Expanding access to STI care with free of charge,convenient services in sexual health walk-in clinics

Abstract

Background: Sexually transmitted infections (STIs) are a long-standing public health issue with increasing incidence in recent years even though most STIs can be effectively treated or even cured with inexpensive medications.

Purpose/Design: In this manuscript, we discuss factors that contribute with this concerning scenario, including modifications in the model of STI care in the United States; barriers for diagnosis and treatment; and scarcity of targeted STI prevention messages. We then describe the approach adopted by AIDS Healthcare Foundation to mitigate STI trends, with a focus on sexual health Wellness Centers.

Results: The main characteristics of this program include free and convenient services with large volume capacity, sex-positive culture, advertisement of available resources, and accessibility to key populations at higher risk for STI acquisition.

Conclusions: This experience could be adapted and expanded to other settings, supporting the public health mission of controlling the spread and detrimental outcomes of STIs.

Introduction

Sexually transmitted infections (STIs) are a long-standing public health concern with increasing occurrence in several countries, including the US.^1,2 The World Health Organization estimates that more than one million curable STIs are acquired every day globally. ³ According to the Centers for Disease Control and Prevention’s STI Surveillance Report, more than 2.5 million cases of syphilis, gonorrhea, and Chlamydia were reported in the US in 2022. ² STIs are associated with detrimental effects to sexual and reproductive health and increased risk of HIV acquisition. STIs are also a frequent cause of social stigmatization. ³

Of the eight pathogens currently linked to the greatest incidence of STIs, four (hepatitis B, herpes simplex virus, HIV, and human papillomavirus) are viral infections for which clinical management can effectively prevent disease progression and reduce or eliminate transmissibility. The remaining four conditions - syphilis, gonorrhea, chlamydia, and trichomoniasis - can mostly be cured with inexpensive medications that have been available for clinical use for decades. ³ So, where and why are we failing?

While the increase in STI rates in the past years likely results from multiple factors, barriers for STI diagnosis and care have been widely acknowledged as key drivers. ⁴ Aiming to mitigate the rising rates of STIs in the second half of the 20^th century, many countries have implemented free of charge, walk-in sexual health services. However, the availability of such facilities has dropped in the US since the 2000s, following cutbacks in public health funding.^5,6 Moreover, with the establishment of the Affordable Care Act in 2014, the model of care for STIs has further shifted from sexual health clinics to primary care units. ⁷ Pros and cons of this shift have long been debated. ⁸ While this change may have favored STI care for the percentage of the population with access to primary care, ⁷ underserved populations including subgroups at higher risk of STIs may now be facing higher barriers to access STI management.^9,10 More recently, during the COVID-19 pandemic, several countries reported cutbacks in STI prevention, treatment, and monitoring services that have not yet been fully reestablished.^11–14

Barriers for timely diagnosis and treatment

A key principle of STI care is the timely management, including early diagnosis, treatment, and sexual partner(s) care. ⁴ Even for persons with access to private or government-funded health services, timely management of STIs may be limited. Walk-in services are often inaccessible, and scheduled appointments sometimes take place several weeks after the initial request. Some health insurance companies restrict the number of yearly appointments for its clients, resulting in suboptimal care for persons at high and recurrent risk of STIs who would benefit from further visits for testing and treatment. Additional limitations include copay and other expenses charged for services; complex and lengthy procedures for reimbursement of expenses; limited working hours in health facilities; institutional protocols that may delay provision of treatment until a diagnosis is confirmed; inability to extend investigation and treatment for uninsured sexual partners; and stigma in healthcare services, with providers often unfamiliar with sexual and gender diversity, or sometimes showing uneasiness when dealing with sexual practices perceived as unusual.^15,16 Altogether, these and other barriers for STI management contribute to the persistence or even the expansion of transmission networks.

Scarcity of targeted STI prevention messages

Since the 1980s, STI prevention messages have been strongly linked to HIV prevention messages, as prophylactic strategies available in the first three decades of the HIV epidemic – condoms and reduction in the number of sexual partners – were effective to both. Prevention campaigns struggled to disseminate the notion that all sexually active persons were at risk for HIV and STIs to some degree, so condoms were recommended for all. In recent years, with the increasing focus on HIV biomedical prevention strategies for highly exposed individuals, prevention messages targeting other STIs have been relaxed. Since HIV biomedical prevention programs include periodic STI testing and early treatment if applicable, a synergistic mitigation of STIs is intrinsically accessible in this context.^17,18 Meanwhile, opportunities to promote STI prevention for persons not receiving HIV biomedical prevention are scarce. ¹⁹

