Rates of sexually transmitted infections rising again after pandemic slowdown

Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be The Informed Patient with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

The rate of sexually transmitted infections has been rising in recent years, but then pandemic quarantines and fears of COVID transmission wound up restricting sexual contact for a lot of people over the last couple of years. Today, I'm talking with Dr. Elizabeth Asiago-Reddy about what happens when Americans start having sex again. Dr. Asiago-Reddy is the chief of infectious disease at Upstate. Welcome back to "The Informed Patient," Dr. Asiago-Reddy.

Elizabeth Asiago-Reddy, MD: Thank you so much for having me.

Host Amber Smith: If I understand correctly, infection rates have been up across the line, regardless of race, gender and age. Is that right?

Elizabeth Asiago-Reddy, MD: Yes, you are correct. And particularly for certain sexually transmitted diseases.

Host Amber Smith: So what are the reasons for that?

Elizabeth Asiago-Reddy, MD: It looks like there are a combination of factors contributing. There are changes in sexual practices, which include reduction in the use of condoms pretty much across the board. Dating apps is another one that is frequently blamed as a reason why people have more sexual encounters and also sexual encounters that may be more anonymous than what we used to (see) in the past.

And then also there has been reduced funding for sexual health, pretty much across the board in all of the states. So that also has likely contributed to increased rates of infection.

Host Amber Smith: Why do you think there's a decrease in condom use?

Elizabeth Asiago-Reddy, MD: My thought on that one: I don't think anyone knows for sure, so this is somewhat theorizing and based on speaking with others who are experts in the field. I think there was a certain level of complacency after a lot of the fear associated with the HIV epidemic in the '80s. So during the height of the HIV epidemic, there was an increase in condom use. And I think over time, as things became safer and better protected from the HIV perspective, there was also a significant decline in public messaging surrounding the ongoing risk of other sexually transmitted infections.

And some of that translated into people's behaviors and reductions in condom use. In a lot of parts of the country, there's increased access to alternate methods of preventing pregnancy, and so condoms, for many people, may not be the mainstay of preventing pregnancy, so you need to remember that your pregnancy prevention methods may not protect against sexually transmitted infections. And then, depending on where you are, you may or may not be receiving health education specific to sexual health or sexually transmitted infections in school.

And so that's an important message that can really contribute to healthy sexual behaviors as people get older.

Host Amber Smith: I read that some of the greatest increases in sexual activity have been among 15 to 25 year olds. And I wonder, is that generation just more promiscuous?

Elizabeth Asiago-Reddy, MD: That's the time in life where people tend to be, most likely to be, sexually active.

I would say pretty much across the board, that's a time where puberty is ending, or else really entering the phase where people become particularly interested in having sex and then throughout young adulthood, of course, people have more freedom and independence to explore their sexuality.

And so, yes, I would say that's been for a long time the group of individuals who are, at the same time, more likely to be impacted by sexually transmitted infections.

Host Amber Smith: If people's sexual activity has been dormant during the pandemic, what do you think is happening as people are starting to socialize again?

Elizabeth Asiago-Reddy, MD: That actually became obvious pretty quickly.

So there was a very brief dip in the rates of sexually transmitted infections early on in 2020. And in most cases that dip ended pretty quickly by late 2020 and end of 2021. And the only sexually transmitted infection that continued to experience lower rates is chlamydia. And unfortunately, it's theorized that it truly doesn't reflect a decrease in the actual prevalence of chlamydia, but in testing. So it's important to remember that there are recommendations for screening for sexually transmitted infections. And if people are not going in for doctor's visits in person, and especially for routine health screenings, you might miss out on some of those diagnoses.

So, specifically for young women, less than age 25, it's recommended that if they're sexually active, they're screened every year for gonorrhea and chlamydia at annual visits, and that's regardless of symptoms. You can imagine why that's a group of people who may have missed out on screenings due to the pandemic, and if they're not being screened as much, then we might end up without as many diagnoses.

Host Amber Smith: I wanted to ask you about the STIs that are of most concern for people in Central New York. You mentioned two of them, chlamydia and gonorrhea.

Can you quickly tell me what chlamydia is, who it affects, how it's treated?

