Chlamydia and gonorrhea testing should be done yearly in people who are sexually active in age 24 and under, and then as needed, and people who are older, with risk factors. And again, yearly is kind of the minimum. So we should be screening more often. And people, again, who have new sexual partners and more than one sexual partner. And in many of our communities, when we're screening for gonorrhea and chlamydia, we should also be screening for syphilis and HIV.
Chlamydia and gonorrhea are two of the most common sexually transmitted infections, or STIs, in the United States. In Wisconsin in particular, rates of both diseases are on the rise. Doctor Jess Dalby joined this episode of the Women's Healthcast to talk about the signs and symptoms of chlamydia and gonorrhea, the risks of untreated disease, and how to get tested and treated for common STIs.
She also talked about a recent study that found chlamydia and gonorrhea are increasing in Wisconsin, and what's behind those rising rates. Doctor Dalby is an associate professor in the School of Medicine and Public Health, Department of Family Medicine and Community Health. She's also a medical consultant on sexual and reproductive health for the City of Milwaukee Health Department from the UW School of Medicine and Public Health, Department of Obstetrics and Gynecology.
I'm Jackie Askins, and you're listening to the Women's Healthcast. I am very excited to welcome doctor, Jess Dalby to the Women's Healthcast today. Thank you so much for joining me. Yeah, thanks for having me. We are here today to talk a little bit about a couple very common, sexually transmitted infections and, some recent research about kind of what those STIs are doing in Wisconsin. But before we get into that, can you tell me a little bit about your day job and why patients come to see you?
Oh, yeah. Sure. So, I am a family medicine provider, which means that I take care of people and their families from newborn through pregnancy and to older age, and tackle everything from jaundice to, constipation in kids to, you know, well, well, child care and adult issues, hypertension, diabetes, all, all the things. So you also serve as a medical consultant on sexually transmitted infections for the city of Milwaukee public Health. What do you focus on in that role? Yeah. Great question.
So, since 2017, so about eight years now, I've been the medical consultant for sexual and reproductive health there. And I, the health department, runs a sexual and reproductive health clinic, that, provides, low cost, and often free services, to people in the Milwaukee area, focusing on, sexually transmitted infections. And a few years ago, we also launched a contraception provision in that clinic.
So today, I guess we're spending some time together to talk about some recent research that's showing an increase in chlamydia and gonorrhea rates in Wisconsin. Before we jump into that research, I thought it might be helpful to kind of lay a groundwork of what are chlamydia and gonorrhea and learn a little bit about, what people should know about these kinds of infections. Yeah, absolutely. So, chlamydia and gonorrhea are common bacterial, sexually transmitted infections.
They can be, transmitted, with any kind of sexual contact, whether it be oral or rectal or penile vaginal, or, even sharing sex toys. Sometimes, some other routes of transmission, but, primarily sexually transmitted. There is also the risk of transmission, when a pregnant person gives birth if they have untreated, if sexually transmitted infections with comedy and gonorrhea, that that would pass to their newborn. How can someone, prevent or reduce their risk of exposure?
The main form to prevent transmission is barrier protection, which would be condoms, either external or internal, or things like dental dams.
Any, any things that we think about, you know, promoting safer sex, you know, also things like reducing, reducing, sexual partners getting tested regularly with or without symptoms, you know, when you have a new partner, and then, what we call doxyPEP are using, doxycycline, an antibiotic, after after intercourse, in, populations, like, men who have sex with men and transgender women. I want to learn a little bit more about kind of each of these STIs in particular.
So we'll start, I guess, alphabetically. We'll start with chlamydia. What are some of the signs or symptoms that someone could be on the lookout for? Yeah. You know, the thing with chlamydia is that most commonly, it has no signs and symptoms. So people can be infected and not know it. And even though they don't have signs and symptoms, it can still cause.
Some important, long term effects, including things like, pelvic inflammatory disease, which leads to scarring in the tubes, which can lead to infertility and increase the risk for ectopic pregnancy. That can also cause chronic pelvic pain. In, men, complications often include, kind of pain and inflammation, in parts of the, epididymis or in the testicles.
So, yeah, untreated it can cause complications, but often people don't have symptoms, when they do have symptoms, which is, you know, not the majority of the time, but when they do have symptoms, and women, it's going to cause, increased vaginal discharge, sometimes pain with intercourse, spotting after sex. In men, often it causes penile discharge, painful urination. How does someone find out then if they do?
