The State of STDs

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode: STDs.

We get the view from one of America's leaders in the fight against sexually transmitted diseases who talks about the work to find and treat those infected.

DR. GAIL BOLAN:
While there’s a lot of advocacy for HIV, most people with STDs live in silence.

JOHNSON:
We discuss the struggle to raise awareness.

DR. NATHANIEL SMITH:
Any of our public health conditions that are related to individual behavior, individual decisions are going to be a challenge because we've got to win that battle every generation.

JOHNSON:
And the critical role of disease intervention specialists.

JEFF STOVER:
They are kind of the hidden warriors, if you will, in the world of STD prevention because they're the folks out there on the front line.

JOHNSON:
Welcome to Public Health Review, a new podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we'll discuss the most pressing public health issues facing our states and territories and explore what health departments are doing to improve the condition of our country's most vulnerable populations.

This episode, we're talking about STDs and the record-high number of cases of chlamydia, gonorrhea, and syphilis in America. Men, women, and children are at risk. Many are infected; often, they have no idea.

Dr. Gail Bolan is director of the CDC's Division of Sexually Transmitted Disease Prevention. She spoke with us recently from Atlanta.

BOLAN:
Well, we are very concerned about the alarming rise in STDs in the United States.

In 2016, we actually saw STDs increase for the third year in a row. We're actually at an all-time high of reported cases of chlamydia, gonorrhea, and infectious syphilis.

JOHNSON:
When you use words like “all-time high,” that has to be fairly troubling for public health professionals everywhere, including you.

BOLAN:
Well, certainly we are in the business of prevention and would like to be seeing much lower, you know, incidents of these cases.

And the other concern that we have is now that we've had these unprecedented levels of syphilis in the United States—which originally were predominantly among men who have sex with men—we've now, in the last few years, started to see an increase among women. And when you start seeing increases among women, that can spill over into women who are pregnant who can infect their fetus.

And, you know, we're concerned that, you know, a pregnant woman infected with syphilis really can face a source of some tragic outcomes from untreated syphilis. And the main concern is the rise in congenital syphilis that we're seeing now. And some of those babies are actually stillbirth babies—the fetus does not survive—and other babies have significant symptoms at the time that they're born that can have lifelong related complications for those infants.

JOHNSON:
I want to ask you why all of this is happening; but first, I would like to have you look back. I mean, I think most people thought that these diseases were under control. What's the history?

BOLAN:
Well, certainly before the antibiotic era, back in the 1930s, you know, we had a huge number of infections in the United States, especially syphilis and gonorrhea. We actually hadn't even identified chlamydia as a bacteria, a sexually transmitted bacteria, at that time.

And with the advent of curative treatment—antibiotics—we were very optimistic that we really could reduce the rates of STDs and this country to, you know, significantly low levels. I mean, we have the tools to detect and treat, but currently, we are challenged by this increase.

So, I would say that, you know, if you look at the history of things, we were doing a good job about until the 2000s. And since that time, we've seen these steady increases related to a number of prevention challenges we have in the United States.

JOHNSON:
So, are people more careless now with their sexual behavior? Or is there some other reason why this is starting to take off again?

BOLAN:
Well, I think that there's a lot of factors that contribute to transmission of sexually transmitted infections.

First of all, our main strategy to prevent transmission and to prevent the complications of these infections is to have timely detection and timely treatment. The sooner you can treat someone with the infection, then they are less likely to develop a complication, and they’re also less likely to transmit to a partner, you know, in their community.

We recognize that, over this time period, there's been sort of an erosion of the public health infrastructure, especially at the state and local level.

States are a part of the prevention response that provides healthcare to their citizens. We at the federal level provide more of the oversight and the core public health functions of assessment assurance and policy. So, we support our states through providing resources to do surveillance, which is where we're counting these cases, and also with disease investigation.

Many people who are infected with sexually transmitted infections actually have no signs or symptoms. So, there's no way to know you have the infection. And the only way you're going to know you're infected is by going in and seeing a provider, and then the provider recognizes that you might be at risk of STIs, and you need to be tested.

