD, should develop STI
Resource Centers (SRCs) for clinical consultation, workforce devel-
opment, and technical assistance to support the planning process
and provide consultation to individual clinical STI providers. At
a minimum, these SRCs should be operational at the level of state
and large municipal jurisdictions.
While some overlap will occur between stakeholders in the commu-
nity planning process and SRCs in certain jurisdictions, most states and
local jurisdictions do not currently have the expert resources needed to
support local planning or to provide consultation to providers. Dependent
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
632 SEXUALLY TRANSMITTED INFECTIONS
on the availability of STI expertise and funding, SRCs may take different
forms. At a minimum, they should involve a formal collaboration between
STI clinical and prevention experts from different institutions, including
local and state health departments, academia, the National Network of
STD Clinical Prevention Training Centers, STI/sexual health centers, and
other STI care providers (see Chapter 11 for additional discussion).
Establishing New Payment and Coverage Options to
Close Gaps in Access to STI Coverage and Services
The current system for financing and delivering STI services in the
United States leaves out too many people. To achieve population health
and control infectious diseases, it is necessary to create accessible, afford-
able, nonstigmatizing, and nondiscriminatory options for prevention,
screening, and treatment services that are available to all persons within
a community. As discussed in Chapter 10, however, STI control efforts are
too frequently limited because the complex and fragmented system leaves
too many individuals with inadequate access to services. Recommenda-
tion 10-1 suggests that HHS and states develop innovative programs to
ensure STI services are available to persons facing access barriers.
Supporting and Expanding the STI Workforce
As the nation looks to the future of the STI response, bolstering cur-
rent efforts is critically important. The workforce of STI professionals is
broad and encompasses clinical providers, educators, researchers, and
public health officials. They are the essential underpinning of any capac-
ity to mount a strengthened STI response. Chapter 11 examines the STI
workforce in detail, highlights the need for it to refocus and improve
the traditional service delivery paradigm, and identifies opportunities
for leveraging health care systems and practitioners to improve STI ser-
vices and strengthen the broader public health workforce to respond to
public health emergencies, including STI outbreaks. Recommendation
11-1 is that sexual health promotion be operationalized and prioritized
in practice guidelines and training curricula and that STI prevention and
management be incentivized and prioritized as a focus area of practice.
Accelerate Biomedical Research and Development
Ensuring a strong investment in STI-focused research is critical to
protecting public health. The U.S. biomedical research enterprise has
scored many remarkable successes over the decades and remains a criti-
cal priority for ongoing support. While STI research takes place in the
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PREPARING FOR THE FUTURE OF THE STI RESPONSE 633
private sector and is conducted by or funded through a variety of federal
agencies, NIH is the flagship for U.S. biomedical research. The agency is
burdened with a multitude of competing demands and a wide variety of
long-standing pressing health and disease threats, as well as emerging
novel threats, as exemplified by COVID-19. Chapter 7 offers a clear expli-
cation of the biomedical tools available for STI prevention and manage-
ment. While the committee supports a broad and diverse approach to STI
research and believes that many of NIH’s investments are both promising
and necessary, it also concludes that there are specific areas where current
opportunities demand greater prioritization and urgency.
Deploy Psychosocial and Behavioral Interventions for Sexual Health
An effective response demands a sophisticated strategy that aligns all
intervention types to help society prevent and control STIs. The commit-
tee seeks to expand the investment and support for developing, adopt-
ing, and disseminating psychosocial and behavioral interventions. Too
frequently, there has been a policy dialogue that has presented a binary
choice between relying on biomedical strategies to attack specific patho-
gens or behavioral tools to guide individual behavior. With this under-
standing, the committee outlines a series of steps in Recommendation
8-1 to ensure sustained funding for psychosocial and behavioral inter-
ventions, establish more uniform national evidence-based standards for
school-based sexual health education, and use psychosocial and behav-
ioral research to support developing more effective community-based
interventions.
EMBRACE INNOVATION AND POLICY CHANGE
TO IMPROVE SEXUAL HEALTH
The Hidden Epidemic was premised on the idea that STIs have not been
sufficiently addressed, in part, because too many members of the public
would prefer to not think about and have to deal with them (IOM, 1997).
An assessment of the current state of STI prevention and control indi-
cates that investments have been too low, the response too fragmented,
and attention on the growing challenge of STIs too fleeting. Because STIs
remain in the shadows, some may think it will be difficult to garner a
focused and strategic response, in addition to a tendency to interpret
cultural and social changes with an innate pessimism that makes a grow-
ing STI threat appear to be foreordained. The committee rejects this view.
Despite recognizing the potential for any number of factors to weaken the
STI response, changes in law and policy, society, and technology create
reasons for optimism that STI outcomes can be improved. Indeed, as the
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
634 SEXUALLY TRANSMITTED INFECTIONS
BOX 12-5
Embrace Innovation and Policy Change to Improve
Sexual Health: Recommendations in Brief
Address Structural Inequities, Including Structural Racism, That
Hinder Sexually Transmitted Infection (STI) Prevention and Control:
Develop a whole-of-government, interagency coordinated approach, in partner-
ship with affected communities, to promote sexual health and eliminate structural
racism and inequities that are barriers to STI prevention, testing, and treatment in
marginalized groups and drivers of STI inequities in the United States. (Chapter 9)
Harness Technological Innovation to Improve STI Prevention
and Control:
Expand the capacity to use technology for STI prevention and control, includ-
ing expanding the types of expertise available and prioritizing expert consultation;
developing timely, novel, and open data systems; and using artificial intelligence–
based mass marketing. (Chapter 6)
nation grapples with an unfolding pandemic, even some of the biggest
challenges caused by COVID-19 may, perhaps paradoxically, create new
opportunities for policy action. See Box 12-5 for a summary of recom-
mended actions.
COVID-19 and STIs
The COVID-19 pandemic has significantly disrupted STI manage-
ment and the delivery of comprehensive sexual health care resulting
from clinic closures, staffing diversions, and COVID-19-related resource
constraints (Krakower et al., 2020; Nagendra et al., 2020; Napoleon et al.,
2020). More challenges are expected as the pandemic continues to unfold
on an uncertain course and spillover effects resulting from economic dis-
ruption and other factors expand.
Importantly, DIS, mostly trained and hired originally to investigate
contacts for HIV, syphilis, and other STIs, have been deployed for COVID-
19 contact tracing, thus leaving a large void for STI and HIV control. This
exposes a fundamental weakness in public health capacity that should
lead to significant investments in public health infrastructure in ways
that, as a result, should strengthen STI prevention, care, and treatment.
Conversely, through strengthening STI and other public health capac-
ity at the local, state, and tribal levels, it is possible to better respond to
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PREPARING FOR THE FUTURE OF THE STI RESPONSE 635
COVID-19 and be better prepared for a future novel infectious disease
threat.
This crisis has underscored the importance of a well-prepared public
health infrastructure and timely, coordinated action at the federal, state,
and local levels. The federal government has a critical role to play in
providing leadership, synthesizing data, and exposing trends unfold-
ing across the country to inform and shape state-level surveillance and
response that feeds into tailored local-level response and service delivery.
It could be said that public health has failed STI prevention, but it would
be better argued that society has failed public health. STIs are a societal
problem that requires a societal solution.
Over the past decade, median per capita expenditures among local
health departments have declined by 18 percent despite increased public
health needs, including burgeoning STI rates (NACCHO, 2020). Since
2008, this funding reduction has translated into the loss of 38,000 state
and local public health jobs (Weber et al., 2020). A 2018 report by lead-
ing national public health experts proposed a new mandatory federal
financing source to fill an estimated $4.5 billion gap in annual funding
for foundational public health activities, with additional increases in state
and local public health investments (PHLF, 2018). Both the COVID-19
pandemic and ongoing STI epidemic spotlight the impact of the erosion
of public health infrastructure and the urgent need to consider additional
resource commitments.
COVID-19 Implications for Prevention and Control of STIs
The COVID-19 pandemic has significantly disrupted STI manage-
ment and the delivery of comprehensive sexual health care, due to clinic
closures, staffing diversions, and related resource constraints. Necessary
social distancing measures also made it difficult to see patients (Krakower
et al., 2020; Nagendra et al., 2020; Pampati et al., 2020). Those working in
STI/HIV services are in a unique position to leverage their existing skill
sets to integrate public health and medical services for STIs alongside
COVID-19 and enhance preparedness for future public health threats.
Reinvesting in public health, specifically sexual health, can be critical to
controlling these health crises. Due to waning budgets, STI/HIV public
health work has developed the means to meet rising demands while limit-
ing costs. Express STI testing is one such innovation, where a triage-based,
patient-centered model has led to increased clinic capacity, decreased
costs, shortened visit times, and reduced time to treatment (Rukh et al.,
2014; Shamos et al., 2008). Many municipal clinics and community health
centers focused on traditional and express STI testing have successfully
converted existing workflows for high-throughput COVID-19 testing
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
636 SEXUALLY TRANSMITTED INFECTIONS
at minimal or no cost (Schneider and Pollack, 2020).15 Mobile STI/HIV
screening is another creative initiative that can economically reach large
at-risk communities, and these too have been transformed into COVID-19
testing venues (Schutz and Myers, 2020). DIS and partner services team
members trained in STI/HIV reporting and notification are highly skilled
contact tracers who may do the work themselves or oversee teams of more
junior staff. Public health workers already have pioneered large-scale
COVID-19 contact tracing efforts for major metropolitan cities (Chase and
Schuba, 2020; Schorsch, 2020). Lastly, those working in sexual health are
experienced in sustainable approaches to promote behavior modification
through understanding personal susceptibility and dismantling stigma.
These skills are essential in practical messaging around prevention for
both STIs and COVID-19 and will be critical as the United States prepares
for future crises.
Health care workers at the front lines of the COVID-19 pandemic
include critical care specialists and hospital staff, but also health care
workers assigned to outpatient services, including HIV and STI care. This
segment of the workforce is at higher risk of COVID-19 infection and
mental health symptoms, including anxiety and depression. In addition,
essential workers, laboratory staff, and other biomedical and support per-
sonnel have been shifted to respond to the pandemic. Preparedness might
allow for continuous HIV and STI care while responding to emerging epi-
demics. This alone supports the need to strengthen the STI workforce. The
United States is expected to need to continue to manage emerging infec-
tious disease epidemics, such as COVID-19 and pandemic influenza, with
some frequency in the future. National and statewide preparedness plans
and workforce development will fail to maintain or improve STI services
if pandemic preparedness plans do not consider needed mitigation for the
rise in STIs and allow for workforce development and logistical planning
(Nguyen et al., 2020; Rivara et al., 2020).
Management of STIs and Delivery of Sexual Health Care
During an Ongoing Pandemic
As the burden of COVID-19 in the United States continues to shift,
sexual health providers need to remain nimble to engage, protect, and
advocate for patients. When in-person patient–clinician contact is limited,
specific strategies can help meet these care delivery challenges (Napoleon
et al., 2020). Due to the need for physical examination and laboratory
15 See also, for example, Chicago: https://howardbrown.org/service/covid-19-services;
Fort Lauderdale: https://careresource.org/testing-hours-locations; New York City: https://
callen-lorde.org/covid-test (all accessed November 13, 2020).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PREPARING FOR THE FUTURE OF THE STI RESPONSE 637
diagnosis, sexual health clinics need to prioritize in-person encounters
for patients with STI symptoms or populations at risk for STI-related
complications (such as persons presenting with vaginal discharge and
abdominal pain, pregnancy, or symptoms that may indicate neurosyphi-
lis) (Bachmann et al., 2020). Telemedicine or other telehealth services can
be used for syndromic management of urethritis, suspected primary or
secondary syphilis, vaginal discharge, and proctitis (Barbee et al., 2020)
(see Chapter 7 for more information on syndromic management). In most
states, EPT for gonorrhea and chlamydia could be used more broadly to
help reduce reinfections within sexual networks (CDC, 2015) (see Chapter
10 for more on EPT). Novel STI care delivery models need to be explored
when facility-based services are limited by withdrawn elective medi-
cal services during COVID-19 outbreaks or concern about transmission
and exposure for patients and clinical staff. This is especially important
because the pandemic has caused decreased STI testing rates (Hoffman,
2020; Tao et al., 2021).
With or without the stress of COVID-19, STI services need to innovate
in the face of rising STI rates. One example is the mobile STI/HIV clinic
that has been shown to be an effective means to reach target populations
not served by municipal sexual health clinics (Ellen et al., 2003). While
successful in engaging marginalized populations and providing cost-
savings benefits, mobile health care has faced challenges integrating into
different health care systems (Yu et al., 2017). Notably, home-based STI/
HIV testing and PrEP services have shown high feasibility and accept-
ability in younger populations, particularly MSM and others with sexual
HIV transmission risk (CDC, 2019d; John et al., 2017). Many private-sector
initiatives already offer home-based STI testing (Frederiksen et al., 2020);
many of these were the first to try to develop and implement a home-
based testing model in the early days of the COVID-19 pandemic (FDA,
2020; KFF, 2020a). Investment in mobile health and home-based services
for STIs while in-person clinical encounters remain limited may be an
effective way to not only retain patients, but potentially engage new
populations when combined with COVID-19 screening, especially when
using rapid testing technologies.
Sexual Transmission of SARS-CoV-2
As with other respiratory infections, in-person contact, such as kiss-
ing, is considered high risk for SARS-CoV-2 transmission due to sharing
saliva and respiratory droplets. While studies have isolated SARS-CoV-2
in urine, stool, and human semen, transmission by these means has not
been established (Chen et al., 2020b; Li et al., 2020). Notably, SARS-CoV-2
has not been detected in vaginal secretions and is inconsistently identified
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
638 SEXUALLY TRANSMITTED INFECTIONS
in semen (Aitken, 2020; Delfino et al., 2020; Li et al., 2020; Qiu et al.,
2020). As with STIs, it is supposed that the infection risk increases with
the number of simultaneous partners; thus, group sex and other simi-
lar gatherings pose a greater threat. Lower-risk sexual activities would
include those that limit exposure to respiratory droplets, such as mutual/
self-masturbation, sex through a physical barrier, and cuddling with a
mask (BCCDC, n.d.; NYC Health, 2020; Turban et al., 2020). The potential
for SARS-CoV-2 to survive on surfaces for hours, and even on skin for 9
hours, presents an additional risk for transmission, although this is not
yet reported or confirmed (Hirose et al., 2020).
People already perform multiple, often simultaneous, risk calcula-
tions to make decisions around intimacy and sex; the COVID-19 pan-
demic adds another variable to these equations. By approaching this
with a harm reduction perspective, persons affected by COVID-19 will be
better able to advocate for their sexual health and participate in intimacy
while protecting themselves and those around them. A strategy com-
monly used in STI/HIV prevention efforts is to tighten a sexual network
by limiting activity to those people know. Similarly, reevaluating and
constricting one’s sexual network will also reduce the risk for COVID-19.
As people begin to engage and reengage in sexual activity, mitigating
SARS-CoV-2 infections resembles STIs in that testing may be advisable
before a sexual relationship. If affected persons routinely meet partners
outside their sexual network, such as through mobile applications, SARS-
CoV-2 screening at regular intervals (monthly or within 5–7 days of an
encounter) may be advisable (BCCDC, n.d.; NYC Health, 2020).
Social Determinants of Health Driving STI/HIV Epidemics
and COVID-19 Pandemic
The impacts of the ongoing STI/HIV epidemics and COVID-19 pan-
demic are not disparate health crises, but rather the result of the same
long-standing health inequities contributing to similar disparities in out-
comes (Millett et al., 2020a). As discussed in Chapters 2 and 3, there are
racial and ethnic disparities across all STIs, with higher rates of infections
in Black and Latino/a persons relative to their white counterparts (Yancy,
2020). Similarly, the most pervasive disparities in COVID-19 cases and
deaths are observed among Black, Latino/a, and Indigenous individuals
(Millett et al., 2020b; Rodriguez-Diaz et al., 2020).
The reasons behind these differences are more complex and nuanced
than race and ethnicity alone. The social determinants of health are the
overlapping social structures and economic systems that are responsible
for most health inequities (NASEM, 2017). Lack of access to health care,
inadequate housing, food insecurity, lack of employment, obesity, poverty,
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PREPARING FOR THE FUTURE OF THE STI RESPONSE 639
and other socioeconomic disadvantages are characteristics commonly
shared by patients facing COVID-19 in the context of rising rates of STI/
HIVs (Golestaneh et al., 2020; Holmes et al., 2020; Rentsch et al., 2020).
Addressing these factors, specifically as they pertain to racism, poverty,
and structural inequities, is critical to design and implement programs
that aim to reduce the burden of disease. The rapid emergence of clear
disparities by race and ethnicity for COVID-19 cases and deaths that
align with deep and persistent disparities in prevalence and access to STI
prevention and care show that not only does medical care need be rooted
in antiracism but it also needs to provide community-driven social and
structural support in order to begin addressing these disparities in health
outcomes (Webb Hooper et al., 2020; Yehia et al., 2020).
The nation would likely have been far better positioned to aggres-
sively mitigate COVID-19 from the start had it not reduced public health
investments for STI control, tuberculosis control, and other key infectious
disease control functions (Interlandi, 2020; Weber et al., 2020). Instead,
the disintegration of basic public health infrastructure at all levels has
provided an environment for COVID-19 and other emergent infectious
diseases to flourish. Unifying STI/HIV and COVID services through sus-
tained policy and funding support, however, could cultivate a pluripotent
public health workforce that could not only address these current crises,
but be poised to pivot toward future pandemic needs as well.
Conclusion 12-10: The COVID-19 pandemic has exposed weaknesses in pub-
lic health preparedness due to weak infrastructure, under-capacitated work-
force, and limited surge capacity. STIs are infectious diseases that require
testing, treatment, and partner notification, and the STI workforce has deep
expertise. Therefore, strengthening the STI infrastructure and expanding its
workforce offers the dual benefits of achieving better STI control and better
positioning the nation for future public health threats.
Address Structural Racism and Other Structural
Inequities That Hinder STI Control
For the nation to strengthen STI prevention, screening, and treatment
to effectively reduce the risk for and harms from STIs, it is necessary to
not only deal with individual factors and behaviors, but look broadly at
the aspects of society that generate and perpetuate inequity. As stated
in Recommendation 9-1, the Secretary of HHS should lead a whole-of-
government, interagency response to counter structural racism and other
structural inequities (such as societal-level policies, practices, and norms)
by developing a coordinated approach, in collaboration with affected
communities, to reduce STI outcomes and inequities.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
640 SEXUALLY TRANSMITTED INFECTIONS
Harnessing Technological Innovation to
Improve STI Prevention and Control
Technology and media have fundamentally changed since the release
of The Hidden Epidemic (IOM, 1997), but the angst over whether their use
will cause changes in behaviors in ways that enhance risk for STI acqui-
sition remains frequently expressed. As discussed in Chapter 6, this is
largely irrelevant because these tools are broadly used by the population
and the role they play in people’s lives can be expected to increase rather
than decrease. Recommendation 6-1 seeks to accept these technologies
and identify strategies to apply them for digital behavior change and in
other ways to strengthen STI prevention and control.
CONCLUDING OBSERVATIONS
As noted in Chapter 1, the committee’s primary focus was on provid-
ing clear policy guidance and a framework for action; it does not uniformly
provide specific implementation steps or metrics for each recommenda-
tion, as this requires a more in-depth understanding of STI resources,
policies, and other circumstances at the state, local, and federal levels.
As stakeholders address the recommendations in this report, however,
implementation strategies that address barriers that impede the adoption
and scale-up of evidence-based behavioral, biomedical, and structural
interventions need to be developed and evaluated. This includes study
designs, such as hybrid designs, that simultaneously address the effec-
tiveness of interventions and important implementation science questions
(Curran et al., 2012; see Chapter 8 for more information). Furthermore,
the successful implementation of effective STI interventions requires an
understanding of stigma, discrimination, and lack of access to health
care, among other macrosystemic factors (Eisinger et al., 2019). Imple-
mentation strategies need to address these important factors. Finally, the
implementation plan for HHS’s STI-NSP provides a valuable opportunity
to highlight the importance of implementation science in the prevention
and control of STIs, much like the Ending the Epidemic Initiative does for
HIV (Eisinger et al., 2019).
People have a universal desire for health for themselves and their
families, and hopefully for their communities and society at large. Sexual
health is an essential component of overall health. Health is often defined
as being free from illness or injury, so this also needs to include being
free from STIs and other forms of disease. Therefore, expanding tools
and knowledge to better prevent, screen for, and treat STIs is a critical
endeavor. The framework adopted by the committee for conducting its
examination, however, is much more expansive than such a narrow vision
of health. Indeed, protecting the public from STIs is simply a critical first
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PREPARING FOR THE FUTURE OF THE STI RESPONSE 641
step toward a future that embraces a broad definition of wellness and
well-being that considers being sexually healthy, being able to experience
pleasure, and maintaining varied and meaningful relationships of one’s
own choosing as the essence of being human.
REFERENCES
Adimora, A. A., and J. D. Auerbach. 2010. Structural interventions for HIV prevention in the
United States. Journal of Acquired Immune Deficiency Syndromes 55:S132-S135.
Aggleton, P., and C. Campbell. 2000. Working with young people—towards an agenda for
sexual health. Sexual and Relationship Therapy 15(3):283-296.
Aitken, R. J. 2020. COVID-19 and human spermatozoa—potential risks for infertility and
sexual transmission. Andrology 9:48-52.
Albalate, D., and P. Bel-Piñana. 2019. The effects of public private partnerships on road safety
outcomes. Accident Analysis and Prevention 128:53-64.
Albis, M. L. F., S. K. Bhadra, and B. Chin. 2019. Impact evaluation of contracting primary
health care services in urban Bangladesh. BMC Health Services Research 19(1):854.
Alirol, E. 2019 (October). GARDP sexually transmitted infections program. Presentation to the
Committee on Sexually Transmitted Infections in the United States, Washington, DC
(October 7). https://www.nationalacademies.org/event/10-27-2019/docs/D738BC46
7711A89DE1858C806A69911041F9EA9CC58B (accessed February 18, 2021).
Allem, J.-P., E. C. Leas, T. L. Caputi, M. Dredze, B. M. Althouse, S. M. Noar, and J. W. Ayers.
2017. The Charlie Sheen effect on rapid in-home human immunodeficiency virus test
sales. Prevention Science 18(5):541-544.
Allen, J. P., R. K. Narr, J. Kansky, and D. E. Szwedo. 2020. Adolescent peer relationship quali-
ties as predictors of long-term romantic life satisfaction. Child Development 91(1):327-340.
Arnold, E. A., and M. M. Bailey. 2009. Constructing home and family: How the ballroom
community supports African American GLBTQ youth in the face of HIV/AIDS. Journal
of Gay & Lesbian Social Services 21(2-3):171-188.
ASHA (American Sexual Health Association). 2020. Understanding sexual health. http://
www.ashasexualhealth.org/sexual-health (accessed May 15, 2020).
Ashcraft, A. M., and P. J. Murray. 2017. Talking to parents about adolescent sexuality. Pedi-
atric Clinics of North America 64(2):305-320.
ASTHO (Association of State and Territorial Health Officials). 2012. The economic case for
health equity. https://www.astho.org/Programs/Health-Equity/Economic-Case-Issue-
Brief (accessed October 25, 2020).
Awale, J., M. Choudhary, R. Solomon, and A. Chaturvedi. 2019. Effective partnership mecha-
nisms: A legacy of the polio eradication initiative in India and their potential for ad-
dressing other public health priorities. American Journal of Tropical Medicine and Hygiene
101:21-32.
Bachmann, L., P. Thorpe, G. Bolan, and J. Mermin. 2020. Dear colleague letter STD treatment
options. https://www.cdc.gov/std/dstdp/DCL-STDTreatment-COVID19-04062020.
pdf (accessed November 4, 2020).
Bailey, M. M. 2009. Performance as intravention: Ballroom culture and the politics of HIV/
AIDS in Detroit. Souls 11(3):253-274.
Barbee, L. A., and M. R. Golden. 2020. Aztreonam for Neisseria gonorrhoeae: A systematic
review and meta-analysis. Journal of Antimicrobial Chemotherapy 75(7):1685-1688.
Barbee, L. A., J. C. Dombrowski, S. Hermann, B. J. Werth, M. Ramchandani, N. Ocbamichael,
E. Barash, and M. R. Golden. 2020. “Sex in the time of COVID”: Clinical guidelines
for sexually transmitted disease management in an era of social distancing. Sexually
Transmitted Diseases 47(7):427-430.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
642 SEXUALLY TRANSMITTED INFECTIONS
Barclay, L. 2019. ASHA presentation: Understanding the patient perspective: Presented at
Meeting 2 of the Committee on Prevention and Control of Sexually Transmitted Infec-
tions in the United States.
BCCDC (British Columbia Centre for Disease Control). n.d. COVID-19 and sex. http://www.
bccdc.ca/health-info/diseases-conditions/covid-19/prevention-risks/covid-19-and-
sex (accessed July 22, 2020).
Bornstein, M. H., and D. L. Putnick. 2018. Parent–adolescent relationships in global perspec-
tive. In Handbook of adolescent development research and its impact on global policy, edited
by J. E. Lansford and P. Banati. Oxford University Press. P. 107.
Bradford, P. A., A. A. Miller, J. O’Donnell, and J. P. Mueller. 2020. Zoliflodacin: An oral
spiropyrimidinetrione antibiotic for the treatment of Neisseria gonorrheae, including
multi-drug-resistant isolates. ACS Infectious Diseases 6(6):1332-1345.
Brady, L. S., and W. Z. Potter. 2014. Public–private partnerships to revitalize psychiatric drug
discovery. Expert Opinion on Drug Discovery 9(1):1-8.
Brandwatch. 2020. The most followed accounts on Twitter. https://www.brandwatch.com/
blog/most-twitter-followers (accessed November 17, 2020).
Brawner, B. M., J. L. Baker, J. Stewart, Z. M. Davis, J. Cederbaum, and L. S. Jemmott. 2013.
“The black man’s country club”: Assessing the feasibility of an HIV risk-reduction
program for young heterosexual African American men in barbershops. Family & Com-
munity Health 36(2):109-118.
Brigham, K. S., M. J. Peer, B. B. Ghoshhajra, and J. P. T. Co. 2020. Increasing vaginal Chlamydia
trachomatis testing in adolescent and young adults. Pediatrics 146(2).
Byrd, A. 2018. Sexual health experts on why “Insecure” needs to practice safer sex. https://www.
colorlines.com/articles/sexual-health-experts-why-insecure-needs-practice-safer-sex
(accessed November 3, 2020).
