Sexually Transmitted Disease Rates are Surging: A Matter of Life and Death

Abstract

After reaching historic lows decades ago, rates of sexually transmitted infections (STIs) have surged since 2020. Health officials claim that the pandemic was responsible for igniting this rise, citing a halt in testing, treatment, and surveillance of STIs as isolation began, and resources were reallocated to address coronavirus disease 2019 (COVID-19) issues. Others cite the overall shift in lawmaking since the early 2000s that has scaled back interventions geared toward controlling STI spread. Regardless of the root cause, this surge demands immediate attention due to the severe damage that these infections can cause, including infertility and pelvic inflammatory disease. In this paper, we examine this issue medically, socially, ethically, and from a public health perspective. The symptoms, treatments, complications, and testing strategies for syphilis, gonorrhea, and chlamydia are analyzed while highlighting at-risk groups and discussing mitigation strategies. The social implications of this current crisis are then explored, reviewing what approaches have been made for this issue so far. Next, we ground this issue in the harm reduction theory to advocate for the ethics of our proposed interventions. We conclude with recommendations at the individual, community, and federal levels to help reverse the surge in STIs and prevent further harm.

1. Introduction

The overall amount of sexually transmitted infections (STIs), namely syphilis, gonorrhea, and chlamydia continues to surge, specifically in the younger population. Combined cases of syphilis, gonorrhea, and chlamydia reached an all-time high after rising for the fifth year in a row. Between 2014 and 2018, cases of chlamydia, one of the most common STIs, increased by 15%. Although less prevalent overall, gonorrhea and syphilis increased by 35% and 50%, respectively [1]. Because these statistics only continue to rise, politically conservative policymakers remain set on limiting adolescent access to sexual health information and services because they believe that efforts to increase access to these resources will encourage sex among these populations; however, there is a range of research against this claim [1]. A shift in the methodology and approach to sexual health education in the youth is needed to turn back the trends in STIs.

Sexual relationships are a perfectly normal aspect of many young adult lives. In the United States, two-thirds of 18-year-olds have had sex; and by age 25, more than nine in 10 people will have had sex [1]. Thus, resources and programs aimed at preventing STIs through preventative education and access to treatment are a must-have aspect of approaching the surging STD rates in the United States.

After reaching a historic low in 2000 and 2001, primary and secondary syphilis rates have been steadily increasing every year, with an increase of 6.8% in 2019–2020 [1]. The US Midwest, Northeast, and the South saw an equal rise in both females and males. All racial groups witnessed a disproportionate increase in non-Hispanic American Indian/Alaska Native and non-Hispanic persons of multiple races.

Since 2000, men have seen an increase in primary and secondary (P&S) syphilis likely due to a rise in incidence among men who have sex with men (MSM), which appears to have slowed during 2019–2020. However, it is evident that MSM are affected disproportionately as they accounted for 53% of male P&S cases in 2020 with an increased syphilis rate witnessed in 18 states during the same period. Although women have a lower incidence of syphilis, it has substantially increased in recent years wherein the United States saw an increase of 147% in 2016–2020, suggesting a rapid increase in the heterosexual syphilis epidemic [1].

The congenital syphilis rate has been on the rise since 2008, with a massive 254% increase in the national rate from 2016 to 2020. This is reflective of the rise in syphilis in the reproductive women age group. There was a 24% increase in women aged 15–44 years [1].

Past years’ data reveal some disparities in terms of age groups and racial minorities. The year 2020 saw 53% reported cases among adolescents and young adults and 32% of syphilis, gonorrhea, and chlamydia cases being non-Hispanic Black population despite making up only 12% of the US population. These expose the differences in access to sexual health care for the minority. Acknowledgment of health inequity is the first step toward empowering affected groups [2].

A mini epidemic of syphilis was seen from 1980 to 1990, with a peak in 1990, subsequently falling to lowest rates in 2000. According to the World Health Organization (WHO) estimate, in 2016, syphilis had a prevalence of 19.9 million and an incidence of 6.3 million [2].

The Centers for Disease Control and Prevention (CDC) report suggested recent increase in drug use could be a reason for increasing syphilis rates among women. Higher rates were seen among women who used methamphetamine, heroin, and intravenous (IV) drugs. Naturally, this increase heralded an increase in congenital syphilis with 2148 cases, 149 stillbirths, and infant deaths reported in 2020 [1, 2].

Another interesting trend is that 46% of MSM with syphilis were found to have coinfection with human immunodeficiency virus (HIV), in comparison to 8% in heterosexual men and 6% in women; men aged 25–29 years seemed to have the highest rates, and Black men seemed to be disproportionately affected with the incidence in 2020 as high as 57.7 per 100,000 versus 23.4 in Hispanic men and 11 in White men [3].

2. Methodology

This chapter is a multifaceted review of the current literature surrounding the rates of sexually transmitted diseases (STDs) and STIs to evaluate the current state of the crisis. We herein present the medical specifics of each disease covering historical perspectives, demographic data, transmission, symptoms, and treatment. In the analysis of the social aspect of this current crisis, we review and summarize various studies that provide a deeper context for our topic based on trends about national health care and political views. Our ethical analysis is similarly informed by national data, as we draw upon the work of renowned bioethicists to support our position in favor of our proposed initiatives as harm reduction techniques. Our public health recommendations are made in light of both evidence that similar interventions have worked in some capacity in the past and the guidelines from national and international health care institutions. The data were obtained from online databases and research articles.

3. Medical analysis

3.1 Syphilis

Syphilis is a sexually transmitted bacterial infection caused by Treponema pallidum. Humans have been plagued by the stigma of syphilis since the beginning of time when it was considered a disgraceful disease because of its means of infection. Historically, each country blamed its neighbors for the outbreak. Germany, Italy, and the United Kingdom called it the “French disease”, Russians called it the “Polish disease”, the Polish named it the “German disease”, and so on [4].

Syphilis is also marred by the infamous Tuskegee study (1932 to 1972) that disregarded bioethics by withholding treatment for syphilis to 431 Black men enrolled after it became available during the study period and providing insufficient information regarding the study to obtain informed consent [5].

3.1.1 Symptoms

Syphilis is also known as “The Great Pretender” because the symptoms mimic several other diseases. Progression of syphilis can last from a few weeks to months to years, advancing through primary, secondary, and tertiary stages. The primary stage is characterized by chancres, which are round, firm, and painless open sores, typically found in unnoticeable places such as the vagina or anus. The source can last from 3 to 6 weeks and will heal regardless of treatment. If left untreated, syphilis will progress to the secondary stage [4, 6]. The secondary stage is marked by a non-itchy rash on skin or mucous membranes, which originate from one area of the body and spread to another. On many occasions, this rash may be very faint to notice. One may also develop a condyloma lata lesion, which is a raised lesion that develops around moist and warm areas such as the axilla, genitals, or mouth. Patients may also experience sore throat, fever, enlarged lymph nodes, hair loss, headaches, or fatigue. Similar to primary syphilis, secondary syphilis symptoms will resolve without treatment, but the disease itself will progress to latent syphilis likely followed by tertiary syphilis [4, 6]. Latent syphilis is the period without any visible signs/symptoms and can last for years [4, 6]. However, tertiary syphilis is one of the most potentially fatal stages, which can develop 10 to 30 years after the infection, affecting multiple organs, such as the brain, nerves, heart, liver, eyes, and bones [4, 6].

