WASHINGTON – The basket of free ultrathin and studded condoms stayed full to the brim – a recurrent reality that no longer surprised the D.C. health workers offering HIV testing this month at a downtown plaza.
Public health authorities are confronting a rise in sexually transmitted infections in a world where condom use has steadily declined – and, with it, one of the most effective ways of curbing the spread of disease.
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“They’ll laugh at it, or sometimes they get it and throw it away,” said Kevins Anglade, a community outreach worker for Whitman-Walker Health, a Washington, D.C.-based LGBT health-care organization that opened in the 1970s as the Gay Men’s Venereal Disease Clinic. “It’s a new normal, which is very sad.”
The United States recorded nearly 2.5 million cases of chlamydia, gonorrhea and syphilis in 2021, more than doubling in the past two decades, according to preliminary data from the Centers for Disease Control and Prevention.
About half of new infections last year were in young people between the ages of 15 and 24. Men who have sex with men contract infections at higher rates than heterosexuals because they are more likely to have multiple recent partners and it’s easier for sexually transmitted diseases (STDs) to circulate in smaller networks of people.
Condoms, once central to campaigns to eradicate STDs at the height of the AIDS crisis, have become a harder sell because of medical advancements such as long-acting contraception and medications that drastically reduce HIV transmission.
Federal family-planning surveys show condoms went from the top contraceptive tool for 75 percent of men in 2011 to 42 percent of men in 2021. Church and Dwight, the maker of Trojan condoms, flagged the trend in declining condom use to investors in its 2021 annual report.
Multiple studies have found a rise in unprotected sex among men who have sex with men. The percentage of high-schoolers who said they used a condom the last time they had sex declined from 63 percent in 2003 to 54 percent in 2019, according to an annual government survey.
“Historically, young people when they’ve used condoms have largely been scared into using them by the threat of HIV or an unintended pregnancy,” said David Harvey, executive director of the National Coalition of STD Directors. “They have more options now to prevent those things.”
Scientists have recently discovered that HIV-positive people cannot spread the virus if they adhere to treatment that reduces their viral load, spurring a campaign known as “undetectable equals untransmittable” to focus on treatment as a form of prevention.
The advent of daily pills and injectable medication taken as pre-exposure prophylaxis, known as PrEP, to prevent HIV infection also enabled people to have condomless sex with a drastically lower risk of contracting HIV, while still leaving them susceptible to other diseases that spread through fluids and skin-to-skin contact.
Health officials are up against a perception that syphilis, chlamydia and gonorrhea are nuisances that can be treated, even though those infected risk lasting complications including infertility and organ damage.
John Guggenmos, a longtime owner of gay bars in Washington, D.C., said condoms have gone from being a fixture at his establishments to largely out of view because customers prefer PrEP to prevent HIV.
“It was a staple in the ’90s: You had vodka behind the bar and condoms at the front door,” said Guggenmos. “Now they are just not used, they get knocked over, so we just stopped. There are some behind the bar, but who is going to ask a bartender for them?”
Whether PrEP is driving an increase in other sexually transmitted infections is a contentious issue among researchers. Studies show PrEP users are less likely to use condoms, but they also undergo required regular screening for STIs to receive the medication.
“In getting diagnosed and treated soon after they acquired the infection, they become less likely to pass that on to others,” said Zandt Bryan, who leads STI prevention for the Washington state health department.
Some experts say racial and income disparities in PrEP use accentuate the need to promote condoms as a solution, too – particularly among high school and college students still forming their sexual habits.
“There are a lot of people who decide they don’t want to go on pills and have distrust in the medical community,” said Brian Mustanski, director of the Institute for Sexual and Gender Minority Health and Wellbeing at Northwestern University, who designed an online education program that a study found was effective in increasing condom use among young men of color. “We should not give up reminding people the value of condoms and teaching people how to use them correctly.”
Officials at Whitman-Walker, the LGBT health center in Washington, D.C., say interest in condoms tends to be higher in the majority-Black neighborhoods where HIV rates are higher and PrEP use is lower. Several older African Americans were among the few who took condoms at the group’s recent outreach event.
But LGBT health providers often rely on government grants for their disease prevention work, and say they lack funding for robust condom distribution campaigns because public health agencies prioritize other forms of prevention such as PrEP.
“A lot of the emphasis focuses on treatment,” said Rama Keita, director of community health at Whitman-Walker. “It’s a tough place that we are currently in.”
Davin Wedel, president of Global Protection Corp., which supplies condoms to governments and nonprofits, said public health agencies have been placing fewer orders since the advent of PrEP. But he said sales have started to rebound in recent months as officials raise alarms about rising sexually transmitted infections, a demonstration that public health has not abandoned condoms even if they are no longer the core focus.
“I cannot imagine a situation where condoms will not be valuable, but at the same time, we have to continue working toward the development of more efficient tools to prevent these infections,” said Leandro Mena, who leads the Centers for Disease Control and Prevention’s STD prevention division.
Scientists and health officials are now focused on vaccine development, affordable at-home testing and medication taken after sex as the next generation of weapons in the battle against sexually transmitted infections.
The most promising of the options is an oral antibiotic taken as soon as possible after sex to prevent bacterial STDs, a strategy known as post-exposure prophylaxis.
Preliminary data from a study funded by the National Institutes of Health showed the method was effective against gonorrhea, chlamydia and syphilis. The CDC is developing clinical guidance to use the antibiotic for STD prevention in gay and bisexual men and transgender women who have HIV or take medication to prevent HIV – groups represented in the NIH study.
While more at-home STD testing kits are entering the market, they are not affordable or distributed widely. Experts hope they can eventually be as accessible as rapid coronavirus tests.
There are no vaccines for syphilis, gonorrhea or chlamydia on the horizon, but officials hope they can eventually join the arsenal alongside shots to prevent hepatitis B and HPV.
“All of this effort has been going on globally to create tools that are not condoms because we are finally getting it: Humans don’t like condoms,” said Jim Pickett, a longtime HIV activist who consults for public health agencies. “And no matter what we do, we are not going to get the kind of use from them that would be required to really make a dent.”
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