Cameron, A., E. Smith, N. Mercer, and B. Sundstrom. 2020. “It is our duty”: Understanding
parents’ perspectives on reproductive and sexual health education. Sexual Education
20(5):535-551.
Campos, K. D. P., J. Cohen, D. Gastaldo, and A. Jadad. 2019. Public–private partnership
(PPP) development: Toward building a PPP framework for healthy eating. The Interna-
tional Journal of Health Planning and Management 34:e142-e156.
CDC (Centers for Disease Control and Prevention). 2015. 2015 sexually transmitted diseases
treatment guidelines. https://www.cdc.gov/std/tg2015/default.htm (accessed October
22, 2019).
CDC. 2019a. BRTA in business. https://www.cdc.gov/hiv/workplace/business.html (ac-
cessed November 4, 2020).
CDC. 2019b. GYT: Get yourself tested. https://www.cdc.gov/std/sam/gyt/default.htm (ac-
cessed October 29, 2020).
CDC. 2019c. PS18-1807 program guidance: Guidance for school-based HIV/STD prevention (com-
ponent 2) recipients of PS18-1807 Washington, DC: Department of Health and Human
Services. https://www.cdc.gov/healthyyouth/fundedprograms/1807/resources/
PS18-1807-GUIDANCE508.pdf (accessed February 19, 2021).
CDC. 2019d. Sexually transmitted disease surveillance 2018. Atlanta, GA: Department of Health
and Human Services.
CDC. 2019e. What is BRTA? https://www.cdc.gov/hiv/workplace/index.html (accessed
November 4, 2020).
CDC. 2020. Community approaches to reducing sexually transmitted diseases. https://www.cdc.
gov/std/health-disparities/cars.htm (accessed October 25, 2020).
Chase, B., and T. Schuba. 2020. Hang-ups, lies and wrong numbers: Contact tracers’
uphill fight against COVID-19. Chicago Sun-Times. https://chicago.suntimes.com/
coronavirus/2020/7/31/21345926/contact-tracers-tracing-coronavirus-covid19-
illinois-pritzker-howard-brown (accessed November 4, 2020).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PREPARING FOR THE FUTURE OF THE STI RESPONSE 643
Chen, E., C. Leos, S. D. Kowitt, and K. E. Moracco. 2020a. Enhancing community-based
participatory research through human-centered design strategies. Health Promotion
Practice 21(1):37-48.
Chen, M. Y., A. McNulty, A. Avery, D. Whiley, S. N. Tabrizi, D. Hardy, A. F. Das, A. Nen-
ninger, C. K. Fairley, J. S. Hocking, C. S. Bradshaw, B. Donovan, B. P. Howden, D.
Oldach, and U. T. Solitaire. 2019. Solithromycin versus ceftriaxone plus azithromycin
for the treatment of uncomplicated genital gonorrhoea (SOLITAIRE-U): A randomised
phase 3 non-inferiority trial. Lancet Infectious Diseases 19(8):833-842.
Chen, Y., L. Chen, Q. Deng, G. Zhang, K. Wu, L. Ni, Y. Yang, B. Liu, W. Wang, C. Wei, J. Yang,
G. Ye, and Z. Cheng. 2020b. The presence of SARS-CoV-2 RNA in the feces of COVID-19
patients. Journal of Medical Virology 92(7):833-840.
Chin, H. B., T. A. Sipe, R. Elder, S. L. Mercer, S. K. Chattopadhyay, V. Jacob, H. R. Wethington,
D. Kirby, D. B. Elliston, M. Griffith, S. O. Chuke, S. C. Briss, I. Ericksen, J. S. Galbraith,
J. H. Herbst, R. L. Johnson, J. M. Kraft, S. M. Noar, L. M. Romero, and J. Santelli. 2012.
The effectiveness of group-based comprehensive risk-reduction and abstinence educa-
tion interventions to prevent or reduce the risk of adolescent pregnancy, human im-
munodeficiency virus, and sexually transmitted infections: Two systematic reviews for
the guide to community preventive services. American Journal of Preventative Medicine
42(3):272-294.
Clark, K., J. B. Fletcher, I. W. Holloway, and C. J. Reback. 2018. Structural inequities and
social networks impact hormone use and misuse among transgender women in Los
Angeles County. Archives of Sexual Behavior 47(4):953-962.
clinicalinfo.hiv.gov. n.d. Clinical guidelines. https://clinicalinfo.hiv.gov/en/guidelines (ac-
cessed November 17, 2020).
Cohen, A. C., F. Zimmerman, M. Prelip, and D. Glik. 2017. A smartphone application to
reduce time-to-notification of sexually transmitted infections. American Journal of Public
Health 107(11):1795-1800.
Cordova, D., F. Alers-Rojas, F. M. Lua, J. Bauermeister, R. Nurenberg, L. Ovadje, K. Fessler,
J. Delva, C. P. Salas-Wright, and Y. L. Council. 2018. The usability and acceptability of
an adolescent mhealth HIV/STI and drug abuse preventive intervention in primary
care. Behavioral Medicine 44(1):36-47.
Coyne, S. M., L. M. Ward, S. L. Kroff, E. J. Davis, H. G. Holmgren, A. C. Jensen, S. E. Er-
ickson, and L. W. Essig. 2019. Contributions of mainstream sexual media exposure to
sexual attitudes, perceived peer norms, and sexual behavior: A meta-analysis. Journal
of Adolescent Health 64(4):430-436.
Cristillo, A. D., C. C. Bristow, E. Torrone, J. A. Dillon, R. D. Kirkcaldy, H. Dong, Y. H. Grad,
R. A. Nicholas, P. A. Rice, K. Lawrence, D. Oldach, W. M. Shafer, P. Zhou, T. E. Wi, S.
R. Morris, and J. D. Klausner. 2019. Antimicrobial resistance in Neisseria gonorrhoeae:
Proceedings of the STAR sexually transmitted infection-clinical trial group program-
matic meeting. Sexually Transmitted Diseases 46(3):e18-e25.
Curran, G. M., M. Bauer, B. Mittman, J. M. Pyne, and C. Stetler. 2012. Effectiveness-
implementation hybrid designs: Combining elements of clinical effectiveness and
implementation research to enhance public health impact. Medical Care 50(3):217-226.
Davis, K. C., W. D. Evans, and K. Kamyab. 2012. Effectiveness of a national media cam-
paign to promote parent–child communication about sex. Health Education & Behavior
40(1):97-106.
DeHaven, M. J., I. B. Hunter, L. Wilder, J. W. Walton, and J. Berry. 2004. Health programs
in faith-based organizations: Are they effective? American Journal of Public Health
94(6):1030-1036.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
644 SEXUALLY TRANSMITTED INFECTIONS
Delfino, M., M. Guida, A. Patrì, L. Spirito, L. Gallo, and G. Fabbrocini. 2020. SARS-CoV-2
possible contamination of genital area: Implications for sexual and vertical transmission
routes. Journal of the European Academy of Dermatology and Venereology 34(8):e364-e365.
Della Rocca, M. 2107. The rising advantage of public–private partnerships. https://www.
mckinsey.com/industries/private-equity-and-principal-investors/our-insights/the-
rising-advantage-of-public-private-partnerships (accessed November 4, 2020).
Denford, S., C. Abraham, R. Campbell, and H. Busse. 2017. A comprehensive review of re-
views of school-based interventions to improve sexual-health. Health Psychology Review
11(1):33-52.
Dickson-Gomez, J., J. Owczarzak, J. St Lawrence, C. Sitzler, K. Quinn, B. Pearson, J. A. Kelly,
and Y. A. Amirkhanian. 2014. Beyond the ball: Implications for HIV risk and preven-
tion among the constructed families of African American men who have sex with men.
AIDS and Behavior 18(11):2156-2168.
Direct Relief. 2018. Medicines360 and direct relief partner to expand access for U.S. women. https://
www.directrelief.org/2018/08/medicines360-and-direct-relief-partner-to-expand-
access-for-u-s-women/#:~:text=Medicines360%2C%20a%20mission%2Ddriven%20
women’s,States%2C%20such%20as%20uninsured%20women (accessed October 25,
2020).
Dittus, P. J., S. L. Michael, J. S. Becasen, K. M. Gloppen, K. McCarthy, and V. Guilamo-Ramos.
2015. Parental monitoring and its associations with adolescent sexual risk behavior: A
meta-analysis. Pediatrics 136(6):e1587-e1599.
Downs, J. S., A. M. Ashcraft, P. J. Murray, E. D. Berlan, W. Bruine de Bruin, J. Eichner, B.
Fischhoff, J. M. Leary, R. B. McCall, E. Miller, J. Salaway, J. Smith-Jones, and G. S.
Sucato. 2018. Video intervention to increase perceived self-efficacy for condom use in
a randomized controlled trial of female adolescents. Journal of Pediatric and Adolescent
Gynecology 31(3):291-298.
Earl, A., and D. Albarracín. 2007. Nature, decay, and spiraling of the effects of fear-inducing
arguments and HIV counseling and testing: A meta-analysis of the short- and long-term
outcomes of HIV-prevention interventions. Health Psychology 26(4):496-506.
Eisinger, R. W., C. W. Dieffenbach, and A. S. Fauci. 2019. Role of implementation science:
Linking fundamental discovery science and innovation science to ending the HIV
epidemic at the community level. Journal of Acquired Immune Deficiency Syndromes
82(Suppl 3):S171-S172.
Ellen, J. M., S. Bonu, J. S. Arruda, M. A. Ward, and R. Vogel. 2003. Comparison of clients of
a mobile health van and a traditional STD clinic. Journal of Acquired Immune Deficiency
Syndromes 32(4):388-393.
Espinosa-Hernández, G., S. Choukas-Bradley, D. van de Bongardt, and M. Van Dulmen.
2020. Romantic relationships and sexuality in diverse adolescent populations: Introduc-
tion to the special issue. Journal of Adolescence 83:95-99.
Estrada, Y., T. K. Lee, S. Huang, M. I. Tapia, M. R. Velázquez, M. J. Martinez, H. Pantin, M.
A. Ocasio, D. C. Vidot, L. Molleda, J. Villamar, B. A. Stepanenko, C. H. Brown, and G.
Prado. 2017. Parent-centered prevention of risky behaviors among Hispanic youths in
Florida. American Journal of Public Health 107(4):607-613.
Ethier, K. A., P. J. Dittus, C. J. DeRosa, E. Q. Chung, E. Martinez, and P. R. Kerndt. 2011.
School-based health center access, reproductive health care, and contraceptive
use among sexually experienced high school students. Journal of Adolescent Health
48(6):562-565.
FDA (Food and Drug Administration). 2020. Coronavirus (COVID-19) update: FDA authorizes
first standalone at-home sample collection kit that can be used with certain authorized tests.
https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-
update-fda-authorizes-first-standalone-home-sample-collection-kit-can-be-used
(accessed October 25, 2020).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PREPARING FOR THE FUTURE OF THE STI RESPONSE 645
Fine, D., L. Warner, S. Salomon, and D. M. Johnson. 2017. Interventions to increase male
attendance and testing for sexually transmitted infections at publicly-funded family
planning clinics. Journal of Adolescent Health 61(1):32-39.
Fobosi, S. C., S. T. Lalla-Edward, S. Ncube, F. Buthelezi, P. Matthew, A. Kadyakapita, M.
Slabbert, C. A. Hankins, W. D. F. Venter, and G. B. Gomez. 2017. Access to and utilisa-
tion of healthcare services by sex workers at truck-stop clinics in South Africa: A case
study. South African Medical Journal 107(11):994-999.
Foerster, S., G. Drusano, D. Golparian, M. Neely, L. J. V. Piddock, E. Alirol, and M. Unemo.
2019. In vitro antimicrobial combination testing of and evolution of resistance to the
first-in-class spiropyrimidinetrione zoliflodacin combined with six therapeutically rel-
evant antimicrobials for Neisseria gonorrhoeae. Journal of Antimicrobial Chemotherapy
74(12):3521-3529.
Foster, C. E., A. Horwitz, A. Thomas, K. Opperman, P. Gipson, A. Burnside, D. M. Stone, and
C. A. King. 2017. Connectedness to family, school, peers, and community in socially
vulnerable adolescents. Child and Youth Services Review 81:321-331.
Frederiksen, B., I. Ivette Gomez, and A. Salganicoff. 2020. A look at online platforms for
contraceptive and STI services during the COVID-19 pandemic. Kaiser Family Foundation.
https://www.kff.org/womens-health-policy/issue-brief/a-look-at-online-platforms-
for-contraceptive-and-sti-services-during-the-covid-19-pandemic (accessed October 10,
2020).
Golestaneh, L., J. Neugarten, M. Fisher, H. H. Billett, M. R. Gil, T. Johns, M. Yunes, M. H.
Mokrzycki, M. Coco, K. C. Norris, H. R. Perez, S. Scott, R. S. Kim, and E. Bellin. 2020.
The association of race and COVID-19 mortality. EClinicalMedicine 25:100455.
Granados Moreno, P., Y. Joly, and B. M. Knoppers. 2017. Public–private partnerships in
cloud-computing services in the context of genomic research. Frontiers in Medicine 4:3.
Grossman, J. M., A. J. Tracy, A. M. Richer, and S. Erkut. 2015. The role of extended family in
teen sexual health. Journal of Adolescent Research 30(1):31-56.
GuideStar. n.d. Corporate alliance to end partner violence. https://www.guidestar.org/
profile/37-1347657 (accessed December 7, 2020).
Guilamo-Ramos, V., J. Jaccard, P. Dittus, A. Bouris, B. Gonzalez, E. Casillas, and S. Banspach.
2011. A comparative study of interventions for delaying the initiation of sexual
intercourse among Latino and black youth. Perspectives on Sexual Reproductive Health
43(4):247-254.
Guilamo-Ramos, V., A. Bouris, J. Lee, K. McCarthy, S. L. Michael, S. Pitt-Barnes, and P. Dit-
tus. 2012. Paternal influences on adolescent sexual risk behaviors: A structured litera-
ture review. Pediatrics 130(5):e1313-e1325.
Guilamo-Ramos, V., J. J. Lee, and J. Jaccard. 2016. Parent-adolescent communication about
contraception and condom use. JAMA Pediatrics 170(1):14-16.
Guilamo-Ramos, V., A. S. Bowman, D. Santa Maria, F. Kabemba, and Y. Geronimo. 2018.
Addressing a critical gap in U.S. national teen pregnancy prevention programs: The ac-
ceptability and feasibility of father-based sexual and reproductive health interventions
for Latino adolescent males. Journal of Adolescent Health 62(3 Suppl):S81-S86.
Guilamo-Ramos, V., A. Benzekri, and M. Thimm-Kaiser. 2019a. Parent-based interventions
to affect adolescent sexual and reproductive health: Reconsidering the best evidence
vs. all evidence. JAMA Pediatrics 173(9):821-823.
Guilamo-Ramos, V., M. Thimm-Kaiser, A. Benzekri, C. Rodriguez, T. Fuller, L. Warner, and
E. Koumans. 2019b. Father-son communication about consistent and correct condom
use. Pediatrics 143:e20181609.
Guilamo-Ramos, V., A. Benzekri, M. Thimm-Kaiser, P. Dittus, Y. Ruiz, C. M. Cleland, and W.
McCoy. 2020. A triadic intervention for adolescent sexual health: A randomized clinical
trial. Pediatrics 145(5):e20192808.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
646 SEXUALLY TRANSMITTED INFECTIONS
Guyer, A. E., J. M. Jarcho, K. Pérez-Edgar, K. A. Degnan, D. S. Pine, N. A. Fox, and E. E.
Nelson. 2015. Temperament and parenting styles in early childhood differentially
influence neural response to peer evaluation in adolescence. Journal of Abnormal Child
Psychology 43(5):863-874.
Henderson, J. T., C. A. Senger, M. Henninger, S. I. Bean, N. Redmond, and E. A. O’Connor.
2020. Behavioral counseling interventions to prevent sexually transmitted infections:
Updated evidence report and systematic review for the U.S. Preventive Services Task
Force. JAMA 324(7):682-699.
Hernandez-Aguado, I., and G. A. Zaragoza. 2016. Support of public–private partnerships in
health promotion and conflicts of interest. BMJ Open 6(4):e009342.
HHS (Department of Health and Human Services). 2020. National Strategic Plan: A roadmap to
end the epidemic for the United States 2021-2025. Washington, DC: Department of Health
and Human Services.
Higgins, J. A., M. Mullinax, J. Trussell, J. K. Davidson, Sr., and N. B. Moore. 2011. Sexual
satisfaction and sexual health among university students in the United States. American
Journal of Public Health 101(9):1643-1654.
Hirose, R., H. Ikegaya, Y. Naito, N. Watanabe, T. Yoshida, R. Bandou, T. Daidoji, Y. Itoh, and
T. Nakaya. 2020. Survival of severe acute respiratory syndrome coronavirus 2 (SARS-
CoV-2) and influenza virus on human skin: Importance of hand hygiene in coronavirus
disease 2019 (COVID-19). Clinical Infectious Diseases. doi: 10.1093/cid/ciaa1517.
HIV.gov. n.d. Campaigns. https://www.hiv.gov/federal-response/campaigns (accessed Oc-
tober 25, 2020).
Hoddinott, J., S. Gillespie, and S. Yosef. 2016. Public–private partnerships and undernutri-
tion: Examples and future prospects. World Review of Nutrition and Dietetics 115:233-238.
Hoffman, J. 2020. People are still having sex. So why are S.T.D. rates dropping? https://www.nytimes.
com/2020/10/28/health/covid-std-testing.html?action=click&module=Top%20
Stories&pgtype=Homepage (accessed November 13, 2020).
Holeywell, R. 2013. Public–private partnerships are popular, but are they practical? https://www.
governing.com/topics/transportation-infrastructure/gov-public-private-popular.html
(accessed November 4, 2020).
Holmes, L., Jr., M. Enwere, J. Williams, B. Ogundele, P. Chavan, T. Piccoli, C. Chinacherem,
C. Comeaux, L. Pelaez, O. Okundaye, L. Stalnaker, F. Kalle, K. Deepika, G. Philipcien,
M. Poleon, G. Ogungbade, H. Elmi, V. John, and K. W. Dabney. 2020. Black-white risk
differentials in COVID-19 (SARS-COV2) transmission, mortality and case fatality in
the United States: Translational epidemiologic perspective and challenges. International
Journal of Environmental Research and Public Health 17(12).
Hook, E. W., 3rd, M. R. Golden, S. N. Taylor, E. Henry, C. Tseng, K. A. Workowski, J. Swerd-
low, A. Nenninger, and S. Cammarata. 2019. Efficacy and safety of single-dose oral
delafloxacin compared with intramuscular ceftriaxone for uncomplicated gonorrhea
treatment: An open-label, noninferiority, phase 3, multicenter, randomized study. Sexu-
ally Transmitted Diseases 46(5):279-286.
Horne, S. G., H. M. Levitt, K. K. Sweeney, J. A. Puckett, and M. L. Hampton. 2015. African
American gay family networks: An entry point for HIV prevention. Journal of Sex Re-
search 52(7):807-820.
Hutchinson, P., and R. Dhairyawan. 2018. Shame and HIV: Strategies for addressing the
negative impact shame has on public health and diagnosis and treatment of HIV.
Bioethics 32(1):68-76.
Interlandi, J. 2020. The U.S. approach to public health: Neglect, panic, repeat. The New York
Times, April 9.
IOM (Institute of Medicine). 1997. The hidden epidemic: Confronting sexually transmitted dis-
eases. Washington, DC: National Academy Press.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PREPARING FOR THE FUTURE OF THE STI RESPONSE 647
Jacobsson, S., R. Kularatne, R. Kittiyaowamarn, V. Maseko, P. Paopang, P. Sangprasert, P.
Sirivongrangson, L. Piddock, T. Wi, E. Alirol, and M. Unemo. 2019. High in vitro sus-
ceptibility to the first-in-class spiropyrimidinetrione zoliflodacin among consecutive
clinical Neisseria gonorrhoeae isolates from Thailand (2018) and South Africa (2015-2017).
Antimicrobial Agents and Chemotherapy 63(12):e01479-19.
Jamison, T. B., and H. Y. Lo. 2020. Exploring parents’ ongoing role in romantic development:
Insights from young adults. Journal of Social and Personal Relationships 38(1):84-102.
Jane, B., and K. Gibson. 2018. Corporate sponsorship of physical activity promotion
programmes: Part of the solution or part of the problem? Journal of Public Health
40(2):279-288.
John, S. A., H. J. Rendina, C. Grov, and J. T. Parsons. 2017. Home-based pre-exposure pro-
phylaxis (PrEP) services for gay and bisexual men: An opportunity to address barriers
to PrEP uptake and persistence. PLoS One 12(12):e0189794.
Johnson-Motoyama, M., M. Moses, T. K. Kann, E. S. Mariscal, M. Levy, C. Navarro, and
P. J. Fite. 2016. Parent, teacher, and school stakeholder perspectives on adolescent
pregnancy prevention programming for Latino youth. Journal of Primary Prevention
37(6):513-525.
Kalmuss, D., and C. Tatum. 2007. Patterns of men’s use of sexual and reproductive health
services. Perspectives on Sexual and Reproductive Health 39(2):74-81.
Kamugumya, D., and J. Olivier. 2016. Health system’s barriers hindering implementation
of public–private partnership at the district level: A case study of partnership for
improved reproductive and child health services provision in Tanzania. BMC Health
Services Research 16(1):596.
KFF (Kaiser Family Foundation). 2020a. At-home SARS-CoV-2 testing: What are the options?
Kaiser Family Foundation. https://www.kff.org/interactive/at-home-sars-cov-2-
testing-what-are-the-options (accessed October 10, 2020).
KFF. 2020b. Greater than AIDS, with support from Walgreens and Orasure technologies, to provide
10,000 free in-home HIV tests to community partners. https://www.kff.org/hivaids/press-
release/greater-than-aids-with-support-from-walgreens-and-orasure-technologies-to-
provide-10000-free-in-home-hiv-tests-to-community-partners (accessed October 25,
2020).
KFF. n.d. BET Rap-It-Up PSAs. https://www.kff.org/bet-rap-it-up-psas (accessed October
29, 2020).
Kirby, D. 2007. Emerging answers: Research findings on programs to reduce teen pregnancy and
sexually transmitted diseases. https://powertodecide.org/sites/default/files/resources/
primary-download/emerging-answers.pdf (accessed November 12, 2020).
Kokku, S. B., B. Mahapatra, S. Tucker, N. Saggurti, and P. Prabhakar. 2014. Effect of pub-
lic–private partnership in treatment of sexually transmitted infections among female
sex workers in Andhra Pradesh, India. Indian Journal of Medical Research 139(2):285-293.
Kornides, M. L., A. L. McRee, and M. B. Gilkey. 2018. Parents who decline HPV vaccination:
Who later accepts and why? Academic Pediatrics 18(2 Suppl):S37-S43.
Krakower, D. S., P. Solleveld, K. Levine, and K. H. Mayer. 2020. Abstract oaclb0104: Impact of
COVID-19 on HIV preexposure prophylaxis care at a Boston community health center. Paper
presented at 23rd International AIDS Conference.
Kresovich, A., and S. M. Noar. 2020. The power of celebrity health events: Meta-analysis of
the relationship between audience involvement and behavioral intentions. Journal of
Health Communication 1-13.
Ksinan Jiskrova, G., and A. T. Vazsonyi. 2019. Multi-contextual influences on adolescent
pregnancy and sexually transmitted infections in the United States. Social Science &
Medicine 224:28-36.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
648 SEXUALLY TRANSMITTED INFECTIONS
Lack, A., M. Hiligsmann, P. Bloem, M. Tünneßen, and R. Hutubessy. 2020. Parent, provider
and vaccinee preferences for HPV vaccination: A systematic review of discrete choice
experiments. Vaccine 38(46):7226-7238.
Lamblin, M., C. Murawski, S. Whittle, and A. Fornito. 2017. Social connectedness, mental
health and the adolescent brain. Neuroscience and Biobehavioral Reviews 80:57-68.
Lane, K., E. Miller, L. Kisloff, and H. C. Wiesenfeld. 2020. Many parents would accept sexu-
ally transmitted infection screening for their adolescent at a pediatric office visit. Journal
of Adolescent Health 66(5):626-628.
Lee, G. Y., and D. Y. Lee. 2019. Effects of a life skills-based sexuality education programme
on the life-skills, sexuality knowledge, self-management skills for sexual health, and
programme satisfaction of adolescents. Sex Education 19(5):519-533.
Leichliter, J. S., C. Copen, and P. J. Dittus. 2017. Confidentiality issues and use of sexually
transmitted disease services among sexually experienced persons aged 15-25 years—
United States, 2013-2015. Morbidity and Mortality Weekly Report 66(9):237-241.
Li, D., M. Jin, P. Bao, W. Zhao, and S. Zhang. 2020. Clinical characteristics and results of se-
men tests among men with coronavirus disease 2019. JAMA Network Open 3(5):e208292.
Linnander, E., C. T. Yuan, S. Ahmed, E. Cherlin, K. Talbert-Slagle, and L. A. Curry. 2017.
Process evaluation of knowledge transfer across industries: Leveraging Coca-Cola’s
supply chain expertise for medicine availability in Tanzania. PLoS One 12(11):e0186832.
Lopez, L. M., T. W. Grey, M. Chen, E. E. Tolley, and L. L. Stockton. 2016. Theory-based in-
terventions for contraception. Cochrane Database Systematic Reviews 11(11):CD007249.
Mahat, G., M. A. Scoloveno, and R. Scoloveno. 2016. HIV/AIDS knowledge, self-efficacy
for limiting sexual risk behavior and parental monitoring. Journal of Pediatric Nursing
31(1):e63-e69.
Maynard, M. 2017. Faith-based institutions as venues for obesity prevention. Current Obesity
Reports 6.
McKay, E. A., and H. B. Fontenot. 2020. Parent–adolescent sex communication with
sexual and gender minority youth: An integrated review. Journal of Pediatric Health
34(5):e37-e48.
Miles, K., M. Conlon, J. Stinshoff, and R. Hutton. 2014. Public–private partnerships in the
response to HIV: Experience from the resource industry in Papua New Guinea. Rural
Remote Health 14(3):2868.
Millett, G. A., B. Honermann, A. Jones, E. Lankiewicz, J. Sherwood, S. Blumenthal, and A.
Sayas. 2020a. White counties stand apart: The primacy of residential segregation in
COVID-19 and HIV diagnoses. AIDS Patient Care and STDs 34(10):417-424.
