Our study on exploration of HCPs’ experiences with SRH promotion during the COVID-19 pandemic revealed telehealth’s major impact on care delivery across the Western and Central regions of New York state. During the pandemic, sexual health care was not regarded as essential [3, 34, 35]. HCPs transitioned from in-person visits to new appointment modalities and use of mail-order pharmacies, and home STI /HIV testing. This significant shift in care provision for clients exposed facilitators and barriers to telehealth use among HCP in SRH. General barriers were a lack of provider comfort to manage sexual health dynamic and socioeconomic health disparities. These impediments have also been reported in previous studies [18, 19, 36] and are indicative of telehealth being a relatively new mode of care delivery. Telehealth was also perceived to reduce sexual health stigma. Findings indicated that with telehealth, people who would not seek health care due to anticipated stigma, associated with seeking care. Also, home-based testing may have helped increase STI screening within sexual networks and help linked people to care including PrEP care [37, 38]. This finding might explain why as testing for HIV and other STIs reduced significantly globally due to the COVID-19 pandemic (39), in Western New York State, the testing services increased and new STI diagnoses increased by 77% [22].

HCPs in this study reported telehealth benefits for easing access to patients, enhancing the provision of family and couple-based care, and increasing patient comfort, which can be foci for training current and future providers. Such training must be population specific and culturally responsive to client needs and perspectives while simultaneously provide modalities of telehealth care that are appropriate for HCP use in SRH. Despite telehealth being commended as a method for sexual health promotion, this study revealed some important determinants for telehealth implementation. Providers reported challenges to implementation that included: loss to follow up, limited physical assessment, internet interruption, and lack of privacy. Some loss to follow up could be addressed by client access to reliable internet service that is free or affordable, a device with video capabilities and audio/headphone features such as noise cancelation, or access to a safe space with privacy. Optimizing telehealth implementation also requires adjustment to new behavioral expectations for engagement such as looking at a camera for direct eye contact instead of the screen displaying the image of the other person [40]. A client may appear to be uninterested or not focused on the discussion when looking away, impacting the HCP’s interpretation of the client’s mood and affect. Yet, the observation may result from technical concerns related to camera and screen positions. HCP narratives also described limitation for assessing clients’ skin conditions for diagnosis, suggesting need for resources and guidance on clothing choice and lighting, as an environment influences appearance during virtual physical assessments. Perhaps clients need to be provided with telehealth resources that include the necessary equipment to maximize the telehealth visit [40].

Promoting telehealth etiquette can impact unintended interruptions and distractions that can include a choice of background images, filters, attire, or nontraditional visit in public locations. A client may willingly disclose elements of their environment or share that they are speaking candidly while others are present (on camera, or off-camera). However, HCP’s might be uncomfortable and distracted during the health care encounter; echoing the need for HCP to consider practice guidance that mutually reflects client’s input related to intended and preferred telehealth etiquette expectations. HCP’s perspectives in this study support other reports that suggest a need for “screen side etiquette” during telehealth assessment and care to optimize settings (e.g., visual, audio, etc.) and reduce interfering factors from the health care setting or client’s environment [41].

Collective HCP perceptions in the current study underscore the lack of infrastructure preparedness and training for broad use of the telehealth modalities described contribute to the field of research. Prior to the pandemic perspectives on the underutilization of telehealth training in primary care and specialty care for nurse practitioners (NP) and students in NP programs had been reported with the need to increase provider comfort, knowledge, and skills necessary for embracing telehealth at the forefront of health care [42].

The implementation of telehealth for sexual health promotion was facilitated by several factors. Organizational-level factors included the health facility’s capacity in tandem with the already existing plans to introduce telehealth prior to the onset of the COVID-19 pandemic restrictions. Narratives indicated that health facilities that had an already existing plan to implement e-health sexual health services, simply expedited their plan and strategically put in measures to help their clientele adapt to the emerging approach to remote sexual health care delivery. For some, the sudden surge in national use without established governmental and organizational guidance was more of a pandemic attribution than initiation of telehealth in practice. This suggests telehealth was underused and understudied until the COVID-19 pandemic, during which reduced regulations and increased payment parity facilitated a rapid increase in telemedicine consultation [50]. This underutilization and the limited studies regarding telehealth in specialty care may explain why some healthcare providers in this study reported their hesitancy and perceived lack of knowledge, demonstrating mistrust of its effectiveness and adherence to ethical standards and advocating for a combination of virtual and in-person care.

