Transcript
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This is a podcast about One Health the idea that the health of humans, animals, plants and the environment that we all share are intrinsically linked.
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Coming to you from the University of Texas Medical Branch and the Galveston National Laboratory.
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This is Infectious Science.
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Where enthusiasm for science?
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is contagious.
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Welcome to another episode of the Infectious Science podcast, your monthly dose of critical trends in infectious diseases and public health insights.
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I'm one of your hosts, dr Dennis Benter.
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Imagine a silent epidemic spreading through our communities, affecting millions, yet often going unnoticed.
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That's exactly what's happening with sexually transmitted diseases in the United States.
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Despite our advanced healthcare systems, STIs rates are soaring, and the reasons might surprise you From the unintended consequences of an HIV prevention methods to the far-reaching impacts of the COVID-19 pandemic, we're facing a perfect storm of factors driving this alarming trend.
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Add to that a cocktail of social disparities, risky behaviors and underfunded public health programs and you've got a recipe for a public health crisis hidden in plain sight.
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In today's episode, we'll peel back the layers of this complex issue, exploring why STIs are on the rise and what it means for our collective health.
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We'll dive into the surprising link between COVID-19 and STI rates, uncover the social factors fueling the spread and discuss why the little pill preventing HIV might be a contribution to a surge in other infections.
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Get ready to challenge your assumptions and gain a new perspective on sexual health in America.
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This is the Infectious Science Podcast, where we take the pulse of infectious diseases, one critical issue at a time.
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All right, this is Camille.
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I'm super excited to be back with you all today.
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We also have an original member of the Infectious Science Podcast.
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We have Dr Matt Dasho joining us Very excited.
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Yeah, thanks for having me back.
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Thanks for letting me back into the podcast club.
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And we also have Dr Caitlin Cotter joining us today.
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Hey, thanks for having me.
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Glad to be here and happy to see how you do this.
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Yeah, absolutely.
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All right, let's dive into this.
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I think that was an excellent introduction to what we're getting into today, and so I think let's just jump right in with what's really driving the rise of STIs in the United States.
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So I have a couple points written down here.
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But, dr Dasho, if you see people in the clinic, what would you say is really driving this rise when you talk to patients?
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Yeah, Also, it's Christina here, Just want to say hey, and I do just want to add to Camille's question Dr Dasho, what exactly is an STI?
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All right, a sexually transmitted infection.
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So this is a broad category that encompasses any kind of infectious pathogen that can be transmitted by sexual contact, which is usually a pathogen that transmits in blood or body fluids.
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So that's the overall umbrella category of STIs.
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We do see this.
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There are certain.
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Obviously, epidemiologically, there are certain populations that are at higher risk and we're going to probably get into how those trends are changing over the, especially the last couple of few decades.
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But yeah, no, typically I think we tend to see sexually transmitted infections in younger people, sexually active people.
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There are certain populations that are at higher risk, people who are not using protection people.
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There are certain populations that are at higher risk, people who are not using protection.
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Men who have sex with men are at higher risk of acquisition of certain STIs because of the particular tissues that are involved and the fluids that are involved.
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It really sort of runs the gamut of not only the pathogens but the risks.
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Yeah, no, and I think that's a great place to start and I'm glad you started with this.
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But one of the first points I found as I was diving into this topic is that a potential driver of this rise in sexually transmitted infections in the United States is that a lot of the sex education we have in schools is abstinence, only focuses on preventing pregnancy, but not necessarily on preventing infection.
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And, of course, if you're only looking to educate people on preventing pregnancy, you miss groups.
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That might be the portion of the population that's men who have sex with men, that might be other people in the LGBTQIA community, but also something that we see.
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If you think about the rate of sexually transmitted infections in like Florida, it's very high and it's often among people that are like 65 and older and there's not a risk of pregnancy, and so people end up not using protection and then you see a greater increase in STIs.
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You looked like you wanted to jump.
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Oh no, I was just going to mention NY, florida, camille, but good old Boca Raton Seems to be a great place to spend your latter years in life.
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Yeah, I think that's well taken.
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That's where I was going with the first statement that I think clinically we tend to say it's young people who are having sex with each other and that's where sexually transmitted infections are happening.
