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Sexually transmitted infections – you may have one and not know it

Image of Infographic about STIs. Service members with questions about protective measures like condoms, testing, or treatment, are encouraged to contact their medical provider or local installation public health nurse (Illustration by Graham Snodgrass, APHC).

During the past year, people have learned to protect themselves and their loved ones from COVID-19 by using three simple public health practices to prevent infection and decrease spread:

  • Maintain distance from potential sources of infection
  • Wear protection
  • Get tested

These same public health practices are similar to those recommended to protect us from other infections that are transmitted from person to person. This includes sexually transmitted infections, or STIs.

STIs include both sexually transmitted diseases, known as STDs, and the many infections that do not progress to disease. A 2021 National Academies Press report describes STIs caused by more than 30 organisms transmitted through skin- and fluid contact during sexual encounters. The report emphasizes promoting responsible sex to reduce transmission and focusing attention for high-risk groups such as the military.

Before falling into the trap of believing that STIs aren't something that may affect you personally, it's important to understand how common STIs are. The Centers for Disease Control and Prevention estimated that one in five people in the United States had an STI on any given day in 2018. STI rates have risen during the last six years, reaching all-time highs when last reported in 2019.

Symptoms can include pelvic, vaginal, or penile pain, inflammation, discharge or odors. Others may present as rashes, painful or painless sores or warts.

Yet one area of special concern are the many asymptomatic cases of STIs, which are people who don't have symptoms but are 'carriers' who can still transmit the infection to others. Many people, both men and women, fall in this category. In the absence of symptoms, those infected typically don't seek testing and treatment, which in turn increases STI spread.

For those who experience symptoms, effects can show up days, weeks, or even months after the exposure, said Maj. James Waters, a public health nurse and doctor of nursing practice in the Army Public Health Nursing Branch at the Army Public Health Center.

"Without treatment, long-term impacts can be serious and permanent," said Waters. "These can include infertility among men and women, chronic pain, increased risk of HIV, certain types of cancer, organ failure and potentially death. Untreated STIs can also be dangerous during pregnancy, both to the mother and her baby."

The NAP and CDC have identified the most commonly reported STIs to be chlamydia, gonorrhea and syphilis. Reporting these STIs is mandated because they are easily spread and there are effective treatment options to prevent serious health problems. While the CDC monitors these STI cases in the U.S. population, the Army's APHC tracks the cases among U.S. soldiers.

"In the U.S., 15-24 year olds account for almost half of these STIs," explains Nikki Jordan, a senior APHC epidemiologist and coauthor of a recent study "A Comparative Analysis of Reported Chlamydia and Gonorrhea Cases among Army Soldiers from 2015-2019." "Since approximately half of the Army is under 25, it is not surprising that soldiers represent a high-risk subgroup of the overall U.S. population."

Picture of a condom Using a condom is one way to protect against sexually transmitted infections or STIs (Army courtesy photo).

Within the Army, like in the overall U.S. population, reportable STI rates have been increasing for the past several years. But when comparing rates between the U.S. and Army populations, Jordan notes the importance of accounting for age and sex differences. This is because the U.S. population includes all ages and is generally evenly split between men and women, whereas the soldier population includes more young adults and 85 percent are men.

Jordan's study found that after controlling for age and sex differences, Army soldiers' chlamydia rates were almost 2 times higher than the rates in U.S. adults. The U.S. adult gonorrhea rates, however, were about 1.35 times higher than the soldier rates. Similar to U.S. population data, soldier STI rates were highest among adults under 25 years, women, and some racial and ethnic minority groups.

"There are many reasons soldiers may have greater STI risk including increased travel, excessive alcohol use, and unique job-related stresses," said Jordan. "Cases may also be more likely to be detected among soldiers, because they have more healthcare access and STI testing than the general population."

Waters explains that the Department of Defense annual chlamydia testing, which often includes a full panel of tests for other STIs like gonorrhea and syphilis, is only required for women under 25 years of age. This is based on recommendations from the U.S. Preventive Services Task Force.

"Since most male Soldiers do not seek STI testing unless they or their partner are experiencing symptoms, we may not be identifying many cases among male soldiers, who can spread the infection to others. So the higher female STI rates we see in reported data may be due to their higher rates of testing," Waters said.

Waters explains that since a majority of these STIs are asymptomatic, prevention and control are challenging, because one cannot generally tell if a person has an STI.

"Those who are infected may not know - so they have a false sense of security, don't feel the need to practice safe sex, and continue to spread the infection," said Waters. "Very importantly, chlamydia, gonorrhea, and syphilis STIs can all be easily detected and cured with a limited course of antibiotics. However, recovery doesn't mean a person can't be re-infected. And there are increasing concerns of antibiotic resistance, especially after repeated treatments."

Recently, the Armed Forces Health Surveillance Division reported a notable decrease in STI rates in 2020. Jordan and her colleagues say this may be partly due to soldiers having fewer social contacts during the pandemic, and – hopefully - also smarter, safer sex practices. But they also point to a decrease in health care access, STI testing, reporting, and contact tracing in 2020.

"Many medical services were put on hold or diverted to support the COVID-19 response, so we don't really know yet if STI rates are actually starting to decrease," said Jordan. "Regardless of the data, we know we still miss a lot of asymptomatic cases, and that STIs continue to be transmitted by millions of Americans, including soldiers, who aren't aware they are infected. The pandemic pointed out weaknesses in the public health system. New solutions need to be considered - like internet-based testing with at-home test kits that are increasingly being used in the civilian sector."

"There are no vaccines for most STIs, including chlamydia, gonorrhea, and syphilis," adds Waters. But these STIs can be easily prevented, tested and treated.

Soldiers with questions about protective measures, like condoms, testing or treatment, are encouraged to contact their medical provider or local installation.

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