Surge in STI Rates Cause Alarm

By: Ranier Simons, ADAP Blog Guest Contributor

Public health in the United States has been challenged heavily in recent years with the coronavirus, meningococcal disease, and monkeypox virus. Newly released data, from the U.S. Centers for Disease Control & Prevention (CDC), paints a grim picture evidenced by the rates of sexually transmitted infections (STIs) sharply increasing during this time.[1] Personal behavior choices, regarding sexual activity, are one of many factors contributing to unfavorable STI numbers. For example, research is indicating that MSM (men who have sex with men) who are taking PrEP are using condoms less.[2] The protection provided by PrEP against HIV is causing MSM to have a false sense of security even though it does not protect against other STI’s.[3] However, behavior modification is only part of the discourse towards solutions.[4] Issues with insufficient public health funding, persistent social stigma, demonizing politics, and inconsistent policy comprise the scaffolding that undergirds the increased STIs rates.

Photo Source: ACT for Youth

Recent CDC reporting of the preliminary data indicates 2.5 million reported cases of chlamydia, gonorrhea, and syphilis in 2021.[1] The numbers will increase as 2021 numbers continue to be reported in 2022. New cases of chlamydia, gonorrhea, and syphilis all increased. In 2021, syphilis infection rates reached the highest level since 1991 and the total number of cases was the highest since 1948.[5] There was a 26% increase in new syphilis infections from 2020 to 2021 in contrast to a 7% increase from 2019 to 2020.[6] The number of gonorrhea and chlamydia infections increased 4%. HIV cases also increased 16% in 2021 from 2020.[5] Increased numbers of congenital syphilis cases coincided with the increase in overall syphilis infections. Higher congenital syphilis numbers mean more child deaths, deformities, blindness, and stillbirths.[5]

Higher STI numbers indicates increases in sexual activity. Surges in sexual activity can partially be attributed to people becoming more active as covid lockdowns ended and people relaxed their social distancing practices. Data also indicates increased substance abuse during the pandemic has led to more unprotected sex and other less safe sexual practices.[5] 

Prevention and treatment are the best ways to combat STIs. However, existing barriers hamper  efforts. During the pandemic, many people lost their jobs which meant a loss of health insurance. Additionally, many free clinics paused in-person testing and some closed. Funding issues existed even before the pandemic. Elizabeth Finley, Director of Communications for the National Coalition of STI Directors states: “The programs and safety net clinics that provide essential services have long been operating on shoestring budgets and are at a breaking point – a trend accelerated by the devastating impact of COVID-19 and monkeypox…It’s long past time to increase program budgets so that they can respond to the exploding number of infections in their communities and to create a dedicated funding stream for STI clinical services.”

The federal Title X program is an example of a funding challenge. In its most recent spending bill, Congress kept the program funding flat at $286 million dollars instead of increasing it. Many state health departments and independent sexual health clinics are part of the Title X family planning program. Keeping funding flat means that the U.S. Department of Health and Human Services had to shift resources to try and reach the areas of the country with the most need. Thus, many providers in the program, in states with high STI rates, received large budget cuts.[7] Title X providers reach those who fear getting an STI test or treatment at a regular doctor’s office for fear of it showing up on insurance statements; especially youth still on parents’ insurance policies. 

Photo Source: Signature Care

Jen Laws, President and CEO of Community Access National Network, states: “Social stigma associated with sex is an extraordinary contributing factor in both the rise of STIs and the refusal of legislators to appropriately fund treatment and prevention programs. The current socio-political environment is toxic – rhetoric demonizing LGBTQ people and ignoring the educational needs of adolescents only fosters an environment where it's increasingly dangerous for patients to seek the care and advice they need to navigate a healthy sex life.”

The Biden Administration has proposed to increase Title X funding to $400 million for 2023, but that will not help the current situation. Other solutions involve the current infrastructure as well as private industry. Leandro Mena, the CDC’s director of STI prevention, suggests that drug addiction treatment facilities should add STI services, and the private sector needs to develop more effective STI tests, treatments, and vaccines.[7] Home test kits for STI’s would be a worthwhile private sector development effort. Kits will make it easier for people to find out if they have an STI as well as take steps to prevent spread in the same manner that home coronavirus test kits do.

A multi-pronged approach is required to battle surging STI rates. Proper funding is required, private sector interest and innovation is necessary, normalizing sexual health as a part of wholistic healthcare, and increasing education efforts. Even though money is a large part of the equation, a paradigm shift is also key to effective change.

[1] CDC. 2022. Preliminary 2021 STI Surveillance Data. Retrieved from https://www.cdc.gov/STI/statistics/2021/default.htm
[2] Hendrie, D. (2018, June 7). Rapid uptake of PrEP linked to declining condom use. Retrieved from https://www1.racgp.org.au/newsgp/clinical/rapid-uptake-of-prep-linked-to-declining-condom-us
[3] Nelson, R., Nagata, J. Condom Use for Anal Sex in the Era of Pre-exposure Prophylaxis (PrEP). Journal of Adolescent Health. 2022. 71(2). 245. DOI: https://doi.org/10.1016/j.jadohealth.2022.05.014
[4] Samuel, K. (2020, Nov 30). How PrEP users decide whether to use condoms. Retrieved from https://www.aidsmap.com/news/nov-2020/how-prep-users-decide-whether-use-condoms
[5] Stobbe, M. (2022, September 19). Out of control STI situation prompts call for changes. Retrieved from https://apnews.com/article/monkeypox-science-health-covid-epidemics-aaac64591251293f45c225d3fe963d0c?utm_campaign=KHN%3A%20First%20Edition&utm_medium=email&_hsmi=226604169&_hsenc=p2ANqtz-9DxmD1qskNMHydAQMYYJt6z-rEy9GkI1vckbWlm85Rf6g4BgWoG5YdpKYLf4iD7wLXHxxFxmWJ3bIHEHk5BX0HmKU0Ng&utm_content=226604169&utm_source=hs_email
6] Muller, M. (2022, September 19) Syphilis cases in the US Surged 26% last year, along with other STIs. Retrieved from https://www.bloomberg.com/news/articles/2022-09-19/us-sees-sharp-rise-in-some-sexually-transmitted-infections
7] Ollstein, A. (2022, April 12) STIs are surging. The funding to fight them is not. Retrieved from https://www.politico.com/news/2022/04/12/STIs-funding-00024678

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. 

STDs and STIs On The Rise Despite Decline In HIV Infections

By: Marcus J. Hopkins, Policy Consultant

"…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.

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).

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.