Stamping out STIs
Combating sexually transmitted infections (STIs) involves recognizing disparities, addressing the stigma that surrounds sexual health care, and viewing testing and treatment as a comprehensive care package rather than individual concerns, experts said.
Sexually transmitted infections (STIs) are by no means a new concern, but a steady increase in rates, exacerbated by the opioid crisis and the COVID-19 pandemic, has raised alarm bells for physicians who've kept their eye on the trends.
In 2022, the most recent year for which CDC data are available, more than 2.5 million cases of chlamydia, gonorrhea, and syphilis were reported in the United States. Although the data show a slight decline in chlamydia rates from 2018 to 2022, additional research published this year in Scientific Reports found a 19.7% relative increase in chlamydia prevalence across the country between 2005 and 2016.
Meanwhile, the rate of reported gonorrhea increased 51% from 2000 to 2022, CDC data show, and from 2018 to 2022, reported cases of syphilis rose by a staggering 80%, a factor that's likely helping drive a national shortage of penicillin G.
“This is not a new phenomenon. STI rates have been rising for years now, and they're continuing to rise,” said Jason Zucker, MD, an infectious diseases physician and assistant professor of medicine at Columbia University in New York City. “It's really unclear what's causing the rise, but like most things in the world, it's probably multifactorial.”
Because the causes are multifaceted, the solutions should be too, said Leandro Mena, MD, MPH, an infectious diseases specialist and owner and senior consultant at All-In Health Solutions LLC.
According to experts, those include recognizing the stark disparities in STI rates, addressing the stigma that surrounds sexual health care, and viewing testing and treatment as a comprehensive care package as opposed to individual concerns.
All of these initiatives can start with primary care, they noted, because ultimately, “sexual health is an integral component of our overall health,” Dr. Mena said.
Root causes
The rise in STIs comes on the heels of a dramatic reduction in HIV rates, a feat achieved by the development and deployment of antiretroviral therapies and pre-exposure prophylaxis (PrEP).
“HIV PrEP is an amazing innovation, and the reduction that we've seen in HIV cases is unbelievable and game changing,” said Dr. Zucker.
But the availability of HIV interventions means “people might be more open to condomless sex than maybe they would have been before, which can allow bacterial STIs to increase,” Dr. Zucker continued.
That hypothesis is borne out in data. The percent of males who reported condoms as their primary form of contraception fell from 75% in 2011 to just 42% in 2021, according to the Office of Population Affairs' Family Planning Annual Report, published in 2022.
Concurrent opioid and methamphetamine epidemics have also contributed to rising STI rates.
“The increase of syphilis in people with childbearing potential has been seen to be associated with drug use, which can be injection drug use, but also meth and cocaine,” said Hilary Reno, MD, PhD, a professor of medicine in the division of infectious diseases at Washington University in St. Louis.
Another factor at play is changing cultural norms and the proliferation of dating apps, which may make anonymous sex more common. “Being able to spread out further and meet new people is fantastic … but also can lead to a wider sexual network and maybe further propagation of STIs,” said Dr. Zucker.
But according to experts, one of the most impactful contributors is a lack of sufficient federal funding to test, treat, and track STIs across the country.
“A significant proportion of STI control programs in the United States rely 100% on federal funding,” said Dr. Mena. “This funding has been, in many ways, level funding [since] 2003, 2004. So … for 21 years, programs have been receiving the same amount of money.”
In the absence of federal funding that's kept pace with population growth and inflation, some local governments have stepped up, Dr. Mena said. For those that couldn't, however, the curbed cash flow led to decreased STI services and a reduction in intervention specialists—issues that were exacerbated by the COVID-19 pandemic.
“Before COVID, we already were experiencing declines in public health infrastructure, disease intervention specialists who are the contact tracers, etc.,” said Laura Bachmann, MD, FACP, chief medical officer for the division of STD prevention at the CDC.
Then, during the pandemic, “sexual health clinics were closed and people weren't getting tested, and when they reopened, resources and disease intervention specialists were often diverted to COVID contact tracing instead of STI contact tracing,” explained Dr. Zucker. “Really, for a long period of time, services were diminished, and I still don't think they've come back fully.”
Dr. Reno, who is also the medical director of the St. Louis County sexual health clinic, has seen this play out firsthand. “Our patient volumes have still not at this point gone back to prepandemic levels,” she said.
Disparities and interventions
Not all populations are equally affected by STIs, prompting experts to call for increased education and more targeted interventions to help decrease rates in vulnerable populations.
“Seeing the STI disparities is incredibly shocking,” said Dr. Reno. For example, “in 2018—and it's fluctuated a little, but it's still about this level—Black citizens in St. Louis County had 19 times the rate of gonorrhea as White citizens,” she said.
Research published by Sexually Transmitted Diseases in 2022 showed annual rates of primary and secondary syphilis were 6.42 and 2.20 times higher, respectively, among Black and Hispanic heterosexual women than in their White counterparts.
It's important that anyone working in health care who has patient contact has “an understanding of the impact of racism on medical care as well as gets training in trauma-informed care delivery, cultural sensitivity training, and has, ideally, the time to reflect on this,” said Dr. Reno.
Disparities exist with regards to sexual orientation and gender identity too, with gay, bisexual, and other men who have sex with men (MSM) and transgender women (TGW) disproportionately affected by syphilis, chlamydia, and gonorrhea.
