Sexually Transmitted Infections, Public Health, and Ethics
Abstract and Keywords
Sexually transmitted infection (STI) control is a core function of public health systems. “Control” refers to public health activities, such as surveillance and contact tracing, focused on preventing and treating STIs, including HIV. Control activities can curtail infection, but they also raise two important types of ethical concerns. The first is how to balance respect for individual liberties with maximizing population sexual health. The harm principle is one approach to navigating these trade-offs. The second is the ethical imperative to address disparities in STI disease outcomes, along with underlying disparities in access to STI information, prevention, and treatment. Both types of disparities map onto other cross-cutting issues of social justice, including poverty, gender, sexual orientation, race, and age. A human rights approach highlights inequalities and underlying structural determinants of health, with the goal of interrupting STI transmission and preventing future infection.
(p. 378) Introduction
A core function of public health systems is to prevent and treat sexually transmitted infections (STIs). STIs are infectious diseases transmitted through vaginal, anal, or oral sexual contact. These include bacterial infections such as gonorrhea, syphilis, and chlamydia; viral infections such as hepatitis B, human immunodeficiency virus (HIV), herpes simplex virus, and human papillomavirus (HPV); protozoal infections such as trichomoniasis; and parasites such as pubic lice.1 Globally, more than one million STIs are acquired each day, and in the United States the number of new STI infections has reached an all-time high (WHO, 2016b; CDC, 2017b). In addition to any symptoms of the infections themselves, STIs are associated with higher than average morbidity and mortality, poor reproductive outcomes, increased health care expenditures, and negative economic growth (HHS, 2017). While STIs differ from each other in type and severity of sequelae, treatment, potential for cure, and transmission through other routes (e.g., blood, mother to child), public health activities focused on their prevention and treatment raise similar ethics issues stemming from their sexual transmissibility.2
STI control activities are public health programs, policies, and practices focused on preventing and treating STIs. These practices may concentrate on the virus (e.g., through universal HIV screening as a part of routine health care [Murphy et al., 2015]), or on human “hosts” (e.g., by providing increased access to condoms, or brief counseling interventions focused on behavior change [Kamb, 1998]). STI control may involve interventions at multiple points along the STI-care continuum, including prevention, early identification, linkage to treatment, engagement in care, and the interruption of subsequent transmission. Control activities also may involve multiple actors, including individuals (p. 379) (e.g., contact tracing for HIV), health systems (e.g., confidentiality policies), communities (e.g., outreach and education), and governments (e.g., disease surveillance, outbreak investigation, and mandated reporting laws).
STI control is part of a broader initiative by the World Health Organization (WHO, 2017) and the US Centers for Disease Control and Prevention (CDC, 2015) to improve sexual health and well-being. The WHO (2006) describes sexual health broadly as
a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination, and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.
As applied to STI control, the twin goals of public health are to maximize population sexual health and individual sexual well-being, and to ensure social justice by reducing disparities in STI outcomes (Munthe, 2008).
In STI control, there are two broad areas of ethical concerns. First are the concerns raised by public health practices to control STIs. These practices include surveillance, contact tracing, and public health laws requiring disclosure, consent, and confidentiality. The second are the ethical concerns raised by STI-related health disparities in access to information, prevention, screening and treatment, and STI outcomes. This chapter first focuses on the balance between individual liberties and population health in STI control practices, drawing upon the harm principle. It then turns to issues of social justice related to inequities in STI services and sexual health outcomes, drawing on a human rights framework to highlight current system failures.
Differences between high- and low-income countries—in terms of STI prevalence, sequelae, and social impact—often raise distinct ethical issues. To illustrate ethically relevant differences, we use examples from both the United States and lower-income countries. We consider ethical issues that arise with both adults and adolescents, because some ethics concerns span the age range, such as mandated reporting of STIs to health departments, while other issues are particularly salient with adolescents, such as confidentiality and consent for one’s own services.
