Editorial: Untangling the Persistence of Syphilis in the South

IN THE LATE 1980s and early 1990s, syphilis staged a remarkable resurgence in the United States. This resurgence came in the form of an epidemic wave that washed across the cities in the Northeast, Midwest, and West, and struck particularly hard at the urban and rural areas of the South.1 At the crest of the epidemic, case rates for primary and secondary syphilis in the southern states were above 40 per 100,000, four times the Year 2000 objective, and higher than those seen in any year since the early 1950s. In the South, urban epidemics were followed by epidemics of syphilis in rural areas, disproportionately affecting women and minorities2 and causing cases of congenital syphilis, many of which were probably unrecognized. That urban and rural areas of the South were hardest hit is consistent with the longstanding pattern of syphilis morbidity in the United States: syphilis has persisted in the southeastern United States, especially among persons of minority race and ethnicity, even during periods when it was practically eliminated in other regions and other population subgroups.1 For several reasons, this syphilis epidemic was perplexing and frustrating. First, syphilis has been nearly eliminated in almost all other Western industrialized countries.1 Second, syphilis prevention programs are particularly well established in the United States. Syphilis has been the major focus of sexually transmitted disease (STD) prevention programs in the United States since World War II. The design of these prevention programs in the 1940s—including clinical services, screening, partner notification, and prophylactic treatment—represented a major advance in public health and has served as a model for the prevention of other communicable diseases.3 Finally, this epidemic of syphilis occurred well after the acquired immune deficiency syndrome epidemic was recognized and human immunodeficiency virus prevention programs were in place. The epidemic of syphilis demonstrated a failure to effectively promote “safer sex” (at least in some population subgroups) and raised the likelihood of increased human immunodeficiency syndrome transmission facilitated by genital ulcers. If syphilis control and prevention has not worked the way we wish in the United States, is it because we are not doing the right things, or because we are not doing things right? Unfortunately, perhaps in part because of the very success of the well-conceived syphilis control efforts of the 1940s and 1950s, little systematic investigation has been pursued regarding the efficacy and cost effectiveness of different components of syphilis prevention programs in the United States. In the wake of this epidemic, after which syphilis rates are now dropping to their lowest levels in 40 years, the Division of STD/HIV Prevention of the Centers for Disease Control and Prevention convened a meeting on January 17–20, 1995, to pursue the problem of persistence of syphilis in the southeastern United States and to reassess the effectiveness of different syphilis prevention strategies. The presentations at this meeting form the basis for the articles in this special issue. In all, the presentations point out that although current syphilis prevention programs have a strong theoretical basis, they appear to be less successful in practice than in theory, for a variety of practical and sociological reasons. If we hope to ever eliminate syphilis from the United States, prevention strategies should be reevaluated and modified to take into account these complex issues. Theoretical Basis for Syphilis Prevention Syphilis transmission in a community can only be maintained if the average number of persons infected by a person with syphilis (the “reproductive rate”) is above 1.0. This reproductive rate can be reduced by decreasing the probability of transmission during a single sexual contact (e.g. through condom use), decreasing the number of persons with whom an infected person has sex, or reducing the duration of infectiousness. Most of the emphasis of syphilis prevention activities is on reducing the duration of infectiousness. This is accomplished through treatment of symptomatic persons seeking care and administration of prophylactic or curative antibiotic treatment to partners of persons with syphilis. Syphilis is particularly well-suited for partner notification and prophylactic treatment because the disease has a longer incubation period than other bacterial STDs. Thus, there is a prolonged opportunity to cure the infection before symptoms appear and the partner becomes infectious. Ideally, all partners would receive prophylactic treatment during their incubation period; under these circumstances the reproductive rate would be zero. However, such effective prophylactic treatment probably occurs rarely. Even if partners are treated after lesions appear, though, such treatment should decrease the duration of infectiousness somewhat, and could therefore reduce the reproductive rate to below 1.0. The Effectiveness of Syphilis Prevention Programs The syphilis epidemic has raised the question of the effectiveness of syphilis prevention strategies in practice, especially among poor, marginalized populations. It often appears that syphilis epidemics in local populations occur and end independently of prevention efforts. Although the stated goal of provider-based partner notification is to treat persons prophylactically, the process more often functions as a form of targeted screening, which may in some settings be more cost-effectively accomplished through other means.6 In addition, the effectiveness of partner notification in slowing the spread of infection depends on the extent to which this strategy can reach the “high frequency transmitters,” the persons who are responsible for the most of secondary infections, and rapidly bring them to treatment. Research shows that partner notification, at least for gonorrhea and chlamydia, may be particularly unsuccessful in reaching these types of individuals.7 Despite questions about the effectiveness and cost-effectiveness of partner notification as it is practiced, this one strategy has been emphasized so much that other important strategies—such as expansion of clinical services and counseling to change behavior—have at times been restricted to accommodate it. Other traditions in syphilis prevention programs also may hinder their effectiveness. In most areas with high rates of STDs, prevention programs have become separated from the larger medical care system. Categorical STD clinics have served as sites to which patients with syphilis are referred. Although this referral may help in provider-initiated partner notification, it diverts syphilis from the general medical care system, reinforcing the lack of education of healthcare providers about syphilis and other STDs. A record review conducted during the early 1990s indicated that providers outside the public STD clinic network often did not provide timely and accurate diagnosis or treatment for syphilis, thereby causing the duration of infectiousness to be longer (Judith Greenberg, unpublished data). Similarly, STD prevention programs have often become isolated from, or sometimes even seen as adversarial to, the communities that they are designed to help. Syphilis as a Social Problem Information presented at the meeting made clear that syphilis in the United States is a marker for social marginalization: the disease is spread disproportionately among poor members of minority groups who