‘Paying the price for decades of inattention’: STDs resurge in US
According to new figures published by the CDC, reported cases of syphilis, gonorrhea and chlamydia hit approximately 2.4 million in 2018 — the fifth straight record-breaking year for STDs in the United States.
Experts said the sharp increase in STDs could be reversed with the introduction of biomedical advances and better prevention strategies.
“I would say that we are paying the price for decades of inattention and lack of funding for sexual health. We’ve had a very pathogen-specific approach, sort of looking at one [disease] at a time, and what we’ve neglected is a more holistic approach of trying to educate people and invest in meaningful and acceptable prevention,” said Infectious Disease News Editorial Board Member Jeanne M. Marrazzo, MD, MPH, FACP, FIDSA, director of the division of infectious diseases and C. Glenn Cobbs, MD, Endowed Professor in Infectious Diseases at the University of Alabama at Birmingham School of Medicine.
Infectious Disease News spoke with Marrazzo and other experts about the recent surge in STDs and what is needed to stop it.
“We know that condoms work well, but they’re clearly not doing the trick here. So, what would work? What would people use? What is acceptable?” Marrazzo said. “These are all important questions, and finding these answers is essential.”
Another record year
According to Elizabeth Torrone, PhD, MSPH, epidemiologist in the CDC’s Division of STD Prevention, some of the increase in STDs is a result of expanded screening.
“Most STDs are asymptomatic, and screening is needed to identify infection. Increased screening will result in more cases identified,” Torrone told Infectious Disease News. “Increasing case rates, in part, reflect a better job in identifying and treating asymptomatic infections, which will prevent adverse health consequences and help halt the spread of STDs in the community.”
However, Torrone said that the observed increases are not likely to be explained by increased screening alone. Instead, they also are reflective of new and changing transmission patterns, decreased condom use among vulnerable groups and cuts to STD programs at both state and local levels.
“Several things are happening,” said Carlos del Rio, MD, FIDSA, executive associate dean at Emory University School of Medicine. “First there has been an increase in STIs among men who have sex with men (MSM) that started after the advent of potent antiretroviral therapy in 1996. Then there is an increase in drug use, not only the opioid epidemic but also meth and other drugs that have led to a ‘sex for drugs’ epidemic. Finally, there are social determinants of health, poverty, lack of opportunities, lack of education, lack of access to care.”
Infectious Disease News Chief Medical Editor Paul A. Volberding, MD, professor of medicine and director of the AIDS Research Institute at the University of California, San Francisco, noted the increasing use of pre-exposure prophylaxis (PrEP) for HIV prevention among MSM, “where it has almost certainly decreased condom usage as a primary prevention strategy.”
“As condomless sex allows STI transmission, many have raised the question of a relationship between wider PrEP rollout and the rapidly increasing problem of syphilis, gonorrhea, chlamydia and other STIs in MSM,” Volberding said.
“Any such relationship should not be a reason to reduce our efforts to support wider PrEP use but would argue to a much more aggressive focus on more effective means of decreasing STI risk in PrEP users,” he continued. “This could include better targeted education, more available STI screening and the availability of STI treatments in all care settings to reduce any barriers to care. Our success in HIV prevention should not risk an increase in other STIs, especially as drug resistance is also a growing concern.”
Regardless of the cause, the continued rise in STDs comes with serious public health consequences, including drug-resistant gonorrhea and infant deaths caused by congenital syphilis.
“STDs can come at a high cost for babies and other vulnerable populations,” Jonathan Mermin, MD, MPH, director of CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, said in a statement when the new report was published. “Curbing STDs will improve the overall health of the nation and prevent infertility, HIV and infant deaths.”
According to the CDC report, cases of primary and secondary syphilis — the most infectious stages of the disease — increased 14.4% from 30,644 in 2017 to 35,063 in 2018, contributing to the 115,045 total reported cases of syphilis.
The CDC also reported a 40% increase in congenital syphilis cases, paralleling the 36% increase in syphilis among women of reproductive age. In 2018, there were a total of 1,306 reported cases — including 78 syphilitic stillbirths and 16 infant deaths — and a national rate of 33.1 cases per 100,000 live births, a 39.7% increase from 2017, according to the CDC.
