Gay Syphilis Surge Fans HIV Fears

Outbreaks of syphilis among gay men in large urban areas, particularly in California, are threatening to reverse progress toward eliminating the disease in this country.

In San Francisco, the number of new infectious cases grew from a historic low of 26 in 1998 to 139 last year. Officials there say the total could easily top 250 this year--which would be the highest in more than a decade.

San Francisco health officials are so concerned that last week they mandated a sweeping set of new requirements on sex clubs and adult bookstores, which include handing out condoms and lubricant to every patron.

Other major cities also are seeing increases in syphilis. New York City reported 282 cases last year, the most since 1995. Los Angeles County logged 187 cases in 2001, up from a low of 88 in 1999. And Miami-Dade County reported 186 cases last year, six times higher than its 1998 low.

The cases in these and many other urban areas disproportionately involve gay or bisexual men--61% in Los Angeles, for example, and 82% in San Francisco.

Though syphilis is treatable with antibiotics, health officials are worried because its sores greatly facilitate the spread of HIV. The outbreaks signal a breakdown in safe-sex practices and often presage a rise in HIV.

In both San Francisco and Los Angeles County, more than half of those testing positive for syphilis are also HIV-positive.

Until now, the effort to eliminate syphilis from the United States--launched by the national Centers for Disease Control and Prevention in 1998--has mostly targeted impoverished minority communities. But the recent rise in infections among gay and bisexual men is undermining the overall elimination goal and is forcing health officials to revamp their strategy.

“I think the national effort to achieve the syphilis elimination goal may not be possible because of the extent to which syphilis has so thoroughly moved into the [gay and bisexual] community,” said Dr. Peter Kerndt, chief of sexually transmitted disease control for the Los Angeles County Department of Health Services.

As recently as November, federal health officials said they saw near-elimination of syphilis as a realistic goal. That was because the rise in syphilis among gay men was overshadowed by declines in the heterosexual population.

Nationally, primary and secondary syphilis cases--which are the early, infectious stages--fell 9.6% in 2000, the CDC reported in November. The national tally takes time to compile and does not reflect the more recent surges among gay men.

The CDC has spent more than a year debating what to say in a report on the increases. Dr. Ronald Valdiserri, a senior STD prevention official, said the agency is still trying to figure out the best approach to take toward high-risk members of the gay community.

“We need to get that out,” Valdiserri said of the report. “It’s going to be given a very high priority.”

Local officials have struggled at times to switch gears, as well.

After an outbreak among gay men in Los Angeles County was reported in March 2000, Kerndt asked county supervisors for money for a prevention campaign and to hire screening teams to work in bathhouses and the County Jail. Supervisors provided money for a two-month media campaign, but not the outreach teams.

Elsewhere, some public health officials acknowledge they don’t know how to respond to the outbreaks. While the CDC has been targeting communities with poor access to health care and information, the issues in the gay and bisexual communities appear to be entirely different. Many of those at risk seem to know the consequences of unsafe sex but practice it anyway, health experts say.

“We don’t know what message to put out there to get their attention, to get them to change their behavior,” said Tom Burns, acting STD program manager at the Miami-Dade County Health Department. “We just see continuous unsafe practices, such as multiple partners and anonymous sex.”

Research suggests that a growing segment of gay men are tired of safe-sex messages or believe AIDS drugs can keep the virus at bay indefinitely.

Dr. Jeffrey Klausner, San Francisco’s STD control chief, said some men see unprotected sex as an issue of personal freedom.

“Right now, there seems to be acceptance that some level [of syphilis] is tolerable in exchange for the right of individuals to have sex where and when they want it,” he said.

Paradoxically, although the surge in syphilis cases has not led to safer sex practices, it appears to have prompted more widespread syphilis testing. Walk-in testing at the Los Angeles Gay and Lesbian Center has doubled in the last year.

Primary syphilis causes a painless sore, and secondary syphilis often creates a rash. If left untreated, syphilis can lead to cardiovascular and neurological diseases, blindness and even death. It can cause stillbirths for infected women.

As CDC officials debate their syphilis strategy, San Francisco officials say they can’t wait to contain its spread. Among their actions:

* In a letter this month, they asked physicians to test all sexually active gay men for syphilis twice a year and to test anyone with a rash-like syndrome, which could be secondary syphilis.

* Sex clubs and adult bookstores were ordered to enforce the “no unprotected anal or vaginal intercourse” policy, in addition to handing out condoms and lubricant at the door. All club and bookstore staff must also attend a city-run training session on safe sex.

* The health department has redirected staff members from other STD programs to syphilis investigation and education. It has also asked the CDC to provide more money.

* They will launch a campaign next month called “Spring Cleaning,” encouraging STD testing.

AIDS prevention agencies in San Francisco are mobilizing as well. Stop AIDS, based in the largely gay Castro district, has begun distributing 2,000 condoms a month to sex clubs and adult bookstores. But the group’s leaders wonder whether their approach will work.

“Syphilis can be cured,” said Steve Gibson, program director for Stop AIDS. But “it doesn’t have the same sense of immediacy” as HIV.

Buzz Bense, owner of Eros Sex Club in San Francisco, said his club already offers condoms within arm’s reach and posts signs warning patrons about the risk of syphilis infection.

“I do have concerns that a sort of hysteria is going to grow out of this,” he said.

“To me, it does not make sense that these men who are practicing high-risk sex would limit it to the clubs,” Bense said.

“They are going to be having the exact same activities in their bedrooms, in bathrooms, parks, wherever.

“The dilemma for prevention people is how do we affect these people’s behavior? No one has a clue.”