This study was funded by the Agency for Healthcare Research and Quality, “under a contract to support the USPSTF.” The authors did not report any relevant financial disclosures.
As the 1990s ended, syphilis was on the decline. At least in part due to safer sexual behaviors prompted by the AIDS epidemic, the rate of incident syphilis declined to fewer than 4 cases per 100,000 by the year 2000, a historic nadir. Now, in 2016, hopes for eradication have long since faded, as have many of the gains realized by the effort. Rates of syphilis have trended steadily upward since 2000, and the CDC’s syphilis elimination efforts officially ended as of December 2013.
The good news is that fixing what has gone wrong does not require huge capital investment, breakthrough technological advances, or massive restructuring of our health care system. Improvements are at hand and require mostly focus and commitment on the part of the health care community. First, awareness of the problem needs to be increased, particularly in clinical settings where patients at higher risk for syphilis are being followed up. These high-risk populations include MSM, HIV-infected persons, and younger sexually active persons, particularly persons of color and those from socioeconomically disadvantaged populations. The syphilis demographic overlaps considerably with the HIV demographic. For example, in 2014, half of all MSM diagnosed with syphilis were also coinfected with HIV. Younger men (aged 20-29 years) have a prevalence rate nearly 3 times that of the national average for men, and persons of color are particularly at risk, with black individuals disproportionately affected in the United States. Rates of primary and secondary syphilis were 18.9 cases per 100000 in blacks compared with 3.5 per 100000 in whites. Rates in other ethnic groups (aside from Asians, whose rates were lowest of all) were intermediate between blacks and whites.
Although imperfect, serologic syphilis screening is highly sensitive and specific in high-prevalence populations, is inexpensive and technically simple, and has minimal potential for harm. These factors argue for much more widespread and comprehensive screening of groups at high risk for syphilis. Because treatment of early syphilis is also highly effective, identifying untreated infected persons by means of the recommended screening strategy has great potential for both eliminating the consequences of later-stage infection and substantially reducing transmission from those with early infection.
Dr. Meredith E. Clement is with the division of infectious diseases at Duke University, Durham, N.C. Dr. Charles B. Hicks is with the department of medicine at the University of California, San Diego. Dr Hicks reported ties with Bristol-Myers Squibb, Gilead Sciences, Merck, Janssen Virology, ViiV Healthcare, AstraZeneca, and UpToDate. He served as associate editor and author for NEJM Journal Watch. Dr. Clement has received royalties from UpToDate. These comments were excerpted from the editorial accompanying the study (JAMA. 2016;315:2281-3).