Do you have coronavirus fatigue?
Are you tired of talking about the coronavirus pandemic? Yeah?
Let’s talk about the other pandemic instead. What other pandemic, you say?
The STI pandemic.
What STI pandemic, you say?
The STI pandemic that no one’s talking about.
What’s going on with STIs?
Over 100 million Americans have an STD at any given time. That’s about one in every three of us. America has the highest rate of curable STDs among all the developed countries in the world.
So, is this just an American thing?
No. Rates of syphilis increased by 70% in the EU between 2010 and 2017. In fact, 2017 was the first year since the early 2000s that more syphilis cases than HIV cases were reported. Syphilis rates increased by 876% in Iceland, 224% in Ireland, 153% in the UK, and 144% in Germany. See ~figure:
World Health Organization data indicate that chlamydia and gonorrhea rates are highest in the Americas and Western Pacific countries, syphilis is highest in African countries, and trichomoniasis is highest in the Americas and African regions.
How bad is it?
Look at some of these U.S. numbers:
- Chlamydia cases have increased by 19% since 2014.
- Gonorrhea had its lowest numbers ever in 2009 – since then the numbers have increased by 83%.
- Syphilis, for which the numbers were falling fast in the 1990s, has increased by 173% among women of childbearing age. And there has been a 185% increase in the number of babies who get congenital syphilis, many of whom do not survive.
It’s really pretty serious, right? The outcomes of untreated STIs, many of which are asymptomatic, are dire: infant death, infertility, chronic pelvic pain, cancer.
Who’s getting these STIs?
Men who have sex with men have the highest rates of STIs followed by heterosexual men, heterosexual women, and lastly, women who have sex with women.
What age range do you think has the highest rate of STIs? Teens, young adults, middle age adults, or over 65s?
Young adults? Nope. Teens. Adolescents only make up about one-third of the population but they have about one quarter of the STIs. They are undereducated and unprepared.
In what age group do you think the rate of STIs are going up the fastest?
Teens? Nope. Over 65s? That’s right! The rate of STIs is increasing the fastest in those people greater than 65 years old.
But there is no age group that is not being affected by the rise in STIs. Nor is any state immune. In 2018, the rate of chlamydia was highest in Alaska, the rate of gonorrhea was highest in Mississippi, the rate of syphilis was highest in Nevada, and the rate of congenital syphilis was highest in Texas. STDs are everywhere.
| U.S. Cities with the Highest STI Rates^ | ||||||
| Rank | City | Cases per 100K people | HIV | Gonorrhea | Chlamydia | Syphilis |
| 1 | Baltimore, MD | 2,004 | 207 | 4,231 | 7,636 | 210 |
| 2 | Jackson, MI | 1,872 | 86 | 1,330 | 3,057 | 52 |
| 3 | Philadelphia, PA | 1,822 | 499 | 7,288 | 21,119 | 459 |
| 4 | San Francisco, CA | 1,754 | 246 | 5,775 | 9,137 | 584 |
| 5 | Montgomery, AL | 1,731 | 71 | 1,045 | 2,828 | 36 |
Why now?
Why we are having an STI epidemic right now? Weren’t the rates going down?
Yes, the numbers were decreasing in the 1990s but the rates now are moving up fast. There are a number of factors that are involved in increasing the rates of STIs:
HIV
It’s incredible how far we’ve come in understanding and treating HIV. (No reason to think we can’t do the same with coronavirus). The current medication regimen for people living with HIV can be so effective in bringing down the viral load, that it is undetectable in HIV tests. And if HIV levels are so low that they’re undetectable, then they are not infectious! They can’t infect someone else! U=U – undetectable equals untransmissible.
Everyone is relieved that the risks of acquiring or dying from HIV have greatly decreased since the end of the century, but with all of the focus on HIV, less attention and less money was being given to programs to prevent and treat the other STIs.
PEP and PrEP
There are now effective medicines that prevent people at risk for acquiring HIV from getting infected. Pre-exposure prophylaxis (PrEP) which is taken before sexual activity and post-exposure prophylaxis (PREP) that is taken after sexual activity are highly effective in preventing HIV infection. But PEP and PrEP do not prevent other STIs.
Since it has become less likely that one might contract HIV and less likely that, if you did get it, you would die from it, some people have become lax about maintaining safe sex practices.
Condom fatigue
After the HIV/AIDS crisis in the 1980s and 1990s, condom use went up a lot and the rates of STIs (and pregnancy) went down. Now though, it seems that “condom fatigue” has set in and people may be not as strict about using condoms consistently as they were before AIDS became a chronic disease instead of a killer disease.
The opioid crisis
People who exchange sex for drugs, are less likely to use condoms and more likely to have multiple sex partners which puts them at higher risk for acquiring STIs. Some drugs increase sexual desire and decrease sexual inhibition. People addicted to drugs exist in all socioeconomic groups and don’t necessarily limit sexual activity to within their drug-using circles.
Other factors
- years of decreased STI program funding decreases clinic hours and access to STI screening and treatment, increasing STI rates and STI damage
- lack of health care insurance negatively impacts being able to afford STI services
- clinic closings because of local and national government withdrawal of support for reproductive health services
- dating apps that increase anonymous sex, the “hookup app effect”
How is COVID-19 affecting the STI situation?
We don’t really know yet. On one hand, with social distancing we expect fewer new sex partners, casual sex partners, and multiple sex partners. The use of telehealth has increased, as has at-home testing kit availability for STIs. On the other hand, 66% of sexual health clinics have had to cut back service hours, 85% of staff have been redirected from STI contact tracing to COVID contact tracing, fewer patients are going to clinics to be tested, and there have been interruptions in access to prescription medicines for HIV treatment and prevention (pre-exposure prophylaxis [PEP] and post-exposure prophylaxis [PrEP]), along with birth control methods that require in-person visits. We have to wait and see what the overall impact of COVID-19 on STI and pregnancy rates will be.
Why isn’t more being done to address the STI epidemic?
As the COVID-19 epidemic is demonstrating, governments find it easy to ignore public health issues until they are in crisis proportions. One big reason that the STI epidemic is growing is that our current political climate is not conducive to helping people, especially underprivileged people, to get the health care coverage, screening, and treatment that they need.
STI stigma, the negative attitudes that society projects onto people who have an STI, includes the judgement that the people who get them deserve them. Stigma makes people fearful to admit they’ve had or might have one, or to talk to health care providers about them, or to seek screening and treatment. So, while stigma is meant to create a negative environment so that people will act to decrease risky behavior and improve society, in fact, stigma prevents people from adopting behaviors that can decrease their personal and their community’s risk.
Our grandparents’ generation didn’t talk about a neighbor’s diagnosis of TB, polio, or cancer outside of the family. These diseases were stigmatized. We are better about that now. Even mental illness is slowly coming out of the closet. So, things can change if we can decrease STI stigma.
What can we do?
Yes, we can lobby for more funding for STI programs, urge our representatives to depoliticize reproductive health care, promote comprehensive sex education in our schools, and donate to sex-positive organizations.
But my message to you is much simpler and more fun: talk about STIs like they were the flu or poison ivy. I can tell you that raising the subject of STIs among your friends can lead to some hilarious conversations. Lift the stigma!
Use condoms, get tested, get treated. Be careful out there!