The Press Democrat September 4, 2017

The rates of sexually transmitted diseases such as chlamydia, gonorrhea and syphilis have been skyrocketing in Sonoma County since 2008 as the spread of HIV has declined slightly, raising alarms among local health care professionals and county public health officials.

The seemingly contradictory trends have local health experts trying to figure out the possible causes. Some point to mobile “hookup” apps that have greatly facilitated consensual and casual sex, or the use of HIV prevention and treatment methods that inhibit the spread of the virus but may be encouraging risky behavior such as no longer using condoms.

Others say county budget cuts have adversely affected prevention and treatment programs aimed at reducing sexually transmitted infections, or STIs. Meanwhile, the number of Sonoma County residents being screened for STIs has grown, likely due to increased access to health care under Obamacare and more intensive screening.

Between 2008 and 2016, the number of reported cases in Sonoma County of chlamydia rose from 910 to 1,893; gonorrhea cases jumped from 69 to 554; and syphilis went from a low of four to 63.

“I do not have the answer for all the reasons why there’s an increase in sexually transmitted infection – people are having a lot of unprotected sex and our ability to prevent HIV transmissions is improving,” said Dr. Karen Holbrook, Sonoma County’s deputy health officer.

Holbrook said the ability to inhibit the spread of HIV may be causing some to relax their use of “barrier methods” such as condoms. She said the spread of the HIV virus can essentially be halted through the strict use of HIV medicines by those who are HIV positive and pre-exposure prophylaxis, or PrEP, by those who are HIV-negative but engage in risky behavior.

But these methods do not prevent transmission of other STIs, Holbrook said. She said there is likely also a general lack of understanding of the risks of unprotected sex.

“I think there are also people who are having sex who don’t understand the risk and they don’t understand that the partners they’re having sex with are at risk for all of these infections,” she said.

HIV treatment therapies effectively reduce the “viral load” in a person’s body, inhibiting their ability to transmit the virus to others. For those who are not HIV positive but at substantial risk of getting it, PrEP has been shown to significantly reduce that risk by as much as 92 percent, according to the federal Centers for Disease Control and Prevention.

Dr. Gary Green, head of infectious disease at Kaiser Santa Rosa Medical Center, said the increases in STI rates were nothing short of “astronomical.” He is convinced the spikes in STI rates were due to the widespread use of online apps that greatly facilitate casual sex. He made a distinction between “hookup” apps like Grindr and Tinder and “dating” apps like or eHarmony.

“Technology has made sex incredibly convenient,” he said.

Green said Truvada, an HIV antiviral drug used for PrEP, has been a game- changer in terms of reducing HIV infections. But it has its downsides, he said.

Since the mid 1990s, when AIDS “miracle drugs” began saving lives, health care providers used a multipronged strategy to fight the spread of HIV, Green said. These strategies included recommending patients limit their number of partners, know their partners’ status, use condoms especially for anal sex, and use HIV drugs to reduce their viral load and, consequently, lower their risk of transmitting the virus.

Green said in the past, these strategies have slowed the spread of HIV but not reduced it.

“Now since PrEP came out, we’ve been able to lower HIV infections,” he said, adding he believes people are using condoms less because they no longer fear contracting the HIV virus.

“For many patients, using Truvada for HIV prevention means no condom,” he said.

But Dr. Danny Toub, the lead chronic viral disease clinician for Santa Rosa Community Health Centers, does not believe PrEP users are changing their behavior.

Toub said that overall in multiple large PrEP studies, there were no increases in sexual risk behavior.

“Some PrEP users reported an increase in risk behaviors, including a decrease in consistent condom use, but some PrEP users reported a decrease in risk behaviors,” he said.

He pointed out that some of his PrEP patients say the treatment is “incredibly liberating” and they feel less fear and shame around sex. That’s reduced the amount of stigma and secrecy, and increased communication and discussion about sexual behavior among those at high risk of HIV infection, he said.

Toub cited a number of possible reasons why STI rates have spiked in recent years. He agreed with Green that geosocial networking apps like Grindr and Tinder may be facilitating sexual networks.

But he also said budget cuts have affected public health department STD clinics and left less expertise and resources for STI prevention and treatment. One example is the county’s closure of its STD clinic in 2010.

Toub also said “screening bias” may also be affecting rates. He said more people are getting screened for STIs due to greater access to health care under former President Obama’s Affordable Care Act. He also said more clinicians are screening for STIs in three areas: urine, mouth and rectum.

Finally, Toub said, people in racial and sexual minority groups can have trouble finding care for preventing and treating STIs.

Green said the majority of STIs occur among gay and bisexual people, but the county is seeing an increase of syphilis in straight women as well. He said there are women who themselves have high risk encounters, but there’s also a population of women whose partners are having high risk exposures they’re not aware of.

Green insists that PrEP has removed one of the strongest motives incentives for people to use condoms — fear.

He said that Kaiser’s PrEP clinic in San Francisco, with more than 1,000 patients, has not had a single person become HIV positive.

“People are not freaked out about HIV,” he said. “They lose the anxiety on PrEP, they’re not afraid.”

Both Holbrook and Green said while STIs such as gonorrhea, chlamydia and syphilis are treatable, they are not without their risk. Gonorrhea, for example, is becoming more resistant to traditional treatment.

Holbrook pointed out that certain STI infections are asymptomatic, meaning many people do not know they have it, don’t get tested and are not treated.

These infections over time can cause such things as pelvic inflammatory disease and infertility among women, and sterility among men, she said.

Syphilis in pregnant women can be transmitted to a fetus and cause congenital syphilis. Such cases have not been seen in Sonoma County this year but have been previously.

“We’ve had a couple of probable cases in the last five years,” she said. “But in California as a whole, theres been a dramatic uptick in congenital syphilis.”

Holbrook called cases of congenital syphilis “the tip of the iceberg,” a sign that syphilis is present in greater numbers in the general population.

“When we see congenital cases it means that syphilis has been circulating in the adult population for a while,” she said.

“When we see congenital cases it means that syphilis has been circulating in the adult population for a while,” she said.

Public health officials encourage a number of strategies for reducing current STI rates, including encouraging people to have conversations with their sexual partners and health care providers so that appropriate screening and testing can occur and people can get diagnosed and treated.

In addition, when somebody discovers they have a sexually transmitted disease, they should notify their sex partners so they also can get tested and treated if necessary.

This article originally appeared in The Press Democrat