How should we deliver sexual health services in the 2020s?

This Special Issue of Sexual Health compiles the latest evidence regarding how we can optimise sexual health services in the 2020s. Despite multiple attempts to control sexually transmitted infections (STI), globally, there are still an estimated one million newly diagnosed bacterial STI each day,¹ leading to significant health, social and economic impact. If we are to reverse the course of rising trends of STIs, we must consider the broader perspective and innovate. A fundamental shift in approach is needed.

The COVID-19 pandemic has forced rapid adaptations in the delivery of health services globally – particularly in accelerating the implementation of decentralised services, patient self-care and digital health interventions. This offers us the opportunity to reconsider how sexual health service delivery should look in the 2020s; what types of services should we continue to invest in, and are there alternate models that should be explored further? Undergirding this adaptation to the new normal, one principle must remain forefront – access to comprehensive, high-quality, and appropriately targeted sexual health services is still one of the cornerstones of controlling STIs. Fairley and colleagues’ review provides an overview of the effectiveness of strategies to control STIs and concludes that accessible health care is the most powerful tool to control STIs and therefore should form part of all comprehensive STI control programs.²

We acknowledge that neither specialist sexual health services nor speciality pathways for workforce development are universally available. Further, in countries where specialist sexual health services exist, they may face threats of being defunded as governments push to decentralise sexual health services to primary care and non-clinical settings. Ramchadi and colleagues’ review stresses the importance of sexual health services to provide care for priority populations and people who are uninsured, demonstrating that they remain the preferred service for STI care.³ In this increasingly resource-constrained environment, Medland et al.⁴ present a strong case for the need for sexual health services in physical locations which concentrates funding, infrastructure and expertise. These centres can also provide support to other clinical services such as general practitioners, who contribute to the provision of accessible clinical services. The authors argue that sexual health care needs are rising both in volume and complexity, not all of which can be adequately met through streamlined, decentralised, off-site care. Similarly, Woodward and colleagues’⁵ retrospective audit in a community health setting in Australia explored how a physically co-located endocrine clinic (with a focus on trans and gender diverse services) with a sexual health service facilitated synergies in providing gender-affirming care and STI testing.

If we are to advocate for specialist sexual health services, what else can we do to improve their efficiency and convince funders for ongoing investment?

Tailoring sexual health services for the right subpopulations with the right interventions is key to using our finite resources more efficiently. Traeger and Stoové⁶ address the issue of identifying groups most at risk for STIs to prioritise resources. The authors challenge us to rethink how we define risk as determined by demographics and sexual behaviours, demonstrating how challenging this can be because of the ongoing stigma associated with STIs, undisclosed risk behaviour, and diversification of STI epidemics beyond traditional risk groups characterised by demographics and sexual behaviours.

Once we identify key populations, how do we increase their chance of attending sexual health services? Clarke and colleagues’⁷ systematic review describes the effectiveness of 13 interventions to increase attendance at pre-booked sexual health clinic appointments. They report that the most common strategies used were information about health consequences, the use of prompts/cues, and information provided by a credible source. However, these strategies were present in both effective and ineffective interventions, highlighting the need for further research to understand why these strategies work or do not work in different contexts. Tan and colleagues’⁸ review gather evidence for participatory (bottoms–up) approaches to developing and implementing sexual health services. The authors discuss how community participation in clinical STI services has been operationalised and the various aspects of clinical STI services in which participatory processes have been implemented. These data have implications for enhancing community participation within clinical STI services, a neglected topic. Kularadhan et al.’s key informant interviews of sexual health service providers in Australia outline the strategies to improve testing among priority populations and future strategies to improve service delivery.⁹ The authors document how Australian services have expanded traditional service models and implemented new approaches to optimise service delivery.

Attendance at sexual health services provides a gateway to offer primary prevention services (to optimise sexual health) and secondary prevention services (to prevent reinfections). Jayes et al.¹⁰ present the strengths and weaknesses of delivering primary prevention interventions in sexual health services. This includes education and awareness building, condom promotion, and the provision of vaccines (human papillomavirus and hepatitis A and B). Golden et al.¹¹ argue for the need to modernise the partner notification (PN) system if we are to create meaningful change. The authors provide a valuable summary of the evidence for various approaches to PN in high-income countries, provide key principles for best practice and list priority research questions. Specifically, they show that we have failed to consistently bring innovations to scale (e.g. expedited partner therapy), define the value of new technologies in promoting PN, and modify PN to capitalise on opportunities to achieve broader public health objectives (e.g. promotion of HIV pre-exposure prophylaxis).

Mycoplasma genitalium complex management remains a unique challenge for sexual health services globally. Sweeney and colleagues’¹² review provides a synthesis of the latest evidence on the emergence of antimicrobial resistance and its practical implications on clinical management. They underscore the need for resistance-guided treatment to prevent misuse of antimicrobials. This issue highlights the broader challenges for antibiotic stewardship, related to use of empiric therapy and high frequency of STI testing.

We must be constantly alert to opportunities to provide better services to our clients. The use of digital technologies to enhance the client’s experience of sexual health services is an ever-developing, fascinating space. Whilst we must be wary of leaving people behind due to the digital divide (i.e. lack of meaningful access to digital technology), it is exciting to ponder how digital technologies could facilitate a fundamental shift in our approach to STI control and modernise our services to reach the right people in a faster, more accessible way.

Tucker and colleagues’¹³ timely review of digital STI and HIV services uses the prevention and care continuum as a framework to demonstrate how digital services can be interwoven into existing clinical pathways or be standalone. Gibbs and colleagues’¹⁴ review describe the opportunities and challenges at the individual, service and population level of measuring and evaluating sexual health using existing digital technologies. Importantly, they provide helpful recommendations informed by a social justice lens to ensure digital health benefits all. Sha and colleagues’¹⁵ trial in China offers an example of how social network-based strategies can promote the uptake of HIV/syphilis self-testing kits among men who have sex with men.

A special mention must be made for the ongoing challenges of Indigenous populations who still carry a disproportionate STI burden compared to non-Indigenous people. Sexual health service delivery to Indigenous populations is unique where traditional barriers (including those related to structural and social determinants of health) to accessing sexual health services are compounded by additional barriers such as historical trauma. Leston and colleagues’¹⁶ review presents a case study of American Indian/Alaska Native populations in the US, where the authors describe their sexual health behaviours and review associated STI epidemiology, clinical services, and public health interventions for these populations. The authors provide a valuable list of resources and publications and examples of sexual health services (albeit inadequate) to provide culturally relevant sexual health and STI interventions. Similarly, Sianturi and colleagues’¹⁷ qualitative study of indigenous Papuans in Indonesia offers critical insights into improving their HIV programs in a setting where HIV prevalence is 24 times higher than in other islands in Indonesia. The authors highlighted missing elements in current HIV programs – sensitivity towards culture-religion concepts, dealing with modernisation-integrated HIV programs and stigma reduction.

We hope our readers enjoy the compendium of papers in this Special Issue that are thought-provoking and provide practical, evidence-based, and actionable insights to optimise sexual health services in the 2020s.

Jason J. Ong is the Special issues Editor for Sexual Health and Christopher K. Fairley is the Editor-in-Chief of Sexual Health, both were blinded from the peer review process for this paper. All other authors declare no conflicts of interest.