Approaches to mitigate STI trends adopted by AIDS Healthcare Foundation

Working closely with communities and relying on flexible operations, non-governmental organizations are well positioned to provide rapid, tailored, and innovative responses to issues that affect their target audience. AIDS Healthcare Foundation (AHF) has provided continued services for HIV prevention and care since 1987, currently supporting more than 2,024,299 clients in the U.S. and 44 other countries. In 2005, AHF implemented its first Wellness Center in Los Angeles, US, with free of charge, confidential services available for persons at need with no appointment required, initially focused on HIV diagnosis and on the management of bacterial STIs for male clients. Since then, AHF expanded the availability and scope of work of its Wellness Centers; currently, 35 facilities are open in 13 US States, assisting clients regardless of gender, race, ethnicity, sexual orientation, or income. The main characteristics of AHF Wellness Centers model of care include:

1. Free STI services. AHF Wellness Centers provide free of charge care, with no limitations regarding the number of appointments or tests per person, irrespective of insurance status. Interestingly, a large percentage of the patients assisted at AHF Wellness Centers have access to a health insurance, highlighting the limitations of existing services.

2. Convenience. AHF Wellness Centers operate in post-commercial hours and weekends; are located in convenient venues, sometimes taking advantage of a “camouflage” setup – such as the Out of the Closet Thrift Stores; provide diagnostic resources with self-collection of specimens whenever possible; and offer higher flexibility in the provision of diagnostic and treatment resources according to the person’s needs rather than the provider’s adjudication. AHF Wellness Centers also offer digital health resources that facilitate registration, exposures and symptoms ascertainment, communication of test results, and includes an artificial intelligence tool to answer clinical and administrative questions that can be assessed at any day or time. Finally, waiting time is minimized by the specific menu of care and quick turnaround times for diagnostic resources.

3. Sex-positive culture. Taboos surrounding sex and sexuality may inhibit the dialog between provider and patient, particularly for sexually diverse persons. While most health workers are trained to provide care with no value judgement, AHF Wellness Centers also promote a sex-positive atmosphere, where behaviors and practices are acknowledged as part of the values, identity, and culture of a person or community. Moreover, the healthcare team includes peer professionals, facilitating relatedness and kinship with service users.

4. Advertising. The scarcity of information regarding where and how to access STI prevention, diagnosis, and care is as much a barrier as the absence of services. AHF has continuously invested in advertising, mainly in billboards and social media, simultaneously promoting STI awareness, informing of the availability of testing and care services, and combating stigma. Figure 1 shows a compilation of recent AHF STI advertisements.

5. Volume capacity. Between January and May 2024, AHF Wellness Centers in the US provided free and confidential services including sexual health counseling to more than 130,000 persons; new pre-exposure prophylaxis (PrEP) prescriptions to almost 6000 persons; distribution of approximately 250,000 condoms; more than 90,000 HIV tests; more than 118,000 syphilis tests; and more than 270,000 gonorrhea and Chlamydia molecular tests. Notably, AHF monitoring reports showed that considering HIV, syphilis, Chlamydia, and gonorrhea combined, 10% of all STIs reported in 11 US health jurisdictions were diagnosed at an AHF facility.

6. Services for key populations. AHF Wellness Centers also stand out for the demographic characteristics of service users: current data shows that 28% of the patients receiving care are Black/African American; 15% are Latino/Hispanic; 10% are transgender, gender non-conforming, or non-binary; and nearly 54% are cisgender gay/lesbian or bisexual. The fact that key populations at higher risk of STI acquisition are accessing AHF Wellness Centers is a major indicator of the program’s successful results.

Figure 1.

Compilation of recent AHF advertisements.

Discussion

Recent epidemiological data has shown that the public health mission of controlling the spread and detrimental outcomes of STIs is far from being accomplished, despite the availability of inexpensive and curative treatments for the most prevalent STIs. Novel strategies should be developed to promote sexual health, improve STI prevention, and facilitate early diagnosis and care. Sexual health walk-in clinics may have a critical role in facilitating access to prevention, diagnostics, and treatment resources, particularly for underserved populations. Collaborations between government, health insurance companies, non-governmental organizations, communities, and other stakeholders are essential to develop an effective response to this challenging public health issue. Finally, healthcare providers working at all levels of care should receive training to deliver comprehensive sexual health services for all sexually active persons, regardless of gender, age, race, social condition, sexual orientation, or sexual practices.

Challenges that contribute with the persistence of STI transmission chains should be scrutinized, and potential solutions should be analyzed, tested whenever possible, and implemented according to local needs. AHF Wellness Centers have implemented bold strategies to remove barriers for STI prevention, diagnosis, and care in the US. This experience could be adapted and expanded to other settings, helping mitigate the spread and detrimental outcomes of STIs.