Mind and Body

Why are STDs on the rise in Rhode Island?

Is it better access to health care and screening? Is it a return to unprotected sex? Who is most at risk? Does it link back to the closing of an STD clinic in 2011?

Image courtesy of Boston Public Health Commission, provided by the R.I. Department of Health

An ad currently being run by the Boston Public Health Commission. Similar ads are planned to be deployed by the R.I. Department of Health in the coming months, agency officials said.

By Richard Asinof
Posted 10/2/17
The dramatic increase in the number of sexually transmitted diseases in Rhode Island for syphilis, gonorrhea and chlamydia in 2016 has prompted the R.I. Department of Health to go public with its concerns. The exact causes for the increases are not known. Some, however, point to the closing of a STD clinic in 2011 for budgetary reasons. A new ad campaign is planned to target online hookup sites for men, urging the practice of safe sex and screening.
Has the availability of PrEP as a prophylactic against HIV led more people to have unprotected sex and not use condoms? Given the plans for a public education campaign targeting teenagers at the mall, would large photographic posters in public restrooms be an appropriate medium? Is there a way to conduct follow-up, systematic outreach to sexual partners, so that re-infection from chlamydia is not the rule? Is Rhode Island willing to have a debate about legislation to create safe injection sites, similar to what is happening in Massachusetts?
In Massachusetts, as reported by Wicked Local Dennis, the possibility of a pilot project for so-called “medically supervised injection facilities” is under preliminary discussion by the Commonwealth, with the Cape a possible site.
Legislation filed by two Mass. state senators seeks to create “a space for people who use drugs to consume pre-obtained drugs under the supervision of health care professionals or other trained staff and may provide other related services including but not limited to needle exchange, overdose prevention, and referrals to treatment and other services.”
Last month, the Mass. Joint Committee on Mental Health, Substance Use and Recovery held a hearing on the Cape.
Dr. Brandon Marshall, associate professor of Epidemiology at Brown, wrote a letter in support of the proposed safe-injection site. Marshall has evaluated data from the Vancouver, British Columbia, safe-injection facility. As reported by Wicked Local Dennis, Marshall said that “a 35 percent reduction in overdose mortality” had been achieved in Vancouver. Further, Marshall was quoted as saying: “Many who come to the injection site, come throughout the year, enabling supervision.”
Joe Carleo, CEO of the AIDS Support Group of Cape Cod, said that drug use and overdoses are an “unprecedented crisis on the Cape and across the state, especially among young people,” according to Wicked Local Dennis.
With a safe-injection facility, Carleo continued, instead of overdosing in a cemetery or stairwell, contact is made which can keep people alive.
When will Rhode Island begin a similar conversation? Which legislators will be courageous enough to step forward to propose similar legislation in the R.I. General Assembly?
In the first six months of 2017, the number of overdose deaths in Rhode Island was reported to be 172, a slight decrease from 179 deaths for the first six months of 2016, according to sources.

PROVIDENCE – Syphilis and gonorrhea and chlamydia, oh my: these three sexually transmitted diseases do not often make it into breaking news alerts. But the dramatic rise in the number of cases, both here in Rhode Island and nationally, prompted public health agencies to sound an alarm.

That news, coupled with the recent research that found 27 viruses can stay alive in semen for months, such as Zika and Ebola, with the potential to be transmitted during sex, should have folks asking: Can you practice safe sex?

In response to dramatic increases in the rates of these three sexually transmitted diseases in Rhode Island in 2016, the R.I. Department of Health offered the three reporters covering health care in Rhode Island [ConvergenceRI, Jennifer Bogdan of The Providence Journal, and Lynn Arditi of Rhode Island Public Radio] an opportunity to talk with Dr. Philip A. Chan, director of HIV/STD Testing and Prevention Services at The Miriam Hospital Immunology Center. Chan is also a consulting medical director at the agency.

