2002 National STD Conference - Abstracts Referenced in Other Presentations/Findings of Interest

Abstract 418: "Patterns of STD Infection, HIV Coinfection, and Risk-Behavior among MSM at a Boston Community Health Center"

SA Golub¹, K Mayer^{1, 2, 3}, W Lo¹, D. Cohen¹

¹ Fenway Community Health, Boston, MA; ² Brown University, Providence, RI; ³ Miriam Hospital, Providence, RI

Background: Several recent reports have documented alarming increases in sexually transmitted infection rates among men who have sex with men (MSM), and a corresponding decline in safer sex practices. After years of successful prevention efforts, this trend may portend a resurgence of HIV infection in the MSM community. Fenway Community Health is a freestanding clinic that follows the largest population of MSM in Boston, and provides primary care to more than 1,000 people living with HIV.

Objectives: To examine recent patterns of STD infection, STD/HIV co-infection, and sexual risk-taking behavior among a group of MSM diagnosed with syphilis or gonorrhea in a Boston community health center.

Methods: A retrospective chart review was conducted, including all MSM who tested positive for gonorrhea, syphilis, or chlamydia in 1999 and 2000. Four types of variables were extracted: 1) demographics; 2) visit variables; 3) clinical variables; and 4) behavioral variables. Analyses included univariate descriptives and both bivariate and multivariate comparisons.

Results: Gonorrhea rates have tripled to more than 100 cases per year, since the mid 1980s. The twelve cases of syphilis diagnosed last year are the largest number in over a decade. Analyses revealed differences in demographic patterns by type of STD and infection site. For example, over 75% of new syphilis cases occurred among MSM ages 30-39, while both rectal and pharyngeal gonorrhea were most common among MSM under 30. Analyses also revealed important findings in patterns of sexual behavior; for example, 21% reported that they were infected through contact with their regular sexual partner. Finally, at least 20% of STD cases occurred among HIV-positive individuals.

Conclusions: Gonorrhea and syphilis have significantly increased in recent years at Fenway Community Health. Different patterns of STD infection and risk behavior are occurring among MSM of different age groups and among HIV-positive and -negative populations.

Implications for Programs/Policy: Additional interventions are needed to address rising rates of STD infection in the MSM community.

Implications for Research: This study points to the need for further research on the determinants and dynamics of risk-behavior among MSM.

Measurable Learning Objectives: By the end of this session, participants will be able to describe key findings from this analysis, and explain demographic and behavioral dynamics that are potentially important to future prevention efforts in the MSM community.

Abstract 280: "Increases in Gonorrhea among Vulnerable Populations: Obstacles to Disease Intervention"

SJ Shapiro^1,2, S Downes¹

¹Maine Bureau of Health; ²Centers for Disease Control and Prevention, Atlanta, GA

Background and Rationale: Gonorrhea in the state of Maine, until recently, had been characterized as isolated occurrences of disease with little or no evidence of transmission within social networks. An outbreak in Waterville in 1999 has been previously described. Ongoing outbreaks among men who have sex with men (MSM) and young women have provided additional opportunities to describe current prevention infrastructure and intervention methods.

Objective: Describe two ongoing outbreaks among vulnerable populations and identify obstacles to disease intervention activities.

Methods: Traditional STD partner notification methods were used to identify, locate, examine, treat, and counsel persons at risk for gonococcal infection during these outbreaks. Recommendations and instructions for use of diagnostic tools were distributed to medical providers statewide. Community outreach activities occurred in partnership with local HIV service organizations.

Results: Gonorrhea among MSM, up 45% in 2001, is concentrated in the largest urban area in the state. Gonorrhea among women aged 15-19, up 200%, is evenly distributed throughout the state. Culture methods for the detection of gonorrhea are generally unavailable. Lack of insurance coverage or disposable income can lead to treatment of partners without diagnostic evaluation.

Conclusions: Traditional disease intervention activities are increasingly more difficult among vulnerable populations. Income status, as well as diagnostic test availability, impacts partner notification activities.

Implications for Programs/Policy: Community-based organizations and state/local health departments can successfully partner to provide accurate and timely information to affected populations and their healthcare providers. Additional mechanisms for financial support for diagnostic testing and therapy are necessary.

Implications for Research: Development of non-culture gonorrhea diagnostic methods for pharyngeal and rectal infections would aid in the epidemiologic analysis of outbreaks, especially among MSM.