So, many people are unaware of their infections and therefore are not getting timely treatment, and they may not be using protection, and maybe continuing to spread infections in their communities.

And we know over the last decade or so, with declining resources in public health, we have fewer STD clinics now for people to go and get same-day treatment and detection. There's less disease investigators who are out in the communities informing people that they've been exposed to a sexually transmitted infection and need to come in for that timely treatment. And so, we recognize that these are factors, you know, challenging us in the prevention of this sort of rising tide of STDs.

We also know there's other factors. Many people are very concerned about having a sexually transmitted infection, that they find it difficult to talk to their providers. We also know providers are not always doing a comprehensive sexual history when they see their patients in the primary care settings.

And many people are just concerned about the stigma, the discrimination, and the embarrassment that can happen with an STD. So, they like to come to the STD clinic because that's where they are actually able to get very confidential services that may not be as confidential in other healthcare settings.

And then lastly, you know, we're concerned about gonorrhea and its ability to mutate and become resistant to the drugs that we use to treat it. We used to have many drugs that we can treat gonorrhea and, you know, since the antibiotics became available, we're now down to really the last class of antimicrobial agents that we can use to treat gonorrhea.

We've been trying to use two drugs at the same time, hoping that we can outsmart the organism and avoid further mutation to the one class we have left, but that's just a short-term gap. And we really are working closely with our industry and NIH partners to really develop new therapeutic options for gonorrhea; not only antibiotics, but I think we're also interested in seeing about vaccine possibilities as well.

JOHNSON:
Talking about working with the pharmaceuticals, pharmaceutical companies, and others to find new treatments, how is that going?

And what is the schedule like? Is there anything on the horizon for the near term?

BOLAN:
Well, we're hopeful.

You know, we're looking at agents that may have been used for other gram-negative organisms—and that's the type of organism gonorrhea is—to see if it has any efficacy against gonorrhea.

I will say that we've had a few clinical trials in the United States. Unfortunately, a few did not get past the phase two trial, but there is a very promising drug now that NIH is looking into, along with WHO. They actually are looking at possibly doing a global clinical trial to see if this is a new drug that might be good for treating gonorrhea. So, at least we've got one in the pipeline.

But we know it takes a long time to develop drugs. And, you know, with the rate this organism can mutate, we feel that we need more drugs in the pipeline than just one. But at least we've got one.

JOHNSON:
The CDC does all it can to make people aware of STDs.

This radio PSA from last year hearkens to a time when awareness was much higher than it is today.

RADIO PSA:
Join CDC in tackling this dangerous return of syphilis.

Once nearing elimination, national data find syphilis is rising. Rates are on the rise among most men, women, newborns—a majority of age groups—all regions in almost every race and ethnicities.

Syphilis’ resurgence highlights its ability to affect many communities at anytime and anywhere. We cannot accept this as the new normal. Together, we can end most of these increases.

To underscore the importance of this issue, we are dedicating the entire month of April to the syphilis prevention. CDC’s STD Awareness Month webpages are filled with the resources and guidance for healthcare providers, as well as individuals who may be impacted by the disease.

There is a lot of work to be done. Let's get to it.

JOHNSON:
So, given the battlefield and the tools available to the public health community, what's the plan for fighting back?

BOLAN:
So, I think we know a lot of people are not getting the care that they deserve. So, we think it's very important for communities to know if these diseases are common in their communities.

You know, as you said, you know, people think syphilis is a disease of the past. We have many providers that don't even know that it's, you know, on the rise, and they’re missing the diagnosis when the patients actually come in with symptoms suggestive of syphilis.

So, that means that people are leaving a clinical setting with infectious syphilis, and it's not been treated. So, they are continuing to transmit until maybe another provider correctly diagnoses their syphilis. So, we want to increase awareness among communities so that people will seek the care that they need.

We're also doing a lot in terms of provider education and educating this next generation of providers so that they're familiar with sexually transmitted infections, how you can easily detect them, and what the appropriate treatments are.

