Benjamin Ryan

The public health workforce tasked with fighting what has been a long-losing battle against sexually transmitted infections now finds itself confronted with a new, unfamiliar outlook: hope.

After having surged to record levels practically every year this century, overall diagnoses of the three top bacterial STIs have crested since the Covid pandemic. From 2022 to 2023, total diagnoses decreased by 2%, to 2.46 million new cases, according to a Centers for Disease Control and Prevention STI surveillance report published Tuesday.

And importantly, diagnoses of primary and secondary syphilis — the most infectious stages of the infection — dropped 10% last year, to 53,000 cases.

The decline was driven by a 13% drop in such syphilis diagnoses among gay and bisexual men, who are about 2% of the adult population but have historically accounted for nearly half of such cases.

STIs also spread disproportionately among young people and racial minorities. Just under half of the top three bacterial STIs were diagnosed among 15 to 24 year olds last year. Nearly one-third of cases were among Blacks, who are 13% of the population.

Overall, gonorrhea declined by 7%, to 601,300 cases, last year; that followed a 9% decline the previous year. Among all stages of syphilis, cases increased 1%, to 209,250 diagnoses. Chlamydia remained stable from 2021 to 2023, at about 1.65 million cases.

“I think we’re at an inflection point, and it’s important that we push forward and take advantage of innovations and investment of STI prevention going forward,” said Dr. Laura Bachmann, chief medical officer of the CDC’s STI prevention division.

The half-dozen other infectious disease experts who spoke with NBC News about the CDC report said they believed the sudden turnaround in syphilis diagnoses among gay and bisexual men was likely to be an early signal of such men’s eager adoption of a new, proven protocol in which the oral antibiotic doxycycline is used for STI prevention.

“That is huge cause for celebration. And I am a little surprised we see that trend at the national level already,” said Dr. Julie Dombrowski, a professor of medicine at the University of Washington. 

Referring to a recent decline in syphilis among men in Seattle, she added, “We definitely have seen it at the local level.”

Some experts expressed hope that doxycycline use among gay and bisexual men would have a positive spillover effect in women of childbearing age.

Syphilis poses the greatest threat to newborns, among whom it can cause severe congenital defects and death. Whereas cases of the STI in newborns increased by 30% annually in recent years — greatly alarming public health experts — the upward trend has decelerated. Such a promising shift was apparently driven in part by nationwide efforts to increase testing among pregnant women.  

In another hopeful development, a shortage that began in early 2023 of the only recommended treatment for syphilis among pregnant women, Pfizer’s Bicillin-LA, has abated.

In recent years, a trio of randomized controlled trials have shown that instructing gay and bisexual men and transgender women to take one 200-milligram tablet of doxycycline within 72 hours of condomless sex lowers cases of chlamydia and syphilis among them by more than 70% and of gonorrhea by about 50%.

The protocol is known as doxyPEP, which is short for doxycycline post-exposure prophylaxis.

San Francisco’s Public Health Department was the first to recommend doxyPEP for gay and bisexual men and trans women, in October 2022. The CDC followed suit in June. So have health departments in other large cities, such as Chicagoand New York, where LGBTQ community health centers have begun offering doxycycline to patients. 

A study of doxyPEP among cisgender women in Africa failed to show efficacy. There is, however, an ongoing trial in U.S. women. 

Thanks to penicillin, the nation made steady progress in fighting syphilis after World War II. By the mid-1990s, public health leaders were entertaining the possibility that the STI could be eliminated.

But the approval of effective HIV treatment in 1996 reduced the public’s fear of AIDS. That helped trigger a long decline in condom use among gay and bisexual men in particular. The subsequent approval of the HIV-prevention pill — called pre-exposure prophylaxis, or PrEP — in 2012 only hastened the decline. 

Bacterial STIs soared accordingly. 

DoxyPEP offers a promising form of harm reduction. It’s cheap and well-tolerated, and it can easily be folded into many gay and bisexual men’s routines for receiving prescriptions to treat or prevent HIV.  

Early analyses suggest doxyPEP is a sleeper hit in that population. 

A study published this month in the journal Sexually Transmitted Diseases found that San Francisco’s guidance on the preventive tool was tied to a decline in STIs among local men. A study published in next month’s edition of the journal found that among about 900 gay and bisexual men recruited for a survey through hook-up apps, half had heard of doxyPEP and nearly all expressed interest. 

A spokesperson for the PrEP-focused telehealth service MISTR told NBC News that since the company started offering doxyPEP in April, three-quarters of users who have filled PrEP prescriptions since then have also requested and received doxycycline. (The representative declined to provide the number of users that entailed but said MISTR serves “over 450,000 patients in all 50 states, D.C. and Puerto Rico.”) Since then, the overall quarterly STI positivity rate among MISTR users has plummeted from 12% to 6%. 

In November 2023, the Food and Drug Administration approved the first at-home tests for gonorrhea and chlamydia, which public health experts hope might also help combat the spread of STIs. 