To help curb these rates, the CDC in June released clinical guidelines for doxycycline postexposure prophylaxis (doxy PEP) specifically for MSM and TGW who have had a bacterial STI diagnosed in the past year. The guidelines were based on trials that showed a 200-mg dose of doxycycline taken within 72 hours of sex reduces syphilis and chlamydia infections by more than 70% and gonococcal infections by approximately 50% in this population.
“Doxy PEP is really the first new STI-related intervention we've had in quite some time,” said Dr. Bachmann, who was the lead author of the guidance. However, the intervention does raise concerns about antimicrobial resistance.
“This intervention is recommended for a group that would be at increased risk of acquiring an STI and therefore already often are exposed heavily to antimicrobials, and so teasing out the effect of doxy PEP versus other impacts will be challenging,” she said. Going forward, physicians should be sure to weigh the risks and benefits of doxy PEP with patients and continue surveillance of gonorrhea and other non-STI pathogens.
With that said, “for people who are more vulnerable to STIs, I think [doxy PEP is] an incredible intervention and may allow us to help finally see a reduction in STIs,” Dr. Zucker said.
Strides have also been made when it comes to STI testing flexibility, as the FDA approved the first chlamydia and gonorrhea test with an at-home sample collection kit in 2023. And in August, the FDA approved the first at-home test for detecting syphilis antibodies in blood, although additional testing is needed to confirm a diagnosis. “One of the silver linings that came from the COVID pandemic is that it really shows the consumers were ready to take home the testing on their own,” Dr. Mena said.
Although at-home tests may not be the sole solution to the STI epidemic, giving people the option to self-collect specimens in their home may encourage some to get tested who otherwise would have avoided an in-person visit.
“It's about having choice and not forcing people to do only one thing,” said Dr. Reno.
Sexual health in primary care
Targeting vulnerable populations and expanding testing flexibility are just two of the many changes experts would like to see when it comes to tackling the STI epidemic, many of which involve primary care physicians.
“Fifty percent of STIs are diagnosed by primary care offices,” Dr. Reno said. “Primary care is really an important place where people go for sexual health care.”
Unfortunately, stigma around the subject can stop patients from bringing up sexual health during visits and prevent physicians from inquiring.
“All sexual health care is health care. We've stigmatized sexual health care, and it really needs to be part of regular discussions without hesitation or embarrassment,” Dr. Reno said.
One way to destigmatize the topic is to simply talk to patients about their sexual health regularly and offer testing to every patient.
“There's lots of data that shows that our patients want to talk to us about sexual health, but they want their provider to bring it up, so normalize that discussion,” said Dr. Zucker. “Asking people to go to a special clinic for sexual health services both contributes to stigma and makes it less likely people will go,” he continued. “If they can get the services at their primary care doctor … or wherever they're going for care routinely, [that's] going to be the way we're going to get it to them; we're going to normalize it the most and get access to the most people.”
He offered the GOALS Training (Give a preamble, Offer HIV/STI tests, Ask open-ended questions, Listen for relevant information) from the AIDS Education & Training Center Program as a resource for physicians looking to talk to patients about their sexual history.
Screening in primary care also doesn't have to be time-consuming, Dr. Mena noted.
“You can say, ‘Are you sexually active, when was the last time you had sex? When you have sex, who do you have sex with?’ Based on those two questions that take me less than one minute, you can find out whether it's relevant to continue asking additional questions that will help you determine what is the appropriate next step for that person.”
For most people, normalizing the conversation around sexual health will take practice, Dr. Bachmann said. Physicians should aim to keep conversations nonjudgmental and open-ended and be sure to recognize their own sexual health biases.
Experts also underscored the importance of shared decision making.
“Some patients are still reluctant to be open and honest with their providers, but they often know what they need,” said Dr. Zucker. “So regardless of what my patients tell me, I'm going to offer them STI testing at every visit.”
Even if patients are hesitant to disclose that they're sexually active or say they're not, they may take you up on the offer of testing, he said.
“What matters the most is that they get access to the [care] they need. So normalizing the discussion and then normalizing the offering of services routinely to everyone so that they can decide what's best for them is really important.”
Once the patient decides to get tested, it's also important to offer comprehensive services and not just test for chlamydia and gonorrhea.
“I would like everyone to think about packaged STI testing,” said Dr. Reno. “If someone's indicated and you're testing for gonorrhea and chlamydia, also consider testing them for HIV and syphilis, really make sure that you're not ignoring these other infections [and] following screening guidelines.”
Dr. Zucker agreed. “We really need to think about sexual health as a comprehensive group of services … and then offer prevention services when appropriate. So whether that's HIV prevention services with HIV PrEP or PEP, or STI prevention services with doxy PEP, really thinking about it as a comprehensive package of things that can be offered to patients, and not breaking it up individually.”
If primary care physicians have questions about managing sexual health, resources are available. Dr. Reno suggested the National Network of STD Clinical Prevention Training Centers, and Dr. Bachmann cited the CDC's guide to taking a sexual history.
“The reality is that we have good tests, we have good treatment. I think that there is so much that we all can do,” said Dr. Mena.
Primary care “is a broad area, there's a lot for an internist to tackle during a visit because of that, but I think there's really an opportunity to, again, have these conversations with people, and set the expectation that this is part of your health, too,” added Dr. Bachmann.
Although more work is needed to combat the STI epidemic, experts stressed that society as a whole has made significant strides in normalizing discussions of sexual health and sexuality in recent years.
“It's amazing that we're able to be much more sex-positive than we were years ago,” said Dr. Zucker. “So, while we have this new problem that we need to address, that doesn't mean that the answer is to go back to the old ways.”
