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Next Article: 2001 Syphilis Rates Show Increase: Does This Portend a New Wave of HIV Infections?
The Centers for Disease Control and Prevention released their final surveillance summary for 2001 syphilis rates in the U.S. in November of this year: Primary and secondary syphilis rates rose for the first time since 1990. Though the overall increase was slight (2.2 cases per 100,000 up from 2.1 per 100,000 in 2000), the increase occurs in the context of a very aggressive national syphilis elimination campaign launched in 1999. The national goal of syphilis elimination is to improve local capacity to respond to every syphilis case so there is no evidence of sustained transmission after an infectious case is detected (i.e., no transmission after 90 days of the report of an imported index case). This goal is numerically comparable to a reduction in the overall number of primary/secondary syphilis cases to less than 1000 by the year 2005. There were 6103 total cases of primary/secondary syphilis in 2001.
Analysis of Current Trends What Might the Current Situation Mean for HIV Transmission? What Does This Mean for HIV Treatment Providers? Summary
In 2001, rates of syphilis increased 15% among men and decreased 18% among women; the male: female ratio of syphilis cases increased 50% (from 1.4 to 2.1). Public health surveillance data do not traditionally include behavioral variables, such as same-sex contact among the men who are represented among reported syphilis cases. However, this rising M:F trend, coupled with the explosive outbreaks of syphilis among men who have sex with other men (MSM) reported in several large U.S. cities [MMWR 2001; 50:117; MMWR 2002; 51:853] indicates that the rise in U.S. syphilis rates for 2001 is due to new epidemics of syphilis among MSM.
Biologic and epidemiologic data support the concept that untreated syphilis biologically enhances HIV transmission. Data from cities reporting new epidemics of syphilis in the MSM community suggest that an increasing proportion of persons with syphilis are also HIV-infected compared to those diagnosed with syphilis in prior years. Thus, rising rates of syphilis among MSM may be a marker of changes in sexual practices among both HIV-infected and -uninfected individuals in this era of HAART and treatment optimism. This may well indicate increasing HIV transmission in many MSM communities.
The CDC surveillance summary underscores the importance of maintaining a high level of suspicion for syphilis. This remains true for all clinicians, but most importantly for clinicians who treat HIV infected patients. Clinicians should be aware that the growing connectivity of this information age allows for diverse opportunities for their patients to meet sex partners in distant cities or on distant continents: Epidemics of syphilis have been described among individuals who met in Internet-based chat rooms or through website postings, so that syphilis epidemics can be rapidly introduced tomorrow into jurisdictions reporting low syphilis morbidity today. Providers should also be aware that the clinical manifestations of syphilis may be atypical: Because oral sex is recognized to be a lower risk activity than other acts with respect to HIV transmission, clinical presentations such as oral chancres (appearing first at the site of T. pallidum inoculation) should always trigger a discussion of sexual risk behavior and serologic testing for syphilis. A request by a patient for HIV testing should prompt syphilis testing as well, and conversely, HIV testing should be recommended for any person treated for syphilis.
In past decades, rising rates of syphilis have preceded rising rates of HIV among specific populations. Though intensification of syphilis control and prevention efforts have markedly reduced syphilis rates in groups most impacted by syphilis in the past decade, these gains have been offset by rising rates among MSM. Developing effective new strategies for education, screening, and risk reduction in the MSM population will be necessary to meet syphilis elimination goals in the U.S.