Supporting a Syndemic Approach: Preventing Sexually Transmitted Infections

December 10, 2023

Introduction

Sexually transmitted infections (STIs) are infections caused by bacteria, viruses, or parasites that are transmitted from person to person through sexual contact. Although STIs are preventable, an estimated 20 million new STI cases occur each year. With a concerted effort to End the HIV Epidemic, CDC now estimates a 12% decline in new HIV infections from 2017 to 2021. However, there were still an estimated 32,100 new HIV infections in 2021. Additionally, the rates of chlamydia, gonorrhea, and syphilis are rising, with more than 2.5 million cases reported in 2021.

With STI rates increasing, public health leaders are exploring new ways to prevent infection. In 2021, the federal government released the STI National Strategic Plan and its implementation plan, providing a roadmap for cross sector collaboration to develop, enhance, and expand STI prevention and care through 2025. Using a syndemic approach—which considers overlapping factors that can complicate STI detection, treatment, and prevention—policymakers can work toward addressing factors that increase risks of multiple STIs.

Legislative Trends

Reducing Congenital Syphilis Rates

Congenital syphilis occurs when a pregnant person infected with syphilis passes the infection onto a fetus or infant during pregnancy or birth. Although congenital syphilis is preventable with screening and treatment and was nearly eliminated in the United States, it surged to more than a 27-year high in 2021 with a total of 2,855 cases, and a case being reported in nearly every state, mirroring the rising rates of syphilis. By improving access to timely prenatal care and syphilis testing, public health leaders can prevent congenital syphilis.

Nearly every state requires syphilis screening during at least one point of prenatal care, either at the first visit, during a visit in the third trimester, and/or at delivery. With rising cases, at least three states enacted legislation during the 2023 sessions to help prevent congenital syphilis. New York enacted SB 4007, which requires universal screening of pregnant persons for syphilis at both a first trimester visit and a third trimester visit. Georgia enacted SB 46, requiring testing for syphilis and HIV at three points of care—during the first prenatal visit, during a third trimester visit, and at delivery. Oklahoma enacted SB 292, expanding syphilis screening from only the first prenatal visit to include universal screening in the third trimester and at delivery for populations at risk for infection or reinfection. The new law aligns with current CDC screening guidance and also requires qualifying health insurance plans to cover medically necessary testing.

As states continue to look for ways to bolster infection detection and prevention, Nevada enacted SB 439, which requires all insurance providers to cover prevention, screening, and treatment for syphilis, chlamydia, gonorrhea, HIV, and hepatitis B and C. This also includes unrestricted coverage of condoms for insured persons and ages 13 or older.

Expanding Access to HIV Prophylaxis

Preexposure prophylaxis (PrEP) is a medication that helps protect against HIV infection for people at risk for acquiring HIV through sex or injection drug use. State policies that increase access to PrEP include authorizing pharmacists to provide PrEP and requiring insurance coverage of (or eliminating cost-sharing for) HIV prevention drugs. States may also pursue actions to address HIV prevention through post-exposure prophylaxis (PEP), a medication that an individual can take after a high-risk exposure to prevent HIV infection.

In 2023, at least 14 states considered legislation related to HIV prevention or PrEP access. Of those, three states—Illinois (IL SB 1344), New Mexico (NM SB 92), and Rhode Island (RI SB 563)—enacted laws related to pharmacist scope of practice. New Mexico and Rhode Island now permit pharmacists to provide PrEP and PEP pursuant to an approved protocol or standing order. Illinois is amending its framework for pharmacist-provided PrEP to include dispensing per a standing order by the Illinois Department of Public Health. Several states—including Colorado (CO SB 23-189), New York (NY AB 1326), and Rhode Island (RI SB 563)—also enacted laws supporting access to PrEP and/or PEP through insurance coverage requirements.

Comprehensive Sex Education

Education is one of the best strategies to prevent STIs, particularly if the education is provided before a person engages in sexual activity. Longitudinal research supports the adoption of comprehensive sex education to improve overall sexual health. Comprehensive sex education refers to an age-appropriate, medically accurate, evidence-based, and culturally responsive curriculum for students through grade 12 focusing on healthy relationships, communication, decision-making, and human development. Currently, sex education is required in 29 states and Washington, D.C., with five states requiring a comprehensive sex education curriculum if sex education is taught.

During the 2023 legislative sessions, at least 15 states considered bills related to sex education, with at least four states—Florida (FL HB 1069), Idaho (ID H 228), Louisiana (LA HB 315), and Mississippi (MS HB 1390)—enacting laws to amend their sex education requirements. Florida and Louisiana’s new laws both restrict sex education to high school, despite evidence showing benefits of sex education to children in earlier grades. Idaho’s law amends its definition of sex education, including specifying that “abstinence” can prevent STIs, while Mississippi’s new law expands the available sex ed curriculums to include “sexual risk avoidance education.”

Looking Ahead

ASTHO expects states to continue adopting laws to reduce STI rates in the upcoming year. In addition to increasing syphilis testing for pregnant people, states may also take steps to:

• Increase access to preventive, diagnostic, and treatment services—such as PrEP—for minors absent parental consent, when warranted.
• Expand routine testing and service programs in areas with high STI prevalence and for populations at increased risk of STI or HIV infection.
• Expanding Medicaid benefits to cover PrEP and other HIV prevention measures as the federal government rolls back Ryan White Funding pandemic expansions.
• Expand comprehensive sex education, including instruction on how to prevent HIV transmission.