Use of Community Health Workers to Help End the Epidemic of Sexually Transmitted Infections

The United States is experiencing an epidemic of sexually transmitted infections (STIs); 2.5 million cases of chlamydia, gonorrhea, and syphilis were reported in 2021. ¹ From 2017 to 2021, the number of reported cases of gonorrhea increased by 28%, and reported syphilis cases increased by 74%. ¹ If untreated, these bacterial STIs can lead to pain, infertility, increased susceptibility to HIV infection, and, for syphilis, death. Reported cases of prenatally acquired congenital syphilis—which can lead to stillbirth, low birth weight, infant death, and other complications—increased by 203% from 2017 to 2021. ¹

These STI numbers are climbing despite the fact that bacterial STIs are detectable and treatable. The challenge for public health and health care systems is connecting individuals and communities with STI screening, diagnostic, and treatment services as well as education about STIs and sexual health. Issues related to stigma, privacy, and medical mistrust can compound barriers to prevention and care and can hamper the kind of engagement needed to address the current epidemic.

Given these challenges, community health workers (CHWs) could play a crucial part in the response to the STI epidemic. The American Public Health Association and the National Association of Community Health Workers define CHWs as “frontline public health workers who are trusted members and/or have a close understanding of the community served.” ² CHWs have a long history in the HIV field; numerous studies have demonstrated CHWs effectively supporting people living with HIV to address social determinants of health, both as part of a clinical team^3-7 and in the community.^8-10 However, the CHW workforce is a largely untapped resource for addressing STIs more broadly. Meanwhile, the Medicaid program, which covers 86 million people ¹¹ and pays for a large share of STI-related visits, ¹² is still in the early stages of determining how to best support and engage the CHW workforce.

The George Washington University team conducted a study to collect information on Medicaid, CHWs, and STIs. The study consisted of a literature review and interviews with state and national experts in sexual health, CHWs, and STIs. Findings from the research project, including all interviewee names and affiliations, are available elsewhere. ¹³ In this commentary, we summarize key considerations and opportunities for STI programs and policy makers to expand the role of CHWs in addressing STIs, identify optimal Medicaid reimbursement approaches, and coordinate CHWs’ role with that of the existing disease intervention specialist (DIS) workforce.

Potential Role of CHWs in the STI Field

CHWs have a strong record of providing support to historically socioeconomically marginalized people living with HIV, including holistic support to address social determinants of health and spending time with patients to establish rapport.^3-7 CHWs are well-suited to recruit people for HIV screening, foster trust, facilitate care, and locate and reconnect people who have dropped out of care.^8,14,15 CHWs have demonstrated effectiveness in HIV prevention by encouraging people to know their HIV status, educating and testing diverse populations, reducing stigma, and linking people who test positive to health care.^4,7-10,16,17

Given the demonstrated strengths and history of CHWs working in HIV prevention and care, CHWs could play a vital role in addressing STIs. In the STI field, CHWs could perform a range of tasks, including aiding in STI prevention and education, referring people to testing and treatment, and helping patients enter and navigate care. Beyond STI-related care, CHWs have a strong referral network for a range of community-level health and social needs, which is important for people who may experience multiple barriers to the health care system. One interviewee noted,

Most of the people who are having these high rates [of STIs], you know, again are probably from more marginalized communities that need other resources. It’s not just about the health, it’s about other resources as well, and they can connect them and that’s what a community health worker does.

CHWs already work across a wide range of settings relevant to addressing STIs and could therefore expand their work from these settings. Common CHW employers include state and local health departments; clinics, such as STI clinics or federally qualified health centers; community-based organizations (CBOs); and health insurance providers, such as Medicaid managed care organizations (MCOs). In addition, CHWs conduct outreach to connect patients to care.

