In 2000, syphilis rates were so low that health officials believed eradication was on the horizon. However, rates rose in 2001, rose steadily over the next two decades, and increased 74% since 2015. There were nearly 130,000 cases nationwide in 2019, according to data released Tuesday by the Centers for Disease Control and Prevention.
In California and the United States, about half of all syphilis cases occur in men who have sex with men. More than a third of women in the western US with syphilis also use meth, a drug that has seen its own surge in recent years.
These are just some of the trends that have caused national STD cases to hit all-time highs, hitting 2.5 million cases for the past six straight years. And the consequences now can be traced back to babies who get syphilis from their mothers. These congenital syphilis rates nearly quadrupled between 2012 and 2019.
This was all before the coronavirus pandemic hit the United States. With contact tracers and testing supplies being redirected from sexually transmitted diseases to COVID-19, the CDC predicts the 2020 numbers won’t be any better.
“We’re pretty concerned about this and have seen this trend over time,” says Dr. Erica Pan, California State Epidemiologist. “Unfortunately, many employees who had focused on sexually transmitted diseases and syphilis follow-up care for years did not have enough public health funding and infrastructure for years and of course last year, both local and state levels, really got diverted to the pandemic.”
Several factors fueling the surge
There are many factors that contribute to the rise in sexually transmitted diseases, and syphilis in particular.
In the gay community in San Francisco, for example, the rise of mobile dating apps like Grindr and Tinder has made finding a date “faster than home delivery of pizza,” said Dan Wohlfeiler, STD prevention specialist and co-founder of Building Healthy Online Communities using these apps to improve gay men’s health.
When the dating apps first hit the market around 2009, it was more difficult for disease researchers to track the spread of STDs and notify potentially infected people because men don’t always know the names of the other men they are joining With.
“Sometimes they only know how they interact online,” says Dr. Ina Park, Associate Professor at the UCSF School of Medicine and author of Strange Bedfellows on the history of sexually transmitted diseases. “And when the sex wasn’t going well, they sometimes block the person from their app and don’t even know how to get back to that person.”
Online dating began in the late 1990s, when effective drugs to prevent the transmission of HIV became available around the same time: first antiretroviral drugs that suppress the virus in HIV-positive patients, and later, in 2012, pre-exposure prophylaxis, or PrEP, that prevents new infections in people who are HIV negative but are considered at risk for exposure to the virus.
With the risk of developing a fatal disease dipping to near zero, condoms have fallen even more out of favor than they already were, Park says.
“If one man is on PrEP and the other is virally suppressed, there is no risk of HIV at all,” she says. “So why use condoms if you don’t mind having a hint of syphilis?”
Diagnosing syphilis is difficult
While syphilis is not benign – it can cause blindness, deafness, or brain damage – it is easy to treat. Usually a shot of penicillin in the buttocks will cure it.
Diagnosing syphilis can be difficult, however, says Park, who treats patients with sexually transmitted diseases at the San Francisco City Clinic. She often crouches deep in the exam room, “lifting her scrotum and lifting her penis” and craning her head to get a view from all angles.
She does this gymnastics to find rashes related to syphilis. Some are obvious, some are subtle. She says doctors in regular family medicine clinics are often not trained in where and when to look.
“The patient came in and said, ‘I’m tired,'” says Park, referring to a common symptom of syphilis. “How many people are going to say, ‘Take off your pants and lift your scrotum, I want to check it out? We only do that in the STD clinic because that’s what we do.”
But specialized public STD clinics, like the one Park works at, have been closed across the country. One reason is persistent underfunding of public health programs, a trend that became apparent during the coronavirus pandemic. Another is the Affordable Care Act. In an odd way, the 2010 Health Care Access Extension Act actually contributed to the closure of STD clinics.