STI Control Practices: Balancing Individual Liberty and Population Health
STI control practices span the STI care continuum, and include prevention, early identification, linkage to treatment, engagement in care, and the interruption of subsequent transmission (Murphy et al., 2015). Operating on multiple levels, these practices have the potential to improve the sexual health and well-being of the individual (e.g., through early identification and linkage to care), their current and former sexual partner(s) (p. 380) (e.g., through disruption of HIV transmission with interventions such as pre-exposure prophylaxis, or treatment-as-prevention for HIV); and communities (e.g., through disruption of transmission and a lower community burden of disease). STI control practices also have risks to the individual, however, including the potential loss of confidentiality associated with mandated reporting, the absence of a requirement for individual consent prior to contact tracing, and a provider’s duty to warn partners at risk.
The Harm Principle
The ethics of STI control practices involve a balance between respecting individuals’ liberty to make their own sexual health decisions and protecting communities from the harms of STIs. The political and legal authority for STI control programs is vested in governments. The moral justification for STI control laws and policies can be understood through John Stuart Mill’s work on the harm principle (Diekema, 2008). Mill ( 2011) writes that in a civil society, the only purpose for which power can be rightfully exercised over individuals against their will is to prevent harm to others. The harm principle recognizes not only the moral importance of individual liberties in a just society, but also that individual liberties can be limited to ensure the health and well-being of others. A corollary is that if liberties must be limited, then the least restrictive approach should be sought (Diekema, 2008). The harm principle incorporates both considerations of effectiveness of public health measures and the importance of always choosing the least intrusive means to achieve the desired effect.
Operationalizing the harm principle requires public health data and careful consideration of contexts. Public health agencies should assess the effectiveness of the intervention, the magnitude and probability of harm to individuals, and the degree of restriction on individual liberties.
Mandatory Reporting and Contact Tracing
To satisfy the harm principle, there must be reasonably strong evidence that STI surveillance activities that limit individual liberty will improve the health and well-being of both the individual and the community. Mandatory reporting laws are an example of an STI surveillance activity that satisfies the harm principle. Mandatory reporting laws require health care providers, hospitals, and/or laboratories to report cases of STIs, as well as identifiable information about the patients (e.g., full name, date of birth), to health departments when those STIs are identified. This information allows health departments to identify cases where immediate disease control and prevention activities are needed (CDC, 2017a). The consent of infected individuals is not required before personal information is provided to health departments. Although there is a risk of violating individual confidentiality, mandatory reporting is justified under the harm principle because the surveillance data can directly benefit individuals and communities.
Contact tracing is the notification of those who may be at risk of contracting an infection from an index case. In the case of STIs, the individuals at risk are sexual partners or injection drug and needle-sharing partners. Health departments notify these contacts to let them know that they may have been exposed to a STI and should be tested and/or (p. 381) treated, but they are not told who referred them (National Coalition of STD Directors, 2016). They are then asked about their contacts so that networks can be created. The index patient’s consent is not required for public health officials to contact his or her present and former partners.
Mandatory reporting and contact tracing can benefit individuals, allowing for early detection and facilitating treatment of STIs for both the index case and contacts. For example, during an HIV outbreak in a small US community in southern Indiana, HIV and hepatitis C testing, followed by contact tracing, identified 181 new HIV infections (Peters et al., 2016). HIV-infected individuals’ health outcomes are markedly improved with early diagnosis and access to antiretroviral medications, shifting HIV from a progressive, deadly disease to a manageable chronic illness in which one can live a long and productive life (WHO, 2016a). Mandated reporting and contact tracing can also benefit communities, as data can be used to better target prevention programs and directly disrupt STI transmission. In the southern Indiana HIV epidemic, contact tracing enabled CDC investigators to demonstrate that HIV infections were transmitted through sharing needles in injection drug networks, rather than sexual networks, permitting scarce public health resources from that rural community to be directed to interventions, such as needle exchanges, that were most likely to interrupt transmission (Conrad et al., 2015).
