What I Didn’t Know About Sexual Health: Reflections From a New Perch

William Smith

We are losing the battle on sexually transmitted infections in the United States, a loss that will have grave implications for public health.  And in the first few months of my new job as executive director of the National Coalition of STD Directors, I've learned some things that will help us be more effective in this battle, if we take heed.

April is National STD Awareness Month and sexual and reproductive health organizations throughout the country urge you to Get Yourself Tested!!  Rewire has partnered with The National Coalition of STD Directors (NCSD) to produce a series of articles on the importance of STD prevention and treatment among populations throughout the United States.  Other articles in this series include one by Sandra Serna-Smith, Dana Cropper Williams and Peter Leone.

I like to think I am relatively knowledgeable. Academically, I have been steeped in political philosophy and can discuss Plato’s Myth of the Cave or the uniqueness of American federalism and how it shapes public health. Important topics, for sure, but not always the most useful in the day-to-day. I also thought my many years of doing sexual and reproductive health work made me an expert of sorts.

Then I entered the world of sexually transmitted infections and diseases…and doubt settled in.

I am now three months into my new role as the executive director of the National Coalition of STD Directors (NCSD) and I have begun to reflect on a few things I did not know previously that have been, well, shocking to me, and have tested what I thought was a well-honed repertoire of knowledge. We’ve been working here at NCSD to highlight some key issues related to STDs given that April is National STD Awareness Month and I thought I would take the liberty of providing a few reflections of my own.

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Here are a few things I did not know that I think every sexual and reproductive health advocate should:

We are on the verge of a highly untreatable gonorrhea epidemic.

Gonorrhea is a bacterial infection and bacteria have a funny way of developing resistance to treatments – their own built-in evolutionary survival mode. This is what has happened with gonorrhea, the second most commonly reported notifiable disease in the United States with more than 336,000 cases reported in 2008.

It is also among one of the most racially- and age-disparate diseases. For example, according to the CDC, though blacks make up only 12 percent of the U.S. population, more than 70 percent of reported cases of gonorrhea in 2008 were among blacks. It also affects young people disproportionately, with the majority of new cases being consistently reported among 15 to 24 year olds. In early 2007, after much reporting of resistance to the class of antibiotics known as quinolones, the CDC stopped recommending them for use in treating gonorrhea. We now have just a single class of antibiotics left to treat gonorrhea but resistance is also developing with this class and the pipeline of new drugs is nearly empty. Future treatment might require multiple drug combinations or multiple doses over a longer period of time and even then, we are not sure what the future holds.

Gonorrhea leads to all sorts of adverse sexual health outcomes including infertility and likely exacerbates susceptibility to HIV. Something called Disseminated Gonococcal Infection that can cause crippling arthritis could become commonplace, and toxic blood and outright organ failure are likely prospects for infected persons if we do not get ahead of this situation with new treatments. I hate to sound alarmist, but the prospects of this situation are frightening.

The public health workforce is full of incredible, unsung heroes.

There are these amazing front line workers in the public health workforce known as Disease Intervention Specialists (DIS) that are just below the radar screen, but are the most fascinating folks whose jobs would make for the most watchable reality television show. DIS are funded by CDC to do STD work, but their expertise goes beyond STDs. For example, many were tapped to deal with the H1N1 situation because their skills were relevant. And what a skill set! DIS-ers do lots of things but their primary job is to find people who’ve had sexual contact with someone who has been diagnosed with a reportable STD – chlamydia, gonorrhea, or syphilis – and get them tested and if necessary, treated. Now that is some work, often requiring Columbo-like detective skills and more chutzpah to get the job done than most professions. But it is also comingled with compassion when they are speaking to patients about a positive diagnosis for HIV or another STD, or doing the much needed behavioral counseling that requires the additional skills of a therapist and social worker. They’re my new heroes in public health.

We aren’t talking to each other

My old world of brave advocates barely talks to my new world – and vice-versa – which is really quite a shame given that I now work with and represent the interests of sexual health public health professionals in every state, territory and in the nation’s largest cities. This hit me square in the face at the National STD Conference held last month in Atlanta. Nearly 1,300 attendees from across the country and from CDC and not an advocacy session in sight. NCSD circulated an action alert at the conference to get folks engaged with their members of Congress in advocating for more money to promote sexual health through STD prevention, but we’ve got a vast network of folks out there who are “the system” and to whom concrete advocacy bridges have yet to be built. We’ll obviously work on that one.

Men depend heavily on STD clinics for their sexual health needs

Professionals in this field have thought long and hard about how best to meet the needs of men in regard to sexual health and lo and behold, it turns out that men disproportionately utilize STD clinics for their sexual health care needs. True, they usually come in when something is not quite feeling or working right, but this venue gives us a unique opportunity for targeted education of a very hard-to-reach population — if only the resources were there to make this happen.  Sadly, even as STD’s are on the rise, federal and state support for STD programs has faltered. This year, NCSD and our colleagues at the American Social Health Association have spearheaded renewed efforts to mobilize federal support and it has been a long time in coming.

We are about to grasp defeat from the jaws of victory in the battle against syphillis

Once on the verge of a major public health success story, the nation’s efforts to combat syphilis – still optimistically termed as an effort to eliminate it – have virtually collapsed. In 2008, we had the highest number of reported syphilis cases since 1995 at 13,500 (these are primary and secondary syphilis cases which is when the disease is most infectious). There were another 431 cases of congenital syphilis in 2008 – cases where mother to child transmission occurs. In Chicago last year, one colleague told me that two babies died of congenital syphilis. Yes – in the 21st century United States of America, children die of syphilis. Where is the outcry? And the disease is now increasingly shifting to men who have sex with men, where syphilis infection in a sexual network can have devastating results both on its own and in increasing susceptibility to HIV infection. NCSD has called for a renewed discussion on our nation’s approach to syphilis control and sexual health and we will be convening a meeting later this year to help pave a new way forward.

So, these are the top five most interesting things to share from my new professional perspective. There are many others – I’ve learned about labs, the appalling situation that rural areas face in promoting public health with a fistful of nickels, protocols for outbreak response, fake STD clinics, and the often mysterious machinations of our partners at CDC. But all in all, what I have discovered most is that promoting sexual health is the common thread between my old perch and my new one…and the task ahead involves making that thread a cord of strengthened steel, and eventually, a real bridge that we traverse with ease and confidence.

Topics and Tags:

Gonorrhea, Sexual Health, syphilis

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