What’s behind the unprecedented rise in levels of STIs in Ireland?

Veteran sexual health doctor Derek Freedman says he has never been so busy. “Last week alone, I saw more cases of gonorrhoea than I would have in any week 20 years ago.”

Many of the sexually transmitted infections (STIs) he deals with remain silent up to the point of testing, despite having serious consequences – inflammation, infertility, easy transmission to others. And along with the traditional scourges that have accompanied civilisation for as long as people have been having sex, he is finding new bugs, some of them already common though not officially notifiable.

“We’re seeing an unprecedented rise in the number of STIs, not just in Ireland but across the world,” according to Dr Freedman, who founded the Society for the Study of Sexually Transmitted Diseases in Ireland back in 1985 and is still working into retirement age.

“Unprecedented” was the word also used by public health doctors in the midwest last week to describe a recent rise in STIs in the region. That prompted a blunt health warning for people to get tested and to wear a condom during sex.

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Yet record numbers of chlamydia and gonorrhoea cases are not a problem confined to any one area of the State. STI cases, also referred to as STDs, have been increasing year-on-year across Ireland for decades, apart from a brief dip during the Covid-19 pandemic. Aside from concerned doctors, though, there is relatively little discussion about this trend.

“STIs have been on the rise for the past five years, with a temporary decline during the early days of the Covid-19 pandemic when many countries were on lockdown,” says Prof Ina Park of University of California San Francisco’s school of medicine, and the author of Strange Bedfellows: Adventures in the Science, History, and Surprising Secrets of STDs.

“There are many reasons for this trend: declining use of condoms due to the availability of HIV pre-exposure prophylaxis (PrEP) and effective HIV treatment, substance use trends in some countries which interact as a ‘syndemic’ with STIs, the rise of dating apps, etc.”

Dr Freedman points out: “We’re living in times when mobile apps make sex readily available. You go on to Tinder or Grindr and find people to link up with instantly. Sex is instantly available.”

‘Underfunded and understaffed’

“There are numerous other factors – huge deprivation in places like the US, reductions in healthcare, influxes of migrants who are often vulnerable during transit.

“And then add in public clinics dealing with infections that are over-subscribed, underfunded and understaffed. Often they operate on an appointment basis, as if the treatment of sexual infections can wait weeks.”

In Ireland, he points out, the majority of new HIV cases are in people who have moved to live here.

Dr Freedman maintains some patients are being inappropriately tested and treated, for example, through the use of the wrong antibiotics or ineffective tests.

And while the introduction of PrEP has been hugely successful because it reduces the chances of a person acquiring HIV, he argues that it has led to “a return to the ‘let’s party’ atmosphere of the 1970s”, a pre-AIDS era notorious for the popularity of risky sex.

But isn’t there evidence showing young people are actually having less sex? “This is true, but there are still sufficient numbers having very casual sexual encounters,” Dr Freedman says.

According to the figures released by Public Health HSE Mid-West, it recorded the highest number of both chlamydia cases (798), and gonorrhoea (188) in the past 10 years in 2022. Already this year, there have been 664 cases of chlamydia and 274 cases of gonorrhoea.

[ Challenging myths about sexual health ]

Nationally, the Health Protection Surveillance Centre notes that STI notifications are back up above pre-pandemic levels. Almost 11,000 cases of chlamydia were reported last year, up 20 per cent on 2019; the 4,000 reported cases of gonorrhoea represented a 45 per cent increase on pre-pandemic levels. Syphilis rates have remained relatively stable.

Pent-up demand

Young people aged 15 to 24, and gay and bisexual men, are most affected. The biggest increase in notifications was in women aged 20 to 24.

According to the latest figures published by the Health Protection Surveillance Centre (HPSC) on Thursday, chlamydia cases this year are up 43 per cent on the same period last year, while gonorrhoea cases have almost doubled (up 95 per cent). Over half of chlamydia cases and almost 40 per cent of gonorrhoea cases are in those aged 15 to 24. Similar trends are being observed in Northern Ireland.

Prof Sam McConkey, infectious diseases consultant at Beaumont Hospital in Dublin, attributes some of the increase to a pent-up demand for services following the pandemic. “We had to close clinics during the pandemic as staff were redeployed, so we weren’t diagnosing cases. And because people weren’t being treated promptly, there was an increase in the amount of disease going around.

“The simple narrative has it that there’s lots more sex since the end of the Covid-19 pandemic and the social distancing that was required. It is true that rates have gone up over the last few years, but this is actually part of a longer-running trend going back 20 years. Patterns of human behaviour are changing.”

He describes the introduction last year of home-based diagnostic kits for testing STIs as “the best of good public healthcare – it’s free, private and reliable. It gets over the embarrassment factor. And if you diagnose infections quickly, you stop spreading them.

[ HIV rates more than double in past year as STI cases rise, latest data shows ]

“But is also messes up the figures. More surveillance shows up more positive cases.”

It is not possible to work out the relative contribution of these different causal factors to the rise in overall cases, he believes.

The HPSC estimates that up to 40 per cent of chlamydia cases and one-quarter of gonorrhoea cases are being picked up via home testing. One in 10 tests is returning a positive result.