And in July, researchers presented findings at a global HIV conference in Munich of studies in which gay and bisexual men in Canada and female sex workers in Japan were instructed to take 100 milligrams of doxycycline daily. The protocol, called doxyPrEP, demonstrated generally comparable efficacy at preventing STIs compared with doxyPEP studies among gay men.

Research is ongoing to address concerns that increased use of doxycycline to prevent STIs might help fuel the burgeoning drug-resistant pathogen crisis. Thus far, researchers have found reassuring signs. 

STI-prevention experts are also concerned that, as with HIV PrEP, doxyPEP will prove disproportionately popular among whites and thus will only widen racial disparities in STI transmission. Research is underway to analyze trends in doxyPEP’s use that could help focus promotion of the intervention where the need is greatest.

Public health experts have attributed this century’s surge in STIs, at least in part, to a steady defunding of state and local public-health clinics.

Dr. Jeffrey Klausner, an infectious disease expert at the University of Southern California who led the first study to demonstrate doxyPEP’s efficacy, called for renewed spending on STI-related care. 

“If Trump is going to make IVF — in vitro fertilization — free,” Klausner said of the president-elect’s emphatic campaign pledge, “he should make STI testing and treatment free.”

As concerns mount about a large outbreak of an especially virulent form of mpox in central Africa and an uptick in U.S. cases since early last year, the mpox vaccine appears to give long-term protection, the Centers for Disease Control and Prevention reported Thursday.

In a separate report, the CDC indicated that overall new mpox infections across the U.S. have remained at a steady, low level —–  about 60 cases weekly, compared with 3,000 cases a week at the outbreak’s summer 2022 peak —– in recent months. However, cases so far this year are elevated nationally compared with the same period in 2023 and have seen a sharp increase in New York City. 

People who have gotten two doses of the Jynneos mpox vaccine are protected against infection and don’t need a booster at this time, according to the CDC. 

Public health experts are concerned that the launch of the summer travel season and the upcoming LGBTQ Pride festivals in cities across the country will drive greater sexual connectivity among gay and bi men and potentially hasten mpox transmission.

Christina Hutson, chief of the CDC’s Poxvirus and Rabies Branch, and other public health experts told NBC News that this is no time for complacency about mpox (formerly called monkeypox). The various factors that likely have kept the U.S. outbreak relatively in check since late 2022 — including vaccination, infection-driven immunity, and sexual behavioral change — may be tenuous.

The mpox outbreak is “poised to return under the right conditions,” said Dr. Jeffrey Klausner, an infectious disease expert at the University of Southern California. Infections rapidly tore around the globe beginning in May 2022 and made that summer a misery for many gay and bisexual men before collapsing worldwide.

Critically, the proportion of at-risk American gay and bi men who are fully vaccinated against mpox is considered inadequate to assure long-term protection for this vulnerable population.

“Vaccination is a critical way to help protect yourself and others,” Hutson said. “It’s important that people at risk for mpox exposure who have not previously recovered from mpox — including certain gay, bisexual, and other men who have sex with men — complete the two-dose Jynneos vaccination series.” 

On May 16, the CDC published an ominous report about nearly 20,000 recent cases of what is known as clade 1 of mpox that have been documented in the Democratic Republic of Congo, or DRC, since January 2023. 

Concerningly, this viral clade appears to be more transmissible and to cause higher rates of severe disease and death compared with clade 2 of mpox, which drove the recent global outbreak. Five percent of those diagnosed with clade 1 in the DRC have died, compared with just 0.2% of the 96,000 people in the global clade 2 outbreak.

To date, there have been no reports of clade 1 cases outside of the handful of African nations where mpox has been endemic for decades. In December, the CDC first alerted health care providers of the possibility that this more harmful viral clade could hit the United States.

“We’re facing a big, potentially dangerous situation,” Ira Longini, a biostatistician at the University of Florida, said of the potential for global spread of clade 1. “But we really don’t know.”

Dr. Boghuma Titanji, an assistant professor at the Emory University School of Medicine, suggested that the Jynneos vaccine will likely provide protection against clade 1. The Jynneos vaccine is approved in the U.S. for mpox regardless of clade. 

“It’s reasonable to anticipate that there would be some immune cross-protection,” she said of immunity stemming both from the vaccine and previous infection with clade 2.

A clinical trial of the Jynneos vaccine is ongoing among health care workers in the DRC. It is not expected to be completed until the end of next year.

But the vaccine has not otherwise been rolled out in the DRC, a lost opportunity to help control the nation’s outbreak and prevent clade 1 from spreading globally, Titanji said.

Dr. Placide Mbala, the head of epidemiology and the global health department at the University of Kinshasa in the DRC, said the nation has seen “a lot of interest” from global public health leaders in providing such assistance. 

“But we are still waiting for concrete action,” Mbala said.

During the clade 2 outbreak, mpox has overwhelmingly transmitted via intercourse, both oral and anal, between men. Transgender people have also been disproportionately affected. The virus has not transmitted readily through the air or surfaces, in health care settings, or through casual, nonsexual contact.

