LEARNING OUTCOME AND OBJECTIVES:  Upon completion of this course, you will be prepared to provide evidence-based care for patients with those sexually transmitted infections (STIs) identified as reaching epidemic levels in the United States. Specific learning objectives to address potential knowledge gaps include:

• Summarize the status of STIs in the United States.
• Discuss the STI National Strategic Plan.
• Analyze the screening, diagnosis, and care of the patient with a major STI identified as affecting population health.
• Identify the challenges in controlling the spread of STIs
• Describe the impact of COVID-19 on the development, identification, and treatment of STIs.

SCOPE OF THE STI PROBLEM

The United States is currently facing a public health crisis due to rising rates of sexually transmitted infections (STIs). During the time period from 2014 to 2018, the rates of these STIs rose dramatically. Primary and secondary syphilis rose 71%, while the rate of increase for congenital syphilis was 185%, gonorrhea 63%, and chlamydia 19% (U.S. DHHS, 2019). Despite a vaccine that targets the strains of human papilloma virus (HPV) that can cause cancer, there are also approximately 35,000 new cases of cervical cancer diagnosed each year (U.S. DHHS, 2020).

According to the Centers for Disease Control and Prevention (CDC), two decades ago the rates of gonorrhea and syphilis had dropped significantly, and new diagnostic techniques made diagnosis of chlamydia easier. In recent years, however, there has been an increase in the rate of STIs that has reached the level of a public health crisis (U.S. DHHS, 2020):

• Chlamydia was the most commonly reported STD/STI in the United States in 2018, with nearly 1.8 million reported cases.
• In the 5-year period from 2014–2018, gonorrhea showed a 63% increase, with 583,405 new cases reported in 2018.
• Syphilis showed a 71% increase from 2014–2018, with 30,644 newly diagnosed cases reported in 2017, up from 17,375 in 2013.
• HPV, while not a reportable disease, infects approximately 13 million adolescents and adults annually.
  (Workowski et al., 2021; CDC, 2021a, 2021d)

According to the CDC, 20% of the U. S. population had an STI (about 68 million infections) in 2018, with nearly half occurring in adolescents and young adults ages 15–24 years. Among those STDs/STIs whose rates are increasing, CDC statistics show a higher incidence of gonorrhea and syphilis in men (especially men who have sex with men [MSM]) than women and a higher incidence of chlamydia in women than men in newly reported cases (CDC, 2021l, 2021d).

Health Consequences of STIs

Because many STIs do not produce symptoms, they can go unnoticed and unknowingly spread to others. A diagnosis of an STI may not be made until serious health consequences have occurred. Social stigma may also keep individuals from seeking care for STIs. Other factors that contribute to the current STI/STD epidemic include poverty, lack of education, and inequalities in access to healthcare (U.S. DHHS, 2020).

Without proper medical care, STIs can result in negative health consequences, such as pelvic inflammatory disease (PID), pelvic pain, infertility, ectopic pregnancy, miscarriage, poor neonatal consequences, and, in the case of HPV, cancer (U.S. DHHS, 2020). Moreover, individuals with chlamydia, gonorrhea, and syphilis are more likely to contract human immunodeficiency virus (HIV) and to transmit the virus to their sex partners.

Relevance of STIs to All Clinical Specialties

Clinicians who work in a variety of healthcare setting may encounter patients with an STI as a presenting symptom or while caring for patients’ other health problems. Therefore, all clinicians should be able to recognize high-risk behaviors and signs and symptoms of STIs, provide basic STI education, deliver STI care following standard recommendations, and know when to refer patients for specialized care.

The following are examples of non-STD clinical settings in which clinicians may encounter patients with STIs/STDs:

• A history and physical examination of a female patient in a fertility clinic may reveal that fertility issues are related to untreated gonorrhea.
• A patient admitted to a medical unit for persistent abdominal pain and urinary tract infections may be diagnosed with chlamydia.
• A preadmission history and physical examination for a patient scheduled for a total knee arthroplasty may reveal that the patient has genital lesions that require treatment prior to surgery.
• A history on an adult during a routine annual examination may reveal multiple sex partners and inconsistent use of condoms, requiring STI testing and education about safe sex practices.
• An adolescent in high school may share symptoms of an STI with the school nurse.
• A school-aged child in a pediatric clinic may have symptoms suggesting an STI and sexual abuse.