Other dangers associated with syphilis include its effects on pregnant mothers and their children. It can be transmitted from a pregnant woman to her unborn baby. Testing is usually recommended during the first prenatal visit and sometimes at the third trimester and delivery as well. People living in areas with higher syphilis rates may also need testing [4, 6]. Multiple sex partners, late prenatal care, methamphetamine use, incarceration, and homelessness all predispose individuals to syphilis during pregnancy. The longer a pregnant woman has syphilis, the higher the chances are for stillbirths. Pregnant women with untreated syphilis experience an infant death rate of up to 40% [4, 6]. Untreated babies who contract syphilis from their mothers can develop seizures, experience developmental delays, or even die. Hence, it is paramount to treat infected mothers with penicillin, as it prevents transmission in 98% of cases [4, 6].

3.1.2 Testing

Testing comprises two strategies: screening and diagnosis. Screening is performed on those who are asymptomatic but at a high risk of infection, whereas diagnostic tests are performed on those who have signs or symptoms of the disease or test positive during the screening. It is important to understand the type of patients we need to test. Knowing that syphilis presents widely, one should have a low threshold for testing. Patients presenting with classic signs such as genital ulcers, rash involving trunk and extremities, and general weakness must be tested. Additionally, a sexually active person with a rash in the palms and soles and an undiagnosed genital ulcer should be tested.

Tests available for syphilis are serologic tests and direct tests. These two tests alone or in combination are used to screen and diagnose individuals [6]. Serologic tests help in obtaining a presumptive diagnosis of syphilis and are usually used in conjunction with nontreponemal tests, which measure the serum reactivity of infected patients to a cardiolipin-cholesterol-lecithin antigen. Despite being nonspecific and nondefinitive, they are inexpensive, easy to perform, and useful following response to therapy. Thus, it has been traditionally used as an initial screening tool for syphilis. Examples of nontreponemal tests are the rapid plasma reagin (RPR) test, the Venereal Disease Research Laboratory (VDRL) test, and the toluidine red unheated serum test (TRUST). These tests are semiquantitative and wane over a period even without treatment. They are reported as titers, and the changing titer denotes a response to therapy [6].

Treponemal tests, on the other hand, are complex and expensive tests. Once nontreponemal tests are positive, treponemal tests are performed and hence are traditional confirmatory tests. However, the advent of advanced technologies has facilitated ease of use, simplicity, and automation, increasing their use as an initial screening test, which is now referred to as reverse screening. Examples of these tests include the fluorescent treponemal antibody absorption (FTA-ABS) test, the T. pallidum particle agglutination assay (TPPA) test, the T. pallidum enzyme immunoassay (TP-EIA) test, chemiluminescence immunoassay (CIA), and microhemagglutination test for antibodies to keep T. pallidum (MHA-TP). These tests detect the antibodies developed by the patient against specific treponemal antigens and hence are more specific than nontreponemal tests. They are reported either as “reactive” or “nonreactive” and usually remain positive for the rest of their lives [6].

The tests that definitively confirm the presence of T. pallidum are called direct tests. These include darkfield microscopy/direct fluorescent antibody testing and polymerase chain reaction (PCR) tests. The former needs advanced equipment and expertise to perform and hence are not routinely used by clinicians. However, some labs have developed PCR tests to detect the bacteria in clinical specimens. One limitation of these, though, is that they have low sensitivity and might detect dead organisms too [6].

Considering all the factors described above, serologic tests are frequently used to make a presumptive diagnosis. Traditionally, nontreponemal tests (e.g., RPR) followed by a treponemal test (e.g., FTA-ABS) have been used for diagnosis. However, in recent years when treponemal tests have become easy to perform as mentioned above, a reverse algorithm is becoming popular. The CDC was the first one to describe this in 2008. An example would be performing TP-EIA followed by RPR or VDRL [6].

3.1.3 Treatment

The data on the treatment of early syphilis support the use of a single intramuscular injection of 2.4 million U of benzathine penicillin G, with studies reporting 90–100% treatment success rates. The value of multiple-dose treatment of early syphilis is uncertain, especially in HIV-infected individuals. Less evidence is available regarding therapy for late and late latent syphilis. Following treatment, nontreponemal serologic titers should decline in a stable pattern, but a significant proportion of patients may remain seropositive (the “serofast state”).6 Serologic response to treatment should be evident by 6 months in early syphilis but is generally slower (12–24 months) for latent syphilis. Evidence defining treatment for HIV-infected persons and for pregnant women is limited, but available data support penicillin as the first-line therapy [5].

While penicillin remains the drug of choice to treat syphilis, doxycycline to treat early and late latent syphilis is an acceptable alternate option if penicillin cannot be used. There are very limited data regarding the impact of additional antibiotic doses on serologic responses in serofast patients and no data on the impact of additional antibiotic courses on long-term clinical outcomes [7]. Here, we will summarize the treatment protocols as listed by the CDC.

3.1.3.1 Adults

3.1.3.1.1 Primary and secondary syphilis

A single dose of 2.4 million units of intramuscular benzathine penicillin G has been effective in healing the rashes and preventing sexual transmission and late sequelae. Additional antibiotics have not been known to enhance the above-mentioned treatment regimen [5].

3.1.3.1.2 Tertiary syphilis

If a patient does not have cardiovascular syphilis, gummas, has absent CSF or clinical findings of neurosyphilis, and is not allergic to penicillin, then the protocol dictates 2.4 million units of intramuscular benzathine penicillin G given once weekly for a total of three doses [5].

3.1.3.1.3 Latent syphilis

Treatment of this stage is meant to prevent complications rather than treat, as latent syphilis is not sexually transmissible. Penicillin is known to be the treatment of choice here as well; however, the choice of duration of treatment has limited evidence. Early latent syphilis is treated with one dose of 2.4 million units of intramuscular benzathine penicillin, whereas latent syphilis needs once weekly dose of 2.4 million units of intramuscular benzathine penicillin for a total of three doses [5].

3.1.3.2 Penicillin allergy

Although penicillin remains the mainstay and most effective medication for the treatment of syphilis, penicillin allergy necessitates the use of effective alternatives. In the case of primary and secondary syphilis, oral doxycycline 100 mg BID for 14 days or oral tetracycline 500 mg 4 times a day for 14 days can be used. For latent syphilis, 28 days of the above-stated regimen is effective. Tertiary syphilis patients allergic to penicillin need a referral to infectious disease [8].

