"Screw Abstinence"

Or so says the t-shirt of the articulate young lady in the picture. The article ends by blaming the rise in STDs on federally-funded abstinence-only education programs, and specifically mentions the rise in syphilis. Seeing as how I'm currently in the middle of a reasonably large syphilis study, trying to explain its rise, I thought I'd just interject that the article leaves out the important detail that the rise in syphilis is only among men. Female syphilis rates haven't risen at all - in fact, they've continued to fall. There's some noise in the series of female syphilis, but it's pretty much flat and downward sloped. I only have data through 2004, so maybe they're referring to something happening 2005-2007. But, I suspect they're talking about the fairly big spike in syphilis that's been happening among men since 1998. Syphilis rates among whites, for instance, had been falling pretty steadily all throughout the 1980s - there's a temporary blip in the late 1980s when it rose, but that was short-lived (for Whites anyway - for Blacks and Hispanics, that blip was a mountain the size of Mt. Everest, but that's another story [read: crack cocaine epidemic was the cause]), and it continued to fall. It hit a valley in 1998: 0.84 cases of syphilis for every 100,000 white men, and 0.86 cases for every 100,000 white women. Then the series diverge. White female cases kept falling, and by 2004 they are sitting at 0.54 (slightly above 0.50 from 2003). White male cases, though, sharply increased. By 2004, they are 5.2 cases per 100,000, representing over a 500% increase in syphilis. When you examine this separately by states, you see astronomical spikes in roughly two dozen states, who are the only states driving this data, as the rest either have no syphilis or very little among White males. California saw its white male syphilis rates rise from 0.88 in 1998 to 16.1 in 2004, representing a 1700% increase in syphilis rates among White men in merely 6 years. So what's going on? The epidemiological and public health literature doesn't believe, as far as I can tell, that this has anything to do with federal funding of sex education abstinence - the increase is only among men, for one, and of all ages, for two, not merely teenagers. It's specifically men who have sex with men (MSM), and not heterosexual men, who are experiencing this increase. And the answer, I believe, is the availability of the highly-active anti-retroviral treatments (HAART) that were developed throughout the 1980 and 1990s, but specifically in 1996, when the protease inhibitor was invented. Protease inhibitors stop the HIV viral from replicating in the host's body, and the consequence of this was a rapid falling of HIV-related mortality. But, the indirect effect was: 1) a sizeable increase in the HIV-positive population due to falling AIDS mortality and (2) a decrease in the risks of unprotected sex and anonymous sex among gay men. Hence we have both an incapacitation and deterrence effect operating on AIDS mortality which is reversed by the discovery of the protease inhibitor.

The story is easy enough to tell, and from what I'm learning, pretty much everyone believes the global increase in syphilis among MSM is caused by protease inhibitors. The difficulty, though, is as always in proving that it is causal and not merely spurious. I'm working on that angle now.