If chlamydia is often asymptomatic or not immediately symptomatic, how does someone find out if they do have. Yeah. So, routine screening it is recommended. So, current guidelines is that for people, under 25 that they should be screened at least yearly. And for older people, and again, even people who are younger that have additional risk factors. So having a new sex partner or multiple sex partners, a partner with an STI, are all reasons to be screened. What does treatment then look like?
Yeah, treatment, for uncomplicated cases is pretty straightforward. For chlamydia, it involves, usually a week long course of antibiotics. And most commonly we use doxycycline, which is, a seven day treatment course. So you described the treatment for chlamydia, which is a course of antibiotics. And I think you mentioned earlier that also one way to prevent infection is to use DoxyPEP, which you said was a, course of doxycycline that you would take after having unprotected sex.
So I'm hearing a lot of antibiotics, I guess, and sometimes I, you know, I hear about this concept of like, quote, antibiotic stewardship or, you know, an idea of being thoughtful about antibiotic prescription and avoiding overuse of antibiotics. And how does something like doxypep like taking a preventive course of antibiotics, kind of square up with that idea of antibiotic stewardship?
Yeah, I think, antibiotic stewardship is a big, is a big question in the field right now and has been a big part of the debate about, doxycycline, post-exposure prophylaxis, doxyPEP, you know, in terms of what is how are we balancing the risks of, you know, preventing STIs with potentially serious complications, versus the risk of, you know, actually, a lot of the unknowns. Like what what happens to the gut microbiome over time, what happens to the emergence of potentially, resistant infections?
I think these are all important questions. You know, that we have to keep in mind, you know, when it comes to things like DoxyPEP, often, you know, what I'm thinking about is that, you know, when we're using DoxyPEP, we're really trying to target, like, the highest risk population.
And so that is, you know, the studies really showed, you know, significant risk reduction by, you know, two thirds in the rates of chlamydia and syphilis, in but their population was men who have sex with men and transgender women who either have HIV or were on PReP and had had a bacterial infection in the last year.
So we're talking, I guess, when I've been thinking about it, you know, we're often not talking about, you know, somebody who's going to get antibiotics or is not going to get antibiotics, but it's when are they going to get antibiotics? Because it's again, start trying to target those, tools to like the highest risk groups. Okay. That makes sense. One more DoxyPEP question. Is it like one dose or does it kind of start like a fall you mentioned like, yeah. So a doxy pep is just a single dose.
It's a 200mg dose taken at once. So, you know, for using a seven day course for treatment of chlamydia, we usually do 100mg twice daily for a week. If we're doing doxy pap, it's 200mg all at once. And it's taken as soon as possible after, an episode of unprotected intercourse where there's risk for, STI acquisition. And but it has to be, again, typically after every sexual event, that has risk, you know, not more than once in 24 hours.
So we've talked about the signs, symptoms and treatments for chlamydia. So let's talk similarly about, gonorrhea relates. Oh, similar question I guess, what are the signs or symptoms that someone should look out for? Yeah. So gonorrhea can also be asymptomatic. You know, especially when it's in the throat, for example. And pharyngeal gonorrhea is, a concern both because people don't have symptoms and aren't always getting tested at that site. So it doesn't always get detected.
You know, some studies have shown that when you do what we call a universal three site screening of the rectum or oropharynx and, genital sites, that you increase detection by about 30%. So if we aren't testing extra genital sites, we're missing, cases. But yeah. So not having any symptoms is one option. You know, gonorrhea tends to be a little bit more symptomatic in the genital sites. So again, men often presenting with your, penile discharge, and discomfort, women with vaginal discomfort.
And discharge, you know, again, also pain with intercourse, spotting, after intercourse, it would be really common and then rarely complicated infections show up as pelvic inflammatory disease in women. So abdominal pain fever, vaginal discharge. And in men you can get, inflammation of the, of the testes. Similarly, how does someone find out if they have gonorrhea? Does it look kind of similar to. Yeah, often chlamydia and gonorrhea are tested with the same swab.
So we often test them at the same time. So, yeah. So typical. Testing is usually, a swab again, either of the throat of the rectum or, preferred testing. And people with a vagina would be a vaginal swab. Whereas in people with a penis, usually we actually take, what we call a first void urine sample. What is that? So, it's when you pee in a cup and it's. But we want to we want to collect, you know, because we're trying to get the bacteria being washed out of, of the penis.
