Healthcare Infrastructure Crisis Compounds America's STI Epidemic

The Centers for Disease Control and Prevention's (CDC) September 2025 release of provisional 2024 STI surveillance data offers proof that public health interventions work: more than 2.2 million cases of chlamydia, gonorrhea, and syphilis represent a 9% decline from 2023, the third consecutive year of decreases. Primary and secondary syphilis dropped 22%, chlamydia fell 8%, and gonorrhea declined 10%. "The overall U.S. STI burden remains substantial, but signs of progress continue," noted Dr. Bradley Stoner, Director of CDC's Division of STI Prevention.

Yet congenital syphilis increased 2% to nearly 4,000 cases in 2024, continuing a 700% climb since 2012 that resulted in 279 stillbirths and infant deaths in 2023 alone. CDC analysis shows 88% of these cases were preventable with timely testing and treatment. This divergence—overall rates declining while the most vulnerable populations remain unreached—reveals a deeper crisis: we are systematically dismantling the healthcare infrastructure necessary to sustain these gains precisely when evidence demonstrates what works.

The Systematic Dismantling

The erosion of STI prevention capacity unfolded across three stages. It started with CDC's Division of STI Prevention losing 40% of its purchasing power since 2003 through chronic underfunding, while local health departments shed 20% of workforce capacity from 2008 to 2019. A Harvard study documented that nearly 50% of state and local public health employees left their jobs between 2017 and 2021. Decades of flat or declining budgets hollowed out the workforce that conducts contact tracing, provides testing and treatment, and links patients to care.

In June 2023, the Fiscal Responsibility Act eliminated $1.3 billion in CDC funding specifically intended to expand Disease Intervention Specialist capacity, with states like Nevada losing over 75% of their STI prevention budgets. These cuts targeted the 2,200 people nationwide who conduct partner services and contact tracing that prevent transmission chains. The 2024 data showing declining rates was collected during this period, demonstrating what the system could achieve even as Congress pulled resources.

Then in March 2025, the Trump Administration terminated $11.4 billion in pandemic-era grants. Under HHS Secretary Robert F. Kennedy Jr., the department eliminated 31% of its workforce. The President's proposed FY 2026 budget cuts CDC funding by 53% compared to FY 2024. A George Washington University analysis projects 42,000 eliminated jobs nationwide, with states losing hundreds of millions in funding. The Administration also withheld Title X grants from 23 states, threatening 200 Planned Parenthood clinics serving 2.8 million people annually. Utah's sole Title X recipient lost $2.8 million, forcing closure of clinics that served 26,000 patients.

The consequences are materializing. Penobscot County, Maine, faces the largest HIV outbreak in state history—28 new cases over two years, seven times typical rates, nearly all among people who use drugs and are homeless. The outbreak emerged after supply shortages forced closure of the region's largest syringe services program, then accelerated following February 2025 clearing of the city's largest homeless encampment. Broome County, New York, reported in September 2025 that new HIV diagnoses among people with injection drug use history exceed the previous four years combined. The 2015 Scott County, Indiana HIV outbreak that infected over 200 people occurred after public health funding cuts eliminated syringe access. We know what happens when we strip prevention infrastructure. We are choosing to repeat it.

Interconnected System Failures

The public health workforce collapse intersects with physical infrastructure deterioration to compound access barriers. American hospitals carry $390 billion in deferred maintenance, with 50% of health systems managing buildings over 50 years old. Deteriorating facilities cannot maintain proper medication storage, provide adequate clinic space for confidential counseling, or support infection prevention protocols that 80% of hospitals lack sufficient staff to implement.

Infrastructure failures drive facility closures that eliminate access entirely. Over 100 rural hospitals closed from 2013 to 2020, forcing residents to travel 20 miles farther for common services and 40 miles farther for specialized care. Deferred maintenance becomes a death spiral: aging infrastructure drives up operating costs, reducing resources for patient care, making facilities financially unsustainable. The closures concentrate in rural areas and communities serving predominantly low-income populations and people of color - the same populations bearing the highest STI burdens. Meanwhile, as we reported in our article titled, “CBO Data Proves Hospital Systems Exploit 340B Drug Program for Billions,” when hospitals do invest in facilities, they target affluent white neighborhoods.

