Issue:  Vol. 48 / No. 11 / 15 March 2018

SF unable to reverse
STD rate increases


This health department graph shows rates for STDs in 2014. Photo: Courtesy SFDPH
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Despite efforts by local health officials to reverse the trend, San Francisco saw cases of sexually transmitted diseases rise for a ninth consecutive year in 2014.

Preliminary year-end data for reportable STDs, released by the city's public health department late last month, show year-over-year increases for chlamydia, gonorrhea, and early syphilis. The majority of cases remain among sexually active gay and bisexual men.

Chlamydia increased by 17 percent, from 5,094 cases in 2013 to 5,972 in 2014. Male rectal chlamydia jumped 20 percent last year, increasing from 1,167 to 1,410 cases.

Gonorrhea increased "even more steeply," noted public health officials in an advisory included in the January 30, 2015 monthly STD report.

Cases of the venereal disease shot up 30 percent in 2014 to 3,283 cases. There were 2,523 cases in 2013. Rectal gonorrhea among men also increased by 9.4 percent last year, from 796 cases in 2013 to 874 cases.

Despite signs of early syphilis cases stabilizing in the first half of 2014, the later half of the year continued a trend of seeing increased cases of the STD between the months of July and December. Overall in 2014, early syphilis increased to 1,114 cases from the 1,021 cases reported in 2013.

Asked if the nearly decade-long rise in STD cases in the city is a "new normal," Dr. Stephanie Cohen, the medical director for the health department's City Clinic, told the Bay Area Reporter , "I hope not."

The goal, Cohen said, remains to see the trend reversed.

"We as the Department of Public Health want to work with the community to find prevention strategies that are effective and acceptable," she said. "We are seeing increases among gay men really in all major cities that have large gay populations. But San Francisco does have a particularly high rate."

Nationwide data on STDs lags a year behind the local health department's surveillance reports. Federal data for 2013 showed mixed results in the effort to curtail infections.

The Centers for Disease Control and Prevention reported 1,401,906 chlamydia cases in 2013, resulting in a rate of 446.6 per 100,000 people. That marked a slight 1.5 percent decrease from 2012.

As for gonorrhea, there were 333,004 reported cases in 2013, equaling a rate of 106.1 per 100,000 people, "overall remaining stable from 2012," noted the CDC.

According to the data for 2013, there were 17,357 reported cases of early syphilis. The total results in a rate of 5.5 per 100,000 people, a 10 percent increase from 2012. The rate had increased 11 percent in 2012 from the year prior.

"Gay and bisexual men continue to be most affected," noted the CDC in an advisory it sent out in December.

The rate of primary and secondary syphilis in 2013 was the highest recorded rate since 1996, according to the National Coalition of STD Directors. In addition, the 10 percent increase in syphilis rates in 2013 was the result of increases in men, mainly gay and bisexual men. According to the coalition, there was no overall increase seen in women in 2013.

Syphilis and HIV co-infection among men who have sex with men is also very common, with 52 percent of MSM with primary and secondary syphilis co-infected with HIV, reported the coalition.

"This second year of double digit increases of syphilis rates is completely unacceptable and also significantly intersects with our HIV epidemic," stated William Smith, executive director of the National Coalition of STD Directors. "This continues to affect populations already disproportionately impacted by all STDs, including HIV, most notably gay men and other men who have sex with men." 

Locally, health officials point to several factors behind the continued increases in STDs.

Many HIV-positive men forgo using condoms by choosing to only partner with other HIV-positive men, a practice known as sero-sorting, thus increasing their risks for contracting STDs from their sex partners.

Negative men using pre-exposure prophylaxis, or PrEP for short, to protect themselves from contracting HIV put themselves at risk for STD transmission if they also forgo using condoms, note health officials.

While the use of PrEP in San Francisco "took off in 2014," said Cohen, there is no evidence linking it to the rise in local STD rates.

"I think that from what we have seen in randomized, controlled PrEP trials, and from early experience in real world settings, risk behaviors do not change among people using PrEP overall," said Cohen.

The health department's STD control branch remains "supportive" of PrEP as part of the city's "overall HIV prevention strategy," stressed Cohen. But users of the once-a-day-pill need to be reminded it does not prevent the transmission of STDs like syphilis and gonorrhea.

"I think the fact that the whole toolkit of biomedical HIV prevention strategies we have, which includes PrEP, have no protection against STDs is really important for people to keep in mind," she said.

Local health officials continue to recommend that all sexually active people be tested for STDs every three to six months.


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