The report also contained concerning numbers for gonorrhea. In 2018, a total of 583,405 cases were reported — a 5% increase from 2017, making it the second most common notifiable condition in the U.S. According to the report, rates increased 6% and 3.6% among men and women, respectively, and increased in all regions of the U.S., and among all racial/Hispanic ethnicity groups. Worryingly, more than half of all gonorrhea cases were estimated to be resistant to at least one antibiotic.
“[This] is the most concerning situation,” Marrazzo said. “The challenge with gonorrhea is that it is becoming increasingly resistant to fluoroquinolone and macrolide classes, which are two of the only alternative classes we have. It’s a huge issue. We know it’s inevitable — other countries are experiencing it, putting us in a precarious position with gonorrhea.”
Matthew Prior, MPH, director of communications for the National Coalition of STD Directors, said the world is down to its “last defense.”
“Recently we’ve seen a superbug gonorrhea that is resistant to our last lines of antibiotics — a case in the United Kingdom, multiple cases in Australia and Asia. It’s become an inevitability that it will hit our shores,” he told Infectious Disease News. “Right now, the line of defense is holding strong in the U.S.; however, it’s only a matter of time before the completely resistant strains hit our shores. And as currently armed, we’re not ready.”
Sancta St. Cyr, MD, MPH, a medical officer in the CDC’s Division of STD Prevention, noted that reducing the overall number of gonorrhea cases can help prevent or delay the development of resistance.
“In the event that untreatable gonorrhea does emerge in the U.S., preventing its ongoing transmission will be critical,” she said.
The most common condition reported to the CDC was chlamydia, with 1,758,668 cases in 2018 — a 2.9% increase from 2017. According to the report, nearly two-thirds of those cases were among young adults aged 15 to 24 years and the reported rate of cases in women was nearly two times the rate in men.
‘If you’re having sex in the US, you’re at risk’
The misconception of risk assessment could be a contributing factor to the rise in STDs, Marrazzo and Prior explained.
“The only people who are safe are the ones not having sex,” Prior said. “In this country, STDS are at an all-time high and rising, so if you’re having sex in the U.S., you’re at risk. The best methods for controlling and preventing these infections — besides first-line prevention methods like condoms — are frequent testing and proper treatment.”
Of course, an obstacle to getting tested and receiving treatment is the stigma associated with STDs.
“Part of it is de-stigmatizing STDs, which people think are associated with shame and being dirty. They associate it with what people think of as promiscuity,” Marrazzo said. “It’s not. It’s the price we pay for being intimate with other people.”
“Risk should be broadly interpreted when it comes to STDs,” she added.
Torrone said asking all patients about their sexual history during routine medical exams can help normalize STD screening.
“Providers can ensure that STD screening is a standard part of medical care, especially for groups vulnerable to STDs, such as pregnant women and gay and bisexual men,” Torrone said.
Recent study findings suggested that many physicians lack onsite antimicrobials to treat gonorrhea and syphilis. William S. Pearson, PhD, MHA, FACE, a health scientist with CDC’s Division of STD Prevention, and colleagues found that around 78% of physicians who evaluate patients for STDs in their offices reported not having penicillin G benzathine onsite, and 56.1% reported not having ceftriaxone. (Editor’s note: For more on this study, click here.)
“Data suggest that most providers provide the recommended treatment; however, continued work is needed to ensure that providers have access to the most up-to-date recommendations, as well as to the specific medications needed to treat STDs,” Torrone said.
Prior suggested that a lack of access to recommendations and data contributes to undereducation among providers who may be feeling overwhelmed by the role they play in their patients’ sexual health.
“There are a number of reasons that STDs are going up — including the lack of knowledge, both among the provider and the consumer. People don’t know their risk and some doctors don’t know what’s going on in the world of STDs,” Prior said. “It’s on providers to do adequate sexual health care, yes, but it’s on public health to keep providers informed about what’s going on. It’s not solely on health care providers; we need to do better to educate providers about what’s happening.”
Prior said a lot is being asked of primary health care providers to be thorough in terms of addressing the sexual health of their patients, which is only a fraction of what they do as doctors.
“This speaks to maintaining and bolstering our nation’s network of STD clinics that are solely focused on STDs and providing sexual health,” he added. “Often, these are our family planning or publicly funded clinics, many of which unfortunately have shuttered their doors, reduced hours and cut staff in recent years.”
