‘Now is not the time to lose momentum’ in the fight against STIs
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For the second year in a row, the CDC’s annual STI report showed an overall decline in combined cases of the three nationally reportable infections — chlamydia, gonorrhea and syphilis.
The numbers indicate a promising trend, according to Jonathan Mermin, MD, MPH, director of the CDC’s National Center for HIV, Viral Hepatitis, STD, and TB Prevention, who said in a press release that “the tide is turning” after years of increasing rates of the three STIs.
“I'm an optimist, and I'd like to think that this is truly the flattening of the curve, and I say that in the context of gonorrhea now being down 2 years in a row... and also the slowing of the increase in syphilis,” Bradley Stoner, MD, PhD, director of CDC’s Division of STD Prevention, told Healio.
“I hope this is the beginning of a trend,” Stoner said, although he also cautioned that the epidemic remains “severe” a “long way” from being over.
Some experts are not as confident that the tide has turned in an epidemic that had been worsening for years.
“I think it's good to have optimism and to hear what sounds like the people representing the CDC having optimism,” Alysse G. Wurcel, MD, MS, associate professor and attending physician in geographic medicine and infectious diseases at Tufts Medical Center, told Healio. “I would say, though, that experience and the numbers provoke more questions that need answering before I have incredible optimism.”
We spoke with Stoner, Wurcel and other experts about the state of the STI epidemic in the United States and what can be done to bring STI rates down further.
‘Encouraging’ data
According to the CDC report, cases of chlamydia, gonorrhea and syphilis totaled more than 2.4 million in 2023 — a 1.8% decrease from the more than 2.5 million cases reported in 2022.
Chlamydia remained the most common among the three STIs, with a slight 0.1% decrease from the 1.649 million cases reported in 2022.
For the second year in a row, rates of gonorrhea fell, declining 7.2% to 601,319 cases after dropping by 8.7% from 2021 to 2022. The CDC noted that this marked a decrease to pre-pandemic levels.
“It’s encouraging in a number of ways, and it offers some hope,” Stoner said. “We take some encouragement in the fact that gonorrhea cases have declined for 2 years in a row and are now below pre-pandemic numbers.”
Although there was not a decline in syphilis, the slight 1% increase in cases after years of double-digit growth — including 2022’s 17% increase — was a positive sign, after years of “steep increases,” Stoner said.
Data showed there were 53,007 cases of primary and secondary syphilis, representing a 10.2% decrease from 2022. There were 53,573 cases of early nonprimary nonsecondary syphilis, which was a 5.9% decrease from 2022.
Margaret R. Hammerschlag, MD, professor of pediatrics and medicine and director of the pediatric infectious diseases fellowship training program at SUNY Downstate Health Sciences University, said reaction to the data may be “a little overoptimistic in the long run.”
“When I look at the numbers, they're not overwhelming,” Hammerschlag told Healio. “They did go down, but it makes you wonder, ‘What does that really mean?’ Does it mean people aren’t getting tested as much?”
‘It doesn’t fit with what I’m seeing’
Hammerschlag and Wurcel said the CDC data do not match their personal experiences.
“It doesn't fit with what I'm seeing,” Hammerschlag said. “Matter of fact, just [recently] I got a health advisory from the New York State Department of Health about an increase in congenital syphilis cases outside of New York City.”
Wurcel suggested that data on testing, which are not included in the annual report, could explain why rates are lower.
“What we don't know is how many tests were done,” she said. “If the number of tests completed went down by any amount, then you're only finding [fewer infections] because you're testing less.”
Stoner called testing an “incredibly important part of the equation” and noted that the CDC does not receive the total number of STI tests performed, which is why the data are not included in the report.
“What we get are the number of positive cases reported from the notifiable disease surveillance data,” he said. “We're seeing more cases identified in emergency departments and prenatal settings, and we're trying to expand testing and outreach in nonclinical sites, such as substance use facilities and certain services programs.”