suffer from poverty, lack of access to healthcare, low ratio of males to females, and breakdown of stable community and personal relationships.4 This puts syphilis in a group of social problems that grew worse in the 1980s and that includes drug use, homelessness (ironically a problem with a high ratio of males to females), and interpersonal violence. It also defines the limits of strictly medical, or even traditional public health, approaches to the problem, and points toward a need for community-based approaches to prevention that promote (or at least build on) positive changes in society as a whole. Rebuilding relationships between public health agencies and communities disproportionately affected by syphilis will be a substantial challenge, given the legacy of mistrust of government health agencies that has included important negative experiences related to syphilis prevention in the past.8 Race, Racism, and Syphilis Underlying the problem of syphilis in the United States, and central to any plans to eliminate it, are the issues of race, racism, and poverty, and our ability to speak frankly and intelligently about these issues. The syphilis epidemic was almost entirely limited to African-Americans living in poverty; syphilis rates nationally are now 60 times higher in African-Americans than whites.1 This disparity explains most of the regional differences in syphilis rates, because poor African-Americans make up a larger proportion of the population in the South and large cities in other regions than they do elsewhere. As described by Aral,4 the “ecologic segregation” of poor African-Americans, which in turn is attributable to a long history of severely limited opportunities for African-Americans (itself a result of racism), is at the heart of the racial and social class difference in rates. It is from a legitimate fear of the consequences of the social stigma of syphilis that many community advocates prefer not to talk about racial differences in syphilis rates. As a result, these differences are usually deliberately obscured in public discussions. This hiding of a key fact about syphilis may be making it difficult for concerned persons to mobilize the kind of support needed for effective prevention programs. For us to make substantial progress toward elimination of syphilis, we must be able to have public discussion on this uncomfortable subject. Simply put, how do we target our prevention resources effectively—including acknowledging and utilizing the strong association of syphilis with race—without stigmatizing? Syphilis Prevention Strategies: Looking Forward Syphilis prevention rests on five basic strategies: clinical services, screening, partner notification, prophylactic treatment, and programs to change sexual behavior. As we reconsider our response to the problem of syphilis persistence in the United States, our challenge is to optimize each of these strategies, and to determine the best mix for the communities and patterns of disease transmission in which the disease resides. Much research and program development must be done to optimize the public health practice of each of these strategies beyond the discussions that took place at the Centers for Disease Control and Prevention meeting, nonetheless certain themes culled from the meeting's discussions can probably be used to modify prevention efforts now: Access to clinical services is limited in areas of high syphilis prevalence, and is limiting syphilis prevention. Methods are needed to appropriately quantify and to document the impact of the lack of access to care among persons and populations at high risk for syphilis. Plans to restructure healthcare systems should incorporate changes to ensure that persons in high-risk areas have ready access to care. Partner notification as it is currently practiced is limited in its ability to interrupt syphilis transmission. This strategy should be reevaluated to fully assess its effectiveness and limitations. In areas with high rates of syphilis, it may be more appropriate to view interviews of syphilis index cases as a means to identify high-risk locales than as a means to identify high-risk individuals; these high-risk communities can be considered as sites for targeted screening and prophylactic or presumptive treatment. Epidemics of syphilis appear to end independent of prevention programs. The focus of syphilis prevention perhaps should be less on response to epidemics than on prevention of epidemics. In particular, a new emphasis is needed to understand the epidemiology of low-prevalence transmission and persistence of syphilis in communities. There must be more community involvement in syphilis prevention efforts. Syphilis prevention will be ineffective as long as there is distrust between communities at high risk for syphilis and public health officials. The dialogue that is needed must be bidirectional, with public health needing to understand the perceptions, concerns, and norms of those communities at least as much as it needs to inform about syphilis and other public health issues. These and many additional ideas discussed at the Centers for Disease Control and Prevention meeting must be further refined and tested, and participation of a broader group of persons is needed to do this. In particular, members of community groups that have high rates of syphilis must be part of the dialogue. Out of such dialogue we hope there will emerge a new consensus about the goals and strategy for syphilis prevention that will ultimately move us forward to the next level. Syphilis Prevention: What is the Goal? In the past, funding for STD control and prevention has been based heavily on morbidity rates and has been frequently reduced when syphilis and other targeted diseases are brought under better control, rewarding lack of success rather than success. Attention is then redirected to other public health problems that currently seem more pressing. When has the epidemiology of syphilis even been evaluated outside of epidemic periods within its oscillating course in the United States?1 Interest, ability to publish research findings, and especially funding are reallocated to other issues when rates decline. Such a system may yield a rational resource allocation for chronic disease prevention, but for a communicable disease with a reservoir only in humans, it represents a commitment to a sort of infectious disease purgatory, alternately tantalized by lower rates only to be blistered by large epidemics whose early detection is made impossible by the dismantling of proper surveillance. Yet, could an elimination effort be contemplated in these skeptical, retrenching times? Yes, but only if several conditions are met. First, it cannot be syphilis elimination for its own sake. This effort would need to be aligned with a set of other broadly shared goals such as a long-term vision for elimination of all STDs including human immunodeficiency virus transmission and promotion of minority health, with syphilis elimination conceptualized as a first step in each of these larger efforts. Second, it will require serious reconsideration of all of the potential tools of syphilis control and prevention, and study of how we combine those tools into effective programs.9 Third, it will take some consistent and concentrated focus, attention, and rallying, because such an effort seems most wasteful of resources, cost-ineffective, and otherwise irrational as the goal is approached. We would need to evaluate our motives and commitment for such an effort at the same time as reassessing our tools.