Summer Sex, Silent STIs, and Sluggish Policy: A Wake-Up Call

Medscape

26-06-2025

Each summer, gonorrhoea, chlamydia, syphilis, and genital herpes cases rise as seasonal risk-taking behaviours lead to more consultations for suspected sexually transmitted infections (STIs). Despite this trend, the coverage of the human papillomavirus (HPV) vaccine remains insufficient, and mpox cases are re-emerging alongside a rise in syphilis cases.
'People in their 20s-40s are among the most frequent patients seeking care — often driven by anxiety after unprotected sexual encounters,' said Jean-Christophe Goffard, MD, PhD, in an interview with MediQualit y, a Medscape Network platform. Goffard is a professor at Université Libre de Bruxelles and director of the Internal Medicine Department at Hôpital Erasme in Brussels, Belgium, where he specialises in infectious disease screening and prevention.
Although this age group is more likely to consult a physician after potential exposure, many others delay care, sometimes because the symptoms are mild or overlooked. In many cases, STIs do not cause any symptoms.
'Many patients are asymptomatic carriers,' Goffard explained. 'They can still transmit the infection or develop complications.' This highlights the difference between infection and disease: One can spread without causing any symptoms. Such clinical silence is particularly problematic in young women, for whom undiagnosed chlamydia or gonorrhoea infection can have serious consequences, such as damage to the fallopian tubes, an increased risk for ectopic pregnancy, and infertility.
While some STI symptoms, such as vaginal discharge, ulcers, and burning, are common, others may be more subtle or misdiagnosed. Syphilis rashes, for example, can appear on the torso, palms, or soles. 'These macules may go unnoticed or be mistaken for other skin conditions,' Goffard warned.
Certain STIs can also present with neurologic or ocular involvement, such as vision loss, making diagnosis more complex and requiring increased vigilance.
Syphilis, once considered an 'old disease,' is returning. 'It is easily transmitted via oral sex, where condoms are rarely used. The epidemic has remained concentrated in certain groups; however, heterosexual transmission is increasing. In the US, universal screening is now recommended — as we did in the past, we should probably restart that here.'
HPV Vaccination
'HPV vaccination coverage remains well below expectations in Belgium, particularly in French-speaking regions. 'In all honesty, we are quite disappointed,'' said Goffard. 'Rates remain low, especially due to vaccine hesitancy, which has only increased since the COVID-19 crisis.'
Goffard emphasised the importance of vaccinating boys, citing the example of Australia, where broad HPV vaccination has contributed to the near elimination of genital warts (condylomas). 'These warts are not only stigmatising, but they can also sometimes be very mutilating,' he said. In Belgium, the HPV vaccine is reimbursed for boys up to 18 years of age; however, vaccination continues to lag behind the expectations. 'It is frustrating to see that while many hope for a cancer cure, a preventive vaccine already exists,' said Goffard.
He stressed that the HPV vaccine prevents cervical cancer, whereas the hepatitis B vaccine protects against hepatocellular carcinoma. On a more positive note, he acknowledged that hepatitis B vaccination has been successfully integrated into Belgium's childhood immunisation schedule.
Resurgence of mpox
Another concern for Goffard was the resurgence of mpox, formerly known as monkeypox. After the 2022 outbreak, the infection seemed to be under control, but it resurfaced, particularly among men who have sex with men. A vaccine exists, but its stock is insufficient. 'We had hoped that targeted vaccination would be enough, but current supply shortages are now preventing us from revaccinating those who missed the first campaign,' said Goffard, urging the government to anticipate another summer wave amid insufficient public awareness.
Lack of Coordination
Goffard highlighted the lack of coordination in vaccine and drug access across Europe as a critical issue.
'Each country currently manages its own vaccines and medicines independently, leading to a serious lack of coordination at the European level. However, infections do not respect borders. Let us not forget that Brussels is the second most cosmopolitan city in the world, after Dubai.'
He argued for a common European public health policy, including centralised negotiations to ensure equitable access and fair pricing of vaccines and medicines.
'We often criticise governments, but we should also question the fairness of the pricing of medicines. Is it acceptable for essential drugs to be so expensive?' he asked. 'Patents are, of course, important to encourage research, but in my view, the prices of generic medicines remain far too high compared to their production costs and the profit margins earned by pharmaceutical giants. And then, we would be much stronger at the European level.'
Alternative Tools
Targeted screening is underused but remains one of the most effective methods for controlling rising STI rates. 'During consultations, practitioners should not hesitate to offer tests even when there are no symptoms, especially in high-risk or sexually active groups,' Goffard argued.
He also highlighted the role of sexual health centres, which provide a multidisciplinary, non-judgemental, and accessible approach. These organisations play a key role in health education and information on contraception, pre-exposure prophylaxis (PrEP), and post-exposure prophylaxis (PEP).
HIV Prevention
PrEP is an essential strategy for preventing HIV infection. It involves the administration of antiretroviral therapy before high-risk encounters. In Belgium, PrEP is available by prescription, reimbursed under certain conditions, and can be administered continuously or on demand. However, it did not protect against other STIs. Oral sex remains a significant route for syphilis and gonorrhoea, and condoms are rarely used.
In cases of HIV exposure, post-exposure treatment remains effective if administered within 72 hours. 'In Brussels, our department can rapidly manage these cases,' said Goffard. Innovations are on the horizon: 'A twice-yearly injection of a new drug promises HIV protection, but it is not yet reimbursed.'
Doxycycline PEP (DoxyPEP Debate)
To curb the rising rates of certain STIs, a new preventive approach, doxyPEP, has emerged. It involves taking an antibiotic within 72 hours after risky intercourse to prevent infections such as syphilis and chlamydia.
'Doxycycline taken after intercourse effectively reduces the risk of syphilis and chlamydia, particularly in high-risk populations. However, widespread use raises concerns about the emergence of bacterial resistance, including in non-targeted germs, such as those in the microbiota or on the skin. This could affect the management of skin and digestive tract infection. Therefore, we do not recommend the routine use of this approach. This may be justified for a small group of patients with recurrent STIs, but it remains a niche approach.'
Community Approach
Beyond the strict medical framework, prevention involves education, accessibility, and proximity. Associations conduct screening campaigns in festive, school, or community settings, making the issue easier to understand and more relatable outside the clinical setting. 'We need to adapt our messages to the realities of our audiences: young people, LGBTQIA+ people, migrants. It is often the most vulnerable who escape traditional campaigns,' Goffard concluded.