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Melanie A. Thompson, MD

This is useful information about how youths understand the risks of oral STIs, how they weigh these risks in making sexual choices, and what might help them use protection. But while the authors focus on encouraging youth to use protection during oral sex, we would probably have more impact by focusing on decreasing overall youth (and adult) STI incidence and improving STI services.

A major focus should be on implementing the STI National Strategic Plan 2021-2025. This plan highlights the high STI vulnerability of adolescents, particularly Black, Hispanic and Asian Islander/Asian Pacific populations (all underrepresented in this study) and emphasizes a health equity approach that is sexual health positive. The paper did not include analysis of gender identity or sexual orientation, but high STI rates in gay and bisexual men and gender-diverse individuals require a non-stigmatizing approach to STI education and services. Stigma perpetuates STIs.

We must ensure convenient, free and nonjudgmental access to screening and treatment for all STIs, HPV vaccinations and HIV pre-exposure prophylaxis if needed. Home testing, point-of-care testing, school health services and mobile outreach should be expanded. We have done an abysmal job of providing routine chlamydia screening to girls but also of vaccinating our youth against HPV, with 39% receiving two doses and 61% just one dose, while neighboring Canada boasts an 83% rate for two doses. The impact of HPV vaccination far exceeds that of condoms and dental dams — even if we could increase their use. Youths actually want these vaccinations when educated about their benefit, even if some parents have reservations.

Ideally, STI services occur in an integrated one-stop health care shop, but many youths (and adults) lack health insurance or primary care providers, particularly in Medicaid non-expansion states. Additionally, health care providers need training — bolstered by incentives and state-level requirements for training — to assist and encourage them to offer evidence-based, stigma-free sexual health prevention and treatment services to all populations.

The longstanding underfunding of public health systems and our dwindling workforce, worsened by COVID-19, also drastically undercut access to STI services. Cost was noted as a barrier by 15% of this cohort but is likely much higher among minority populations not robustly represented in this sample. We simply will not end the STI epidemic without STI screening, care and treatment without cost to the recipient.

Teacher education and curriculum development for evidence-based, stigma-free, comprehensive sexual health education must be addressed at federal and state levels, but also by local school boards where direct advocacy can be highly impactful — for better or for worse. Direct-to-youth availability of high-quality online and social media sources should also be a priority and could be instituted at the federal level. (Perhaps a Tik-Tok sexual health channel?) Easy access to parental education materials is also important, including nonjudgmental training on how to talk about the taboo subjects of sexual health and sexuality.

Finally, as the authors note, we need better STI prevention methods, requiring more federal, state and private funding for research on STI vaccines, antimicrobial prophylaxis, and novel delivery methods. Youths cannot do this alone, and condoms and dental dams just are not good enough — even for the small numbers of youth who will actually use them.


Bruni L, et al. Prev Med. 2021;doi:10.1016/j.ypmed.2020.106399.

STI strategic plan. Accessed Feb. 14, 2022.

Melanie A. Thompson, MD

Member, Infectious Disease News Editorial Board
HIV physician, researcher and policy advocate in Atlanta Past chair, HIV Medicine Association
Co-chair, HIV Medicine Association/Infectious Diseases Society of America HIV Primary Care Guidance

Disclosures: Thompson reports no relevant financial disclosures.

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