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But we know that we're a species just like any other species and sexual relationships are part of the propagation of the species.
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Right, this can happen anywhere along the lifespan, and what's happening in especially elder populations as the population ages, more people are moving into group living situations, and it's not something that people are always comfortable talking about or thinking about is that elder people are still sexually active, or thinking about is that elder people are still sexually active.
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We've developed a variety of interventions that help potentiate the sexual lives of people into their 70s, 80s and 90s.
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There are some drugs to help people to achieve erections when the natural propensity to achieve erections goes away and people move into group homes and they form relationships and maybe they don't use protection because they're not worried about getting pregnant.
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And so it is actually in elderly populations that we do see spikes in risk for sexually transmitted infections.
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Yeah, for sure, for sure, and I think sort of what's interesting to think about this is that I do think sort of the ecology of how these infections are transmitted has changed, probably even within the last 25 years, with the rise of like hookup apps and just an accessibility to like casual sex culture that certainly like casual sex cultures are always been there, but it's changed and it's altered, like people's accessibility to that and just also the normalcy of it, and that most young people are active on these apps and protection isn't often something that's talked about, or even just knowing the status of your partner.
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And I think something that might also be unique to the United States that we've never really gotten into on the podcast is that we have a very interesting way of covering healthcare costs here in the US.
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That's very kind of unique.
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You know money moves through different pathways.
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I know that there are some insurances will only cover STI testing once a year, and so potentially for people that are trying to be responsible and if they're changing partners are, getting STI testing once a year may not be that often for them, and so not having it covered by insurance is also an aspect that I think can definitely be contributing to it and also just the normalcy of are we testing for these?
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And I think there's a lot of stigma about talking about it, which is why we're doing a podcast episode on it.
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Yeah, I think you mentioned a lot of different things, camille.
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One of the things I think we get real excited about kind of new things the dating apps.
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Stis have been with us really since the dawn of man, right.
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These pathogens started appearing from ancient Egyptian times.
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There were documentations of people suffering from symptoms and signs of sexually transmitted, various types of sexually transmitted infections.
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There's stories of some of the great composers of music suffering from and even dying from likely prematurely from, sexually transmitted infections, given the nature of their work and where they.
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So I think, yes, we want to be sensitive to the change in conditions that may be driving the spread of sexually transmitted infections, especially as we've seen over the last five years, a pretty high, I think.
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For me, it's less about sexually transmitted infections have been with us for generations.
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I think what's very interesting are the particular conditions that we find ourselves in now, and I think it's some of the things you've mentioned the educational part, the preventive behaviors, the cultural aspect, the potentially the prohibitive cost of detection or testing, health-seeking behavior.
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I think we can't point to one thing and say that's the smoking gun, it's the dating apps, that's what's doing it.
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It's the old folks' homes, that's what's doing it.
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It's the focus on abstinence-only education.
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That's what's doing it.
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It's always an amalgam of all of these things, plus the sort of natural cadence of what these pathogens do throughout society although initially the STIs went down in the beginning of the pandemic, things have changed quite a bit due to COVID, and so the pandemic actually helped with the increase or the surge of the STIs right.
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Yeah, we were looking into this and it really looks like there was a disruption of STD services during the pandemic.
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That really contributed a lot to that.
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Additionally, there was a reallocation of resources right, everybody was focused on COVID-19 instead of anything else.
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Then there was a decreased testing associated with that and then, in addition, there was increased test positivity.
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So what that means is the number of tests that we did have.
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The proportion of those tests that were positive was higher.
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So what that means is that people were tested because they were symptomatic, right, and so we went from a screening philosophy to testing only when people were symptomatic, because we had this reallocation of resources and this disruption of STD services.
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I love that you mentioned that, caitlin, because you know I think we can't emphasize that enough.
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I think there's always sensationalization of the numbers, right, and you have to take into account what were we doing before the pandemic and then what we're doing during the pandemic and that we're redoing after.
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Tell us that people who are under the age of 24, who are sexually active, should be screened regularly for sexually transmitted infections.
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We know that everybody should have the right to at least one HIV test.
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Sexually active people should probably get tested pretty regularly and there are populations over the age of 24 or 25 that then would get screened.
