Creating a path forward: understanding the context of sexual health and sexually transmitted infections in American Indian/Alaska Native populations – a review

Abstract

This review assessed sexual health and sexually transmitted infection (STI) burden among American Indian/Alaska Native (AI/AN) peoples within the context of current clinical and public health services. We conducted a review of published literature about sexual health and bacterial STIs among AI/AN populations in the United States using Medline (OVID), CINAHL (EbscoHost) and Scopus. Peer-reviewed journals published during 1 January 2005-2 December 2021 were included and supplemented by other publicly available literature. A total of 138 articles from reference lists met inclusion criteria, including 85 peer-review articles and 53 additional references. Results indicate a disproportionate burden of STIs is carried by AI/AN populations compared to non-Hispanic Whites. Risk for STIs in AI/AN people has origins in historical trauma and structural and social determinants of health. STI services are available for AI/AN populations, but many barriers to care exist. Community-based sexual health programming has been successful, but has thus far focused primarily on adolescents and young adults. A myriad of factors contributes to high rates of STIs among AI/AN populations. Longstanding disparities show a clear need to increase the availability of integrated, low-barrier STI prevention and treatment services. Implementation of multi-level (individual, physician, clinic, healthcare organisation, and/or community level), culturally relevant sexual health and STI interventions should be community-based and person-centred, acknowledge social determinants of health, and grounded in deep respect and understanding of AI/AN histories and cultures.

Integrated response to address a resurgent syphilis epidemic in a rural American Indian community, Whiteriver, Arizona, January 2022 – June 2023

“…1 Significant disparities in syphilis between AI/AN communities and the general public exist and are a manifestation of a complex interplay of poverty, lack of access to healthcare, lower levels of education, and the aftereffects of colonization, like historical trauma. 3 We believe that the integrated nature of public health and clinical care at the WRSU enhances and expedites the diagnosis of communicable diseases like syphilis. However, we do not believe that the disparity reflected in the high rates observed is simply explained by increased case ascertainment.…”

“…The WRSU recorded an annualized IR of 1000 T. pallidum infections per 100,000 persons from January 2022 to June 2023, a rate that is over 18 times higher than the rate in the US general population (53.2 per 100,000) 1 . Significant disparities in syphilis between AI/AN communities and the general public exist and are a manifestation of a complex interplay of poverty, lack of access to healthcare, lower levels of education, and the aftereffects of colonization, like historical trauma 3 …”

“…2 Historically, American Indian/ Alaska Native (AI/AN) populations experienced higher syphilis rates than their non-Hispanic White counterparts. 3 Currently, AI/ AN populations have both the highest and fastest growing rates of primary/secondary and congenital syphilis with rate increases of >300% and >700%, respectively, since 2017. 1 Syphilis screening guidelines primarily focus on priority populations (e.g., men who have sex with men and pregnant women) 4 but mention that clinicians should consider "other factors associated with increased prevalence rates" including "geography [and] race/ethnicity."…”

“…Rates of syphilis, the infection caused by Treponema pallidum , have increased exponentially in recent years across the United States 1 and represent the most recent declaration of the worst syphilis epidemic in the past 50 years 2 . Historically, American Indian/Alaska Native (AI/AN) populations experienced higher syphilis rates than their non-Hispanic White counterparts 3 . Currently, AI/AN populations have both the highest and fastest growing rates of primary/secondary and congenital syphilis with rate increases of >300% and >700%, respectively, since 2017 1…”

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

“…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.…”