Elizabeth Asiago-Reddy, MD: Chlamydia is a bacterial infection that infects the genital area. It's pretty strictly located to the genitals and occasionally to the rectal area as well. It can have impacts in transmission to localize infections during delivery of a baby, so particularly ocular infections is a possibility, so that would be infections of the eyes. But the biggest concern that we have with chlamydia is its association with reduced fertility and pelvic inflammatory disease in women.

And those are situations where if you have an infection that is not detected, so the infection is asymptomatic and it's not treated, then there's a likelihood of a possibility that there could be ongoing inflammation that could impact the genital tract and result in reduced fertility or increased risk of ectopic pregnancy, which is when a pregnancy does not implant in the uterus but implants instead in the fallopian tubes or another area outside of the uterus.

Gonorrhea is actually a very similar situation in terms of the types of risks associated with having gonorrhea, and another thing I want to mention with gonorrhea, that I have seen clinically that has impacted both women and men, is pelvic pain after an infection.

So there are individuals who have what seems to be a fairly standard and limited course of infection treated with antibiotics, but they continue to have pain for weeks or months after the infection. And so obviously that's something that we'd want to try to avoid. And then I hope you will be asking me about syphilis because it's a very important thing that we need to bring up as well.

Host Amber Smith: That was my next question, because I thought syphilis was an old-time disease, but you're seeing it now?

Elizabeth Asiago-Reddy, MD: Absolutely. So, syphilis -- you're right, I mean, it's been described since ancient times -- in the 1930s and '40s in the U.S., it was actually very prevalent and common, and there can be significant long-term effects from untreated syphilis.

With the advent of the availability of penicillin, people began to be able to be treated for syphilis. And to date penicillin is the recommended treatment for syphilis. So once we actually had availability of a treatment for syphilis, there started to be recommendations by most states that people test for syphilis prior to marriage. And those laws had significant impact in dropping rates of syphilis down to very low levels, with another spike that occurred during the time of the HIV epidemic, which again went way down afterwards. And so in the late 1990s, early 2000s, there was a period of time where we thought, oh, we're doing so well with syphilis, we can eradicate it. And unfortunately, for the reasons that we've just described, with the rise in other sexually transmitted infections, reduction in condom use, reduction in availability of sexual health services, rates increased, and what's especially concerning is that syphilis is an infection which can be passed from mother to infant during pregnancy.

And it has very, potentially very, serious consequences for the developing infant, and that can impact infants or fetuses throughout pregnancy. And it's also totally preventable by identifying mothers who have infection early on in pregnancy and treating. This is a situation that we've become particularly concerned about over the last couple of years, because looking at the data from 2016 to 2019, there was a 235% increase in congenital syphilis in the United States, and so, it's definitely something that, I think there's a huge effort at this point, from public health to try and get a handle on this and bring it back down.

Host Amber Smith: So is syphilis a disease that an obstetrician would check for when a woman comes for prenatal care?

Elizabeth Asiago-Reddy, MD: Yes. And the recommendations have expanded. It initially was that there would be one check recommended at the time that care is established during pregnancy. And now it's recommended that there be three checks during the course of pregnancy: at the first prenatal visit, at the beginning of the third trimester and then again at delivery.

And really again, that's because we're so concerned about this elevated risk and the fact that there's a possibility that syphilis could be acquired at different points throughout pregnancy. And at each point we need to be able to treat, to prevent the severe kinds of outcomes that we can see in fetuses and infants.

Host Amber Smith: What about HIV, the human immunodeficiency virus, that causes AIDS? Is this still a concern in our community?

Elizabeth Asiago-Reddy, MD: It's absolutely still a concern, but I'm happy to report that we have some good news on that front, at least as of the most recently available data, which are from 2019. So it takes a lot longer because of a lot of the very detailed types of reports that we like to put out for HIV to release, HIV data.

The national data are from 2019, but for the first time in quite some time, there is a significant decrease, of on the order of about 30,000, so the average number of infections has been hovering around 36,000 to 37,000 for several years,and it dropped into the 34,000s, so still many more than we would want to see. But when you look at the lines, it's kind of like a flat line for several years, and then, what was really thought to be a significant drop in 2019. So that was encouraging, and some of our highest-risk groups, as well, also experienced a drop during that period of time, and we think that this is at least in part related to the use of PrEP medications of pre-exposure prophylaxis for HIV, which is a medication to help prevent HIV among people who are very high-risk.

