STDs are rising. What can providers do?
In 2014, U.S. syphilis rates hit a 20-year high with 19,999 cases reported, a 22.7% increase over the prior year, according to the Centers for Disease Control and Prevention. Syphilis rates in women also increased during that time, sparking a 37% surge in congenital syphilis cases — those passed from mother to infant.
Citing these figures, a federal panel last month reaffirmed its 2004 recommendation that all people living with HIV, men who have sex with men and other individuals at high risk of exposure be screened for sexually transmitted diseases.
“Clinicians play an important role in helping to control the rising rates of syphilis infection and should focus on screening those at increased risk,” Ann E. Kurth, a member of the U.S. Preventive Services Task Force, which issued the government guidelines, said at the time.
Other diseases on the rise
Reported cases of chlamydia and gonorrhea also are on the rise, up 2.8% to 1.4 million and 5.1% to 350,062, respectively, the CDC’s 2014 STD surveillance report shows.
According to Kalorama Information, roughly one in every five dollars earned in infectious disease testing is the result of test for an STD or women’s health test.
But that’s just folks who actually get into a public health clinic or physician’s office for testing. Of the nearly 20 million new STD cases occurring in the U.S. each year, about half go undiagnosed and untreated, according to the National Coalition for STD Directors.
Causes for concern
A big part of the problem is federal funding, says NCSD Executive Director William Smith. Since 2003, Congress has reduced funding levels for the CDC’s Division of STD Prevention (DSTDP) by $21 million — a 40% cut in buying power for the agency and its state, local and territorial grantees, Smith says.
“We are currently experiencing unprecedented STD increases, and the federal investment to respond to these epidemics is woefully inadequate,” says William Smith, executive director of the National Coalition of STD Directors. “The evolving healthcare delivery system, though an important partner, cannot — and is not — able to deal with the scale of this crisis."
So what can providers do to reduce the incidence of STDs?
“Recognizing behaviors and conducting appropriate sexual risk assessment are strategies that can be incorporated into all types of healthcare visits,” says Dr. Eloisa Llata, a DSTDP epidemiologist. “We want doctors to discuss STDs and risk-reduction strategies with their patients, ensure STD testing for at-risk individuals, and adhere to CDC’s treatment guidelines.”
Smith agrees, saying too many providers still don’t screen their patients regularly.
Because most STDs are asymptomatic, infected individuals may be infected and not know it, unwittingly transmitting them to their partners in the meantime. Those who suspect have an STD may be reluctant to talk to their doctor because of the stigma attached, and doctors are often reluctant to talk to their patients about their sexual health, so they don’t know and test for risky behaviors.
The NCSD recommends routine STD screening for sexually active patients with more than one partner. It also urges widespread adoption of expedited partner therapy in both heterosexual and single-sex relationships — a strategy advocated by the CDC as well.
According to the agency, studies have shown that patients whose partners received EPT were 29% less likely to be reinfected than those who simply advised their partners to see a doctor — making it an effective and cost-efficient way to reduce the spread of STDs.
“We encourage the medical community to endorse EPT where it’s permissible and provide physicians with guidance on how to implement it,” says Llata.
The payer side of the story
Access is also an issue, experts say. While most health insurers cover routine screening for STDs, those who are an increased risk may not have health coverage or have confidentiality concerns about using the insurance to cover an STD test—particularly young people, who comprised the largest at-risk group.
In its 2014 STD Prevention Resources, the Association of State and Territorial Health Officials calls for officials to identify programs within their agency that have developed third-party billing mechanisms and “ensure those tools and lessons learned are shared with the STD program.” This is particularly important as access to public and private insurance grows, while federal funding declines, the group says.
Some organizations are working to increase STD detection and treatment. The CDC cites STD success stories: A team within the California Department of Public health is working to prevent primary care physicians and public health programs from working in silos, providing PCPs with the latest chlamydia screening guidelines while gleaning valuable information about how to increase screening rates. And the New Hampshire Department of Health is conducting in-person trainings at PCP offices on topics such as integrating HIV screening into routine care and implementing best testing and treatment practices.
Llata says there’s no single answer to why STDs have been on the rise. More widespread implementation of STD screening recommendations and increased screening of nongenital anatomic sites, such as the throat and anus, may be boosting detection of chlamydia and gonorrhea in men, she says. But with the erosion of state and local STD resources, many patients can’t access timely diagnosis and treatment.
“Because STDs are preventable, significant reductions in new infections are not only possible, they are urgently needed.” Llata says. More information is needed to understand what is driving the increases so that interventions can be tailored and targeted to specific at-risk populations, she adds.