Gregg Masters 00:07
This is PopHealth Week on HealthcareNOW Radio. I’m Gregg Masters Managing Director of Health Innovation Media and the executive producer and co-host of the show. Joining me in the virtual studio is co founder and principal co-host Fred Goldstein, president of Accountable Health, LLC. PopHealthWeek engages industry leadership and stakeholder voices spanning payer-provider, patient, vendor and regulatory communities in population health best practices and strategies connect with us via www.popupstudio.productions or follow and direct message me on Twitter at @GreggMastersMPH and that’s Gregg with two G’s. On today’s episode, our guest is Leandro Mena, MD, MPH, the Director of the Division of sexually transmitted diseases prevention in the CDC National Center for HIV AIDS, Viral Hepatitis, STD, and TB prevention, where he manages the implementation and evaluation of CDC supported sexually transmitted infections prevention programs in the United States. Dr. Mena is the Founding Chair of the Department of Population Health Sciences at the University of Mississippi Medical Center, John D. Bower School of Population Health. He currently serves as professor of population health science and professor of medicine in the Division of infectious diseases and directs the Center for HIV AIDS research education and policy at the Myrlie Evers-Williams Institute for Elimination of Health Disparities. And with that introduction, Fred, over to you.
Fred Goldstein 01:48
Thanks so much, Gregg and Leandro. Welcome back to PopHealth Week.
Leandro Mena 01:50
Thank you glad I’m so honored to be here.
Fred Goldstein 01:54
Yeah, it’s fantastic to get you back on. There’s been a little bit of a change in your career since the last time we spoke. I think it’s just over a year now, you’ve been at the CDC. So you could you give us some information on what what you’re doing there at the CDC?
Leandro Mena 02:07
Yes, absolutely. I mean, as you said, in August, you know, last year, I joined the division of STD prevention at CDC. So now I direct you know, the division a division is a within the Center for HIV, Viral Hepatitis, STD and tuberculosis prevention at CDC.
Fred Goldstein 02:33
And your group as the director of that group oversees the sexually transmitted infections area.
Leandro Mena 02:39
Yes, that is correct.
Fred Goldstein 02:40
So what does that encompass?
Leandro Mena 02:41
Well, you know, CDC plays an important role in combating, you know, in a STIs in the United States, you know, and the work of the division includes, you know, assisting health departments, healthcare providers, and other work and others, working to address STD prevention time with timely science-based information and guidelines on the testing and treatment of these infections. You know, for instance, you know, we have our STI treatment guidelines, you know, a documents, a and a companion piece called recommendations for providing quality STD clinical services, that highlights the services, healthcare settings can offer to provide to provide the highest quality STD care for their patients. I have to mention that the STI treatment guidelines are probably one of the most, if not the most downloaded document at the CDC website. You know, we also provide significant funding to state and local health department’s on STD programs, as well as national STD and public health organizations. I mean, roughly 85% of the division funds go to programs and grants.
Fred Goldstein 03:48
Wow. And so when I think about it, I know that in some of the statistics, we continue to see an increase in, in STDs in the areas you’re working. And it looks like it’s 1.6 million cases of chlamydia, which actually has dropped since 2017. But the others, for example, with gonorrhea, are up 25% Since 2017, and syphilis up 68%. So we’re continuing to see these increases, I guess, and you’re working to try to reduce that. So what are some of the things that are you’re doing in the communities or with the clinics to try to help with that?
Leandro Mena 04:23
Well, Fred, you know, I have to tell you, we actually released last week, our 2021 preliminary surveillance report, and, and a STI is, you know, continue to increase again in 2021. You know, some of the decreases, we saw chlamydia primarily, you know, as we suspect that were probably caused because of the impact of impact of COVID-19. You know, we are seeing, you know, when it comes to primary secondary syphilis, we saw the biggest year-to-year increase, you know, 26% increase between 2020, 2021 This is the largest number of cases that we have seen, you know, while you’re sitting in 73 years, since 1948, we have not seen, you know, this such a high number of cases of primary and secondary syphilis in the US. And even more dramatic has been the increase that we have in congenital syphilis oh, about 24% between 2020 and 21. You know, a case of congenital syphilis has three have tripled since 2017, in the past five years. And it’s important because congenital syphilis is the one condition, you know, the one STI, that is associated with significant mortality, about 7% of congenital syphilis cases, might end up in the infant or a mortality.
