Analysis Sexual Health

Title X and The Role of Family Planning Providers in Preventing and Treating Sexually Transmitted Infections

Clare Coleman

To ensure quality sexual and reproductive health and address economic burdens, continued efforts to educate, screen, test, and treat for STDs is critical to our nation’s public health and well-being.

This article is published in partnership with the National Coalition of STD Directors (NCSD) as part of our joint series on STD Awareness

Over the past 40 years, Title X family planning providers have played a critical role in ensuring access to a broad range of family planning and related preventive health services for millions of low-income and uninsured individuals. Screening, testing, and treatment of sexually transmitted diseases (STDs) are key components of the essential health education and services provided by family planning providers each year. In 2010, the Title X family planning network performed over 6 million STD tests, a 3.5 percent increase over the previous year, and over 1.1 million HIV tests, a 10 percent increase over 2009. Family planning and sexual health programs have a tremendous amount of expertise in targeting “hard-to-reach” populations, particularly through education and counseling.

Family planning providers have long understood the role sexual health plays in the lifelong health and well-being of their patients. Suspected of being the number one cause of preventable infertility, chlamydia – a curable infection – is the most common bacterial STD in the US, with an estimated 2.8 million infections annually. Annual US gonorrhea infections are estimated to be as high as 700,000 a year. If left untreated, both infections can spread into the uterus or fallopian tubes and cause pelvic inflammatory disease (PID). PID and other infections in the upper genital tract can cause damage leading to infertility, chronic pelvic pain, and potentially fatal ectopic pregnancy.

Recognizing the important role publicly funded family planning providers can and do play in STD prevention, the US Centers for Disease Control and Prevention (CDC) supports chlamydia and gonorrhea prevention efforts in family planning health centers through the Infertility Prevention Project (IPP). Begun as a demonstration project in 1988 to address the leading STD-based causes of infertility, IPP has expanded to all ten of the federal Health and Human Service regions, supporting screening and treatment among sexually-active, low-income women.

Like This Story?

Your $10 tax-deductible contribution helps support our research, reporting, and analysis.

Donate Now

CDC estimates that undiagnosed and untreated STDs such as chlamydia and gonorrhea cause at least 24,000 women in the US each year to become infertile. In addition to the health burdens that result from chlamydia and gonorrhea, chlamydia in particular has severe economic costs within the health care system. Over $2 billion is spent every year on the medical management of chlamydia and related complications. The total lifetime medical cost has been estimated at $315 per case for women. Furthermore, a single case of PID costs between $1,060 and $3,180 (in 2000 dollars).

To ensure quality sexual and reproductive health and address economic burdens, continued efforts to educate, screen, test, and treat for STDs is critical to our nation’s public health and well-being. The Title X family planning network is proud to be an essential safety-net provider in these efforts to improve access for populations that may have nowhere else to turn for these services.

Roundups Sexual Health

This Week in Sex: The Sexually Transmitted Infections Edition

Martha Kempner

A new Zika case suggests the virus can be transmitted from an infected woman to a male partner. And, in other news, HPV-related cancers are on the rise, and an experimental chlamydia vaccine shows signs of promise.

This Week in Sex is a weekly summary of news and research related to sexual behavior, sexuality education, contraception, STIs, and more.

Zika May Have Been Sexually Transmitted From a Woman to Her Male Partner

A new case suggests that males may be infected with the Zika virus through unprotected sex with female partners. Researchers have known for a while that men can infect their partners through penetrative sexual intercourse, but this is the first suspected case of sexual transmission from a woman.

The case involves a New York City woman who is in her early 20s and traveled to a country with high rates of the mosquito-borne virus (her name and the specific country where she traveled have not been released). The woman, who experienced stomach cramps and a headache while waiting for her flight back to New York, reported one act of sexual intercourse without a condom the day she returned from her trip. The following day, her symptoms became worse and included fever, fatigue, a rash, and tingling in her hands and feet. Two days later, she visited her primary-care provider and tests confirmed she had the Zika virus.

Like This Story?

Your $10 tax-deductible contribution helps support our research, reporting, and analysis.

Donate Now

A few days after that (seven days after intercourse), her male partner, also in his 20s, began feeling similar symptoms. He had a rash, a fever, and also conjunctivitis (pink eye). He, too, was diagnosed with Zika. After meeting with him, public health officials in the New York City confirmed that he had not traveled out of the country nor had he been recently bit by a mosquito. This leaves sexual transmission from his partner as the most likely cause of his infection, though further tests are being done.

The Centers for Disease Control and Prevention (CDC)’s recommendations for preventing Zika have been based on the assumption that virus was spread from a male to a receptive partner. Therefore the recommendations had been that pregnant women whose male partners had traveled or lived in a place where Zika virus is spreading use condoms or abstain from sex during the pregnancy. For those couples for whom pregnancy is not an issue, the CDC recommended that men who had traveled to countries with Zika outbreaks and had symptoms of the virus, use condoms or abstain from sex for six months after their trip. It also suggested that men who traveled but don’t have symptoms use condoms for at least eight weeks.

