"…not that long ago, gonorrhea rates were at historic lows, syphilis was close to elimination, and we were able to point to advances in STD prevention, such as better chlamydia diagnostic tests and more screening, contributing to increases in detection and treatment of chlamydial infections. That progress has since unraveled. The number of reported syphilis cases is climbing after being largely on the decline since 1941, and gonorrhea rates are now increasing. This is especially concerning given that we are slowly running out of treatment options to cure Neisseria gonorrhoeae. Many young women continue to have undiagnosed chlamydial infections, putting them at risk for infertility (Centers for Disease Control and Prevention, 2018)."The above quote is taken directly from the Foreword of the 2017 Sexually Transmitted Disease Surveillance 2017 report published annually by the Centers for Disease Control and Prevention’s (CDC’s) National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, and it is a damning condemnation of our nation’s abject failure to adequately educate Americans about sexual health.
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| Photo Source: on health.com |
For those of us who grew up in the 1980s and 90s, the threat of becoming infected with HIV was an existential threat, especially if you happened to be a gay male. Being gay was far less accepted, then, as it is, now, and visibility of the LGBT community was largely relegated to punchline status – the wacky gay best-friend of the adorable straight girl; the butch lesbian or transsexual gym teacher; the fruity, yet sophisticated Elder Gay whose surprisingly vast disposable income afforded him a gigantic Manhattan apartment. And then, there was the “Dying of AIDS Gay” – the character who was supposed to teach us all a very valuable lesson about compassion towards people living with AIDS.
In addition to all of this stereotyping, the 1990s also gave us Comprehensive Sex Education (CSE) that included scientifically accurate information about HIV and other Sexually Transmitted Diseases (STDs) and Sexually Transmitted Infections (STIs), as well as scientifically accurate information about sex and pregnancy. I was lucky enough to receive this education at my public schools in both West Virginia and Tennessee, and I can safely say that it was both accurate, and slightly terrifying. But, my generation (which graduated in 2000) may have been the last to receive this kind of CSE.
CSE programs were, and still are, highly controversial in the U.S. The Republican Party, alongside Conservative Democrats, Christian groups, and a bevy of parents who are flummoxed that people other than themselves have or will have sex before marriage have sought to foist Abstinence-Only-Until Marriage (AOUM) sex “education” programs upon America’s school children. Between 1996 and federal Fiscal Year (FY) 2018, Congress has funneled over $2.1 billion in taxpayer dollars into AOUM programs (Sexuality Information and Education Council of the United States, 2018). Every time Republicans seize control of legislation chambers, at both the state and federal levels, funding streams are created for AOUM programs, and every time those programs are introduced into U.S. schools, the outcome is the same: a drastic increase in the number of STDs and STIs.
Despite the best efforts of U.S. local, state, and federal governments, HIV education organizations, advocates, and activists, and nearly forty years of living with the specter of the HIV virus, testing rates for HIV outside of urban areas remains “suboptimal,” according to a report published in a recent edition of the Morbidity and Mortality Weekly Report (Pitasi et al, 2019). This report analyzed testing data from seven states with a disproportionate incidence of HIV infections in rural areas compared to other states (AL, AR, KY, MS, MO, OK, and SC) and found that <40% of the total U.S. adult population had ever been tested for HIV, and that areas of the country where rates of reported HIV infections were high also had high rates of overall HIV testing (i.e. – more people getting tested for HIV resulted in more reported cases of new HIV infections). The converse was also true: in areas where HIV testing rates were lower reported fewer new HIV infections (Pitasi et al).
In the seven jurisdictions where HIV incidence was disproportionate in rural areas compared to those states’ urban areas, even though “ever testing for HIV” rates was lower, those rural areas were still disproportionately impacted by new HIV infections (Pitasi). This disparity indicates the need for much more rigorous testing campaigns, and perhaps locally tailored testing drives to help increase the number of people being tested.
This testing disparity doesn’t stop at HIV, however; testing for every STD/STI is less common in rural and suburban areas, compared to rural areas:
The most common STD in the U.S. is Chlamydia, with 1,708,569 cases reported in 2017 for a rate of 528.8 cases per 100,000 population – a 6.9% increase from 2016. This increase was demonstrated in all regions of the U.S. and among all racial and Hispanic ethnicity groups. Almost two-thirds of cases were among persons aged 15-24, and among women aged 15-24, the rate of infection 3,635.3 per 100,000 (CDC). The second-most common STD is Gonorrhea, with a total of 555,608 cases in 2017 – an 18.6% increase over 2016. The third-most common is Syphilis, with a total of 30,644 cases of Primary and Secondary Syphilis – a 10.5% increase over 2016 (CDC).
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| Photo Source: ealth.wyo.gov |
These numbers are incredibly alarming, not only because they are increasing so rapidly, but because they represent only those cases reported to the CDC. There are potentially thousands more cases of people infected with these STDs who are unaware of them. This represents, again, an abject failure on the part of U.S. federal, state, and local governments to educate Americans about sexual health and disease transmission. The government, however, is not the only party at fault for failing to staunch the bleeding, as it were; physicians have also failed their patients by refusing to include STD/STI testing as part of a comprehensive battery of annual tests.
Recommendations for STD testing in the U.S. are unsurprisingly lax, focusing primarily upon sexually active women and gay and bisexual Men who have Sex with Men (MSM). Sexually active women should be tested annually for Chlamydia; all MSM should be tested annually for everything. Of course, there’s little mention of straight men getting tested, save for a brief mention about annual HIV testing if you have “unsafe sex.”
