Sadly Predictable: STIs & HCV Rates Rising Again
The U.S. Centers for Disease Control and Prevention (CDC) recently shared data showing a rise in most sexually transmitted infections (STIs) in 2020, despite a reduction in screening due to the COVID-19 pandemic disrupting public health programs aimed at STIs screening and treatment. While the statement focused on syphilis, chlamydia, and gonorrhea, Hepatitis C and HIV can also be transmitted via sexual contact. Dr. Juno Mermin, the CDC’s Director of the National Center for HIV, Viral Hepatitis, STD, and TB Prevention, blames some of the issue on a historical lack of investment in public health and stigma.
While Dr. Mermin’s sentiments are well appreciated, the potential for a developing “blind spot” as a result of COVID-19 diverting already scarce resources serving these programs in order to address COVID-19, including human resources (disease investigation specialists – DIS – to be specific), was well-noted and should not be considered to be well-understood as of 2022. Public health surveillance and other aspects of infectious disease monitoring have been direly harmed by the diversion of these brain and labor trusts as opposed to a national effort to strengthen these amid a compounded public health emergency. Indeed, we’re just now beginning to assess the potential damage caused by COVID-related disruptions in pre-existing public health programs, specifically those designed to address STIs. And while we’re doing all of this effort to better understand what’s happened, we’re at risk of state legislators underappreciating the necessity of the moment as politically driven distaste for public health programming is resulting in states considering massive cuts to their health departments (ie. Louisiana’s House just passed a budget gutting the health department by $62 million, despite the agency struggling to recruit and retain talent due to years of disinvestment – and Louisiana isn’t alone).
The disease burden of these rising infections falls most heavily among Black communities and young people, with a special note to be given to the incredible rise of congenital syphilis infections, especially among impoverished pregnant people struggling with access to care. Dr. Mermin has emphasized a need to invest in both public health programs and prophylactic vaccines to prevent the bacterial infections. To be clear, when we talk about public health investments, we mean:
funding increases so that public programs can compete with private industry for labor and talent recruitment and retention;
infrastructure increase so that health departments and their funded service contractors and grant subrecipients can afford things like modernized software, functioning computers, and integrated data systems that aren’t reliant on fax machines;
flexibilities and appropriate funding for support services, especially those designed to address housing needs of served communities;
federal funding leveraged to increase linkage and retention in care services (including transportation to medication retrieval as well as medical service visits); and
federal funding incentivizing stigma and bias reduction in medical and service providers who are also grant recipients and subrecipients.
In addition to public investments, private investments are long overdue in terms of antibiotic treatment developments, especially with regard to multidrug resistant STI-causing bacterium. The last time a truly novel antibiotic was developed was 35 years ago in 1987 and the [pipeline isn’t looking particularly promising. The lack of investment in developing more effective and new antibiotics is so stark, Pew just kinda gave up on tracking it in December 2021.
Beyond access to care and treatment, education regarding STIs has been under attack for…well…as long as any of us can remember and 2022 has found politicians claiming this kind of education, when presented comprehensively, might be considered “grooming” children (referring to psychological training of vulnerable people to make them more compliant with being sexually exploited and assaulted). Despite thirty years of research showing comprehensive sex education reduces the incidence of STIs among youth and well into adulthood politicians continue their assault on public by making particularly disingenuous claims regarding the nature of sex education n publicly funded schools. Let me back that up, these folks are outright lying in order to leverage fear, ignorance, and already existing social tensions to exploit and marginalize already vulnerable populations.
The unfortunate nature of public health, especially for those who had zero knowledge of public health prior to COVID-19 screaming onto the scene, is the more we disinvest, the more harm we see come to those communities and people who can least afford the ability to cope with said harms. The further we lower the bar on medically focused sex education, the more likely young people will have to face higher rates of youth pregnancy, HIV, and STIs. The more we see attacks on and defunding of health departments, the fewer people are going to want to work there.