We're trying to collect, like, the first part of the sample cup directly in the cup. And I, say that distinctly because, for example, people might be familiar if they've ever had a urinary tract infection. We try to get something called a clean catch, where we try to ask you to, like, pee in the toilet, then hold your pee, then pee in this cup because we want to get a midstream urine.
But again, actually, for detecting STIs, we want to get something called a, clinically, we often refer to it as like, a dirty urine, but we're we want to get like, that first void. Like that's when your urine, it's like washing out the potential bacteria and capture that in the in the cup. Okay. That makes sense to. Yeah. And then, treatment for gonorrhea, is that similar or different from chlamydia.
You know, it's different in that the preferred treatment for gonorrhea is an intramuscular injection of antibiotics. So still antibiotics we usually use ceftriaxone. We used a pretty big dose. So it's typically 500mg. Although for individuals who weigh more than 300 pounds, we actually need to increase that dose once 1000mg then, but so it's like a fairly high dose of ceftriaxone. And, and that's an injection into the muscle.
Something else I've learned a little bit about is expedited partner therapy. And, I'm hoping you can tell me a little bit more about sort of what this is. And can it be used in treatment of chlamydia and gonorrhea? Yeah. Great question. So expedited partner therapy is, kind of a legal framework that allows providers to treat the partner of a patient without having an existing provider patient relationship with that partner. So it is, most useful. It's been shown to reduce reinfection
of the person you're treating. And, and again, not always the best route because ideally that partner would be evaluated and treated, you know, evaluating the partner, allows for screening for other important sexually transmitted infections like syphilis and HIV. Evaluating the partner or treating the partner is going to allow for optimal treatment of gonorrhea with an IM injection, for example. But we know, that, there are many barriers to healthcare access and treatment.
And if a, if the person who's who you're treating for a sexually transmitted infection like gonorrhea, chlamydia, specifically is if their partner doesn't have, access to evaluation and treatment on a timely basis, then it is legally permissible to write a prescription. To treat chlamydia and gonorrhea, that way.
So it means writing a prescription for the partner, that then the patient delivers to that partner with, you know, information about there's, like, state required, information sheets that go with it, along with the prescription. And so it's an important tool in the toolbox to help, treat more members of the community and reduce community spread. And, and again, specifically, it's been shown to reduce, the infection, the reinfection of the person that you're treating initially.
I'm really glad you mentioned reinfection, because that was one of my other questions, which was, you know, can someone be infected with chlamydia or gonorrhea more than once? I guess you sure can. And and often we recommend that, people and their partners get treated, around the same time and that they abstain from sexual intercourse for a full seven days. After they've both been treated. Because, again, if, if you get treated but your partner doesn't get treated, you will just get re-infected.
And, you know, we sometimes see kind of almost what we describe as a game of ping pong where you're just passing it back and forth. If people aren't getting treated, adequately in a similar time frame. So yes, reinfection definitely happens. And, and as common as common, we actually recommend that everybody who is treated for a sexually transmitted infection gets retested with or without symptoms at three months. Because we know that, having an STI puts you at risk for having more STIs.
Tell me more about the recommendations for testing and screening for, like, chlamydia and gonorrhea, but also in general, STIs. Who who should be getting, regular testing? What's the recommended frequency or cadence? Kind of. What does that look like for kind of optimal sexual reproductive health? Yeah. So there are a couple of different entities that put out guidelines that vary slightly.
So, many clinicians follow the Center for Disease Control, guidelines that come out on sexually transmitted infection. There is also the US Preventive Services Task Force that puts out recommendations. ACOG and the American Academy of Family Physicians, you know, usually put out consensus statements, but sometimes have, recommendations that differ slightly. You know, this is especially true for syphilis, for example, which is, been gaining a lot of ground as an important STI.
And we've seen kind of dramatic increases in syphilis rates.
So, you know, ACOG in April of 2024, for example, put out a guideline that said we should be doing universal screening of all pregnant women for syphilis, both at, you know, the first prenatal visit at, in the early third trimester, at 28 weeks and, and at delivery, which has which differed a little bit from other, organizations like the CDC who had said, we should, screen everybody at the start of pregnancy and think about screening again
for people who are, at high risk or living in high risk communities. For a long time, there wasn't good guidance about what a high risk community, is. But more recently they've come out with, like, defined like if the rates of primary and secondary syphilis are greater than 4.6 per 100,000.
