Syphilis. The estimated global burden of new cases of infection with Treponema pallidum among adults in 1999 was 12 million (WHO, 2001d). As with other STDs, the greatest number of cases occurs in South and Southeast Asia and sub-Saharan Africa (4 million each), followed by Latin America and the Caribbean (3 million). The newly independent states of the former Soviet Union have recently seen a dramatic rise in syphilis rates, from 5–15 per 100,000 people in 1990 to 120–170 per 100,000 of population in 1996 (WHO, 2001d). Although the primary and secondary syphilis rates in the United States declined by 90 percent from 1990 to 2000, the disease remains an important problem in the South and among certain subgroups. In 2001, the rate of primary and secondary syphilis reported among African Americans (11.0 cases per 100,000 people) was nearly 16 times greater than the rate reported among non-Hispanic whites (0.7 cases per 100,000 people) (CDC, 2002h). Recent outbreaks of syphilis among men who have sex with men may indicate an increase in high-risk sexual behavior that places them at risk for all STDs (Wolitski et al., 2001; CDC, 1999a,b; Aral, 1999). Expanding partner notification to include more high-risk populations through social networks and increasing screening among high-risk populations may improve control of inner-city syphilis epidemics (Gunn et al., 1995).

BOX 3-9 A Behavior Paradox

Antiretroviral therapy is a principal factor in prolonging the life of AIDS patients in the United States and in delaying the progression of AIDS in HIV-infected individuals receiving this multidrug regimen. Ironically, however, the role played by antiretroviral therapy in decreasing the death rate from AIDS may now be a factor in the increasing rate of unsafe sexual behaviors—potentially increasing the rate of new HIV infections. For example, men who have sex with men and believe that antiretroviral therapy decreases HIV transmission are more likely to engage in unprotected anal sex (Huebner and Gerend, 2001; Ostrow et al., 2002). Risky sexual behavior has also been associated with the belief that antiretroviral therapy improves health in HIV-positive men (Ostrow et al., 2002). Other studies have revealed that similar attitudes about antiretroviral therapy have led to increased sexual risk taking among both HIV-negative and HIV-positive illicit drug users. The increased rates of unprotected sex that have been associated with the availability of antiretroviral therapy reflect an ongoing trend (Chen et al., 2002b)



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