New CDC Guidance Backs DoxyPEP Amid STI Surge, Political Controversy
The United States is grappling with a surge in sexually transmitted infections (STIs), with alarming increases in syphilis, gonorrhea, and chlamydia. According to the Centers for Disease Control & Prevention (CDC), syphilis rates have risen by 80% since 2018, gonorrhea cases have increased by 11%, and chlamydia remains high despite a slight decrease. This underscores the urgent need for innovative prevention strategies. One such strategy, Doxycycline Post-Exposure Prophylaxis (DoxyPEP), has emerged as a powerful tool in the fight against STIs, but it has also become a target of politically-motivated attacks fueled by misinformation and bigotry. DoxyPEP involves taking a dose of the antibiotic doxycycline after condomless sex to prevent bacterial STIs. While studies have repeatedly demonstrated its safety and efficacy, certain politicians, most notably Florida Senator Marco Rubio, have launched a crusade against DoxyPEP, jeopardizing the health and well-being of countless people.
While Senator Rubio and others leverage misinformation to fuel a politically-motivated crusade against the CDC’s new DoxyPEP guidelines, the evidence is clear: DoxyPEP is a safe, effective, and urgently needed tool to combat the nation's skyrocketing STI rates, particularly among the LGBTQ+ community already facing systemic healthcare disparities.
DoxyPEP: Backed by Science, Embraced by Communities
Fortunately, the effectiveness of DoxyPEP isn't based on conjecture or political ideology; it's firmly rooted in scientific evidence. Numerous studies have demonstrated its remarkable ability to reduce STI rates among those most vulnerable. In the groundbreaking DoxyPEP trial, researchers observed a sustained decrease in STI incidence among participants taking DoxyPEP, even with a short-term increase in sexual partners and condomless sex acts, as reported in Infectious Disease Special Edition. Further bolstering these findings, a separate study from the University of California, San Francisco, revealed that DoxyPEP reduced the risk of chlamydia and gonorrhea by nearly 70% among participants. These findings, along with a growing body of research, make it clear that DoxyPEP is a powerful tool with the potential to significantly impact the STI epidemic.
Real-World Success
The positive impact of DoxyPEP extends beyond clinical trials and into real-world settings. In San Francisco, where public health officials have proactively implemented DoxyPEP, the results have been significant. A study by the San Francisco Department of Public Health found that among participants, overall STI incidence fell by 58% after starting DoxyPEP. Chlamydia cases dropped by 67%, and early syphilis cases decreased by 78%. These real-world outcomes highlight the potential of DoxyPEP to effectively curb STI transmission when embraced by the community.
Addressing Resistance Concerns
One of the most frequently raised concerns about DoxyPEP is its potential to contribute to antibiotic resistance. While this is a valid concern that warrants careful consideration, the evidence suggests that the benefits of DoxyPEP outweigh the risks when implemented responsibly. As the CDC states in its report, "The potential for DoxyPEP to increase antimicrobial resistance is a theoretical concern, but current data do not suggest that DoxyPEP use has resulted in substantial increases in resistance." This finding is further bolstered by a study from the University of California, San Francisco, which found no significant increase in antibiotic resistance genes among DoxyPEP users. Additionally, the CDC emphasizes that the short course of doxycycline used in DoxyPEP, coupled with ongoing monitoring for resistance trends, can help mitigate this risk. These findings should reassure policymakers and the public that DoxyPEP, when implemented responsibly as part of a comprehensive STI prevention strategy, is unlikely to exacerbate the already concerning issue of antibiotic resistance.
Community Acceptance
Not only is DoxyPEP backed by robust scientific evidence, but it has also been met with enthusiasm and acceptance from the very communities it aims to protect. When offered DoxyPEP as a prevention option, people at risk for STIs have demonstrated a strong desire to incorporate this tool into their sexual health practices. In San Francisco, for example, Dr. Hyman Scott reported that "about 39% of people ultimately decided that they wanted DoxyPEP as an STI prevention tool." This positive reception speaks volumes about the willingness of people to take charge of their sexual health and embrace new strategies for protecting themselves and their partners.
