Over the past 20 years, rates of reportable sexually transmitted infections (STI) have been rising in the United States. In 2019, the numbers of reported gonorrhea, chlamydia, and early syphilis cases were the highest since 1991 in the United States.1 The reasons behind these increases are not fully understood, but changes in sexual behavior as a result of more effective HIV treatment and prevention methods (including preexposure prophylaxis), diagnosis of asymptomatic extragenital infections with increased use of testing at all potentially exposed anatomical sites, and the ongoing opioid epidemic seem to be playing a role.2,3 In addition, budget cuts resulting in declining access to publicly funded STI services4 reduce the likelihood that infected persons are diagnosed and treated, resulting in ongoing STI transmission.

Increasingly, the delivery of STI services is becoming dependent on a wide array of private and public care providers, including primary care, family planning, school-based clinics, HIV care providers, emergency departments, and correctional facilities, in addition to publicly funded STI clinics.5 Innovations in noninvasive diagnostics especially nucleic acid amplification tests have facilitated the expansion of STI testing and treatment outside of traditional STI clinics, and the future availability of high-quality rapid point-of-care testing may strengthen this trend. Medicaid expansion under the Affordable Care Act has resulted in health care coverage for more than 14 million Americans, which may further increase the demand for STI care occurring in primary and community care settings that may be unfamiliar with guidelines around STI management and treatment as published by the Centers for Disease Control and Prevention (CDC).6 Therefore, adequate training is necessary for clinical providers and other health professionals to enhance their skills in taking sexual histories as a standard of care, the provision of appropriate STI diagnostics and treatment, and the delivery of prevention services including STI prevention counseling and administration of the human papillomavirus vaccine.6,7

To provide STI clinical training, the CDC established a network of regional STI training centers in 1979. Known today as the National Network of Sexually Transmitted Disease Clinical Prevention Training Centers (NNPTC), the network comprises 8 regional training centers that support clinical providers in diagnosing and treating STIs by providing clinical and laboratory training and technical assistance nationally.8 In addition, the 8 regional training centers (located in California, Washington, Colorado, Missouri, Alabama, Maryland, New York, and Massachusetts) are assisted by national centers within the network to support overall coordination, curriculum development, quality improvement, and evaluation. Previous studies have demonstrated the effectiveness of trainings provided by the NNPTC, including posttraining effects on provider behavior9 and practice changes.10 Of note, the impact of experiential “hands-on” trainings is still significant in the digital age, with a substantial number of clinical providers reporting persistent improvements in knowledge and clinical skills as a result of these trainings.10

The purpose of this article is 2-fold: to describe the professional and demographic characteristics of clinical providers trained through the NNPTC between 2015 and 2020, and to correlate the number of individual training episodes with reported STI rates at the county level.

METHODS

The NNPTC routinely collects demographic information on clinical providers using the Health Professional Application for Training (HPAT) form. Variables include clinical providers race, gender, zip code of employment, profession, functional role, and employment setting. Data on training courses and HPAT forms are collected in the NNPTC's Learning Management System for analysis. The Learning Management System is an online system with built-in class setup, registration, and evaluation capabilities. Data collection during the grant cycle began in April 2015, and this study includes data through March 2020.

Training events for which HPAT data were collected vary from 1-hour webinar series to multiple-day, in-person trainings. The HPAT data set did not include in-depth information on the nature of each training event, and for purposes of this report, all training events were treated equally. Data included one entry for each training attended and thus contained multiple entries for each person who attended more than one training event during the evaluated time interval (henceforth designated as “trainee events”).

All forms and data collection instruments were approved by the US Office of Management and Budget.

Rates of reportable STI (chlamydia, gonorrhea, and primary and secondary syphilis) were examined at the county level. Data were downloaded for the reporting year 2018 from the CDC's Atlas Plus Web site (https://www.cdc.gov/nchhstp/atlas/index.htm), the most recent year for which STI surveillance data were available. The dataset included reporting information on 3218 counties for analysis. Data for chlamydia, gonorrhea, and primary and secondary syphilis were analyzed both separately and combined. Because subanalyses did not reveal any differences, we used the composite STI rate in our analyses. We grouped county data by quartile of STI rates and used a simple χ2 analysis to test for statistical significance across quartiles.

