Back in time
The return of syphilis is by far the most disturbing. The emblematic disease of the writers and cursed poets of the 19th century, it had almost disappeared from our regions by 2000. The Center for Disease Control in the United States, even congratulated himself at the time of the success of its eradication campaign.
In Quebec, in 1998, only 3 cases had been declared. Twenty-five years later, the province is reporting more than 1,200 new infections per year. The same is true for congenital syphilis, which is transmitted from mother to fetus during pregnancy and is potentially fatal for the fetus: 13 cases were reported in the province in 2022. Across Canada, these cases have increased from 4 in 2016 to 117 in 2022. However, this transmission is easily preventable through screening of pregnant women and subsequent treatment.
According to Karine Blouin, such cases tend to occur among women who are very vulnerable from a socio-economic point of view, who have not undergone prenatal screening or who contracted the infection before arriving in Canada. “This is not something we should see here!” also deplores Réjean Thomas.
HIV is also on the rise across Canada, at least compared to pandemic years, while remaining close to the average observed over the past decade (2,000 new cases per year). While the situation is not getting worse, it is not getting better either.
As for human papillomaviruses (HPV), they are also gaining ground. “Public health agencies do not track the progression of these viruses in populations. However, they seem to be increasingly common, despite an effective vaccine,” says Alex McKay, executive director of the Canadian Sex Information and Education Council. “We know this because one of the consequences of HPV is the occurrence of cervical cancers. [chez les femmes] and throat [dans l’ensemble de la population]and that they are becoming more frequent.”
Indeed, according to a report published in November 2023 According to the Canadian Cancer Society, the incidence of cervical cancer has increased by nearly 4% each year since 2015.
In addition to cancers, all of these conditions can have serious consequences: infertility, chronic pain, immune deficiency, or even effects on the fetus during pregnancy (miscarriages, malformations, etc.).
That said, they can all be easily prevented by basic protective measures, such as using condoms. And all of them, except HIV infection, can be treated with antibiotics (or prevented by vaccines in the case of HPV). So how do we explain these numbers?
Multifactorial increase
Karine Blouin attributes part of the increase in cases to the arrival of more efficient tests. “In 2010, more sensitive tests for gonorrhea and chlamydia appeared. We also started taking extra-genital samples [pharynx et rectum]which allowed many new cases to be detected.”
But progress in screening alone is far from explaining the overall picture. “There have been changes in testing, yes, but it didn’t start last year,” exclaims Dr. Thomas. “And the quality of testing for other diseases, such as syphilis, hasn’t changed.”
As for gonorrhea, part of the increase could also be attributable to the rise in antibiotic resistance, and therefore to the ineffectiveness of treatments. “It’s a bacterium that easily acquires resistance,” explains Karine Blouin, “because it can persist silently in sites like the throat. This can promote the exchange of genetic material with other bacteria.” [déjà résistantes]. So we have a surveillance program: when we see resistant bacteria in our samples, we issue directives to change the first-line antibiotics.”
Prevention 101
But according to specialists interviewed by Québec Sciencethe explosion of STIs is mainly explained by the drop in vigilance of the populations.
“People don’t realize how common these diseases are,” says Alex McKay. “In most cases, STIs don’t cause symptoms. Many people don’t think they’re at risk. When you look at condom use, you see that teens and young adults are using them a lot. But as women move to hormonal contraception, the use of condoms is decreasing. STIs are clearly not being addressed.”
For Réjean Thomas, the current increase could even be a side effect of HIV treatments developed in the 1990s. “We protected ourselves from STIs because we were afraid of dying of AIDS. As soon as AIDS became a chronic disease, we stopped paying attention,” he believes. “No one is afraid of gonorrhea, even though it can cause significant complications.”
At the same time, prevention campaigns have virtually disappeared from public spaces. In Quebec, the last prevention campaigns targeting HIV date back to 2011. In response to our questions, the Ministry of Health and Social Services (MSSS) states that this type of media campaign is no longer in the plans, since ” […] The scientific literature on the subject shows that, to be effective, the prevention of STIs requires actions and messages that are adapted to the needs and realities of the different groups primarily affected. The deployment of these actions is done in the living environments of these groups by stakeholders from the health network, the education network and community organizations.
The same goes for the federal government, which last February, launched an action plan against STIs. This plan proposes to achieve global targets for STIs by 2030, namely no new HIV infections and a 90% reduction in cases of syphilis and gonorrhea. On the prevention side, this plan mainly proposes local interventions in targeted populations.
But for Dr. Thomas, this is not only insufficient, it is downright bad faith. “At-risk populations are already very informed. This is not the case for others. Statistics from 2021 show that at least 15% of new HIV infections occur in people who have no risk factors. Their approach does not seem to be producing very good results, since we have an explosion of STIs!”
Besides, the figures speak for themselves: Syphilis cases tend to decline among men who have sex with men, while they skyrocket among heterosexual women.
Several research teams believe that there is a lack of data to fully understand the “drivers” of this resurgence, but that the evolution and diversification of sexual practices could contribute to this: increase in the number of partners thanks to dating apps, feeling of absence of risk during oral-genital intercourse, increase in unprotected heterosexual anal intercourseetc.
To stop the epidemic, several learned societies are calling to a generalization of screeningin particular through the frontline physicians“Among heterosexuals, most clinics generally only seek to screen for gonorrhea and chlamydia. HIV and syphilis should be added, and access to testing and treatment should be facilitated,” says Réjean Thomas.
“There is still stigma around STIs,” adds Alex McKay. “People are hesitant to seek information, get tested or get treated. Even simple solutions like the HPV vaccine remain underused. This really needs to come back on the public health agenda.”
There is therefore an urgent need to bring STIs out of the shadows. “We always do prevention against smoking, even if everyone knows that smoking is dangerous,” notes Réjean Thomas. “For STIs too, we always have to start again, there is no miracle.”