Political Roadblocks: Rubio's Disinformation Campaign
Despite the overwhelming scientific evidence and the positive response from those most impacted by STIs, DoxyPEP faces a formidable roadblock: a politically-motivated disinformation campaign spearheaded by figures like Senator Rubio. Driven by what appears to be a combination of ideological opposition and a disregard for evidence-based policymaking, Rubio has repeatedly attempted to discredit DoxyPEP and undermine its adoption.
In a press release riddled with inflammatory language, Senator Rubio proclaimed, “The CDC’s unscientific recommendation is dangerous and could lead to more antibiotic-resistant infections and deaths." This statement, however, directly contradicts the findings of the CDC itself, which clearly show that current data do not suggest that DoxyPEP use has resulted in substantial increases in resistance. Furthermore, Rubio's assertion that the CDC's recommendation is "unscientific" ignores the rigorous research and clinical trials that have consistently demonstrated DoxyPEP's safety and efficacy.
By cherry-picking statistics about antibiotic resistance without acknowledging the nuances of DoxyPEP's implementation and the evidence mitigating those risks, Rubio engages in a dangerous game of misinformation. His tactics, unfortunately, have the potential to dissuade patients from accessing a potentially life-saving prevention tool and hinder efforts to curb the STI epidemic.
Unmasking the Agenda
A closer look at Senator Rubio's record reveals a disturbing pattern of opposition to policies that benefit the LGBTQ+ community, raising serious questions about the motivations behind his crusade against DoxyPEP. His voting history, as reflected in his 0 out of 100 score on the Human Rights Campaign's Congressional Scorecard, paints a picture of an anti-LGBTQ+ agenda. From opposing marriage equality to supporting discriminatory bathroom bills, Rubio has consistently aligned himself with those who seek to marginalize and harm the LGBTQ+ community.
As HRC President Kelley Robinson aptly stated, "Throughout his career, Sen. Rubio has repeatedly put his personal beliefs ahead of the needs of his constituents, particularly LGBTQ+ Floridians." His stance on DoxyPEP, a measure that would primarily benefit men who have sex with men (MSM) and transgender women, aligns with this pattern of disregard for the well-being of the LGBTQ+ community. By framing a scientifically sound public health intervention as "dangerous" and "unscientific," Rubio perpetuates harmful stereotypes and undermines efforts to address a health crisis that disproportionately impacts LGBTQ+ people.
The Dangers of Politicized Health
The case of DoxyPEP lays bare a disturbing trend in contemporary politics: the cynical manipulation of public health for political gain. When evidence-based interventions like DoxyPEP are distorted and demonized, the consequences extend far beyond a single policy debate. Allowing political agendas to dictate public health decisions undermines trust in science, erodes support for vital programs, and ultimately puts lives at risk.
This pattern of politically-motivated attacks on healthcare is particularly pronounced when it comes to the LGBTQ+ community. Across the country, conservative lawmakers at all levels of government are pushing a discriminatory agenda that seeks to restrict access to essential healthcare services for LGBTQ+ people. From attempts to ban gender-affirming care for transgender youth to efforts to allow healthcare providers to refuse service to LGBTQ+ patients, these attacks represent a clear and present danger to the health and well-being of an already marginalized community.
Senator Rubio's crusade against DoxyPEP must be understood within this broader context. His actions are not about protecting public health; they are about scoring political points by exploiting prejudice and fear. When those in positions of power prioritize ideology over evidence and demonize vulnerable communities, the consequences can be devastating.
The Path Forward: Equity, Access, and Comprehensive Prevention
To effectively address the STI epidemic, we must move beyond the politically-motivated roadblocks erected by those who prioritize ideology over evidence. A truly effective response requires a commitment to equity, access, and comprehensive prevention strategies that center the needs of those most impacted.