Host Amber Smith: OK. Now what about herpes? Is there a lot of herpes in our community?

Elizabeth Asiago-Reddy, MD: Herpes is actually one of the most misunderstood infections that can cross the spectrum of nonsexually transmitted or sexually transmitted infection. So I'll explain it a little bit. There are two types of herpes, which I think many of us have heard of, Type 1 and Type 2.

And Type 1 can infect the oral area, so your mouth, or it can infect the genital area. Type 2 specifically prefers to live in the genital area. Most of us actually become infected with herpes Type 1 throughout childhood or adolescence, without even knowing that we have it. So herpes Type 1 most typically would cause cold sores or fever blisters, and these are blisters that typically would come out on the lips and sometimes can be provoked by stress or another infection bringing them on.

Interestingly, and for reasons that we don't understand, despite the fact that most of us have harbored this virus, not everyone gets fever blisters, right? So it's only a small proportion of people who actually have symptoms, but if you test our blood, most of us have actually been exposed.

For Type 2 herpes, which, as I mentioned, is specific to the genital area and can cause outbreaks of blisters in the genital area, that is impacting about one-third of people. So about one in three people has been exposed at some point, but again, whether or not someone has symptoms is highly variable. So there are many people who, if you test their blood, it looks like they have been infected, but they've never had any symptoms. So this makes, as you can imagine, this makes herpes particularly difficult to control, and even to explain to patients, because it is a lifelong infection, but the degree to which people will have symptoms over time is highly variable.

Host Amber Smith: These diseases we've discussed -- chlamydia, gonorrhea, syphilis, HIV, herpes -- a re they all transmitted through standard sexual intercourse or could they be transmitted through oral sex or kissing?

Elizabeth Asiago-Reddy, MD: Yes. Actually all of these can be transmitted through oral sex as well, some better than others. HIV is very rarely transmitted through oral sex. It can be, it has been reported, but it's quite rare.

Chlamydia similarly is quite rare to be transmitted through oral sex. Gonorrhea and syphilis are actually quite common. And this is a big problem, I believe, driving the syphilis epidemic, is that in order to reduce risk of sexually transmitted infections, including HIV, and not use condoms, I think a lot of people reverted to oral sex as a safer option.

And like I said, for some things that may be safer and for others, it's not. So unfortunately for syphilis, it's really not. And syphilis is very contagious even through oral sex. So I'm glad that you asked that question. Similarly gonorrhea: It can be more difficult to treat when somebody has a case of gonorrhea impacting the throat. Antibiotics sometimes don't work the first time around and sometimes need to be repeated. And fortunately in the U.S., we've done a good job in preventing severely drug-resistant gonorrhea by staying ahead of the curve and making new recommendations for how to treat gonorrhea. But if you look throughout the world, there have been significant challenges where there are severely drug-resistant strains of gonorrhea that may require somebody to even go into the hospital and receive IV antibiotics in order to be treated.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith, talking with Dr. Elizabeth Asiago-Reddy. She's the chief of infectious disease at Upstate, and we're talking about sexually transmitted infections, which are infections transmitted through sexual behavior.

Now, let me ask you about HPV (the human papillomavirus). That's the disease that can cause cervical cancer, right?

Elizabeth Asiago-Reddy, MD: Correct. HPV is a virus that lives on the skin, and there are specific types of the HPV virus that tend to reside more in the genital tract. And you're absolutely right, a chronic, or long-term, HPV infection can result in cervical cancer or anal cancer or head and neck cancer as well, which are things that we have come to realize more in the last several years. The good news for HPV is that the strains that are most likely to lead to cancer over time are covered in the HPV vaccine, which is widely available and recommended early in adolescence. So the more that the HPV vaccine is adopted, the less likely we are to see over time that these cancers are problematic.

Host Amber Smith: In general, what can happen when an STI is left untreated, if it's never diagnosed and the person just lives with whatever symptoms? Can that cause lasting damage?

Elizabeth Asiago-Reddy, MD: Yes, it definitely can. And it depends a lot on which one it is that we're talking about. The two most significant chronic sexually transmitted infections are HIV and syphilis.

So HIV -- certainly, its critically important that people get into care as soon as possible. And if they do, then, the life-restoring treatment is available, and we can very much limit any kind of damage caused to the immune system by HIV, by starting treatment as soon as possible. So that's the case for HIV.

