December 18, 2003
In accordance with California law, cases of syphilis are reported to SFDPH by laboratories and public and private health-care providers. A case of early (i.e., <1-year duration) syphilis was defined as a case of primary, secondary, or early latent syphilis diagnosed in a San Francisco resident. Early syphilis cases had darkfield-positive lesions, reactive serologic tests for syphilis and accompanying symptoms, or reactive serologic tests with evidence of syphilis infection occurring during the preceding year.
Persons with early syphilis were interviewed by SFDPH staff. Interviewers obtained demographic data (e.g., sex, age, race/ethnicity, address, and sexual orientation) and risk-behavior information (e.g., sexual behavior, condom use, number and sex of partners, venues for meeting partners, alcohol and recreational drug use, and self-reported HIV status) for the period when syphilis might have been acquired or transmitted. This period was determined on the basis of stage of disease at the time of treatment (i.e., 3 months before treatment for primary syphilis, 6 months for secondary syphilis, or 12 months for early latent syphilis). Interviews were accompanied by disease-intervention counseling, which assisted in locating and treating sex partners.
During 2002, a total of 434 cases of early syphilis among MSM were reported to SFDPH. The median age of MSM with early syphilis was 38 years (range: 14-66 years). Of these 434 patients, 289 (66.6%) were white, 69 (16.0%) were Hispanic, 34 (7.8%) were Asian/Pacific Islander, 31 (7.1%) were black, and 11 (2.5%) were from other racial/ethnic populations; 293 (67.5%) were HIV seropositive. Information about sexual behavior and sex partners was obtained from 415 MSM. These men reported a total of 6,482 sex partners during the period when syphilis might have been acquired or transmitted (median: six partners; range: zero to 500 partners). The most common venues for meeting sex partners reported by the 415 patients with early syphilis were the Internet (32.6%), bars (20.6%), bathhouses (13.3%), sex clubs (12.6%), and adult bookstores (5.5%). During January 2000-December 2002, the proportion of MSM with early syphilis who reported meeting sex partners on the Internet increased significantly (pFigure 2).
In a review of 151 early syphilis cases among MSM interviewed for partner management during January-April 2003, a total of 67 (44.4%) men reported meeting sex partners over the Internet; 14 (20.9%) provided information about 44 sex partners for whom the only locating information was an Internet e-mail* address. Eleven (25%) of the 44 Internet partners lived outside of the San Francisco Bay Area. SFDPH staff located 15 (34%) of the Internet partners and ensured that they were evaluated and treated appropriately. The following two case reports are illustrative of successful online partner notification, evaluation, and management.
This report describes the increasing association between early syphilis infection and use of the Internet as a means for MSM to meet sex partners. Often the only link that these men have to their Internet partners is an e-mail address. This report demonstrates how an Internet e-mail address can be used successfully to notify persons that they have been exposed to syphilis. The findings also suggest that the Internet facilitates MSM meeting sex partners when they travel. Meeting new sex partners while traveling might explain, in part, the rapid dissemination of syphilis among MSM throughout the United States and western Europe.4-7
Health departments should learn how the Internet is used to meet sex partners and how health agencies can use the Internet to contact partners for disease intervention. Concerns about the notification of sex partners through the Internet include protecting confidentiality and ensuring that notification messages are not discarded as junk mail or "spam." To respond to these concerns, SFDPH developed interim practices for performing partner notification online (Box). SFDPH is continuing to refine its online partner management program.
The findings in this report are subject to at least three limitations. First, the findings are largely descriptive. Second, not all MSM with early syphilis infection in San Francisco were interviewed; the observations described in this report might not reflect all MSM with early syphilis. Finally, the findings might not be representative of all MSM with early syphilis in the United States.
Local health departments in other cities that have had large increases in early syphilis cases among MSM should consider using the Internet for partner notification and management. Internet partner management might serve as a useful new tool in addressing this epidemic, even though it might reach only a small number of partners. In contrast to anonymous partners met in sex clubs, bathhouses, and adult bookstores, effective disease intervention is possible for Internet partners. Online prevention activities can include individual outreach, banner ads with links to sexual health promotion sites, and other social marketing activities.8 CDC is coordinating local and national efforts to engage the gay and bisexual community, Internet service providers, and public health officials in developing effective Internet-based prevention strategies.
As has been observed in other cities,4-6 a high proportion of MSM with early syphilis in San Francisco also were co-infected with HIV. Because STDs increase the risk for HIV transmission9 and MSM are among persons at highest risk for HIV infection,10 controlling syphilis among MSM also might be important for preventing further HIV transmission. The findings in this report underscore the importance of coordinated STD- and HIV-prevention efforts among the gay and bisexual community, public health officials, and health-care providers.
C.K. Kent, M.P.H., W. Wolf, M.P.A., G. Nieri, W. Wong, M.D. and J.D. Klausner, M.D. are with the San Francisco Dept of Public Health, San Francisco, California. T.A. Peterman, M.D. is with the Division of STD Prevention, National Center for HIV, STD, and TB Prevention, CDC.
This report is based on contributions by the Syphilis Team; R Kohn, M.P.H., San Francisco Dept of Public Health, San Francisco, California. Syphilis Rapid Response Team, Div of STD Prevention, National Center for HIV, STD, and TB Prevention, CDC.
* E-mail service provided by an Internet service provider or an Internet-based e-mail account.