3.1.3.3 Pregnant women

The treatment regimen for pregnant women is the same for adults for their respective stages but with certain special considerations. Those with penicillin allergy should undergo desensitization and be treated with their recommended doses of penicillin. Allergy testing through skin tests and graded oral dose challenges can help identify those at risk [9].

3.1.3.4 Syphilis with HIV infection

Treatment for this population group is the same for adults without HIV for their respective stages. Those with HIV and latent syphilis must be monitored closely for treatment response at 6, 12, 18, and 24 months [10].

3.2 Gonorrhea

Gonorrhea is a sexually transmitted infection caused by Neisseria gonorrhea and is the second most common bacterial STI after chlamydia. In fact, these infections often occur together. It spreads through semen or vaginal secretions during sexual intercourse, oral or anal sex, and the sharing of sex toys with someone who is infected. Additionally, because symptoms often go unnoticed, it is easily transmissible to partners [11].

3.2.1 Symptoms

Females are often affected and more than 70% are asymptomatic. Some patients can have cervicitis, urethritis, pelvic inflammatory disease (PID) and even complications of pregnancy. In cervicitis, when symptoms do occur, they emerge in the form of vaginal itching and/or pus discharge. On cervical examination, one may see frank pus and friable mucosa [12]. In urethritis, the female might be asymptomatic or can have burning urination, urinary urgency, or urinary frequency. PID is a serious complication of cervicitis where a patient can have abdominal tenderness, a tender uterus, and cervical motion tenderness, among other symptoms. PID can be further complicated in the form of perihepatitis, also called Fitz Hugh Curtis syndrome [12]. One of the major areas of impact is pregnancy where the mother with gonorrhea can have complications such as preterm birth, small for gestational age infants, and low birth weight [12].

Males often contract urethritis or epididymitis. They present with penile discharge and dysuria, unilateral testicular swelling, and pain in the epididymitis [12].

3.2.2 Testing

Women less than 24 years old who are sexually active and women over 25 years old who are at increased risk of infection are recommended by the United States Preventive Services Task Force (USPSTF) to be screened for gonorrhea. Insufficient evidence regarding benefit versus harm exists for testing men [13].

Historically, the gold standard test for gonorrhea was culture. It is a low-cost method and has a sensitivity of 72–95%, which increases to 95–100% in the hands of experienced lab technicians. DNA extracted from the cultures has become the best method to perform genomic analysis because clinical specimens tend to contain either not enough DNA or have DNA from other bacteria and human cells [13].

Microscopy is the method of choice in resource-deficient settings where gram-stained samples are visualized under a microscope. Sensitivity and specificity can differ based on the site of sample collection but usually range between 89 and 98% for urethral swabs. It is not suitable for specimens obtained from the pharynx or rectum [13].

The nucleic acid amplification test (NAAT) is the diagnostic method of choice in resource-rich environments. It allows noninvasive testing because the specimen needed is either urine or self-collected vaginal swabs. Storage and transportation of specimens are easy because viable organisms are not required for NAAT [14]. Other advantages include rapid results, automation, and the ability to detect other STI pathogens such as chlamydia. However, the disadvantage is that one cannot obtain antimicrobial resistance data and strain characterization through this method, which removes the ability to assess resistance patterns and strain prevalence [14].

3.2.3 Treatment

Uncomplicated gonococcal infection affecting the pharynx, urethra, rectum, or cervix is treated with a single intramuscular shot of ceftriaxone at 500 mg if the patient weighs less than 150 kg and 1 g of ceftriaxone if the patient weighs more than 150 kg according to CDC. In case of allergy, a single intramuscular dose of gentamicin (240 mg) and a single dose of oral azithromycin (2 g) are effective [15]. If intramuscular ceftriaxone cannot be given or is not available, a single dose of oral cefixime (800 milligrams) can be given. Recent sexual partners who are engaged in sexual activity less than 60 days before the onset of symptoms in the patient are to be referred for evaluation and testing [15].

3.3 Chlamydia

Chlamydia is currently the most common bacterial STI. It is caused by Chlamydia trachomatis and reportedly affects around 1.5 million people a year. Chlamydia usually does not have signs and symptoms; hence, it goes unreported in most cases. People who are more likely to contract this infection are teens or young adults between 15 and 24 years old, men who have sex with men, and members of the Black and Hispanic populations [16]. It is transmitted through oral, vaginal, or rectal intercourse with an infected person. Additionally, a pregnant mother can pass it on to the infant during childbirth [17].

3.3.1 Symptoms

About 70% of women and 50% of men remain asymptomatic [18]. Common symptoms include cervicitis, pelvic inflammatory disease, urethritis, hepatitis, epididymitis, proctitis, prostatitis, reactive arthritis, conjunctivitis, ammonia, pharyngitis, and lymphogranuloma venereum [19].

3.3.2 Testing

CDC recommends screening any symptomatic patient. Other than that, certain high-risk groups are screened as they demonstrate high prevalence. These groups are sexually active women younger than 25 years old, pregnant women, and men and women with multiple sexual partners.

When the cell culture method is used, samples are typically collected from the anus, urethra, cervix, or conjunctiva. However, cell culture is rarely used today, as it is laborious, time-consuming, has average sensitivity, and has specific storage and transportation requirements. Nevertheless, they are useful in determining antimicrobial sensitivity and in cases of sexual assault where you need the highest level of specificity [20].

Nucleic acid amplification tests (NAAT) have become the gold standard of testing because of the ease of storage and transportation, non-dependency on viable pathogens, and specificity comparable to culture [20].

One drawback to NAATs is that they were centrally performed in a laboratory, which meant that samples would be sent to the laboratory, and once the results were generated, they were sent back to the physician. This meant that the patient had to make two visits to know the results. This is where rapid diagnostic tests (RDTs) became popular, as they were point-of-care tests providing results within minutes, enabling initiation of antibiotics immediately after. They work on the principle of immunochromatography [20]. Overall, though, NAATs are most sensitive and specific and are the test of choice.

3.3.3 Treatment

Chlamydia can cause serious complications such as PID and infertility. In men, chlamydia and gonorrhea often coexist and require diagnosis and treatment. Partners of affected patients should be tested, instructed to avoid sex for 1 week after starting the therapy, instructed to consider an HIV test, and provided counseling regarding high-risk behaviors [19].

Oral doxycycline (100 mg) twice per day for 7 days is the recommended regimen in adolescents and adults. Alternatively, one can use a single dose of oral azithromycin (1 gram) or oral levofloxacin (500 mg) daily for 7 days [19].

Abstinence from sex is advised while being on the 7-day therapy or until symptoms resolve, and all the sexual partners should be treated as well. Sexual partners must undergo screening and treatment if they had sex within 60 days of symptom emergence in the affected individual [21].

3.4 MSM and syphilis

Men who have sex with men (MSM) and syphilis have a very interesting relationship. They are one of the most disproportionately affected groups in several countries, and many factors are contributory to this incidence and prevalence.

