Publications

California has a long tradition of providing publicly funded family planning services to low-income residents. The Affordable Care Act (ACA) increased contraceptive coverage in 2012, and in January 2014 it extended Medicaid eligibility by increasing the income cut-off from 100 percent to 138 percent of the federal poverty level and allowing individuals without dependent children to enroll. We assessed the impact of the ACA's Medicaid expansion on low-income Californian women's receipt of health insurance and needed health care, including contraceptive counseling and prescription contraception, using data for the period 2013-16 from 4,567 women ages 18-44 with low incomes (less than 138 percent of poverty). After the ACA expansion, the proportion of uninsured low-income women in California decreased significantly, while the share enrolled in Medicaid increased. However, the proportion of the women who reported using health care and family planning services remained unchanged. Despite the ACA's explicit attention to contraceptive services, improvements in the delivery of family planning services have yet to be fully realized in California.

BACKGROUND

Seventeen years into a sustained epidemic, early syphilis (ES) rates in San Francisco (SF) are continuing to increase and the demographics of the affected population are changing. We provide a historical overview of ES in SF among men who have sex with men (MSM) and describe trends in the epidemiology and disease investigation outcomes.

METHODS

We examined data from the SF Department of Public Health's patient-based registry of integrated STD surveillance, clinical, and field investigation data to describe demographic and behavioral characteristics of ES cases, as well as outcomes of syphilis partner services (PS). χ Tests were performed to examine categorical differences across periods. Analysis of variance was used to examine differences in continuous variables.

RESULTS

In 2016, 1095 ES cases were reported among males in SF, a 219% increase from the 343 cases identified 10 years ago. Between 1996-1999 and 2010-2016, an increasing proportion of ES cases were among MSM younger than 25 years, nonwhite, and HIV negative (P < 0.05). A decreasing proportion of ES cases were assigned for PS, among whom a smaller proportion of reported sex partners were identified by name, resulting in an overall decline in the proportion of cases who had at least one named partner treated as a result of PS (Disease Intervention Rate) from 30.5 in 2000-2004 to 14.8 in 2010-2016.

CONCLUSIONS

Syphilis case rates continue to increase in SF and the epidemic is expanding beyond a core population. Additional resources and innovative prevention approaches are needed to reduce the burden of syphilis among MSM.