Sexually transmitted disease, or STD, rates in California are at a more than 25-year high. In 2018, there were more than 25,000 cases of syphilis, nearly 80,000 cases of gonorrhea and almost 250,000 reported cases of chlamydia. More astonishingly, STDs such as chlamydia are more likely to occur in young adults less than 25 years old. Furthermore, the dramatic increase in cases of congenital syphilis, a condition that can cause stillbirth and birth deformities, has reached the same magnitude observed 20 years ago in California. With a functioning public health system that advocates for early testing and treating, STDs are 100% preventable, but right now our public health system is failing.
The rise of dating apps may contribute to increased sexual activity. The best data we have to examine sexual activity at the population level comes from surveys such as the California Health Interview Survey and the Centers for Disease Control and Prevention’s Youth Risk Behavior Survey, which are two large, population-level surveys. The most recent data from the California Health Interview Survey found that less than 20% of 14-17-year-olds reported being sexually active in 2015-16. Similarly, the Youth Risk Behavior Survey showed no increase in the proportion of those who are sexually active or the proportion of those with multiple partners. So, contrary to popular opinion, dating apps do not seem to be causing an increase in sexual activity among youth. California’s youth actually seem to be delaying sexual activity and not having as much sex as their parent’s generation.
A second driver of the recent rapid rises in STDs in California could be decreases in condom use. For that measure, there is strong evidence from the Youth Risk Behavior Survey that condom use during sexual intercourse is decreasing. A little more than half, or 53.8%, of sexually active adolescents reported condom use during last sexual intercourse in 2017, down from nearly two-thirds, or 62.8%, in 2005. Condom use could be decreasing because of less awareness and less fear of human immunodeficiency virus, or HIV, infection and acquired immunodeficiency syndrome, or AIDS, as well as increased access and use of hormonal contraceptives. Apparently, the consequences of successes in some areas such as HIV/AIDS and preventing teen pregnancies can come at the expense of other areas of sexual health, like STDs.
The most important reason California is experiencing its worst STD epidemic in more than a generation is due to our own public policies and investments in sexual health. When I was a public health officer in San Francisco in the late 1990s and 2000s, there was a robust interest in sexual health and publicly funded services that supported community-level awareness, education, access to testing and treatment for STDs in a variety of populations. We supported STD screening and treatment programs in jails and created new services for sex workers and men who have sex with men. We conducted outreach in communities burdened with high STD rates and sent public health staff to meet people to deliver timely treatment.
With the Great Recession, however, many of these programs suffered because of budget cuts. Elected officials have not restored budgets to the prior levels, resulting in persistent shortages in public health staffing, closed or severely limited clinic services and an absence of public health education or campaigns to promote testing. California has one of the smallest STD prevention and control budgets in the United States on a per capita basis, with about $15 million dollars allocated for STD-related activities in a state with a population of nearly 40 million residents. Public health programs work, but only if they are funded. In the 1940s and ‘50s, the United States saw near elimination of syphilis and gonorrhea with robustly funded government efforts. Unfortunately, as it currently stands, STD prevention budgets in California and at the national level are so low that public health programs cannot control STDs.
In the era of technology, we now have novel, low-cost strategies that can bring sexual health services privately to people’s homes. A National Institutes of Health-funded study by UC researchers demonstrated in four California counties that an e-STD testing program was acceptable, feasible and cost-effective. Unfortunately, while successful, state officials never introduced the system into public health practice. Commercial providers of home e-STD testing such as MyLabBox.com exist, so there seems to be no reason why California officials could not collaborate with such businesses to increase access to testing and treatment.
In a democracy, the community must support public health and demand basic public health services such as STD awareness efforts, education, clinical and screening services. We must hold our elected officials accountable for failing to support public health programs. California has some of the best experts in public health; however, they cannot do their job without adequate resources, and right now, they have very little support. Californians must take immediate action to restore budget cuts to fund STD prevention and control activities in the state.
Jeffrey Klausner is a professor of medicine and public health at UCLA and is a former president of the California STD/HIV Controllers Association.