While this overall trend is worrying experts, syphilis makes for an especially striking case study. The rates of primary and secondary syphilis (also called P&S syphilis, these are the most infectious stages of the disease) reached a historic low at the turn of the century. In 2000 and 2001, there were 2.1 cases of P&S syphilis per 100,000 people, according to the Centers for Disease Control and Prevention (CDC). But the national reported rate of this illness has climbed nearly every year since 2001, jumping 72.7 percent from 2013 to 2017, when the rate of syphilis reached 9.5 cases per 100,000 people.
To wrap our heads around these ballooning stats, we spoke to a couple of STI experts about why rates of syphilis are rising, who this condition is affecting, what’s being done to solve the issue, and how you can stay safe in the meantime.
What syphilis is and how it spreads
Syphilis is a bacterial sexually transmitted infection caused by the pathogen Treponema pallidum, according to the CDC. It can spread during vaginal, anal, and oral sex if someone makes direct contact with a syphilitic sore known as a chancre. Chancres can appear on or around the genitals or mouth. Also, in what’s called congenital syphilis, a pregnant person can pass the infection to their fetus.
The way syphilis presents and progresses can make it hard to catch without STI screenings, Peter Leone, M.D., M.P.H., adjunct professor at the UNC School of Medicine and adjunct associate professor of epidemiology at the Gillings School of Global Public Health, tells SELF.
To understand why, you’ll need to know that syphilis advances in four stages: primary, secondary, latent, and tertiary. It can take years to make your way through all of these stages, according to the CDC.
In the primary stage, chancres (usually firm, round, and painless) appear at the site of infection. This is often a difficult-to-see spot, like the anus or inside the vagina, which can make the sores easy to miss. They typically pop up around three weeks after transmission and go away within three to six weeks, even if you don’t get treatment, per the CDC. That’s another reason why someone in the primary stage of syphilis may not realize anything’s up with their health.
If the person is not diagnosed and treated, syphilis progresses to the secondary stage, in which additional symptoms can include a skin rash, sores in mucous membranes like the mouth and vagina, fever, and swollen lymph nodes, per the CDC. But these symptoms can be mild and resemble those of other health issues, the CDC explains, giving this infection yet another chance to fly under the radar.
Next is the latent stage, where there are no signs of infection. Basically, the immune system has controlled the infection enough for symptoms to fade, but some bacteria remain and can continue to multiply. It’s still possible to spread syphilis in this stage, Dr. Leone explains.
The final stage is tertiary syphilis, which is rare but can cause serious complications affecting organs like the heart and brain, according to the CDC. Symptoms will depend on which organs tertiary syphilis is attacking. At this stage, syphilis can be fatal.
Syphilis carries other serious risks, too. At any stage, it can damage the nervous system (neurosyphilis) and cause symptoms like paralysis and altered behavior, or the eyes (ocular syphilis), potentially causing permanent blindness, according to the CDC. And due to the open sores that make infection transmission easier overall, people with syphilis are more vulnerable to HIV. Those with P&S syphilis are two to five times more likely to wind up with HIV if they’re exposed, according to the CDC. And about half of men who have sex with men (MSM, in CDC parlance) with P&S syphilis also have HIV.
Then there’s the worrisome potential toll of congenital syphilis. If a pregnant person acquires syphilis in the four years leading up to birth and doesn’t get it treated, there’s up to an 80 percent chance that the fetus will contract syphilis, too, the CDC says, adding that this is thought to lead to stillbirth or infant death in up to 40 percent of those cases. Granted, the CDC is citing historical data from 1950 for those figures, but congenital syphilis is clearly still a pressing threat even if these numbers aren’t recent.
Who syphilis typically affects
Syphilis can technically affect anyone, but the infection has historically affected mostly men and particularly MSM. That includes most of the increases experts have seen since 2000. We’ll discuss potential reasons why below, but let’s start with the numbers: In 2017, nearly 90 percent of P&S syphilis cases were among men while 68.2 percent were among those who had sex with other men, according to the CDC. Specifically, men aged 20 to 34, black men, and men living in the Western U.S. had the highest prevalence of syphilis in 2017.
But the recent swell in syphilis rates has widened to include more heterosexual women, too. From 2013 to 2017, P&S syphilis rates among women have gone up 155.6 percent, according to the CDC. The rate of congenital syphilis has shot up accordingly, increasing 153.3 percent between 2013 and 2017.
There has been particular concern about syphilis surging in rural areas, and some local reports out of states like Missouri suggest this is valid. But the CDC hasn’t published a deep dive looking at the differences in syphilis rates between rural and urban areas, so it’s hard to get a complete understanding here. It is clear, however, that 70.4 percent of reported P&S syphilis cases in 2017 were in the 50 most populous metropolitan areas, per the CDC. While syphilis is clearly a problem impacting various parts of the United States, more research is necessary to uncover where it may or may not have more of a presence and why.
Why syphilis rates are rising
The factors involved here paint a complicated picture.
