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Am Fam Physician. 2021;103(4):199-200

Original Article: Syphilis: Far from Ancient History

Issue Date: July 15, 2020

To the Editor: Drs. Ricco and Westby provide a timely review of syphilis as a rising public health concern. The authors describe two subpopulations with the highest prevalence—men who have sex with men and patients who are HIV positive.1 However, highlighting these populations for increased scrutiny may lead to under surveillance and missed opportunities for detection and treatment in other patients who are at high risk. It also adds to the stigma that men who have sex with men and HIV-positive populations face when seeking health care.

People who exchange sex for money, formerly incarcerated people, and people with substance use disorders are among the populations who also warrant syphilis screening.2 Stigma surrounding syphilis can compound these populations' already existing health inequities. Stigma is a significant contributor to health inequities in marginalized populations, including people with minority sexual or gender orientation and those who are HIV positive.3 Additionally, stigmatization in health care of lesbian, gay, bisexual, transgender, and queer people, and of patients who are HIV positive further exacerbates low rates of engagement with primary care because of perceived or actual judgment from health care professionals.4,5

To address this crisis, we must make care accessible to all patient populations. Maintaining appropriately broad screening for all patients at increased risk of syphilis infection reduces the stigmatization of this diagnosis in men who have sex with men and in patients who are HIV positive and is essential to reducing syphilis transmission rates.

The author thanks Dr. Jennifer Middleton for help preparing this Letter to the Editor. Dr. Middleton is a contributing editor for AFP.

In Reply: We thank Dr. Amin for the thoughtful and patient-oriented letter about broad screening for syphilis in all patients. We agree that stigma toward marginalized populations can contribute to increased health inequities and is a barrier to seeking health care. Our intention was to highlight recommendations from the Centers for Disease Control and Prevention and the U.S. Preventive Services Task Force about specific high-risk subpopulations based on the best available evidence.13 Table 2 in our article highlights additional subpopulations at increased risk of syphilis; however, the data for some of these at-risk groups are less clear regarding the frequency of screening. Additionally, because syphilis is often transmitted within small social networks, a history of syphilis should be considered a significant risk factor for future infection.

We attempted to balance a broad approach to screening while also providing specific evidence-based guidance for health care professionals in a clinical setting. We agree that future recommendations should cast a wide net to identify the highest-risk populations while attempting to avoid contributing to stigma and bias toward particularly vulnerable groups.

Email letter submissions to Letters should be fewer than 400 words and limited to six references, one table or figure, and three authors. Letters submitted for publication in AFP must not be submitted to any other publication. Letters may be edited to meet style and space requirements.

This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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