And, you know, women of, reproductive age, we should be screening, actually, at those three times, but actually we should be screening every body in a community if we're screening for sexually transmitted infections. So I would say, you know, currently we kind of mentioned already that chlamydia and gonorrhea, testing should be done yearly in people who are, sexually active at age 24 and under. And then, as needed.
And people who are older, with risk factors and again, yearly is kind of the minimum. So we should be screening more often. And people, again, who have new sexual partners, more than one sexual partner or, engage in any other high risk sexual behavior for transmission. And in many of our communities, when we're screening for gonorrhea and chlamydia, we should also be screening for syphilis and HIV. Where does someone go for testing or screening? How does someone access those services?
Yeah, I think there's a lot of, a lot of good options. So, you know, for people who are established with primary care or an ObGyn, you know, they can go into those settings to be tested. There are many public health departments around the state that offer, often free or low cost STI testing. So that's a really great resource. There are also online services. There's and that's really been expanding over the last several years, like there are several, online services.
They send you a kit, you pick your you prick your finger to get a blood sample. You see what you might, you know, swab your throat or your rectum. You pee in a cup. And then you send those samples via the mail back to the company where they, give you a report of your results. So that's another option.
When you were talking about recommended, syphilis screenings and the ACOG recommendation, the American College of Obstetricians and Gynecologists, their recommendation to screen at three points through pregnancy, including right before delivery. The importance of that is that syphilis passed from parent to child during birth can be very, bad. It has, has the potential to to cause some pretty significant illness for the baby.
And I wanted to ask about similar risks with chlamydia and gonorrhea transmitted from like parent to baby. Yeah, sure. So, it is a common cause of, conjunctivitis or inflammation of the eye that could even lead to blindness. And, also a cause of pneumonia. So, you know, we currently treat, we recommend treating all babies with erythromycin eye ointment, after delivery. So that's, one way that we kind of as a take a public health approach to preventing that important complication.
But again, yeah, conjunctivitis and pneumonia are both complications that can happen. If this is due in the leads, we can skip it. Don't worry. If someone is tested sort of at the time of, of, like, coming in to the hospital to give birth, can they be treated for chlamydia or gonorrhea in that time frame? What what happens? Yeah. Good question.
You know, the labor process looks very different, and it probably depends on, the the labor process looks different for different people, is what I should say. And it it, probably depends how long they're in labor. In terms of if there is time to both I would say practically testing for gonorrhea and chlamydia, at the time of delivery. Because tests often, you know, take, you know, a while to come back.
They may not, we may not be able to treat the, birthing parent in time to affect, transmission to the newborn, but it would be an important thing for the newborn provider to be aware of and to monitor for for signs and symptoms of concern. So one thing I also I wanted to talk to you today about is, a study that you coauthored that found an increase in, chlamydia and gonorrhea rates in Wisconsin from about 2010 to 2022. I think that's like the available stretch of data.
And I wanted to ask if you have any, like, thoughts or impressions about what contributed to this increase in STIs. Yeah. So I think there's a multitude of of potential factors, but I think there's kind of three that I will highlight in particular. You know, one is changes in sexual networks over time with the advent of dating apps. So, you know, through the use of dating apps, people have, access to a wider network of partners and tend to have more partners.
You know, at the same time, over the same timeframe, we've really seen, an increase in, opioid use and misuse. And so that, like kind of syndemic, we'll call it both of like increasing rates of STIs and increasing, substance use disorders. So we know people engage in riskier sexual behaviors, when they're using substances. And then finally I will say that, we also have good data that shows that people are using condoms less frequently.
You know, with the advent of PReP, which stands for pre-exposure prophylaxis for HIV, you know, people, are has dramatically reduced their risk of acquiring HIV and, are using less, are using condoms less. When we look at this data that shows this increase, do we find that the increases are kind of evenly distributed across gender, age and race in Wisconsin? Or did we find some disparities? And who seems to be most impacted by the increase of those?
