Will reinforcing condom use in gay and bisexual men reduce syphilis incidence?

Will reinforcing condom use in gay and bisexual men reduce syphilis incidence?

Daniel Storer | AFAO Policy Analyst

Syphilis rates among gay and bisexual men in Australia have fluctuated between 2010-2016, with a declining trend in both HIV positive and HIV negative gay and bisexual from 2014-2016, yet incidence is still high[1].

So, would a renewed focus on condoms be likely to have an impact on syphilis infections among gay and bisexual men in Australia?

Condoms have been a large part of safer sex messages, particularly since the early 1980s when HIV & AIDS emerged. Of course, they not only protect against HIV, but most other STIs, including syphilis, as they create a physical barrier during sexual acts, including oral sex, and anal and vaginal penetration.

It has been shown that consistent and correct condom use reduces syphilis transmission. Syphilis can also be passed on through direct contact with sores or lesions, so gloves and dams are encouraged during sexual contact.

However, several international studies and research in Australia by the Kirby Institute has shown that significant behavioural change, particularly in regard to condoms, would need to occur for a prolonged period to reduce the current levels of syphilis infections and rate of transmission among gay and bisexual men.

Condom use has been declining[2] since the introduction of effective antiretroviral treatments in the late ‘90s[3]. Developments in treatment and prevention, particularly since 2012, have further changed the way that gay and bisexual men engage with condom use for STI prevention.

In their 2015 research paper in Sexual Health, Stoltey & Cohen note that ‘Latex condoms offer protection against syphilis transmission when used consistently and correctly but require the condom cover the ulcer or condyloma latum (wart-like lesion) entirely’[4]. The likelihood of syphilis transmission increases if ulcers or lesions are not completely covered.

Rates of correct and incorrect condom use[5] have varied through studies and have generally been considered primarily through heterosexual encounters[6]. Further studies are needed to determine whether consistency of use and correct use of condoms among gay and bisexual men would aid in reducing syphilis transmissions. Research is also required to determine the barriers that prevent gay and bisexual men from using condoms for oral sex. Further, if these barriers were removed would there be any appreciable impact on rates of syphilis transmission.

Research for the World Health Organisation in 2004 acknowledged that ‘in no [condom effectiveness] study has the effectiveness been 100%’, but the authors concluded that “balanced STI and HIV prevention programs should include condom promotion strategies” that target their intended audience[7].

Changes in gay and bisexual men’s behaviour towards condoms have been signaled as an area for intervention to reduce syphilis transmission. The suggestion for behavioural change links increased condom use with a reduction in sexual partners over an extended period of time.

In Phase A of the National Syphilis Action Plan (Action Plan)[8], questions on the acceptability of these interventions for controlling syphilis in Australia were put to focus groups of gay and bisexual men. Reducing sexual partners as a syphilis prevention strategy was considered unacceptable as a means of prevention and was seen as a restriction on sexual liberty. Focus groups’ results indicate that men who are most willing to engage in behavioural change, are using complementary behaviours to reduce syphilis transmission. The Action Plan identified that it is those most at risk of syphilis infection that are less likely to undertake these changes in behaviour.

Biomedical advancements in prevention have given gay and bisexual men more confidence in protecting themselves against HIV. The combination of historical declines in condom use and the current rates of syphilis incidence places these men at increased risk of syphilis transmission.

Health promotion campaigns geared solely towards changing the sexual practice of gay and bisexual men are not likely to be effective in reducing syphilis transmission, especially due to the length of time the Action Plan outlined it would need to occur.

Although condoms are effective in the prevention of syphilis transmission, they may not be the most appropriate response to reducing the risk of syphilis transmission among gay and bisexual men in Australia. Other interventions such as sustaining increases in testing, alongside consistent messaging about condom use, need to be incorporated into health promotion messaging to assist in reducing the syphilis incidence among our community.


[1] Kirby Institute. HIV, viral hepatitis and sexually transmissible infections in Australia: annual surveillance report 2017. Sydney: Kirby Institute, UNSW Sydney; 2017 [cited 2018 March 14]. Available from: https://kirby.unsw.edu.au/sites/default/files/kirby/report/SERP_Annual-Surveillance-Report-2017_compressed.pdf

[2] Declining condom use refers to increases in self-reporting of having any condomless anal intercourse with regular and casual partners.

[3] Gray RT, Hoare A, McCann PD, Bradley J, Down I, Donovan B, Prestage G, Wilson DP. Will changes in gay men’s sexual behavior reduce syphilis rates? Sexually Transmitted Diseases 2011;38(12):1151-8

[4] Stoltey JE, Cohen SE. Syphilis transmission: a review of the current evidence. Sexual Health 2015;12(2):103-9

[5] Correct and incorrect condom use refers to participants in these studies using condoms as per the instructions or not.

[6] Duerr A, Gallo MF, Warner L, Jamieson DJ, Kulczycki A, Macaluso M. Assessing male condom failure and incorrect use. Sexually Transmitted Disease 2011;38(7):580-6

[7] Holmes KK, Levine R, Weaver M. Effectiveness of condoms in preventing sexually transmitted infections. Bulletin of the World Health Organization 2004;82(6):454-46

[8] Kirby Institute. Phase A of the national syphilis action plan: modelling evidence and research on acceptability of interventions for controlling syphilis in Australia [Internet]. NSW: Kirby Institute, 2009 [cited 2018 March 14]. Available from: https://kirby.unsw.edu.au/sites/default/files/kirby/report/SHP_Syphilis-Technical-Report-%28Australia%29-2009.pdf