Supply Chain Vulnerabilities in First-Line Treatments for Sexually Transmitted Infections: Implications for U.S. Public Health Preparedness.

Objectives: To evaluate supply-chain vulnerabilities affecting medications essential for treating sexually transmitted infection in the United States and identify disruption mechanisms that may predispose these therapies to shortages. Methods: We conducted a qualitative, structured supply-chain vulnerability assessment of first-line medications for five priority sexually transmitted pathogens recommended by the Centers for Disease Control and Prevention and the World Health Organization: azithromycin, doxycycline, ceftriaxone, benzathine penicillin G, metronidazole, tinidazole, acyclovir, and cefixime. Using a predefined framework derived from pharmaceutical supply-chain disruption literature, we evaluated 13 disruption categories spanning raw material sourcing, active pharmaceutical ingredient production, manufacturing, distribution, market dynamics, information systems, and post-distribution loss mechanisms. Each category was assessed using four binary indicators and classified as relevant when at least two criteria were satisfied. Results: Multiple disruption domains applied across the drug set. Recurrent vulnerabilities included geographically concentrated active pharmaceutical ingredient production, limited manufacturing redundancy in low-margin generic markets, manufacturing constraints affecting sterile injectable products, reliance on consolidated distribution networks, and susceptibility to demand surges and information-system disruptions. All eight drugs exhibited at least one regulatory or market signal consistent with potential supply vulnerability, including documented shortages, product discontinuations, or limited manufacturer participation. Conclusions: Supply-chain vulnerabilities were identified across multiple first-line sexually transmitted infection therapies, indicating that disruption risk is not confined to a single drug. There is a need for policy interventions to strengthen supply-chain resilience, including diversification of active pharmaceutical ingredient sourcing and distribution networks, as well as incentives for sustainable generic production.