April 2006 Syphilis Epidemic in Los Angeles County S EXUALLY T RANSMITTED D ISEASE P ROGRAM

2 Primary and Secondary Syphilis Rates in the United States, 1981–2004* Rate (per 100,000 population) Source: Tom Peterman, Division of STD Prevention, National Center for HIV, STD, and TB Prevention. Centers for Disease Control and Prevention

3 P&S Syphilis Rates by Sex in the United States, 1981–2004 Men Women Rate (per 100,000 population) Source: Tom Peterman, Division of STD Prevention, National Center for HIV, STD, and TB Prevention. Centers for Disease Control and Prevention

4 P & S Syphilis: Rates by Race and Ethnicity, 1981–2003 Source: Tom Peterman, Division of STD Prevention, National Center for HIV, STD, and TB Prevention. Centers for Disease Control and Prevention Rate (per 100,000 population)

5 P&S Syphilis Rates by Sex and Race, United States, Black men Black women White men White women Rate (per 100,000 population) Source: Tom Peterman, Division of STD Prevention, National Center for HIV, STD, and TB Prevention. Centers for Disease Control and Prevention

6 National Plan to Eliminate Syphilis: Definitions lNational Level: The absence of sustained transmission in the United States. –Healthy People 2010 Objective (per 100,000 population): lNational Target = 0.2 lNational (2004) = 2.7 lLocal Level: The absence of transmission of new cases within the jurisdiction except within 90 days of report of an imported index case. Source: CDC Syphilis Elimination Executive Summary

7 Syphilis Elimination l“It is anticipated that these definitions will translate to <1,000 cases (0.4/100,000 population) of primary and secondary (P&S) syphilis reported nationally each year. “The national goal, therefore, is to reduce Primary & Secondary syphilis cases to 1,000 or fewer and to increase the number of syphilis-free counties to 90% by 2005” Source: CDC Syphilis Elimination Executive Summary

8 Cross Cutting Strategies lEnhanced surveillance : –includes complete, accurate, and timely reporting of positive syphilis tests; effective, timely, and regular data analyses; development of a framework for and implementation of syphilis surveillance; and ongoing evaluation of the amount of syphilis in a community by monitoring positive syphilis tests. lStrengthened community involvement and partnerships: –acknowledges and responds to the effects of racism, poverty, and other relevant social issues on the persistence of syphilis in the U.S.; develops and maintains partnerships to increase the availability of and accessibility to preventive and care services; and assures that affected communities are collaborative partners in developing, delivering, and evaluating syphilis elimination interventions. Source: CDC Syphilis Elimination Executive Summary

9 Intervention Strategies lRapid outbreak response : –includes both the development of an outbreak response plan and establishment of area-specific criteria that determine when the outbreak response plan should be implemented. lExpanded clinical and laboratory services: –provides accessible and timely client-centered counseling, screening, and treatment services in sites frequented by populations at risk for syphilis; and ensures high quality syphilis preventive and care services. lEnhanced health promotion: –includes implementation and evaluation of appropriate and effective health promotion interventions; and timely delivery of high quality, confidential, and comprehensive client-centered partner services to patients, partners, and other identified high-risk individuals. Source: CDC Syphilis Elimination Executive Summary

10 National Plan to Eliminate Syphilis lWhile national in scope, the NPES focuses on two area categories: 1. areas with high syphilis morbidity; 2. those areas with potential for syphilis re-emergence. lHigh Morbidity Areas (HMAs): areas with continuing syphilis transmission; HMAs must address all five of the syphilis elimination strategies. Source: CDC Syphilis Elimination Executive Summary

11 National Plan to Eliminate Syphilis lPotential re-emergence areas (PRAs): areas that currently experience little or no syphilis transmission but that are at significant risk for syphilis reintroduction because –1. History f high syphilis rates in the 90s or more recently. –2. A port or border jurisdiction or are located along migrant streams –3. Located along drug corridors –4. They include groups that are disproportionately affected by syphilis lPRAs should focus primarily on enhanced surveillance and rapid outbreak response, including the involvement of affected communities in implementing these strategies. Source: CDC Syphilis Elimination Executive Summary

12 Source: LAC DHS STD Program; N=51,749 Reported Sexually Transmitted Diseases, Los Angeles County (n=51,759), 2004

13 Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, 2005

14 Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, 2005

15 Reported Primary, Secondary and Early Latent Syphilis Cases, Los Angeles, California, United States, YearLos Angeles (1) California (2) United States (3) P&SELP&SELP&SEL ,9799, ,1038, , ,8628, , ,1778, , ,9807, N/A

16 Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, 2005

17 Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, 2005

18 Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, 2005

19 Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, 2005

20 Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, 2005

21 Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, 2005 SPAs with less than 6% included in “Other”

