Rise in syphilis, cuts in funding a worry in Philadelphia

A spike in syphilis cases and sharp cuts in state funding to Philadelphia for HIV/AIDS are presenting a challenge to public-health workers tasked with preventing the spread of sexually transmitted diseases.

Infectious syphilis rose 45 percent in the city last year, with far greater increases among women - a group whose reported cases, while still small, barely registered until recently.

"It is very disturbing to see these outbreaks among women," said Jo Valentine, chief of syphilis elimination and STD disparities at the U.S. Centers for Disease Control and Prevention.

Local health officials have tamped down a handful of similar eruptions around the country in the last few years, Valentine said. But a 34 percent cut in state HIV funding for the city beginning July 1 - some of the money is already gone - could hamper efforts in Philadelphia, home to more than half the HIV patients in Pennsylvania.

The $2 million was used for HIV testing and prevention in minority communities, which have the highest rates of sexually transmitted diseases nationwide. It would have covered tests for an estimated 8,000 people next year, and prevention and risk-reduction services for 4,000.

All state-funded support groups aimed at prevention have already ceased to operate.

Danielle M. Parks leads a five-week risk-reduction program for heterosexual black women. The health educator's final session of SISTA - Sisters Informing Sisters about Topics on AIDS, which reached 136 women last year - was two weeks ago.

"These women need this," Parks said, because otherwise "they are going to continue life as usual."

During her last group, she told students about women who had recently tested positive for HIV. One was a 43-year-old Latina whose husband of 16 years, it turned out, had been aware of his infection for three years but did not know how to tell his wife. Another was a 36-year-old African American mother of three with private insurance and a college degree.

"It doesn't matter if you have been in a relationship for three months or 30 months," Parks told them. "Just having sex with someone who is African American puts you at higher risk, because the rates within the community are so high."

Syphilis is spread through skin-to-skin sexual contact and thus is more infectious than HIV, which is passed in bodily fluids. But they follow similar patterns, and tactics employed to prevent one often do the same for the other. Testing is considered the prime strategy.

"When people learn their status and it is positive, their behavior changes," said David S. Metzger, an HIV prevention researcher at the University of Pennsylvania School of Medicine. Even if the test is negative, he said, "just the consideration of infection helps people to practice safer behaviors."

STD rates are driven in part by an economic downturn that is leaving more people without insurance. And some women who are already living on the edge are more likely to barter with their bodies.

"People will have sex in order to stay in an apartment or house, basically survival sex," Metzger said.

Then there's fading memory. AIDS is no longer a death sentence, and as syphilis declined through the 1990s and the early 2000s, risky behaviors have increased, experts say. This is especially true for heterosexuals, who typically do not consider themselves to be in danger.

Blacks are eight times as likely as whites to be found to have primary and secondary syphilis, the key infectious stages; Latinos are four times as likely, according to the CDC.

Men are five times as likely to be infected as women. The category "men who have sex with men" (MSM), which reflects behavior rather than self-identity, accounts for roughly two-thirds of cases here and nationally.

Rates in all groups had risen through 2008, the most recent year for which national data are available.

The biggest jump in Philadelphia's 2009 statistics is based on the smallest numbers: women ages 15 to 29 went from five cases to 23. But those are key childbearing years, and infection during pregnancy can cause congenital syphilis.

"A single case is tragic," said Lenore Asbel, an infectious disease specialist in the Philadelphia Department of Public Health's STD clinic.

Early in pregnancy, syphilis often causes stillbirth or spontaneous abortion. In the second and third trimesters, it can lead to bone abnormalities, hearing loss, and mental retardation that may continue to develop up to age 3. Penicillin treatment is usually successful even late in pregnancy.

"These are preventable cases. We don't have to see them," said Dimitrios S. Mastrogiannis, director of maternal/fetal medicine at Temple University Hospital, who delivered two of the four babies with congenital syphilis reported in the city last year.

One mother had received no prenatal care and came into the delivery room with preeclampsia, a dangerous combination of high blood pressure and other conditions that requires immediate delivery or abortion. Her baby, born with a rash and bone abnormality typical of syphilis, remained in the neonatal intensive care unit for 10 days.

NICU treatment costs between $10,000 and $100,000, Mastrogiannis said, compared with about $10 to test the mother during pregnancy. He said Temple last year began screening every pregnant woman not receiving prenatal care who comes into the ER for any reason - "even if she has a toothache."

Across the city, the health department is trying various remedies, from offering free antibiotics to medical providers who need them to launching an interactive Web site (www.stdphilly.org) with candid advice. It also allows users to send anonymous e-cards telling former sex partners their bad news.

"I hate to tell you this," reads one, "you may have been exposed to STDs. Please get checked soon."

Last month, the city alerted doctors to a new recommendation: annual syphilis testing for females 15 to 40 who had had more than one sexual partner in the previous year.

The cuts will not affect these strategies, and most HIV testing in Philadelphia - at the high volume clinics, city health centers and prisons - is underwritten by Washington.

What's on the cutting floor is money secured in recent years from Harrisburg by State Sen. Vincent Hughes (D. Phila.) He won it as part of a deal with the Democratic leadership for his vote to legalize gaming in 2004, he said.

"We have been able to help thousands of people," Hughes said. "To have these cuts go into place seriously cripples the fight."

The Obama administration has proposed small budget increases for HIV/AIDS while states and cities around the country are cutting deeply.

New Jersey appears to be an exception: Funding for HIV/AIDS was unchanged the last two years, and Gov. Christie this week proposed modest increases despite major cuts to the Department of Health and Senior Services three years in a row.

Some cuts are expected throughout Pennsylvania next year, though not as deep as those to Philadelphia.

The cuts here will affect two dozen organizations, said Jane M. Baker, director of the city's AIDS Activities Coordinating Office (AACO). The calculations assume that other funding, including city money that may depend on new taxes on soda and trash, remains stable.

"I'm afraid that agencies will go out of business, and the ripple effect will be greater than the simple reduction in the number of tests might suggest," said Metzger, the Penn researcher.

Toni Mullins, 30, participated in one of the last SISTA classes that Parks led for the Health Federation of Philadelphia.

She said she enrolled in SISTA in January because the risk of sexually transmitted diseases has always been in the back of her mind.

After two years in an exclusive relationship, she was using condoms only about half the time. Mullins said the program helped her raise the issue with her partner, and now they use a condom "100 percent of the time."

Without the course, she said, "I don't think I would have brought it up at all."