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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.


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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