Millett, G. A., A. T. Jones, D. Benkeser, S. Baral, L. Mercer, C. Beyrer, B. Honermann, E.
Lankiewicz, L. Mena, J. S. Crowley, J. Sherwood, and P. S. Sullivan. 2020b. Assess-
ing differential impacts of COVID-19 on Black communities. Annals of Epidemiology
47:37-44.
Mitchell, K. 2018. In the wake of frightening new STD stats, the missing condoms on “Insecure”
are even more striking. https://rewirenewsgroup.com/article/2018/09/13/in-the-wake-
of-frightening-new-std-stats-the-missing-condoms-on-insecure-are-even-more-striking
(accessed November 3, 2020).
Montaño, M. A., J. C. Dombrowski, S. Dasgupta, M. R. Golden, A. Duerr, L. E. Manhart, L.
A. Barbee, and C. M. Khosropour. 2019. Changes in sexual behavior and STI diagnoses
among MSM initiating PrEP in a clinic setting. AIDS and Behavior 23(2):548-555.
Morris, A. S., L. M. Squeglia, J. Jacobus, and J. S. Silk. 2018. Adolescent brain development:
Implications for understanding risk and resilience processes through neuroimaging
research. Journal of Research on Adolescence 28(1):4-9.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PREPARING FOR THE FUTURE OF THE STI RESPONSE 649
Morris, J. L., S. A. Lippman, S. Philip, K. Bernstein, T. B. Neilands, and M. Lightfoot. 2014.
Sexually transmitted infection related stigma and shame among African American
male youth: Implications for testing practices, partner notification, and treatment. AIDS
Patient Care and STDs 28(9):499-506.
Moss, R. D. 2018. Is it safe? How Insecure can be a force in shaping Black women’s sexual
health. https://www.theroot.com/is-it-safe-how-insecure-can-be-a-force-in-shaping-
blac-1829120278 (accessed November 3, 2020).
Myer, L., C. Morroni, C. Mathews, and M. Tholandi. 2001. Structural and community-level
interventions for increasing condom use to prevent HIV and other sexually transmitted
infections. Cochrane Database of Systematic Reviews (4).
NACCHO (National Association of County and City Health Officials). 2020. NACCHO’s
2019 profile study: Local health department capacity to prepare for and respond to public health
threats. Washington, DC: National Association of County and City Health Officials.
Nagendra, G., C. Carnevale, N. Neu, A. Cohall, and J. Zucker. 2020. The potential impact
and availability of sexual health services during the COVID-19 pandemic. Sexually
Transmitted Diseases 47(7):434-436.
NAPA (National Academy of Public Administration). 2018. The impact of sexually transmitted
diseases on the United States: Still hidden, getting worse, can be controlled. Washington, DC:
National Academy of Public Administration.
NAPA. 2019. The STD epidemic in America: The frontline struggle. Washington, DC: National
Academy of Public Administration.
Napoleon, S. C., M. A. Maynard, A. Almonte, K. Cormier, T. Bertrand, K. L. Ard, and P. A.
Chan. 2020. Considerations for STI clinics during the COVID-19 pandemic. Sexually
Transmitted Diseases 47(7):431-433.
NASEM (National Academies of Sciences, Engineering, and Medicine). 2016a. Applying a
health lens to business practices, policies, and investments: Workshop summary. Washington,
DC: The National Academies Press.
NASEM. 2016b. Rapid medical countermeasure response to infectious diseases: Enabling sustain-
able capabilities through ongoing public- and private-sector partnerships: Workshop summary.
Washington, DC: The National Academies Press.
NASEM. 2016c. The role of public–private partnerships in health systems strengthening: Workshop
summary. Washington, DC: The National Academies Press.
NASEM. 2017. Communities in action: Pathways to health equity. Washington, DC: The National
Academies Press.
NASEM. 2019a. Faith–health collaboration to improve community and population health: Proceed-
ings of a workshop. Washington, DC: The National Academies Press.
NASEM. 2019b. The promise of adolescence: Realizing opportunity for all youth. Washington, DC:
The National Academies Press.
NASEM. 2020a. Health-focused public–private partnerships in the urban context: Proceedings of a
workshop. Washington, DC: The National Academies Press.
NASEM. 2020b. Reorienting health care and business sector investment priorities toward health and
well-being: Proceedings of a workshop—in brief. Washington, DC: The National Academies
Press.
NBLCH (National Black Leadership Commission on Health). 2020. Black health. https://
nblch.org (accessed July 8, 2020).
NCSD (National Coalition of STD Directors). 2020. Seventeen national groups form first-ever
national STI coalition in reponse to crisis. https://www.ncsddc.org/seventeen-national-
groups-form-first-ever-national-sti-coalition-in-response-to-crisis (accessed February
19, 2020).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
650 SEXUALLY TRANSMITTED INFECTIONS
Nguyen, L. H., D. A. Drew, M. S. Graham, A. D. Joshi, C. G. Guo, W. Ma, R. S. Mehta,
E. T. Warner, D. R. Sikavi, C. H. Lo, S. Kwon, M. Song, L. A. Mucci, M. J. Stampfer,
W. C. Willett, A. H. Eliassen, J. E. Hart, J. E. Chavarro, J. W. Rich-Edwards, R. Davies,
J. Capdevila, K. A. Lee, M. N. Lochlainn, T. Varsavsky, C. H. Sudre, M. J. Cardoso, J.
Wolf, T. D. Spector, S. Ourselin, C. J. Steves, and A. T. Chan. 2020. Risk of COVID-19
among front-line health-care workers and the general community: A prospective cohort
study. Lancet Public Health 5(9):e475-e483.
Nightingale, M. 2019. Something to talk about: Sex education on Netflix. https://powertodecide.
org/news/something-talk-about-sex-education-netflix (accessed November 3, 2020).
NIH (National Institutes of Health). n.d. Employee assistance program. https://www.ors.
od.nih.gov/sr/dohs/HealthAndWellness/EAP/Pages/index.aspx (accessed Novem-
ber 4, 2020).
Noar, S. M., J. F. Willoughby, J. G. Myrick, and J. Brown. 2014. Public figure announcements
about cancer and opportunities for cancer communication: A review and research
agenda. Health Communication 29(5):445-461.
Nunn, A., W. L. Jeffries, P. Foster, K. McCoy, C. Sutten-Coats, T. C. Willie, Y. Ransome, R. G.
Lanzi, E. Jackson, J. Berkley-Patton, M. Keefer, and J. D. Coleman. 2019. Reducing the
African American HIV disease burden in the Deep South: Addressing the role of faith
and spirituality. AIDS and Behavior 23(Suppl 3):319-330.
NYC (New York City) Health. 2017. Health department announces historic expansion of HIV
and STI services at sexual health clinics. https://www1.nyc.gov/site/doh/about/press/
pr2017/pr003-17.page (accessed April 3, 2020).
NYC Health. 2020. Safer sex and COVID-19. https://www1.nyc.gov/assets/doh/down-
loads/pdf/imm/covid-sex-guidance.pdf (accessed June 30, 2020).
Ochillo, M. A., E. van Teijlingen, and M. Hind. 2017. Influence of faith-based organisations
on HIV prevention strategies in Africa: A systematic review. African Health Sciences
17(3):753-761.
Omobowale, E. B., M. Kuziw, M. T. Naylor, A. S. Daar, and P. A. Singer. 2010. Addressing
conflicts of interest in public–private partnerships. BMC International Health and Human
Rights 10:19.
O’Sullivan, L. F., M. D. McKee, S. E. Rubin, and G. Campos. 2010. Primary care providers’
reports of time alone and the provision of sexual health services to urban adolescent
patients: Results of a prospective card study. Journal of Adolescent Health 47(1):110-112.
Owens, D. K., K. W. Davidson, A. H. Krist, M. J. Barry, M. Cabana, A. B. Caughey, S. J. Curry,
C. A. Doubeni, J. W. Epling, Jr., M. Kubik, C. S. Landefeld, C. M. Mangione, L. Pbert, M.
Silverstein, M. A. Simon, C. W. Tseng, and J. B. Wong. 2019. Preexposure prophylaxis
for the prevention of HIV infection: U.S. Preventive Services Task Force recommenda-
tion statement. JAMA 321(22):2203-2213.
Oziransky, V., D. Yach, T. Tsu-Yu, A. Luterek, and D. Stevens. 2015. Beyond the four walls: Why
community is critical to workforce health. New York: Vitality Institute.
Pampati, S., K. Emrick, S. A. J., and J. Jones. 2020. Changes in sexual behavior, PrEP adher-
ence, and access to sexual health services due to the COVID-19 pandemic among a
cohort of prep-using MSM in the South. MedRXiv Preprint.
Pariera, K. L., and E. Brody. 2018. “Talk more about it”: Emerging adults’ attitudes about
how and when parents should talk about sex. Sexuality Research & Social Policy: A Jour-
nal of the NSRC 15(2):219-229.
Peek, M. E., S. C. Wilson, R. Gorawara-Bhat, A. Odoms-Young, M. T. Quinn, and M. H. Chin.
2009. Barriers and facilitators to shared decision-making among African-Americans
with diabetes. Journal of General Internal Medicine 24(10):1135-1139.
Phillips, K. 2019. Review of the American Sexual Health Association (ASHA). Journal of
Consumer Health on the Internet 23(2):187-194.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PREPARING FOR THE FUTURE OF THE STI RESPONSE 651
PHLF (Public Health Leadership Forum). 2018. Developing a financing system to support public
health infrastructure. https://www.resolve.ngo/docs/developing-a-financing-system-
to-support-foundational-public-health-capabilities-final-draft-10.2.pdf (accessed Octo-
ber 9, 2020).
Powell, T. W., F. H. Weeks, S. Illangasekare, E. Rice, J. Wilson, D. Hickman, and R. W. Blum.
2017. Facilitators and barriers to implementing church-based adolescent sexual health
programs in Baltimore city. Journal of Adolescent Health 60(2):169-175.
Power to Decide. 2016. Survey says: Parent power. https://powertodecide.org/system/files/
resources/primary-download/Talking%20is%20Power_Survey%20Says_002.pdf (ac-
cessed November 4, 2020).
Prado, G., H. Pantin, S. Huang, D. Cordova, M. I. Tapia, M.-R. Velazquez, M. Calfee, S.
Malcolm, M. Arzon, J. Villamar, G. L. Jimenez, N. Cano, C. H. Brown, and Y. Estrada.
2012. Effects of a family intervention in reducing HIV risk behaviors among high-risk
Hispanic adolescents: A randomized controlled trial. Archives of Pediatrics and Adolescent
Medicine 166(2):127-133.
Prado, G., Y. Estrada, L. M. Rojas, M. Bahamon, H. Pantin, M. Nagarsheth, L. Gwynn, A. Y.
Ofir, L. Q. Forster, N. Torres, and C. H. Brown. 2019. Rationale and design for ehealth
Familias Unidas primary care: A drug use, sexual risk behavior, and STI preventive
intervention for Hispanic youth in pediatric primary care clinics. Contemporary Clinical
Trials 76:64-71.
Qiu, L., X. Liu, M. Xiao, J. Xie, W. Cao, Z. Liu, A. Morse, Y. Xie, T. Li, and L. Zhu. 2020. SARS-
CoV-2 is not detectable in the vaginal fluid of women with severe COVID-19 infection.
Clinical Infectious Diseases 71(15):813-817.
Ransome, Y., L. M. Bogart, A. S. Nunn, K. H. Mayer, K. R. Sadler, and B. O. Ojikutu.
2018. Faith leaders’ messaging is essential to enhance HIV prevention among Black
Americans: Results from the 2016 National Survey on HIV in the Black Community
(NSHBC). BMC Public Health 18(1):1392.
Rentsch, C. T., F. Kidwai-Khan, J. P. Tate, L. S. Park, J. T. King, Jr., M. Skanderson, R. G.
Hauser, A. Schultze, C. I. Jarvis, M. Holodniy, V. Lo Re, 3rd, K. M. Akgün, K. Crothers,
T. H. Taddei, M. S. Freiberg, and A. C. Justice. 2020. Patterns of COVID-19 testing and
mortality by race and ethnicity among United States veterans: A nationwide cohort
study. PLoS Medicine 17(9):e1003379.
Rivara, F. P., S. D. Fihn, and E. N. Perencevich. 2020. JAMA Network Open and COVID-19.
JAMA 324(12):1153-1154.
Rodriguez-Diaz, C. E., V. Guilamo-Ramos, L. Mena, E. Hall, B. Honermann, J. S. Crowley,
S. Baral, G. J. Prado, M. Marzan-Rodriguez, C. Beyrer, P. S. Sullivan, and G. A. Mil-
lett. 2020. Risk for COVID-19 infection and death among Latinos in the United States:
Examining heterogeneity in transmission dynamics. Annals of Epidemiology 52:46-53.
Rojas, L. M., M. Bahamón, R. Wagstaff, I. Ferre, T. Perrino, Y. Estrada, S. M. St. George,
H. Pantin, and G. Prado. 2019. Evidence-based prevention programs targeting youth
mental and behavioral health in primary care: A systematic review. Preventive Medicine
120:85-99.
Ross, J. D. C., C. Brittain, M. Cole, C. Dewsnap, J. Harding, T. Hepburn, L. Jackson, M. Keogh,
T. Lawrence, A. A. Montgomery, T. E. Roberts, K. Sprange, W. Tan, S. Thandi, J. White, J.
Wilson, and L. Duley. 2019. Gentamicin compared with ceftriaxone for the treatment of
gonorrhoea (G-TOG): A randomised non-inferiority trial. Lancet 393(10190):2511-2520.
Ross, L. 2017. Reproductive justice: An introduction. Vol. 1. Oakland, CA: University of Cali-
fornia Press.
Rukh, S., R. Khurana, T. Mickey, L. Anderson, C. Velasquez, and M. Taylor. 2014. Chlamydia
and gonorrhea diagnosis, treatment, personnel cost savings, and service delivery im-
provements after the implementation of express sexually transmitted disease testing in
Maricopa County, Arizona. Sexually Transmitted Diseases 41(1):74-78.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
652 SEXUALLY TRANSMITTED INFECTIONS
Saadeh, D., I. A. Al-Khatib, and S. Kontogianni. 2019. Public–private partnership in solid
waste management sector in the west bank of Palestine. Environmental Monitoring and
Assessment 191(4):243.
Santa Maria, D., C. Markham, S. Bluethmann, and P. D. Mullen. 2015. Parent-based adoles-
cent sexual health interventions and effect on communication outcomes: A systematic
review and meta-analyses. Perspectives on Sexual Reproductive Health 47(1):37-50.
Santa Maria, D., J. Rafferty, M. Lau, V. Guilamo-Ramos, K. Tebb, N. Chadi, A.-E. Ambresin, E.
Vyver, and A. V. Marcell. 2018. Advocating for adolescent and young adult male sexual
and reproductive health: A position statement from the Society for Adolescent Health
and Medicine. Journal of Adolescent Health 63(5):657-661.
Santelli, J. S., L. M. Kantor, S. A. Grilo, I. S. Speizer, L. D. Lindberg, J. Heitel, A. T. Schalet,
M. E. Lyon, A. J. Mason-Jones, T. McGovern, C. J. Heck, J. Rogers, and M. A. Ott. 2017.
Abstinence-only-until-marriage: An updated review of U.S. policies and programs and
their impact. Journal of Adolescent Health 61(3):273-280.
Schalet, A. 2011. Not under my roof: Parents, teens, and the culture of sex. Chicago, IL: The
University of Chicago Press.
Schneider, J. A., and H. A. Pollack. 2020. Flipping the script for coronavirus disease 2019
contact tracing. JAMA Health Forum 1(9):e201129.
Schoenberg, N. E., H. E. Bundy, J. A. Baeker Bispo, C. R. Studts, B. J. Shelton, and N. Fields.
2015. A rural Appalachian faith-placed smoking cessation intervention. Journal of Reli-
gion and Health 54(2):598-611.
Schorsch, K. 2020. Meet the Chicago virus hunters who are tracking down COVID-19. https://
www.npr.org/local/309/2020/04/21/839755005/meet-the-chicago-virus-hunters-
who-are-tracking-down-c-o-v-i-d-19 (accessed November 4, 2020).
Schutz, P., and Q. Myers. 2020. COVID-19 across Chicago: Englewood. https://news.wttw.
com/2020/05/20/covid-19-across-chicago-englewood (accessed November 4, 2020).
Scull, T. M., J. B. Kupersmidt, C. V. Malik, and E. M. Keefe. 2018. Examining the efficacy of an
mHealth media literacy education program for sexual health promotion in older ado-
lescents attending community college. Journal of American College Health 66(3):165-177.
Shamos, S. J., C. J. Mettenbrink, J. A. Subiadur, B. L. Mitchell, and C. A. Rietmeijer. 2008.
Evaluation of a testing-only “express” visit option to enhance efficiency in a busy STI
clinic. Sexually Transmitted Diseases 35(4):336-340.
Shay, L. A., A. S. Baldwin, A. C. Betts, E. G. Marks, R. T. Higashi, R. L. Street, Jr., D. Persaud,
and J. A. Tiro. 2018. Parent–provider communication of HPV vaccine hesitancy.
Pediatrics 141(6).
Shrivastava, R., P. N. Fonjungo, Y. Kebede, R. Bhimaraj, S. Zavahir, C. Mwangi, R. Gadde,
H. Alexander, P. L. Riley, A. Kim, and J. N. Nkengasong. 2019. Role of public–private
partnerships in achieving UNAIDS HIV treatment targets. BMC Health Services Research
19(1):46.
Sieving, R. E., A. L. McRee, B. J. McMorris, R. J. Shlafer, A. L. Gower, H. M. Kapa, K. J. Beck-
man, J. L. Doty, S. L. Plowman, and M. D. Resnick. 2017. Youth–adult connectedness:
A key protective factor for adolescent health. American Journal of Preventative Medicine
52(3 Suppl 3):S275-S278.
Silliman, J., M. Gerber Fried, L. Ross, and E. R. Gutierrez. 2004. Undivided rights: Women of
color organizing for reproductive justice. Cambridge, MA: South End Press.
Slaoui, M., and M. Hepburn. 2020. Developing safe and effective COVID vaccines—Operation
Warp Speed’s strategy and approach. New England Journal of Medicine 383(18):1701-1703.
Sofaer, S. 2018. National Academy of Public Administration: First phase report on STDs for
the National Coalition of STD Directors: Presented at Meeting 2 of the Committee on
Prevention and Control of Sexually Transmitted Infections in the United States.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
PREPARING FOR THE FUTURE OF THE STI RESPONSE 653
Sommantico, M., A. R. Donizzetti, S. Parrello, and B. De Rosa. 2019. Predicting young adults’
romantic relationship quality: Sibling ties and adult attachment styles. Journal of Family
Issues 40(5):662-688.
St. Cyr, S., L. Barbee, K. A. Workowski, L. H. Bachmann, C. Pham, K. Schlanger, E. Torrone,
H. Weinstock, E. N. Kersh, and P. Thorpe. 2020. Update to CDC’s treatment guidelines
for gonococcal infection, 2020. Morbidity and Mortality Weekly Report 69(50):1911-1916.
STI Regional Response Coalition. 2020. St. Louis STI regional response team. http://www.
stlstirr.org (accessed April 13, 2020).
Stoner, B. P., J. Fraze, C. A. Rietmeijer, J. Dyer, A. Gandelman, E. W. Hook, 3rd, C. Johnston,
N. M. Neu, A. M. Rompalo, G. Bolan, and National Network of S.T.D. Clinical Preven-
tion Training Centers. 2019. The National Network of Sexually Transmitted Disease
Clinical Prevention Training Centers turns 40—a look back, a look ahead. Sexually
Transmitted Diseases 46(8):487-492.
TAG (Treatment Action Group). 2019. Gonorrhea, chlamydia, and syphilis pipline report. https://
www.ncsddc.org/wp-content/uploads/2019/03/TAG_Pipeline_STI_2019_draft.pdf
(accessed October 25, 2020).
Tao, J., S. C. Napoleon, M. A. Maynard, A. Almonte, E. Silva, E. Toma, C. T. Chu, K. Cormier,
S. Strong, and P. A. Chan. 2021. Impact of the COVID-19 pandemic on sexually trans-
mitted infection clinic visits. Sexually Transmitted Diseases 48(1):e5-e7.
Taylor, S. N., J. Marrazzo, B. E. Batteiger, E. W. Hook, 3rd, A. C. Sena, J. Long, M. R. Wierz-
bicki, H. Kwak, S. M. Johnson, K. Lawrence, and J. Mueller. 2018. Single-dose zoliflo-
dacin (etx0914) for treatment of urogenital gonorrhea. New England Journal of Medicine
379(19):1835-1845.
The Balm in Gilead. 2020. The Balm in Gilead. https://www.balmingilead.org (accessed July
8, 2020).
The Oral Cancer Foundation. n.d. Michael Douglas. https://oralcancerfoundation.org/
people/arts-entertainment/michael-douglas (accessed November 3, 2020).
Throat Cancer Foundation. 2013. Michael Douglas, oral sex, and HPV. https://www.
throatcancerfoundation.org/michael-douglas-oral-sex-and-hpv (accessed November
3, 2020).
Turban, J. L., A. S. Keuroghlian, and K. H. Mayer. 2020. Sexual health in the SARS-CoV-2 era.
Annals of Internal Medicine 173(5):387-389.
Underhill, K., D. Operario, and P. Montgomery. 2007. Systematic review of abstinence-plus
HIV prevention programs in high-income countries. PLoS Medicine 4(9):e275.
U.S. Supreme Court. 2020. Bostock v. Clayton County. https://www.supremecourt.gov/
opinions/19pdf/17-1618_hfci.pdf (accessed June 15, 2020).
USC (University of Southern California) Schaeffer Center. 2019. Using the drug pricing Net-
flix model to help states tackle the hep C crisis. Health Policy. https://healthpolicy.usc.
edu/article/using-the-drug-pricing-netflix-model-to-help-states-tackle-the-hep-c-crisis
(accessed November 2, 2020).
Vaidya, V., G. Partha, and M. Karmakar. 2012. Gender differences in utilization of preventive
care services in the United States. Journal of Women’s Health 21(2):140-145.
Valdiserri, R. O., and D. R. Holtgrave. 2019. Ending HIV in America: Not without the power
of community. AIDS and Behavior 23(11):2899-2903.
Vigliotti, V., T. Taggart, M. Walker, S. Kusmastuti, and Y. Ransome. 2020. Religion, faith,
and spirituality influences on HIV prevention activities: A scoping review. PLoS One
15(6):e0234720.
Villarreal, Y. 2018. “Insecure”’s Jay Ellis breaks down his top-secret return and weighs in on Issa
and Lawrence’s future. https://www.latimes.com/entertainment/tv/la-et-st-jay-ellis-
lawrence-insecure-20180916-story.html (accessed November 3, 2020).
Vrangbaek, K. 2008. Public–private partnerships in the health sector: The Danish experience.
Health Economics, Policy and Law 3(Pt 2):141-163.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
654 SEXUALLY TRANSMITTED INFECTIONS
Webb Hooper, M., A. M. Nápoles, and E. J. Pérez-Stable. 2020. COVID-19 and racial/ethnic
disparities. JAMA 323(24):2466-2467.
Weber, L., L. Ungar, M. R. Smith, H. Recht, and A. M. Barry-Jester. 2020. Hollowed out
public health system faces more cuts amid virus. The Associated Press. https://khn.
org/news/us-public-health-system-underfunded-under-threat-faces-more-cuts-amid-
covid-pandemic (accessed November 4, 2020).
Weeks, F. H., T. W. Powell, S. Illangasekare, E. Rice, J. Wilson, D. Hickman, and R. W. Blum.
2016. Bringing evidence-based sexual health programs to adolescents in Black churches:
Applying knowledge from systematic adaptation frameworks. Health Education & Be-
havior 43(6):699-704.
White, R. M. 2000. Unraveling the Tuskegee study of untreated syphilis. Archives of Internal
Medicine 160(5):585-598.
Widman, L., S. Choukas-Bradley, S. W. Helms, and M. J. Prinstein. 2016a. Adolescent suscep-
tibility to peer influence in sexual situations. Journal of Adolescent Health 58(3):323-329.
Widman, L., S. Choukas-Bradley, S. M. Noar, J. Nesi, and K. Garrett. 2016b. Parent–
adolescent sexual communication and adolescent safer sex behavior: A meta-analysis.
JAMA Pediatrics 170(1):52-61.
Widman, L., R. Evans, H. Javidi, and S. Choukas-Bradley. 2019. Assessment of parent-based
interventions for adolescent sexual health: A systematic review and meta-analysis.
JAMA Pediatrics 173(9):866-877.
Wingood, G. M., and R. J. DiClemente. 2008. The ADAPT-ITT model: A novel method of
adapting evidence-based HIV interventions. Journal of Acquired Immune Deficiency Syn-
dromes 47:S40-S46.
Wingood, G. M., L. Simpson-Robinson, N. D. Braxton, and J. L. Raiford. 2011. Design of
a faith-based HIV intervention: Successful collaboration between a university and a
church. Health Promotion Practice 12(6):823-831.
Workowski, K. A., and G. A. Bolan. 2015. Sexually transmitted diseases treatment guidelines,
2015.
Yancy, C. W. 2020. COVID-19 and African Americans. JAMA 323(19):1891-1892.
Yehia, B. R., A. Winegar, R. Fogel, M. Fakih, A. Ottenbacher, C. Jesser, A. Bufalino, R.-H.
Huang, and J. Cacchione. 2020. Association of race with mortality among patients
hospitalized with coronavirus disease 2019 (COVID-19) at 92 U.S. hospitals. JAMA
Network Open 3(8):e2018039.
Young, L. E., A. B. Jonas, S. Michaels, J. D. Jackson, M. L. Pierce, and J. A. Schneider. 2017.
Social-structural properties and HIV prevention among young men who have sex with
men in the ballroom house and independent gay family communities. Social Science &
Medicine 174:26-34.
Yu, S. W. Y., C. Hill, M. L. Ricks, J. Bennet, and N. E. Oriol. 2017. The scope and impact of
mobile health clinics in the United States: A literature review. International Journal for
Equity in Health 16(1):178.
Zheng, C., Q. Zhang, S. Young, and W. Wang. 2020. On-demand influencer discovery on social
media. Paper presented at Proceedings of the 29th ACM International Conference on
Information & Knowledge Management, Virtual Event, Ireland.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Characteristics of Major STIs
in the United States
655
Copyright National Academy of Sciences. All rights reserved.
