The Modern Epidemic of Syphilis- A NEJM review
Syphilis has had a major effect on several at-risk populations over time. Since 2000, for example, the increase in rates of primary and secondary syphilis in the United States has been largely attributable to an increase in rates among men by a factor of more than 3; in 2018, men accounted for 86% of all patients with syphilis. More than half of men with incident syphilis reported having sex with men, and 42% of those men were infected with the human immunodeficiency virus (HIV), a finding that highlights the strong association between incident syphilis and an increased risk of HIV infection, which can also be accompanied by other sexually transmitted infections. Similar increases in syphilis among men who have sex with men have been reported in Europe and China.

A second, more recent epidemic in the United States is affecting heterosexual men and women. Rates of primary and secondary syphilis among women more than doubled between 2014 and 2018. Alarmingly, the number of incident syphilis cases rose by a factor of 6 among women who used methamphetamine, heroin, or other injected drugs or who had sex with a person who injected drugs. The remarkable increase in the number of cases of primary and secondary syphilis among women of childbearing age is mirrored by increasing numbers of congenital syphilis cases and increasing infant mortality.

All stages of syphilis in pregnant women pose a risk of transmission to the fetus, but the risk is considerably higher with early syphilis than with later stages of disease. These data suggest a link between illicit drugs and the rise of congenital syphilis in the United States.

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