The Silver Lining: Progress and Promise in Combating STIs

The latest CDC data on sexually transmitted infections (STIs) offers, as Jonathan Mermin, MD, MPH, director of the CDC National Center for HIV, Viral Hepatitis, STD, and TB Prevention, believes, “a glimmer of hope” that modern endeavors to combat the STI epidemic are turning the tide. Persistently high rates of STIs have solidified this epidemic as a critical public health concern, especially considering that STIs often remain asymptomatic, and untreated infections can lead to serious health complications while advancing the spread of disease.¹

Doxycycline is commonly prescribed as treatment for various STIs | image credit: luchschenF - stock.adobe.com

Although STI cases remain high—exceeding 2.4 million annually in the US—new evidence suggests the frequency of chlamydia, gonorrhea, and syphilis infections are slowing down. Additional CDC data has also indicated declining rates of HIV over the years.² The advent and availability of novel pre- and post-exposure techniques have surely changed the game; however, STI stigma and disparities persist, underpinning the need for continued prevention and educational efforts to keep this momentum going. 

Hidden Consequences

Everyone should be tested for STIs at least once a year if they are sexually active, no matter their sexual history or orientation, because it is possible to carry an STI without knowing. When and how often someone should get tested depends on the individual’s relationship status, orientation or gender identity, number/frequency of partners, drug use, among other factors. The CDC has an updated list of recommendations and STI screening guidelines for those with any questions or who need a screening plan.³

When left untreated, STIs may cause significant health complications. Curable infections such as chlamydia gonorrhea can lead to pelvic inflammatory disease (PID) and increase the risk of infertility.⁴ Bladder problems or meningitis can develop if genital herpes is not effectively treated or managed. The risk of various cancers increases if human papillomavirus (HPV) or hepatitis B go untreated. Syphilis contributes to a plethora of complications, and without proper treatment can cause cardiovascular, renal, and bone issues, blindness, impair motor skills, and lead to dementia.

STIs additionally endanger pregnancies. An untreated STI could very well be passed from parent to child during childbirth, resulting in significant infection or even prevent someone from carrying to term. Stillbirths, premature births and miscarriage are more likely to occur in situations, for example, where chlamydia has been left untreated.

Growing Optimism

Since 2022, new gonorrhea cases have dropped by 7% after declining for the second consecutive year. Now, these rates have returned to pre-COVID-19 pandemic levels.¹

During the last year, syphilis cases grew by 1%—marking a drastic improvement compared with the previous years that continually saw double-digit growth. Notably, primary and secondary syphilis (referring to the stage of infection) rates decreased by 10% overall and, substantially, 13% in gay and bisexual men. The CDC emphasized how this reduction is the first considerable decline in syphilis cases in over 20 years; furthermore, gay and bisexual men have never exhibited such a drop in cases since the CDC first started tracking trends in that demographic. There is also some optimism about congenital syphilis (newborn syphilis), as these rates are slowing. In the past, data have reported 30% annual increases in cases; however, in 2022 the national increase was only 3%.

Despite incidence growing for some STIs, these slowdowns should be celebrated as reported cases of syphilis, gonorrhea, and chlamydia have increased by 90% in the last 2 decades.

Lingering Concerns

Stigma surrounding STIs remains a large concern and requires careful attention moving forward. The shame and negative stereotypes related to having an STI can significantly impact people’s willingness to get proper tests, seek adequate treatment, and disclose their status with past, future, or current partners.⁵ Negative stigma has reportedly led to diagnostic delays, which only raise risks of exposure or additional health consequences. Furthermore, affected individuals can experience anxiety or depression after a diagnosis, which only exacerbates the impact of stigma, reaffirming the need to holistically address this public health concern.

Antimicrobial resistance (AMR) has also raised concerns over the years as current medications and practices have become less effective in some cases. AMR for syphilis or chlamydia is not as prevalent; however, AMR in these infections have been reported, underscoring the need for prompt diagnosis, treatment, and prevention awareness. At present, gonorrhea has exhibited the strongest resistance to antibiotics and even multidrug-resistant strains have emerged that will likely shape and challenge future approaches to STI treatment.⁶

A Positive (but Undetectable) Note: Enhanced Prevention

Pre-exposure prophylaxis (PrEP) was granted FDA approval in 2012 as an effective medication to prevent the transmission of HIV. PrEP is designed as a preventative measure for individuals without HIV and is taken daily in the form of an oral pill. Today, 3 PrEP medications are approved and available: tenofovir disoproxil fumarate (Truvada), tenofovir alafenamide (Descovy), and cabotegravir (Apretude; a long-acting injection that is administered in 6-month intervals). Once exposed, and after a small grace period for the medication to build up in the blood stream, PrEP can stop HIV from planting itself and spreading throughout the body.^6,7

The US has the highest global coverage of PrEP and, when taken as prescribed, this drug has demonstrated to be 99% effective at preventing an individual from contracting HIV.⁸