The CDC is known for its flagship document, the STD Treatment Guidelines, which is an evidence-based document that really gives you the latest information to providers to know how to detect and treat these infections. So, we're doing a lot to make sure our guidelines are up-to-date and we’re doing a lot to disseminate those guidelines so that providers know they have this resource available to them, especially if they don't see that many cases.

A lot of times, when you don't see a lot of cases, you may not be up on the latest advancement. So, we actually have an app for providers that they can easily use and just log on and find out what the latest treatment for chlamydia, gonorrhea, syphilis, and other sexually transmitted diseases are.

We're also trying to get more people to detect these asymptomatic infections—that's what's called screening. You are doing a test in someone who feels well to identify the infection. And we know that our screening rates for chlamydia, gonorrhea, and syphilis are not where we'd like them to be.

On a national average, we estimate about 60% of sexually active young people get screened for chlamydia and gonorrhea. We would like to see that number much higher. And we also know that gay, bisexual, and other men who have sex with men are not getting the screening that they deserve when they're seeking care.

And in some high-risk populations, we're even recommending that screening be as frequent as every three to six months because people are living in communities where there's a lot of infection. And so, once you get treated, you are susceptible again to another infection if you are having unprotected sex. And so, we know that there's a lot of transmission in those high prevalence communities.

JOHNSON:
We like to leave the audience with a little bit of a commentary or a thought about what's coming or what to expect.

Can you look down the line, given your knowledge and breadth of experience on this topic, and give us either a call to action or something to look forward to?

BOLAN:
Well, I think that we've already issued a call to action for syphilis, and we recognize that it's going to take, you know, a village to really address and tackle these problems.

We also recognize that we've got different problems occurring right now: that we've got the rising infections among men who have sex with men; we have different issues among pregnant women and youth.

So, it is something that we want everyone to be engaged in. We want, you know, individuals to be talking to their sexual partners. We want parents to be talking to their children about healthy relationships.

And I would have to say that I think we also want more biomedical advances. You know, when you look at syphilis, we are using an antibody test that was developed in 1906 with no innovation since then. We are using a drug, a form of penicillin, that was developed in the ‘40s with no other drugs to treat syphilis.

So, while the field of medicine has made huge strides, especially, you know with all the work that was done with HIV and the treatment, and the diagnostic technologies, we have not moved very far in the field of STDs.

So, I am hopeful because we are now seeing interest because of these rising rates of advancing our diagnostic tests. I would hope, you know, in a few years from now, you could walk into a clinic and actually get your result within an hour while you're waiting in the clinic and then you know whether or not you have the infection. You can get treated right then and there.

I think because we know patients can do a lot for themselves, I think there's going to be more opportunity for home testing.

We also know that pharmacies are playing a larger role in the healthcare system, and we know pharmacies are open 24 hours a day; and so, there might be opportunities to expand these express visits to being available in the pharmacy setting on the weekends, where obviously some of our clinics, you know, would not be open.

So, I think there's a lot of opportunity, and we just need to help our providers and empower our communities to tackle these issues and make sure that people are getting the appropriate and timely diagnosis.

SMITH:
There's a number of things that I could highlight. One thing I'd like to talk about, though, is one of the sexually transmitted infections we've not talked about yet, but it's the most common—it's human papillomavirus, HPV.

JOHNSON:
Dr. Nate Smith is the director and state health officer for the Arkansas Department of Health. His department, like every other, is fighting to stem the tide of STD cases in his state, including the disease he thinks has the potential to be controlled, if not almost eliminated.

SMITH:
That one is not reportable, and it's oftentimes not diagnosed, but it's the one that is potentially the most preventable because we have a very effective vaccine for that. And there is a strong motivation to roll that out because HPV also causes a number of types of cancer.

We think of HPV in the context of cervical cancer; but now, in the United States, HPV-associated oropharyngeal cancers actually now exceed those from cervical cancer. So, this is a critical intervention measure for both men and women.

And we have a relatively low uptake of HPV vaccination, both among girls but particularly among boys. And that's an area that we are really targeting in Arkansas because this is the most common STD, and it's the one that we can basically completely prevent, or at least the strains that cause most of the HPV-related cancers.

