Unraveling the Modern STI Epidemic in America

This episode tackles the alarming rise of sexually transmitted infections (STIs) in the United States, exploring our hidden epidemic and the multitude of factors leading to this increase. We delve into the impact of COVID-19, the necessity for comprehensive sex education, the influence of cultural norms, and the importance of destigmatizing conversations around sexual health. Tune in to learn about:

• One Health and its relevance to STIs 
• How the COVID-19 pandemic affected public health services around STIs 
• The role of inadequate sexual education in exacerbating STI rates 
• The impact of dating apps and hookup culture on sexual health behaviors 
• Specifics on the rising rates of syphilis and other STIs 
• Importance of proactive testing and screenings for all individuals 
• The call for inclusivity in sexual health discussions and education 
• The need to destigmatize conversations around sexual health 

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Transcript

Speaker 2 0:09

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.

Speaker 1 0:17

Coming to you from the University of Texas Medical Branch and the Galveston National Laboratory.

Speaker 2 0:21

This is Infectious Science. Where enthusiasm for science?

Speaker 1 0:25

is contagious.

Speaker 3 0:32

Welcome to another episode of the Infectious Science podcast, your monthly dose of critical trends in infectious diseases and public health insights. I'm one of your hosts, dr Dennis Benter. Imagine a silent epidemic spreading through our communities, affecting millions, yet often going unnoticed. That's exactly what's happening with sexually transmitted diseases in the United States. 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.

Speaker 3 1:17

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. 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. 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. Get ready to challenge your assumptions and gain a new perspective on sexual health in America. This is the Infectious Science Podcast, where we take the pulse of infectious diseases, one critical issue at a time.

Speaker 4 2:06

All right, this is Camille. I'm super excited to be back with you all today. We also have an original member of the Infectious Science Podcast. We have Dr Matt Dasho joining us Very excited.

Speaker 2 2:20

Yeah, thanks for having me back. Thanks for letting me back into the podcast club.

Speaker 4 2:25

And we also have Dr Caitlin Cotter joining us today.

Speaker 5 2:29

Hey, thanks for having me. Glad to be here and happy to see how you do this.

Speaker 4 2:32

Yeah, absolutely. All right, let's dive into this. 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. So I have a couple points written down here. But, dr Dasho, if you see people in the clinic, what would you say is really driving this rise when you talk to patients?

Speaker 6 2:53

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?

Speaker 2 3:02

All right, a sexually transmitted infection. 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. So that's the overall umbrella category of STIs. We do see this. There are certain. 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. But yeah, no, typically I think we tend to see sexually transmitted infections in younger people, sexually active people. There are certain populations that are at higher risk, people who are not using protection people. There are certain populations that are at higher risk, people who are not using protection. 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. It really sort of runs the gamut of not only the pathogens but the risks.

Speaker 4 3:59

Yeah, no, and I think that's a great place to start and I'm glad you started with this. 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. And, of course, if you're only looking to educate people on preventing pregnancy, you miss groups. 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. 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. You looked like you wanted to jump.

Speaker 6 4:53

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.

Speaker 2 5:05

Yeah, I think that's well taken. 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. But we know that we're a species just like any other species and sexual relationships are part of the propagation of the species. 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.

Speaker 2 5:45

We've developed a variety of interventions that help potentiate the sexual lives of people into their 70s, 80s and 90s. 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. And so it is actually in elderly populations that we do see spikes in risk for sexually transmitted infections.

Speaker 4 6:16

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.

Speaker 4 6:50

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. That's very kind of unique. You know money moves through different pathways. 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? And I think there's a lot of stigma about talking about it, which is why we're doing a podcast episode on it.

Speaker 2 7:34

Yeah, I think you mentioned a lot of different things, camille. One of the things I think we get real excited about kind of new things the dating apps. Stis have been with us really since the dawn of man, right. These pathogens started appearing from ancient Egyptian times. There were documentations of people suffering from symptoms and signs of sexually transmitted, various types of sexually transmitted infections. 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.

Speaker 2 8:11

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. For me, it's less about sexually transmitted infections have been with us for generations. 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. 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. It's the old folks' homes, that's what's doing it. It's the focus on abstinence-only education. That's what's doing it.

