Episode 5: A Conversation in the Rio Grande Valley

A special dual episode in English and Spanish. Hosts Larry Prescott and Amy

Carter welcome guests Maricruz Ayala, Public Health Region 11, and Dina

Balladares, University of Texas-Rio Grande Valley, to talk about what makes the

Rio Grande Valley of Texas unique. They spotlight what syphilis is, the

challenges the valley faces with disease intervention, and the unique

approaches they take to address the rising rates of syphilis and congenital

syphilis in this special part of Texas. This episode is also available in

Spanish, hosted by DSHS Surveillance Data Coordinator Diego Martinez.  

https://www.dshs.state.tx.us/hivstd/info/cs/public.shtm

www.facebook.com/prevent_congenital_syphiis

https://www.tapchw.org/

https://dshs.texas.gov/CHWNetworksandAssociations.pdf

Larry Prescott 0:00

Welcome to exploring an epidemic, congenital syphilis in Texas. I'm your host, Larry Prescott. In this podcast series we will explore what's happened with syphilis and congenital syphilis in Texas through interviews with national and local experts. Talk about babies diagnosed with congenital syphilis in Texas and discuss how we can address the rise and rates of congenital syphilis in Texas. After all, this is a 100% preventable disease with tests and treatment at our disposal, if we all do our part.

In our episode today ladies and gentlemen, we'll be discussing the unique portion of the state of Texas. We have a border region along the size of the state of Florida, but we'll be discussing specifically an area in Texas known as the Rio Grande Valley. Within that particular area we find out that the population is 80% Hispanic as compared to 25% statewide. We are going to be exploring some areas and challenges that we have around syphilis and congenital syphilis. I'm so glad to have my co-host with me, Amy Carter today. Amy just thanks for being with us once again.

Amy Carter 1:03

Thanks Larry. Yeah, the Rio Grande valley is a very unique part of Texas that has its own culture. And like you said, it is close to 85% Hispanic and Latino, and there's some parts of Texas that have historically always reported congenital syphilis, like our Dallas, our Houston, our San Antonio, our big Metro areas. But, this is a very rural area, we're seeing more congenital syphilis reported in this area. And so, we wanted to really highlight what makes it different, the different strategies that are used for that area than we would see in our big urban areas. We have some great guests today, I'm really excited. They're definitely experts in the field and doing the work on the ground in Brownsville, and McAllen, and Laredo, and the whole Rio Grande Valley area.

Maricruz Ayala 1:48

Hello my name is Maricruz Ayala, I'm the supervisor for the HIV/STD Program for the state of Texas. What we do is we investigate sexually transmitted infections here in south Texas, which is region 11, all of south Texas from Laredo all the way to B-ville, and all the Rio Grande Valley. We locate people that test positive for infections, such as HIV and syphilis, and we contact them, help them into care, and we follow up with their partners as well.

Dina Balladares 2:13

I'm Dina Balladares, I am the graduate researcher here at the University of Texas Rio Grande Valley, or known as UTRGV. I research local area resources for congenital syphilis, conduct some research analysis of the valley. Our project in itself, or the preventing congenital syphilis, is to provide resources for The Valley.

Larry Prescott 2:34

We want to thank both of you for being here with us today. And we looking forward to hearing from each of you to share your stories, your experiences, as well as your expertise in dealing with these challenges that we face in the Rio Grande Valley area. Maricruz, just could you explain to us, what syphilis is and what congenital syphilis is? Can you kind of tell us in terms of, if you was talking to a client who didn't know anything about that, what it is?

Maricruz Ayala 3:01

Sure. Syphilis is a bacterial infection that's transmitted sexually from an exposure to a lesion or a sore from a person that has syphilis, and it can be transmitted sexually. Most important thing to know about this, is that there's different types of symptoms. Like I said, the first one would be with the lesion, a sore that comes out. Someone might have it in their mouth, on their penis, in the anal area, and without knowing is spreading it. So say for instance, if an individual has it on their mouth and they're performing oral sex on someone, they can't transmit it that way, or vaginal sex if the person has it on their penis area, they can transmit it.

It's important to know that with syphilis, the most contagious stage is when that lesion or that sore is present. Since it's a painless sore, most people don't know they have it. It comes out for a few days, and what happens is, since someone doesn't feel it, they're not looking for it. So if it's in their mouth, unless you feel something in your mouth, you're not looking around in your mouth, it's on bottom of your penis, in your anal area. Unless there's something that's uncomfortable, most people don't pay attention to it, and it goes away and sometimes it's misdiagnosed. People will get cream and put cream on it and it goes away, but it would've gone away without the cream. It goes away, but it doesn't mean it was treated.

