A Syndemic Approach to STI Interventions and Prevention

Some answers have been edited for clarity.

What is a syndemic?

A syndemic is when one or more public health issues intersect in populations, and usually, those are ensconced in social and economic environment that exacerbates their effects.

For sexually transmitted infections, syndemics are really important because STIs themselves are syndemics. You have gonorrhea, syphilis, chlamydia, HIV, and other infections that overlap in populations and make getting the job done harder.

Why is a syndemic approach relevant to STIs?

STIs are critically important for public health because of the magnitude of the problem and the opportunities that we have right now to reverse the trajectories. For the past eight years, we've had increasing STIs in the United States, and our most recent information indicates that there were over 2.5 million sexually transmitted infections in the last year; so, this creates a burden for the public health system as well as for all the people who are getting STIs.

At the same time, we have recognized approaches that are effective in preventing and treating STIs and new interventions that science has produced over the past year that—if put into place—could greatly reduce sexually transmitted infections in the country.

What are approaches to combat rising STI rates?

When we think of syndemic approaches, we can think in four categories. The first is people. Since there are populations where different epidemics intersect—so, for example, gay, bisexual, and other men who have sex with men are more likely to have STIs and HIV than heterosexual men and women.

By having interventions brought to people focused on their specific situations, we can make a difference in multiple ways. For example, we have a screening panel for pregnant women, including syphilis, so that any infection that could potentially harm a mother or her infant could be diagnosed and treated.

The second issue with syndemics would be the concept of place. So, place in terms of geography, we are obligated as public health officials to put our money where our epidemics are. But also, place in terms of opportunities, so having multiple different interventions available at an STI clinic or a federally qualified health center or community-based organization means that instead of thinking about each disease separately, we're bringing interventions together that can treat entire populations.

And in many ways, I think of a syndemic approach as similar to a primary care physician who doesn't just think about one particular disease but thinks about the holistic person that they're trying to bring health services to. The same thing we can do as public health officials is to bring those holistic services to populations.

The third aspect of syndemics is thinking about the social determinants of health and how policy interventions can have much broader effects—and sometimes more long-lasting ones–than individual activities. So, thinking about things like Medicaid expansion, expedited partner therapy for STIs, or other kinds of interventions that will have a broad effect on multiple different STIs and other syndemics.

And then the fourth is science. Science is critical to a syndemic approach to public health. Sometimes we can have tests, for example, that diagnose multiple infections, so we don't have to think about each one separately. Or we have new interventions like pre-exposure prophylaxis for HIV that—because it tests for STIs as part of our routine services—can have multiple positive effects beyond just HIV infection itself.

How can state and territorial health agencies further support their jurisdictions' STI programs?

There are systems that we can put into place and policies that we can put into place that will lead to decreased STIs for entire populations. And those can include things from ensuring that STI clinics are available in areas where STIs are disproportionately affecting populations and that these clinics are well-resourced.

And sometimes, they're policy-level changes, like ensuring that expedited partner therapy is enabled in your state so that we can more easily treat people exposed to and with STIs.

Making sure that we have disease investigation specialists going out and finding the people who might have been exposed and bringing them the testing and other services that can help protect them from STIs.

Because STIs live in this kind of social and economic context that can worsen their burden on populations or improve on it, we have to think about them as part of a public health system and as part of society as a whole.

Certain partners can make a particularly important difference, whether it's your schools ensuring that evidence-based sex education is being provided to students who are at risk for STIs or ensuring condoms are available in places where people can have access to them.

Ensuring that we have pre-exposure prophylaxis for HIV prevention available in the clinics and other sites that people can access. Making sure that we have diagnostics for STIs and HIV available in clinics.

And also thinking about other interventions that can make a difference, like syringe service programs so that people who inject drugs have access not only to STI and HIV screening and treatment but also to clean needles and syringes and naloxone that will help them, if they do overdose, not die of that overdose.

We have met significant public health challenges in the past, and as a nation, we've seen tremendous reductions in some STIs for decades, so it is possible to reverse these trends. But it will take concerted, thoughtful action, good science, important and thoughtful policies, and enough resources.