As Covid-19 has rampaged across the United States, government officials have struggled with the basic steps needed to contain the pandemic. Should everyone get tested, or just people with symptoms? Should public health officials require Americans to wear masks or not? What’s the best way to track the infection, particularly in marginalized communities?
For one set of public health experts, the heated debates over testing, wearing masks and contact tracing were eerily familiar — as odd as it might seem, these are similar to arguments that officials and academics working to eradicate sexually transmitted diseases have been having for decades as they’ve worked to bring down the rates of infections like HIV, syphilis, gonorrhea and chlamydia.
It may seem incongruous — even inappropriate — to compare a respiratory disease to a sexually transmitted infection. After all, it’s emotionally harder (if logistically easier) for someone to tell a contact tracer who they’ve been intimate with than it is to list everyone who has shared their airspace.
But the cycles of infection we’re watching with Covid are similar to patterns we’ve long seen in diseases like HIV and tuberculosis, where a successful suppression of infection rates is followed by funding cuts and the abandonment of vulnerable communities, allowing viruses and bacteria to make a comeback.
Sexual health experts say the lessons they’ve learned from both these triumphs and failures could make a major difference now in suppressing the coronavirus. Their insights suggest smart ways forward that might well cross party lines — including that you can't fix a problem just with finger-wagging and new rules, but you can't wish it away and move on with your life, either.
Here are the top lessons they’ve learned that could help battle the Covid-19 pandemic:
1. From condoms to masks, fear and shame don't work.
Sexual health experts who have spent decades promoting condom use have some advice for their public health counterparts struggling to convince people to wear face masks: attempts to scare or shame people into compliance will backfire.
“When we tell people: ‘If you don’t like wearing a mask, you’re really not going to like a ventilator’ — those kinds of fear-based messages are not very effective,” said Julia Marcus, an assistant professor at Harvard Medical School who specializes in HIV prevention. “Even if there’s truth to them, they make people associate this simple intervention with sickness and death. Similarly, messages that have associated condoms with disease and death didn’t exactly make people hot to put them on in a moment of pleasure and intimacy.”
Marcus says officials should be aware that resistance to wearing condoms and resistance to wearing masks are driven by some of the same misperceptions about their effectiveness and insecurities about manliness. But there are ways to get around them. She pointed to videos produced by California’s health department that acknowledge and address head on some of the reasons people don’t wear masks — from concerns it telegraphs weakness to small annoyances like fogging up glasses and making it harder to read facial expressions — as an example of a more effective strategy.
Experts say mask campaigns should also emulate successful HIV prevention campaigns that appealed to people’s altruism, like one popular message developed a few years ago pushing HIV-positive people to adhere to their drug regimen to protect both themselves and their sexual partners.
As with condoms and HIV drugs, the most effective message is that masks don’t just protect us; they protect others. And that’s not getting across.
“It’s the notion that … you're doing good for your fellow person and your community,” said Perry Halkitis, dean of the Rutgers School of Public Health. “That's completely lacking in the [mask] messaging right now.”
2. Abstinence is a fool’s errand.
Researchers who have watched decades of abstinence-only education fail to bring down the number of unintended pregnancies and STDs say the government should not counsel the Covid equivalent of abstinence — strict quarantines and social isolation.
“You need to give people safe ways to navigate the pandemic just like you need to give people safe ways to have sex,” Halkitis said. “If you don't, people are going to develop mythological understandings of how biology operates so they can accommodate their needs and their desires.”
Not everybody can work remotely, many lack space in the home to keep separate from other family members, and long-term isolation can be emotionally crippling. So Halkitis and other STD experts say the government should instead adopt a “harm reduction” approach — one that helps people understand the spectrum of risk of different activities so they can make informed decisions. For instance: If you can stay home, stay home. If you can’t, stay six feet apart and wear a mask. Outdoors is safer than indoors. Small groups are better than large ones.
But so far, there’s been more of a black-and-white, all-or-nothing approach — reflected in language used by both Democrats and Republicans like “shutdown,” “lockdown” and “reopening” that doesn’t convey nuance. Jeanne Marrazzo, a physician and HIV and infectious diseases expert at the University of Alabama at Birmingham, said a more empathetic and supportive approach from officials — i.e. “How can I help you stay safe?” — works better than a punitive tone that often leads to people doubling down on risky behavior.
“This approach of vilifying people who violate the rules has never worked,” she said. “It’s never worked for HIV or STDs or drug use, and it’s not working now for people having frat parties on college campuses.”
3. Testing needs to be free, convenient and routine or it will fail.
The U.S. response to the coronavirus pandemic has been plagued by testing failures — from supply shortages to surprise medical bills to a dangerously inadequate effort to test those without symptoms — that have allowed the virus to spread far and wide.
These missteps could have been avoided, public health experts say, if the government had ensured from the beginning that testing was universally free, convenient and routine, and that it covered people regardless of whether they have symptoms.
