In the world of infectious diseases, making progress against one pathogen sometimes means losing ground on another.
In 1990, the U.S. had its highest syphilis rate in 40 years, while HIV/AIDS incidence was entering its peak. Then, after the first protease inhibitor was approved in 1995, people living with HIV finally had a chance of survival. On the heels of that progress, the number of syphilis cases declined by 86% in 1998 to about 7,000 total cases, according to the CDC.
Then, in 1999, the CDC announced a national plan to virtually eliminate syphilis by 2005. But the sexually transmitted disease (STD) fought back in a big way. After reaching a historic low in 2000 and 2001, the rate of primary and secondary syphilis has increased almost every year since. In 2018, the number of cases ballooned to more than 35,000, the most reported since 1991, according to the CDC's annual surveillance report, published in October 2019.
“It was kind of a paradox: As soon as you announce your intention to eliminate a disease, the disease rates go back up,” said Bradley P. Stoner, MD, PhD, FACP, an associate professor of internal medicine and anthropology at Washington University in St. Louis.
He said some experts are concerned that the progress made around HIV has caused people to feel a greater sense of security around sex and less worry about bacterial sexually transmitted infections (STIs) that are treatable with antibiotics. (Many experts in the U.S. use the terms STI and STD interchangeably.)
“I've had patients tell me, ‘Well, I'm not too worried about syphilis. If I get it, I'll just get it treated because it's curable,’” Dr. Stoner said.
It's not just syphilis that's climbing. Since 2013, cases of chlamydia, gonorrhea, and syphilis have all risen sharply in the U.S. In fact, cases of these STIs reached an all-time high in 2018, approaching 2.5 million, according to the CDC's most recent surveillance report. That year, more than 580,000 cases of gonorrhea (the most since 1991) and more than 1.7 million cases of chlamydia (the most ever) were reported to the CDC.
Just in time for STD Awareness Week, which runs from April 12 to 18 this year, experts offered potential explanations for these recent increases and recommended talking more openly with patients about sexual health to help prevent adverse health consequences of STIs.
Why STIs are on the rise
Although surveillance data cannot explain why STIs are on the rise, increased screening is responsible for some of the increase in diagnosed and reported cases, said ACP Member Laura Bachmann, MD, MPH, chief medical officer for the CDC's Division of STD Prevention in Atlanta.
“Increasing case rates, in part, reflect a better job in identifying and treating asymptomatic infections, which will prevent adverse health consequences and help halt the spread of STDs in the community,” she said.
However, the uptick is likely due in part to increasing new infections as well, said Dr. Bachmann. Socioeconomic factors, such as poverty and drug use, make it difficult for some people to access quality STD prevention and care, and changing transmission patterns are affecting more women and heterosexual men in recent years, she said.
In addition, diminished fears of getting HIV infection have affected people's sexual behaviors, as seen in the comeback of syphilis. Data show that condom usage is declining among vulnerable groups, such as young people and gay and bisexual men, said Dr. Bachmann.
In addition, men taking pre-exposure prophylaxis (PrEP) may be less likely to use condoms, said Jeanne Marrazzo, MD, MPH, FACP, the C. Glenn Cobbs, MD, Endowed Professor in Infectious Diseases and director of the division of infectious diseases at the University of Alabama at Birmingham School of Medicine.
“PrEP clearly has been associated with increases in unprotected sexual behavior, particularly in gay men, and that is a group that we continue to see really astronomical increases in incidence of classic STIs like syphilis,” she said.
And for people living with HIV, there is also the “undetectable equals untransmittable” (U=U) concept. Those who achieve and maintain an undetectable amount of HIV in the blood by adhering to antiretroviral therapy as prescribed cannot sexually transmit the virus to others, according to the NIH.
“U=U, and therefore, the use of condoms isn't really necessary (at least in the heads of a lot of people), as far as HIV transmission is concerned,” said Anne M. Rompalo, MD, ScM, professor of medicine at Johns Hopkins University School of Medicine in Baltimore.
Technology, such as mobile dating apps, has also increased the availability of partners, and if individuals are being exposed to more partners, they're more likely to get STIs, said Nicholas J. Van Wagoner, MD, FACP, associate professor of medicine and associate dean for students at the University of Alabama at Birmingham School of Medicine. “It's easier than ever to access casual relationships and to identify people who are also interested,” he said.
But the jury is still out as to whether the apps themselves are contributing to increasing STI rates overall, said Dr. Stoner. “It would be hard to test because dating apps have become so commonplace, particularly among young people,” he said.
A final reason for increasing rates is reduced funding for STD programs nationally, said Dr. Bachmann. “In recent years, more than half of state and local programs have experienced budget cuts,” she said.