Speaker 3 9:01

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.

Speaker 5 9:35

Yeah, we were looking into this and it really looks like there was a disruption of STD services during the pandemic. That really contributed a lot to that. Additionally, there was a reallocation of resources right, everybody was focused on COVID-19 instead of anything else. Then there was a decreased testing associated with that and then, in addition, there was increased test positivity. So what that means is the number of tests that we did have. The proportion of those tests that were positive was higher. 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.

Changing Stigmas in Sexual Health

Speaker 2 10:20

I love that you mentioned that, caitlin, because you know I think we can't emphasize that enough. 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. Tell us that people who are under the age of 24, who are sexually active, should be screened regularly for sexually transmitted infections. We know that everybody should have the right to at least one HIV test. 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. 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. I think we're only now starting to see the sequelae of those, of those interventions. Of course, emergency interventions were needed during the emergency.

Speaker 4 11:27

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. We haven't quite found out what all the side effects of COVID has had on the rest of our health system. We're still sort of 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, 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. It can be, but certainly a lot of these diseases might end up being like silent infections. 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.

Speaker 5 12:14

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? So then, as a clinician, what do you think about? How do you think about that in terms of promiscuity?

Speaker 2 12:33

Yeah, I think that's a great question. 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. It's like this thing that we shouldn't talk about. We shouldn't do it unless we're in very ideal circumstances. But it is a natural behavior, right, and so the way I approach it is that everybody gets a sexual history. 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. They feel that the system or the clinician is going to judge them. They feel that if they're engaging in sexual activity, they're doing something wrong. 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.

Speaker 4 13:37

I think that's absolutely so. True, those are difficult conversations to have. 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. 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. There's this judgment on the type of sex that's happening. So I think that's a really good point.

Speaker 2 14:29

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.

Speaker 2 14:37

It's a thing, it's going to happen. 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. 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. It's a very open conversation. People should feel comfortable sharing those things with their clinician. They should feel like that's a safe space. They should not feel judged. 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.

Speaker 4 15:42

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. 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. 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. Everyone got that kind of care.

Speaker 2 16:40

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. They don't necessarily talk about it if there's nothing wrong, right, and if there's not something happening.

Speaker 4 16:49

But if something's wrong, aren't we already a lot of times like too late, right, Because we could? 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. Or here's what we have for something that's viral that like we can't cure you of.

Speaker 6 17:04

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?

Speaker 2 17:15

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.

Speaker 2 17:26

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. We were talking about sex education and destigmatizing things. I mean, the way that information is presented is also part of the public health system. 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. If you're frequenting commercial sex workers, you should get tested. Right, it was just hey, this is a thing that happens, this is a thing that people do. If it's done, hey, this is a pathway for you.

Speaker 4 18:21

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. 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. We have different, they're like Psy Cafe talks, and I just wanted to touch on briefly that. 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.

Speaker 4 19:02

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. Neither of these and I read a lot of books. 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.

Speaker 3 19:42

But, camille, what you said earlier, it sounded a little bit contradictory to me. You said we have greater access to information nowadays through the internet and so on. Right, you can read any book online and access any book online if you want to. Exactly, yeah, but you get my point right, but so if we have better access to information, shouldn't the people be more informed? And it could cause the opposite and a decline in STIs.

Speaker 4 20:10

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. Does a kid have 25 bucks to buy them?

Speaker 5 20:37

I think it's difficult for a child to know that they should learn about STIs True.

Speaker 4 20:42

Why? Yeah, because it's not talked about.

Speaker 6 20:44

And I will just say, access does not necessarily mean understanding.

Speaker 5 20:48

Yeah.

Speaker 6 20:48

So you might have access. You have access to the entire NIH database. That doesn't mean that I understand everything that's going on there, that's true.

Speaker 4 20:55

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. But I was also very fortunate to like have parents who were willing to give me something like that.

Speaker 2 21:12

Sounds like you were raised in the Northeast. You would be correct. Oh, I mean, I was raised in the South and I got the same books. But I think to your point. I think it is important. Public education is important. When I ask people, when we talk about public health, we say where did you learn about healthy behaviors? Where did you learn about safe sex? Where did you learn about condoms or about your body changes or about different sexual behaviors? Right, I mean, some people learn from their parents, some people learn from books, some people learn from school. Right, there's mandatory health education and public education education, and then some people. Now there's any number of places that you can go to find information that some of it may be woefully inadequate and inaccurate.

