Cases of sexually transmitted diseases in Central Oregon have skyrocketed over the past five years, reversing decades of progress in reducing infection rates and leaving county health officials scrambling to keep up.
Chlamydia cases have been rising since 2010, increasing from 432 cases in Deschutes County in 2008 to 675 in 2017. Cases have nearly doubled over that time frame in Crook County, and rose 52 percent in Jefferson County. Gonorrhea diagnoses rose sharply starting in 2013, from single digits in the early part of the decade, to 65 cases in Deschutes County, 49 in Jefferson County and 14 in Crook County last year. Syphilis cases have also seen a substantial increase.
“It’s been an increase that I haven’t seen before in all my years of public health in Central Oregon, said Karen Yeargain, communicable disease coordinator for Crook County Health Department. “And it’s been sustained. It hasn’t gone away.”
Public health officials say the evolution of HIV infection into a manageable condition has reduced the perceived risk of unprotected sex for many, allowing chlamydia, gonorrhea and syphilis to spread more rapidly.
The trend has coincided with the emergence of dating websites and phone apps that have made sex more readily available and more anonymous, while public health funding to battle transmission continues to shrink.
The trends match patterns on both state and national levels. The Centers for Disease Control and Prevention announced in September that the number of chlamydia, gonorrhea and syphilis cases in 2016 surpassed 2 million for the first time ever. While those conditions can be cured with antibiotics, left untreated they can led to serious health consequences including infertility, life-threatening ectopic pregnancies, stillbirth and an increased risk for HIV transmission, CDC officials said.
Those conditions have historically been more prevalent among African Americans and men who have sex with men, but are now increasingly spreading among other demographic groups.
Central Oregon has been hit particularly hard with both Deschutes County and Jefferson County well above the national average for STD transmission rates.
Local health officials said it was unclear why those counties had above-average rates, but indicated many of the trends driving rates nationally were also in play locally.
Traditionally, health officials have interviewed those diagnosed to get a list of sexual partners who are then notified they may be infected. State regulations allow clinics to prescribe antibiotics to those partners, even before they are tested.
But county health officials say partner notification is becoming more challenging.
“It’s harder these days to reach people than it used to be,” said Kathy Christensen, sexual health supervisor for the Deschutes County Public Health. “Some people don’t take calls on their phone. They don’t do voicemail. Some people only text.”
Last year, for example, county health officials were able to interview only 36 of the 65 patients diagnosed with gonorrhea.
In the 1980s and ’90s, when an HIV infection was generally a fatal condition, public health officials stressed safe sex involving condom use. That drove down infections of many other sexually acquired conditions.
But medical advances have now reduced the risk of HIV and that has affected condom use. Pre-exposure prophylaxis, known as PrEP, can prevent HIV infection with a daily pill. And among those already infected, HIV medications can now drive the virus down to undetectable levels with a negligible risk of transmission.
“It’s now more a chronic disease than it is a scary death sentence,” said Ruth Helsley, STD prevention manager for the Oregon Health Authority. “The generations that didn’t live through that epidemic think HIV is a chronic disease: you don’t want to get it, but if you get it, it’s treatable.”
That same mindset exists for syphilis and gonorrhea, she says, but fewer people are aware those conditions are still circulating. People also have more birth control options today, including long-acting contraceptives that offer no protection against sexually transmitted diseases.
It’s also unclear how much of the increase is the result of better surveillance. Some health departments have increased outreach in an effort to interrupt transmission. In 2017, Deschutes County health officials made a concerted push on partner notification for chlamydia cases. That meant more people got diagnosed and treated, and led to a jump of 137 cases from the previous year, a 25 percent increase.
Testing has also become easier, requiring only a urine sample, instead of a urethral swab which may have discouraged some people from getting tested in the past.
Still, epidemiological studies have concluded there has been a real increase in the spread of sexually transmitted diseases. And it comes at a time when health departments are least equipped to deal with it.
“Unfortunately we’ve had large federal, state and local cutbacks to STD prevention programs and services over the last decade,” said David Harvey, executive director of the National Coalition of STD Directors. “And this is having a direct impact on the people’s lack of awareness about their risk of getting STDs.”
It’s also left smaller health departments struggling to keep up. Jefferson County Health Department relies mainly on part-time staff who must find extra time to do partner notification.
“When the nurses are doing that, they’re not able to provide direct services (to patients),” Jefferson County Health Director Michael Baker said. “It takes away from the other services we provide.”
Dating websites and mobile apps, such as Tinder or Grindr, have made it easier for people to find sexual partners, and increasingly, sex is becoming more anonymous. County health departments run into roadblocks trying to use those sites to track down partners.
Many of the sites include graphic content and government employees are often blocked from accessing them at work. In some cases, STD coordinators at county health departments must ask Oregon Health Authority staff to message individuals through the sites on their behalf.
Health officials say dating sites are a likely contributor, but not the sole driver of rising STD rates. And while site owners and app developers have been accused of being less than cooperative in working with health authorities around partner notification, Dan Wohlfeiler, director of Building Health Online Communities, says there are technical challenges in doing so.
Many sites do not require users to register with a full name, much less contact information. And many apps only show individuals who are nearby. Someone appearing who came to Bend from Portland and used a dating app to find a partner locally would no longer be visible on the app after leaving the region.
Wohlfeiler’s group is a consortium of public health leaders, gay dating websites and app owners who are collaborating on online prevention efforts.
“Our whole goal is to find common ground between HIV and STD prevention and the dating apps,” he said. “Their goals are very similar to our goals, which is to help people get tested, to help people talk about their health with each other and get really accurate, up-to-date information.”
Dating sites and mobile apps generally allow individuals to create a profile that includes things like height, weight, race and age. But increasingly sites are allowing information about preferences for safe sex behavior as well.
“Not long ago, it was ‘Safe sex: yes or no?’ And safe sex meant condoms,” Wohlfeiler said. “But now we have so many more options.”
Users can now indicate a preference for condom use, that they’re taking PrEP, or have an undetectable viral load. The group has also worked with site owners to push public health messaging about safe sex or getting testing.
“They tend to be much savvier about social media than we are,” he said.
The group worked with one site, Daddyhunt, which caters to young gay men seeking older partners, to create five public health videos on the use of PrEP and condoms, or about having an undetectable viral load. Those videos have garnered more than 3 million views.
The group has been working with researchers at the University of Washington to assess interest in mobile app-based partner notification strategies. Their surveys and focus groups have found that while app users believed they had a responsibility to notify partners themselves, they would welcome help from public health agencies.
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