In the subsequent decades after the introduction of penicillin for the treatment of syphilis in the 1940s, rates went up in the MSM group. The 1980s witnessed HIV/AIDs that was coupled with a rise in syphilis rates, hence exposing the potentiation effect of both STIs. The 1990s saw a sharp fall in syphilis rates as the CDC pushed for elimination. However, this was short-lived, as the rates resurged in the 2000s, and this time, they were associated with methamphetamine use. Between 2020 and 2021, 36% of syphilis cases reported were from MSM and bisexual men [22]. A meta-analysis of the data from 2000 to 2020 revealed a 7.5% global pooled prevalence of syphilis among MSM [23].

Behavioral aspects that drove these changes were unsafe sex, anonymous sex, higher usage of dating apps, visiting bathhouses, and as stated above, the use of crystal methamphetamine. In addition to this, because of the stigma and discrimination associated with homosexuality, MSM may either not disclose their sexual identity or avoid seeking testing and treatment.

Syphilis in MSM remains a major infectious disease conundrum. To address the disparity and to tackle high syphilis rates in MSM, health care needs to implement enhanced screening for those at increased risk every 3–6 months, improve access to testing, address discrimination, tailor counseling, advocate condom use, and educate regarding pre-exposure prophylaxis.

By addressing syphilis in this population, we can work toward reducing the overall burden of this preventable infection [24]. The CDC now has a new recommendation that can dramatically reduce the rates of certain STIs in MSM, bisexual men, and transgender women. A study demonstrated that a single dose of oral doxycycline (200 mg) when taken within 24–72 hr. of unprotected anal sex is an effective post-exposure prophylaxis. The study found to reduce the incidence of chlamydia and syphilis by 70 and 73%, respectively [25].

3.5 STIs and minorities

Health equity stands for equal chance at health regardless of race, sex, ethnicity, income, gender, religion, sexual identity, and disability. Among the above, race and ethnicity play a major role in accessing health care. It is noted that certain racial or ethnic minorities have a higher prevalence of STI. What is important to understand that this is not due to their heritage or ethnicity but the factors that affect them specifically, such as poverty, lower employment rates, and lower education rates, which make it harder for marginalized groups to stay healthy.

Low socioeconomic status restricts access to quality health care. Many minorities have lower trust in the health care system because of the fear of discrimination from doctors and other health care workers. With all of this, once STD rates rise within a community, sexually active groups are now more likely to meet infected individuals from their community [26].

It is crucial to establish specialized prevention and screening measures catered to the requirements of particular communities to overcome these racial discrepancies. This could entail expanding access to testing and treatment, offering care that is culturally sensitive, addressing social and economic risk factors, and including partnering with communities in prevention initiatives. Addressing racial disparities in STIs is crucial for achieving health equity and enhancing the general health of all communities.

3.6 Implications

Every day, over 1 million people acquire STIs [27]. According to the Centers for Disease Control and Prevention (CDC), gonorrhea, syphilis, and chlamydia combined accounted for more than 2.4 million cases in 2018, and 1.8 million cases in 2013, with half of these cases noted in the youth [28].

The recent increase in STIs is a concerning public health issue that has to be addressed immediately. The increase in STDs has significant ramifications for persons of all ages, public health organizations, and the society. A few of these are listed below:

3.6.1 Health risks

The following significant, sometimes fatal side effects can result from STDs: malignancy, infertility, ectopic pregnancy, spontaneous abortion, stillbirth, low birth weight, chronic pain, neurologic impairment, and even death. The rise in STD rates means that more people are at risk of experiencing these health problems.

3.6.1.1 Women

There exists an array of reasons for women being more prone than men to experience STD problems. Female biology predisposes women to a higher chance of contracting STI when exposed to one. It is easier for many STIs to travel from male to female than vice versa. Women are also more likely to experience delayed identification and treatment of STIs, which raises the likelihood of negative outcomes [29].

Salpingitis and infertility are two widely known sequelae of STIs. Trichomonas vaginalis, Mycoplasma genitalium, and other bacteria could possibly cause tubal damage and other potential infertility causes. Furthermore, a number of STI infections are linked to a higher risk of miscarriage and infant mortality [30].

The most prevalent reportable disease in the United States is C. trachomatis, with an estimated 3 million infections per year among the population [31]. An asymptomatic chlamydia infection can induce a fallopian tube infection. Infertility may result from irreversible damage to the fallopian tubes, uterus, and surrounding tissues brought on by PID and “silent” infection in the upper vaginal tract [32]. Gonococcal PID has been demonstrated to be a significant contributor to fallopian tube damage, significantly raising a woman’s chance of tubal factor infertility (TFI) similar to chlamydial PID. Clinical manifestations of acute PID are present in 10–19% of women with cervical N. gonorrhoeae infections [32].

Syphilis, with an incidence of over 10 million cases per year, dramatically affects pregnancy; almost one-third of untreated pregnant women lose their child to stillbirth or neonatal mortality. The remaining one-third are born with congenital syphilis, which leads to another 300,000 perinatal deaths every year [32].

3.6.1.2 Men

Men can be rendered infertile by chlamydia and other STIs that can cause complications such as orchitis, particularly epididymo-orchitis, and prostatitis [33]. Studies on animals have demonstrated that chlamydial infection results in a large loss of germ cells due to spermatogonial apoptosis, leaving only Sertoli cells in the most damaged seminiferous tubules, which also exhibit elevated apoptotic activity [34]. Neisseria can cause vestibulitis, penile edema, prostatitis, orchitis, or chronic epididymitis if the disease is untreated [35].

Acute epididymo-orchitis frequently causes poor semen quality and reduced sperm motility and count. In addition, if ascending infections are not appropriately treated, they may result in testicular injury or azoospermia because of blockage.

However, despite advancements, pelvic inflammatory disease is still a problem due to the infeasibility of programs designed to prevent pelvic inflammatory disease in a large portion of the developing world and the suboptimal reproductive outcomes among treated patients [36].

Preventing and controlling STIs caused by C. trachomatis or N. gonorrhoeae is the most crucial public health approach for the prevention of pelvic inflammatory disease. Based on evidence from randomized controlled trials showing that detecting and treating cervical C. trachomatis infection can reduce a woman’s risk of pelvic inflammatory disease by roughly 30–50% over a year, numerous high-income countries have put in place programs to screen and treat women for asymptomatic C. trachomatis infection [37].

3.6.2 Economic costs

In the United States, STDs have a considerable impact on morbidity and death. They range from conditions that, for the most part, only result in brief discomfort and inconvenience to conditions that shorten life expectancy, affect fertility, or cause long-term morbidity [29]. The rising STD prevalence could impose a strain on public health budgets and health care systems because of the high cost of treating STDs. This may result in higher health care expenses and less access to care for other medical conditions. Eight major STIs’ direct medical expenses are thought to cost the US $16.7 billion. This estimate considers the costs of gonorrhea, chlamydia, syphilis, trichomoniasis, hepatitis B, illnesses brought on by sexually transmitted HPV, genital HSV-2 infections, and HIV infection in the United States in 2008 [38].

