For the first time in years, rates of chlamydia, gonorrhea and syphilis, which had been on track in 2020 to hit record highs in the United States, have taken an abrupt downturn.
This should be good news. The coronavirus pandemic has certainly kept more people away from bars, nightclubs and large parties, reducing opportunities for unsafe sex, studies show.
But the drop is more likely a harbinger of bad news, experts in reproductive and sexual health believe. They say the pandemic has seriously hindered efforts to mitigate sexually transmitted infections that can lead to pelvic inflammatory disease, chronic pain, infertility and even blindness and death in newborns. Rather than showing sexually transmitted diseases are on the run, the upbeat numbers likely signal instead that they are now going largely undetected.
In communities across the country, contact tracers for gonorrhea and syphilis, which had already been severely understaffed, have been diverted to COVID-19 cases. Eighty percent of sexual health screening clinics reported having to reduce hours or shut down altogether sometime during the pandemic, according to a survey by the National Coalition of STD Directors. In New York City only one of eight facilities was open this spring; now just three are open, which are steadily busy because they are more of a safety net service than ever, said Dr. Julia Schillinger, an assistant commissioner at the New York City health department.
Doctors also believe that many patients who might otherwise seek treatment for STD symptoms have been avoiding the clinics for fear of being exposed to COVID-19.
And in some regions, essential supplies to test for STDs are running low because manufacturers of swabs, tubes and reagents are redirecting their products for use in coronavirus tests. As a result, there is a growing shortage of tests for the diseases.
“Our most effective tool for control is timely diagnosis and treatment,” said Dr. Gail Bolan, director of the Division of STD Prevention at the Centers for Disease Control and Prevention. ‘We’re very concerned that we’ll have continued, unchecked and sustained increases now if people can’t access screening now.”
In short, desperate efforts to contain one pandemic could well inflame the spread of another. The CDC’s preliminary 2019 figures, the sixth consecutive record year, indicate 1.76 million cases of chlamydia and 602,000 of gonorrhea. Cases of newborn syphilis alone increased 22% from 2018.
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Alarmed, officials at the CDC issued alerts throughout the summer to clinicians nationwide. In its latest letter last month, the agency recommended that priorities for screening and testing should go to patients with symptoms, women who are younger than 25 or pregnant and people at high risk for STDs, including those with HIV.
Patients with chlamydia or gonorrhea are often asymptomatic; only testing, then, detects infection. But until the pandemic-related restrictions can be relaxed, the letter advised, “Routine screening visits should be deferred.”
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In the greater St. Louis area, only about 11 of 128 testing sites remained fully open this spring and summer, and in one health care system, testing dropped by 45%. Although many sites have begun to reopen, during one recent week, the St. Louis County Sexual Health Clinic had no urine test kits for gonorrhea and chlamydia, according to Dr. Hilary Reno, its medical director. Area hospitals had been on the hunt as well.
One reason that public health officials believe that the drop reflects test shortages and limited clinic access rather than less sexual activity is that the rates of decrease are more pronounced in gonorrhea and chlamydia, for which the test supplies have been affected, rather than in syphilis and HIV, which are detected through blood tests.
Bolan is also troubled by the breakdown in reporting of cases.
“It’s not just data for the purpose of collecting it,” she said. “Surveillance is the backbone of public health. It’s how we allocate our resources. Without timely and accurate data, we feel like we have blindfolds on while trying to figure out where our hot spots are.”
Doctors and nurses who work in clinics that serve mostly poor and minority patients say that the burden of the extreme service cutbacks and lack of testing falls most heavily on them. Those who work with teenagers said that many clinics that distribute free condoms have closed.
Dr. Joy Friedman directs adolescent medical services at the Einstein Medical Center, in a low-income neighborhood in Philadelphia. Teenagers tell her how difficult it is to discuss condom use with partners. Regular testing is the one way they have to protect themselves. And now, she said, “they need to know that testing won’t be available.”
