Bay Area Reporter - November 10, 2005
Bob Roehr

"The CDC estimates that 19 million STD infections occur every year, almost half of them in young people age 15 to 24," said Dr. Ronald O. Valdiserri, acting director for HIV, STD and TB prevention at that agency. Direct medical costs associated with STDs are an estimated $13 billion.

The report focused on syphilis, gonorrhea, and chlamydia, each of which "increases the risk of HIV transmission."

The number of new cases of syphilis reached an all time low in 2000 but has increased every one of the last four years, to 7,980 cases in 2004, "largely due to increases among men," Valdiserri said.

"The rate of syphilis increased 11 percent in men, from 2003 to 2004," said the CDC's Dr. John Douglas. "There are clear signs that increases have increased primarily among men who have sex with men [MSM]." He estimates that MSM account for 64 percent of all primary and secondary syphilis in 2005, up from only 5 percent in 1999.

Douglas said data from individual U.S. cities indicates that half of the gay men who become infected with syphilis already are HIV-positive. It is not clear how the HIV infection affects their vulnerability to becoming infected with syphilis or transmitting it to others.

Unsafe sex appears to be increasing among gay men, and that has resulted in increased rates of other STDs. Two years ago the CDC feared that the increase in syphilis in MSM would result in increases in HIV infections, but that has not been borne out in the data, at least not yet.

Valdiserri suggested some possible factors contributing to this outcome. One is serosorting, where HIV-positive and -negative men tend to have sex with others of the same HIV status, and/or modify their sexual practices when they have sex with a person of another HIV status.

Some gay men have restricted their repertoire to engaging only in oral sex, based upon the understanding that it is very difficult to transmit HIV through oral sex. However, many of them do not know that one can easily become infected with syphilis through oral sex.

Gonorrhea has declined to an all-time low, but that is still more than 700,000 new infections a year. A survey of 28 cities found that resistance to the standard first line therapy for treating the clap, the fluoroquinolone family of antibiotics, continues to grow. And again, gay men are in the vanguard - they are eight times more likely than heterosexuals to become infected with a drug resistant form of gonorrhea.

Because resistance is so high, last year the CDC issued a recommendation that fluoroquinolones not be used to treat gonorrhea in any person in California or Hawaii, and in any gay man anywhere in the country.

STDs, except for syphilis, are more likely to be present in women, often because they are without noticeable symptoms and therefore go untreated. The highest rates of infection for both sexes are likely to be seen in those ages 15 to 24.

But again, MSM are different; the peak rates of infection of syphilis and gonorrhea for gay men are later, when they are in their 30s.

San Francisco

San Francisco had the highest rate of primary and secondary syphilis in 2004; 45.9 cases per 100,000, or 10 times the national rate of 4.7 cases per 100,000. The increase in syphilis had been noted earlier and in 2005 both the CDC and the local health department were supporting an all-out public education, testing, and treatment campaign to knock it back down.

San Francisco STD director Dr. Jeffrey Klausner said those efforts already have brought a decline in syphilis in that city. He attributed it to programs that target gay men and health care providers, and also the links to Viagra and methamphetamine use.

"The community has taken that information and acted. Right now, 70 percent of men who have sex with men have had a syphilis test within the last six months, which is extraordinary. It went from probably close to zero to 70 percent in the past six months."

Klausner sees the Internet as the third major factor that helped to fuel the outbreak of STDs by facilitating the ease with which gay men can meet sex partners.

He said, "Sites like AOL and m4m4sex.com have done little or nothing to support safer sex and educate their users. Craigslist has done a bit more, while Manhunt.net leads the community in promoting testing, safer sex, and collaborating with local public health departments."

He said the key the their success in San Francisco has been building capacity to handle both the education and testing. That surge has broken the budget earmarked for syphilis but Klausner is committed to finding money to continue the heightened activity.

A sexually active gay man should be screened for all STDs on a regular basis. Syphilis and HIV are blood tests, while gonorrhea and chlamydia require throat, penile, and anal swabs and plate culturing to detect the infection.

Klausner says that few clinics offer all of those tests, and even fewer automatically do them on a routine basis. It is often a question of resources. "The bottom line is that nothing is routine." Patients need to request the tests they want.

Public health is a chronically underfunded area of medicine and government services. What does draw attention and dollars these days are the hypothetical threats of bioterrorism and mutant avian flu that could spread to humans.

Valdiserri acknowledged that state and local health officials have limited resources for controlling STDs. As for the CDC part of the equation, he said, "We still have to do the best job possible with the resources we have."

The CDC report is available at www.cdc.gov/std

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