(Psst - Guess what: if you’re having “unsafe sex,” you should probably get tested annually for more than just HIV. Just a thought.)
Other nations, however, take a far more intelligent approach: once you become sexually active, you should be tested annually for everything…BY YOUR GENERAL PRACTITIONER.
For whatever reason, American physicians rarely question their patients about their sexual activity, and as such, rarely offer testing as part of a comprehensive battery of tests provided. Add into this the populations who either have no family physician, can’t afford visits to the doctor, or simply don’t go, and you’ve got a gigantic pool of sexually active people who have no idea whether or not they are infected with or infecting others with STDs/STIs.
In 2018, a cluster of Syphilis and HIV infections affected at least 125 people, including high school students, in Milwaukee, WI (Causey & Spicuzza, 2018). Walla Walla County in Washington State is currently experiencing a Gonorrhea outbreak (Yazwinkski, 2019). Alaska’s rate of Chlamydia continues to rise (KTVA, 2019). Rock Island County in Illinois is experiencing a Gonorrhea outbreak (Galvin, 2019). These aren’t isolated incidents; they are part of an overall picture that desperately needs addressing.
Beyond just the risk of failing to test and risking the further spread of common STDs and STIs, there is the growing risk of those STDs/STIs mutating to become treatment resistant. We have already seen this manifest in the form of Gonorrhea becoming increasingly resistant to the antibiotic drugs used to treat it. Now, as we begin to see global rates of new HIV infections decline, we are also seeing drug resistant mutations of the HIV virus, particularly in areas of the world where inconsistent access to supplies of medications over the past twenty-plus years has resulted in patients building up resistances to certain older HIV regimens (specifically efavirenz- and nevirapine-based regimens). This has occurred primarily in countries in Africa, Asia, and South and Central America, where supplies may not always be consistent to provide patients with a constant supply of HIV medications allowing them to be compliant with their regimens (World Health Organization, 2019).
It’s time we start taking STD and STI prevention seriously, again, and the first step in doing so is to do away with AOUM sex education, in its entirely. It doesn’t work; it has never worked; it will never work, because it ignores basic human nature and sexuality. People – yes, including teenagers – are going to have sex, whether or not their parents, their churches, or Republicans like it. It’s time to stop pretending that these programs work, and to stop bowing to pressure from organizations that pretend to care about “family values” and parents who insist that their children shouldn’t be “subjected” to CSE. It is time to do what is best for America’s sexual health, critics bedamned.
References:
- Causey, J.E. & Spicuzza, M. (2018, March 06). HIV, syphilis cluster affecting at least 125 people discovered in Milwaukee. Milwaukee, WI: Milwaukee Journal Sentinel. Retrieved from: https://www.jsonline.com/story/news/local/milwaukee/2018/03/06/hiv-syphilis-clusters-affecting-least-125-people-including-high-school-students-discovered-milwaukee/397534002/
- Centers for Disease Control and Prevention. (2018, September). Sexually Transmitted Disease Surveillance 2017. Atlanta, GA: United States Department of Health and Human Services: Centers for Disease Control and Prevention: National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Retrieved from: https://www.cdc.gov/std/stats17/2017-STD-Surveillance-Report_CDC-clearance-9.10.18.pdf
- Galvin, G. (2019, April 23). Gonorrhea Outbreak Declared in Illinois County. Washington, DC: U.S. News and World Report: Healthiest Communities. Retrieved from: https://www.usnews.com/news/healthiest-communities/articles/2019-04-23/gonorrhea-outbreak-declared-in-illinois-county
- KTVA. (2019, April 23). Alaska’s chlamydia rates still on the rise amid STD outbreaks. Anchorage, AK: KTVA. Retrieved from: https://www.ktva.com/story/40355743/alaskas-chlamydia-rates-still-on-the-rise-amid-std-outbreaks
- Pitasi, M.A., Delaney, K.P., Brooks, J.T., DiNenno, E.A., Johnson, S.D., & Prejean, J. (2019, June 28). HIV Testing in 50 Local Jurisdictions Accounting for the Majority of New HIV Diagnoses and Seven States with Disproportionate Occurrence of HIV in Rural Areas, 2016–2017. Morbidity and Mortality Weekly Report, 68(25), 561-567. DOI: http://dx.doi.org/10.15585/mmwr.mm6825a2external icon
- Sexuality Information and Education Council of the United States. (2018, August). A History of Federal Funding for Abstinence-Only-Until-Marriage Programs. Washington, DC: Sexuality Information and Education Council of the United States. Retrieved from: https://siecus.org/wp-content/uploads/2018/08/A-History-of-AOUM-Funding-Final-Draft.pdf
- World Health Organization. (2019, July). HIV drug resistance report 2019. Geneva, SW: World Health Organization: HIV/AIDS: Publications. Retrieved from: https://apps.who.int/iris/bitstream/handle/10665/325891/WHO-CDS-HIV-19.21-eng.pdf?ua=1
- Yazwinsky, T. (2019, July 31). Walla Walla County experiencing gonorrhea outbreak. Walla Walla, WA: KEPR. Retrieved from: https://keprtv.com/news/local/walla-walla-county-experiencing-gonorrhea-outbreak
Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.
