Abstract
Common sexually transmitted infections (STIs) in the United States include genital herpes, HIV, and human papilloma virus. In 2017, the Centers for Disease Control and Prevention released a report detailing a surge in chlamydia, gonorrhea, and syphilis infections in the United States. The authors summarize current trends and discuss epidemiologic factors, disease burden, and patient care. It is important to be aware of the recent increases in these 3 STIs and to be prepared to screen for, diagnose, and manage these infections and their complications.
At least 16 sexually transmitted infections (STIs) are commonly found in the United States: anogenital warts, bacterial vaginosis, chlamydia, gonorrhea, genital herpes (herpes simplex virus [HSV]), HIV, human papillomavirus (HPV), granuloma inguinale, lymphogranuloma venereum,
Mycoplasma genitalium, pubic lice, scabies, syphilis, trichomonas vaginalis, viral hepatitis, and vulvovaginal candidiasis.
1 In September 2017, the Centers for Disease Control and Prevention (CDC) released a report that identified a surge in STIs, specifically, chlamydia, gonorrhea, and syphilis (
Chlamydia trachomatis,
Neisseria gonorrhoeae, and
Treponema pallidum, respectively).
2 The surge in the incidence of chlamydia, gonorrhea, and syphilis in the United States has reached a cumulative all-time high.
2 In 2016, more than 2 million new cases of these 3 STIs were reported in the United States, setting a record for the second year in a row.
2 Of note, these 3 infections, along with HIV, are the only STIs with federally funded control programs and are therefore reportable conditions.
2
The majority of new STIs diagnosed in 2016 were chlamydial, with 1.6 million newly diagnosed chlamydia infections—a 4.7% increase in incidence from 2015.
2 Chlamydia infection rates are highest among young females aged 15 to 24 years but are also increasing among men. Also, 470,000 new cases of gonorrhea were diagnosed in 2016. Compared with 2015, gonorrhea cases rose 22.2% among men and 13.8% among women in 2016.
2
The CDC reported 28,000 cases of primary and secondary syphilis in 2016, an increase of 18% from 2015. Most cases (88.9%) were seen in men, with a 14.7% increase from 2015. Men who have sex with men (MSM) accounted for 80.6% of male cases, and 47.0% of MSM cases were also HIV positive. Although men make up the majority of syphilis cases, rates in women have more than doubled since 2012. In that time, cases of congenital syphilis rose 86.9% (8.4 cases per 100,000 live births in 2012 compared with 15.7 cases per 100,000 live births in 2016). There were 628 cases of congenital syphilis reported in 2016, including 41 deaths among newborns.
2
The increase in gonorrhea and syphilis infections represents a sharp shift from previous trends. In 2009, the rate of gonorrhea cases reached a historic low of 98.1 cases per 100,000 population. Seven years later, the rate increased by almost 150%.
2 In 2000 and 2001, syphilis was reportedly close to elimination in the United States, with rates at their lowest since reporting began in 1941.
2
The rates of other common STIs in the United States have either declined or remained stable, including chancroid, HPV, HSV, and trichomonas.
2 However, their rates are often difficult to track, as most are not reportable conditions.
2 Human papilloma virus is the most common STI in the United States; however, the introduction of HPV vaccines has resulted in a significantly decreased prevalence in the postvaccine era (2009-2012) compared with the prevaccine era (2003-2006), particularly in females aged 14 to 24 years.
2 Rates of HSV are difficult to measure, as HSV is often subclinical and may never be formally diagnosed.
2 The prevalence of HSV-2 has decreased when comparing 1988-1994 and 2007-2010 rates.
2 Orolabial HSV-1 cases are declining in adolescents aged 14 to 19; however, genital HSV-1 cases may be increasing, owing to a variety of factors.
2 Trichomonas vaginalis rates also seem to have remained stable since the 1990s.
2 New diagnoses of HIV have been steadily declining, with a rate of 12.3 individuals per 100,000 population in 2016 compared with 13.5 in 2011.
3
All nonpregnant sexually active female patients younger than 25 years should be screened for chlamydia and gonorrhea. Women older than 25 years and at increased risk for infection may also be screened. Patients with a diagnosis of chlamydia or gonorrhea should be rescreened 3 months after treatment is completed. There are currently no guidelines for screening nonpregnant females for syphilis.
All pregnant patients younger than 25 years (or >25 years and at increased risk) should be screened for chlamydia and gonorrhea at the first prenatal visit, with repeated chlamydia screening in the third trimester. Pregnant patients with a chlamydia diagnosis should be rescreened 3 to 4 weeks after treatment and again 3 months later. Pregnant patients with a gonorrhea diagnosis should be rescreened 3 months after treatment. All pregnant patients should be screened for syphilis at the first prenatal visit, with repeated screening early in the third trimester and at delivery if at high risk.
Physicians and medical students have a duty to educate themselves and their patients about STIs. Familiarization with the prevention, screening, diagnosis, and treatment guidelines for STIs is essential. But it is also important to recognize the variety of STI presentations and the multitude of both acute and chronic complications that occur with unrecognized or untreated cases.
The National Coalition for Sexual Health recommends that a sexual history be taken for all teenagers and adults at least annually.
12 Topics to consider addressing include the 5 Ps: partners, practices, past STI, protection, and pregnancy prevention. When taking a sexual history, physicians should use neutral terms (eg, partner) and avoid making assumptions about a patient's sexual behaviors, sexual orientation, or gender identity.
12
Sources of additional STI training and education include the National Network of STD Clinical Prevention Training Centers
13 and the CDC.
14 Cardea Services has a sexual history–taking toolkit, which includes a comfort scale self-assessment, sample history forms, and a pocket guide.
15
Advocating for funding for affordable STI screening and treatment programs at the state or national level is important, particularly for patients in underserved areas. Additionally, advocating for expansion of expedited partner therapy would be of benefit to potential infected partners and would help reduce the spread of STIs.
The rates of chlamydia, gonorrhea, and syphilis infections are alarmingly high. These STIs can cause grave medical consequences for affected persons, especially when the STIs are undiagnosed and untreated. It is imperative that health care professionals perform thorough sexual histories, be familiar with STI presentations, enact routine screening for STIs in sexually active patients, and provide patient education. By remaining proficient in the current diagnosis and treatment guidelines and committing to continuing education, they can play a role in reversing this alarming trend in the United States.