LAUSR

As thoughtfully described throughout this issue, current public health strategies for syphilis prevention are no longer working for certain populations, including some men who have sex with men (MSM) and pregnant women, and newapproaches are urgently needed. This matters because we have increasingly seen devastating complications of this ancient disease in the United States, such as permanent vision loss after ocular syphilis, and increases in congenital syphilis cases. Furthermore, the funding environment continues to be a challenge and resources to address syphilis at the state and local levels are sparse. The Division of Sexually Transmitted Disease (STD) Prevention at the US Centers for Disease Control and Prevention (CDC) has seen its budget cut by 9.6% over the past 14 years, and state and local public health programs that have not been able to secure other funding have been reporting reduced scope of services. Historically, a large proportion of STD prevention resources have been targeted to syphilis prevention. Disease intervention specialists (DISs) from state and local health departments, as well as CDC federal assignees have long interviewed infectious syphilis cases to obtain demographic and risk factor data to inform local, state, and national epidemiology, but primarily to identify partners who could then be preventively treated, theoretically decreasing incidence of new infections to zero. Given that syphilis has only a human host, has not been shown to develop resistance to recommended antibiotics, and has a relatively long incubation period, syphilis elimination is plausible, but only if enough partners can be found and treated. However, with the increased popularity of location-based applications for sex, fewer and fewer MSM partners are identified and treated. Increasing overall numbers of cases have also included increases in women and congenital infections. At the same time, numbers of highly skilled DIS staff are only stable or even decreasing; in many jurisdictions, they are also being appropriately leveraged to maximize other important public health field work, including increasing access to HIV prevention and treatment. Although we came close, we were never were able to achieve syphilis elimination, and this now begs the question: what next?