Gay and bisexual men appear to have led the way in an increase in syphilis cases in the U.S. for the second consecutive year. The Centers for Disease Control and Prevention ( CDC ) released the numbers for 2002 in a telephone news conference with the gay press Nov. 19.
Chicago is a rare exception, where public health and community education programs have helped lead to a decrease.
Reported U.S. cases of primary and secondary syphilis, representing recent rather than long established infections, increased 12.4% to 6,862 in 2002. Other sexually transmitted diseases ( STDs ) are a much larger problem and they appear to have increased as well, but the national data on those infections is not as complete.
Ronald O. Valdiserri, Deputy Director of the National Center for HIV, STD & TB Prevention at CDC, fears that the increase in syphilis "May signal the potential for a resurgence of HIV infection. Another concern is that the presence of syphilis may speed the progression of HIV disease in people who are coinfected."
John Douglas, Director of the Division of STD Prevention at CDC, "estimates that more than 40% of the reported cases in 2002 were among men who have sex with men."
Most jurisdictions do not collect or report information on the partner of the infected patient, so CDC looks at the ratio of male to female patients to make that estimate. A broadly based infection, such as the flu or HIV in Africa, has a male/female ratio of about 1:1. That is true for a STD when it is being transmitted largely through heterosexual sex, but the ratio will increase when the disease is concentrated within a population of men who have sex with men ( MSM ) .
The ratio for syphilis in the U.S. increased to 3.5:1 in 2002, compared to 2.1:1 the previous year. In San Francisco, the ratio was an astounding 78.8:1 and was highly concentrated within the gay community. The ratio in New York City was 27.5:1, and in Los Angeles 19.2:1. In fact, among the jurisdictions reporting more than 50 cases of syphilis, only Memphis reported more infections among females than males.
In New York City, which does collect data on sexual orientation and coinfections, "HIV-positive men comprised 61% of new syphilis cases in 2002, compared with 20% in 1999," said Douglas.
Bob Wood, Director of the HIV/AIDS Control Program for Seattle and King County, said they have been gathering data on all STDs and the sex partners of patients for more than 20 years. Those numbers showed a dramatic decline in STDs among gay men in the mid-1980s as the threat of AIDS became clear and safer-sex practices were adopted. But they began to inch back upward in the mid-1990s.
Syphilis is rare among the general population of Seattle, less than 1 in 100,000 people are infected. "It is 200 times higher in MSM," said Wood. "And the rate of infection in the subset of men who have HIV is at least 800 times higher than it is in" heterosexuals.
"Although it would be great to eliminate syphilis, it is not our greatest concern," he said. That is because other STDs are much, much more common and they have similar biological effects of increasing the transmission of and susceptibility to HIV infection. And, like all coinfections, they seem to increase the progression of HIV among those who are already infected.
"Gonorrhea and chlamydia rates have increased back towards the rates that we saw in the early days of HIV in the early 1980s. Those are on the order of seven times higher for gonorrhea in gay men than they are in heterosexual men. And chlamydia rates are higher as well," Wood said.
Valdiserri fears that these increases represent an increase in unprotected sex among gay and bisexual men, and that may result in an increase in new HIV infections. While the numbers do appear to confirm his first fear, they do not appear to be translating into the second—at least not yet.
Douglas acknowledged that research from individual cities "suggests that between 20% and 74% of recent syphilis cases were among people [ already infected with ] HIV," most of whom were in care for that disease.
Wood said that despite an increase in STDs, "Our latest data suggests that our HIV rates in 2003 won't be increased." He explained, "We definitely have seen people coming in for a second and third time with syphilis and gonorrhea. I think there is no question that there are core groups" that engage in high-risk activity and are fueling the epidemic.
Valdiserri said the CDC has added a focus on MSM to its syphilis prevention activities and has funded targeted programs in eight cities. Challenges include substance abuse, depression, discrimination, and sometimes partner violence.
Jeffrey Klausner, director of San Francisco Department of Public Health STD Prevention and Control Services, said their aggressive campaign has resulted in identifying a large number of cases of syphilis. Those cases peaked in the second quarter of 2003 and have declined in the third quarter.
Chicago is another example of success. "Primary and secondary cases of syphilis are down 33% for the first eight months of 2003," said Christopher Brown, assistant commissioner for STD/HIV/AIDS at the Chicago Department of Public Health.
The theme of the Chicago effort is a simple one: "If you're sexually active, make testing part of your routine." Brown said, "We are very pleased to see that all of our efforts around awareness, testing and treatment are paying off."
The CDC recommends that those who engage in anonymous sex, have unprotected sex, use crystal meth or poppers, or who have partners who do so, should be tested for STDs every 3-6 months. All STDs are curable with a short course of antibiotics. However, the CDC is concerned with the recent appearance of drug-resistant gonorrhea.
The syphilis numbers "underscores the acute need for additional research to explore the factors that have led to this resurgence," the Gay Men's Health Crisis ( GMHC ) said in a statement. Their experience, and that of other health providers in New York City, is that "drug use, and crystal methamphetamine use in particular, seems to play a key role in promoting syphilis among urban white men who have sex with men."
Terje Anderson, executive director of the National Association of People With AIDS ( NAPWA ) , pointed to the examples of San Francisco and Chicago as what can be accomplished when there is an aggressive program of testing and treatment. Anderson said, "We need the CDC to do more to encourage healthcare providers to consider the offer to STD testing a standard of care."
STD Hotline 1-800-227-8922.