Speaker 3 22:01

But, matt, I would argue, a lot of people also learn from friends. Yes, your social groups.

Speaker 2 22:08

No, absolutely no I agree with you.

Speaker 2 22:10

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. 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. 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. And that's it, full stop. It's not our job to legislate the ethics or the morality of different behaviors. It's our job to legislate good public health.

Speaker 4 23:03

Yeah, and a lot of this in the US gets bogged down in morality. 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. This is my viewpoint and it is morals based, and so this is then what you think is the epidemiologic reality.

Speaker 5 23:43

I'm curious how is this information shared, especially information on sexually transmitted infections in Germany?

Speaker 3 23:51

From what I heard from you guys, I think it's similar. Right, we have sex ed in school. 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. So I think it's very similar. 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. 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. In the US and in Europe it's less stigmatized than it is in the US.

Speaker 2 24:40

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. From the pandemic Saw it globally, by the way, with TB issues. With TB, we had more MDR, we had more uncontrolled TB during the pandemic because fewer people were accessing those services. 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.

Resurgence of Syphilis in America

Speaker 4 25:34

Yeah, let's talk about things getting a little bit worse. Let's talk about specific infections. Syphilis is actually the one that really inspired this whole episode. I was shadowing in an infectious disease.

Speaker 2 25:43

clinic Syphilis is inspirational. Is that what you're saying?

Speaker 4 25:45

It was for this.

Speaker 2 25:48

That's spirochete.

Speaker 4 25:52

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. 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. 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.

Speaker 2 26:21

We were all in black and white.

Speaker 4 26:23

I mean Like that was pre-internet, that was yeah, it was pre-colored TV. 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?

Speaker 4 26:33

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. So just briefly, syphilis is a sexually transmitted bacteria. Unlike a lot of other sexually transmitted bacteria, it is not antibiotic resistant that I know of. It's actually quite susceptible. So it's pretty wild that we are seeing this rise. You know it's bad when large pharmaceutical companies are like, hey, this is bad. Pfizer, which is a major pharmaceutical company, you might know them for making COVID vaccines and all kinds of other stuff. Viagra, yeah, making Viagra, okay, they're part of the problem.

Speaker 2 27:12

They're part of the cause and the solution.

Speaker 4 27:13

But in fact, pfizer blamed the penicillin shortage on soaring syphilis cases in the United States. 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. Okay, that's almost a quarter. That is a really high amount. So, particularly in Texas, we're not keeping up on this.

Speaker 2 27:44

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.

Speaker 2 27:55

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. And then some weeks later comes another rash and they're like maybe add a little reaction to something. It's just very easy to ignore it, right? Especially if you don't want to be looking for it and if you're worried about it. And of course, then you can have the sequelae that's primary and then secondary and then tertiary. Syphilis is the neurosyphilis. This is the one that gets everybody worried. 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?

Speaker 4 28:40

yes, fun fact or not. So fun fact for al capone is that he was actually sprung from alcatraz because of his complications with neurosyphilis. His wife made a case that he should be essentially released early, and they did release him because of his complications with neurosyphilis. His wife made a case that he should be essentially released early, and they did release him because of his complications with neurosyphilis. So certainly if it goes untreated does not do good things for the central nervous system.

Speaker 2 29:03

Camille, the number of famous artists that were likely sufferers of neurosyphilis is profound.

Speaker 4 29:14

I can imagine.

Speaker 2 29:15

You know, some of the great composers, like Schumann, Schubert, were suspected to have syphilis. We were talking earlier about Scott Joplin, the king of ragtime, who cut his teeth in brothels because that's where jazz was being created and these were the environments, and so these were environments in which the pathogen could circulate very, very easily. So a lot of artists and then terrible people like Adolf Hitler was suspected to also be suffering from syphilis. So yeah, throughout history, some of the people we think of as big figures also suffer from that condition.