A Center for Economic and Policy Research analysis documents that hospitals serving communities of color receive systematically less infrastructure investment. Hospital occupancy rates are 11 percentage points higher than pre-pandemic, driven by a 16% reduction in staffed beds. Overcrowded, understaffed, aging facilities cannot deliver consistent prenatal screening to prevent congenital syphilis.

Medication access compounds these failures. Pfizer's April 2023 Bicillin L-A shortage, ongoing through 2025 with July 2025 recalls further limiting supply, eliminates the only CDC-recommended treatment for syphilis in pregnancy. A November 2023 survey found 68% of health departments stated the shortage would directly increase syphilis rates. Among 2022 congenital syphilis cases, 37.9% of birth parents received no prenatal care whatsoever.

Who Bears the Cost

Geographic and economic barriers determine who suffers these system failures. Thirty-five percent of U.S. counties are maternity care deserts with no birthing facility or obstetric clinician, affecting 2.3 million people of reproductive age. Patients in these areas face twice the uninsured rates, 13% increased preterm birth risk, and average drive times of 38 minutes versus 16 minutes nationally. These are the predictable results of decades of policy choices that prioritized cost containment over access.

Racial disparities reveal who we are willing to sacrifice. Black populations account for 32.4% of all chlamydia, gonorrhea, and primary/secondary syphilis cases despite comprising 12.6% of the population, experiencing gonorrhea at 7.7 times the rate of White populations. American Indian and Alaska Native infants face congenital syphilis rates 75 times higher than Asian families, with maternal syphilis among American Indian and Alaska Native mothers increasing 783% from 2016 to 2022. Mississippi data shows African American infants account for 71.1% of congenital syphilis cases while representing 43.3% of the general population, with 92.6% of cases among Medicaid recipients.

CDC acknowledges explicitly: "Differences by race and/or Hispanic ethnicity cannot be understood without consideration of long-standing structural contributors that are not adequately captured in case notification data such as systemic racism, challenges with healthcare access, and disparities in social determinants of health." Eight percent of Americans—27.1 million people—lack insurance coverage, with 1.5 million in the Medicaid coverage gap in ten non-expansion states, over 60% people of color.

The 2% increase in congenital syphilis amid overall STI declines tells us exactly who cannot access care: pregnant people, disproportionately Black and brown, in maternity care deserts, served by overwhelmed safety-net systems, facing medication shortages, unable to reach closing clinics. This is the distribution of harm we accept when we defund infrastructure.

The Choice Before Us

The 2024 data was collected before March 2025 grant terminations fully materialized, before spring clinic closures accelerated, before proposed 53% CDC budget cuts take effect. The encouraging trends reflect a system already deteriorating through chronic underfunding and workforce elimination. They do not reflect what comes next if current trajectories continue.

We have evidence. Disease Intervention Specialists, syringe services programs, prenatal screening, Bicillin access, Title X clinics—these interventions work. The 22% drop in primary and secondary syphilis demonstrates it. The HIV outbreak in Maine after syringe program closure demonstrates the cost of abandonment. The congenital syphilis crisis demonstrates who pays when we moralize instead of invest.

This is not a resource constraint. It is a priority choice. We can reverse the 2025 funding cuts and restore public health workforce capacity. We can address the $390 billion hospital infrastructure deficit with focus on facilities serving communities of color. We can secure medication supply chains through domestic manufacturing and emergency stockpiles. We can eliminate maternity care deserts and expand Medicaid in ten remaining states. We can fund what works.

The 2024 data proves progress is possible. The 2025 policy choices determine whether it endures or whether we return to climbing rates, preventable infant deaths, and widening disparities. Tough budget choices may be required. But the health and survival of pregnant people and their babies should not be on the chopping block. We know what works. The question is whether we value those lives enough to fund it.