The COVID-19 pandemic and sexually transmitted infections: Where do we go from here?

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of Coronavirus Disease 2019 (COVID-19) and responsible for a global pandemic. There are currently over 30,000,000 confirmed cases in the United States (US) alone.¹ Restrictions and mitigation efforts to reduce COVID-19 transmission have been implemented across the US including in outpatient clinical settings. Although some outpatient clinical settings shifted to telehealth and were able to do so successfully,² COVID-19 mitigation measures have continued to have an impact on reductions in those seeking non-emergency related medical care. This is true for the care and treatment of sexually transmitted infections (STIs) including syphilis, gonorrhea, and chlamydia which may be asymptomatic and perceived as non-urgent by many people. Prior to COVID-19, STIs were already significantly increasing. The Centers for Disease Control and Prevention (CDC) estimates 1 in 5 people in the US are living with an STI at any given time with nearly 1 in 2 of them between the ages of 15 to 24 years.³ Data on how the COVID-19 pandemic has affected STI rates is starting to emerge and suggests an overall decrease in testing and possible increases in some STIs.^4,5

In their recent study, Bonett and colleagues (2021) found that testing for gonorrhea and chlamydia decreased significantly during the pandemic while test positivity increased among patients ages 15–21 in a large 31-clinic pediatric primary care network serving 250,000 youth annually in the state of Pennsylvania.⁶ Compared to the corresponding eight-month period in 2019, STI testing during the pandemic from March 2020 to October 2020 decreased by approximately 26% for both testing and patients seeking care (N=4,699 tests among 3,723 unique patients in 2020 versus N=3,476 tests among 2,770 unique patients in 2021). Gonorrhea and chlamydia positivity rates increased 1.7% and 10.4%, respectively. The authors speculate this may be due to prioritizing visits for symptomatic patients. However, as they note, many adolescents and young adults may be asymptomatic and at greater risk for consequences of STIs than the general population (e.g. likelihood of transmitting to multiple partners, susceptibility to HIV infection, pelvic inflammatory disease, and infertility). This is yet another study demonstrating the challenges of providing ongoing STI care during a pandemic. This study also identified the potential consequences of restricted access to walk-in STI testing services, including an increased burden of testing and treatment in primary care settings. Especially concerning are that younger women are at increased risk of complications from gonorrhea and chlamydia and those who are sexually active should be routinely screened.^7,8

To date, several studies have attempted to capture changes in sexual behavior and STI testing and rates, as well as HIV and pre-exposure prophylaxis (PrEP) care and treatment during the COVID-19 pandemic. There have been service disruptions related to STI, HIV, and PrEP clinical care, including difficulty in accessing antiretroviral medications, particularly for individuals from marginalized and underserved communities.^9–12 Some groups have attempted to model the impact of reduced number of sexual partners and clinical care service disruption on HIV and STI cases over the next several years. Models have predicted slightly different results; however, all show service disruption as associated with increases in new STIs including HIV and emphasize the importance of continued STI care.^13–15 Increasing PrEP distribution may be one way to reduce incident HIV infections. However, for STIs no equivalent preventive approach exists.¹⁶

Primary care and specific specialty clinics (i.e. STI clinics) serve a critical role in addressing sexual health, reproductive health, STI screening and prevention, and providing safety-net services in many states. However, to reduce risk of COVID-19 transmission, many clinics have limited or canceled clinical visits, limited elective procedures, shortened clinic hours, decreased number of staff in clinic, and switched from in-person to telemedicine visits. At the start of the pandemic, it was clear that there needed to be shifts in how outpatient clinical care functioned to continue to address the needs of their patients. Multiple approaches have been implemented in outpatient settings including symptom screening for COVID-19 prior to appointments, improving infection control, providing specific appointment times, limiting the number of staff in the clinic, using proper personal protective equipment (PPE), offering presumptive therapy for patients with STI exposure or symptoms, utilizing expedited partner therapy, use of second-line oral regimens, and employing telemedicine as allowed by state guidelines.¹⁷ Several clinics implemented these strategies in order to continue to offer optimal care to patients, while limiting potential for COVID-19 exposure for patients and clinic staff. Overall, patient volume for STI testing and preventive care has decreased.^4,18

There are multiple reasons for decreased STI care and testing during the COVID-19 pandemic including foremost the fears of SARS-CoV-2 infection.¹⁹ Data from Italy showed reduced pediatric visits due to COVID-19²⁰ and effects for pediatric and preventive adult care have been similar in the U.S. with many individuals foregoing routine appointments and causing smaller private practices to close.²¹ Additionally, there have been substantial global and domestic socioeconomic impacts of COVID-19 including job loss and insurance coverage disruption,²² which may be an additional reason for avoiding specialty care medical appointments, including STI screening. Reduced sexual activity may have led to decreased actual and/or perceived risk of STIs and therefore less testing. A combination of these reasons have likely contributed to decreased STI care and testing during the COVID-19 pandemic.

There are several considerations in terms of addressing STIs post-pandemic. First, we need to understand how COVID-19 has affected STI rates. It is unclear whether STI incidence has declined due to COVID-19 mitigation efforts, or if only testing rates and therefore the number of observed STI cases has decreased. Continued sexual behaviors without STI testing could mean that there are a significant number of STIs that have yet to be diagnosed and treated and we may see an emergence of cases and disease complications over the next year. Second, COVID-19 has underscored existing disparities within our communities and disproportionately impacted underserved and marginalized groups.^23–25 These same groups continue to be most affected by STIs and most in need of care and treatment are least likely to have regular access to testing and treatment options.²⁶

The CDC has released the following recommendations for addressing rising rates of STIs during COVID-19: (1) allow walk-in STI testing and treatment, (2) partner with pharmacies and retail health clinics for STI services, and (3) expand telehealth options and self-collection and self-testing to ensure access in underserved areas.³ These recommendations are useful and provide a guide for how to move forward. Although many settings have halted or discontinued walk-in services because of COVID-19, revisiting these policies should be considered given the potential negative public health impact on STI outcomes. Primary care and/or point of service care in pharmacy or health clinic settings could provide additional settings for testing and treatment. Finally, telehealth has increased access and provided medical care to patients in their homes as well as reducing transportation, scheduling, and other barriers to traditional in-person medical care including wait times and stigma of having to present for care. This telehealth infrastructure should be continued and expanded to support STI testing, so that underserved populations can access care with fewer barriers. In some settings, home-based COVID-19 testing has been implemented and such approaches may be an effective way to increase STI testing rates. Research has shown that self-collection methods are feasible and preferred by patients.²⁷ These important lessons could be applied to address the STI epidemic.

In conclusion, the COVID-19 pandemic has led to multiple challenges in the care and prevention of STIs. STI testing rates are down and the overall effect of the pandemic on STI incidence is unknown. However, the pandemic has also led to creative and innovative solutions related to expanding and enhancing clinical care which could be applied to STIs. Specifically, telehealth and advances in testing diagnostics and approaches should be considered to address the STI epidemic.