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Q+A: Let’s Talk About Sex – ually Transmitted Diseases

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U.S. rates of three sexually transmitted diseases — gonorrhea, syphilis and chlamydia—reached an all-time high in 2017, according to a recent report from the Centers for Disease Control and Prevention. With nearly 2.3 million cases, this surpassed the previous record set in 2016 by more than 200,000 and marked the fourth consecutive year of sharp increases in these STDs.

Compounding the problem is the threat of antibiotic resistance, a growing concern for infectious disease experts.

There are multiple factors contributing to the rise in STDs, says Sara Schultz, MD, an assistant professor in the Division of Infectious Diseases and HIV Medicine at Drexel University’s College of Medicine. Schultz is also a physician at Drexel Medicine’s Partnership Comprehensive Care Practice (the Partnership), the largest HIV care center in Philadelphia, which turns 25 this year.

Below, Schultz discusses how educators, doctors, patients and policymakers can work together in the fight against STDs.

Why are STD rates rising in the U.S.?
This is a loaded question with a complicated answer. Likely, we are seeing a combination of several behavioral factors, a decline in condom use (which is quoted to be around 30 percent), a slash in federal funding for STD outreach, and changes in the sexual landscape following the availability of excellent HIV medication.

Like many diseases, STDs tend to affect the most vulnerable — in this case, particularly young adults and teens, racial and sexual minorities, individuals without access to preventive care, and those engaged in drug use or commercial sex work.

Dating apps have added a new layer of complexity to treating STDs, since they have facilitated a multiple-partner, “hookup” culture. Doctors tell patients with STDs that their partners need to be treated, as well but with lots of patients finding sex partners on apps, their partners can be difficult to track down. It’s the hamster wheel of STDs, because these people go on to infect others.

This increase in STDs appear to be a symptom of a larger problem — this is just one example of an area where cracks in public health infrastructure can lead to an explosion of disease.

If not treated properly, what kinds of more severe health problems can STD lead to? In women, the most devastating consequences of untreated STDs can lead to loss of fertility or congenital infection in children. In men, STDs can cause proctitis (inflammation of the rectum), as well as epididymitis (testicular pain and swelling) and other genital complaints. Infection with some strains of human papilloma virus (HPV) can cause many different types of cancers; this is an example of an STD that is actually preventable with a vaccine! Diseases like syphilis can affect both men and women in almost any organ if untreated — skin changes, meningitis, vision or hearing loss, hepatitis, neurologic disease like strokes or cardiac disease just to name a few of the manifestations we have seen recently.  We also know that STDs can increase your risk for acquiring HIV.

Do all STDs show symptoms? How often should people get tested?
No!  STDs can be sneaky and often cannot cause any symptoms, so patients can unknowingly spread STDs to their sex partners. A general rule of thumb, if you think you should be tested for STDs, you should be tested. Pregnant women need to be screened for STDs to prevent devastating congenital infection. Men who have sex with men are a particularly high-risk group, as are trans women. At the partnership clinic, we screen high-risk individuals every 3 months.

With the advent of penicillin, syphilis was mostly eradicated in the U.S. Why has it made a comeback?
We are currently seeing an explosion of syphilis in Philadelphia mirroring the national trend, as the number of cases of syphilis in the city doubled from 622 to 1,089 between 2000 and 2016.  It is important to know that the syphilis epidemic is disproportionally affecting a subgroup of the larger population. At least 60 percent of the syphilis cases in Philadelphia are in men who report having sex with another man (MSM). Nationwide, this is closer to 83 percent.  About one third of cases are in people less than 25 years old, and 70 percent are in African-Americans. About half of these cases are also HIV-positive. We know what group we need to target our interventions: young, black MSM, who either have HIV, or are at high risk of getting HIV.

Should we be worried about antibiotic resistance when it comes to treating STDs?Yes! Antibiotic resistant gonorrhea is one of the scariest “super bugs” that infectious disease doctors are worried about. Gonorrhea has shown that it can become resistant to every class of antibiotics. We currently only have treatment options that require an injection AND pills. This means we cannot just send medication into a pharmacy, but patients need to return to a doctor to be treated — which is a huge barrier to getting gonorrhea treated. Despite our long history with syphilis, thankfully it remains exquisitely susceptible to penicillin.

What can policymakers, doctors and the public do to prevent the spread of STDs?The most basic place to start is with education about sexual health. Sadly, how we protect our young people from STDs has become politicized issue and not a medical one. We tell our kids to wear sun block and a helmet, why would we not tell them to use a condom when they have sex?  We also need to fiercely protect places that can provide sexual health care in all its forms. There can be unintended consequences from even small actions and budget cuts that lead to an irreversible road of antibiotic resistance.

Also, doctors don’t like talking or asking about sex and can miss opportunities to screen and treat. STDs are tricky and can look like other things; it is easy for a doctor to miss an STD unless they have a high index of suspicion. We need to reduce stigma around sexual health and testing. Patients go see their doctor to get their cholesterol checked. Going to get a “sexual health” check-up to get screened for STDs should be no different.

Here at Drexel Medicine, we are looking to prevent the spread of syphilis in high risk groups.  We are actually launching a clinical trial right now looking at the use of a doxycycline, an antibiotic, taken daily to prevent syphilis in MSM.  We know that doxycycline can work against syphilis and other STDs. This is just a novel way to go “outside the box” to prevent the explosion of syphilis.

Although it does not protect against STDs, PrEP, the HIV prevention pill, is a once daily pill that prevents HIV. People who are at high risk for acquiring HIV either through high risk sexual behavior or IV drug use should talk to their doctor about PrEP.

To make an appointment at Drexel Medicine’s Partnership Comprehensive Care Practice (the Partnership), call 215.762.2530. For media inquiries, contact Lauren Ingeno at or 215.895.2614.

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