Another part of the equation is testing location, Wurcel said. She explained that gonorrhea and chlamydia can occur in several locations — oral, rectal, in the urine or in the cervix. Urine, she said, is the easiest and most commonly checked location.
“If clinicians are only testing urine and say, ‘We didn't find it in the urine,’ then we're essentially missing it,” she said.
Success of doxy-PEP
Whether the CDC report accurately reflects a significant decline in STIs, experts agreed that some tools to combat STIs are working.
“We continue to have an out-of-control STI epidemic in America,” David C. Harvey, MSW, executive director of the National Coalition of STD Directors (NCSD), told Healio. “But this report provides us with the first indication that some of our smartest investments in the past few years have had a strong positive impact.”
Stoner cited doxy-PEP as a new, impactful intervention. Short for doxycycline post-exposure prophylaxis, doxy-PEP involves taking the antibiotic within 3 days of having condomless sex. Numerous studies have demonstrated its ability to reduce the risk for STIs, especially against chlamydia and syphilis.
“We know that [doxy-PEP] has been ramped up in some parts of the country, and we're trying to expand use of that,” Stoner said.
This includes CDC guidance published in June 2024 recommending that providers counsel certain patients on using doxy-PEP. Specifically, the guidance recommends that providers counsel transgender women and men who have sex with men (MSM) with a history of at least one bacterial STI during the past 12 months about the benefits and harms of doxy-PEP. Providers should also offer doxy-PEP through shared decision-making in the context of a “comprehensive sexual health approach,” including risk reduction counseling, STI screening and treatment, recommended vaccination, and linkage to HIV PrEP, HIV care or other services as appropriate, the CDC guidance says.
As part of the guidance, the CDC recommends that providers assess a patient’s ongoing need for doxy-PEP every 3 to 6 months.
Some areas rolled out doxy-PEP long before the CDC issued its guidance, including San Francisco, whose health department began recommending the intervention in 2022. According to Harvey, one sign that doxy-PEP is working are data showing there was a 13% decrease in syphilis among MSM.
“DoxyPEP created new opportunities to address the ongoing disparities in STI numbers among MSM,” he said.
Benefits of public health spending
Stoner said another major factor in combating STIs was an “unprecedented but temporary infusion of funding into health departments and disease intervention specialists following the COVID-19 pandemic.”
“This helps health departments ramp up their outreach and contact-tracing activities, at least for a time,” he said. “I think that probably had an impact as well.”
Harvey said the 2023 STI numbers provided “the most comprehensive look yet at the impact Congress had by providing health departments with resources to hire disease intervention specialists (DISs).”
“STI prevention relies on tried-and-true efforts like testing, treatment and community outreach, and having an influx of staff last year to carry out that work and adapt to the most crucial needs was important,” he said.
“Unfortunately, Congress rescinded the funds for DIS in last year’s debt ceiling deal,” Harvey added, referring to a deal struck by Congress and the White House that, according to the NCSD, pulled $400 million in DIS funding.
“We will be watching closely to see if communities can sustain this progress or if they’ll slide backward without the workers they need to protect their communities,” Harvey said.
Congenital syphilis: Still a crisis
Cases of congenital syphilis continued to increase in 2023, rising 3% from 2022 to 3,882 cases — the most since 1992, according to the CDC, which noted that the increase was significantly lower than the roughly 30% increase reported in previous years. Most cases “could have been prevented with timely testing and treatment,” Stoner said.
In 2023, the CDC called the surge of congenital syphilis a “crisis.” That is still the case, according to Harvey.
“Even with the slowdown, cases are 10 times higher than what they were a decade ago,” he said. “A cross-governmental task force has helped hold different federal agencies more accountable for using existing resources to prevent congenital syphilis, but prevention programs in the states still need funding to reduce the risk to moms and babies.”
In late 2023, the NCSD called for the Biden administration to declare a public health emergency over congenital syphilis and dedicate $1 billion to address STIs in the U.S.
