Syphilis Epidemic Among Inner Sydney Gay Men

The report showed a ten-fold increase in notifications, from six cases in 1999 to 162 in 2003.

The report combined NSW Health data on infectious syphilis notifications from 1998-2003, a case series of 57 homosexually active men diagnosed with early syphilis in inner Sydney from December 2002 to January 2004, and a prospective cohort study of syphilis among 1333 HIV-negative homosexually active men in Sydney recruited from June 2001 to December 2003.

Information was collected on sexual behaviour, recreational drug use, HIV status, treatment-seeking behaviour, knowledge about syphilis and demographic factors.

Co author, Andrew Grulich, head of the HIV Epidemiology and Prevention Program at the National Centre in HIV Epidemiology and Clinical Research at the University of New South Wales, said that of 57 men with early syphilis in the case series, 54 per cent were HIV positive and 32 per cent reported no symptoms of syphilis.

"These 57 men were highly sexually active and likely to report recreational drug use," Associate Professor Grulich said.

Syphilis was common up until the onset of the HIV epidemic in the early 1980s, which saw a dramatic decline in the incidence of the disease in homosexually active men in Australia.

But an increase in sexually risky behaviour in gay communities around the world in the mid 1990s saw an increase in the incidence of syphilis in the United States, Canada and western Europe.

In response to trends overseas, the Central Sydney Public Health Unit introduced enhanced surveillance in 1999 and the South Eastern Sydney Public Health Unit did so in 2001.

The authors say men with asymptomatic or symptomatic but undiagnosed syphilis could be an important source on ongoing transmission, pointing to the importance of screening in high-risk populations.

Syphilis can cause neurological and cardiovascular disease in adults and can potentially increase the risk of HIV transmission.

Both the case study and the cohort study established risk factors, including sexual practices such as having more partners, looking for sexual partners at beats and by telephone sex, unprotected anal intercourse with casual partners or with HIV-positive partners, insertive oral sex with casual partners and the use of recreational and injecting drugs. While oral sex is relatively safe in terms of the spread of HIV, it is a risk factor in the spread of syphilis.

Both the Australian chapter of Sexual Health Medicine and the Centres for Disease Control and Prevention in the United States have recently recommended that homosexually active men should be tested for syphilis at least annually.

The authors say surveillance data from Victoria indicate that a similar outbreak of syphilis in men is beginning in Melbourne and that it is probably only a matter of time before urban gay communities throughout Australia are affected.

In Victoria, notifications have increased more than five fold in the past decade. In a letter in the same issue of the Journal, Rebecca Guy, epidemiologist at the Centre for Epidemiology and Population Health Research, supports the findings of Jin et al's report, adding that it's important to have local data to ensure interventions are targeted appropriately and cost effectively.

Guy outlines Victorian initiatives, including an alert to general practitioners to encourage men who have sex with men to have syphilis testing, and individual counselling and syphilis testing of men who have sex with men at a popular sex-on-premises venue over a 4-week period.

Other responses could include enhancing outreach at Internet chat rooms, intensive counselling of HIV-positive men who have sex with men, and peer-led community-based strategies for countering unsafe sex and substance-use behaviours.

In the same issue of the Journal, Professor Christopher Fairley, Director of the Melbourne Sexual Health Centre agrees, saying that while syphilis is on the rise, it is not unstoppable. Fighting the current epidemic requires intensive education of clinicians and men who have sex with men, as well as targeted screening.

"We need to learn from Australia's effective and early response to the HIV epidemic that was characterised by community partnership, bipartisan government support, a commitment to harm minimisation and dynamic, original strategies," Professor Fairley said.

The Medical Journal of Australia is a publication of the Australian Medical Association.

CONTACT Professor Andrew GRULICH 0414 385317 / 02 9385 0900

Rebecca GUY 0417578 010 / 03 9282 2290

Professor Christopher FAIRLEY 0438 155 536 / 03 9341 6236

Judith TOKLEY, AMA Public Affairs, 0408 824 306 / 02 6270 5471