How the CDC plans to reverse the STI epidemic in the United States

Sexually transmitted infections have been on the rise in the United States for some time. In 2019, the country reached an all-time high for the sixth consecutive year. Then COVID-19 hit and health care in the United States was deeply disrupted.

A report released this month by the Centers for Disease Control and Prevention highlights that STI rates remained alarmingly high in 2020, with reported cases of some infections continuing to rise.

“We already had a strained and crumbling public health infrastructure. There are many communities in the United States that don’t have STI clinics,” Jonathan Mermin, a senior CDC official, said in a call with reporters. “Which led to an exacerbation of already growing trends.”

The pandemic may have worsened the STI epidemic, experts say, but it has also forced medical professionals to start thinking about better ways to tackle the problem. In particular, home testing for STIs is showing promise as a strategy to get more people tested.

Disturbing trends

Much of the burden of STI prevention and treatment efforts has fallen on public health agencies that are chronically underfunded and understaffed, says Amesh Adalja, an infectious disease physician and principal investigator at the Johns Hopkins Center. for Health Security.

“And when the pandemic happened, many public health agencies had to completely change their minds and focus exclusively on COVID-19,” he says. “So that meant pulling resources that could have been used to [sexually transmitted disease] screening, STD testing and STD clinics and moving all that staff to COVID-19. »

At the same time, Adalja says, many primary care doctors were not doing routine physical exams — where STI counseling and testing often takes place — or limiting in-person visits. In addition, many people lost their jobs and health insurance or postponed medical examinations. The new CDC report indicates that all of these circumstances may have facilitated the spread of STIs while being less diagnosed and treated.

[Related: America’s sexually transmitted disease rates are out of control]

In 2019, 2.5 million cases of chlamydia, gonorrhea, and syphilis were reported in the United States. The following year, 2.4 million cases of these common STIs were reported. From 2019 to 2020, reported chlamydia cases actually dropped by 13%. However, the CDC report points out that it’s probably not because there have been fewer new infections; chlamydia is often asymptomatic, and the drop in reporting likely occurred because fewer people were getting tested.

Meanwhile, reports of gonorrhea and early-stage syphilis declined during the lockdowns but then jumped 10% and 7%, respectively, above 2019 levels by the end of the year. Congenital syphilis, which can cause serious health problems and even death in babies, also increased in 2020.

Of particular concern is the rise in reported gonorrhea and syphilis despite reduced STI testing, says Matthew Golden, an infectious disease specialist and professor of medicine at the University of Washington School of Medicine. He suspects that the true incidence of these infections is underestimated.

“If we do less screening and don’t identify those asymptomatic cases, then they have a higher chance of transmission,” Golden says.

The steady rise in cases of congenital syphilis indicates that more work is needed to target people who are pregnant or could become pregnant, he says. Additionally, he says, more testing is needed for populations at high risk for STIs, including the homeless, people who inject drugs, the incarcerated, or sex workers.

Although COVID-19 hasn’t made things better, rising rates of gonorrhea and syphilis are “just one more facet” of a larger problem, he adds. “On some important level, these are a consequence of our epidemics of homelessness and substance abuse,” says Golden. “And those aren’t issues that we’ve been very good at dealing with.”

Just because the novel coronavirus has become the top priority of federal, state and local governments doesn’t mean other infectious diseases such as STIs have gone away, Adalja says. “They don’t take a break when COVID-19 happens,” he says. “ISTs didn’t say, ‘Okay, we’ll wait until you come back. “”

What can be done

It may be some time before we know the full impact of the COVID-19 pandemic on STI rates. The extent to which delays in diagnosis and treatment contribute to complications such as pelvic inflammatory disease and infertility also remains to be seen, the CDC concluded in its report.

“We must prioritize on-the-ground support for STD prevention and surveillance programs through disease investigation, contact tracing, training, partnerships and community engagement,” wrote the agency.

In March, Congress decided to allocate less funding than in previous years to sexual health clinics that provide services such as free and subsidized STI testing. However, the pandemic and its detrimental effects on STI prevention and control efforts underscore the importance of systematic investment in public health services, Adalja says. Going forward, he adds, it is crucial that voters impress on their elected officials that sexually transmitted infections are an issue of concern to them, just as HIV activists have done in the past.

“STD funding is not politically very interesting for them; we have a sort of puritanical culture so they don’t want to talk about that stuff, it’s not something they can brag about when they do well,” says Adalja. “If you say, ‘I’m going to vote based on your position in our county’s health department,’ then they’ll start to care.”

Another strategy to combat rising STI rates that is gaining popularity is testing that can be done at home. In a home test, a person typically collects blood, urine, or other samples on their own and mails them in for testing. One of the benefits of this approach is that it allows people who do not feel comfortable visiting a doctor or clinic, particularly if they have experienced discrimination in the past, to get tested.

“For communities that don’t fit into the normal mold – whether it’s sexuality, race, gender identity – there’s a much smaller barrier to accessing care in that you don’t have explain who you are, how you have sex, who you have sex with,” says David Stein, CEO and co-founder of home diagnostics startup Ash Wellness. , which can be a huge barrier to care and a reason why people don’t even seek them out.”

[Related: Insurance coverage for at-home tests could help stop the rise in STIs]

Stein adds that confronting the lingering stigma around sexually transmitted infections is important to moving forward. “STIs are normal…but the only way to prevent epidemics like this and the HIV epidemic is to have testing campaigns and the ability to find follow-up care and treatment,” he said. he.

Home testing can help “decongest” an overburdened healthcare system, Golden says. It’s also convenient, especially for people who can’t afford to take time off work to get tested.

On the other hand, this approach doesn’t work as well for people who don’t have stable housing or constant internet access. For this reason, increasing STI testing programs at sites such as prisons, emergency rooms and methadone clinics will remain important, Golden says.

Another key question is when and how often insurance companies will pay for home testing. “That’s one of the biggest hurdles,” Stein acknowledges. However, he says, “We are finally getting to a point where self-testing is the norm, in part popularized by home self-testing for COVID.”

We have already started to see this game play out. California recently became the first state to require insurance plans to cover home STI testing. “COVID-19 home testing has opened up the possibility of really looking at home testing policies and making that much easier,” says Adalja.

Along with the convenience and comfort of doing a COVID-19 self-test at home, they provide almost immediate results without the need for lab analysis. This is also the case for an FDA-approved rapid HIV self-test. There is no technological barrier to developing rapid tests for STIs as well as other diseases, says Adalja, co-author of a 2020 report on the potential of self-testing for any disease .

“For COVID, people do a rapid test before going to a high-risk event or being around someone who is immunocompromised,” he says. “You could also use home STI screening this way.”

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