Two recent studies showed other benefits of STD clinics on those attending them. In one, there was a significant decline between 2010 and 2016 in the prevalence of anogenital warts among adults who attended 27 STD clinics in cities throughout the country, including from 6.2% to 2.9% among MSM. Another study found that HIV diagnoses were common among MSM receiving care at local STD clinics, suggesting the need for more efforts to promote HIV prevention strategies to MSM at these clinics.
New and old strategies
With STDs at an all-time high, it is critical to devise new tactics, develop new vaccines and improve prevention methods that are already in place, experts said.
“The fact is that we could have a vaccine for most of the major STDs if we put the necessary resources into that. Syphilis, gonorrhea, and chlamydia would be the top three for that,” Marrazzo said. “We need to put the same sort of resources and energy toward STDs as we do HIV to be effective.”
Prior agreed, adding that the STD field has a lot to learn from the HIV field.
“We’ve seen tremendous advances in preventing and managing HIV through the advent of biomedical solutions like PrEP and treatments as prevention,” Prior said. “These have all come from investment in research in HIV and HIV prevention and that’s something that’s often overlooked and underfunded in the realm of STDs. HIV advocates and researchers have moved mountains in HIV, and this just hasn’t been matched in the STD field.”
The National Institute of Allergy and Infectious Diseases recently awarded the University of Alabama at Birmingham a 3-year contract worth up to $10 million to study Bexsero (GlaxoSmithKline), a meningococcal B vaccine approved in the U.S. since 2015 for the prevention of gonorrhea — the first large-scale trial of a gonorrhea vaccine candidate.
In 2017, researchers in New Zealand reported the first evidence that a MenB vaccine could effectively prevent gonorrhea: a reduction in gonorrhea cases that coincided with a vaccination campaign to stop an epidemic of the disease in the late 1990s. Researchers in Australia and England followed up with a study that indicated Bexsero might offer cross-protection against gonorrhea.
Marrazzo will serve as the principal investigator of the NIH-funded phase 2 study of Bexsero, which also will include researchers from Emory and Louisiana State University.
“Modeling studies suggest that a vaccine that is even moderately effective against gonorrhea could enhance the reproductive and sexual health of millions of people globally,” she said. “It’s really exciting.”
According to Prior, there are also vaccine trials underway for chlamydia, and researchers are studying antimicrobial PrEP for STDs.
“The STD field is desperate for innovation. We need more investments in those things — vaccines and biomedical interventions,” he said.
Marrazzo said new drug development is important, too. She noted that syphilis is being treated with the same drug — penicillin — that was being used in the 1940s.
“The rates are through the roof and we’re using the same drug we had when it was discovered. Drug development for infections that are neglected in that regard is really important for the future,” Marrazzo said.
One promising prevention strategy may be to use doxycycline as prophylaxis to prevent bacterial STDs. In a recent state-of-the-art review, Jeffrey D. Klausner, MD, MPH, professor of infectious diseases and epidemiology at the UCLA David Geffen School of Medicine and Fielding School of Public Health, and colleagues found two small, short-term, randomized control trials that demonstrated it was highly effective. They reported that five clinical studies are underway or in development to examine the efficacy and safety of doxycycline prophylaxis.
“Doxycycline prophylaxis might be very effective at preventing syphilis and chlamydia in high-risk people,” Klausner told Infectious Disease News at the time. “More research [is needed] on the best way to use doxycycline — daily or as a single dose after sex — community acceptability; on its impact on the microbiome and antimicrobial resistance; and how to implement it as a STD control strategy.”
Researchers in Australia reported recently on findings they said could improve early detection of syphilis in MSM, shortening the duration of infectivity and improving control. In an analysis of 559 MSM aged 16 years or older with syphilis, Vincent J. Cornelisse, PhD, adjunct research associate at Monash University in Melbourne, and colleagues found that secondary syphilis cases were more common among patients who reported practicing anal receptive intercourse compared with those who practiced insertive anal intercourse.
Cornelisse and colleagues said the trend was potentially related to the difficulty of identifying syphilitic ulcers in the anal canal, and compared it with the observation that heterosexual men more commonly present with primary syphilis than do women, who are more likely to present with secondary syphilis, “presumably because cervical and vaginal chancres are easily missed.”