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But, as you mentioned, during the pandemic, fewer people going for routine screenings, much less focus on those routine screenings and we saw a lot of other conditions in the US start to become a little bit more out of control because we were so focused on COVID-19.
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I think we're only now starting to see the sequelae of those, of those interventions.
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Of course, emergency interventions were needed during the emergency.
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Oh yeah, I just want to touch a little more on that point and I just want to say that I think that that's absolutely right.
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We haven't quite found out what all the side effects of COVID has had on the rest of our health system.
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We're still sort of unraveling all of that.
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But I think what's interesting that I just want to make a note of here, like early in the podcast, unraveling all of that but I think what's interesting that I just want to make a note of here, like early in the podcast, is that a lot of times when anyone in the infectious disease field or in the public health field talks about STIs, they're talking about linking it to promiscuity and that's not really necessarily true.
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It can be, but certainly a lot of these diseases might end up being like silent infections.
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People might not know and it's probably not the norm for people to ask for necessarily their partner's sexual history, even though it could be right and that's something that could change and that's something that, if it did change, would help people maintain their health.
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I have a question for Matt about that, about the promiscuity idea, because I'm wondering if, in your practice, or maybe back in medical school, did you learn that the number of sexual partners is a risk factor, right?
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So then, as a clinician, what do you think about?
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How do you think about that in terms of promiscuity?
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Yeah, I think that's a great question.
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For me, I think even the word like promiscuity has this sort of stigma attached to it and I think has this sort of stigma attached to it, and I think we have a tendency in society to stigmatize sex.
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It's like this thing that we shouldn't talk about.
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We shouldn't do it unless we're in very ideal circumstances.
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But it is a natural behavior, right, and so the way I approach it is that everybody gets a sexual history.
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We talk about it, and whether we are a young person, a middle-aged person or an old person, people tend to be nervous about talking about their sex lives.
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They feel that the system or the clinician is going to judge them.
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They feel that if they're engaging in sexual activity, they're doing something wrong.
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This is a problem, right, and that limits our ability to engage in good public health practice as clinicians, because then we're not able to apply what we know from the epidemiology in the clinical practice.
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I think that's absolutely so.
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True, those are difficult conversations to have.
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It's like having conversations about mortality, and I say it's like there's like this resistance to talking about it, and I think, though, that is fair to say, that there is still like stigmatization occurring and people don't necessarily know when that's going to happen.
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I can think of a very close friend of mine who's gay and is not promiscuous in any way, but continue to go to like one healthcare provider, and when he changed partners would get STI testing, and he was told that he was high risk, he wasn't being promiscuous, he was using protection, he was just having the testing done because he wanted to know his own health status, and that definitely can get bound up in emotional reaction of being judged, and I think that these things do still occur, particularly in certain populations.
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There's this judgment on the type of sex that's happening.
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So I think that's a really good point.
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Well, I think one of the things that we have to emphasize, then, is that part of harm reduction, right part of we're not going to stop people from having sex.
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It's a thing, it's going to happen.
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So what we have to do is we have to create environments in which people feel comfortable sharing details that can sometimes feel really uncomfortable, right, and that's about the training that we offer to our clinical students, the opportunities that we create for them to practice those skills, and creating the type of environment for the people we take care of, where they feel comfortable.
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I've taken care of young people, taken care of elderly people, I've taken care of same-sex couples, I've taken care of hetero couples, and the conversation is always the same.
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It's a very open conversation.
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People should feel comfortable sharing those things with their clinician.
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They should feel like that's a safe space.
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They should not feel judged.
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They should feel that because if we don't have the information, if we don't know what is happening, where it's happening, with whom it is happening and the various mechanisms in which it is happening, we actually can't have a conversation about the potential risks and help our patients make good decisions.
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I feel like that could be a good goal though no-transcript For sure, and I think, jumping off that, expectations around what medical education looks like, what good health care looks like, are always shifting and I think what's interesting I had not thought about this until a friend brought it up with me, but we do have every year.
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Most women are encouraged and most of the women I know go to a well woman visit and that's oftentimes like the place where that conversation happens for women, because you're already like in a super uncomfortable environment getting a pelvic exam.
