Point-of-care screening for STIs

Sexually transmitted infections are on the rise. Family physicians are well-equipped to help prevent, diagnose and treat them.

Reported cases of chlamydia, gonorrhea, and syphilis all increased between 2020 and 2021, reaching a total of more than 2.5 million reported cases, the Centers for Disease Control and Prevention said this spring. In its final surveillance data for 2021, the agency reported: ʯ Gonorrhea rates increased more than 4%. ʯ Syphilis rates surged, increasing nearly 32% for combined stages of the infection. Among the syphilis data, cases of congenital syphilis (i.e., a disease that occurs when a mother with syphilis passes the infection on to her baby during pregnancy) rose by 32% and resulted in 220 stillbirths and infant deaths. ʯ Chlamydia rates increased nearly 4%, but – unlike gonorrhea and syphilis – still did not return to pre-pandemic levels. This raises concerns that screening continued to be impacted by COVID-19related disruptions the second year of the pandemic.

“The reported increase in new sexually transmitted infections does concern me but it does not surprise me,” says Kristyn Brandi, MD, MPH, FACOG, Darney-Landy Fellow at the American College of Obstetricians and Gynecologists. “Since 2020, because of the COVID-19 pandemic, many patients fell out of their normal screening habits. We also need additional help addressing barriers to healthcare access – things like transportation, childcare support, cost of screening and treatment, and more access for prenatal health care and screening for young people.”

Julie Fadel, director, global commercial services, Sekisui Diagnostics, says, “It is troubling but not entirely surprising to see the reported rise in STIs, especially given the dramatically reduced access to screening, testing and education during the COVID-19 pandemic. Troubling, because of the serious risks associated with untreated infections, such as [pelvic inflammatory disease], infertility and pregnancy complications. Not surprising, because there are likely many contributing factors, such as a lapse in an individual’s health insurance, limited exposure to fact-based information on STIs, or the lack of a local, affordable, and accessible healthcare facility due to resource and funding challenges.”

Wide range of factors

While STIs are common in all U.S. regions and across all groups, some communities are hit especially hard, says the CDC. The 2021 data show STIs continue to disproportionately affect gay and bisexual men and younger people. Additionally, a disproportionate number of cases were diagnosed among Black/ African American and American Indian/Alaska Native people, groups more likely to face social conditions that make it more difficult to stay healthy.

According to the CDC, a wide range of factors can contribute to high levels of STIs. These include: ʯ Reductions in services – e.g., screening, treatment, prevention and partner services for sexually transmitted diseases (STDs) – at the state and local level. ʯ Increases in substance use, which has been linked to less safe sexual practices. Already more than a decade old, the national opioid crisis continues to put more people at risk for HIV, viral hepatitis and STDs. ʯ Social and economic conditions that make it more difficult for some populations to stay healthy, including poverty, stigma, lack of medical insurance or provider, unstable housing, and a higher burden of STDs in some communities. ʯ Decreases in condom use by some groups, including young people and gay and bisexual men. ʯ The continued stigmatization of STIs. “This stigma can bury the truth that all people deserve quality sexual healthcare in order to live healthy lives and deter people and groups from taking action to prevent and treat sexually transmitted infections,” according to a CDC spokesperson.

The COVID-19 pandemic compounded many of these challenges, exacerbating pre-existing disparities in healthcare and prevention access, according to the agency.

“Physicians play a critical role in the fight against rising STI numbers,” says Fadel. “With many STIs linked to significant health issues if left untreated and the often asymptomatic presentation, patients directly benefit when healthcare providers are able to test and treat patients at the point of care, in a single visit. This also affords the provider with the opportunity to deliver age-grouptargeted education and prevention

The physician office

CDC is calling for STI testing and treatment to be made more accessible, including through the development and approval of point-ofcare rapid tests and self-tests, and by expanding ownership for STI testing and treatment to more organizations and settings.

