Fight fire with fire: Innovations to address syphilis among men who have sex with men

To the Editors:

We appreciated Nguyen et al.’s analysis of the San Francisco Department of Public Health’s Sexually Transmitted Disease (STD) integrated database that found syphilis cases in San Francisco have recently been increasing and expanding beyond a core population of men who have sex with men (MSM) (1). Nguyen et al. found that among syphilis cases, the proportion of those who reported use of geosocial networking applications (apps) increased from 1.4% in 2010 to 45% in 2016. Raising concern, they also found that among early syphilis cases use of partner services declined from 98.1% in 1996–1999 to less than 8% since 2000, the proportion of interviewed cases who named at least one sex partner declined from 62.9% in 2000–2004 to 31.7% in 2010–2016, and the disease intervention rate, defined as the proportion of total early syphilis cases with at least one named partner who was treated, decreased from 30.5% in 2000–2004 to 18.0% in 2010–2016.

Nguyen et al. demonstrate that the syphilis epidemic is back. With new biomedical prevention for human immunodeficiency virus (HIV) infection and as people transition from meeting sex partners at brick-and-mortar venues to “eVenues,” traditional approaches for controlling syphilis are failing. Novel approaches for syphilis prevention, testing, and linkage to care are needed (see Table).

Table. Suggested interventions to control syphilis among men who have sex with men.

Increase screening:
Testing promotion on apps (e.g., testing reminders within profiles, access to sexual health clinic location finders, and non-judgmental sexual health information)
Use of online testing services (e.g., MyLabBox.com)
Standing syphilis testing orders in routine medical care for those with HIV- infection and those using pre-exposure prophylaxis for HIV infection  New community-based rapid same-day testing and treatment  Expanded use of rapid point-of-care syphilis tests
Enhanced partner notification and treatment services:
Anonymous partner notification) (6)  eVenue monitoring and user notification (7)
Use of oral agents (e.g., doxycycline bid × 14 days) for partner treatment among those unwilling/unable to obtain intramuscular benzathine penicillin
Research on alternative oral agent regimens for partner treatment (e.g., cefixime 400 mg bid × 10 days)
Biomedical interventions
Use of daily or post-coital doxycycline prophylaxis among those with two or more syphilis infections past two years
Renewed investment in syphilis vaccine development

Prior research has shown that persons that use the Internet to meet partners may engage in higher-risk sexual behaviors (2). App use to meet new sex partners should be considered as a marker for increased risk of syphilis. Targeted advertisements on sex partnering apps for HIV self-testing have been shown to be effective (3). Similar methods of app-based outreach and linkage to web-based sites to order kits for home-based specimen collection for syphilis testing, e.g., the website MyLabBox.com, should be evaluated. In addition to regular testing, counseling, and promotion of condom use, biomedical prevention for syphilis with regimens like prophylactic doxycycline should also be considered for those with increased risk of syphilis (4).

With the increased number of syphilis cases, not only in San Francisco, but across the United States (5), it is clear that the current approach for addressing syphilis is inadequate. We agree with Nguyen et al.’s message that new technologies, like use of social networking apps to meet partners and biomedical prevention methods for HIV are contributing to the increased spread of syphilis. It makes sense to “fight fire with fire.” The increased use of social networking apps calls for social network and app-specific interventions. With new technologies that increase sexual network size and cause risk compensation, public health leaders need to innovate to address the growing syphilis epidemic.