Increases Risk
656
for Acquisi-
Frequency of tion or Trans- Effective Curative
STI Routes of Asymptomatic Major Long-Term Health mission of Treatment Available/
(etiologic agent) Transmission Infections Consequences HIV Infection? Vaccine Available?
Chlamydial • Vaginal, anal, and Very common for • Pelvic inflammatory Yes Antibiotics can cure.
infection oral sex men and women disease No vaccine. (Gottlieb
(Chlamydia • Pregnant • Infertility in women and and Johnston, 2017)
trachomatis) person-to-infant possibly men (Bryan et al.,
(CDC, 2016, 2017a) transmission with 2019)
eye inoculation • Ectopic pregnancy
• Chronic pelvic pain
• Ophthalmia neonatorum
and pneumonia in infants
Gonorrhea • Vaginal, anal, and Women: very • Pelvic inflammatory Yes Antibiotics can
(Neisseria oral sex common disease cure (but antibiotic-
gonorrhoeae) • Pregnant Men: commona • Infertility in women and resistant strains
(CDC, 2017e, 2019b) person-to-infant men exist). No vaccine.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
transmission with • Ectopic pregnancy (CDC, 2020a; Gottlieb
eye inoculation • Chronic pelvic pain and Johnston, 2017)
• Possible • Ophthalmia neonatorum
association with • Septic arthritis
kissing (Chow et
al., 2019)
Syphilis (all stages) • Vaginal, anal, and Women: common • Ocular and neurologic Yes Antibiotics can cure.
(Treponema pallidum) oral sex Men: common or less morbidity No vaccine. (CDC,
(CDC, 2017f) • Pregnant common (IOM, 1997) • Cardiovascular, bone, 2017g; Gottlieb and
person-to-infant skin, and other organ Johnston, 2017)
Copyright National Academy of Sciences. All rights reserved.
transmission system morbidity
• Blood-borne • Congenital syphilis
Congenital syphilis Pregnant person-to- May be asymptomatic • Preterm birth Yes Antibiotics can cure,
(Treponema pallidum) infant transmission in the first few weeks • Stillbirth but possible lifelong
(CDC, 2019a; after birth • Infant death sequelae.
Yeganeh et al., • Severe lifelong disabilities,
2015) including blindness,
deafness, and bone
deformity
Human Vaginal, anal, and Very common for • Genital tract dysplasia Probably yes Ablation of lesions
papillomavirus oral sexual contact men and women and cancer, most (Houlihan et can treat but not
infection commonly the cervix and al., 2012) cure. Three vaccines
(human anus, but also the vagina, available for
papillomavirus) vulva, and penis (Arbyn prevention. (CDC,
(CDC, 2017d) et al., 2012) 2020d)
• Oral dysplasia and cancer
Genital herpes • Vaginal, anal, and Very common for • Genital tract lesions that Yes No cure, but
(herpes simplex oral sex men and women are often painful and can medications can
virus types 1 and 2) • Pregnant be debilitating reduce severity
(CDC, 2017b,c) person-to-infant • Congenital and neonatal and duration of
transmission herpes, which can lead to symptoms. No
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
preterm birth, stillbirth, vaccines.
infant death, or severe
disabilities (Corey and
Wald, 2009)
Trichomonas Vaginal, anal, and Very common for • Cervicovaginal or penile Yes Antibiotics can cure.
vaginalis infection oral sex men and women discharge No vaccine. (Gottlieb
(Trichomonas • Inflammatory changes and Johnston, 2017)
vaginalis) with vaginitis or
(CDC, 2017h; urethritis
Copyright National Academy of Sciences. All rights reserved.
Tompkins et al.,
2020)
657
continued
Increases Risk
658
for Acquisi-
Frequency of tion or Trans- Effective Curative
STI Routes of Asymptomatic Major Long-Term Health mission of Treatment Available/
(etiologic agent) Transmission Infections Consequences HIV Infection? Vaccine Available?
Hepatitis B virus • Vaginal or anal Early infection may • End-stage liver cirrhosis No No cure, though both
infection sex; not oral sex be asymptomatic, or hepatocellular active and passive
(hepatitis B virus) • Pregnant with symptoms carcinoma immunization highly
(CDC, 2020c; person-to-infant emerging many years • Perinatal transmission efficacious. (Schillie
NASEM, 2016, transmission later from pregnant person to et al., 2018)
2017) • Blood-borne (A minority of child, with high risk of
patients with sexually eventual liver disease in
acquired infection an untreated infant
may experience
chronic infection
leading to sequelae.)
Chancroid Vaginal, anal, and Women: Very • Genital tract lesions that Probably yes Antibiotics can cure.
(Haemophilus oral sex common are often painful and can No vaccine.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
ducreyi) Men: Less Common be debilitating
(CDC, 2015a; Lewis,
2003)
Lymphogranuloma Vaginal, anal, and Common for men • Genital tract lesions that Unknown Antibiotics can cure.
venereum oral sex and women are often painful and can No vaccine.
(C. trachomatis be debilitating
serovars L1, L2,
and L3)
(CDC, 2015b; Rönn
et al., 2014)
Copyright National Academy of Sciences. All rights reserved.
Mycoplasma Vaginal, anal, and Common for men • Cervicovaginal or penile Possibly yes Antibiotics can cure,
genitalium oral sex and women discharge (Napierala but recurrence is
infectionb • Inflammatory changes Mavedzenge common. Antibiotic
(Mycoplasma with vaginitis or urethritis and Weiss, resistance is a
genitalium) 2009) concern. No vaccine.
(Horner and (CDC, 2020a)
Martin, 2017;
Wiesenfeld and
Manhart, 2017)
Human • Vaginal and anal Flu-like symptoms • Immunodeficiency with — Medications can slow
immunodeficiency sex noted in some during life-threatening risks of disease progression.
virus (HIV) • Less often oral sex acute infection, opportunistic infections or No vaccines, but pre-
infection • Pregnant but then may be malignancies exposure prophylaxis
(HIV) person-to-infant asymptomatic for is available for
(CDC, 2019c, 2020b) transmission years prevention.
• Blood-borne
a Most women with gonorrhea are asymptomatic. Many men with gonorrhea are asymptomatic (CDC, 2019b).
b Emerging STI; see Chapter 2 for more information.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Copyright National Academy of Sciences. All rights reserved.
659
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
660 SEXUALLY TRANSMITTED INFECTIONS
REFERENCES
Arbyn, M., S. de Sanjosé, M. Saraiya, M. Sideri, J. Palefsky, C. Lacey, M. Gillison, L.
Bruni, G. Ronco, N. Wentzensen, J. Brotherton, Y. L. Qiao, L. Denny, J. Bornstein,
L. Abramowitz, A. Giuliano, M. Tommasino, and J. Monsonego. 2012. Eurogin 2011
roadmap on prevention and treatment of HPV-related disease. International Journal of
Cancer 131(9):1969-1982.
Bryan, E. R., R. I. McLachlan, L. Rombauts, D. J. Katz, A. Yazdani, K. Bogoevski, C. Chang,
M. L. Giles, A. J. Carey, C. W. Armitage, L. K. Trim, E. A. McLaughlin, and K. W.
Beagley. 2019. Detection of chlamydia infection within human testicular biopsies. Hu-
man Reproduction 34(10):1891-1898.
CDC (Centers for Disease Control and Prevention). 2015a. 2015 sexually transmitted diseases
treatment guidelines—chancroid. https://www.cdc.gov/std/tg2015/chancroid.htm (ac-
cessed November 10, 2020).
CDC. 2015b. 2015 sexually transmitted diseases treatment guidelines—lymphogranuloma venereum
(LGV). https://www.cdc.gov/std/tg2015/lgv.htm (accessed November 10, 2020).
CDC. 2016. Chlamydia—CDC fact sheet (detailed). https://www.cdc.gov/std/chlamydia/
stdfact-chlamydia-detailed.htm (accessed September 15, 2020).
CDC. 2017a. Chlamydia—CDC fact sheet. https://www.cdc.gov/std/chlamydia/Chlamydia-
FS.pdf (accessed September 15, 2020).
CDC. 2017b. Genital herpes—CDC fact sheet (detailed). https://www.cdc.gov/std/herpes/
stdfact-herpes-detailed.htm (accessed November 9, 2020).
CDC. 2017c. Genital herpes—CDC fact sheet. https://www.cdc.gov/std/herpes/Genital-
herpes-FS.pdf (accessed November 9, 2020).
CDC. 2017d. Genital HPV infection—CDC fact sheet. https://www.cdc.gov/std/hpv/HPV-
FS-print.pdf (accessed November 9, 2020).
CDC. 2017e. Gonorrhea—CDC fact sheet. https://www.cdc.gov/std/gonorrhea/Gonorrhea-
FS.pdf (accessed September 15, 2020).
CDC. 2017f. Syphilis—CDC fact sheet (detailed). https://www.cdc.gov/std/syphilis/stdfact-
syphilis-detailed.htm (accessed October 21, 2020).
CDC. 2017g. Syphilis—CDC fact sheet. https://www.cdc.gov/std/syphilis/syphilis-fact-
sheet.pdf (accessed October 21, 2020).
CDC. 2017h. Trichomoniasis—CDC fact sheet. https://www.cdc.gov/std/trichomonas/
trichomoniasis-factsheet.pdf (accessed October 21, 2020).
CDC. 2019a. Congenital syphilis—CDC fact sheet. https://www.cdc.gov/std/syphilis/cong-
syph-oct-2019.pdf (October 20, 2020).
CDC. 2019b. Gonorrhea—CDC fact sheet (detailed version). https://www.cdc.gov/std/
gonorrhea/stdfact-gonorrhea-detailed.htm (accessed October 20, 2020).
CDC. 2019c. HIV transmission. https://www.cdc.gov/hiv/basics/transmission.html (ac-
cessed October 20, 2020).
CDC. 2020a. 2019 AR threats report. https://www.cdc.gov/drugresistance/biggest-threats.
html (accessed October 21, 2020).
CDC. 2020b. About HIV. https://www.cdc.gov/hiv/basics/whatishiv.html (accessed No-
vember 10, 2020).
CDC. 2020c. Hepatitis B. https://www.cdc.gov/hepatitis/hbv/index.htm (accessed October
26, 2020).
CDC. 2020d. Human papillomavirus (HPV) vaccination: What everyone should know. https://
www.cdc.gov/vaccines/vpd/hpv/public/index.html (accessed October 21, 2020).
Chow, E. P. F., V. J. Cornelisse, D. A. Williamson, D. Priest, J. S. Hocking, C. S. Bradshaw,
T. R. H. Read, M. Y. Chen, B. P. Howden, and C. K. Fairley. 2019. Kissing may be an
important and neglected risk factor for oropharyngeal gonorrhoea: A cross-sectional
study in men who have sex with men. Sexually Transmitted Infections 95(7):516-521.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
APPENDIX A 661
Corey, L., and A. Wald. 2009. Maternal and neonatal herpes simplex virus infections. New
England Journal of Medicine 361(14):1376-1385.
Gottlieb, S. L., and C. Johnston. 2017. Future prospects for new vaccines against sexually
transmitted infections. Current Opinion in Infectious Diseases 30(1):77-86.
Horner, P. J., and D. H. Martin. 2017. Mycoplasma genitalium infection in men. The Journal of
Infectious Diseases 216(Suppl 2):S396-S405.
Houlihan, C. F., N. L. Larke, D. Watson-Jones, K. K. Smith-McCune, S. Shiboski, P. E. Gravitt,
J. S. Smith, L. Kuhn, C. Wang, and R. Hayes. 2012. Human papillomavirus infection
and increased risk of HIV acquisition. A systematic review and meta-analysis. AIDS
26(17):2211-2222.
IOM (Institute of Medicine). 1997. Appendix B: Characteristics of major STDs in the United
States. In The hidden epidemic: Confronting sexually transmitted diseases. Washington, DC:
National Academy Press. P. 448.
Lewis, D. A. 2003. Chancroid: Clinical manifestations, diagnosis, and management. Sexually
Transmitted Infections 79(1):68-71.
Napierala Mavedzenge, S., and H. A. Weiss. 2009. Association of Mycoplasma genitalium and
HIV infection: A systematic review and meta-analysis. AIDS 23(5):611-620.
NASEM (National Academies of Sciences, Engineering, and Medicine). 2016. Eliminating the
public health problem of hepatitis B and C in the United States: Phase one report. Washington,
DC: The National Academies Press.
NASEM. 2017. A national strategy for the elimination of hepatitis B and C: Phase two report.
Washington, DC: The National Academies Press.
Rönn, M., G. Hughes, P. White, I. Simms, C. Ison, and H. Ward. 2014. Characteristics
of LGV repeaters: Analysis of LGV surveillance data. Sexually Transmitted Infections
90(4):275-278.
Schillie, S., C. Vellozzi, A. Reingold, A. Harris, P. Haber, J. W. Ward, and N. P. Nelson. 2018.
Prevention of Hepatitis B virus infection in the United States: Recommendations of
the Advisory Committee on Immunization Practices. Morbidity and Mortality Weekly
Report 67(1):1-31.
Tompkins, E. L., T. A. Beltran, E. J. Gelner, and A. R. Farmer. 2020. Prevalence and risk fac-
tors for Trichomonas vaginalis infection among adults in the U.S., 2013-2014. PLoS One
15(6):e0234704.
Wiesenfeld, H. C., and L. E. Manhart. 2017. Mycoplasma genitalium in women: Current knowl-
edge and research priorities for this recently emerged pathogen. Journal of Infectious
Diseases 216(Suppl 2):S389-S395.
Yeganeh, N., H. D. Watts, M. Camarca, G. Soares, E. Joao, J. H. Pilotto, G. Gray, G. Theron,
B. Santos, R. Fonseca, R. Kreitchmann, J. Pinto, M. Mussi-Pinhata, M. Ceriotto, D. M.
Machado, B. Grinzstejn, V. G. Veloso, M. G. Morgado, Y. Bryson, L. M. Mofenson, K.
Nielsen-Saines, and NICHD HPTN 040P1043 Study Team. 2015. Syphilis in HIV-infect-
ed mothers and infants: Results from the NICHD/HPTN 040 study. Pediatric Infectious
Disease Journal 34(3):e52-e57.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
STI Screening and Treatment
Guidelines Issued by Health
Professional Societies
SUMMARY
The Centers for Disease Control and Prevention (CDC) and the United
States Preventive Services Task Force (USPSTF) provide national guid-
ance to prevent, screen/test for, and treat sexually transmitted infections
(STIs). This analysis compared the CDC/USPSTF recommendations to STI
guidelines published by various health professional organizations, includ-
ing the American Academy of Family Physicians (AAFP), the American
Academy of Pediatrics (AAP), the American College of Obstetricians and
Gynecologists (ACOG), the American College of Physicians (ACP), the
American Academy of Physician Assistants (AAPA), the American Public
Health Association (APHA), and various nursing organizations (Ameri-
can Nurses Association [ANA]). Some organizations required a member-
ship in order to view the entirety of materials on their site, so additional
guidelines may have been published that are not publicly available and
thus not included in this analysis.
Professional organizations overall provided recommendations that
are consistent or mostly consistent with CDC and USPSTF guidelines. It
was more common for professional organizations to publish a paucity
of information rather than inaccurate information. Many organizations
directed readers to CDC or USPSTF for more detailed guidelines and
focused more on the guidelines that pertained only to their population
of specialization (such as women for ACOG and pediatrics for AAP). It
was also more common for medical societies to offer specific screening/
663
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
664 SEXUALLY TRANSMITTED INFECTIONS
treatment recommendations, in contrast to organizations for nursing,
physician’s assistants, or public health, which tended to publish policy
recommendations.
Recommendations are coded as follows:
• Recommendations consistent with CDC/USPSTF recommenda-
tions are noted with a plus sign+
• Recommendations that are partially inconsistent with CDC/USP-
STF are noted with a number sign#
CHLAMYDIA
Summary Statement
While some professional organizations have not published guidelines
regarding chlamydia (ACP, AAPA, ANA), those from ACOG, AAP, and
AAFP are largely in consensus with CDC/USPSTF, with some minor dif-
ferences. AAFP recommends screening for men who have sex with men
(MSM) if at risk (rather than all sexually active MSM), while ACOG rec-
ommends routinely screening all pregnant women (rather than just those
under 25 and those >25 with risk factors).
TABLE B-1 Screening and Treatment Recommendations, Chlamydia
Screening/Testing Recommendations Treatment Recommendations
CDC Women: Sexually active women under Recommended Regimens:
25 years of age. Sexually active women Azithromycin 1 g orally in a
aged 25 years and older if at increased single dose
risk (new sex partner, more than one sex OR Doxycycline 100 mg orally
partner, a sex partner with concurrent twice per day for 7 days
partners, or a sex partner who has a (Azithromycin in pregnancy)
sexually transmitted infection). Retest
approximately 3 months after treatment. Alternative Regimens:
Pregnant Women: All pregnant women Erythromycin base 500 mg
under 25 years of age. Pregnant women, orally four times per day for 7
aged 25 and older if at increased risk days
(see above). Retest during the third OR Erythromycin ethylsuccinate
trimester for women under 25 years of 800 mg orally four times per
age or at risk. Pregnant women with day for 7 days
chlamydial infection should have a test OR Levofloxacin 500 mg orally
of cure 3–4 weeks after treatment and be once daily for 7 days
retested within 3 months. OR Ofloxacin 300 mg orally
Men: *Consider screening young men twice per day for 7 days
in high prevalence clinical settings
(adolescent clinics, correctional facilities,
STD clinics) or in populations with high
burden of infection (e.g., MSM).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
APPENDIX B 665
TABLE B-1 Continued
Screening/Testing Recommendations Treatment Recommendations
MSM: At least annually for sexually Expedited Partner Therapy
active MSM at sites of contact (urethra, (EPT): Unless prohibited by law
rectum) regardless of condom use. or other regulations, medical
Every 3–6 months if at increased risk providers should routinely offer
(including those with HIV infection if EPT to heterosexual patients
risk behaviors persist or if they or their with chlamydia or gonorrhea
sexual partners have multiple partners). infection when the provider
Persons with HIV: For sexually cannot confidently ensure that
active individuals, screen at first HIV all of a patient’s sex partners
evaluation, and at least annually from the prior 60 days will be
thereafter. More frequent screening treated. If the patient has not
might be appropriate depending on had sex in the 60 days before
individual risk behaviors and the local diagnosis, providers should
epidemiology. attempt to treat a patient’s most
(CDC, 2015) recent sex partner.
(Workowski and Bolan, 2015)
USPSTF Women: Screening for chlamydia in
sexually active women age 24 years and
younger and in older women who are at
increased risk for infection (Grade B).
Men: Current evidence is insufficient
to assess the balance of benefits and
harms of screening for chlamydia and
gonorrhea in men (Grade I).
(USPSTF, 2014)
AAFP Screening: Treatment:+
• Women <25 who are sexually active+ • Not pregnant: Azithromycin
• Older women or pregnant women if (1 g PO) or Doxycycline (100
at risk+ mg PO BID for 7 days)
• MSM if at risk# • Pregnant: Azithromycin (1
• HIV+ people+ g PO) or amoxicillin (500
(AAFP, 2019) mg TID for 7 days) (AAFP,
n.d.-b)
EPT:+ EPT and patient-delivered
partner therapy should be
provided whenever possible
and in accordance with local
law. (AAFP, n.d.-a)
continued
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
666 SEXUALLY TRANSMITTED INFECTIONS
TABLE B-1 Continued
Screening/Testing Recommendations Treatment Recommendations
AAP Screening:+ Treatment: No guidelines found
• Annual screen all sexually active
females <25 EPT:+ Support as option for
• Annual for MSM (rectal and partners or heterosexual males/
urethral screen) if engaging in anal females within past 60 days if
intercourse (every 3–6 months partner unlikely to access in-
if multiple partners, or sex with person care. Support research
drug use) to evaluate EPT effectiveness
• For other sexually active males, in MSM and WSW. (Burstein et
consider annual screening based al., 2009)
on individual/population factors
(in jails, presenting to STD clinics,
high school clinics, adolescents with
multiple partners)
Testing
• After treatment, retest at 3 months
(AAP, n.d.-b; AAP and ACOG, 2017;
Committee on Adolescence and Society
for Adolescent Health and Medicine,
2014)
ACOG Screening: (For women only) Treatment: No guidelines
• Women <25: yearly screening+ found—references CDC STI
• Women >25: screening based on risk treatment guidelines website for
factors+ more information
• Routine screen in pregnancy# EPT:+ Support EPT for GC/CT
• HIV+: annual screen+ for partner(s) within past
Testing: 2 months if unwilling or unable
• After treatment, retest in 3 months to seek care; should include
(for reinfection) written treatment instructions
(AAP and ACOG, 2017; ACOG, 2020d) for partner(s). Clinician should
first assess risk of IPV with
partner notification. (ACOG
Committee Opinion, 2018)
ACP No explicit guidelines for STIs on its Clinical Guidelines and
Recommendations page: “For more screening and preventive care
guidelines, the ACP recommends visiting the United States Preventive
Services Task Force (USPSTF) and the Canadian Task Force on Preventive
Health Care websites.” (ACP, n.d.)
AAPA Did not find screening/treatment guidelines
Nursing Did not find screening/treatment guidelines
Orgs.
NOTE: For CDC, if marked by asterisk, not a formal recommendation.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
APPENDIX B 667
GONORRHEA
Summary Statement
While some professional organizations have not published guidelines
regarding gonorrhea (ACP, AAPA, ANA), those from ACOG and AAP
are in consensus with CDC/USPSTF. AAFP guidelines may be slightly
out of date; they differ from those of the CDC/USPSTF by recommend-
ing screening for MSM at risk (rather than all sexually active MSM),
and their treatment lacks azithromycin (needed given growing antibiotic
resistance).
TABLE B-2 Screening and Treatment Recommendations, Gonorrhea
Screening/Testing Recommendations Treatment Recommendations
CDC Women: Sexually active women under Recommended Regimen for
25 years of age. Sexually active women uncomplicated infection of cervix,
age 25 years and older if at increased urethra, rectum, and pharynx:
risk (new sex partner, more than one sex Ceftriaxone 250 mg IM in a single
partner, a sex partner with concurrent dose PLUS Azithromycin 1 g
partners, or a sex partner who has an STI, orally in a single dose.
inconsistent condom use among persons
who are not in mutually monogamous NOTE: Toward the end of the
relationships; previous or coexisting development of this report,
sexually transmitted infections; and the treatment guidelines for
exchanging sex for money or drugs). gonorrhea were updated by
Retest 3 months after treatment. CDC (on December 18, 2020)
Pregnant Women: All pregnant women as follows: A single 500 mg
under 25 years of age and older women intramuscular dose of ceftriaxone
if at increased risk. Retest 3 months after for uncomplicated gonorrhea.
treatment. Treatment for coinfection with
Men: No recommendation. Chlamydia trachomatis with oral
MSM: At least annually for sexually doxycycline (100 mg twice
active MSM at sites of contact (urethra, daily for 7 days) should be
rectum, pharynx) regardless of condom administered when chlamydial
use. Every 3–6 months if at increased infection has not been excluded
risk. (St. Cyr et al., 2020). The
Persons with HIV: For sexually active treatment comparisons made in
individuals, screen at first HIV evaluation this table reflect the treatment
and at least annually thereafter. guidelines prior to this change.
More frequent screening for might be
appropriate depending on individual risk
behaviors and the local epidemiology.
(CDC, 2015)
continued
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
668 SEXUALLY TRANSMITTED INFECTIONS
TABLE B-2 Continued
Screening/Testing Recommendations Treatment Recommendations
Alternative Regimens if
ceftriaxone is not available:
Cefixime 400 mg orally in a
single dose PLUS Azithromycin
1 g orally in a single dose (in
December 2020 this was changed
to 800 mg oral dose of cefixime
[St. Cyr et al., 2020]).
EPT: Unless prohibited by law
or other regulations, medical
providers should routinely offer
EPT to heterosexual patients
with chlamydia or gonorrhea
infection when the provider
cannot confidently ensure that all
of a patient’s sex partners from
the prior 60 days will be treated.
If the patient has not had sex
in the 60 days before diagnosis,
providers should attempt to
treat a patient’s most recent sex
partner.
NOTE: CDC has more
information about treatment
for conjunctivitis, disseminated
disease, neonates).
(Workowski and Bolan, 2015)
USPSTF Women: Screening for gonorrhea in
sexually active women age 24 years and
younger and in older women who are at
increased risk for infection (Grade B).
Men: Current evidence is insufficient
to assess the balance of benefits and
harms of screening for chlamydia and
gonorrhea in men (Grade I).
(USPSTF, 2014)
AAFP Screening: Treatment:#
• Women <25 who are sexually active+ • Cervical/urethral/rectal
• Older women or pregnant women if infection: ceftriaxone (125 mg
at risk+ IM) or cefixime 400 mg PO.
• MSM if at risk# • Pharyngeal: ceftriaxone (125
• HIV+ people+ mg IM). (AAFP, n.d.-a)
(AAFP, 2019) EPT:+ EPT and patient-delivered
partner therapy should be
provided whenever possible and
in accordance with local law.
(AAFP, n.d.-b)
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
APPENDIX B 669
TABLE B-2 Continued
Screening/Testing Recommendations Treatment Recommendations
AAP Screening:+ Treatment: No guidelines found
All sexually active females <25, annual
screen. EPT:+ Support as option for
• Annual for MSM if engaging in partners or heterosexual males/
oral or anal intercourse (every 3–6 females within past 60 days if
months if high risk). partner unlikely to access in-
• For males, consider annual screening person care. Support research
based on individual/population to evaluate EPT effectiveness in
factors. MSM and WSW. (Burstein et al.,
Testing: 2009)
• After treatment, retest at 3 months.
• No test of cure needed if urogenital/
rectal. Test of cure at 14 days if
pharyngeal.
(AAP, n.d.-b; AAP and ACOG, 2017;
Committee on Adolescence and Society
for Adolescent Health and Medicine,
2014)
ACOG Screening:+ Treatment:+
• Women <25: yearly screening. • First-line regimen: dual
• Women >25: screening based on risk therapy with ceftriaxone (250
factors. mg IM) and azithromycin (1 g
• During pregnancy (if <25 or if in PO).
area where gonorrhea common). • Alternative regimens if CTX
• HIV+: annual screen. not available or patient has
Testing: severe penicillin allergy. (AAP
• After treatment, test of cure and ACOG, 2017)
not needed for uncomplicated
urogenital/rectal. If pharyngeal and EPT:+ Support EPT for GC/
tested with alternative regimen, test CT for partner(s) within last 2
for cure in 14 days with culture or months if unwilling or unable
NAAT. to seek care; should include
• Retest in 3 months b/c risk of written treatment instructions for
reinfection (or in third trimester if partner(s). Clinician should first
pregnant). assess risk of IPV with partner
(AAP and ACOG, 2017; ACOG, 2020d) notification. (ACOG Committee
Opinion, 2018)
ACP No explicit guidelines for STIs on its Clinical Guidelines and
Recommendations page: “For more screening and preventive care
guidelines, the ACP recommends visiting the United States Preventive
Services Task Force (USPSTF) and the Canadian Task Force on Preventive
Health Care websites.” (ACP, n.d.)
