Rates of sexually transmitted infections in Hawaii are at their highest in decades, largely due to lack of preventative screening, health officials say.
Because of the stigma associated around STIs, many people do not realize some STIs are as common as the flu, says Gerald Hasty, an epidemiologist at the Hawaii Department of Health.
“Chlamydia and gonorrhea are reported more frequently on an annual basis than influenza,” he said.
Chlamydia, a bacterial infection that’s easily cured with antibiotics, is by far the most prevalent STI in the islands.
Nearly 8,000 cases of chlamydia were reported in Hawaii last year, compared to almost 6,000 cases a decade ago, according to the Department of Health STI Surveillance team. The 2018 rate of chlamydia in Hawaii was 542 people per 100,000, placing it on the higher end of the national spectrum.
Gonorrhea, the second most prevalent STI in Hawaii, is treatable in most cases, but when untreated it can cause irreversible harm. The number of cases reported rose more than two-fold from 611 cases in 2009 to 1,496 last year.
The national ‘comeback’ of syphilis is also of great concern among health officials.
Syphilis rates in Hawaii remain much lower than other states, but reported cases of early syphilis in Hawaii have risen steadily up to 180 cases last year, which is nearly three times the rate per capita it was a decade ago. This steep incline comes after the disease was nearly eradicated in the 1990s.
Herpes — another common STI that affects one in six people between the ages of 14 and 49 — is not classified as a “notifiable disease” by the federal health agency and therefore any increase in its prevalence is not tracked by DOH.
The upward trend in STI cases is mirrored across the nation.
For people who are sexually active, STI screening is recommended every three to six months and it can be as simple as a urine sample. But people often forgo screening unless their health care provider includes it as a routine part of their care. Some STIs can be contracted without recognizable symptoms.
“If patients are being seen in a community health center or practice that specializes in sexual and reproductive healthcare, they’re probably being screened more closely with the guidelines, but that may not be true across all practices,” said Dr. Shandhini Raidoo, an obstetrician-gynecologist who also teaches at the University of Hawaii John A. Burns School of Medicine.
Because of their asymptomatic nature, “most people assume they’re fine,” she said.
Most federally qualified health centers are Title X sites that receive federal grant funding for confidential testing and treatment of STIs. But clinics have limited hours, reach capacity quickly and cannot always offer the services for free.
Out of pocket costs for a diagnostic test or screening vary, and that doesn’t include treatment costs, which can cost several hundreds of dollars.
Officials with Planned Parenthood, which offers STI testing and treatment at multiple clinics in Hawaii, say they’ve seen the number of STI-related visits increase. But this year, its clinics could no longer offer STI tests for free. The change stems from the organization’s recent decision to opt out of receiving federal funds.
On Maui, it’s had a significant impact. The Hawaii health department’s Maui clinic used to refer patients to get screening and diagnostic tests at Planned Parenthood because the DOH Maui clinic does not provide gonorrhea or chlamydia testing, only HIV testing.
“One of our clinicians saw a young woman who was 16 years old and found out she had gonorrhea and chlamydia but wasn’t able to pay for services,” said Lisa Humes-Schulz, director of strategic initiatives at Planned Parenthood of the Great Northwest and the Hawaiian Islands.
If infections are caught early before the onset of symptoms, most cases are treatable.
But what clinicians see at Planned Parenthood are often infections that have developed and become serious. When untreated, STIs can cause pelvic inflammatory disease, infertility and chronic pain. Pregnant women and newborns are especially vulnerable.
“These people are waiting until they have severe symptoms,” she said. “It’s more expensive to treat.”
Noticing the need, the Maui AIDS Foundation began to offer free gonorrhea and chlamydia testing in February. It is now the only clinic that offers those tests for free on Maui.
Hasty, a former resident of Kauai, said accessibility to healthcare services is generally more difficult on neighbor islands. Kauai has just two locations that provide chlamydia and gonorrhea testing.
In general, “there’s no question that there’s less access,” he said. “It’s also true that there’s less access to services provided by DOH because we don’t have the staff and infrastructure in the neighbor island districts that we do on Oahu.”
But even the department’s Oahu clinic has its limitations.
“We’ve had chronic short-staffing problems for several years, probably most-concentrated in the last one to two years,” Hasty said. “That decreases our service capacity.”
The specialized STI/HIV Clinic at the Department of Health’s Diamond Head Health Center handles between 4,000 and 5,000 patient visits per year and closes at 4 p.m. due to high demand.
“Many say they are coming here even though they have a primary care provider because they feel this is a very private health circumstance, and maybe they don’t have a level of rapport or comfort with their family care provider,” said Hasty.
Outside private health providers throughout the state also rely heavily on the Department of Health for laboratory services and treatment medications.
“We probably do four times as much testing through that route as we do through our public health clinics,” Hasty said.
Sometimes, patients are forced to pay out of pocket, which can dissuade many from getting screened on a regular basis.
Hasty said if a patient has symptoms of an infection, the diagnostic testing is typically covered by insurance.
“But screening, which is really what’s needed to catch infections before readily recognizable symptoms develop, is sometimes a problem,” Hasty said.
“Even health care providers with whom we work who receive care just like the rest of us have remarked that when they go to see their health provider they are not always asked about their sexual history to understand what the exposure risks might be in their lives, and as a consequence, they are not offered screening services.”
Raidoo believes part of the reason why STI rates have increased in Hawaii is because of how sex-education curricula varies. She has conducted research on how young people in Hawaii perceive sexually transmitted infections and diseases and how they decide to protect themselves.
They may learn about different STIs, but not necessarily understand that they could unknowingly be infected and pass it to their partners, she said. They also may not be aware that condoms do not always prevent transmission of STIs.
“Most sexual health education has tended to focus on extreme representations of STIs, using scare tactics using very severe or advanced disease that sort of desensitizes students to the idea that it could happen to them,” she said. “I think the ideal sexual health curriculum would cover not only pregnancy prevention and STI prevention, but also have a realistic representation of STIs.”
Hawaii, like most states, allows “expedited partner therapy,” so doctors may quickly prescribe medications to someone’s partner. But even with that advantage, controlling the spread of STIs is “extremely difficult,” she said.
“We still aren’t able to contain the diseases,” she said.
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