At the time, Harvey told Healio that public health emergencies are about “taking practical measures as much as they are about raising awareness.” In this case, declaring a public health emergency would give power to federal agencies and state and local health departments to respond in “nimble and smart ways,” and overcome many existing barriers, he said.
As of December 2024, a national emergency still had not been declared.
To bolster efforts to lessen the congenital syphilis burden, members of the U.S. House of Representatives introduced H.R. 8839, the bipartisan Maternal and Infant Syphilis Prevention Act in the summer of 2024. The bill calls for HHS to issue guidance and practices for screening pregnant patients. The bill has also been introduced in the Senate.
“We are urging Congress to pass this important legislation to hold state Medicaid programs accountable for testing pregnant women for syphilis and alerting providers to the elevated syphilis numbers,” he said.
Making sexual health accessible
Although strides are being made to combat STIs, experts agreed more can be done. Wurcel said access to care is key.
“We need to literally and figuratively meet people where they are to offer them sexual health services,” she said. “We should not be gatekeepers to sexual health where only on Fridays between the hours of 12 and 12:30 can you get an appointment. People have busy lives. They have other priorities. Bringing sexual health and STI prevention to them, making it more accessible to them, making it lower cost — that should be the goal.”
Hammerschlag noted that several other barriers need to be removed, including syndromic testing, which she noted does not always work for women, for example, because approximately 80% chlamydia infections in women are asymptomatic.
“You cannot rely on syndromic treatment. It is inaccurate,” she said. “You're going to overtreat and undertreat. You'll treat a lot of people who don't have chlamydia and/or gonorrhea and not treat the people who do have chlamydia and/or gonorrhea.”
She also explained that the closures of labs and clinics have reduced the ability to analyze tests, leading to longer turnaround times for test results and fewer clinics for patients to visit.
“One of the important reasons why people weren't treated was how far they lived from the clinic,” she said. “Something very simple — like trying to get from point A to point B — becomes an issue.”
Stoner said that addressing STIs should be a federal, state and local priority.
“I think we are guardedly optimistic that we're reaching a point where we can say STIs are starting to come under control, and now is not the time to lose the momentum,” Stoner said. “We have to maintain focus and continue our commitment to preventing these serious health conditions.”
References:
- Bachmann LH, et al. MMWR Recomm Rep. 2024;doi:10.15585/mmwr.rr.7302a1.
- CDC. National overview of STIs in 2023. https://www.cdc.gov/sti-statistics/annual. Posted Nov. 12, 2024. Accessed Dec. 19, 2024.
- Congress.gov. H.R.8839 – Maternal and Infant Syphilis Prevention Act. https://www.congress.gov/bill/118th-congress/house-bill/8839. Accessed Dec. 30, 2024.
- Congress.gov. S.5203 – Maternal and Infant Syphilis Prevention Act. https://www.congress.gov/bill/118th-congress/senate-bill/5203/text/is. Accessed Dec. 30, 2024.
- Despite over 2 million sexually transmitted infections reported in 2023, CDC data suggest that the STI epidemic may be slowing. https://www.cdc.gov/media/releases/2024/p1112-sti-slowing.html. Published Nov. 12, 2024. Accessed Dec. 19, 2024.
- National Coalition of STD Directors. NCSD marks debt ceiling deal as a devastating blow to the fight against rising STI rates. https://www.ncsddc.org/ncsd-marks-debt-ceiling-deal-as-a-devastating-blow-to-the-fight-against-rising-sti-rates/. Published June 13, 2023. Accessed Dec. 19, 2024.
- Scott H, et al. Abstract 127. Presented at: Conference on Retroviruses and Opportunistic Infections; March 3-6, 2024; Denver.
For more information:
- Margaret R, Hammerschlag, MD, can be reached at press@downstate.edu.
- David C. Harvey, MSW, can be reached at dharvey@ncsddc.org.
- Bradley Stoner, MD, PhD, can be reached at dstd2@cdc.gov.
- Alysse G. Wurcel, MD, MS, can be reached at alysse.wurcel@bmc.org.
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