JOHNSON:
Do you have a program that you're running, in particular, on that issue that people should know about?

Or are you following the protocols that others are using as well?

SMITH:
We are trying to learn from other states as well; but we do have a coalition, Immunization Action Coalition, that has targeted HPV as a priority. And we will be having an HPV summit to bring together stakeholders and refocus our efforts in the next, within the next couple of months.

One of the issues here is connecting HPV vaccination with cancer prevention. I think in the past, there's been a connection between HPV vaccination of children with STDs, and that sometimes strikes a discordant note among parents and others. Connecting HPV with cancer prevention, though, I think gives a strong message that this is an intervention that will allow benefit throughout the lifespan of the individual.

JOHNSON:
But like all other STDs, Smith says interest in prevention depends on the audience.

SMITH:
The attitudes of parents and communities towards HPV vaccination varies quite a bit from location to location, from community to community. Across the country, we actually see better HPV vaccine rates among those who are receiving services in public programs than those who are higher economic attainment and who are using private insurance, for example.

JOHNSON:
The Commonwealth of Virginia is pushing back, fighting rising rates of infection with fewer resources.

Recently, its General Assembly gave approval for expedited partner therapy, an approach that allows STD patients to provide medications to their sexual partners, even if those partners don't come to the clinic.

Virginia also has grown its army of health detectives who work in the community each day, looking for those who are suffering in silence.

We discussed both with Jeff Stover, operations director for population health at the Virginia Department of Health.

STOVER:
A large part of how we deal with STDs is through a public health staff known as disease intervention specialists; we also call them DIS—that's their acronym.

And they are kind of the hidden warriors, if you will, in the world of STD prevention because they're the folks there on the front line who are, you know, interviewing individuals who may come in with an STD like syphilis, for example.

They're doing their best to ascertain their risk behaviors. They are doing their best to track down, you know, potential partners, and those who may be at risk of acquiring the specific STD.

So, that's not an easy job. Those folks are out there doing it on a daily basis. And, obviously, you can imagine there are a large number of people who don't want to talk about such things, especially to a stranger.

So, those DIS become really important in the fight to prevent additional STDs, and they're also really important to us when it comes time to really look at increasing STDs, increasing morbidity, and how we can really tackle that.

So, we've been going through some processes in Virginia over the last several years where we've actually increased our DIS by about eight staff across the state. And, you know, we're putting them in geographic areas of highest importance. And we've done that really based on some modeling, using a lot of different data to determine what we would kind of refer to as the high-risk areas where we need personnel the most. So, we've done that.

We have been able to, you know, get some assistance from our HIV colleagues. They have been able to put in some financial resources to help us get some additional staff in place. And we also, in Virginia, just recently passed legislation, our General Assembly did, just over the past couple of months for what's called expedited partner therapy.

And we are the 42nd or 43rd state, I believe, a project area to actually implement some kind of legislation that involves expedited partner therapy, which allows patients who were diagnosed with chlamydia or gonorrhea to actually provide medications to their sexual partners without them having to come into a clinic to be seen.

JOHNSON:
I'm really interested in both of these. I'm going to ask you to talk about each in a little more detail.

Let's start with this team of people who go out and interview folks in the communities. What does their day look like? Explain that.

I assume this isn't a new program that you're doing, maybe other states are too; but just tell us about it, what, you know, put us in their shoes.

STOVER:
Sure.

So, a disease intervention specialist, the type of position has been around for a very long time, longer than you or I have been in our careers.

So, these folks, when they're hired into this kind of position, they do some pretty rigorous training so that they understand the epidemiology of these diseases: you know, they understand the surveillance aspects; they understand the infectiousness of these conditions; they understand how they're transmitted; how they can prevent the transmission of them.

And, in addition to that, they have to have really, really good people skills, right. They need to be able to get the folks they are talking to trust them, that they're there in their best interest, they're there in the best interest of their partners, et cetera.