In the interviews, Chan provided some potential reasons for the causes behind the spike in the number of cases of STDs: better access to health care and increased screening, continuing health disparities, and the growing popularity of hookups for male sex partners through online sites.

The burden of STDs in Rhode Island, Chan said, occurs mostly in urban centers, with 80 percent of the cases located in Providence County, according to the data. They intersect with health disparities related to education, access to health care and lower socio-economic status, according to Chan.

Chan also noted the significant spike in gonorrhea and chlamydia in teenagers between the ages of 15 and 19, recommending that sexually active women under 24 be tested, because the STDs are often asymptomatic.

The conversations were embargoed until Sept. 26, when the R.I. Department of Health, in coordination with a nationwide public relations effort by the Centers of Disease Control and Prevention, officially released data detailing how rates of infections for syphilis, gonorrhea and chlamydia had jumped significantly in the last few years.

Provider alert issued a month earlier
News is not so much what happens but what you do not know. A month earlier, on Aug. 22, the R.I. Department of Health had issued a provider advisory to doctors, nurses and health systems with much of the same information:

“In 2016, the number of new diagnoses of sexually transmitted diseases, including chlamydia, gonorrhea, and syphilis, continued to increase. The number of people diagnosed with chlamydia was the highest ever in the past decade, with 4,936 cases diagnosed in Rhode Island in 2016,” the Aug. 22 advisory said.

Further, the advisory warned, “Women are diagnosed with chlamydia more frequently than men and are also at risk of complications, including infertility, pelvic inflammatory disease, ectopic pregnancy, and chronic pelvic pain.”

The advisory continued: “Cases of gonorrhea and syphilis were also the highest they have been in the last decade with 716 cases of gonorrhea and 153 cases of syphilis reported in 2016.” In the last year, there were dramatic increases in the number of cases of syphilis [33 percent] and gonorrhea [23 percent] in Rhode Island, according to agency officials.

ConvergenceRI spoke on Tuesday morning, Sept. 26, with Chan and Thomas E. Bertrand, chief of the Center for HIV, Hepatitis, STD and TB at the R.I. Department of Health, the day that the embargo was to be lifted.

ConvergenceRI: How much of the rise in sexually transmitted diseases can be tied to the current epidemic in drug use, both here in Rhode Island and nationally?
: That’s a great question. We don’t know for sure. There is not great data. There was an outbreak of syphilis in Indiana tied to injected drug use. In terms of injection drug use, we are not seeing [similar] increases in new HIV infections in Rhode Island, in part because of harm reduction programs.

Increases [in the number of cases] of syphilis and gonorrhea [appear] to have been driven by men having sex with men and bisexual partners.

ConvergenceRI: Do you believe that a safe injection site, similar to what is being done in Vancouver, and what is currently being debated in Massachusetts, with a recent hearing on the Cape, would be a preventive step to cut down the rate of transmission of STDs?
I am not familiar with the program. There could be benefits. What we do know is that there is a lot of risk with substance use for sexually transmitted diseases.

ConvergenceRI: What kind of outreach exists in Rhode Island with community health workers to engage with folks in the field to offer them testing for STDs? Are you collaborating, for instance, with Project Weber/Renew, and its efforts to engage with commercial sex workers and survivors of sex trafficking?
Great question. We collaborate very closely with Project Weber/Renew on HIV testing, both through the Department of Health and through [the STD clinic] at Miriam.

There is one important caveat. For HIV, there are rapid tests; you can do a test in a parking lot. For STDs such as gonorrhea and chlamydia, you need a urine sample or to draw blood, with the need for the tests to be run in a specialized laboratory. That is not easily done in a community setting; it’s something that’s not feasible for a community organization to do.

For STDs, we don’t have any data specifically for that group. They are extremely high risk.

ConvergenceRI: Should screening for STDs be added to the things that primary care providers check for as part of their ongoing care provided to patients?
With the larger health systems, and with some of the community health centers, we are working with them to educate providers to provide routine screenings for STDs.

