Some STIs down in SF last year

  • by John Ferrannini, Assistant Editor
  • Wednesday March 8, 2023
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Dr. Stephanie Cohen. Photo: Rick Gerharter
Dr. Stephanie Cohen. Photo: Rick Gerharter

Rates of some sexually transmitted infections in San Francisco declined slightly in 2022, according to year-end numbers released by the city's Department of Public Health.

The numbers came just before the U.S. Centers for Disease Control and Prevention warned about an increase of "extensively drug-resistant" Shigella bacteria that can be spread sexually.

All told, rates of syphilis declined by about 7% (1,879 reported in 2021 compared to 1,684 reported in 2022) and rates of gonorrhea declined by less than 1% (5,264 cases reported in 2021 compared to 5,229 reported in 2022). Rates of chlamydia rose by about 4% (6,198 reported in 2021 compared to 6,467 reported in 2022).

More people tested positive for antibodies to HIV at San Francisco City Clinic in 2022 than in 2021 (55, compared to 39), though there were more tests administered (3,859 tests in 2022 compared to 3,488 tests in 2021). The full HIV epidemiology report for the city for 2022 will be released later this year, according to the health department. The most recent year-end HIV numbers, for 2021, showed a 16% increase in diagnoses, the first year-over-year rise in nearly a decade, as the Bay Area Reporter previously reported.

The B.A.R. had also previously reported that medical experts were concerned about a mix of factors leading to a rise in STI rates after the COVID pandemic lockdowns eased — including the end of social distancing, antibiotic resistant bacteria, and untreated STIs due to a decline in testing.

But Dr. Stephanie Cohen, a straight ally who is the section director for HIV/STI prevention with the health department, told the B.A.R. that another confluence may have led to last year's reported rates not being so astronomically high. First, testing is less frequent. Second, another health crisis led to behavioral change, she said.

"We aren't seeing the rates we saw before COVID," Cohen said. "Our testing numbers aren't quite back to pre-pandemic, so we aren't seeing the same number of people getting screened."

Indeed, compare 2019's rates with 2022's: reported cases of gonorrhea went from 5,565 to 5,229, reported cases of chlamydia went from 9,438 to 6,467, and reported cases of syphilis went from 1,860 to 1,684.

Second, Cohen cited the mpox outbreak, which peaked last summer. Many of the same sexual behaviors that are correlated with the spread of STIs — such as unprotected sex, and sex with multiple partners — were seen with the spread of mpox, which primarily affected men who have sex with men and their sexual partners.

"People reported changing sexual behaviors due to the mpox outbreak, so perhaps it is the change in those behaviors that prevented a big increase in 2022," Cohen said.

In fact, according to DPH's mpox case counts, there hasn't been a reported case of the virus since January 20.

Syphilis cases decline

Cohen also wanted to particularly highlight the decline in syphilis for 2022. Syphilis cases had increased considerably since 2000, and untreated syphilis can lead to serious damage to the internal organs and death.

"I think the 7% decline in syphilis is a positive trend," Cohen said. "It's the trend we want to see and, if it's correlated to the effects of the mpox outbreak, or the decline in transmission during COVID, it's certainly a good thing to see."

Cases of congenital (infant) syphilis were the same in 2022 as in 2021 (three in each year), and cases of syphilis in women were about the same (182 in 2021; 186 in 2022). However, reported cases of neurosyphilis — the invasion of the central nervous system by the syphilis bacteria Treponema pallidum — were cut in half, from 28 to 14.

As for the other STIs, "it's a little early to say" what the 2022 numbers mean for sure, said Cohen.

Nurse practitioner Clarissa Ospina-Norvell, the interim co-medical director of the San Francisco Community Health Center, told the B.A.R. that at-home STI testing, and offering testing in the community as opposed to having patients come into clinics for testing, are both measures that could help.

"A couple of things that we can do to maintain this downward trend include expanded STI testing for communities that are not likely to go to a traditional clinic," Ospina-Norvell said. "For example, offering home-based STI testing and offering STI testing in venues where people might be seeking non-medical resources. We implemented STI testing at the Tenderloin Linkage Center, which was well received. Our Street Medicine Team offers STI screening for those who are unhoused and not likely to come into the clinic. We are hoping to expand STI testing to other non-traditional locations in the near future."

The Tenderloin Linkage Center, later renamed the Tenderloin Center, was a place near United Nations Plaza where unhoused people could go to receive services during Mayor London Breed's state of emergency in the neighborhood. The center closed in December.

Ospina-Norvell also said that the "implementation of Doxy-PEP by more providers" would help.

Doxy-PEP, or doxycycline post-exposure prophylaxis, is a 200-milligram dose of the antibiotic that reduces by two-thirds the chance of acquiring gonorrhea, chlamydia, and syphilis after unprotected sex, according to studies.

Ospina-Norvell cited studies done by DPH, Zuckerberg San Francisco General Hospital/UCSF, and the University of Washington that have demonstrated decreased rates of STIs in those offered Doxy-PEP.

"Of concern to me is that the rates of STIs still remain higher in the African American community, of all age groups. More work needs to be done in reaching these communities," Ospina-Norvell added.

While Doxy-PEP has not been shown to be effective in cisgender women, Cohen wanted to assure people that with regard to Doxy-PEP "right now, at this point, we do think the benefits outweigh the risks in those who've had an STI in the past 12 months."

"So far — in the studies conducted — there has not been evidence of a significant increase in antibiotic resistant bacteria in people who use Doxy-PEP," Cohen said. "There are ongoing studies on that."

Drug-resistant Shigella

Cases of infection with Shigella, a bacteria genetically closely related to E. coli and that can cause dysentery, are not counted as sexually transmitted infections. Nonetheless, since it travels through the oral-fecal route, it can be spread through sexual acts such as anilingus ("rimming") or anal intercourse.

The CDC reported last week that it "has detected an increase in extensively drug-resistant (XDR) Shigella infections (shigellosis) reported through national surveillance systems."

"Clinicians should understand the nuances of testing and managing infections, especially when treating patients from populations at increased risk of drug-resistant shigellosis including: young children; gay, bisexual, and other men who have sex with men; people experiencing homelessness; international travelers; and people living with HIV," the CDC stated. Data also showed 85% of reported cases from 2016 onward were in men, with just one in a child.

The B.A.R. asked DPH how concerned people should be, and what they can do to mitigate their risk.

"The percentage of shigellosis cases in the U.S. that are 'extensively drug resistant' (XDR) is estimated to have increased to 5% in 2022," DPH stated. "These cases are resistant to all of the antibiotics typically used to treat Shigella infection but can be treated with a broad-spectrum antibiotic usually reserved for severe infections in hospitalized patients. Most individuals infected with Shigella recover without antibiotic treatment, but those with more severe infection, such as infection that leads to hospitalization, or who may be immunocompromised (including living with HIV), may benefit from antibiotics."

Washing hands and cleaning genital and anal areas with soap is important, DPH said. Use of condoms and dental dams during sex, particularly anilingus, significantly reduces risk.

"If you are sick and have diarrhea: Contact your health care provider, Abstain from sex (anal, oral, penile, or vaginal) while you have symptoms and until two weeks after symptoms end, After resuming sex, closely follow safer sex practices for at least two weeks after resuming sex to prevent the spread of any remaining bacteria. Do not prepare food for others, [and] stay out of recreational water, including swimming pools, hot tubs, and the ocean," DPH advised.

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