The final rates for sexually transmitted disease diagnoses in San Francisco last year show a rise in many iterations of syphilis, part of a troubling nationwide trend, officials said.
The December 2020 STD report, which includes year-end numbers, was released by the San Francisco Department of Public Health March 5.
Cases of syphilis citywide declined from 1,864 in 2019 to 1,730 in 2020. However, cases of syphilis in women rose from 158 to 178, which precipitated a rise in congenital syphilis (four to five cases). Congenital syphilis is when a person with syphilis passes the infection on to their baby during pregnancy.
Also on the rise were cases of latent syphilis heretofore unknown (96 to 211), and late-latent cases (235 to 246).
Dr. Ina Park, a straight ally who is an associate professor at the UCSF School of Medicine, told the Bay Area Reporter that the increases are significant from a public health perspective.
"In terms of formal statistical significance, I can't do that on the fly, but the increase of syphilis among women — 13% — is significant," Park said. "The congenital syphilis I know are small numbers, but of public health and clinical significance: it's huge. It's huge because for years there were zero cases in San Francisco and this for years mirrors what's happening nationally."
Cases of congenital syphilis nationwide have risen 261% from 2013 to 2018 (the most recent year for which numbers are available), according to researchers with the U.S. Centers for Disease Control and Prevention. Much of that rise is occurring in Southern and Western states.
In 2018, according to CDC statistics, California had one of the highest rates of syphilis in the nation, second only to the District of Columbia (No. 1) and Nevada (No. 2).
While the CDC states that "[Men who have sex with men] continued to account for the majority of [primary and secondary] syphilis cases in 2018 ... During 2014-2018 the P&S syphilis rate among women more than doubled (172.7% increase). During 2017—2018, the P&S syphilis rate among women increased 30.4%."
Park said that the increase in syphilis among women "intersects with the crystal meth epidemic and intersects with the Central Valley as well."
"There has been a crystal meth epidemic in the Central Valley for years, with Fresno being a hotspot," Park explained. "Congenital syphilis infections are known to be associated with maternal meth/substance use, homelessness, lack of access to prenatal care, incarceration. So there is an intersection of the crystal meth epidemic with the rise of syphilis in women, which has led to increases in congenital syphilis."
According to Park's book, "Strange Bedfellows: Adventures in the Science, History and Surprising Secrets of STDs," Fresno had recorded two cases of congenital syphilis in 2011, "similar to other neighboring counties in the Central Valley."
"By 2015, that number had increased to 42. That year the number of congenital cases in Fresno exceeded every other county in California, including Los Angeles County, which has a population ten times its size," Park wrote. In 2017, the number rose to 60 before it began to fall. In 2019, the most recent year for which numbers are available, there were 42 cases again in Fresno County of congenital syphilis and 335 cases of syphilis among all women of childbearing age, down from 563 in 2016.
"These are things we didn't see 20 years ago," she cautioned. "Most disturbing of the things I see, we're seeing more of these unknown, latent and late-latent cases." These are syphilis infections that were not caught at the more acute stages.
"People aren't getting caught at the early stages of infection," Park said. "When we get testing ramped up back to what it was before [COVID-19], I really feel syphilis is going to go through the roof."
COVID impacts testing rates
Park echoed what Dr. Stephanie Cohen, a straight ally who is the medical director of the DPH's City Clinic in the South of Market neighborhood, told the B.A.R. earlier this year.
"We know that STI testing rates have dramatically declined and it's most likely the decline in testing that is behind the decrease in case counts," Cohen said, using the acronym for sexually transmitted infections. "It could be a change in behaviors that is decreasing community transmission of STIs, but I am quite concerned, because HIV and STI screening is one of our core strategies for promoting healthy sexual lives."
The B.A.R. at the time did not have hard testing numbers to report, but subsequent to that article, the San Francisco AIDS Foundation responded to a request for comment about the tests performed at its Magnet sexual health clinic at Strut in the Castro.
According to spokesperson Chad Ngo, the number of visits to the clinic that had a chlamydia, gonorrhea, or syphilis test (or two or all of these) decreased from 23,110 in 2019 to 13,013 in 2020.
Further, Magnet conducted 10,418 HIV tests in 2020, compared to 19,190 in 2019.
And indeed, experts agree that the decline in many STD diagnoses reflects this decline in testing.
Gonorrhea rates were down to 4,109 in 2020 from 5,571 in 2019. Male rectal gonorrhea cases were down to 1,160 in 2020 from 1,562 in 2019.
Chlamydia rates were down to 5,735 in 2020 from 9,454 in 2019. Male rectal chlamydia cases were down to 1,565 in 2020 from 2,428 in 2019.
Of particular concern to Park, however, is the fact that at City Clinic there were more people diagnosed as HIV-positive in 2020 than in 2019 (38 to 32) even though testing had declined by more than half at that location (2,670 tests in 2020 compared to 5,795 tests in 2019).
"At City Clinic, the percent positivity of the tests in 2019 was 0.5% and in 2020 was 1.4%," Park calculated, adding that the pandemic could have impacted the result in two ways.
"In the past, folks could go to City Clinic to be tested because they requested it," Park said. "Now, the people that were coming in to be tested had to be symptomatic of an STI. What I'm thinking is that these positive tests reflect folks who have been at higher risk. I hope it doesn't reflect folks having a gap in their PrEP because of the pandemic, and became positive. I hope it doesn't."
Still, like Cohen, Park noted that public health experts need to think ahead to the potential confluence of untreated STIs, antibiotic resistant STIs, and the expected resurgence of socializing this year and beyond, without demonizing sex.
"Some people, sexually, are going to make up for lost time," Park said. "I think that we see this coming and we need to get access to screening ramped up and nip this in the bud before we get an outbreak of antibacterial resistant gonorrhea."
Racial, ethnic disparities
The numbers also show racial and ethnic disparities in case-positivity rates, reflecting the health care treatment and outcome disparities the COVID pandemic has illuminated.
The report classifies individuals as Asian/PI, African American, Hispanic, and White. For example, the case rate of early syphilis among whites is 141.7 per 100,000 people, and among Asian/PIs is 57.2. Among Hispanics, however, the case rate is 268.5 and among African Americans the case rate is 376.2.
Similar case rate disparities exist in the rates for gonorrhea and chlamydia.
"The data were stark in the racial disparities in infection rate between African American and Hispanic communities compared to white and Asian communities," Park said. "Understanding as well from the vaccine roll out, there is distrust, and we have to reach out to serve."
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