Hard-Won Gains Against Sexually Transmitted Infections Could Slip Away 

People of every gender, race, age, and ethnicity are affected by sexually transmitted infections (STIs). Currently, the United States is experiencing the largest epidemic of congenital syphilis since the 1990s, with thousands of babies being born with the potential for lifelong disabilities and death each year. On the other end of the life spectrum, the 60-plus crowd is moving into retirement communities with the most rapidly rising rates of STIs of any age group.  

At the same time, we have seen monumental advances in STI prevention and testing that could dramatically reverse the course of the STIs. The HIV prevention medication, Pre-Exposure Prophylaxis, or PrEP, has created the first opportunity to essentially end the HIV epidemic since it came to market a decade ago. Point-of-care tests that can be provided in community-based locations have been game changers in diagnosing HIV and Hepatitis C in populations where health care has not done a good job reaching people who need services and care. Just in the last few months, the first at-home tests for chlamydia, gonorrhea, and trichomonas were approved by the Food and Drug Administration (FDA). The ability to test at home, without fear of judgement, advances our ability to achieve sexual health on a new level.  

These are just a smattering of the STI gains we have made in recent years. Now, suddenly, we face drastic destabilization of public health, defunding of critical research, and widespread firing of national experts by the Trump administration. So, what do we stand to lose at this moment? 

Vaccination take-up. We have made tremendous progress in preventing avoidable cervical cancers, and potentially head and neck cancers in older adults, with timely HPV vaccination. Yet the US Health and Human Services Secretary has been a key contributor to a lawsuit against the biggest manufacturer of the HPV vaccine. As a family doctor and STI clinician, I see young adults who have aged out of the opportunity to get an HPV vaccine when it was covered by their insurance. Now many cannot afford the vaccine series and have already been exposed to this cancer-causing virus — a completely avoidable health care failure that is likely to become more widespread in an anti-vaccination environment. 

Testing and tracing advances. Mycoplasma genitalium (Mgen) is an old STI that we can now diagnose and treat since the first FDA test was approved in 2019, but it isn’t yet tracked by our public health surveillance systems. In North Carolina, we were one of the first states to embed PrEP and Mgen testing and treatment in the Medicaid family planning benefit, but as anticipated federal cuts to Medicaid push down to states, these types of “extras” stand to get cut. Moreover, county and state public health departments are reducing outreach and contract tracing services following a substantial loss of federal funds rather than building capacity to improve their data systems and contact tracing resources. 

Research. While the first new antibiotic with a potential to treat drug resistant–gonorrhea has just been FDA approved, Mgen already demonstrates significant antibiotic resistance. But the funding and workforce to study antimicrobial resistance might be a footnote in a litany of other casualties of public health defunding. The Federal Advisory Committee for Antimicrobial Resistance, among other federal advisory committees, is on hold at the direction of the new administration and federal staff positions that supported many of these committees have been eliminated.    

We also need to continue to study the impact of Doxy PEP, an antibiotic used after unprotected sex to prevent infection, to drive evidence-based care. So far, Doxy PEP has been shown not only to alleviate human suffering and reduce spread of infections, but also to save health care dollars. Yet the draconian cuts to CDC staffing and funding mean the promotion of this new tool and the opportunity to study its benefits or risks, and monitor for antimicrobial resistance, are lost. 

Access to HIV prevention. Despite PrEP’s success, in the last several months, federal grants funding critical research on HIV prevention have been reduced or cut, and the administration has proposed eliminating the CDC’s Office of HIV Prevention. In addition, Congress’ proposed Medicaid cuts will widen gaps in PrEP access and treatment — and the President’s 2026 budget cuts funding for HIV treatment, prevention, and vaccine development by 1.5 billion dollars.   

Insurance coverage. Payer coverage of services like telehealth has been critical for consumers looking for ways to access sexual health care differently. Yet Medicare and many private payers have recently stopped or limited telehealth coverage. Moreover, with the forthcoming federal cuts to Medicaid funding, states are considering what services to eliminate. For the average American to access STI home tests, payers and public health will need to help subsidize the cost of telehealth services. Without it, only the wealthy will be able to access timely, self-directed sexual care, further exacerbating STI disparities. 

The Cost of Inaction 

The noteworthy advances in sexual health — and threats to progress — have been overlooked in the noise the current administration has brought to bear, but they are real. Institutional memory is being erased, which could set us back decades in one of the few health fights this country is winning.  

What is the cost of inaction? More cancers from HPV and hepatitis. More miscarriages, stillbirths, blindness, and deafness from congenital syphilis. Reverse gains made from HIV investments. Increase our long term spend managing chronic disease rather than preventing it. We have choices: 

• Spend <$1000 for a woman to receive the HPV vaccine series or >$100,000 treating cervical cancer 
• Spend <$50,000 treating hepatitis C infection or $300,000 treating hepatocellular carcinoma  
• Spend $500 preventing congenital syphilis or $50,000 on a 2-week NICU stay or $5,000,000 over a lifetime for the care of congenital blindness 

Recommended Actions 

Continued progress on sexual health is possible. There are actions states and advocates must take, including:   

• Prioritize public health funding and resource allocation at the state and county level. 
• Reinforce the importance of Medicaid funding that allows states to take advantage of federal match, which unburdens states from covering the cost of care of their lowest-income citizens and stabilizes the financial viability of safety net providers.  
• Maintain momentum on gains on STI prevention efforts; work smarter, not harder by learning from partner states and sharing widely.    
• Educate lawmakers about reportable diseases and the critical function of contact tracing to prevent chronic disease and the spread of infections. These funds come from federal and state appropriations that are now being eliminated.  
• Support local public health efforts to provide STI data in a timely fashion and support federal agency efforts to digest the data and turn it into recommendations rapidly. When data lags by two years, we have lost the chance to make it actionable. We should be increasing funding for disease surveillance, not cutting it. 

Over the past decade we can claim the most significant advances in sexual health since the discovery of condoms, which dates back to the Roman era. If we want to avoid regressing the sexual health of this country, we must take definitive action to overcome the setbacks we are currently witnessing.