3.6.3 Social stigma

“The shroud of stigma, shame, and anxiety,” which affects both patients and health care professionals, is another underlying factor in the epidemic and one that continues to thwart efforts to control STDs [39]. Because STDs are frequently stigmatized and linked to unfavorable stereotypes, those who get them may experience prejudice and shame. As a result, patients may be reluctant to admit they have issues, ignore them, or attribute them to other factors. Additionally, this stigma may discourage individuals from getting tested and treated, which may further the spread of STDs.

3.6.4 Sex education

Comprehensive sex education has been demonstrated to alter many of the behaviors, attitudes, and beliefs that have been linked to an increased risk of contracting STIs [40]. The increase in STD incidence emphasizes the need for more thorough sexual education programs in communities and schools. These initiatives can promote testing and treatment, disseminate knowledge about safe sexual practices, and assist to stop the spread of STDs. Families, communities, and several other facets of society must work together to support teenagers in making healthy decisions, and schools play a crucial role in this process [41].

3.6.5 Public health policies

To counteract the rising STD prevalence, governments may need to adopt or amend public health policies and programs. This might entail boosting financing for screening and treatment, expanding access to medical care, and putting more potent preventative measures in place. Given that structural interventions, including policies, have the potential to reach a large number of people with less effort and expense than many other interventions, they may be of particular importance to public health. In general, the rising incidence of STDs has a big impact on people, communities, and society. A complex strategy involving education, prevention, and therapy is necessary to address the problem.

3.7 STDs and HIV

HIV infection risk may be higher for those with STDs. One explanation is that actions such as not using condoms, having several partners, or dating anonymous people frequently put someone at risk for various illnesses. In addition, since STDs and HIV frequently co-occur, having an STD means that the person who contracted it may also have HIV or other STDs at risk. Finally, an STD or inflammation may cause HIV infection that would have been prevented by healthy skin [42]. It is commonly recognized that STDs can greatly raise a person’s risk of contracting HIV, but many individuals are still unaware of why this is the case or how STDs can easily enable infection, even in otherwise low-risk situations such as oral sex. The likelihood of contracting one of these illnesses is increased by the fact that many of them go misdiagnosed.

Defensive cells such as CD4 and CD8 T-cells are enlisted to the front lines in a localized infection, such as STD. The “killer” CD8 T-cells are guided by the “helper” CD4 T-cells to neutralize the infection. Ironically, HIV preferentially targets CD4 cells for infection, the very cells designed to signal an attack. Consequently, the likelihood that HIV will be able to get beyond the body’s first line of defenses increases with the strength of the pathogenic onslaught and the recruitment of target cells [43]. In general, people who have other STIs including chlamydia, gonorrhea, and syphilis are more likely to get HIV if they have unprotected sexual contact with a partner who is infected. Co-infection with HIV and syphilis is prevalent and affects patient groups with similar characteristics. All patients with syphilis should be provided with HIV testing, and all HIV-positive patients should get routine syphilis screenings [44]. This co-infection has a detrimental effect on immunological recovery and antiretroviral efficacy [45].

A meta-analysis and systematic review performed by Meng Yin Wu et al. showed that there was a twofold increase in the incidence of HIV in patients already infected with syphilis. This could stem from high-risk behaviors that are common for the acquisition of STIs such as unsafe sex and IV drug abuse. As mentioned earlier, certain ethnic and racial groups might not seek or get quality health care because of stigma or discrimination that then extends into HIV going undiagnosed for a longer time or the continuation of high-risk behaviors [46].

Other studies found a 19.6% prevalence of other STIs in those who tested positive for HIV. Erbelding et al. found that HIV transmission is soon followed by another STD where he demonstrated that men took 415 days and women took 176 days to contract a new STI following the diagnosis of HIV [47]. HIV and syphilis co-infection has seen a rise in recent years after a decline during the COVID-19 pandemic. Most recent numbers indicate a tripling of prevalence in the United States from 2013 to 2018, a 50% increase in Europe from 2009 to 2018, a doubling in Canada from 2008 to 2017, and a 135% increase in Australia from 2013 to 2017 [47].

There are several contributory reasons for this increase. Earlier in the 1990s, because of the scare of HIV infection, individuals reduced high-risk sex behaviors, which in turn led to a fall in syphilis rates. However, once antiretroviral therapy came into existence and improved life expectancy and quality of life, there was a resurgence of syphilis in the past 2 decades mainly in the United States, Europe, Canada, Australia, and China. This has been further compounded by the availability of pre-exposure prophylaxis, the increasing trend of casual sex through dating apps, drug use during sex, and even a reduction in public health spending in several regions. Syphilis rates are rising across a wide range of groups in several geographic locations. Modern clinicians must be especially vigilant of syphilis in high-risk patients, such as those who are MSM or have risk factors for HIV acquisition [48].

3.7.1 Complications

Several patients with STDs often do not present any symptoms [49]. However, if untreated, there may be negative long-term side effects that could be disastrous, such as:

• Syphilis, in its advanced and complicated stages, causes neurosyphilis that leads to dementia, tabes dorsalis and sensory deficits; ocular syphilis that can present as anterior or posterior uveitis; cardiac syphilis that causes aortic aneurysm and coronary arteritis; and when passed onto the neonate during birth, it causes congenital syphilis.

• Blindness: C. trachomatis infection causes trachoma, an eye condition that can result in blindness. About 1.9 million people worldwide have blindness or visual impairment as a result of this public health issue. Blindness brought on by trachoma is permanent [50]. Other syphilis and gonorrhea, two STDs in particular, can induce eye infections that, if ignored, can impair eyesight or even result in blindness.

• Hepatitis B and C are sexually transmitted diseases that can result in chronic hepatitis, which can harm the liver and even result in cancer.

• Cancers: Hepatitis B and C can raise the chance of liver cancer, and HPV (human papillomavirus) can cause cervical cancer. Most malignancies of the cervix, vagina, vulva, anus, and penis are now thought to be caused by certain forms of sexually transmitted human papillomavirus.

• PID, or pelvic inflammatory disease, which can affect a woman’s fallopian tubes and cause sterility.

• Tubal pregnancy (growth of the fetus in the fallopian tube)

• Congenital birth defects

• Death

4. Social implications

In the early months of the COVID-19 pandemic, there was a decrease in the number of reported cases of STDs such as syphilis, gonorrhea, and chlamydia, yet the prevalence of these diseases surged toward the latter half of 2020. Rather than a true decrease in the number of infections, it seems more likely that this decrease was instead due to a lack of adequate reporting measures amid the initial public health COVID-19 response. This breakdown of reporting methods of the public health infrastructure for STD reporting was influenced by several factors as follows: reduced frequency of in-person health care services as routine visits decreased …; diversion of public health staff from STD work to respond to the COVID-19 pandemic; STD test and laboratory supply shortages; lapses in health insurance coverage due to unemployment; and telemedicine practices that led to some infections not being captured in the national data [51]. Not all groups were affected equally, rather, the majority of this increase was within racial and ethnic minority groups, homosexual and bisexual men, and the nation’s youth.

