The rate of new syphilis infections in the U.S. in 2000 and 2001 was at the lowest level ever recorded (about 5 cases per 100,000 population each year), and health officials had hoped to eliminate the disease.

However, in 2001 the rate rose slightly in men while continuing to decline in women, as a result of rising rates in men who have sex with men. In King County, the syphilis rate in gay and bisexual men increased dramatically from 1997 to 1999 and in the last three years has remained at high, unacceptable levels. Gonorrhea and chlamydia rates also are high and rising in gay and bisexual men. Similar trends in syphilis or other STDs have been reported in almost all industrialized countries; other urban areas with such trends include Los Angeles, San Francisco, New York, Houston, Chicago, and Vancouver, Canada; Rotterdam, Holland; London, England; and Sydney, Australia. Syphilis in gay and bisexual men now is the single greatest threat to the U.S. Public Health Service's campaign to eliminate syphilis in this country.

The epidemic of early (i.e., infectious) syphilis in gay and bisexual men continues in King County. 50-60 cases have been diagnosed and reported each of the past three years. Almost all cases are occurring in gay and bisexual men.

About 70% of gay and bisexual men with syphilis and 15% of those with gonorrhea or chlamydia are HIV-infected.

Some of the cases are occurring in young, newly sexually active men, some of whom are following very risky lifestyles, including a lot of recreational drug use beyond marijuana and alcohol. However, half of all gay and bisexual men with syphilis are age 35 years or older, and half of those with gonorrhea or chlamydia are age 30 or older. This probably means that many men who followed safer sex guidelines for many years now are behaving unsafely once again.

At first glance, 50 to 60 cases of syphilis a year may not seem a lot. However, when almost all these cases are gay or bisexual men, a populations estimated to number about 42,000 in King County, the rate of syphilis in gay and bisexual men in King County is extremely high:

• About 150 out of every 100,000 gay and bisexual men acquire syphilis each year in King County.
  
  
• In contrast, the rate of syphilis in heterosexual men and women in King County is less than 1 case each year out of every 100,000 persons.
  
  
• And, incredibly about one percent of HIV-infected gay and bisexual men acquire syphilis each year.

Other STDs also have increased among gay and bisexual men. The graph at the right shows the rate of reported gonorrhea in gay and bisexual men and in heterosexuals in King County. The rate of gonorrhea in gay and bisexual men is about ten times higher than in heterosexual men and women. Rates of chlamydia in gay and bisexual men also are rising.

The current rates of unsafe sex and STDs in gay and bisexual men may be almost as high as those seen in the late 1970s and early 1980s, before the appearance of AIDS. This is certainly true now for syphilis. It might be expected that men attending Public Health's STD Clinic would be at highest risk. But a research study done by investigators at the University of Washington, in collaboration with Public Health, found that those attending other health care facilities (usually for care of their HIV infections) were equally unsafe as men at the STD Clinic, and had similar rates of gonorrhea or chlamydia. A particularly disturbing finding is that rectal gonorrhea and chlamydial infection were just as high in HIV-positive men as in those without HIV.

Rising rates of STDs can only be due to one of two things: increased diagnosis (i.e., more persons at risk being tested); or more frequent unsafe sex among persons at risk. Public Health believes that increased testing accounts for much of the rise in chlamydia and part of the rise in gonorrhea, but for none of the increase in syphilis. In addition, surveys of gay and bisexual men in King County and more conclusive studies in San Francisco show increasing rates of unsafe behaviors, such as unprotected anal sex with men of opposite HIV status or whose HIV status is unknown.

Several reasons are believed to explain the high and rising rates of unsafe sex among gay and bisexual men in King County and elsewhere:

• Complacency: Most gay and bisexual men know that untreated HIV usually is fatal and that treatment is difficult. However, some seem to believe that treatment is easy and that AIDS no longer is serious, so they are less careful.
  
• Psychological Effects of Improved HIV Treatment: Improved HIV treatment and survival may have reduced the sense of urgency and motivation for safer sex for some men. Only a few years ago, almost every gay man in King County had friends, co-workers, or former lovers who were sick or had died of AIDS, so they were confronted with the seriousness of the disease on an immediate, day-to-basis. The improved treatments are a miracle, but they probably have reduced the "in your face" aspect of HIV infection, perhaps leading some men to let down their guard. Looked at another way, people who feel healthy are more likely to be sexual than persons who feel and look sick. This applies not just to individuals, but to entire communities.
• Multiple Partners: Many gay and bisexual men with syphilis and other STDs acknowledge unprotected sex with multiple anonymous partners, often in bath houses or sex clubs. Others are very safe as far as their own behavior is concerned, but are having sex with partners who remain at high risk.
• Safer Sex Burn-out: Most extraordinary healthy behaviors are hard to maintain for long periods of time; just think about stopping smoking, starting to diet, and to exercise. The same applies to safer sex. After following safer sex guidelines for many years, some men may be having trouble staying with the program. And some HIV-positive men may be taking their meds but giving in emotionally to drug use and loneliness.
  
• Drug Use: Drug use, especially of crystal methamphetamine ("crystal") and inhaled nitrates ("poppers"), is very closely linked to anonymous partnerships, unsafe sex and STDs. Other street drugs, such as Ecstasy and Viagra, may also be linked with high risk.

It is virtually certain that HIV transmission is also increasing among gay and bisexual men - a second wave of infection is probably occurring here as has been well shown in SF and other cities.

• STDs and HIV are transmitted through the same risk behaviors. Gonorrhea, chlamydia, and syphilis are transmitted through unprotected vaginal, anal, and oral sex; these are the same sexual behaviors known to transmit HIV
  
  
• HIV transmission is more likely when an STD is present. An HIV-infected person with gonorrhea, syphilis, chlamydia or herpes is more likely to transmit HIV to his or her sex partners. And it works the other way too; if someone with an STD with an STD is exposed to the virus, he or she is much more likely to become infected with HIV.

The data are not yet clear on whether HIV infections actually are increasing in gay and bisexual men in King County. This doesn't mean it isn't happening, only that the data are not conclusive here. Rising rates of new HIV infections have been found in nearby cities with increased STD rates in gay and bisexual men, such as San Francisco and Vancouver, Canada.

Recommendations:

Most HIV-infected persons remain sexually active and many of these continue to have unsafe sex at least some of the time. Others may be safe, but their partners may have other partners.

• To protect themselves and the gay and bisexual and broader communities, all sexually active persons have a responsibility to help protect their sex partners from HIV and other infections. This means that if you are a gay or bisexual man, you should know your HIV infection status. If you are at risk and don't know, have an HIV test.
  
  
• All gay and bisexual men should always tell their partners whether or not they have HIV before having sex. Both HIV+s and HIV-s should disclose and not rely on the other person. Expecting to use a condom or to follow other safer sex practices does not change this; condoms can break or slip off, and a plan to avoid safer or anal sex may change in the heat of the moment.
  
  
• Most gay and bisexual men with HIV should have periodic screening tests for STDs.
  
  
• Specifically, gay and bisexual men should request that their health care providers order a blood test for syphilis at least once a year. More frequent testing-for example, every 3 to 6 months-is recommended for those who sometimes have unprotected sex with new, multiple, or anonymous partners or who use crystal meth or poppers; or whose partners do these things.
  
  
• Periodic testing for gonorrhea, chlamydia, and other STDs also is recommended.
  
  
• And most important, gay and bisexual men should think hard about the choices they have. Avoiding drugs, knowing your partner well, and avoiding the riskiest practices-such as anal sex without condoms-is just common sense and is essential if the gay and bisexual communities are to achieve health.