In an interview earlier this year, CDC epidemiologist Dr. Jennifer McQuiston said mpox “needs to be thought about as an STD. The good news is it’s a preventable STD.”

Multiple studies of real-world uptake of the Jynneos vaccine have suggested that receiving both doses is associated with a 66% to 89% lower infection rate and one dose is 36% to 75% effective.

In one of the new CDC reports, agency investigators analyzed demographic data and clinical characteristics concerning 271 mpox cases from the U.S. outbreak’s outset in May 2022 to May 2024 among fully vaccinated people in 27 U.S. jurisdictions that provided sufficient related data. 

According to a CDC official, the agency estimates that only 0.1% of the fully vaccinated population developed a breakthrough infection. Reported such cases amounted to 0.8% of all 32,819 mpox diagnoses nationally. Thirteen percent of mpox cases were in partially vaccinated people.

The CDC estimates that 2 million men in the U.S. are at significant risk of mpox because they engage in sex with multiple male partners or otherwise are HIV positive; people with HIV have had a high mpox diagnosis rate. Of the overall group of at-risk gay and bi men, only approximately 25% have been fully vaccinated and an additional 14% have received one Jynneos shot.

In keeping with previous studies, the CDC’s new report found that full vaccination was associated with less severe disease and a lower hospitalization rate.

All 56 mpox deaths were among unvaccinated people.

Recent research has raised concerns that the antibodies Jynneos prompts wane over time. But the CDC investigators found evidence that, at least so far, the vaccine’s actual protection against infection hasn’t waned, possibly due to what’s known as innate or cell-based immunity.

Shortly after the vaccine was first rolled out in midsummer 2022, U.S. health authorities began stretching the temporarily short supply by changing its administration from a traditional subcutaneous (under the skin) shot to an intradermal (within the skin) shot that allowed for a much lower dose.

The new CDC report found no evidence that this vaccine-application shiftcompromised vaccine effectiveness.

A separate new CDC analysis of recent U.S. mpox diagnoses found the virus is still overwhelmingly seen among gay and bi men. Just 0.4% of recent cases were in people younger than 18.

Between October and April, 1,802 probable and confirmed mpox cases were reported to the CDC by 42 jurisdictions — for an average weekly rate, which remained essentially steady, of 59 cases. By stark contrast, the nation saw 2,000 to 3,300 weekly cases at the outbreak’s peak between mid-July and late August 2022.

And yet, CDC records show that the nearly 750 mpox cases seen this year through mid-April is more than twice the figure reported during the comparable period in 2023. New York City has seen a nearly five-fold case-rate increase between these two periods, with 191 cases thus far in 2024.

As for concerns about how a U.S. outbreak of clade 1 might transpire, infectious disease experts said they could only speculate whether higher quality health care, for one, might yield a lower death rate than in the DRC. Global clade 2 deaths have largely occurred among peoplethose with compromised immune systems, mostly due to untreated HIV.

Other unknowns include how and among which groups clade 1 might tend to transmit in Western nations. The DRC outbreak has occurred both in men with multiple male sex partners and in female sex workers and their contacts. And two- thirds of the DRC’s clade 1 outbreak has been in people under age 16; only a bit over 1% of the global clade 2 outbreak was in minors.

Epidemiologists see evidence of sustained person-to-person transmission in one DRC province, where cases are primarily in adults. 

While this transmission apparently has largely been through sex, compared with clade 2 of mpox clade 1 shows signs that it can nevertheless transmit more readily absent sexual contact. However, clade 1 still seems to require close personal contact, and nonsexual transmission appears largely limited to household settings. Also, the substantial transmission in children could be driven in part, the recent CDC report suggested, by multiple spillovers from wild animals encountered by young people in rural settings.

CDC officers believe that widespread transmission of clade 1 among children in the U.S. is much less likely, owing to a lack of an animal reservoir, less- crowded living quarters, and better cleaning and hygiene.

Emory’s Titanji reported worries that the gay and bi men she cares for quickly lost interest in mpox vaccination after the outbreak stopped being a primary concern for them. During the fall of 2022, the nation’s weekly distribution rate of Jynneos shots plummeted in tandem with the mpox case rate. 

Since then, no substantial progress has been made in raising the proportion of at-risk gay and bi men who have received both Jynneos doses.

“If you’re not yet vaccinated and you meet criteria, go and get vaccinated,” Titanji said. “We can’t be complacent about the response now moving forward.”

The Food and Drug Administration’s first-ever approval of an at-home test for chlamydia and gonorrhea could help drive earlier detection and treatment of these sexually transmitted infections amid a ballooning epidemic in the U.S. But some sexual health advocates worry that the FDA’s proposal to begin stepping up regulation of over-the-counter self-testing of STIs could backfire.

The need for new tools to combat these infections is dire. 

