Concerted efforts by Alaska's public health authorities helped bring down disproportionately high rates of gonorrhea and chlamydia in 2012. But, five years on from a severe outbreak, figures from the first half of 2013 suggest that gonorrhea might be on the rise again, with rural Alaska -- and the southwest region in particular -- still the epicenter of the state's sexually transmitted diseases.
In 2012, Alaska reported 731 new cases of gonorrhea, a 26 percent decrease in the number of reported cases from 2011. A rate of 100 cases per 100,000 people also brought the state in line with or even a little below the U.S. average.
Alaska also saw a decrease in the number of new cases of chlamydia, down 7 percent to 5,482 new cases.
Samuel Senft, a state health program manager, said Thursday he wanted to qualify the perception that STD rates were going down.
"We're feeling a little bit hesitant about that now. In particular with gonorrhea, we're worried about an increase we've seen in the first half of this year."
Ups and Downs
Donna Cecere, STD program coordinator for the Division of Public Health's Section of Epidemiology, said that early 2013's upward trend in gonorrhea cases does look to be sustained for the moment.
"If it stays at this level we'll back up to higher rates by the end of the year," Cecere said Friday.
She added that a rebound in cases of the disease would not be outside its pattern of behavior. "Gonorrhea is considered an episodic disease," she said. "It spikes really fast, and just kind of fizzles out after that."
Rapidly increased testing, treatment, and screening of infected individuals' partners could all help contain a potential spike, Cecere said.
Gonorrhea rates have been climbing again since the last quarter of 2012, according to a June bulletin from Alaska's Department of Health and Social Services. In the first quarter of 2013 alone, 235 new cases were reported, with February seeing a particularly sharp spike.
Chlamydia rates, meanwhile, are still far above the national average, and since 2000 the 49th state has traded places with Mississippi for the unwelcome accolade of having the nation's highest rates of infection for the most common sexually transmitted disease in the U.S.
Alaska experienced a major outbreak of gonorrhea in 2008. This peaked in 2010, with the state reporting a rate of infection of 180, close to double the U.S. average.
A recent problem
In the early 2000s, sexually transmitted diseases flared up as a serious problem for the state, having been an issue in the past -- for example in the 1970s -- and became a focus of public health.
Now, hints that gonorrhea could again be on the increase would mark a setback for state authorities, which have worked hard to contain the epidemic. Senft credited a campaign to promote safe sex and raise awareness of STDs, particularly in rural Alaska, with aiding the recent dip.
He also pointed to a program called expedited partner therapy, in which doctors can dispense medications for infected patients to give to their partners, who for whatever reason don't come in for medical treatment.
Rural concentration
Outbreaks of both gonorrhea and chlamydia have been concentrated in the Alaska Native communities living in rural Alaska, specifically the north and southwestern parts of the state.
In 2010, the southwestern region had a rate of gonorrhea of 1,125 per 100,000 people, the highest in the state and more than 10 times the national average. Senft confirmed that the Yukon-Kuskokwim Delta and the hub city of Bethel were the epicenter -- along with the Arctic northwest -- of STDs in Alaska.
Alaska Natives have rates of chlamydia infection six times higher than white Alaskans, according to Alaska Native Tribal Health Consortium's website.
Senft was reluctant to name a single reason for the recent high incidence of sexually transmitted diseases among Alaska Natives, and explained instead that once a STD enters a particular population, it tends to spread. Drug and alcohol use, while not statistically tracked by health authorities, were likely aggravating factors, he said.
The diseases have also been concentrated among young people, who Senft said were more likely to engage in high-risk sexual behavior.
Villages present unique challenges
Combatting sexually transmitted diseases in Alaska's remote, close-knit villages is not always a straightforward process.
While Cecere described some villages as displaying a "progressive" and "proactive" attitude to combating STDs -- including inviting in speakers and dispensing condoms in school, in others the importance of practicing safe sex, and even sex itself, can be sensitive -- if not taboo -- topics.
She refused to speculate on what might lie behind these different attitudes.
Cecere said young people in villages who were concerned about their sexual health were often reluctant to visit village health clinics.
"They often don't like to go to the village health clinic, because they're related to the community health aides," she said.
As a result, people often wait for an itinerant nurse to come through a village, or eventually make it to a hub like Bethel or Nome, before they are tested.
Cecere said that health authorities tried to circumvent more conservative attitudes and the reality of small communities -- where many are related and privacy can be scarce -- by reaching out to young people online.
She pointed to a recent media campaign, called Wrap it up Alaska, from the Division of Public Health that promoted a website, Iknowmine.org, set up by the Alaska Native Tribal Health Consortium.
Senft said that collaborating with ANTHC was vital to promoting to awareness among the communities hit hardest by sexually transmitted diseases in a "culturally competent manner."
In addition to offering factual information on STDs, safe sex practices, and substance abuse, the website -- which is geared toward young people, especially teenagers -- allows visitors to order testing kits and free condoms to be mailed to them. Cecere said the site's traffic "doubled and then tripled" after the state's media campaign, and that promoting the website would be a continuing focus of public health efforts.
HIV less of a problem in Alaska
In contrast to gonorrhea and chlamydia, HIV has never been a serious epidemic in the state, and even less of a presence in rural villages. Senft said that while you might expect to see different sexually transmitted diseases cluster together, gonorrhea and chlamydia have impacted very different social networks in Alaska than the population hit with HIV.
The vast majority of HIV-positive individuals in Alaska, from the 1982-2012 tracking period, have been men, according to the state's HIV Epidemiologic Profile 1982-2011. The majority has also been white and living in the Anchorage/Mat-Su area. 49 percent of all HIV-positive cases have been among men who have sex with men.
However, among females, who have made up just under 20 percent of HIV cases, 40 percent have been Alaska Native, even though that demographic only makes up around 15 percent of Alaska's total population.
Senft said that many Alaskan women from rural and native backgrounds with HIV contract the disease in urban areas, before perhaps returning to rural Alaska. He attributed this problem to individuals finding themselves in urban areas in "out-of-context situations," becoming involved in prostitution and substance abuse that involves sharing needles.
Senft estimated a "steady trickle" of 30 new reported HIV cases every year in Alaska, with another 30 coming in from out of state. In 2011, Washington, D.C. had the highest rates of HIV diagnoses in the U.S., with 178 cases per 100,000 people, according to the Center for Disease Control.
Still, with the nation's top rates of chlamydia and 2008's gonorrhea epidemic potentially on the rebound, STDs look set to remain a significant headache for public health authorities, and the latest health scourge to afflict Alaska's remote, rural communities.
Contact Eli Martin at eli(at)alaskadispatch.com
CORRECTION: Article has been updated to reflect the fact that sexually-transmitted diseases were a major problem in Alaska prior to 2000.