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Weekly / February 15, 2019 / 68(6);144–148

Sarah E. Kidd, MD1; Jeremy A. Grey, PhD1; Elizabeth A. Torrone,
PhD1; Hillard S. Weinstock, MD1 (View author affiliations)

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Summary
What is already known about this topic?

During 2013–2017, the primary and secondary (P&S) syphilis rate
increased 72.7% nationally and 155.6% among women.

What is added by this report?

During 2013–2017, reported methamphetamine, injection drug, and
heroin use increased substantially among women and heterosexual
men with P&S syphilis.

What are the implications for public health practice?

Heterosexual syphilis transmission and drug use, particularly
methamphetamine use, are intersecting epidemics. Collaboration
between sexually transmitted disease control programs and
substance use disorder services providers will be essential to
address recent increases in heterosexual syphilis transmission.
Linking syphilis patients with substance use disorders to
behavioral health services and providing syphilis screening for
persons receiving substance use disorder services are needed to
address these co-occurring conditions.

During 2013–2017, the national annual rate of reported primary
and secondary (P&S) syphilis cases in the United States
increased 72.7%, from 5.5 to 9.5 cases per 100,000 population
(1). The highest rates of P&S syphilis are seen among gay,
bisexual, and other men who have sex with men (collectively
referred to as MSM) (2), and MSM continued to account for the
majority of cases in 2017 (1). However, during 2013–2017, the
P&S syphilis rate among women increased 155.6% (from 0.9 to 2.3
cases per 100,000 women), and the rate among all men increased
65.7% (from 10.2 to 16.9 cases per 100,000 men), indicating
increasing transmission between men and women in addition to
increasing transmission between men (1). To further understand
these trends, CDC analyzed national P&S syphilis surveillance
data for 2013–2017 and assessed the percentage of cases among
women, men who have sex with women only (MSW), and MSM who
reported drug-related risk behaviors during the past 12 months.
Among women and MSW with P&S syphilis, reported use of
methamphetamine, injection drugs, and heroin more than doubled
during 2013–2017. In 2017, 16.6% of women with P&S syphilis used methamphetamine, 10.5% used injection drugs, and 5.8% used
heroin during the preceding 12 months. Similar trends were seen
among MSW, but not among MSM. These findings indicate that a
substantial percentage of heterosexual syphilis transmission is
occurring among persons who use these drugs, particularly
methamphetamine. Collaboration between sexually transmitted
disease (STD) control programs and partners that provide
substance use disorder services will be important to address
recent increases in heterosexual syphilis.

P&S syphilis case report data were extracted from the National
Notifiable Diseases Surveillance System, the system through
which CDC receives syphilis and other notifiable sexually
transmitted disease data from all 50 states and the District of
Columbia. P&S syphilis case report data include demographic
information and also risk factor information, such as
information about sex partners and drug use within the past 12
months, which is obtained through case interviews or
investigation by the local health department.

For this analysis, men with syphilis were categorized as MSM if
they reported having sex with any male partner in the last 12
months; men who reported having sex with only female partners in
the last 12 months were categorized as MSW. To assess drug-
related behaviors, the following are included in the case report
data as separate yes/no variables: use of injection drugs,
methamphetamines, heroin, cocaine, crack, nitrates/poppers,
erectile dysfunction drugs, other drugs, no drugs; and sex with
a person who injects drugs within the last 12 months. The
percentage of persons reporting use of each drug or behavior was
calculated separately, using those with a “yes” response to the
relevant variable as the numerator. For the injection drug use
and sex with a person who injects drugs variables, the
percentage of persons reporting these behaviors was calculated
among persons with “yes” or “no” responses for that behavior
(i.e., those with missing or unknown responses were excluded
from the denominator). Because some local health departments
collected data on the remaining drug use variables (e.g.,
methamphetamine and heroin use) differently and did not
routinely report “no” responses to these variables, persons with
missing and unknown responses for these remaining drug use
variables were included in the denominator if they had a “yes”
response to any of these variables and also did not have a “no”
response to any of these variables (i.e., for these persons,
missing and unknown responses were assumed to be “no”
responses). SAS statistical software (version 9.3, SAS Institute
Inc.) was used for all analyses.

During 2013–2017, the percentage of persons with P&S syphilis
who reported methamphetamine use, sex with a person who injects
drugs, injection drug use, or heroin use within the past 12
months more than doubled among women and MSW (Table 1). The
percentage of persons with P&S syphilis reporting
methamphetamine use increased from 6.2% to 16.6% among women,
and from 5.0% to 13.3% among MSW, but decreased from 9.2% to
8.0% among MSM. The percentage of persons with P&S syphilis
reporting sex with a person who injects drugs increased from
5.5% to 12.4% among women and from 3.6% to 9.3% among MSW, but
increased only slightly among MSM (from 4.3% to 5.2%). Injection
drug use increased from 4.0% to 10.5% among women with P&S
syphilis and from 2.8% to 6.3% among MSW, but remained stable at
3.5% among MSM. Heroin use increased from 2.1% to 5.8% among
women with P&S syphilis and from 0.8% to 2.7% among MSW, but
remained relatively stable (increased from 0.7% to 0.8%) among
MSM.

