Commercial Sex Venues: A Closer Look At Their Impact on the Syphilis Epidemics Among Men Who Have Sex With Men in Los Angeles Getahun Aynalem, MD, MPH, Kellie Hawkins, MPH, Lisa V. Smith, Ms, Dr PH, Cathleen Bemis, MS, Melanie Taylor, MD, MPH, Peter Kerndt, MD, MPH Los Angeles County Department of Health Services STD Program

Early Syphilis By Sexual Orientation & Month Of Diagnosis, * Does not include cases lacking partner information Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, Cases Los Angeles County - DHS

Early Syphilis Cases By HIV Serostatus & Sexual Orientation, 2000 – 2003 (n=1465) Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, 2003 Sexual Orientation Los Angeles County - DHS

Objectives 1.To identify the demographic and behavioral characteristics of MSM diagnosed with syphilis that reported using commercial sex venues for sexual encounter during the “Critical period” for syphilis infection. 2.To assess the difference in risk behaviors between those who use commercial sex venues for sexual encounter and those who do not. 3.To assess whether MSM were also using other venues for the same purpose. Critical period: Primary syphilis - 90 days, Secondary syphilis months preceding the onset of symptoms; and Early latent – one year prior the date of treatment. Los Angeles County - DHS

Methods Study population Data collection Data elements Data analysis Los Angeles County - DHS

Age Comparison of MSM with Early Syphilis Who Did and Did not Frequent Commercial Sex Venues Demographic Characteristics Total Had sex or met sex partner at bathhouses & sex clubs Yes N (%) No N (%) P - value Over all (27.3) 666 (72.7) Age (y) 0.03 * < (1.9) (15.9) 133 (19.9) (46.2) 270 (40.4) 40 – (29.1) 170 (25,5) 50 + Median Age (8.8) (12.3) 35 * p-value < 0.05 Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, 2003 Los Angeles County - DHS

NO (N=668) YES (N=251) Age Comparison of MSM with Early Syphilis Who Did and Did not Frequent Commercial Sex Venues p-value = 0.03 Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, 2003 Los Angeles County - DHS

Race/ethnicity and HIV Status Comparison of MSM with Early Syphilis Who Did and Did not Frequent Commercial Sex Venues Demographic Characteristics Total Had sex or met sex partner at bathhouses & sex clubs Yes N (%) No N (%) P - value Race/ethnicity0.33 White (51.8) 306 (47.4) African American (9.2) 71 (10.6) Hispanic (32.7) 254 (38.0) Other/Mixed (6.4) 37 (5.5) HIV Status 0.01 * Positive (70.1) 377 (60.6) Negative (29.7) 245 (39.4) * p-value < 0.05 Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, 2003 Los Angeles County - DHS

NO (N=622) YES (N=239) HIV Status Comparison of MSM with Early Syphilis Who Did and Did not Frequent Commercial Sex Venues p-value < 0.01 Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, 2003 Los Angeles County - DHS

Risk Behavior Comparison of MSM with Early Syphilis Who Did and Did not Frequent Commercial Sex Venues Risk Behaviors Total Had sex or met sex partner at bathhouses & sex clubs Yes N (%) No N (%) P - value Anal insertive0.09 Yes (85.8) 521 (80.9) No (14.2) 123 (19.1) Anal receptive0.19 Yes (83.1) 503 (79.1) No (16.9) 133 (20.9) Oral sex 0.05 * Yes (97.6) 612 (94.4) No 42 6 (2.4) 36 (5.6) Anonymous partner 0.01 * Yes (92.3) 479 (74.0) No (7.7) 168 (26.0) * p-value < 0.05 Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, 2003 Los Angeles County - DHS

Risk Behavior Comparison of MSM with Early Syphilis Who Did and Did not Frequent Commercial Sex Venues Had sex or met sex partner at bathhouses & sex clubs Risk Behaviors TotalYes N (%)No N (%)P - value Condom used0.78 Yes25868 (31.8)191 (32.8) No (68.2)391 (67.2) Incarcerated past year 0.57 Yes348 (3.7)26 (4.6) No (96.3)545 (95.4) IV Drug user0.06 Yes209 (3.8)11 (1.7) No (96.2)639 (98.3) Non-IV drug user0.02 * Yes26084 (35.7)176 (27.3) No (64.3)469 (72.7) *p-value<0.05 Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, 2003 Los Angeles County - DHS

Risk Behavior Comparison of MSM with Early Syphilis Who Did and Did not Frequent Commercial Sex Venues *P < 0.05 Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, 2003 Los Angeles County - DHS

Drug Use Comparison of MSM with Early Syphilis Who Did and Did not Frequent Commercial Sex Venues Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, 2003 Los Angeles County - DHS

Influence of Demographic and Behavioral Characteristics on Having sex or Meeting sex Partners at Commercial Sex Venue Among MSM with Syphilis Diagnosis 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 Los Angeles County - DHS

Other Venues Use Comparison of MSM with Early Syphilis Who Did and Did not Frequent Commercial Sex Venues Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, 2003 Los Angeles County - DHS

Conclusions MSM diagnosed with syphilis that frequent commercial sex venues are: –twice more likely to be HIV infected –five times more likely to report having sex with anonymous partners –one and half times more likely to use drugs (non- injection) than those who did not. The most common drug used at commercial sex venues is methamphetamine (60%). Cases who attended CSV were: –more likely to report condom non-use, IV drugs –less likely to have sexual encounters at other venues (bars/clubs, motels, parks, Internet, dancehalls, streets). Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, 2003 Los Angeles County - DHS

Limitations Behavioral and HIV status data are self reported and it is possible that study subjects may have been reluctant to report their risk behaviors Therefore, our findings are likely to be conservative estimates of the role commercial sex venue play in syphilis and HIV epidemics in Los Angeles. The study sample did not consist of participants randomly selected for this study which limits generalization of our finding to MSM and the general population. Los Angeles County - DHS

Recommendations General: HIV and STDs prevention interventions tailored to MSM who frequent commercial sex venues is an immediate priority if we are to control syphilis, HIV and other STDs infections in this population. Venue and behavioral specific interventions that foster communication, risk awareness, HIV testing, disclosure of HIV status and condom use should be delivered onsite. Los Angeles County - DHS

Recommendations Venue specific: CSV must develop and enforce guidelines that eliminate drug use and unprotected anal sex by maintaining an environment that fosters communication, risk awareness, HIV testing, disclosure of HIV status, and condom use. CSV guideline should include structural elements such as adequate light, facility for HIV/STD testing and counseling services, and notice to patrons of the risk for HIV and STD transmission and acquisition. Provide safe sex materials and supplies such as condoms and lubricants. Drugs use should not be tolerated. Los Angeles County - DHS

Recommendations Individual specific: Practice positive behaviors that reduce risk such as: –HIV/STD testing –Disclosure –Condom use –Recreational drug non-use Further study is needed to identify specific barriers for positive attitudes and social norms at these environments. Los Angeles County - DHS