Fred Goldstein 05:47
And so when you talk about congenital syphilis, you’re talking about children who are infected at birth, or pre-birth in
Leandro Mena 05:54
children who are infected in uterus, you know, or at birth. Yes.
Fred Goldstein 05:57
Wow. And 7% of those are associated with death
Leandro Mena 06:01
by stillbirth? Yes.
Fred Goldstein 06:03
And how did COVID impact the work of the CDC? I know, they put a lot of effort focusing obviously, on COVID itself, were some of those resources moved from the STI groups to focus on that, and how did that impact potentially monitoring and prevention,
Leandro Mena 06:20
you know, a COVID impact, honestly, has really been interesting, right? in one side increased, you know, awareness of something that we have long known about STIs, which is the long-standing and ingrained social, economical factors that need to be addressed; so everyone can achieve optimal health, you know, a, but the COVID 19 pandemic it strained an already crumbling public health infrastructure, you know, we had, you know, a because of decreased public health funding, over almost two decades of insufficient funding, health departments experience reductions in screening, treatment, prevention, and partner services. A, all contributing to increasing STIs in a way before the pandemic. But because of the pandemic, during the pandemic, we saw also significant reductions in personal in personal health care services, resulting in less frequent STD screening, we saw diversion of public health staff to respond to the COVID pandemic, and some of the staff was actually permanently assigned, you know, to COVID-19. So we really have not seen restoration of that. A, and then there were the lapses, you know, the people having health insurance coverage, you know, though, because due to unemployment, you know, we were lucky enough to as part of the American rescue plan, you know, a CDC, you know, received $1 billion, you know, to help support and rebuild some of that this isn’t original specialist infrastructure capacity. But then those funds came again, a little bit, you know, late and, and, and a still, you know, a, and although still, you know, are being used, right, to try to rebuild, you know, a, the infrastructure that really was, you know, very weak, you know, at the time of the COVID pandemic started.
Fred Goldstein 08:17
I also wonder Leandro, and you’ve done a lot of work in HIV and focused on programs to help prevention and people better monitor their health and things like that, with some of this increase, potentially due to the messaging around COVID was so loud and out there, which it needed to be that maybe there was a turning away from individuals themselves focusing on STIs and things like that, or thinking about them as much as they would have. Because of that,
Leandro Mena 08:49
you know, Fred you know, as you know, most of these issues are really multifactorial. And when we think about what’s driving the STI increases, I mean, there is no doubt that is a multi-level factors, you know, in addition to the socio-economic conditions, you know, that make people more difficult to enforce domain for more population more difficult to stay healthy, you know, as you know, poverty stigma, lack of medical insurance provider, unstable housing, history, you know, a high burden of STIs in some of these communities. You know, we also a recognize that, as I mentioned, the reduction services that I mentioned, but we also see the increase, you know, in substance use, which has been linked to less safe sexual practices. We are more than a decade into the national opioid crisis that is putting more people at risk of HIV, viral hepatitis, and STIs. I think about the methamphetamine epidemic. We have also seen decrease in condom decrease condom use among youth and among some group of gay and bisexual men. So it’s important we really must ensure that provider a provider provision partners are equipping those who no longer using condoms for HIV prevention With the tools and information that they need to protect themselves against other STIs but also, we see the stigma around STI, right? You know, STI is continued to be stigmatized and a stigma can really be a powerful, you know, a deterrent, right from a that keeps people from accessing the care. Right, you know, that they need both, you know, treatment, and treatment and testing and treatment services. You know, as, as I mentioned, you know, the COVID pandemic has really compounded, you know, many of these challenges, and exacerbated the pre-existing disparities rising healthcare, and prevention access, and further straining again our public health infrastructure.
Fred Goldstein 10:45
Yeah, it’s it was fascinating when I was looking at this state of STDs report that you released in 2021. And you talked about the racial-ethnic minority groups. In the and, we, you know, we see that negative impact across it COVID highlighted it like crazy, obviously, with STIs, we see it as well. But what really stood out to me was young people aged 15 to 24, are a group that is much more affected, and sometimes we don’t think about the younger population around health care. So can you comment some on that? And some of the areas, maybe we can help work with that?
