by Matthew S. Bajko
Syphilis is on the rise again in San Francisco, a reversal of years of declining rates first noted three years ago.
From January through August of this year, the city reported 341 early syphilis cases, a 54 percent increase over the same period in 2007. Including late latent cases of the STD brings the total up to 409 total cases of syphilis so far this year, compared to 305 during the first eight months of 2007.
At the current rate, health officials estimate there will be 493 early syphilis cases in 2008, the greatest number since 2005, when the health department documented 551 cases.
“I am very concerned about this recent increase because it comes after three years of consistent and steady declines,” said Dr. Jeffrey Klausner, the health department’s director of STD control.
Between 2006 and 2007 syphilis cases in the city had dropped nearly 20 percent. The rising number of cases this year mirrors an upsurge of cases nationwide. Early and secondary cases increased 12 percent last year over 2006, reaching a total of 11,181 in the United States, according to Centers for Disease Control and Prevention data.
While syphilis cases normally spike in the summer and early fall months, the city has seen a steady rise in cases each month since the start of the new year, compared to the number of cases in that month in 2007.
“We do see a trend in the wrong direction. For the last eight months in a row there has been a steady increase. August was the highest month we have seen in years, probably since 2004,” said Klausner. There were 70 cases reported last month; in 2007 there were only 27 cases.
The number of tests has not increased, said Klausner, adding they may have recently decreased. He estimated that half of the city’s HIV uninfected men got tested within the last six months, while about 70 percent, or little more than two out of three, HIV infected men got tested.
While the number of cases has increased, the characteristics of patients with syphilis continue to be the same: 97 percent male, 86 percent men who have sex with men, and 65 percent HIV-infected individuals. White men make up the bulk of the cases at 61 percent, with the next largest group Hispanic males at 19 percent. African American men account for 13 percent of cases, Asians 6 percent, and Native American and Pacific Islander under 1 percent.
More alarming to Klausner has been the return of syphilis cases among African American women, a population that has not been impacted by the STD in over a decade.
“They are often associated with substance use or incarceration. They are still less than 5 percent of cases overall, but going from no cases to less than 5 percent is concerning on multiple levels,” said Klausner. “If it gets back into the heterosexual population, then there is the chance of having congenital cases, meaning babies born with or who die from syphilis.”
Part of the problem, said Klausner, has been a reduction in resources this year, hampering the STD control section’s ability to combat the rise in syphilis cases. Klausner’s budget was cut from $900,000 to $450,000 at the beginning of the year, and his staff assigned to STD prevention and outreach was cut from eight to four people.
“We continue to work with the CDC to put in requests for additional staff and additional resources. The CDC has been very slow to respond,” said Klausner. “We are currently reprioritizing some of our own resources and staff to address these recent increases.”
No longer are staffers able to do outreach online on a daily basis, and visits to bars and clubs now occur once a week instead of daily. While the STD section had a booth at last weekend’s Folsom Street Fair, it did not have the money to screen and test for STDs as in years past.
“Locally, we have been unable to make up those deficits. We have had to pullback on some of our syphilis control programs,” said Klausner. “As you can imagine, that has handcuffed our ability to do major campaigns.”
Klausner also made cuts to community-based organizations, such as the Stop AIDS Project and Magnet, which used to be funded to do syphilis prevention. Magnet, the gay men’s health center in the Castro, saw its funding reduced by $45,000 but is still receiving $96,000 from the city.
It has not had to reduce its services, however, because the San Francisco AIDS Foundation, its parent agency, backfilled the lost funding. This month, it hired a new medical assistant to work in its clinic.
“Our services haven’t changed,” said Kevin Roe, Magnet’s associate director, who added that the center will have a booth in front of its 18th Street space during this Sunday’s Castro Street Fair.
So far this year, Magnet has done 3,314 blood tests for syphilis and treated 210 people for the disease. Roe said the center has seen an up-tick in people getting tested this year due to its expansion of hours. He also said promoters of Cockpit, a private sex party for HIV-positive men, have also been encouraging participants to get tested at Magnet both prior to, and after, the event.
Men seeking STD and HIV testing “can still get the whole shebang here,” said Roe. “We have increased capacity by over 50 percent in the last year. So the lines out the door or people not being able to get in are generally a thing of the past.”
Stop AIDS saw a $20,000 cut. It is no longer sending staffers into gyms to recruit people to get tested, and its mobile van no longer is used to test for STDs, though it is used to do HIV testing in collaboration with the AIDS Health Project.
“It is concerning because you can reach a tipping point in a population,” said Stop AIDS deputy director Jason Riggs. “We have been pretty fortunate in San Francisco seeing declines across the board because of the diligence of gay and bi men in San Francisco and the diligence of our Department of Public Health.”
Riggs added that the reduced funding for targeting STDs is a major hurdle in reversing the upward climb of cases.
“It decreases our ability to find really hard cases in people who may not seek services. What we are seeing here is a situation where obviously we need to go in and do more testing in certain parts of San Francisco where the outbreak is being seen,” he said. “It is questionable if the city has the resources to do that now.”
The lack of funds has also translated into less visibility for the STD section’s “Dogs are talking” campaign, where canines are used to educate gay and bisexual men about the need to be tested for syphilis. Whereas the former Healthy Penis ad campaign, credited with helping bring syphilis cases down, could be seen in community papers twice a month and on television, the current ads appear less frequently, about once every six weeks.
The dog-based campaign will be scrapped, and Klausner expects to launch a new syphilis prevention campaign sometime in early 2009.
“Currently, we are rigorously re-evaluating our social marketing programs. We will see something new,” said Klausner. “It is always important when overall things are not going in the right direction, you need to reassess, re-evaluate, and try to look for ways to try to improve.”
Last week the health department launched its new Web site www.STDtest.org in hopes of combating the latest rise in syphilis. Individual donors are privately funding the effort.
“It is an online sexual health service that will enable people to get free and regular STD testing, including syphilis,” said Klausner.
The health department advises all sexually active men who have multiple partners to get tested for syphilis every three months. For HIV-positive men, every time they give blood they should ask their doctors to also test for syphilis, advised Klausner.
“It is important people know the symptoms of what syphilis looks like. If they have a sore in the mouth, on their penis or anus, they need to get a checkup. They should not wait for it to go away,” he said. “If there are symptoms of a rash or fever, swollen glands, if people are sick in that way they also need to get a checkup. A flu-like illness and feeling really fatigued, tired, a little feverish can certainly be consistent with syphilis.”