Larry Prescott 4:16

Okay. And how do we treat this particular disease?

Maricruz Ayala 4:19

Syphilis is treated with penicillin G, Bicillin, and it's a form of penicillin. So what happens here, and one of the things that being in the valley, we have access to medication right across. I know from personal experience that, you know we go to the dentist, we go to the doctor, or even if we go to our doctors here locally, and we have penicillin that maybe we got for maybe a sore throat or an infection for our teeth, you take it and people think "Well, I took penicillin, I'm okay", because it is a form of penicillin, but it's not the same exact thing. This is actually, it's a lot of penicillin and it is specific. It is an injectable and it's the only treatment for pregnant females. Even if you're allergic to penicillin, unfortunately because it is the only treatment for someone that is pregnant, they have to go into a hospital to get the treatment. There are also alternatives, but Bicillin, which is a penicillin that we use, is what CDC recommends.

Amy Carter 5:12

Yeah, and that's really important too, because you might have taken some and the signs and symptoms that you're talking about, like that sore may go away, but it wasn't enough to treat all of the bacteria that you may have in your body. And so going to a clinic, whether it's a state health department, the university, your local doctor, and getting specifically that Bicillin penicillin prescribed and injected is what's going to treat that. And like you said, It's the only available treatment for pregnant people, we can't give anything else.

It also is, given depending on those stages, so Maricruz was talking a little bit about primary syphilis. We've got to remember that if you've never been tested for syphilis, you don't have that sore, you don't have the rash that comes in secondary syphilis, or the warts in the genital region that we sometimes see. You have to get three doses, seven days apart, ideally, to be considered adequately treated. So, that can present another challenge.

Maricruz Ayala 6:12

I think that earlier when I mentioned the penicillin, I think that's one of those challenges that we come across as investigators when we're out there looking, is that people may not remember taking medications. And so that's one of the reasons we go back and we'll ask "Maybe they gave you some type of antibiotic". We don't necessarily say penicillin, just an antibiotic, because most people don't know the names, the medications they take. So like, say for instance, "Did you go to the doctor?" "Did they give you any type of medication?" Because you're right, it does cover symptoms. People aren't aware that they had those symptoms.

One of the things that we do recommend is that people who are sexually active, that they get tested every year, at least once a year to give us a baseline. It makes a big difference from getting three very heavy injectables, to one treatment, instead of having three treatments every seven days. People hesitate, because they know they're afraid of needles, but it's really important to, if we are having sex that we get tested at least once a year, regardless of whether we're just with that one partner.

Amy Carter 7:02

Yeah, and we keep saying it's one dose. But, in actuality, because it is so much penicillin, it's two shots. They divide it because there's so much and it's such a thick medicine. So, your doctor may go in and say "Oh, we're going to treat you for this". And you're expecting to get one shot and they're like "Nope, we're going to do one in each hip". We consider that one dose.

Maricruz Ayala 7:24

You're right. Because we've had people say "Well I got six shots", because it was divided into two different injections. There's some doctors and we actually carry the one dose sometimes with the one injection, which is a very huge shot. So this why they divide it into two. Depending where you get your medication, you're right, it could be one shot or two, but it's actually one dose every seven days, whether it be the one shot or the two shots.

Larry Prescott 7:49

And we talking about it being a sexual transmitted disease. So, when we start talking about infants, you know, somebody again, I'm playing a person that doesn't know anything about it. Well, if it's a sexually transmitted disease and I've got a brand new baby who's not engaging in anything, how did my brand new baby get this disease called syphilis? Can you tell us or give our audience a good picture of how that happens?

Maricruz Ayala 8:14

Well, what happens is a mom is tested positive for syphilis or has syphilis, at this point syphilis can be transmitted to their baby through umbilical cord. If the mom is not treated adequately then that can cause so many other issues if the mom goes untreated. This is where we go into having, not just regular syphilis, but it would be congenital syphilis because it's passed on to the baby through the umbilical cord. So this is how it's transmitted. It's not that they're having sex, but mama transmit unknowingly to a baby.

Larry Prescott 8:42

Yeah. I mean, we want to make sure people get a clear picture of exactly what we talking about, that's good information for them to know. Tell us what is the recommended treatment for syphilis.