Leandro Mena 11:17
Yeah, absolutely. You know, the US epidemic, STI epidemic they’ve got tremendous, you know, big disparities, right, you know, they are, you know, in geography, you know, people don’t think about geography, a United States has over 3,000 counties, right. 3% of US counties are responsible of 50% of all gonorrhea, 50% of all chlamydia, 50% of all, primary, secondary syphilis. And we know that 48 counties right represent 50% of all HIV infection. So we see, despite this when it comes to age, you know, as you mentioned, you know, individuals who are 15 to 24 years old, represent 50% of all overall sexually transmitted infections. Racial ethnic minorities, and African Americans represent about 38% of all, you know, primary, secondary Syphilis and Gonorrhea. In many ways, it may represent you know almost 50%, of all primary secondary syphilis, you know, when they are only 2% of the US population. So you think about these populations. Right. And I talked earlier about it, I mentioned earlier about the social and economical circumstances, right, that, that that that weighed so heavily into the chance into the into what the term is the risk of exposure, right? And access, you know, to appropriate care, then you have to start thinking about, how can we distribute resources? In those geographic areas, right, or they are most needed? You know, and then within those geographic areas? Who are the population? What, which one are the populations, right? That most disproportional impacted, and work with those populations to develop, tailored interventions that are specifically responsive to the needs of those populations. And I’m saying that, for example, the way you address a syphilis outbreak in Arizona, in Navajo Nation is not how you’re gonna address a syphilis outbreak in Jackson, Mississippi, right? You know, it’s so so that I think that’s the kind of tailor approaches that we need.
Fred Goldstein 13:33
Yeah, and something you’ve been talking about for years, and we’ve talked about on the show, etc. It’s this whole idea of culturally appropriate approaches to the community. And, and I know that you actually, you know, look at this from an implementation and evaluation perspective, as part of this evaluating how these programs work. What are you seeing as some of the best practices out there? Where you that that address some of these issues you’ve raised?
Leandro Mena 13:58
Ah, well, you know, I think that they are number of things, you know, that we can do. I think, you know, first of all, you know, and I can tell you, it starts right with us. You know, we recognize that we cannot do this alone. And we believe, you know, that we have to work, increasing accountability, you know, and responsibility to responding to STIs you know, CDC, STD programs cannot really take care, respond, be the only ones responding to the essential health needs of the nation. If we’re going to turn this epidemic around, it requires increasing ownership of the program. You know, there is a lot of work, right, that needs to be done and to address this epidemic, and it will, it’s going to take a larger group, you know, within that engaging local healthcare systems, you know, clinics, community-based organizations, they’re uniquely situated to respond to emerging STIs. And these groups can really play a critical role in promoting, you know, STD prevention at the local level, you know, and empowering individuals to prioritize their sexual health. You know, we need also help multi sectorial you know, solutions, healthcare, healthcare, you know, private sector players, you know, have a role in developing in delivering new STI testing and treatment innovation that are desperately needed. And then, you know, I think health care providers, you know, can really play an important and pivotal role in reducing stigma, by integrating STI prevention and sexual health into a routine practice and creating a welcoming environment to all people. The other thing is that we really have to work, you know, into adopting as endemic approach, you know, that takes, you know, in consideration, all these co-current, you know, ay, ay, ay infections with current conditions that contribute to people’s exposure to risk, you know, and we have seen, you know, a lot of this happening, you know, in many places in the country, where programs are really being creative, you know, embracing, you know, categorical funding, right, you know, to focus around the needs of the individual, and meeting people, meeting people where they are, where they are, right, there are excellent examples, for example, in Chicago, or Baltimore, basically, where they’re working with a injection drug user communities, right, and using mobile vans to bring, you know, this package, you know, of screenings, you know, that includes, you know, provide clinical services, that includes includes viral hepatitis, you know, STI and HIV services are together.
Fred Goldstein 16:33
And so, this really is oyu know one of the key areas to look at integration of all services, and you talk some about practices. So what should clinicians and practices try to do? Or where can they get some assistance to try and bring in some of these tools?
