Dr. Raymond Martins, of Whitman-Walker Health in Washington, D.C., examines a patient. REUTERS/Larry Downing

The sexually transmitted infection is easy to treat but can be difficult to detect.

It's hard to miss "SYPHILIS EXPLOSION" ads that prominently feature those capitalized words before a fiery red erupting volcano. They were plastered across BART stations in the Bay Area and billboards in Los Angeles late last year courtesy of the AIDS Healthcare Foundation, which says the campaign has already appeared in or is heading to Cleveland, Columbus, Baton Rouge, Brooklyn and other cities.

Syphilis, which can cause serious health problems if untreated, is on a troubling upswing across the United States. The rate of primary and secondary syphilis infections fell by nearly 90 percent between 1990 and 2000, but has increased most years since, according to a Centers for Disease Control and Prevention report analyzing public health data through 2013. This recent wave of syphilis is mostly a problem confronting gay men—or, to use the broader medical term, men who have sex with men. Between 2000 and 2004 alone, the CDC reports that the estimated proportion of primary and secondary syphilis infections attributable to men having sex with men rose dramatically, from 7 percent to 64 percent.

Nationwide, the CDC reports that primary and secondary syphilis rates increased by 10 percent between 2012 and 2013—an infection rate more than twice as high as figures from 2001. The Atlanta, Baltimore, Detroit, Los Angles, Miami, Orlando, Portland, San Antonio, San Diego and San Francisco metro areas have some of the highest syphilis rates, according to the CDC.

Advertisements warning of an increase in syphilis infections have appeared in recent months in major U.S. metro areas. (Courtesy AHF)

In the San Francisco Bay area, reported cases rose from 438 in 2009 to 814 in 2013. In Washington, D.C., Dr. Raymond C. Martins, senior director of clinical education at Whitman-Walker Health, says that the clinic saw a 32 percent increase in syphilis cases among patients between 2011 and 2014. And in recent months, at least 15 cases of ocular syphilis, a serious complication of the disease that can cause blindness, have been reported in California and Washington state, according to an alert released earlier this month by the CDC. Most of these infections have occurred among HIV-positive men who have sex with men.

Syphilis, which can spread through sexual contact and also from a pregnant woman to her fetus, is easy to treat: antibiotics typically do the trick. But it is hard to detect and easy to spread because the early-stage symptom, a sore called a chancre, typically takes about three weeks to appear. Symptoms can also later disappear for a time, giving infected persons the false impression that they are clear of the disease. It remains a much larger problem in poorer countries, causing hundreds of thousands of pregnancy complications annually to mothers with the disease. But its upswing in the United States has public health officials worried.

A decline in the use of condoms is one obvious culprit. The percentage of men who have sex with men estimated to have had unprotected anal sex within the previous 12 months rose from 48 percent in 2005 to 57 percent in 2011, according to the CDC. But while it is clear that syphilis is spreading fast, and that it is spreading especially among men having sex with men, public health and medical experts still don't know the answers to some really basic and important questions.

"We haven't really seen enough data to help us understand why there is this increase," says Jay Laudato, executive director of the Callen-Lorde Community Health Center, which provides health care to New York's LGBT communities.

One theory is that the disease may be spreading in part because HIV-positive gay men are choosing to have unprotected sex with HIV-positive partners, a phenomenon called seroadaptation or serosorting. In one important respect, this is a laudable risk-reduction strategy that can protect exposing HIV-negative people to HIV. But it can also put HIV-positive men at greater risk for STIs like syphilis. Many of the men having sex with men diagnosed with syphilis, CDC data indicate, are also HIV-positive.

"There are a number of people who are on networks disclosing their HIV status, which we support. And for those people, they are choosing to have condomless sex if both partners know that they have HIV," says Laudato. "That's something that's been happening for quite some time. And it absolutely does lead to increased STIs."

*****

The rise in syphilis and decline in condom use among HIV-positive gay men are at the center of a heated debate over the drug Truvada. Truvada is used as a form of PrEP, or pre-exposure prophylaxis, as a prevention option for people who are at high risk of getting HIV. Michael Weinstein, president of the AIDS Healthcare Foundation, blames public health officials, including the CDC, for promoting Truvada, which he argues is encouraging high-risk individuals to forgo condoms. AHP has warned that “the CDC's ill-advised strategy of mass treatment with Truvada poses a significant risk to the condom culture" developed during the AIDS crisis, "which while it has eroded, has still prevailed among gay men for three decades.”