ConvergenceRI: What kind of outreach through social media is happening in Rhode Island? Has there been any effort to target Internet sites that promote sex hookups?
Great question. One point I would like to make. With the three STDs, and the dramatic increases we’ve seen for syphilis, gonorrhea and chlamydia, some of the increases may be due to better screening practices and better access to health care.

With chlamydia, there are more cases with women. With gonorrhea, there are more cases with men, by a slight margin, and with syphilis, there is a predominance of men.

ConvergenceRI: In the past, you have collaborated with Amy Nunn, the executive director of the R.I. Public Health Institute at the School of Public Health at Brown University, to do outreach ads to promote safe sex on male hookup sites, targeting prevention of new HIV infections. [See link to ConvergenceRI story below.]

Are you considering ramping up that program again for STDs such as syphilis, gonorrhea and chlamydia?
Working with Dr. Nunn, we found that [there is a high risk] of STDs involving gay and bisexual men, based upon our research, for men who are meeting partners online on sites such as Grindr and Manhunt.

We launched an advertising campaign targeted at men who are meeting men online. It was a really successful campaign; it ran for about six months. It lit up the dashboard at the Health Department. The campaign was funded through the Centers for Disease Control and Prevention.

BERTRAND: We are planning to run a similar campaign in the coming months, targeting STDs.

ConvergenceRI: What kind of public outreach is being done with high school students, given the high number of teenagers infected with chlamydia?
Another great question. We’ve started to partner with high schools, including Central Falls High School, working with the health clinic run by Blackstone Valley Community Health Care.

ConvergenceRI: Is there a geographic breakdown of the incidence of sexually transmitted diseases for Rhode Island?
The burden of [sexually transmitted diseases] is in urban centers, according to the data. What we have found is that the majority – 80 percent of the cases – are located in Providence County.

We see an intersection with health disparities, related to education, access to health care, and lower socio-economic status. A lot of that is centered in and around Providence. We do see a disproportionate number of African Americans and Latinos [affected by STDs].

ConvergenceRI: Given the high number of teenagers who are contracting chlamydia in Rhode Island, what is the outreach strategy to reach young people?
We are looking at what social media platforms they are using, to find out where they are. Our research shows that some 98 percent spend some time at the mall. We are planning a broad-based campaign, urging them to use protection and to get screened.

CHAN: A lot of times, the medical community is reluctant to ask about STDs. We want to encourage them to test for STDs.

All these STDs, especially in women, can have severe impacts on future health, such as fertility. They can also increase the risk of HIV acquisition by three- to five-fold. STDs are [often] asymptomatic. That is whey we really encourage people to be routinely tested.

More, better questions and conversation
As so often happens these days, the real reporting – and the real dialogue – occurs not in the news media, but on Facebook and it was not fake news.

It was a dialogue kicked off by Dr. Peter Simon on his Facebook page, posing a question in response to The Providence Journal by Jennifer Bogdan on Sept. 27:

PETER SIMON: Article does not mention that there is no case investigation by Health Department STI workers for chlamydia, or that there is no systematic outreach to sexual partners for chlamydia, so re-infection is the rule.

LYNN BLANCHETTE: Where is the discussion about PrEP? [Pre-exposure prophylaxis, or PrEP, is a way for people who do not have HIV but who are at substantial risk of getting it to prevent HIV infection by taking a pill every day, according to CDC.]

PETER SIMON: HIV is not lumped in with STI’s, reported separately. But, you are right to wonder if same has happened with HIV. If not, that suggests that contact tracing is key to get partners to be aware of risk and use “safer” sex strategies.

LYNN BLANCHETTE: But having PrEP is leading more people to have unprotected sex, no more condoms.

NANCY GREEN: How are we on access to medical care for this? I remember when we had “specialty clinics,” one was across the street from St. Joseph’s Hospital. What do we have now?

KEN FISH: There are no state clinics any more. How can this be a surprise?