Leandro Mena 16:50
Ah, you know, I think, you know, first of all, I think, when it comes to, you know, sexual health, you know, which is, again, a, I think, in many ways, the port of entry, you know, to a lot of these, a, really an excellent tool, you know, for a clinician to build a relationship with their patients, you know, clinicians need to start to routinize, you know, sexual history in their routine clinical encounters, patient is going to decrease the stigma is going to allow them to, to get to know their patients in a different level, I always say, you know, a, I used to say, when I train, right, we give, you know, we don’t give enough credit, right to the lives that our patients lead, you know, a, and, and, and that’s the starting point, I mean, the second thing is that, A, we have to take care of the individual, when we see them and meet them where they are, you know, many of these, you know, populations, right, have all these overlapping needs. And I understand that health care is not going to take care of poverty is not gonna take care of food insecurity, will not take care of location. But as a health care provider who takes care, if you work in a place where you take care of populations who may have these needs, it’s important to be aware of who are the service providers in your community, right, that are going to address the needs of your patients, and somehow establish a relationship with them in the same way that you can send patients to them, you know, they will refer, you know, clients to you, right, you know, so so you can work collaboratively, you know, with those organizations to improve, you know, the, the overall well being of your patients that we know will be connected to improving, you know, the health outcomes of your patients.
Gregg Masters 18:36
And if you’re just tuning in, you’re listening to PopHealth Week on HealthcareNOW Radio, our guest is Dr. Leandro Mena, the Director of the CDC’s division of sexually transmitted diseases prevention.
Fred Goldstein 18:49
So integrating their practices with those community resources. And it was it’s fascinating, you talk about the fact that they would refer back in which I think is a great point. Because if they’re comfortable with what you’re doing and understand what you’re doing, they’re gonna help to identify people who could utilize those resources you have and send them back to your practice, which is not really an area I’ve thought too much about, but an interesting approach, where do you see over the next couple of years as funding is picked up? And hopefully continues to pick up? You going with some of this work?
Leandro Mena 19:22
You know, you’re very optimistic when it comes to the funding, picking up, you know, but I can tell you the things that are really committed, you know, I’m really committed to improving you know, as I talked about expanding accountability, but the other important area is we have to increase access to sexual health services. You know, I think that a, I would love to see in the next 18 to 24 months, how screening for STIs right, gets out of the clinical setting, I mean, even tests that we currently have for self-collected patients in clinical setting should be done outside of a clinical setting. So people can do it from the comfort of their home, you know, from or from a their neighbor’s home or from a pharmacy, right? I think that will be in many ways equivalent, you know, to the to, to intensive expansion of access to gonorrhea, chlamydia screening to what we had 20 years ago, when nucleic acid amplification was adopted. I foresee one day where screening for STIs is as simple as inexpensive as going to a pharmacy and getting a pregnancy test. I think that in order to be able to do that right, we need to also invest in innovation and discovery, you know, we need to have better, you know, methods to diagnose diseases, you know, like syphilis, right, that we still having to rely on serologic testing that requires, you know, interpretation, requires very often sometimes, you know, expert interpretation and access to, to serologic history that sometimes is only available in the health department. We need, you know, a better oral treatments, you know, for some of our infections, like gonorrhea or syphilis, for which we only have really one injectable alternative. And then finally, I think we need vaccines. Right. That will be the Holy Grail. I mean, we have some good news in recent years, about the Meningococcal vaccine, the outer membrane vaccine, you know, a, a being 40% affecting retrospective studies reducing incident of gonococcal infection. So I think that that, that it will be fantastic, right, you know, if we could have the investment and develop, you know, and see the developing of vaccines that will prevent, you know, gonorrhea, chlamydia, herpes, you know, or treat herpes, and syphilis.
Fred Goldstein 21:55
Wow, so you really talked about, and we’ve seen some of this rapid change, obviously, with COVID. And it sounds like a couple of things are sort of related to that perhaps in-home testing you mentioned. And you see something like that for STIs. And STDs, as well as technology. Do you think some of the move to telehealth might help with some of that access issue? If we can set those up, perhaps just a telehealth for STDs or something like that?
