Gynecologist testing vaginal swab for STD
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Dr Zisis Kozlakidis and Sandra Nanyonga discuss public health strategies, then and now, with a focus on the prevalence of STDs

Many public health strategies in the past decades successfully responded to growing infectious disease outbreaks, such as viral hepatitis (HCV), human immunodeficiency virus (HIV) and sexually transmitted diseases (STDs), with the aim of immediate containment. The subsequent stage has been the provision of effective clinical treatment pathways, in the case of HIV with triple antiretroviral combination therapy (introduced widely in the 2000s), and in the case of HCV with direct-acting antivirals (introduced widely in the 2010s). However, these approaches were often considering the disease in isolation, and/or only for a narrow window of time, relevant to the course of the clinical treatment provision.

The public health strategies of the future would need to incorporate the existing knowledge, as well as take complexity into account. For example, in the case of STDs, they may result in severe, long-term, and costly complications, including facilitation of tubal infertility, adverse outcomes of pregnancy, and cervical and other types of anogenital cancer. Here we consider some of these complexities and how public health strategies are adapting to take them into account.

Moving from acute treatment towards population health & wellness

The U.S. Institute of Medicine characterised STDs as the “hidden epidemic” because their scope and consequences are under-recognized by the public and health care systems.(1) In more recent years, there have been concerted efforts to better delineate the long-term scope and consequences of STDs, as well as to establish the burden they pose to public health both directly and indirectly. Thus, the emerging population health strategies describe a shift in our healthcare systems: from a model of acute care targeted at the individual patient to a model that focuses on the health and overall wellness of the broader population it serves.

The U.S. Institute of Medicine characterised STDs as the “hidden epidemic”

However, further complexity requires to be incorporated in shifting towards the latter model. This includes, for example, the integration of information from a range of clinical care providers into single access points (i.e., access to the same electronic healthcare records across primary to tertiary care), as well as a wider focus on health promotion and chronic disease prevention, which can complement existing clinical care and eventually ease the pressures on acute care, through the comprehensive and overall improvement of population health.

New public strategies are attempting a dual approach

Therefore, the new strategies are attempting a dual approach – maintain a high level of acute care provision, while identifying areas where lasting improvements for population health and wellness can be achieved.

This public health strategy adaptation is necessary, as healthcare systems across the world face persistent and multiple pressures. These include the rise of the overall burden of illness attributable to major chronic diseases such as different cancer types; entrenched inequalities in social care and healthcare provision, e.g., between high-income and resource-restricted settings; as well as increasing costs of delivery for cutting-edge healthcare treatments, e.g., chimeric antigen receptor (CAR) T-cell therapy.

For example, one such area of improvement was highlighted in 2012 by the US Institute of Medicine (IOM)(2) and others subsequently,(3) being the greatest collaboration and eventual integration between primary care and public health provisions, as management of chronic communicable diseases, e.g., HIV and HSC, as well as non-communicable diseases and cancer prevention fall within the scope of both, yet these sectors function independently of each other, due to a number of legacy and systemic reasons. In Europe, a similar path

was advocated as part of the ‘Health 2020 European Policy Framework’, with several countries implementing collaborative models of healthcare and strengthening collaborative capacity in clinical settings. (4)

The social determinants of health

While the integration of services already poses a herculean task of systemic integration and operations, the public health strategies of the future would need to further adapt and tackle the complexities that influence overall health, if they are to remain successful. These complexities are collectively called the ‘social determinants of health’.

The World Health Organization’s Commission on the Social Determinants of Health (SDH) has defined SDH as “the conditions in which people are born, grow, live, work and age” and “the fundamental drivers of these conditions”.(5) The term “social determinants” is not restricted the health-related behaviours (e.g., individual exercising or consumption of healthy foods) but includes socioeconomic factors as the fundamental causes of a wide range of health outcomes.

For example, in the case of STDs, people of lower socio-economic status are often less likely to adhere to HIV treatments than those of higher socio-economic status. This lack of adherence may be independent of the level of acute healthcare provision and be caused by difficulties in maintaining medical appointments (due to lack of transportation and inflexible work schedules) and an inability to pay for prescriptions. However, the impact to the individual would be of an incomplete treatment resulting in a higher disease burden, and to the healthcare system the impact would be quantified in terms of appointments missed and the cost of a recurring cycle of incomplete treatments.

Public health strategies increasingly promote greater connectivity between the different arms of health and social care

It is hoped that as public health strategies increasingly promote greater connectivity between the different arms of health and social care, this adaptation would have a profound impact on the health demands of the population. However, the challenges on the ground remain significant, requiring the building of more integrated infrastructures able to meet a broader range of health needs, and supported by a matching fiscal and regulatory policy framework. The recent pandemic has sharpened the focus of public health strategies, as it highlighted how different aspects of health and social care require greater connectivity to respond effectively to increasing pressures. The emerging strategies hold much promise in addressing long-standing issues by placing a greater emphasis on prevention and early intervention, and in building systems that are at the same time more resilient, effective, and equitable.

1. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Institute of Medicine. Committee on Prevention and Control of Sexually Transmitted Diseases. Washington, DC: National Academy Pr; 1997:1-432.
2. Primary care and public health: exploring integration to improve population health. Washington, D.C.: National Academies Press; 2012.
3. Shahzad, Mohammad, et al. “A population-based approach to integrated healthcare delivery: a scoping review of clinical care and public health collaboration.” BMC Public Health 19.1 (2019): 1-15.
4. World Health Organization. ‘Health 2020: the European policy for health and well-being’ (2018). Available from:
5. WHO Commission on Social Determinants of Health, and World Health Organization. Closing the gap in a generation: health equity through action on the social determinants of health: Commission on Social Determinants of Health final report. World Health Organization, 2008. Available from:

Where authors are identified as personnel of the International Agency for Research on Cancer/WHO, the authors alone are responsible for the views expressed in this article and they do not necessarily represent the decisions, policy, or views of the International Agency for Research on Cancer/WHO.

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Laboratory Services and Biobank Group
International Agency for Research on Cancer World Health Organization
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Biotechnologist with laboratory industrial experience
Côte d’Azur University, France
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