Tagged CDC

Two Crises In One: As Drug Use Rises, So Does Syphilis

Public health officials grappling with record-high syphilis rates around the nation have pinpointed what appears to be a major risk factor: drug use.

“Two major public health issues are colliding,” said Dr. Sarah Kidd, a medical officer at the Centers for Disease Control and Prevention and lead author of a new report issued Thursday on the link between drugs and syphilis.

The report shows a large intersection between drug use and syphilis among women and heterosexual men. In those groups, reported use of methamphetamine, heroin and other injection drugs more than doubled from 2013 to 2017.

The data did not reveal the same increases in drug use among gay men with syphilis, the group with the highest rates of the disease.

Researchers said the results suggest that drug use — and the risky sexual behaviors associated with it — may be driving some of the increase in syphilis transmission among heterosexuals.

People who use drugs are more likely to engage in unsafe sexual behaviors, which put them at higher risk for sexually transmitted diseases, experts said. The CDC also saw increases in syphilis among heterosexuals during the crack cocaine epidemic of the 1980s and 1990s, and use of the drug was associated with higher syphilis transmission.

“The addiction takes over,” said Patricia Kissinger, an epidemiology professor at Tulane University School of Public Health and Tropical Medicine.

For example, people using drugs may avoid condoms, have multiple sex partners or exchange sex for drugs or money — all significant risk factors for sexually transmitted diseases, said Dr. Sara Kennedy, medical director of Planned Parenthood Northern California.

“I think it’s impossible to eradicate syphilis and congenital syphilis unless we are simultaneously addressing the meth-use and IV-use epidemic,” Kennedy said.

Syphilis rates are setting records nationally. They jumped by 73 percent overall and 156 percent for women from 2013 to 2017. The highest rates were reported in Nevada, California and Louisiana.

Syphilis — which had been nearly eradicated before its resurgence in recent years — is treatable with antibiotics, but if left untreated it can lead to organ damage and even death. Congenital syphilis, which occurs when a mother passes the disease to her unborn baby, can lead to premature birth and newborn deaths.

The study’s authors analyzed syphilis cases from 2013 to 2017 and determined which patients had also reported using drugs. They discovered methamphetamine was the biggest problem: More than one-third of women and one-quarter of heterosexual men with syphilis reported using methamphetamine within the previous year.

Substance use among both populations was highest in 13 Western states and lowest in the Northeast. In California, methamphetamine use by people with syphilis nearly doubled for women and heterosexual men from 2013 to 2017, according to the California Department of Public Health.

The intersecting epidemics of sexually transmitted infections and substance abuse make it harder to identify and treat people with syphilis because drug use makes people less likely to go to the doctor and to report their sexual partners, Kidd said.

Pregnant women also may be reluctant to seek prenatal care and get syphilis testing and treatment because of concerns their doctor will report the drug use.

To stem the transmission of syphilis, the CDC urges more collaboration between programs that address STDs and programs that treat substances abuse.

Drug use is an “incredibly huge contributing factor” to somebody getting an STD and transmitting it, said Jennifer Howell, sexual health program coordinator for the health district in Washoe County, Nev.

“Everybody needs to see that we are dealing with a lot of the same clients,” she said.

Fresno County has the highest rate of congenital syphilis in California. Its health department analyzed 25 cases of congenital syphilis in 2017 and determined that more than two-thirds of the mothers were using drugs, said Joe Prado, the county’s community health division manager.

The county has started offering STD testing for people entering inpatient drug treatment facilities, Prado said. “That’s our opportunity to get them screened,” he said.

Those who return for the results are offered incentives such as gift cards. The county also gives people in drug treatment a care package that contains condoms and education materials about sexually transmitted infections, Prado said.

The city of Long Beach sends a mobile clinic to drug treatment facilities, where it provides HIV testing, said Dr. Anissa Davis, the city’s health officer. She said Long Beach hopes to expand services to include screening for other sexually transmitted infections.

Although increased collaboration between drug treatment providers and STD clinics is essential, it’s not always easy because they traditionally have not worked together, said Kissinger of Tulane.

“The STI people are hyperfocused on STIs and the substance abuse people are focused on substance abuse,” she said. It is an “opportunity lost” if people in drug treatment aren’t screened for syphilis and other sexually transmitted infections, she added.

Fighting the rising rates of syphilis will also require more resources, said Dr. Jeffrey Klausner, a professor of medicine and public health at UCLA.

“The STD workforce has almost entirely disappeared,” he said. “While policies could be put in place that require syphilis testing, those policies also have to come with resources.”

Two Crises In One: As Drug Use Rises, So Does Syphilis

Public health officials grappling with record-high syphilis rates around the nation have pinpointed what appears to be a major risk factor: drug use.

