Summary: The COVID-19 pandemic has led to a significant rise in sexually transmitted infections (STIs), underscoring the need for improved STI testing and diagnostics.

Takeaways:

  1. Increased STI Rates: STI rates have surged to an all-time high due to factors like reduced screening during the pandemic, increased risky sexual behavior post-pandemic, and greater use of dating apps.
  2. Screening vs. Testing: A distinction is made between STI screening for asymptomatic individuals and diagnostic testing for those with symptoms, with a need for more comprehensive screening practices.
  3. Role of Education and Stigma: Enhancing education and reducing stigma around STIs, along with improving patient-provider relationships, are crucial for better STI prevention and treatment.

Among the ramifications of COVID-19 has been a significant increase in sexually transmitted infections. STI testing and diagnostics are key in cutting infection rates

By Chris Wolski

It will likely take several years for the full ramifications of the COVID-19 pandemic to be understood. But one fact is certain: STI rates have hit an all-time high. There are numerous reasons why STIs have seen a marked increase—lack of screening during the pandemic, increase in risky sexual activity after the pandemic, the rise of dating apps, and access to screening. There are certainly more.

CLP recently spoke with Alyssa Davis, MS, PA-C, medical science liaison U.S. Region, Women’s Health & Cancer, Scientific Affairs for BD Integrated Diagnostic Solutions. The wide-ranging interview explored the state of STI infections in the U.S., why they have reached epidemic proportions, and how laboratories are key in helping to lessen the number of STIs.

Answers have been edited for length and clarity.

CLP: To start, what do the STI rates in the U.S. currently look like? Are they bad?

Alyssa Davis: That’s a great starting point. As with many other things, we are continuing to see the ramifications of COVID-19 on this area of the healthcare system. We are seeing higher rates of STIs in the U.S.  It boils down to the changes within the healthcare system that happened during COVID. We are seeing the highest rates we have seen in quite a while for a lot of STIs in the U.S. According to 2018 data from the CDC, one in five people in the U.S. have an STI. This means that 68 million infections were present in the U.S. during that year. If we break that down, we are looking at around 35 million women, which is about twice the population of New York, who have had an STI on any given day.

CLP: Are people getting tested? What does testing for STIs look like now in the post-pandemic world and in light of the STI epidemic?

Davis: From a provider standpoint, when it comes to STIs, there is a significant difference between screening and testing.  Screening is used for an asymptomatic patient. This person is not having any symptoms, but they may have had exposure, and it is a concern for them. STI testing is on the diagnostic side, meaning they do have symptoms. It is difficult to collect data that points to these numbers. Unfortunately, STIs often go undiagnosed as many don’t have symptoms.

CLP: What do you think is fueling the increased incidence of STIs and the lack of testing? Is it because of COVID? Is it simply a lack of testing or screening? Or is it because of patient fear and embarrassment?

Davis: It is multifactorial. I don’t think that there is any particular incident, or behavior that we can attribute this kind of increased incidence, too. I do think it is a perfect storm of all these things, at this particular time in U.S. history. COVID has played a factor but STIs have been a been a chronic issue for public health.

It always boils down to education and knowledge as well as access to care. Many patients will not know they have an STI, as they are likely asymptomatic. If patients do not have symptoms there is nothing to fuel them to seek care. Unless they have knowledge on when to be screened as a preemptive measure, they are only acting after the fact.

If you get screened for STIs early enough, you can receive treatment and prevent long-term complications. But there’s a stigma associated with STIs. People will associate them with poor behavior or a lack of hygiene, which is not the case. We need to address the stigma associated with STIs. This ties back to better education and then the lack of access to care and quality diagnostics.

CLP: Is part of the lack of screening and diagnosis a result of generally poor health care education and knowledge?

Davis: Providers and patients need to have a symbiotic relationship. Patients should feel comfortable and trust their provider to do what is in their best interest and advocate for them. The relationship is important because the more that a patient can trust their provider, the more likely they are going to be open about their sexual preferences. This allows providers to better educate and evaluate that patient for what their individual STI risk is.

During the pandemic we saw a big shift in health education and advocacy through social media. There are qualified genuinely caring and passionate providers who address and take down misinformation. This has provided education for patients in a different manner and has further empowered patients to speak up when they see their provider or maybe switch providers if they don’t feel comfortable. Overall, a symbiotic relationship between patient and provider is what we need to better tackle stigma.