Speaker 6 29:52

Yeah, and I think that it's really important, matt, to speak about what you were saying, how syphilis itself kind of waxes and wanes throughout these phases, and so it becomes really difficult to test for syphilis at times, right Until it gets to those later progressions and those more dangerous phases. I actually had no idea until I entered medical school that pregnant women are actually preemptively screened for syphilis as well as chlamydia, gonorrhea, hiv and hepatitis I think it's a mix of those and it depends, obviously, state to state what's actually required. But they're tested for these infections because of the devastating effects that they can have on the fetus or on the child, as the child is being birthed, and syphilis is particularly one that is pretty intense and the manifestations in the newborn are pretty intense. Just some of the things that congenital syphilis can cause in a newborn is blindness, deafness, deformities of the skeleton and also of the face, and then also nervous system complications.

Speaker 6 31:04

And I think it's important to note that, while infections like chlamydia and gonorrhea are transmitted to the fetus via vaginal delivery, syphilis itself is an infection that can be transmitted transplacentally. So if the mother is in a part of the world or in an area where she's not tested, or let's say she doesn't have access to prenatal visits and well woman's health care throughout her pregnancy, and she's not tested for this. It's very easy to pass that infection on to her unborn child, and so it just shows how important it is to be testing frequently, and screening frequently, because it not only affects the person and their partner, but it can also have effects on a lot of other people too.

Speaker 3 31:51

So, christina, for the listeners that probably don't know what congenital means or what placenta means and so on, can you explain how the disease is given from the mom to the baby and especially the timing? When does the mom get infected, when does the baby get infected? And in rough terms, right Like so that people can understand?

Speaker 6 32:12

I don't know if I know the specifics so much with the timing. I think I know in general that later the mother is infected with syphilis. So you want to do an early testing for syphilis and then you also in the third trimester, want to do another testing for syphilis, because the later the infection with syphilis apparently in the pregnancy, the more detriment it can do to the fetus, which I didn't know. Normally it's vice versa. Normally the fetus itself is very susceptible to infections and to devastating effects by infections in the earlier stages. But from what I think I read in from Mass General, it's vice versa with syphilis.

Speaker 6 32:48

So transplacental infection essentially means that, okay, let's picture this Baby and mother is within a little pouch and that pouch is in the uterus and that pouch is the placenta. I hope I'm saying this right. Okay, you're doing great, great. Not a lot of infectious pathogens can actually cross this pouch and also not a lot of antibodies but that's for another day can cross this pouch either. However, some really big buggers and syphilis just happens to be one of them can cross the pouch. And when it crosses the pouch, that's when it can really do damage to this developing life.

Speaker 2 33:28

Yeah, and it tends to be sort of a slate of different pathogens that can traverse that boundary. We've talked about them in a previous episode about the torch infections and hopefully Christina has them all memorized and written down for her step exams. But we know that there are some of these pathogens that can cross the placenta and cause these problems in the fetus.

Speaker 4 33:52

Yeah, so I think I want to get into another infection that we are. Are we done with syphilis? We are. Is there more syphilis to talk about? Any more syphilis facts? No, I don't have any more fun facts on syphilis.

Speaker 2 34:04

I think the only thing we've left is, especially in certain populations we're seeing a much greater rise, especially men who have sex with men and other populations where there may be more multiple concurrent partnerships and things like that. And one of the things we talked about was whether well-intentioned interventions to reduce the risk of STI transmission, like PrEP, right pre-exposure prophylaxis for HIV, have potentially increased the number of people who are having unprotected sex and with more partners and in more of a dating app culture and the bars are back open and everything post-COVID.

Speaker 2 34:47

Now nobody's thinking about it because all of the funding for education and for outreach to detect these things is down. So multifactorial situation. But I think especially in those populations syphilis is being seen to a much greater degree.

Speaker 4 35:02

For sure, and that's actually what I wanted to get into next. So PrEP for our listeners who aren't familiar with it, pre-exposure prophylaxis, yes, and so what it does is basically reduces your risk of acquiring HIV. So it's something that came out, I believe, in the early 2000s, and since then there has been this question that you brought up of. Is this potentially increasing other infections because people feel more comfortable or safer, because they feel that they're protected from HIV, and so HIV is something that I think people the world over are really familiar with by now. Viral infection can be transmitted by sex, blood, breast milk, but what we're seeing in the United States, where we're seeing new cases of HIV, is dependent on where you are geographically. So 49% of new HIV cases in the US in 2022 occurred in southern states. That includes Texas. All of those factors we talk about that are contributing to the rise of STIs are likely driving HIV, which is preventable with PrEP or with safe sex practices or just with people knowing their status.