For the first analysis, that is, the professional and demographic description of clinical providers, we unduplicated the HPAT database at the individual level. For clinical providers with multiple training events, we selected the last record in the database, which would contain the most current data. We provided a percent range across the 8 funded regional training centers for each demographic category. For the second analysis, that is, the correlation of trainee events to county-level STI rates, we retained all trainee events in the HPAT database, thus including multiple events for individual trainees, and merged this database with the CDC Atlas Plus STI rates.

For statistical analyses, we first conducted simple linear regression analyses to assess the relationship between the number of trainee events and the STI rates in each county. Second, we examined the number of trainee events in each of the four quartiles of counties as determined by STI rates and examined statistical significance by analysis of variance. In these analyses, we also examined possible confounding effects, including whether counties were located within a state where any of the regional training centers are housed (further referred to as counties from “PTC states”).

Data on STI case rates at the territory level were not available for all territories, so the analysis focuses on the 50 US states and the District of Columbia.

All analyses were conducted in IBM SPSS Statistics 23 (Armonk, NY) and SAS Enterprise Guide 7.1 (Cary, NC).

RESULTS

Between April 1, 2015, and March 31, 2020, the 8 regional PTCs collected HPAT data for 21,327 clinical providers, attending 28,120 trainee events in 1313 courses, for an average of 1.3 events per clinical provider. Course lengths ranged from 0.75 hours (a webinar) to 203 hours (a clinical practicum).

Demographic and professional details of clinical providers are summarized in Table 1.

n % Range Among PTCs*, % Race  White 13,446 63.0 (47.5–79.8)  African American 3558 16.7 (5.1–36.3)  Asian American 1051 4.9 (1.4–8.2)  More than one race 628 2.9 (1.9–4.20)  American Indian or Alaskan Native 431 2.0 (0.2–5.2)  Native Hawaiian or Pacific Islander 4 0.0 (0.0–0.1)  Missing 2209 10.4 (2.0–18.4)  Total 21,327 100.0 Hispanic, Latino/a, or Spanish origin  No 17,732 83.1 (68.0–96.6)  Yes 2248 10.5 (3.2–19.9)  Missing 1347 6.3 (0.2–13.6)  Total 21,327 100.0 Gender  Female 17,065 80.0 (80.5–91.3)  Male 2877 13.5 (8.5–18.3)  Transgender: female to male 51 0.2 (0.1–0.5)  Transgender: male to female 48 0.2 (0.0–0.6)  Missing 1286 6.0 (0.0–0.6)  Total 21,327 100.0 Profession  Registered nurse 7239 33.9 (25.5–52.5)  Advanced practice nurse 3605 16.9 (12.3–30.7)  Physician 2409 11.3 (5.6–24.2)  Other 2303 10.8 (5.5–15.5)  Community health worker 2040 9.6 (3.0–16.0)  Health educator 1350 6.3 (1.5–13.2)  Social worker 576 2.7 (1.5–5.2)  Physician assistant 571 2.7 (1.4–6.4)  Licensed practical nurse 517 2.4 (1.5–3.8)  All others combined† 694 3.3 (1.1–4.5)  Missing 23 0.1 (0.0–0.3)  Total 21,327 100.0 Functional role  Clinician/care provider 9005 42.2 (28.0–59.3)  Administrator (director, coordinator, manager, supervisor) 3270 15.3 (9.4–18.9)  Other 2088 9.8 (7.7–11.2)  Student/graduate student 1122 5.3 (1.3–12.0)  Disease intervention specialist/partner services provider 1085 5.1 (1.8–9.2)  Case manager 984 4.6 (2.4–7.0)  Outreach staff 683 3.2 (0.6–8.7)  Client/patient educator 665 3.1 (1.2–5.2)  Intern/resident 547 2.6 (1.1–6.6)  Clinical/medical assistant 484 2.3 (1.7–3.0)  Researcher/evaluator 311 1.5 (0.8–2.0)  Teacher/faculty 300 1.4 (0.7–1.9)  Client/patient counselor 254 1.2 (0.5–2.0)  All others combined‡ 513 2.4 (0.5–3.0)  Missing 16 0.1 (0.0–0.2)  Total 21,327 100.0 Employment setting  State/local health department 7723 36.2 (20.1–64.7)  Community health center (e.g., FQHC) 2874 13.5 (8.3–21.2)  Hospital/hospital-affiliated clinic 2276 10.7 (4.3–20.7)  Academic health center 1339 6.3 (3.4–13.8)  Other 1303 6.1 (4.4–7.9)  College/university 1172 5.5 (3.4–12.1)  Community-based service organization 1094 5.1 (2.1–9.2)  Other nonprofit health center 1078 5.1 (2.9–7.7)  Private practice (solo/group) 473 2.2 (1.0–5.0)  Tribal/Indian health service facility 366 1.7 (0.0–5.0)  Not working 359 1.7 (0.7–3.9)  Correctional facility 310 1.5 (0.4–3.8)  Rural health center 245 1.1 (0.3–2.1)  All other combined§ 715 3.4 (1.0–5.0)  Missing 20 0.1 (0.0–0.4)  Total 21,327 100.0 (0.0–0.4)

*The range refers to the minimum to maximum percent for each demographic category found across the 8 regional prevention training centers whose data were included in this analysis.

