We found that since the start of COVID-19 pandemic the number of STI reported cases was 51% less than expected, reaching an average of 56% during lockdown (50 and 45% during de-escalation and new normality) with a maximum decrease of 72% for chlamydia and minimum of 22% for syphilis. Our results indicate that STIs were less reported in females, people living in more deprived areas, people with no previous STI episodes during the last three years, and without HIV infection.
We hypothesize that the decline in the number of STI reported cases was higher in females based on the annual STI notification rates in the region where chlamydia has been usually higher among females and syphilis among males [1]. STIs, including chlamydia infection are predominantly asymptomatic in females, and are detected primarily through screening. During lockdown, mobility restrictions may have decreased healthcare seeking behaviour in asymptomatic individuals with high-risk exposures. This decrease could be even greater for people living in more deprived areas. Additionally, people who already visited sexual health care for previous STI episodes in the last three years, or HIV positive are more likely to seek health care.
To the best of our knowledge, few analysis have described the estimated magnitude and impact of the COVID-19 pandemic on the expected number of STIs compared to the most recent historical data. Although few articles have analysed STI incidences during lockdown, some authors argue that the plausible decrease of sexually relations during the COVID-19 pandemic may partially explain the apparent drop in the number of STI incidence [12,13,14]. In spite of these, different stakeholders have started raising awareness about disruptions in sexual health services including STI and HIV testing and detection [15, 16]. Moreover, it has been estimated that in the Atlanta (State of Georgia, United States), if sexual behaviour rebounds while service interruption persists, cases will increase in hundreds for HIV and in thousands for STIs for the next five years [17]. Berzkalns et al. performed a study in King County (State of Washington, United States) where the number of sexual health clinic visits decreased 55% during lockdown. Although after lockdown numbers returned to pre-lockdown values, around lockdown, from January–July 2020, the number of STIs diagnosed declined differently depending on the STI, from 9% for gonorrhoea to 22% for early latent syphilis [18]. They suggested that a real decline may have happened, but the larger decline in asymptomatic STIs probably indicates decreased screening. Similarly, Chow et al. described that, although a relevant decrease in the total number of consultations occurred in the Melbourne Sexual Health Centre during the lockdown, for more severe conditions such as pelvic inflammatory disease or infectious syphilis, a similar number of consultations to the pre-lockdown period was observed [19]. Recently, an article from the EuroTEST COVID-19 impact assessment consortium described that, among 34 countries in the World Health Organization (WHO) European Region and in different testing settings, 95% of them declared to have tested less than half the expected number of people between March and May 2020, a decline that continued at lesser degrees until August 2020 [20]. Then, this decline probably is due to the effect of a combination of factors; changes in the people’s behaviour, sexual relationships or fear of visiting a health care setting [21], less available resources to diagnose and notify STIs (including human resources), and surveillance systems which were not able to integrate the immediate reaction to a pandemic, while coping with their regular surveillance activities.
