An expanding syphilis epidemic in China: epidemiology, behavioural risk and control strategies with a focus on low-tier female sex workers and men who have sex with men

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Abstract
Syphilis has made a dramatic resurgence in China during the past two decades. During the Cultural Revolution (1966–76), sexually transmitted infections (STI) were so uncommon that they were removed from standard Chinese medical training curricula.1 As China's market economy expanded during 1980s economic reforms, reported STI, including syphilis infection, quickly re-appeared. An evolving STI reporting infrastructure largely assembled in the 1990s has noted increasing syphilis cases, particularly during the past 5 years (figure 1).2 3 Now syphilis is among the top five reported communicable diseases in many major province-level municipalities and provinces.4 While China's syphilis case reporting system and potential determinants of spread have been outlined in other reviews,2 there have been many studies on syphilis infection among female sex workers (FSW),5 6 this review analyses syphilis in China from the perspective of two critical high-risk populations: men who have sex with men (MSM) and low-tier FSW. Here we define low-tier FSW as women who usually solicit clients on the street or public outdoor places and sell sex for less than approximately €2–10 per client. Although preventing adverse outcomes associated with syphilis in pregnancy is important,7 this review focuses on adult syphilis infections in China. The purpose of this review is to examine syphilis epidemiology, risk behaviours, control strategies and research priorities in the Chinese context.

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