22 Trends in Early Syphilis in Los Angeles County, Women lFemale incidence has increased 97% between 2001 (69) and 2005 (136). –African American and Hispanic women each comprised 41% of 136 ES cases reported for women in 2005 –17% of these cases were pregnant l91% of pregnant cases were either African American or Hispanic lNearly one-third of female ES cases in 2005 were from SPA 6, followed by SPA 4 at 18%, SPA 8 at 15%, and SPA 7 at 12%. l1.5% syphilis cases were co-infected with HIV

23 Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, 2005

24 Trends in Early Syphilis in Los Angeles County, Men lThe Syphilis epidemic has been concentrated in the Hollywood-Wilshire Health District (SPA 4, Metro) lEpidemic is centered around the MSM and MSM/W populations –Primarily amongst White and Latino MSM lApproximately 60% of MSM were co-infected with HIV

Behavioral Risk Factors for MSM Syphilis Cases

26 Sexual Encounter Venues Among MSM Early Syphilis Cases, Los Angeles County, Bars/Clubs (n=846) Internet (n=512) CSVs (n=429) Source: Epidemiology Unit, STD Program, 2006.

27 Sociodemographic Characteristics Associated with Behavioral Risk Factors, 2004 Variables Odds ratio (95% CI) Univariate analysisMultivariate analysis Demographic Age (y) (0.4 – 0.9)0.7 (0.4 – 1.1) Race/ethnicity White vs. Non-white1.3 (0.9 – 1.7)1.1 (0.8 – 1.6) HIV Positive Yes vs. No1.5 (1.1 – 2.1) * 1.6 (1.1 – 2.5) * Behavioral Anal insertive Yes vs. No1.4 (0.9 – 2.1)1.6 (0.9 – 2.9) Anal receptive Yes vs. No1.3 (0.8 – 1.9)1.0 (0.6 – 1.7) Oral sex Yes vs. No2.3 (0.9 – 5.6)0.5 (0.2 – 1.7) Anonymous Partners Yes vs. No4.2 (2.5 – 6.9) * 4.7 (2.4 – 9.2) * Condom Use No vs. Yes0.9 (0.7 – 1.3)0.9 (0.6 – 1.4) Incarcerated Yes vs. No0.8 (0.4 – 1.9)0.8 (0.3 – 2.1) IV Drug User Yes vs. No2.3 (0.9 – 5.6)2.4 (0.7 – 8.6) Non-IV drug User Yes vs. No1.5 (1.1 – 2.0)*1.4 (1.2 – 2.1)* * p<0.05

28 Commercial Sex Venues lCompared to those who did not, MSM diagnosed with syphilis that frequent commercial sex venues were: –Two times as likely to be HIV infected –Five times as likely to report having sex with anonymous partners –One and half times as likely to use non-IV drugs lThe most common drug used at commercial sex venues was methamphetamine (60%). lThey were also: –more likely to report condom non-use, IV drugs use than those who do not. –less likely to have sexual encounters at other venues (bars/clubs, motels, parks, Internet, dancehalls, streets).

29 MSM and the Internet lOverall 19% MSM who were diagnosed with early syphilis infection met their sexual partners through the Internet –65% were HIV positive lMSM with early syphilis who do use the Internet to meet their sexual partners were: –2.6 times more likely to be White –3.8 times more likely to have anonymous sex –2.6 times more likely to use injection drugs lIndependent predictors of meeting sexual partners via the Internet among MSM with early syphilis were: –White race –Having anonymous sex partners

30 Conclusion lDespite national progress toward syphilis elimination syphilis remains an important problem in the South and in urban areas in other regions of the country. lIn Los Angeles County syphilis rates amongst MSM populations have continued to rise since In this population, the epidemic has been characterized by high HIV-co-infection rates.

31 Conclusions (cont’d) lIn 2004, syphilis rates increased for men and women in almost all racial and ethnic groups. lIn 2004, half of the total number of P&S syphilis cases in the US were reported from 19 counties and 1 city 1.Los Angeles County 2.San Francisco County, CA 3.Cook County, IL 4.New York County, NY 5.Fulton County, GA 6.Dade County, FL 7.Harris County, TX 8.Baltimore (City), MD 9.Dallas County, TX 10.Broward County, FL

32 Syphilis Elimination Conclusions “Elimination of syphilis would have far-reaching public health implications because it would remove two devastating consequences of the disease –increased likelihood of HIV transmission and compromised ability to have healthy babies due to spontaneous abortions, stillbirths, and multi-system disorders caused by congenital syphilis acquired from mothers with syphilis. In addition, more than $996 million is spent annually as a result of syphilis. Eliminating syphilis in the United States would be a landmark achievement because it would remove these direct health burdens, and it would significantly decrease one of this Nation's most glaring racial disparities in health.” Source: CDC Syphilis Elimination Executive Summary

Dante’ Tolbert, MPH Epidemiology Analyst, STD Program (213) S EXUALLY T RANSMITTED D ISEASE P ROGRAM