Diagnoses of gonorrhea, chlamydia and syphilis have soared in the past two decades. Public health experts argue that this is at least partially driven by woeful long-term flat funding of the Centers for Disease Control and Prevention’s budget to fight the spread of STIs during this period. 

Some public health officials and advocates expect that greater FDA oversight will help legitimize home STI testing, making it easier to get insurance coverage and actually expanding its use.

Other home tests for these three bacterial STIs are already available over the counter. But the FDA, which has not previously sought to enforce regulation or require that their manufacturers apply for formal approval, cannot vouch for their accuracy.

A consortium of LGBTQ sexual health advocates has objected to a recent FDA policy proposal that, if enacted, would require the companies already offering at-home medical tests, including for STIs, obtain regulatory approval. A central worry is that the expense of meeting the FDA’s demands could drive some companies out of the STI self-testing market and otherwise drive up the cost of the tests. 

There are also concerns that the newly approved test does not cover syphilis and is not well suited to address gay and bisexual men’s needs. 

The test kit, called Simple 2, does not screen for syphilis, which typically requires at least a finger-prick blood sample. There were at least 177,000 syphilis cases in 2021, a 74% increase since 2017, according to the CDC. Most concerningly, CDC data shows that rates of syphilis in newborns, which can be fatal, rose more than tenfold in the past decade.

Dr. Boghuma Titanji, an infectious disease specialist at Emory University, said that the inconvenience of having to go into a clinic was a major barrier to getting at-risk people tested for STIs.

“Just remove that requirement, that will make the access better for a lot of patients,” she said.

Dr. Leandro Mena, director of the Division of STD Prevention at the Centers for Disease Control and Prevention, believes the new at-home test’s approval will indeed increase testing for gonorrhea and chlamydia. 

Self-testing, he said, provides “a tremendous opportunity to empower people to control when, where and how they get tested, and how they learn about their test result, so they can get appropriate treatment for these STIs.”

Chlamydia and gonorrhea are the most common STIs in the U.S., diagnosed in 1.6 million and 710,000 people respectively in 2021, according to the CDC. They can often be asymptomatic and are easily cured with antibiotics. However, if left untreated, the infections can lead to infertility and can be especially harmful to women, leading, for example, to pelvic inflammatory disease. They spread disproportionately among adolescents and young adults, gay and bi men, and people of color.

Will FDA oversight help or hinder the STI fight?

On Nov. 15, the FDA granted marketing authorization for adults to use the over-the-counter Simple 2 Test for gonorrhea and chlamydia, from the home-testing company LetsGetChecked. The test kit, currently sold for $99 through the company’s website, can be activated online, where the consumer fills out a health questionnaire before shipping in samples to a laboratory.

If the results are positive, the company would then put the individual in contact with a physician.

Previously, HIV was the only other sexually transmitted infection to have an FDA-approved at-home test.

Other at-home STI tests are available through telemedicine companies and major pharmacy chains. However, these tests exist in a legal gray zone. Because they’re based on samples that are not taken in a lab, they don’t qualify for an exemption from requiring FDA approval that the agency grants to so-calledlaboratory-developed tests.

The FDA has generally not sought to exert control over home-based tests. However, on Sept. 29, the agency opened a two-month public comment period on a proposed new plan to require companies offering medical self-testing kits for any purpose to seek formal marketing authorization for their products. The FDA’s move followed reports of faulty self-tests that led to undertreatment or improper treatment for heart disease and cancer. 

The goal, according to the FDA, is to “ensure the safety and effectiveness of these tests.”

In response, a group that includes sexual health advocates and owners of gay dating apps that provide free at-home HIV and STI testing, began circulating a petition that calls for the FDA to exempt such public health programs from the proposed new demands. Gaining approval for existing STI tests, the petition states, would involve a “time-consuming and expensive process.”

“Many public health leaders are concerned that new FDA regulations will create additional barriers to public health testing,” said Jen Hecht, director of the consortium Building Healthy Online Communities.

Dr. Matthew Golden, who leads the HIV and STI control program at Seattle’s public health department, said that the FDA is playing catch-up in an effort to enforce regulation of an industry that has grown fast since Covid.

“At some level, the horse has left the barn,” said Golden, noting that self-testing kits have been widely used for years. However, he said that for “some of those tests, how well they perform is not well known. So cleaning this up makes sense.”

A source familiar with FDA policies and practices told NBC News that if the agency decides to demand that self-testing companies obtain regulatory approval, it would not likely interrupt the availability of existing medical self-tests during the application process. 

That said, it is likely that once a critical mass of self-testing companies obtained or otherwise sought approval, the agency would go after any laggards.

Gay men’s needs are left out — for now

The Simple 2 Test is effectively geared only toward STI exposures from vaginal intercourse.

The kit can process a urine sample and a swab of the vaginal area. Chlamydia and gonorrhea infections, however, can be localized in the throat, urogenital area or rectum. A urine sample can detect urogenital infections in men and women. For people who may have otherwise been exposed through oral or anal sex, oral and rectal swabs would also be needed.

