Arizona needs to pull up its pants.

When it comes to the three most common sexually transmitted diseases in terms of bacterial infections (chlamydia, gonorrhea and syphilis), Arizona has two cities that stand out above the rest: Show Low and Tucson.

Situated on the Mogollon Rim in northern Arizona, Show Low is ranked No. 49 out of 100 for the most sexually-diseased cities in the United States, according to data compiled by the Centers for Disease Control and Prevention (CDC) in 2013.

Show Low is far removed from any major metropolis, about 175 miles northeast of Phoenix. The town has a population of around 10,730 people with over 1,110 recorded cases of STDs in 2013, with chlamydia No. 1 with 926 cases, according to the CDC. Such a concentration of disease in a rural population could be attributed to a number of factors, but dwindling financial resources from the state takes precedent over all.

“In Navajo County, we have traditionally high STD rates for the last several years due to lack of funding … funding that we could use for education and outreach to help reduce STDs,” said Janelle Linn, interim assistant director for the Navajo County Public Health Department. “In recent years, we’ve tried to increase testing efforts, trying to identify cases to get treated to stop spread, to identify more people in population.”

Within the last 18 months, the Navajo County Public Health Department implemented numerous education strategies to combat the high number of STDS: There is a family planning program with services that reach out to schools, targeting teens on the dangers of STDs and how to protect themselves, Linn said.

The health department also goes out to provider offices, educating them on the most recent testing recommendations so patients are treated properly and don’t develop drug resistance. Additionally, Linn said the department works with the Indian Health Service (Navajo Area) and local hospitals to develop an STD task force to deepen testing strategies and treatments.

“We have implemented an expedited partner therapy treatment program (EPT), so they don’t have to bring their partner [to the hospital], they can take the medicine home with them, as to reduce the risk of infection.”

However, the biggest problem faced by the Navajo Health Department is lack of money. When it comes to small counties, funding tends to look at population instead of needs, Linn said.

There are other theories besides funding for the high number of STDs on the Navajo Reservation, such as the change in attitudes, said Dr. Sean Elliott, medical director for infection prevention at Banner — Health University Medical Center. For example, HIV/AIDS was considered a death sentence in the past, whereas now it’s a chronic illness that is treatable.

“That removes the fear of death and unleashes the barriers,” Elliott said. “Trends … of the population to participate in bisexual encounters and then hetero encounters after, and more unprotected sex.”

Another theory could be the presence of drugs on Navajo lands, such as “meth and heroine and Epi injection, perhaps out of desperation or because it’s there, followed by high risk sexual practices,” Elliott said.

And it’s not just the Navajo Reservation in Arizona; American Indians and Alaska Natives are disproportionately affected by STDs throughout the U.S. as well. According to the Indian Health Surveillance Report in 2011, “reported rates of chlamydia, gonorrhea and P&S [primary and secondary syphilis] among AI/AN were 1.2 to 4.6 times higher than comparable to whites.”

Though Tucson is the second largest city in the state, it is the second most sexually-diseased city in Arizona, beating out Phoenix. Here, funding would seem to be available, as Tucson boasts a metropolitan population of over 1 million citizens.

In 2013, there were around 608 STD cases per 100,000 people in Tucson, according to the CDC. There is not a rational answer for why Tucson has such a high number, but Miguel Soto, HIV program coordinator for the Pima County Health Department, has some ideas.

“In terms of why … it’s a hard question to ask because when you look for it, you find it … STDs are in every community,” Soto said. “It’s not so much on that we have more STDs, but that we test and see a lot more people.”

However, this year there has been a decrease in positive STD tests, and it could be because of education, Soto said. The Pima County Health Department’s STD program uses mobile outreach to target populations.

Workers use an education van to do free rapid HIV testing, blood draws, throat swabs, and urine collections—just about everything except a physical exam, Soto said. The van participates at venues and events such as gay bars, the UA, Second Saturdays in Downtown Tucson, and Fourth Avenue. Additionally, the van has a program called “Testing After Dark,” where the mobile unit goes to specific populations, offering a secluded testing center for individuals who might not be as willing to go to a public facility.

The Pima County Outreach and Education Team also has a different mobile clinic that does high school testing for no charge.

“We don’t turn anyone away,” Soto said. “We park outside the venues, so if someone comes up and they are, for example, underage, they can get tested just by coming to the van.”

In terms of syphilis, there is good news.

Syphilis is on the rise on a national level. In Pima County (whose number of cases hit a high of 104 in 2014, causing a public health alert, according to the Pima County Health Department) is beginning to see a decline in cases per sample size.

“Back in 2014 when we had that syphilis rise, it was mainly in the community with men who have sex with men,” said Azucena Huerta, communicable disease investigator for the Pima County Health Department. “We did a lot of ads and signs on bus stops, mobile outreach … more testing at the gay bars, and it has decreased 30 percent. We’re getting there.”

Arizona’s syphilis rate is going down compared to the national rates. From 2012-2014, there has been a steady increase of congenital syphilis cases, where a mother transmits the disease to baby during pregnancy, across the U.S. A recent report by the CDC said there were “11.6 cases per 100,000 live births in 2014, the highest congenital syphilis rate reported since 2001.”

There are solutions to reducing the high number of STDs in Arizona, they just take resources.

“Even if these [STDs] are treatable and survivable, there are other harmful long-term health affects,” Elliott said. “We just need to stop being so nice and show the need to use condoms.”

Callie Kittredge is a reporter for Arizona Sonora News, a service from the School of Journalism with the University of Arizona. Follow her on Twitter.