A year ago, the federal government announced a record high number of newly diagnosed sexually transmitted diseases in the country, marking the fourth straight year of sharp and steady increases and a comeback of the infectious bogeyman of past generations.
Syphilis was back, gonorrhea had returned with a vengeance, and the nation was “sliding backward,” a federal official warned.
“It is evident the systems that identify, treat, and ultimately prevent STDs are strained to near-breaking point,” Jonathan Mermin, who leads the US Centers for Disease Control’s effort to prevent STDs, said in a press release at the time.
Consider them further strained.
Planned Parenthood announced last week it would forgo the federal funds that pay for STD testing and treatment at its health centers across the country. The funding program, known as Title X, is better known for subsidizing birth control for low-income patients, and also supports preventative care services, such as Pap smears and mammograms.
Although the organization plans to rely on financial reserves and new fund-raising to make up the difference, specialists worry about further erosion to public health efforts to confront a worrisome and worsening trend. Planned Parenthood health centers serve 41 percent of all Title X patients, according to the organization.
“STDs are at an all-time high and Title X and Planned Parenthood’s services are a crucial component of safety net services for people experiencing STDs in the United States,” said David C. Harvey, executive director of the National Coalition of STD Directors. “We’re already starting from a place of deficit.”
Planned Parenthood decided to forfeit $60 million rather than comply with a new federal rule that bars programs that receive Title X funding from providing information about abortion. Citing patients’ rights to have full information and alternatives, the organization called the rule a gag order. The rule also calls for a physical separation between a clinic that accepts Title X and one that performs abortions and would require structural changes for clinics to continue doing both.
Planned Parenthood is challenging the rule in court, and states including Massachusetts, Vermont, Connecticut, and Rhode Island have signed on.
Maine Family Planning, a separate nonprofit that gets the state’s only Title X dollars, has also challenged the rule in court and is relying on financial reserves and fund-raising to continue operating its 18 clinics, all of which offer abortion services.
Evelyn Kieltyka, senior vice president of program services at Maine Family Planning, said the clinics do get additional funds for STD screening through a CDC program — but that applies only to high-risk patients.
“We are scrambling to figure out how, without the Title X funds, we’ll continue to meet the screening needs beyond the high-risk populations,” she said.
STD specialists are also still scrambling to figure out why rates are on the rise — even as diagnoses of HIV continue to decline. The CDC analysis issued last year examined three key STDs, comparing 2017 preliminary data to new diagnoses reported in 2013. Chlamydia was up 22 percent. Syphilis had spiked 76 percent. And gonorrhea surged 67 percent. More than a half-million new cases of gonorrhea were identified in 2017, the CDC found.
“No one really understands why the rates are going up. It’s kind of a conundrum,” Kieltyka said. “We’re all kind of scratching our heads.”
The trend, which predates the Trump administration, is attributed in part to a lack of awareness among both patients and doctors. Without routine screening, many STDs go undiagnosed and untreated for some time. Patients, often asymptomatic, spread the infections unaware; until they are identified, they can’t even be counted in the government data, meaning the true rate of infection is higher than the data suggest.
Harvey also points to changing sexual behaviors — including the increased use of dating apps that are bringing strangers together. Funding has not been sufficient, he said. And people may have become complacent about condom use as the AIDS scare has faded from public memory and such contraceptives as IUDs have come into more widespread use.
“We’ve not done a good job of updating our message about the continued need to use condoms,” said Harvey. “We’re not doing a good job of giving comprehensive sexual health education to young people and to adults about these newer contraceptive technologies and prevention tools, while noting the continuing need to use condoms. We have work to do in this area.”
As Planned Parenthood withdraws from Title X, some states, including Vermont and Massachusetts, are stepping in to close the funding gap. Massachusetts patients will not see any interruptions in service, since Governor Charlie Baker and the Legislature agreed in March to direct $8 million in state money to programs losing federal funds.
On Friday, the Department of Public Health notified the federal government it was withdrawing from the Title X program entirely and would continue its mission indefinitely with state funds. “The Department’s longstanding commitment to ensuring critical and comprehensive family planning access to all Commonwealth citizens remains unwavering,” the letter said.
But here, as in most places, STDs are on the rise. The Massachusetts Department of Public Health, in data comparing 2013 and 2o17, reported 1,091 new cases of syphilis — a 56 percent increase. Gonorrhea cases climbed to 7,307, a 144 percent increase.
Over the past five years, Massachusetts has also seen a 23 percent increase in the number of cases of chlamydia, a common STD for which young people, and men who have sex with men, are at particular risk. One in 20 sexually active young women has chlamydia in the United States, the government says, and while the infection itself can be cured with antibiotics, it often goes unnoticed and asymptomatic. Untreated chlamydia can lead to pelvic inflammatory disease and ectopic pregnancy and make it difficult or impossible to get pregnant.
In New Hampshire, the surge in STD cases was so striking that the state declared outbreaks of both gonorrhea and syphilis in 2017. That status continues today, said Jake Leon, director of communications for the state Department of Health and Human Services.
“Syphilis was close to being eliminated in the United States back in 2000, but over the last decade it has been making a resurgence,” New Hampshire state epidemiologist Dr. Benjamin Chan said in a press release. “And unfortunately, New Hampshire is not immune to the impact of increasing STDs.”
Syphilis causes rashes and lesions and, if left untreated, can spread to the brain and nervous system and cause blindness, paralysis, and dementia. Gonorrhea, once known as the clap, causes burning and pain in men; though women often don’t show symptoms, they can suffer long-term health problems — including pelvic inflammatory disease, long-term abdominal pain, and infertility.
All those STDs are transmitted by vaginal, anal, and oral sex and can only be completely prevented by abstinence. The risk is dramatically lowered for those who use condoms correctly, every time, and who are in long-term mutually monogamous relationships with partners who have been tested.
Harvey, of the National Coalition of STD Directors, noted a few bright spots on the horizon for STD treatment: The Trump administration plans to release the nation’s the first-ever federal action plan on sexually transmitted diseases next year. And it has launched an initiative to eradicate HIV — an effort that could also reduce incidence of other STDs.
Though HIV incidence is not on the rise, more than 30,000 new HIV cases are still diagnosed each year in the United States.
Continued vigilance and continued funding for public health are key, Harvey said.
“There are lots of lessons here to learn about HIV,” Harvey said. “We cannot cut back funding for these various public health challenges and think that they’ll be solved.”Stephanie Ebbert can be reached at Stephanie.Ebbert@globe.com.