Mayor Nutter on Thursday will announce the city's biggest new prevention effort in 20 years, beginning with the winning wrapper design for a free new Philadelphia condom - an attempt to make prophylactics fun and, it is hoped, get more people to use them. The campaign by the Department of Public Health will include a teen-friendly website, mail-ordering, dozens of new distribution sites for a planned one million new condoms - the city already gives away 1.5 million - and a GPS-enabled iPhone application that will, as disease-control director Caroline Johnson memorably put it, "tell you where your local condom is."
The choice of a condom as a headliner underscores the lack of good options for health workers facing a major challenge: how to persuade teens and young adults to do the two things they seem least wired to do - have less sex, or at least stop and think about having it more safely.
Haneef Williams learned he was HIV positive three years ago, at age 19. He said he had not used a condom with his first partner. With his second, a committed relationship that lasted 2.5 years, "we were using condoms, but there came a point when we stopped," he said. After five months, they both felt safe, he said.
HIV is no longer the death sentence that it once was. But there is constant blood work and doctor visits and drugs and shots for protection against all the other diseases to which you are more vulnerable, the added risk of heart disease and cancer - not to mention the way others react to you. "My life could have been so much different if I would have protected myself," said Williams, 22, who lives in West Philadelphia.
Williams is part of the biggest and fastest-growing HIV demographic: young African American men who have sex with men. An astounding 29 percent of them ages 20 to 24 are living with HIV or AIDS, according to city health officials' estimates. But rates for young women are not falling, and an estimated 1.3 percent of all city residents in that age group are living with HIV or AIDS.
For reasons that are not clear, Philadelphia teenagers are more promiscuous than their counterparts in every other major city in the country except Baltimore on several measures - sexually active (64 percent vs. 46 percent nationally), first had sexual intercourse before age 13 (15 percent vs. 6 percent), have had four or more partners (26 percent vs. 14 percent), had intercourse within the previous three months (47 percent vs. 34 percent) - according to the Youth Risk Behavior Surveillance System, a federal survey of high school students.
Philadelphia teens actually practice risky sex at a slightly lower rate than elsewhere: 37 percent said they did not use a condom the last time they had intercourse, compared with 39 percent nationally. But that doesn't mean they used protection correctly or consistently, and plenty didn't do so at all.
Physicians, educators, and teenagers say that the older and easily treated sexually transmitted diseases, such as syphilis and the more widespread gonorrhea and chlamydia, have become so common that teens aren't scared into taking precautions. HIV, on the other hand, is not talked about much - except to demean and ruin a child's reputation.
And, being teenagers, they think they will not get it themselves.
"One of the biggest things is they say, 'Well I looked at him and he was clean,' " said pediatrician Jill A. Foster, director of the pediatric and adolescent HIV center at St. Christopher's Hospital for Children. "It is mainly wishful thinking."
Although Philadelphia has long had high rates of sexually transmitted diseases, the issue took on more urgency a little over a year ago, when infectious syphilis - traditionally not one of the worst here - spiked 45 percent in 2009, with the biggest jumps in a population that generally has low rates: young women. Although the numbers were small, the rise was alarming: more than 300 percent.
Gonorrhea, which is cyclical, continued its decadelong decline - a trend that ended dramatically in 2010, with a one-year rise of 36 percent, including a 48 percent jump in women ages 20 to 24. (The citywide syphilis rate increased 9 percent more in 2010.)
Worried about the future, Health Commissioner Donald F. Schwarz asked members of his staff if they could use high school screening data to determine whether STD diagnoses meant that students were at greater risk for HIV.
Philadelphia has the most comprehensive STD screening program in the country, which also is part of why the city reports high rates of infections; the screening finds them. In every high school, every year, health department workers screen every child who agrees and whose parents don't object, and follow up positive tests with treatment.
Nearly one-third of girls and 12 percent of boys test positive for an STD during their high school career. Many get infected more than once.
Health department epidemiologists were able to match 80,197 STD screenings with separate HIV records compiled by the city. They found that a positive screening test meant that a boy was 2.5 times more likely to contract HIV within a few years than a negative test; a girl was 3 times more likely. And three or more STD positives meant a boy was 4 times more likely; for a girl, 6 times.
The findings were unique: Almost no research has been done on STD-HIV links in teens anywhere.
But the results were depressing, and probably due to a combination of factors. Medically, the open sores of syphilis and inflammation of gonorrhea and chlamydia make HIV transmission easier. Behaviorally, kids who do risky things keep doing them even after an STD diagnosis.
"It doesn't look like kids learn," said Schwarz.
The data also seemed to confirm a circular pattern of behavior that worsens all of the epidemics. It is called a sexual network.
"If all of your sex is in one zip code when you are a teenager, and the zip code surrounding you has high HIV and you are having lots of sex, then eventually you are going to have sex with someone who has HIV," said Claire Newbern, an epidemiologist who did much of the analysis.
Change won't be easy.
"Kids now, they think that the worst part of HIV is how people are going to react to you," said Foster, the St. Chris pediatrician. "The people that have HIV are seen as dirty. 'AIDS girl' or 'AIDS boy' gets sprayed on their door."
"Gonorrhea or chlamydia, [they] sort of laugh over it. Nobody is going to tell anybody that they have HIV."
Contact staff writer Don Sapatkin at 215-854-2617 or email@example.com.