It's crucial to acknowledge that STIs do not impact all communities equally. As highlighted in the U.S. Department of Health and Human Services' National Strategic Plan for addressing STIs, certain populations, including gay and bisexual men, transgender people, and young people, bear a disproportionate burden of these infections. This disparity is driven by a complex interplay of factors, including stigma, discrimination, and barriers to accessing quality healthcare. For example, in 2018, more than 50% of primary and secondary syphilis infections occurred among MSM. These disparities demand a targeted and equitable approach to STI prevention, one that prioritizes the needs of those most vulnerable and addresses the systemic factors that contribute to their increased risk.
The Urgency of Action
The urgency of the STI epidemic demands swift and decisive action. We can no longer afford to let misinformation and political maneuvering hinder the implementation of evidence-based solutions like DoxyPEP. As Dr. Jonathon Cherabie, an Infectious Disease physician, pointedly stated on Twitter, "To state that this move [DoxyPEP implementation] is 'political' when two MAJOR trials have shown how beneficial this intervention is, in the midst of a massive increase in STIs especially syphilis is disingenuous." Dr. Cherabie goes on to highlight the hypocrisy of fixating on unfounded fears of antibiotic resistance with DoxyPEP while ignoring its use for other purposes like acne and malaria prophylaxis. His words serve as a potent reminder that the opposition to DoxyPEP often stems not from legitimate scientific concerns, but from a desire to undermine the health and well-being of LGBTQ+ people. Every day that passes without readily available DoxyPEP represents missed opportunities to prevent new infections and protect the health of marginalized communities.
A Multifaceted Approach
It's important to recognize that DoxyPEP, while a powerful tool, is not a standalone solution to the STI epidemic. To truly make a lasting impact, we need a comprehensive approach that addresses the complex nature of this public health crisis.
This comprehensive strategy must prioritize:
Expanded Access to Testing and Treatment: Timely and affordable access to STI testing and treatment is paramount. We must remove financial and logistical barriers that prevent people from seeking care, ensuring that everyone can get tested and treated promptly and effectively.
Comprehensive Sexual Health Education: Accurate, inclusive, and age-appropriate sexual health education is fundamental to empowering people to make informed decisions about their sexual health. We must move away from abstinence-only approaches and embrace education that encompasses a wide range of topics, including consent, contraception, and STI prevention methods.
Addressing Stigma and Discrimination: Stigma surrounding STIs prevents people from seeking testing and treatment, perpetuating the cycle of transmission. We must foster open and honest conversations about sexual health, challenge harmful stereotypes, and create a more supportive and inclusive environment for those affected by STIs, especially at points of care.
Adequate Funding for Public Health Initiatives: Effectively combating the STI epidemic requires robust and sustained funding for public health programs. This includes resources for research, surveillance, prevention programs, and healthcare infrastructure.
Conclusion
The alarming rise of STIs in the United States demands our unwavering attention and a commitment to evidence-based solutions. Inaction is not an option; it carries the weight of preventable infections, long-term health complications, and lives needlessly impacted. DoxyPEP represents “the most exciting intervention for STI prevention in two decades,” a scientifically sound intervention with the potential to significantly curb the STI epidemic, particularly among the LGBTQ+ community. We cannot allow political maneuvering and misinformation campaigns to derail this progress.
As advocates, policymakers, and industry professionals, we have the power to turn the tide against this epidemic:
Integrate DoxyPEP into Policy Agendas: For policymakers, champion legislation and funding initiatives that expand access to DoxyPEP, ensuring its inclusion in Medicaid, ADAPs, and private insurance plans. Advocate for comprehensive sexual health education and robustly funded public health programs.
Harness Your Platform to Disseminate Accurate Information: Leverage your professional networks, social media platforms, and public speaking engagements to counter misinformation surrounding DoxyPEP. Share the overwhelming scientific evidence supporting its efficacy and safety, and challenge those who prioritize political agendas over public health.