While powerful tools in STI control, particularly in epidemics, mandatory reporting and contact tracing carry the potential to violate the confidentiality of both the index patient and her or his partners, with resulting stigma and social harms. Although contacts are not provided with the name of the index patient, when a person has a limited number of sexual partners or resides in a small community, the index patient’s name may be easy to deduce. All STIs carry the risk of stigma and social harm. Those harms will vary by infection (e.g., HIV carries a high risk of stigma) and the contexts of transmission (e.g., via anal sex or via mother-to-child transmission). Applying the harm principle, the use of mandatory reporting and contact tracing should be limited to those infections with strong evidence for improved individual and community health outcomes, and they must be done in the least restrictive manner and with the highest levels of protections for individual confidentiality.
HPV and School Vaccination Mandates
From the harm principle, it can also be argued that if there is sufficient evidence of effectiveness, and if the limitations on personal liberties can be minimized, then an STI control initiative should be undertaken. An example is the use of school mandates to improve HPV vaccination rates for eleven- to twelve-year-olds. School mandates, or policies requiring immunization for entry into schools, are a highly effective method of increasing vaccination rates (Brandt et al., 2016). The rates of serious side effects from the HPV vaccine are low, and there is clear evidence that the vaccine reduces the incidence of HPV-related disease, including cervical, penile, oral, and anal cancers (Kahn et al., 2016). However, in most US states, HPV has not been added to school vaccine mandates, and HPV vaccination rates remain low. Other childhood vaccines, such as (p. 382) measles, mumps, and rubella (MMR), which are mandated for public school attendance, boast high rates of vaccination.
Opponents of HPV vaccination mandates have argued that the mandates violate their right to individual liberty, including religious liberty, to make decisions regarding their children’s health care (Ferrer et al., 2014). Some argue that because HPV is sexually transmitted, mandating the vaccine gives adolescents permission to have sex. That argument, which is unique to STI vaccines, is not supported by data linking HPV vaccination to increased risk behaviors (Coles et al., 2015).
Stronger arguments against school mandates for the HPV vaccine have been based upon the harm principle. Because HPV is sexually transmitted, nonvaccination does not present a direct risk to other school children in the same way that nonvaccination against diseases spread by respiratory illness, such as measles, does (Ferrer et al., 2014). Thus, HPV mandates limit parents’ liberty to choose not to vaccinate their children, without sufficient benefit to other children in the school. However, this harm/benefit analysis shifts if one considers the health of the community as a whole. School vaccine mandates present a unique opportunity to markedly increase community-wide vaccine rates, and to improve public health through the prevention of cervical, penile, oral, and anal cancers, along with the pain and suffering and costs associated with these vaccine-preventable cancers. Additionally, high levels of vaccination provide “herd immunity” (also known as “community immunity”), preventing transmission even if a disease enters a community, resulting in protection of those who cannot be vaccinated for medical reasons (Diekema, 2014).
In ethics, an error of omission may be considered as ethically problematic as an error of commission (e.g., not enacting a policy that can effectively reduce pain and suffering may be considered as ethically problematic as enacting a policy that causes pain and suffering). This applies to STI control interventions that can improve public health outcomes with an acceptably low impact on individual liberties. Given the low rate of serious side effects from HPV vaccination, the effectiveness of the vaccine for both individuals and communities in preventing cancer and other HPV-related illness, and the effectiveness of school mandates in increasing community vaccination rates, an ethical argument can be made for school HPV vaccine mandates using the harm principle.
Criminalizing HIV Transmission
Conversely, if public health policies lack evidence of effectiveness or have evidence to suggest harm, the harm principle may also be violated. The harm principle requires that there be some potential for effectiveness if STI control interventions threaten individual liberties. An example is criminalizing HIV transmission. On the surface, laws that permit a state to prosecute an HIV-infected individual who knowingly infects another person may appear to make sense. HIV is a potentially life-threatening illness that is frequently asymptomatic. The presumptive purposes of these laws are to encourage disclosure and to punish HIV-infected individuals who knowingly expose others to harm by choosing not to disclose their HIV status. Disclosure of HIV status between sexual partners allows disruption of transmission through safer sex behaviors, such as condom use.
