Incidence rates of many sexually transmitted infections (STIs) have increased in the years leading up to the COVID-19 pandemic. There is evidence that STIs have continued to rise during the pandemic, according to the results of a new study.1
STI data from the Centers for Disease Control and Prevention (CDC) lag a couple of years behind what is happening on the ground, but one bellwether shows syphilis cases increased sharply in 2019 and have continued to rise in 2020 and 2021.1,2
“Congenital syphilis, from early provisional reports in 2020, has increased again from 2019,” says Matthew M. Hamill, MBChB, PhD, MPH, MSc, assistant professor of medicine at Johns Hopkins University School of Medicine in Baltimore. “Because people are tested for syphilis during pregnancy, we can be confident that rates of syphilis are increasing if congenital syphilis has increased.”
Congenital syphilis numbers are ahead of broader statistics, says Stephanie S. Arnold Pang, senior director of policy and government relations at the National Coalition of STD Directors in Washington, DC.
“Congenital syphilis is a canary in the coal mine,” Arnold Pang says. “We’re seeing increases in congenital syphilis over pre-pandemic levels.”
Before the pandemic, congenital syphilis increased fourfold, from 500 cases in 2015 to about 2,000 cases in 2019.2
“It’s continued to go up in 2020 and 2021,” she adds. “You see stillbirths, the health effect in births themselves.”
When there is a rise in congenital syphilis, it means there is an overall rise in syphilis among women of reproductive age, Arnold Pang says.
California legislators passed a bill requiring health insurers to pay for home STI test kits and to pay for the laboratory costs of processing the kits.3
“It’s a tool in the toolbox and an innovation that came out of COVID,” Arnold Pang says. “It used to be we had testing for pregnancy at home, and that was about it. Now, people are used to testing at home, and testing innovations are coinciding with that change.”
California’s approach reduces barriers for people who cannot access testing or who are uncomfortable seeking that testing. Now, they can take the STI test at home, or they can use it in a clinical setting. Some STD clinics use at-home tests in their clinics if they do not have enough providers or testing spots. Insurance coverage for testing breaks down barriers related to out-of-pocket costs, since the STI tests can be expensive.
“We think STD prevention care should be testing, treatment, contact tracing, and support,” Arnold Pang says. “If you use that home testing kit in a clinical setting, then the STD will be reported by that clinic, and the health department can do contact tracing.”
Telehealth options are available for those who order kits online, including mailing treatment to patients’ homes. This also could lead to STI reporting.
While the California law’s STI testing kits have received a lot of attention, Arnold Pang cites the other positive provisions that could help reduce STI rates. “One piece of the law is that it ties syphilis screening requirements to the most recent guidelines published,” she says. “That means it requires screening for syphilis in the first and third trimester of pregnancy. Often, women will not be screened in the third trimester, which misses potential congenital syphilis cases. We’re excited the law will increase screening during pregnancy and tie it back to state guidelines.”
About one in five U.S. adults contracted an STI in 2018. Rates of gonorrhea and chlamydia have continued to rise, as have rates of syphilis.1
“Syphilis reached historic low rates in 2000 and 2001, and then it’s increased almost every year since then,” Hamill says.
Both gonorrhea and syphilis showed increased infection rates after World War II, and again in the late 1960s and early 1970s, when society experienced big changes in sexual behavior. By the late 1980s and early 1990s, rates of those STIs began to decline, probably because of the HIV epidemic and changes in sexual risk behavior, Hamill explains.4
The recent rise in STI rates may be partly due to people no longer fearing death from HIV/AIDS. “There’s a whole generation of people not having ever experienced people they know who are sick with HIV or dying of AIDS,” Hamill says.
Another explanation is the shrinking investment in sexual health services over the past decade. “It’s human nature for us to look toward the behavior of individuals with STIs, but not to examine the wider societal things that also have contributed to increases in STIs,” Hamill says.
“In the 1990s, there was a syphilis elimination effort,” Arnold Pang says. “Syphilis levels were so low, we thought we could eliminate it.”
That period also saw the highest levels of funding for tackling STIs. After the 1990s, public funding was cut to the point that it is $200 million less now, when adjusted for inflation. That change does not take into account the diversion of STI staff to COVID-19 testing during the pandemic.
“In August 2020, we found that 80% of the [public health] workforce was redeployed to the COVID emergency,” Arnold Pang says.
Since work in STIs includes labor-intensive contact tracing, these infections — many of which are asymptomatic — have been left to spread with little contact tracing and recommendations to people to get tested.
The reported STIs are the tip of the iceberg. “Most STIs don’t have symptoms, or have minor symptoms that a person doesn’t [think belong] to an STI,” Hamill explains. “If we acknowledge that, we know that screening is not comprehensive.”
Providers need to proactively make sexual health a normal part of any medical consultation, Hamill says. “And we need to find ways to help people overcome their reticence or shyness in discussing it — and that’s on providers, too,” he adds.
Reproductive health providers also should raise awareness of extragenital infections in the throat and rectum, which are hugely overlooked.
“They are a pool of undiagnosed and untreated STIs, and they continue to spread,” Hamill says.
Gonorrhea, syphilis, and chlamydia can infect people in areas other than their genitals. (See story on chlamydia infections in this issue.)
Also, the COVID-19 pandemic has taught healthcare professionals to find ways to provide access to testing.
“Some online offerings are really good, so people can order [test kits] online and get them mailed to their home, and they can mail them back for results,” Hamill says. “We need to find more ways to decrease barriers to STI care.”
For example, one website, IWantTheKit.org, founded by Johns Hopkins University School of Medicine, allows people in Maryland and Alaska to order a free and confidential STI/HIV home test kit.
“People need to get testing in a way that suits them, at a time that suits them,” Hamill adds. “Online isn’t perfect, but it’s one part of the jigsaw puzzle.”
REFERENCES
- Tuddenham S, Hamill MM, Ghanem KG. Diagnosis and treatment of sexually transmitted infections: A review. JAMA 2022;327:161-172.
- Centers for Disease Control and Prevention. National overview — sexually transmitted disease surveillance, 2019. Updated April 13, 2021.
- California SB-306 Sexually transmitted disease: Testing. Oct. 5, 2021.
- Aral SO, Fenton KA, Holmes KK. Sexually transmitted diseases in the USA: Temporal trends. Sex Transm Infect 2007;83:257-266.
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