Yeah, no. Unfortunately there are significant disparities. So, and actually Wisconsin has some of the worst, disparities, racial disparities nationally. So if we look at the data for the past 12 years or so, what we see is that the rates of gonorrhea, for example, in the black community, is about 30 times higher than what we see in the white community. You know, also, we see that chlamydia rates over time actually have increased a little bit.
But, you know, maybe like 5% where actually gonorrhea rates are markedly increased the higher the significant increases in gonorrhea, similar to what we're seeing in syphilis in, you know, men who have sex with men who have multiple partners, for example. And with the advent of PReP, maybe using condoms less frequently, is, is a common driver in those groups.
You know, I think we see this, really specifically with, syphilis, for example, where we see that, you know, for a long time, syphilis predominantly affected men who have sex with men. And then as we started to see huge increases corresponding with, like, the onset of the COVID pandemic and decreased access to, to care, and you know, diversion of public health resources away from STIs to COVID. You know, we saw a huge shift in the percentage of women being affected.
And then consequently, now we're seeing the effects on, congenital syphilis on on the effect on newborns, with large rates, you know, so similarly, you know, gonorrhea increases, kind of also follow that pattern, where again, as we increase risk, as we increase infection rates in higher risk communities, it spreads, you know, outside of those networks to other communities as well.
What can be done or done differently than is currently to help reduce some of the disparities that we're seeing in, straight in Wisconsin and in general, kind of reduce folks risk of encountering STIs in our state and beyond. Yeah. I mean, this, this requires, you know, by in it so many levels. So when we think about racial disparities in sexually transmitted infections, you know, this really comes down to social determinants of health.
You know, so, you know, poverty and economic disadvantage, are a huge driver, which, you know, with limits where people have limited access to health care, where people have, you know, increased stress and, you know, those situations also, you know, drive risk, in like transactional and survival sex as well. You know, I think in Wisconsin, we also, have a really, marked and challenging, you know, history of, racial residential segregation.
So with historical redlining and then also, you know, and continued, you know, structural racism that impacts, you know, that concentrates, neighborhoods of disadvantage, which shapes sexual networks, and higher, you know, and augments community risk in certain communities. And, you know, when we think of barriers to health care as well.
So, you know, again, the fact that Wisconsin has not, you know, didn't take the Medicaid Medicaid expansion, you know, when people are uninsured, you know, the most common tests we use are quite expensive, like, you know, where like the technology behind doing, what we call nucleic acid amplification and testing for STIs, like, you know, it's it's amazing technology that's really sensitive and costly and can really impact access.
And so, you know, all of the things that pose barriers to healthcare access, whether it be like transportation, access to a clinic, insurance status. You know, I think if we were going to, really address this in the way it needs to be addressed again, it it takes so many levels of, buy in, I think, increasing access to Medicaid. So increasing insurance availability makes a big difference. Increasing public health funding.
Both because public health STI clinics provide an important resource for testing, but also because, public health, provides what we call disease investigation, which, for example, in things like syphilis is critical to preventing community spread. You know, what that means basically is, you know, working with the person who's infected to help, identify partners and help those partners get treated as well.
You know, I can say, in my experience, leading the sexual reproductive health program at the Milwaukee Health Department, as things from COVID started to taper off, there was still, enhanced public health infrastructure.
that we were able to leverage to, really go after, syphilis and, do what we, we, you know, we had, probably for the first time in, many, many years, we had a fully staffed disease investigation specialist program, which, again, are people who are, helping to, find partners, bring them to treatment, make sure people, who have adequate treatment and, you know, in the city of Milwaukee, over the past several years, we have seen, amazing and hopeful declines in the rates of syphilis.
So, you know, at its high, there was, you know, maybe 500 cases of primary, secondary syphilis in the city of Milwaukee. In at the peak in 2021. And, you know, last year we were down under 200 of primary and secondary syphilis. Doctor Dalby, thank you so much for being here today. Yeah. Thank you. It's been a pleasure. The Women's Healthcast is a production of the UW School of Medicine and Public Health, Department of Ob-Gyn. This episode was produced and engineered by Rob Garza.
You can listen to the Women's Healthcast on Apple Podcasts, Spotify, or wherever you get your podcasts, and you can find the UW Department of Ob-Gyn on social media under the handle @WiscObGyn. Let us know how we're doing. Rate and review us in your podcast app, and let us know what health issues you'd like to learn about at the link in our episode description. Thanks for listening.