To D.C. health workers, the news that sexually transmitted diseases nationwide reached a record high in 2016 — with some of the highest levels found in the District — shows serious work remains in combating infections.
But some local health providers looking at the numbers in the federal reportsay the rise in reported cases is a sign that screening programs are working.
"It's not that there is more disease out there, but we know more about it," said Raymond Martins, an internal medicine physician and a senior director at Whitman-Walker Health in D.C.
The District has borne a heavy STD burden for years.
In 2016, it saw roughly 1,083 reported cases of chlamydia per 100,000 residents, placing it far ahead of Alaska, the state with the second highest rate at 772, according to the September report from the Centers for Disease Control and Prevention. The District also had the highest rates of gonorrhea as well as primary and secondary syphilis among states, ahead of Louisiana.
The District's statistics are less extreme when compared to similarly sized cities. Last year, Baltimore reported higher STD rates than D.C., and San Francisco saw a higher rate of reported syphilis.
The CDC surveillance report provides a snapshot of trends in sexual health but not why those trends are happening, the agency said in a statement to The Washington Post. It added that many factors can have an impact on trends in complex diseases, including access to testing.
Officials at clinics, hospitals and outreach programs in the District are looking at the local trends for causes and for ways to enhance prevention.
By expanding to primary care providers, the Affordable Care Act has increased testing and reports, said Jonathan Zenilman, head of infectious disease at Johns Hopkins Bayview Medical Center in Baltimore and a leading voice in STD research.
Screening for STDs is much easier and more widely available, especially for young people, Zenilman said.
In the D.C. health community, there has also been a widespread acceptance of a pill that has been proven significantly effective in reducing a person's chance of contracting HIV — and requires regular testing every three months to monitor a patient's exposure. The regular testing has increased screening, which could surface other STDs.
It is not clear whether those tests account for the rise in reported cases, but Gilead Sciences, which makes the pill, saw prescriptions swing up in early 2014, in the same time frame the CDC began recording a rise in reported STD cases.
The pill, which is a pre-exposure prophylaxis, or PrEP, is intended for those considered to have a high risk of contracting HIV. At Whitman-Walker, a community health center that prides itself on serving diverse urban and LGBT populations, Martins said about 13 percent of its 9,000 patients primarily come for the pre-exposure pill.
The prevention regimen is not without critics, including medical care providers and health counselors who argue it could provide a sense of security that leads to riskier sexual behaviors.
Some studies have shown higher STD rates among those taking the drug, but there are no clear answers about how it affects behavior. Martins said his experience of over 10 years with Whitman-Walker does not support the idea that the pill increases risky practices and says it will drive down exposures.
"I think this is the next most important thing [in sexual health]," Martins said.
Better access to health providers and routine screenings cannot entirely explain what the CDC called a record high indicating "urgent need for prevention." This leads to the question of how to reduce new infections.
Rates of sexually transmitted disease among men who have sex with men remain very high, which Zenilman said is troubling. The CDC attributes nearly all of the increases in syphilis cases nationwide to men having sex with men.
Among his patients in the District, Martins has noticed a general decline in condom use over the last decade — in part, he believes, because HIV no longer seems like a fatal disease.
Behavioral interventions, like encouraging condom use, are rarely effective, he said.
That view is shared by Michael Kharfen, the D.C. Health Department's senior deputy director in charge of the HIV/AIDS, Hepatitis, STD and TB Administration.
The two men's experiences overseeing two of the city's largest STD clinics suggest success lies in treating infections before they can spread.
Outside of testing in a clinic, the Department of Health offers self-testing that enables a person to test themselves at home and return samples to the department for results. It also has a program that allows health workers to prescribe treatment to a person's partner at the same time to quickly tackle any spread of a disease.
"If you look at places that have been successful, it's where there's easy access to preventive services and a nonjudgmental approach to reproductive services," Zenilman, of Hopkins, said.
That's the kind of culture the D.C. Department of Health is working to create, Kharfen said.
The latest report and the department's own research send a stark message that the current conversation around sexual health isn't working, he said. The D.C. department has programs providing confidential STD testing in high schools — people ages 15 to 24 account for nearly half of all STD cases nationally, the report shows — that Kharfen said have been effective. But the department realized it needed a new, sex-positive attitude.
That recognition led to a youth campaign launched last month called "Sex Is," which focuses on having young people and the adults in their lives have safe and constructive conversations about sex.
"It is our mission to promote a sexually healthy, physically and emotionally, young generation in D.C.," Kharfen said.
Kharfen and Martins, of Whitman Walker, said that while parts of the country have seen STD programs take cuts or lose clinics, they each plan to expand programming in coming months.
"We are taking very seriously what the numbers are telling us," Kharfen said.