Amy Carter 8:50

Specifically for syphilis it is penicillin, which we refer to as Bicillin. 2.4 million units intramuscular, so it's a shot. There is an alternative for it, but that is not given during pregnancy because it can harm the baby. The only acceptable CDC recommended treatment for syphilis is Bicillin, which is a penicillin derivative, 2.4 million units. Depending on the stage of syphilis, depends on how many times you get that dose. So, if it's early syphilis, you get one dose. If it's later or we can't tell what type of syphilis you've had, if you've had it for a long time, it's three doses given a week apart.

Larry Prescott 9:35

Maricruz, you mentioned earlier about dealing with people in the valley and working with different segments of the population in the valley. Can you give us an example of some of the challenges that you have, like with finding people or maybe even how you get them the motivated to talk to the DIS, to come in to get the treatments that we talking about, can you expand on that a little bit?

Maricruz Ayala 9:53

Sure. Just thinking about different challenges. We have a lot of people that live in rural areas, what we call colonias. They don't have the paving. Recently with a lot of rains and storms, there are areas where people can't even make it out of their home because the water's all the way up to their door. Then it takes days for the water to come down and once the water comes down, the roads are muddy, you can't get in there because you'll get stuck. There's financial challenges. They may not be fortunate enough to say "If I don't work today they pay me, and I need, I'm barely making it with money that I make every single week". And so, it's really important that people make it to work every single day. Or if, say for instance, a spouse works and maybe they work out of town. So people are let with that one parent at home and they're the ones that pick up the kids and drop them off. Maybe they have a child at home and because they don't work, they don't qualify for any type of childcare.

So those are some extenuating challenges that we don't face in a city like Houston or Dallas, and some of our other areas in the state of Texas. This is why we want to make sure that we get this information out about why it is such a challenge to address the issues of syphilis and congenital syphilis. I want to ask Dina to talk about how we destigmatize the syphilis and congenital syphilis there in the Rio Grande Valley. Dina, can you talk to us a little bit about that?

Of course, yes. I think Maricruz shines a light to the uniqueness of the valley, as you mentioned. Yes, there's cases everywhere. But the valley has those uniqueness, those barriers, those challenges that we face. And one of them also is talking about it, talking about this conversation culturally, it's kind of makes you feel uncomfortable to talk about it. Even me now that I'm Latina, Hispanic is so like "Oh, I'm having a conversation about syphilis, congenital syphilis". It still has some stigma around it. But I think for me in the future, if I was to have children or something related, I would have the conversation and say "I heard this or this about syphilis" or I saw it. I think that's maybe when the promotoras can come in and as we talk about promotoras, their community health workers, people that go from your community and go out and talk about a topic, a health topic.

There are people like your Tia or your aunt, your uncle, or like be people from here that can have that conversation with you. It's not being afraid to have that conversation because it's not just for you, but also for the baby or your child. Even the ways to prevent it is like "Hey, I heard this topic", or let's say, for example, this podcast, when it comes out. You talk to your son or even a teacher can say "Hey guys, I heard this information or this resource and you guys should look at it". And then that starts the conversation.

Now, that's a really good point that you make with how important the promotoras are, because it sounds like they're community unto themselves. By having those promotoras or those community health workers who are from that area, who are from the valley, they're from those colonials, to be able to be a resource and have those conversations.

I know in our larger areas, we have our fetal infant morbidity review boards. We've talked to moms who have lost babies because of their syphilis diagnosis. They've talked a lot about the guilt and the shame that they have received from themselves, but also from providers, and being able to have those conversations has helped them. Maricruz, how do our partner services or disease intervention specialists, DIS workers, what do they do to help destigmatize these conversations as well?

I think it's really important when we go out, we let people know that everything that we speak about is confidential and we reassure them that they're not the only ones and that it doesn't discriminate. It could happen to any one of us. We're trying really hard to stop it by educating people, getting the information out there so that they're aware and to remind people that they do need to get tested.

And that gives me a thought come in my head when you start talking about all of this information about, how do people obtain this information? What are the ways they're using down there in the valley so people can obtain this information?

One of the things that we had talked about is, how do you talk about it? UTRGV does have a Facebook group. That Facebook group or page is where people ask questions. They ask a lot of questions about syphilis treatment, prevention, cases that they've had, experiences that they've had. Not only do you feel a sense of community personally, but also socially.

I think everybody is familiar with Facebook, including me. What's the most common questions you get?

Somebody asks "What's the name of the syphilis page?" "Hi, I'm a member, I have a few questions". "Is there a cure?" "If I tested positive, how might you know if syphilis, if I passed it successfully or will I deliver a baby successfully?" "After how many days or months can I be cured?" "Was I correctly treated?"

