There is some bad news and worse news in the 2018 Sexually Transmitted Disease Surveillance Report, published earlier this month by the U.S. Centers for Disease Control and Prevention (CDC). The report showed that, for the fifth year in a row, cases of three sexually transmitted diseases (STDs, also called sexually transmitted infections, or STIs) -- syphilis, gonorrhea, and chlamydia -- were up.
Now for the bad news. Regarding STDs, the CDC's 2018 surveillance report found more than 2.4 million cases of chlamydia, gonorrhea, and syphilis. Those include:
More than 115,000 syphilis cases. The most infectious stages of syphilis increased 14% to more than 35,000 cases, the highest number reported since 1991.
Gonorrhea at 580,000 cases, up 82.6% from a historic low in 2009.
Chlamydia increased 3% to more than 1.7 million cases, also the most ever reported to the CDC.
Even worse, syphilis among newborns (congenital syphilis) increased 40% between 2017 and 2018, to more than 1,300 cases, and deaths associated with congenital syphilis increased 22% in one year.
The report found that rates of reported gonorrhea and chlamydia were highest among teens and young adults. The report concluded that primary and secondary syphilis cases were highest among adults ages 25 to 29, and half of all new STD cases are acquired by youth ages 15 to 24. One in four sexually active adolescent girls has an STD, the report said. Those conclusions underscore the 2017 Youth Risk Behavior Surveillance, published last year by the CDC, which found that condom use among sexually active high school students decreased from 62.8% to 53.8% between 2005 and 2017. Estimates of an increase in unprotected oral sex among young people may also be contributing to the STD incidence increase.
STDs have serious health consequences, including infertility and congenital syphilis, which can cause infant death. Antibiotic resistance is rising too, and gonorrhea is increasingly resistant to pharmaceutical defenses, according to the surveillance report. And recent research concludes that gonorrhea and chlamydia are driving new HIV infections among men who have sex with men.
Not long ago, gonorrhea rates were at historic lows, and syphilis was close to elimination. So what happened? In the report, the CDC didn't make any firm conclusions for reasons explaining the spikes, but it has suggested that increasing heterosexual syphilis transmission is tied to meth and opioid epidemics and could be addressed by better access to counseling and health care.
Beyond the recent drug use epidemics, advocates say three factors are causing a perfect storm for increasing STD infection rates: Funding cutbacks in STD and sexual health services, the rise in abstinence-only education, and the fragmented health care system in the U.S. create multiple barriers to care and are contributing to the spike in STDs.
Less Money, Fewer Clinics, Less Culturally Competent Care
Following the release of the CDC surveillance report, the National Coalition of STD Directors (NCSD) said that "steep increases in STDs are largely due to federal, state, and local funding cutbacks," and called on Congress to increase funding for CDC's STD prevention services by $70 million, "the bare minimum it will take to support an effective response to this crisis."
A recent report conducted by the public health research group Trust for America's Health estimated that 55,000 jobs were cut from local public health departments from 2008 to 2017. The CDC has reported that budget cuts resulting in clinic closures, higher caseloads, and a lack of patient follow-up have affected half of local STD-prevention programs in recent years.
"Since 2003 the STD prevention line at the CDC was either cut or flat funded every year," said Matt Prior, M.P.H., director of communications at NCSD. "These programs are operating at a 40% reduction in funding since 2003, adjusted for inflation. To us it's clear that public health workforce reaches fewer people today."
Jennifer Wagman, Ph.D., a professor of infectious diseases and gender inequality at UCLA, was part of a research team funded by the CDC in 2018 to find the root causes of a spike in congenital syphilis in Kern County in California's Central Valley. The intent, she said, was to interview pregnant women and natal care providers, but though she thought it would be easy to visit drop-in clinics and get people to participate, Wagman and her team found that none of the clinics were autonomous.
"We had to go through corporate offices. In this region, almost all clinics were part of one or two big health care networks. The WIC clinics, with their sliding scale, are no longer options. The little clinics have been bought out." That corporatization causes a barrier to care, Wagman said, because it creates hurdles for people in poverty or without insurance. Beyond that, many providers didn't have testing kits for syphilis. And those that did have testing kits, didn't have rapid testing, and required patients to go to the local health department to get test results. "That's a level of patient drop-off right there," Wagman said.
