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What is syphilis?
JW: Syphilis is a bacteria, and symptoms show up in stages. In the first stage of syphilis, open sores will show up on the type of skin called mucus membrane, wherever the person had contact with someone who had syphilis. Mucus membranes are the skin on our lips, inside our mouths, in our digestive tract, in all of our genitals, external and internal. And who hasn’t had a painful sore on the inside of our mouths at some point in time? This is why we call syphilis “the great imitator.” The symptoms can look very benign—they can look like a popped pimple, an ingrown hair, or a fever blister. Even if you don’t get treatment, those symptoms will eventually go away, but the syphilis isn’t gone.
Without treatment, syphilis very easily moves into the second stage. These symptoms can include a rash on the palms of the hands and the bottoms of the feet. More and more we see this rash show up on other parts of the body. It can cause patchy hair loss or wart-like lesions. These are mostly painless symptoms, but any unknown skin rash is a good reason to go to a doctor.
How is syphilis spread?
JW: It’s easiest to spread syphilis when sores are open. All the bacteria in this sore, the second it comes into contact with any other mucus membrane, it is going to spread. So it can spread through any kind of sex, including oral sex.
SG: We also see “vertical transmission” from a mother who has syphilis to her baby; this is congenital syphilis. Nationally, there was 10 times more congenital syphilis in 2022 than in 2012. There are so many complications for a newborn. Pretty much any organ can be involved. They can go deaf or experience blindness—the liver, the bone cartilage, everything can be affected. No newborn should be born with syphilis in this day and era when we have testing, when we have screening, when we have treatment.
What happens if syphilis isn’t detected and treated?
BR: Syphilis can affect your brain, causing blindness, deafness, or dementia. If you don’t get treatment, syphilis doesn’t go away; you just lose all your antibodies that are fighting it.
SG: We want to treat syphilis as early as possible when found. While the central nervous system involvement can happen at any stage of syphilis, the sooner the diagnosis, the less complicated treatment and course generally tend to be. For a woman in pregnancy there is not a large window to miss weekly shots of penicillin if the treatment is needed weekly for three weeks. For missed doses, we will have to restart series of injections in most cases in pregnancy.
This infection sounds serious! Why don’t we talk about it more?
BR: Most people don’t know that they need to be tested for syphilis. They don’t know that syphilis is a thing that still exists, they don’t know how infectious syphilis is, they don’t know how dangerous or deadly syphilis is.
JW: Quite frankly, we also have to address historical context. Syphilis is sometimes familiar to people because of the evil, racist Tuskegee experiments, where doctors deliberately harmed Black men by injecting them with syphilis and withholding treatment. We’re working within that history and that very real injury. So we have to acknowledge the harm that happened.
When should someone be tested for syphilis?
SG: It’s very important to be familiar with VDH’s new screening guidelines for syphilis. Counties are deemed high-risk if they have primary and secondary syphilis of 4.6 cases per 100,000. Richmond and Henrico both fall in that category. Anyone who lives in these localities and is sexually active between the ages of 15 and 44 should all be offered and recommended screening at doctor’s offices and clinics. We also have regular screening for our HIV population, for people on PrEP, and for people who are pregnant.
BR: Having a documented syphilis testing history is really helpful for people. If you’ve been getting tested every year or every six months and then you test positive, we know we don’t have to give you three times the amount of treatment.
What happens if I test positive for syphilis?
SG: Other than getting treated appropriately, another important part is making sure partner(s) are getting tested and treated. You can treat a person with syphilis but then they can be infected again by an untreated partner. And that’s where DIS come in and they do a fantastic job of contact tracing, testing, and treatment.
JW: DIS talk to patients in the clinic to educate them about the specific infection—how it works, how it spreads. After the education, we try and ask for partners, try and figure out who could benefit from a test. We’re the people who call partners to say, “I wanted to let you know that someone has named you as a contact for syphilis. When can we offer you a free test?”
There’s no judgement on our end. Everyone practices sex differently. We all get tired and we sleep. We all get hungry and we eat. And we all have sex. We as humans shame ourselves for the third one. How we present the information and talk about it should show we’re not sitting here in judgment. The hope is that patients will recognize this is a different conversation. And sometimes we do witness very real healing.
What does treatment look like?
SG: Diagnosing patients to know what stage they’re in will determine [http://xn--when%20you%20test%20early,%20the%20chance%20is%20youll%20catch%20syphilis%20early%20on,%20so%20youll%20only%20need%20one%20shot%20and%20not%20three%20shots-lf44hlb.%20and%20that%20matters%20from%20a%20patient%20standpoint:%20who%20wants%20to%20get%20three%20shots%20when%20one%20is%20all%20you%20need/?]the course of treatment. For primary and secondary syphilis or early stages without neurological involvement, it’s usually a one-time penicillin shot. For Syphilis that is diagnosed as late latent, the treatment is one penicillin injection weekly for 3 weeks. For Syphilis involving the eye or central nervous system, we treat with intravenous syphilis for 10-14 days. When you test early, the chance is you’ll catch syphilis early on, so you’ll only need one shot and not three shots.
BR: Syphilis is curable, and treatment can be free. We even set up a process where Hope and Bremo pharmacies can receive federally subsidized medication to treat our patients. They have more appointment availability generally speaking, their appointments are quicker, you get in and out faster, they’re a more convenient location for some people, so being able to send people to the pharmacies really does keep people receiving their treatment at the time they need it. I love the pharmacy partnership so much. It’s so collaborative, and everyone’s really on board and active.
What can I do to protect myself against syphilis?
SG: We have to go back to the basics of safer sex. We can’t take that out of the equation. RHHD does offer DoxyPEP now, which helps prevent STIs after unprotected sex within 72 hours, but by no means does it take away from trying to prevent it in the first place by practicing safe practices.
JW: If someone is on PrEP, that’s great, you’re safe against HIV. But PrEP is a chemical barrier for HIV only, and it will not protect against syphilis or any other infections. Depending on what community you’re a part of, depending on how you practice sex, depending on your relationship status, you might not use a condom. Condoms and testing are important tools when we know infections like syphilis, chlamydia, and gonorrhea will continue to spread.
Thankfully, lots of wonderful places will test for syphilis if you ask for it. There are so many people who go to their provider and say, “I need an STI check, please make sure I’m safe.” People communicate it in very vague terms all the time. And then they pee in a cup or they do their swabs, and they don’t always get a syphilis test. Make sure you are asking for a syphilis test specifically.
Questions? Interested in scheduling a test? Call RHHD at 804-205-3501 or visit our STI Clinical Services page.
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