David Harvey, executive director of the National Coalition of STD Directors, said that public health experts “expect and need” the FDA ultimately to approve at-home tests for syphilis and for oral and rectal gonorrhea and chlamydia infections, “so we’re also reaching others who are at high risk, including gay men.”

The CDC’s Mena said he hoped that the agency and the FDA will confer with LetsGetChecked or other testing companies about pushing for additional approvals.

The FDA’s authorization for the Simple 2 Test was based on data indicating that consumers could successfully use the home tests, understand the results and then take any necessary subsequent action.

It’s unclear whether the test will be available outside LetsGetChecked website or whether $99 kit will be covered by insurance. The company didn’t respond to requests for comment. 

Tristan Schukraft, CEO of MISTR, a telehealth company that provides the PrEP HIV prevention pill, is supportive of greater FDA oversight of home tests, but expressed concern that tighter regulation could increase the cost of testing. 

“Labs are going to be required to spend additional money and resources on studies, quality systems, reagents and software systems,” Schukraft said.

In addition, MISTR requires that PrEP recipients undergo testing every three months for chlamydia, gonorrhea and syphilis. At least 85% of MISTR customers on PrEP opt for at-home testing. The company advises people who test positive — about 13.5% of the kits detect at least one STI — to seek medical care and provides assistance in connecting people to care for those who need it.

Schukraft suggested that greater regulation could lead companies to pull such tests from the market. 

If so, he said, “the FDA would be doing harm to public health.” 

A new antibiotic has proven as effective as the last remaining recommended treatment for gonorrhea, helping to assuage mounting fears among public health experts about the emergence of drug-resistant strains of the sexually transmitted infection.

Gonorrhea is the second most common STI in the U.S. and has developed resistance to all antibiotics used to treat it, except for the recommended combined therapy of an injection of the antibiotic ceftriaxone with one dose of azithromycin pills. In recent years, ominous reports have suggested that this antibiotic arsenal might not maintain its robust effectiveness against the fast-evolving pathogen for much longer.

On Wednesday, results from a late-stage clinical trial of a new antibiotic called zoliflodacin showed the drug cured so-called uncomplicated gonorrhea infections as effectively as ceftriaxone and azithromycin. The drug was developed by the Global Antibiotic Research & Development Partnership, a Swiss nonprofit, and the U.S.-based Innoviva Specialty Therapeutics.  

“Zoliflodacin gives us a new tool in the treatment of gonorrhea, and if used wisely, a barrier against the further spread of resistant infections,” said Dr. Jeffrey Klausner, an infectious disease expert at the Keck School of Medicine of USC, who was not involved in the trial.

The antibiotic, which would be the first new gonorrhea treatment approved in decades, could make it to market by 2025.

The World Health Organization estimates that globally there are more than 82 million new gonorrhea cases every year. In the U.S., in the wake of decades of cuts to state and local public health departments, STIs have soared to record heights. In 2021, there were 710,151 diagnosed cases of gonorrhea, a 28% increase since 2017, according to the Centers for Disease Control and Prevention.

Gonorrhea spreads through sexual contact and can separately infect the genitals, rectum and throat.

The STI is especially common among adolescents and young adults and occurs disproportionately among gay and bisexual men, the CDC reports. Left untreated, gonorrhea poses a risk of infertility and can prove especially damaging to women, leading to pelvic inflammatory disease and ectopic pregnancy. The infection can also raise the risk of HIV transmission.

In recent years, global health authorities have issued increasingly urgentwarnings that gonorrhea has been acquiring resistance to ceftriaxone and azithromycin, with cases of highly drug-resistant gonorrhea reported in multiple nations.

In January, the Massachusetts Department of Public Health reported the first two U.S. cases of gonorrhea that had resistance or reduced response to five classes of antibiotics. Ceftriaxone did cure those cases, but public health officials said they served as a harbinger for the emergence of strains that could evade the antibiotic.

Without a new antibiotic weapon, curing highly drug-resistant strains of gonorrhea could require intensive treatment with multiple antibiotics, according to Dr. Jeanne Marrazzo, director of the National Institute of Allergy and Infectious Diseases. This so-called kitchen-sink approach, she said, would strain medical resources and raise the risk of driving the emergence of further microbial drug resistance to those other antibiotics.

The ultimate fear is that eventually, gonorrhea could prove wholly untreatable, in at least some people.

According to an Innoviva representative, the company aims to file for approval of the antibiotic with the Food and Drug Administration “as quickly as practicably possible.” Innoviva expects an expedited review, meaning the FDA would take about six months to issue a decision.

Zoliflodacin belongs to a new class of antibiotics, and attacks gonorrhea in a novel way. In previous laboratory studies, zoliflodacin proved effective at neutralizing gonorrhea strains that were highly resistant to ceftriaxone and azithromycin and strains that had resistance to other antibiotics as well.

