NCSD's position statement on the role of STD Programs in "Ending the HIV Epidemic: A Plan for America." The Administration recently launched this plan in early 2019 and NCSD developed the following principles to show how the STD field can be supportive of that effort.
Full Text of NCSD’s position statement
The administration has stressed the importance of active partnerships to the success of President Trump’s initiative to reduce new HIV infections by 90 percent in the next 10 years (Fauci, Redfield, Sigounas, et al., 2019). The syndemic nature of HIV and STDs makes STD programs and providers essential partners in Ending the HIV Epidemic: A Plan for America. For both behavioral and biological reasons, people with STDs are more likely to get HIV if not on PrEP. People who are both HIV positive and have another STD are more likely to transmit HIV to their sexual partners if not being treated with ART. Building on the existing infrastructure, the national, state, and local STD program will be of enormous value to the administration’s efforts to end the epidemic.
STD programs and clinics serve populations at high risk for HIV infection and already play a significant role in HIV testing and linkage to care. A convenience sample of 10 jurisdictions—eight of them hotspots targeted by the administration’s new initiative— suggests that STD clinics diagnose approximately 10-35 percent of HIV cases (Golden & Kerndt, 2010). Cuffe and her colleagues (2017) identify public STD clinics as important venues for providing HIV services to populations in need. Similarly, Castro and Alcaide (2017) conclude that STD clinics can be “premier sites” for identifying HIV- positive individuals with high-risk behaviors in need of targeted interventions, and Campos-Outcalt and his colleagues (2006) recommend the addition of routine HIV testing at public STD clinics. A recent modeling study by Jones (2019) found that 10% of HIV infections among MSM in the U.S. are caused by gonorrhea or chlamydia infection, further contributing to the link between STDs and HIV.
As the national membership organization representing the public health jurisdictions charged with STD prevention, it is NCSD’s position that resources should be allocated to mobilize and leverage the STD field to implement the four strategies that inform the initiative—diagnose, treat, protect, and respond – through the following:
STD clinics are underused resources for HIV testing and linkage to care. Initiative funds should be provided to STD programs and clinics in the 48 hotspot counties, D.C., and Puerto Rico to both build and leverage their capacity to contribute to ending the HIV epidemic by providing an array of HIV-related services, including routine screening for rectal gonorrhea (the single biggest indicator of HIV), HIV testing, HIV counseling, behavioral prevention, PrEP, linkage to HIV care, extra-genital screening, connecting people to medical homes, and same-day initiation of ART.
Cohen and her colleagues (2016) highlight the role that STD clinics and community health centers can play in expanding PrEP access nationwide, and some clinics and programs across the country are successfully providing PrEP education resulting in PrEP uptake and the regular STD screenings that are the standard of care for PrEP.
Initiative funds should be provided to STD programs and clinics in the targeted hotspots to greatly expand their capacity to make PrEP available to the high-risk populations they serve, including same-day PrEP initiation models such as Metro Denver STD Clinic’s Same Day Start program.
The administration proposes to fund the creation of local HIV HealthForces in the targeted jurisdictions. The DIS workforce—boots on the ground experts in community work around both STDs and HIV—should be prominent members of those teams, providing partner services, outbreak investigations, linking people to care and re- engaging people in care, and serving as PrEP navigators. DIS also have the legal authority to operate state-wide, and not just in one area that is connected to a clinic’s network, and can legally access surveillance data to help facilitate outreach and outbreak investigations, making them a crucial part of the workforce to end HIV infections. With additional funding, the DIS workforce can expand and improve their existing contribution to preventing HIV, including expanding to assist Ryan White programs in their efforts to re-engage and maintain HIV positive individuals in care.
Biomedical HIV prevention has made ending the HIV epidemic an achievable goal, but condoms remain a necessary component of any effort to end HIV. Not everyone will have access to PrEP, and not everyone will choose PrEP uptake. The message that consistent, correct use of condoms is a highly effective way to reduce the risk of HIV transmission must remain part of the equation. STD programs have a lot of experience with condom distribution and initiative funds should be provided to the jurisdictions to implement best practices learned through STD programs and assure free condom distribution in diverse venues as a structural intervention to increase the availability, accessibility, and acceptability of condom use (CDC, 2015).
Given the intertwined nature of the STD and HIV epidemics, reducing new HIV infections 90 percent in 10 years will require integrated data sharing, analysis, and utilization across jurisdictional STD and HIV surveillance systems. Initiative resources— both financial and technical—should be provided to the hot spot jurisdictions to build their capacity to share and use data across STD and HIV surveillance systems in order to reduce comorbidities and improve retention, linkage, and re-engagement in HIV care.
HHS promises to work with local communities as part of the initiative’s “Respond” strategy. NCSD urges that HHS guidance for local planning efforts require that local STD programs—including both public health programs and community-based programs and providers—be fully represented in the planning process and that the plans are required to include all five STD service areas mentioned above.
Campos-Outcalt, D., Mickey, T., Weisbuch, J., & Jones, R. (2006, March-April). Integrating routine HIV testing into a public health STD clinic. Public Health Reports, 121, 175-180.
Castro, J.G., & Alcaide, M.L. (2016). High rates of sexually transmitted infections in HIV- infected patients attending an STI clinic. Southern Medical Journal, 109(1), 1-4. doi:10.14423/SMJ.0000000000000389.
CDC. (2015, May). Condom distribution as a structural-level intervention. https://www.cdc.gov/hiv/pdf/programresources/guidance/condoms/cdc-hiv-condom- distribution.pdf
Cohen, S.E., Vittinghoff, E., Bacon, O., & Doblecki-Lewis, S., et al. (2015, April 1). High interest in pre-exposure prophylaxis among men who have sex with men at risk for HIV-infection: Baseline data from the US PrEP Demonstration Project. Journal of Acquired Immunodeficiency Syndrome, 68(4), 439-448. doi:10.1097/QAI.0000000000000479
Cuffe, K.M., Precious, E., & Leichliter, J.S. (2017, April 7). HIV services provided by STD programs in state and local health departments—United States, 2013–2014. Morbidity & Mortality Weekly Report, 66(13), 355-358.
Fauci, A.S., Redfield, R.R., Sigounas, D.G., Weahkee, M.D., & Giroir, B.P. (2019, February 7). Ending the HIV epidemic: A plan for the United States. Journal of the American Medical Association, 321(9), 844-845. doi:10.1001/jama.2019.1343.
Golden, M.R., & Kerndt, P.R. (2010). Improving clinical operations: Can we and should we save our STD clinics? Sexually Transmitted Diseases, 37, 264–265.