“We realized way back in the 1960s and 70s that many, if not most, people [with STDs] were asymptomatic and to get ahead of the curve you had to find the people who had the highest risk and were most likely to transmit it,” said Cornelis Rietmeijer, the former head of Denver’s STD control program. “You have to do screening, not just diagnostic testing.”
Rietmeijer cited the hard-won battle that led to the CDC recommending in 2014 that all sexually active women under 25 be screened every year for chlamydia as an example of the kind of broad based strategy that works; STDs that don’t have the same level of routine testing, like syphilis, have seen epidemics.
“One of the things happening in the U.S. that’s a disaster is the increase in congenital syphilis,” he said, referring to an STD passed from a pregnant mother to her child. "That’s something you usually only see in the third world. It's totally preventable if women get tested in their first trimester.”
Other successful strategies include using mobile vans to bring testing to vulnerable neighborhoods and providing at-home testing kits — some of which allow people to swab themselves and mail the sample into a lab and others that deliver rapid results at home. Similar mail-in tests for Covid are becoming more available, and testing companies are trying to develop simple, instant at-home tests, like pregnancy tests. But while there are open questions about their accuracy, experts say the government should more aggressively pursue, perfect and promote this option.
"Some people experience discomfort in clinical settings, while others say they just don’t know where to go to get tested," said Jen Hecht with the group Building Healthy Online Communities, which has researched how at-home HIV testing kits can expand access. “And at home, there’s no need to deal with anything related to transportation or taking time off work.”
4. Build trust with marginalized populations.
Like STDs, Covid has been far more prevalent among marginalized groups, including communities of color and the poor, who because of centuries of abuse and neglect by the medical system are often reluctant to come in for regular testing and treatment of infectious diseases — one reason they have disproportionate rates of both STDs and Covid-19.
Advocates and government officials have made some progress on tackling sexual health disparities by pushing local health departments to recruit and hire disease investigators who are from the communities they’re trying to reach, and to create messaging specifically tailored to minority groups — two actions they say aren’t happening enough during the Covid-19 pandemic.
In Arkansas, for example, immigrants from the Marshall Islands comprised nearly 20 percent of Covid-19 cases in two hard-hit counties although they made up only 1.5 percent of the population, according to a CDC team that flew in to investigate this summer. At the time , the state had only one contact tracer who spoke Marshallese, out of a team of 200, and its public health phone alerts were not available in that language.
But STD experts have learned that hiring bilingual public health workers and translating guidance isn’t enough. To build trust, it’s essential to have staff who have backgrounds that reflect the communities at highest risk of infection — such as LGBT people, immigrants, the formerly homeless and those recovering from addiction.
Marrazzo said she fears inadequate consultation with marginalized groups in the development of a Covid-19 vaccine will mean that the people who need it most won’t trust or take it if and when it becomes available. A poll conducted in late August found that 72 percent of Black Americans said they would not get a coronavirus vaccine when it’s available, compared to 49 percent of white respondents.
“The only way you’re going to get something that works for people is to involve them in the research from the beginning,” she said. “We learned that the hard way with sexual health and we’re making the same mistakes again now.”
5. Don’t stop something that’s working.
The U.S. has long been trapped in a dangerous cycle of ignoring and defunding public health programs during times of calm and only to throw money at a problem later when it becomes a crisis.
“It happened with tuberculosis in the 1960s and 70s,” recounted Rietmeijer. “When TB came under control, they dismantled all the clinics in New York City. Then it increased again and we were all caught with our pants down.”
More recently, states and the federal government invested heavily in global health and infectious disease prevention after 9/11 drew attention to bioterrorism threats, but that funding was gutted in the wake of the 2008 recession . It never recovered, allowing STD rates to soar and leaving the nation highly vulnerable to the Covid-19 pandemic.
“The lesson is that prevention works, but what tends to get defunded is prevention,” Halkitis said. “Putting the money in the front end, while costly, is going to save money in the long run. But we as a country totally suck at that.”
Leaders like former CDC Director Tom Frieden are lobbying for a permanent health security fund that operates outside of Congress’ normal budgetary dealings, so that funding isn’t approved only when a pandemic or other crisis is already underway.
As Covid-19 deaths level off at the still-high rate of around 1,000 per day, experts stress that it’s not too late to implement these strategies from the sexual health world and turn the tide of the pandemic. The real danger, they say, is to continue on the current path.
“People say public health has failed on sexually transmitted infections,” Rietmeijer said, citing the country’s current record rates of gonorrhea, syphilis and chlamydia. “But I say, society has failed public health. We’ve let it go by the wayside. There's been complacency when there is no urgency.”
This story is part of a reporting fellowship on health care performance sponsored by the Association of Health Care Journalists and supported by the Commonwealth Fund.