These trends are not unusual in health care, rather, these populations experience disparities in health care generally due to longstanding social and economic factors such as poverty and health insurance status… [which] create barriers, increase health risks, and often result in worse health outcomes for some people [51]. Similar to attempting to promote social justice and equity in other health care disparities, public health officials and policymakers must understand how structural and institutional barriers lead to some individuals receiving a disproportionately low amount of care and therefore poor health outcomes. Over the last 50 years, there has been a common regression in the number of health care facilities available to poverty-stricken areas because hospitals and doctors are following privately insured patients to more affluent areas rather than remaining grounded in communities having the greatest health care needs [52]. This drop has been significant. The number of hospitals in 52 major cities in the United States has fallen from its peak of 781 in 1970 to 426 in 2010, a drop of 46% [52]. This lack of access to primary care for these vulnerable populations leads to a disproportionately low number of intervention and therefore higher rates of STDs and STIs. A study to determine the relationship between basic health care access and the rates of sexually transmitted relations found that by increasing the percentage of residents with a primary care provider was associated with a 39% lower STI risk [53]. Overall, greater health care access generally is correlative with fewer STDs and STIs. Further research should look to evaluate the pathways through which health care access influences STIs and take action to combat these pathways on a structural level.

As the combined cases of syphilis, gonorrhea, and chlamydia among young adults in the United States reach new record highs each year, conservative policymakers maintain their intent to limit the number of sexual education that our youth receives [1]. There is a broad range of factors to be blamed for the increasing prevalence of STIs among the youth including the following: decreased condom use; declining local, state, and federal investment in STI programs; expanding sexual networks facilitated by dating apps; the rise of antibiotic-resistant strains of certain STIs; and, potentially, increased testing [1]. One intervention that could help to mitigate the effects of nearly all other factors is the increase in sexual education, equipping individuals with the skills necessary to foster healthy relationships and healthily express their sexual nature, understanding consent, and good sexual habits [1]. The current all-or-nothing mindset that conservative policymakers have toward sexual education, which is the abstinence-only option, does not align with the reality of adolescents’ sexual activity and does not prepare them for sex in adulthood [1]. To fully prepare this generation to be capable of managing their sexual relationships in a safely and healthily, a complete sexual education program that stresses the importance of practicing safe sex is a requirement for the long-term fight against STIs among adolescents.

5. Ethical analysis

5.1 Harm reduction as practical ethical justification

The STD epidemic in the United States shows no signs of slowing. Reported cases of sexually transmitted infections (STIs) chlamydia, gonorrhea, and syphilis all increased between 2020 and 202, reaching a total of more than 2.5 million reported cases according to the CDC’s final surveillance data. To reverse this trend, CDC is calling for more groups from the local health care industry and public health sectors to contribute to STI prevention and innovation efforts [54]. Various recommendations have been proposed to control the spread of STDs: increasing condom availability and use; developing new safe and effective vaccines, adult voluntary medical male circumcision, microbicides, partner treatment, information, education and counseling especially among the minority populations; increasing resources for screening and treatment; increasing funding and access to quality sexual health care services; and doing advanced scientific research exploring new interventions. Many of these recommendations are being proposed as an ethical way to decrease the STD epidemic as part of the harm reduction technique. Harm reduction is an approach focused on minimizing the negative results that go hand-in-hand with drug abuse and risky sexual behavior [55, 56]. Harm reduction techniques have both medical and ethical impact on the individual and society. Harm reduction techniques accept the individuals as they are while also tailoring that person’s treatment to fit his or her needs [57]. Furthermore, there are certain principles that are quintessential to an understanding of harm reduction, as listed by the Harm Reduction Coalition as follows:

• Accepts, for better or worse, that licit and illicit drug use and risky sexual behavior are part of our world and chooses to work to minimize its harmful effects rather than simply ignore or condemn them.

• Understands drug use and risky sexual behavior as a complex, multifaceted phenomenon that encompasses a continuum of behaviors from severe abuse to total abstinence and acknowledges that some ways of using drugs and engaging in sexual relations are clearly safer than others.

• Establishes quality of individual and community life and well-being—not necessarily cessation of all drug use and sexual behavior—as the criteria for successful interventions and policies.

• Calls for the nonjudgmental, noncoercive provision of services and resources to people who use drugs and engage in risky sexual behavior and the communities in which they live in order to assist them in reducing attendant harm.

• Ensures that drug users and those with a history of drug use and those individuals who are HIV or have STDs routinely have a real voice in the creation of programs and policies designed to serve them.

• Affirms drugs users and those who engage in risky sexual behavior themselves as the primary agents of reducing the harms of their drug use and sexual behavior and seeks to empower these individuals to share information and support each other in strategies that meet their actual conditions of use and behavior.

• Recognizes that the realities of poverty, class, racism, social isolation, past trauma, sex-based discrimination, and other social inequalities affect both people’s vulnerability to and capacity for effectively dealing with drug-related harm and risky sexual behavior.

• Does not attempt to minimize or ignore the real and tragic harm and danger associated with licit and illicit drug use and risky sexual behavior [55].

The recommendations proposed in this paper to end the current STD epidemic have the potential to be used as a harm reduction agent in and of itself as it can save lives. Furthermore, many individuals who become STD infected did not receive necessary medical education to increase STD prevention and have become infected. Advocating for our proposed recommendations that include increasing resources, decreasing stigmatization, increasing better quality of health care services, and decreasing out-of-pocket expenses possibly could save many preventable infections and even deaths. If we value human life as sacred, we must find a way to prevent these deaths. Creating a national strategic plan, which increases health care resources especially among the minority populations, encourages screening, testing, and treatment and strengthens the capacity to monitor STD trends as part of a comprehensive STD prevention and health care program that is directed by trained health care professionals as a harm reduction agent presents a viable form of prevention to address the increasing STD diagnoses in the United States. In addition, it has the potential to save thousands of lives.

Critics of the harm reduction approach argue that these initiatives are a waste of taxpayer’s money. First, many argue that the use of a harm reduction technique only encourages people to continue their destructive action. In the case of increasing accessibility and use of condoms, critics believe it will only lead to a higher STD infection rate because it will give some people a false sense of protection. Similarly, critics argue that these approaches lead people away from seeking testing and treatment because they now have a safety net of sorts for their risky behaviors. Some critics also believe that we would be wasting valuable money, when that money could be spent on prevention programs that are more ethical and socially acceptable. Proponents of the harm reduction theory point to the various successes of this approach. The needle and syringe exchange programs have decreased the HIV infection rate among IV drug users in the United States. The opioid substitution therapy (PST) or opioid replacement therapy (ORT) replaces illegal opioids, such as heroin, with a longer acting but less euphoric opioid such as methadone or buprenorphine under medical supervision. In addition, supervised injection sites provide sterile injection equipment, information about drugs and basic health care, treatment referrals, and access to health care professionals. All three examples show the efficacy of the harm reduction theory. Finally, to address these criticisms and to strengthen the arguments for this harm reduction approach, it must be determined whether broader access to the recommendations proposed would promote more good than harm, not only for the minority population but also for their associates and communities at large.

