Two hundred ninety-six percent.
That’s how much the gonorrhea rate in Des Moines County in southeast Iowa increased between 2016 and 2017, making it the highest rate in the state for that year.
The number of infections rose from 36 cases to 142 among a population of 39,000, startling public health officials and spurring a reaction from local health care providers.
“No one can really explain why that huge jump happened in 2017,” said Cherry Klein, clinical manager at Family Planning of Southeast Iowa in Burlington. “It’s not just one thing. ... Why so much of it happened in Des Moines County, we’ll probably never know.”
Des Moines County was not the only county in the state that saw a concerning increase in sexually transmitted diseases, or STDs.
Iowa has experienced an overall upward trend in gonorrhea, chlamydia and syphilis for the past several years, driven in part by changing sexual habits and more high-risk behavior. While many agree that is a major driving factor, some experts argue it has less to do with sexual habits and more to do with decreased access to sexual health services. And with recent legislative policy decisions and budget cuts aimed at hobbling providers who offer STD-related services, the issue may get worse.
Officials with Planned Parenthood of the Heartland, which includes Iowa, point out that gonorrhea cases rose in Des Moines County the same year three Planned Parenthood clinics in Iowa’s Southeast region closed due to state funding cuts.
Today, there are no testing sites beyond private providers available in Lee County, Klein said.
“I know that there are some providers in certain areas who have tried to step in, but I just don’t think that they can maintain the total number of patients that we had been serving in those places,” said Clara Quinn, nurse and assistant center manager for the Iowa City Planned Parenthood clinic.
It’s “hard to definitively say” whether the closures of Planned Parenthood’s clinics contributed to the spike in gonorrhea cases, said George Walton, STD program manager at the Iowa Department of Public Health. Likely, it was a conglomeration of factors.
“But I will say, any time you’re reducing access for test and treatment of sexually transmitted diseases, I do think that is a problem and can lead to increases,” Walton said.
Cases on the rise
A sexually transmitted disease is an infection passed to others through sexual contact. If left untreated, it can lead to long-term complications such as infertility. But if providers can identify these diagnoses and provide treatment early on, the patient can avoid adverse health outcomes. Walton said.
Gonorrhea, chlamydia and syphilis must be reported to state public health officials. Their data shows STD cases have been on the rise in recent years.
Iowa had 19,807 cases of chlamydia, gonorrhea and syphilis in 2018, according to the Iowa Department of Public Health. That includes:
• 14,685 cases of chlamydia
• 4,839 cases of gonorrhea
• 283 cases of syphilis
That is an increase of more than 1,800 from 2017, which saw 17,941 cases.
A decade ago, state public health officials reported 11,147 STD cases.
Iowa is not alone in this upward trend. The Centers for Disease Control and Prevention reported a record number of cases in 2017 — about 2.3 million nationwide, an increase of 200,000 from the previous year.
Chlamydia was the most common STD nationwide with more than 1.7 million cases, according to the CDC. Officials also reported gonorrhea and syphilis climbed 67 percent and 76 percent, respectively, between 2013 and 2017.
According to a 2015 report published by the General Society Survey, U.S. adults between 2000 and 2012 had more sexual partners and were more likely to have more casual sex than adults who responded to the same survey in the 1970s and 1980s.
Public health officials recently have seen more cases among individuals who use substances such as methamphetamine.
Walton said social stigma still is attached to the issue and can be a barrier to health officials’ efforts to encourage regular testing.
Increasing rates also could indicate that public health efforts are identifying and reporting more of the infections in individuals. Walton said testing has been improving in recent years, so providers are better equipped to diagnose an STD.
However, it also could indicate providers are missing undiagnosed pockets of the population. There’s an increased risk in transmission among those who are asymptomatic or otherwise unaware they are infected.
“We know that when we’re not getting tested regularly, then we’re going to miss more and more people who are infected with these different STDs,” Iowa City Planned Parenthood’s Quinn said.
