By Jamie Ducharme
August 29, 2018
TIME Health
For more, visit TIME Health.

The numbers are clear: With nearly 2.3 million cases of chlamydia, gonorrhea and syphilis diagnosed in 2017, rates of sexually transmitted diseases (STDs) are at an all-time high in the U.S., according to new data from the Centers for Disease Control and Prevention (CDC). What’s harder to pinpoint, however, is the reason behind those soaring statistics.

On paper, it seems like STD rates should be dropping. Condom use is up. Teenagers and millennials are having less sex with fewer partners than generations past. Stigmas around sexuality and sexual health are beginning to break down. And yet, for four consecutive years, STD rates have broken records. Why?

The problem is complicated, says Dr. Bradley Stoner, medical director of the St. Louis STD/HIV Prevention Training Center at Washington University in St. Louis. But a good portion of it, he says, can be traced back to lackluster funding for federal resources like the CDC, which has seen its budget for STD prevention sit stagnant for almost two decades. Increasing federal funding, he says, could allow organizations like the CDC to hire more people focused on STD prevention, increase public health education campaigns and make testing and treatment resources more accessible.

Without adequate resources, however, Stoner says the STD prevention community doesn’t have the manpower to take steps that could really work — things like building out systems and procedures for contacting and screening the partners of people who are diagnosed with infections, who may be carrying and spreading STDs without knowing it. (Many STDs are asymptomatic, often making it difficult to know if you have one, Stoner says.)

“If we could bump up the STD workforce, in terms of things like partner notification and outreach, education and awareness, then we would have a better chance at bringing these rates down,” Stoner says.

The nationwide closure of publicly funded STD clinics hasn’t helped matters, either, Stoner says. “With the Affordable Care Act, there was a sense that people are going to have a medical home and you’re not going to need these publicly funded clinics,” Stoner says. But as these facilities close their doors, more and more people are either unable to get the care they need, or are turning up at emergency rooms or urgent care clinics “where they may not have the STD expertise” necessary to screen and treat patients properly, Stoner says.

Alison Marshall, a clinical expert at the Sylvie Ratelle STD/HIV Prevention Center of New England and a clinical instructor at Boston College’s Connell School of Nursing, says a counterintuitive factor may also be contributing to riskier sexual behaviors: medical advances against HIV and AIDS.

In the past, Marshall says, people thought of AIDS as a “death sentence,” and took precautions accordingly. But today, with effective treatments and preventive measures on the market, “our younger generations didn’t grow up with that pressure. We wonder if that public health message dimming down a little bit has had the repercussions of certain people choosing not to use contraception,” Marshall says.

That effect may be particularly pronounced among men who have sex with men, who accounted for around 70% of syphilis diagnoses in 2017, according to the CDC report. Even still, syphilis is slowly but surely spreading to other populations, according to the CDC, which could point to changing cultural norms.

“There’s a lot of sexual fluidity right now,” Marshall says, with more and more people identifying as bisexual or gender fluid, or deciding not to self-identify at all. These “bridge populations,” Stoner says, may spread traditionally group-specific diseases, such as syphilis, to new communities.

Syphilis is also a good case study for how socioeconomic factors can influence STD prevalence. Rates of congenital syphilis — infections that affect babies at birth — are also up, which Stoner says points, at least in part, to lax screening practices among doctors. But diagnoses are also concentrated among mothers in the South, “where health care access for under-resourced women is pretty poor,” Marshall notes. “Part of the congenital syphilis problem is access to care.”

Similar trends occur at the local level for virtually any kind of STD, Stoner says. “You can look and map STDs in any city, and you’ll find some parts of town that have higher rates than others,” he says. “A lot of it’s along those gradients of economic disparity and other markers of societal marginalization.”

That pattern, Marshall says, partially explains why national STD rates are increasing, even in the face of seemingly promising research about things like more widespread condom use. “People who tend to think about STI prevention are often the people who are risk-averse” — that is, people who don’t abuse substances or have sex with multiple partners, she says. “You can have 10 non-risky people adopt using condoms and really have no effect on the STD rate. But if you have one risky person who’s not using them, you can have a multiplier effect.”

That problem, she says, again gets back to funding for STD prevention, and the need for a renewed focus on public health campaigns and education. Stoner agrees.

“This is not a moment where people are really excited about tax and spend opportunities,” Stoner says, “but I really do think there’s a responsibility of public health systems to use tax money for the betterment of the entire community.”

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