Speaker 4 36:09

Probably you've been in an ER. They've asked you if you wanted like an HIV test or at least they ask in Northern states. Like anybody who walks in, it doesn't matter if you're walking in for an allergic reaction. You've broken your arm. They're like would you like to be tested for HIV? I've never I've been to an ER down here and I don't think they ever asked, but up there they do.

Speaker 2 36:27

It's happening. It's definitely there's more of that happening of HIV screening taking place in emergency settings. But you're right on, camille. I mean the HIV research world is always about prevention, right.

Speaker 4 36:40

Oh yeah.

Speaker 1 36:41

Or mitigation yeah.

Speaker 2 36:42

And people have been trying to study PrEP for a long time. It's really only in the last five to 10 years that there has been really solid data that PrEP works when deployed at a population level.

Speaker 2 36:53

And it's become very commonplace to see PrEP and for people to be looking for PrEP, and it's not just for men who have sex with men, it's for anybody who might be at increased risk and it's something that anybody who is sexually active that is thinking to have sex with multiple different people in given years it's something that people should ask about because it is extremely effective. It's a very good, effective intervention to help mitigate HIV transmission, as is treatment. So treatment is prevention. We learned that in the last 15 years that when people get their viral load suppressed, when they get their CD4 counts up, the risk of transmission goes down profoundly, you know, by between 90 and 95%. When people are well controlled, it's harder for them to transmit this. So all of these things, it's never one thing right, it's all of those interventions together, taken as an amalgam, that help impact the health population.

Speaker 4 37:52

Yeah, and I work in a lab that we do substance use research but also HIV research, because those are comorbid issues in the United States at the moment and I just think it's so important to point out because I feel like people don't know this. The CDC actually recommends everybody anybody get tested for HIV at least once in their lifetime. It's not just if you feel at risk. They recommend it for anyone at least once, just their lifetime. It's not just if you feel at risk, like they recommend it for anyone at least once, just to know your status, and so it's not in any way linked to what they see as just like sexist anymore. It's anybody get tested once. So we're doing an STI episode, but just worth throwing out there. That's the public health recommendation.

Speaker 2 38:29

So I like it.

Speaker 4 38:31

All right, let's talk about a infection that's ubiquitous. I'd be curious if people can guess what this is. According to the CDC, nearly every sexually active person will get this infection at some point in their lives. Do we have any Jeopardy buzzers? What is HPV?

Speaker 5 38:48

The human papillomavirus.

Speaker 1 38:50

The human papillomavirus.

Speaker 4 38:52

So HPV is a viral infection spread by sex that can cause cancer and really the drive to prevent it is really to prevent the cancers that this infection can cause Anyone who's ever had a pap smear. Really, what they're looking for is, like coelocytes, so they're looking for abnormalities, so they're looking for cellular abnormalities, but you're looking specifically for coelocytes, which are these cellular abnormalities that you get around the cervix when someone has had an HPV infection, and we test for those because we are trying to prevent cancer. But there's now a vaccine for HPV. It's not new. I say that like it's new. It's not new.

Speaker 4 39:31

I remember getting this vaccine when I was 11, I believe. So it's been out. Yeah, it's been out like at least 10 years. It's been out a while.

Speaker 2 39:39

Yeah, dennis and I are looking at each other because we were too old by the time the vaccine came out for us to get it. Otherwise, I think we would have probably both wanted to get it, because we love vaccines.

Speaker 1 39:49

Yes, all vaccines.

Speaker 4 39:51

I love all vaccines.

Speaker 2 39:51

I tried to find an excuse to get it. You can get it up to the age of 45 with certain risk factors.

Speaker 3 39:58

So maybe next time we see each other we'd say hey, what's the latest vaccine you got?

Speaker 2 40:08

Exactly. I have something I want to say about HPV. A lot I want to say about HPV. It is the most common sexually transmitted infection. It is across species, so it has manifestations in many animals, including humans. There are animal transmitted papillomaviridae and there are human transmitted papillomaviridae. That's the HPVs there are.

