San Francisco health officials continue to see rates of sexually transmitted diseases drop, a significant difference from most other parts of the state and country where STDs remain on a six-year-long rise.
The same is not true, however, for the city's HIV rates. After holding out hope that the city would continue to see a decline in new HIV infections, a top health department epidemiologist now concedes that the city's HIV infections have flat-lined.
In effect the city has seen its HIV epidemic morph into an HIV endemic, meaning HIV rates are likely to hold steady at around 1,000 new cases a year for years to come, said Dr. Willi McFarland, director of the health department's HIV/AIDS Statistics and Epidemiology section. Last year, McFarland had held out hope that a slight decline in HIV cases in 2006 could point to a years-long downward trend.
"I stopped short of using endemic in 2006. I was much more optimistic then. Now, the data indicates there is not as much cause for optimism," McFarland told the city's HIV Prevention Planning Council at its November 8 meeting. "It is true to say endemic now. Technically, that is correct."
Contributing to the leveling off of the decline is a plateauing in the number of men who are serosorting, reasoned McFarland. Serosorting refers to when gay men choose to have sex with men of the same serostatus.
In San Francisco many HIV-positive men adopted serosorting on their own as an HIV prevention strategy, restricting the men they had sex with to other positive men. The practice is believed to have led to declines in the city's HIV rates that began in 2001 but plateaued this year.
"Maybe it has reached as much as it is going to change," said McFarland.
The switch to an HIV endemic should not be hailed as good news, stressed McFarland. He said the health department's main goal remains seeing a reduction in the number of people contracting HIV.
"This is pretty scary. This is not good news. It means there will be a lot of disease and death we will have to deal with for decades to come," said McFarland. "It is not inevitable. This is still a preventable disease."
The city will need to develop new approaches in order to reverse course and push HIV rates down, McFarland said. Yet he said he was at a loss as for what the best strategies should be.
"What do we do differently? I don't know right now. I have some ideas," he told the council, which oversees the health department's HIV prevention policies. "That is your job here."
The council last week did endorse several new strategies it believes will further reduce HIV rates and that the city should implement. Among the recommendations is to create a safe needle injection center for drug users; increase awareness of the increased risk for HIV infection from poppers use; and require all bars and clubs - both gay and straight - to have condoms and lube available.
The council also endorsed using incentives to get people to test for HIV and voted to require agencies funded to do HIV prevention to offer late night services.
Council member Eiko Sugano, who helped draft the proposal, called the council's stance "a radical, cultural shift." The health department's HIV prevention section will now determine how to implement each proposal before it goes before the Health Commission to become actual policy.
SF sees STDs decline
One source of good news is that the city continues to see drops in cases of gonorrhea, chlamydia, and syphilis. All three STDs can lead to higher risks for HIV infection.
According to the latest monthly STD report, which covers data collected through September of this year, gonorrhea cases fell to 1,528 during the first nine months of 2007 compared to 1,874 cases during the same time period in 2006. Male rectal gonorrhea cases also declined, with 369 cases reported so far this year compared to 432 during the same time period in 2006.
Chlamydia fell from 2,880 cases so far this year from 3,093 during the same time frame in 2006. Male rectal chlamydia did rise to 423 cases so far this year from 388 reported in 2006, but the increase is likely due to increased testing.
Syphilis rates also dropped, from 341 so far this year compared to 425 reported last year during the same time period. The falloff continues a decline first detected in 2005, when cases of syphilis first began to drop after steadily climbing every year since 1998.
"We have seen some very good news here in San Francisco," said Dr. Jeff Klausner, director of the health department's STD prevention and control section. "Because of the comprehensiveness and breadth of our programs, we have seen a sustained decline in new STD cases."
The reverse is true for the rest of the country. According to a new report from the Centers for Disease Control and Prevention released Tuesday, November 13 the rates for gonorrhea, chlamydia, and syphilis continued to increase in the United States last year. When combined with cases of several other STDs, the CDC estimated roughly 19 million new infections occur each year, with almost half of them among young people ages 15 to 24.
Reported cases of chlamydia rose to more than 1 million cases last year, up from 976,445 in 2005. The increase could be a reflection of increased screening and improved testing methods. Gonorrhea cases also climbed last year for the second year in a row. The gonorrhea rate was 120.9 cases per 100,000 population, an increase of 5.5 percent since 2005.
Women, particularly young girls and African American women, accounted for the rise in both STDs. Men, on the other hand, were responsible for a rise in syphilis rates, which increased 13.8 percent between 2005 and 2006, from 2.9 to 3.3 cases per 100,000 population. The number of cases rose from 8,724 to 9,756.
In 2006, the CDC estimates that 64 percent of all syphilis cases were among men who have sex with men. The rate of syphilis among men has risen 54 percent over the last five years.
"MSM are driving the rates. Given the increased HIV risk, they are of particular concern," said Dr. John M. Douglas Jr., director of the CDC's Division of Sexually Transmitted Disease Prevention, during a conference call Tuesday with reporters.
Gay men still account for the bulk of San Francisco's STD cases, with HIV-positive men accounting for two-thirds of syphilis cases, said Klausner. As for chlamydia, he said a third of cases are in gay men, and with gonorrhea, about three-quarter of cases are in gay men.
The reason the city has not seen STD rates rise may be due to a new practice of sero-adaptation, he said, where men not only sero-sort but also sero-adapt their sexual practices based on their partner's HIV status.
"We haven't seen any significant changes in condom use. We still see increases in sero-adaptation, which includes both sero-positioning and sero-sorting," said Klausner. "It is a more inclusive term for how both positive and negative men who have sex with men adapt their sexual behavior."