Judgment, stigma, and lack of urgency from clinical providers can deter patients from seeking community-based services for STI treatment and contribute to loss to follow-up. To mitigate the effects of these negative experiences, CHWs could serve as patient advocates both within and outside clinical settings, while providing sexual education and patient navigation. One interviewee said,

It’s a different type of wraparound to be physically present in a way that . . . case managers and nurses can’t, I think. There’s an element of support that looks a little bit different, especially with peers with lived experience.

Although only a subset of CHWs are likely to specialize in STIs and sexual health, other CHWs could benefit from STI-related training because questions related to STIs and sexual health can arise for any client. For example, CHWs who focus on chronic disease management or on upstream determinants of health could receive training related to STIs, allowing CHWs to address issues raised by their clients and refer clients to appropriate resources.

Public health departments could promote the role of CHWs in STI programs through the following steps:

• • Identify CHWs who are already providing sexual health–related services in the community and, if so, in what settings. Assessing the existing CHW landscape locally, and whether any CHWs are doing work in the sexual health field, is an important first step. Many states have a CHW association or network, whose leaders and members could help STI programs understand and forge connections with CHWs. ¹⁸

• • Consider the feasibility of hiring CHWs for STI prevention programs at state and local health departments. CHWs could play a range of roles in STI prevention programs, including conducting community outreach and referral to services, providing community or school-based sexual education, and creating trust between public health departments and the community.

• • Work with substance use disorder agencies in the region to develop joint programs for CHWs. Given the high comorbidity of substance use disorder and STIs, employees at divisions in public health departments focused on STIs could reach out to colleagues in the substance use disorder field to develop specialized training or other programs for CHWs on upstream risk factors for both challenges.

• • Work with health clinics and CBOs in the sexual health field to integrate CHWs into their programs to provide more holistic, culturally sensitive STI services and outreach. In clinical programs with a high volume of STI patients, CHWs could be focused entirely on STIs, offering navigation, peer support, referral to social service needs, and outreach to patients who drop out of care. Nonclinical organizations could hire CHWs to provide community-level outreach, sexual education, and referral to services.

In addition, at the national level, the Centers for Disease Control and Prevention could collaborate with partners to develop national CHW educational materials on STIs. For example, federal groups involved in STI prevention, such as the Centers for Disease Control and Prevention, could consider developing a module on STI prevention and sexual health. Many states have voluntary CHW certification programs, and an STI module could be made available for initial training requirements and continuing education.

Medicaid Support of CHWs

Studies confirm the effectiveness of CHWs in improving health outcomes among low-income and racial and ethnic minority populations.^19-22 Return-on-investment analysis has shown that CHWs can provide economic benefits and are a cost-effective way to connect patients with care.^23-26 Because of growing recognition of the contribution of CHWs in improving health and reducing costs, state Medicaid programs have increasingly developed reimbursement models that include this workforce.

Although Medicaid programs typically do not pay for some traditional CHW services, such as outreach or community education, other CHW services fit neatly into existing Medicaid benefit categories. For example, under federal regulations, Medicaid programs may reimburse CHWs and other nonlicensed providers for providing preventive services if the services have been recommended by licensed providers.^27,28 Currently, 14 states provide direct reimbursement for certain CHW services through Medicaid; in 10 states, Medicaid MCOs reimburse for CHW services or hire CHWs directly.^29,30 Coverage can take various forms, ranging from fee-for-service reimbursement for CHW services to more flexible approaches, such as monthly care coordination payments for teams that can include CHWs or MCOs that directly employ CHWs to serve their enrollees’ needs. In addition to direct reimbursement for CHW services by some states, other states include CHW services in innovative Medicaid payment models. ²⁴

Reimbursement through Medicaid could benefit CHWs and their clients, offering more sustainable support than time-limited grants or annual appropriations. However, any approach to CHW coverage and reimbursement could have substantial unintended effects on CHWs’ practice. For example, as interviewees in our research study noted, paying for specific units of service or time delivered by CHWs could limit CHW flexibility and effectiveness. In addition, any quality measures linked to Medicaid reimbursement could create unintended consequences, such as steering CHWs toward lower-acuity clients or leading CHWs to focus unduly on certain factors. One interviewee noted:

Part of what a CHW is doing is building relationships in the community and building that trust. It’s really hard to measure that and it’s hard to do that in 20 minutes, 30 minutes, or an hour. It may take a half a day of being with somebody to earn the trust level that you need to talk about the things you need to talk about with somebody. And it may take repeated visits to do that.

