First national plan to combat sexually transmitted infections could face obstacles

The Biden administration on Thursday issued its new multiagency plan to address rising rates of sexually transmitted infections, but experts see possible legislative and judicial hurdles that could thwart that effort.

The plan directs five departments and 15 agencies to implement more than 200 steps by 2030, and comes as rates of the most common STIs have reached record highs for eight years.

But the lofty goal laid out in the plan could face challenges because of parallel policy developments that could stifle efforts to reverse the trend.

Public health advocates worry the debt limit law and caps on domestic appropriations would limit the funding increases needed to ramp up research or the workforce, as could ramifications from the COVID-19 pandemic and a split Congress. A federal court case also seeks to lift requirements to cover HIV-prevention medication.

Centers for Disease Control and Prevention data published in April documented more than 2.5 million cases of chlamydia, gonorrhea, and syphilis in 2021—or a 7 percent increase in yearly cases compared to 2017. Syphilis rates increased 74 percent over a five-year period.

“When left untreated, STIs can lead to long-term, irreversible health issues, such as chronic pelvic pain, infertility, and in some cases, cancer. STIs can also increase a person’s risk of getting or transmitting HIV,” said Assistant Secretary for Health Rachel Levine. “The data we are seeing across the country calls for immediate and sustained action.”

The larger issue extends beyond the U.S. The UK Health Security Agency released data Tuesday showing 2022 had the highest number of cases of gonorrhea and the highest rates of syphilis since 1948.

Policy

The new national plan is broken down into five sections and seeks to prevent new infections, reduce adverse outcomes, ramp up STI research, decrease STI disparities and inequities and coordinate epidemic control efforts. It involves coordination between HHS agencies as well as the departments of Defense, Education, Veterans Affairs and Housing and Urban Development.

“With the publication of the first-ever STI Federal Implementation Plan, these efforts serve as a call to action for collaboration across sectors in a coordinated national response to STIs,” said Kaye Hayes, Deputy Assistant Secretary for Infectious Disease and the director of the Office of Infectious Disease and HIV/AIDS Policy.

There are more than 30 types of STIs but the plan focuses on chlamydia, gonorrhea, syphilis, and human papillomavirus, citing their higher rates of morbidity. Aside from HPV, these STIs are tracked through the National Notifiable Disease Surveillance System and HHS said this data can be used to model efforts to address other STIs.

HHS will use seven indicators to measure progress, such as increased percentages of teens receiving doses of the HPV vaccine, increased screening of chlamydia in 16-24 year old females, and reductions to the congenital syphilis rate. Seven other indicators will determine progress to reduce disparities by region, sexual orientation and race.

Funding obstacles

But full implementation of the broad ranging plan may face some barriers from Congress and the courts.

Last week, public health advocates warned that rescissions under the debt limit law could decimate funds used to employ disease intervention specialists, who work on infectious disease prevention and treatment.

The law’s caps to domestic spending would also lessen the likelihood of boosting resources for STI research, family planning or prevention efforts.

National Coalition of STD Directors Executive Director David C. Harvey, speaking ahead of the plan release, warned the debt agreement would likely limit the ability to implement the coming plan.

“This will affect the brand new STI implementation plan that calls for a whole of government approach to fighting an out of control STI epidemic,” he said. “We have a new plan. We had some new funding, and now it’s being pulled back at the very moment that we were seeing some forward momentum and progress on combating these epidemics.”

The document itself acknowledges that funding could present issues.

“Many entities are involved in STI prevention and treatment. Yet, funding streams and restrictions have challenged integration and coordination of programming across stakeholders. The Strategic Plan is a direct response to calls for an agile, innovative, and sustained approach to STI prevention and control in the United States,” it reads.

It also acknowledges that its multiyear plan may need to “respond to policy and funding decisions.”

“All activities included in this document are subject to budgetary constraints and other approvals, including the weighing of priorities and available resources by the Administration in formulating its annual budget and by Congress in legislating appropriations,” the STI plan reads.

Harvey, in a statement Wednesday, questioned having a plan without funding to support it.

“While we had been excited to welcome a new Federal STI Implementation Plan to address the out-of-control STI epidemic, let’s be clear: a plan without the funding needed to execute it is not worth the paper it is written on,” he said. “While the President’s right hand cuts funding, his left hand seeks an expansion of public health programs to fight STIs and syndemics. This hypocrisy makes no sense and we call upon the Administration to reverse this outrageous and deeply disappointing decision.”

Courts

Ongoing litigation in Braidwood Management Inc. v. Becerra could also threaten the plan’s success.

The 5th Circuit Court of Appeals heard arguments Tuesday in the case that could determine the fate of the preventive health care services including reducing the risk of HIV.

The 2010 health law requires most insurance plans to cover services recommended by the U.S. Preventive Services Task Force including Pre-Exposure Prophylaxis or PrEP, which reduces the risk of contracting HIV.

HIV, hepatitis B and hepatitis C have separate national strategies that are not not signaled in the new plan, but untreated STIs can facilitate HIV transmission. People who use injectable drugs are also at higher risk of contracting STIs, and can be linked to syndemics—or clustered outbreaks of two or more diseases.

Public health advocates worry the Braidwood case could limit access to the drug, with downstream effects for HIV transmission or congenital syphilis screenings, which are commonly administered during prenatal appointments. The 5th Circuit has asked the Justice Department and plaintiffs to come to an agreement on the terms of a stay by Friday.

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