When Fredrick Echols joined the St. Louis County Department of Public Health as director of communicable disease control services a couple of years ago, he did an assessment of the county’s sexually transmitted disease (STD) program. It wasn’t hard to see where things could be improved. “I saw some gaps in services,” Echols says, “particularly in the community.”

Echols is referring to the fact that the county had made almost no effort to involve community members in a conversation about safe sex. The absence of a discussion has contributed in part to its distinction for more than a decade as home to the nation’s highest rate of STD infections. The number of chlamydia cases in St. Louis County increased by more than 500 in 2016, gonorrhea cases were up by 1,300 and syphilis cases also spiked, according to the Centers for Disease Control and Prevention (CDC).

But what’s particularly troubling is that St. Louis County isn’t alone. With more than 2 million cases reported in 2016, STD rates nationwide are at a record high. “STDs are a persistent enemy, growing in number and outpacing our ability to respond,” Jonathan Mermin, director of the CDC division that deals with STD tracking and prevention, said in a press release accompanying a September report on the issue.

The CDC noted a surge of syphilis cases in women and newborns, with mothers passing the disease along thanks to injectable drug use. There’s also been a spike of chlamydia cases among gay men, which a 2014 report says is associated with an increase in casual sex due to the use of smartphone apps.

Even before the CDC numbers were released, Echols says, his team in St. Louis County was already working with a sense of urgency. He hired several disease intervention specialists who go into the most impoverished areas in the community and connect people to care. Echols also worked with the city health department to train barbers and beauticians to talk to customers about the importance of safe sex and getting tested. Now many salons and barbershops carry condoms and information on testing next to the cash register.

St. Louis County had a brief reprieve from its No. 1 ranking when the new CDC data showed Etowah County, Ala., with the nation’s highest rate of sexually transmitted diseases. But the numbers were incorrect, due to a glitch in the reporting system; Etowah County actually showed a slight improvement in its STD rates from 2015.

That may be good news, but it’s hardly cause for celebration. Karen Landers, medical director for communicable diseases at the Alabama Department of Public Health, notes that the state dealt with a syphilis outbreak last year, and those numbers remain steady. “We know that sex in exchange for drugs is the primary driver of these rates, although getting syphilis from injectable drugs is also an issue,” she says.

Like Echols, Landers focuses on educating people in the community about STDs. But at a point when STD rates are at an all-time high, more money and resources are also needed. “It’s just a challenge to get fully funded at every level,” Landers says.