Among women with P&S syphilis, increases in methamphetamine use,
sex with a person who injects drugs, injection drug use, and
heroin use were observed in every region of the United States
(Table 2). Among MSW with P&S syphilis, the increase in sex with
a person who injects drugs was observed in every region, and the
increases in methamphetamine, injection drug, and heroin use
occurred in all regions except the Northeast (Table 3). Although
trends were generally similar across regions, the prevalence of
these behaviors among women and MSW with P&S syphilis varied
considerably by region. In 2017, the percentages of both women
and MSW reporting these behaviors were highest in the West and
lowest in the Northeast. In the West, methamphetamine use during
the past 12 months was reported by 34.8% of women with P&S
syphilis and 25.0% of MSW with P&S syphilis. In addition, 22.6%
of women with P&S syphilis in the West had sex with a person who
injects drugs, and 21.2% used injection drugs (Table 2). In
contrast, <3% of women or MSW with P&S syphilis in the Northeast
reported these behaviors in 2017 (Table 2) (Table 3). Additional
data on other behaviors and characteristics reported among
persons with P&S syphilis, such as number of sex partners, HIV
status, and other drug use data, are available online in a
supplemental syphilis surveillance report (https://www.cdc.gov/std/stats17/syphilis2017/).

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Discussion
Since reaching a historic low in the United States in 2000–2001,
the annual national rate of reported P&S syphilis cases has
increased, and the rate in 2017 (9.5 per 100,000 population) was
the highest reported since 1993 (1). Until 2013, the increase
was primarily among MSM, and rates of P&S syphilis among women
remained low and relatively stable (3). However, during
2013–2017, the P&S syphilis rate increased among both men and
women (1). This report demonstrates that, during this same
period, the prevalences of methamphetamine use, sex with a
person who injects drugs, injection drug use, and heroin use
within the past 12 months more than doubled among MSW and women
with P&S syphilis, but not among MSM with P&S syphilis.

These findings indicate that a substantial percentage of
heterosexual syphilis transmission is occurring among persons
who use methamphetamine, inject drugs or have sex with persons
who inject drugs, or who use heroin, and that heterosexual
syphilis and drug use are intersecting epidemics. A linkage
between heterosexual syphilis and drug use has been observed
previously. In the late 1980s and early 1990s, increases in
heterosexual syphilis were associated with crack cocaine use
(4,5). Drug use, particularly use of methamphetamine and
injection drugs, is associated with sexual behaviors that
increase the risk for acquiring syphilis and other sexually
transmitted diseases, including having multiple sex partners or
concurrent sexual partnerships, inconsistent condom use, and
exchange of sex for drugs or money (6–8). In addition, among
persons who use drugs, stigma and mistrust of the health care
system along with other social determinants of health (e.g.,
unstable housing, poverty, incarceration, and lack of health
insurance or a medical home) might contribute to decreased
health care utilization and reluctance or inability to identify
and locate sex partners, resulting in delays in diagnosis and
treatment (4,5). These complications likely contribute to
increasing syphilis incidence in communities and pose
significant challenges to syphilis prevention and control
efforts.

Pilot projects have demonstrated the feasibility and benefit of
implementing substance use disorder interventions in STD clinics
(9,10). STD programs should consider partnering with substance
use disorder prevention and treatment programs and other
organizations that provide services to persons who use drugs in
the local community. Heterosexual networks and sexual risk
behaviors are linked with drug use, and STD programs should work
with substance use programs to facilitate referrals to substance
use disorder treatment services when needed and to integrate STD
and substance use disorder prevention and treatment services
when possible. Substance use disorder programs and other
community organizations that provide services to persons who use
drugs can also provide opportunities for STD prevention and case-
finding, through promotion of safer sex practices, condom
distribution, and testing for syphilis and other sexually
transmitted infections.

The findings in this report are subject to at least three
limitations. First, syphilis case report data do not include
data on opioid use other than heroin, so it was not possible to
assess nonheroin opioid use among persons with syphilis. Second,
cases with incomplete data on variables of interest were
excluded from this analysis. Overall, depending on the year and
variable, 18%–25% of reported cases of P&S syphilis among women,
MSW, and MSM were missing data on methamphetamine use, sex with
a person who injects drugs, injection drug use, or heroin use
during 2013–2017. If persons whose records had missing data were
less likely to have a risk factor, it is possible that this
analysis overestimated the prevalence of these risk factors
among persons with syphilis. Finally, because of stigma
surrounding these risk behaviors, some persons might have been
reluctant to disclose drug use, leading to misclassification and
underestimates of the true percentage of persons with syphilis
who used these drugs.

The recent increases in heterosexual syphilis, together with the
concurrent increases in percentage of persons with P&S syphilis
reporting methamphetamine use, sex with a person who injects
drugs, injection drug use, and heroin use, are causes for
concern. Heterosexual syphilis and drug use, particularly
methamphetamine use, are connected and interrelated epidemics in
the United States. Collaboration between STD control programs
and partners that provide services for persons with substance
use disorders will be essential to address recent increases in
heterosexual syphilis and link patients to clinical and
prevention services.

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Corresponding author: Sarah E. Kidd, skidd@cdc.gov, 404-639-8314.
 

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