AAPA Did not find screening/treatment guidelines
Nursing Did not find screening/treatment guidelines
Orgs.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
670 SEXUALLY TRANSMITTED INFECTIONS
SYPHILIS
Summary Statement
While some professional organizations have not published guidelines
regarding syphilis (ACP, AAPA, ANA), those that have are in consensus
with CDC/USPSTF.
TABLE B-3 Screening and Treatment Recommendations, Syphilis
Screening/Testing Recommendations Treatment Recommendations
CDC Women: No recommendation. Primary and Secondary Syphilis
Pregnant Women: All pregnant women Recommended Regimen for
at the first prenatal visit. Retest early in Adults: Benzathine penicillin G
the third trimester and at delivery if at 2.4 million units IM in a single
high risk. dose.
Men: No recommendation.
MSM: At least annually for sexually Recommended Regimen for
active MSM. Every 3–6 months if at Infants and Children: Benzathine
increased risk (those with HIV infection penicillin G 50,000 units/kg
if risk behaviors persist or if they or their IM, up to the adult dose of 2.4
sexual partners have multiple partners). million units in a single dose.
Persons with HIV: For sexually active
individuals, screen at first HIV evaluation See CDC treatment guidelines
and at least annually thereafter. More for recommendations for latent
frequent screening might be appropriate syphilis, tertiary syphilis,
depending on individual risk behaviors neurosyphilis, and considerations
and the local epidemiology. for persons with HIV infection
(CDC, 2015) and pregnant women.
(Workowski and Bolan, 2015)
USPSTF Pregnant Women: Early screening for
syphilis infection in all pregnant women
(Grade A).
At Risk: Screening for syphilis infection
in persons who are at increased risk for
infection (Grade A).
(USPSTF, 2016)
AAFP Screening:+ Treatment:+ Penicillin G
• Pregnant individuals benzathine (AAFP, n.d.-a)
• HIV+ individuals
• MSM and other adults/adolescents if
at risk
(AAFP, 2019)
AAP Screening:+ Screen based on individual Treatment: No recommendations
risk factors (MSM annually or every 3–6 found
months if high risk, pregnant people).
(AAP, n.d.-b; AAP and ACOG, 2017;
Committee on Adolescence and Society
for Adolescent Health and Medicine, 2014)
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
APPENDIX B 671
TABLE B-3 Continued
Screening/Testing Recommendations Treatment Recommendations
ACOG Screening:+ Treatment:+ Treat patient and sex
• Do NOT recommend routine partner(s) with penicillin. (AAP
screening for women who are not and ACOG, 2017)
pregnant.
• Pregnant Women: Screen at first
prenatal visit, later in pregnancy, and
at delivery if high risk.
• HIV+ Women: Screen annually.
(AAP and ACOG, 2017)
ACP No explicit guidelines for STIs on its Clinical Guidelines and
Recommendations page: “For more screening and preventive care
guidelines, the ACP recommends visiting the United States Preventive
Services Task Force (USPSTF) and the Canadian Task Force on Preventive
Health Care websites.”
AAPA Did not find screening/treatment guidelines
Nursing Did not find screening/treatment guidelines
Orgs.
HERPES SIMPLEX VIRUS (HSV)
Summary Statement
While some professional organizations have not published guidelines
regarding HSV (ACP, AAPA, ANA), those that have are in consensus with
CDC/USPSTF.
TABLE B-4 Screening and Treatment Recommendations, HSV
Screening/Testing Recommendations Treatment Recommendations
CDC Women: *Type-specific HSV serologic First Clinical Episode
testing should be considered for women Recommended Regimens*
presenting for an STD evaluation Acyclovir 400 mg orally three
(especially for women with multiple sex times per day for 7–10 days
partners). OR Acyclovir 200 mg orally five
Pregnant Women: *Evidence does times per day for 7–10 days
not support routine HSV-2 serologic OR Valacyclovir 1 g orally twice
screening among asymptomatic per day for 7–10 days
pregnant women. However, type-specific OR Famciclovir 250 mg orally
serologic tests might be useful for three times per day for 7–10 days
identifying pregnant women at risk for *Treatment can be extended if
HSV infection and guiding counseling healing is incomplete after 10
regarding the risk for acquiring genital days of therapy.
herpes during pregnancy.
Men: *Type-specific HSV serologic testing
should be considered for men presenting
for an STD evaluation (especially for men
with multiple sex partners). continued
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
672 SEXUALLY TRANSMITTED INFECTIONS
TABLE B-4 Continued
Screening/Testing Recommendations Treatment Recommendations
MSM: *Type-specific serologic tests See CDC treatment guidelines
can be considered if infection status for suppressive therapy, episodic
is unknown in MSM with previously therapy for recurrent genital
undiagnosed genital tract infection. herpes, severe disease, neonatal
Persons with HIV: *Type-specific HSV herpes, etc.
serologic testing should be considered (Workowski and Bolan, 2015)
for persons with HIV infection.
(CDC, 2015)
USPSTF The USPSTF recommends against
routine serologic screening for genital
herpes simplex virus (HSV) infection in
asymptomatic adolescents and adults,
including those who are pregnant
(Grade D).
(USPSTF, 2016)
AAFP Screening:+ Do not recommend routine Treatment:+ Acyclovir,
screening. Test based on clinical history. famiciclovir or valacyclovir
(AAFP, 2019) (doses depend on if primary
outbreak, recurrent, or for
suppression). (AAFP, 2019)
AAP Screening: No recommendations found. Treatment in Neonates: Acyclovir
Testing: For mucocutaneous HSV, (treatment for other populations
clinical diagnosis typically enough. not found). (AAP and ACOG,
(AAP, n.d.-b) 2017)
ACOG Screening:+ Treatment:+
• In pregnancy: Routine screening • In pregnancy, antiviral meds
not recommended (even if history (acyclovir or valacyclovir)
of HSV but asymptomatic). Should recommended during
ask all women about symptoms of outbreak or on daily regimen
herpes or prior history. for prophylaxis.
Testing:+ • Recommend pregnant women
• Test based on symptoms (unless with active outbreak be on
with HIV, in which case, can offer suppressive therapy at 36
testing if unknown HSV status). weeks gestation (level B
(ACOG, 2020c) evidence).
(ACOG, 2020c)
ACP No explicit guidelines for STIs on its Clinical Guidelines and
Recommendations page: “For more screening and preventive care
guidelines, the ACP recommends visiting the United States Preventive
Services Task Force (USPSTF) and the Canadian Task Force on Preventive
Health Care websites.” (ACOG, 2020c)
AAPA Did not find screening/treatment guidelines
Nursing Did not find screening/treatment guidelines
Orgs.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
APPENDIX B 673
HUMAN PAPILLOMAVIRUS (HPV)
Summary Statement
Discussion of HPV in publications by professional organizations
mostly focuses on the oncogenic strains: how to screen for cervical cancer
and encourage the HPV vaccine. Discussion of genital warts caused by the
nononcogenic HPV strains is less common. For cervical cancer screening,
organizations are in consensus with CDC/USPSTF; however, for the HPV
vaccination, ACP only recommends it for boys aged 22–26 if they have
additional risk factors, while AAPA recommends it for people aged 27–45
if indicated, which has been the subject of ongoing debate and research.
TABLE B-5 Screening and Treatment Recommendations, HPV
Screening/Testing
Recommendations Vaccine/Treatment Recommendations
CDC Screening for Cervical Cancer: HPV Vaccines: Three-dose series of
Women: Women 21–29 years of IM injections over a 6-month period,
age every 3 years with cytology. with the second and third doses given
Women 30–65 years of age every 1–2 and 6 months after the first dose,
3 years with cytology, or every respectively. The same vaccine product
5 years with a combination of should be used for the entire three-dose
cytology and HPV testing. series.
Pregnant Women: Screened at For Girls/Women: Either vaccine
same intervals as nonpregnant (quadrivalent or 9-valent) is
women. recommended routinely at ages
Persons with HIV: Women should 11–12 years and can be administered
be screened within 1 year of sexual beginning at 9 years of age (16); girls
activity or initial HIV diagnosis and women aged 13–26 years who have
using conventional or liquid- not started or completed the vaccine
based cytology; testing should be series should receive the vaccine.
repeated 6 months later.
(CDC, 2015) For Boys/Men: The quadrivalent or
9-valent HPV vaccine is recommended
routinely for boys aged 11–12 years;
boys can be vaccinated beginning at
9 years of age. Boys and men aged
13–21 years who have not started or
completed the vaccine series should
receive the vaccine.
continued
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
674 SEXUALLY TRANSMITTED INFECTIONS
TABLE B-5 Continued
Screening/Testing
Recommendations Vaccine/Treatment Recommendations
Other Populations: For previously
unvaccinated, immunocompromised
persons (including persons with HIV
infection) and MSM, vaccination is
recommended through age 26 years.
The vaccines are not licensed or
recommended for use in men or women
aged >26 years. HPV vaccines are not
recommended for use in pregnant
women.
Treatment (oncogenic HPV): Treatment
is directed to the macroscopic
(e.g., genital warts) or pathologic
precancerous lesions caused by HPV.
Subclinical genital HPV infection
typically clears spontaneously;
therefore, specific antiviral therapy is
not recommended to eradicate HPV
infection.
Treatment (nononcogenic HPV):
Recommended regimens for external
anogenital warts (i.e., penis, groin,
scrotum, vulva, perineum, external
anus, and perianus) patient-applied:
Imiquimod 3.75% or 5% cream OR
Podofilox 0.5% solution or gel OR
Sinecatechins 15% ointment provider–
administered: Cryotherapy with liquid
nitrogen or cryoprobe OR Surgical
removal either by tangential scissor
excision, tangential shave excision,
curettage, laser, or electrosurgery OR
trichloroacetic acid or bichloroacetic
acid 80%–90% solution.
(Workowski and Bolan, 2015)
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
APPENDIX B 675
TABLE B-5 Continued
Screening/Testing
Recommendations Vaccine/Treatment Recommendations
USPSTF Women Aged 21–65: Screening for
cervical cancer every 3 years with
cervical cytology alone in women
aged 21–29 years. For women
aged 30–65 years, the USPSTF
recommends screening every
3 years with cervical cytology
alone, every 5 years with high-risk
human papillomavirus (hrHPV)
testing alone, or every 5 years with
hrHPV testing in combination with
cytology (cotesting) (Grade A).
Women >65: Recommends against
screening for cervical cancer in
women older than 65 years who
have had adequate prior screening
and are not otherwise at high risk
for cervical cancer (Grade D).
Women <21: Recommends against
screening for cervical cancer in
women younger than 21 years
(Grade D).
(USPSTF, 2018)
AAFP Screening: Vaccination:+ Endorses HPV
• Any patient with a cervix aged vaccination. (AAFP, n.d.-a)
21–29: Pap only+
• Any patient with a cervix aged
30–65: Pap and HPV every
5 years or HPV alone every
5 years#
(Rerucha et al., 2018)
AAP Screening: n/a for adolescents Vaccination:+ Support routine HPV
immunization for all 11- and 12-year-
olds and catch-up vaccination for
adolescents and young adults 13–26
years. (AAP, n.d.-a)
continued
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
676 SEXUALLY TRANSMITTED INFECTIONS
TABLE B-5 Continued
Screening/Testing
Recommendations Vaccine/Treatment Recommendations
ACOG Screening+ for Cervical Cancer: Vaccination:+ Recommend routine
• Women <30: do not cotest for vaccination for boys/girls aged
HPV with Pap. 11–26 (can be given at age 9). (ACOG
• Women 30–65: cotest HPV Committee Opinion, 2020)
and Pap every 5 years or HPV
alone every 5 years or Pap
alone every 3 years.
• For women with HIV, continue
screening past 65.
• More complex testing
algorithms exist for those with
abnormal Paps.
(ACOG, 2020a)
ACP Screening:+ Vaccination:
• Do NOT screen average-risk • Recommend vaccine for females
women <21 for cervical cancer. ages 11–26.+
• Do NOT test for HPV if <30 • Recommended vaccine for males
years. ages 11–21, 22–26 if have additional
• Screen with Pap 21–29 every 3 risk factor or another indication.#
years. (Kim and Hunter, 2019)
• Women ≥30 years: Screen with
Pap and HPV every 5 years
if patient prefers that to more
frequent screening every
3 years.
• Stop screening average-risk
women >65 years if they have
had three consecutive negative
cytology results or two
consecutive negative cytology
plus HPV test results within
10 years, with the most recent
test performed within 5 years.
(Sawaya et al., 2015)
AAPA Screening: Vaccination:
• Do not recommend screening • National guidelines recommend
for oral HPV (no screening tool that all children receive the HPV
currently exists). (Sheedy and vaccine by age 11 or 12 years,
Heaton, 2019). although they can start as early
• No mention of cervical cancer. as 9.+
• Expand to 27–45 years if indicated.#
Nursing Did not find screening/treatment guidelines
Orgs.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
APPENDIX B 677
HEPATITIS B
Summary Statement
Hepatitis B is mentioned less often (or in less detail) than other STIs
in publications by professional organizations. Despite this, consensus
is apparent on screening recommendations, particularly for pregnant
women, and on routine vaccination.
TABLE B-6 Screening and Treatment Recommendations, Hepatitis B
Screening/Testing Vaccine/Treatment
Recommendations Recommendations
CDC Women: Women at increased risk. Vaccine: Two products have
Pregnant Women: Test for HBsAg at been approved for hepatitis
first prenatal visit of each pregnancy B prevention: hepatitis B
regardless of prior testing; retest at immune globulin (HBIG) for
delivery if at high risk. post-exposure prophylaxis
Men: Men at increased risk. and hepatitis B vaccine. The
MSM: All MSM should be tested for recommended hepatitis B virus
HBsAg. (HBV) dose and schedule varies
Persons with HIV: Test for HBsAg and by product and age of recipient.
anti-HBc and/or anti-HBs.
Treatment: No specific therapy
Increased risk = (persons born in is available for persons with
regions of high endemicity ≥ 2% acute hepatitis B; treatment is
prevalence), IDU, MSM, persons supportive. Persons with chronic
on Immunosuppresive therapy, HBV infection should be referred
Hemodialysis patients, individuals with for evaluation to a provider
HIV, and others. experienced in the management
(CDC, 2015) of chronic HBV infection.
Therapeutic agents cleared by
FDA for treatment of chronic
hepatitis B can achieve sustained
suppression of HBV replication
and remission of liver disease.
(Workowski and Bolan, 2015)
USPSTF Pregnant Women: Screening for hepatitis
B virus (HBV) infection in pregnant
women at their first prenatal visit
(Grade A). (USPSTF, 2019)
Persons at High Risk: Screening for
hepatitis B virus (HBV) infection in
persons at high risk for infection
(Grade B). (USPSTF, 2020b)
continued
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
678 SEXUALLY TRANSMITTED INFECTIONS
TABLE B-6 Continued
Screening/Testing Vaccine/Treatment
Recommendations Recommendations
AAFP Screening:+ Vaccination:+ Endorses Hepatitis
• Pregnant individuals at first visit B vaccination. (AAFP, n.d.-a)
• HIV+ individuals (annually)
• Those at increased risk
(AAFP, 2019)
AAP No mention found No mention found
ACOG Screening:+ In pregnancy, routine Vaccination:+ Universal
prenatal screening recommended. (AAP vaccination of all infants born in
and ACOG, 2017) the United States.
Treatment:+
Newborns born to Hepatitis B
carriers should be treated with
immunoprophylaxis (HBIG and
hepatitis B vaccine) within 12
hours.
(AAP and ACOG, 2017)
ACP Screening for HBV:+ Vaccination:+
• High-risk persons (persons born in • Recommend vaccination
countries with >2% HBV prevalence, in all unvaccinated adults
MSM, persons who inject drugs, (including pregnant women)
HIV+, household and sexual contacts at risk for infection (including
of HBV-infected persons, persons health care and public safety
requiring immunosuppressive workers, adults with chronic
therapy, end-stage renal disease, liver disease, end-stage
people with hepatitis C virus (HCV), renal disease (including
blood and tissue donors, elevated hemodialysis patients), or
ALT, incarcerated persons, pregnant HIV infection; travelers to
women, and infants born to HBV- HBV-endemic regions).
infected mothers). • (No mention of pediatric
(Abara et al., 2017) population).#
Treatment:
Provide or refer all patients
identified with HBV (HBsAg-
positive) for posttest counseling
and hepatitis-B-directed care.
(Abara et al., 2017)
AAPA Did not find screening/treatment guidelines
Nursing Did not find screening/treatment guidelines
Orgs.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
APPENDIX B 679
TRICHOMONIASIS
Summary Statement
Publications by professional organizations mention trichomoniasis
less often (or in less detail) than other STIs, despite that being one of
the more common infections. The consensus appears to be that routine
screening for average-risk women is not advised and testing should be
determined by symptoms. For women living with HIV, there is also con-
sensus that annual screening is recommended. ACOG, in line with CDC
guidance, suggests that EPT may be helpful. While this does not seem to
be routine practice now, it may constitute a new opportunity in the field.
TABLE B-7 Screening and Treatment Recommendations,
Trichomoniasis
Screening/Testing Recommendations Treatment Recommendations
CDC Women: *Consider for women receiving Recommended Regimen:
care in high-prevalence settings (e.g., Metronidazole 2 g orally in a
STD clinics and correctional facilities) single dose OR Tinidazole 2 g
and for women at high risk for infection orally in a single dose.
(e.g., women with multiple sex partners,
exchanging sex for payment, illicit drug Alternative Regimen:
use, and a history of STD). Metronidazole 500 mg orally
Pregnant Women: No recommendation. twice per day for 7 days.
Men: No recommendation.
MSM: No recommendation. EPT might have a role in partner
Persons with HIV: Recommended for management for trichomoniasis
sexually active women at entry to care and can be used in states where
and at least annually thereafter. permissible by law.
(CDC, 2015) (Workowski and Bolan, 2015)
USPSTF No recommendation.
AAFP Screening:+ Routine screening not Treatment:+ Metronidazole or
advised. tinidazole. (AAFP, 2019)
Testing if symptoms (saline wet mount,
rapid antigen testing, or culture). (AAFP,
2019)
AAP Screening:+ Routine screening not Treatment: No mention found
recommended. Screen if HIV+ female
annually, or those at high risk (new or
multiple partners, history of STIs, or
those who exchange sex for payment,
intravenous-drug users). (Committee on
Adolescence and Society for Adolescent
Health and Medicine, 2014)
continued
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
680 SEXUALLY TRANSMITTED INFECTIONS
TABLE B-7 Continued
Screening/Testing Recommendations Treatment Recommendations
ACOG Screening:+ For women with HIV, EPT:+ Committee opinion on EPT
annual screen recommended. suggests this may be helpful for
trichomoniasis as well. (ACOG
Committee Opinion, 2018)
ACP No explicit guidelines for STIs on its Clinical Guidelines and
Recommendations page: “For more screening and preventive care
guidelines, the ACP recommends visiting the United States Preventive
Services Task Force (USPSTF) and the Canadian Task Force on Preventive
Health Care websites.” (ACP, n.d.)
AAPA Did not find screening/treatment guidelines
Nursing Did not find screening/treatment guidelines
Orgs.
HEPATITIS C
Summary Statement
CDC describes hepatitis C as an emerging issue but writes that “HCV
is not efficiently transmitted through sex…. However, data indicate that
sexual transmission of HCV can occur, especially among persons with
HIV infection.” Information about hepatitis C was hardly ever included
in STI resources/guidelines from professional societies, as it was instead
considered more as a blood-borne infection, indicating that it may not
be routinely thought of as an STI. For reference, the CDC and USPSTF
guidelines regarding hepatitis C are shown below.
TABLE B-8 Screening and Treatment Recommendations, Hepatitis C
Screening/Testing Recommendations Treatment Recommendations
CDC Women: Women born between 1945 and Treatment: Providers should
1965. Other women if risk factors are consult with specialists
present. knowledgeable about
Pregnant Women: Pregnant women born management of hepatitis C
between 1945 and 1965. Other pregnant infection. Furthermore, they can
women if risk factors are present. consult existing guidelines to
Men: Men born between 1945 and 1965. learn about the latest advances in
Other men if risk factors are present. the management of hepatitis C.
MSM: MSM born between 1945 and (Workowski and Bolan, 2015)
1965. Other MSM if risk factors are
present. Annual HCV testing in MSM
with HIV infection.
Persons with HIV: Serologic testing at
initial evaluation. Annual HCV testing
in MSM with HIV infection.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
APPENDIX B 681
TABLE B-8 Continued
Screening/Testing Recommendations Treatment Recommendations
Risk factors = Past or current
injection drug use, receipt of blood
transfusion before 1992, long-term
hemodialysis, born to mother with
hepatitis C, intranasal drug use, receipt
of an unregulated tattoo, and other
percutaneous exposures.
(CDC, 2015)
USPSTF Adults at High Risk: For adults aged 18
to 79 years screen for hepatitis C virus
(HCV) infection (Grade B).
(USPSTF, 2020c)
SEXUAL HEALTH/STI RECOMMENDATIONS
(MISCELLANEOUS)
TABLE B-9 General Sexual Health/STI Recommendations
CDC Several recommendations regarding (1) sexual history and physical
examination, (2) prevention, (3) screening, (4) partner services, (5)
evaluation of STD-related conditions, (6) laboratory, (7) treatment, and (8)
referral to a specialist for complex STD or STD-related conditions. (Barrow
et al., 2020)
USPSTF Intensive behavioral counseling for all sexually active adolescents and for
adults who are at increased risk for STIs (Grade B). (USPSTF, 2020a)
AAFP Endorses the following prevention and management strategies:
• Screening for STIs should include accurate sexual history.
• Support effective ways to prevent the STI transmission, including
abstinence and maintenance of a mutually monogamous relationship
with an uninfected partner.
• Consistent and correct use of barrier methods.
• Pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP)
in patients who are at risk for exposure.
• Reducing congenital and perinatal infections through appropriate
counseling, screening, diagnosis, and treatment of pregnant and
breastfeeding individuals.
• Oppose discrimination against patients receiving STI-specific therapies,
such as PrEP or PEP for HIV.
(AAFP, n.d.-a)
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
682 SEXUALLY TRANSMITTED INFECTIONS
TABLE B-9 Continued
AAP • AAP recommends that pediatricians provide confidential time
during health maintenance visits to discuss sexuality, sexual health
promotion, and risk reduction. Confidentiality is extremely important
for adolescents when discussing STIs (but be aware consent and
confidentiality laws vary state to state, so providers should be familiar
with these). (AAP, 2016)
• Both AAP and the Society for Adolescent Health and Medicine support
adolescents’ universal access to sexual and reproductive health care.
• AAP offers guidelines for sexual history taking for adolescents (and
specifically for LGBTQ youth). (Levine, 2013; Marcell and Burstein,
2017)
• AAP opposes “abstinence-only education and endorse[s] comprehensive
sexuality education that includes both abstinence promotion and
accurate information about contraception, human sexuality, and STIs.”
(Breuner and Mattson, 2016)
• Policy statement: Condom use by adolescents abstinence most
effective way to prevent STIs, but pediatricians should actively
support/encourage the consistent and correct use of condoms for those
who are sexually active. Restrictions to condom availability should
be removed (adolescents should have access to condoms at free or
low cost, clinicians encouraged to provide at offices and school-based
settings). (Committee on Adolescence, 2013)
ACOG • Sexual health: should be addressed at well-woman visits throughout the
life span. (ACOG, 2020e)
• Recommend comprehensive sex education should include information
about STI prevention. (ACOG, 2020b)
ACP No specific policies/recommendations
AAPA No specific policies/recommendations
APHA • Policy statement: Sexuality Education as Part of a Comprehensive
Health Education Program in K–12 Schools supports comprehensive
sex education rather than abstinence only. (APHA, 2014)
• Policy statement: Prevention and Control of Sexually Transmitted
Infections and HIV in the Adult Film Industry supports state/federal
regulations to require use of condoms in adult films. (APHA, 2010)
• Policy statement (2019) APHA opposes Title X changes restricting
access to basic reproductive and sexual health services. In effect, the
new rule stops providers offering the full range of reproductive health
services from using Title X funds for basic health care, including cancer
screening, STI testing, and contraception. (APHA, 2019)
• Published supplement with articles on STIs (2018) in the American
Journal of Public Health. (APHA, 2018)
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
APPENDIX B 683
TABLE B-9 Continued
Nursing ANA: Position statement: Education and Barrier Use for Sexually
Orgs. Transmitted Diseases and HIV Infection identifies STIs are major public
health issue. Supports condom use and advertising. Supports educational
and preventative health measures. (ANA, 1991)
American Journal of Nursing: Article: Improving Adolescent Sexual
and Reproductive Health Across Health Care Settings Table 2 gives
recommend Counseling, Screening, Vaccination, and Testing Talking Points
for Nurses. (Santa Maria et al., 2017)
REFERENCES
AAFP (American Academy of Family Physicians). 2019. Screening for sexually transmitted
infections: Practice manual. Leawood, KS: AAFP.
AAFP. n.d.-a. Prevention and management of sexually transmitted infections. https://www.aafp.
org/about/policies/all/prevention-sti.html (accessed February 10, 2021).
AAFP. n.d.-b. Women’s health clinical recommendations & guidelines. https://www.aafp.org/
family-physician/patient-care/clinical-recommendations/recommendations-by-topic/
women-health-clinical-recommendations-guidelines.html (accessed February 10, 2021).
AAP (American Academy of Pediatrics). 2016. Confidentiality protections for adolescents and
young adults in the health care billing and insurance claims process (statement of endorsement).
https://pediatrics.aappublications.org/content/pediatrics/137/5/e20160593.full.pdf
(accessed February 15, 2021).
AAP. n.d.-a. Human papillomavirus (HPV). https://www.aap.org/en-us/advocacy-and-
policy/aap-health-initiatives/adolescent-sexual-health/Pages/HPV.aspx (accessed
February 10, 2021).