"I think there's a subtle message that condom use is not that important any longer," says Weinstein. He doesn't so much blame the actual use of Truvada, he says, "because almost no one is taking it," but rather that its promotion sends the wrong message about safe sex.

Weinstein, a prominent AIDS activist with decades of experience, worries that young gay men who didn't live through the worst of the AIDS crisis may not understand the true risks of unprotected sex. But his sometimes harsh criticism of Truvada, especially after he called it a "party drug" last year, has drawn opprobrium from others in the AIDS health community.

"His thoughts on PrEP, I feel, based on the data we have, it's more emotional than realistic," says Dr. Martins, of Whitman-Walker.

Weinstein says that his position on PrEP has been misconstrued, and that it might be a good fit for an individual patient. But he argues it is a misguided public health strategy in part because the drug's effectiveness declines if patients don't take the drug daily as prescribed—and he believes that many won't.

Many public health and AIDS advocates, however, celebrate PrEP because it offers the benefit of very strong protection against HIV when taken regularly. Laudato, of New York's Callen-Lorde Community Health Center, says that some people will not be persuaded to use condoms and, for them, the benefits of PReP far outweigh the risks.

"HIV is incurable and untreated results in death," says Laudato. "And anything that reduces HIV is a good thing."

Laudato doubts that PrEP is the main culprit behind declining condom use since the New York neighborhoods where syphilis seems to be rising the most are low-income areas, where the drug is not commonplace.

"PrEP being a panacea for all sexually transmitted infections ... is not the purpose of PrEP. The purpose of PrEP is to stop HIV infections."

*****

Weinstein and his critics agree that huge advances in treating HIV/AIDS have reduced many infected persons' viral loads to the point where they are much less likely to transmit it—which may be giving some people the erroneous impression that condomless sex is risk free. It's great that AIDS is no longer such a tragic centerpiece of gay life in America. But Weinstein worries that subsiding fear may foment riskier behavior.

"I think that people are less afraid of HIV," he says. "We're a victim of our own success."

That said, scientists are exploring the possibility that the use of PrEP drugs could actually be helping reduce the transmission of STIs like syphilis. Research published in the journal PLOS ONE found "no evidence of risk compensation that would offset the benefits of PrEP" among patients in a PrEP study. It also found lower rates of syphilis.

Because PrEP patients are often required to have quarterly lab tests before their prescriptions are renewed, says Laudato, such drugs might also be helping to improve sexual health across the board.

"We may be simply by virtue of people coming in and being engaged in care, identifying syphilis more frequently ... and more quickly than we otherwise would have identified it," says Laudato. "PrEP may be contributing to the control of syphilis rather than causing increases in it."

In San Francisco, PrEP is a key component of the city's Getting to Zero consortium working to eradicate new HIV infections.

"Opposing PrEP is not the view or the opinion of me personally or of public health in general," says Dr. Susan Philip, director of disease prevention and control at the San Francisco Department of Public Health. "It is a false assumption that PrEP should be removed because of this risk of [other] STDs. What is true is that we are going to have to work collaboratively" to prevent syphilis and other infections.

Successes in the fight against HIV, Philip says, do require a new approach to sexual health. While PrEP should be promoted to reduce new HIV infections, regular testing must be promoted to identify and treat other STIs.

"We are in the middle of regrouping and rethinking about exactly how to do this," she says. "A prior way of thinking is that we would package HIV prevention and STD prevention together."

Philip says that an aggressive response can stop syphilis. Officials in San Francisco attempt to speak with patients immediately after their diagnosis, work with them to get treated, and to identify, test and treat their sexual partners. She emphasizes that anyone who helps public health officials locate sexual partners can maintain their anonymity.

Those who engage in high-risk sexual encounters should be tested every three to six months, she says, more often than the CDC recommends. The goal is to "interrupt the cycle of syphilis," she says. The approach, however, must be realistic and not moralistic, she says—a harm reduction strategy that recognizes that human sexual behavior is hard to change.

"We are very sex positive in San Francisco," says Philip. "We believe that having a healthy and enjoyable sex life is fundamental to being a human being." She cites a famous quote attributed to a World War II-era medical officer: "The sex act cannot be made unpopular."

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