Speaker 2 40:28

The reason that it became extremely important is because this became a vaccine preventable cancer, right, and that's why it's so important. Is because this became a vaccine-preventable cancer, right, and that's why it's so important. There was a time where people would get cervical cancer, they'd get oropharyngeal cancer, nasopharyngeal cancers, some actually skin cancers that are related to HPV, and there was nothing you could do about it. But now there's a vaccine. If you get the vaccine, you reduce profoundly your risk of getting a particular type of cancer, which is amazing. If you told people 30, 40 years ago, hey, if you get this vaccine, you're going to reduce the risk of cancer. It's amazing, right, and it's one of those amazing technological advancements I think we've made. And it's not just cancer. It's not just cervical cancer or penile cancer or oropharyngeal cancer, but it's also certain types of warts venereal warts, skin warts. Most of the warts that you see that people get that are on the fingers or on the body are actually HPV.

Speaker 2 41:32

So they're all some subtype of HPV and the majority of the types that both cause cancer and skin warts. Venereal warts especially, are covered by the vaccines that are commercially available and that are recommended for young people and adolescents.

Speaker 3 41:49

So, Matt, as a virologist, I have to ask you a question. It sounded like when you said papillomaviruses are cross-species, but I think what you want to say is that there are papillomaviruses for every species, but they're normally very species-specific, just like pox viruses for example yes, absolutely.

Speaker 2 42:08

Yeah, so a bird species can spread a bird papillomavirus. It infects the skin cells and so it causes them to heap up and replicate, and there's a whole, probably other episode you could do just about papillomaviridae.

Speaker 5 42:24

Because I know that you guys like to talk about One Health a lot and you like to mix messages or talk about the interdisciplinarity between veterinary medicine and human medicine. Any listeners out there with puppies that go to a dog park and then the dog ends up with a little kind of cauliflower piece of tissue on its lip or gums? That is papillomavirus. It's really not dangerous, though. What you can do is actually go to the veterinarian and they'll physically take it off and then the immune system will take care of it and it'll go away. So interesting.

Speaker 6 42:58

Is that DPV Dog? Oh my gosh, that's funny.

Speaker 4 43:02

Something I do want to mention about the Gardasil vaccine, though you touched on, but just to make it really clear to anyone who's listening is that it's a fantastic vaccine, but it's most effective when it's given before someone is exposed to the virus and, as I previously stated, at least according to the CDC, nearly every sexually active person will get HPV at some point in their life. So it works best when you catch people before they become sexually active and are exposed to HPV. So that's why this vaccine is recommended for 11 to 12 year olds. That's why I ended up getting it when I was 11. I think it was two or three doses, but that's why it's given so young. It's because it's most effective but again, prevents cancer. That's so cool, it's fantastic.

Speaker 2 43:41

And it's not just girls, it's boys too.

Speaker 4 43:42

Yes, my brother got it same time as I did.

Speaker 2 43:49

They lined us up and they were like here's a huge dose. And again it's one of these where the episode. But about 58.5% of eligible people are vaccinated, which is great, and that means that there's about 41.5% of people in the state that are not vaccinated against HPV.

Speaker 4 44:07

And essentially every single one of them will be exposed.

Speaker 2 44:10

Yeah, it's the most common sexually transmitted infection worldwide. The most common.

Speaker 3 44:15

All right, and I think one of the issues with and I think that you were trying to touch on that is, I think, if you bring up the topic of getting vaccinated, I think you bring up the topic of being sexually active and I think that's why so many parents are against it, right? I don't know if that's gender specific, but it seems like not a lot of boys get the vaccine correct.

Speaker 4 44:40

I didn't look into males versus females on who gets vaccinated. I remember getting it at the same time as my brother. They just lined us up in the pediatric thing. They were like here's your shot. But I think people can be hesitant and that's something we see around many vaccines in the United States and there's a lot of reason for that, but certainly everything we talked about earlier on what's driving this rise in STIs in the United States. A lot of it is that people don't want to talk about it. But this is something that anyone who's sexually active is pretty much guaranteed to get and it prevents cancer and I think it doesn't really get better than that.

