1. 1 Syphilis Among Men Who Have Sex with Men: Limitations of Traditional Case and Partner Services, San Diego, CA, 2000 - 2003 Robert A.Gunn, MD, MPH Azi Maroufi, MPH Thomas A. Peterman, MD, MSc Field Epi Unit, ESB, Div STD Prev, CDC STD and Hepatitis Prevention San Diego, CA 619-692-8614 robert.gunn@sdcounty.ca.gov

2. 2 BACKGROUND (1) Cornerstone of syphilis control – Case identification – Case treatment – Partner treatment Timeliness is important Focus on primary and secondary syphilis cases that are infectious. Attempt to make the duration of infectiousness as short as possible, which affects “D” in the reproductive rate equation.

3. 3 BACKGROUND (2) STD Reproductive rate equation R = B x D x C B = Efficiency of transmission 0.01 - 1.0 C = No. of sex partners 1 or more D = Duration of infectiousness 0.002 - 1.0 (1 day to 365  365) R = Reproductive rate, 1.0 steady state

4. 4 BACKGROUND (3) STD interventions focus on “D” – Prompt case treatment – Partner treatment for possible incubating spread partner, “D” = 0 – Focus on “D”, but little analysis reported Anecdotal info – STD traditional interventions not very effective in MSM syphilis outbreaks.

5. 5 Primary and Secondary Syphilis Total Cases by Year of Report, San Diego 1990-2003* * * Estimated from cases Jan-Jun 2003

6. 6 Primary and Secondary Syphilis Total and MSM Cases by Year of Report, San Diego 1995-2003* 52 35 23 25 27 26 37 116 * * Estimated from cases Jan-Jun 2003

7. 7 METHODS P&S syphilis cases 2000 – 2003 (4 years) Stage at diagnosis Assumption – Primary more infectious – Longer infectious period = more transmission Examine differences in stage at diagnosis between MSM and hetero males. During 2000 – 2003, 201 P&S cases

8. 8 P&S STAGE AT DIAGNOSIS Group P&S Cases_ No. (%) Primary No. (%) RR P MSM144(72)47(33) 0.540.01 Male Het. 28(14)17(61) Ref Female 22(11) 2 (9) Male Unk 7_ 201 (3) (100) 2 68 (29) (34)

9. 9 Explanation for Difference? Were anal or oral primary lesions not being detected among MSM?

10. 10 MSM P&S SYPHILIS Anal Recept. No. Primary No. (%)RRP Yes98 23(23) 0.44 0.001 No46 144 24 47 (52) Ref

11. 11 INFECTIOUS PERIOD Are MSM infectious for a longer period than heterosexual men? Difference in stage at Dx suggests MSM will have a longer infectious period “D”.

12. 12 “D” INFECTIOUS PERIOD # days from date onset to Rx – Duration of primary + secondary symptoms For secondary cases, duration of primary determined by patient history or assigned as 21 days, if Hx negative

13. 13 INFECTIOUS PERIOD Group Infectious Period Mean Median P MSM 38 360.08 Hetero Males 31 22 Range – Maximum limited to 84 days (4 weeks primary, 8 weeks secondary), 6 males > 84 days of symptoms.

14. 14 INFECTIOUS PERIOD Infectious Period Primary N Mean Median P MSM44 21 21 0.11 Hetero Males17 17 15 Secondary MSM93 46 42 0.03 Hetero Males 9 59 63

15. 15 SEX PARTNERS AND PARTNER SERVICES Opportunities to preventively Rx spread partners, D = 0 Identify other infectious P & S cases and treat Identify and Rx infected but non-infectious persons

16. 16 DEFINITIONS Sex partners – estimated number of partners during the interview period – Primary cases 90 day period – Secondary cases 180 day period Contacts – Person’s named with some locating information – also called initiated partners Local contacts – Contacts residing in San Diego County

17. 17 SEX PARTNERS ENUMERATED No. Partners__ GroupCases#Mean MedianP MSM1441544 10.73.0 0.002 Hetero Males 2875 2.72.0 Range – maximum No. partners limited to 100 5 males enumerated >100 partners

18. 18 SEX PARTNERS AND CONTACTS GroupCases No. Partners No. Contacts(%)P MSM1441544247(16)< 0.001 Hetero Males 28 7530(40) Contacts = 0 MSM = 51 (35%), hetero males = 10 (36%)

19. 19 SEX PARTNERS LOCATED Contacts____ __ GroupCases Partners # All # Local # Located # (%) MSM1441544247197151(77) Hetero Males 2875302216(73) Contacts outside of jurisdiction – MSM 50, hetero male 8; treatment results not in data base.

20. 20 SEX PARTNERS TREATED Local Contacts_____ GroupCases Partners # Located # Treated # (%) Total Rx † # (%) MSM1441544151122(8)172 (11) Hetero Males 28751613(17) 21 (28) † Best case - All out of jurisdiction contacts located and Rx. – 50 MSM, 8 Hetero Males

21. 21 CONCLUSIONS Syphilis cases among men have many infectious days before Rx Among MSM, many primary infections may be missed (receptive anal or oral) Among MSM sex partners, only a small portion receive preventive Rx Community-level traditional case and partner service effectiveness appears limited, especially among MSM

22. 22 RECOMMENDATIONS Continue to focus on “D” 1)Evaluate programs to improve symptom recognition and health care seeking by MSM

23. 23 SYMPTOM RECOGNITION Provide symptom cards to MSM – HIV/MSM physicians’ offices – HIV/STD prevention programs – High-risk venues – HIV counseling/testing sites Emphasize seriousness of acute neurosyphilis – permanent disabilities

24. 24 RECOMMENDATIONS 2)Evaluate programs to improve clinician diagnosis and reporting

25. 25 PHYSICIAN DIAGNOSIS/REPORTING Provide educational materials Frequent visits – Use skills and approaches of pharmaceutical reps Outcome – To improve collaboration and develop referral pathways to STD, HIV and substance abuse programs

26. 26 RECOMMENDATIONS Focus on “D” may not be enough, more emphasis on “B” and “C.” Prioritize “core” transmitter intervention Prevention case management - screening, risk reduction 2 - 3 mos. Work closely with HIV programs to develop innovative prevention and control strategies while maintaining efficient and effective traditional case and partner services.

27. 27

28. 28 CLUSTERS TREATED Group Cluster Initiated No. Local Located # (%) Rx No (%) MSM61 43(70) 23 (58) Hetero Males 10 71 10 53 (100) 2 (20) 25 (35)

29. 29 1990-92 OUTBREAK P&S syphilis (N = 696) San Diego, 1990 – 92, among heterosexual, African Am, Crack, CSW – No. sex partners = 2901 (4.2 case) – Contacts = 1045 (36%) – 22% of cases named no partners – Estimated only 26% of partners Rx

30. 30 FURTHER STUDY Review interview records – Among secondary cases- -- History of primary, missed Dx – Among all cases -- Missed / delayed Dx Consider planned evaluation of symptom recognition, access to care, timely Dx, and reporting.