Infectious syphilis in women and heterosexual men in major Australian cities: sentinel surveillance data, 2011–2019

To the Editor: Carter and colleagues recently reported on infectious syphilis among women and heterosexual men attending sexual health services in major Australian cities.1 Of note, the authors found that among women, recent injection drug use was associated with an increased risk of syphilis. This follows data from Canada and the United States where substance use, including injection drug use, has been reported among many people diagnosed with syphilis in recent years.2,3 All these authors have suggested syphilis testing needs to be offered to people attending alcohol and other drug services. Given how difficult it is to achieve a reduction in sexually transmissible infections (STIs) once they are widespread in population groups, we wholeheartedly support this notion, and implore that this be given greater attention in state and national STI strategic plans and associated funding allocations.

It is important to note, however, that there is a limited understanding of syphilis and STI testing generally among people who inject drugs, including people who do not attend alcohol and other drug or related services. Further, previous Australian models of care focusing on STIs among people who inject drugs have had mixed results. An outreach model of care provided to young people injecting drugs in the central business district of Melbourne over 20 years ago found chlamydia prevalence to be 6% among 213 people.4 The prevalence of gonorrhoea and syphilis was much lower than that of chlamydia; however, this study was conducted well before the epidemiological shifts seen more recently. In early 2011, efforts to increase STI testing were undertaken at a community run needle and syringe program in Sydney.5 Despite initial interest, only four people had an STI test and the service was discontinued. This suggests that further research with the involvement of people who inject drugs as partners is urgently needed. This will help to ensure that any efforts to improve STI testing among people who inject drugs are acceptable, feasible and sustainable. When programs are not successful, there needs to be open communication5 so that others can learn from and improve on these efforts.