December 2021

Going… going… not gone: the unwelcome return of syphilis

As syphilis continues its stealthy resurgence in Australia, people who use drugs may unknowingly be among those at greater-than-average risk.

“It’s not the mechanism of drug use itself – how people might be using drugs. It’s all to do with networks and the fact particular people might not be engaged well with health services,” Dr Diane Rowling, Public Health Physician at Metro North Public Health Unit in Brisbane and one of the founders of the Queensland Syphilis Surveillance Service (known as the Syphilis Register), says.

“It’s the same with any sexual network: once you introduce an infection that has the ability to be transmitted to a lot of people and may not be recognised or treated, and then their contacts aren’t treated, it has the opportunity to spread widely.”

Dr Phillip Read, Director of both Kirketon Road Centre in Kings Cross and Sexual Health and Blood Borne Viruses for South East Sydney Local Health District (with a population of about one million residents), echoes this.

“Globally there have been syphilis outbreaks associated with things like crack cocaine use in the United States, the UK and the Caribbean but it’s not the driving factor in Australia. Recreational drug use and syphilis don’t cause each other but they certainly can co-occur.

“When we’ve looked at the data, injecting drugs hasn’t come out in the heterosexual population as an independently large risk factor across the whole of Australia but in particular populations it is a factor because syphilis spreads when people socialise and as part of that sometimes have sex with one another. People who inject drugs are a very close and well-connected community so of course if it gets into a particular group it spreads.

“The drug use per se is not the risk factor. It’s more that the drug use coalesces with why they are together: they have something in common and enjoy doing something together, and perhaps as part of that they’re using drugs for enhancing sexual pleasure, so it’s an overlapping risk factor.”

Rapid rise

Philip has seen syphilis cases in New South Wales jump from about 400 in 2011 to roughly 1,800 in the space of a decade – “and that’s on the back of an equally large increase in the five or six years before that”, he says.

“It’s similar across most of the urbanised areas of Australia.

“Predominantly these are mostly in men – the majority are gay men or men who have sex with other men: that’s about 3,800 of the 4,500 cases in Australia at present.

“But the other 650-odd are women. The number of diagnoses in men has doubled but the number in women is about four times what it was, albeit from a lower base, so the rate in women is actually going up faster in places like Sydney and Melbourne.”

Within Victoria’s Department of Health, Principal Epidemiologist of Blood-borne Viruses and Sexually Transmissible Infections Alvin Lee and Manager of Sexual Health and Viral Hepatitis Michael West are among those working most closely to monitor and respond to syphilis.

In Victoria over the past decade… annual cases of infectious syphilis – which we define as an infection of two years or less duration – in particular have increased almost five-fold.

Alvin Lee

Alvin Lee

“There’s been a substantial increase in the number of cases in Victoria over the past decade,” Alvin says. “Annual cases of infectious syphilis – which we define as an infection of two years or less duration – in particular have increased almost five-fold: 1,659 cases were notified in 2019 compared with 332 in 2011.

“Of concern is the increase of infectious syphilis in women, which has increased more than six-fold over the past decade, from 30 in 2011 to 186 in 2020.”

Babies at risk

Michael classifies the re-emergence of congenital syphilis as “a significant public health issue”.

“The transplacental transmission of syphilis to the unborn baby during pregnancy or from the birth parent to the baby during birth can have serious consequences, including miscarriage, stillbirth, prematurity or low birthweight, and is entirely preventable,” he says. “For the 25 years 1991–2016 there were two cases of congenital syphilis in Victoria but there have been 12 cases notified to our department since 2017. In this time there have also been at least 242 infectious syphilis cases involving women who were pregnant at the time of diagnosis, the majority of which were diagnosed through antenatal screening.”

The more you test, the more likely you are to find an infection.

Dr Phillip Read

Dr Phillip Read

Phillip Read adds: “The more you test, the more likely you are to find an infection, and many women in their life will become pregnant and have a syphilis test during pregnancy so that does mean that the average heterosexual woman throughout her reproductive years will have more syphilis tests than the average heterosexual man.

“In NSW the response has been screening pregnant women multiple times during pregnancy if they’re at risk, ensuring that emergency departments, midwives, obstetricians and general practitioners working in shared care around pregnant women are aware and informed about making pathways to treatment clear.”

Diane Rowling says the loss of a baby to congenital syphilis – which she terms “the public face of this disease” – is a particular threat for women in vulnerable situations. “They may not have had an opportunity to have that testing. When we at the Syphilis Register look at the missed opportunities in the cases we’re able to follow up, people are often presenting out of hours to various services, whether it be at the emergency department or 24-hour medical centres. Getting education out there to both at-risk people and their health care providers is an important way of addressing this.

