Trend of main STIs during COVID-19 pandemic in Milan, Italy.

The outbreak of the COVID-19 pandemic (caused by SARS-CoV-2) is a public health emergency of magnitude.1 The rapid spread of the novel coronavirus in such a densely populated area as Lombardy threatened the capacity of the health system. All health facilities were reorganised to contain the spread of the virus. Unprecedented social isolation measures (lockdown) were adopted to control the epidemic.2 In relation to sexual health, one would assume that the lockdown should reduce the opportunity for sexual encounters and acquisition opportunities for STIs. In Milan, the main city of the Lombardy region, there are two main STI centres which account for about 80% of STI diagnosis. On 8 March, regional ordinance limited outpatient activity to acute cases only. The two STI centres remained open for ‘emergencies’. Patients with symptoms, or at risk of STIs, were able to access the two centres on a ‘walk-in’ basis. Priority was assessed by triage. All information about the management was rapidly written on the websites. We considered the number of confirmed diagnoses for the the most common STIs in the period 15 March–14 April 2020 and compared it to the number of diagnoses reported in the same period in 2019 (figure 1).

Figure 1

Number of sexually transmitted infections observed in the period March 15–14 April of each year 2019 and 2020. Red column: number of patients in 2019; grey column: number of patients in 2020. HSV, herpes simplex virus.

The different STIs showed very different trends in our two centres. The number of cases fell, but the fall was in the non-acute cases. The number of acute bacterial infections associated with MSM increased. We conclude that the lower number of attendances in the 2020 period can be explained by only symptomatic patients attending who were triaged on arrival for medical intervention, while asymptomatic patients and those with non-acute conditions such as genital warts and molluscum contagiosum did not attend our centres due to the pandemic. However, acute infections seemed not to be affected by the pandemic and the lockdown measures; in fact we observed a light increase in secondary syphilis and gonorrhoea and no changes in primary syphilis. It appears that the COVID-19 pandemic, despite lockdown and advice on social/physical distancing, did not inhibit risky behaviours especially among MSM. When HIV/AIDS burst on us in the 1980s, it induced a behavioural change fuelled by fear and resulted in a steep decrease in these infections. The same could have been expected with COVID-19, which caused multiple fatalities in the region. It is paradoxical that infections have not markedly decreased with social distancing and lockdown. Possibly, the concentration of morbidity and mortality in the elderly made the younger, more active cohort feel protected. While it is unrealistic to prevent people from having sex, even in this extraordinary pandemic, close contact during sexual intercourses inevitably involves an increased risk of SARS-CoV-2 contagion. This failure to observe social/physical distancing could have the consequence of extending the lockdown time with increasing physical and psychological consequences, impacting in particular on sexual health. The pandemic and its consequences will be prolonged and will change the way we live and work with STIs.