December 5, 2000
Milwaukee -- Many gay and bisexual men lack key information about syphilis, including how to identify signs and symptoms of the sexually transmitted disease (STD), according to a study presented at the National STD Prevention Conference being held December 4-7 in Milwaukee. The study comes as increasing evidence -- including new studies presented at the STD conference -- indicates that the annual incidence of syphilis and other STDs is rising among gay men in a number of U.S. cities.
"Syphilis and other STDs that many have long forgotten continue to pose a significant health risk to gay men," said Helene Gayle, M.D., M.P.H., director of CDC's National Center for HIV, STD, and TB Prevention (NCHSTP). "Efforts to prevent sexually transmitted diseases must be revitalized and reshaped to stop this increasing toll."
Based on a survey of 683 men who have sex with men (MSM) attending a gay event in Chicago, researchers found that 42.5 percent of those surveyed did not know that syphilis facilitates HIV transmission, and 52.3 percent were unaware that syphilis is increasing among gay men in some communities. The study was led by Carol Ciesielski of the Chicago Department of Health.
Only 26 percent of respondents correctly identified rash as a sign of syphilis, while 61.5 percent incorrectly identified urethral discharge as a symptom. The majority of those surveyed knew that penile, oral, and anal ulcers are signs of the disease.
According to Ronald O. Valdiserri, M.D., M.P.H., deputy director of CDC's HIV, STD, and TB programs, the findings do not imply that gay and bisexual men are less knowledgeable about syphilis than other groups at risk, but are likely indicative of a low level of understanding across the entire population. Yet, given recent data, the CDC believes that expanded education among gay and bisexual men should be a priority.
"Prevention has to begin with awareness and basic education," added Valdiserri. "Together with other recent reports of upswings in risk behavior and STD rates, this survey underscores an urgent need for syphilis education appropriately tailored to the gay community." ["Knowledge and Awareness of Syphilis among Attendees of the International Mr. Leather Competition," C. Ciesielski, et al.]
Cornelius Rietmeijer, M.D., Director for AIDS at the Denver Department of Public Health, and his colleagues analyzed patient records at the Denver Metro Health Clinic, and found that gonorrhea rates among MSM visiting the clinic dropped from 6.4 percent in 1990 to 5.4 percent in 1995, before they began to increase significantly, to 7.9 percent in 1996 and 12.8 percent in 1999. Gonorrhea rates among HIV-positive MSM also increased during this period, from 9.3 percent in 1995 to 19.7 percent in 1999. This upward trend contrasts with gonorrhea rates seen in heterosexual men visiting the clinic, which fell from 8.2 percent in 1995 to 5.7 percent in 1999.
The increase in gonorrhea among MSM was accompanied by an increase in the reported rate of anal intercourse, which increased from a stable level of 55 percent through the end of 1996 to 79.1 percent in 1999. Rietmeijer noted that these trends coincided with the availability of effective new HIV/AIDS treatments, which may be causing some MSM to become complacent about safe sex practices. ["Trends in Gonorrhea Rates Among Men who have Sex with Men, Denver 1990-1999," C. Rietmeijer, et al.]
Handsfield's analysis shows that 68 MSM in King County were reported with infectious syphilis in 1999, compared to only five MSM in 1997. MSM also represented a growing share of all syphilis cases in the county, increasing from 28 percent (five out of 18 cases) in 1997 to 84 percent (32 out of 38 cases) by the first half of 2000. Most of the MSM with syphilis (73 percent) were also infected with HIV. These data represent a dramatic resurgence of the disease in the county, where just four years earlier, in 1996, there were no syphilis cases.
The study also found that gonorrhea and chlamydia rates among MSM in the county have increased significantly in recent years. By the middle of the 1990s, gonorrhea rates among MSM had been reduced tenfold below the rates of the early 1980s. However, this trend began to reverse as gonorrhea rates among MSM in the county increased from 225 cases per 100,000 in 1997 to at least 475 cases per 100,000 in 1999. By comparison, in 1999 the gonorrhea rate in the remainder of the county's population was approximately 44 to 49 cases per 100,000. The researchers identified a similar trend for cases of chlamydia among MSM in the county.
Handsfield attributed the STD trends to increased frequencies of unsafe sex among MSM, likely related to improvements in treatment, which have resulted in more people living with HIV, as well as the belief among some MSM that HIV is no longer as serious a disease. He said the changes have significant implications for HIV transmission among MSM and for the nation's initiative to eliminate syphilis transmission in the United States. ["Re-emergent STDs Among Men who have Sex with Men: A Public Health Crisis," H. Hunter Handsfield, et al.]
Valdiserri also noted that CDC is studying ways to expand access to effective prevention programs for gay and bisexual men. These programs will address the unsafe sexual practices and complacency that have resulted in part from advances in treatment, and help men to establish and maintain safer behaviors over a lifetime.
From August 1999 through May 2000, the researchers surveyed 904 gay and bisexual men at a variety of clinical settings about their sex and drug use practices. The men were also offered testing for gonorrhea, chlamydia and syphilis.
The study found that many MSM in the county reported having unprotected sexual intercourse, and that many were infected with an STD. Among MSM who reported having anal sex during the preceding two months, 43 percent reported either "never" or only "sometimes" using condoms. Among MSM surveyed at STD clinics, rectal gonorrhea or chlamydia was found in 10.8 percent of HIV-negative men and 14.7 percent of HIV-positive men.
A significant proportion of MSM surveyed acknowledged that they had used drugs in the preceding two months, with higher rates of drug use among HIV-positive men. Twelve percent of HIV-negative men and 20 percent of HIV-positive men said they had used methamphetamines, and 37 percent of HIV-negative men and 53 percent of HIV-positive men said they had used amyl nitrate (commonly known as "poppers"). ["Sleepless in Seattle: Risk Behaviors and Bacterial STDs Among HIV Positive and HIV Negative Men who have Sex with Men," W.L.H. Whittington, et al.]
In a conference presentation, Wendy Wolf, M.D., of the San Francisco Department of Health reported on successful efforts to provide STD prevention information through the Internet following this syphilis outbreak. Website staff worked with health workers to post information about syphilis on a popular gay Internet home page, which was linked to the Department of Health STD clinic website, and also visited chat rooms to educate participants about syphilis and to encourage people who had met partners in the chat room to seek medical evaluation.
In the month following the awareness campaign, there was an 18 percent increase in the number of gay men evaluated at the city's STD clinic, and there are plans to expand the campaign with the Internet service providers. ["Partner Notification in Cyberspace," Wendy Wolf, et al.]
In Denver, Sheana Bull, M.D., of the AMC Cancer Research Center collaborated with the Denver Public Health Department to conduct a survey to determine whether sexual partners who meet over the Internet are more likely to practice risky sexual behaviors. Bull and her colleagues analyzed surveys from 4,601 respondents, aged 18 years or older, who were living in North America. These respondents were overwhelmingly male (71.2 percent), well educated (50 percent had college degrees) and white (81.3 percent).
When respondents did have Internet partners, those partners were predominantly male (63.4 percent). The responses indicated that 55.8 percent of partners who made contact on the Internet used condoms the last time they had anal or vaginal intercourse, compared to 40.8 percent of non-Internet partners, suggesting that while people who seek partners over the Internet do engage in STD risk behaviors, they may actually be more likely to use condoms than those who seek partners offline. ["Risk Behaviors Related to Internet Sex Partner Solicitation: Results from an Online Survey," Sheena Bull, et al.]