As recently reported in the New York Times (Stack, 2019), sexually transmitted infections (STIs), including chlamydia, gonorrhea, and syphilis diagnoses, continue to rise in the U.S. despite current public health efforts. Rates of chlamydia have reached an all-time high with 1.8 million cases in 2018 (Centers for Disease Control and Prevention, 2019c) (Fig. 1). Gonorrhea and syphilis infections have also increased 39% and 42%, respectively, from 2014 to 2018 (Figs. 2, 3). Women, adolescents and young adults, and gay, bisexual, and other men who have sex with men (MSM) continue to bear a disproportionate burden of STIs. Sixty-five percent of chlamydia cases were reported in women, and of all reported cases of chlamydia among women, 68% were among young women 15–24 years of age. Rates of chlamydia are lower in men compared to women, likely due to screening recommendations for women, but diagnoses increased 38% from 2014 to 2018 in men. Rates of gonorrhea have increased 79% among men and 45% among women from 2014 to 2018. The increased rates among men may reflect screening recommendations for MSM (Table 1). Gonorrhea rates continue to be the highest among young adults 20–24 years of age (702.6 and 720.0 out per 100,000 cases of women and men, respectively). Men accounted for 86% of all primary and secondary syphilis cases with 54% reported among MSM.
There are multiple reasons for the ongoing increases in the number of cases of STIs. One possible reason is that more people are being tested, resulting in an increase in reported cases. For some populations (e.g., sexually active young women, MSM), more frequent testing may be driving the increases in reported cases to the CDC. Recent trends also suggest that changing sexual behaviors may be contributing to these increases. While the number of U.S. adolescents and adults currently having sex has decreased over the past two decades (Centers for Disease Control and Prevention, 2019a; Smith, Davern, Freese, & Morgan, 2019), riskier sexual behaviors are on the rise. For example, data from the Youth Risk Behavioral Survey demonstrate that condom use during the last sex event decreased among 9th through 12th grade students from a peak of 63% in 2003 to 54% in 2017 (Kann et al., 2018). During this same time period, oral contraception also increased from 17 to 21% in this group which may have had an impact on condom use (Kann et al., 2018). Data from the National Survey of Family Growth found mixed results: Condom use at last sex remained unchanged among women (23–24%) but increased in men (30–36%) from 2002 to 2017 (Centers for Disease Control and Prevention, 2019b).
Condom use rates may be influenced by a decreasing concern about HIV given advances in treatment and prevention, including the HIV Undetectable = Untransmittable (U = U) initiative (Eisinger, Dieffenbach, & Fauci, 2019). Furthermore, increased rates of primary and secondary syphilis among MSM are a growing concern because it is associated with HIV transmission (Kidd, Torrone, Su, & Weinstock, 2018) and approximately 36% of primary and secondary syphilis cases in 2017 were among MSM who are HIV positive (Centers for Disease Control and Prevention, 2019c). Importantly, approximately 10% of all new HIV infections may be attributed to gonorrhea and chlamydia infections (Jones, Sullivan, & Curran, 2019). Significant increases in STIs have also been observed among MSM taking pre-exposure prophylaxis (PrEP) for HIV prevention (Montano et al., 2019). Although the total number of partners may be unchanged, MSM on PrEP may use condoms less, increasing the risk of acquiring STIs (Oldenburg et al., 2018). Increases, however, may reflect more frequent screening for STIs among men taking PrEP (Montano et al., 2019). MSM taking PrEP should be screened for other STIs every 3 months (Centers for Disease Control and Prevention, 2015), which would be much more frequent than observed among MSM not on PrEP (Hoots, Torrone, Bernstein, & Paz-Bailey, 2018). This may contribute, in part, to the observed increases in STIs in this population.
To address the burden of STIs, the U.S. must address healthcare access. Multiple individual, interpersonal, community, and societal factors may impact access to health care, including appropriate STI screening, diagnoses, and treatment. The most common barriers to STI testing include lack of access to clinical services, out-of-pocket costs for both uninsured and underinsured, confidentiality concerns, and stigma associated with testing (Montgomery et al., 2017). These barriers may be more pronounced in racial and ethnic minorities with rates of chlamydia and gonorrhea highest in Black/African Americans in 2018. Furthermore, rates of reported syphilis increased 78% from 2014 to 2018 among Hispanic/Latinos. State and federal budget cuts to STI programs (e.g., STI clinics) have a direct impact on access to these services, especially in safety-net settings and among racial and ethnic minority groups.