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So it's what's the conversation on top of that, but there's not really a male equivalent for that of like, here's your yearly visit where, like, you're given the opportunity to talk just about sexual health, and so I think it's interesting, that's also a norm that I think it would be a really exciting to like shift towards that.
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Everyone got that kind of care.
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Yeah, at least in my experience and I think the data support this men will talk about it a bit more freely and men will talk about it when there's something wrong.
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They don't necessarily talk about it if there's nothing wrong, right, and if there's not something happening.
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But if something's wrong, aren't we already a lot of times like too late, right, Because we could?
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We have so much potential for a conversation around like prevention, rather than conversation around here's what we have for something that's maybe antibiotic resistant.
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Or here's what we have for something that's viral that like we can't cure you of.
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Or, at the same time, like I think Dr Cotter brought up, you're testing for something that's already symptomatic, you know what I mean?
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Versus actually preventing the proliferation of that infection, and that's overall what we want to do, right, yeah, and I think that sort of speaks to the broader issue which we were talking about a little bit earlier, which is that it's not just what happens in the clinic.
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If you're in the clinic and it's the first time someone is hearing about these things or having a conversation about these things, as a public health system, we've failed.
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We were talking about sex education and destigmatizing things.
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I mean, the way that information is presented is also part of the public health system.
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There was a time where I remember, when I teach about public health to our global health students, I would show a picture of a like an older poster, like a public health poster, where it would show someone engaging in potentially high-risk sexual activity or a person with whom they might engage, like a commercial sex worker or something, and say, hey, you better get tested.
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If you're frequenting commercial sex workers, you should get tested.
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Right, it was just hey, this is a thing that happens, this is a thing that people do.
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If it's done, hey, this is a pathway for you.
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Yeah, and I think I want to jump off that on, the information people have access to is also changing and that's potentially also driving this sort of rise that we see in STIs.
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And something I can think about is there's research that the best interventions for health don't necessarily occur in a hospital, right Like they can occur in other areas, like whether that's education through your schools, whether that's you attending here from UTMB.
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We have different, they're like Psy Cafe talks, and I just wanted to touch on briefly that.
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Something that's really been on the rise that might come back to bite us later from a public health perspective is that there's been a lot of moves towards banning books, and that's banning people's access to information that might be one of their only sources of information, and I just wanted to talk about that.
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A lot of the times these are books that are targeted towards talking about bodies or talking about sex, and like books that have been banned in Texas include like Safe Sex 101, an overview for teens, and then another that's been banned is Taking Responsibility teen's guide to contraception and pregnancy.
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Neither of these and I read a lot of books.
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I'll be honest, I haven't read these two, but I did look into them, and neither of them looked to me like things that are in any way something people shouldn't have access to, particularly if it's a young person who might not be comfortable having these conversations with their parents, and they might not necessarily have regular access to health care that family isn't present at, so they might not have someone to talk to and they need a route of information that maybe isn't the internet.
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But, camille, what you said earlier, it sounded a little bit contradictory to me.
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You said we have greater access to information nowadays through the internet and so on.
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Right, you can read any book online and access any book online if you want to.
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Exactly, yeah, but you get my point right, but so if we have better access to information, shouldn't the people be more informed?
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And it could cause the opposite and a decline in STIs.
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I would say that access to good information like you have access to everything, right, but you have access to all kinds of things and sorting out what's good information, what's not, is, I think, something that we shouldn't put that expectation on young people Like I think that's a really difficult thing to say and you might have more access, but even like these two books like they're paywalled right, like you need to buy them.
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Does a kid have 25 bucks to buy them?
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I think it's difficult for a child to know that they should learn about STIs True.
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Why?
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Yeah, because it's not talked about.
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And I will just say, access does not necessarily mean understanding.
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Yeah.
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So you might have access.
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You have access to the entire NIH database.
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That doesn't mean that I understand everything that's going on there, that's true.
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And I can remember like I was given books like this by my parents and I can remember like how useful they were and it explains everything for like all the cycles for like puberty and things like that, and it was so useful to like have that as a kid.
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But I was also very fortunate to like have parents who were willing to give me something like that.
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Sounds like you were raised in the Northeast.
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You would be correct.
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Oh, I mean, I was raised in the South and I got the same books.
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But I think to your point.
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I think it is important.
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Public education is important.
