St. Louis has long been known as the sexually transmitted disease (STD) and infection (STI) capital of the United States. According to the Centers for Disease Control and Prevention’s most recent STD Surveillance report, released in September 2017, St. Louis City ranks highest in the nation for the chlamydia infection, which appeared in about one in every 72 St. Louis City residents, and gonorrhea, which had a rate of one in every 133 residents.

These striking statistics beg the question: Why does St. Louis continue to rank so highly?

The answer can in part be found in the separation between St. Louis City and County, which skews the appearance of the region as having an abnormal concentration of sexually transmitted diseases and infections, as the suburban outskirts of most other cities in the report lie within city boundaries.

“Other cities our size that have the same level of STD problem look better than we do because they have larger higher-socioeconomic-status suburban periphery that helps dilute the urban core numbers,” Dr. Bradley Stoner, associate professor of sociocultural anthropology and infectious diseases/internal medicine at Washington University, who also serves as director of the St. Louis STD/HIV Prevention Training Center, said. “So our urban community has about the same STD [rate] as any other city our size.”

A 2017 St. Louis County STI report revealed that one in every 162 residents had chlamydia and about one in every 382 had gonorrhea, a stark difference from the much higher rates in the city. The discrepancies between the rates within the two jurisdictional areas are rooted in the drastic difference in socioeconomic status between the urban and suburban sectors, as the poverty rate in the city is about 2.5 times higher than that of the county, according to United States Census Bureau.

“These STDs kind of flow along lines of lack of access and social marginalization, for lack of a better word, so I think that’s why the rates are higher in the city,” Dr. Stoner said. “Just look at income as a marker and you would see lack of access to care correlates with higher rates of chlamydia and gonorrhea. And that’s the issue to me, is that it’s really a lack of access.”

This inaccessibility is also reflected in the city’s racial disparities, as black youth are 10 times more likely to be diagnosed with chlamydia than white youth, according to the City of St. Louis Equity Indicators Project.

Although Dr. Stoner acknowledged the similarity of the rates of STDs and STIs in the St. Louis City to those of other urban core areas, he still stressed the severity of the crisis, as rates in the entire St. Louis region continue to rise.

“You still have a relatively high rate of people who don’t have health insurance,” Stoner said. “And that, coupled with the closing of a number of the publicly funded clinics, not just in St. Louis but all over the country, has led to this kind of disconnect between people who need care and then what care’s available.”

In order to try to increase the kind of care that Stoner mentioned, the City of St. Louis developed a contract to pay health clinics to screen and treat low-income and uninsured residents, which went into effect July 1, 2018. Recipients of this grant money included the St. Louis County Department of Public Health, Planned Parenthood and the St. Louis Effort for AIDS.

“The [St. Louis County Department of Public Health] clinic has provided specialized sexual health services regardless of jurisdiction and at no cost,” Dr. Frederick Echols, director of communicable diseases at the County Department and soon to be director of the St. Louis City Department of Health, said. “This funding opportunity that was presented by the city just allowed the St. Louis County Health Department to receive some reimbursement for the services that they were already providing. It helps to make sure that the services that we’re providing are sustainable.”

Although the city faces a far higher percentage of STD and STI cases, the County Department is receiving the funds, as the city has no public sexual health clinic, while the County Department has one that can now afford to treat St. Louis City residents.

Though the contract took effect in July 2018, it is still too early to determine the impact it is having on the crisis.

“The contract period started in July,” Janice Thomas, Vice President of Patients and Research at Planned Parenthood of the St. Louis Region and Southwest Missouri, said. “We were not really operational or functioning within the confines of the grant until about September, and given the longevity of this issue in the St. Louis community, five months is not enough time to really tell any change.”

However, Thomas feels that the grant will have an impact on the extent of services Planned Parenthood and other organizations can provide at no cost.

“Just being able to offer more patients free services I think is a positive,” Thomas said. “I suspect that there are some people who if they couldn’t get it for free and didn’t know that they could come here for free maybe would not be tested.”

Thomas also expressed the importance of the city taking action to fight STDs/STIs, as increased funding not only improves services offered within the community but also makes residents more aware of the issue.

“The real beauty of these kinds of initiatives is that we’re talking about [STDs/STIs] again,” Thomas said. “It’s not just something that’s being discussed in the healthcare community or the communicable disease community. It is being talked about in the larger community. And because it’s being talked about in the larger community, I just think that that takes some of the stigma out of it.”

