What challenge was your STD program experiencing?

For years, many young clients accessing STD/HIV screening services also requested birth control methods, but they were not readily available and accessible. Guam is an island that is predominantly Catholic so the word “family planning” equated to having “pre-marital sex” which is not appropriate according to the Catholic faith. Over the years, STD screenings demonstrated a 20 percent chlamydia prevalence rate among clients screened. This prompted the STD/HIV/Viral Hepatitis Program to recognize that young people are a vulnerable population, not just for STDs, but also for HIV infection and unplanned pregnancies. The Guam team started discussing the importance of comprehensive adolescent health and prevention services as essential in order to make an impact. Being a resource-constrained area and being so far from the US mainland, our team wanted to come up with an approach so that young sexually active clients were able to access low and affordable sexual health services. Repeat clients diagnosed with STDs were most concerning, especially at such a young age because this indicated that they were not only at risk for HIV infection but also for unplanned pregnancies. We have also seen returning young clients come in, not only with a repeat STD but also pregnant several months later. The only free walk-in STD clinic on the island was seeing a majority of young clients and felt the need to pursue a way to approach health in a comprehensive and culturally appropriate way, offering not only STD/HIV testing, health education, and risk reduction, but exploring opportunities for those who wanted to plan their future and wanted to be safe from diseases and unplanned pregnancies. Collectively as a team, we felt responsible for ensuring that adolescent health services were comprehensive and felt the need to combine our efforts with the other public health units and teams. We felt that these efforts would lead to better outcomes for the next generation.

Guam Family Planning and Reproductive Health Service Project (GFPRHP) funded under the Title X Project successfully reinstated Family Planning Services in the US Pacific Island Territory. The GFPRHP demonstrated a strong need to target age group 15 -24 based on the Adolescent Health Profile developed through the support of the NCSD Policy Academy led by Ms. Toni Junious, a former Public Health Field Officer. After launching the Title X Grant services at the selected site, the Northern Community Health Center Women’s Health Clinic in collaboration with the STD Program GFPRHP made available chlamydia, gonorrhea, HIV, and syphilis testing, pap smears, and access to birth control that is now low cost and affordable.

Implementing a referral system for sexual health services (SHS) in collaboration with Guam Department of Education (GDOE) is a challenge for the STD Program and GFPRHP because it will need an expert team to develop the capacity for GDOE health counselors to be trained and to develop policies, protocols, and procedures of the SHS to ensure stakeholders understand how the referral system will work within the piloted high school and ensure that this system has been properly piloted and tested.

In 2020, 16 percent of the island young population is between 15-24 age group. The Adolescent Health Profile reflected that this population is sexually active based on the Youth Risk Behavioral Survey, has four times the teenage pregnancy rate of the US mainland population, and has high rates of chlamydia based on CDC STD Surveillance Disease Reports. These indicators demonstrated that a public health strategy to target youth and adolescents are needed to ensure optimal health outcomes for young people on our island.

What specific technical assistance tools and resources were provided to you? How did you use the tools and resources to address your challenge?

Ms. Dulce Mendoza, a Public Health Field Officer working under the STD/HIV/VH Program led the adaptation of the technical assistance tools and resources available from NCSD. She utilized the resources “Developing a Referral System for Sexual Health Services: An Implementation Tool Kit” and “Establishing Organizational Partnerships to Increase Student Access to Sexual Health Services: A Resource Guide for Education Agencies.” By utilizing these tools from NCSD, she helped create a work plan for Guam and enhanced our collaboration between GDOE and Department of Public Health and Social Services (DPHSS). As a result of the development of the SHS, key stakeholders met. Mr. Vince J. Aguon, who now serves as Acting Program Supervisor for the STD/HIV/VH Program, encouraged Ms. Mendoza to present to GDOE stakeholders an updated Adolescent Profile and the proposed referral system for SHS in collaboration with GFPRHP. Her presentation proposed key concepts based on the tool kit. It was well received by GDOE and as a result, led to buy-in from GDOE and next action steps.

Both programs, in collaboration with our internal stakeholders, combined efforts to secure resources for young people to strengthen our capacity to respond to sexual health needs by ensuring preventive health care were accessible and available. However, in order to reach age group 15-24 years old, the STD/HIV/VH Program maintains efforts with GFPRHP to ensure that a comprehensive approach to adolescent health will be pursued with GDOE. In a small island like Guam, low and affordable STD/HIV services, family planning, and birth control options were not readily available for sexually active youth and adolescents health prior to the Title X GFPRHP unless an individual was willing to pay out of pocket costs or had health insurance.

Our challenge will now be the implementation phase of SHS.

What are the next steps your STD program plans to take (or have already taken) to address your challenge?

DPHSS STD/HIV/VH Program and GFPRHP collaboration was key to obtain buy-in from GDOE Curriculum and Instruction (C and I). As a result, DPHSS drafted a Memorandum of Understanding, and updated the MOU as agreed by GDOE and DPHSS based on reviews and further committed to ensure effective public health strategies are appropriately developed for GDOE C and I. We are also taking into consideration that GDOE has implemented a school-based State Personal Responsibility Education Program (State PREP).

It will take a team of subject matter experts to move on to the next phase, implementation. The greatest needs are training, and policy protocols, and procedures development for the schools. These training resources will be needed to successfully launch this specific SHS program within GDOE. This is the first time ever that this bold step will be established in the schools. Our team will need technical assistance and subject matter expertise to ensure that the proposed SHS adapted for our island is launched with all stakeholders.

Once the GDOE State PREP concurred with the SHS, GFPRHP in partnership with the STD/HIV/VH Program provided recommendations for the development of a referral system for SHS in partnership with GDOE. A pilot referral system for SHS was identified as a strategy that can be designed and implemented with the currently available existing programs and resources available. Due to the COVID-19 public health emergency in Guam declared on March 14, 2020, the SHS project in collaboration with GDOE was placed on hold. Expected date to resume SHS implementation is during fall 2020.

Resources on the ground level will be key in the next phase so that this vital strategy results in a successful outcome. It is quite overwhelming thinking about this task and I often ask, will we succeed or will the project fade away? If there is one public health innovative strategy that will define the health of our next generation, I would say SHS.

Resources

• Developing a Referral System for Sexual Health Services: An Implementation Tool Kit
• Establishing Organizational Partnerships to Increase Student Access to Sexual Health Services: A Resource Guide for Education Agencies