One approach to CHW coverage—requiring Medicaid MCOs to employ a certain ratio of CHWs to enrollees, as Michigan currently does ³⁰ —could be a promising way to provide long-term employment opportunities for CHWs while affording them the flexibility to best support enrollees. In addition, some novel Medicaid payment models, such as value-based payment and accountable care organizations, include flexible funding that could allow the inclusion of CHWs to address STIs and other health issues.

A limitation of Medicaid coverage for CHWs is that support would be most accessible for CHWs who work in clinical settings, because their employers are likely already billing Medicaid for other health care providers and services. In contrast, nonclinical CBOs and some health departments could face challenges in initiating Medicaid billing for CHW services. This problem may be particularly salient in non-Medicaid expansion states, in which many low-income adults lack health insurance and, thus, have few interactions with clinical providers. Some potential models for connecting CHWs in nonclinical settings to Medicaid reimbursement could include having clinics collaborate with CBOs, supporting CHWs at CBOs through memoranda of understanding, or facilitating development of centralized entities that could conduct billing for CHWs across a range of settings. ³¹ One interviewee noted:

I hope we will look at not just paying for people in health care settings to do the [work of] community health workers. I hope we will [pay CHWs who are] community based and community placed and are not part of the health care system, because we are one of the states that have not expanded Medicaid. We have a lot of people who don’t have any insurance, who don’t have a medical home. . . . We have a lot of people in the community who need someone to help them navigate the system, to help them understand we have free and reduced-price clinics, that we’ve got people who will see them on the sliding scale or get hooked up in other ways of assistance when they’re not insured.

To ensure that coverage approaches meet the needs of CHWs who are involved in STIs and sexual health, STI programs in health departments and STI service providers should consider the following:

• • Identify and engage CHWs in ongoing state-level discussions of Medicaid reimbursement for CHWs. Programs should engage CHWs to ensure that payment approaches support the unique strengths of CHWs and the flexibility of CHWs in meeting the needs of individuals and communities. In addition, having a seat at the table for this planning will give programs involved in STIs and sexual health insight into the best way to leverage Medicaid funding for CHWs working entirely or partly on STI services.

• • Reach out to Medicaid MCOs in the state about CHW reimbursement. Medicaid MCOs typically have substantial flexibility to fund CHWs. Even if a state Medicaid agency has not formally added CHW services to the state plan, a Medicaid MCO could fund CHWs to help their enrollees.

• • Help identify funding sources to sustainably support CHWs who serve uninsured or underinsured populations. A focus on Medicaid reimbursement is important but insufficient to support all who need CHW services, particularly in non-Medicaid expansion states where substantial numbers of low-income adults are uninsured.

• • Work with Medicaid programs and MCOs to ensure that payment models allow for continued flexibility for CHWs to effectively address STIs and other health issues in the community. Key considerations include avoiding rigid processes or outcome measures that could unduly constrain CHW flexibility and carefully creating mechanisms to prevent adverse outcomes.

• • Create opportunities for Medicaid to support CHWs in the community. CHWs who work outside the clinical setting can serve a broader range of people and a broader set of needs than CHWs who work only in a clinical setting. STI control programs (and interested partners in health departments) could work with Medicaid agencies or MCOs to develop ways to support CHW work in community settings through clinical−community partnerships, cooperative agreements, or other approaches.

• • Consider required ratios for CHWs to enrollees in MCO plans. This approach, already in place in some states, gives CHWs a large panel of MCO members to serve. Although the work for CHWs in MCO plans would not be focused on STIs exclusively, health departments can work with MCOs to ensure that CHWs have key information on STIs and sexual health, as well as appropriate referral resources.

