Robert A.Gunn, MD, MPH Marjorie Lee, MPH Thomas A. Peterman, MD, MSc

1. Syphilis Among Men Who Have Sex with Men: Are Occult Primary Stage Lesions Limiting the Effectiveness of Traditional Case and Partner Services? San Diego, CA, 2000 - 2005 Robert A.Gunn, MD, MPH Marjorie Lee, MPH Thomas A. Peterman, MD, MSc Field Epi Unit, ESB, Div STD Prev, CDC HIV, STD and Hepatitis Branch San Diego, CA 619-692-8614 robert.gunn@sdcounty.ca.gov

2. BACKGROUND (1) PRINCIPLE UNDERLYING STD CONTROL STD REPRODUCTIVE RATE • B - Transmission efficiency Inherent probability of transmission 1.0 - 0.001 • D - Duration of infectiousness Infectious days / 365 0.003  1.0 • C - No. of susceptible partners • Partners/year 1.0  • R - Reproductive Rate > 1.0 cases < 1.0 cases = 1.0 Steady State

3. BACKGROUND (2) • Cornerstone of syphilis control – • Prompt case and partner identification and treatment to decrease “D” duration of infectiousness. • Focus on infectious cases ─ primary most infectious, secondary less (mucous patches, condyloma lata). • Attempt to make the duration of infectiousness “D” as short as possible.

4. SYPHILIS OUTBREAK ─ SAN DIEGO • Mid-2002 to current • Most cases Dx secondary or latent • MSM 75% of P&S cases • Many anonymous partners • How much impact on “D” possible?

5. Primary & Secondary SyphilisTotal Cases by Year of Report, San Diego 1990-2005 * *Preliminary Data

6. Primary & Secondary Syphilis Total and MSM Cases by Year of Report, San Diego 1995-2005 192 * 136 109 52 35 38 23 23 25 27 27 *Preliminary Data

7. METHODS • P&S cases Jan 00 – Aug 05 (~ 6 years) • Stage at diagnosis - MSM and men who have sex with women exclusively (MSWe) • 478 P&S cases, 361 (76%) MSM (includes 24 probable MSM) • Data from interview records collected at time of diagnosis

8. P&S STAGE AT DIAGNOSIS

9. PRIMARY STAGE • MSM were 37% and Females 79% less likely than MSWe to be diagnosed in primary stage • Site undiagnosed occult primary MSM – anal, oral Females – vaginal, anal, oral

10. MSM ANAL RECEPTIVE SEX

11. OCCULT ANAL LESION • MSM having receptive anal sex 48% less likely than MSM not reporting receptive anal sex to be Dx primary stage. • Overall data by stage, and these data on anal sex, support concept of primary stage occult painless anal ulcers may contribute substantially to MSM syphilis transmission.

12. PRIMARY LESION • Site of primary lesions • Secondary cases – Hx primary • Reported duration of primary • Total primary infectious days

13. LESION SITE

14. SECONDARY SYPHILIS WITH PRIMARY LESION HISTORY

15. PRIMARY INFECTIOUS DAYS – MSM

16. PRIMARY INFECTIOUS DAYS - MSWe

17. PRIMARY INFECTIOUS DAYS

18. SEX PARTNERS AND CONTACTS

19. CONCLUSIONS (1) • MSM, MSWe, and females - many untreated primary infectious days • MSM and MSWe primary symptoms - onset to Rx >15 days (median) • Many (66%) MSM pass through primary stage untreated – occult primary – most likely anal/rectal

20. CONCLUSIONS (2) • Only 13% MSM with secondary syphilis have Hx of primary lesion • MSM many partners (11.8/cases), only 13% named as contacts with locating info • Suggests that usual STD field services for MSM have limited access to primary infectious cases and partners = limited effectiveness in preventing transmission

21. RESEARCH QUESTIONS • Delay in seeking care – primary symptoms • Physicians’ knowledge about syphilis clinical signs and symptoms • Missing penile primary ─ circumcision? • Secondary without primary ulcer? • Relapse of early latent syphilis? • Anoscopy – case series of possible occult primary – titer ≤ 1:8, no symptoms

22. RECOMMENDATIONS (1)STD CONTROL PROGRAMS • Prioritize case and partner services to primary syphilis and possible occult primary • Develop category of possible occult primary • Working definition – asymptomatic MSM RPR ≤ 1:8 (or high-risk female ≤ 1:8)

24. RECOMMENDATIONS (2)SURVEILLANCE

25. RECOMMENDATIONS (3)PATIENT EDUCATION • Symptom cards to MSM • Include rectal and oral symptoms • Frequent serologic screening for high-risk MSM • Dispensing Sites • HIV/MSM physicians’ offices • HIV/STD prevention programs • High-risk venues • STD clinic, HIV test sites

26. RECOMMENDATIONS (4)PHYSICIAN EDUCATION • Provide educational materials ─ Occult primary – titer ≤ 1:8 encourage oral exam, anal exam/anoscopy ─ Frequent syphilis screening high-risk MSM, 1-2 months (neg to ≤ 1:8) • Frequent visits to physicians by staff ─ Use approach of pharmaceutical reps to improve collaboration and develop referrals to STD, HIV and drug abuse

27. RECOMMENDATIONS (5) • Focus on “D” may not be enough to substantially ↓ “D”, more emphasis on “B” (condoms) and “C” (limit partners) • Since traditional case and partner services may have limited effectiveness among MSM • develop modified case and partner services for MSM – more impact for the effort • work closely with HIV programs to develop innovative STD prevention and control strategies

28. ACKNOWLEDGEMENTS Co-Authors Marjorie Lee, MPH - Epidemiologist San Diego County HHSA Thomas Peterman, MD – Field Epidemiology Unit. ESB, Div. STD Prevention, CDC Slide Preparation Rita Perry Jody Thomas San Diego County, HHSA

29. EXTRA SLIDES

30. PRIMARY INFECTIOUS DAYS

31. LIMITATIONS • Routine DIS interview records • Duration of lesion may be inaccurate • Secondary cases – Hx primary may be underestimated • Record review planned

32. MSM PRIMARY (N = 121)

33. MSM SECONDARY (N = 240)

34. MEN SEX WOMEN (MSWe) PRIMARY (N = 34)

35. MEN SEX WOMEN (MSWe) SECONDARY (N = 30)

36. SEX PARTNERS ENUMERATED