Confronting HIV and Other STDs

By all accounts, the United States is on the cusp of a remarkable new phase in its response to HIV. After a decade of scientific and programmatic innovations, President Trump’s stated commitment to end the HIV epidemic within 10 years is not only welcome, it is within the realm of possibility.

Often neglected, however, is the fact that HIV cannot be eliminated unless we also reinforce the prevention of other sexually transmitted diseases (STDs). On that front, we are moving in exactly the wrong direction. Even as HIV diagnoses gradually decline, the incidence of other STDs has rapidly risen to all-time highs in the face of insufficient federal funding. Undiagnosed and untreated STDs drive a substantial portion of ongoing HIV transmissions, and STDs represent a major strain on our nation’s health and finances in their own right.

HIV clinicians have an enormous stake in reversing these trends. As important guardians of their patients’ sexual health, they can directly improve STD diagnosis, treatment, and prevention in communities most affected. Just as importantly, as a community, HIV care providers have the credibility to demand the investments and policy changes on which our collective success depends.

The HIV and STD epidemics are inextricably linked

STDs are an underlying driver of new HIV infections, increasing the risk of HIV transmission as much as five-fold. A recent Emory University study found that 10 percent of new HIV infections are attributable to gonorrhea and chlamydia—and many others are linked to syphilis infections. Even with all the progress that has been made in HIV prevention and with an infusion of new resources from the proposed federal Ending the HIV Epidemic plan, transmission of HIV will continue if STD rates remain unchecked.

The current outlook is not good. In 2017, the most recent year with reported data, approximately 2.3 million cases of chlamydia, gonorrhea, and syphilis were diagnosed in the United States a more than 30 percent increase over the last five years and the highest reported case count in history. Several state surveillance reports show these figures increasing in 2018.

HIV and other STDs are also linked by the populations they affect. As HIV clinicians know, people at risk for HIV are typically also at risk for other STDs. Broadly speaking, this includes racial and ethnic minorities, people with limited access to healthcare, transgender women, and black and Latino women. It also includes gay and bisexual men, who are by far the most affected by HIV and have experienced alarming increases in other STDs in recent years. Providing quality care means addressing these populations’ sexual health needs beyond HIV prevention and treatment. This is also a key component to effectively combat the HIV and STD epidemics in this country.

Why are STDs on the rise?

It is not uncommon for people to attribute recent STD increases to progress in HIV treatment and prevention. As the use of pre-exposure prophylaxis (PrEP) for HIV prevention increases and as more and more people living with HIV achieve viral suppression (rendering their infections “undetectable” and therefore “untransmittable”), it is logical to assume that condom use would decline as people’s chosen safer sex option. In fact, we have seen a decrease in condom use, but this trend existed before the rise of PrEP. Evolving safer sex choices, like opting for methods other than condoms, can increase STD transmission risk for some individuals. However, some modeling suggests that the healthcare and STD testing requirements that accompany HIV treatment and PrEP can also have a positive influence, increasing diagnosis and reducing STD rates in these populations in the future.

Ultimately, the sum total impact of advances in HIV prevention on the risk of other STDs remain debatable. But that is not the debate we should be having—it is not where we will find answers to our STD crisis. There are two fundamental areas where our nation’s approach to STDs is falling short: funding and integration with HIV-related services.

Inadequate funding has hampered STD prevention efforts for too long. The federal government’s commitment to STD prevention has dwindled for more than a decade, even as HIV prevention receives a well-deserved injection of resources and attention. Since 2003, federal funding for STD prevention has seen a 40 percent decrease in purchasing power.6 In parallel, local funding has lagged. On average, states and cities contribute roughly 43 cents to STD prevention budgets for every federal dollar, but that figure varies substantially state-to-state. Th e good news is that that Congress may be poised to inject some much needed funding into federal STD prevention at CDC with the House approving a $10 million budget increase for FY 2020. Unfortunately, this new money would amount to a down payment on what’s truly needed to address this growing crisis.

STD clinics have been particularly strained by declines in STD prevention funding. Th e cuts have significantly curtailed the services they’re able to provide—forcing some to reduce hours of operation and others to close altogether. This has devastating consequences for STD and HIV prevention and public health. Many Americans—including those who are at increased risk for HIV and other STDs—rely on publicly-funded clinics for testing, treatment, and partner notification services. For at-risk populations, these clinics also serve as a critical entry point to the healthcare system and other health services. This includes HIV diagnosis and treatment and, critically in this era, opioid and other substance misuse prevention and treatment.

To the detriment of both, HIV and STD prevention have too oft en been addressed as separate issues. At the state level, HIV and STD programs oft en have divergent if not entirely separate funding streams and budgets. In most cases there is good reason for this, but it demands that coordination be effective and consistent, which it oft en is not. Surveillance and medical record systems are often siloed, offices are housed in different buildings or even cities, and, in some cases, these programs are integrated on paper, but operate separately. For true coordination to work, these programs need to be at the same tables and working from the same data. In many parts of the U.S. we have a long way to go to truly make this happen.