Integrating CHWs With the DIS Workforce

The DIS workforce and CHWs have largely distinct educational requirements, training, and roles. ¹³ DIS positions typically require at least a college degree and training on DIS services, whereas CHWs are generally permitted to practice without meeting specific education or training requirements, although many states offer voluntary certification programs. In contrast to the broad range of outreach, navigation, support, and other services that CHWs can provide, DISs are typically focused on targeted disease outreach, case investigation, and partner notification.

According to interviewees, DIS staff are rarely aware of CHWs working in the sexual health field, and vice versa. However, combining the complementary strengths of DIS staff and CHWs could increase their effect. CHW engagement could help alleviate the current DIS workforce shortage, with CHWs trained to perform some of the tasks more commonly performed by DISs. ³²

Integrating DIS services into a community setting can also increase their effectiveness in connecting with patients and conducting partner services. For example, the City of Chicago supports DIS-like partner services in a community-based clinic. These staff are not called CHWs, although the DIS role has merged with many of the key strengths of CHWs. As part of the comprehensive response to the syphilis outbreak in 2002, the Chicago Department of Public Health funded and established a community-based DIS program at Howard Brown Health, a multisite, federally qualified health center with comprehensive health and social services focused on the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community. ³³ The Howard Brown Health Partner Services program conducts patient interviews and partner notification, 2 tasks typically performed by DISs working in public health departments, for clients seen in their clinics who are diagnosed with HIV or syphilis (Michael Castro, MPH, director of disease investigations, Chicago Department of Public Health, interview, June 13, 2022).

Like DISs in the Chicago Department of Public Health, specialists in Howard Brown Health Partner Services perform a range of tasks to help patients navigate their diagnoses, such as linkage to care and providing pretest and posttest counseling. Specialists also reflect their client population and undergo training related to LGBTQ sensitivity, structural racism, immigration, and community trust.

In any jurisdiction, shifting the roles of CHWs can cause tension or perceived disruption among other health professionals. ³⁴ However, because of their distinct roles and the urgent need for further personnel to address sexual health, a thoughtful approach to CHW and DIS integration or collaboration could mitigate such concerns. As one interviewee said,

I would not see [CHWs] as being the folks who do the work around contact tracing or contact investigation like the disease intervention specialists do. I see [CHWs] as being the ones who say, “Well, this is why you need to tell them all your sexual contacts and why you need to get tested before having your baby.” That’s the CHW role, more than tracking people down and telling them they’ve been exposed.

To integrate the existing DIS workforce with CHWs as a way to bolster the overall response to STIs, STI programs in public health departments could do the following:

• • Create additional opportunities for CHWs and DISs to better understand each other’s roles. For example, a public health department could host a convening of DIS staff and CHWs working in the sexual health field in the community, to share knowledge of STIs and sexual health and to identify opportunities for collaboration.

• • Supplement the DIS workforce in public health departments with CHWs. CHWs could supplement the work of DIS staff through task-shifting components of the DIS role. CHWs could also extend the reach of DIS staff in the community, for example, by providing ongoing support and/or sexual education to clients after their initial DIS encounter.

• • Consider opportunities for cross-training. DIS teams could participate in CHW training modules to advance their skills in community knowledge and engagement. Conversely, CHWs could undergo DIS training, either to support a shift to a formal DIS role or to play a DIS-like role in a community setting.

Conclusion

Numerous challenges, from funding shortages to competing public health priorities to barriers to patient trust and care, continue to fuel the STI epidemic. CHWs have the skills and demonstrated effectiveness to help connect individuals and communities to STI education, prevention, testing, and treatment. By tapping into existing Medicaid coverage and reimbursement efforts and coordinating thoughtfully with the existing DIS workforce, STI programs can integrate CHWs to strengthen STI response efforts.