A downside of zoliflodacin is that a previous, phase two clinical trial published in 2018 found that it was not as efficacious at treating gonorrhea infections in the throat as in the genital or rectal areas. However, Marrazzo, who was a co-author on that study, said that this disparity is common among gonorrhea treatments.

“Gonorrhea in the throat is probably going to be a major Achilles heel in our battle to control gonorrhea going forward,” Marrazzo said.

But according to Dr. Margaret Koziel, chief medical officer of Innoviva, the new zoliflodacin trial showed “encouraging” results in the small number of participants with rectal or throat infections. 

The company “will certainly engage the FDA about whether the label indication might be for urogenital disease or for all uncomplicated gonorrhea,” Koziel said.

According to Dr. Manica Balasegaram, executive director of Global Antibiotic Research & Development Partnership — Innoviva’s partner in the trial — zoliflodacin holds promise in retaining potency against gonorrhea for a longer period than previous treatments for the infection, because it was developed solely as a treatment for that STI. Ceftriaxone and azithromycin are each used to combat numerous other infections; and the more they are used, the more opportunity gonorrhea has to develop resistance to them.

“This new drug is also given orally instead of an intramuscular injection with ceftriaxone; this is an advantage,” said Dr. Jean-Michel Molina, who studies STI prevention at the University of Paris and was not involved in the clinical trial.

Molina is the head of one of the multiple clinical trials currently running of a meningitis B vaccine as prevention for gonorrhea. He said he expects to present final results of his trial at a scientific meeting in 2024.

The new zoliflodacin study enrolled 930 men, women and adolescents, including people with HIV, with uncomplicated gonorrhea at 16 trial sites in five nations, including Belgium, the Netherlands, South Africa, Thailand and the U.S. Participants were randomized to receive a single oral dose of zoliflodacin or a ceftriaxone injection plus oral azithromycin.

The WHO has called the emergence of drug-resistant pathogens one of the top 10 global public health threats facing humanity and has identified gonorrhea in particular as a priority pathogen.

The zoliflodacin trial is the first to address such a priority pathogen that was marshalled by a nonprofit organization. Established in 2016 by the WHO to help shepherd new antibiotics to market, efforts by the Global Antibiotic Research & Development Partnership’ represent a promising new front in the vital effort to spur research and development of new antibiotics. Offering only thin profit margins, antibiotics do not tend to attract investment by pharmaceutical companies.

“Treating gonorrhea, it’s not going to be your next Ozempic,” said Marrazzo.

As an increasing proportion of Americans identify as LGBTQ, leaders in sexual and gender minority health care say that the nation’s medical schools are largely failing to adequately prepare the next generation of doctors to properly care for this population.

The need is critical, according to experts in medical education and LGBTQ care. Lesbian, gay, bisexual, transgender and queer people, as stigmatized minorities, often have difficulty accessing health care that properly addresses their health concerns, that is sensitive to their sexual and gender identities and that is not flat-out discriminatory, researchers have found.

“It’s terrible that there’s a whole population of people who aren’t getting the health care they need,” said Ann Zumwalt, an associate professor of anatomy and neurobiology at the Boston University Chobanian & Avedisian School of Medicine and a leader in the effort to improve medical school curricula pertaining to LGBTQ care.

In 2014, the Association of American Medical Colleges, or AAMC, released a call for the 158 U.S. and Canadian medical schools to provide comprehensive training in caring for LGBTQ people and those born with sex-development differences. 

Since then, the need for such instruction has only ballooned, given the dramatic increase in LGBTQ identification among young people in particular. 

“The current political and social climates are unfortunately leading to many, many health care-professional students and residents feeling uncertain and frightened to engage in LGBTQ+ education and training.”

DR. DUSTIN NOWASKIE, OUTCARE HEALTH

A constellation of medical schools has heeded the AAMC’s call — progress that inspires hope among queer-health advocates. But the schools’ adoption of comprehensive LGBTQ-focused curricula are the exceptions to the rule. The organization’s call, which was buttressed by a 300-page roadmap for reform but lacked the teeth of a mandate, has mostly gone unheeded nearly a decade later.

Progress at medical schools has been stymied by a myriad of factors, including the lack of LGBTQ-related content in medical licensing exams; inadequate or nonexistent knowledge and clinical experience among educators; administrators and the medical old guard’s resistance to change and concerns about competing educational priorities; and outside political pressures as conservatives seize upon transition-related care for minors and diversity policies as wedge issues and as they scrutinize higher education. 

Dr. Alex S. Keuroghlian, director of education and training at the LGBTQ-focused Fenway Institute in Boston, and six other medical educators who asked to remain anonymous out of fear of the very reprisals they described told NBC News that recent state-level efforts to restrict diversity programs in education and transition-related health care for transgender minors have instilled fear in some medical schools that their LGBTQ-related medical training could draw increased scrutiny and punitive attacks from legislators. 

Keuroghlian, who is also an associate professor of psychiatry at Harvard Medical School, said that the recent state gender-care bans would likely have a chilling effect “on our ability to teach in an evidence-based way that is grounded in human rights and autonomy.”