Ethically, the harm reduction theory can be grounded in the principle of proportionate reason. Proportionate reason refers to a specific value and its relation to all elements in action [58]. The specific value in following the recommendations to decrease the STD rate is to preserve human life by decreasing HIV infections, limiting other health care issues that result from STDs and encouraging responsible sexual behavior to vulnerable members of society. The harm, which may come about by trying to achieve this value, is the foreseen but unintended possibility that some may view this as condoning and even encouraging risky sexual behavior. The ethical question is whether the value of preserving human life outweighs the harm of the foreseen, but unintended, possibility of scandal and possible increased risky sexual behavior. To determine if a proper relationship exists between the specific value and other elements of the act, ethicist Richard McCormick, S.J. proposes three criteria for the establishment of proportionate reason as follows:

1. The means used will not cause more harm than necessary to achieve the value.

2. No less harmful way exists to protect the value.

3. The means used to achieve the value will not undermine it [59].

The application of McCormick’s criteria to follow the recommendations in this paper supports the argument that there is a proportionate reason for not only allowing these recommendations but also for actively advocating for them. First, according to public health officials, without a “massive national public health effort” and increased funding and education, especially among the minority populations, the STD rate in the United States will continue to increase and more lives could be lost. According to public health officials, “Information, education and counseling can improve people’s ability to recognize the symptoms of STIs and increase the likelihood that they will seek care and encourage sexual partners to do so; unfortunately, lack of public awareness, lack of training among health workers, and long-standing, widespread stigma around STIs remain barriers to greater and more effective use of these interventions” [27]. Unless we can address this epidemic now, the long-term effects can be devastating. According to Cleveland Clinic, more than 25 million sexually transmitted infections occur each year in the United States. Worldwide, we estimate 374 million sexually transmitted infections occur annually. According to CDC, 2.5 million cases of chlamydia, gonorrhea, and syphilis occurred in the United States in 2021. About half of these cases occur in people ages 15–24 years, and the majority are among minority populations [60]. We know STDs can lead to HIV infections and AIDS, can damage organs and the nervous system, and infect a developing fetus, increase ectopic pregnancies and pelvic inflammatory disease (PID). Unless we take drastic steps to decrease this STD rate, people’s lives will continue to be in jeopardy. Second, at present, there are not any alternatives other than those we recommend for the at-risk population. It is true that other means of prevention exist such as abstinence, but according to health care authorities, abstinence is not realistic for many at-risk individuals. In the United States, 1 out of 8 HIV infected people out of the 1.2 million infected are unaware that they were infected and continue to infect others. Many of these infected and those with STDs are participating in risky sexual behavior. Advocating for the recommendations we propose such as correct and consistent condom use, safe and effective vaccines, money for new vaccine research, biomedical interventions that include voluntary medical male circumcision, microbicides, and partner treatment are the only methods that will help decrease the STD rates. This will entail educating our public health workers so that they can educate and counsel those who are most vulnerable. This human contact allows health care workers to form personal relationships with at-risk individuals and thus provides the opportunity to offer them appropriate health care, personal counseling, testing, and referrals to treatment centers. Various scientific studies have confirmed that intravenous drug users reduce risk-laden behaviors when pertinent information and services, such as counseling are made available, and especially when they are offered by peers who are members of the drug-using subcultures [61, 62, 63]. The same can be said for those participating in risky sexual behavior. Advocating for these recommendations to at-risk individuals by trained health care professionals has the potential not only to save human lives but also to foster human dignity and respect. Third, our recommendations do not undermine the value of human life. One can argue convincingly that the intention of making these recommendations available to at-risk individuals by trained health care professionals is to save human lives. This is a public health issue that must be addressed because innocent people are becoming infected and potentially these lives could be lost. It seems clear that there is a proportionate reason to put these recommendations into a national policy to be made available to all Americans using taxpayers’ money. These recommendations contribute to the well-being of at-risk individuals and society because this tool has the potential to decrease the STD infection rate and ultimately save medical resources and human lives. It also offers those who are at risk the opportunity to realize that they are valued as individuals and, with the appropriate assistance, STD infections can be avoided, and the STD epidemic can be minimized. Therefore, it is ethically justified under the principle of proportionate reason to create a national policy with our proposed recommendations and to make these recommendations available to at-risk individuals at approved community-based organizations that are coordinated by health care professionals. Ethically, the greater good of those individuals at risk and the common good of society are advanced by financially supporting these recommendations in major cities in the United States.

6. Discussion and public health recommendations

With the causes of the recent surge in STI rates in mind, it is important to consider new and innovative methods to combat further increases. We herein propose initiatives that address current shortcomings from educational, accessibility, and financial perspectives.

6.1 Local partnerships

One barrier that prevents sexual education from resulting in behavioral changes is the relationship between the educator and the student. In schools, oftentimes, the teacher-student relationship may not be the best setting to survey this type of material. Additionally, many schools promote abstinence-based curricula, which do not reduce rates of self-reported STIs or pregnancy [64]. However, in settings that individuals trust, such as the barbershop, this barrier is removed, and education on this topic has the potential to be much more effective. In fact, a 2017 study of surveyed barbers found that the barbershops are embraced as a setting suitable for sexual education discussions given the close relationship between barbers and their clients [65]. As an example of this suitability, St. Louis began its “Fading Out HIV” initiative in 2015, as its Department of Health partnered with barbershops to administer free condoms and HIV/STI prevention education to clients of the shops [66]. The data from the city’s HIV dashboard reveal that the rate of new HIV diagnoses in the city fell from 33 per 100,000 people in 2016 to 18 per 100,000 people in 2020 before rising again during the nationwide surge [67]. Similarly, in other locations, programs run through churches having increased mammograms and HIV testing among Black women [68]. While only a sample size of one city, this initiative has shown promise, and more importantly, has shown that trusted settings can be a launching pad for education, testing, and condom use.

6.2 TakeMeHome kits

In 2006, CDC announced a recommendation that anyone considered high-risk for HIV exposure should undergo HIV testing annually [69]. However, the stay-at-home orders brought on by the pandemic made this difficult to satisfy. Therefore, in March 2020, TakeMeHome HIV testing kits were distributed as a home care option for those disproportionately affected by HIV [58]. Marketing focused on gay, bisexual, and MSM communities [58]. A study by CDC revealed that 36% of kit users reported never having tested before, and over 50% last tested over a year prior to receiving the kit [58]. Encouragingly, over 10% of respondents who tested themselves accessed additional STI testing services, and 8% accessed pre-exposure prophylaxis (PrEP) treatment [58]. This intervention represents another potential method of improving access to testing and other services among at-risk communities.