All others combined include the following:

†Pharmacist, mental/behavioral health professional, substance abuse professional, other dental professional, dentist, dietitian/nutritionist, clergy/faith-based professional.

‡Trainer/technical assistance provider, mental/behavioral health therapist, peer support provider, agency board member.

§Military health system/Veterans Health Administration facility, nonhealth setting, health maintenance organization/managed care organization, community/retail pharmacy.

FQHC indicates federally qualified health center; PTCs, prevention training centers.

The majority of clinical providers were White (63%) and female (80%). The 3 highest ranked categories of professions were registered nurse (34%), advance practice nurse (17%), and physician (11%). Forty-two percent of clinical providers listed clinician/care provider as their primary functional role, followed by administrator (15%) or other category not listed (10%, including primarily medical/clinical assistants, researchers, and community-based organization workers). The most common work setting for clinical providers was state/local health department (36%) followed by community health center (13.5%) and hospital or hospital-affiliated clinic (11%).

We found a significant association between the number of trainee events and STI rate at the county level in the analysis of variance analysis (B = 0.00967, P < 0.0001; Table 2). Specifically, we found an increase in training events from 0.7 events per county in the lowest quartile to 24.5 events per county in the highest quartile. The number of counties with no training events during the observation period decreased from 78.4% to 28.9% when comparing counties with the lowest to the highest STI quartile. Counties in PTC states also had higher rates of trainee events (24.5/county) compared with counties in states with no PTC (6.2/county). Both STI rate quartiles and being a county in a PTC state were highly significantly associated with the number of trainee events in the multivariate analysis (both P < 0.0001; Table 2). Other variables considered were not associated with county-level number of trainee events, including clinical provider demographic and professional variables, and county level variables, such as presence or absence of Medicaid expansion in the county's state.

TABLE 2 - Trainee Events (TE) by County STI Rate and Residing PTC State No. Counties TE TE/County P* Counties With No TE P † n n n/n n (%) STI quartile  0–255.6 804 529 0.7 <0.0001 630 (78.40) <0.0001  255.7–399.5 804 1882 2.3 465 (57.8)  399.6–650.1 804 6005 7.5 329 (40.9)  >650.1 804 19,678 24.5 232 (28.9) PTC state  Yes 443 10,869 24.5 <0.0001 208 (47.0) <0.05  No 2773 17,225 6.2 1448 (52.2)

*Multivariate analysis of variance with TE as the dependent variable and STI quartile and PTC state as independent variables.

†Univariate χ2 analysis.

DISCUSSION

This analysis of >20,000 clinical providers attending NNPTC trainings between April 2015 and March 2020 found that the clinical providers reached through training were predominately female, White, and working in nursing professions. There was a strong association between the number of clinical providers providing care in counties that have high rates of STIs, indicating that the NNPTC is targeting training resources appropriately.

Many of our findings, including clinical provider professional disciplines and demographics, were unsurprising. Whereas US physicians are disproportionally male, the overwhelming majority of nursing professionals are female.11 Sexually transmitted infections disproportionally affect non-White populations and men who have sex with men. Black men and women represent, respectively, 49.7% and 43.4% of US gonorrhea cases, whereas only 17% of the training population identified as African American. Currently, the NNPTC does not ask sexual orientation of clinical providers on the registration form. Given that 80% of clinical providers were female, our findings suggest that more male providers, specifically more gay or bisexual male providers, would be an important focus to diversify the workforce. Although the NNPTC does not directly influence hiring of the STI workforce or clinical providers, it is important for them to discuss these discrepancies with clinical providers in training.

Our findings lead to some additional considerations.

