April 26, 2017
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Q&A: Stigma remains major challenge in combating STD epidemic in US

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Each year, the CDC recognizes April as STD Awareness Month to raise public awareness about the impact of STDs and the importance of prevention, screening and treatment. This year, the CDC is particularly focused on syphilis prevention, as the rate of reported cases is the highest it has been in 20 years.

According to the CDC’s annual Sexually Transmitted Disease Surveillance Report, primary and secondary syphilis cases rose 19% from 2014 to 2015, with nearly 24,000 cases identified in the U.S.

In addition to an increase in syphilis cases, the number of chlamydia cases rose 5.9% to more than 1.5 million, and the number of gonorrhea cases increased 12.8% to nearly 400,000 cases. Altogether, the three nationally reported STDs reached a record high of approximately 1.9 million cases. An overall estimate of the prevalence of new and existing STDs, including the syphilis, chlamydia, gonorrhea, herpes simplex virus type 2, hepatitis B virus, HIV, HPV and trichomoniasis, is 110 million cases nationwide.

Jeanne Marrazzo

In recognition of STD Awareness Month, Infectious Disease News spoke with Jeanne Marrazzo, MD, MPH, director of the division of infectious diseases at the University of Alabama at Birmingham School of Medicine, about the STD epidemic in the U.S. and how clinicians can combat it. – by Stephanie Viguers

Why is STD prevalence at an all-time high in the U.S.?

This is a complicated question because the answer depends on what STDs we’re talking about. When looking at trends in men who have sex with men (MSM) over the last 2 to 3 decades, we saw a really dramatic decline in the prevalence of most of these infections, especially syphilis and gonorrhea. Unfortunately, we are not seeing that right now. In fact, we are seeing dramatic increases in this group. We are not sure whether this is because these men are engaging in higher risk behavior now that people are doing better on ART, or whether it is something else. Whatever the reason, the fact remains that syphilis, for example, is at a historic high among MSM. When I was a fellow in Seattle in the mid-1990s, there was 1 year where we had one case of syphilis. Last year in Seattle, they recorded more than 530 cases. I think there are a few things going on, but that group in particular is clearly having a very substantial increase.

For the population in general, we do not have a very good STD control program. Even when we do have a good STD program, we are not always assured that it is being appropriately implemented. For example, even though the U.S. Preventive Services Task Force and CDC recommend that young women who are sexually active be screened every year for chlamydia infection, that happens probably less than half of the time. Another great example is the HPV vaccine. We absolutely could end the HPV epidemic probably in the way that Australia has done, but we don’t have the political and scientific will to make that happen. That’s been very challenging.

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What are some of the challenges that clinicians face when treating patients with STDs?

The big one, to be perfectly honest, is stigma. It prevents people from giving an honest, accurate and full disclosure of what their risk is. It still takes a lot for people to feel comfortable talking to their health care providers about their sexual behavior, particularly when that sexual behavior may be seen as different than what the provider is used to. That is just a fact of life that I don’t think we have been able to get around in the United States. In the Deep South, there is a lot of stigma around acknowledging same-sex behavior, and that is probably one of the reasons that we have such a hard time getting young men into HIV prevention care services.

I also think that there are a lot of misconceptions about STDs among health care providers. It is not always emphasized in medical school curriculum to get good experience in STD evaluation. Medical students need to train with somebody who has seen it, understands it and is willing to talk about it. In addition to a lack of provider education, there is a lack of political will. For example, you might want to give your patient an HPV vaccine, but it is expensive and you have to go through some hoops to get it.

Another challenge is that we do not have a good point-of-care diagnostic test for STDs. We rely on screening to detect asymptomatic infection and that can be very hard to do if you do not have a good test. Even with great tests, the results still take some time before being read. That is an important barrier because clinicians cannot automatically get the precise results of the test when they are seeing the patient.

Which patients are most at risk for STDs, and how can they prevent becoming infected?

Right now, I would say young people. They are more at risk partly because their immunity is not as strong as that of older adults. Another high-risk group is MSM. There are also impressive racial and ethnic disparities around nonwhite races compared with the white race. There are a lot of theories for why that is, such as access to care, but those populations are very vulnerable to those infections and their effects.

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It is really important for high-risk patients to educate themselves on what their risks are. They should not assume that just because the health care provider does not bring up STDs, that they are not worth talking about. Patients should also definitely take advantage of vaccines that are available to them. The HPV vaccine is probably one of the most important public health tools that we have right now and there should be widespread availability. It is now recommended for all young men and women and MSM who wish to receive it.

What can be done to improve the current approach to STD prevention in the U.S.?

I think linking the idea of STD prevention with sexual health makes a lot of sense. We need to start emphasizing the positive aspects of understanding and protecting yourself from STDs. The positive aspects for women include the effects on fertility. The worst thing about chlamydia is that it is the major infectious cause of infertility in the U.S. If people really understood that, they would likely feel somewhat differently about the need to be screened regularly.

What is the most important message for clinicians during STD Awareness Month?

These are incredibly common infections. For example, when you start having sex, your lifetime risk of acquiring HPV is about 50%. That has nothing to do with being “promiscuous. ” That word should really be removed from the vocabulary of the clinician. So, an important message is that sexual health doesn’t necessarily mean being disease free, and we have to rethink what we mean when we say disease in that context. It is also important to know how to talk about patients’ sexual risk with comfort. They want to be able to talk to you and ask questions about this. It’s really important to make them feel like they can do that in a comfortable setting where they are not going to be judged. That will allow them to get the help that they need.

Disclosure: Marrazzo reports no relevant financial disclosures.