Contact Information: Steven Shapiro, 207-287-4473

Abstract 272: "Changing Epidemiology of Syphilis and Other Sexually Transmitted Diseases Among Men Who Have Sex with Men"

C McLean¹, G DeSimone², H Calvet³, R Bronzan¹, G Paz-Bailey¹

¹Centers for Disease Control and Prevention, Atlanta, GA; ² Whitman Walker Clinic, Washington DC; ³Long Beach Department of Health and Human Services, Long Beach, CA

Background: While primary and secondary syphilis rates have declined almost 90% in the last decade, large outbreaks of syphilis have occurred in several US cities among men who have sex with men (MSM). Data from these outbreak investigations and reports from behavioral surveys indicate that some MSM are participating in high-risk sexual behaviors that place them at increased risk for sexually transmitted diseases (STDs) and HIV infection. Similar findings have been reported internationally. Because syphilis increases the likelihood of acquiring and transmitting HIV infection and because a large proportion of MSM with syphilis in these outbreaks are HIV positive, the rise in syphilis among MSM may indicate an increase in the incidence of HIV infection.

Objective: To describe the epidemiology of recent syphilis outbreaks among MSM and to present data from prevalence monitoring of STDs and HIV risk behaviors among MSM.

Content: Findings will be presented from recent syphilis outbreak investigations in Los Angeles, New York City, and Miami, and from the Monitoring Trends in Prevalence of STDs, Tuberculosis, and HIV Risk Behaviors Among MSM Project (MSM Project) in nine cities.

Implications for Programs/Policy: As the epidemiology of syphilis changes, reviewing local STD and HIV surveillance data, including behavioral data, from MSM and other at-risk populations will be increasingly important. Because surveys suggest that concern about HIV infection may be declining among MSM, efforts to prevent HIV infection in this population may need to be evaluated and strengthened. Results from outbreak investigations and the MSM Project may help direct local and national efforts to decrease STD and HIV transmission among MSM.

Implications for Research: Data from outbreak investigations and the MSM Project highlight questions requiring further research, including potentially modifiable risk factors for the acquisition of STD and HIV among MSM.

Learning Objectives:

By the end of this session, participants will be able

1) To describe the epidemiology of recent syphilis outbreaks among MSM

2) To describe the prevalence of STDs and HIV risk behaviors among MSM participating in a 9 city prevalence monitoring project

Contact information: National Center for HIV, STD and TB Prevention, Office of Communications: 404-639-8895

Abstract 444: "Changes in the Epidemiology of Syphilis in New York City, 1999-2001"

G Paz-Bailey¹, A Meyers², L Markowitz¹, J Brown², S Rubin^1,2, S Blank^1,2

¹Centers for Disease Control and Prevention, Atlanta, GA ²STD Control Program, Department of Health, New York City, NY

Background: Since 1990, primary and secondary syphilis (P&S) rates have declined in New York City (NYC), from 58.2 per 100,000 in 1990 to 1.67 in 2000. However, in 2000 and 2001 there was an increase in the number of P&S syphilis cases among men who have sex with men (MSM), many of whom are co-infected with HIV. Similar outbreaks among MSM have been reported in other US cities.

Objective: To describe an outbreak of P&S syphilis among MSM in New York City.

Study Methods: We reviewed case interview records and syphilis surveillance data for P&S syphilis cases reported to the NYC Department of Health from 1999 through June 2001.

Results: From January to June 2001, 132 cases of P&S syphilis were reported, compared to 130 and 117 for all 1999 and 2000, respectively. Overall, 121 (92%) were male; the mean age was 34 years. The number of cases among whites increased from 9 in 2000 to 46 cases in 2001. More than 50% of males were MSM. Of those with known HIV status (n=24), 8 (33%) were sero-positive; 7 of these were MSM. Of MSM cases, 42% were white, 55% were from the borough of Manhattan and 54% were reported by private providers. Ten MSM cases, but no non-MSM, reported anonymous sex.

Conclusions: The current outbreak in NYC involves mainly men who have sex with men, many of whom are co-infected with HIV.

Implications for Programs/Policy: The high proportion of co-infection of syphilis with HIV is of particular importance since syphilis increases the risk of transmitting and acquiring HIV.

Implications for research: The increase in P&S syphilis among MSM might be signaling changes in sexual practices and attitudes which needs to be addressed by further prevention research.

Learning Objectives: By the end of this session, participants will be able to describe the epidemiology of a recent syphilis outbreak among MSM in New York City.