Many cities are shutting down publicly funded STD clinics and outsourcing care to federally qualified health centers and medical homes, said Dr. Stoner. “But there's still a barrier for some people who just don't have insurance, particularly those people who have drug addiction. … People with clinical symptoms don't always have places to go to get treated, and they end up in emergency rooms,” he said.
The St. Louis region used to have several publicly funded clinics, but now Dr. Stoner works at the last remaining one, which is unable to meet the demand for free STD care. “We can only see 40 patients a day, so we turn people away every day. … I'm sure it's the same elsewhere,” he said.
Still, 2020 is poised to see some federal heft thrown at the STI epidemic. HHS and other federal agencies are developing an STI Federal Action Plan, which is scheduled to be released this year.
What's an internist to do?
Perhaps most of all, experts said, internists should feel comfortable talking with patients about sexual health and should routinely ask about it. And if adults are at increased risk for STIs, clinicians should provide behavioral counseling, according to a B-grade draft recommendation statement from the U.S. Preventive Services Task Force, published in December 2019. “Sexual health care is primary health care,” said Dr. Marrazzo.
But research has shown that often, physicians and clinicians of all levels don't ask about sexual health, said Dr. Rompalo, who is also medical director of the STD/HIV Prevention Training Center at Johns Hopkins. “The biggest challenge is for the physician or clinician to feel comfortable asking the question,” she said.
For many physicians, it's not necessarily discomfort around asking sexual health questions, but the concern around making their patients feel uncomfortable, added Dr. Van Wagoner. “It can be difficult to have a candid conversation around sexual behaviors, and I think societally, it's also difficult to have those conversations,” he said.
If you're not comfortable, try to practice a little more, said Dr. Marrazzo, “because patients are very, very good at picking up your discomfort … and that's not a good feeling for patients.”
On the other hand, patients appreciate the opportunity to answer questions about a part of their lives they might not want to bring up themselves, said Dr. Rompalo. “Actually, once you approach the subject in a nonthreatening manner, I think patients are more than happy to talk about it,” she said.
About half of STDs are among young people ages 15 to 24 years, according to the CDC. “But the thing is that those demographics, while still true, are changing a lot because we are seeing now increases in ‘older’ people,” said Dr. Marrazzo, adding that recent syphilis cases are much more common in men who are in their 30s. In addition, with greater life expectancies and longer sex lives, increasing numbers of people in their 50s, 60s, and 70s are acquiring gonorrhea, chlamydia, and, to a certain extent, syphilis, Dr. Stoner said.
With pregnancy off the table after menopause, many older people who start new relationships may not feel that they're at risk for STDs and decide not to use condoms, he said. Dr. Stoner noted that while infection rates in this group are lower than in teenagers and young adults, asking questions about sexual risk in older patients is still important. (See sidebar for tips on taking a sexual history.)
Since people's lifestyles, life choices, and sexual history often change with age, it's best not to assume what's going on in the bedroom, Dr. Marrazzo said. “The days of people never having another marriage, of course, are long gone, so people who have been married for a long time can enter into a new sexual relationship in their 50s,” she said. “And that's a great time for somebody, for example, to maybe get a new herpes infection because they never had been exposed.”
Of course, with so much to do in such a limited time, it's easy for internists to prioritize concerns like cardiovascular disease and diabetes ahead of sexual health conversations, said Dr. Van Wagoner. “I certainly understand that. But when I also think about the part that relationships play in our lives—they're pretty important—I always try to come back to the idea that our goal is to take the best care of patients we can,” he said.
There are ways to save time, such as an electronic or paper questionnaire that patients fill out before a visit, said Dr. Rompalo. “But you have to look at that,” she said, adding that nurses can also ask whether patients are sexually active and if they have any concerns.
Whether it's an in-person conversation or a questionnaire, asking about sexual health sends a signal to patients that the physician sees this information as important, said Dr. Van Wagoner. “I think it's something that gives [patients] a little bit more self-efficacy to say, ‘Hey, I want to talk about this,’” he said.
A routine yearly visit is a great time to let patients know you'd like to be thorough in your annual exam and bring up a simple sexual-health question, such as, “Is there anything going on sexually that you want to talk about?” said Dr. Marrazzo. On the other hand, a one-month follow-up visit for hypertension would not be the time to get a sexual history, Dr. Van Wagoner added.
When you do bring up the conversation, embed it into your normal visit for any person, regardless of age, gender, marital status, or sexual orientation, said Dr. Marrazzo. “Routinely create the opportunity, and don't bring judgment into the conversation,” she said.
One way to help normalize the subject is by telling patients that you ask everyone about their sexual behaviors. In other words, preface a conversation about sexual health by letting the patient know that it's “just another day at the office,” Dr. Stoner recommended.
“What I say to patients is, ‘I'm going to ask you some questions that may seem personal and sensitive, but I ask everybody the same questions, and I'm doing this to get the best information I can to provide the best care to you,’” he said.