In March, the federal government sent Title X health providers a budget that will result in further slashes to programs that screen, test, trace, and treat people with sexually transmitted infections (STIs).1 STI rates are rising sharply for the sixth year in a row.
Early data from the CDC show that syphilis, gonorrhea, and other STIs continued to increase during the COVID-19 pandemic.2,3 Syphilis cases increased 34% in women and 9% in men. The data were based on cases reported through March 2022.2
“California faced a devasting cut in Title X funding despite the need we have in our state for equitable family planning services for patients with low incomes, as well as STI services,” says Amy Moy, chief external affairs officer at Essential Access Health in Berkeley, CA.
California’s Title X program lost $8 million in funding — a surprising blow and the largest cut the program has faced in its more than 50-year history.
The budget cut is in the context of rising STI rates in the state and across the nation, Moy adds. Congress failed to meet the needs of essential reproductive health and STI services.
“Rising STI rates are a public health crisis that has gone ignored for far too long,” Moy explains. “Way before the COVID-19 pandemic, we had STI epidemics that were not addressed, and at the same time, public health funding decreased.”
During the pandemic, the situation worsened as the already-limited resources and infrastructure for testing, tracing, and treating STIs had to pivot to handling COVID cases.
“California has the most reported cases of STIs in the nation,” Moy says. “Since 2010, we’ve had a 200% increase in gonorrhea, a 56% increase in chlamydia, and there’s a steep rise in syphilis cases with rates up to 265%.”
Increases in cases of congenital syphilis are alarming. Rates have increased by 600%. “Currently, STIs are at a 30-year high,” Moy says. The CDC’s early data show a nationwide 6% increase in congenital syphilis cases.
Some Title X programs were notified of acceptance in Title X’s latest round, but were told they would not receive funding for this current fiscal year. For those facilities, STI services are in even greater jeopardy.
“The stark reality is there is not enough money for the program to support service areas in a meaningful way with unfunded grants,” says Audrey Sandusky, MPH, senior director of policy and communications at the National Family Planning & Reproductive Health Association (NFPRHA) in Washington, D.C. “What we’re seeing is fewer resources that can go to family planning health centers that provide low- or no-cost STI services. Those are vital healthcare services at a time when we’re seeing these alarming increases in syphilis and gonorrhea.”
Healthcare providers do not possess the resources they need to stop the rising tide of STI rates, and up to 150 health centers in California could lose Title X funding.
“Funding doesn’t even come close to keeping pace with the resources needed to reduce STI rates. It makes a bad situation worse,” Sandusky says.
For example, Title X funding cuts led to a reduced workforce at Carson City Health and Human Services (CCHHS) in Nevada. The clinic could see 30 patients a day before. Now, they can only handle a smaller caseload, must schedule patients a week or more in advance, and send some patients to an urgent care facility if they experience acute symptoms and are not scheduled at the facility. But patients who visit urgent care have to pay for STI services out of pocket, says Katharyn Kurek, MHL, BSN, RN, CEN, clinical services manager at CCHHS. The program received half of its funding from Title X.
This is a major problem for low-income and uninsured patients because even the nearest federally qualified health center is scheduling patients for a month or more in advance.
“These are devastating impacts on healthcare,” Kurek says. “If patients are not seen immediately, it can cause life-long issues with STIs.”
For instance, an untreated case of syphilis in a woman of reproductive age could result in congenital syphilis, possibly causing miscarriage, stillbirth, preterm delivery, or low birth weight in her newborn. Also, the babies who survive congenital syphilis could be left with deformed bones, enlarged liver and spleen, brain and nerve problems (including vision loss or hearing loss), and other health problems.4
The pandemic already dealt a blow to STI services when CCHHS’s nurses all shifted to COVID-19 testing in 2020 and it was harder to schedule in-person patient visits during the early months of the crisis.
“We were able to get telehealth platforms and see patients online as much as we could,” Kurek explains. “Our STI testing and tracing all plummeted in the pandemic years.”
For these reasons, Kurek is certain gonorrhea, chlamydia, and other STI rates will increase in 2023 and beyond. “I feel our efforts with reproductive health went by the wayside because we were so focused on the pandemic, and we’ll see repercussions of it,” she adds.
Solving the Title X funding problem will require a multipronged strategy. “We need to make sure we don’t have a disruption in access and that we can continue to make progress in reducing barriers to both contraception and STI services,” Moy notes. “We’re looking at calling on our members of Congress to include an increase for Title X in any reconciliation package considered by Congress over coming months. We’ll also look for an increase for Title X funding in the fiscal 2023 budget.”
In the meantime, California’s Title X sites cannot provide STI services through technical assistance and training. In recent years, the program had worked to expand STI services through technical assistance, learning cohorts, and other activities.
“We’ll no longer be able to continue those activities,” Moy says. “The reduction in Title X funding also can result in potentially longer wait times, reductions in family planning staff, and less capacity to conduct outreach and education activities that connect community members to Title X services, including birth control and STI care.”
REFERENCES
- Whitfield BN. Primary contraceptive method use and sexually transmitted infections in a nationally representative sample of young women. J Pediatr Adolesc Gynecol 2022;S1083-3188(22)00186-3.
- Centers for Disease Control and Prevention. Preliminary 2021 data: Syphilis. April 29, 2022.
- Centers for Disease Control and Prevention. The state of STDs — Infographic. April 12, 2022.
- Centers for Disease Control and Prevention. Congenital syphilis — CDC fact sheet. April 12, 2022.
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