Last October, the Allegheny County Health Department, which encompasses Pittsburgh, announced a shocking finding: Between 2014 and 2015, the county experienced a 90 percent increase in syphilis cases, from 68 cases to 129. Of those cases, 93 percent were among men who have sex with men (MSM).
For a county with a population of 1.23 million people, that may not seem like a lot, but it's a startling statistical increase, and what's happening in Allegheny mirrors what's being seen in gay populations across the country: MSM are getting syphilis at epidemic rates, alongside other STDs like gonorrhea and chlamydia, and if something isn't done soon to address it, incurable forms of the diseases may soon wreak irreversible damage on the country's LGBTQ population.
Between 2014 and 2015, reported syphilis cases increased by 19 percent nationwide. Gonorrhea and chlamydia cases increased by 12.8 and 5.9 percent respectively nationwide over the same time frame, but combined, the Centers for Disease Control (CDC) said that total reported cases of all three STDs reached the highest number ever recorded. CDC also reported that MSM accounted for the majority of new gonorrhea and syphilis cases, and the report prompted the director of CDC's National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention to declare the findings represent "a decisive moment for the nation"—a turning point in how we must approach our country's STD treatment infrastructure.
In Allegheny, the jump led the Pittsburgh AIDS Task Force (PATF), the region's largest and oldest AIDS service organization, to add rapid syphilis testing and treatment to its list of available services last month. And although PATF hasn't officially conducted research or analysis on the phenomenon, Dr. Sarah McBeth, PATF's medical director, has a few theories about the region's spike.
"Gay men here have a close-knit community," said McBeth, "and a lot of my patients are very open to talking about sexual health, so they may be telling partners or friends to get tested, and if they have a positive test, to inform their partners and encourage them to test, too."
"It's never a good thing to see an increase like that," she added, "but an increase in testing invariably leads to an increase in diagnoses."
Syphilis is incredibly easy to spread. Although it sometimes presents with one or more oral or genital lesions or a body rash, it's very common for people with primary- or secondary-stage infections to be completely asymptomatic, and it's easy to mistake its small, painless lesions for ingrown hairs or razor bumps. And unlike HIV, transmission doesn't require an exchange of bodily fluids—just skin-to-skin contact with a lesion via oral or genital contact.
Left untreated, the disease progresses through four stages (primary, secondary, latent, and tertiary), the last of which can cause irreversible damage to the nervous system, brain, bones, joints, eyes, and heart, and even result in paralysis or blindness.
At the national level, some have speculated that the rise of PrEP, the prevention strategy where HIV-negative people at a high risk of acquiring the virus take preemptive antiretroviral drugs, may be to blame for lowered rates of condom use among MSM—and, consequently, higher STD rates. But McBeth doesn't think that theory holds water.
"In general, patients who are willing to jump through all the hoops they have to jump through to get PrEP and take a pill every day because they're worried about their HIV risk are also going to worry about other STIs," she said. "In my experience, PrEP users tend to be very conscientious. I don't think those are necessarily the patients who are not using condoms."
Indeed, a recent study by the CDC concluded that condom usage has been steadily declining among American MSM for decades, suggesting that neither PrEP nor the prevalence of increasingly effective HIV treatments are to blame.
McBeth also said the CDC recommends STI screening every three months for PrEP users, which also points to her original conclusion—that an increase in testing may have led to an increase in diagnoses. She adds that when PrEP patients come in for screening every three months (far more often than her clinic sees many other patients), PATF doctors use the opportunity to reiterate the benefits of safe sex. "And we always give them free condoms," she says. "Lots and lots of condoms. Always."
McBeth also notes that while syphilis is currently very treatable—it's one of the few things we actually still use penicillin for, so if that stops working, we have plenty of backup options to try—other STIs, like gonorrhea, pose a much more imminent threat of an incurable STD epidemic.
That's a sentiment echoed by experts at Gay Men's Health Crisis (GMHC) in New York and Whitman Walker Health (WWH) in Washington, DC, two of the largest HIV/AIDS clinics in the nation.
"Incurable STIs are certainly on the horizon," said Matthew Rand, a health educator at WWH. "Many organisms evolve or adapt to their environments, and bacteria are particularly good at this, since they have shorter life cycles. Specifically with STDs and STIs, gonorrhea is one type of bacteria that is highly adaptable and is of concern for antibiotic resistance."
Rand and McBeth both point out that we're nearing the last line of defense against the bacteria responsible for gonorrhea, with the CDC recommending treatment using two powerful types of antibiotics.
"We have seen antibiotic resistance spread across Asia, and there have been documented cases in Europe," Rand said. "In a global society, it's only a matter of time before incurable infections make their way here."
Kelsey Louie, the CEO of GMHC, says he believes an incurable STD epidemic will only be prevented by "crafting public policy and providing adequate funding to expand access to screening, education, and treatment, as well as spur innovation"—all things that seem unlikely to become a priority under the Trump administration, which as of December had no plans for tackling HIV/AIDS. Key members, like Vice President Mike Pence and Tom Price, Trump's health secretary nominee, have lackluster records when it comes to dealing with the virus and reproductive rights.
"The highest rates of infection occur within our most vulnerable communities," Louie says. "In its recent report, the CDC noted that 20 health department clinics had closed in a single year. While these closures aren't wholly responsible for a lack of affordable access to healthcare, they do represent the continued struggle to ensure access to testing and treatment."
McBeth said that her patients seem more inclined to request syphilis testing now, or more willing to undergo testing if she recommends it.
"I think people are generally still pretty horrified to get a syphilis diagnosis," she said. "People have these archaic connotations with it, and it's a more dangerous of a disease if left unchecked, so it still carries a little more stigma than something like gonorrhea—even though that's actually the thing that's becoming harder and harder to treat."