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When I ask people, when we talk about public health, we say where did you learn about healthy behaviors?
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Where did you learn about safe sex?
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Where did you learn about condoms or about your body changes or about different sexual behaviors?
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Right, I mean, some people learn from their parents, some people learn from books, some people learn from school.
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Right, there's mandatory health education and public education education, and then some people.
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Now there's any number of places that you can go to find information that some of it may be woefully inadequate and inaccurate.
00:22:01.809 --> 00:22:04.839
But, matt, I would argue, a lot of people also learn from friends.
00:22:04.839 --> 00:22:06.998
Yes, your social groups.
00:22:08.490 --> 00:22:09.951
No, absolutely no I agree with you.
00:22:10.051 --> 00:22:31.383
And so that's where I think, if we are being thoughtful health care practitioners, if we're being thoughtful of public health workers and we're thinking about what that ecosystem looks like, we're thinking people are not all getting the same information and the system needs to address this problem dispassionately.
00:22:31.383 --> 00:22:41.564
Problem dispassionately this is not a the system, the public health system of prevention does not need to further stigmatize or add labels to these, to the behaviors or to the disease.
00:22:41.564 --> 00:22:51.303
We know that pathogens are there, we know that they have a mechanism of transmission and we should design epidemiologic-based interventions that address those risks.
00:22:51.303 --> 00:22:52.973
And that's it, full stop.
00:22:52.973 --> 00:22:59.435
It's not our job to legislate the ethics or the morality of different behaviors.
00:22:59.435 --> 00:23:02.442
It's our job to legislate good public health.
00:23:03.210 --> 00:23:06.698
Yeah, and a lot of this in the US gets bogged down in morality.
00:23:06.698 --> 00:23:35.349
I remember I think you said it in a class that a public health campaign based on fear and shame never, ever works, and we still haven't necessarily picked up on that everywhere, like in some places, absolutely, there are great and I don't want to disparage that like there are people working to make our communities healthier and doing the best they can with that, but there are definitely a lot of issues with censoring people's access to information or biasing that information towards.
00:23:35.349 --> 00:23:42.152
This is my viewpoint and it is morals based, and so this is then what you think is the epidemiologic reality.
00:23:43.275 --> 00:23:50.915
I'm curious how is this information shared, especially information on sexually transmitted infections in Germany?
00:23:51.617 --> 00:23:54.132
From what I heard from you guys, I think it's similar.
00:23:54.132 --> 00:23:56.851
Right, we have sex ed in school.
00:23:56.851 --> 00:24:06.077
I don't know what grade it was, but it's like the basic classes, but it also depends on what your parents tell you and circle of friends and so on.
00:24:06.077 --> 00:24:07.942
So I think it's very similar.
00:24:07.942 --> 00:24:21.400
But I feel and this is my personal opinion right Growing up in Europe and then moving to the United States, the morality aspect here is much greater.
00:24:21.400 --> 00:24:33.877
In the US, we all know that there are certain taboo topics that you don't talk about and I had to learn this as a European that you don't talk about politics, you don't talk about sex, you don't talk about religion.
00:24:33.877 --> 00:24:39.797
In the US and in Europe it's less stigmatized than it is in the US.
00:24:40.157 --> 00:25:08.510
I think that's really pretty important because and thanks for that, caitlin, for that kind of entree because I think one of the issues that we face as we're seeing rates of these STIs go up, we're seeing more syphilis I'm sure that Camille is going to tell us a little bit about the specific diseases in a minute but that we're seeing more and more of these things now, and some of that is related to issues with healthcare access and resource allocation.
00:25:08.510 --> 00:25:13.240
From the pandemic Saw it globally, by the way, with TB issues.
00:25:13.240 --> 00:25:21.349
With TB, we had more MDR, we had more uncontrolled TB during the pandemic because fewer people were accessing those services.
00:25:21.349 --> 00:25:33.500
But I think, from our side, mixing the morality and the stigma is only causing things to get a little bit worse, and so it's really on us to figure out how we reverse that trend.
00:25:34.049 --> 00:25:35.897
Yeah, let's talk about things getting a little bit worse.
00:25:35.897 --> 00:25:37.596
Let's talk about specific infections.
