Syphilis Control Among Men Who Have Sex With Men: Public Health Response to an Outbreak

After the epidemic years of 1986 through 1990, US syphilis rates steadily declined to an all-time low of 2.5 cases per 100,000 population in 1999, leading the CDC to create a national plan for syphilis elimination. Nevertheless, multiple US areas continue to experience disease outbreaks and a resurgence of STDs among men who have sex with men (MSM). Because syphilis is increasingly characterized by sporadic outbreaks, rapid outbreak response should include enhanced surveillance of groups at high risk.

Los Angeles County Men's Central Jail (LACMCJ) maintains an inmate unit that houses approximately 300 self-identified MSM voluntarily segregated from the general inmate population. During an outbreak of syphilis among MSM, the Los Angeles County Sexually Transmitted Diseases Program (LACSTDP) initiated a syphilis control program in the MSM unit of LACMCJ that consisted of screening, mass prophylactic treatment, high-risk behavior detection, and education. The segregation of MSM from other inmates presented the opportunity to screen and treat patients with syphilis and detect risk behaviors among newly incarcerated MSM. The mass screening and treatment of a correctional population segregated on the basis of sexual orientation has not been previously reported.

Voluntary syphilis and HIV screening of all inmates in the MSM unit of LACMCJ began in March 2000. All current and newly incarcerated inmates were offered screening with informed consent. Pre- and post-test counseling and risk reduction counseling was provided. Chlamydia and gonorrhea screening were added for all new MSM inmates in April 2000.

The LACSTDP began prophylactically treating inmates with single-dose azithromycin in April 2000. All inmates were offered azithromycin, regardless of whether they accepted screening or the behavioral survey. Those who accepted took the treatment under observation. Azithromycin prophylaxis for new inmates was discontinued in August 2000.

A voluntary behavioral survey was offered, with informed consent, to all inmates entering the MSM unit beginning in June 2000, whether or not they accepted syphilis screening or azithromycin prophylaxis. The survey was administered in a classroom as part of new inmate processing.

From March through August 2000, 811 inmates were screened for syphilis, and 38 (5 percent) tested positive. Of the 38 inmates with positive tests, 29 had previously treated syphilis and nine had newly identified syphilis. Two cases were identified in preoperative male-to-female transgender persons. Inmates who tested positive for syphilis reported a total of 135 partners but provided names for only 5. Consensual high-risk sex among MSM while incarcerated was reported by some inmates. A total of 765 inmates accepted azithromycin therapy (94 percent acceptance). A total of 73 inmates tested positive for HIV, 20 for chlamydia, and 7 for gonorrhea. Newly incarcerated MSM were predominantly white and younger than 35 years; approximately one-third were black. Eight percent identified as transgender persons, 87 percent had been incarcerated before, and 20 percent had a history of prostitution. At the time of the survey, four percent of the inmates presented with symptoms of syphilis. Of participants, 76 percent reported not using condoms with their main partner; 70 percent reported not using condoms with other partners.

Screening in the correctional setting enabled identification and treatment of 9 new cases of syphilis and 29 previously treated cases. The high acceptance of azithromycin prophylaxis indicates the feasibility of mass therapy as a disease containment measure among incarcerated MSM. The mass therapy intervention to treat incubating syphilis was justified, given that 4 percent of surveyed inmates were experiencing symptoms of syphilis. The increased prevalence of HIV in this population indicates the need for specialized HIV/AIDS case managers in correctional facilities. Syphilis outbreak response plans should include mechanisms to reach incarcerated MSM, who are especially vulnerable because of coinfection with HIV and participation in high-risk sex, the authors concluded.

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