STD Clinic–Academic Partnerships: Contributors to Public Health STI Control

Public sexual health clinics (SHCs) play a central role in evaluation, management, and prevention of sexually transmitted infections (STIs). These clinics come in many shapes and sizes, ranging from clinical services integrated into other clinical activities in smaller health departments to large, dedicated clinics that operate daily to see hundreds of clients. They are the place that clinicians call when they have patient management questions, they are a mainstay of reporting for federal STI surveillance, they serve as the base for public health disease intervention specialists who conduct and manage surveillance and partner notification activities, and they serve as a safety net to provide low or no cost care for persons with and at risk for STIs. Some also serve as resources for generation of new knowledge regarding STI diagnosis and management and provide sexual health training opportunities for health care professionals. The clinics involved in research and training often rely on partnerships between academia and public health. Below, we discuss the history of these partnerships and models of academic–public health collaboration, the rationale and potential challenges affecting these partnerships, and how the federal partners might promote new partnerships to improve the US STI clinical and research infrastructure. In the 1970s, partnerships between the Public Health—Seattle & King County and the University of Washington, as well as by Denver Health and Hospitals in affiliation with the University of Colorado, promoted a new sort of relationship with mutual benefits and increasing equality for partners. For over 50 years, these partnerships led to sustained public health-academic partnerships that benefited patient care and public health while also generating new knowledge. This more collaborative model has also served to train health care providers who would create similar public health–academic partnerships in other locations. The models provided in King County and Denver have since been applied with mixed success to create other public health-academic partnerships in diverse settings including San Francisco; St. Louis; Baltimore; New Orleans; Indianapolis; Winston-Salem; Pittsburg; Durham, NC; Detroit; and Birmingham, among others. In most instances, the origins of these relationships are based on interpersonal interactions and have often fluctuated over time or even dissolved upon changes in the personnel involved on either the health department or the academic side of the relationships. The argument for building stronger relationships between public health HIV/STI programs and academia is compelling. When successful, such collaborations allow health departments to expand access to clinical expertise, facilitate patient referrals for primary and specialty care, and enhance health departments' ability to develop local guidelines and build relationships with the wider medical provider community. Collaborations also benefit academic partners, facilitating clinical and public health training and research and providing students and faculty with a public health career path that many trainees do not know even exists. Both partners, as well as the public at large, benefit insofar as these partnerships enhance the relevance of research by grounding it in real-world experience. Public health–academic partnerships are particularly critical for research. A large portion of STI diagnosis and treatment research is carried out in health department SHCs where investigators can efficiently enroll relatively large numbers of persons with and at risk for STI. Indeed, in the absence of such clinics, many STI research studies could not be done in the United States. In addition, programmatic initiatives such as routinized testing for HIV, partner-delivered therapy for STIs, and doxycycline prophylaxis for STI prevention were initially evaluated in SHCs. Although the rationale for expanding collaborations between health departments and academia is compelling, experience in this area has often been fraught. Historically, investigators from academic institutions had sometimes been viewed as practicing academic “colonialism” in which they expected access to health department records and/or clients and adjustments to health department operations to conduct their research. Following completion of research, investigators would all too often depart the facility without acknowledging the crucial contributions of the health departments and, on occasion, when research involved demonstration projects, having raised expectations which could not be sustained after research funding was no longer available. By the same token, some academic settings had negative perspectives about public health agencies and professionals, viewing them as unsophisticated in modern epidemiology and providing substandard clinical care in poorly funded clinics. They also sometimes perceived public health partners as having negative perspectives on clinical research and dedicated to unnecessarily “protecting” patients from participation in clinical and epidemiologic investigation. Today, such negative perspectives on either side of the academic–public health spectrum probably are less common than in the past, but such experiences and beliefs still can inhibit close collaboration. Our experience working for decades to build and sustain public health–academic partnerships provides us with perspectives on factors that can help make these collaborations successful. First and foremost, such partnerships must be based on a sense of mutual respect and equality that bring value to both sides. To do this, understanding and support of institutional leadership (i.e., boards of health, health department directors, university deans, chairs, and division directors) is a necessity. An important indicator of this is shared institutional financial support of persons working with a “foot in each world.” In the most successful instances, such relationships can be often supplemented to the benefit of all involved through grants and contracts from federal agencies, foundations, and industry. This support should not require health departments to support full salaries for academic physicians; a central benefit of collaboration is that it expands health department capacity in a way that is economical. A second important component is a commitment to the conduct of research with the potential to directly benefit patient care in the clinics where the research is conducted. This may occur in a variety of ways, including support of additional clinical staff, access to improved diagnostic tests and therapies, helping to understand most effective measures for counseling, and encouragement of behavior change, among others. Perhaps more than anything, success requires a commitment to build a long-term relationship that can be sustained through changes in leadership and weather the disagreements that will inevitably arise. The Centers for Disease Control and Prevention (CDC) and other federal partners can and should play a role in promoting greater integration of public health and academia. Currently, a network of public health SHCs are integral parts of the CDC-funded National Network of STD Prevention Training Centers (https://www.nnptc.org/about.php). Eight regional centers assist clinicians in their training areas. Most prevention training centers (PTCs) are conducted through public health–academic partnerships, and many PTC faculty hold joint appointments within their health departments and local medical schools. Although the PTCs have traditionally focused primarily on providing clinical training and consultation, in recent years, they have also sought to improve clinical operations through technical assistance. Public health–academic partnerships have benefitted National STI control efforts by providing experts who have served on CDC committees, including faculty who advise on revisions to the CDC's most widely used document, the STI Treatment Guidelines. Such faculty also conduct CDC- and National Institutes of Health–funded research and serve on nongovernmental advisory committees. The CDC and partner organizations such as the National Coalition of STD Directors should do more to promote academic–public health partnerships. Such efforts might include integrating funding into public health grants to support academic physician or PhD-level staff to work in collaboration with public health and expanded support for trainees to work on collaborative academic–public health projects. The ultimate winners in such partnerships are the patients we serve in our clinics and the public at large.