Syphilis cases continue to climb in the years following the COVID-19 pandemic, and public health programs and clinicians struggle to reverse this trend.
Congenital syphilis nearly doubled between 2018 and 2022, according to the most recent data from the Centers for Disease Control and Prevention (CDC).1
“We’re seeing syphilis cases on a dramatic rise — both congenital and full stages of syphilis,” says Darren L. Whitfield, PhD, associate professor at the University of Maryland School of Social Work in Baltimore.
Part of the increase in reported syphilis cases is related to syphilis among the population of men who have sex with men (MSM). Many MSM take pre-exposure prophylaxis (PrEP) to prevent human immunodeficiency virus (HIV) infection. This requires monthly tests for HIV and sexually transmitted infections (STIs), Whitfield adds.
Syphilis at all stages increased by 79% between 2018 and 2022, and gonorrhea increased by 11% in that time period.1
Prevention is the optimal approach to reducing STIs. People need to be aware of their STI status, need to know about what STIs are and why they should be tested, and need to know about ways to prevent transmission of an STI through vaccination for human papillomavirus (HPV) and condom use.
Sexual and reproductive healthcare providers and clinicians also play an important role in reducing STI rates in their communities, Whitfield says.
One way they can do this is to think through their own biases and stereotyping and recommend screening and testing to every patient who is sexually active, he adds.
They also need to offer treatment options to patients and not simply assume that patients with certain demographics would be unable to handle a weeklong treatment regimen, he says.
“Oftentimes, [providers] assume that people with low socioeconomic status or people of color are not going to be compliant, so they give them a one-time dose of antibiotics, and those have gastrointestinal side effects, which make people more reticent to seek treatment because the last time they did, they got sick,” Whitfield explains. “Instead, offer patients a seven- to 10-day medication, which has less side effects.”
Providers should tell patients about the benefits and drawbacks of both regimens and allow them to choose which they would prefer, he adds.
Another factor affecting STI rates is that people at risk of STIs and HIV may be using condoms less frequently than previous generations. Since PrEP can prevent HIV, and women can obtain highly effective contraception, young people may believe that condoms are not needed.
“We’re seeing folks who are willing to forgo condoms more than what we would have seen prior to the implementation of PrEP,” Whitfield says. “The messaging around HIV was that condoms were one of the few ways to prevent infection. Now, people can prevent HIV without using condoms.”
This places more young people who are sexually active at risk of other STIs, he adds.
“I believe we need to reconceive our messaging both in terms of STIs but also in terms of pregnancy and HIV,” Whitfield says. “The old days of saying, ‘Just use a condom,’ doesn’t work because you don’t necessarily just need to use a condom, but you need to know there are real reasons to use condoms in terms of STIs.”
Data on chlamydia show a 6% decrease, but those lower numbers — along with the gonorrhea data — are likely because of undertesting, says Yukari Manabe, MD, FIDSA, FRCP, professor of medicine in the Division of Infectious Diseases, Department of Medicine, at Johns Hopkins University School of Medicine in Baltimore, MD.
More testing, especially free STI testing, is needed to reach all of the people at risk of acquiring an STI. And thanks to mail-in STI testing, there are additional options for people.
But the question about mail-in testing is how useful it is, and this depends on the company offering the test kit and laboratory services.
A new study found that there are various limitations and options available through 20 programs in the United States that offer STI mail-in, self-collection testing services.2
For example, mail-in, self-collection services exist all states except New York and Rhode Island, but no-cost STI testing is available to consumers in less than half of the states.2
The usefulness of the self-test kit results depends on the program offering the testing. Mail-in test kits sometimes provide STI results without counseling or information regarding what a person needs to do about a positive test.
“Some labs will offer tests that are not clinically meaningful, and the results go straight back to the patient,” Manabe says.
Also, some of these laboratories offered testing for herpes, which should not be offered because most people in the United States will test positive for herpes and most are asymptomatic — making a positive finding meaningless, she adds.
HPV is another STI for which a positive finding does not mean much because the infection is ubiquitous.
“It’s great we’re starting to offer people different ways to get STI testing because we’re clearly not testing enough people, and it’s very important for women to know their status,” Manabe says. “The CDC recommends all women under age 25 get tested every year for chlamydia and gonorrhea,” she adds. “Most people know they have chlamydia, and public knowledge of it is high, but for HPV and herpes, public knowledge is not high.”
A person who receives a positive test for herpes would be worried unless they were told that 70% of people were exposed to herpes at some point in their lives.
The benefit of mail-in, self-collection for STI testing is that it provides people a little more confidentiality than they would experience walking into a public clinic or private doctor’s office. For people who do not want to be seen walking into a clinic that tests for STIs, this privacy is important.
But it also is important that people know which mail-in STI kits are the most useful. For clinicians recommending a mail-in kit, one option is the IWantTheKit.org program, Manabe says.
This program offers a free or low-cost and confidential STI/HIV home test kit for people in many states.
Visitors to its website can learn more about the different STIs, with links to information on 12 different STIs, including all of the commonly tested ones, as well as bacterial vaginosis, hepatitis B, hepatitis C, mpox (monkeypox), trichomonas, and Mycoplasma genitalium.
For example, the link on HPV discusses the potential of genital warts and cervical cancer and how people can be vaccinated to prevent infection.
“The website tells you how to find a condom and tells you about PrEP,” Manabe says.
Expanding access to STI testing through a mail-in test is a great option for many people, she notes.
“We should make sure these are reputable labs and people are not paying for testing where they do not know what to do with the results,” she adds. “This would increase stigma, panic, and other bad things.”
Another aspect of mail-in testing that patients need to know is that these test results are reported to state health authorities in the same way as an in-person clinic STI test result is.
“If it’s positive, it has to be reported,” Manabe says.
Increasing STI testing and treatment requires a better public health campaign and approach, including efforts to destigmatize infections, she says.
“I think as a high-income country, we should be doing better with these kinds of public health infections and decrease stigma around STIs,” Manabe adds.
REFERENCES
- Centers for Disease Control and Prevention. Sexually Transmitted Infections Surveillance, 2022. Last reviewed Jan. 30, 2024. https://www.cdc.gov/std/statistics/2022/default.htm
- Pontes MF, Armington G, Fink R, et al. Landscape review of mail-in self-collection programs for sexually transmitted infections. Sex Transm Dis 2023;50:336-341.