First, the finding that the majority of clinical providers are providing direct care in high-morbidity counties suggests that the PTCs are reaching providers who are providing STI care in counties with high STI burden. Because a large proportion of reported STIs in the United States are diagnosed in primary and private health care settings,1 the PTCs were directed in the last funding cycle to widen their reach into primary care. In our study, about a third of clinical providers worked in community health centers where populations disproportionally affected by STIs tend to seek care because of sociodemographic disparities.

The implications of these findings are not immediately obvious. With close to 1 million primary care providers (physicians, nurses, advanced practice nurses, physician assistants, and other allied health professions), combined with the very limited resources of the PTCs, expanding training to primary care providers has proven to be a challenging task. Primary care providers are an important workforce given that a significant proportion of reportable STIs are diagnosed in this setting. However, it is important to recognize that this group of providers also manages many other health conditions that take priority, including cardiovascular disease, pulmonary disease, and so on. For these providers to attend STI-specialty training courses may not be a reasonable expectation and, from the PTC perspective, the in-person training of primary care providers who see few STI's may not be the best use of already very limited resources. However, there are other ways to reach this population of providers, including the provision of online resources. For example, prior analysis of a comprehensive online, continuing medical education–accredited STI course developed by the PTC at the University of Washington indicates that this course has reached more than 25,000 providers worldwide, including 25% working in primary care.11 Nonetheless, primary care providers that serve populations with higher STI prevalence will benefit from more intensive training and should be encouraged to attend appropriate PTC course offerings. Thus, there is a need for a menu of options for providers, including primary care providers, of varying degrees of intensity/involvement, based on their unique circumstances and characteristics of their practice. This is one of the important ways that the NNPTC has continued to evolve over time.

Second, although the strong relationship in our study between the provision of training and county-level STI rates is encouraging, many counties seemed to be underserved and more than 25% of high-incidence counties had no trainee events at all. It is possible that STI resources are available in adjacent counties, but nonetheless, PTCs along with their collaborators in local and state health departments should be encouraged to assess the apparent lack of training in some high-incidence counties and develop plans to address these disparities.

Third, the only county-level factor besides high STI incidence that predicted higher number of trainee events was location of the county in 1 of the 8 states with a resident PTC. Most of the PTCs have a long-standing history and are well-known resources within their state but may be less so outside of their resident state. However, a more likely explanation is that out-of-state trainings often require a multiday commitment and considerable travel and lodging costs that comprise a significant barrier. Likewise, PTCs do not have the resources to provide stipends to cover travel expenses to clinical providers. Over the past decade, there has been a significant shift from in-person to online training and technical assistance modalities, including webinars, an online clinical consultation network (Sexually Transmitted Diseases Clinical Consultation Network),12 and clinical leadership virtual meetings, in addition to the already mentioned online STI course. The COVID pandemic has further enhanced this trend.

In terms of hands-on training, prevention training centers should be encouraged, and resources devoted, to identify additional STI specialty clinics in their region and provide technical assistance and quality improvement projects, not only to enhance the level of care at these clinics7 but also to engage them in clinical training for local providers.

There are several limitations to our findings. Even though the study sample is large, there is bias in self-selection of clinical providers, and it is not clear to what universe of providers this sample may be generalizable. This bias is suggested by our finding that clinical providers from states with a resident PTC were overrepresented. Furthermore, for many of the demographic and clinical provider variables, there were rather wide ranges among PTCs. These differences could be explained by regional variance in race/ethnicity and provision of clinical services. Thus, further studies are indicated to assess these differences and assure that PTCs are serving appropriate audiences.

Nonetheless, PTCs and other organizations involved in STI workforce development should consider how to work with medical and nursing schools, and in particular, historically Black colleges and universities to develop sexual health training curricula that at a minimum should include proper sexual health history taking, the principles of STI prevention, and the appropriate offering of STI testing in general practice settings. Focusing on historically Black colleges and universities could further diversify the STI provider workforce.

For the future of STI clinical training and workforce development, there are important recommendations from the recently released report from the National Academies of Sciences, Engineering and Medicine (NASEM), Sexually Transmitted Infections—Adopting a Sexual Health Paradigm. The report underscores the importance of the work of the NNPTC but also recognizes its limitations in terms of reaching those regions disproportionally affected by STI. To make clinical and technical support available where it has the most impact, the NASEM report calls for the development of STI resource centers at the level of states and large local jurisdictions and specifically calls out to the NNPTC to assist in the development of these centers (recommendation 11–5).13 Although our study demonstrated that training resources do reach the highest-affected areas in the country, the NASEM recommendation calls for additional resources to reduce the centralization of STI training resources that our study also identified.

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