Sexually transmitted infections: What doctors wish patients knew

While sexually transmitted infections (STIs) are preventable, there are more than 20 million new cases in the U.S. each year, with rates continuing to soar. And while many patients may think they learned all they need to know about STIs in sex ed, that’s not the case. There’s much more to know.

About one in five people in the U.S. had an STI in 2018. There are nearly 68 million STIs in the U.S. and 26 million new infections with nearly half of all new infections happening among people 15–24 years old.

The AMA’s What Doctors Wish Patients Knew™ series provides physicians with a platform to share what they want patients to understand about today’s health care headlines.

For this installment, Jason Zucker, MD, assistant professor of medicine at the Columbia University Irving Medical Center and assistant medical director at NYC STD Prevention Training Center, took time to discuss what patients need to know about sexually transmitted infections.

“Bacterial sexually transmitted infections are what we think of most commonly. That includes infections like chlamydia, gonorrhea and syphilis,” said Dr. Zucker.

“In addition to bacterial STIs there are also viral STIs that are common as well, things like herpes,” human papilloma virus (HPV) and human immunodeficiency virus (HIV), he said.

“For bacterial sexually transmitted infections, we treat them with antibiotics,” Dr. Zucker said. “So, gonorrhea, chlamydia and syphilis can all be cured with antibiotics.”

That means bacterial STIs “can be completely eliminated with treatment,” he said.

“Viral infections are much harder because antibiotics don’t work on viruses. For herpes, antiviral medications can help prevent recurrences but do not eliminate the virus,” Dr. Zucker said. “For HIV, antiviral medications can suppress the virus effectively, allowing people to live long healthy lives without complications.

“In fact, antivirals can lower the amount of virus so much that people can’t spread the virus to others,” he added. Then, “for HPV, we don’t have an antiviral or a cure, but we have something just as important, which is a vaccine.”

“Vaccination can prevent infection with most of the major types of HPV that can cause cancer,” Dr. Zucker said. “However, even if vaccinated, make sure to get regular check-ups and pap smears if recommended by your doctor. These can help identify HPV complications early.”

“For bacterial STIs like chlamydia and gonorrhea, you’re generally looking for pain when you urinate or discharge from your penis or vagina,” Dr. Zucker said. “While a genital infection is most common, you can also get gonorrhea and chlamydia in other places involved in sexual activity. 

“Many people don’t know you can get chlamydia and gonorrhea in your rectum, which can present with rectal pain or discharge, and you can even get it in your throat which can present with a sore throat with or without a white coating,” he added.

“While I previously mentioned looking out for symptoms, one thing that people are often surprised by is that you can have an STI even if you have no symptoms,” Dr. Zucker said. “And that’s important because it emphasizes the need for routine testing and treatment.”

“Just because you don’t have any symptoms doesn’t mean you don’t have an STI, and it doesn’t mean you can’t spread that STI to other people,” he said.

“About 50% of STIs occur in 15- to 24-year-olds, which is one of the reasons there’s such a heavy focus on testing younger people,” Dr. Zucker said. “But that’s only half. The rest are people older than that, including elderly patients. It’s important to realize that any sexually active person can get an STI.”

“One of my big things is talking to all patients about sexual health. It’s certainly much harder to talk to our patients who are our parents’ age because it feels weird to talk to them about sex,” he said. “But they also need and want a sexual history taken. A sexual history is part of good comprehensive health care.”

Mpox, formerly known as monkeypox, “transmits like a sexually transmitted infection. It’s transmitting during close physical contact, like that occurs frequently during sex,” Dr. Zucker said. “Places like New York actually temporarily designated mpox as an STI because it provides additional resources and also provides the ability for adolescents to consent to testing, treatment and prevention without requiring parental consent.”

That is “important because given the community most affected by mpox you wouldn’t want the diagnosis of mpox to accidentally disclose an adolescent’s sexual identity to their family,” he said. “Requiring parental consent may actually discourage adolescents from seeking care which is the last thing you want during an outbreak.”

“The World Health Organization has a long list of infections that transmit sexually, but the real question of mpox is whether or not it transmits primarily sexually,” Dr. Zucker said, noting that a recent position statement highlights this discussion about mpox as a sexually transmitted disease.

“There are a variety of ways to prevent sexually transmitted infections,” Dr. Zucker said. “Using things like condoms or barrier protection are probably the most effective ways of preventing sexually transmitted infections.

“But they don’t work for everybody,” he added.

“For people who can’t or don’t want to use condoms, there are other things you can do to protect yourself,” Dr. Zucker said. “You can get tested regularly and treated if you test positive.”

“Additionally, if a partner tells you that they tested positive you can get empiric treatment, which means you can get treated even before your test results come back, which is another way to help ensure you stay healthy,” he said. “Waiting to get your STI treated can lead to harm, including spreading STIs to more people.

“And, over time, gonorrhea and chlamydia can lead to pelvic inflammatory disease and infertility in women, so it is really important that we get people tested and treated as best we can,” Dr. Zucker added, noting “you should be tested every three to six months if you're sexually active with a new partner.”

“Testing and treatment are easy, so don’t hesitate to come in and get tested even if you don’t feel like you have any symptoms,” he said.

“For HPV, getting vaccinated to prevent getting most strains of HPV that can cause cancer is incredibly effective not just for preventing cervical cancer in women, but also for throat and rectal cancer in men,” Dr. Zucker said, emphasizing that “everybody benefits from HPV vaccination.”

The HPV vaccine approval has recently been expanded from age 26 to now being “approved up to age 45,” he said. “However, HPV vaccination may not be for everyone,” the CDC’s Advisory Committee on Immunization Practices (ACIP) “recommends that clinicians consider discussing with their patients who are not adequately vaccinated earlier, whether the vaccine is right for them.”

“It’s a relatively expensive vaccine, so the way the ACIP wrote it where they should discuss it with their patient and see if it’s right, makes sense,” Dr. Zucker said. That means “if you’re single or non-monogamous you may decide that you might benefit from this vaccine. If you’re in a long-term monogamous relationship, you may decide that this vaccine is not right for you.”

PrEP “is an incredible intervention,” Dr. Zucker noted. “If you take one pill once a day—or for men who have sex with men, take a pill before and after sex—you can with almost 100% success prevent HIV.

“It really is an underused intervention for people who may be exposed to HIV,” he added. “It is something you should be able to go to your local primary care doctor or local sexual health program and be able to get. At many sites they can even start you same day.”

And for those who do not like pills, “there are even injectable forms of PrEP now, so you only need an injection every two months and that can prevent you from getting HIV,” Dr. Zucker said.

“There’s too much STI-related stigma. We all need to be more open about sexual health and STIs, talk about it more and encourage people to get tested,” Dr. Zucker said. “Some ways to do that are to offer routine screening for STIs. Don’t only offer STI testing to patients who you think might be exposed to STIs.”

Instead, “offer STI testing to all of our patients so that they can assess their own need for it and then accept or decline,” he said. “And make taking sexual history routine in practice to also make patients more comfortable talking about their sexual experiences, but also bringing up concerns like STI testing and other sensitive topics with their physician.”

This also includes talking with your partner, which is “incredibly important,” Dr. Zucker said. “Having open discussions with your partners about testing, treatment and exposures is really important.”

“You should not hesitate to talk with your doctor about sexually transmitted infections and sex in general,” Dr. Zucker said. “That’s what we’re there for and that’s part of our job.”

“If your physician’s uncomfortable, then you should find a clinic that does more sexual health focused work and talk to them,” he said. “But you should always be able to have a physician you’re comfortable with.”