The other day, my patient, who I’ll call Sam, came in for a routine sexually transmitted infection (STI) screening for two reasons. First, he said that he just started a new relationship with someone he met on a dating app and wanted to make sure he was in the clear. He didn’t have any symptoms that day. Second, he read somewhere that STIs are on the rise and he was concerned.
“Test me for everything,” he said anxiously, even though he was recently uninsured.
Sam was right, there has been a noticeable increase in STI rates in the past few years. According to the Centers for Disease Control and Prevention, cases of gonorrhea, chlamydia, and syphilis have shown “steep, sustained” increases since 2013. Based on the data, syphilis cases almost doubled and gonorrhea cases increased by 67 percent. Chlamydia cases remained high and it continues to be the most common STI reported to the CDC. Recent attempts to shift funds away from organizations that provide full-spectrum sexual and reproductive healthcare and education, like the Title X “Gag Rule,” could potentially cause a further increase in rates of STIs, especially among uninsured patients like Sam.
But these numbers warrant a closer look as to why as well as what this means for patients moving forward. According to the United States Preventive Services Task Force, age is the strongest risk factor for chlamydial and gonorrheal infections; the highest infection rates occur among cis women and cis men between the ages of 20 to 24. If left undetected or untreated, gonorrhea and chlamydia can cause pelvic inflammatory disease, infertility, complications of pregnancy, as well as chronic pelvic pain. Chlamydia is 10 times more common than gonorrhea because chlamydial infections often don’t cause symptoms. If you don’t have symptoms, you’re less likely to get tested and treated and therefore more likely to spread infection.
Because STIs can cause infection without causing symptoms, the CDC has recommended regular screening for young, sexually active people. While we may be detecting more cases through screening, there are still many groups who are not being screened at all, or not nearly as much as they should. People of color, LGBTQIA, and young people can be marginalized from accessing health services due to poverty, stigma, lack of sex education, discrimination, and harmful government policies. The same factors that limit their access to healthcare also put them at risk for STIs. Ensuring low cost or free STI screenings through the Title X program has made it so that these marginalized groups can get the care they need.
The majority of the syphilis cases, approximately 81 percent, were among gay and bisexual men in 2016, according to the CDC. In 2012, the FDA approved Truvada for pre-exposure prophylaxis (PrEP), a once-daily pill taken to prevent HIV infection among those who are at higher risk. When patients are prescribed PrEP, we have them follow up for STI testing every three months. Recent research has shown that with the uptake of PrEP, condom usage has declined and STI rates have increased. Methamphetamine use has also been linked to the rise in syphilis (because meth increases sex drive and is often used at parties), and people who use substances are less likely to seek medical services. More recently, there has been a rise in syphilis cases among pregnant women, particularly young black women living in the South.
My patient Sam told me that he met his new partner on a dating app (apps have been linked to the rise of STIs, but also as a potential avenue to promote STI prevention). Dating apps are now part of our culture and this calls for serious changes to our healthcare infrastructure to facilitate improved detection and treatment. Again, we must ensure that people have accessibility to STI screenings through government-funded programs like Title X.
Sure, more sex can lead to higher rates of infections, but that’s not really the point here. As a physician, my job is to determine risk factors for various STIs and to screen accordingly. I understand what is contributing to the increase STI rates, but now we need to focus on what we can do to make sure we’re screening patients appropriately. This doesn’t mean I encourage patients to have less sex, just more safe sex. From a public health perspective, we should be focusing our energy on comprehensive sex education and reaching the most vulnerable populations.
Returning to my patient Sam, I first start with a sexual history. He is a 22-year-old cis male and has been sexually active with one cis female partner in the last three weeks. They recently decided to become mutually monogamous. In the last three months, he was meeting cis men and cis women from several dating apps and was sexually active with many of them. Based on his sexual behaviors, we decided to screen for gonorrhea and chlamydia (from the urine, the anus, and the pharynx), HIV, syphilis and hepatitis A, B, and C.
Given that Sam was reporting anal sex, he was offered an anal swab for gonorrhea and chlamydia. Gonorrhea and chlamydia can now be tested from the urine, so a urethral swab is no longer necessary.
Hepatitis A is traditionally thought of as a foodborne infection, but in fact, it can be transmitted through the sexual practice of anilingus (or “rimming”). We discussed pre-exposure prophylaxis (PEP) for HIV and he didn’t feel that he was a candidate at this time. We did a quick, rapid HIV test that gave Sam the result in just under two minutes.
Routine testing for herpes is not recommended (in other words, testing should only be done if a patient has symptoms, and even then, a blood test is not recommended, just a swab of the bump or lesion). And routine testing for human papillomavirus is not recommended in those without a cervix. But we did confirm that he completed his HPV vaccination series when he was younger. And finally, we discussed how he could prevent unplanned pregnancy with his new partner.
Sam was relieved that he was able to receive thorough STI testing and counseling, despite being uninsured. I had also screened Sam for intimate partner violence and substance use, as they are important risk factors for STI transmission (he denied both). We focused on his sexual behaviors when determining his risk for various STIs, not his gender identity or his sexual orientation. Testing for and treating STIs early (even when symptoms aren’t present) can prevent uncomfortable symptoms like discharge and burning as well as complications of infertility and chronic pain. Regular testing and treatment of STIs can also prevent spread from person to person. And knowing that you’ve been tested and counseled on risk reduction can also help improve sexual pleasure.
The good news is that even though we’ve seen a surge in STI diagnoses, they can be screened for and cleared with antibiotics. The bad news is that so many people are left undiagnosed. And rates of STIs may get worse, especially with cuts to the Teen Pregnancy Prevention Program (to instead promote abstinence only, which research has shown to be ineffective) and Title X funding that supports STI screenings for low-income people. Well-researched programs that support comprehensive sexual education and access basic sexual and reproductive healthcare will help curb this rise in STIs.
Dr. Meera Shah, MD, MPH, MS is the Associate Medical Director of Planned Parenthood Hudson Peconic in New York and a fellow with the Physicians for Reproductive Health.