00:25:37.596 --> 00:25:41.221
Syphilis is actually the one that really inspired this whole episode.
00:25:41.221 --> 00:25:43.574
I was shadowing in an infectious disease.
00:25:43.594 --> 00:25:44.875
clinic Syphilis is inspirational.
00:25:44.875 --> 00:25:45.537
Is that what you're saying?
00:25:45.698 --> 00:25:46.519
It was for this.
00:25:48.762 --> 00:25:49.625
That's spirochete.
00:25:52.010 --> 00:25:59.336
I was shadowing in an infectious disease clinic and I got talking with a couple of the docs there and so I did not know this.
00:25:59.336 --> 00:26:08.144
I don't know that it's necessarily talked about, but according to the CDC, syphilis cases have increased by 80% from 2018 to 2022.
00:26:08.144 --> 00:26:21.454
So in the United States we have the highest case numbers of syphilis since the 1950s, which is absolutely wild If you think about the 50s versus now.
00:26:21.575 --> 00:26:22.676
We were all in black and white.
00:26:23.618 --> 00:26:28.656
I mean Like that was pre-internet, that was yeah, it was pre-colored TV.
00:26:28.656 --> 00:26:33.895
So I mean, imagine everything was in black and white back then yeah, so what that was also like before we got to the moon, right?
00:26:33.915 --> 00:26:44.773
So like yeah, like, I mean, like this was you know some time ago, but that's where we're at now with case numbers and I think that's absolutely wild.
00:26:44.773 --> 00:26:46.138
So just briefly, syphilis is a sexually transmitted bacteria.
00:26:46.138 --> 00:26:51.113
Unlike a lot of other sexually transmitted bacteria, it is not antibiotic resistant that I know of.
00:26:51.113 --> 00:26:52.855
It's actually quite susceptible.
00:26:52.855 --> 00:26:56.963
So it's pretty wild that we are seeing this rise.
00:26:56.963 --> 00:27:00.861
You know it's bad when large pharmaceutical companies are like, hey, this is bad.
00:27:00.861 --> 00:27:06.412
Pfizer, which is a major pharmaceutical company, you might know them for making COVID vaccines and all kinds of other stuff.
00:27:06.412 --> 00:27:11.682
Viagra, yeah, making Viagra, okay, they're part of the problem.
00:27:12.349 --> 00:27:13.813
They're part of the cause and the solution.
00:27:13.873 --> 00:27:20.724
But in fact, pfizer blamed the penicillin shortage on soaring syphilis cases in the United States.
00:27:20.724 --> 00:27:37.992
So I think that's pretty wild that we've gotten to this point that syphilis is back to these levels, and I don't know that people necessarily think about, but that syphilis can be congenital, and so 24.9% of congenital syphilis cases in the United States in 2022 occurred in Texas.
00:27:37.992 --> 00:27:39.476
Okay, that's almost a quarter.
00:27:39.476 --> 00:27:41.621
That is a really high amount.
00:27:41.621 --> 00:27:43.836
So, particularly in Texas, we're not keeping up on this.
00:27:44.900 --> 00:27:54.968
Yeah, and it's a really hard one because it can be very subtle and the initial presentation it's usually a shank or it's a sore, but then that goes away.
00:27:55.209 --> 00:28:05.992
So if someone can ignore it and say this thing is kind of ugly, but then it starts to get better, say maybe it was just a skin infection and maybe it was just like a rash or whatever, and then it goes away.
00:28:05.992 --> 00:28:11.736
And then some weeks later comes another rash and they're like maybe add a little reaction to something.
00:28:11.736 --> 00:28:14.807
It's just very easy to ignore it, right?
00:28:14.807 --> 00:28:18.638
Especially if you don't want to be looking for it and if you're worried about it.
00:28:18.638 --> 00:28:25.321
And of course, then you can have the sequelae that's primary and then secondary and then tertiary.
00:28:25.321 --> 00:28:26.692
Syphilis is the neurosyphilis.
00:28:26.692 --> 00:28:28.497
This is the one that gets everybody worried.
00:28:28.497 --> 00:28:40.440
That's where behavior changes, encephalitis, blindness, all kinds of of things, and that can be years to decades after the initial infection can I jump in with an interesting pop culture reference here?