Advocate for FDA Approval: While the CDC has issued guidelines for DoxyPEP, it remains an off-label use of doxycycline. Advocate for the FDA to formally approve this use, which would further solidify its legitimacy, potentially expand insurance coverage, and increase confidence among healthcare providers and patients.
The fight for effective STI prevention is a fight for public health, for equity, and for the well-being of us all. Let's leverage our collective influence to ensure that DoxyPEP becomes a standard tool in our arsenal against this urgent public health crisis.
The Congenital Syphilis Crisis
At the turn of the century, the United States was nearing elimination of syphilis. However, in the 23 years since then, congenital syphilis has alarmingly resurfaced, revealing significant vulnerabilities in our healthcare system. Highlighted by a newly released Centers for Disease Control and Prevention (CDC) report, syphilis’ resurgence is a critical public health concern demanding immediate and comprehensive action.
The Escalating Crisis
Since 2017, recent CDC data indicates a dramatic 75% increase in syphilis cases in the United States, with congenital syphilis cases tripling in the same timeframe. In 2020, 2,148 newborns were affected, a jump from 1,870 in 2019. This worrying trend extends globally, as a Lancet study corroborates, and the World Health Organization (WHO) estimates nearly 1 million annual congenital syphilis cases worldwide. These cases often result in severe outcomes, including stillbirths, neonatal deaths, and lifelong health complications.
The surge in congenital syphilis necessitates a critical examination of its root causes, including inadequate prenatal care, healthcare access barriers, and insufficient sexual education.
Integrated Response to Syphilis Resurgence
The re-emergence of syphilis is deeply rooted in social and healthcare dynamics and exacerbated by the COVID-19 pandemic. This situation calls for an integrated response from the medical community and society as a whole, addressing both the underlying factors and the immediate challenges.
The CDC has identified significant disparities in syphilis rates among Native American, Native Hawaiian, Pacific Islander, and Black populations. These disparities are linked to broader social determinants of health, which have been further strained by the COVID-19 pandemic, as noted by the American Journal of Public Health. The pandemic's impact on healthcare services has led to increased sexually transmitted infection (STI) rates, including syphilis, due to reduced healthcare access.
Challenges and Care in Syphilis Prevention and Treatment
The medical community, including the Health Resources and Services Administration (HRSA) and dermatologists as discussed in JAMA Dermatology, plays a crucial role in addressing the syphilis epidemic. Their efforts are key to bridging healthcare access gaps and tackling systemic challenges. However, these initiatives are hindered by significant hurdles, such as medical resource shortages, emphasizing the need for a sustained, integrated approach to this public health crisis.
A major challenge is the shortage of Bicillin L-A, the primary treatment antibiotic, as highlighted by The New York Times. This shortage, caused by increased demand and manufacturing constraints, poses a significant risk, especially for pregnant women and birthing persons, and necessitates alternative strategies and early intervention to prevent mother-to-child transmission.
Coordinated Multi-sector Response
Recognizing these challenges, the medical community, led by organizations like the National Association of County and City Health Officials (NACCHO), is advocating for a coordinated response. This approach involves:
Rapid Testing and Treatment: Prioritizing rapid syphilis testing for pregnant women and birthing persons, especially in underserved areas, to prevent congenital syphilis.
Educational Campaigns: Launching culturally sensitive educational campaigns about prenatal care and regular syphilis testing during pregnancy.
Enhanced Prenatal Care Access: Expanding access to quality prenatal care, integrating routine syphilis testing into prenatal check-ups, and ensuring affordable treatment options.
Policy and Funding Support: Advocating for increased funding and policy support to enhance resources for syphilis testing, treatment, and prenatal care services.
Community Engagement and Education
To effectively combat the resurgence of syphilis, a multifaceted community engagement and education strategy is essential. This approach should encompass:
Integrated Awareness Initiatives: Implement targeted campaigns across diverse platforms to educate on syphilis risks, prevention, and treatment. These should be inclusive, culturally sensitive, and utilize local media, social platforms, and community events for maximum reach and impact.
