Slim Silver Lining Appears for STI Rates

The persistent epidemic of sexually transmitted infections (STIs) in the United States is showing signs of a slowdown in cases of syphilis, gonorrhea, and chlamydia, according to the latest data from the US Centers for Disease Control and Prevention (CDC).

More than 2.4 million cases of these three nationally notifiable STIs were reported in the United States in 2023 but represent a 1.8% decrease from 2022, based on a new CDC report, Sexually Transmitted Infections Surveillance, 2023.

The 2023 report indicates a 7.2% decrease in gonorrhea, which accounts for most of the decrease.

Although syphilis cases increased overall, they did so by only 1% compared with double-digit increases in previous years, according to the report. Primary and secondary syphilis decreased by 10% compared to 2022 overall, with a 13% decrease in cases among gay and bisexual men.

Congenital syphilis rates increased by 3%. However, the 3% increase represents a significant drop from the 30% increases each year in recent years, according to the report.

Chlamydia rates remained essentially stable, with a decrease of less than 1.0% overall. Reported chlamydia rates increased by 1.3% among men and decreased by 1.7% among women.

Despite the declines, overall disparities persist, with higher rates of STIs among gay and bisexual men, as well as American Indian/Alaska Native, Black/African American, and Hispanic/Latino populations, according to the report.

CDC Cautiously Optimistic

The CDC is “guardedly optimistic that the new data represent a turning point in terms of syphilis and gonorrhea,” said Bradley Stoner, MD, director of the CDC’s Division of STD Prevention, in an interview.

However, a tremendous amount of work remains to be done, notably in addressing disparities in care, said Stoner.

New techniques for diagnosis and treatment, such as the increased use of doxycycline (doxy PEP) for the prevention of STIs after sex for high-risk populations with a history of STIs, are likely contributing to the overall decrease, Stoner said. Other contributing factors include improved communication and awareness of STI treatment options at the community level in emergency departments, substance use facilities, and syringe use programs, he added.

Although the United States has not yet turned the corner in reducing STIs, “We are at an inflection point in the epidemic after years of increases,” Stoner told Medscape Medical News. “The CDC is committed to keeping the momentum going and turning things around,” he said. Although congenital syphilis rates are slowing down, it remains a significant problem with severe outcomes for mothers and infants, he noted.

The message to healthcare providers on the front lines is to increase awareness, screen widely, and provide effective treatments, Stoner emphasized.

Looking ahead, more research is needed to identify the settings in which prevention tools can be best utilized, such as urgent care or other programs, said Stoner. “My hope is that implementation science research will give us some clues,” he said. In addition, better tools for detection and treatment of STIs are always needed, notably better diagnostics for syphilis, which still requires a blood test, although research is underway for more efficient testing, he said.

Spotlight on Disparities, Syphilis

“I think these are very nuanced results,” said David J. Cennimo, MD, associate professor of medicine and pediatrics in the Division of Infectious Disease at Rutgers New Jersey Medical School, Newark, New Jersey, in an interview. “I am happy, on first pass, to see that STI rates have declined,” he said. However, a closer look reveals that most of the improvements are driven by the 7% drop in gonorrhea, whereas chlamydia and syphilis rates are relatively stable, he noted.

The decreases may reflect that the public is receiving the messaging about the need for screening and safer sex, Cennimo said. “Clinicians also have been educated on the need for screening,” he added. However, “we are still 90% above the [STI] rates from 20 years ago.” 

Clinicians also must recognize the disparities in STI rates by race and other demographics, Cennimo told Medscape Medical News. The current report “is a call to make sure that STI and other medical services are targeted to specific groups as needed and are widely available, especially in under-resourced areas,” he said.

“I am still dismayed by the high syphilis rates, which are also resulting in congenital syphilis,” Cennimo said. “Syphilis in pregnancy is very dangerous, and any case of congenital syphilis is a failure of preventive care and screening; it is a potentially devastating disease,” he emphasized.

“We have good treatments for STIs, but we must continue to monitor for resistance,” said Cennimo. “More work is needed to reach high-risk individuals and to provide preventive care and screening,” he said.

The research was supported by the CDC. Stoner and Cennimo had no financial conflicts to disclose.