(p. 383) Data, however, do not support criminalization of HIV transmission as an effective way to encourage disclosure or to decrease transmission. Awareness of criminalization laws has not been associated with increased disclosure or behavior change (Harsono et al., 2017). A review of published research in Canada suggests that, particularly for women, criminalization laws may actually act as a barrier to access at all points in the HIV care cascade, discouraging testing, linkage to treatment, and engagement in care (Patterson et al., 2015). Because empiric data do not support the presumptive purpose (increased disclosure and interrupted transmission), almost all STI control professionals oppose this type of legislative intervention (Harsono et al., 2017; Lazzarini et al., 2013).
The second purpose of criminalization laws is to punish an HIV-infected individual who knowingly exposes another person to harm without providing a warning through disclosure. Disclosure would provide the at-risk individual an opportunity to take preventive action (e.g., avoid intercourse, use condoms, or engage in other safer sex behaviors). The argument in favor of punishing individuals for knowingly transmitting HIV is predicated on the co-occurrence of three factors—transmissibility, (in)curability, and severity. Some STIs, like syphilis, have the potential for equally severe sequelae but are curable. Other STIs, like herpes, are not curable, but their clinical course is usually more indolent. In HIV, there is both lack of a cure and the potential for severe medical and social sequelae.
The ethical reasoning for universal criminal punishment for nondisclosure of HIV is less compelling, given our current understanding of HIV transmission and treatment. The effectiveness of HIV treatment has led to a “treatment as prevention” approach. Individuals living with HIV who maintain undetectable viral loads have almost no chance of transmission. While there is still no HIV cure, with modern antiretroviral treatment and good adherence, HIV is no longer a certain death sentence and is now considered a chronic disease. Per the harm principle, in an HIV-infected individual with good adherence and an undetectable viral load, one could argue that broad criminalization of HIV transmission is an unacceptable restriction on personal liberties. In contrast, nondisclosure from a person living with HIV who knows his or her diagnosis, has a high viral load, and has sexual practices that put the encounter at highest risk for transmitting HIV presents a different harm scenario. These contrasting cases support the necessity of flexibility and individualization.
The duty to warn is related to criminalization of HIV, but instead of obliging individuals living with HIV to disclose their HIV status to prospective partners, it obliges health care providers to warn potential partners of their risk of contracting HIV. The legal duty to warn is most often associated with psychiatry, and in the United States it is grounded in a court case, Tarasoff v. Regents of the University of California, in which a patient disclosed to a therapist his intention to commit homicide, which he later proceeded to commit (Huprich, Fuller, and Schneider, 2003). The court found the therapist at fault because he did not warn the victim of the threat to her life. The duty to warn is codified in the American Medical Association (AMA) Code of Medical Ethics, which allows providers to break confidentiality when they judge that there is a “reasonable probability” that a patient will “inflict serious physical harm on an identifiable individual” (p. 384) (AMA, Opinion 3.2.1). The provider’s duty to warn has been applied to HIV in cases where individuals living with HIV neither disclose their HIV status to a partner nor practice safer sex, putting their partner(s) at risk for HIV infection (Odunsi, 2007).
The duty of providers to warn at-risk partners, like criminalization of HIV, is based upon an belief that HIV is always highly transmissible and uniformly fatal. As described above, current antiretroviral therapy has reduced HIV transmissibility in individuals with very low viral loads, shifting the course toward that of a chronic illness. The harm principle would argue against a universal policy of warning all partners who can be identified and have not been disclosed to. An individual living with HIV, who has an undetectable viral load but has not disclosed, may not present a “reasonable probability” of harm to others through HIV transmission to justify the loss of confidentiality and individual liberty posed by a universal duty to warn policy (Huprich, Fuller, and Schneider, 2003). Because of the importance of case specifics in the probability and severity of harm, the duty to warn should be flexible and individualized to account for individual circumstances, risks to partner, and provider judgment.
