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Relationship of Syphilis to Drug Use and Prostitution -- Connectic ut and Philadelphia, Pennsylvania
Since 1984, in many areas of the United States, reported rates of
syphilis have greatly increased (1). Between 1984 and 1987, annual
rates of syphilis (primary and secondary) increased 70% in the
state of
Connecticut and 74% in the city of Philadelphia (Figure 1). These
trends have continued in 1988; in the first quarter of this year,
annualized rates increased by 70% in Connecticut and by 25% in
Philadelphia compared with 1987 annual rates. Investigations were
conducted at these two sites to identify factors associated with
this
increase.
In Philadelphia and Connecticut, over 80% of all newly diagnosed
patients with early syphilis are interviewed and counseled. Cases
are
detected through reporting by public clinics and private
health-care
providers and through laboratory screening. During the interviews,
information is collected about patients' lifestyles to help locate
sexual contacts. In Philadelphia and Connecticut, records from
these
interviews were abstracted and analyzed for the years 1985-1987. In
Connecticut, all interviews of persons with primary and secondary
syphilis were abstracted; in Philadelphia, a sample of interviews*
was
chosen that involved persons with primary, secondary, and latent
syphilis present less than 1 year.
At both sites during the 3-year period, the proportion of men with
syphilis who reported sexual contact with men decreased
substantially.
In Connecticut, the proportion of men with syphilis who reported
being
homosexual or bisexual decreased from 38% (48/126) in 1985 to 11%
(21/197) in 1987; in Philadelphia, the percentage declined from 53%
(49/93) to 18% (25/137) during this 3-year period.
In contrast, recorded use of illicit drugs and reported
prostitution
or contact with a prostitute among heterosexual syphilis patients
increased greatly during this period. Among females at both study
sites, the proportion reporting to be prostitutes increased more
than
threefold and the proportion reporting use of drugs increased more
than
sixfold (Figure 2). Heterosexual male syphilis patients showed
similar
but smaller increases in recorded drug use. Prostitute contact by
this
group occurred more frequently in Connecticut than in Philadelphia
but
increased at both sites.
Reported by: G Joachim, JL Hadler, MD, State Epidemiologist,
Connecticut Dept of Health Svcs. M Goldberg, RG Sharrar, MD,
Philadelphia Dept of Public Health; R David, MD, State
Epidemiologist,
Pennsylvania State Dept of Health. Div of Sexually Transmitted
Diseases, Center for Prevention Svcs; Div of Field Svcs,
Epidemiology
Program Office, CDC. Editorial Note
Editorial Note: Although prostitution has long been associated
with
syphilis (and other sexually transmitted diseases) (2), it appears
to
have been relatively unimportant in the overall epidemiology of
syphilis in the United States during the last 2 decades (3,4). Drug
use
has only recently been associated with the spread of syphilis (1).
Since drug use and prostitute contact were not recorded
systematically
on case interview forms, the true frequency of these behaviors
among
syphilis patients is probably underestimated. This underreporting
of
these behaviors, if combined with changing interviewers'
perceptions,
could bias the findings in Connecticut and Philadelphia. However,
the
consistency between the two sites and the magnitude of the increase
in
reporting of prostitution and drug use suggest that the trends
observed
in Connecticut and Philadelphia reflect real changes in the
epidemiology of syphilis.
The decrease in the proportion of male syphilis patients who are
homosexual/ bisexual has been noted in California and New York City
(5), in outbreaks in Manitoba (6) and Florida (7), and in a sample
of
states with recent increases in syphilis (8). In the Florida
outbreak,
prostitutes were also found to be an important risk group. The
results
of the studies in Connecticut and Philadelphia support these other
findings and suggest that the emergence of syphilis among
prostitutes,
drug users, and their sexual contacts may be a widespread national
phenomenon.
The possibility of an increase in syphilis among persons in these
risk
groups has important implications for the control of syphilis and
other
sexually transmitted diseases, including human immunodeficiency
virus
(HIV) infections. Prostitutes tend to have large numbers of
anonymous
sexual partners who are difficult to locate by traditional methods
of
partner notification. Prostitutes who also frequently use
intravenous
(IV) drugs and, in some parts of the country, those with a history
of
IV-drug use have high rates of infection with HIV (9). Recent
studies
have suggested that sexually transmitted diseases that cause
genital
ulcers, such as syphilis, greatly increase the likelihood that HIV
infection, when present, will be transmitted (10-12). To limit
the spread of syphilis, which may also help limit the spead of HIV,
public health officials may need to modify current control methods
to
better identify and treat syphilis-infected prostitutes, drug
users,
and their sexual contacts (1).
References
CDC. Syphilis and congenital syphilis--United States, 1985-1988.
MMWR 1988;37:486-9.
2.Brandt AM. The syphilis epidemic and its relation to AIDS.
Science
1988;239:375-80.
3.Willcox RR. Prostitution and venereal disease. Br J Vener Dis
1962;38:37-42.
4.Perine PL, Handsfield HH, Holmes KK, Blount JH. Epidemiology of
the
sexually transmitted diseases. Ann Rev Public Health 1985;6:85-106.
Disclaimer
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