Speaker 6 45:14

Absolutely, and I think, dennis, just like going towards what you were talking about, I feel like a way that we're making the topic of the HPV vaccine more accessible to parents, or at least presenting it in a way that is more acceptable, is also by just explaining its other benefits.

Speaker 6 45:34

So, for example, I spent a little bit of time working in a dermatology clinic recently and we saw multiple children who had presented with hand warts Super common, very common and with each one of those parents and those children we had a conversation about the Gardasil vaccine, because not only does it help prevent the sexually transmitted HPV, does it help prevent the sexually transmitted HPV, but it also has a cross effect, apparently, with providing at least increased immunity towards other strains of HPV, like Matt talked about that are passed through just physical contact, right, and that's what causes those hand warts. So by maybe relaying the other benefits that the vaccine could potentially have, that we could open up the conversation a little bit more with parents and just try to get them to feel more comfortable with the idea of setting their children up for success in the future and potentially avoiding something that could be life-threatening.

Speaker 2 46:31

The first HPV vaccine only prevented against two subtypes and it was four. Now it's nine Gardasil 9. So Gardasil 9. And that encompasses both the cancer-causing ones and the skin-worked-causing ones. All right, what's next, camille?

Speaker 4 46:47

Yeah, so let's talk briefly about MPOX, because that's something we're seeing in the news and we are a One Health podcast, so it's always important to talk about, like, how infections move around, and so I think that, briefly again, another virus we're talking about spreads through close contact. That can include sex, but not necessarily, and this is one of the diseases that we've seen arise and because of our global interconnectivity, so previously it was endemic only in certain places, but we're seeing it spread and I know the WHO just put out that this is something to be mindful of globally. And what's interesting is we do have a vaccine, but there's certainly been issues getting it into places that need it, which is not a new narrative. We saw that with COVID. We certainly saw that with other aspects, but I just wanted to briefly bring that one up because I think it's important to talk about, because I think there is a lot of fear mongering around any sort of new disease that we see and it's not new, but maybe new in certain places.

Speaker 2 47:46

Yeah, From my end.

Speaker 2 47:48

I think when we had the initial 2021, 2022 outbreak, I think there was a very good public health campaign to vaccinate populations that were at increased risk and then there was a very good public health campaign to vaccinate populations that were at increased risk and epidemiologically those were, you know, men who have sex with men, other folks that might have increased sexual contact, skin-to-skin contact. What's interesting about the most recent experience with clade 1b, which is the clade that's now emerging I think that's the whole issue is that this is a more virulent strain and it's crossing populations and they've now found it outside of where it started to originate, in DRC. There's been cases in Sweden and some other countries as well.

Speaker 3 48:33

In some other countries as well. The way I understand it is that clade 1b has been endemic in the DRC for a long time for at least two decades, maybe longer than that and that is the more virulent, the more aggressive one. But the outbreak that we saw in 2022 was clade 2b, which is the less virulent one, and that's why it was able to spread, because the symptoms are subtle and it's more. I think, from what I understand, it's also the what do you call it?

Speaker 3 49:05

the postules, what do you call it, that you see, are more localized in the genital region and not more visible in any other part of the body. That's why it was able to spread more in certain groups of society, but the outbreak that we've seen now is the clade 1b, which is the more virulent one.

Speaker 4 49:27

All right, yeah, that's really all I want to say on mbox. Any kind of closing thoughts on what we can do to reduce the stigma around STIs is just talking about it.

Speaker 5 49:38

I did have one thought while you all were talking about HPV, and that's that I was speaking with a physician one time, and what they said was oh, I don't even consider HPV to be an STI.

Speaker 6 49:49

And I think that's an interesting consideration just to think of it as a human virus, because it's so common and because it's so diverse in its presentation because of the numerous amount of strains that HPV has, and each strain has a different presentation. So I think that's a really interesting way to view it.

Speaker 4 50:09

I think that's interesting because it also applies to most of what we talked about. All of the other infections we talked about can be spread other ways besides sex, so I think that that's a really good point, that the language that we use around it and the labels yeah.

Speaker 2 50:20

Yeah, I think for me, the take home, whether we're talking about HPV or we're talking about syphilis, we're talking about chlamydia, gonorrhea, hiv, herpes, simplex whatever we're talking about is that we have to be aware we have to do more to destigmatize it.

