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The Persistence of Syphilis and Issues of Health Equity in America

Syphilis elimination, a term that may now seem inappropriate for a period of fiscal constraint, was launched in October of 1999 at a time when syphilis rates were low and over half of all incident cases where located in 28 counties nationally. In concept, it served a purpose in galvanizing attention to the inequities surrounding syphilis rates in the United States. Jeffrey Kaplan, the then-director for the CDC said so himself:

“This disease, like others, serves as a sentinel for broader health and societal problems that we need to address. People who live in poverty, lack employment, and who lack access to quality health care are vulnerable to this and other diseases. So, as we target our efforts and work at strengthening and involving the state and local health departments, community groups, and communities of faith, we should see a difference not just in syphilis rates, but in a range of other health conditions that go hand in hand with it.” [1]

The disparities of this historically endemic disease were and still are tied to poverty, the lack of guaranteed access to medical care, the continued stain of racism, and the contextual factors that contribute to the many non-sexual health inequities we see in our society.[2] Still, throughout much of the Southern United States, the Syphilis Elimination Effort brought the rates for heterosexually-transmitted disease to new historic lows -- only to now see overall disease rates rise again across the US and with a newer, more narrowed population.

The current epidemic is a different one, but one that still most adversely affects those so often marginalized in our society. This twenty first century epidemic shifted from one of primarily heterosexual transmission to one that affects men who have sex with men (MSM) in ever-higher numbers. While heterosexual transmission reached historic lows, congenital syphilis increased by 23 percent from 2005 to 2008. Most of this increase occurred among infants born to black mothers in the South.  Syphilis elimination had a setback in the two outcomes that mattered most, HIV and congenital syphilis.

From the start, we knew an approach that was primarily “medical” could never eliminate a pathogen whose existence is so tied to societal inequities.  We knew it then, but we lacked the political will to address the underlying factors that contributed to the persistence of this centuries old scourge.   We may hold out that health care reform might indeed lift all boats, but even the politicization of that effort underscores the sad news that this courage is still profoundly wanting and when demonstrated, splits our nation in two.  All the while, syphilis continues its ravenous onslaught.

To complicate matters further, the current economic crisis has led to a cutting of funding resources to STD control programs and a closing of many categorical STD clinics.  The situation is not pretty, but as we seek to address the drivers of health inequity in our society, we must nonetheless reconsider our approach to syphilis going forward if indeed we hope to again bring rates down.  And I would argue, tackling two facets of the current epidemic drive at the very heart of the health inequity issue and can, as Jeffrey Kaplan reminds us, help us on both fronts.

First, a concerted, robust, and honest focus on both men who have sex with men (MSM) and HIV infected individuals must be prioritized. The synergy of syphilis and HIV has been well described and should be a priority for everyone working to promote sexual health among MSM and those living with HIV.  Syphilis and HIV are engaged in a bizarre dance with one another, and it is playing itself out among these two populations.  For example, the recent increases of syphilis in young MSM of color preceded the increase in both the incidence and prevalence of HIV in this population.[3] [4] In North Carolina, co-infection of HIV in men with incident syphilis went from 5 percent in the late nineties to nearly 50 percent in 2009. These realities require a greater integration of screening for HIV and syphilis in clinical settings such as STD clinics, non-traditional HIV test sites targeting MSM, and HIV clinics.  These actions cut to the core of efficiency and effectiveness in a budget constrained environment. 

And at the same time, the societal factors that drive this situation among MSM and those with HIV can serve as additional longer-term aspirations to ensure greater sexual health. 

Second, congenital syphilis – mother-to-child transmission of syphilis – reflects a profound breach in our health care system and not a mere failure of screening programs.  All states require syphilis screening of pregnant women with a resulting near universal screening of women who are engaged in prenatal care.  And while congenital syphilis is an entirely preventable disease, it persists in the US and is almost exclusively limited to women outside of prenatal care.  In essence, the persistence of congenital syphilis continues to underscore that too many pregnant women are not linked to and retained in early prenatal care. Yet, the benefits of universal enrollment in prenatal care, and efforts to ensure retention, far overshadow the cost and health outcomes in just “preventing” congenital syphilis. Collaboration between maternal/child health and STD programs is essential but not sufficient to eliminate congenital syphilis in the US. The recent increase in congenital syphilis cases demonstrate the danger of even low level syphilis transmission in populations where sex is linked to economic survival and to the use of crack cocaine. 

The emerging domestic notion of a “sexual health” agenda, with accompanying attention to the types of health services that ensure it, compels us to move away from siloed programmed thinking.  On the horizon is a greater integration of services and population level outcomes with health rather than individual disease case numbers as the sole measure of success or failure.  And syphilis reminds us of why this is so utterly necessary. 

So as we move beyond a singularly medical model for syphilis control, it is accompanied by a commitment that syphilis is not possible through test and treat if the conditions that allow its persistence are not addressed too. A focused effort to reduce the impact of syphilis on HIV transmission and congenital syphilis is possible while we continue to understand and commit as a society to reducing health and social inequities.

[1] Sex Transm Dis.2000 Feb;27:63-66

[2] Sex Transm Dis. 2006 Jul;33(7 Suppl):S39-45

[3] Curr Opin Infect Dis. 2007 Feb;20(1):54-9. Review

[4] J Acquir Immune Defic Syndr. 2008 Feb 1;47(2):234-40


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