Syphilis Outbreaks Among Gay Men in Urban Areas May Signal Lack of Safe-Sex Practices, Rise in HIV Infections

Syphilis is on the rise among gay and bisexual men in many major U.S. cities, including Los Angeles and San Francisco, causing public health officials to fear that an increase in HIV infections is not far behind, the Los Angeles Times reports. The number of syphilis cases in San Francisco rose to 139 in 2001 from an all-time low of 26 in 1998 and could top 250 this year. Los Angeles, New York City and Miami-Dade County have seen similar increases, with the majority of new cases recorded among men who have sex with men. However, new syphilis cases have declined nationally due to large decreases of cases in the heterosexual community. Because the new cases among men who have sex with men likely signal a rise in unsafe sexual practices and because syphilis sores facilitate HIV transmission, health officials are concerned that a rise in new HIV cases in the gay and bisexual community could follow the upswing in syphilis. More than half of those testing positive for syphilis in San Francisco and Los Angeles also tested positive for HIV.

The rise in syphilis cases has forced public health officials to "revamp" their strategies for combatting the disease, which is treatable with antibiotics but can lead to death if left untreated. Federal health officials said that as late as November 2001 they believed syphilis could be eradicated in the United States, and their efforts mainly focused on low-income minority communities. Now, however, elimination "may not be possible because of the extent to which syphilis has so thoroughly moved into the (gay and bisexual) community," Dr. Peter Kerndt, head of STD control for the Los Angeles County Department of Health Services, said. Designing new prevention strategies that target men who have sex with men is particularly difficult because, unlike poor minority communities that did not appear to be aware of the disease, most gay and bisexual men in major cities "seem to know the consequences of unsafe sex but practice it anyway," according to health experts. Dr. Jeffrey Klausner, head of STD control for the San Francisco Department of Public Health, said unprotected sex is an "issue of personal freedom" for many gay and bisexual men who see syphilis as "tolerable in exchange for the right of individuals to have sex where and when they want it." This attitude has frustrated health experts. "We don't know what message to put out there to get their attention, to get them to change their behavior," Tom Burns, acting STD program manager for the Miami-Dade County Health Department, said.

San Francisco officials have taken several steps to curb infection, such as requiring sex clubs and adult bookstores to supply condoms and lubricant to all patrons and enforce a policy of "no unprotected anal or vaginal intercourse" on their premises. Club and bookstore staff must also attend city-led educational sessions on safe sex. City officials also sent a letter to area physicians last month asking them to test all sexually active gay male patients for syphilis twice a year, as well as testing anyone with a "rash-like syndrome" that could signal secondary syphilis infection. The city health department has also devoted more staff to syphilis prevention and asked the CDC for more funds. It is also launching a "Spring Cleaning" campaign next month to promote STD testing (Ornstein, Los Angeles Times, 3/27).