Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

Reversing the Backslide: Sexually Transmitted Infections in the US


Open, non-judgmental, respectful, medically-relevant conversations need to be the cornerstone of all therapeutic relationships. As long as patients feel valued and at the center of their care, patients are willing to engage in discussions about sexually transmitted infections.

Consider a 45-year-old treated unnecessarily for many months with steroids for inflammatory bowel disease, a 26-year-old with complete, irreversible unilateral visual loss, a 60-year-old with a dense hemiplegia unable to self-care, and a neonate with jaundice and growth restriction. What do these diverse scenarios have in common? They are all the result of STIs not considered, diagnosed, or treated in a timely fashion.



STIs are associated with poor health outcomes for the individual, his/her sexual partners, and potentially his/her children. They also represent a major, preventable public health burden. Examples of morbidity include infertility, pelvic inflammatory disease, and stroke, many of which are decades distant from the incident infection.



In 2017, the last year for which we have full STI data from the CDC, the headlines were dire. Overall rates of three key bacterial STIs, chlamydia, gonorrhea and syphilis, had increased by 31% over the preceding five years, from 1.8 to 2.3 million cases. Early infectious syphilis had increased by 76% in that same time frame. Associated with this was a twenty-year high of a more than 100% increase in congenital syphilis – a devastating condition where babies are born to syphilis infected mothers – in only four years. This is the tip of the iceberg, not accounting for changes in incidence in non-reportable STI, such as Trichomonas vaginalis and herpes simplex virus.



“We are sliding backward,” said Jonathan Mermin, MD, MPH, director of CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention in the 2018 US CDC STD Surveillance Report. “It is evident the systems that identify, treat, and ultimately prevent STDs are strained to near-breaking point.”



The relentless bad news on the parlous state of STIs in the US can weigh so heavily and can feel so overwhelming that any individual provider’s action is the tiniest drop in the deepest ocean. However, as so often, a patient interaction rides to the rescue; progress is built on a series of small steps and assisting a patient with a troubling STI diagnosis can be the first of these. Despite the underinvestment and lack of resources, diagnosis, treatment, and prevention of STIs and their complications starts with raising the profile of sexual health.




Clinicians, patients, policy makers, and community organizations share the capability to start conversations about STIs. To do so normalizes the idea of routine testing in a time of dramatic increases in incidence. Analogous to this are public health-focused conversations on other behaviorally-mediated health issues such as obesity and opioid use disorder. We cannot afford to shy away or cautiously sidestep the issues, they are fundamental aspects of human nature.



Extra-genital STIs

Another critical consideration is where, anatomically, these STIs are located. Chlamydia, gonorrhea, and syphilis infections in the oropharynx and anorectum are most commonly asymptomatic, they go unrecognized, untested, and untreated. These so-called ‘extra genital’ STIs cause morbidity, can persist for months, and are capable of onward transmission.



Patient-collected tests

Patient self-collected swabs for STI detection are the norm in many settings and increase the acceptability of testing, are time saving, and preclude a genital examination in those patients without clinical symptoms. Self-collected tests can be used for genital and extra-genital sampling. Modern STI diagnostics perform much better than older technology and there is a burgeoning interest in moving near-patient tests, with results within thirty minutes, into clinical settings.



Talk, Test, Treat

Open, non-judgmental, respectful, medically-relevant conversations are the cornerstone of all therapeutic relationships. In that sense, conversations around STI testing and treatment are no different from any others. My experience over the past twenty years in both private and public health settings on three continents is that as long as patients feel valued and at the center of their care, are aware of the reasons we ask questions, and that these inquiries are designed to help make or exclude a diagnosis, patients are happy and willing to engage in such discussions. In the words of the CDC: Talk, Test, Treat.