“Sex: the thing that takes up the least amount of time and causes the most amount of trouble.” - John Barrymore
First, a confession: when my kids were reaching sexual maturity, I found frank discussions of sex difficult. But in the early 1980s that changed—a newly recognized sexually transmitted disease (STD): HIV/AIDS, emerged. Unlike other STDs, HIV infection was uniformly fatal (nobody survived in those days, and without treatment that is essentially true to this day). It wasn’t the happiest topic of dinner conversations, but it boiled down to this: unsafe sex kills.
Within the context of considering how infectious agents are acquired by humans, I’ve often thought about how clever sexual transmission is as a strategy. There are more than 20 types of STDs. Of course, the bacteria, viruses, parasites, and yeast that cause them don’t know how smart they are to have evolved a mode of transmission that is both essential to our existence and so difficult to control. Thus, it should come as no surprise that more than 1 million STDs are acquired every day worldwide. Furthermore, each year, there are an estimated 376 million new infections with one of these four STDs: chlamydia, gonorrhea, syphilis, and trichomoniasis.
But what should come as a surprise, and a call to action, is the immediate press release on October 8, 2019, by the Center for Disease Control and Prevention (CDC) that statistics from 2018 show that STDs continue to rise in the U.S., and tragically, that newborn deaths from congenital syphilis increased by 40%!
The CDC’s annual report on STDs focuses on gonorrhea, chlamydia, and syphilis. (HIV is reported separately, and overall case rates have remained stable in recent years.) The report always lags by nearly a year, as it takes time to collect and analyze all the data. Discouragingly, this represented the fifth year in a row that STDs hit all-time highs. In 2018, the CDC received 580,000 reports of gonorrhea (up 5% since 2017), and chlamydia broke an all-time record, hitting 1.7 million cases. Cases of the most infectious forms of syphilis increased by 14%, hitting 35,000—the highest number since 1991.
Of greatest concern to the CDC is a large uptick in congenital syphilis, a disease that afflicts newborns that can cause serious health problems throughout life. Characteristics of late congenital syphilis include bone pain, retinitis pigmentosa (a serious eye disease), and Hutchinson’s triad (peg-shaped upper teeth, interstitial keratitis, and deafness). Reports of 1,300 cases were received in 2018, representing a 40% increase, and related fatalities also went up by 22%. Sadly, with proper screening of pregnant women and antibiotic treatment, all of these deaths were preventable.
So, you may ask, as I did when I saw these reports, what’s up? As you might suspect, the answer is: it’s complicated. In some cases, the drug abuse epidemic plays a role. And although teens are waiting longer these days to have sex, CDC data suggests that young people, along with gay and bisexual men, are using condoms less reliably. An increase in unprotected oral sex among young people may also be a factor. Health departments in southern California, Rhode Island, and New Zealand recently reported that the sharp increase they are seeing in STDs is fueled by more widespread use of social media sites like Tinder, Grindr, and Facebook which allow users to readily connect with and meet others.
The good news with the “big three STDs”— gonorrhea, chlamydia, and syphilis—that the CDC closely tracks—is that they are all caused by bacteria and thus can be treated with antibiotics. The bad news, however, is that because of widespread antibiotic use, Neisseria gonorrhoeae (the cause of gonorrhea), has joined the ranks of the so-called “superbugs” (microbes that are resistant to multiple types of antibiotics).
Another major factor underlying the skyrocketing increase in STDs is a reduction in access to counseling and healthcare targeting disease prevention. The CDC reports that more than half of local STD-prevention programs have experienced budget cuts in recent years, resulting in clinic closures and more limited screening and patient follow-up. In the case of prevention of congenital syphilis, pregnant women aren’t getting properly tested for Treponema pallidum infection (a simple blood test is all it takes), and infected sex partners aren’t getting tested and treated.
Currently, human papillomavirus (HPV), hepatitis A, and hepatitis B are the only STDs that can be prevented by vaccines. HPV causes several types of cancer, including cervical cancer. Since the introduction of the vaccine in 1996, cervical cancer rates have fallen by almost 30%. However, vaccines to prevent gonorrhea, syphilis, and chlamydia don’t exist. So, prevention depends totally on practicing safe sex.
Controlling the epidemics of syphilis, gonorrhea, and chlamydia relies on strong public health infrastructure. The U.S. Department of Health and Human Services, which includes the CDC, is developing a Sexually Transmitted Infections (STI) Federal Action Plan to be implemented in 2020 that addresses the nation’s STD epidemic. However, urgent action from all types of stakeholders is necessary to help control the increase in STDs. This includes more open discussions of safe sex, not only around dinner tables but wherever sexually active people congregate. Additionally, the use of social media can help get the right message out—use condoms, get tested, get treated. Finally, keep in mind that unsafe sex not only kills, but it can be ruinous to your health and the lives of others, including unborn children.
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