Social Justice and Human Rights
STI-Related Health Disparities
Inequalities in sexual and reproductive health intersect with several cross-cutting health disparities of high importance to public health ethics, including poverty, ethnic minority status, gender, sexual violence, sexual minority status, and youth (OHCHR, 2016b). STIs track with poverty and inequities in wealth. The global burden of HIV and STIs is concentrated in the countries with the lowest per capita incomes (OHCHR, 2016b). Within high-income countries, STIs cluster in high-poverty communities (UNAIDS, 2014). In many cases, the poor not only experience higher rates of STIs and lower access to services, but also higher levels of stigma and fear (Harling et al., 2013; Holtgrave and Crosby, 2003). Similarly, racial and ethnic minorities bear a disproportionate burden of STIs, including HIV (Wabiri and Taffa, 2013). In the United States, for example, rates of gonorrhea for African American individuals are almost ten times those of white individuals, and rates of syphilis are five times higher (CDC, 2016b).
Of global importance, large disparities in STIs can be attributed to gender and sexual violence. Women, particularly young women, have some of the highest rates of STIs, most notably HIV (UNAIDS, 2014). In the United States, young women have the highest rates of chlamydia and gonorrhea, with attendant sexual health sequelae, including infertility (CDC, 2016b). Globally, even when STI prevention and treatment are available, women are less likely to utilize those services because of disproportionately high levels of discrimination and stigma associated with STIs coupled with inequalities in economic power that limit women’s ability to access and utilize services independently (OHCHR, 2016b). For example, in rural South Africa, for every 1 percent increase in community-level stigma, women’s rates of HIV testing dropped 3 percent (Treves-Kagan et al., 2017). Sexual violence exacerbates the situation, such that the population most in need of sexual health services is the least able to access it (Dunkle et al., 2004).
Sexual and gender minorities also experience inadequate access to sexual health information and STI-related services. In the United States, most new HIV infections occur in African American and Latino men who have sex with men (MSM) (CDC, 2016a). Broad structural disparities directly contribute to these disparities in both STI information and services. Among MSM, HIV and unprotected anal intercourse happen in the contexts of structural factors such as mental health disorders, substance abuse, violence, sexual stigma, and homelessness (Santos et al., 2014).
Globally, lesbian, gay, bisexual, and transgender (LGBT) individuals are frequently denied basic civil rights, including denial of the right to marry and criminalization of same-sex relationships (OHCHR, 2015). LGBT individuals experience discrimination in accessing economic and social rights and are often targets for hate crimes and violence (Hatzenbuehler and Pachankis, 2016). LGBT individuals also report high rates of STI risk factors, including sexual violence (Whitton et al., 2016). Human rights approaches to STIs support broad access to sexual health care and freedom from discrimination. This is of particular importance for LGBT individuals and obliges states to take action to address these disparities in access and outcomes, and to change the above discriminatory practices and policies (O’Flaherty and Fisher, 2008).
Adolescents also experience disparities in access to sexual health information, STI care, and STI outcomes. While access to medically accurate sexual health information to maximize sexual health and well-being is a basic human right (Coliver, 1995), many sex education programs in the United States and globally focus on abstinence and heterosexual youth, and do not provide essential information on STI prevention, risk reduction, gender, discrimination, or sexual orientation (Santelli et al., 2006). Although human rights documents support confidential STI care (OHCHR, 2016a), and adolescents report that a lack of confidentiality will decrease the likelihood that they will access care (Jones and Boonstra, 2004), many adolescents still find themselves unable to access confidential sexual health care. As a consequence, they may delay STI prevention, diagnosis, and care (Sam-Agudu, Folayan, and Ezeanolue, 2016), any one of which may put the adolescents and their communities at heightened risk.