We need the political will, the private support, and collaborative spirit of advocates across issue areas to face this moment. Syphilis untreated or untreatable is deadly, gonorrhea and chlamydia untreated or untreatable can and will render people infertile among other permanent injuries to internal organs, and untreated HIV and HCV is also deadly. The communities most affected by these illnesses are also least likely to be able to afford health care, housing, and have adequate health insurance. The people most affected by these illnesses are often Black, Brown, young, queer, or assigned female at birth. We need to care more about achieving health Justice and we need to do it together.
Deceptive Masks: COVID’s Threat to STI Surveillance
In April, the Centers for Disease Control and Prevention (CDC) released its annual sexually transmitted infections (STIs) surveillance report, reflecting an increase in overall rates for the sixth year in a row, with a nearly 30% increase in STIs from 2015 to 2019. While sharpest increases in incidences were of syphilis among newborns, the infection burden is not equal with young (ages 15-24) people, gay and bisexual men, and people of color facing exceedingly disproportionate diagnoses. What’s important to note is traditional CDC surveillance reports lag by about two years – these data do not account for COVID-19 impacts among screening and treatment of STIs.
In the report’s press release, the CDC acknowledged COVID-19 posed extreme threats to screening, treatment, and prevention, as public health programs and staff typically used to address STIs had largely been repurposed in response to COVID-19, citing a survey from January showing about one third of local and state health department STI staff were still deployed to COVID-19 activities. Shortages also include screening supplies, according to a September 2020 “Dear Colleague Letter” with regular updates posted on the agency’s drug and diagnostic test notices page showing marginal improvement as reported by testing kit and supplies manufacturers.
The aforementioned survey of local and state health departments was conducted by the National Coalition of STD Directors (NCSDDC), “a national public health membership organization representing health department STD directors, their support staff, and community-based partners”. While NCSDDC usually throws most of its resources into advocating for public health policy changes, funding, and offering technical assistance, throughout the COVID-19 public health emergency, NCSDDC has found itself in the unique position of reporting on the situational needs of health departments and their staff, tasked with meeting a multitude of needs in any given community. The organization summarized its Phase III survey results as follows:
“This continued diversion of staff and other resources has caused delays in providing disease intervention services, leaving some STDs completely unchecked. STD programs continue to report clinic closures, reduced clinic hours and services, STD testing kit shortages, and diminished laboratory capacity. Additionally, STD programs report severe burnout as disease intervention specialists (DIS) pivot from COVID-19 investigations and contact tracing back to STD disease intervention and partner services work.”
For context, NCSDDC, in March of 2020, initially phrased the state of local and state health departments responding to COVID-19 as a “starved public health system in distress”. An indication that despite pledges from the White House and billions in funding allocated by law makers, “on the ground” not much has yet changed for the first responders of public health.
Complicating matters, some health officials are debating the implications of initial surveillance reports for 2020 seemingly showing certain decreases in STI diagnoses, according to one news report, as either a reduction in sexual activity among at risk persons during stay at home orders or a lack of screening. Given the context of reduced capacity, staffing, and supplies, entertaining the possibility of decreased sexual activity rather than decreased access to services shifts the responsibility (and pressure) on state lawmakers and executive offices to appropriately fund and support public health programs to that of undersupported health departments, contracted service providers, their staff, and the vulnerable communities they serve.
As discussed in HEAL blog posts from earlier this year, COVID-19’s impact on public health activities is still being discovered, largely through emerging surveillance gaps (lack of screening) and, as the CDC’s STI report shows, at a lag of data rather than a decrease of incidence, leaving communities vulnerable to outbreaks.
Later this month, on June 30th, NCSDDC will be joining Community Access National Network and Community Education Group for a virtual Community Roundtable on COVID-19’s impacts on HIV, HCV, STIs, and substance use disorder, providing stakeholders and advocates a space to further explore where public health efforts have been strained and can be strengthened in light of COVID-19.