AAP. n.d.-b. S TI screening guidelines. https://www.aap.org/en-us/advocacy-and-policy/
aap-health-initiatives/adolescent-sexual-health/Pages/STI-Screening-Guidelines.aspx
(accessed February 10, 2021).
AAP and ACOG (American College of Obstetricians and Gynecologists). 2017. Guidelines
for perinatal care. 8th ed. Elk Grove, IL: American Academy of Pediatrics and American
College of Obstetricians and Gynecologists.
Abara, W. E., A. Qaseem, S. Schillie, B. J. McMahon, and A. M. Harris for the High Value Care
Task Force of the American College of Physicians and the Centers for Disease Control
and Prevention. 2017. Hepatitis B vaccination, screening, and linkage to care: Best
practice advice from the American College of Physicians and the Centers for Disease
Control and Prevention. Annals of Internal Medicine 167(11):794-804.
ACOG (American College of Obstetricians and Gynecologists). 2020a. Cervical cancer screening
(update). https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/
2018/08/cervical-cancer-screening-update (accessed February 10, 2021).
ACOG. 2020b. Comprehensive sexuality education. Committee Opinion Number 678 (reaf-
firmed 2020). https://www.acog.org/clinical/clinical-guidance/committee-opinion/
articles/2016/11/comprehensive-sexuality-education (accessed February 23, 2021).
ACOG. 2020c. Management of genital herpes in pregnancy: ACOG practice bulletin sum-
mary, number 220. Obstetrics & Gynecology 135(5):1236-1238.
ACOG. 2020d. Routine tests during pregnancy. https://www.acog.org/womens-health/
faqs/routine-tests-during-pregnancy?utm_source=redirect&utm_medium=web&utm_
campaign=otn (accessed February 10, 2021).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
684 SEXUALLY TRANSMITTED INFECTIONS
ACOG. 2020e. Well-woman visit. Committee Opinion Number 755 (reaffirmed 2020). https://
www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/10/well-
woman-visit (accessed February 23, 2021).
ACOG Committee Opinion. 2018. Expedited partner therapy. Obstetrics & Gynocology
131(6):e190-e193.
ACOG Committee Opinion. 2020. Human papillomavirus vaccination. Obstetrics & Gynecol-
ogy 136(2):e15-21.
ACP (American College of Physicians). n.d. Clinical guidelines & recommendations. https://
www.acponline.org/clinical-information/guidelines (accessed February 10, 2021).
ANA (American Nurses Association). 1991. Education and barrier use for sexually trans-
mitted diseases and HIV infection. ANA Position Statement (September 6, 1991). Silver
Spring, MD: ANA.
APHA (American Public Health Association). 2010. Prevention and control of sexually
transmitted infections and HIV in the adult film industry. Policy Number 20102. Wash-
ington, DC: American Public Health Association.
APHA. 2014. Sexuality education as part of a comprehensive health education program
in K to 12 schools. Policy Number 20143. Washington, DC: American Public Health
Association.
APHA. 2018. AJPH publishes supplement with new research on disparities in HIV, viral hepatitis,
sexually transmitted diseases and tuberculosis. https://www.apha.org/news-and-media/
news-releases/ajph-news-releases/2018/ajph-cdc-disparities-supplement (accessed
February 15, 2021).
APHA. 2019. APHA opposes Title X changes restricting access to basic reproductive and sexual
health services. https://www.apha.org/news-and-media/news-releases/apha-news-
releases/2019/title-x (accessed February 15, 2021).
Barrow, R. Y., F. Ahmed, G. A. Bolan, and K. A. Workowski. 2020. Recommendations for
providing quality sexually transmitted diseases clinical services, 2020. MMWR Recom-
mendations and Reports 68(5):1-20.
Breuner, C. C., and G. Mattson. 2016. Sexuality education for children and adolescents.
Pediatrics 138(2):e20161348.
Burstein, G. R., A. Eliscu, K. Ford, M. Hogben, T. Chaffee, D. Straub, T. Shafii, and J.
Huppert. 2009. Expedited partner therapy for adolescents diagnosed with chlamydia or
gonorrhea: A position paper of the society for adolescent medicine. Journal of Adolescent
Health 45(3):303-309.
CDC (Centers for Disease Control and Prevention). 2015. Screening recommendations and
considerations referenced in treatment guidelines and original sources. https://www.cdc.
gov/std/tg2015/screening-recs-2015TG-revised2016.pdf (accessed February 10, 2021).
Committee on Adolescence. 2013. Condom use by adolescents. Pediatrics 132(5):973.
Committee on Adolescence and Society for Adolescent Health and Medicine. 2014. Screening
for nonviral sexually transmitted infections in adolescents and young adults. Pediatrics
134(1):e302-e311.
Kim, D. K., and P. Hunter on behalf of the Advisory Committee on Immunization Practices.
2019. Recommended adult immunization schedule, United States, 2019. Annals of In-
ternal Medicine 170(3):182-192.
Levine, D. A. 2013. Office-based care for lesbian, gay, bisexual, transgender, and questioning
youth. Pediatrics 132(1):e297.
Marcell, A. V., and G. R. Burstein. 2017. Sexual and reproductive health care services in the
pediatric setting. Pediatrics 140(5):e20172858.
Rerucha, C. M., R. J. Caro, and V. L. Wheeler. 2018. Cervical cancer screening. American Fam-
ily Physician 97(7):441-448.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
APPENDIX B 685
Santa Maria, D., V. Guilamo-Ramos, L. S. Jemmott, A. Derouin, and A. Villarruel. 2017.
Nurses on the front lines: Improving adolescent sexual and reproductive health across
health care settings. American Journal of Nursing 117(1):42-51.
Sawaya, G. F., S. Kulasingam, T. D. Denberg, A. Qaseem, for the Clinical Guidelines Commit-
tee of the American College of Physicians. 2015. Cervical cancer screening in average-
risk women: Best practice advice from the clinical guidelines committee of the Ameri-
can College of Physicians. Annals of Internal Medicine 162(12):851-859.
Sheedy, T., and C. Heaton. 2019. HPV-associated oropharyngeal cancer. Journal of the Ameri-
can Academy of PAs 32(9):26-31.
St. Cyr, S., L. Barbee, K. A. Workowski, L. H. Bachmann, C. Pham, K. Schlanger, E. Torrone,
H. Weinstock, E. N. Kersh, and P. Thorpe. 2020. Update to CDC’s treatment guidelines
for gonococcal infection, 2020. Morbidity and Mortality Weekly Report 69(50):1911-1916.
USPSTF (United States Preventive Services Task Force). 2014. Final recommendation state-
ment chlamydia and gonorrhea: Screening. https://www.uspreventiveservicestaskforce.
org/uspstf/document/RecommendationStatementFinal/chlamydia-and-gonorrhea-
screening (accessed June 2, 2020).
USPSTF. 2016. Final recommendation statement: Syphilis infection in nonpregnant adults
and adolescents: Screening. JAMA 315(21):2321-2327.
USPSTF. 2018. Screening for cervical cancer: US Preventive Services Task Force recommenda-
tion statement. JAMA 320(7):674-686.
USPSTF. 2019. Screening for hepatitis B virus infection in pregnant women: US Preventive
Services Task Force reaffirmation recommendation statement. JAMA 322(4):349-354.
USPSTF. 2020a. Behavioral counseling interventions to prevent sexually transmitted in-
fections: US Preventive Services Task Force recommendation statement. JAMA
324(7):674-681.
USPSTF. 2020b. Screening for hepatitis B virus infection in adolescents and adults: US
Preventive Services Task Force recommendation statement. JAMA 324(23):2415-2422.
USPSTF. 2020c. Screening for hepatitis C virus infection in adolescents and adults: US Pre-
ventive Services Task Force recommendation statement. JAMA 323(10):970-975.
Workowski, K. A., and G. A. Bolan. 2015. Sexually transmitted diseases treatment guidelines,
2015. MMWR Recommendations and Reports 64(RR-03):1-137.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Measuring the Impact of Worrying
About STIs on Quality of Life
Authored by: Zachary Wagner1 and Matthew Crane,2 October 2020
INTRODUCTION AND BACKGROUND
Sexually transmitted infections (STIs) have a heavy burden on those
who are infected. The reductions in quality of life (QoL) for many differ-
ent STIs are well documented (Chesson et al., 2017). These estimates are
based on the fact that people infected with these illnesses live fewer quality-
adjusted life-years (QALYs). However, the burden from STIs is underesti-
mated if people who are not currently infected experience QoL reductions
simply because they are at risk of acquiring STIs. For example, people
might worry about getting an STI in the future or about past exposure,
which could reduce their well-being in the present. Concerns about STI
risk could also lead people to have fewer sexual partners than they would
otherwise prefer or to have less enjoyable sexual experiences. Research
has not addressed the impacts of worrying about STI risk on well-being.
The goals of this paper are to (1) explore the usefulness of a research
agenda aimed at identifying the effects of STI risk on QoL for those at risk
and (2) introduce a methodology for estimating the burden of STI risk.
The application of QoL measures outside of direct health impacts
has been limited in the literature. One tool is the Adult Social Care Out-
comes Toolkit, which examines utility weights across varied domains of
social care–related QoL and has been extended for use in carers (Malley
et al., 2012; Rand et al., 2015; Towers et al., 2016). The ICEpop CAPability
1 RAND Corporation.
2 Johns Hopkins University School of Medicine.
687
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
688 SEXUALLY TRANSMITTED INFECTIONS
measure for older people is comparable in some settings to that toolkit,
measuring both QoL and capability through attributes of attachment,
security, role, enjoyment, and control (Flynn et al., 2011; van Leeuwen et
al., 2015). The Lupus Patient-Reported Outcome tool employs a similar
concept; it identifies health-related QoL (HRQL) and also explicitly inves-
tigates non-health-related QoL through the domains of desires and goals,
social support, coping, and satisfaction with treatment (Jolly et al., 2012,
2019). Despite exploring topics beyond direct health impact, these tools
remain constrained to specific settings and measurement outcomes. Some
STI research has discussed the negative impact on QoL that may arise
due to mental stress or other life effects associated with STI screening or
positive STI tests (Cvejic et al., 2020; Jackson and Roberts, 2016; Qi et al.,
2014). However, these results have not been translated beyond tools that
concentrate on health domains of QoL and may fail to capture broader
considerations of well-being.
This pilot study examines the impact of STIs on QoL for those who are
at risk of contracting an STI. In Phase 1, the share of the population that
worries about STIs was estimated. This quantifies the population whose
well-being is likely to be impacted by STI risk. In Phase 2, a survey was
piloted with 1,732 participants to examine the impact of STI risk on well-
being using the time trade-off (TTO) method, a standard technique for
measuring HRQL (Muennig and Bounthavong, 2016; Torrance and Feeny,
1989) that allows us to create utility weights for a state in which people
have current levels of STI risk compared to a state with no STI risk. These
utility weights are comparable to HRQL scores and thus can be used to
estimate the impact of STI risk on QALYs. In Phase 3, we combined esti-
mates from Phases 1 and 2 to estimate the impact of STI risk on QALYs
in the United States.
Phase 1: Estimating the Share of the U.S. Population
That Is Worried About Contracting an STI
Data from a nationally representative Kaiser Family Foundation (KFF)
survey that asked respondents “how worried are you about contracting
an STI in the next year?” were used. Table C-1 presents the results: 8
percent of the public is very or somewhat worried. These are the people
whose well-being is likely to be most affected by STI risk. This percent-
age is larger for younger people; 20 percent of people aged 18–29 express
concern. While this is a useful way of assessing the extent to which
population well-being is affected by STI risk, people who are “not very
worried” might also experience an improvement in well-being if there
were not STI risk (e.g., if they would have more partners or better sex
without that risk).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
APPENDIX C 689
TABLE C-1 How Worried Are You That You May Contract a
Sexually Transmitted Infection in the Next Year?
Full Sample
Very worried 3%
Somewhat worried 5%
Not very worried 15%
Not at all worried 77%
NOTE: Data available by request via the project Public Access File via email at publicac@
nas.edu.
SOURCE: Kaiser Family Foundation.
Phase 2: Pilot Survey and TTO Method
In Phase 2, an online pilot survey with two main objectives was
implemented:3
1. Collect information on respondents, such as demographics, sex-
ual history, and level of worry about getting an STI.
2. Assess how many years of life respondents would be willing to
sacrifice to live in a world with no STI risk.
Pilot Survey Platform and Quality Control
The pilot survey was performed on Mechanical Turk (M-Turk), an
online platform where workers complete surveys in exchange for a small
fee. Workers were paid $1.00–$1.50 for completing the survey, which
took 7–12 minutes. Most workers take many surveys in one sitting and
use this site as a source of income. The payment was consistent with
an hourly wage of about $8. While clearly not representative, the pool
of workers includes people from a wide range of ages, demographic
backgrounds, and geographies. Respondents have a strong incentive to
complete surveys quickly, which can diminish data quality. Several qual-
ity control measures were applied, including restrictions on who could
complete the survey and which surveys were included in the analysis.
Only workers with 98 percent quality ratings and who had successfully
3 The pilot survey questions are available by request via the project Public Access File
online at https://www8.nationalacademies.org/pa/managerequest.aspx?key=HMD-
BPH-18-11 (accessed November 16, 2020) or via email at [email protected].
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
690 SEXUALLY TRANSMITTED INFECTIONS
completed more than 1,000 other surveys were allowed to participate. An
“attention check” question was presented in the beginning and locked
out the 7 percent of respondents who failed. This helps ensure that the
sample includes people who intend to provide deliberate and thoughtful
responses. In addition, surveys that exhibited patterns consistent with
“clicking through” were dropped—some people always clicked the same
response in the TTO exercise, some reported a number of partners that
was illogical, and some reported indifference between painful cancer and
perfect health. This removed an additional 40 percent of surveys, leaving
944 for analysis.
Description of Sample
Table C-2 presents demographics and STI risk characteristics of the
remaining respondents. Data from this study include respondents from
48 states, covering 766 zip codes. The average age was 38, and 58 percent
of the sample was male. More than 40 percent of the sample earned less
than $50,000 per year, and 18 percent earned more than $100,000. Most
of the sample was white (80 percent), but Hispanic, Black, and Asian
Americans had substantial representation. Only 38 percent of the sample
was married, but an additional 15 percent was living with a partner. We
expected that these individuals will be less impacted by STI risk. Only 3
percent of the sample was men who have sex with men, and it had only
one transgender woman. These groups are particularly high risk for many
STIs; however, the small sample sizes prohibit analyzing them separately.
Nearly all (90 percent) of respondents were sexually active in the last
12 months, with an average of 0.28 casual sexual partners in that time.
Seventeen percent of the sample was previously diagnosed with an STI.
While most of the sample was not worried about getting an STI (53
percent, see Table C-3), a substantial portion was somewhat or very wor-
ried (10.4 percent); we expect that subset’s well-being to be most sensitive
to changes in STI risk. Substantial variation was found in the likelihood
that a respondent would have more sexual partners (26 percent said it was
likely or very likely) and better sexual experiences (49 percent said likely
or very likely) without STI risk.
TTO Exercise
The TTO exercises asked respondents to compare two scenarios, one
with STI risk at current levels and one with it set to zero (see Figure C-1
for example). They were then asked to compare different durations of life
under the two scenarios and choose which they preferred (e.g., 10 years
of life with their current STI risk or 7 years of life with no STI risk). Five
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
APPENDIX C 691
TABLE C-2 Sample Summary (n = 944)
Means/Proportions
(standard errors)
Age 38.1
(0.368)
Male (%) 58.3
(1.60)
Income
Under $50,000 (%) 41.9
(1.61)
$50,000–$99,999 (%) 40.4
(1.60)
More than $100,000 (%) 17.6
(1.24)
Race/Ethnicity
White only (%) 79.8
(1.30)
Hispanic (%) 8.26
(0.896)
Black (%) 8.47
(0.906)
Asian (%) 9.11
(0.936)
Relationship Status
In relationship, living with partner (%) 17.0
(1.22)
In relationship, not living with partner (%) 14.8
(1.16)
Married (%) 37.5
(1.58)
Single (%) 30.5
(1.50)
STI Risk
MSM (%) 2.75
(0.532)
Sexually active in last year (%) 90.2
(0.977)
Number of casual partners 0.277
(0.038)
Ever diagnosed with an STI (%) 17.7
(1.24)
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
692 SEXUALLY TRANSMITTED INFECTIONS
TABLE C-3 Worry About STI and Change in Sex Life If No STI
Proportions
Worried About Getting an STI
Not at all worried 52.7%
Not very worried 36.7%
Somewhat worried 9.1%
Very worried 1.3%
More Partners If No STI Worry
Very unlikely 41.3%
Unlikely 32.9%
Likely 18.1%
Very likely 7.6%
Better Sex If No STI Worry
Very unlikely 26.8%
Unlikely 24.2%
Likely 31.4%
Very likely 17.4%
NOTE: All questions refer to the next 12 months.
years was used as the starting point for the first 100 surveys, and then
it switched to 7 years. No difference in results was found based on the
starting point. After the respondent made a choice, a new comparison of
life-years for the same scenarios appeared that narrowed or widened the
gap in life-years between the two options depending on the response.
This process continued until respondents were indifferent between the
two options. The number of years of life with current levels of STI risk
at which they are indifferent divided by 10 is their utility weight. For
example, if they are indifferent between 10 years of life with current levels
of risk and 10 years of life with no risk, then their utility weight is 1, and
eliminating STIs will have no effect on QoL. However, if someone is indif-
ferent between 8 years with current STI risk and 10 years with no risk,
then their utility weight is 0.8, implying that eliminating STI risk would
add 0.2 QALYs each year.
Several TTO tasks for STIs of interests were conducted—all STIs,
HIV, human papillomavirus (HPV), and chlamydia/gonorrhea/syphilis
(combined)—but also for “painful cancer.” Respondents completed TTO
exercises that compared having the illness versus perfect health and their
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
APPENDIX C 693
Question: Which would you prefer?
You will die at the end of both periods
(Please choose one option)
10 years of life with current likelihood of catching an STI (Scenario A)
10 years
Option 1
OR Death
5 years of life with no possibility of catching an STI (Scenario B)
5 years
Option 2
Death
FIGURE C-1 Example of time trade-off exercise.
NOTES: The length of time in Option 2 fluctuated based on which response was
chosen, and this exercise was repeated until the respondent changed their choice.
If they first chose Option 2, the next screen would show Option 2 as having 4
years of life. If they chose Option 1, the next screen would show 6 years of life
for Option 2.
current level of risk to no risk. This section began with instructions for
how to think about the exercise, followed by a practice with a clearly
logical choice (10 years of life with perfect health versus 8 years of life
with painful cancer). Respondents had to get the practice correct before
proceeding.
Table C-4 shows the average utility weight for each illness category
compared to perfect health. Painful cancer, the most severe of the ill-
nesses presented, had the lowest utility weight (0.296), followed by HIV
(0.613). The estimated utility rates are in the range of those estimated in
the literature. Prior studies document utility weights (or HRQL scores)
for HIV of 0.5–0.9 depending on the stage of the illness (Tran et al., 2015);
HRQL scores for chlamydia are 0.57–0.9, and scores for HPV are 0.74–0.86
(Jackson et al., 2014; Ong et al., 2019).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
694 SEXUALLY TRANSMITTED INFECTIONS
TABLE C-4 Utility Weights for Having Illness Versus Perfect Health
Utility Weight (average) 95% Confidence Interval
Painful cancer 0.296 0.282–0.311
HIV 0.613 0.589–0.637
Chlamydia 0.729 0.706–0.752
HPV 0.776 0.753–0.798
As expected, preference weights for risk elimination were closer to 1
(i.e., less pronounced) than those for actually having the illness. Current
STI risk produced a utility weight of 0.890 compared to no STI risk. This
implies that, on average, people were indifferent between 8.9 years of
life with no STI risk and 10 years with their current levels of STI. Figure
C-1 shows the distribution of utility weights for STI risk. Utility weights
for individual STIs should be higher than for all STIs because “all STIs”
encompasses each individual STI. While HPV risk is higher, the utility
weights for chlamydia/gonorrhea/syphilis and HIV are lower. This
could be because these illnesses are more salient for some people than
general STIs.
A final question was included to help validate the STI risk utility
weight, asking respondents directly how many years of life they would
be willing to give up (assuming they had 20 years left to live) if they had
no risk of getting an STI in the remaining years. The number of years that
they reported divided by 20 and subtracted from 1 gives an alternative
utility weight that can be used to compare against the TTO utility weight.
These measures were found to perform very similarly (see Figure C-2,
Panel B); the mean of the validation measure was 0.86.
As expected, utility weights for STI risk were highly correlated with
the reported level of STI worry. Figure C-3 shows that the utility weight
for people who reported “not at all worried” was 0.92 compared to 0.88,
0.78, and 0.61 for people who reported “not very worried,” “somewhat
worried,” and “very worried,” respectively.
While the analysis shows the level of STI worry appears to be most
predictive of STI risk utility weights, other characteristics were found to
be associated with these weights (see Figure C-4); people who had sex
without a condom with a casual sex partner in the last year had lower
weights than those who did not (0.85 versus 0.90), and men had slightly
lower weights than women (0.88 versus 0.91). Age and marital status did
not appear to impact utility weights.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
APPENDIX C 695
A. Distribution of TTO Measure
.5
.4 .3
Fraction
.2
.1
0
0 .2 .4 .6 .8 1
STI Risk Prefererence Weight
B. Validation of TTO Measure
8
6
4
2
0
0 .2 .4 .6 .8 1
STI Risk Prefererence Weight
TTO Measure Validation Measure
FIGURE C-2 Distribution of STI risk utility weight.
NOTE: The validation measure asks people directly how many years they would
be willing to give up if they had no STI risk in their remaining years (assuming
they have 20 years remaining).
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
696 SEXUALLY TRANSMITTED INFECTIONS
1
.9
.8 .7
Utility Weight
.5 .4
.3
.2
.1.6
Not at all worried Not very worried Somewhat worried Very worried
FIGURE C-3 Utility weights for STI risk by level of worry about getting an STI
in the next 12 months.
NOTE: Error bars are 95% confidence intervals.
Phase 3: Estimating Impact of STIs on the Well-
Being of the Uninfected Population
To assess the impact of STIs on QALYs, the utility weights from Phase
2 were used with the share of the U.S. population with each level of worry
from Phase 1. Because the sample is not representative of the U.S. popu-
lation, we used its applied utility weights that correspond to each level
of worry (see Figure C-3) to the real number of people with each level of
worry in the United States. The estimated total number of people with
each level of worry was based on the total 18 and over population in the
country (see Table C-5, column 2), and the share of the population with
each level of worry was estimated from the KFF data (see Table C-5, col-
umn 1). This gives a “weighted” utility weight that serves as a proxy for
the average utility weight in the population (0.899). This can then be used
to estimate the number of QALYs lost each year due to STI risk. Table C-6
presents these calculations. With an over-18 population of 268 million and
an average utility weight of 0.899, roughly 27 million QALYs are lost each
year due to STI risk compared to a world in which there was no STI risk.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
APPENDIX C 697
Casual Partner Last 12 Months
Casual Partner
No Casual Partner
Marital Status
Married
Unmarried
Utility Weight
Age
45+
30-44
18-29
Biological Sex
Male
Female
.8 .82 .84 .86 .88 .9 .92 .94 .96 .98 1
FIGURE C-4 Heterogeneity in utility weights by age, sex, marital status, and STI
risk level.
NOTE: Error bars are 95% confidence intervals.
TABLE C-5 Utility Weights for Current Risk of Getting Illness
Versus No Risk
Utility Weight 95% Confidence
(average) Interval
Risk of painful cancer 0.769 0.755–0.782
Risk of STI 0.890 0.879–0.901
Risk of HIV 0.871 0.859–0.884
Risk of chlamydia, gonorrhea,
and syphilis 0.888 0.877–0.900
Risk of HPV 0.913 0.902–0.923
Copyright National Academy of Sciences. All rights reserved.
698
TABLE C-6 Calculation for Annual Number of QALYs Lost as a Result of STI Worry
(1) (2) (3) (4) (5)
Level of Worry About Getting Share Population Utility Weight for QALYs Under QALYs Lost Due
an STI Next 12 Months (from KFF Survey) (over 18) STI Risk Current Conditions to STI Concerns
Very worried 3% 8,040,000 0.612 4,916,770 3,123,230
Somewhat worried 5% 13,400,000 0.788 10,556,395 2,843,605
Not very worried 15% 40,200,000 0.887 35,647,089 4,552,911
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Not at all worried 77% 206,360,000 0.920 189,764,178 16,595,822
Total 100% 268,000,000 0.899* 240,884,432 27,115,568
* Weighted average.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
APPENDIX C 699
Interpretation
While this research is exploratory, it provides a framework for under-
standing the full impact of STIs on population well-being in the United
States. This work suggests that worrying about the risk of STIs has a non-
trivial impact on population well-being and leads to millions of QALYs
lost each year.
Limitations and Guidance for Future Research
This work was exploratory and intended to provide a proof of con-
cept for measuring the extent to which worrying about illness risks can
reduce well-being. A variety of limitations can be improved on in future
research. First, the utility weights are smaller than expected across the
board. For example, people that were not at all worried about STI risk
had a utility weight of 0.92. Although some of them would have better
sex or more partners with no STI risk, this still seems rather low. If these
are underestimated, this would inflate the estimates of the number of
QALYs lost. However, even if the estimates are inflated, it would have
to be by orders of magnitude for the impact of worrying about STIs to
cease to be meaningful. For example, even if the average utility weight
for STI risk was 0.99, this would still result in more than 2 million QALYs
lost each year. Future work should validate these measures to get more
precise utility weight estimates. Using in-person enumerators and ex-post
qualitative interviews could help ensure respondents are understand-
ing and thinking deeply about the exercise. Second, the sample includes
a very small number of men who have sex with men and one trans
woman, two groups that are highly affected by STIs and could be the
most worried about infection. Future work should oversample these and
other high-risk groups to better understand how they are affected. Third,
M-Turk could produce less accurate results than other survey modalities;
its respondents are hurrying to complete as many tasks as possible. The
TTO exercises required careful attention, and it is possible that people in
a rush did not completely understand the survey.
REFERENCES
Chesson, H. W., P. Mayaud, and S. O. Aral. 2017. Sexually transmitted infections: Impact and
cost-effectiveness of prevention. In Major infectious diseases, edited by K. K. Holmes, S.
Bertozzi, B. R. Bloom, and P. Jha. Washington, DC: The International Bank for Recon-
struction and Development/The World Bank. Pp. 203–232.
Cvejic, E., I. M. Poynten, P. J. Kelly, F. Jin, K. Howard, A. E. Grulich, D. J. Templeton, R. J.
