Charlotte Kent
STD Prevention and Control
1360 Mission Street
San Francisco, CA 94103
August 28, 2000
Dear Ms. Kent:
This letter is to follow up on our August 23, 2000 phone conversation regarding the abrupt disappearance of diagnosed
male rectal gonorrhea cases from the latest San Francisco Monthly STD Report.
As you recall, my concern centered on the fact that Department of Public Health (DPH) Director Mitch Katz has widely
publicized this epidemiological category as one of ten important HIV indicators. These indicators, in turn, have
recently been used by DPH and representatives of the University of California at San Francisco (UCSF) to concoct an
overnight tripling of this city's estimated HIV rate.
Prior to my disruption and arrest at the August 9, 2000 city hearing convened to investigate the alleged HIV rate surge,
DPH Director Mitch Katz asserted, "We are seeing increases in rectal gonorrhea among men who have sex with men.
Previously, these rates were consistently decreasing. Now they are increasing. "
I and others objected to this gross statistical misrepresentation by shouting "He's lying!" since there has been no such
increase in this sexually transmitted disease (STD) category. In fact, the number of diagnosed male rectal gonorrhea
cases per number of administered gonorrhea tests has dramatically decreased indicating that there are fewer cases of
this disease than ever before.
Using the data distributed at the city hearing from Table 5 of The San Francisco Department of Public Health and AIDS
Research Institute/UCSF Response to the Updated Estimates of HIV Infection in San Francisco, 2000 ("Number of cases of
male rectal gonorrhea diagnosed at City Clinic [and] tests performed") one finds that the rate of male rectal gonorrhea
is at the lowest level ever at 7.12%.
Year # Cases # Tests % Rate
---- ------- ------- ------
1994 49 531 9.22%
1995 61 576 10.59%
1996 54 660 8.18%
1997 85 803 10.58%
1998 113 1,111 10.17%
1999 111 1,474 7.53%
2000 108 1,516 7.12%
While this subset of male rectal gonorrhea data does not include all cases in the city, it does represent the best and
most complete data on the testing of high-risk, low-income patients. One can conclude that the data gleaned from the
City Clinic population sample would overestimate the number of male rectal gonorrhea cases when generalized to all gay
men since clients at this testing site are some of the most sexually active, drug using members of the gay community.
Ms. Kent, I have spoken with you and epidemiologist Bob Kohn on numerous occasions to get to the bottom of the
statistics your unit publishes each month. Specifically, when it comes to cases of male rectal gonorrhea, the numbers of
positive cases are phenomenally low for a metropolitan area the size of San Francisco. Furthermore, it is difficult for
the public to discern whether the small numerical rises of diagnosed cases offered in your report are the result of
increased transmission or increased STD testing. Nowhere in your monthly reports do you reveal to the public the number
of gonorrhea, syphilis or chlamydia tests performed so that one can place the number of diagnosed cases in the necessary
context.
For this very reason, I was surprised to hear you admit to me over the telephone:
"We decided to remove the category of male rectal gonorrhea cases from our monthly report because we wanted to include
it in our quarterly or possibly annual summary in order to talk about increased screening. As you know, screening has
increased and it is difficult to interpret data because the more screening you have the more infections you will find."
As your last published yearly report shows, San Francisco is in the midst if its lowest levels of STD cases since the
1950s. If, in fact, the HIV indicator category of male rectal gonorrhea cases has been manufactured from some
statistical sleight-of-hand, how many of the remaining nine categories have been similarly doctored? More importantly,
how is it possible for San Francisco's HIV rate to be suddenly increasing when the city's STD rates -- acknowledged in
the scientific literature as predicting the spread of HIV -- have been declining for two decades?
Ms. Kent, I believe that you and Bob Kohn of the STD Prevention and Control Unit along with DPH Director Mitch Katz are
engaging in a statistical shell game by reporting only the number of diagnosed STD cases without revealing the number of
tests administered. During the recent city hearing DPH Director Katz stated that "all exact HIV indicator data is open
and always is open in the San Francisco Department of Public Health." Therefore, on behalf of ACT UP San Francisco's STD
Epidemiology Working Group, please forward me each month for community inspection the number of diagnosed male rectal
gonorrhea cases at City Clinic along with the total number of tests given to arrive at that number.
I look forward to your prompt reply.
Sincerely,
David Pasquarelli
cc: Mitch Katz - Department of Public Health; Tom Ammiano, Mark Leno, Leslie Katz - Board of Supervisors; Cynthia Laird
- Bay Area Reporter; Kim Corsaro - San Francisco Bay Times; Kathleen Wilkinson - San Francisco Frontiers, Ulysses
Torassa - San Francisco Examiner
=====
The San Francisco Department of Public health and AIDS Research Institute/UCSF Response to the Updated Estimates of HIV
Infection in San Francisco, 2000
Author: Unknown
-----
Table 5. Reported cases of male rectal gonorrhea
Year/# cases of male rectal gonorrhea/# cases of male rectal gonorrhea diagnosed at City Clinic/# tests performed at
City Clinic
1994 / 72 / 49 / 531
1995 / 97 / 61 / 576
1996 / 134 / 54 / 660
1997 / 129 / 85 / 803
1998 / 158 / 113 / 1111
1999 / 160* / 111* / 1474*
2000 / 186** / 108** / 1516**
* Preliminary number for 1999 ** Projected based on cases reported to end of June 2000
Comment:
The number of reported cases of rectal gonorrhea among men in San Francisco increased between 1994 and 1999, the largest
number diagnosed at the city's municipal STD clinic (City Clinic). There were 93 cases of male rectal gonorrhea cases
reported in the first six months of 2000. Given reporting delays in physician and laboratory reporting, we project the
annual number of cases in 2000 to exceed the number reported in 1999 at the present rate. Men with rectal gonorrhea
represent persons who have engaged in unprotected receptive anal intercourse, a behavior that carries a high risk for
acquisition of HIV and a co-factor in HIV transmission (Vittinghoff et al, 1999; Fleming, 1999).
Technical notes:
Physicians and laboratory directors are required by law to report cases of gonorrhea to the health department. Because
some persons with gonorrhea may receive empiric treatment without laboratory diagnosis, these numbers are likely to be
underestimates of the true number of rectal gonorrhea cases. Although rectal gonorrhea is often symptomatic, some
infected persons may not be aware of their infection or seek treatment. Delays in reporting and reassignment of dates of
diagnosis may changes [sic] preliminary figures, particularly for more recent years.
Key potential biases and limitations may result from temporal changes in screening practices. While there have been
increases in the number of cases of rectal GC reported to SFDPH, part of this increase may be explained by increases in
case detection from increased screening. Since 1994, the municipal STD clinic has experienced an increase in the number
of MSM patients, the number of tests performed to detect rectal gonorrhea, and a decrease in the prevalence of gonorrhea
among screening tests performed. Nonetheless, increased disease transmission in the city cannot be ruled out.
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ACT UP San Francisco 1884 Market Street * San Francisco, CA 94102 Phone: (415) 864-6686 * Fax: (415) 864-6687 * www.actupsf.com