A 32-year-old woman who was 36 weeks pregnant came to me for a consultation regarding HIV pre-exposure prophylaxis. Her male partner had been recently diagnosed with HIV infection and asked her, "Wouldn't life be much easier if we were both positive?"
Although she denied feeling unsafe at home, she said she didn't want to take any chances when she was about to become a new mother. Thankfully, my patient was HIV-negative.
However, although her first-trimester rapid plasma reagin had been nonreactive, her RPR for PrEP screening was 1:64. This soon-to-be mother had early latent syphilis, acquired sometime during the intervening months of pregnancy. What was unknown was the extent of damage to her unborn son.
I contacted my patient's obstetrician to plan for her treatment and for care of the newborn in the hospital after birth. My patient had answered a query from the obstetrician to say she was sexually active with one partner, so this doctor had placed my patient in a low-risk category, meaning no need for further STI screening after the first trimester. What my patient had not disclosed, however, was that her partner had dozens of sexual encounters outside of their relationship through dating apps.
Most clinicians utilize identity as a surrogate marker for many types of risk; even if it has its pitfalls, it is efficient. Considering early prostate cancer screening for African American men is one example with uncertain benefits. Depending on identity to predict situational and behavioral risk has even more pitfalls. Although a heterosexual woman with a single partner is a demographic considered at low risk for STIs, the obstetrician was beside herself for drawing the wrong conclusions based on perceived identity.
All of us would have to wait weeks to learn the baby's outcome.
My patient's prenatal care was within guidelines. The CDC recommends routine first-trimester screening for HIV and syphilis for all pregnant women, but HIV/STI screening during later prenatal care is at the discretion of the physician. Unfortunately, although public health stakeholders and policymakers are discussing mandated third-trimester screening, guidelines have not yet caught up to the frightening, emerging new epidemiology of STIs.
According to the CDC's recently released 2018 Sexually Transmitted Disease Surveillance Report, reported cases of syphilis, gonorrhea and chlamydia reached an all-time high in our country for the fifth straight year. In 2013 -- before more recent spikes in reported cases -- the CDC estimated the direct medical costs of STIs to be $16 billion a year. The overall costs to our patients are even greater, including infertility, ectopic pregnancies, pelvic inflammatory disease and increased HIV susceptibility.
Less than a generation ago, we talked about eliminating syphilis in parts of the country. But newborn deaths related to congenital syphilis increased 22% from 2017 to 2018 (from 77 to 94 deaths).
The reasons for this dramatic increase of STIs are complex and not the focus of this post. Instead, I would like to explore the role of primary care in more effectively identifying those who would benefit from early prevention and treatment.
Sexual minority status and the behaviors associated with this identity are still very much stigmatized in our culture. Although racial identity is often more readily apparent, being a sexual minority can be a "concealable stigma." Even being seen as associated with stigmatized groups, such as being a partner of someone living with HIV infection, carries a fear of rejection and can affect disclosure. One way that patients cope with concealable stigmas is by managing information about themselves. Patients will choose what to disclose to their physicians based on anticipated stigma to minimize the chance of rejection or judgment. The fear of stigma makes it exceedingly hard to find patients who may be at risk for an STI.
Public health researchers have searched for ways to improve disclosure from stigmatized groups to better target health interventions. For example, the use of audio computer-assisted self-interviewing is one way to find the truth. Researchers in Nigeria found that men who have sex with men were more likely to identify as gay and more likely to disclose higher-risk sexual behaviors with women and men when offering information through ACASI compared with those who had face-to-face interviews. Similarly, in a study conducted in Kenya among sex workers, females were much more likely to report having paid for sex, an unexpected finding, when using ACASI compared with those who were interviewed face to face.
Furthermore, researchers are finding they can effectively identify at-risk populations through novel use of advertisements on dating apps.
In searching for ways to address the resurgent STI epidemic, what is largely absent from the discussion is recruiting primary care in the fight and the important role family physicians can play as a specialty responsible for one in five U.S. office visits. With ongoing efforts to defund public health clinics, which provide vital health infrastructure for treating STIs, patients will increasingly need a trusted and reliable place to turn for care. What family physicians have that few other clinicians do are a longitudinal relationship and a resultant foundation of trust that is an excellent starting point for honest conversations with our vulnerable patients.
And we must have those conversations. A recent study that involved interviewing sexually active young adults found that primary care physicians infrequently initiated conversations with these patients. Yet patients express a desire to have these conversations with their physicians in an open, nonjudgmental way.
In another study, a young female participant said it this way: "I just want them (clinicians) to ask me. And if they ask me, I'm gonna be honest. I do that. I'm not gonna say that (HIV/STI risk behaviors) unless they ask me. I really want to discuss it, but I'm not gonna say anything until you ask."
My patient's son was born at term. He had to endure a lumbar puncture on day one of life and treatment for congenital syphilis, but thankfully, he appeared to have no sequelae from the infection. Everyone breathed a sigh of relief. My patient had allowed her physicians to maintain false assumptions of risk based on a misperception because it was easier than the uncomfortable explanation of the messiness and complexity of life.
The AAFP has a new STI screening manual and other free resources to help physicians elicit accurate and complete information about patients' sexual practices. When we reflect on the difficult discussions and the rich conversations we have with our patients every day, we know that family physicians already have many of the vital skills to address the STI epidemic. Let's put them to work.