Syphilis Epidemic 2026 — Why Cases Are Rising in the US

US syphilis cases have risen dramatically since 2017. Congenital syphilis — mother-to-baby transmission — has quintupled in the past decade. The CDC has declared the situation a national priority. Cases are concentrated in specific populations but the upward trend is broad.

Here's what's happening and what works.

The short answer

• Total syphilis cases: From ~30,000 in 2010 to ~200,000+ in 2024
• Congenital syphilis: From ~330 in 2010 to ~3,800+ in 2024 — including stillbirths and infant deaths
• Most affected populations: MSM (decades-long trend), heterosexual men + women (newer; rising fastest), pregnant women, indigenous communities, certain regions
• Drivers: Inadequate prenatal care, drug use intersecting with sex work, healthcare system gaps, post-COVID infrastructure damage
• What works: Universal pregnancy screening + repeat in 3rd trimester + delivery in high-risk areas, increased screening of MSM, doxyPEP for MSM, sexual education, treatment access

The numbers

Adult syphilis (primary, secondary, early latent)

Congenital syphilis (newborns)

Stillbirths and infant deaths

• Approximately 280+ stillbirths/year from syphilis in 2022 (vs 65 in 2012)
• Increased congenital syphilis-related infant deaths

These trends reverse decades of progress.

Who's most affected

Adult syphilis

• MSM: Continue to bear majority of cases historically, though heterosexual cases growing faster recently
• Heterosexual men and women: Fastest-growing demographic; closing the gap with MSM
• Black, Latino, indigenous communities: Disproportionately affected
• Geographic hotspots: South, parts of West (Arizona, New Mexico), parts of Midwest
• People who use drugs: Methamphetamine + sex work overlap drives outbreaks
• People experiencing homelessness

Congenital syphilis

• Pregnant women without adequate prenatal care: Major risk
• Pregnant women using drugs: Increased risk
• Pregnant women in poverty or rural areas: Access barriers
• States with limited Medicaid or restrictive maternal care: Higher rates

Why cases are rising

Healthcare system factors

• Decline in public health infrastructure (1990s-2000s)
• STI program funding cuts in many states
• Disease intervention specialists laid off
• Reduced contact tracing capacity
• Loss of free or low-cost STI clinics
• COVID-19 pandemic disrupted screening and follow-up

Social factors

• Methamphetamine epidemic — links to sex work and risky behavior
• Online dating and hookup apps — more anonymous partners
• Decline in condom use in some populations
• Decreased perceived risk due to HIV prevention success
• Stigma reducing care-seeking

Pregnancy-specific

• Inadequate prenatal care access in many states
• Limited maternal Medicaid coverage
• Mid-pregnancy screening gaps
• Late-pregnancy screening not universal in low-prevalence areas
• Drug use during pregnancy creating barriers to care

COVID effect

• Screening disruptions 2020-2021
• Delayed routine prenatal visits
• Public health workforce reassigned
• Continued backlog of preventive care

What CDC is recommending

For adults

• Annual syphilis screening for MSM
• Annual screening for heterosexual women 25+ in high-prevalence areas
• More frequent screening (every 3-6 months) for high-risk MSM
• DoxyPEP for eligible MSM
• HIV PrEP for HIV-negative MSM
• Universal opt-out HIV testing in healthcare settings

For pregnancy

• First prenatal visit: All women
• At 28 weeks: All pregnant women in high-prevalence areas
• At delivery: All women in high-prevalence areas + high-risk women everywhere
• Treat immediately if positive — don't wait for confirmation

Geographic prioritization

• States with rising rates getting additional federal resources
• Maternal-child health programs receiving congenital syphilis prevention funding
• Increased disease intervention specialists in hot spots

What works (evidence-based)

Adult prevention

• DoxyPEP for MSM: reduces syphilis 87% in trials
• Condoms: reduce transmission ~30-50% (lower than for fluid-borne STIs)
• Treatment as prevention — treated people don't transmit
• Partner notification — disease intervention specialists matter
• HIV PrEP visits — opportunity to catch and treat syphilis early

