Syphilis Relapse

Cases soar in the city

In 1998, syphilis rates were so low the Centers for Disease Control announced a plan to completely eliminate the disease. The agency began an all-out prevention campaign, stepping up syphilis surveillance in New York City and the few counties across the country where it still existed. By 2000, the sexually transmitted infection was at its lowest point since 1941. Soon, the country's top doctors predicted, the dread illness that afflicted Henry VIII, Ivan the Terrible, and even a pope would be nothing more than an unpleasant memory, gone the way of smallpox and other eradicated diseases.

But just six years after the bold elimination plan, syphilis is back. Nationally, cases in gay men shot up more than 15 percent in 2001. In New York City, the number of people with symptoms of syphilis has gone up even further, increasing a total of more than 500 percent between 1998 and 2003, from 82 to 531 people, according to preliminary health department data. As of last week, there were an additional 953 people infected with syphilis but without apparent symptoms, according to the health department. Many more cases of syphilis likely go unreported.

"All of a sudden cases were climbing again," says Susan Blank, assistant commissioner for sexually transmitted disease control at the city's Department of Health. "We first noticed the uptick in 1999. Manhattan has been the most highly affected, but now we're beginning to see a rise in Brooklyn and the Bronx, too."

So while the national headlines recently trumpeted good news about STDs—herpes rates fell significantly throughout the 1990s, especially among young people—the local, untold story was scarier. An all but banished disease was making a serious comeback—and it wasn't the only one. "The fact of the matter is we have seen increases in gonorrhea, chlamydia, and syphilis," says Blank. The health department doesn't keep tabs on herpes cases, but the tracking of these other STDs paints a dark picture. Last year, there were 35,000 cases of chlamydia, a key cause of infertility. Girls between 10 and 14 years old account for a small but fast-growing fraction of that number. And while the national gonorrhea rate went down between 1999 and 2001, it went up slightly in the city in the same period, with cases almost doubling in girls between 10 and 14.

But at the center of heightened concern about the rising tide of STDs is syphilis, which Blank calls "the high-profile disease of the day." Caused by tiny corkscrew-shaped bacteria, the disease has long been feared for its stealth ability to cause severe nervous system damage. The initial infection usually appears as a sore, which breaks out anywhere from 10 to 90 days after unprotected sex with someone with an active infection. The sore is most often painless and goes away by itself. If caught, the disease can almost always be stopped at this point with antibiotics.

Without treatment, though, syphilis will progress. The second stage of the disease usually announces itself with a rash on the palms or feet; around this time, people might also start losing their hair and feel achy and exhausted. And its final phase is what gives syphilis its reputation as a cruel and wily illness: After a symptom-free period that can stretch for decades, the bacteria can come back and wreak terror on an unsuspecting body, causing blindness, paralysis, and even, in rare cases, death.

"This disease is something I don't wish on anybody," says Michael Augenbraun, medical director of the STD clinic at Kings County Hospital. Augenbraun saw the first of this wave of cases trickle into his office three years ago, when he and other doctors were only occasionally testing patients for syphilis.

"Before that, trainees would come to our hospital wanting to see what syphilis looked like. And I would tell them, 'Sorry to disappoint you, but we don't see that anymore,' " says Augenbraun. But in the past few years, he says, he has seen the hair loss and rash of second-stage syphilis "many, many times," and has even recently seen patients with clouded vision, uneven gaits, and personality changes due to syphilis infection.

Frightening as the statistics are, this latest outbreak of syphilis may be more significant as a harbinger of the next stage of the city's HIV epidemic than as a direct health threat. "In my mind, it's a marker that people are having unprotected sex," says Dawn Harbatkin, medical director of the Callen-Lorde Community Health Center. "In the relative scheme of things, I'm more worried about crystal meth use and new HIV infections. But I think they're all linked. It's not just the syphilis, but what it means for these other issues."

Harbatkin's fears are founded. In a health department study comparing 88 men with infectious syphilis to a control group, more than half of the infected men reported barebacking, or having anal sex without condoms. Drugs are also clearly implicated in the recent outbreak. One-third of men with syphilis reported using Viagra. And infected men were also more likely to use crystal meth, poppers, and pot.

The study also found that men with syphilis were more than twice as likely to have HIV. "It's a potentially explosive situation for the spread of HIV," says the health department's Blank. "People with HIV are leading longer and healthier lives than was possible in the '80s and early '90s. Part of that involves feeling good—and feeling good enough to have sex." And having active syphilis makes it easier to both pass on and contract HIV when you have sex. Being HIV-positive can also affect the course of syphilis, shortening the length of time it takes for the bacteria to move through their cycles and cause real damage.

But some are finding that their campaigns to fight syphilis and HIV end up at odds. "It's complicated when you're selling a syphilis and an HIV message," says Russell Westacott, associate director of the Institute for Gay Men's Health at the Gay Men's Health Crisis. "There's confusion around how people get syphilis. People think it's only through unprotected sex"—and thus the same risk for HIV. "They rarely consider oral sex or other sexual contact as a risk, even though it is."

While Westacott and others have been advising people who have multiple partners to get tested for syphilis even if they use condoms, that message is taking a while to sink in. "What we sometimes hear in the testing center is that if it's not HIV, I don't need to worry so much about it," says Drew De Los Reyes, assistant director of the David Geffen Center for HIV Prevention and Health Education, also at GMHC.

The availability of new rapid HIV tests, which gives results the same day, also cut into the likelihood that patients will get—and come back to pick up the results from—a syphilis test. "Since we started offering rapid testing, we have seen somewhere between a 40 and 45 percent decline in the number of people testing for syphilis," says De Los Reyes.

So those on the front lines are trying to find creative ways to sound the alarm about syphilis's return. The Institute for Gay Men's Health passed out information to beachgoers on Fire Island last summer. The health department has been holding regular "healthy men's nights out," offering free screenings for syphilis and other STDs at bars and other locations in Chelsea and elsewhere. (The next is April 26 at Urge in the East Village.) And doctors who treat STDs are beginning to broach the subject with their patients, male and female alike.

Indeed, though, for now, the majority of new cases are in gay men, experts say others shouldn't consider themselves immune. "These things eventually follow the pattern of getting into the heterosexual population," says Kings County's Augenbraun. "If history teaches us anything, it's that, if we allocate resources for prompt treatment and testing of syphilis, we may be able to see a decline. On the other hand, if we don't, then I guarantee you this disease will move out of this relatively small group into a broad cross-section of New York City."


Sharon Lerner is a senior fellow at the Center for New York City Affairs at New School University.

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