Addressing the STI epidemic will require a combined approach to improve routine testing and treatment in primary care settings, as well as in safety-net settings (i.e., STI clinics). The CDC and United States Preventative Services Task Force recommend routine testing for people at risk of STIs (Table 1). The primary care workforce is essential to engage in STI prevention efforts which should include routine testing in at-risk populations. Quality measures such as the Healthcare Effectiveness Data and Information Set demonstrate that in the case of chlamydia, only 47% of sexually active women less than 25 years have been screened despite recommendations (Khosropour et al., 2014). Sexual history taking is often not performed with less than one-third of primary care providers reporting taking a sexual history at their last patient visit (St Lawrence et al., 2002). Men who report same-sex behaviors are often not identified, screened appropriately for STIs, and offered appropriate preventative care (i.e., PrEP) (Scott & Klausner, 2016). Safety-net settings in the form of STI clinics are also important for marginalized populations who are at risk and may not have access to primary care, including MSM. STI clinics also often serve as important referral sites for complicated cases, as well as centers for education and training in the community.
Screening for gonorrhea and chlamydia should also include throat and rectal swabs in MSM (extragenital testing) to access infection at these sites (Centers for Disease Control and Prevention, 2014). Extragenital screening among MSM showed that > 70% of chlamydia and > 80% of gonorrhea infections would have been missed with urine testing alone (Anschuetz, Paulukonis, Powers, & Asbel, 2016). Testing in women is currently not recommended, although approximately 14% of chlamydia and 30% of gonorrhea infections among women may be missed with urine-only testing (Trebach, Chaulk, Page, Tuddenham, & Ghanem, 2015). Chlamydia and gonorrhea infections at extragenital sites are often asymptomatic in men and women (Bamberger, Graham, Dennis, & Gerkovich, 2019; Chan et al., 2016). Culture detection is available for testing at extragenital sites, but the nucleic acid amplification test (NAAT) is more sensitive than cell cultures and is the preferred method for laboratory detection of chlamydia and gonorrhea. Extragenital screening using NAAT is available at many local, state, and commercial laboratories and is approved by the Food and Drug Administration (Centers for Disease Control and Prevention, 2009; Johnson Jones et al., 2019; U.S. Food and Drug Administration, 2019).
Important gaps in research also exist, which may hinder efforts to effectively address rising rates in STIs. Screening for gonorrhea and chlamydia in cis-gender, heterosexual men is not recommended due to lack of evidence of a population-level benefit although it stands to reason that most women are acquiring these infections from sex with men. Extragenital testing is also not recommended in cis-gender, heterosexual men and women given lack of benefit of extragenital screening on potential sequelae. Extragenital infections in heterosexual men and women do occur (Chan et al., 2016), and there is evidence that infection at extragenital sites can be transmitted to the urogenital tract (den Heijer et al., 2017). Importantly, future research efforts should identify systematic efforts to improve screening and early diagnoses and treatment efforts. These may include specific quality measures by insurers, which include financial incentives to promote screening among primary care providers and others.
In conclusion, STI cases continue to rise across the U.S. which likely reflects more sensitive screening and detection methods as well as increased sexual risk behaviors. Increased screening, diagnoses, and treatment of STIs—including asymptomatic infections—will be important to reduce the overall prevalence. Further reductions in the incidence of STIs will require the promotion of sexual health among all people with focused efforts on women, adolescents and young adults, and MSM who continue to bear a disproportionate burden of STIs. Finally, future efforts are needed to effectively address these increases across research, clinical, and public health practice.
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Scott-Sheldon, L.A.J., Chan, P.A. Increasing Sexually Transmitted Infections in the U.S.: A Call for Action for Research, Clinical, and Public Health Practice. Arch Sex Behav 49, 13–17 (2020). https://doi.org/10.1007/s10508-019-01584-y