August 30, 2018, MedPage Today 

Sexually transmitted disease (STD) diagnoses have increased every year since 2013, with the number of new STD diagnoses the highest ever in 2017, CDC researchers found.

There were 2.3 million cases of chlamydia, gonorrhea, and syphilis diagnosed in 2017, with syphilis diagnoses up by 76% and gonorrhea diagnoses up by 67% since 2013, according to preliminary data released by the CDC at the National STD Prevention Conference in Washington.

At a press briefing, Gail Bolan, MD, director of the CDC division of STD prevention, characterized this as a "continuation of a persistent and troubling trend," particularly noting that rates of diagnosis for gonorrhea "nearly doubled" among men and increased one-fifth among women, "something we haven't seen in a long time," she added.

The CDC reported that chlamydia remained the most common condition reported to the CDC, with more than 1.7 million cases diagnosed in 2017, with a little under half among women ages 15 to 24.

Bolan cited another troubling statistic about the looming threat of antibiotic resistance regarding gonorrhea treatment. The CDC currently recommends a two-dose therapy for gonorrhea consisting of an intramuscular dose of ceftriaxone -- the only "highly effective" antibiotic used to treat gonorrhea in the U.S. -- and oral azithromycin.

But Bolan reported that a "small, but growing fraction" of lab specimens of gonorrhea are showing "signs of antibiotic resistance." While she added that there has never been a "confirmed treatment failure" when using this recommended treatment, the worry is there may eventually be a strain of gonorrhea that does not respond to ceftriaxone.

"Our nation urgently needs new treatment options for gonorrhea," Bolan said. "But CDC alone cannot turn the tide on rising STDs. It requires new commitment from the healthcare sector, scientists, industry, state and local health departments."

"Commitment" usually means "money," and state and local health officials spoke candidly about the country's "eroding public health infrastructure" that they felt contributed to the tremendous increase in STDs. Specifically, officials cited years of cutbacks in funding for STD prevention, with state and local health departments who rely on federal funding to support their STD programs, working with budgets that are half of what they were 15 years ago.

"We maintain our bridges and roads, and we see them on TV when they crumble. You don't always see a crumbling public health infrastructure," said Michael Fraser, PhD, executive director, Association of State and Territorial Health Officials (ASTHO). "We know what works with STD prevention. We just don't want to pay for all of it."

David C. Harvey, MSW, executive director, National Coalition of STD Directors, called for an additional $70 million in funding to "immediately arm state and local health programs to combat this crisis." He said that treatment for STDs costs more than $16 billion a year.

"It is time that President Trump and Secretary Azar declare STDs in America a public health crisis," adding that emergency access to funding is also needed to bring these rates down.

In addition to cutbacks in federal and state funding, Harvey cited other factors for the rise of STDs in America, namely the "extreme lack of awareness and education about STDs and sexual health." But he also said providers and patients played a significant role as "doctors are not screening and testing for STDs and patients don't know they need to ask for screening and treatment."

Bolan added that screening needs to be "routine care" and that providers and patients need to be having that conversation about testing.

Harvey added a plea to Congress for more funding for provider training, through the CDC STD Prevention Training Centers, where funding has also been cut over the last 20 years.

But Fraser pointed out that the solution to the rising STD problem is not going to be "treating our way out of it," and that a solid public health infrastructure is also needed. He specifically noted that cuts in funding have affected programs that support "disease investigators," who meet with individuals, talk about their sexual behavior, do contact tracing, and try to prevent future infections.

"Expecting a physician in an already hurried day-to-day practice to do a slew of [recommended STD testing] is probably not realistic, given the way physicians practice," he said. "Public health can take some of the pressure off the clinical system. You don't need a medical degree to prevent an STD -- you need to talk with people about using condoms."

Bolan said that the full 2017 STD surveillance report is expected to be released in late September.