Featuring our Faculty: Suggestions vary for cutting STD rates in SF

By: Matthew S. Bajko

This article was originally published in The Bay Area Reporter

Dr. Jonathan Fuchs
Dr. Jonathan Fuchs
Dr. Susan Phillip
Dr. Susan Phillip

As HIV cases continue to decrease in San Francisco, local health officials are increasing their efforts to see a similar trend in cases of sexually transmitted diseases.

This week the Department of Public Health’s section responsible for STD prevention turned directly to gay and bisexual men for help. They held two town hall forums to hear from men who have sex with men what their ideas are for reducing transmission of STDs.

The suggestions varied from reframing HIV prevention messages to be more broadly aimed at sexual health, emphasizing condom usage as an STD prevention tool, and placing social marketing campaigns outside of the gay Castro district in neighborhoods more home to youth and people of color.

Austin Nation, a queer black man who is a nursing doctoral student at UCSF, attended the July 6 meeting held in the Tenderloin at Glide, a church and provider of various health and social support services. He applauded the health department for holding the town hall in the neighborhood and urged the agency to look at employing new strategies to reduce rates of STDs.

“I hope this turns into more than an idle conversation,” Nation, who volunteers at Magnet, the gay men’s health center in the Castro, told the B.A.R. following the meeting.

Less than 20 people attended the first town hall, with a majority either DPH staff or people with some connection to agencies that provide health services. Much of the conversation focused on how the patients they interact with are more concerned about becoming HIV-positive than contracting a sexually transmitted infection, since nearly all STDs are curable.

Asked to fill out a survey with questions about STDs and condom usage, the majority of people in attendance, 57 percent, said it is uncommon for gay, bisexual, and transmen in San Francisco to mention condoms “but people use them if they want to.”

No one felt that condoms are no longer used, nor did anyone say they believe “mentioning condoms means you might not get laid.”

Dr. Jonathan Fuchs facilitates a town hall discussion. Photo by Rick Gerharter, originally published in The Bay Area Reporter.
Dr. Jonathan Fuchs facilitates a town hall discussion. Photo by Rick Gerharter, originally published in The Bay Area Reporter.

But several men said that condoms are too often associated with HIV prevention due to past public health campaigns and need to be repositioned more as a way to prevent STD transmission. Views on the need to use condoms have changed, said the men, due to the recent focus on PrEP, short for pre-exposure prophylaxis, the once-a-day pill aimed at keeping people HIV negative, and treatment as prevention, where people who test positive for HIV are encouraged to immediately start taking HIV medications to keep the virus in check and reduce the chance of transmitting HIV to their sexual partners.

One person commented that nowadays “condoms are seen for preventing pregnancy, they aren’t for gay men.”

Deputy Health Officer Dr. Susan Philip, the director of disease prevention and control in the health department’s population health division, told those at the meeting that their suggestions will be “really helpful” for her section’s efforts at addressing the rise in STD transmissions.

“We are really trying to think broadly and build on the wisdom, experience and knowledge we know exists in the gay community and other communities in San Francisco,” said Philip.

She listed several of the strategies the city already employs to combat STDs, from providing direct health services to treat infections at City Clinic, Magnet and other medical settings to distributing condoms for free throughout the city at various locations.

“We do know what works against STDs. Condoms do work,” said Philip. “We also know these strategies have to be acceptable and originate from the community. It can’t be something DPH does alone. We have to partner together to make San Francisco a healthy city overall.”


Data unclear on PrEP, STD rates

One challenge facing the department, acknowledged Philip, is how to encourage condom usage while at the same time supporting PrEP, which some men see as a way to have condomless sex without putting themselves at risk for HIV. PrEP, however, does not protect them from acquiring an STD.

So far it is unclear what impact, if any, PrEP usage in San Francisco is having on STD rates. Philip noted that the drug intervention has only been available for 18 months, whereas STD rates, “well before the introduction of PrEP,” have been climbing for years.

“We don’t want PrEP to be the scapegoat for STD increases,” she said. “Condoms are being used less in San Francisco, but we don’t think PrEP is the sole reason that has occurred.”

Health officials have long suggested the increase in STD cases is likely attributable to several sexual practices gay and bisexual men have adopted as community norms. 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.

HIV-negative men who sero-position, meaning they determine how they have condomless anal sex based on the HIV status of their sexual partners, also are at risk of contracting an STD.

The result has been a steady decrease in HIV infections, which have been on the decline in the city since 2006 and hit a new low of 304 cases in 2014. At the same time the polar opposite has occurred with STD rates.

As the Bay Area Reporter has documented since 2005, cases of syphilis, gonorrhea, and chlamydia have all been on the rise over the last decade. According to the health department, 40 percent of chlamydia cases and 70 percent of gonorrhea cases in San Francisco in 2014 were among patients identified as MSM.

The most recent monthly STD report, with data through the end of May, showed that cases of syphilis, gonorrhea and chlamydia are all out pacing the numbers seen during the same period in 2014.

During the first five months of 2015, gonorrhea cases numbered 1,688, compared to the 1,197 cases seen during the same period in 2014. Chlamydia cases totaled 2,812 between January and May of this year, a significant increase from the 2,312 cases reported during the same time frame last year.

As for syphilis cases, the city reported 606 cases as of May; in 2014 the number stood at 527 cases by this point. The year-to-year increase in cases is likely to continue throughout the rest of 2015, as STD cases historically have been higher in the summer and fall.

But by deploying new STD prevention methods embraced by the public, health officials are confident the rising rates can be reversed as has been done with HIV.

“We have seen an amazing decline in HIV. We want to build on this success story,” said Philip.

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