ROBERT CRAUSMAN: This was predicted when the state pulled funding from the state STD clinic.

PETER SIMON: How would closing a clinic cause increase in cases other than from lack of follow up and contact tracing? More likely due to increase screening by primary care providers and increased enrollment in Medicaid.

ROBERTY CRAUSMAN: By closing the clinic we increased the number of high-risk patients who are untreated or get delayed treatment thereby increasing the spread of illness; especially as it relates to sex workers and their clients.

PETER SIMON: How many high-risk patients used clinic to get annual testing?

ROBERT CRAUSMAN: I really can’t remember the numbers but it was in the vicinity of 1,500 patients per year. It was sufficient to keep a half-time nurse practitioner working year-round.

Here [is a link to] a contemporaneous article written at the time of closing pointing to just how pennywise a decision it was:

[Rather than a link, here is the complete article:]

Bad Medicine in Rhode Island: The Damaging Effects of Budget Cuts on Prevention of STDs

By Thomas Bertrand

July 11, 2011

State budget cuts have eliminated clinics in Rhode Island at a time of rising rates of sexually transmitted infections. Allowing the erosion of Rhode Island’s public health infrastructure is bad public policy – eventually, a steep price is paid, usually by our most vulnerable communities.

THE TRADITIONAL public-health response to rising infectious-disease rates is to conduct awareness campaigns, engage community leaders as partners, and promote public access to screening and treatment to prevent the spread of disease. Amidst rising statewide rates of sexually transmitted diseases (STDs) in Rhode Island, the opposite occurred on July 1, when the Whitmarsh Clinic’s doors were quietly closed to patients in response to state budget cuts.

Operated by Providence Community Health Centers, the Whitmarsh Clinic was the only public STD clinic of its kind in the state. The timing of the clinic closure announcement in mid-June, 2011, was ironic: a team of experts from the federal Centers for Disease Control and Prevention had just landed in Providence to conduct an investigation into recent alarming increases in annual syphilis cases.

As a backdrop to the climbing rates of syphilis, other STDs have remained a persistent public-health burden in Rhode Island with 3,480 cases of chlamydia reported in 2010.

With [more than] 1,500 patient visits in 2010, the Whitmarsh Clinic provided confidential, affordable and patient-friendly services through a mix of revenue streams, including insurance billings, patient out-of-pocket payments and state funding. In an era of health-care reform that has as its intent to expand affordable access to health care, the loss of the Whitmarsh Clinic represents a significant step backwards toward reaching this goal.

STDs are among the most common reportable communicable diseases in Rhode Island. STDs are linked to serious health problems, such as infertility and some cancers, and the presence of a STD facilitates HIV transmission. This is why Rhode Island invests so much into the state-supplied childhood vaccine program – to make sure that children are protected as adults from vaccine-preventable STDs, such as Hepatitis B and human papillomavirus (HPV).

An important lesson can be learned from neighboring Massachusetts, which closed its STD clinics in late 2008. Since then, STDs have been a growing public-health problem in the Bay State. The Massachusetts experience suggests the need to thoughtfully assess the impact of the Whitmarsh Clinic closure on the health of Rhode Island’s families, as well as on Rhode Island’s health-care system.

Allowing the erosion of Rhode Island’s public-health infrastructure is bad public policy – eventually, a steep price is paid, usually by our most vulnerable communities.

TOM BERTRAND: Thanks Dr. Crausman for posting the above. I was the author of the article.

ROBERT CRAUSMAN: I saw that. It was a well-done article then and well worth rereading now with the benefit of hindsight.

Mea culpa
Last week, ConvergenceRI spoke with Dr. Michael Fine, the former director of the R.I. Department of Health, about the rise in STDs in Rhode Island and the closing of the Whitmarsh Clinic for budgetary reasons.

Fine, in retrospect, told ConvergenceRI that it had been a mistake to close the clinic, and that he had to own that mistake. “It’s on me,” Fine said.


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