Public health officials still do not know the full effect of the pandemic on the incidence of sexually transmitted infections (STIs) in the United States.

The COVID-19 pandemic disrupted STI testing. It is unknown if people engaged in risky behavior during various regional and national shutdowns.1

“The big message is we’re not really sure what is happening,” says Philip A. Chan, MD, MS, infectious diseases physician and associate professor at Warren Alpert Medical School and School of Public Health at Brown University. “When we talk about sexually transmitted disease cases, those are based on medical diagnoses and people testing positive. The way the pandemic impacted healthcare is people didn’t present to doctors, so there was a decline in diagnosed STI cases.”

But that could be an illusion. “None of us think there is a true decrease because we’re not sure,” says Chan, an attending physician at The Miriam Hospital Immunology Center in Providence, RI. “The word on the street is people are having fewer sexual partners. We’re not sure what’s happening with STIs in the pandemic. As things reopen, there’s a huge concern that we may see things spike.”

This interim period — post-vaccine and before the end of the pandemic — is an important time for public health agencies and reproductive health providers. “It’s a critical time to encourage people to get tested, stay vigilant, and stay engaged with education about sexually transmitted infections and health,” Chan says. “In the last decade, we’ve seen exponential increases in chlamydia, gonorrhea, and syphilis, and then the pandemic hit. We [may be] still on an upward trend.”

The Centers for Disease Control and Prevention (CDC) reported in 2019 that the United States saw the highest-ever recorded rates of chlamydial, gonococcal, and syphilis infections. Young women, ages 15 to 24 years, had the highest rates of chlamydia. Adolescents also had the highest gonorrhea rates.2

But STI testing was disrupted in 2020 because of the redirection of scarce public health resources to accommodate widespread testing of SARS-CoV-2, says Fareeda Haamid, DO, pediatrician in the division of adolescent medicine at The Ohio State University College of Medicine. The shift to accommodate COVID-19 testing led to a scarcity in STI testing materials, especially laboratory supplies and testing kits.

“This had an impact globally, was far-reaching, and was mostly concentrated around chlamydia and gonorrhea testing,” Haamid explains. “Our microbiology colleagues in the lab ordered these supplies in advance, and noticed a dwindling supply and it not being replenished.”

The CDC wrote a letter on Sept. 8, 2020, encouraging continued screening of asymptomatic, sexually active females younger than age 25 years, as well as men who have sex with men, when STI diagnostic tests experienced only moderate shortages. The letter also suggested judicious use of diagnostic testing within the adolescent population, with decisions guided by local shortages and supply limitations.2

“They were aiming to test and treat as many infected people as possible and prioritize the potential for STI complications,” Haamid says.

There are several potential causes of the pre-pandemic trend of rising STIs cases. “There are issues with access to STI prevention and treatment due to poverty, stigma, drug use, and unstable housing, which all impact access to care,” Haamid explains. “There also has been a decline in condom use among young people, who are the most vulnerable.”

Funding to pay for STI programs has been cut at the state and local levels. “We’ve seen in recent years that almost half of local programs had budgetary cuts and clinics closing, resulting in reduced patient follow-up and diminished screening capacity,” she says. “It’s these three things: access issues, decline in condom use, and budgetary cuts.”

More research is needed to determine the reason for the decline in condom use, but one theory is that as young people increasingly use long-acting reversible contraceptives, they are less likely to use condoms, Haamid says.

It also is possible that people have more sex partners, which could contribute to asymptomatic spread of STIs. “We think network spread is how some of these STIs spread,” Chan says.

For example, chlamydia is asymptomatic in 80% to 90% of the people with the STI, Chan says.

Access also is an issue. “There may be a lack of access to condoms; the verdict’s still out on all of the ‘whys’ that this is happening,” Haamid says.

The solution is for providers to offer STI tests, when available, to everyone, especially young women, letting patients know about how infections can be asymptomatic. “The reason for the focus on women is for the risk of complications,” Chan notes. “Complications include infertility, chronic pelvic pain, and pelvic inflammatory disease, which is when it infects the ovaries and causes abscesses and serious infection.”

Providers also should consider the possibility of infections of areas other than the vagina and urethra. “Over the last 10 years, we’ve realized that people who perform oral sex or have receptive anal sex can get gonorrhea or chlamydia in the throat or rectum, and that would not be picked up if you just have the urine test,” Chan says.

Men who have sex with men, and heterosexual men and women could become infected in those areas. Clinics should test with swabs for the throat and rectum. “A lot of clinics have people do it themselves, giving them a swab and great instructions on doing it,” he says. “We make it more acceptable to patients by having them do it themselves.”

Reproductive health providers also could stress harm reduction strategies. “Find creative, flexible ways to reach adolescents, and know the population you are serving,” Haamid adds.

REFERENCES

  1. Rogers B, Tao J, Murphy M, Chan P. The COVID-19 pandemic and sexually transmitted infections: Where do we go from here? Sex Transm Dis 2021. doi: 10.1097/OLQ.0000000000001445. [Online ahead of print].
  2. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. New CDC report: STDs continue to rise in the U.S. Oct. 8, 2019.