Post-exposure prophylaxis (PEP) is another form of medication designed to be taken within 3 days of exposure to HIV as a potential preventative measure. This medication is not 100% effective, but can reduce individual risk of infection by 80% when taken correctly.⁹

The amount of virus in a person’s body is an important factor in transmitting the disease. Antiretroviral therapy (ART), while it does not cure HIV, has demonstrated to be greatly effective for reducing someone’s viral load of HIV, stopping HIV replication, and forcing the disease into what is referred to as viral suppression. Viral suppression means that a person has fewer than 200 copies of HIV per milliliter of blood. This functionally grants an “undetectable” status, meaning that standard laboratory tests will not be able to detect the disease, so long as these levels remain so low. Achieving an undetectable status also means that an individual can no longer transmit HIV, and therefore their partner’s risk during sexual activity—so long as the person with undetectable status continues their ART as prescribed—is essentially 0.¹⁰

Aside from HIV prophylaxis, the introduction of the doxycycline PEP (doxyPEP) method has bolstered prevention efforts against chlamydia, gonorrhea and syphilis. First recommended for public use in San Francisco in 2022, this medication includes taking 2 oral pills at the same time within 72 hours of a sexual interaction or potential STI exposure.¹¹ This approach differentiates from typical treatments against these diseases that would implore 1 pill, taken twice a day for 7 days. Real-world data out of various San Francisco sites have demonstrated the significant benefits of doxyPEP, with the City Clinic witnessing a 90% decline in positive chlamydia tests in a pre- and post-doxyPEP rollout analysis. Additional clinical trials have indicated the medication contributes to nearly a 70% decline in chlamydia cases, as well as 50% to 78% reduction in syphilis cases. Gonorrhea cases also improved in multiple locations and trials, but this was not seen as statistically significant just yet.

As health care providers and officials continue working to combat the STI epidemic, ensuring patients are aware of their testing, treatment, and prevention options remain among the most effective methods for tackling this public health issue. Equally important, however, is creating shame-free environments that allow patients to ask the right questions about their sexual health and seek treatment, as soon as possible, whenever they need.

References

1. 2023 CDC data suggests the STI epidemic may be slowing. CDC. November 12, 2024. Accessed November 14, 2024. https://www.cdc.gov/media/releases/2024/p1112-sti-slowing.html

2. Fast Facts: HIV in the United States. CDC. April 22, 2024. Accessed November 14, 2024. https://www.cdc.gov/hiv/data-research/facts-stats/index.html

3. Screening Recommendations and Considerations Referenced in Treatment Guidelines and Original. March 22, 2024. Accessed December 2, 2024. https://www.cdc.gov/std/treatment-guidelines/screening-recommendations.htm

4. Boskey E. Risks Associated With Untreated STIs. Verywellhealth.com. September 15, 2024. Accessed December 2, 2024. https://www.verywellhealth.com/what-could-happen-if-i-dont-get-tested-for-stds-3132741

5. Lichtenstein B. Stigma as a barrier to treatment of sexually transmitted infection in the American deep south: issues of race, gender and poverty. Soc Sci Med. 2003;57(12):2435-45. doi:10.1016/j.socscimed.2003.08.002

6. Krupp K, Madhivanan P. Antibiotic resistance in prevalent bacterial and protozoan sexually transmitted infections. Indian J Sex Transm Dis AIDS. 2015;36(1):3-8. doi: 10.4103/0253-7184

7. Pre-Exposure Prophylaxis (PrEP) to Prevent HIV. NIH. Updated September 13, 2024. Accessed December 2, 2024. https://www.niaid.nih.gov/diseases-conditions/pre-exposure-prophylaxis-prep#:~:text=The%20Food%20and%20Drug%20Administration,oral%20PrEP%20in%20cisgender%20women

8. Let’s Stop HIV Together. CDC. February 7, 2024. Accessed December 2, 2024. https://www.cdc.gov/stophivtogether/hiv-prevention/prep.html

9. Post-Exposure Prophylaxis (PEP) to Prevent HIV. NIH. February 6, 2024. Accessed December 2, 2024. https://hivinfo.nih.gov/understanding-hiv/fact-sheets/post-exposure-prophylaxis-pep#:~:text=What%20is%20PEP?,%2DExposure%20Prophylaxis%20(PrEP)

10. 10 Things to Know About HIV Suppression. NIH. February 8, 2024. Accessed December 2, 2024. https://www.niaid.nih.gov/diseases-conditions/10-things-know-about-hiv-suppression#:~:text=Antiretroviral%20therapy%20keeps%20HIV%20from,is%20imperative%20to%20stay%20undetectable

11. Samuel K. DoxyPEP: Using antibiotics to prevents STIs. Aidsmap. July 4, 2024. Accessed December 2, 2024. https://www.aidsmap.com/about-hiv/doxypep-using-antibiotics-prevent-stis#:~:text=women%20and%20men.-,Real%2Dworld%20experience,this%20was%20not%20statistically%20significant