1. 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

2. Early Syphilis By Sexual Orientation & Month Of Diagnosis, 2001-2003 * Does not include cases lacking partner information Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, 2003 2001 2002 2003 Cases Los Angeles County - DHS

3. 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

5. 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 - 6.5 months preceding the onset of symptoms; and Early latent – one year prior the date of treatment. Los Angeles County - DHS

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

7. 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 919 251 (27.3) 666 (72.7) Age (y) 0.03 * < 20 13 0 13 (1.9) 20 - 29 173 40 (15.9) 133 (19.9) 30 - 39 386 116 (46.2) 270 (40.4) 40 – 49 243 73 (29.1) 170 (25,5) 50 + Median Age 10422 (8.8) 37 82 (12.3) 35 * p-value < 0.05 Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, 2003 Los Angeles County - DHS

8. 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

9. 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 436 130 (51.8) 306 (47.4) African American 94 23 (9.2) 71 (10.6) Hispanic 336 82 (32.7) 254 (38.0) Other/Mixed 53 16 (6.4) 37 (5.5) HIV Status 0.01 * Positive 545 168 (70.1) 377 (60.6) Negative 316 71 (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

10. 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

11. 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 726 205 (85.8) 521 (80.9) No 157 34 (14.2) 123 (19.1) Anal receptive0.19 Yes 704 201 (83.1) 503 (79.1) No 174 41 (16.9) 133 (20.9) Oral sex 0.05 * Yes 851 239 (97.6) 612 (94.4) No 42 6 (2.4) 36 (5.6) Anonymous partner 0.01 * Yes 708 229 (92.3) 479 (74.0) No 187 19 (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

12. 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) No537146 (68.2)391 (67.2) Incarcerated past year 0.57 Yes348 (3.7)26 (4.6) No756211 (96.3)545 (95.4) IV Drug user0.06 Yes209 (3.8)11 (1.7) No867228 (96.2)639 (98.3) Non-IV drug user0.02 * Yes26084 (35.7)176 (27.3) No620151 (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

13. 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

14. 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

15. 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) 300.6 (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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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