The Centers for Disease Control and Prevention reported Tuesday unprecedented year-after-year rises in rates of sexually transmitted infections (STIs) in the United States. As physicians who care for patients with these infections and who oversee public health responses to STI outbreaks, we, like many of our colleagues, are frustrated and challenged by the anemic responses to this escalating public health epidemic.
Our concerns are especially acute because the medical and public health communities know how to prevent these infections, yet as a country we have failed to implement basic public health practices that could reverse these trends.
STIs are at an all-time high. Nearly 2.3 million cases of chlamydia, gonorrhea, and syphilis were diagnosed in the U.S. in 2017 and cases of congenital syphilis — infants born with syphilis contracted from their undiagnosed and untreated mothers — more than doubled from 2013 to 2017. Congenital syphilis is especially worrisome because it can cause miscarriage, premature birth, stillbirth, or death of newborn babies.
This marks the fourth consecutive year of significant increases in STI rates. During this time, gonorrhea has become more likely than ever to be caused by antibiotic-resistant organisms.
The U.S. can’t control sexually transmitted infections without a rapid and definitive shift in priorities, policies, and resources. An effective response will need to include at least six steps:
Reverse underfunding. Public health has suffered from chronic underfunding. But in recent years, flat funding at the federal level coupled with decreases in state investments have resulted in layoffs and understaffing at local health departments, leading to gaps in services, insufficient education programs for clinicians, and inadequate access to affordable STI screening and treatment. Increased funding for the CDC’s efforts to prevent STIs is urgently needed to rebuild essential public health infrastructures so we can identify and treat people with STIs and their partners. The bill that will provide fiscal year 2019 federal funding for domestic health programs belatedly restores $5 million cut from CDC’s STI prevention budget in 2017, but falls well short of providing resources needed to change the epidemic’s trajectory.
Eliminate congenital syphilis. Transmission of syphilis from pregnant moms to babies is completely preventable, yet many women lack access to prenatal health care. We urge that increased resources be devoted to improve the diagnosis and treatment of pregnant women with syphilis or other STIs and that a commitment be made to ongoing support for public health clinics serving low-income women and women of color, particularly family planning clinics often funded by Title X.
Make medications and screening tools available and affordable. The tools needed to fight public health epidemics must be available to and affordable for all who need them. Industry, the Department of Health and Human Services, and Congress all have roles to play to reduce drug prices for older medications with little or no competition that are vital to public health. High prices for preferred diagnostics and treatments place them out of reach for many patients. For example, Pfizer’s (PFE) benzathine penicillin G (Bicillin L-A), the preferred treatment for syphilis and the only treatment recommended for pregnant women infected with or exposed to syphilis, is an old and inexpensive drug that has been intermittently out of stock. Yet it now costs some clinics $350 a dose, and reimbursement from private insurance, Medicare, and Medicaid often falls short of drug costs.
Drug shortages of Bicillin L-A have occurred due to disruption in its sole-source manufacturing supply line, causing clinics to revert to less effective second-line drugs for syphilis treatment. Plans must be implemented to prevent future shortages, and to increase transparency about drug availability.
Screening for chlamydia and gonorrhea should be done by taking swabs of the mouth, genital and urinary systems, and rectum. The preferred lab tests are expensive, priced at more than $600.
We urge industry to address cost and access issues for benzathine penicillin G and for diagnostic tests for STIs, and urge HHS and Congress to ensure that the treatments and diagnostics needed to protect public health are appropriately available and affordable.
Declare a public health emergency. The head of HHS has the power to declare a public health emergency when a significant outbreak of infectious disease exists. We believe it is time for Secretary Alex Azar to do this. An emergency declaration would focus attention on this serious public health threat and provide immediate access to additional funds and personnel while the process for appropriating an increase in sustainable longer-term funding is set in motion. Declaring a public health emergency could also provide additional flexibility for clinics and providers to access benzathine penicillin G at greatly reduced prices through the 340B drug discount program.
Commit to proven interventions. Even as funding for proven STI prevention interventions, like the services offered by the Office of Adolescent Health’s Teen Pregnancy Prevention Program and the Health Resources and Service Administration’s Title X Family Program, have remained flat, abstinence-only education, a disproven intervention, is slated for a $10 million increase for fiscal year 2019. Federal and state education policy continues to neglect evidence-based interventions while squandering millions on abstinence-only programming that has been proven not only to be ineffective in reducing STIs, but has also been associated with increased rates of human papillomavirus infection and pregnancy in the U.S.
Provide more education for clinicians. Clinicians in primary care settings are on the frontlines of the STI epidemic, but many lack knowledge of guidelines and recommendations about diagnosis, screening, and treatment of STIs, including those for syphilis and HIV. With syphilis rapidly on the rise, providers must be reacquainted with its symptoms to allow for timely diagnosis and treatment.
Swift action by policymakers and public and private stakeholders is the only way to avert this accelerating public health crisis. It will require well-coordinated responses at the national, state, and local levels, as well as adequate funding of scientifically sound public health strategies. Most importantly, we need leaders to demonstrate their political will to safeguard our nation’s public health.
Melanie Thompson, M.D., is chair of the HIV Medicine Association, an HIV clinician, and principal investigator at the AIDS Research Consortium of Atlanta. Matthew Zahn, M.D., is chair of the Infectious Diseases Society of America’s Public Health Committee and medical director of epidemiology at the Health Care Agency of Orange County, Calif.