To increase the amount of syphilis testing, labs need to remove moral judgement and acknowledge the STI as just another infection.

By Chris Wolski

Among all of the STIs on the very long list of infections spread through sexual activity, syphilis is currently experiencing renewed prevalence. According to the Centers for Disease Control and Prevention, there were 203,500 reported cases of syphilis in 2022 (the latest year for which there is data). 

Rise in Syphilis Infections

What makes this number significant is that it represents a 17% year-over-year increase and a 78.9% five-year increase at the same time chlamydia and gonorrhea saw either a plateauing (chlamydia) or a decrease (gonorrhea). The cases of syphilis, including congenital syphilis, are continuing to rise with California being a particular hotspot.

What’s Driving Syphilis Infections?

There are several specific factors that are driving the rising instances of syphilis, according to Ina Park, MD, who is a medical faculty member at the University of California San Francisco, the medical director for the California Prevention Training Center, and the site PI for the multicenter CDC-funded HPV-Impact project, which monitors the population-level effects of HPV vaccination. Among the most common proximate causes:

  • Dating apps—which is increasing the size of sexual networks, exposing more people to risky behaviors and partners who may be infected.
  • Less condom use—which has been driven by effective treatments and preventive measures against HIV.
  • Meth amphetamine—a Western U.S. phenomenon, for which Park notes, there’s no clear correlation other than the fact that users of this specific class of drugs seem to be more prone to syphilis infections.

What is clear, though, the largest population being affected by the syphilis outbreak are women and newborns.

Hurdles Affecting Syphilis Testing

There are two hurdles affecting syphilis testing, according to Park: access and social stigma.

“Testing is hard,” she notes. “You have to call and make an appointment and go into a lab or office.” 

She cited several programs and testing providers who supplied at-home tests to patients during the pandemic, who could then mail in their sample. Unfortunately, with the end of COVID, in-office or in-lab testing became more common again.

The Impact of Social Stigma

Social stigma is another barrier for many people to get tested. Park noted a recent lecture she gave at Tulane University during which she asked students who had been tested for an STI by a show of hands if they received a “clean” or “unclean” diagnostic result. The hands were overwhelming that they had received this clear judgement.

This categorization of “clean” and “unclean” is at the root of the diagnostic problem, Park says.

“There’s an enormous amount of stigma,” she says, instead there needs to be an acknowledgement that an STI is just a result of living, equivalent of being infected by COVID or a disease during a trip. “It’s just an infection.”

Improving Access to Syphilis Testing, Overcoming Stigma

What can labs do to improve access and overcome the stigma associated with syphilis testing? 

There’s two ways that this can be done—one is material and the other is attitudinal.

First, Park says, she’s encouraged that some commercial labs are providing direct-to-consumer syphilis testing, making it easier and more convenient to test, though she notes there also has to be clear considerations related to price—so patients aren’t priced out of access.

Second, labs need to be careful about making patients feel judged for being tested or for testing positive for syphilis or another STI.

“There shouldn’t be comments or other signs from front-line health professionals,” Park says. “Patients will pick up even on the little subtle things.” 

Staff at every level should be free of moral judgement related to syphilis testing or any STI testing.

While there has been some progress, there’s more work to be done to overcome the twin hurdles of access and stigma.

“I think we can make barriers lower,” says Park. 

Chris Wolski is chief editor of CLP.