Based on this case—the first to suggest female-to-male transmission—the CDC may extend these recommendations to couples in which a female traveled to a country with an outbreak.

More Signs of Gonorrhea’s Growing Antibiotic Resistance

Last week, the CDC released new data on gonorrhea and warned once again that the bacteria that causes this common sexually transmitted infection (STI) is becoming resistant to the antibiotics used to treat it.

There are about 350,000 cases of gonorrhea reported each year, but it is estimated that 800,000 cases really occur with many going undiagnosed and untreated. Once easily treatable with antibiotics, the bacteria Neisseria gonorrhoeae has steadily gained resistance to whole classes of antibiotics over the decades. By the 1980s, penicillin no longer worked to treat it, and in 2007 the CDC stopped recommending the use of fluoroquinolones. Now, cephalosporins are the only class of drugs that work. The recommended treatment involves a combination of ceftriaxone (an injectable cephalosporin) and azithromycin (an oral antibiotic).

Unfortunately, the data released last week—which comes from analysis of more than 5,000 samples of gonorrhea (called isolates) collected from STI clinics across the country—shows that the bacteria is developing resistance to these drugs as well. In fact, the percentage of gonorrhea isolates with decreased susceptibility to azithromycin increased more than 300 percent between 2013 and 2014 (from 0.6 percent to 2.5 percent).

Though no cases of treatment failure has been reported in the United States, this is a troubling sign of what may be coming. Dr. Gail Bolan, director of CDC’s Division of STD Prevention, said in a press release: “It is unclear how long the combination therapy of azithromycin and ceftriaxone will be effective if the increases in resistance persists. We need to push forward on multiple fronts to ensure we can continue offering successful treatment to those who need it.”

HPV-Related Cancers Up Despite Vaccine 

The CDC also released new data this month showing an increase in HPV-associated cancers between 2008 and 2012 compared with the previous five-year period. HPV or human papillomavirus is an extremely common sexually transmitted infection. In fact, HPV is so common that the CDC believes most sexually active adults will get it at some point in their lives. Many cases of HPV clear spontaneously with no medical intervention, but certain types of the virus cause cancer of the cervix, vulva, penis, anus, mouth, and neck.

The CDC’s new data suggests that an average of 38,793 HPV-associated cancers were diagnosed each year between 2008 and 2012. This is a 17 percent increase from about 33,000 each year between 2004 and 2008. This is a particularly unfortunate trend given that the newest available vaccine—Gardasil 9—can prevent the types of HPV most often linked to cancer. In fact, researchers estimated that the majority of cancers found in the recent data (about 28,000 each year) were caused by types of the virus that could be prevented by the vaccine.

Unfortunately, as Rewire has reported, the vaccine is often mired in controversy and far fewer young people have received it than get most other recommended vaccines. In 2014, only 40 percent of girls and 22 percent of boys ages 13 to 17 had received all three recommended doses of the vaccine. In comparison, nearly 80 percent of young people in this age group had received the vaccine that protects against meningitis.

In response to the newest data, Dr. Electra Paskett, co-director of the Cancer Control Research Program at the Ohio State University Comprehensive Cancer Center, told HealthDay:

In order to increase HPV vaccination rates, we must change the perception of the HPV vaccine from something that prevents a sexually transmitted disease to a vaccine that prevents cancer. Every parent should ask the question: If there was a vaccine I could give my child that would prevent them from developing six different cancers, would I give it to them? The answer would be a resounding yes—and we would have a dramatic decrease in HPV-related cancers across the globe.

Making Inroads Toward a Chlamydia Vaccine

An article published in the journal Vaccine shows that researchers have made progress with a new vaccine to prevent chlamydia. According to lead researcher David Bulir of the M. G. DeGroote Institute for Infectious Disease Research at Canada’s McMaster University, efforts to create a vaccine have been underway for decades, but this is the first formulation to show success.

In 2014, there were 1.4 million reported cases of chlamydia in the United States. While this bacterial infection can be easily treated with antibiotics, it often goes undiagnosed because many people show no symptoms. Untreated chlamydia can lead to pelvic inflammatory disease, which can leave scar tissue in the fallopian tubes or uterus and ultimately result in infertility.

The experimental vaccine was created by Canadian researchers who used pieces of the bacteria that causes chlamydia to form an antigen they called BD584. The hope was that the antigen could prompt the body’s immune system to fight the chlamydia bacteria if exposed to it.

Researchers gave BD584 to mice using a nasal spray, and then exposed them to chlamydia. The results were very promising. The mice who received the spray cleared the infection faster than the mice who did not. Moreover, the mice given the nasal spray were less likely to show symptoms of infection, such as bacterial shedding from the vagina or fluid blockages of the fallopian tubes.

