Reducing STI Stigma Through Inclusive Care Strategies

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode: changing the way we treat and prevent sexually transmitted infections.

LEANDRO MENA:
But the challenge is that STD control approaches have really remained unchanged since the 1930s.

THOMAS DOBBS:
In addition to making it part of routine care, there are barriers in routine care that, even for people with resources, are an impediment. So we need to lower every impediment and bring the resources that our people need.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today: whole person and status-neutral care models of STI treatment and prevention. How do they work? What are the advantages? And can they help curb rising rates of many types of STIs in the United States?

Dr. Thomas Dobbs is the former state health official in Mississippi. He says they are well designed and effective approaches, but does he think they'll solve the problem? He's along later to answer that question. But first, we hear from Dr. Leandro Mena, director of the CDC's Division of STD Prevention.

MENA:
One of the challenges is that STD control approaches have really remained unchanged since the 1930s. You know, our focus has been identifying and treating STIs and we have relied on one health education, promotion, and behavior change.

Over the years, we have focused on specific infections. First came gonorrhea, next syphilis—all the way back to the 1930s, right. We tried to eradicate syphilis with a big push in the 1990s, early 2000s, but really failed to get rid of this in part because we failed to address the root cause of these infections.

So, why is this, right? What is the real root cause of this infection? And the question is that if we have a much broader approach to health promotion, can we permanently squash future outbreaks? So how do we preemptively keep the next STI from taking a hold? Probably we need to shift our response. And we have the opportunity to inform that shift on decades of prevention activity.

To address STIs, it is critical for programs to work together to discover new, innovative ways to use resources wisely and efficiently take advantage of multiple disciplines and share knowledge and promote holistic equitable approaches that go beyond the disease to address the health and wellbeing of the individual.

JOHNSON:
So two of those approaches that have been mentioned are whole person care and status-neutral care. Are those effective? And if so, why?

MENA:
When we talk about whole person care, we're talking about holistic, patient-centered care that really focuses on the whole person and not a specific disease. It means helping empower individuals and families and communities and populations, really, to improve their health in multiple interconnected areas that include the biological and behavioral, the socioenvironmental factors.

JOHNSON:
So it would be your assessment, then, that they are indeed effective?

MENA:
Oh, absolutely. I think, again, they focus on the needs of the individual. They give the individual what they need. It's a person-centered approach, regardless of any particular status that a person may have, just focusing on their needs.

JOHNSON:
Are there any challenges when it comes to implementing these models?

MENA:
No, the challenges are not really that these are unfamiliar for the current system and groups implementing these models. The challenges include sustainability of the program elements: insufficient—for example, if you want to address unstable housing, insufficient housing inventory; data sharing with partners and health information technology infrastructures that will allow you to connect data to patients so you can identify the needs of the person. Then, there is the challenge that people are having with hiring timelines and retaining staff once hired. And gaining partner buy in to engagement for care coordination.

So all of these challenges are familiar both to people working in the space of status-neutral HIV prevention and care and trying to provide the kind of holistic care that we think should be implemented when people are accessing sexual health services. So I think they're important lessons learned from a recent experience, especially with COVID, that we can implement to be able to overcome some of these challenges, starting by recognizing that infectious diseases are really a whole society issue. The health inequities must be understood as a source, and timely access to quality data is needed to be able to effectively take care of people and implement some of these prevention objectives, and that innovative strategies are really critical to infectious disease prevention.

JOHNSON:
Where is this working?

MENA:
The U.S. Department of Veterans Affairs has really taken a whole health approach and aims to improve the health and wellbeing of veterans, and to address lifestyle and environmental root causes of chronic diseases. This shift is really from disease-centered focus to a more personalized approach. It's to engage and empower veterans early and through their lives to prioritize healthy lifestyles changes. For example, conventional testing and training are combined with complimentary and integrative health approaches that may include acupuncture, massage therapy, yoga, and meditation.

Let me give an example. When I came to Mississippi—I spent 20 years in Mississippi—there is a community-based organization, My Brother's Keeper, with whom I had the opportunity to collaborate almost 10 years ago, opening a clinic. There is a truly community-driven clinic that, from the very beginning, understood that in order to care for and to address the HIV and STD prevention needs of this population, a whole person, holistic approach was needed. And the clinic was available as a primary care clinic that took care of the individual and all of their needs as the means to address, as I said before, the HIV and STD prevention needs of the population.

JOHNSON:
What kind of resources and partners do agencies need if they want to pursue these models?