Despite considerable efforts to reduce STDs, reported cases at the beginning of 2020 were higher than those during the same period in 2019, according to the CDC. But by early March, as the nation began complying with stay-at-home orders, those levels plummeted. In early April, weekly reports of chlamydia were 53% below 2019 numbers, with both gonorrhea and syphilis down 33%. Gonorrhea had been expected to hit an April monthly total of 54,127. But only 26,771 cases were reported.
As of mid-June, chlamydia numbers remained depressed, but reporting of gonorrhea and syphilis had returned to expected rates. Given the limitations on testing and clinic closures, however, cases may well be higher.
“If sexual behavior rebounds while service interruption persists, we project an excess of hundreds of HIV cases and thousands of STI cases,” researchers from Emory, Harvard and the University of North Carolina, Chapel Hill, wrote in a preprint study of the sexual practices of Atlanta men who had sex with men during the pandemic.
Social scientists are exploring how the coronavirus outbreaks have affected sexual behavior. Justin Lehmiller, a social psychologist at the Kinsey Institute, which has been issuing surveys during the pandemic to about 2,000 people — gay, straight and bisexual — said that even those in continuing relationships reported having less sex in the first months.
“Higher levels of stress and anxiety are pushing down desire,” he said. “Singles have more challenges to hooking up.”
But when doctors and nurse practitioners who work with teenagers were asked if the pandemic had slowed down their patients’ sexual activity, they replied that, anecdotally speaking, not at all. Bolan said that one New York pediatrician reported that she’d treated many teenagers for STDs.
Kaytlin Renfro, a CDC researcher, noted that in various studies, a range of 39% to 76% of participants reported a decrease in sexual partners during quarantine. But a University of Michigan survey of 696 gay and bisexual men found that only about one-third found it important to decrease the number of partners during the pandemic.
Even if sex has declined, researchers question how long it can remain suppressed. Lehmiller noted that online dating apps report record business. Whether that translates into sexual activity rather than virtual meetups is unclear, he said. If people are returning to normal levels of encounters, they may not want to admit it.
“There is shaming about traveling, social events and gatherings during the pandemic, so sex and dating is seen as part of that,” he said.
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For now, triage at clinics is pervasive. Pre-pandemic, the San Francisco City Clinic would typically send more than 100 specimens to be processed daily at the health department laboratory. Because those supplies have dwindled, the clinic is resorting to a smaller, more expensive backup system that can only process several dozen gonorrhea and chlamydia tests a day, said Dr. Ina Park, an associate professor of community and family medicine at the University of California San Francisco School of Medicine.
Men who take PrEP to prevent HIV transmission should be screened for STDs every three months, but many clinics have spaced out those screenings to every six months, she said.
A Michigan colleague who had run out of urine testing kits for chlamydia and gonorrhea, she said, was returning to techniques that had been replaced almost 20 years ago: “using older swabs that have to be placed a few centimeters inside the urethra of the penis and twirled around to obtain a specimen. It’s highly unpleasant for the patient and doesn’t encourage them to return for testing,” Park said.
“I’m concerned that this will worsen mistrust in the medical establishment, which is already an issue with some of the patients we serve,” added Park, author of “Strange Bedfellows,” a book out in February on the history and science of sexually transmitted diseases.
David Harvey, executive director of the National Coalition of STD Directors, said clinics are trying to come up with creative solutions, such as telemedicine visits. In a few districts where the biggest challenge is reduced clinic access, administrators are trying out test kits that allow patients to collect specimens at home, which they then mail to labs. And some clinics are working with pharmacies that can draw blood and have standing orders for some medications. Public health officials see these innovations as a silver lining that may continue after the pandemic abates.
But for Friedman in Philadelphia, the current situation presents a social justice issue as well as a medical one. Her young, predominantly African American and Latino patients, she said, have high rates of STDs because many do not have ready access to health care, and there is pervasive fear and distrust of medical institutions, which the inability to test for STDs is only exacerbating.
“No one says we should curtail testing for COVID-19,” Friedman said. “I don’t understand why it has to be one or the other.”