At the level of federal policy, one doesn’t have to look any further than the Ending the HIV Epidemic plan to understand that there are gaps in how well other STDs are addressed. STDs are mentioned just a handful of times in the proposal for how CDC funding for the plan will be spent. Thankfully, state and local planning teams are recognizing the importance of including STD prevention specialists and advocates in the planning process and my hope is that this will ensure STDs are given the attention they deserve as part of implementation.

At the clinical practice level, the uncomfortable truth is that healthcare providers—including HIV care providers—are not consistent enough in addressing their patients’ other sexual health needs, including STD testing, treatment, and prevention. For example, research suggests that screening for chlamydia and gonorrhea, even among HIV-positive gay and bisexual men known to be at higher risk, is far below what is recommended by CDC guidelines.

The solution

To put our nation on the path to ending HIV, we need to embrace STD prevention as a priority at every level—from the clinic to the halls of Congress.

In the clinic, we must adopt an integrated approach to sexual health, encompassing patients’ HIV care and prevention needs together with STDs and other aspects of sexual well-being. This should include:

• Following STD screening guidelines for all patients and taking thorough sexual health histories
• Taking a consistently non-judgmental approach to care that is supportive of diverse lifestyles, sexual identities, and sexual health choices
• Addressing sexuality as a core element of a person’s overall health, whether they are living with HIV or not
• Promoting healthy and respectful sexual behaviors as critical to overall mental and physical health
• Embracing effective biomedical HIV prevention and HIV therapy as benefits to sexual health, and opportunities to engage people in care
• Coordinating more closely with our mental and behavioral health allies to provide more holistic care to address HIV and STDs

HIV care providers must be on the vanguard in this effort—and I am thankful that many already are. Changes in how sexual health services are delivered can play an important role in reversing STD trends and ensuring the drive to end HIV has the best chance of success. We will not get far, though, without real action from Congress.

Substantial new investments are needed to reverse declines in STD prevention funding. Research shows that STD prevention is a high-value investment. For every dollar spent on STD prevention, $43 is spent on STD-related treatment. Furthermore, in the past 15 years, CDC-funded STD programs prevented an estimated 5.7 million cases of gonorrhea, syphilis, and chlamydia, and 3,300 STD-attributable HIV infections, saving an estimated $2.4 billion in lifetime medical costs.

My organization, the National Coalition of STD Directors, has called on Congress to allocate an additional $70 million to next year’s federal budget to support federal STD prevention at CDC so we can stave off what could be a public health catastrophe. These dollars would help re-open the doors to clinics nationwide, boost surveillance activities that allow us to respond more quickly to STD outbreaks in specific populations or locations, support greatly needed prevention and awareness campaigns, and engage people in high quality sexual healthcare, positively affecting both the HIV and STD epidemics.

In addition to ensuring adequate funding, we must foster a more integrated, comprehensive response to HIV and other STDs at the national level. The STI Federal Action Plan—due out next year—will be an important first step. For it to be successful, it will need to address STDs comprehensively—including (though not only) by:

• Reflecting an integrated approach to HIV, STDs, and overall sexual health
• Addressing health disparities and stigma in a meaningful way
• Attending to the overlapping nature of the drug, opioid, and STD epidemics
• Proposing concrete steps to increase training of healthcare providers in how to take sexual health histories and test for STDs
• Improving surveillance systems to allow for better information sharing between HIV and STD programs, as well as increasing data sharing between jurisdictions
• Increasing coordination on STD prevention, including testing and treatment, across all federal agencies
• Aligning with the Ending the HIV Epidemic plan, to ensure coordination and synergy

We know from experience that success is possible when political will, financial resources, and clinical approaches are aligned in addressing HIV and STDs together.

Perhaps the best example comes from New York City, where in 2015, as part of New York State’s strategy for “getting to zero” new HIV infections and eliminating disparities, the city launched its own “Ending the Epidemic” plan. The plan was comprehensive—addressing issues from the integration of harm reduction and biological HIV interventions, to the importance of training doctors to provide holistic, culturally-informed sexual healthcare.Key elements of the strategy included transforming STD clinics into destination clinics for sexual health services, establishing clinics as a gateway for HIV treatment and prevention by launching same-day starts for PrEP and antiretroviral therapy, and committing to making New York City a “status neutral” (stigma-free) jurisdiction. According to Demetre Daskalakis, deputy commissioner for the Division of Disease Control of the New York City Department of Health and Mental Hygiene, these efforts not only improved the effectiveness of New York City’s HIV and STD prevention efforts, but they converted local HIV activists into some of the city’s strongest advocates for sexual health.

While HIV care providers and their allies are just one part of the solution, they have a tremendous potential to shape our nation’s future on HIV and STDs. In the clinic, they can serve as a model for all healthcare providers in providing the integrated sexual healthcare that patients need. As a community, they have the credibility to serve as advocates for a fully funded, well-coordinated approach. It is our hope that this issue of HIV Specialist will inform and inspire the community to embrace that potential.