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Research at the 2006 National STD Prevention Conferences Highlights Impact of Syphilis on African Americans and Men who Have Sex with Men (MSM); CDC Launches Updated Elimination Plan to Respond to New Syphilis Challenges

 National prevalence study shows disproportionate impact of syphilis among African Americans

 New studies of MSM risk factors provide direction for prevention interventions

 Innovative website addresses barriers to partner notification among MSM

Jacksonville, Fla. (May 8) – Data from a large, national population-based study of syphilis prevalence, presented at the 2006 National STD Prevention Conference, show the disproportionate impact of syphilis on blacks in the United States. Other studies presented at the conference provide important insights into syphilis risk among men who have sex with men (MSM), and suggest directions for prevention efforts in this population.

In response to new challenges – especially the increasing impact of syphilis among MSM – the Centers for Disease Control and Prevention (CDC) today launched an updated national syphilis elimination plan to reverse recent increases in U.S. syphilis rates. The new plan updates and refines recommendations from CDC’s 1999 elimination plan to ensure that progress to date is maintained among African Americans and other populations originally targeted, while new strategies are designed to reverse the rising rates of syphilis among MSM in recent years.

Since the 1999 plan was issued, there have been significant declines in syphilis rates among key populations at risk, including African Americans, women, and newborns, and a significant drop in the black-white racial disparity in syphilis diagnoses.

New prevalence data show blacks most affected
A new CDC prevalence study analyzed data collected between 2001 and 2004 from a nationally representative household survey of more than 5,700 people, and found that, while just 0.71 percent of Americans between the ages of 18 and 49 had been infected with syphilis at some point in their lives, 4.3 percent of blacks in this age group had been infected. Blacks were significantly more likely than whites (0.07% infected) and Mexican-Americans (0.98% infected) to have had the disease (Poster 297).

Studies provide new insights into syphilis risk among MSM
In Chicago, reported syphilis infections among MSM increased by 87 percent between 2004 and 2005, following significant declines in the previous two years, according to a new study by the Chicago Department of Public Health. MSM also accounted for three quarters (73%) of all cases of syphilis in the city in 2005, a sharp increase from just over half (54%) of all cases in 2004 (Poster 309).

Understanding the reasons why MSM are at greater risk for syphilis infection is crucial to finding ways to reverse rising infection rates. Two other studies may provide important clues. In Chicago, 10 percent of MSM diagnosed with syphilis between 2000 and 2005 acquired the infection more than once. In comparison, only 1 percent of women and 0.5 percent of heterosexual men had repeat infections, according to a CDC analysis of the medical records of individuals with reported cases of syphilis during the study period (Oral 375).

“Repeat infection with syphilis among a subset of gay and bisexual men may be an important factor behind the sustained transmission of the diseases in this population,” said Dr. Kevin Fenton, Director of CDC’s National Center for HIV, STD and TB Prevention (NCHSTP). “Finding ways to reach this group with effective prevention interventions is critical if we are to reverse rising rates of syphilis cases in the United States.”

Another study, led by researchers in San Diego, found that MSM are significantly less likely than heterosexual men to have syphilis infections diagnosed in the earliest stage of the disease, when it is most infectious. Researchers believe this is because, among MSM, the lesions that are often the only symptom of primary syphilis are more likely to be in the anus or mouth and therefore to go unrecognized. After analyzing the medical records of all reported cases of syphilis in San Diego County between 2000 and 2005, researchers found that MSM were
37 percent less likely than heterosexual men to be diagnosed during the primary stage of infection, and MSM who reported practicing receptive anal intercourse were 48 percent less likely than other MSM to be diagnosed in the earliest stage of the disease (Oral 371).

“Delayed diagnosis among men who have sex with men may result in continued risk behavior during the period in which syphilis can be most easily transmitted, as men may be unknowingly spreading the disease,” said Dr. John M. Douglas, Jr., Director of the Division of STD Prevention at NCHSTP. “Based on these findings, we recommend frequent testing among these men at risk of syphilis and education of clinicians and the men themselves to increase the likelihood that syphilis lesions are recognized.”

CDC launches updated plan to eliminate syphilis
At the conference, CDC announced the launch of the update to its national syphilis elimination plan – Together We Can: The National Plan to Eliminate Syphilis from the United States. The document updates CDC’s 1999 plan and is designed to eliminate the sustained transmission of the disease in the U.S. Syphilis elimination is defined as less than 1,000 cases of primary and secondary (P&S) syphilis reported per year.

The nation has experienced significant declines in syphilis rates among populations at risk. Between 1999 and 2004, P&S syphilis rates among blacks decreased 37 percent (from 14.3 to 9.0 cases per 100,000), and the black-white racial disparity fell from 28.6:1 to 5.6:1. Rates among women overall decreased 60 percent (from 2.0 to 0.8 cases per 100,000), and rates among newborns declined by 39 percent (from 14.5 to 8.8 per 100,000 live births).

Despite important gains in many populations, however, overall rates have been on the rise since 2001, largely due to increases among men. Overall, the P&S syphilis rate among men increased 68 percent from 1999 to 2004. While surveillance data are not available by risk behavior, a separate CDC analysis suggests that approximately 64 percent of all adult P&S syphilis cases in 2004 were among MSM, up from an estimated 5 percent in 1999.

“We have made great strides in reducing the burden of syphilis among African Americans, women, and newborns since the launch of the plan in 1999,” said Dr. Fenton, who led the development of the revised plan. “This updated plan calls for renewing our efforts in those communities to ensure that we maintain the progress made. It also lays out an innovative and comprehensive strategy to stem the tide of rising infections among MSM. We have heard from the community that new efforts to reduce syphilis infections are urgently needed, and this plan provides the framework to eliminate syphilis as a significant public health threat in the United States.”

The new plan focuses on three primary strategies: a) enhancing public health services, including surveillance, laboratory capacity, clinical care, and partner notification programs;
b) prioritizing and targeting interventions to the populations at greatest risk, with particular attention to MSM, African Americans, and women; and c) improving the accountability of prevention efforts through investment in training, data-driven planning and evaluation, and research to design improved tools for syphilis diagnosis, prevention, and control.

The plan recommends several new strategies to address syphilis infections among high-risk groups. This includes better assessing access to healthcare and specific STD prevention services among minority populations in order to develop culturally appropriate interventions that reach those most at risk. It also means broadening partnerships with community-based organizations (CBOs), which have already played a major role in the progress made in those communities to date. To help better define and track syphilis among MSM, the plan recommends that state and local health departments expand the data collected during routine partner notification efforts, and begin to report the gender and sexual orientation of the sexual partners of all individuals infected with syphilis. The new plan also prioritizes the development of novel Internet-based initiatives to reach the increasing number of MSM who meet partners online.

Innovative online partner notification program used by thousands of MSM
Several recent studies have shown that MSM are increasingly using the Internet to meet sexual partners. A new program, called “inSPOT.org,” launched in San Francisco in 2004, is now using the Internet to help MSM notify past partners that they may have been exposed to an STD. Thousands of men have used the site to send illustrated “ecards,” which include personalized messages urging partners to be tested for STDs. Senders can indicate the STD they have been diagnosed with, and can send the cards anonymously. In 2005, almost 24,000 cards were sent to 39,000 recipients. More than one-third (36 percent) of recipients clicked on an Internet link to obtain information about STDs and how to get tested. The program is expanding to other cities across the country and will soon include content to reach women and heterosexual men (Oral 61).