STDs increasing

 A recent CDC report confirmed that several sexually-transmitted diseases have been increasing in prevalence (see https://www.cdc.gov/std/statistics/2020/overview.htm#Disparities ).

 

 

Chlamydia 

-- in 2020 there were 1,579,885 cases reported to the CDC, the most commonly reported STD, representing a rate of 481.3 cases /100K population 

-- this represents a decrease of 13% compared to the rate of 2019, with the exception for rates among non-Hispanic persons of multiple races

-- however, chlamydial infections are more typically asymptomatic, and these numbers reflect screening rates; so, it is highly likely that the screening rates decreased significantly in asymptomatic people during the Covid pandemic

-- the rates of reported chlamydia are highest among adolescents and young adults, with 61% among persons 15-24 years old

 

Chlamydia rates in women age 15-44 by age group, 2011-2020

 

Gonorrhea 

-- in 2020, a total of 677,769 cases were reported to the CDC, the second most common STD reported

-- the rates have increased 111% since the low of 2009

    -- during 2019 to 2020, there was a 5.7% increase in reported gonorrhea; this was true for males and females, and those from the Midwest, Northeast, and South of the US. This increase was especially true for most racial minorities/Hispanic ethnicity groups

    -- and, gonorrhea has quickly been developing resistance to antibiotics (see commentary below)

 

 

case reports of gonorrhea by sex, from 2011-2020

 

Syphilis 

-- in 2020, 133,945 cases were reported, 41,655 of primary and secondary syphilis (the most infectious stages of the disease)

-- since historic lows of 2000-2001, rates of syphilis have been increasing almost every year, 6.8% during 2019-2020

-- MSM have the highest rates of syphilis, however rates among women have increased substantially in recent years (21% during 2019-2020, and 147% from 2016-2020)

-- congenital syphilis has been increasing consistently since 2008

    -- in 2020, there were 2148 cases of congenital syphilis reported, including 149 stillbirths and infant deaths related to congenital syphilis

        -- during 2019-2020, the rate of primary and secondary syphilis increased 24% among women aged 15-44, and there were 5726 cases of syphilis diagnosed amongst pregnant women, an increase of 16% from 2019

 

syphilis in pregnant women and cases of congenital syphilis, from women aged 15-44

 

Disparities in STDs:

-- 53% of new STDs were among adolescents and young adults aged 15 to 24

-- there were increased rates among racial minorities/Hispanic ethnicity groups, as well as MSM

-- per the CDC report, “it is important to note that these disparities are unlikely explained by differences in sexual behavior and rather reflect differential access to quality sexual health care, as well as differences in sexual network characteristics” (e.g. in those areas with higher prevalence of STDs, there is a greater risk of transmission of an STD with each sexual encounter, and this is independent of sexual behavior patterns)

 

Commentary:

-- these increases in STDs are very concerning, since these infections can have profound long-term implications

-- for example, infertility is increased in those with chlamydia and gonorrhea infections, presumably related to tubal scarring. This also puts women at increased risk of ectopic pregnancies and the potential for serious/fatal outcomes

-- and untreated syphilis has the potential for long-term profound complications throughout the body (neurosyphilis including dementia, cardiac complications,  etc)

-- there is also a huge concern about gonorrhea becoming untreatable, as resistance patterns have increased dramatically over time, especially to azithromycin but to all the other antibiotics as well (see http://gmodestmedblogs.blogspot.com/2016/07/gonorrhea-resistance-increasing.html for a report of increasing gonorrhea resistance in the US and globally, with concerns by the WHO that resistant gonorrhea may be untreatable in the future)

-- one other concern that I have is related to HIV infections. It is clear that people who get other STDs are at high risk of getting HIV as well. This brings up a few issues:

    -- I do realize that for me, as well as others who’ve treated patients in the bad old HIV days when essentially everyone died, that we have a PTSD-like reaction to new cases of HIV that may scare us more to new HIV cases

    -- and, of course, HIV has become just another chronic disease, given the profound improvements of HIV treatment, with the  vast majority of patients having virologic cures with a single pill once a day.

    -- But, even those achieving long-term undetectable HIV viral loads still often have persistent inflammation, with evidence of increased cardiovascular disease, cognitive dysfunction, and certain malignancies.

    -- there is also increased risk of osteoporosis, though it is hard to tease out whether this is related to the HIV disease (see https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4663974/pdf/nihms735955.pdf ), or medications to treat HIV. I am particularly concerned about the chronic long-term use of tenofovir, even tenofovir alafenamide TAF, especially in younger people who are likely to be on meds for decades, given the potential for future development of renal failure and osteoporosis. TAF is also associated with lots of weight gain (see http://gmodestmedblogs.blogspot.com/2021/03/hiv-taf-inc-weight-metabolic-changes.html). There is a great alternative for HIV therapy: the tenofovir-free combination of dolutegravir/lamivudine (eg see http://gmodestmedblogs.blogspot.com/2020/10/hiv-treatmentprevention-guidelines-2020.html ). Every patient I have switched to this 2-drug combination has maintained an undetectable viral load, including 2 patients who had acute renal deterioration on switching from TDF to TAF but improved quickly with this 2-drug combination

    -- and my concern is that current messaging around HIV infection does not emphasize the potential long-term effects of even treated HIV, despite the advances in antiviral therapy

    -- one option is pre-exposure prophylaxis (PrEP) to prevent HIV transmission. there have been lots of studies showing benefit, though the studies were mostly in MSM/transgender women (see  http://gmodestmedblogs.blogspot.com/2020/01/on-demand-prep-works-if-fewer-meds-and.html ) and there are no studies with TAF/FTC for heterosexual men/women or those using injecting drugs. But the results of PrEP are quite strongly in favor of its efficacy.  unfortunately, PrEP is used by a minority of high-risk people

Limitations:

-- these are the CDC-reported case numbers. As mentioned above by the CDC, there was less testing done during the covid pandemic, many cases (especially chlamydia and gonorrhea) are asymptomtic, so reporting would significantly understate the numbers of cases. I would add that there may even be under-reporting just because of the pandemic: many health care facilities with “running on empty”, barely keeping their heads above water being chronically understaffed and stretched thin, etc: so (my guess) reporting cases to the CDC may not have been the number 1 priority even in symptomatic people

 

So, there is now some general sense of relief that people can get back to much of what we were doing pre-covid, with more travel, more indoor dining, more socializing, and (probably) more sex. the alarm raised by this above study is that there should be caution in unprotected sexual relationships. 

    -- in particular, it does make sense to try to minimize contact with crowds since Covid is still around: eg people should probably continue to use masks on airplanes, especially prior to takeoff and landing when the HEPA air filters are not so effective, or in other potential superspreading events (large parties, gatherings). And we health care types should have a heightened awareness to help people prevent STDs (use of barrier methods when having sex, PrEP for high-risk people) as well as consistent broad-based STD testing with frequency determined by the patient's risk

 

geoff

 

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