“Two major public health issues are colliding,” said Dr. Sarah Kidd, a medical officer at the Centers for Disease Control and Prevention and lead author of a new report issued Thursday on the link between drugs and syphilis.

The report shows a large intersection between drug use and syphilis among women and heterosexual men. In those groups, reported use of methamphetamine, heroin and other injection drugs more than doubled from 2013 to 2017.

The data did not reveal the same increases in drug use among gay men with syphilis, the group with the highest rates of the disease.

Researchers said the results suggest that drug use — and the risky sexual behaviors associated with it — may be driving some of the increase in syphilis transmission among heterosexuals.

People who use drugs are more likely to engage in unsafe sexual behaviors, which put them at higher risk for sexually transmitted diseases, experts said. The CDC also saw increases in syphilis among heterosexuals during the crack cocaine epidemic of the 1980s and 1990s, and use of the drug was associated with higher syphilis transmission.

“The addiction takes over,” said Patricia Kissinger, an epidemiology professor at Tulane University School of Public Health and Tropical Medicine.

For example, people using drugs may avoid condoms, have multiple sex partners or exchange sex for drugs or money — all significant risk factors for sexually transmitted diseases, said Dr. Sara Kennedy, medical director of Planned Parenthood Northern California.

“I think it’s impossible to eradicate syphilis and congenital syphilis unless we are simultaneously addressing the meth-use and IV-use epidemic,” Kennedy said.

Syphilis rates are setting records nationally. They jumped by 73 percent overall and 156 percent for women from 2013 to 2017. The highest rates were reported in Nevada, California and Louisiana.

Syphilis — which had been nearly eradicated before its resurgence in recent years — is treatable with antibiotics, but if left untreated it can lead to organ damage and even death. Congenital syphilis, which occurs when a mother passes the disease to her unborn baby, can lead to premature birth and newborn deaths.

The study’s authors analyzed syphilis cases from 2013 to 2017 and determined which patients had also reported using drugs. They discovered methamphetamine was the biggest problem: More than one-third of women and one-quarter of heterosexual men with syphilis reported using methamphetamine within the previous year.

Substance use among both populations was highest in 13 Western states and lowest in the Northeast. In California, methamphetamine use by people with syphilis nearly doubled for women and heterosexual men from 2013 to 2017, according to the California Department of Public Health.

The intersecting epidemics of sexually transmitted infections and substance abuse make it harder to identify and treat people with syphilis because drug use makes people less likely to go to the doctor and to report their sexual partners, Kidd said.

Pregnant women also may be reluctant to seek prenatal care and get syphilis testing and treatment because of concerns their doctor will report the drug use.

To stem the transmission of syphilis, the CDC urges more collaboration between programs that address STDs and programs that treat substances abuse.

Drug use is an “incredibly huge contributing factor” to somebody getting an STD and transmitting it, said Jennifer Howell, sexual health program coordinator for the health district in Washoe County, Nev.

“Everybody needs to see that we are dealing with a lot of the same clients,” she said.

Fresno County has the highest rate of congenital syphilis in California. Its health department analyzed 25 cases of congenital syphilis in 2017 and determined that more than two-thirds of the mothers were using drugs, said Joe Prado, the county’s community health division manager.

The county has started offering STD testing for people entering inpatient drug treatment facilities, Prado said. “That’s our opportunity to get them screened,” he said.

Those who return for the results are offered incentives such as gift cards. The county also gives people in drug treatment a care package that contains condoms and education materials about sexually transmitted infections, Prado said.

The city of Long Beach sends a mobile clinic to drug treatment facilities, where it provides HIV testing, said Dr. Anissa Davis, the city’s health officer. She said Long Beach hopes to expand services to include screening for other sexually transmitted infections.

Although increased collaboration between drug treatment providers and STD clinics is essential, it’s not always easy because they traditionally have not worked together, said Kissinger of Tulane.

“The STI people are hyperfocused on STIs and the substance abuse people are focused on substance abuse,” she said. It is an “opportunity lost” if people in drug treatment aren’t screened for syphilis and other sexually transmitted infections, she added.

Fighting the rising rates of syphilis will also require more resources, said Dr. Jeffrey Klausner, a professor of medicine and public health at UCLA.

“The STD workforce has almost entirely disappeared,” he said. “While policies could be put in place that require syphilis testing, those policies also have to come with resources.”

Former Rep. John Dingell Dies; Longest-Serving Congressman Was A Force In Health Policy

Former Rep. John Dingell, the Michigan Democrat who holds the record as the longest-serving member of the U.S. House, died Thursday night in Michigan. He was 92.