Some maintain the issue can be connected directly to funding reductions to health care providers.
According to a survey of STD clinics nationwide between 2013 and 2014, the most common results of budget cuts were fewer clinic hours, reduced routine patient screenings and reductions in services for patients’ sexual partners.
The National Coalition of STD Directors said in a statement the boom in STD rates “is largely a result of cutbacks in federal resources.”
According to data from the coalition, federal funding for STD prevention has seen a 40 percent decrease in purchasing power since 2003.
“It’s not a coincidence STDs are skyrocketing — state and local STD programs are working with effectively half the budget they had in the early 2000s,” NCSD Executive Director David Harvey said in a statement.
‘When you exclude provers’
In 2017, Planned Parenthood closed four clinics in Iowa, including the three locations in Burlington, Bettendorf and Keokuk. A fourth location closed in Sioux City. The closures occurred after the state Legislature shifted state family planning funding away from providers who offer abortion services, thus eliminating about $2 million from the organization’s budget.
Rep. Joel Fry, R-Osceola, issued a statement at the time arguing that by shifting the program, funding for services would be more available to providers in rural areas “rather than concentrated in Iowa’s largest cities.”
State lawmakers instead created the $3 million Family Planning Program, funneling state money to cover family planning services. But a Gazette report found in the first months of the program, enrollment was down 46 percent from the former family planning system — which advocates have concluded means patients were not receiving services.
Enrollment numbers for 2018 are not yet available.
According to data from the Iowa Department of Public Health, overall STD cases in the four counties where those closures took place increased 20 percent in the first year after. That’s compared to an average 2 percent per year increase in the years before the closures.
In August, Planned Parenthood also opted to withdraw from the federal Title X grant program after the Trump administration began enforcing new anti-abortion requirements. Five Iowa clinics lost about $1 million altogether for family planning services that included STD testing and treatment.
“Now that we’ve lost the Title X funding, it’s really the first time that we’ve had to tell patients at the window that have shown up for their appointment ‘we don’t have the same funding that we had three months ago,’ ” Quinn said. “A lot of times people don’t have that money. We’ve literally had patients have to walk away because they just had no resources.”
Nearly 3.9 million patients in the United States accessed services through Title X last year, most of whom were young, female and low-income.
In 2018, Title X-funded clinics performed more than 2.14 million chlamydia tests, 2.4 million gonorrhea tests and more than 1.2 million HIV tests, according to the U.S. Department of Health and Human Services.
“When you exclude certain providers, it’s going to limit (access),” Jodi Tomlonovic, executive director of the Family Planning Council of Iowa, said at the time of the announcement. “Iowa, as we know, is not a place that has a lot of health care providers, so limiting access to family planning services is something that we’re very concerned about.”
Klein, of the Burlington family planning clinic, said providers in Des Moines County acted quickly after Planned Parenthood departed the area.
“If the county public health department had not started screening and the (Family Planning of Southeast Iowa) wasn’t opened relatively quickly, I definitely think we would have had a much more severe problem,” Klein said.
Filling the gap
Around the same time Planned Parenthood’s Burlington clinic permanently closed, Des Moines County Public Health expanded clinic hours to offer more STD screening services, recalled Christa Poggemiller, county public health director.
On June 25 — about a year after the clinics closed — Great River Health System established the Family Planning Clinic of Southeast Iowa to fill the gap in services provided by Planned Parenthood.
“There was already talk of this high STD rate, which was happening statewide, that started to occur before that closure,” Klein said. “Then a lot of people familiar with Planned Parenthood services realized there were a lot of patients going there for services. Even if other providers could absorb that patient load, that was a lot to take on.”
Overall, experts say access to STD testing and treatment is a key piece of the conversation — ideally from clinics that specialize in reproductive services, such as family planning clinics.
Walton said they are an ideal environment for STD screening, as these providers often are more familiar with the signs and symptoms than a primary care doctor.
But cutting funding to these providers “is definitely not going to help,” Klein added.
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