The Changing Landscape of Controlling Sexually Transmitted Infections in the U.S. Military

Evolving personnel policies, advancing medical research, innovations in laboratory science, a new vaccine, and the capacity of microorganisms to adapt to their human hosts’ defenses have changed the clinical and public health practice of venereology in the U.S. military over the last 25 years. Since the end of World War II, many barriers that prevented women from training in military schools and performing military jobs have been removed, and the numbers of women in the U.S. Armed Forces have increased substantially.¹ In 2012, the 214,098 women in uniform constituted 14.6 percent of the active duty U.S. military, with even higher percentages in the Reserves (19.5%) and the National Guard (15.5%).²

As the uniformed services adjusted to the increases in women in the 1990s, medical researchers recognized that the traditional focus on the sexually transmitted diseases (STDs) syphilis and gonorrhea had to be broadened to include Chlamydia trachomatis (CT) and human papillomavirus (HPV) infections, both of which were highly prevalent and often caused serious sequelae.^3-9 The need to identify these mostly silent infections and to intervene to prevent complications like pelvic inflammatory disease (PID), chronic pelvic pain, ectopic pregnancies, infertility, and cervical cancer prompted a shift in terminology from “STDs” to sexually transmitted infections (STIs).^9-10

Fortunately, rapid advances in medical laboratory technology led to the availability of molecular amplification tests that greatly improved sensitivity for detecting STI agents and offered practitioners a wide selection of sample types, to include urine, cervical swabs, vaginal swabs and penile swabs.¹¹ These tests were extremely useful in conventional clinical settings, but proved especially valuable as an efficient and economical way to identify people with silent CT infections through population-based screening in sexually active populations.^12-14 Since the serious sequelae occurred in women and the presumption prevailed that infected men would tend to be symptomatic, initial emphasis was placed on screening asymptomatic women.^4,15,16 In order to implement population-based screening of service members, military public health practitioners had to confront the problems of securing funding and identifying locations where screening could be efficiently and economically conducted with minimal disruption of critical military activities.

Over time, with the focus on screening women, the Navy, Air Force, Marine Corps and Coast Guard adopted the recommendation of the now defunct Armed Forces Epidemiological Board and initiated mass screening at basic training sites as part of their trainee health care programs.¹⁷ The Army chose not to conduct a population-based program to inform, test and treat soldiers during basic training. Rather, the Army opted to initiate screening of new female members sometime in their first year of service after basic and advanced training had occurred. Th is policy was associated with higher rates of PID in the Army, compared to the Navy, and the identification of large numbers of women soldiers infected with CT soon after reporting for duty in Korea, a critical overseas location.^18,19 Recently, the Army designated advanced training sites as the locations for initially screening military women for CT.

In 2006 the U.S. Food and Drug Administration (FDA) licensed a human papillomavirus quadrivalent vaccine (HPV4) to protect against HPV strains 6, 11, 16 and 18, which are responsible for 70 percent of cervical cancers and 80 percent of genital warts.²⁰ Uptake of the HPV vaccine has been less than hoped for, not only in the civilian community but also in the military community, where the vaccine is not required but is offered without charge.²⁰ Several researchers, including some in the U.S. military, have found that the early impact of the quadrivalent HPV vaccine in preventing genital warts has been very encouraging, suggesting that the vaccine should be given to those needing it as early as possible in service members’ military careers.²⁰

Determining the opportune times and places to test for CT and to administer the six-month, 3-dose HPV vaccine series are challenges that can be overcome with timely epidemiologic data and sound administrative policies. Surveillance for CT infections and for PID and other sequelae are ongoing and should inform military public health practitioners on the effectiveness of the service screening programs. Serological studies to assess HPV immunity in new military members and in those who have not completed the full HPV vaccine regimen are underway. Additionally, the occurrence of genital warts in military members will be monitored to assess vaccine effectiveness.

Two recent developments, one much more daunting than the other, require immediate attention. These are the repeal of the “Don’t Ask, Don’t Tell” policy (DADT)²¹ and the declining susceptibility of Neisseria gonorrhoeae to existing antibiotics, in conjunction with a paucity of new antimicrobials on the horizon.^22-23

The DADT policy, in place from 1993 to 2011, allowed gay men, lesbians and bisexuals to remain in the military services as long as they kept their sexual orientation secret. Concerns about revealing their secrets may have caused some service members to seek medical care outside the Military Health System (MHS).²⁴ With the repeal of DADT, these service members can now use the MHS without fear of discovery. The challenge to the MHS is to ensure that clinical providers and public health workers have the skills to address the needs of gays, lesbians and bisexuals. Useful information for health professionals can be found on the website of the U.S. Navy Sexual Health and Responsibility Program (SHARP).²⁵ Additionally, military infectious diseases and preventive medicine specialists have engaged the Centers for Disease Control and Prevention, Atlanta, GA, and the New England Sylvie Ratelle STD/HIV Prevention Training Center (http://www.ratelleptc.org/) to provide web-based continuing medical education sessions for military medical personnel as early as spring of this year. These sessions will cover STI diagnosis, treatment and control for all Department of Defense (DoD) beneficiaries.

Most concerning is the progressive acquisition of resistance to available antimicrobial agents by N. gonorrhoeae.^22,23,26 N. gonorrhoeae isolates resistant to the cephalosporins, the last remaining class of effective antimicrobials and the only antibiotics recommended for gonorrhea treatment, have been reported in Asia and Europe and, most recently, in North America.^22,23 New antibiotics are urgently needed but few are in the pipeline leading to FDA licensure.

The DoD must join with civilian public health agencies in aggressively promoting awareness, bolstering surveillance and laboratory capabilities, and ensuring that appropriate treatment regimens are universally applied. DoD surveillance systems must contribute useful and timely data and information on STIs among DoD health care beneficiaries. Additionally, U.S. military public health workers must collaborate with health care workers of host nation countries where U.S. forces are stationed to develop robust laboratory and surveillance systems.