And while his name was not familiar to many, his impact on the nation, and on health care in particular, was immense.

For more than 16 years Dingell led the powerful House Energy and Commerce Committee, which is responsible for overseeing the Medicare and Medicaid programs, the U.S. Public Health Service, the Food and Drug Administration and the National Institutes of Health.

As a young legislator, he presided over the House during the vote to approve Medicare in 1965. As a tribute to his father, who served before him and who introduced the first congressional legislation to establish national health insurance during the New Deal, Dingell introduced his own national health insurance bill at the start of every Congress.

And when the House passed what would become the Affordable Care Act in 2009, leaders named the legislation after him. Dingell sat by the side of President Barack Obama when he signed the bill into law in 2010.

Dingell was “a beloved pillar of the Congress and one of the greatest legislators in American history,” said a statement from House Speaker Nancy Pelosi. “Yet, among the vast array of historic legislative achievements, few hold greater meaning than his tireless commitment to the health of the American people.”

He was not always nice. He had a quick temper and a ferocious demeanor when he was displeased, which was often. Witnesses who testified before him could feel his wrath, as could Republican opponents and even other committee Democrats. And he was fiercely protective of his committee’s territory.

In 1993, during the effort by President Bill Clinton to pass major health reform, as the heads of the three main committees that oversee health issues argued over which would lead the effort, Dingell famously proclaimed of his panel, “We have health.”

Dingell and his health subcommittee chairman, California Democrat Henry Waxman, fought endlessly over energy and environmental issues. The Los Angeles-based Waxman was one of the House’s most active environmentalists. Dingell represented the powerful auto industry in southeastern Michigan and opposed many efforts to require safety equipment and fuel and emission standards.

In 2008, Waxman ousted Dingell from the chairmanship of the full committee.

But the two were of the same mind on most health issues, and together during the 1980s and early 1990s they expanded the Medicaid program, reshaped Medicare and modernized the FDA, NIH and the Centers for Disease Control and Prevention.

“It was always a relief for me to know that when he and I met with the Senate in conference, we were talking from the same page, believed in the same things, and we were going to fight together,” Waxman said in 2009.

Dingell was succeeded in his seat by his wife, Rep. Debbie Dingell, herself a former auto industry lobbyist.

Trump Pledges To End HIV Transmission By 2030. Doable, But Daunting.

Noting that science has “brought a once-distant dream within reach,” President Donald Trump on Tuesday night pledged to eliminate HIV transmission within 10 years.

“We have made incredible strides, incredible,” Trump said in the annual State of the Union address. “Together, we will defeat AIDS in America and beyond.”

It’s a goal long sought by public health advocates. But even given the vital gains made in drug therapies and understanding of the disease over nearly 40 years, it is not an easy undertaking.

“The reason we have an AIDS epidemic is not just for a lack of the medication,” said Dr. Kenneth Mayer, medical research director at the Boston LGBT health center Fenway Institute. “There are a lot of social, structural, individual behavioral factors that may impact why people become infected, may impact if people who are infected engage in care and may impact or affect people who are at high risk of HIV.”

Health and Human Services Secretary Alex Azar, who provided details of the initiative after Trump’s announcement, said the administration will target viral hot spots by providing local groups more resources, using data to track the spread of the disease and creating local task forces to bolster prevention and treatment.

Neither Azar nor other federal officials who briefed reporters offered cost estimates for the program.

Azar said the plan seeks to reduce new infections by 75 percent in the next five years and 90 percent in the next decade.

That goal is predicated on growing use of current medications that suppress the virus to such low levels that it is not transmitted during sexual intercourse. PrEP, a drug combination available to individuals with a negative HIV status but may become infected, can reduce their risk of getting the virus by 97 percent, Azar said.”

“This is not the HIV epidemic of the 1990s,” said Terrance Moore, acting executive director of NASTAD, a nonprofit organization that represents officials who administer HIV and hepatitis programs. “We have the tools to end this epidemic.”

Gay and bisexual men made up two-thirds of the nearly 40,000 new HIV cases in 2017, but one clear signal of that difference in the epidemic today is the geography. The nation’s HIV hotbeds are no longer located just in coastal metropolitan areas. In 2017, more than half of the new cases were diagnosed in Southern states.

HHS said it will focus its efforts on the heart of the epidemic: 48 counties across 19 states; the District of Columbia; San Juan, Puerto Rico; and rural areas in seven states, many of which are in the South.

The new federal initiative would expand PrEP access in community health clinics for low-income patients and quickly refer any new clinic patients with HIV to specialized care.

Medications alone are not the answer. Lawmakers must have the political will to move forward with policies based in science, said Moore. Existing programs do not provide enough infrastructure to achieve this goal, he added.

