Sexually transmitted infections (STIs) have afflicted humans for as long as records exist, but despite significant medical advances, we are not managing to keep them at bay. Instead, we see rising infection rates and even the re-emergence of some old foes, including syphilis.
Young people are disproportionately affected by STIs. In New Zealand, 67% of chlamydia cases and 57% of gonorrhoea cases are among people between the ages of 15 and 24. This is not solely due to sexual behaviour. Young women, for example, are more vulnerable to STIs as the vagina’s natural defences to infection have not fully matured.
Early detection and treatment are crucial if we want to reduce infection rates. In our research, published today in the Australian and New Zealand Journal of Public Health, we identify several barriers that stop young people from being tested for STIs.
An ongoing battle against STIs
Even in the presence of a human papillomavirus (HPV) vaccine and sophisticated antiretroviral therapy to manage human immunodeficiency virus (HIV), the pathogens that cause these STIs are not yet beaten. They continue to infect people, and we are perpetually in response mode.
Since the discovery of penicillin, antibiotics have been used to fight the bacterial STIs, such as chlamydia, gonorrhoea and syphilis. However, in many countries infection rates remain a serious issue. In New Zealand, rates of some STIs are higher than in other countries. For example, diagnosed rates of chlamydia are around 1.4 to 1.7 higher than those reported in Australia, the USA and the UK.
What’s more, it has become apparent over the past few years that syphilis is staging a comeback. Rates of syphilis in the UK have doubled over the last five years, and similar trends have been reported for Australia, the USA and New Zealand.
Antibiotic resistance and STIs
Antibiotic resistance arises when an infectious microorganism is no longer susceptible to an antibiotic to which it was previously sensitive. If an infection has been identified to be resistant to a conventional treatment, it can usually be treated with an alternative antibiotic. However, the number of antibiotics available is limited, and multi-drug resistance is becoming a reality for several organisms.
The bacterium that causes gonorrhoea is one such organism. It has developed ways to resist every single class of antibiotics introduced for its treatment since the mid-1930s. The only options for first-line treatment for gonorrhoea are the extended spectrum cephalosporins. However, isolates with decreased susceptibility to cephalosporins have now been reported in several countries, including New Zealand.
After this antibiotic fails, there are no more treatment options. Without new therapies we face a return to the pre-antibiotic era, which would mean waiting for the body to naturally clear a gonorrhoea infection with only painkillers for comfort and months of abstinence to avoid onwards transmission.
Barriers to testing and treatment
Our research identifies several barriers to STI testing. One of the most common reasons young people don’t get tested is that they underestimate the risk of contracting an STI.
Some people, especially young men, were afraid of the test procedure itself, imagining it to be invasive and painful. However, a regular check during symptom-free times usually requires only a urine test.
Other barriers include the misconception most STIs are not serious, embarrassment about a physical examination, being too busy, and the cost of tests. Many study participants expressed a preference for a same-sex health professional, but most said they would not be deterred from having a test if that was not possible.
Finally, the stigma associated with STIs remains a pervasive barrier to testing. A diagnosis suggests a violation of social norms and values, such as engaging in unprotected sex, sex with multiple partners, or sex with disreputable partners. Some participants in our study reported they were worried about their reputation if they were seen going for a test.
Consequences of STIs
If left untreated, STIs can cause serious and painful health problems, such as pelvic inflammatory disease in women, which can result in infertility. Among men, there is also some evidence that untreated STIs can lead to infertility.
Complicating matters is the fact that some STIs, chlamydia for example, usually don’t cause any obvious signs or symptoms. Nevertheless, timely detection and treatment is important to prevent future health impacts for the individual as well as the spread to others.
Our results imply that making people aware of their own risk and the severity of STIs may be one way to encourage early testing. Making STI tests free for everyone would remove the cost barrier. In New Zealand, STI tests are generally free to those under 22, but may attract a fee for older people who seek testing through their general practitioner.
The biggest challenge, however, is to lessen the social stigma associated with STIs. Normalising these infections by talking about them more openly with friends and family, as well as highlighting the importance of testing as part of general health care is a step towards overcoming these barriers and helping to bring down STI rates over time.