Summer of love: STI cases dropped during the pandemic, will they rise again as we reopen?

As Ontario closed its doors in the spring of 2020, Ontarians stayed in — and rates of some sexually transmitted infections dropped.

The number of reported cases of chlamydia and gonorrhea plummeted during the early days of the COVID-19 pandemic, though they crept back up throughout the summer and fall of 2020 as restrictions loosened — and the same could happen again as the province reopens this summer, experts say.

In April 2019, Ontario reported 4,188 cases of chlamydia, according to data from Public Health Ontario. For the same month a year later, there were only 1,637 cases reported. Gonorrhea cases dropped similarly too.

“You can see we had kind of normal monthly levels for January, February of 2020. And then from March, you see a pretty significant drop off of cases, or almost less than half of the number of typical number of cases for chlamydia, gonorrhea and syphilis,” said Dr. Michelle Murti, medical director at Public Health Ontario.

This might partly be as a result of social distancing.

“We know from some of the evidence that’s available that our sexual activity has changed,” said Nathan Lachowsky, an associate professor in the School of Public Health and Social Policy at the University of Victoria. “For a lot of people, it’s reduced both in terms of number of partners or in terms of the kind of sex that people are having.”

“So, that on a network level or a population level means that our STI epidemics are being interrupted to some extent.”

Even the company Match Group Inc., which owns a number of dating apps like Tinder, OkCupid and Hinge, noted in its 2020 annual report that subscriptions fell during lockdown periods as meeting in person was restricted.

“Over the summer, as users began to meet outdoors first-time subscribers increased to above COVID-19 levels. Since the end of the summer, the resurgence of COVID-19 lockdowns has once again negatively impacted first-time subscriber trends, though not as severely as in the spring of 2020,” the report reads.

But Murti thinks the primary reason STI numbers fell is simply that people weren’t getting tested. When in-person medical appointments were highly restricted, she said, case numbers dropped. Getting laboratory results for tests was also harder at the height of the pandemic’s first wave.

Some STIs don’t always present with obvious symptoms either, she said.

“For some people, they do have common symptoms of chlamydia or gonorrhea: pain with peeing, some discharge, irritations, rash symptoms,” Murti said. “So they might go to their health care provider to seek testing because of those symptoms. But also, about 50 per cent of people with chlamydia and gonorrhea have no symptoms. So often they’re picked up through more usual preventive routine care.”

If people were skipping routine medical appointments, they might not have had the kinds of incidental tests that would pick up asymptomatic infections, she said.

Notably, while gonorrhea and chlamydia cases rose and fell alongside the first and second waves of the COVID-19 pandemic, diagnoses for syphilis and HIV remained fairly steady, with only a small blip at the beginning of the first wave. B.C. reported similar trends in these two diseases too.

Lachowsky thinks this might be an indication that the communities who are disproportionately affected by these diseases still maintained some access to care.

Murti says it may also have to do with how the disease progresses. It takes months for someone who contracted HIV to be able to test positive for it, she said, so someone who tested positive in March 2020 would have acquired the infection much earlier.

She’s particularly concerned by the three cases of congenital syphilis — syphilis passed from an infected pregnant woman to her baby — that Ontario recorded in 2020. Normally, all pregnant women get screened for this infection and treated if they have it, she said, with the result that Ontario normally records only one or two cases per year.

“If women aren’t getting the access to care that they need in terms of getting treatment during pregnancy, then that’s a real failure of the system,” she said.

Lachowsky agrees that the data is likely missing a lot of people with STIs.

“What I think is important to note, though, is that if someone was living with an STI without diagnosis and treatment, that STI is still going to persist,” he said.

If left untreated for months, even mild or asymptomatic cases of gonorrhea or chlamydia can lead to more serious conditions like pelvic inflammatory syndrome, or even infertility in severe cases, Murti said, adding that cases are unlikely to resolve on their own.

And while most chlamydia is treated with an oral medication, the primary treatment for syphilis and gonorrhea is an injection — so people who haven’t gone to a doctor’s office probably weren’t treated, she said. Murti also noted that early on in the pandemic, there were even shortages of some of the medications used to treat syphilis, though that has since been resolved.

So what does that mean for the summer, as more people get vaccinated against COVID-19 and gathering restrictions begin to lift?

Unfortunately, Canada has seen an uptick in STI cases over the last few years, except in 2020, and Murti doubts the pandemic has stopped the overall trend.

“I think that the numbers we saw, even if they’re similar to last year, are actually probably still very much an undercount of what actually has been happening out there,” she said. “And I wouldn’t be surprised at all if we actually see much higher numbers going into the remaining part of 2021 and 2022, just as people sort of start taking care of that kind of preventative health again and we have more ability to look for these infections.”

“I think that, naturally, there will be an increase in terms of sexual activity, and I think that’s something that a lot of people are probably looking forward to and excited about,” Lachowsky said. “And so we need to make sure that our health system is able to make sure that we support those people and those networks.”

That means returning to public sexual health messaging like “condoms, condoms, condoms!” and encouraging people to get tested, Murti said.

“If you at all think that you might have symptoms or may have been exposed, then it’s important to go and get tested and make sure you follow up on that treatment, as well as ensuring that all your partners get treated as well.”