MENA:
I think they, first of all, need to understand that it will take time, right, for whole person care or substance-neutral approach models to be adopted across the country. With millions of STIs diagnosed each year, it will take all of us working together to implement these models and stem this epidemic. However, you know, there is significant strength in the numbers, and it's important that we work together as a collective to find and implement solutions.

In terms of partnership, it's important to bring together not only the healthcare sector and the public sector, but also the communities who are going to be the recipients of these interventions or these approaches, right, and make sure that they're engaged from the very beginning in the design, the implementation, and the evaluation of these efforts.

There's also opportunity for the private sector to be able and philanthropy to be able to promote and support some of these efforts, as well as some of the agencies and organizations that may help to mitigate the impact of these social determinants of health that we recognize can get in the middle of people achieving the health that they need.

JOHNSON:
How can people in public health get involved?

MENA:
There are many different actions that leaders at every level can take when it comes to implementing whole person institutional care. State and local health departments can review their current funding and care delivery models to further integrate services such as HIV into STI and primary care settings, or vice versa, especially community health centers, sexual health clinics, and health access points for people who use drugs.

They should also identify ways to braid funding from multiple sources and work with CBOs—or community-based organizations—and other providers to gather and share best practices and lessons learned in implementing these care models within the healthcare providers, for example. And CBOs offer another important piece of this puzzle. They can offer dynamic supportive care to integrate culturally affirming messages and prioritize each patient's individual needs. They can consider, for example, expanding the kind of services provided, selecting those that overlap with a patient's health concerns and improving their patient's overall health, such as STI and viral hepatitis screening, mental healthcare, substance use and counseling, and also linkage to other social services.

JOHNSON:
Last question for you: why is it important for public health officials across the country and communities at large to support these initiatives?

MENA:
To make progress until we end this epidemic, we really need to meet people where they are. We need to develop, tailor, and localize interventions where they can have the greatest impact. And we clearly cannot do this unless we address the socioeconomic conditions that make it more difficult for people to stay healthy.

So, it's important to recognize that public health really cannot do this alone. We need to get more groups from local healthcare industry, public health sector, to contribute to the prevention of STIs—including HIV—and really the development of these newer innovations to address our epidemics.

JOHNSON:
Dr. Thomas Dobbs is dean of the University of Mississippi Medical Center's School of Population Health. Before that, he was in state government, wrapping up a fourteen-year public health career in July. He tells us about some of the challenges associated with implementing the whole person and status-neutral care models.

DOBBS:
There's a couple things that make it really challenging for entirely different reasons. If you look at STI diagnoses, we've seen an increasing proportion being diagnosed outside of STD clinics, right, or public health clinics where we've done a lot of our traditional work. So they're really going to be happening at primary care docs and those sorts of locations, which is great, right, because we want people to have sort of holistic care. But we also have the challenge that most primary care providers, physicians, are not well versed in risk assessments, in making sure that the essential testing is done as part of routine care, and then also around diagnostics and treatment. So certainly, there needs to be a lot more work integrating STI diagnosis and treatment into primary care.

From sort of like the traditional sort of public health mentality, or even within the HIV treatment world, we have a real challenge in the sense that there is a separation in HIV and STD diagnosis and treatment, right. So we'd run into these problems all the time where there are restrictions in the Ryan White funded clinics about what they can do—it's very specific to folks with HIV. And then the STD clinics or STI clinics, which are really usually less funded, don't really have the same sort of resources to provide holistic care. So we have this almost like schism between STIs and HIV that makes operationalizing it that much more difficult.

JOHNSON:
Thinking about the whole person and status-neutral care models, have you seen any successes?

DOBBS:
We have seen some of that. To be sort of holistic, it really should be all avenues of care. But certainly we've seen different partners in Mississippi specifically, such as My Brother's Keeper and some other folks, where they are inclusive of diabetes screening, blood pressure screening, sexual health screening such that it destigmatizes it, right. It's easy to walk into a mobile unit and get your blood pressure checked and not feel like that you're being sort of singled out because of risk. And so, that that's been extremely helpful.

But I think the absolute answer is having integrated primary care where people have access to preventive services. It's a real challenge in the state of Mississippi, though, because we have a very high rate of uninsured folks. And we haven't accepted any of the federal support for insurance, like Medicaid expansion. And so, we do have a lot of folks who do not have insurance.

JOHNSON:
What are some of the best arguments in favor of these models?