“For all vulnerable groups in our population, we need to make it easy to be tested and treated appropriately, and for women in particular there can be issues around informing partners because of domestic violence and so forth. It’s about normalising testing and removing stigma. People who use drugs are already affected by the stigma of that – it’s further complicated if they have to admit that they’ve acquired a sexually transmitted infection (STI) as well.”

Diane says ground has certainly been ceded since the late 1990s, when “in the United States and Australia we all had hopes of eliminating syphilis entirely”.

“That certainly hasn’t happened.

Syphilis has been around since at least the 15th century; it’s an ancient infection that’s now reinvented itself for modern times.

Dr Diane Rowling

Diane Rowling

“Syphilis has been around since at least the 15th century; it’s an ancient infection that’s now reinvented itself for modern times.

“It’s easily transmissible through oral, anal and vaginal sex and it can have a very long period of infectivity – at least a year. It’s also a tricky infection because a lot of the initial symptoms can be missed both by the patients themselves and by their health care providers if they do seek assistance.”

Queensland had 112 syphilis cases on the books in 2001 (or 3.1 people per 100,000 residents); by 2019 that had ballooned to 1,129 (22.9/100,000).

While the rate of infectious syphilis in Victoria dipped slightly in 2020 to 1,439 cases, Alvin Lee says this was most likely due to a combination of reduced testing and changed behaviour due to the state’s pandemic response. “There’s evidence sexual health consultations and asymptomatic screening decreased last year during the lockdowns and we’re seeing a similar trend this year, which means people may have an undiagnosed STI such as syphilis and potentially be at risk of transmitting that to a partner.”

Methamphetamine link

“We know there’s a high degree of stigma associated with drug use broadly, and meth use means people are less likely to seek treatment for problematic substance use or concerns relating to blood-borne viruses and STIs,” Michael West says.

We know there’s a high degree of stigma associated with drug use broadly, and meth use means people are less likely to seek treatment for problematic substance use or concerns relating to blood-borne viruses and STIs.

Michael West

Michael West

“Meth use has also been associated with higher rates of unsafe sexual encounters. One study found that condoms were used only 52 per cent of the time by meth users engaging in anal sex, and we’re aware of recent reports of increased meth use among women and heterosexual men with primary and secondary syphilis in the US.”

Michael says Victorian agencies “have also highlighted that the disengagement from care and hardship resulting from unemployment dur to COVID-19 restrictions may have resulted in increases in a range of health issues and pronounced risk behaviours in vulnerable communities, including people who use drugs”.

Frontline response

The Department of Health is trialling a ‘syphilis in pregnancy’ project to support marginalised pregnant women in Victoria who have complex needs. Launched in July 2020, it has so far prevented the development of congenital syphilis in 45 cases. It also assists clinicians to notify partners so that they can be tested and treated, if necessary, and provides public health follow-up for all female patients of childbearing age.

Syphilis was highlighted statewide during Victoria’s 2021 STI Testing Week in October, following on from an earlier awareness campaign in the Mildura region in response to a localised increase in infectious cases.

Phillip Read says recent advances in the way health professionals are able to respond to syphilis are helping. “Doctors can now keep syphilis treatment in their medical bags so they don’t have to send somebody off to a pharmacist, and there have also been innovations in syphilis testing so in some settings non-traditional tests – ‘rapid tests’ or ‘point-of-care tests’ – can be used to try to diagnose and treat people straight away.”

In Queensland, QuIHN has begun rolling out dedicated syphilis testing through its chain of primary NSPs stretching between the Gold Coast and Townsville.

“As part of our hepatitis C treatment management program we do sexual health testing,” QuIHN Project Officer Amanda Kvassay says. “We’ve been testing for syphilis as part of our pathology since 2018 but we’ve now taken on the challenge of offering point-of-care testing carried out by our own NSP staff.

“We started very slowly at our Brisbane NSP towards the end of October, with a plan to extend it to all five sites within a month or so once we got some learnings and made sure we had everything down pat. It’s part of trying to offer something to our clients that’s quite accessible, that’s free, that’s a fingerprick rather than a venous blood draw – there are a lot of benefits to our client group.”

Amanda says her QuIHN’s colleagues have responded enthusiastically to having another service at their disposal. “Our harm reduction staff are enjoying having something fresh to learn. It’s just one more thing they can provide once they’ve been trained.

“Clients have a rapport with their workers already so being able to have this testing done by us will help them to be more comfortable. It’s 20 minutes to sit down to have the test done and get the results and then they can be out the door again.”

Amanda says the key to QuIHN’s early success in syphilis testing has been its links to complementary organisations. “Having a good relationship with Diane at the Queensland Syphilis Register and other services that are experienced in sexual health has allowed us to lean on them and be guided to make sure we’re going in the right direction in our pre-testing counselling, for example. It’s all about those partnerships and trying to address a gap potentially in access for people.”

– Rosalea Ryan