Think Out Loud

Syphilis cases among homeless populations rise in Multnomah County.

By Chris Gonzalez (OPB)
March 22, 2022 5:04 p.m. Updated: March 22, 2022 8:21 p.m.

Tuesday, March 22

Syphilis is on the rise in Multnomah County, specifically among populations that have not traditionally had access to testing or treatment. Nowhere is this more pronounced than for people experiencing homelessness. We talk to disease intervention specialist David Cuevas and community testing coordinator Chris Hamel to learn about their efforts to stop the spread, and the challenges of tracking down cases.


The following transcript was created by a computer and edited by a volunteer.

Dave Miller:  Syphilis is on the rise in Multnomah County. According to the latest statistics the rate of cases among men in the county nearly doubled between 2015 and 2020. Among women the rate increased sevenfold. Health officials say that marginalized communities including people experiencing homelessness have often been most affected. But there are teams to address this and other sexually transmitted diseases. David Cuevas supervises the disease intervention specialist program for multnomah County. Chris Hamel is the county’s community testing coordinator. How do you explain the rise in syphilis cases?

David Cuevas:  I mean syphilis has been, as you say, on the rise for years in Multnomah County. I mean syphilis is a disease that is particularly insidious.  It has a long incubation period. It can be difficult to diagnose. And during the pandemic limited access has been one of the barriers for people to get tested. So that’s what we’ve been seeing a lot and the numbers are showing that [it] just keeps increasing. Syphilis is still rare but the numbers are showing that as individuals have difficulty accessing care (because during the pandemic a lot of the time, the health systems have limited access), we noticed that. And that is probably one of the reasons we see the increase.

Miller:  Those numbers that I mentioned were from the county. Those were from 2015-2020. I’m not sure when in 2020, but it seems like a lot of that increase, which was gigantic, was even pre-pandemic. You’re saying since then it’s gotten even worse?

Cuevas:  Correct, yes. And as we know, people move from one place to the other, definitely, there’s been an increase of syphilis. It’s been going on nationwide for the most part and we’re seeing the numbers here at Multnomah County as well.

Miller:  What populations are most at risk right now?

Cuevas:  I think the populations that are more at risk are usually gay bisexual men, people living with HIV, people who use drugs and their partners. Those are usually the individuals who are probably more at risk.  But as more cases are happening in the community we are seeing that more individuals [who] probably don’t think themselves [being] at risk are developing the disease.

Miller:  You’re the community testing coordinator for Multnomah County. How has testing changed over the last say five years?

Chris Hamel:  I think, as David was mentioning, we have some historical groups of folks that we’ve sort of been telling that have been at risk for syphilis. You know, gay and bisexual men, for example, are told as part of their health care. We’re getting to see more groups that haven’t been given that message starting to test positive at higher rates. So in the last few years, one of the things that we’ve done is [to] increase access to testing in nontraditional locations.

So we do have our main public public health clinic in downtown Portland. We have a harm reduction clinic in East Portland and we also have been expanding our outreach testing to include all sorts of places, community centers, places that serve meals to houseless folks - all sorts of places out and about so that no one has barriers to testing.

Miller:  Is it hard to convince people to get tested? I mean it’s one thing to make testing more available more widely or where people are living. But I don’t imagine that’s the same exact thing is actually getting them tested.

Hamel:  That is a very good point and a very continuous challenge. One of the ways that we meet that is to show up over and over again in the same locations so that people come to trust us. People come to slowly open up about their own experience with syphilis, other STDs, other infectious disease.


It gives us an opportunity to talk about other infections that people are concerned about. For example, HIV and hepatitis C. So by being there week after week and handing a cup of coffee to folks and starting a frank conversation about this, we are making inroads and we’re hearing more feedback from folks that they’re hearing the message.

Miller:  You noted that one of the challenges with syphilis is its long incubation period. What do you mean? How does that increase the challenge here?

Cuevas:  Yeah, I mean, one of the things with syphilis is [that] once you get exposed to syphilis, you can take up to three months, 90 days, to develop the symptoms. So it has a long incubation period. And sometimes the first signs of syphilis, usually a sore, is painless. So a lot of people just completely ignore that and they continue to have sex, you know, and then transmit it. By the time they are tested, sometimes they already are having secondary symptoms or different kinds of symptoms and the infection has been going for a while.

So the amount of people they probably got infected can be a lot. So that’s why it adds a lot of difficulty with the incubation period to diagnose the disease. Always, we recommend individuals to get tested. Get a test as part of the routine check up and talk to your provider about your risk back to your medical professional and this justice with them.

Miller:  And just to be clear, if people do test positive, there is medicine that people can get right?

Cuevas:  Yeah, definitely, [that’s] something that we want to pass on. Syphilis has been around for more than 100 years and it’s very easy to treat. You take antibiotics and it goes away. So I want people to understand that it is an illness that is easy to treat.

Miller:  Can you explain how the program that you supervise, the disease intervention specialist program works? What does a disease intervention specialists do?

Cuevas:  So the disease intervention specialists’ role was created by the CDC back in the 1920′s-30′s to protect the health basically of the community. We are public health workers that stop the spread of infection. That’s our role. Increased access to medical care, educate the public about disease transmission, help medical providers with education and we link them with the health department to also prevent and help us control the spread of disease. So we’re like the pillar of public health.

And when somebody tests positive for a communicable disease, we end up calling them - with the variation of like what we’re seeing when COVID was around - like contact tracers. We are like the original contact tracers. We reach out to the individuals and walk them through the whole process from the diagnosis to getting them treated and talking to their partners.

Miller:  Obviously we heard a lot about contact tracing because of the COVID 19 pandemic. But the questions that we talked about contact tracers asking with regard to COVID 19 seemed less sensitive than the ones we’re talking about with sexually transmitted diseases. For COVID 19 it was, ‘were you within six feet of somebody indoors for a while without wearing masks? Were you in a choir next to them?’ as opposed to ‘have you had sex with somebody in the last six months or unprotected sex?’ What are the qualities you look for in a disease intervention specialist given that we’re talking about much more sensitive conversations?

Cuevas:  The intervention specialists have a special set of skills. Our team provides culturally and linguistically sensitive prevention tools. It’s very different to see, to ask somebody when yes, like you know, when you’re in a room with certain people that have been exposed to somebody that hey, you know, um, you had sex with an individual a lot of times. You know, sex is tied to feelings and to relationships and to groups of people and culture. So,we are very sensitive. We speak their language. We’re members of the community. We understand the community and we’re there to walk into the process. Definitely, it can be very isolating when you get an STD [diagnosed], you can feel very isolated and on top of that you are part of a sexual minority or gender minority or sexual orientation minority. I mean, you can be very isolated.

So some of the work that we do is walk into this through the whole process, walking them [through] an understanding of what the disease is, coaching them to talk to their partners about what syphilis is, what [they] need to tell them and helping them get treated. We have an STD clinic in downtown Poland. And that’s where a lot of people can come and get a test for syphilis and we’ll provide other resources for access [to] treatment.

Miller:  What role does social media play now in the toolbox of people focused on testing like you or disease disease intervention specialists like David was talking about?

Hamel:  I think social media is just one other example of meeting people where they’re at. I mentioned before how we meet people at outreach sites and we do non-clinical testing at a street level. That’s meeting people where they’re at. So is contacting people on social media, advertising events online. It’s an inextricable tool. It’s super important to be able to be present for people and to at least begin a conversation in a context that people feel comfortable with and in a way that is discreet and trustworthy.

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