Collaborative Community Leadership and Healthcare Partnerships: Engage community leaders, influencers, and healthcare providers in a collaborative effort. This includes disseminating information, advocating for prevention and treatment, and organizing educational workshops and seminars. These partnerships are vital for credibility and creating effective referral systems for medical consultation or treatment.
Enhanced Comprehensive Sex Education: Strengthen sex education programs in schools and community centers, covering all aspects of sexual health. This should include STI prevention, contraception, and healthy relationships, tailored to be culturally sensitive and inclusive.
Active Community Involvement and Feedback: Encourage community feedback and involvement in the planning and implementation of syphilis education and prevention programs. This ensures the initiatives are relevant, effective, and address specific community needs.
The Role of Sex Education in Preventing Congenital Syphilis
Comprehensive sex education is a pivotal element in combating congenital syphilis. This education equips people with essential knowledge and tools for informed decisions about sexual health, playing a critical role in STI prevention, including syphilis.
Key Insights and Evidence:
Gap in Education and Its Consequences: Reports from sources like NPR and the Texas Tribune highlight the link between the rise in congenital syphilis and inadequate sex education. This gap, which is especially pronounced in resource-limited areas, leaves many, particularly adolescents and young adults, vulnerable due to a lack of essential sexual health knowledge.
Societal and Cultural Barriers: Cultural stigmas and taboos, as discussed in BBC Future, often impede the implementation of comprehensive sex education, leading to misinformation and increased STI risks.
Supporting Data for Comprehensive Education:
◦ The American College of Obstetricians and Gynecologists (ACOG) and studies in the Journal of Adolescent Health underscore the effectiveness of comprehensive sex education in reducing risky behaviors and STI rates.
◦ Research from PubMed Central and the Guttmacher Institute links inadequate sex education to higher STI and unintended pregnancy rates, advocating for inclusive and comprehensive programs.
Importance of Cultural Sensitivity: Studies emphasize the need for culturally sensitive and inclusive sex education, which has been shown to positively impact sexual behavior and contraception use among adolescents.
Policy, Public Health, and Community Approach to Syphilis
The fight against the syphilis epidemic necessitates a unified approach, combining policy initiatives, public health strategies, and community involvement. Central to this effort is the Pasteur Act, reintroduced in Congress to foster antibiotic research and development, a critical step in combating drug-resistant pathogens and diseases like syphilis. This act also highlights the need for equitable access to treatments, particularly for marginalized communities disproportionately affected by congenital syphilis.
Focused Policy and Public Health Efforts:
Support for the Pasteur Act: Advocacy for this act is crucial to stimulate antibiotic innovation and ensure the availability of new treatments for those in need, particularly in underprivileged communities.
Increased Funding for Public Health Campaigns: Investing more in public health campaigns is essential to educate high-risk communities about syphilis prevention and treatment.
Strengthening Healthcare Systems: There's a pressing need to enhance healthcare infrastructure, especially in areas lacking adequate medical resources, to manage the rising cases of congenital syphilis.
Ensuring Equitable Healthcare Access: Policies should aim to provide universal access to quality healthcare, including STI testing and treatment, with a focus on reaching marginalized groups.
Community and Healthcare Provider Engagement:
Healthcare Providers' Role: Emphasizing prenatal care and routine syphilis testing for pregnant women and birthing persons during every patient encounter is critical to prevent the transmission of syphilis to newborns.
Community Involvement: Supporting comprehensive sex education and advocating for the destigmatization of sexual health are essential. Communities and individuals should be encouraged to practice regular testing and safe sex.
This collective effort, integrating medical, educational, and policy measures, is vital to significantly reduce the incidence of congenital syphilis. By working together, we can protect future generations and address the broader aspects of this public health challenge.
For more information, the CDC's congenital syphilis fact sheet provides detailed insights into prevention strategies and the impact of the disease.
