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Syphilis Rising in a Connected Age
In 2013, the rate of reported primary and secondary syphilis in the U.S. was more than double the lowest-ever rate reported in 2000.
By Michael Smith, MedPage Today
Medically Reviewed byZalman S Agus, MD
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Syphilis, by its nature, should be a relatively easy public health problem.
Humans are the only reservoir, for the most part it's transmitted sexually, and it's relatively easy to cure.
Why, then, is the rate of syphilis rising in the U.S.? Specifically, why is it rising mainly among gay and bisexual men, while dropping in most other groups? And why is it rising now, rather than, say, a decade ago?
It's a combination of factors, according to experts who spoke toMedPage Today.
"Syphilis has gone from being a disease of heterosexual inner-city folks (prostitutes and their clients, for instance) to primarily a disease of gay men," according to Jonathan Zenilman, MD, of Johns Hopkins University School of Medicine.
Those men, he said, have several important characteristics: they engage in risky sex, they have a large number of anonymous partners, and many of them are HIV-positive.
But that's not entirely new. The last time syphilis numbers were driven by gay and bisexual men, Zenilman said, was in the 1970s, a period of wide-open sex in most gay communities in the U.S.
To some extent, the start of the HIV/AIDS pandemic put an end to that: when unprotected sex can be a death sentence there is a strong incentive to be careful, to limit the number of partners, to take precautions.
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The unintended consequence of fear of HIV/AIDS was lower numbers of other forms of sexually transmitted infections.
But, according to the CDC, syphilis is again booming. In 2013, the agency reported, the rate of reported primary and secondary syphilis in the U.S. was 5.3 cases per 100,000 population.
That's more than double the lowest rate ever seen -- 2.1 cases per 100,000 population in 2000.
From 2005 through 2013, men contributed an increasing proportion of cases and by 2013 accounted for 91.1% of all primary and secondary syphilis cases. Importantly, a single birth cohort appears to be playing a key role -- men who were 20 through 24 in 2005 to 2009 saw their contribution to the numbers rise by a factor of 1.49, while men who were 25 through 29 from 2009 through 2013 had 48.4% increase.
Moreover, the CDC analysis showed, in regions that reported the sex of sexual partners the proportion of cases among men that were attributed to sex with men rose from 77% in 2009 to 83.9% in 2012.
The upshot is rising numbers of syphilis cases in gay communities, according to Susan Philip, MD, of the San Francisco Department of Public Health, one of the agencies with the most experience of sexually transmitted diseases among gay and bisexual men.
In San Francisco, she toldMedPage Today, her department recorded 890 cases in 2012 and 1,014 in 2013, almost all among gay and bisexual men.
"We're seeing this mirrored across the country," she said.
Why Syphilis? Why Now?
When a sexually transmitted disease starts rising, there are three central questions to be asked, Zenilman said: "Did the bug change? Did the people change? And was there a public health management or structural change?
Gonorrhea, for instance, has changed -- it has become more resistant to antibiotics and currently only a few drugs can be relied on to knock down an infection.
Not so for syphilis, Zenilman toldMedPage Today. The treatment for primary, secondary, and early latent syphilis is a single intramuscular injection of long acting Benzathine penicillin G. And three shots will cure later stages.
"The treatment for syphilis is exactly the same as it has been for 50 years," Zenilman said, and it's the same regardless of the patient's background -- with a few exceptions, there are no subgroups of people who need different or more intensive therapy.
"The bug hasn't changed," he said.
Moreover, there's a 2- to 3-week period between exposure and infectiousness. With good contact tracing -- a public health mainstay unchanged for decades -- "you can pretty much control an epidemic," Zenilman said.
What has changed, he said, is behavior, Zenilman said. Gay and bisexual men -- thanks to social media -- can easily find multiple and anonymous sex partners. And thanks to the reduced fear of HIV, many take fewer precautions.
To those factors, Philips would add social stigma. In San Francisco, he said, HIV testing is pretty much routine -- it's "normalized" in the gay community -- but there is still stigma about syphilis.
Sexually active men should get screened for the disease every 3 to 6 months, she said, "but stigma and others fears may limit that."
Social Media Has an Effect
Moreover -- again, thanks to social media -- controlling an outbreak through traditional contact tracing is more and more difficult.
Many men don't know anything about partners they met on the Internet. Social media handles can change from site to site and from day to day. A man might not even remember what site he used to find a partner.
In San Francisco, health officials recognized the problem early, Philips said -- in the early 2000s, her department already had an online presence, prowling AOL chat rooms trying to help identify partners of infected men.
Currently, six or seven staffers -- the numbers vary -- spend some or all of their time online in a program called Internet Partner Services.
It's not easy. The staffers can't simply go on to a bunch of websites and say something like: "Anyone using the handle #BIGSTUD probably has syphilis." Instead, they have to tread carefully, maintaining confidentiality, and simply suggesting some people might want to call the department.
And it's difficult to measure success, Philips said.
"The challenge with it is that we don't always know what happens," she said. "People don't always report back to us" that they were tested and either treated or found to be negative for syphilis.
Departmentally, there are other challenges. Many public agencies might boggle at the thought of staff members spending hours cruising what are, after all, adult websites.
"It requires cooperative buy-in of the entire health department," Philips said.
Interestingly, she's not sure about the role that HIV plays in the syphilis epidemic.
In San Francisco, about 94% of gay and bisexual men know their HIV status -- much higher than the national average -- and new HIV infections have been declining slightly, possibly because HIV treatment, offered broadly in the city, helps prevent transmission.
In her city, she said, it's now "very possible" to have unsafe sex, remain at low risk of HIV (because most partners would either be HIV-negative or on treatment), and at the same time be at high risk of another sexually transmitted infection.
"It's difficult to grapple with on a public health basis," she said.
The increasing rate of syphilis in the gay community might also amplify the risk of infection in the first place, according to the CDC.
Even without the Internet effect, "high background prevalence among partners and small sexual networks" mean men who have sex with men are at increased risk, simply because they're more likely to meet an infected partner, a CDC spokesman toldMedPage Todayby email.
The bottom line, Philip says, is that treatment, contact tracing, and prevention can only go so far, regardless of how effective they are.
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