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Public health laboratories can play vital role in halting STI increases

APHL President Daphne Ware introduces the Dr. Katherine Kelley Distinguished Lecturer, Leandro Mena, who spoke virtually at the 2022 APHL Annual Conference.

By Melanie Padgett Powers, writer

As the rates of sexually transmitted infections (STIs) continue to rise dramatically in the US, the challenge offers opportunities for public health laboratories, said the keynote speaker during the 2022 APHL Annual Conference May 19 “Dr. Katherine Kelley Distinguished Lecture: New Approaches and Innovations to Rising STIs and the Role of the Public Health Laboratory,” in Cleveland, OH.

“When we look at the incredible work public health laboratories did during COVID, we saw just how quickly we can pivot our work,” said Kelley Lecturer Leandro Mena, MD, MPH, director of the Division of Sexually Transmitted Disease (STD) Prevention in the Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention at the Centers for Disease Control and Prevention (CDC). “These may not be so much new lessons but lessons we need to bring back into focus.”

Mena was the STD medical director for Mississippi from 2005 to 2021 and the former medical director of the Five Points Clinic, a public STD clinic in Jackson, Mississippi. He co-founded Open Arms Healthcare Center, Mississippi’s first LGBTQ clinic and is the founding chair of the Department of Population Health Science at the University of Mississippi Medical Center John D. Bower School of Population Health.

The rates of gonorrhea, syphilis and congenital syphilis have increased sharply in the US recent years. In 2020, there were 678,000 cases of gonorrhea, a 10% increase over 2019 and a 45% increase since 2016. Gonorrhea is increasing among both men and women; between 2019 and 2020 cases were up 15% in women and 7% in men. Over the past 10 years, rates among men increased 144% and 62% among women. Among men who have sex with men (MSM), gonorrhea cases increased 263% from 2010 to 2019.

Syphilis, with 134,000 cases in 2020, increased 3% since 2019 and 52% since 2016. The increases among women were dramatic: From 2011 to 2020, the rates of primary and secondary syphilis increased 422% among women.

The rates of congenital syphilis—with 2,148 cases in 2020—saw the highest rise overall, with a 235% increase since 2016. In the early 2000s, rates of congenital syphilis hovered around eight to 12 cases per 100,000 live births in the US, Mena said. By 2020, there were 57 cases per 100,000 live births.

Mena pointed to a couple of missed prevention opportunities that could be driving the congenital syphilis increase: In 2016–2020, 39% of mothers in the US did not receive timely prenatal care or syphilis testing, while 37% received timely syphilis testing but no adequate maternal treatment.

Cases of chlamydia, with 1.6 million cases in 2020, decreased 30% since 2019. “We’re still exploring what the decrease of chlamydia means,” Mena said. Possible reasons include decreased screening during the COVID-19 pandemic, CDC guidance prioritizing diagnosis and treatment of gonorrhea and syphilis cases, more focus on symptomatic cases (most chlamydia cases are asymptomatic), presumptive treatments and limited STD resources.

Mena pointed to several reasons for STI rate increases: decreased condom use among some groups, including young people and gay and bisexual men; a connection to the opioid epidemic, with people engaging in risky sexual behavior; increased use of dating apps; massive budget cuts to state and local STI programs; and social determinants of health such as STI stigma, discrimination, poverty, transportation challenges, unsafe housing and lower access to health care and education.

Mena’s Division of STD Prevention is currently updating its five-year strategic plan, which will have strategies that align with the five goals in the first-ever STI National Strategic Plan released in 2020. The goals are:

  1. Prevent new STIs.
  2. Improve the health of people by reducing adverse (harmful) outcomes of STIs.
  3. Accelerate progress in STI research, technology and innovation.
  4. Reduce STI-related health disparities and health inequities.
  5. Achieve integrated, coordinated efforts that address the STI epidemic.

Opportunities for public health laboratories

Lessons learned during the COVID-19 pandemic can be translated to improving STI prevention and control, Mena said. “So much innovation took place during COVID,” he said. “How do we harness that innovation and adapt that to improve less stigmatizing sexual health services?”

Mena outlined several opportunities for public health laboratories to play a vital role in improving STI rates:

  • Increase consumer testing options by setting up STI testing clinics and supporting antibiotic-resistant gonorrhea surveillance. People could register and receive their results through an online portal. Rooms connected to public health laboratories could be set up for specimen collection and blood draws, providing a location less stigmatizing that local STI clinics.
  • Expand gonorrhea and chlamydia amplification testing.
  • Foster development of self-testing. “The ultimate empowerment is when we have an STI test as affordable and as accessible as a pregnancy test that people can get in the pharmacy,” Mena said.
  • Support training and quality control for CLIA-waived (Clinical Laboratory Improvement Amendment) point-of-care testing with more involvement of community organizations that serve marginalized communities.
  • Serve as reference lab for antimicrobial resistance testing.
  • Perform multiplex testing for trichomoniasis and Mycoplasma genitalium and know their challenges.

“Most importantly, we must move from a disease-focus approach to a sexual health promotion and well-being framework,” Mena said. “We must remember to meet people where they are at.”

Melanie Padgett Powers is a freelance writer and editor specializing in health care and public health.

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