6.3 Expedited partner therapy (EPT)

EPT is an approach to STI transmission reduction that involves clinicians prescribing STI treatment to partners of their patients without requiring clinical assessment of the partner [70]. This ideally allows partners to go pick up treatment prescriptions for the particular STI without going through the hassle of visiting a physician and obtaining the prescription himself or herself, which can be a barrier to treatment for some people. Additionally, some experts see this as a way to promote treatment in the age group of teenagers and young adults who may not know where to get treatment, may fear telling a parent about possible infection, or may not have the transportation to reach a provider [71]. A 2019 study simulating the effects of EPT over a 10-year period found that it has the potential to reduce population-level STI rates [72].

The legal situation surrounding this type of provider-patient relationship is an important aspect that cannot be overlooked when analyzing this as a possible solution to the surge in STI rates. Forty-six states currently have EPT as at least permissible by law, whereas in the other four, it is potentially permissible. Evidence suggests that having legislation explicitly supporting EPT could lead to decreased rates of STI, such as one 2018 study found to be true of chlamydia [73]. A CDC study found that among gonorrhea patients, 13% reported receipt of EPT in states in which EPT is supported by law, whereas only 5% of patients in states without supportive legislation received EPT [74]. Pennsylvania recently passed legislation to increase EPT freedoms for providers, which marks another possible remedy to the surging STI rates if more states follow suit.

6.4 Prophylactic doxycycline

Recent research suggests that a single dose of doxycycline within 72 hr. of exposure can significantly reduce the risk of bacterial STI transmission [75]. One study analyzing the effect of post-exposure prophylactic doxycycline treatment found that chlamydia and syphilis incidence dropped by 70 and 73%, respectively, whereas gonorrhea rates did not fall as much [76]. While CDC has yet to issue a formal recommendation for the use of doxycycline in this context, several other studies have since confirmed similar findings. In addition, some cities, such as San Francisco, are already offering this as a viable preventative option [77]. As with any antibiotic intervention, antimicrobial resistance is a concern with such an initiative should it become more widespread. However, experts have seen no evidence that single-dose doxycycline used in this context contributes to antibiotic resistance strains of bacterial STIs [66]. The current shortage in bicillin, the primary antibiotic used to fight syphilis infection, reinforces the importance of a prophylactic intervention so that patients avoid infection in the first place and are not left without antibiotics after the infection progresses [78]. Thus, based on available evidence, this appears to be a viable option to help combat the surge of STI transmission rates.

6.5 Further recommendations at the national level

1. Federal Sexual Health Funding: One of the more obvious contributions to the recent surge in STI rates is the decrease in funding for sexual health clinics nationally. According to the National Coalition of STD Directors, federal funding for STD programs decreased from $168.5 million in 2003 to $152.5 million in 2022 [79]. This represents a 40% decrease when accounting for inflation [68]. In the United States, the recent mpox outbreak has shone a spotlight on this deficiency, and this must be remedied to truly reverse the trend of current STI rates.

2. Promote the U.S. National Strategic Plan: The WHO’s position with regard to containing STIs worldwide is to support any country that adopts a concrete plan of action to prevent and treat STIs [80]. The Department of Health and Human Services released such a 5-year plan in 2020 for STIs control in the United States [81]. It is our recommendation that this become a focal point of government health and wellness initiatives nationwide to increase awareness of the issue.

3. Primary STI Prevention and Care Expansion: We also recommend that STI prevention be more intrinsic to regular primary care in the United States. This can include expanded condom availability in such settings and more education on prevention topics, among other tools.

4. Strengthen Ability to Monitor STI Trends and Respond to Antimicrobial Resistance (AMR): We recommend that monitoring capabilities of STIs be strengthened to remain abreast with the latest effects that the infections are having on the population. This includes remaining vigilant about AMR versions of the pathogens and improving the country’s ability to respond to the inevitable rises in AMR infections.

5. Increase Research and Development for New Vaccines: While such research is advanced for genital herpes and HIV, further efforts for chlamydia, gonorrhea, and syphilis are needed [69].

6. Promote the Use of Other Biomedical Interventions: We recommend the encouragement of other interventions, such as adult voluntary circumcision, microbicides, and pre/post-exposure prophylaxis to help mitigate the risk of transmission nationwide [69].

We understand that none of these interventions are single silver bullets that will fix the problem altogether and that there are many potential arguments against each of these initiatives. For example, the aforementioned “Fading Out HIV” initiative run in St. Louis barbershops has proven to be effective in certain communities, but one may argue that this effectiveness will not spread to other areas of the country where barbershops may not be a central or necessarily trusted part of the community. We recognize this concern and other concerns of this type, but we would counter that other institutions such as churches have also shown promise and that this recommendation of “Local Partnerships” can be extrapolated to whatever is the trusted and comfortable setting in a particular community or culture.

Expedited partner therapy is an initiative that has been particularly controversial given the apparent threat it poses to the traditional physician-patient relationship and the assumed dangers of giving medication to a patient that was never evaluated. Additionally, critics may argue that by providing EPT, the partner of the patient is missing out on a potential encounter with a physician that could reveal other health issues and counseling opportunities. However, we believe that the partner still has the ability to be evaluated despite the EPT if he or she so desires. In addition, the potential public health benefits of stemming the spread of infection at the level of two partners as quickly as possible outweighs many of the concerns noted by the critics of EPT.

We also acknowledge that perhaps the most popular critique of a prophylactic doxycycline pill after a sexual encounter is the risk of antimicrobial resistance. As mentioned previously, there has yet to be evidence supporting this idea that prophylactic doxycycline has this effect. Thus, it is our position that given the benefits currently posed by this intervention, we recommend its broad implementation. However, we acknowledge that upon possible future evidence, it increases the prevalence of antimicrobial resistance, we may alter our recommendation, as the benefits may no longer outweigh the risks of this intervention.

We also understand that many of the other proposed interventions require vast amounts of monetary investment and that large upfront costs for interventions that prove to have long-term benefits is not exactly a popular idea among politicians and taxpayers alike. However, as mentioned previously, it seems as though the government is valuing public health less and less as evidenced by the decrease in funding toward establishments such as STD clinics. However, we remain steadfast in our belief that given the long-term costs associated with untreated STIs, both medically and financially, increased investment in STI prevention is the most ethical and intelligent path forward from the U.S. government perspective.

7. Conclusions

Overall, with the rates of chlamydia, gonorrhea, and syphilis continuing to surge each year, there must be a change in methodology in the way that policymakers are facing the issue. This methodology shift should lean toward providing the youth with a comprehensive education and set of resources in order to be best prepared to have safe sexual relationships, rather than trying to limit the amount of education and resources that this group has access to. Through programs such as these, barriers to resources and education could be broken down; and with this, knowledge of health sexual encounters and resources for treatment, the transmission rates of these diseases could begin to fall; and it is imperative that they do.