When a population is emerging from under a cloud of fear that has hung over it for a generation, how is it best to discuss risks they face without appearing to shove them right back underneath again?
Last month, the Centers for Disease Control and Prevention released a report about an alarming rise in STI diagnoses over the past year. More than 200,000 more cases of gonorrhea, chlamydia, and syphilis were diagnosed last year than in 2016, which had previously held the record for the most diagnoses. Gonorrhea cases increased by 67 percent, and more than 1.7 million cases of chlamydia were diagnosed, 45 percent of which were in young women from the ages of 15 to 24. Of the more than 30,000 cases of syphilis, nearly 70 percent were in men who have sex with other men, aka MSM.
The CDC data do not make clear if the increased rate of diagnosis is due to a surge in infections or an uptick in testing, which results in the identification (and treatment) of more cases. What is apparent is the need for medical providers to be much more vigilant in screening their patients for STIs. The new numbers shouldn’t make anyone panic. They should convince doctors that in 2018, STI testing must be a part of routine care.
Caught early enough, syphilis is reasonably easy to cure with common antibiotics. It usually presents with a sore near the site of infection or in a later stage with rash and fever. Left untreated for too long, though, it can cause severe organ damage, invade the nervous system, and has the potential to be fatal. It can also cause serious birth defects if untreated during pregnancy, a fact worth considering even when focusing on MSM, given that many also have sex with women.
While raising concerns about the number of STI cases, what the CDC report doesn’t do is give any reasons to explain the rise. It’s difficult to know what factor or factors may be having a significant effect on these numbers. An accurate discussion of the increasing rates on infection is complicated and defies easy explanation.
“The CDC report unfortunately confirms anecdotal reports from the local health departments I work with. We have known about the trajectory of the increase in the ‘big 3’ bacterial STIs for several years, but it is still shocking and alarming to see these statistics,” Neal D. Goldstein told me. Goldstein is an assistant research professor of epidemiology at the the Drexel University Dornsife School of Public Health. “While syphilis is particularly concerning among MSM, it remains very treatable.”
“We also need to recognize there is a large racial disparity in these numbers, and be careful that this doesn’t get used to further marginalize and stigmatize any group,” Goldstein continued. “Data indicate that black and Hispanic MSM are more likely to screen positive for syphilis. But if you look at the behavior in these groups, especially among black MSM, they actually have fewer sexual partners and more condom use. This paradox can be in that smaller sexual networks and pools of sexual partners make it easier for STIs like HIV and syphilis to move around in these groups, through no fault of the men.”
Kim Toevs, STD-HIV–adolescent sexual health equity director for Multnomah County Health Department, agreed. “When we look at mathematic modeling of disease transmission, completely agnostic of moral judgment, things that tip the balance to keep an infection propagating have to do with infectiousness of the microbe or virus, duration of infection, frequency of partner overlap or change, and number of partners,” Toevs said. The Multnomah County Health Department’s STD-prevention program runs the main full-service STI clinic for Oregon and southwest Washington. Toevs attended at the CDC conference where the new STI report was presented.
“The size of the sexual network can also concentrate and increase risk of disease, higher with a smaller sexual network like racial minority populations,” she told me. “Racial disparities remain egregiously high. These are a result of long term structural racism and inequities in terms of housing, education, health care, and criminal justice. We are going to have to work hard upstream and downstream to solve these inequities.”
In addition to racial disparities in syphilis rates, other factors behind the numbers in the CDC bear further consideration.
Treatment as prevention is among the methods of preventing the spread of HIV that doesn’t require the use of condoms. For HIV-infected people who take a combination of medications (commonly known as HAART) to lower the amount of virus in their bodies to levels undetectable in blood tests, there is no risk of passing the virus to sexual partners. Pre-exposure prophylaxis, or PrEP, a once-daily medication that is highly effective at lowering risk of infection when taken consistently by uninfected people, is an additional condom-free means of preventing the spread of HIV.
“We have really effective ways to reduce HIV risk that don’t involve condoms, but unfortunately they don’t protect against bacterial STIs,” said Toevs. “There is a lot of safe sex going on vis-a-vis HIV, but not bacterial STIs. And in a community that has been so impacted for so long in such a deep traumatic way about HIV, it is really no wonder that folks cannot get the same level of motivation going for ‘all condom all the time’ for things that can be treated with antibiotics.”
“Many individuals see HIV as a chronic, manageable condition and are willing to forego using a condom, especially since the introduction of HAART,” said Goldstein. However, attributing the rise in STI diagnoses entirely to complacency about HIV likely misses other contributing factors.
“Among gay men, public health has done a great job of getting more people tested, hence we have this surveillance bias,” Goldstein continued. “Especially in the era of PrEP, as PrEP requires regular visits to the provider (every three months if you follow CDC guidelines) and STI screening. This may just be an artifact of more frequent testing.”
“PrEP hasn’t been linked to an increase of STIs,” said Pierre-Cédric Crouch, director of nursing at the San Francisco AIDS Foundation. “In fact, recent research has shown that PrEP can help people identify and treat these infections quickly.”
Some researchers have raised concern that use of PrEP will lead men to engage in riskier sex than they have otherwise. But Crouch disagrees, citing new research showing that men taking the medication did not have an increase in other infections.
“While syphilis is a serious infection, these increases are a call to action and not a call to panic,” said Crouch. “Prevention strategies making sex unpopular have never been effective, and condoms aren’t always feasible for people to use. There are more realistic interventions that we still need to explore, such as increased easy access to rapid testing, or using antibiotics after sex which have been shown to decrease syphilis and chlamydia rates.”
When I spoke to Crouch and other providers of medical care to MSM for an earlier article about PrEP, I heard a consistent message about the importance of avoiding stigma and helping MSM to recover from the trauma of the AIDS crisis and reclaim sex without the specter of disease. The Los Angeles LGBT Center’s “F*ck W/o Fear” campaign was easily the most evocatively named PrEP awareness campaign I came across, delivering the message with refreshing clarity. (It appears to have been replaced by “PrEP’d AF,” which is similarly frank.)
“What’s great about our bold F*ck W/Out Fear campaign: It encouraged medical providers to educate their clients not only about HIV but also about STDs, and it allowed everyone to discuss all things pertaining to sexual health in a sex-positive manner,” said Jeffrey Rodriguez, the senior program manager of the center’s Sexual Health Education Program. “We have to educate and empower gay and bisexual men of all ages to make good sexual health decisions based on what’s right for them.”
Everyone I spoke with viewed the new CDC report as an indication that too few people are aware of their own risks of STIs like syphilis, and too few providers are screening and treating for it appropriately.
“Most people do not know about syphilis, let alone how it’s contracted,” said Rodriguez. “Just as alarming, there are plenty of providers globally who don’t know who should be tested for syphilis and how to treat it correctly.”
All men who have sex with other men should know what their risks are, and all providers who treat MSM—which is to say, all providers who treat men, since you can never know if patients are telling you everything—should recognize the illness and know how to manage it. But taking these new data and using them as a means of shaping behavior through fear or stigma is unlikely to do anything but make the problem worse.
As Kim Toevs put it, “Shame is worthless for motivating health behavior change.”