STD cases fell in 2020, but not for a lack of sex

Reports of sexually transmitted diseases, including HIV, appear to have dropped sharply in the Bay Area in 2020. But public health officials fear it’s not because people stopped having sex during the pandemic — it’s because STD testing was pushed aside while everyone’s attention was on COVID19.

In other words: People were still getting STDs, but many of them didn’t know it.

Most counties don’t yet have complete STD data for 2020, but early reports suggest large decreases in cases. San Francisco recorded drops for all types of sexually transmitted diseases, according to preliminary data. That would be a remarkable turnaround after more than five years of cases climbing or holding

steady for every type of STD except HIV.

“We did see a decrease in cases, and in normal years we would celebrate that. But in 2020 we know it’s because we didn’t do enough testing,” said Dr. Stephanie Cohen, medical director of San Francisco City Clinic, the city’s STD testing and treatment hub. “So, rather than celebrating, it makes us worried that there are undiagnosed infections out there that could be resulting in new transmissions.”

State and regional pandemic lockdowns probably did result in people having less sex and therefore a drop in sexually transmitted diseases early in the pandemic, public health experts say. But those who work directly with patients say that at least anecdotally, people started mingling more in the summer — when the first shelterinplace orders started to lift — and then never really stopped.

But they weren’t necessarily getting tested for STDs. People with gonorrhea, chlamydia and early HIV infection may not experience symptoms and think to get tested right away. And after months of being told to stay away from medical offices during the pandemic if they didn’t have urgent health issues, they wouldn’t necessarily be eager to go to a clinic.

Plus, counties had redirected staff and other resources to the pandemic. Many closed STD clinics altogether. Even basic testing equipment like swabs and glass vials for collection were diverted to COVID19.

Reporting was so offkilter in 2020 that “we may just have to throw it away and say it’s not useful as far as looking at trends,” said Dr. Ina Park, a UCSF family medicine physician who consults with the state and the federal Centers for Disease Control and Prevention on STD control. “Lack of testing, lack of test kits, delays in reporting — I feel like we’re not going to fully understand the impacts of the pandemic” on STDs.

San Francisco is one of the few places in California that has released preliminary STD data for 2020. From 2019, cases of gonorrhea were down about 25%, syphilis about 7% and chlamydia about 40%.

New cases of HIV in 2020 were down about 20%, to 132. That would be the lowest annual total since the earliest years of the AIDS epidemic in the 1980s. Although new cases have been falling for nearly a decade, this much of a drop is unexpected and almost certainly an artifact of the pandemic, public health officials said.

Nationally, all types of STDs hit record highs in 2019, the CDC said last month. The agency does not yet have data for 2020 but said surveys suggest that the pandemic impeded efforts to test and treat STDs.

As recently as January — 11 months into the pandemic — many public health departments reported that STD staffers were still deployed in the COVID19 response, according to a survey by the National Coalition of STD Directors. Among those who had returned to STD surveillance work, many reported burnout from the pandemic.

“I basically tried to juggle two roles,” said Cohen, who kept an eye on San Francisco’s STD/HIV response while also doing case and outbreak investigations for COVID19. She’s mostly back to her STD work, but not quite full time.

As with the coronavirus, testing is a key component of disease control with sexually transmitted infections. Many STDs don’t have obvious symptoms, so people may not know they’re infected without a positive test — which means they could unwittingly pass the disease on to others.

Testing is especially critical for HIV control and is a cornerstone of San Francisco’s efforts to end the spread of the disease. Although HIV can’t be cured, people who test positive can take antiviral drugs and control the virus to the point where they’re unable to pass it on to others.

“HIV is what I’m most worried about in terms of new diagnoses,” said Dr. Monica Gandhi, medical director of the HIV outpatient clinic at San Francisco General Hospital. She said many clinics that do regular HIV screening all but stopped testing during the pandemic. One urgent care clinic she works closely with resumed screening last month — testing almost every patient who came in, regardless of why they were there — and found three cases in a week.

“Already seeing this uptick has me very alert,” Gandhi said. “We are going to be making a concerted effort to push testing.”

That should be a priority across all types of sexually transmitted infections as the Bay Area emerges from the pandemic, public health experts say. People who remained sexually active throughout the pandemic may need testing to detect earlier infections, and those who stayed locked down and are only now starting to reengage with others will need to get back in the habit of screening.

Dr. Curtis Moore, director of the STD unit for the Alameda County Department of Public Health, expects to see more cases of advanced infections in people who have delayed testing and treatment. He worries about high school and college students who haven’t had access to campus services for testing or education.

“Schools have not been in session for an extended period in the county,” he said. “I’m not sure where those teenagers and young adults were getting screened, or if they were at all.”

Park, the UCSF family medicine physician, said she anticipates a spike in infections as people emerge from more than a year of sheltering. She’s supportive of people resuming their sex lives in ways that feel appropriate for them. But she worries they may be reckless.

“Now that people are vaccinated, I feel like some people are making up for lost time,” Park said. “The fact that people might have been compliant with maskwearing, I don’t think necessarily means they’ll be compliant with barriers like condoms. I would encourage people to have sex and do so as safely as they can. And to go out and be tested.”