Young women are biologically more vulnerable in terms of catching bacterial STIs. The cervix has a greater quantity of certain cell types that are targets for gonorrhoea/chlamydia in particular

—  Prof Ina Park, of University of California San Francisco’s school of medicine

New bugs

Yet official figures most likely underestimate the burden of disease in the community, and not just because many infections remain hidden. Dr Freedman highlights the spread of new bugs such as Mycoplasma genitalium, which is not officially notifiable but cropped up in his clinic twice last week. “The young men presented with pain in their testicles. This is like a mild form of chlamydia, but can also cause infertility, and yet it’s often not tested for.”

Meanwhile, the HPSC hasn’t produced specific yearly reports for gonorrhoea and syphilis since 2018, due to the pandemic.

Sexually transmitted diseases have been around for as long as mankind. The Victorians obsessed about them, partly because of their potential impact on the fighting ability of British army. In the 19th century, women suspected of being prostitutes could be locked up for up to nine months under legislation that applied around army barracks in Cork, Cobh and the Curragh.

The site next to the offices of The Irish Times in Dublin, which is now a sports centre, was once a hospital for treating venereal disease, I found out while researching this article.

Even after independence and the birth of a State heavily influenced by Catholic morality, STIs remained a challenge. In 1924, more than 300 of the army’s 15,000 soldiers were infected with gonorrhoea or syphilis. Dublin suffered a deadly syphilis outbreak in the 1930s.

Yet there were a time, not very long ago, when STIs were declining around the world. In the US, syphilis was nearly eradicated around the start of this century; gonorrhoea reached its lowest rates of infection in 2009. Doctors grew unfamiliar with once-common infections because they had become so rare.

Not any more: the World Health Organisation (WHO) estimates more than 1 million STIs are acquired every day worldwide, the majority of which are asymptomatic. In the UK, syphilis cases last year reached their highest level since 1948.

While most STIs are easily treatable if detected, Prof McConkey says the presence of such infections in young women presents a key challenge. “They can be vulnerable to chlamydia, where scarring of their tubes can lead to ectopic pregnancies and infertility. That’s not something anyone wants.”

Female infertility

Chlamydia may be responsible for up to 15 per cent of female infertility but years may pass before a woman discovers, in a later stage in life, that she cannot have children, according to Dr Freedman. “The woman may never know what caused her infertility.”

In the US, cases among heterosexual woman have shot up, due in part to increasing drug use that leads on to risky sexual behaviour among both men and women.

“Young women are biologically more vulnerable in terms of catching bacterial STIs,” according to Prof Park. “The cervix has a greater quantity of certain cell types that are targets for gonorrhoea/chlamydia in particular.

“Men who have sex with men are also more likely to acquire STIs, due to higher rates of infections in their sexual networks and higher numbers of partners than men who only have sex with women.”

Meanwhile, the number of HIV cases this year is up 10 per cent on 2022, which was already a record year for new notifications.

“These figures remain stubbornly high,” says Stephen O’Hare, executive director of HIV Ireland. “It is unclear how much of the trend is driven by new transmissions of HIV or by cases which were previously diagnosed in another jurisdiction and merely linking into the Irish health services for the first time.”

Here too, the introduction of self-testing for HIV may be contributing to the rise in cases. New retroviral medicines can, if given early enough, make it impossible for a person to pass on HIV sexually, he says. But this doesn’t stop the transmission of other infections.

PrEP, if taken in advance of unprotected sex, can stop a person acquiring the virus. By reducing barriers to PrEP, Amsterdam reduced the number of new transmissions of HIV to just nine last year, an achievement Mr O’Hare hopes Ireland can emulate.

‘Silent’ STIs

One bright spot is Mpox, caused by the monkey pox virus, which flared up significantly in recent years but appears to have peaked for now.

The challenge for doctors is that many STIs are “silent”, making them more difficult to detect and treat. “If a man has gonorrhoea in his throat, there is no sign of it. Anal gonorrhoea, too, is completely silent,” says Dr Freedman.

STIs are not mere inconveniences to be batted away with a round of antibiotics without changes in sexual practice, he warns. “There’s a reason why smallpox is so named; syphilis is the great pox. It can kill you. It still has serious consequences for 25 per cent of victims if left untreated.”

What can we do to guard against these scourges? Anyone intending to have sex with a new partner should go to their GP or order a home testing kit, Prof McConkey counsels.

“If we’re changing partners we should be getting a check-up, just as we do with for our cars or our teeth. If you’re with the same partner for the last 30 years, you don’t need it.”

For those engaging in casual sex, he recommends a check-up every three months, along with the use of condoms.

“We urgently need to destigmatise and normalise STI/HIV testing and increase access to free or low-cost sexual health services,” says Prof Park. “Increased access to home-based STI testing also greatly lowers barriers.”

“Know who you are having sex with,” Dr Freedman advises. “Wear a condom, it’s hugely protective. Yet people think condoms are just for penetrative sex, not oral sex.”

Anyone who is sexually active with new partners should get tested every three months, he also recommends. “Some couples get checked before they get going. That can be very useful – though I do advise them to make their first night very special.”