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As COVID pandemic eases, STD epidemic on the rise

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SF City Clinic director Dr. Stephanie Cohen. Photo: Rick Gerharter
SF City Clinic director Dr. Stephanie Cohen. Photo: Rick Gerharter  

Rates of sexually transmitted diseases rose in San Francisco in 2021, according to a year-end report released by the city's Department of Public Health.

Dr. Stephanie Cohen, a straight ally who is the medical director of DPH's City Clinic in the South of Market neighborhood, told the Bay Area Reporter that "the impact of COVID-19 on sexual health services" led to statistics that were probably lower than the real rate of community infections.

"In 2021, we fortunately saw an increase in engagement with sexual health services," Cohen said. "With that we did more tests in 2021 and, because of that, we did see more cases. Paradoxically, that's a good thing. The bump in cases was largely a sign of recovery of testing and screening."

But Cohen did acknowledge that the COVID-19 lockdown notwithstanding, STD diagnoses have been on an upward trajectory in the city, state, and nation for the last several years.

Jorge Roman, director of clinical services with the San Francisco AIDS Foundation, told the B.A.R. it's difficult to say which was a bigger factor in the rise in the reported rates.

"As a baseline, unfortunately, there's an uptick," Roman said. "I think it's both. Both of those factors were important."

Roman said that the AIDS foundation's Magnet clinic at Strut in the Castro neighborhood keeps data on the positivity rate of the total number of tests it provides, which helps to paint a broader picture of the prevalence of infection among those accessing sexual health services.

The B.A.R. obtained this data, which shows the positivity rate for gonorrhea, chlamydia, and syphilis at Magnet went down in 2021, after having risen 2020 from 2019 levels.

In 2021, the positivity rate for gonorrhea at the clinic was 5.17%, compared to 5.26% in 2020 and 5.09% in 2019.

These changes are more pronounced in the case of the other two major bacterial STDs. In 2021, the positivity rate was 3.56% for chlamydia, compared to 4.56% in 2020 and 4.16% in 2019. Syphilis last year had a 2.25% positivity rate, compared to 2.92% in 2020 and 2.18% in 2019.

For the city as a whole, every measured STD was more diagnosed in 2021 than in 2020. Gonorrhea cases were up to 5,259 from 4,109 in 2020 (in 2019 the number was higher than in 2021, with 5,571 diagnoses).

Male rectal gonorrhea cases were up to 1,812 from 1,160 in 2020 (in 2019 the number was lower than in 2021, with 1,562 diagnoses).

Chlamydia cases were up to 6,185 from 5,735 in 2020 (in 2019 the number was higher than in 2021, with 9,454 diagnoses).

Male rectal chlamydia cases were up to 1,867 from 1,565 in 2020 (in 2019 the number was higher than in 2021, with 2,428 diagnoses).

One innovation that may help with rectal gonococcal and chlamydia cases is the first condom that is specifically intended for use during anal intercourse. The federal Food and Drug Administration authorized the marketing of the prophylactics for the first time February 23.

"The One Male Condom is a natural rubber latex sheath that covers the penis," an FDA news release states. "It has three different versions: standard, thin, and fitted. The fitted condoms, available in 54 different sizes, incorporate a paper template to aid in finding the best condom size for each user. When used during anal intercourse, the One Male Condom should be used with a condom-compatible lubricant."

"The risk of STI transmission during anal intercourse is significantly higher than during vaginal intercourse," stated Courtney Lias, Ph.D., director of the FDA's Office of GastroRenal, ObGyn, General Hospital, and Urology Devices in the Center for Devices and Radiological Health. "The FDA's authorization of a condom that is specifically indicated, evaluated and labeled for anal intercourse may improve the likelihood of condom use during anal intercourse."

Syphilis cases
Syphilis cases in San Francisco were up to 1,922 from 1,687 in 2020 (in 2019 the number was lower than in 2021, with 1,864 diagnoses).

Cohen said that syphilis is appearing in cisgender, heterosexual women more than before.

Female syphilis cases were up in 2021 — 195 diagnoses compared to 171 the year prior and 158 in 2019.

"We have been seeing this about four years now — rising cases of syphilis in cisgender women who have sex with men," Cohen said. "What we saw in 2020 was an increase on the 2019 numbers. This is very concerning to us because when syphilis affects someone who is pregnant, it can lead to disastrous outcomes, such as pre-natal death and birth defects."

Fortunately, congenital syphilis cases declined from five in 2020 to two in 2021.

Dr. Ina Park, a straight ally who is an associate professor at the UCSF School of Medicine, told the B.A.R. last year, the crystal meth epidemic in the Central Valley, when combined with homelessness and lack of access to medical care, is partly to blame for the statewide rise in syphilis cases.

Cohen was relieved that antibacterial resistant strains of gonorrhea haven't materialized in San Francisco — yet.

"It's an area of public health concern," she said, adding that the city works with the federal Centers for Disease Control and Prevention "to monitor emerging strains of gonorrhea" because "we want to know if they're out there and prevent their spread."

HIV testing
The number of human immunodeficiency virus tests jumped from 2,670 in 2020 to 3,489 in 2021. The number of tests finding an acute infection went from two in 2020 to five in 2021, and the number of tests finding antibodies (indicating a longer-term infection) stayed exactly the same at 37.

Roman told the B.A.R. that policymakers can help decrease the prevalence of STDs in the community by "realizing that sexual health is part of essential health services and realizing that people in the community need to be able to access sexual health services, like testing, without appointments."

Cohen wanted to tout that the health department already has at-home testing programs. One, Take Me Home (https://takemehome.org/), provides kits through the mail including three-site testing for gonorrhea and syphilis. Another, Don't Think Know, LINK: https://sf.dontthinkknow.org/ also provides tests through the mail but is geared toward young women seeking a vaginal swab.

"We want San Franciscans to know they have that access to confidential and private testing," Cohen said.

Nationwide shortage of blood test tubes
The National Coalition of STD Directors is sounding the alarm that the tubes used for blood tests — which are used to test for syphilis and HIV — are a victim of the global supply chain crisis. It was one reason why SFAF in January canceled certain services at Magnet, as the B.A.R. reported at the time.

"Blood specimen collection tubes are essential for providing routine, standard of care blood testing for laboratory analysis, including sexual health testing," stated Jennifer Mahn, the coalition's director of clinical and sexual health, in a news release. "This shortage is leading to widespread disruptions in vitally important sexual health services."

The U.S. Food and Drug Administration is urging labs to consider conservation strategies, which the coalition says will only hurt "as STI rates continue to skyrocket across the country."

The coalition is calling on the Defense Production Act to be invoked to help address the shortage. As of February 8 Magnet resumed PrEP follow-up appointments and routine STI and HIV testing appointments, as the B.A.R. reported. SFAF posted a note on its website that the services no longer needed to be on hold "due to COVID-19 surge-related supply chain issues."


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