And then syphilis is a fully curable sexually transmitted infection, but it also is a systemic infection, meaning that it goes into your entire body: your lymph nodes, frequently it goes into the brain as well. And if it's not treated within 10 to 30 years after the initial infection, somebody could develop very severe symptoms, to include things likeproblems with your cardiovascular system, like the aorta, the big blood vessel that sends blood to most of your body; that can become infected and become weakened.You can develop dementia or neurocognitive problems, such as along the dementia spectrum, related to syphilis. So it's very important to be tested and treated, again, early in the course of an infection, to prevent these types of things from happening over the long run.

And of course, we already talked about the situation with transmission during pregnancy.

Host Amber Smith: Regarding fertility, because I've heard some of these diseases can impact a woman's fertility, is it all female fertility, or do any of the diseases affect a man's ability to father children?

Elizabeth Asiago-Reddy, MD: It appears to be primarily female fertility that's impacted.

And very unfortunately for women, women are more likely to be asymptomatic, specifically with chlamydia and gonorrhea. So chlamydia and gonorrhea can impact fertility, but they also may go undetected because women may not have symptoms at all.

So men are more likely to have symptoms, which can include things like burning during urination or a discharge from the penis, whereas women might not feel anything at all. And in fact, they do have this, which is why there's recommendation for standard screening for all sexually active women, less than age 25, as I had mentioned, because that falls into that age group that you had brought up earlier as being the highest risk. So we want to try and identify those individuals and treat them before any kind of chronic inflammation or damage occurs.

Host Amber Smith: If someone has developed one sexually transmitted disease, is it common for them to also become infected with another? Or could they get more than one disease at the same time?

Elizabeth Asiago-Reddy, MD: Yes, for two reasons. One is that there are certain subpopulations of people who tend to have sex with each other. So basically, we live in certain social groups, and we often have sex within certain social groups as well. So if there are certain groups of people that are at higher risk for sexually transmitted infections, that can often stay within one community. Additionally, just from the perspective of the fact that sexually transmitted diseases cause inflammation of the genital tract, and then inflammation can put you at risk for acquiring another sexually transmitted disease.

So this has very classically been looked at with HIV in trying to understand why it is that some individuals and populations seem to have increased risks of HIV, and across the board, all of the sexually transmitted infections that we've discussed, such as gonorrhea, chlamydia, herpes and syphilis, they're going to be associated with an increased risk of acquiring HIV because of the inflammation that exists in the genital tract at the time somebody might be exposed to HIV.

Host Amber Smith: Just talking about these diseases, they can sound scary. So if people are going to be sexually active, what steps can they take to minimize their risk of infection?

Elizabeth Asiago-Reddy, MD: Great question. Regular testing is very important, so if you're getting a new partner, then I am always very happy to see (that). I used to work over at the STD center at the county Health Department. And we would have folks show up sometimes with their partners saying, "You know, we've met each other, and now we want to be tested before we have sex." And that would really literally make me happy to see because that's exactly a safer approach to trying to enjoy a relationship, where you're not worried about that being a part of it. And then obviously, again, condom use. Condom use remains incredibly effective for people who are having sex, where a condom could be beneficial.

And, again, it's unfortunate that condoms have waned in popularity. Their effectiveness is very, very high, and there were periods of time where, similar to how certain groups of people were very pro-masking and pro-testing before going to public gatherings due to COVID, there were periods of time where things like that would be expected, related to condoms.

Not even thinking about having sex without a condom was much more common in the past than it is now, and many of us in public health hope that that will change. And then, I like the type of teaching that is offered in schools where it's a holistic approach to sexual health and really wanting to have all the options on the table: Who are your partners? Do you want to have sex right now? Do you not want to have sex right now? Are you in a good place to have sex from an emotional standpoint? So all of those factors can go into actually improving rates of sexually transmitted infections.

Host Amber Smith: Well, Dr. Asiago-Reddy, this has been very informative, and I appreciate your time.

Elizabeth Asiago-Reddy, MD: Thank you so much for having me.

Host Amber Smith: My guest has been the chief of infectious disease at Upstate, Dr. Elizabeth Asiago-Reddy. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed.

I'm your host, Amber Smith, thanking you for listening.