Findings also suggests the need for patient orientation to seeking sexual health considering that telehealth is currently being integrated into the health system. In contrast, agencies that had no existing facilities reportedly were challenged by initiating telehealth use for SRH services. Such that meeting typical and standard SRH needs slowed down or ceased altogether to focus on COVID-19 prevention and care activities.

Providers eventually within their roles began strategizing on how to meet patient’s health needs via telehealth and started slowly to implement telehealth services. Thus, the health providers’ attitude and knowledge of telehealth, and the cordial working relationship between physicians, advanced nurses, nurses, and social workers facilitated and enhanced the patients’ access to sexual and reproductive health care, vital elements in continuity of care [43].

The healthcare providers in this study, like in other previous studies [19] reported the challenges they faced with health insurance not willing to cover the cost when some modalities such as phone calls were used. It was under such circumstances that the healthcare providers’ understanding and willingness to meet the healthcare needs of the patients was essential. This gesture was commendable and aligned with the multifaceted patient-centered sexual healthcare delivery framework which Ohta, Ikeda and Sawa [44], Cuomo, Zucker and Dreslin [45], Gunaratne and Hansen [46] advocated for during the pandemic. Implementation of telehealth was made possible due to provider willingness to render sexual health services even when the facility was faced with profit loss due to reimbursement prohibitions the HCP narratives presented in this study and in other study reports [47].

Additionally, patients’ and HCPs’ understanding of telehealth and its necessity allowed telehealth to be doable, speaking to sustainability of this modality. Notably, 48 states including Washington, D.C., covered some degree of telemedicine in 2016 compared to only 24 states in 2005, based on American Telemedicine Association Coverage and Reimbursement report [48]. Therefore, telehealth reimbursement, although an increased priority for wide-spread enactment, was not a novelty due to the pandemic, as policies and logistics were previously established nationally. Despite increased national dialog, HCPs and patients were not well oriented to telehealth, and most may have needed more time to adjust, due to the rapid uptake of the modality warranted by COVID-19 and in-person restrictions [47]. Therefore, more research, provider and patient training, and orientation are required to develop better strategies and trust care in provision via telehealth service for sexual health promotion [49].

An interdisciplinary lens and subsequent cordial working relationship among the nurses, physicians and the social workers was also reported to facilitate the telehealth services. The nurses were reported to help with other visits that did not necessarily require the physician’s attention such as PrEP management and STI care, while the social workers helped by following up with patients who missed appointments and needed treatment refills, in addition to making sure partners of those diagnosed with STIs were treated. This finding is consistent with previous studies that reported telehealth physicians to be more dependent on their social systems, particularly nurses, than physicians working in-person [50]. During the pandemic, nurses have been reported to play a significant role in ensuring the visit is well coordinated and in ensuring a smooth workflow [50]. Thus, nurses are essential in the delivery of telehealth-based care.

Additionally, the narratives in this study showed that social workers are also critical to the implementation of telehealth for SRH promotion and care. Previous research suggest that social workers help to harness a range of skills and competencies of importance to the emerging needs of the patients during the pandemic including risk assessment, crisis management, advanced care planning, case management, systems navigation, problem solving, resource allocation, and community mobilization [51, 52]. These results show that a meaningful collaborative and mutually respectful interdisciplinary relationship is critical for achieving quality outcomes for patients and for the longevity of the telemedicine operation.

As in-person health services resume, health agencies must consider strategizing to maintain telehealth services in their facilities. Moreover, providers in this study, reportedly saw the merit for telehealth beyond COVID restrictions. Nevertheless, studies report differing views regarding whether telehealth is sustainable for delivering sexual and reproductive health services and that there are some considerations for planning integration of telehealth services. In a previous study by Yelverton et al [19], the participants questioned whether it was feasible for HIV testing services and PrEP to be provided entirely through telehealth and suggested a hybrid combination of remote and in-person delivery. The study also showed that participants questioned whether HIV home testing was done in a proper manner and stressed the need for in-person coaching of clients to ensure high-quality HIV testing and reliable results.

Hollander and Carr [10] report that telehealth needs to be prioritized when healthcare providers are planning health visits. They suggest that health facilities that have telehealth services need to leverage them. Systems lacking such programs can outsource similar services to physicians and support staff provided by multinational telemedicine and virtual healthcare companies. Hollander and Carr [10] and Yelverton et al [19] observe that the current major barrier to large-scale telehealth, is HIV/STI screening that can be overcome by proper coordination of testing and expanding testing sites. It is pivotal to educate future health care providers about these social determinants so that they can work to mitigate the resulting disparities and thereby improve the health of patients and their communities.