Failure to respect the human rights of marginalized populations, such as the poor, women, racial and ethnic minorities, sexual minorities, and adolescents, impedes effective STI control. Discrimination and stigma cause these at-risk, marginalized populations to remain hidden, which in turn reduces their access to screening, treatment, referral, and prevention programs, and ultimately limits the effectiveness of STI control. To counter that outcome, STI control must include efforts to address the social injustices underpinning existing health disparities.
A Human Rights Framework for STIs
A human rights approach best addresses issues of social injustice in the context of access to STI information and care. Persons are at increased vulnerability to STIs in part (p. 386) because they are unable to realize their civil, political, economic, social and cultural rights (OCHR, 2016b). Social justice in STI control involves securing a sufficient level of sexual health for all, as well as narrowing inequalities in access to sexual health information, access to STI prevention and treatment, and STI outcomes. Notions of social justice can be derived from human rights principles, including the right to the best attainable sexual health, as well as the right to access STI services, including education, prevention, testing, and treatment.
Poor or marginalized communities experience a higher prevalence of treatable STIs, likely due, in part, to their lack of access to STI treatment. A recent global analysis of trends in STIs found that syphilis was most prevalent in the African World Bank region and was associated with low national income and more limited access to antenatal syphilis testing in those areas (Newman et al., 2015). The discrimination and stigma accompanying STI (particularly HIV) diagnoses can lead to human rights violations, which frequently hamper effective public health responses (OHCHR, 2016b). For example, women living with HIV in low- and middle-income countries experience higher levels of interpersonal violence and economic marginalization, which in turn impedes linkage, access to, and retention in treatment (Ippoliti, Nanda, and Wilcher, 2017). The WHO’s (2017) consolidated guideline on sexual and reproductive health and rights of women living with HIV recognizes the associations among discrimination, stigma, and HIV, and incorporates recommendations such as universal screening for violence, empowerment interventions focused on the individual woman, and economic interventions focused on the broader community.
Multiple human rights documents make specific recommendations that STI policies and programs include the human rights to sexual health information, sexual health services (both prevention and treatment), and freedom from discrimination—including the Convention on the Elimination of All Forms of Discrimination against Women (OHCHR, 2016b), the Convention on the Rights of the Child (OHCHR, 1990), and the International Covenant on Economic, Social and Cultural Rights (United Nations, 2000; UNAIDS, 2016). These documents support an individual’s right to the best attainable sexual health and emphasize the importance of upholding human rights as a mechanism to address the disparities in STI and HIV prevalence. Because governments are often the source of stigma and discrimination, these documents clearly address the role of the state in supporting human rights and eliminating stigma and discrimination—steps that are critical for STI control (OHCHR, 1990).
Summary and Recommendations
Enormous disparities in STI rates exist among groups, both between and within countries. These disparities in disease outcomes track with disparities in access to sexual health information, STI prevention modalities, and STI treatment services. Marginalized groups, such as women, ethnic minorities, sexual minorities, adolescents, and individuals in (p. 387) poverty, are disproportionately affected, meaning that those with the greatest need have the least access to the knowledge and resources necessary to improve health outcomes.
Ethical approaches to STI control are supported by the harm principle and the protection of human rights. The harm principle protects individual liberties up to the point at which those liberties have a high potential to harm the community. Even then, individual liberties should be infringed upon in the least restrictive manner. Policies that threaten individual liberties, such as contact tracing, should be conducted in a manner that is respectful of individual rights while protecting the health of others within the community.
Human rights approaches are essential to achieving social justice in STI control. This ethical position is supported by the WHO, which recommends that STI control programs be delivered with respect for human rights and the dignity of persons with STIs (OHCHR, 2016b). By maintaining a human rights focus, STI control policies can potentially reduce, rather than reinforce, disparities in information, prevention, and treatment modalities, while at the same time interrupting STI transmission and preventing future infection.
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(1.) STI and HIV control activities are often separated because of differences in funding streams; however, HIV is sexually transmitted, and there is substantial overlap between STI and HIV control activities and the ethical issues those activities raise. For the purposes of this chapter, we consider the ethics of STI and HIV control together, except where we specifically indicate HIV.