Special Report: Milwaukee battles 'silent epidemic' on multiple fronts

Groups working to prevent the spread of sexually transmitted infections pass out information at community health fairs. (Photo by Heather Ronaldson)

With the help of modern technology, patrons of certain Milwaukee bars can pick up a free “safer sex” kit, compliments of the AIDS Resource Center of Wisconsin.

Here’s how it works. ARCW representatives set up shop in a bar and then log in to Grindr, a dating application available on the iPhone. When bar patrons log in to Grindr and see ARCW’s icon, they know they can pick up a “safer sex” kit in person.

“We provide free condoms and safer sex kits in the bars so patrons can get them, no questions asked,” said Bill Keeton, vice president for government and public relations at ARCW. The kits include condoms, lubricant, and information on how to properly and safely use a condom and on where to get tested.

This outreach strategy is just one of the approaches that Milwaukee nonprofit organizations and clinics are taking to prevent the spread of sexually transmitted infections (STIs), also referred to as STDs (sexually transmitted diseases).

The rate of chlamydia in Milwaukee County is almost three times the national average, according to the Centers for Disease Control and Prevention (CDC).

In 2010, 40 percent of all reported cases of chlamydia occurred in just 54 U.S. metropolitan areas. Milwaukee County ranked sixth. If left untreated, chlamydia can lead to infertility.

Paul Biedrzycki, director of disease control and environmental health for the City of Milwaukee Health Department, called the high rates of STIs and HIV in Milwaukee a “silent epidemic.”

“I think STIs are underreported in the community because people are under-aware,” said Biedrzycki. “I don’t think there’s good understanding about how prevalent this is. In urban settings, they’re rampant.”

The rate of chlamydia in zip code 53205, which encompasses the Lindsay Heights neighborhood, is almost three times the rate for Milwaukee County. In zip code 53210, which encompasses Enderis Park, the rate of chlamydia is more than double that of Milwaukee County. Capitol Heights is also one of the hardest hit neighborhoods, according to a report from the Wisconsin Department of Health Services.

The “silent epidemic” is fueled by lack of awareness, lack of education and the stigmatization that prevents communities from addressing the problem openly, Biedrzycki said. Low-income communities suffer the greatest burden due to poverty, education, and social and cultural barriers, he added.

“One of the biggest drivers is something we call social determinants of health, the things that people can’t control about where they grow up: lower access to primary health care, poverty, education,” said Keeton.

“Milwaukee is a city that is really struggling to overcome a lot of these barriers,” Keeton added. “In the state, 50 percent of all new HIV infections and 50 percent of people living with HIV are here in Milwaukee County. We have one-fifth to one-sixth of the state’s population, and we have half of the state’s cases of HIV.”

(Graphic by Jim McGowan)

The HIV prevalence rate in black men ages 15-59 who have sex with men is three times higher than for Latino MSM and 500 times higher than the adult population of Wisconsin, according to the Wisconsin Department of Health Services. The department reported that the cases of HIV in young, black MSM tripled between 2002 and 2011.

“We’re seeing a lot of black men, heterosexual, gay and bisexual, who are not aware of their bodies and how to take care of themselves,” said Paula Phipps, executive director at the STD Specialties Clinic, 3251 N. Holton St. “I think that’s probably why we’re seeing an increase in HIV in young gay males.”

Lack of knowledge about transmission could also contribute to high rates of STIs and HIV.

“There is a growing fundamental lack of knowledge of how it’s transmitted and how it occurs. That awareness is lacking in many populations, in particular minority populations,” Biedrzycki said.

Phipps also attributes the problem to a lack of conversation.

“I think it’s an issue we’re never going to overcome, because it’s a private thing,” she said. “STDs shouldn’t be closeted.”

Opening up the conversation

Maria Barker works to bring conversations about sex and sexually transmitted infections out of the closet. Eight years ago, Barker began hosting health parties in the homes of community members to discuss topics including STIs.

“They’re very similar to Tupperware parties, except obviously we don’t sell Tupperware,” said Barker, multicultural programs manager at Planned Parenthood of Wisconsin. “It allows people some time to vent and talk about their beliefs.”

To host a home health party, community members choose a topic and gather a group of friends and family. Topics up for discussion include STIs, anatomy, cultural values pertaining to sexuality, adult-child communication and birth control, among others. Barker works primarily within the Latino community, so the majority of home health parties occur in Spanish.

“The information we give is age-appropriate, family-oriented, and there is no cost,” Barker said. In fact, the program provides hosts with a stipend to offset the cost of food served during the party. The discussions are informative but informal. “We sit around the kitchen table; we share food; we laugh,” she said.

