Of Andhra Pradesh’s 45 deaths, 35 were among men – even though men accounted for less than a third of the state’s reported cases. Experts say the data reflect delayed diagnosis and poor health-seeking behaviour, especially among men with mild or no symptoms.
Published Apr 14, 2025 | 7:00 AM ⚊ Updated Apr 14, 2025 | 7:00 AM
Syphilis is a sexually transmitted disease caused by the bacterium Treponema pallidum. (iStock)
Synopsis: Syphilis cases rose sharply across the Telugu states in 2021–22, with Telangana reporting the most cases in India by 2022 and Andhra Pradesh recording nearly all related deaths. Andhra Pradesh saw 45 deaths, mostly among men, despite a drop in infections, pointing to late diagnosis and poor access to care.
Syphilis infections rose sharply in Telangana between 2021 and 2022, while Andhra Pradesh recorded the highest number of deaths from the disease, according to data from the National Health Profile 2023.
Together, the two states accounted for a significant share of India’s syphilis burden, but with vastly different trajectories.
In 2021, Andhra Pradesh reported more cases than any other state, with 13,007 infections. Telangana, by contrast, logged just 2,870.
But in 2022, the trend flipped. Telangana’s caseload jumped more than fivefold to 15,798 – the highest in the country – while Andhra Pradesh saw infections fall by 38 percent, to 8,107.
Despite the drop in cases, Andhra Pradesh recorded 45 of India’s 49 syphilis-related deaths that year. Telangana, in contrast, reported no deaths in either 2021 or 2022.
Of Andhra Pradesh’s 45 deaths, 35 were among men – even though men accounted for less than a third of the state’s reported cases. Public health experts say the data reflect delayed diagnosis and poor health-seeking behaviour, especially among men with mild or no symptoms.
“Syphilis can be sneaky,” Dr Kartik Vedula, Consultant of Infectious Diseases at Yashoda Hospital in Hyderabad told South First. “It’s often latent – symptoms might disappear for a while and then show up weeks or even months later. We sometimes call it the ‘great mimic’ because it can look like so many other diseases. In that sense, it’s a bit like HIV (human immunodeficiency virus) in how it presents.”
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Believed to have been introduced to India by European explorers in the late 16th century, syphilis posed a major public health threat during the British Raj.
Despite the advent of antibiotics and mass awareness campaigns since independence, the sexually transmitted infection – caused by the bacterium Treponema pallidum – has never fully disappeared.
“Primary syphilis usually starts with a painless sore or chancre – typically in the genital or oral areas,” said Dr Vedula. “Then comes secondary syphilis, where people might get rashes, skin lesions, or even neurological symptoms like seizures – that’s what we call neurosyphilis.”
If untreated, the disease can progress to a latent or tertiary stage, with potentially serious internal damage. But many cases today are detected incidentally, with patients showing no symptoms.
“In clinical practice, we mostly see latent cases – people who do not show any symptoms at all,” Dr Vedula said. “A lot of times, it is women who are diagnosed during routine antenatal check-ups. They come in for pregnancy screening, and syphilis shows up in the standard tests.”
Routine health screenings also catch asymptomatic infections: “People go for general health packages, and if syphilis pops up in their report, they are sent to us. These folks are usually asymptomatic too – they only come in because the lab test flagged it.”
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While the rise in Telangana’s infections may seem alarming, the state’s zero-death count suggests that its antenatal screening and early detection systems are functioning well. The gender breakdown helps explain why.
In Andhra Pradesh, women made up about 69 percent of all reported cases in 2021, and 70 percent in 2022 – largely due to high screening rates during pregnancy. In 2022, out of 8,107 reported cases in the state, 5,643 were in women, and just 2,464 in men.
In Telangana, the distribution was more balanced: 7,982 female cases and 7,816 male cases were reported in 2022.
“Generally, research shows a slight male predominance in syphilis infections – something like 2.5 men for every woman. But when you look at surveillance data from places like Andhra Pradesh, you often see more reported cases in women,” said Dr Vedula.