Leandro Mena 22:22
Yeah, absolutely. I think that, you know, a telehealth, you know and home collection, or self-testing, combined can really close important gaps, you know, when it comes to access to care, think about how many people living in rural areas, for example, in part, because of the stigma around STIs, you know, even when you may have a provider there, you know, the local provide that may not be the place that they’re comfortable going, you know, I work, you know, as you know, as medical director of an STD clinic, you know, for almost 20 years in Mississippi, and a good proportion of my patients had a primary care provider, right? You know, and when I asked that, well, why don’t you go to your primary care provider, so he can take care of the things as well? I’m not comfortable, you know, going to them, you know, talking to them about these things. So people, you know, I think there is a place and there will always be a place for specialized STD care. Because people look for that, because of the expertise people will come, you know, because of the confidentiality, right, you know, the people also come because of the convenience in terms of working, you know, and low costs, and telehealth can really, you know, become one more tool to increase access, right? To do all that.
Fred Goldstein 23:38
Yeah, when you think about some of the issues, I remember, you know, even from a mental health perspective, you know, people didn’t want to park out in front, you know, somebody might see their car there. And so you have the same issues with the stigma around STDs, etc. So obviously, having a place where you can feel safe and confidential. And expertise, obviously, is another critical area. How has it been for you in your transition from the university setting in the clinic in Jackson, to working at the CDC?
Leandro Mena 24:06
You know, it’s been interesting, Fred, it’s, it’s a very different environment, a totally, totally different environment. And to be honest with you, I’ve been here for one year, and I still feel that I’m learning, you know, to identify which tools you know, I have available, you know, to be effective and how to once you know and how to use those tools. So, so, I think, you know, I have a long way, you know, a, I’m trying to do the best, you know, I can, I’m lucky to be here working with such an amazing group of smart, very committed people, you know, who really see it their goal, you know, every day, you know, their goal is to improve the sexual health of American citizens, American people.
Fred Goldstein 24:54
Yeah, that’s fantastic. And just one final thought in closing, you mentioned this this need for taking the public health infrastructure and linking that with the private health care system? We’ve seen how that sort of potentially started with COVID. Do you see that continuing on? I mean, that’s obviously a key piece of this. And are you hearing more discussions about that?
Leandro Mena 25:16
You know, I think we have to. I mean it’s certainly I mean, in my division. That’s our goal, right? We one of the priorities that we have is really expanding partnerships, you know, not only again, with the private sector, but even we think the federal government, right, we talk about, you know, how housing has such an influence, right in health outcomes, HIV outcomes, STD outcomes, so we have to work with our partners, you know, in HUD, you know, to see how we can, you know, leverage, you know, and integrate, you know, and work together to improve a housing in some of these very vulnerable populations with a goal, overall goal to improve to improve health. So engaging the private sector, engaging the larger healthcare system is going to be important to really improve, you know, public health and population health.
Fred Goldstein 26:11
Oh, that’s a fantastic way to end up this show. Leandro, I want to thank you so much for coming on, and discussing this issue. And I’d love to get you back on again, as you get your feet more settled. And to learn more about the work you guys are doing.
Leandro Mena 26:24
Happy to Fred, thank you so much for having me. It’s been a joy.
Fred Goldstein 26:28
It’s our pleasure. And back to you, Gregg,
Gregg Masters 26:30
and that is the last word on today’s broadcast. I want to thank Dr. Leandro, Mena, the Director of the CDC’s Division of sexually transmitted diseases prevention for his time and insights today do follow Dr. Mena’s work on Twitter by @CDSTD and @CDCGOV, respectively, and on the web via www.cdc.gov/STD. And finally, if you’re enjoying our work here at PopHealth Week, please like the show on the podcast platform of your choice. Share with your colleagues and do consider subscribing to keep up with new episodes as they’re posted. We stream live on HealthcareNOW Radio weekdays at 5:30 am 1:30 pm and 9:30 pm Eastern, and for you left coasters 2:30 am 10:30 am, and 6:30 pm Pacific for PopHealth Week my co-host Fred Goldstein. This is Gregg Masters saying please stay safe everyone. Bye now.