For instance, the CDC is still investigating the role of drug use in rising syphilis rates, Jami Leichliter, Ph.D., a behavioral scientist in the CDC’s Division of STD Prevention, tells SELF. According to a Morbidity and Mortality Weekly Report the CDC published in February 2018, data indicate that a “substantial” proportion of heterosexual syphilis transmission is happening in people who also use non-injected heroin, non-injected methamphetamine, and injectable drugs. (It’s not that the injections or drugs themselves increase transmission, but that drug use can make people more likely to have risky sex.) The researchers found that from 2013 to 2017, the prevalence of the use of these drugs, as well as sex with someone who injects drugs, more than doubled in women and heterosexual men with P&S syphilis, yet not in MSM. The reasoning behind the disparity isn’t clear, and correlation doesn’t necessarily equal causation anyway. But it is an interesting fact to note.
Some experts, including Dr. Leone, believe the more widespread adoption of pre-exposure prophylaxis (PrEP)—a treatment at-risk populations can take to prevent HIV infection—may have inadvertently led MSM to decrease condom use and STI testing frequency because of their reduced risk of contracting HIV. For instance, a 2018 Clinical Infectious Diseases review of 16 observational studies and one clinical trial found that the use of PrEP was associated with a significant increase in the likelihood of being diagnosed with an STI, as well as evidence of an increase in sex without condoms. However, CDC spokesperson Brian Katzowitz tells SELF that there is not yet a consensus on this connection.
The CDC does believe that changing transmission patterns (i.e., shifts in sexual behavior) may play a role, Leichliter says. As SELF previously reported, people may simply have more sex partners these days, and condom use is not as high as it should be.
Other factors we know very well, like a lack of health care resources and access. In the CDC’s 2017 STD Surveillance Report, the director of the Division of STD Prevention, Gail Bolan, M.D., called the resurgence of syphilis a “symptom of a deteriorating public health infrastructure and lack of access to health care.”
Part of this is the fragmented nature of our health care system. Leichliter cites a “lack of a medical home,” or basically a need for primary care delivery where people have a home base for receiving comprehensive, coordinated, accessible, patient-centered health services, according to the Agency for Healthcare Research and Quality (AHRQ). Another potential issue, per Dr. Leone: Even if heterosexual cisgender men in particular do have great primary care doctors, they may not see them every year. These men don’t have recommended yearly well-woman visits or specific STI screening guidelines, so regular check-ups can fall through the cracks.
Then there’s dire lack of funding. According to the National Coalition of STD Directors, the CDC’s Division of STD Prevention has had its annual funding cut by $ 21 million since 2003. Due to inflation, that equates to 40 percent less buying power today. And a 2017 Sexually Transmitted Diseases analysis that Leichliter co-authored found that 61.5 percent of the 331 local health departments studied saw cuts to the government-funded portion of their STI program budgets from 2011 to 2012. For many, this resulted in clinic closures and higher fees for patients along with decreases in clinic hours, routine screenings, and staffing.
This might sound surprising, but effective public health efforts like STI services are traditionally one of the first things to get squeezed by budget crunches, Dr. Leone says. When these programs are well-funded, outbreaks are curbed, and those in power who allocate funding can take that to mean there’s no longer a real threat. As Dr. Leone explains, “The tendency is to say, ‘Well, we don’t see this, why are we putting so much money into it?”
It’s not just STI clinics though. Spiking congenital syphilis rates indicate an overall failure to deliver good prenatal care, Dr. Leone says. “Too many pregnant women are falling through the cracks of the system before they are diagnosed [with syphilis] or treated,” Leichliter adds.
What’s being done
Public health officials including those at the CDC are conducting research to better understand the factors behind the resurgence of syphilis, Leichliter says. The CDC is also collaborating with local and state health departments and partnering with community organizations to strengthen local STI prevention systems, Leichliter adds. This includes increasing STI screenings, providing timely STI treatment, finding and alerting potentially exposed sexual partners, and improving reporting of syphilis cases.
The CDC is also trying to increase awareness and action in the medical community. According to their 2017 Call to Action plan to control syphilis rates, too many clinicians don’t know how to diagnose and manage syphilis. The CDC advises doctors to complete sexual histories for their patients, provide STI counseling, test all pregnant people for syphilis, and immediately report all cases of the condition, among other steps.
How to stay safe
No matter who you are, the best way to prevent syphilis transmission is to practice safe sex. This means using protection every time unless you are in a long-term mutually monogamous relationship and have both been tested. (Chancres can show up on areas not covered by condoms and dental dams, so this isn’t a fail-safe method of prevention, but it’s absolutely still worth practicing.)
If you have multiple partners and/or don’t use protection (but haven’t been tested), getting tested regularly is equally important. This may be as often as every three to six months, according to the CDC. “Make this a routine part of [your] sexual health,” Dr. Leone says. “It’s something you should be doing for yourself and the community you’re in.”
That includes if you are pregnant. In that case, the CDC recommends asking your doctor about getting tested for syphilis at your first prenatal care appointment, no matter the status of your sex life. Practice safe sex throughout your pregnancy and talk to your doctor about if it makes sense to get retested later on, like during your third trimester and at delivery, the CDC says.
If you do test positive for syphilis at any point, your doctor can prescribe antibiotics to help rid your body of the bacteria as quickly as possible. As with so many other STIs, prompt detection and treatment are of the essence.