Syphilis prevention vs. politics

Last week’s New York Times featured a great article on a syphilis outbreak in Oklahoma. Reporter Jan Hoffman documented some of the impressive work state health investigators are doing to contain the outbreak, from using Facebook to discern likely transmission routes to showing up at the homes of people with positive test results and offering them rides to treatment centers.

CDC warned earlier this year that syphilis rates are on the rise throughout the US. Primary and secondary syphilis, the disease’s most infectious stages, rose 19% in a single year (2014-2015), and that trend appears to be continuing. The majority of these P&S cases are among men who have sex with men, but rates are also rising among women and some newborns. Pregnant women with untreated syphilis can pass the disease to their fetuses; congenital syphilis, which can cause stillbirth as well as severe illness and death in infants, has also been increasing since 2012. CDC’s map shows Oklahoma as one as several states where the syphilis rate experienced a 101-200% change from 2011 to 2015; Oregon, Idaho, Utah, North Dakota, Nebraska, Kansas, Iowa, West Virginia, and Hawaii showed changes of more than 200% over the same time period.

Source: Centers for Disease Control & Prevention, 2017: CDC Call to Action: Let’s Work Together to Stem the Tide of Rising Syphilis in the United States

A few months before that, when CDC released its STD surveillance report for 2015 (read Kim Krisberg’s report on that here), the agency’s news release sounded an alarm:

“We have reached a decisive moment for the nation,” said Dr. Jonathan Mermin, director of CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. “STD rates are rising, and many of the country’s systems for preventing STDs have eroded. We must mobilize, rebuild and expand services – or the human and economic burden will continue to grow.”

In recent years more than half of state and local STD programs have experienced budget cuts, resulting in more than 20 health department STD clinic closures in one year alone. Fewer clinics mean reduced access to STD testing and treatment for those who need these services.

Chlamydia, gonorrhea and syphilis are curable with antibiotics. Widespread access to screening and treatment would reduce their spread. Most STD cases continue to go undiagnosed and untreated, putting individuals at risk for severe and often irreversible health consequences, including infertility, chronic pain and increased risk for HIV. STDs also impose a substantial economic burden: CDC estimates STD cases cost the U.S. healthcare system nearly $16 billion each year.

In other words, we’re failing to stop the preventable spread of STDs because the people in charge of budgets are being penny wise but pound foolish. For 2017, federal STD prevention funding suffered a $5 million cut (to $152 million), and President Trump’s proposed 2018 budget slashes it by 17%. In Oklahoma, the state legislature passed a 2018 budget that cuts the state health department budget by 3%.

Years of cuts to public health budgets are problematic on their own, but now they’re coupled with increased federal hostility to the programs and providers we need in order to address STDs (and other aspects of sexual and reproductive health) effectively. It’s not new for House Republicans to try to eliminate the Title X program, which funds reproductive healthcare for millions of low-income people, or to deny reimbursement to Planned Parenthood for services it provides to Medicaid beneficiaries, but this is the first time in a while they’ve had a president who’s likely to sign off on such destructive moves. Title X clinics performed nearly six million STD tests in 2014. Planned Parenthood provides more than 4.2 million tests and treatments for STDs — and, as Texas learned recently, there’s no easy replacement for Planned Parenthood.

As US Representative Nita Lowey (D-New York) noted in an opinion piece for The Hill, “The attacks on women’s health don’t stop at our own borders.” One of President Trump’s first executive actions was a worse-than-ever version of the global gag rule, which is harming many other countries’ efforts to reduce STD transmission — and as Zika cases have demonstrated, infections acquired in other countries can end up sexually transmitted here.

In addition to testing for and treating STDs, we also need prevention efforts that help people avoid unprotected sex. The Trump administration has attacked these, too, with abrupt early termination of Teen Pregnancy Prevention programs in communities across the country. As Kim Krisberg reported recently, grantees were testing and disseminating sexual health interventions aimed at improving sexual health, including strategies to reduce STDs and sexual violence. One of the projects facing early termination, she noted, is the Seattle-King County FLASH curriculum, which is in the process of rolling out to schools across the country and “is designed to be inclusive of LGBT students and is just as relevant for young people who decide to abstain from sex as it is for those who don’t.”

Among TPP grant programs — all of which appear to have lost funding — are three in Oklahoma. Choctaw Nation of Oklahoma is “replicating evidence-based teen pregnancy prevention programs in middle schools, high schools, and alternative schools in Choctaw, McCurtain, and Pushmataha counties, three counties in Southeast Oklahoma with some of the highest teen pregnancy rates.” Oklahoma City-County Health Department collaborates with local partners to bring elementary and middle schools evidence-based programs such as Cuidate!, Making Proud Choices, Making a Difference, Be Proud! Be Responsible!, Draw the Line/Respect the Line, and Sisters Saving Sisters. Youth Services of Tulsa, Inc. by 2020 aimed to serve 10,000 youth in middle school, high school, alternative school, juvenile detention, community-based, specialized, and clinic settings. Unless their TPP funding is restored or replaced, thousands of teens will miss out on important sexual health education as a syphilis outbreak threatens health in their state.

Evidence-based sexual health education that’s inclusive of LGBT students — or adults, for that matter — is especially important for stopping the spread of syphilis, given that the majority of cases are in gay and bisexual men and other men who have sex with men. Turning away from inclusive, evidence-based sex ed and taking an anti-LGBTQ tone, as this administration has done, risks cutting LGBTQ individuals off from information that can help them make healthy decisions when it comes to sex. “Abstinence-only sex ed and ‘no pro homo’ laws keeps kids in the dark, leaving them with bodies they don’t fully understand and experiences they have no context for,” writes BuzzFeed contributor John Paul Brammer. “I was uneducated — about gay sex, about consent — and that made me more vulnerable.”

Reading about hardworking Oklahoma public health investigators in the New York Times makes me proud of what public health can do — and fearful of how bad things will get as support for effective public health programs keeps eroding.