The impacts of the novel coronavirus pandemic on health care are sweeping, but sexual health experts believe we’re only just beginning to see its effects on sexually transmitted infections, or STIs.
Cases of STIs in Ontario dropped considerably between January and April this year. The most significant decline is clear between March and April — when the coronavirus triggered a countrywide “stay home” order.
Ontario recorded 4,865 cases of chlamydia in January but only 1,223 in April. That’s down from 3,044 in March. For gonorrhea, January’s 1,103 cases came down to 286 in April. Ontario recorded 232 cases of syphilis in January but only 85 in April.
STI cases were steadier in Ontario throughout 2019. Chlamydia, for example, lists 4,564 in January and 4,188 in April.
Experts believe the drop likely reflects a decrease in testing, but they agree there’s no magic answer to the decline overall.
“People have had less access to services,” said Michelle Murti, a physician with Public Health Ontario (PHO). “Even then, the numbers aren’t telling the full story yet.”
In mid-March, many medical clinics opted to shut their doors, reduce hours or go virtual. Canadians were encouraged to stay home and only seek health care for emergencies.
That means STI screenings, like many other routine check-ups, were happening far less, said Murti.
“Many or most STIs don’t have symptoms. So the most important part is regular screening. That’s what prevents ongoing transmission, picking it up as early as possible,” she said.
“So when the ability to come in for screening is significantly reduced, and you wait until you have symptoms, that’s a lot worse.”
It also brings down the overall number of tests being conducted. Quantifying the impact of decreased testing on the numbers is the tricky part, said Murti.
Only the positive cases are reported to public health. Even by the end of the year, there’s never a “true number” of tests conducted for the province because tests are done at places other than PHO clinics, like LifeLabs and other private laboratories.
HIV is the exception, she said, since PHO does the “vast majority” of testing in the province and can tally an annual report that includes the number of tests overall.
How distancing plays a part
The drop-off in testing isn’t the only pandemic-related impact to STI cases, according to Dustin Costescu, an OB-GYN and assistant professor and sexual health specialist at McMaster University in Hamilton.
“I think we’re starting to see the beginning of changes in behaviour,” he said. “I think that people are, at this point, choosing to have fewer partners or engage in intimacy in ways that don’t put them at a lot of risk.”
Physical distancing has been at the heart of recommendations from public health experts to combat the spread of COVID-19. In the beginning, it was “stay home.” Now, it’s forming a “bubble” with limited people and maintaining at least a two-metre distance from most.
Costescu said he’s seen a drop in unplanned pregnancies and abortions, “suggesting people really were isolating.”
Even then, simply based on the numbers, he said it’s hard to say for certain.
“A lot of behaviour gets driven underground,” Costescu explained. “We don’t really know the true incidents of people meeting in clandestine ways during the pandemic. Those people may also be less likely to screen because they don’t want to be identified as breaking the rules.”
That may change as provinces begin to loosen rules and guidelines, making way for more socializing.
The data from PHO from both 2019 and 2018 shows an incline in STI cases during the summer months. Now, in 2020, as provinces get the green light to expand social circles and return to bars and restaurants, Costescu said the opportunities for people to hook up will grow both due to seasonality and more social avenues. Dating apps may play a role of their own, he added.
“I think it will be important for people not to panic when we start to see numbers go up because it’s always hard to pinpoint the true incidence,” he said. “Some of the changes in numbers will be related to doing the tests themselves, and some will be related to the true incidents. That goes hand in hand with testing. When you’re not testing, you’re spreading more.”
Rates in other provinces
Unlike Ontario, most testing volumes in British Columbia monitored by the B.C. Centre for Disease Control (BCCDC).
Jason Wong, a physician epidemiologist at the BCCDC, who tracks STIs, said the province has also seen a decrease in the number of cases during the COVID-19 pandemic.
The lab has also seen a drop in testing volumes for both syphilis and HIV.
In Saskatchewan, however, there was already a struggle with increasing STIs as the province prepared for COVID-19. Syphilis cases have increased in the province this year.
In the first three months of 2020, there were 158 cases of syphilis in the province; that’s up from 58 from the same period in 2019.
Rates of chlamydia and gonorrhea decreased by 7.4 per cent and 14.7 per cent, respectively, during the same period, though the Saskatchewan Health Authority (SHA) said those reductions may, in part, be due to lab equipment being redeployed to detect COVID-19.
That’s a factor that could also be skewing the numbers for Ontario, said Murti.
There’s been a “diversion of public health services” in Ontario towards COVID-19, she said. As health units try to catch up, the number of cases for the first four months of 2020 could fluctuate.
“It’s not a static system,” Murti said. “When the first results come in, the time from getting that result to putting it into the data system might be delayed as well just because of the resources going into other data entry right now. Plus, the investigation into each case. Some might be open for longer.”
There’s a myriad of factors that could be at play in these numbers, Costescu said. Untangling what’s the most prevalent will be difficult.
He said data from the next few months — May and June — might be more telling. But if physical distancing habits are kept up, he said there’s a chance the numbers could stay low.
“There are other downstream effects to isolation. … People are limiting their number of partners and limiting it to people they know well or close contacts,” he said.
“In the same way with coronavirus, if you only have sex with one other person, you’re much less likely to get an STI than if you’re having it with multiple people.”