Hillman, C. Law, and J. M. Roberts. 2020. Psychological and utility-based quality of life
impact of screening test results for anal precancerous lesions in gay and bisexual men:
Baseline findings from the Study of the Prevention of Anal Cancer. Sexually Transmitted
Infections 96(3):177-183.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
700 SEXUALLY TRANSMITTED INFECTIONS
Flynn, T. N., P. Chan, J. Coast, and T. J. Peters. 2011. Assessing quality of life among British
older people using the ICEPOP capability (ICECAP-O) measure. Applied Health Econom-
ics and Health Policy 9(5):317-329.
Jackson, L. J., and T. E. Roberts. 2016. Measuring health and quality of life for women un-
dergoing testing and screening for chlamydia: A systematic review. Sexually Transmitted
Diseases 43(3):152-164.
Jackson, L. J., P. Auguste, N. Low, and T. E. Roberts. 2014. Valuing the health states associ-
ated with Chlamydia trachomatis infections and their sequelae: A systematic review of
economic evaluations and primary studies. Value in Health 17(1):116-130.
Jolly, M., A. S. Pickard, J. A. Block, R. B. Kumar, R. A. Mikolaitis, C. T. Wilke, R. A. Rodby, L.
Fogg, W. Sequeira, T. O. Utset, T. F. Cash, I. Moldovan, E. Katsaros, P. Nicassio, M. L.
Ishimori, M. Kosinsky, J. T. Merrill, M. H. Weisman, and D. J. Wallace. 2012. Disease-
specific patient reported outcome tools for systemic lupus erythematosus. Seminars in
Arthritis and Rheumatism 42(1):56-65.
Jolly, M., W. Sequeira, J. A. Block, S. Toloza, A. Bertoli, I. Blazevic, L. M. Vila, I. Moldovan,
K. D. Torralba, D. Mazzoni, E. Cicognani, S. Hasni, B. Goker, S. Haznedaroglu, J.
Bourre-Tessier, S. V. Navarra, C. C. Mok, M. Weisman, A. E. Clarke, D. Wallace, and
G. Alarcón. 2019. Sex differences in quality of life in patients with systemic lupus
erythematosus. Arthritis Care & Research 71(12):1647-1652.
Malley, J. N., A.-M. Towers, A. P. Netten, J. E. Brazier, J. E. Forder, and T. Flynn. 2012. An as-
sessment of the construct validity of the ASCOT measure of social care-related quality
of life with older people. Health and Quality of Life Outcomes 10(1):21.
Muennig, P., and M. Bounthavong. 2016. Cost-effectiveness analyses in health: A practical ap-
proach. 3rd edition. San Francisco, CA: Jossey-Bass.
Ong, K. J., M. Checchi, L. Burns, C. Pavitt, M. J. Postma, and M. Jit. 2019. Systematic review
and evidence synthesis of non-cervical human papillomavirus-related disease health
system costs and quality of life estimates. Sexually Transmitted Infections 95(1):28-35.
Qi, S.-Z., S.-M. Wang, J.-F. Shi, Q.-Q. Wang, X.-S. Chen, L.-J. Sun, A. Liu, N. Zhang, N.
Jiang, and P. Siva. 2014. Human papillomavirus-related psychosocial impact of patients
with genital warts in China: A hospital-based cross-sectional study. BMC Public Health
14(1):739.
Rand, S. E., J. N. Malley, A. P. Netten, and J. E. Forder. 2015. Factor structure and construct
validity of the Adult Social Care Outcomes Toolkit for carers (ASCOT-carer). Quality of
Life Research 24(11):2601-2614.
Torrance, G. W., and D. Feeny. 1989. Utilities and quality-adjusted life years. International
Journal of Technology Assessment in Health Care 5(4):559-575.
Towers, A.-M., N. Smith, S. Palmer, E. Welch, and A. Netten. 2016. The acceptability and
feasibility of using the Adult Social Care Outcomes Toolkit (ASCOT) to inform practice
in care homes. BMC Health Services Research 16(1):523.
Tran, B. X., L. H. Nguyen, A. Ohinmaa, R. M. Maher, V. M. Nong, and C. A. Latkin. 2015.
Longitudinal and cross sectional assessments of health utility in adults with HIV/
AIDS: A systematic review and meta-analysis. BMC Health Services Research 15(1):7.
van Leeuwen, K. M., J. E. Bosmans, A. P. Jansen, E. O. Hoogendijk, M. W. van Tulder,
H. E. van der Horst, and R. W. Ostelo. 2015. Comparing measurement properties of
the EQ-5D-3L, ICECAP-O, and ASCOT in frail older adults. Value in Health 18(1):35-43.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Public Meeting Agendas
FIRST PUBLIC MEETING
August 26, 2019
Videoconference via Zoom
1:00 Welcome
• Sten Vermund, Dean, Yale School of Public Health;
Committee Chair
1:05–1:45 Presentation of the Statement of Task, background, and
discussion
• Gail Bolan, Director, Division of STD Prevention
National Center for HIV/AIDS, Viral Hepatitis,
STD, and TB Prevention, Centers for Disease
Control and Prevention
1:45 Open session adjourn
701
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
702 SEXUALLY TRANSMITTED INFECTIONS
SECOND PUBLIC MEETING
September 9, 2019
National Academy of Sciences Building
2101 Constitution Avenue, NW
Lecture Room
Washington, DC 20418
10:00–10:15 Introduction and opening remarks
• Sten Vermund, Dean, Yale School of Public Health;
Committee Chair
10:15–10:35 Discussion of Statement of Task
• Gail Bolan, Director
• Raul Romaguera, Deputy Director
Division of STD Prevention, National Center
for HIV/AIDS, Viral Hepatitis, STD, and TB
Prevention, Centers for Disease Control and
Prevention
10:35–11:50 Trends in sexual behavior and reproductive health
• Lynn Barclay, President and Chief Executive Officer,
American Sexual Health Association
• Gail Wyatt, Director, University of California,
Los Angeles, Sexual Health Program (via Zoom)
• Maria Trent, Professor of Pediatrics, Johns Hopkins
University School of Medicine; President, Society
for Adolescent Health
• Eli Coleman, Director, Program in Human Sexuality,
University of Minnesota
11:50–12:15 American Sexually Transmitted Diseases Association
• Barbara (Bobbie) Van Der Pol, President, American
Sexually Transmitted Diseases Association
12:15–1:15 Lunch
1:15–2:05 STI prevention and control: Opportunities and barriers
at the state and local levels
• Gretchen Weiss, Director, HIV, STI, and Viral
Hepatitis, National Association of County and City
Health Officials
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
APPENDIX D 703
• Elizabeth Ruebush, Director of STD, HIV, and Viral
Hepatitis, Association of State and Territorial Health
Officials
• George Walton, Board of Directors and Vice Chair
of the Public Policy Committee, National Coalition
of STD Directors; STD Program Manager, Iowa
Department of Public Health
2:05–3:05 Examples and experiences at the state and local levels
• Leandro Mena, STD Medical Director, Mississippi
State Department of Health; Professor, University of
Mississippi Medical Center
• Demetre Daskalakis, Deputy Commissioner,
Division of Disease Control, New York City
Department of Health and Mental Hygiene (via
Zoom)
• Joanna Shaw-KaiKai, Infectious Disease Physician
and Associate Medical Director, Communicable
Disease Control Bureau, Metro Public Health
Department, Nashville/Davidson County
• Naveen Patil, Medical Director for Infectious
Diseases, Arkansas Department of Health
3:05–3:20 Break
3:20–3:50 Report overview: The Impact of Sexually Transmitted
Diseases on the United States: Still Hidden, Getting
Worse, Can Be Controlled
• Shoshanna Sofaer, Director, Strategic Research
Planning for Health Policy Research, American
Institutes for Research; National Academy of Public
Administration study fellow
3:50–4:10 Public comment
4:10 Open session adjourn
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
704 SEXUALLY TRANSMITTED INFECTIONS
THIRD PUBLIC MEETING
October 7, 2019
Keck Center of the National Academies
Room 100
500 Fifth Street, NW
Washington, DC 20001
8:45–9:00 Introduction and opening remarks
• Sten Vermund, Dean, Yale School of Public Health;
Committee Chair
9:00–9:25 STI services in HIV care settings and primary care
• Laura W. Cheever, Associate Administrator
for HIV/AIDS, Health Resources and Services
Administration
9:25–10:15 Structural interventions
• Kim M. Blankenship, Professor, Department of
Sociology; Associate Dean of Research, College
of Arts and Sciences; Co-Director, Social and
Behavioral Sciences Core, DC CFAR, American
University
• Susan Sherman, Professor, Department of Health,
Behavior and Society; Co-Director, CFAR Baltimore
Collaboratory; Co-Director, Bloomberg American
Health Initiative Addiction and Overdose
Workgroup, Johns Hopkins Bloomberg School of
Public Health
10:15–10:25 Break
10:25–11:30 Biomedical STI interventions
• Brenda Korte, Technology Consultant, POC Device
Consulting
• Emilie Alirol (remote), STI Project Leader, Global
Antibiotic Research and Development Partnership
• Manos Perros (remote), President and Chief
Executive Officer, Entasis Therapeutics
• Eliav Barr (remote), Senior Vice President, Global
Medical Affairs, Merck & Company, Inc.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
APPENDIX D 705
11:30–12:00 Overview of NIAID’s STI research portfolio
• Carolyn D. Deal, Chief, Enteric and Sexually
Transmitted Infections Branch, National Institute of
Allergy and Infectious Diseases
12:00–12:50 Lunch
12:50–1:40 Behavioral interventions and role of stigma
• John Pachankis, Susan Dwight Bliss Associate
Professor, Yale School of Public Health
• Seth C. Kalichman, Professor of Psychology,
University of Connecticut
1:40–2:10 STI economic burden
• Harrell Chesson, Health Economist, Division
of STD Prevention, Centers for Disease Control
and Prevention
2:10–2:35 STI federal action plan
• Carol S. Jimenez, Deputy Director for Strategic
Initiatives, Office of Infectious Disease and HIV/
AIDS Policy, Department of Health and Human
Services
2:35–2:40 Stretching break
2:40–3:30 mHealth, eHealth, communications, technology-assisted
interventions, and community-engaged research
• Liz Chen, Assistant Professor, Department of Health
Behavior, Gillings School of Global Public Health,
University of North Carolina at Chapel Hill
• José A. Bauermeister, Penn Presidential Professor
and Penn Fellow, Department of Family and
Community Health, School of Nursing, University
of Pennsylvania
3:30–4:00 Public comment
4:00 Open session adjourn
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
706 SEXUALLY TRANSMITTED INFECTIONS
FOURTH PUBLIC MEETING
December 16, 2019
Beckman Center of the National Academies
Huntington Room
100 Academy Way
Irvine, CA 92617
12:30–12:40 Introduction and opening remarks
• Sten Vermund, Dean, Yale School of Public Health;
Committee Chair
12:40–1:10 STI services in primary care settings
• Shannon K. McDevitt (remote), Bureau of Primary
Health Care, Health Resources and Services
Administration
1:10–2:15 Opportunities to prevent and treat STIs
• Ina Park, Associate Professor, University of
California, San Francisco, School of Medicine;
Medical Director, California Prevention Training
Center; Medical Consultant, Division of STD
Prevention, Centers for Disease Control and
Prevention
• Dan Wohlfeiler, Co-Founder, Building Healthy
Online Communities
2:15–3:05 Report overview: The STD Epidemic in America: The
Frontline Struggle
• Georges C. Benjamin (remote), Executive Direc-
tor, American Public Health Association; National
Academy of Public Administration study fellow
National Coalition of STD Directors perspective
• David C. Harvey, Executive Director, National
Coalition of STD Directors
3:05–3:15 Break
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
APPENDIX D 707
3:15–4:05 Biomedical strategies to prevent and treat STIs
• Jeffrey D. Klausner, Professor of Medicine, David
Geffen School of Medicine; Professor of Public
Health, Fielding School of Public Health, University
of California, Los Angeles
4:05–5:30 Opportunities to prevent and treat STIs online
• Sean Howell, Chief Executive Officer, LGBT
Foundation; Co-Founder, Hornet Gay Social
Networks
• Evgeniy Gabrilovich (remote), Senior Staff Research
Scientist, Google
• Emmett Patterson (remote), Global Health Projects
Manager, Grindr for Equality
5:30–5:45 Public comment
5:45 Open session adjourn
FIFTH PUBLIC MEETING
January 30, 2020
Videoconference via Zoom
1:00 Opening remarks and introductions
• Sten Vermund, Dean, Yale School of Public Health;
Committee Chair
1:05 Perspectives from the field and discussion
• Kate Washburn, Senior Director, Public Health
Outcomes Improvement, Planned Parenthood
Federation of America
• Krishna Upadhya, Senior Medical Advisor, Planned
Parenthood Federation of America
• Kevin Ault, Professor and Director, General
Obstetrics and Gynecology, University of Kansas
Medical Center; Fellow, American College of
Obstetricians and Gynecologists
2:00 Open session adjourn
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
708 SEXUALLY TRANSMITTED INFECTIONS
SIXTH PUBLIC MEETING
May 19, 2020
Videoconference via Zoom
12:00 Welcome and opening remarks
• Sten Vermund, Dean, Yale School of Public Health;
Committee Chair
12:10–1:00 Presentations
• Janet Wilson, President, IUSTI
• Henry de Vries, Department of Infectious Diseases,
Public Health Service of Amsterdam, Netherlands
• Meg Doherty, Sami Gottlieb, & Melanie Taylor,
World Health Organization
1:00–1:30 Q&A/discussion with panelists
1:30 Open session adjourn
SEVENTH PUBLIC MEETING
September 9, 2020
Videoconference via Zoom
1:00–1:10 Welcome and introductions
• Amy Geller, Study Director
1:10–1:50 Lived experience panel #1
1:50–2:05 Discussion
2:05–2:45 Lived experience panel #2
2:45–3:00 Discussion
3:00 Open session adjourn
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
APPENDIX D 709
EIGHTH PUBLIC MEETING
September 14, 2020
Videoconference via Zoom
3:00–3:10 Welcome and introductions
• Amy Geller, Study Director
3:10–3:50 Lived experience panel #1
3:50–4:05 Discussion
4:05–4:45 Lived experience panel #2
4:45–5:00 Discussion
5:00 Open session adjourn
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
Committee Member
and Staff Biographies
Sten H. Vermund, M.D., Ph.D. (Chair), serves as the dean of the Yale
School of Public Health, the Anna M.R. Lauder Professor of Public Health
(Epidemiology of Microbial Diseases), and a professor of pediatrics in
the Yale School of Medicine. His research has focused on health care
access in low-income nations, adolescent sexual and reproductive health,
and preventing mother-to-child HIV transmission. Dr. Vermund’s early
work included illuminating the importance of HIV infection in human
papillomavirus–mediated cervical pathogenesis. He is a member of the
National Academy of Medicine. Dr. Vermund received his M.D. from the
Albert Einstein College of Medicine at Yeshiva University and his Ph.D.
from Columbia University.
Madina Agénor, Sc.D., M.P.H., is the inaugural Gerald R. Gill Assistant
Professor of Race, Culture, and Society in the Department of Community
Health at Tufts University. She is also the director of the Sexual Health
and Reproductive Experiences Lab at Tufts University and adjunct faculty
at the Fenway Institute. As a social epidemiologist and health services
researcher, Dr. Agénor investigates health and health care inequities in
relation to various dimensions of social inequality—especially sexual
orientation, gender identity, and race/ethnicity—using an intersectional
lens. Specifically, she uses quantitative and qualitative research methods
to elucidate the patient-, provider-, and policy-level social determinants
of sexual and reproductive health and cancer screening and prevention
among marginalized U.S. populations, especially women and girls of
711
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
712 SEXUALLY TRANSMITTED INFECTIONS
color, sexual minority women and girls, transgender and non-binary
individuals, and lesbian, gay, bisexual, transgender, and queer people of
color. As the principal investigator of a career development (K01) award
from the National Cancer Institute, she is examining how Medicaid state
expansions influence sexual orientation and racial/ethnic disparities in
human papillomavirus (HPV) vaccination and other sexual and repro-
ductive health outcomes among U.S. women. She is also exploring health
care providers’ beliefs, attitudes, decision-making processes, and practices
related to HPV vaccination among sexual minority women and women of
color in the United States. As a Research Education Institute for Diverse
Scholars Fellow at the Center for Interdisciplinary Research on AIDS at
Yale University, she is leading a mixed-methods study examining the
multi-level social determinants of HIV and sexually transmitted infection
testing among transmasculine U.S. young adults. Before joining the Tufts
faculty, Dr. Agénor was an assistant professor of social and behavioral
sciences at the Harvard T.H. Chan School of Public Health, where she
earned an Sc.D. in social and behavioral sciences. She also has an M.P.H.
from Columbia University’s Mailman School of Public Health and was a
Cancer Prevention Postdoctoral Fellow at the Harvard T.H. Chan School
of Public Health and the Dana-Farber Cancer Institute.
Cherrie B. Boyer, Ph.D., FSAHM, is a professor of pediatrics in the Divi-
sion of Adolescent and Young Adult Medicine at the University of Cali-
fornia, San Francisco. She also serves as the associate division director for
research and academic affairs. Dr. Boyer is an internationally recognized
health psychologist with more than 30 years of research experience in
the area of adolescent and young adult health. She has received many
grant awards and been a productive investigator, publishing widely in
the area of sexually transmitted infections (STIs) and HIV prevention in
adolescents and young adults. Dr. Boyer’s research focuses on developing
and evaluating cognitive-behavioral and community-level intervention
strategies using both culturally competent and positive youth develop-
ment frameworks to promote sexual health and reduce the risk of STIs,
HIV, and unintended pregnancy and their sequelae in adolescents and
young adults. Dr. Boyer was a member of the Adolescent Trials Net-
work, funded by the National Institutes of Health, where she served as
a lead investigator and collaborated on a number of community-based
participatory research community mobilization studies to examine social
determinants and structural barriers to improve HIV prevention for at-
risk youth and linkage, engagement, and retention in long-term HIV
health care for affected youth. She has recently conducted research with
the San Francisco Department of Public Health Community Equity Pre-
vention Section to identify and characterize factors associated with the
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
APPENDIX E 713
disproportionately high rate of STIs in African American adolescents in
San Francisco. Her other research examines social determinants and other
environmental influences on pre-exposure prophylaxis access and uptake
in African American and Latin/x young adult men in San Francisco. Dr.
Boyer earned her M.A. and Ph.D. from Stony Brook University.
Myron S. Cohen, M.D., is the Yeargan-Bate Eminent Professor of Medi-
cine, Microbiology, and Immunology and a professor of epidemiology at
the University of North Carolina (UNC) at Chapel Hill. He is the director
of the Institute for Global Health and Infectious Diseases. Dr. Cohen is
also the associate director of the UNC Center for AIDS Research and Asso-
ciate Vice Chancellor for Global Health and Medical Affairs. Dr. Cohen’s
research focuses on HIV transmission and prevention, with emphasis on
the role played by sexually transmitted infections (STIs) and coinfections.
Dr. Cohen is the architect and the principal investigator (PI) of the mul-
tinational HIV Prevention Trials Network study (HPTN052) that demon-
strated that antiretroviral treatment prevents the sexual transmission of
HIV-1. He is a member of the American Society of Clinical Investigation,
the American Association of Physicians, and the National Academy of
Medicine. He earned his M.D. from Rush Medical College. Dr. Cohen
directed the first National Institutes of Health (NIH) STI Clinical Trials
Group. Most recently, Dr. Cohen has served as the co-PI of the NIH HIV
Prevention Trials Network. Dr. Cohen was on the NIH AIDS Research
Advisory Council and the NIH Office of AIDS Research Council and
currently serves on the Council of the NIH Fogarty International Center.
Jeffrey S. Crowley, M.P.H., is a distinguished scholar and the program
director of infectious disease initiatives at the O’Neill Institute for National
and Global Health Law at Georgetown Law. Mr. Crowley is a widely
recognized expert on HIV/AIDS and disability policy. His research has
covered a range of health policy issues, with an emphasis on Medicaid
and Medicare policy, especially as these programs impact people with
HIV and other disabilities. Mr. Crowley previously served as the director
of the White House Office of National AIDS Policy and the senior advi-
sor on disability policy for President Barack Obama, where he led the
development of the first domestic National HIV/AIDS Strategy. He also
coordinated disability policy development for the Domestic Policy Coun-
cil and worked on the policy team that spearheaded the development and
implementation of the Patient Protection and Affordable Care Act. Mr.
Crowley has also served as an informal resource and counsel for congres-
sional staff, and he advised national consumer coalitions, including the
HIV Health Care Access Working Group and the Consortium for Citizens
with Disabilities. He is an alumnus of the U.S. Peace Corps, where he was
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
714 SEXUALLY TRANSMITTED INFECTIONS
a volunteer/high school science teacher in eSwatini. Mr. Crowley received
his M.P.H. from the Johns Hopkins Bloomberg School of Public Health.
Charlotte A. Gaydos, Dr.P.H., M.S., M.P.H., is a professor emerita in the
Division of Infectious Diseases of the Johns Hopkins University School of
Medicine. She has joint appointments in emergency medicine and epidemi-
ology and population and family health at the Johns Hopkins Bloomberg
School of Public Health. She is a member of the Johns Hopkins University
Center for Global Health and former director for the National Institutes
of Health–funded Center for Point-of-Care Tests for Sexually Transmitted
Diseases and the International STI, Respiratory Diseases, and Biothreat
Research Laboratory at Johns Hopkins. She has 50 years of laboratory
expertise in microbiology. Dr. Gaydos conducted multiple Food and Drug
Administration clinical trials for new diagnostics for sexually transmit-
ted infections (STIs) and respiratory pathogens. Her laboratory has been
a core diagnostic/reference laboratory for international studies of STIs,
respiratory diseases, and trachoma. Dr. Gaydos has extensive labora-
tory experience in developing and evaluating molecular amplification
testing techniques for respiratory, urogenital, and biothreat specimens,
as well as epidemiology expertise. Dr. Gaydos has performed original
research developing DNA amplification tests for Chlamydia trachomatis,
C. pneumoniae, C. psittaci, Trichomonas vaginalis, N. gonorrhoeae, Mycoplasma
genitalium, and the agents of genital ulcer disease. She invented, devel-
oped, and published on an STI educational and home screening website,
“I Want the Kit,” which has screened more than 10,000 persons with at-
home, self-collected urogenital, rectal, and oropharyngeal samples. Dr.
Gaydos received her M.S. from West Virginia University and her M.P.H.
and Dr.P.H. from the Johns Hopkins Bloomberg School of Public Health.
Vincent Guilamo-Ramos, Ph.D., M.P.H., L.C.S.W., R.N., ANP-BC,
PMHNP-BC, AAHIVS, FAAN, is a professor and an associate vice pro-
vost of mentoring and outreach programs at New York University (NYU).
He is the director and the founder of the Center for Latino Adolescent and
Family Health. Dr. Guilamo-Ramos also serves as the pilot and mentoring
core director at the Center for Drug Use and HIV Research, a National
Institute on Drug Abuse–funded center at the NYU School of Public
Health. As of July 1, 2021, Dr. Guilamo-Ramos will be the dean of the Duke
University School of Nursing and the vice chancellor for nursing affairs.
Dr. Guilamo-Ramos is a clinical social worker and a nurse practitioner and
is board certified in HIV/AIDS nursing and as an HIV specialist. Clini-
cally, he has expertise in the primary care of HIV-positive adolescents,
pre-exposure prophylaxis for youths at risk of HIV, and screening and
treatment of sexually transmitted diseases. Dr. Guilamo-Ramos studies
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
APPENDIX E 715
the role of families in promoting adolescent health, with a special focus
on preventing HIV/AIDS, sexually transmitted infections, and unplanned
pregnancies and improving treatment outcomes for youth living with
HIV and those at risk. He is a fellow of the American Academy of Nursing
and the American Academy of Social Work and Social Welfare. In addi-
tion, Dr. Guilamo-Ramos serves as a member of the Health and Human
Services (HHS) Presidential Advisory Council on HIV/AIDS and the
HHS Panel on Antiretroviral Guidelines for Adults and Adolescents. He
is also the vice chair of the board of directors for the Latino Commission
on AIDS and a board member of Power to Decide. Dr. Guilamo-Ramos
received his Ph.D. from the State University of New York at Albany and
his M.S.W. and M.P.H. from NYU. He also holds an M.S. from the Robert
F. Wagner Graduate School of Public Service at NYU and an M.S.N. from
the Duke University School of Nursing.
Edward W. Hook III, M.D., is an emeritus professor of medicine at The
University of Alabama at Birmingham (UAB), where he was previously a
professor of medicine and microbiology in the School of Medicine and a
professor of epidemiology in the School of Public Health. Dr. Hook is the
co-director of the university’s Interdisciplinary Center for Social Medicine
and STDs. He is also a senior scientist at the UAB AIDS Center, the Minor-
ity Health and Research Center, and the Arthritis and Musculoskeletal
Disease Center. Dr. Hook was previously the medical director of the sexu-
ally transmitted diseases (STDs) control program at the Jefferson County
Health Department in Birmingham, where he remains a contract physi-
cian. As an internist with subspecialty expertise in infectious diseases, he
spent much of his academic career focused on managing and preventing
STDs. He has directed public health STD control programs in two cities
(Birmingham, Alabama, and Baltimore, Maryland); clinical studies with
operational and epidemiologic end points; clinical trials of new diagnostic
tests, vaccines, and therapies for a wide variety of STD pathogens; and an
internationally recognized reference laboratory for STD pathogens (Neis-
seria gonorrhoeae, Chlamydia trachomatis, and syphilis). He has served as a
consultant and a committee member for a number of national and interna-
tional organizations, including the National Academies of Sciences, Engi-
neering, and Medicine; National Institutes of Health; Centers for Disease
Control and Prevention; and World Health Organization. Before joining
UAB, he worked at Johns Hopkins University and with the Baltimore City
Health Department. He earned his M.D. from Cornell University.
