Important note: Information in this article was accurate in 2008. The state of the art may have changed since the publication date.
Bay Area Reporter - March 13, 2008
Bob Roehr
Unlike the rest of the nation, where syphilis has been on an upsurge, San Francisco has seen a steady decline in cases since 2005. The health department's monthly STD Report for January listed a year-to-date total of 202 cases of primary and secondary syphilis in 2007, compared with 243 cases in 2006, a decline of about 20 percent.
The rate of syphilis infection in U.S. men is six times that of women, and 64 percent of the male infections are in men who have sex with men. Men who are infected with HIV and are on therapy constitute a significant portion of those infections, historically, about half in some cities.
Hilliard Weinstock, with the CDC's division of STD prevention, said this "presents a major concern for the health of MSM" because coinfection with syphilis "can increase the likelihood of HIV transmission two to five-fold."
"For individuals already infected with HIV, syphilis can increase viral load, which can accelerate HIV disease progression," Weinstock said. Coinfection also can result in more rapid progression of syphilis, particularly within the brain, where it can result in blindness and dementia if left untreated.
John Douglas, director of STD prevention at the CDC, said part of the increase in syphilis among HIV-positive gay men may be due to their attitude. "They have already taken the big hit of getting a fatal disease and have survived it, there is the potential of seeing other STDs as a nuisance."
The CDC recommends that sexually active gay men be screened at least once a year for all sexually transmitted diseases, and high-risk individuals even more frequently. Those tests should include syphilis, chlamydia, and gonorrhea in the penis, rectum, and throat.
A gonorrhea infection in the urethra of the penis often is painful and so the person goes to a doctor for treatment. But infection in the throat or rectum often is asymptomatic or the symptoms are so mild that they are easily ignored.
One study presented at the conference found that a third of all rectal gonorrhea infections and a quarter of those in the throat of MSM were not identified or treated because those anatomic sites were not tested. Another study looked at data from more than 10,000 HIV-negative MSM and found that only 39 percent were tested for syphilis and 36 percent were tested for gonorrhea at any site.
Douglas called regular screening for these STDs "one of our best tools for insuring prompt diagnosis and treatment and slowing the transmission of these diseases." He said these studies reinforced the need for increased screening among gay men.
Douglas acknowledged that public health resources are tight at the national, state, and local levels. However, he noted that many gay men have private health insurance and should have access to regular health care. There is a failure of physicians to conduct recommended annual screening for STDs, and of patients to demand them.
He said it is "part of a larger national fabric of difficulty talking about sex." He sees "a need to address the reality of sexuality in the population." Part of the solution is greater "cultural competency of physicians in working with their gay patients."
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