"In the focus group discussions with pregnant or new moms, there was perceived stigma around care, [and that] deterred them from feeling safe to discuss sexual health. Several women struggling economically, high rates of drug use and recovering addicts. Drug use was a 'dirty issue,' they said, and they didn't want to discuss it with providers," Wagman said. "They were afraid of arrest and having babies taken away. Many women already delivered a syphilis baby which later died, and then they were infected [with syphilis] again."
Infectious disease experts know that access to care is a key determinant in whether a person will get tested and treated, and there are many drop-offs even for people who are able to access care.
Primary care should be testing for STDs routinely, but isn't, according to Emily McCloskey, director of policy and legislative affairs with the National Alliance of State and Territorial AIDS Directors (NASTAD). "There is a stigma among patients about asking for STI tests," McCloskey said. "For under 26 year olds on parents' insurance, they may be wary to get tested. And when I've asked for [STI tests], my doctor has said, 'Are you sure you need that?' I think that reluctance to test is not uncommon. A lot of people are getting missed."
"It is not the fault of the patient that the doctor is dropping the ball," said Ace Robinson, director of strategic partnerships at NMAC. Robinson said he's seen evidence that doctors are even more reluctant to test black, Latinx, and LGBT patients, and that a lack of cultural sensitivity can prevent these populations from getting tested. "If you are trans Latina, your experience of STI treatment is different than a white gay man. It is never the patients' fault for not receiving competent culturally responsive care. You shouldn't have to teach your doctor how to treat you."
Rob Stephenson, M.Sc., Ph.D., a professor and director of the Center for Sexuality and Health Disparities at the University of Michigan, said that when people do access the public health workforce, either in doctors' offices or clinics, they aren't always getting the full battery of STI tests, even when they ask for them.
"There must be comprehensive STI testing where the doctors won't necessarily look," Stephenson said. "That has to be more than just a blood test or peeing in a cup and should include rectal and throat swabs." Stephenson said he just concluded a study that could provide an alternative to testing (or non-culturally sensitive care) in doctor's offices and clinics. The study gave home testing kits to 50 young male couples, including rectal and oral swabs, and found, according to Stephenson, "a high rate of STIs" that might not have been found with blood or urine tests.
What Are the Schools Teaching?
A growing body of research suggests that federal efforts to encourage abstinence-only sex education do not prepare young people to avoid unwanted pregnancies or STDs.
Robinson pointed out that funding increased for sexual education that promotes abstinence, even in the Obama era. "Abstinence-only" is now called "sexual risk avoidance" and gets $35 million from the federal government, spread out among school districts in the U.S. But Robinson says, it's not even clear what's being taught, if anything, on sexual health from school to school.
"The onus is on the principal to see curriculum is being taught," Robinson said. "Some principals don't do [any sex ed]. There is not enough funding for surveillance to go around to schools to see what is being taught."
Don't Blame PrEP
The increase in these three STDs began not long after pre-exposure prophylaxis (PrEP) became available, which could lead to the perception that PrEP is a factor in rising STI prevalence. The thinking is, if people engaging in anal sex think PrEP protects them not only from HIV but from other diseases -- or, because they're so focused on HIV that they stop using condoms, the key HIV prevention method before PrEP, of course they'll leave themselves exposed to STDs.
But, of course, correlation is not causation. The CDC doesn't have data on STD rates for pre- and post-PrEP use, which could make a causation link. But Robinson says that, logically, PrEP use should make users less likely to contract and spread STDs. "What we can say is people who use PrEP are screened at higher frequency. An HIV-negative man in 2010 with rectal gonorrhea has the ability to pass it on for years. PrEP comes along and that cycle stops. I love anything that gets people into health care, and PrEP does that."
A report released by NCSD in 2018 called for an urgent expansion in funding, tailored STD awareness campaigns, more stigma-free education on sexually transmitted infections, and better coordination between federal, state, and local surveillance, reporting, testing, and education. The U.S. Department of Health and Human Services announced that its Federal Action Plan on sexually transmitted infections will be finalized and released next year.