Patricia Kissinger, Ph.D., M.P.H., B.S.N., is a professor at Tulane Uni-
versity and an infectious disease epidemiologist. She has worked both
nationally and internationally for more than three decades in the field
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
716 SEXUALLY TRANSMITTED INFECTIONS
of HIV, sexually transmitted diseases (STDs), and women’s reproductive
health in Africa, Haiti, and the United States. Dr. Kissinger focuses on the
dynamics of STD/HIV transmission, particularly among vulnerable pop-
ulations, examining issues of STD/HIV partner notification, expedited
partner treatment, sexual networks, substance abuse, pregnancy preven-
tion, and repeat STDs. The ultimate goal of her research is to reduce
STD-related health disparities. She has been the principal investigator
on dozens of federally funded research grants and published more than
160 manuscripts and numerous book chapters. Dr. Kissinger is a frequent
reviewer for the National Institutes of Health, an expert consultant for
the Centers for Disease Control and Prevention, and an associate editor
of the journal Sexually Transmitted Diseases. She earned her B.S.N. from
Marquette University and her M.P.H. and Ph.D. from Tulane University.
Guillermo (“Willy”) J. Prado, Ph.D., is a professor of nursing and health
studies, public health sciences, and psychology at the University of
Miami, where he also serves as the vice provost for faculty affairs and
the dean of the graduate school. Dr. Prado is also the director of the
Investigator Development Core for the Center for Latino Health Research
Opportunities. Dr. Prado’s research focuses on developing, evaluating,
and translating family-based preventive interventions for addressing
smoking, alcohol, drug abuse, HIV/sexually transmitted infections, and
obesity health disparities among Hispanic youth. His research has been
recognized by professional organizations, such as the Society for Preven-
tion Research, the National Hispanic Science Network on Drug Abuse,
and the Society for Research on Adolescence. He is currently a board
member of Research!America and the president of the Society for Preven-
tion Research. Dr. Prado earned his Ph.D. from the University of Miami.
Cornelis (“Kees”) Rietmeijer, M.D., Ph.D., M.S.P.H., is an independent
sexually transmitted infection (STI) consultant. His expertise is in the
areas of STI clinical operations and workforce development. He is a pro-
fessor of community and behavioral health at the Colorado School of
Public Health. Until his retirement in 2009, he was the director of the
sexually transmitted disease (STD) control program and clinic at the Den-
ver Department of Public Health. As a consultant, he continued to work
for the department as the director of the Denver STD Clinical Prevention
Training Center until 2020. He is a past president of the American Sexu-
ally Transmitted Diseases Association and a past director of the Interna-
tional Union Against STIs—North American Region. Between 2009 and
2016, Dr. Rietmeijer worked and traveled extensively in southern Africa,
where he was the director of an HIV/STI prevention course for the South-
ern African Prevention Initiative and the principal investigator of the
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
APPENDIX E 717
Zimbabwe STI Etiology study, both funded through the President’s Emer-
gency Plan for AIDS Relief. Dr. Rietmeijer is a current associate editor of
the journal Sexually Transmitted Diseases, a consultant to the World Health
Organization on developing guidelines for STI syndromic management,
and a volunteer physician at the Denver STD clinic. Dr. Rietmeijer earned
his M.D. and Ph.D. from the University of Amsterdam and his M.S.P.H.
from the University of Colorado Denver.
Alina Salganicoff, Ph.D., is the senior vice president and the director of
Women’s Health Policy at the Kaiser Family Foundation (KFF). Widely
regarded as an expert on women’s health policy, she has written and
lectured extensively on health care access and financing for low-income
women and children. Her work at KFF focuses on health coverage and
access to care for women, with an emphasis on challenges facing low-
income and underserved women throughout their life span. Dr. Salgani-
coff was also an associate director of the Kaiser Commission on Medic-
aid and the Uninsured and worked on the health program staff of the
Pew Charitable Trusts. She has served on numerous federal, state, and
nonprofit advisory committees focusing on improving women’s qual-
ity of and access to health care, including for the Agency for Healthcare
Research and Quality, the Health Resources and Services Administration,
the Centers for Disease Control and Prevention, the Department of Vet-
erans Affairs, the Department of Health and Human Services’ Office on
Women’s Health, and the National Academies of Sciences, Engineering,
and Medicine. She is a member of the advisory panel for the American
College of Obstetricians and Gynecologists’ Women’s Preventive Services
Initiative and the public policy advisory committee of Power to Decide.
Dr. Salganicoff holds a Ph.D. from the Johns Hopkins Bloomberg School
of Public Health.
John Schneider, M.D., M.P.H., is a professor of medicine and epidemiol-
ogy, a network epidemiologist, and an infectious disease specialist in the
Departments of Medicine and Public Health Sciences at the University of
Chicago. He is also the director of the Chicago Center for HIV Elimina-
tion, where he works on developing Getting to Zero strategies informed
by social determinants of health integrated within computational models.
Dr. Schneider’s research focuses on how social networks can be lever-
aged to improve the health of community members vulnerable to HIV
and other sexually transmitted infections (STIs) in resource-restricted
settings, where he also implements network interventions guided by
data and community input to eliminate new HIV transmission. Clinically,
he specializes in sexual health, HIV/STI prevention and treatment, and
gender-affirming care and has a specific interest in providing high-quality
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
718 SEXUALLY TRANSMITTED INFECTIONS
care to sexual and gender minority community members of color. Dr.
Schneider has experience with advancing the physician–patient relation-
ship in resource-restricted settings, including at Howard Brown Health
55th Street, where he is the medical director, and during his time working
in South India. Dr. Schneider received his M.D. and M.P.H. from Tufts
University.
Neeraj Sood, Ph.D., is a professor and the vice dean for faculty affairs and
research at the University of Southern California (USC) Sol Price School
of Public Policy and a founding member of USC’s Schaeffer Center. He
is also a research associate at the National Bureau of Economic Research.
Dr. Sood’s research focuses on economic epidemiology, pharmaceutical
markets, health insurance, economics of innovation, Medicare, and global
health. He has published more than 100 papers in peer-reviewed journals
in economics, medicine, and policy. Dr. Sood has testified frequently on
health policy issues and has been on expert committees for the National
Academies of Sciences, Engineering, and Medicine. His work has been
featured in media outlets, including The New York Times, The Washington
Post, U.S. News & World Report, and Scientific American. Dr. Sood was
the finalist for the 16th and 21st annual National Institute for Health
Care Management Health Care Research Award, recognizing outstanding
research in health policy. He was awarded the Eugene Garfield Economic
Impact Prize, which recognizes outstanding research demonstrating how
medical research impacts the economy. Dr. Sood is a board member of
the American Society of Health Economists. Before joining USC, he was a
senior economist at RAND and a professor at the Pardee RAND Graduate
School, where he also received his Ph.D.
Jessica Willoughby, Ph.D., is an associate professor at the Edward R.
Murrow College of Communication at Washington State University. Her
research focuses on health communication strategies, with an emphasis
on adolescents and mobile technologies. Her recent work has been on
adolescents’ use of technology for sexual health information, specifi-
cally examining the North Carolina BrdsNBz sexual health text message
service. Dr. Willoughby previously worked as a research health analyst
contracting with the Center for Communication Science at RTI Interna-
tional. She earned her Ph.D. from the University of North Carolina at
Chapel Hill.
Sean D. Young, Ph.D., M.S., is an associate professor in the Departments
of Emergency Medicine and Informatics at the University of California,
Irvine, and the executive director of the University of California Insti-
tute for Prediction Technology, which studies how social big data (e.g.,
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
APPENDIX E 719
social media, wearable devices, and online search) and machine learning/
data mining can be used to predict real-world events, such as disease
outbreaks. Dr. Young’s research focuses on two main areas: (1) using
social “big data” and artificial intelligence to monitor and predict public
health issues, such as HIV, substance use, and crime; and (2) designing
and testing technologies to address public health issues among at-risk
populations, including African Americans, Latinx, and men who have
sex with men. He is the author of the international best-selling book Stick
with It on the science of behavior change. Dr. Young previously worked
as a faculty member at the University of California, Los Angeles, School
of Medicine and at the NASA Ames Research Center. He received his
Ph.D. in psychology and master’s degree in health services research from
Stanford University.
Carmen D. Zorrilla, M.D., is a professor of obstetrics and gynecology at
the University of Puerto Rico School of Medicine. She is also the principal
investigator of the University of Puerto Rico clinical trials unit, which
includes adult and pediatric AIDS trials. Certified by the American Board
of Obstetrics and Gynecology and the American Academy of HIV Medi-
cine, Dr. Zorrilla has experience in both obstetrics/gynecology and HIV-
related research. This work includes behavioral interventions and clinical
trials with populations living with HIV or at risk and with pregnant and
nonpregnant women. Dr. Zorrilla has participated in diverse clinical and
behavioral research projects for women living with HIV. In 1987, she
established the first longitudinal clinic for women living with HIV in
Puerto Rico and was instrumental in making AZT available to pregnant
women living with HIV there. Her clinic, in which more than 600 infants
have been born to women living with HIV, has had a nearly zero trans-
mission rate during the past 16 years. Dr. Zorrilla also implemented the
first group prenatal care program in Puerto Rico; this new model of care
evidenced a reduction in preterm births and low birthweights. She is also
one of the leaders who spearheaded the research response to the emerging
Zika epidemic among pregnant women in Puerto Rico, and she helped
establish a multidisciplinary clinic for these women. Dr. Zorrilla is also
evaluating the impact of Hurricane Maria on mothers and infants; her
team developed a hurricane preparedness session for pregnant women
during group care. Dr. Zorrilla has been a consultant for national and
international organizations, including the National Institutes of Health,
the Maternal and Child Health Bureau, the Centers for Disease Control
and Prevention (CDC), the Agency for Healthcare Research and Quality,
and the Institute for Healthcare Improvement. She is also a former mem-
ber of the Office of Women’s Health Advisory Committee and the CDC/
Health Resources and Services Administration AIDS and STD Advisory
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
720 SEXUALLY TRANSMITTED INFECTIONS
Committee and a current member of the National Advisory Council on
Minority Health and Health Disparities. Dr. Zorrilla earned her M.D. from
the University of Puerto Rico School of Medicine.
STAFF
Amy B. Geller, M.P.H., serves as the study director for the Commit-
tee on Prevention and Control of Sexually Transmitted Infections in the
United States and is a senior program officer in the Health and Medicine
Division (HMD) on the Board on Population Health and Public Health
Practice. At the National Academies, Ms. Geller has staffed committees
spanning many topics, including advancing health equity, reducing
alcohol-impaired driving fatalities, workforce resilience, vaccine safety,
reducing tobacco use, drug safety, and treating posttraumatic stress dis-
order. She was the study director for the recently released HMD reports
Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance
Health Equity and Communities in Action: Pathways to Health Equity. She
also directs the HMD/National Academy of Medicine DC Public Health
Case Challenge, which aims to promote interdisciplinary, problem-based
learning for college students at universities in the Washington, DC, area.
Aimee Mead, M.P.H., is an associate program officer on the Board
on Population Health and Public Health Practice. She has staffed the
National Academies’ consensus reports on eliminating hepatitis B and
C in the United States, reducing alcohol-impaired driving, reviewing
the public health consequences of e-cigarettes, and evaluating opioid
addiction grant programs. She has also supported the Roundtable on
Environmental Health Sciences, Research, and Medicine, most recently
working on a workshop on the implications of California wildfires. She
received her M.P.H. from the Yale School of Public Health and her B.S.
from Cornell University.
Sophie Yang is a research associate in the Health and Medicine Division
(HMD) on the Board on Population Health and Public Health Practice.
She has staffed consensus studies on promoting health equity in the pre-
natal through early childhood periods, reducing fatalities from alcohol-
impaired driving, eliminating hepatitis B and C in the United States, and
promoting health equity through community-based solutions. She also
staffs the DC Public Health Case Challenge, a joint activity of HMD and
the National Academy of Medicine. She received her B.A. in Asian studies
and economics from Bowdoin College in 2013.
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
APPENDIX E 721
Harika Dyer, L.L.B., is a senior program assistant in the Health and
Medicine Division on the Board on Population Health and Public Health
Practice. She supports the Committee on Prevention and Control of Sexu-
ally Transmitted Infections in the United States and the Roundtable on
Population Health Improvement. She has staffed workshops and webi-
nars on rural health, integrative health care, community-driven initiatives,
and COVID-19. Before joining the National Academies, Ms. Dyer worked
as a medical scribe and as a sustainability program associate at Booz Allen
Hamilton. She received her L.L.B. from the University of the West Indies
and her B.A. in political science from Georgia State University.
Hayat Yusuf was a senior program assistant in the Health and Medicine
Division on the Board on Population Health and Public Health Practice
from March 2019 through March 2020. She supported the Committee on
Prevention and Control of Sexually Transmitted Infections in the United
States and the Committee on Addressing Sickle Cell Disease: A Stra-
tegic Plan and Blueprint for Action. Ms. Yusuf is currently a program
coordinator within the Department of Health Systems Administration at
Georgetown University. Before joining the National Acadamies, Ms. Yusuf
was a research assistant with Johns Hopkins University conducting data
collection for a study that examined intravenous drug use patterns in
rural communities and the implementation of a population-level needs
assessment for essential public health services.
Rose Marie Martinez, Sc.D., is the senior director of the National Acad-
emies’ Board on Population Health and Public Health Practice (1999–pres-
ent). The board has a vibrant portfolio of studies that address high-profile
and pressing issues that affect population health. The board addresses
the science base for population health and public health interventions
and examines the capacity of the health system, particularly the public
health infrastructure, to support disease prevention and health promotion
activities, including educating and supplying the health professionals
necessary for carrying them out. The board has examined such topics as
the safety of childhood vaccines and other drugs; systems for evaluating
and ensuring drug safety after marketing; pandemic influenza planning;
the health effects of cannabis and cannabinoids; the health effects of envi-
ronmental exposures; the integration of medical care and public health;
women’s health services; health disparities; health literacy; tobacco con-
trol strategies; and chronic disease prevention. Before joining the National
Academies, Dr. Martinez was a senior health researcher at Mathematica
Policy Research (1995–1999), where she conducted research on the impact
of health system change on the public health infrastructure, access to
care for low-income populations, managed care, and the health care
Copyright National Academy of Sciences. All rights reserved.
Sexually Transmitted Infections: Adopting a Sexual Health Paradigm
722 SEXUALLY TRANSMITTED INFECTIONS
workforce. Dr. Martinez is a former assistant director for health financing
and policy with the U.S. General Accounting Office, where she directed
evaluations and policy analysis in the area of national and public health
issues (1988–1995). Her experience also includes 6 years directing research
studies for the Regional Health Ministry of Madrid, Spain (1982–1988).
Dr. Martinez is a member of the Council on Education for Public Health,
the accreditation body for schools of public health and public health pro-
grams. Dr. Martinez received her Sc.D. from the Johns Hopkins School of
Hygiene and Public Health.
Copyright National Academy of Sciences. All rights reserved.
You might also like
- Global Infectious Disease Surveillance and DetectionNo ratings yetGlobal Infectious Disease Surveillance and Detection285 pages
- Confronting AIDS Directions For Public Health, Care and Research 1986 David BaltimoreNo ratings yetConfronting AIDS Directions For Public Health, Care and Research 1986 David Baltimore393 pages
- Infectious and Noninfectious Conditions: Risks and ResponsibilitiesNo ratings yetInfectious and Noninfectious Conditions: Risks and Responsibilities55 pages
- Sexual Health A Reference Handbook - 1st Edition ISBN 1598843664, 9781598843668 Full Version DownloadNo ratings yetSexual Health A Reference Handbook - 1st Edition ISBN 1598843664, 9781598843668 Full Version Download16 pages
- Leading Health Indicators 2030: Advancing Health, Equity, and Well-Being. ISBN 0309671876, 978-0309671873100% (33)Leading Health Indicators 2030: Advancing Health, Equity, and Well-Being. ISBN 0309671876, 978-030967187323 pages
- The 1st Annual Crossing The Quality Chasm Summit Institute of Medicine Full100% (11)The 1st Annual Crossing The Quality Chasm Summit Institute of Medicine Full90 pages
- Contagion of Violence Workshop Summary Patel Deepali Simon Instant DownloadNo ratings yetContagion of Violence Workshop Summary Patel Deepali Simon Instant Download55 pages
- Infectious Disease Movement in A Borderless World Workshop Summary 1st Edition Forum On Microbial Threats 2025 Easy DownloadNo ratings yetInfectious Disease Movement in A Borderless World Workshop Summary 1st Edition Forum On Microbial Threats 2025 Easy Download131 pages
- Health and Behavior The Interplay of Biological Behavioral and Societal Influences 1st Edition Institute of Medicine Committee On Health Behavior Institute of Medicine Available Full Chapters100% (9)Health and Behavior The Interplay of Biological Behavioral and Societal Influences 1st Edition Institute of Medicine Committee On Health Behavior Institute of Medicine Available Full Chapters82 pages
- Building Communication Capacity To Counter Infectious Disease Threats Proceedings of A Workshop 1st Edition and Medicine Engineering National Academies of Sciences PDF DownloadNo ratings yetBuilding Communication Capacity To Counter Infectious Disease Threats Proceedings of A Workshop 1st Edition and Medicine Engineering National Academies of Sciences PDF Download80 pages
- Eliminating The Public Health Problem of Hepatitis B and C in The United States Phase One Report 1st Edition Medicine Engineering National Academies of Sciences Newest Edition 2025No ratings yetEliminating The Public Health Problem of Hepatitis B and C in The United States Phase One Report 1st Edition Medicine Engineering National Academies of Sciences Newest Edition 2025162 pages
- Sexual Harassment of Women - Climate, Culture and ConsequencesNo ratings yetSexual Harassment of Women - Climate, Culture and Consequences312 pages
- Infectious Disease Movement in A Borderless World Workshop Summary 1st Edition Forum On Microbial Threats PDF DownloadNo ratings yetInfectious Disease Movement in A Borderless World Workshop Summary 1st Edition Forum On Microbial Threats PDF Download52 pages
- Emerging Infections Microbial Threats To Health in The United StatesNo ratings yetEmerging Infections Microbial Threats To Health in The United States309 pages
- Women's Health Research Progress Pitfalls and PromisesNo ratings yetWomen's Health Research Progress Pitfalls and Promises438 pages
- Health and Behavior The Interplay of Biological Behavioral and Societal Influences 1st Edition Institute of Medicine Committee On Health Behavior Institute of Medicine Download100% (7)Health and Behavior The Interplay of Biological Behavioral and Societal Influences 1st Edition Institute of Medicine Committee On Health Behavior Institute of Medicine Download60 pages
- Considerations For Viral Disease Eradication 1st Edition Forum On Emerging Infections All Chapters Available100% (2)Considerations For Viral Disease Eradication 1st Edition Forum On Emerging Infections All Chapters Available86 pages
- The Right Thing To Do, The Smart Thing To Do: Enhancing Diversity in Health Professions - Summary of The Symposium On Diversity in Health Professions in Honor of Herbert W. Nickens, M.D..100% (22)The Right Thing To Do, The Smart Thing To Do: Enhancing Diversity in Health Professions - Summary of The Symposium On Diversity in Health Professions in Honor of Herbert W. Nickens, M.D..23 pages
- The New Public Health and STD/HIV Prevention Personal, Public and Health Systems Approaches Full Text Download100% (10)The New Public Health and STD/HIV Prevention Personal, Public and Health Systems Approaches Full Text Download15 pages
- High Quality The New Public Health and STD/HIV Prevention Personal, Public and Health Systems Approaches Multiformat DownloadNo ratings yetHigh Quality The New Public Health and STD/HIV Prevention Personal, Public and Health Systems Approaches Multiformat Download15 pages
- Ebooks File Insuring America S Health Principles and Recommendations 1st Edition Committee On The Consequences of Uninsurance All Chapters100% (9)Ebooks File Insuring America S Health Principles and Recommendations 1st Edition Committee On The Consequences of Uninsurance All Chapters84 pages
- The New Public Health and STD/HIV Prevention: Personal, Public and Health Systems Approaches., 978-1461445258100% (28)The New Public Health and STD/HIV Prevention: Personal, Public and Health Systems Approaches., 978-146144525823 pages
- Health Professions Education A Bridge To Quality Quality Chasm Series 1st Edition Committee On The Health Professions Education Summit Ready To Read100% (3)Health Professions Education A Bridge To Quality Quality Chasm Series 1st Edition Committee On The Health Professions Education Summit Ready To Read162 pages
- Long-Term Health Effects of Covid-19: Disability and Function Following Sars-Cov-2 Infection (2024)No ratings yetLong-Term Health Effects of Covid-19: Disability and Function Following Sars-Cov-2 Infection (2024)265 pages
- The Encyclopedia of Sexually Transmitted Diseases100% (3)The Encyclopedia of Sexually Transmitted Diseases353 pages
- Handbook of Sexuality Related Measures 4th Edition Robin R. Milhausen Instant DownloadNo ratings yetHandbook of Sexuality Related Measures 4th Edition Robin R. Milhausen Instant Download48 pages
- The New Public Health and STD HIV Prevention Personal Public and Health Systems Approaches 1st Edition Sevgi O. Aral Ma Instant DownloadNo ratings yetThe New Public Health and STD HIV Prevention Personal Public and Health Systems Approaches 1st Edition Sevgi O. Aral Ma Instant Download113 pages
- The Science and Applications of Microbial Genomics - Workshop SummaryNo ratings yetThe Science and Applications of Microbial Genomics - Workshop Summary429 pages
- Public Health Systems and Emerging InfectionsNo ratings yetPublic Health Systems and Emerging Infections129 pages
- Clinical Practice Guidelines We Can Trust.100% (29)Clinical Practice Guidelines We Can Trust.23 pages
- Exploring Lessons Learned From A Century of Outbreaks - Readiness For 2030No ratings yetExploring Lessons Learned From A Century of Outbreaks - Readiness For 2030231 pages
- Women S Health Research Progress Pitfalls and Promise 1st Edition Institute of Medicine PDF DownloadNo ratings yetWomen S Health Research Progress Pitfalls and Promise 1st Edition Institute of Medicine PDF Download109 pages
- Preventing Intimate Partner Violence in Uganda Kenya and Tanzania Summary of a Joint Workshop by the Institute of Medicine the National Research Council and the Uganda National Academy of Sciences 1st Edition National Research Council Institute Of Medicine Board On Global Health Forum On Global Violence Prevention Louise Flavahan pdf download100% (4)Preventing Intimate Partner Violence in Uganda Kenya and Tanzania Summary of a Joint Workshop by the Institute of Medicine the National Research Council and the Uganda National Academy of Sciences 1st Edition National Research Council Institute Of Medicine Board On Global Health Forum On Global Violence Prevention Louise Flavahan pdf download49 pages
- National Center For HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of STD PreventionNo ratings yetNational Center For HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of STD Prevention187 pages
- Hidden Costs Value Lost Uninsurance in America Insuring Health 1st Edition Committee On The Consequences of Uninsurance PDF Available100% (2)Hidden Costs Value Lost Uninsurance in America Insuring Health 1st Edition Committee On The Consequences of Uninsurance PDF Available144 pages
- Final ScribdLeadership by Example: Coordinating Government Roles in Improving Health Care Quality.100% (20)Final ScribdLeadership by Example: Coordinating Government Roles in Improving Health Care Quality.23 pages
- Global Infectious Disease Surveillance and Detection Assessing The Challenges Finding Solutions Workshop Summary 1st Edition Stanley M. Lemon Download100% (6)Global Infectious Disease Surveillance and Detection Assessing The Challenges Finding Solutions Workshop Summary 1st Edition Stanley M. Lemon Download71 pages
- Phac STIs Blood Borne Infections Ethnocultural MinoritiesNo ratings yetPhac STIs Blood Borne Infections Ethnocultural Minorities40 pages
- Surveillance and Response 1st Edition Committee For The Assessment of Dod Geis Influenza Surveillance and Response Programs100% (2)Surveillance and Response 1st Edition Committee For The Assessment of Dod Geis Influenza Surveillance and Response Programs114 pages
- 3 - Measures of Association in Case-Control StudiesNo ratings yet3 - Measures of Association in Case-Control Studies10 pages
- 2 - Examples Study Base in Case-Control StudiesNo ratings yet2 - Examples Study Base in Case-Control Studies6 pages
- Asylum Seekers Perspectives On Vaccination and SCNo ratings yetAsylum Seekers Perspectives On Vaccination and SC11 pages
- 1 - Introduction To Case-Control StudiesNo ratings yet1 - Introduction To Case-Control Studies22 pages
- Causes and Evaluation of Hyperkalemia in Adults - UpToDateNo ratings yetCauses and Evaluation of Hyperkalemia in Adults - UpToDate41 pages
- Cirrhosis in Adults - Etiologies, Clinical Manifestations, and Diagnosis - UpToDateNo ratings yetCirrhosis in Adults - Etiologies, Clinical Manifestations, and Diagnosis - UpToDate41 pages
- Overview of The Management of Acute Kidney Injury (AKI) in Adults - UpToDate - UpToDateNo ratings yetOverview of The Management of Acute Kidney Injury (AKI) in Adults - UpToDate - UpToDate28 pages
- Definition and Staging Criteria of Acute Kidney Injury in Adults - UpToDate - UpToDateNo ratings yetDefinition and Staging Criteria of Acute Kidney Injury in Adults - UpToDate - UpToDate9 pages
- Etiology and Diagnosis of Prerenal Disease and Acute Tubular Necrosis in Acute Kidney Injury in Adults - UpToDate - UpToDateNo ratings yetEtiology and Diagnosis of Prerenal Disease and Acute Tubular Necrosis in Acute Kidney Injury in Adults - UpToDate - UpToDate27 pages
- Respiratory Distress Syndrome (Hyaline Membrane Disease)No ratings yetRespiratory Distress Syndrome (Hyaline Membrane Disease)98 pages
- PrEP-Training Slides For Providers (Autosaved)No ratings yetPrEP-Training Slides For Providers (Autosaved)152 pages
- Communicable Diseases Module: 1. Basic Concepts in The Transmission of Communicable DiseasesNo ratings yetCommunicable Diseases Module: 1. Basic Concepts in The Transmission of Communicable Diseases20 pages
- Cheston B. Cunha (Editor) - Schlossberg's Clinical Infectious Disease (Team-IRA) (True PDF) - Oxford University Press (2022)No ratings yetCheston B. Cunha (Editor) - Schlossberg's Clinical Infectious Disease (Team-IRA) (True PDF) - Oxford University Press (2022)1,521 pages
- Sexually Transmitted Disease: Shree Gulabrao Devkar College of Pharmacy, Shirsoli, JalgaonNo ratings yetSexually Transmitted Disease: Shree Gulabrao Devkar College of Pharmacy, Shirsoli, Jalgaon15 pages
- Final National Strategic Plan Triple EMTCT July 2021No ratings yetFinal National Strategic Plan Triple EMTCT July 202161 pages
- HIV/AIDS Psychosocial Counseling ManualNo ratings yetHIV/AIDS Psychosocial Counseling Manual86 pages