“Patients need to be able to receive care in places that go beyond traditional STD clinics, i.e., spaces that are more accessible or where people may feel more comfortable than they would in an STD clinic or health department,” says the CDC spokesperson. “Implementing express clinics – STD testing without a full exam – and specimen selfcollection in settings where people already access services or healthcare can reduce barriers related to stigma, affordability and accessibility.” These spaces could include LGBTQ centers, free clinics, syringe services programs, drug treatment or medication-assisted therapy programs, or retail pharmacy clinics.

information while minimizing the risk of patients lost to follow-up.”

Says Dr. Brandi, “This is a problem that needs to be addressed both through a public health approach and through our everyday interaction with patients. Part of the problem is stigma, so it’s important that we, as doctors, talk to our patients about the importance of screening at every health encounter – not just in the OB/GYN exam room – and that we do so without bias or judgement. That can help us reach patients who may have a primary care provider but not an OB/GYN or other specialist.

“For patients without access to healthcare, public campaigns to share information about where free and low-cost screening is available are important,” she adds. “As abortion restrictions cause clinic closures across the country, we’re going to see more patients lose access to STI screening. And of course, keeping STI screenings low-cost or free as preventative services is incredibly important.”

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Daron Gersch, MD, FAAAFP, a family physician in Long Prairie, Minnesota, and vice speaker of the American Academy of Family Physicians, says that “despite the development of screening recommendations and programs aimed at treating patients with STIs to limit transmission and reinfection, screening rates are still lower than they should be, especially given the persistent rise in cases.”

Family physicians are wellequipped to help prevent, diagnose and treat STIs, he says. “The unique physician-patient relationship, often formed over years or even decades, creates a foundation of trust where patients are more likely to be open about difficult or sensitive subject like STIs. This creates an opportunity for important conversations that can lead to proactive screening and subsequent treatment, minimizing the chance for transmission or the adverse effects that could arise if left untreated.

“Many factors outside the doctor’s office impact patients’ access to care, including access to transportation, food, shelter and education,” he adds. “Addressing the increase in STIs will take a concerted effort in both physicians’ offices and public health settings, however family physicians are in an ideal position to help. We get to know our patients on a personal level and can connect patients to resources to address social needs that may be creating

Congenital syphilis highest since 1994

barriers to care, including screening and treatment of STIs.”

Says Julie Fadel, “We need to remove the stigma and normalize talking about STIs, especially with young people, and make it easier for people from all walks of life to readily access timely, affordable, and reliable detection and treatment. This will require a multifaceted approach, with education, access to testing, and appropriate treatment provided by primary care physicians’ offices, pediatric practices, women’s health centers, urgent care clinics, etc., as well as public health settings.”

Congenital syphilis (CS) is a disease that occurs when a mother with syphilis passes the infection on to her baby during pregnancy. CS cases have more than tripled in recent years, with more than 2,000 cases reported in 2021 alone, according to the Centers for Disease Control and Prevention. This is the highest number reported in one year since 1994. Per the CDC, congenital syphilis can cause:

For babies born with CS, CS can cause: ʯ Deformed bones ʯ Severe anemia ʯ Enlarged liver and spleen ʯ Jaundice ʯ Brain and nerve problems, such as blindness or deafness ʯ Miscarriage ʯ StillbirthPrematurity ʯ Low birth weight ʯ Death shortly after birth ʯ

It is possible that a baby with CS won’t have any symptoms at birth. But without treatment, health problems may develop in the first few weeks after birth, but they can also happen years later. Babies who do not get treatment for CS and develop symptoms later on can die from the infection. They may also be developmentally delayed or have seizures.

Source: Centers for Disease Control and Prevention, www.cdc.gov/std/syphilis/stdfact-congenital-syphilis.htm

Editor’s note: The American Academy of Family Physicians’ policy states that any program focused on the diagnosis and treatment of STIs should emphasize family medicine and the role of primary care physicians. AAFP’s statement on “Prevention and Management of Sexually Transmitted Infections” can be accessed at www.aafp.org/about/policies/ all/prevention-sti.html.