The incidence of sexually transmitted diseases (STDs) in San Francisco has been rising steadily over the past several years, mirroring a national trend. And Southside neighborhoods – including Potrero Hill, Bayview, Hunters Point, Visitation Valley, and the Mission – have among the highest STD rates in the City, with the Castro and Duboce Triangle/Upper Market exhibiting alarming disease frequencies.
According to Stephanie Cohen, medical director of San Francisco City Clinic, a number of factors contribute to specific neighborhoods experiencing elevated STD rates. “We know that in San Francisco, like many parts of the nation, STDs disproportionately impact certain populations,” explained Cohen. “The populations with the highest rates are men who have sex with men, “MSM”, and young women of color. As a result, STD rates are highest in the parts of San Francisco where they live; where the highest population of MSM and people of color are…While I don’t know the exact population of the different sections of the City, I think that it is agreed upon that certain areas of the City experiencing high STD rates have higher numbers of these population groups.”
A 2012 article posted on Trulia.com, “Welcome to the Gayborhood,” indicated that the Castro has the most same sex couples per capita in the country.
According to Cohen, a neighborhood with a concentration of MSMs or people of color will tend to have higher, and more persistent, rates of STDs. “Where it’s already high it tends to stay high, and it’s hard to break out of that cycle,” she explained.
“Social and economic conditions, such as high rates of poverty, income inequality, unemployment, low educational attainment and geographic isolation can make it more difficult for individuals to protect their sexual health,” stated a 2012 surveillance report issued by the Centers for Disease Control and Prevention. “People who struggle financially are often experiencing life circumstances that increase their risk for STDs. Those who cannot afford basic necessities may have trouble accessing and affording quality sexual health services…In communities where STD prevalence is higher, individuals may have a more difficult time reducing their risk for infection. With each sexual encounter, they face a greater chance of encountering an infected partner than those in lower prevalence settings. Acknowledging the inequity in STD rates by race or ethnicity is one of the first steps in empowering affected communities to organize and focus on this problem.”
According to the California Department of Public Health (CDPH), “There are a number of things that contribute to disparities in STD rates, including societal factors, such as poverty, homelessness, substance use, and exchange of sex for money/resources; as well as limited access to education, health insurance, and quality sexual health services.”
Cohen emphasized that geographical disparities are a result of “a challenging interplay of structural violence and racism.” She mentioned that high rates of incarceration among African-Americans separates partners and plays a part in this “critical health issue.”
In 2014, the San Francisco Department of Public Health (SFDPH) reported that the rate of chlamydia among African-American adolescents/young adults was almost six times that of European-American adolescents/young adults. The gonorrhea rate among Black adolescents/young adults was almost five times that of White adolescents/young adults. The chlamydia rate for African-American adolescents/young adults dropped 36 percent since 2010. However, the gonorrhea rate among this population jumped 55 percent between 2013 and 2014.
Frequent partner turnover is a dominant factor driving the higher STD rates seen in MSMs and youth.
A new contributing influence, which has been linked to STD rates rising among MSMs, is the divergence of HIV and STD prevention. Health care officials are seeing decreased condom use as a result of biomedical HIV prevention; antiretroviral treatment, such as pre-exposure prophylaxis, also known as PrEP. Since this new preventative method calls for taking a daily pill rather than using a condom, some individuals forego using a latex prophylaxis all together, leaving them at greater risk for other STDs, such as gonorrhea, syphilis, and chlamydia.
San Francisco is on the leading edge of rising STD rates among MSMs, with the Castro reporting the highest numbers of gonorrhea, syphilis, and chlamydia: more than 4,000 cases per 100,000 residents in 2015. Potrero Hill had more than 1,500 per 100,000 residents, while the City as a whole experienced in excess of 1,200 cases per 100,000 residents. Every year Potrero Hill falls above the City average, as does the Castro and most Southside neighborhoods.
Overall, STD rates have steadily increased since 2000. While some years and some neighborhoods, with no defining trend, have experienced a lull, overarching STD counts have risen. 2014, in particular, saw a jump in rates: 1,117 early syphilis cases were reported that year, an increase of 9.4 percent from 2013, the highest syphilis total since 1984. Potrero Hill reported 20 cases. Only one-quarter of the 44 tallied neighborhoods reported higher numbers.
According to CDPH, “gay, bisexual, and other men who have sex with men are at increased risk of STDs and have disproportionately high rates compared to their heterosexual counterparts. San Francisco’s large MSM population may partially explain high STD rates. In so far as at-risk populations reside in different parts of the City, which could explain regional differences in rates.”
“Gay and bisexual men and other men who have sex with men have the highest prevalence’s of gonorrhea, chlamydia, and early syphilis. Transgender residents also have higher rates of STD than San Francisco residents as a whole,” SFDPH stated in its 2014 report.
SFDPH groups addresses into 44 neighborhoods to track STD rates. However, while its legally required to include addresses in clinicians’ STD reports – City Clinic and Magnet – in 2014, 10 percent of all gonorrhea and chlamydia reports failed to include addresses. These cases, along with situations involving homeless individuals, aren’t included in the county’s cumulative data at all. As a result, the reported data reflects the minimum number of STDs in the City. In all 44 districts, rates have continued to rise throughout the decade.
CDPH hasn’t identified the cause of recent increases in STD rates. “San Francisco is fortunate to have a county-funded STD clinic that provides comprehensive STD screening, diagnosis and treatment services,” a department spokesperson said. “Solutions are multi-factorial and involve ensuring that people at risk for STD are knowledgeable about these risks, know how to protect themselves, have access to prevention (e.g., condoms), and seek STD clinical services when needed. Additionally, it is important to ensure the medical providers are skilled at assessing risk and understand current recommendations for testing and treatment. Notifying sexual partners is another key component to reducing STD transmission; a responsibility shared by clients, providers, and the health department.”