Syphilis is surging in the United States, but cases of chlamydia have leveled off and gonorrhea has declined, according to the latest sexually transmitted infections surveillance report. The Centers for Disease Control and Prevention report reflects familiar disparities, with gay men accounting for a disproportionate share of cases and Black people having the highest STI rates.
The news comes at a time when COVID has diverted attention and resources, funding for STI and sexual health services is under pressure, and the public health workforce has been cut, leading health officials and advocates to call for a greater focus.
"The CDC's latest STI data shows that our nation is facing a rapidly deteriorating public health crisis with real lives at stake," the National Coalition of STD Directors said in a statement. "STIs — especially syphilis — will continue to spiral out of control until the administration and Congress provide communities with the funding they need to provide the most basic screening, treatment and prevention services."
Fortunately, there's a new tool in the STI prevention toolbox, at least for gay and bisexual men and transgender women. Studies have shown that taking a single dose of the antibiotic doxycycline within 72 hours after sex — known as doxyPEP — can reduce the risk of chlamydia and syphilis for these groups by around 70% to 90% and the risk of gonorrhea by 50% to 60%. DoxyPEP did not significantly reduce STI risk in a study of young women in Africa, but this approach might still work for those who achieve good adherence. The CDC issued the first doxyPEP guidelines in October, as the Bay Area Reporter previously reported.
"In the United States, syphilis was close to elimination in the 1990s, so we know it's possible to reverse this epidemic," stated Dr. Jonathan Mermin, director of the CDC's National Center for HIV, Viral Hepatitis, STD and TB Prevention. "I have hope for innovative prevention tools — such as a pill after sex that prevents STIs and better tests for syphilis — but they will only be successful if they reach the people who will benefit."
Three major STIs
According to the CDC report released January 30, the three major reportable bacterial STIs — chlamydia, gonorrhea, and syphilis — collectively rose by about 2% between 2018 and 2022, exceeding 2.5 million total cases. But the combined data hide contrasting trends for the three diseases.
Chlamydia, the most common notifiable STI, was roughly stable between 2021 and 2022, with a slight 0.3% uptick, bringing the total to nearly 1.65 million cases. But the five-year trend shows a substantial 6% decline, driven by a 9% reduction among women.
Young people in their late teens and 20s accounted for more than half of all chlamydia cases in 2022, with women having a more than twofold higher rate than men. Men who have sex with men do not appear to have a substantially higher prevalence than heterosexual men and women. Black people (who make up about 13% of the U.S. population) had the highest chlamydia rate by a large margin, accounting for 28% of cases. The states with the highest rates were concentrated in the southeast.
Gonorrhea, in contrast, decreased by about 5% among men and by about 14% among women from 2021 to 2022, falling to about 648,000 cases — the first decline in at least a decade. Despite this drop, the five-year trend still shows an 11% rise since 2018. Gonorrhea is increasingly resistant to antibiotics, but most circulating strains remain susceptible to ceftriaxone, the primary recommended treatment.
Young people also accounted for the largest share of gonorrhea cases, but here, men had a higher rate than women. Black people again accounted for a disproportionate share of cases, at 38%. Gay and bisexual men generally had a higher rate than heterosexual men and women, but this varied by city. The states with the highest gonorrhea rates were again mostly in the southeast, but California and New York had high rates among men.
Syphilis saw the greatest increase, rising by 17% between 2021 and 2022 to reach 203,500 total cases. Numbers have jumped by 80% over the past five years — hitting levels not seen since the 1950s — but it is not clear why syphilis is rising even as gonorrhea is falling.
From 2021 to 2022, cases of primary and secondary syphilis — the most infectious and most treatable stages — rose by 10%, exceeding 59,000 cases. But syphilis is often not diagnosed and treated promptly, and late or unknown duration syphilis increased even more steeply, exceeding 87,500 cases. Left untreated, the bacteria can damage organs throughout the body, including the eyes, heart, bones, and brain. One of the most effective penicillin formulations used to treat syphilis is currently in short supply.
Men had about a fourfold higher syphilis rate than women in 2022. Gay men accounted for the largest proportion of cases, at 29%, with another 5% among men who have sex with both men and women. Black people accounted for about a third of cases, but Native Americans and Alaska Natives saw the highest rate - 2.8% - given their population size being 0.7%.
While men account for more syphilis cases, the dramatic rise among women is alarming. Over the past five years, primary, secondary, and late syphilis among women have risen by nearly 200%. This has led to a parallel surge in congenital syphilis, which occurs when a mother transmits the bacteria during pregnancy or delivery, potentially leading to miscarriages, premature births and serious complications for the baby. Congenital syphilis rose by 31% from 2021 to 2022, reaching 3,755 cases.
"The STI field has reached a tipping point," Dr. Laura Bachmann, acting director of the CDC's Division of STD Prevention, said in a statement. "We have long known that these infections are common, but we have not faced such severe effects of syphilis in decades. Recent public health emergencies diverted program resources and threatened the health of those already disproportionately affected by STIs. We must move now to pick up the pieces."
San Francisco, however, has departed from national trends for all three STIs. As the B.A.R. previously reported, the city saw a 4% increase in chlamydia, a stable gonorrhea rate, and a 7% decline in syphilis from 2021 to 2022.
In an effort to curb the syphilis surge, the U.S. Department of Health and Human Services last year established a National Syphilis and Congenital Syphilis Syndemic Federal Task Force, led by Assistant Secretary for Health Admiral Rachel Levine, a transgender woman.
"Addressing the resurgence of syphilis and congenital syphilis requires a concerted effort," Levine stated. "We can collectively work towards reducing the incidence of syphilis and its devastating consequences, and we will turn the tide on the syphilis epidemic."
Health officials stress that more work is needed to bring down STI numbers, address disparities, and ensure equitable access to health services. All three major STIs were much more likely to be diagnosed outside of STI or sexual health clinics, according to the report, underscoring the need for prevention, testing, and treatment in primary care and other settings.
"There are no shortcuts, and we have to meet people where they are. Some people face tremendous barriers to STI prevention and health services," Bachman said. "We cannot continue to use decades-old prevention strategies to address today's STI epidemic."
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