Where are the needs? 

Researchers who have assessed the capacity of the nation’s health care workforce to serve the specific needs of LGBTQ Americans have found them woefully unprepared, especially to care for transgender people. And LGBTQ people remain in dire need of improved physical and mental health care, according to a trove of studies.

Despite the population skewing younger, 23% of LGBTQ people report being in poor health, compared with 14% of the non-LGBTQ population, according to the health-care analysis nonprofit KFF. And research finds that as many as 1 in 5 LGBTQ people have experienced discrimination during health care encounters, including refusals to prescribe medication and even verbal attacks.

Resulting alienation from the health care system, researchers say, is a key driver of the various health disparities that plague LGBTQ Americans. Such apparent consequences include elevated rates of heart disease, cancer, depression and anxiety, substance use disorders and risk of suicide. These disparate outcomes, according to researchers, are likely also fueled by the damage that being a member of a stigmatized minority can apparently inflict upon the mind and body. These are pervasive problems that the health care establishment would ideally mitigate, not exacerbate. 

And yet a 2011 survey of 176 U.S. and Canadian medical schools found that their students received a median of just five hours of LGBT-related training. One in 3 schools devoted no such time during clinical rotations.

Dr. Dustin Nowaskie is the founder and president of OutCare Health, a nonprofit LGBTQ health-equity organization that is at the forefront of a growing movement to improve medical training on this front and has developed queer-medicine training programs for both medical students and physicians. Nowaskie, who uses gender neutral pronouns, argued in a 2020 paper that medical schools should, in fact, provide at least 35 hours of such training. This instruction, according to Nowaskie, should start with basic terminology and cultural sensitivity and expand to issues such as health conditions that occur at higher rates among LGBTQ people, including sexually transmitted infections and skin cancer.

“These skills should absolutely be required,” Nowaskie said, because of the expanding LGBTQ population and the inevitability that doctors will frequently treat such patients. Nowaskie said they consistently hear from medical students nationwide that LGBTQ-specific instruction is “often minimal,” and that it is “very outdated,” relying on language, terminology and an overall understanding of queer people that has otherwise been retired thanks to recent social progress. 

A recent Gallup poll found that over the past decade, the proportion of Americans openly identifying as LGBTQ has doubled, to 7.2%, and that 1 in 5 young adults say they identify as something other than a cisgender heterosexual. The Williams Institute at UCLA Law recently estimated that 0.5% of older adults identify as transgender, compared with 1.4% of adolescents and 1.3% of young adults.

A team directed by Dr. Carl Streed, research lead for the Center for Transgender Medicine and Surgery at Boston Medical Center, is preparing to publish an update of the 2011 medical school survey. Streed was keen to highlight medical schools that have adopted comprehensive LGBTQ-related curricula — including, among many others, the University of Kentucky at Louisville, Stanford University and Boston University, where Streed is an assistant professor. But Streed tempered expectations that his team would identify much of an uptick in overall training. 

“Who ends up being remotely comfortable and competent” in caring for sexual and gender minorities, Streed said, “is a matter of wherethey trained rather than whether they’ve been trained.” 

Any progress over the past decade has transpired against a split-screen backdrop of sweeping advances for LGBTQ civil rights and, in response, a fierce backlash against transgender rights, in particular. At least 20 states have now passed various restrictions on transition-related care for minors — a legislative effort that even many physicians who express misgivings about the science backing such treatment say they oppose.

“The current political and social climates are unfortunately leading to many, many health care-professional students and residents feeling uncertain and frightened to engage in LGBTQ+ education and training,” Nowaskie said.

“At the same time,” Nowaskie said, “these climates are perpetuating health care stigma among biased, discriminatory providers.” 

How medicine can fail LGBTQ people

Delia M. Sosa, a first-year medical student in Ohio, wants to focus on LGBTQ care. Sosa, who uses gender-neutral pronouns, said they are motivated, in part, by their own alienating encounter with the medical old guard. 

After growing up in what they described as a conformist Christian community in New England, Sosa came into their trans and nonbinary identity in their early 20s. At 21, they sought to establish a relationship with a primary care physician in their hometown in hopes of eventually having a double mastectomy, or what’s known in trans medical care as top surgery. But after Sosa disclosed to the doctor their queer identity and the fact that they were dating a nonbinary person, they recalled, “she looked at me with a look of confusion” that was also “mixed with frustration.”

“Medicine is playing catch-up in a lot of ways. … I get some really seasoned, experienced physicians who come up to me and say, ‘I never had a chance to learn about this, yet I know this is something I need to learn.’”

DR. SARAH PICKLE

Sosa said they spent the bulk of the appointment providing the doctor a trans-identity 101 tutorial, including breaking down the difference between gender and sex, what it means to be nonbinary, what gender neutral pronouns are and how sexual orientation can be fluid with respect to the gender of partners. They found the experience so off-putting, they let three years pass before seeking surgery again, which they ultimately had last year.

