Health officials in the US are concerned about how to divert key resources to combatting a rise in sexually-transmitted infections (STI) that is now continuing despite the social restrictions of the coronavirus pandemic and is now in its sixth consecutive year of increase.

America has continually combatted rising STI rates pre-pandemic, one of many poor public health outcomes in the US, despite massive spending on healthcare. But, following an artificial dip in STI rates during the Covid-19 pandemic, STI rates are now on the rise again while health funding is still being allocated to address the pandemic.

“All told, at the end of the day, STI rates are at their highest numbers in American history and that has continued through the pandemic up to the current time,” said executive director of the National Coalition of STD directors (NCSD) David C. Harvey.

Experts have called the rebound of STI cases – and a projected increase in infections – the result of a perfect storm of sluggish STI testing, changing behaviors as pandemic restrictions are lifted nationwide and persistent problems around STI education, falling condom use and a weak public healthcare infrastructure.

STI increases also reflect societally unequal trends in health outcomes, with communities of color and southern states disproportionately affected by increases in STI and its consequences.

“Bottom line: STIs didn’t go anywhere and they’re going to come right back. There’s no reason to think that we won’t bounce right back to what we were seeing prior to the pandemic,” said Dr Ina Parks, a professor at the University of California at San Francisco School of Medicine and author of Strange Bedfellows, a book on STIs.

While neglected, the STI crisis presents a serious public health problem.

STIs, when left untreated, can have long-term health consequences including infertility, cancer, birth defects and even death. Regular testing, at least once a year for those who are sexually active, as well as key preventive strategies such as condom use, limiting sexual partners and testing between partners, is even more critical given that many STIs can appear asymptomatic.

For many health epidemics, including STIs, the pandemic complicated the ability of US doctors to diagnose and treat patients. Many sexual health clinics that would normally screen patients shut down in the early stages of the pandemic, with four out of five clinics suspending service or shutting down completely according to a poll from NCSD.

Additionally, routine healthcare was suspended as hospitals were--and in some cases remain--overwhelmed with coronavirus cases, further limiting testing and treatment. Contact tracers used to keep track of infections like chlamydia, gonorrhea, and other STIs and STI testing kits were also greatly reduced and diverted to help with the pandemic efforts.

“There was a massive interruption to our ability to test and treat in America and that exacerbated and made the problem worse,” said Harvey.

Changes in sexual behavior as Covid-19 restrictions lifted across the nation have also led to an increase in STI rates. As noted by Park, people who had previously limited casual sex during the pandemic have continued pre-pandemic behaviors, only this time with STI testing efforts being dampened because of the pandemic.

“A lot of my patients were sort of flexing their vaccination status on their dating app to try entice partners into having sex,” said Park.

America also has a poor healthcare infrastructure to facilitate adequate amounts of testing and treatment of STIs, Park and Harvey noted. STI prevention is continually underfunded with the CDC budget on STI prevention decreasing by 40% since 2003 after adjusting for inflation.

“We have not kept [up] with the needed investments in public health prevention programs that we need to be doing in order to educate the public about their risks about sexually-transmitted infections,” said Harvey.

Testing for STIs also remains antiquated. Compared to investing in expansive online testing that would make STI detection more accessible, the US still lags behind, with sparse online testing systems in place. While telemedicine has expanded the detection of STIs slightly, accessibility barriers such as cost make it an imperfect option, noted Park.

“We are one of the most wealthy and technologically advanced countries in the world and we could be leveraging both of those strengths to be better responders to the STI epidemic,” said Park.

Additionally, Park and Harvey attributed the rise to chronic sexual health problems in the US. Many people have a limited understanding of STI given lacking sexual health education in the US. Condom use, a core component of preventing STIs, is also in decline amid already low rates, according to Park, particularly among young people engaging in sex for the first time. Park also noted that increased use of the HIV prevention drug PReP has caused other preventative measures such as condom use to decrease despite PReP not protecting against other infections.

Amid STI increases, the federal government is making some moves to increase funding and create a comprehensive plan around STD testing and treatment. In 2020, Congress increased funding for STI prevention by $3.5m, a historic amount given ongoing decreases. Health officials have also created the first ever STI National Strategic Plan, of which Park was a contributor for, which would spell out how to improve sexual health nationwide between 2021 to 2025.

But Harvey warns that a coordinated effort by national health agencies such as the Centers for Disease Control and Prevention, the National Institutes of Health and Centers for Medicare and Medicaid Services is needed to combat the waning STI crisis.

“Absent a massive national effort and an increase in funding, we will continue to see increases in sexually transmitted infections, unfortunately,” said Harvey.