“But that does not necessarily mean more women are getting infected,” he clarified. “What it really shows is how effective antenatal care has become. During pregnancy, women are routinely screened for STIs (sexually transmitted infections) – including syphilis – usually in the first trimester. So many infections are caught early, even when the woman does not have any symptoms.”
“In contrast,” he said, “men usually only come in when they notice symptoms – like lesions or discomfort – and even then, it is often out of fear, guilt, or concern that a partner might find out. Especially if the infection happened through high-risk behaviour, like contact with commercial sex workers.”
Stigma and cultural barriers further limit early detection – especially among men and non-pregnant women. “There is still a lot of stigma around sexual health. Women, in particular, may be less likely to come forward or even recognise a need to get tested – unless it is part of routine care like during pregnancy. That leads to underreporting,” he said.
“So really,” Dr Vedula added, “it is not always about who is more infected – it is about who is more likely to be tested and diagnosed. And with stronger antenatal care systems in place, we are catching a lot more female cases early – which is crucial, because untreated syphilis in pregnancy can lead to serious complications like stillbirth or developmental issues in the baby. That is why syphilis screening during pregnancy is such a high priority.”
Testing for syphilis involves two types of laboratory tests. “We usually start with a VDRL (Venereal Disease Research Laboratory) or RPR (Rapid Plasma Reagin) test – those are non-treponemal,” said Dr Vedula. “If that comes back positive, we do a confirmatory test like TPHA (Treponema pallidum haemagglutination assay), which is treponemal-specific. Once we have confirmed the diagnosis, we move ahead with treatment.”
Treatment itself is simple: patients are given a course of weekly injections over three weeks.
But awareness remains low – even among high-risk groups. “Syphilis affects around 0.5 percent of the general population, based on available data. But if you look at sexually transmitted infections as a group, the prevalence is much higher – in some states, it can go up to 10 percent,” he said. “There has definitely been a global rise in syphilis cases over the last two decades – and India is not an exception. Infections are going up, but awareness has not kept up.”
According to Dr Vedula, stigma remains the biggest obstacle. “There is a huge social taboo around STIs. People associate them with things like premarital or extramarital sex, multiple partners, or contact with commercial sex workers. These are all sensitive topics – and because of that, many people hesitate to talk about it or even seek help,” he said.
“What makes it harder is that syphilis often starts with painless lesions – especially in the genital area – so people may not even know they are infected. And even if they notice something unusual, fear or shame holds them back from going to a doctor,” he said.
“A lot of the cases we end up treating are discovered through routine laboratory tests – not because the patient came in saying something was wrong. Some get diagnosed during pregnancy check-ups, and others might walk into a dermatology clinic for a completely different skin issue. That is when we catch it.”
“The problem is, when people do not know they are infected – and do not get treated – they keep unknowingly passing it on to others.”
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Though syphilis is sometimes seen as a disease of the poor or vulnerable, Dr Vedula said that assumption is misleading.
“Syphilis is mainly spread through sexual contact, and it is most common in people aged 20 to 40,” he said. “There have been attempts to correlate it with socioeconomic status, but the evidence is mixed.”
“You will find cases in educated, white-collar professionals – people with graduate degrees – as well as among drivers, daily wage workers, and people in rural areas,” he said. “So we cannot assume that being literate or financially well-off protects you. Risky sexual behaviour cuts across all levels of society.”
Key risk factors such as unprotected sex, multiple partners, same-sex relations (men who have sex with men – MSM), and extramarital affairs are present across social classes. Migration and separation from partners also contribute, he said.
“Take migrant workers and truck drivers – they are often away from home for long periods. That separation and loneliness, combined with lack of awareness, can lead to high-risk sexual encounters. That is where the risk spikes,” he said.
More worryingly, syphilis and HIV frequently coexist.
“We see a higher prevalence of syphilis among people living with HIV. Both are sexually transmitted, and they share common risk factors,” said Dr Vedula. “In HIV-positive individuals, syphilis can be more aggressive and progress faster. The risk of transmission is also higher.”
“This is why, when someone tests positive for one STI, we usually screen them for others – like HIV, hepatitis B, or gonorrhoea,” he added. “Because the behaviours and transmission modes overlap, early and comprehensive screening becomes really important.”
(Edited by Dese Gowda)