There are many steps to go before this vaccine could become available. The researchers need to test it on other strains of the bacteria and in other animals before testing it in humans. And, of course, experience with the HPV vaccine shows that there’s work to be done to make sure people get vaccines that prevent STIs even after they’re invented. Nonetheless, a vaccine to prevent chlamydia would be a great victory in our ongoing fight against STIs and their health consequences, and we here at This Week in Sex are happy to end on a bit of a positive note.

Commentary Sexual Health

Know Your Status: Working to Destigmatize Routine STI Screening

Dr. Megan L. Evans

April marks STD Awareness Month and the Get Yourself Tested campaign: There is no time like the present to check your status, discuss testing with your sexual partner, and talk about safer sex with your provider.

“Would you like screening for sexually transmitted infections today?”

As an obstetrician and gynecologist, it is a question I ask multiple times a day to the patients I see in my office. Most patients think about my question for a moment, maybe look down at the floor or nervously check their smart phone, and then say “sure!” The question is a simple one but it is obvious that, for some patients, sexually transmitted infection (STI) testing carries the weight of stigma or embarrassment.

Although the Centers for Disease Control and Prevention (CDC) recommends routine STI testing for all women under the age of 25, STI cases in all age groups are on the rise, as indicated in a recent report. In 2014 alone, there were approximately 350,000 new cases of gonorrhea and more than 1.4 million new cases of chlamydia. Unfortunately, many of these infections may go untreated or undiagnosed and can have detrimental health effects, particularly among women who can experience disseminated infections requiring hospitalizations, infertility, and pelvic inflammatory disease.

So, whether they are age 17 or 45, in the women’s clinic or the community health center, everyone I see is offered the opportunity—and encouraged—to check their STI status.

Like This Story?

Your $10 tax-deductible contribution helps support our research, reporting, and analysis.

Donate Now

And it’s not just women or young people who should get tested. In February, the CDC released a study finding that half of gay and bisexual Black men and a quarter of gay and bisexual Latino men will be diagnosed with HIV in their lifetimes. As a health-care provider, I believe that encouraging everyone to know their STI status, regardless of their sexual orientation or gender identity, can not only prevent serious medical conditions, but can encourage safe and healthy sexual practices.

It’s important, however, for everyone to understand: Both patients and providers have an important role to play in destigmatizing routine STI screening.

We as physicians can do a better job at creating a safe environment for patients to ask questions about sex and sexuality. One study suggested that when physicians do discuss sexual health issues with adolescents, the discussion averages 36 seconds. When the topic of sexuality is discussed in the health-care setting, fewer than 10 percent of young people reported receiving information on STIs and HIV from their provider.

Surveys of U.S. teens and young adults show that these group, which are greatly affected by STIs, understand the importance of routine testing. One survey found that 81 percent of youth reported thinking that people who get STI testing are taking care of their sexual health; 58 percent said they are responsible partners, and 56 percent said they do it regularly as part of their routine health care. When asked by a sexual partner about getting STI screening together, 78 percent said they would be glad a test was suggested and 89 percent thought it reflected their partner being responsible.

However, significant barriers may exist that are keeping adolescents and young adults from knowing their STI status, like access to care. Though all 50 states allow minors to get STI screening without parental notification, young people may face barriers to accessing clinics in general or fear their parents will be notified they are requesting STI services (as at least 18 states allow physicians to do so).

Research shows us that confidentiality and of course stigma can exist around getting tested, which may prevent a person—especially a young person—from knowing their STI status. A 2014 study published in JAMA Pediatric reported that one-third of teens did not talk about sex or sexuality during their annual visits with their health-care provider and many teens felt uncomfortable talking with their provider about topics including sexuality and STIs.

As a patient, you should not hesitate to bring up questions about STI screening as well as your general health with your provider. If you do feel uncomfortable asking these questions and requesting screening with your provider, you can always go to a local Planned Parenthood or other health centers that openly offer screening.

April marks STD Awareness Month and the Get Yourself Tested campaign spearheaded by a partnership between the Kaiser Family Foundation, MTV, Planned Parenthood, and other organizations. There is no time like the present to check your status, discuss testing with your sexual partner, and talk about safe sex with your provider. Whether getting tested with a primary care physician, an OB-GYN, or at a local health center, taking this step is an important part of taking care of your health and is generally quick and easy. A routine STI check can be completed by a simple urine test and blood test in most health centers.

As providers, asking about STI screening should be routine and offered to all patients. This helps to open the conversation to your patients about their sexuality and may prompt further discussion about safer sex. The message is a simple one: getting tested is part of staying healthy and taking care of your body.

Remember that sexuality is a natural and healthy part of life and is an important component of physical and emotional development. Everyone deserves good sex: sex that is consensual, healthy, pleasurable, safe, and respectful. Having a healthy sexuality also includes knowing your STI status.

Full disclosure: Dr. Megan Evans is on the Young Friends Steering Committee of Planned Parenthood.