DOBBS:
Well certainly, people don't live in a vacuum, right? People's medical problems overlap one with the other. So having a comprehensive approach is good because if we look at—of course, we've seen an explosion of STDs in our country and in Mississippi more so even than other states. But if we look at what's causing early death and morbidity, a lot of it's going to be diabetes-related, it's going to be hypertension-related, it's going to be people having strokes in their 40s—which is very common, unfortunately, or early heart attacks. So there are real benefits to incorporating these together and not seeing them siloed; so much of what we've traditionally done has been a siloed approach.

In addition to having holistic care for the benefit of the person, you do have that destigmatization, right, that happens with thinking about it in general. If someone comes in—and I've seen this before, very much that—someone comes in and they say, "Just check me for everything." I was like, "Okay, I will." So I'll do cholesterol, and the normal sort of age-based, risk-based screenings, and of course, do HIV and it becomes normalized, right? So it just becomes part of the normal process.

The flip side of that is—and I've had this happen so many times—where I'll have someone who is newly diagnosed with HIV, and I'll ask them, "Have you been tested for HIV before?" And very often times, they'll say yes. I was like, "Great. When did they do it?" Well, they'll say, "I'm sure my primary care physician did it when I went into my routine checkup," but they didn't. So I think there's even an acceptance and an expectation that that can be, or should be, part of routine care, and hasn't really translated necessarily into medical practice.

JOHNSON:
Dr. Mena answered this question, we'd like to pose it to you as well: tell us about the resources and partners that need to be in place in order to do this well.

DOBBS:
Well, if we think about the sort of general screening, holistic approach—diabetes, blood pressure, that sort of thing—there are several great partners that we've been able to work with. Certainly community-based organizations have been key: you can get out in the community, go to where folks want to be seen.

But there's other partnerships that we've had that have been extremely successful. Barbershops specifically have been very successful around blood pressure screening and COVID vaccination, and also have a major role for STI and HIV screening. Faith-based organizations have been really fantastic as far as—you know, most big churches have a health ministry and incorporating that into health ministry is also a great way to reach people in the community, right? Because it's a pain to go to the doctor: it's expensive, it takes a lot of time, it's hard to get an appointment. So we have barriers. And so, if we can bring stuff to people's community where after church I'm gonna get a blood pressure screen and someone's gonna prick my finger, that's fantastic. It's lowering the barriers, making access as easy as possible.

So, I think in addition to making it part of routine care, there are barriers in routine care that even for people with resources are an impediment. So we need to lower every impediment and bring the resources to where people need them.

JOHNSON:
How can people in public health get behind these STI initiatives?

DOBBS:
I think building partnerships aggressively and taking the time to develop relationships, partnerships. Some of these things take years and years to build out, and be patient in doing that.

And be willing to push money out the door. What we've seen, and I think sometimes it's hard for us to acknowledge it, we've seen a systematic dismantling of the public health system as we once knew it. We've seen, you know, the funding is either evaporated, or it's been so heavily siloed that the public health system that we used to have in the county health departments back in the '90s and even early 2000s no longer exists in most places. It might some places, but in places that I'm familiar with, they do have some valuable functions, but it's just not the same.

So, understanding that we're unlikely to go back to the old system, we've got to build partnerships. And I think being willing to develop those partnerships and to try to find ways to maximize flexibility for folks to be able to get out in the community and do the work, and then to give them money.

So kind of as an example, but this is a small-scale thing: we did have some flexibilities here in COVID that really I think were phenomenally successful. We were able to set up a network of COVID vaccine partners throughout the state where we said, "You're going to give COVID vaccine to the community, and we're going to pay you X dollars per vaccine. And in exchange for that, you're going to be on call for community events. And churches or community groups are going to call us and we're just going to have you on a rotation. And if you want to get paid, you can be part of this process, you will be deployable." This is something that there's no way, as a health department, we could have done this. But by recruiting partners—they can be health centers, community health centers can be crucial but also other clinics who have not only some resources but also pre existing connections with the local community—we're able to sort of really leverage those advantages to the benefits of the folks who live there.

JOHNSON:
As we all know, many STIs are on the rise. What is the potential of these models to help address those concerns?

DOBBS:
It's going to take a lot for us to turn this around. It's going to take a whole lot. And this isn't the silver bullet, it's not going to fix everything. But it's a really well-designed, effective way to meet part of that need. So it's maybe necessary but not sufficient as part of the suit to bring this around. So it's a phenomenal tool if we can implement it right, bring in our community partners, and really just make this sort of whole person approach available to folks where they live.

JOHNSON:
Thank you for listening to Public Health Review.

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For Public Health Review, I'm Robert Johnson. Be well.