Emily Cadden, a health educator at Richmond City Health District, demonstrates to a patient how to perform a self-administered STD test. (Wyatt Johnson/ DoingItRVA)

Emily Cadden’s favorite shift is Tuesday nights. While most government employees are packing up to go home, Cadden, a health educator with the Richmond City Health District, is preparing to conduct free sexually transmitted disease tests.

“A lot of patients end up thanking us for providing this service and say they wouldn’t have gotten tested otherwise,” Cadden said, who helps administer the screenings from 5 to 6:30 p.m. every Tuesday night at the Richmond City Health Department.

The weekly event is hosted by DoingItRVA, a sexually-transmitted infection awareness campaign by RCHD that coordinates prevention and treatment of HIV and STIs in Richmond, provides education on sexual health and wellness and works to reduce stigma surrounding substance abuse use and mental health.

Justin Wallace, an HIV prevention supervisor at VDH, said DoingItRVA focuses on people aged 15-19, 20-24 and 25-29. According to VHD, those age ranges accounted for 49 percent of new HIV diagnoses in 2018 in central Virginia.

The second group DoingItRVA targets are historically marginalized populations, including the homeless, low income people and drug users, Wallace said.

“Although there is some overlap between these populations, the latter tends to be older than the young adults subgroup,” he said.

Cadden is also responsible for calling patients to inform them of positive test results.

“I’ve had patients who are very distressed when they get a positive result,” Cadden said. “You just have to talk to them and say, ‘It’s just another infection. Everything is going to be just fine. What’s important is that you’re taking care of your health.’”

Rising rates

According to preliminary data from VDH, in 2018 Virginia has seen a 22 percent increase in chlamydia diagnoses, from 33,825 in 2013 to 41,377 last year. Syphilis cases jumped by 52 percent, from 327 to 498. The biggest jump has been in gonorrhea diagnoses, with a 71 percent increase from 7,105 to 12,141.

This sharp increase is largely because gonorrhea has been developing antibiotic resistance. When treating gonorrhea, Oana Vasiliu, epidemiology and surveillance manager with the Department of Health, said healthcare providers are down to their “last drug option.”

“On a case by case basis, clinicians may be able to try other antibiotic combinations, but it would require additional testing to determine what drugs might work in each case,” Vasiliu said.

This spike in STD rates is not unique to Virginia. The federal Centers for Disease Control and Prevention’s latest report on the topic found that nearly 2.3 million cases of chlamydia, gonorrhea and syphilis were diagnosed in the U.S. in 2017. This marked the fourth consecutive year of increases in the three sexually transmitted diseases, according to the report.

However, Vasiliu said the true number of STI cases nationally and statewide is likely much higher.

“Many infections remain undiagnosed,” Vasiliu said. “You can have a STI and not know it, because not everyone has symptoms that might prompt them to get tested.”

Though it’s difficult to pinpoint the exact causes of rising STD and STI rates, Vasiliu said encouraging routine testing and increasing general awareness of sexually transmitted diseases are important tools to “address these concerning trends.”

City health departments throughout Virginia are aiming to do just that. Both the Central Shenandoah and New River Valley Health Districts have mobile units that offer free testing for STDs and HIV. In Winchester, the Aids Response Effort has offered housing services, free HIV and hepatitis C testing, outreach education and more for over 25 years.

Noelle Bissell, director of the New River Health District, said STI rates are rising because “we are victims of our own success with contraception.”

“People don’t reach for a condom anymore to prevent pregnancy because we have so many excellent options for birth control,” Bissell said. “But birth control doesn’t prevent STIs.”

Diana Prat, director of STD Prevention and Surveillance with the Virginia Department of Health, said STI awareness initiatives by city health departments are encouraging more people to get tested. Therefore more cases of STD diagnoses are being reported, which is likely another reason STD rates in Virginia are on the rise.

After receiving a $540,000 grant from the Virginia Department of Health, in March 2018 the Alexandria Health Department launched the “Getting to Zero” campaign. With the slogan “Zero Infections, Zero HIV Deaths, Zero Stigma,” the initiative pushes for universal HIV testing across Alexandria.

“In treatment, people with HIV can live just as long as someone without HIV. That’s how good we’ve gotten with treating HIV,” said Tiyia Jeanne-Pierre, a family nurse practitioner and project manager of Getting to Zero.

According to the CDC, approximately 1.1 million people in the U.S. are living with HIV today.  About 15 percent — or one in seven — of those individuals are unaware they are infected.

In Virginia, the City of Alexandria has the fifth highest rate of persons living with HIV/AIDS and the highest rate of HIV infection in Northern Virginia.

“I’ve had patients tell me they’ve never gotten tested because they are uninsured, or they can’t afford it,” Jeanne-Pierre said. “That’s why we’re going out and testing whenever we can.”

Similarly to the DoingItRVA campaign, Getting to Zero frequently hosts free STD and HIV testing events throughout the community.

“We go to university campuses, transitional homes, homeless shelters, churches — whoever will have us,” Jeanne-Pierre said.

Another major component of the Getting to Zero initiative is conducting “educational sessions on provider education” for private healthcare providers. According to the CDC, sexually active individuals between the ages of 13 and 64 should be tested for HIV at least once in their lifetime.

Jeanne-Pierre said she can’t recall the last time a healthcare provider asked her whether or not she has been tested for an STD or HIV.

“We’re pushing the importance of universal [STD/HIV] testing… But we’re finding a lot of providers in the community are not providing this as they should,” Jeanne-Pierre said.

‘Erase the stigma’

In 2018, VDH mailed approximately 16,000 packets to private healthcare providers on how to communicate with patients regarding STDs, terms of STD screenings and other useful CDC resources on the topic.

“Getting sexual history from patients is extremely important,” Visaliu said. “If it’s done right by a healthcare provider, we can treat patients correctly in terms of what kind of tests and treatment they need.”

Bissell said “educating our youth with a comprehensive sexual health education” is another key ingredient in decreasing STD and HIV diagnoses.

“Studies show that those who get such a curriculum delay sexual activity longer and practice safer sexual behaviors,” Bissell said. “We need to erase the stigma around STIs. People are afraid to talk about sex and are afraid to get tested.”

This negative stigma surrounding STDs, STIs and HIV is something both the local campaigns in Richmond and Alexandria hope to change.

“There’s no stigma behind going to the dentist office. … There shouldn’t be with this either,” said Taylor Clark, a health counselor with Richmond City Health District. 

Above all else, Prat, the state health official, recommends patients know a partner well enough to “truly be themselves with them” before engaging in sexual activity.

“A question I often ask young patients is, ‘If you were a billionaire, would you give this person access to your money?’ Well, then why would you give them full access to your body? Your body is worth more than money, and you only have one body. … Make sure this is the person that you can truly be yourself with,” Prat said.

Launching the Getting to Zero campaign has been the most challenging hurdle of Jeanne-Pierre’s career. But when patients come back and thank the team for the services they are offering, it makes the work “so worth it.”

“When people say you guys are really the only ones offering free testing and I’m thankful for you doing what you’re doing … It might be a small sentiment, but that’s the most meaningful for me,” Jeanne-Pierre said. “This is really, really hard work, but those little things is what keeps us going.”

To find Virginia cities that offer free STD screening, visit https://www.stdtestingfree.com/st/virginia.