Contact Information: National Center for HIV, STD and TB Prevention, Office of Communications, 404-639-8895

Abstract 321: "Sexually Transmitted Diseases, HIV Testing, and HIV Risk Behaviors Among Men Who Have Sex with Men Seeking Care at Howard Brown Health Center"

CA Ciesielski^1,2; J Flynn ³, C McLean²

¹Chicago Department of Public Health, Chicago, IL; ²Centers for Disease Control and Prevention, Atlanta, GA; ³Howard Brown Health Center, Chicago, IL

Background: There has been a resurgence of gonorrhea (GC) and syphilis among men who have sex with men (MSM), as well as decreasing use of condoms during receptive anal intercourse (RAI).

Objectives: To prospectively monitor the prevalence of STDs, HIV, and risk behaviors in MSM clients of Howard Brown Health Center (HBHC).

Methods: Medical charts were abstracted for all MSM who attended HBHC's primary care and STD clinics (including bathhouse screening) between 1/1/00 and 12/31/00.

Results: Included in the analysis were 1,283 MSM. Sixty-four (10%) of 653 men tested were infected with CT, 108 (17%) of 622 had GC, and 15 (2%) of 644 had infectious syphilis. Comparing MSM with and without STDs, 39% vs 26%, respectively, reported RAI in the past 60 days, and 20% vs 13% reported sex in bathhouses (p< 0.05). Of those reporting RAI, 40% vs 54% reported always using condoms; 49% vs 20% sometimes did, and 25% vs 26% reported never using condoms (p=0.03). While 74% of MSM with STDs had been HIV tested, only 31% of those without STDs had been (p<.001). Of those with STDs, 16% of those tested were HIV infected, compared to 19% of MSM without STDs (p>.05). However, of those with syphilis, 40% were HIV infected.

Conclusion: These data identify a relatively high prevalence of STDs among the MSM presenting for medical care and STD screening. Of particular concern is the HIV prevalence among those with STDs, indicating recent unsafe sexual activities among these men.

Implications for Programs: Continued monitoring of STDs and high risk behaviors among MSM is critical to evaluate trends in sexual practices and the impact of prevention efforts in this high risk population in Chicago.

Implications for Research: These data highlight the urgent need for behavioral studies to identify more effective prevention methods for MSM.

Measurable Learning Objectives:

1) To identify the extent of the STD morbidity among MSM clients of Howard Brown Health Center

2) To understand the implications of high STD morbidity among MSM for STD program

3) To recognize the research implications of high STD morbidity among MSM

Contact Information: Carol Ciesielski, 312-747-0105

Abstract 403: "'Barebacking' in a Diverse Sample of MSM"

G Mansergh¹, G Marks¹, G Colfax², R Guzman², M Rader¹, S Buchbinder²

¹Centers for Disease Control and Prevention, Atlanta, GA; ²San Francisco Department of Public Health, CA

Background: "Barebacking" was defined as intentional unprotected anal sex with a non-primary partner and assessed among MSM who had heard of the term, an assessment of barebacking as a sociocultural phenomenon.

Objectives: Session participants will be able to describe the prevalence of and motivations for barebacking in an ethnically diverse sample of HIV-positive and -negative MSM.

Methods: Cross-sectional survey of MSM from the San Francisco Bay Area. Men were recruited in 2000-01 outside multiple venues and later interviewed as participants in the MSM Prevention Messages Study.

Results: The sample (n = 554) included MSM who identified as African-American (28%), Latino (27%), white (31%) and other race/ethnicity (14%); 35% self-identified as HIV-positive. Most men (70%) were aware of the term "barebacking." Of those who were aware, 14% barebacked in the previous 2 years (22% of HIV-positive vs. 10% of HIV-negative men, p<.001), with a median of 3 bareback partners in the past year. In their last bareback encounter, nearly half of these men had a partner whose HIV-status was different or unknown to the respondent. Increased physical stimulation and emotional connectedness were primary motivators for barebacking.

Conclusions: It is critical to reduce risk of STD/HIV transmission among MSM through new approaches that consider their needs and motivations, particularly men who engage in intentional unprotected anal sex with non-primary partners.

Implications for Programs/Policy: Innovative behavioral and biomedical interventions are needed for MSM who bareback. Policies should address the fact that both HIV-positive and -negative men intentionally engage in unprotected anal sex outside of primary relationships.

Implications for Research: More research should be undertaken regarding innovative behavioral and biomedical interventions. Research is needed on awareness and prevalence of barebacking in other MSM communities and geographical areas.

Contact Information: National Center for HIV, STD and TB Prevention, Office of Communications: 404-639-2863

Continued