There is a lot of questions on there that the community feels comfortable enough to ask. Sometimes I think it's easier just to type something and to go talk about it. So that is something there for people, that is a resource available to anybody.

And who's answering those questions Dina? Is it just like anybody or is there specific people that answer those questions?

We do have a doctor on there. He obviously won't answer very specific questions, but usually it's the UTRGV School of Medicine, the Department of Peds is on there.

So, it's pediatric doctors and trained medical doctors that are answering these questions. People can trust that when it's the UTRGV that's responding to them, it's a trained medical professional that's answering those questions and giving them correct information. And also I've been on it, I've looked at it. You guys also direct to the local clinics because that's one thing that people may not know is where that clinic is. And with that, the regional office does a lot of work too. So Maricruz, can tell us a little bit about the resource that is Department of State Health Services, region 11 office?

We do in-house treatment here for those that may not have a provider, for those who may not have access to any type of insurance, we do provide testing and treatment here in the Hidalgo County area. We do refer to Accesses Esperanza, but on said they have five clinics in five different cities, which is really helpful because you might have one that's in your neighborhood instead of having to drive.

Now, if there's someone that needs testing and they're concerned because they were told that they were exposed, they mentioned "I don't have a car, I may not have this". We'll send out one of our investigators to go out to their home, to draw blood in their home. We try to work with people. It is something that they might feel, you know, it is private and of course we do follow HIPAA. Your medical information is your medical information and we don't share any of your information.

We try to accommodate people to make them feel safe in their environment or wherever they may choose to. I've drawn blood in parking lots in a car, wherever they might feel comfortable. I mean, it is crazy. We have one of those most interesting jobs that we draw blood anywhere. We've done them in bars, in bathrooms and you know, just wherever. If a person's on a break and they're like "I have a 15 minute break, can you come? I'm not going to get up until nine o'clock tonight and the clinics closed". Yeah, we'll go and meet them outside their place of employment, somewhere away where people can't see and draw their blood really quick and send them on their way. So we try to do that, and of course once, if they need it, if they've been exposed, we do recommend treatment. Then we have clinics that we can refer after hours.

Yeah. And you guys also are a resource for the clinicians too. So the doctors can call you, they can get that history as well. You're constantly talking to those different clinics and those different doctors and nurses to make sure that they are getting the treatments out and that they're checking people's histories and all of that information too. There's a lot of work that you guys do. I don't want y'all to undersell yourself either.

Yeah. We do get several calls a day, HIV, syphilis, gonorrhea and chlamydia are reportable to our agency. So people call us and they'll ask, and when they're reporting syphilis or HIV, it is really important to get people's history so doctors will know how to treat a patient.

Doctors will call us and sometimes they'll say "Well, I prescribed the medication, but they can't get the medication". We also deliver and provide medication to the providers to provide to the patients so that all patients don't have to worry about that cost because that medication can be expensive. We don't want that to be a barrier, when a provider calls, say for instance, they just screen the person. We try to deliver the medication so when the patient goes in, they're not having to go back and forth. We do think about the patient having to miss work for one test and they come back for treatment. We try to make it convenient for the patients. What we do is we make sure by the day that they go to their doctor, that we delivered medication, so they get that preventive treatment. So they don't have to go back a second time after the results.

Dina, what is the one thing that you want people to take away from this podcast on today?

I was thinking about that right now. I was like, all of it. No, I'm just kidding. I think I would say, don't be afraid to have a conversation, not just for yourself, but also for the babies and the effects that it could have. So I think it's, let's try to break the stigma of it.

I think that we need to learn to advocate for ourselves and to take care of ourselves and stay healthy. And that's trying to find whatever resource we can or know that resources are available so that we can stay healthy and we can prevent congenital syphilis. The valley is very family oriented. We love our families. We love our children. This is so important that if people understand that this can be prevented, even as it might be a little bit of an inconvenience and in the long run it saves so much more.

I want to thank our guests today for all the information that they shared with us. And of course, thank my co-hosts Amy for injecting her expertise in our podcasts today. We will continue to explore this epidemic, congenital syphilis in Texas. I'm your host, Larry Prescott.

This podcast was developed by the Texas department of state health services in collaboration with the Denver Prevention Training Center.

Additional links and information about the Rio Grande Valley, Border Health, and any other topics Maricruz and Dina discussed today, can be found in our show notes.