New STI Surveillance Report – It’s Not Good
In late 2021, ProPublica profiled the efforts of a local public health worker, Mai Yang, Mai Yang, as she sought to track down a pregnant client recently screened for syphilis Yang was urgent in the need to find this client and get her curative treatment, three uncomfortable injections of penicillin, completed at least 30 days before giving birth. Congenital syphilis is a killer with a near 40% chance of a newborn dying or being stillborn. Beyond death, congenital syphilis risks a range of difficulties, from disabling deformities to cognitive dysfunction. COVID-19 impacts were readily felt throughout the story as Yang’s client, Angelica, struggled with housing, a language barrier required an interpreter, and, eventually, the clinic Yang sought to link Angelica to was not able to accommodate a walk-in appointment, despite Yang having gotten assurances they could.
Last week, the Centers for Disease Control and Prevention (CDC) released its annual sexually transmitted infection (STI) surveillance report for the year 2021, and the news, while not surprising in retrospect, is not good. Both syphilis and congenital syphilis cases rose about 32%, compared to 2020. 2020, on its own saw a moderate rise in both syphilis and congenital syphilis. However, the CDC notes 2020 as the most affected year in STI surveillance with a marked decreases in screening activities in much of 2020 and higher than previous baseline diagnoses throughout much 2021 (mostly around the 150% level but a massive spike well above 200% around November 2021 – or about the time of ProPublica’s report being published).
Gonorrhea and chlamydia cases rose, though not as dramatically. Herpes, despite being a prevalent STI, is not a reportable illness and thus not tracked in the annual report.
This marks the eight consecutive year of increasing STI diagnosis, as noted by the National Coalition of STD Directors and Association of State and Territorial Health Officials. The situation is dire, going forward. Public health offices across the country are expecting to see an exodus of staff in the next 5 years. Between low pay and poor benefits relative to the private sector and displeasure with supervisors (which may be attributed to a lack of flexibility befitting the modern world or political pressures exerted at the appointment level), young and even well-established professionals are planning on leaving this space. And none of that necessarily reflects struggles with private partners or contracted clinics, which are equally struggling with securing funding and meeting ever increasing demands to do more with less.
In the ProPublica article, former CDC Director Dr. Tom Frieden reflected on how the United States has a terrible tendency to go through “a deadly cycle of panic and neglect”. And the same might be considered here. When President Biden announced in May of 2021 that his administration would be working to secure funding for “tens of thousands” of jobs to respond to COVID-19 and support local public health officials, there was an implication those dollars (secured in the American rescue Plan) would also fund positions that had been left to atrophy or were usurped by COVID-19 activities – most notably, disease intervention specialists. But COVID-19 is winding down, in so far as the Biden Administration seems prepared to invest much in the way of workforce dollars, and that promise made in 2021, was supposed to extend through 2026. If comments from federal legislators last year were any indication, there’s not much hope yet in this Congress choosing to ensure funding is secured to help these programs meet their goals.
In a recent interview, U.S Food and Drug Administration (FDA) Commissioner Dr. Robert Califf said “misinformation” was a leading cause of a decline United States life expectancy. And while that may one element of the issue, an abject failure to appropriately fund, stay competitive with the private market, and retain the talent needed to execute public health programs is core and central to this issue. The latest STI surveillance report shows us this plainly. Technology can only do so much in terms of outreach and extending capacity – in order to meet the demands of public health, the human element must be sufficiently supported.
Advocates would do well to take the long-view of their work. It is critically necessary to support existing public health programming and to address disparities being laid bare by annual surveillance data in order to reach an equitable health dynamic in this country – health justice. We cannot get there without supporting public health entities, shielding them from the politicalization of their mission work, and ensuring they’re appropriately appreciated for the life-saving work they do. We cannot represent patients when we don’t know who they are. We must participate with our partners in elevating the STI crisis for what it is – a public health emergency.