Speaker 2 50:37

People need to be able to talk about it. People need to be able to ask their doctors or their nurses or their other health workers about it. Public health needs to be able to do the things that public health does well, which is inform the public, create interventions that reduce the risk of spread. And if we continue to endorse or embrace a system in which these things continue to be stigmatized where we accept that it's okay for them to be stigmatized, where it's not okay to talk about them then we're going to be having the same conversation in a year or two years. We're going to be looking at charts with these numbers going up even more, because just because it's in one population doesn't mean it's not going to get into another population, right?

Speaker 2 51:25

Infectious diseases are infectious diseases. They spread in populations that are at risk and you know. You can think that you are the most safe and most puritanical and the most low-risk population ever, but the truth is that you never know, and it's super important for us to create an environment in which these pathogens can be talked about, can be screened for and can be addressed before they continue to rise in the population.

Speaker 5 51:54

Absolutely.

Speaker 3 51:54

I think my take-home message is very similar to Matt's message. To me. The evidence is clear, right? We have so much evidence that shows that we have prevention methods, we can take care of certain things and it will stop the spread. And to close your eyes towards certain things and to limit access and to say it will go away if we don't look at it, that just doesn't work out. We've tried that many times in the last thousands of years and it doesn't work. And just one thing we touched on but I think we should emphasize is the HPV vaccine campaign is one of the most successful campaigns. That has reduced the cancer numbers dramatically. And think about all the other cancers that we have. We wish we would have a vaccine against melanoma or against pancreatic cancer or something like that, and we don't. We do have a vaccine for HPV and for the related cancer and it's working and it's working really well and we should celebrate that and we should use it as a model and not just the information is not promoted as much, I think. Caitlin, what's your takeaway?

Speaker 4 53:06

I have two.

Speaker 2 53:07

Oh wow, yeah you're only allowed one.

Speaker 4 53:11

I think just one last time. We're emphasizing that that high risk has no connection to morality. So I think that's an important one. But I think something I also want everyone to think about that just popped into my head as you were talking is when I think about COVID.

Speaker 4 53:27

I was a contact tracer in New York and people didn't want to get tested because they didn't want to know. They were like, oh, I might be sick, but if I don't get tested for COVID, I don't have positive tests, I don't know. It's out there, it's not a real tangible thing. And I get that mentality because when I first got COVID I was like, yeah, I'm sick and this is probably what it is, and I took the test very quickly. But I was like, oh, my God, it's like. Now I know that this is what it is and it then affects your life. You have to make a decision based on that and, I think, just understanding that that's a very human reaction but that it's also the discomfort of you know. But then you can do something about it and I think that's the take home message.

Speaker 4 54:07

I want people to get around STIs. If that can happen. For something like COVID, which people did not see as a morality issue. They just saw it as like I'm not sick, I'm not going to have a positive testing, I'm sick, sick, I'm not going to have a positive testing, I'm sick. I think people can definitely still get into that sort of mentality of like oh, if I just don't know, then it's fine. But like, know for yourself, know for your own health status, and there's so many wonderful people that work in this field that can connect with free testing or testing that fits into schedules or whatever, and I think that that's worth pursuing.

Speaker 6 54:31

Yeah, absolutely. I just want to echo what Camille said there, for sure, and I think that, as healthcare practitioners and as people with the privilege to have access to healthcare and to work in the field of healthcare, I think it's also our job to do what we can to make this testing accessible to everyone and these treatments as accessible as we can. I know that right now there's a lot going on in our world and this one line isn't going to do anything, probably, but I just think that it's important to put out there that there are so many resources that are being taken away from people who don't have necessarily the privilege to go and visit a physician if they feel like they do have something going on. And I think that, just as figures I don't want to sound self-important, but as figures of influence maybe it's our job to just make sure that we advocate for the populations that can't really advocate for themselves, especially when it comes to STIs and healthcare in general.

Speaker 4 55:31

Yeah, All right. Thank you to all of our listeners, especially for coming this far. You've also done your part to destigmatize SDIs. Thanks for clicking on this episode. Thanks for listening.

Speaker 1 55:40

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Speaker 2 55:51

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Speaker 1 56:00

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Speaker 2 56:09

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