“These data suggest that sexual positioning predicts the site of primary infection, and that when primary syphilis occurs at the anus it is often not recognized by the patient, resulting in delayed presentation and treatment,” Cornelisse and colleagues wrote.
In a related perspective written for Infectious Disease News, Matthew Hamill, MBChB, PhD, MPH, MSc, assistant professor of medicine at Johns Hopkins University, said the analysis “might well change health promotion messages to individuals who have receptive anal sex.”
In another study, researchers found that an online intervention program for young HIV-negative MSM resulted in significantly lower STD incidences and a decrease in high-risk behavior. Brian Mustanski, PhD, director of the Institute of Sexual and Minority Health and Wellbeing at Northwestern University Feinberg School of Medicine, and colleagues enrolled more than 900 MSM aged 18 to 29 years who reported condomless anal sex and randomly assigned half to the Keep It Up! Program intervention, which involved various types of content, including videos, interactive animation and games.
According to the study, STD incidence at 12 months was 40% lower among participants in the intervention program (RR = 0.6; 95% CI, 0.38-0.95) with fewer participants in the intervention program reporting condomless anal sex.
‘The action of many’
According to Torrone, the CDC is taking action to combat STDs by monitoring national trends, providing up-to-date screening, treatment and prevention guidance and funding health departments to conduct local surveillance, although she added that the CDC cannot fight STDs alone.
“Turning back the rise in STDs requires the action of many,” she said, noting how health departments, health care providers, sexually active patients and researchers can help.
Heath departments should monitor and analyze the local STD burden, identify and link people with STDs to treatment and care, and share up-to-date disease trends and preventive resources with providers, she said.
Providers should take sexual histories as a part of routine medical exams and screen, rapidly diagnose and treat their patients and partners according to CDC recommendations, ensuring timely treatment.
Patients should talk openly and honestly with their partners about sex and STDs to identify strategies that would work for them to protect their sexual health, such as using condoms the right way from start to finish and reducing their number of sex partners, as well as talking to their health care providers about sexual history and risk.
Finally, she said researchers can help by investigating new diagnostics and innovative prevention strategies, including vaccines.
“We need to better fund STD programs, which are woefully underfunded, and we need to scale up STD screening and access to care,” del Rio said. “It is not rocket science, but we are not doing it well.” – by Caitlyn Stulpin
- CDC. 2018 STD Surveillance Report. https://www.cdc.gov/nchhstp/newsroom/2019/2018-STD-surveillance-report.html. Accessed October 15, 2019.
- Cornelisse VJ, et al. Clin Infect Dis. 2019;doi:10.1093/cid/ciz802.
- Grant JS, et al. Clin Infect Dis. 2019;doi:10.1093/cid/ciz866.
- Hall MT, et al. The Lancet Public Health. 2019;doi.org/10.1016/S2468-2667(18)30183-X.
- Mann LM, et al. J Infect Dis. 2018;doi:10.1093.infdis/jiy684.
- Mustanski B et al. Am J Prev Med. 2018;doi:10.1016/j.amepre.2018.04.026.
- Pearson WS, et al. Emerg Infect Dis. 2019;doi:10.3201/eid2511.190764.
- Petousis-Harris H, et al. Lancet. 2017;doi:10.1016/S0140-6736(17)31449-6.
- Semchenko EA, et al. Clin Infect Dis. 2018;doi:10.1093/cid/ciy1061.
- For more information:
- Carlos del Rio, MD, FIDSA, can be reached at email@example.com.
- Jeanne M. Marrazzo, MD, MPH, FACP, FIDSA, can be reached at firstname.lastname@example.org.
- Matthew Prior, MPH, can be reached at mprior@NCSDDC.org.
- Sancta St. Cyr, MD, MPH, and Elizabeth Torrone, PhD, MSPH, can be reached at email@example.com.
- Paul A. Volberding, MD, can be reached at firstname.lastname@example.org.
- Disclosures: Del Rio, Klausner, Prior, St. Cyr and Torrone report no relevant financial disclosures. Marrazzo reports serving on advisory committees for Gilead Sciences, BD Diagnostics and BioFire. Volberding reports serving on a data and safety monitoring board for Merck.