Covid chaos fueled another public health crisis: STDs

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Now, as Covid cases decline precipitously, public health experts are calling for new investments, including more money for STD testing and treatment, in an effort to reverse the increases. But a boost in public health spending is stalled in Congress, and Obamacare opponents are asking a federal judge to overturn a part of the law that requires the kind of free preventive care that can avert STDs.

Sexual health experts and government officials are warning that without federal action, millions of Americans could face severe, even fatal, consequences if infections go untested and untreated, with the burden of disease disproportionately falling on low-income Americans, young people and people of color.

“Unfortunately all signs indicate that the numbers are getting worse and that they’re not going to get better until we adopt some new approaches and invest further in STD and public health programs,” said David Harvey, the executive director of the National Coalition of STD Directors. “We have a lot of work to even get back to where we were pre-pandemic.”

Over the last two years, the pandemic forced sexual health clinics across the country to close their doors or cut back their hours and services. Government disease investigators who had spent years contact-tracing for STDs were reassigned to Covid work, and many quit the public health field entirely. Federal agencies saw widespread shortages of swabs, glass vials and other testing supplies. Millions of people lost their jobs and, with them, their health insurance. And a surge in addiction and mental health problems contributed to riskier behavior, such as trading sex for drugs, seeking out anonymous sex and skipping routine health care.

“People can’t live in fear for two years. People are still having sexual encounters,” stressed Barbara Van Der Pol, a professor at the University of Alabama at Birmingham who sits on the board of directors of the American Sexually Transmitted Diseases Association. “But when life goes on and you don’t have services accessible, there is a higher chance of infections in the population.”

The growing STD crisis, brewing in the shadow of Covid-19, costs the American health system billions every year and is largely preventable. But the rampant spread of STDs, which affect one in five Americans, is only expected to increase, and local health departments, stretched to a breaking point by the pandemic, are ill-equipped to mount an effective defense.

While Congress included a $2.5 million funding increase to fight STDs in its budget bill, the far larger effort to revamp the nation’s public health system appears to be going nowhere. The Democrats’ social spending package, which passed the House in November, included $7 billion over five years to support public health infrastructure, but that bill is unlikely to pass the Senate.

“It’s not a lot of money in terms of what is needed to make a serious dent in the problem,” Harvey said of the small bump in federal STD prevention funds. “We are looking to Biden and the Congress to ramp up next year.”

A more immediate concern for advocates is the latest anti-Obamacare lawsuit, pushed by Texas individuals and business owners and supported by Trump administration alumni, which threatens to gut the provision of the decade-old health reform law that requires health insurance plans to cover STD testing, HIV prevention drugs, HPV shots and other preventive care services.

District Court Judge Reed O’Connor, who is expected to hear the case in the coming weeks, has a long record of ruling against the Affordable Care Act, leading people on both sides of the suit to speculate that there’s a real chance Obamacare’s provisions could be further eroded.

With the nation’s abysmal STD rates exacerbated by the pandemic, officials warn the suit could hamper efforts to curb transmission of syphilis, gonorrhea, chlamydia and HIV by potentially putting preventive services and treatment financially out of reach for many people and overloading the country’s remaining free sexual health clinics with patients who now rely on their insurance.

“Anything that puts an obstacle in a person’s way to accessing preventative services is antagonistic to public health,” Jonathan Mermin, the director of the CDC’s National Center for HIV, Viral Hepatitis, STD, and TB Prevention, told POLITICO. “An ounce of prevention is worth a pound of cure.”

The Texans mounting the case argue they shouldn’t have to pay for services they don’t need and with which they have religious objections, and that they should have the right to deny that coverage to their employees as well.

“This coverage facilitates and encourages homosexual behavior, drug use, and sexual activity outside of marriage between one man and one woman,” they argued in a recent court filing. “The government cannot possibly show that forcing private insurers to provide PrEP drugs, the HPV vaccine, and screenings and behavioral counseling for STDs and drug use free of charge is a policy of such overriding importance that it can trump religious-freedom objections.”

Depending on how the case shakes out, health insurance plans could also be allowed to drop other coverage beyond STD and HIV services, from vaccines to colonoscopies.

“If they win, all of the preventative services would have to go back to the drawing board,” explained Roger Severino, the former head of HHS’ Office of Civil Rights under the Trump administration who now works at the Ethics and Public Policy Center. “Congress would have to act quickly.”

According to the most recent federal data, nearly 68 million people have an STD. Nearly half of those people are between the ages of 15 and 24. Black people and LGBTQ people also have disproportionately high rates of chlamydia, gonorrhea and syphilis — disparities that federal officials say are caused by differences in access to health care, not behavior.

Some innovations spurred by the pandemic have helped, though access to them might end when the Covid-19 emergency does. For example, more people who live far from a provider could use telehealth for the first time to diagnose and manage many STDs, and more cities and states have started mailing people free at-home test kits for HIV and common STDs.

But experts like Van Der Pol say progress with those tools hasn’t made up for the massive disruption to routine screenings caused by Covid. While people suffering symptoms from an STD are still seeking testing and treatment, many more are likely walking around with an asymptomatic infection they could spread to others. Most women who contract gonorrhea, for example, don’t experience any symptoms, while chlamydia is asymptomatic for as much as half of men and 80 percent of women.

While federal data for 2021 isn’t yet available, reports from state and local health departments are bleak.

New York officials announced in February that the state saw a 23 percent increase in gonorrhea cases and a 17 percent increase in syphilis cases in women in the first half of 2021 compared with the first half of 2019, and the officials say the true number is likely higher because of the drop-off in testing during the pandemic.

Efforts to lower HIV rates — the nation’s one success story in recent years when it comes to STDs — have also been hampered by Covid.

The CDC estimates that around 1.2 million people in the U.S. are at risk of contracting HIV and would benefit from taking the pill PrEP, which can help prevent the infection. The agency announced a goal in 2019 to have 50 percent of those at risk taking the pills by 2030. The country, at the time, seemed on track with about 22 percent of that population taking the drug. Then came the pandemic.

“It was harder to continue that momentum during the time of Covid,” said Mermin, noting that usage ticked up less than a full percent during 2020 after much bigger gains in recent years.

The waning of the nation’s PrEP campaign also bodes poorly for other STDs since a prescription for the drug requires patients to come in for routine testing. This January, after a big push from advocacy groups, the Biden administration told insurance plans they had to cover the screenings and doctor visits associated with PrEP use in addition to the drug itself.

Given the steep decline in condom use over the last decade-and-a-half, public health experts say the drug is needed more now than ever to prevent people from contracting HIV, even as some studies have found that people who take the pills have higher STD rates because they are less likely to take other precautions.

And if the latest lawsuit against the Affordable Care Act succeeds, insurance companies could offer skimpier plans that either don’t cover STD tests, PrEP or other sexual health services, or charge patients co-pays for them.

Just like in other areas of health care, even nominal charges could trigger a steep decline in people getting tested and treated.

“I think that we sometimes forget how difficult it can be to be poor,” the CDC’s Mermin said. “When people have to make very difficult decisions about whether they care for their own health or the needs of their family, small obstacles can become big ones.”

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