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Structural Interventions for Sexually Transmitted Infection Prevention and Sexual Health

Rietmeijer, Cornelis A. MD, PhD

doi: 10.1097/OLQ.0000000000000018
The Real World of STD Prevention

From the Colorado School of Public Health, University of Colorado Denver, Denver, CO.

Conflicts of interest: None declared.

Correspondence: Cornelis A. Rietmeijer, MD, PhD, Colorado School of Public Health, University of Colorado Denver, 533 Marion St, Denver, CO 80218. E-mail:

Received for publication June 16, 2013, and accepted June 18, 2013.

The main concept behind the journal’s Real World of STD Prevention section is that the effectiveness and impact of any public health intervention are determined by the efficacy of the intervention under optimally controlled conditions and the sum of factors that act as barriers and facilitators in the environment where the intervention is implemented. Because these barriers and facilitators often relate to structural factors (eg, laws, policies, resources, and workforce), efforts to optimize the environment to maximize effectiveness of prevention interventions are themselves referred to as structural interventions.

Structural interventions operate at different levels. At the macrolevel, for example, laws can be changed or designed to decrease unhealthy behaviors or encourage healthy behaviors. In the former category, tobacco ordinances have been credited with creating an environment that is conducive to smoking cessation.1 In the latter category, changes in drug paraphernalia laws have allowed the implementation of needle exchange programs that, in turn, have been associated with a decrease in HIV transmission among injection drug users.2

Closer to home, in this month’s installment of the Real World of STD Prevention, Cramer and colleagues3 report on data collected through the STD Surveillance Network suggesting a causal link between the enactment of state laws and policies favoring expedited partner therapy (EPT) and actual receipt of EPT by patients diagnosed as having gonorrhea in states where these changes have been implemented versus patients in states where they have not. In line with other structural interventions, the positive effect of these changes was relatively small. However, because of the inherently large coverage of these types of interventions, the ultimate public health impact may be considerable.

A second macrolevel structural intervention in our field is reported by Steiner et al.4 In 2007, the Centers for Disease Control and Prevention National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention introduced the Program Collaboration and Service Integration (PCSI) strategic initiative to strengthen a collaborative engagement addressing prevention needs among populations that are often at risk for 1 or more of these infections simultaneously. Such an integrated, synergetic approach, it is argued, will be more effective and efficient and will also yield higher public health benefits than a continuation of currently segregated and fragmented programs. Steiner et al. describe progress of the PCSI initiative, including efforts to overcome barriers, evaluation of the impact of currently ongoing PCSI demonstration projects, and next steps necessary for the scale-up of this approach.

Program Collaboration and Service Integration clearly relates to another policy concept that has emerged over the past half decade: sexual health—which in a way extends the PCSI concept beyond sexual disease into an area of promotion of healthy sexual behaviors. From that perspective, it is curious that PCSI never explicitly included family planning and contraceptive care under its umbrella. Although this may be understandable from the fact that family planning is not a part of the portfolio of the agency that initiated PCSI, this political reality should not have influenced a large-vision public health policy that is aimed at jurisdictions where this exclusion does not make much sense.

The article by Shlay et al.5 therefore fills a void because it demonstrates that family planning services can be integrated into a busy sexually transmitted infections (STIs) and HIV testing clinic and serve people that are simultaneously at risk for STI, HIV, and unplanned pregnancies. Moreover, this study shows that STI clinic staff can be trained in the provision of the most current forms of contraception, including the placements of intrauterine devices. Because STI clinics are one of the few areas of care where at-risk men present, the STI clinic is an important venue to engage men in family planning. The article by Shlay et al. thus illustrates how PCSI can be locally operationalized as a structural intervention at the microlevel. The article offers yet another example of a microlevel structural intervention: a prompt programmed into the clinic’s electronic medical record resulted in a significant increase in the offering and uptake of family planning services for both men and women. A similar prompting mechanism was previously shown to increase the uptake of EPT in the same clinic.6

Finally, the article by Fenton and Steiner7 brings the 2 latter articles together in an editorial that concludes that PCSI “has great potential to serve as a foundational approach that complements and enhances disease-specific programs and services”—and may thus fundamentally change the Real World of STD Prevention.

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1. Grucza RA, Plunk AD, Hipp PR, et al. Long-term effects of laws governing youth access to tobacco. Am J Public Health 2013.
2. Vlahov D, Junge B. The role of needle exchange programs in HIV prevention. Public Health Rep 1998; 113 (suppl 1): 75–80.
3. Cramer R, Leichliter J, Stenger M, et al. and the SSUN Working Group. The legal aspects of expedited partner therapy practice: Do state laws and policies really matter? Sex Transm Dis 2013. This issue.
4. Steiner R, Aquino G, Fenton K. Enhancing HIV/AIDS, viral hepatitis, STD and TB prevention in the United States through program collaboration and service integration (PCSI): The case for broader implementation. Sex Transm Dis 2013. This issue.
5. Shlay J, Bell D, Maravi M, et al. Integration of family planning services into an STD clinic setting. Sex Transm Dis 2013. This issue.
6. Mickiewicz T, Al-Tayyib A, Thrun M, et al. Implementation and effectiveness of an expedited partner therapy program in an urban clinic. Sex Transm Dis 2012; 39: 923–929.
7. Fenton J, Steiner R. Making program collaboration and service integration the default choice. Sex Transm Dis 2013. This issue.
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