Pregnancy prevention

• First prenatal screening: Catches most maternal infections early
• Repeat screening at 28 weeks + delivery: Catches infections acquired during pregnancy
• Immediate treatment when positive
• Partner treatment to prevent reinfection during pregnancy
• Penicillin desensitization for allergic patients (NO alternatives in pregnancy)

Community-level

• Free or low-cost STI clinics — make care accessible
• Mobile testing programs
• Targeted outreach to high-risk communities
• Drug treatment programs that integrate STI care
• Anti-stigma campaigns

What individuals can do

If you're sexually active

• Get screened per recommendations (annual minimum for most; every 3-6 months for high-risk)
• Use condoms (helpful but not 100% protective for syphilis)
• Consider doxyPEP if MSM with risk factors
• Test partners before unprotected sex when possible
• Don't ignore lesions or rashes — see provider

If you're pregnant

• Start prenatal care early (first trimester ideally)
• Get screened at first visit — universal recommendation
• Repeat screening at 28 weeks and delivery in high-prevalence areas
• Treat if positive — penicillin, no delay
• Partner notification if positive
• Don't skip prenatal visits

If you're treating someone

• Don't delay treatment while waiting for confirmation
• Treat empirically if clinical suspicion is high
• Treat partners presumptively
• Document treatment clearly
• Schedule follow-up testing for treatment response

The treatment

For non-pregnant adults:

Primary, secondary, early latent syphilis

• Benzathine penicillin G 2.4 million units IM single dose

Late latent or unknown duration

• Benzathine penicillin G 2.4 million units IM weekly for 3 weeks

Tertiary or neurosyphilis

• Aqueous crystalline penicillin G IV for 10-14 days

Pregnancy

• Penicillin is the only effective treatment — no good alternatives
• Penicillin allergy → desensitization required
• Treat without delay

Penicillin allergy (non-pregnant)

• Doxycycline 100 mg twice daily for 14 days (primary, secondary, early latent)
• Doxycycline 100 mg twice daily for 28 days (late latent)
• Doxycycline is NOT used in pregnancy

Penicillin shortages

Periodic shortages of long-acting penicillin have hampered congenital syphilis prevention. FDA and CDC have managed these by:

• Prioritizing pregnant women and children
• Stockpiling
• Working with manufacturers

If a shortage affects your area, providers know how to navigate. Don't skip treatment because of perceived availability issues.

The follow-up

After treatment, repeat RPR testing:

• Primary/secondary: 6 and 12 months
• Latent: 6, 12, and 24 months
• Expected fourfold drop in titer = response
• Persistent or rising titers = treatment failure or reinfection

See syphilis testing process.

What's still uncertain

• How much DoxyPEP scaling will reduce US rates
• Whether geographic targeting strategies will be sufficient
• How long it will take to rebuild public health infrastructure
• What new approaches (vaccine? more frequent screening?) might be needed

What's clear

• The current syphilis epidemic is preventable
• The interventions that work are well-established
• The barriers are mostly systemic (access, funding) not biological
• Individual screening + early treatment + partner notification work

Reframing

The US syphilis epidemic isn't a mystery — it's a consequence of:

1. Public health infrastructure decline
2. Healthcare access barriers
3. Pregnant women not getting care
4. Reduced screening adherence

Solutions exist. They require investment in public health, accessible STI clinics, comprehensive sex education, and Medicaid expansion in states without it.

What you can do as a citizen

• Support public health funding
• Advocate for sex education
• Push for prenatal care access
• Support harm reduction programs
• Reduce stigma in your community
• Get screened yourself + recommend to others

Bottom line

US syphilis is at epidemic levels with congenital syphilis particularly devastating. The drivers are largely systemic. The solutions are largely known.

If you're sexually active: get screened. If you're pregnant: get screened multiple times. If you test positive: get treated immediately.

This is a preventable crisis. It requires action at individual, healthcare system, and policy levels.

For related content, see syphilis testing process, syphilis symptoms by stage, STI testing during pregnancy, STI statistics 2026, and doxyPEP.