Improving care for sexually transmitted infections

Rising rates of reported sexually transmitted infections (STIs) in the US and Europe are a public health priority and require a public health response. The diagnosis and treatment of STIs have been the cornerstone of STI control and prevention for many decades and, historically, publicly funded STI clinics have played a central role in the provision of STI care. Innovations in non-invasive diagnostic techniques, especially nucleic acid amplification tests in the mid-1990s, have facilitated the expansion of STI testing and treatment outside traditional STI clinics, including primary care, family planning, school-based health, outreach, corrections, emergency departments and HIV prevention and care settings. As a result, the continued need for categorical STI clinics has been debated. In this Commentary, we discuss how practice can be improved at each level of STI care.

STI practice improvement plans should be tailored to the strengths of each care setting. Thus, in primary care, the focus should be on improving STI screening rates, the provision of hepatitis B and human papillomavirus vaccines and, in jurisdictions where this is legal, expedited partner therapy for gonorrhoea and chlamydia. Extragenital (pharyngeal and rectal) testing for gonorrhoea and chlamydia should be available in settings serving populations more vulnerable to STI acquisition at these anatomical sites, including men who have sex with men. In family planning settings with a mostly female patient population, there are opportunities to serve male partners with both contraceptive and STI services. STI screening rates can also be improved in other settings serving populations at increased risk for STIs, including school-based clinics, emergency departments, correctional health facilities and providers of HIV care and prevention. These improvements are predominantly logistical in nature and not dependent on extensive STI clinical expertise. While some providers in these settings may have the clinical knowledge and skills to evaluate symptomatic patients, many do not, and STI speciality clinics must be available for consultation and referral and evolve from "safety net" providers of last resort to STI centres of excellence.

A tailored practice improvement plan can be envisioned to achieve an optimally functioning STI care continuum.