Dr. Sarah Pickle, a family physician and medical educator in Ohio, is a leading proponent of medical schools cultivating a deft hand in up-and-coming physicians in how to care for LGBTQ people. Pickle insists that such training, which focuses, for example, on speaking with sensitivity and inclusivity regarding queer people’s differences, can be crucial in keeping LGBTQ people engaged in care.

“Medicine is playing catch-up in a lot of ways,” Pickle said. “I get some really seasoned, experienced physicians who come up to me and say, ‘I never had a chance to learn about this, yet I know this is something I need to learn.’”

Sosa discovered their own evidence of the potential perils of physicians’ lack of knowledge about treating LGBTQ patients when researching trans people’s experiences with cancer care. Some oncologists, Sosa found, were confounded over how to manage such treatment in a patient taking cross-sex hormones. 

“I can’t tell you how many stories I heard of trans folks where they had delayed care because an oncologist didn’t know what to do with them,” Sosa said.

One expert in LGBTQ medicine, who preferred to remain anonymous because of attacks from the far right, described an often cavalier attitude among specialists toward trans patients’ hormone therapy. A cardiologist, they said, might advise a patient to simply go off hormones due to cardiovascular risk, rather than thoroughly reviewing the risks versus benefits of a therapy that is fundamental to many trans people’s sense of self and well-being.

This health care provider and medical educator expressed frustration that such doctors often remain ignorant to studies that provide insight into managing hormonal therapy in the context of certain health problems. 

Who is leading the change? 

Keuroghlian stands at the vanguard of the movement to train doctors in caring for trans and gay patients. 

At Harvard, he and a team of colleagues led a three-year effort to design and implement a new curriculum that provides comprehensive training in such care.

The curriculum, which other schools are free to adopt, permits all professors, regardless of their own identity or experience, to weave LGBTQ themes and practices into their own instruction. So, for example, a course on endocrinology would include instruction on cross-sex hormonal treatment and an embryology course would teach about intersex variations.

Bringing a broad swath of medical educators up to speed is crucial, Keuroghlian said. A major roadblock to progress has been the fact that the professors, who are meant to pass on their own acquired knowledge, have typically never received their own training in sexual and gender minority care. So, in addition to the four-hour training he helped craft for Harvard faculty about how to teach this subject, Keuroghlian is among the educational pioneers, a group that includes Nowaskie, who are designing medical education seminars to train other health care providers nationwide.

Dr. Christopher Terndrup, an associate professor of medicine at Vanderbilt University Medical Center in Nashville, Tennessee, noted that most demand for LGBTQ health education “is actually pushed by the medical students themselves.”

But such eagerness from the new generation can hit old bureaucratic walls, according to Dr. Nelson Sanchez, an associate professor of clinical medicine at Weill Cornell Medicine and the chair of the annual LGBT Health Workforce Conference. Sanchez said administrators often resist calls for such curriculum by insisting that a zero-sum game governs all medical-school education hours.

Dr. Lily Rolfe, who recently graduated from Rush Medical College in Chicago and is matriculating to a residency in family medicine, with a focus on caring for LGBTQ patients, at Swedish Hospital in Seattle, conducted an informal survey of students at Chicago area medical schools about the quality of their education in caring for LGBTQ people. 

“It’s always, ‘The gay guy has HIV,’” Rolfe quipped regarding the typical way the respondents characterized their limited education on this front.

“HIV is important,” Rolfe said. “We should learn about it. But that shouldn’t be the entirety of LGBT health.”

Otherwise, the Chicago students said that social determinants of health pertaining to sexual and gender minorities were commonly addressed. But the survey respondents, Rolfe said, “noticed a lack of discussion about trans people, including gender dysphoria; gender euphoria; medical, social, legal and surgical transitioning; and a lack of the discussion of the over pathologization of trans people.”

Harvard’s LGBTQ curriculum, meanwhile, goes beyond just infectious disease, including basic concepts and terminology about gender and sexuality; stigma’s impacts on health inequities; major health concerns that are more common in LGBTQ people, such as anal cancer in gay men or breast cancer in lesbians; effective doctor-patient communication methods; navigating power imbalances and implicit bias; addressing microaggressions; and how to generate learning opportunities if an LGBTQ patient responds negatively to a physician’s words or actions.

Other med schools that have also established substantial training efforts on such subjects include Louisiana State University, the University of Mississippi at Jackson, the University of Wisconsin at Madison, Vanderbilt University, the University of Pennsylvania and Cedars-Sinai in Los Angeles.

The current hostile political environment notwithstanding, Keuroghlian said he remains optimistic for how well prepared the next generation of doctors will be.

“People in medical school are increasingly passionate about doing this work, because there’s more understanding for the need for skilled, culturally responsive care,” Keuroghlian said of sexual and gender minority care.

“There’s also a sense of social justice and health equity that drives young people to do this work,” he said. “They see this as one of the major health rights issues of their generation, and that’s very engaging for them.” 

But, he acknowledged, “we have a long way to go.”