And they are really working to develop, you know, a reputation in their communities so that they can work with these folks on a regular basis. And, you know, word gets around, obviously, you know, who is who, so it really helps that they can develop rapport with the STD clientele who come into the clinics.

It also really helps for them to develop a clientele, excuse me, to develop a reputation with the various healthcare providers in their communities. Because they will oftentimes need to go to those providers to get assistance from them to be able to track down relevant people from the standpoint of ensuring that they've been treated appropriately, et cetera.

So, a normal workday for those folks is really about coming into the office. You know, they're gathering the information they need for that day about who they need to be in touch with. They're making contact with individuals sometimes on the phone. They're in the car; they are going out, knocking on doors, sometimes they are at a residence where someone lives or where they believe they live.

They may be at a workplace where someone, you know, it was perhaps an anonymous sexual partner, and the patient that they were talking to in the clinic doesn't really know the name of the individual, but they're able to describe them. And they're able to say that they work at such and such place, you know, on the corner of such and such streets.

And so, they are out there doing their detective work trying to find these individuals on an ongoing basis. They’re following up with them, they are getting phone calls back; they’re playing voicemail tag, if you will.

As you can imagine, in today's world, various DIS across the country are also using social media to try and contact various partners as well. We all know that the internet is a primary way for people to communicate today. The same holds true for those who are finding sexual partners on the internet. So, that vehicle was also really important to the work of a DIS being able to track down the individuals they need to find.

JOHNSON:
And the goal of their effort every day is to find people who have these diseases and get them to treatment.

STOVER:
That's correct.

JOHNSON:
How does it work? Does it work well? I mean, it's been going on a long time, you say, so I assume it does.

STOVER:
Yeah. I would say it does, you know.

Sometimes it's one of those aspects of jobs that's a little hard to prove that it works well. You know, they find people on a regular basis. You know, we can use metrics, like things we call contact indices, to be able to say that a certain sexual partner, you know, a certain DIS, excuse me, may have, you know, a partner or a contact index of three, meaning that for every person with syphilis that they interviewed, they were able to get three additional names, or three sexual partners, from that individual whom they then also go out and find. You are creating, you know, a bit of a sexual web, in a sense.

And sometimes you find those partners who are being named by multiple other people, and those become critical clients, obviously, because they could be folks who are transmitting diseases to multiple people.

So, they are looking for those people on a regular basis, and we are tracking those metrics routinely so that we can ensure that we're getting those people not only diagnosed, if they were not diagnosed previously, but ensuring that they were treated adequately.

JOHNSON:
On the subject of expedited partner therapy, explain that a little bit more. Some folks may not have heard of that either, even though it sounds like almost every state now has that authority in the program.

It seems to me like that might allow you to really expand your reach because the person who is getting treated may be embarrassed to come in and can send someone else on his or her behalf.

STOVER:
Sure.

Yeah, you're correct, most project areas around the country now do allow ex-partner therapy in some form or fashion. And, as I stated earlier, we just passed legislation, so that won't go into effect until July of this year.

But when it does, it will then allow practitioners at a local health department. So, when someone comes into an STD clinic or perhaps a family planning clinic in a local health department, then if we were able to determine that they were diagnosed with gonorrhea, then we can provide the medications for gonorrhea and provide it to that patient along with, you know, relevant documentation to go back to their sexual partner or partners, and they're able to get them those medications.

And as you said, sometimes they are not very comfortable coming into the clinic or it could be a convenience factor. And they're able to get the medications that they need to stop the transmission of their particular STD at the same time, which is the name of the game at the end of the day. We are all about stopping transmission, preventing additional STDs from occurring in first place.

JOHNSON:
For more information about STDs, check out the link to the CDC web page in the show notes. You can also find links to the agency's STD guidelines and its 2018 awareness campaign.

Next time on Public Health Review, we'll discuss the concept of a chief health strategist and why state and local public health departments should consider adopting this approach inside their organization.

Public Health Review is a production of the Association of State and Territorial Health Officials.

If you have comments or questions, we'd like to hear them. Email us at pr@astho.org—that's PR at ASTHO dot org.

For Public Health Review, I'm Robert Johnson. Be well.