“You can’t be simultaneously attacking and undermining the needs of these communities, while claiming that you want to support them and end the AIDS epidemic,” said Scott Schoettes, HIV project director for the LGBT advocacy group Lambda Legal.

The Trump administration has pursued policies that may hinder the president’s goal. And efforts in the South face additional challenges, like higher levels of poverty, difficulty providing health care in rural areas and historical racial tension.

“I don’t think that these things are things that we cannot overcome,” said Greg Millett, vice president and director of public policy at the HIV research foundation amfAR. “But I also think that we need to be very clear about what the obstacles are and to start thinking now innovatively about how we’re going to be able to obviate them.”

Here are some of the challenges that experts said the president’s plan could face.

Health Insurance

Insurance coverage plays a crucial role in keeping HIV patients healthy.

Comprehensive insurance helps patients access the expensive medications needed to keep the virus under control and vital tests to check on virus levels and white blood cell counts — key health indicators. HIV patients are also often susceptible to infections because the virus compromises the immune system. And they tend to have higher rates of mental health conditions, which could affect their ability to adhere to HIV medication if left untreated.

The Affordable Care Act opened up coverage for thousands of HIV patients with its guarantee of insurance for people with preexisting conditions, but many Republican officials are still calling for the law’s repeal.

In addition, the ACA’s Medicaid expansion led to a substantial jump in the number of people with AIDS who got that coverage, according to the Kaiser Family Foundation. But many states, especially in the South, have not expanded Medicaid. (Kaiser Health News is an editorially independent program of the foundation.)

A federal judge in Texas in December ruled the ACA unconstitutional in a lawsuit waged by a faction of conservative states and supported by the president.

“If you’re not going to provide it through the Affordable Care Act,” Schoettes said, “then there needs to be something that’s as comprehensive in terms of getting people care.

Housing

Although the federal government provides some housing assistance for people with HIV, it does not fill the need.

Those who are homeless or have unstable housing have lower access to HIV medications and poorer treatment outcomes.

A study from the Centers for Disease Control and Prevention found that among individuals living with HIV in certain impoverished urban areas across the country, the lower the household income, the higher the rate of HIV in the area. 

The federal government provides assistance through a program called Housing Opportunities for Persons With AIDS, known as HOPWA. In 2016, HOPWA changed its  funding formula to better allocate its resources to Southern areas hardest hit by HIV.

However, some of these HOPWA programs have waiting lists that can extend years. The nation is also experiencing an affordable housing shortage, which further limits options for low-income individuals living with HIV and their families.

Stigma And Mistrust

Experts continue to cite stigma as a key obstacle for treatment. Twenty-six states have laws that penalize an HIV patient for exposing someone to the virus, including 19 that require people who are aware they are infected to notify sexual partners and 12 that mandate disclosure to needle-sharing partners, according to the CDC.

The problems extend to doctors and medical staff. One study, published in 2016, found widespread stigma against HIV patients among health care staff in Alabama and Mississippi, especially among whites and men.

Gina Brown, a community engagement manager for the Southern AIDS Coalition, in part blames the culture of the South, where religious beliefs often clash with gay culture, for perpetuating these problems. “We are still in Bible Belt country, where religion plays a huge part in how we talk about sex or not talk about sex,” she said.

But federal policies, such as the Trump administration’s ban on transgender men and women serving in the military, also play a role.

Federal officials acknowledged these difficulties and affirmed the program would not discriminate against transgender patients.

In addition, minority communities hard hit by the HIV epidemic harbor lingering distrust toward the medical system due to historical abuses such as the Tuskegee syphilis trials, said Mayer.

Injection Drug Use

The scourge of addiction has killed tens of thousands across the nation, spread hepatitis C and is now leading to spikes in HIV transmission, as drug users share needles. In 2015, Scott County, Ind., sought to combat an HIV outbreak fueled by injected opioid use that infected 215 people. Drug use has also been connected to multiple HIV clusters in Massachusetts and Kentucky.

HHS reported that injection drug users accounted for 1 in 10 new HIV cases in 2016.

Expanding syringe exchange programs across the country could minimize this problem, experts said.

“Unfortunately, in the United States we haven’t done as good a job as other Western countries in making sure that those programs are widely available for those Americans who need them,” said Millett.

The CDC and HHS consider syringe exchange programs effective interventions, but some cities, such as Charleston, W.Va., that implemented the programs have now shut them down because of neighborhood complaints, funding concerns and opposition from citizens who object to providing injection equipment.

Federal funds can be used to support this intervention, but these dollars cannot go directly toward purchasing needles.