CLP: There is a huge variety of STIs. What are the most common STIs fueling this epidemic?

Davis: We have the viral, bacterial, as well as protozoan STIs. Speaking to bacterial sexually transmitted infections, chlamydia and gonorrhea are the two most reported in the U.S. and recognized by the general public. There’s also trichomoniasis which when you look at prevalence estimates is higher than the combination of chlamydia and gonorrhea.

The reason that it’s an estimate for trichomoniasis, is that it’s not a reportable STI. The fact that these estimates alone are higher than both chlamydia and gonorrhea combined, I think we would be very surprised if we had the true values.

CLP: Why do you think that trichomoniasis has come to the forefront and why is it ignored?

Davis: The general rule for STI testing is testing those with the highest risk. People who are at risk for chlamydia and gonorrhea are still at risk for trichomoniasis. The reason that it is being clinically ignored among the STI bundling is because right now the CDC does not consider trichomoniasis to be a reportable STI. When someone tests positive for a reportable STI like chlamydia and gonorrhea, the lab or the provider has to notify the CDC that someone has tested positive, that they received treatment, follow-up testing, and partner notification.

Right now, trichomoniasis does not meet the criteria to be considered reportable. On the flip side of that, I do not think we will check those boxes to meet the criteria unless we test for trichomoniasis more often.

CLP: Women are less likely to be screened and treated for STIs in general, which can cause fertility implications and potential long-term consequences for their children. Why do you think women are less likely to be screened or treated?

Davis: It ties back to knowledge, education, stigma, and access to care. STIs are often not diagnosed or treated, because they are asymptomatic. Patients may not realize the importance of screening. If patients felt comfortable discussing their sexual behaviors openly with their provider, they would be prompted to offer STI screening. There is stigma around any sort of vaginal infection, whether it be an STI or not, that may cause women to feel uncomfortable discussing the topic with their provider. Vaginal STIs and non-STIs can share overlapping signs and symptoms, which can lead to misdiagnosis.

The fear around seeing a provider and undergoing a vulnerable pelvic exam is a deterrent for so many women. It is important that patients are educated and aware that STI tests are painless, quick, non-invasive, and easy.

The more patients know, the more they feel empowered, and the better they can take control of their own health.

CLP: Let’s get into what BD is doing for STI testing. What technology does BD offer for STI testing?  How is this technology helping support women’s health?

Davis: Like we discussed earlier, the three most common bacterial STIs are chlamydia, gonorrhea, and trichomoniasis, and should all be considered equally for screening.  BD has a 3-in-1 FDA-cleared test called the BD CTGCTV2 assay designed to detect these three prevalent non-viral sexually transmitted infections simultaneously and separately. As a 3-in-1 test, we are getting three results from one swab. The results can come for all three or they can essentially be ordered individually based on what a provider is more interested in or someone’s risk. The test provides flexibility in testing and reliable results with high sensitivity and specificity to support informed clinical decision-making.

Patients also have an option for self-collection (in a clinical setting) to collect their own specimen, which would be vaginal/endocervical swab, urine (both male and female) and liquid-based cytology. If they don’t feel comfortable with that, and they would prefer for a provider to do it, then the provider can certainly collect the sample as well. The BD CTGCTV2 assay is really a nice comprehensive STI panel that has that flexibility of specimen.

CLP: How can labs and laboratorians get the word out about screening and testing STIs?

Davis: Labs are the unsung superheroes of all of this. Providers are the ones who are ordering and conducting the testing, but as soon as we screw the cap on the bottle, and it is put into the collection box it is in the laboratory’s hands. What happens in the lab is critical to making sure that those providers have the information they need for the best management and care.

We need to make sure the tests we are using are FDA-approved. When it comes to a public health concern, specifically STIs, women deserve to have quality diagnostics that have been held to the highest standards and achieved FDA-approval.

We should be offering comprehensive panels, like the BD CTGCTV2 assay that detects the three most prevalent non-viral sexually transmitted infections. Also, it is important to accommodate a variety of patient preferences and comfort levels.

Labs need to educate providers and let them know what options they have available to them. By creating a good working relationship, providers will feel comfortable with what they’re ordering. What they order is ultimately what they’re basing their treatment from. We rely on our lab colleagues to help guide us.

Chris Wolski is chief editor of CLP.