No new statistics have been released since 2017; however, it is likely that STD/STI rates are still on the rise.

“We’re hearing from our colleagues at the State of Missouri that they’re seeing increases relevant to 2017 throughout 2018,” Dr. Stoner said, explaining that 2018 data is currently being organized and will most likely be released during late summer 2019.

Dr. Echols acknowledged that the increased amount of people acquiring STD/STI screenings could be a factor in the continuous rise of STD/STI rates, as a higher percentage of cases are being reported.

“As individuals become more comfortable with sexual health screening and more educated about the transmission of and risk factors associated with sexually transmitted infections, we anticipate that the number of people getting screened will continue to rise,” Dr. Echols said. “And as more people are getting screened, we anticipate that more individuals will screen positive for sexually transmitted infections such as gonorrhea, chlamydia, syphilis and HIV.”

However, Dr. Stoner believes that the increasing rates directly correlate to increased spread of disease and infection in the St. Louis area.

“When I go to the STD clinic where I work, I’m actually seeing more cases than I have [before],”Dr. Stoner said. “So I think there may be some of that [increased percentage of cases being reported possibly skewing rates] going on, but I think the rates are real. I think there’s just more disease out there.”

Although Wash. U. students constantly speak of the “Wash. U. bubble,” separating students from the St. Louis community, the University is not completely bubbled off from this issue.

“I think the reality is that people on campus date and have sex with people who don’t live on campus, who aren’t students at Wash. U. or even who are students at different universities in St. Louis,” Ashley Kuykendall, sexual health promotion coordinator at Habif Health and Wellness Center, said. “There’s a lot of opportunity for STI transmission to happen between people who live in the St. Louis community and people on campus for that reason. And I think the other myth at play is that there aren’t STIs on Wash. U.’s campus, which is just not true.”

Chlamydia rates among Wash. U. students rose by 50 percent between 2013 and 2017, while the percentage of students with gonorrhea rose 300 percent, according to Wash. U.’s National College Health Assessment data, which was collected through voluntary student self-reporting. Kuykendall noted that STD/STI rates within the Wash. U. student body may be underreported due to the stigma associated with testing.

“I think that fewer people get tested because of that stigma of even going to be safe. One thing that we work a lot on is emphasizing that going to get screened for STIs is a really healthy preventative tool that we can use to make sure that our bodies are healthy and that we’re being safe,” Kuykendall said. “Also, we are actually getting involved with informed consent. I think a lot of times people think about consent as an enthusiastic ‘yes’ to different kinds of sexual activity, and while I think that’s true, knowing your STI status is a really important part of consent so that you can share information with a partner about any STIs that you might have.”

The 2019 Student Life sex survey found that only 62 percent of responders who said they had had sex also said they had been tested for an STI. 4.62 percent of all responders said they’d had an STI.

“I think that it’s important to know that lots of people have STIs and it’s not a death sentence and it’s not something that has to define your life, but I think a lot of people think that’s true so they don’t get tested because it’s easier not to know,” Kuykendall said.

Dr. Echols also expressed the importance of destigmatizing STDs/STIs in order to prevent them from spreading further.

“There remains a huge stigma around sexual health screenings, particularly around HIV and syphilis, and I think that one of the challenges that we face as public health professionals is to really remove some of that stigma,” Dr. Echols said. “And being in a very conservative state, it’s really important for us to be innovative in how we get that message out.”

In order to reduce rates across the St. Louis area, Dr. Stoner stressed the need for the city and county to work together in order to increase accessibility of testing and treatment to all residents.

“I think there should be a unified city-county STD control program that includes clinical services, outreach, awareness and testing,” Dr. Stoner said. “And that way you could use city and county revenue. The county is relatively wealthy compared to the city, and the city has greater need relative to the county. It’s a matter of health equity. I think the people in the city of St. Louis are challenged because of this lack of resources and I think it’s the right thing to do for the community.”

In order to prevent the further spread of STDs/STIs across the area, it’s vital that all residents have access not only to services but to information, raising awareness about how to stay safe when engaging in sexual activity.

“The most important component of community engagement is education,” Dr. Echols said. “As public health professionals, medical professionals, our primary responsibility is to ensure that our client population within the jurisdiction that were serving has accurate information.”

Dr. Stoner echoed this message, stressing the importance of reaching out to those in the St. Louis community who have lacked opportunity to learn about prevention techniques.

“If you look at what’s worked in the past, a lot of it is outreach, education, awareness.”