The program became so successful that Barker couldn’t keep up with demand by herself, she explained. This year, she trained 25 health promoters to host parties in Milwaukee and Madison. Over the course of the year, Barker and the team of health promoters will host approximately 400 home health parties.

Barker said the program is being evaluated to see if attendees get tested for STIs or utilize other related services as a result of what they learned.

Practicing innovative outreach strategies

ARCW practices “face-to-face, boots on the ground” methods of prevention and outreach. The nonprofit organization is working to “embrace new technologies and … provide access through them,” Keeton said.

The iPhone application Grindr is one of these technologies. With the application, Grindr users can locate each other in bars and then meet face-to-face if they choose.

“It’s basically a dating site for gay men. It interfaces with the phone’s GPS to show you other people around you, and you can start chatting with each other,” Keeton explained.

“What’s concerning … is that this might be the kind of sexual encounter that happens after people have been drinking,” Keeton said.

Sixteenth Street Community Health Center also practices outreach and prevention in bars and clubs, according to Jose Salazar, HIV department manager at Sixteenth Street.

“We usually go to the gay bars because of the higher risk of HIV infection,” Salazar said. “We create different schedules every month to target different places, but we will go back to each bar once a month.”

He said they try to calculate when the crowds will be largest and go during that time, often during a happy hour or special event.

Sixteenth Street representatives also practice outreach and prevention at schools, churches and community resource fairs, Salazar said, with presentations in both Spanish and English.

“We always customize it, depending on the population,” he added.

According to Salazar, organizations such as ARCW and clinics such as Sixteenth Street and the STD Specialties Clinic must work together to address the STI and HIV epidemic in Milwaukee.

“When I started working, all these different organizations were fighting against each other [and] working with different populations,” Salazar explained. “But then we discovered that this wasn’t the right way. Our program depends on how we target the community and how we’re helping the community. Since 2009, we have been doing a lot of collaboration.”

Sixteenth Street now partners with other clinics and organizations for a variety of events throughout the year to educate the Milwaukee community and provide STI testing.

Changing legislation: expedited partner therapy

Legislation is also changing to allow for new courses of STI treatment. In 2010, Wisconsin legalized expedited partner therapy (EPT), a treatment method that prevents re-infection in patients who have been treated for chlamydia, gonorrhea and trichomoniasis.

Dr. Paul Hunter, associate professor at the University of Wisconsin School of Medicine and Public Health and associate medical director for the City of Milwaukee Health Department, described the EPT process.

The patient sees a doctor, who prescribes antibiotics for the STI. The doctor recommends that the patient’s partner come in and get tested. If the patient tells the doctor that there is no way that would happen, the doctor can write a prescription for the partner.

“While that may seem like playing it fast and loose, it has been known to reduce STIs in the community,” Biedrzycki said of EPT.

According to Hunter, EPT is not as controversial as it may seem. It’s encouraged by the CDC and Wisconsin health care providers as a means of preventing re-infection.

“In general, the ban on prescribing without medically evaluating the person taking the medications in the prescription prevents medical complications, insurance fraud and diversion of narcotics,” Hunter said.

But in the case of STIs such as chlamydia, gonorrhea or trichomoniasis, “you know by definition that the partner is infected,” he said. Therefore, it’s actually good medical practice to prescribe medication without requiring an evaluation.

While Milwaukee-specific data on the effectiveness of EPT is not yet available, studies sponsored by the CDC show that “patients who received prescriptions of antibiotics to give to their partners were less likely to get a second infection than those who did not get the prescription for expedited partner therapy,” Hunter said.

What’s next?

Despite these innovative prevention and treatment efforts, rates of STIs and HIV in Milwaukee County are still alarming.

“I think you could make a pretty strong argument that we’re doing the right thing. We just need to be able to do more of it,” Keeton explained. “As an agency, we make about 150,000 HIV prevention contacts per year, but that 150,000 is spread out among a large population of people who are at risk.”

Biedrzycki suggested “talking about these issues in a much more upfront, blunt way.”

“I think that’s one of the biggest problems; people don’t talk about this. They don’t even talk about it with their partners,” Salazar said.

According to Biedrzycki and Keeton, long-term solutions to Milwaukee’s STI epidemic will involve more than outreach, prevention and treatment.

“One of the biggest things that we can do, especially in the fight against HIV/AIDS, is provide access to healthcare,” Keeton said. “We know if we get someone tested, they’re less able to transmit it to someone else. It really speaks to the need for universal healthcare.”

“Low-income, minority populations suffer the greatest burden of disease,” Biedrzycki said. “If we solve poverty issues and racism, we can solve some of these health disparities.”