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Syphilis is most easily detected during its primary and secondary stages and is cured by a hefty dose of penicillin. It also has a well-defined evolutionary cycle, which if caught during the first two stages allows researchers to determine the time period in which a person contracted the infection.
But once the outward symptoms recede, the disease -- while still curable with penicillin -- is only detectable in the blood. No longer infectious, the blood-borne pathogen begins eating away at the body's organs. The final stage, known as neuro-syphilis, can cause blindness, deafness, even insanity -- though that is rare, and the process takes decades.
That is, until recently.
"There are a couple of keys: First, if you are HIV positive and develop syphilis, you are far more likely to progress to secondary syphilis earlier," says Kevin Fenton, chief of the Centers for Disease Control and Prevention's National Syphilis Elimination Effort. "There are also a number of reports that untreated syphilis among HIV-positive men may progress more rapidly to neuro-syphilis."
Though there is a dearth of good information regarding the interplay of syphilis and HIV, preliminary reports indicate that co-infected individuals can advance to neuro-syphilis in a matter of months. In other words: A disease that in an otherwise healthy body takes decades to affect the organs can move through an immuno-compromised body with pirhana-like speed.
That's not all. As an organism, syphilis has traditionally been limited by one severe drawback: Though highly infectious, it has a small window of time during which to switch hosts, thus ensuring the species' survival. HIV, on the other hand, is able to extend that transmission window.
"If you're HIV positive and you develop syphilis, you'll often get more ulcers," Fenton explains. "It will also elongate the secondary syphilis phase, which can be very infectious."
Syphilis infection can in turn facilitate HIV transmission. "The lesion gives HIV a sort of portal to enter the body," says Fenton, adding that white blood cells often congregate around a lesion, providing HIV direct access to the body's immune system. "If you're HIV positive and have an ulcer onboard, that can increase your risk of transmitting HIV two- to six-fold. So that's the kind of magnitude we're talking about."
But the biological relationship between the two diseases is only part of the story. The social aspect is equally important. "We know that people who acquire syphilis are individuals who tend to have far more sexual partners than the average person," Fenton says. "This means that if you have both syphilis and HIV on board, not only is your individual risk of transmitting infection increased, but you're also more likely to have sex with many more individuals."
In other words, a few highly sexual carriers can drive an epidemic.
On a recent Thursday night, Duane Westhoff has commandeered two round tables near the door at Coffee Cartel. The Central West End coffee bar hums with chatter as the latte-sipping throng spills onto the patio. Dressed in light-brown slacks and a black T-shirt, Westhoff has strewn condoms and STD-prevention literature across his tables. As the young crowd mills about, the occasional straggler offers up a guilty look before plunging a hand into Westhoff's plastic jug filled with free condoms.
At age 28, Westhoff holds the rank of "captain" in the Guardian Project, a collaborative effort between city government and community groups to raise HIV awareness. He and his fellow "guardians" hold court at the Coffee Cartel each Thursday night, offering "smart sex" education and free HIV tests. Though the project targets young gay men, Westhoff takes all comers. Tonight's crowd isn't in a buying mood. Three-quarters of the way into their two-hour session, Westhoff and his cadre of young volunteers have yet to perform a single HIV test.
"Everyone knows why we're here," he says, noting that many in the crowd have already been tested. "But an eighteen-year-old gay white male is more likely to open up to a peer, so it's important that we put a face on the message."
Effective messaging is one of the biggest obstacles community prevention groups and health department officials face when trying to reach the gay community. The population has been hearing the "safe sex" message for two decades now. They know the dangers of sexually transmitted diseases, and, theoretically, they know how to protect against them. But while syphilis and HIV rates declined during the mid- to late '90s, syphilis is spiking and HIV rates are beginning to follow suit. Health workers attribute much of the rise to a gay population that increasingly flouts safe-sex practices.
"People are tired of hearing the same message. They've been hearing this message for twenty years," says Carolyn Guild, prevention supervisor for the community-based St. Louis Effort for AIDS. "They're tired of dealing with it as a community. It's not a gay disease, but I think that white men who have sex with men are tired of feeling like it's something they need to own."
Health workers also cite "condom fatigue" as an impediment to getting gay men to practice safe sex. For two decades the population has been admonished to use condoms, and while a negative status is a laudable goal, it also has the drawback of not making a person's life better than it had been.
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