LAC - DHS

1. The Internet: An Emerging Venue for Syphilis Epidemics Among Men Who Have Sex with Men in Los Angeles Getahun Aynalem, MD, MPH, Kellie Hawkins, MPH Lisa V. Smith, MS, Dr. PH, Cathleen Bemis, MS, Melanie Taylor, MD, MPH, Peter Kerndt, MD, MPH Los Angeles County Department Health Services STD Program LAC - DHS

2. Introduction Since the last quarter of 2000, there has been an outbreak of syphilis primarily affecting MSM in Los Angeles. Traditionally, popular sex venues for the MSM population have been bathhouses, bars/clubs, streets, motels, and parks and the use of these venues to meet sexual partners. Recently, the use of the Internet among MSM in California is emerging as a dominant venue for meeting sexual partners. Although it has been shown that popular sex venues have been associated with drug use, unprotected anal intercourse and anonymous sex, little is known about: the impact of Internet on the incidence of STDs, including HIV and syphilis. the difference between MSM with syphilis who use the Internet for sexual encounter and those who do not. LAC - DHS

3. Introduction 1 1 *Does not include cases lacking partner information Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, 2003 LAC - DHS

4. Early Syphilis Cases By HIV Serostatus & Sexual Orientation, 2001–2003 (n=1,465) Sexual Orientation LAC - DHS Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, 2003

5. Objectives To identify the demographic and behavioral characteristics of MSM diagnosed with syphilis that reported using the Internet for sexual encounter during the“Critical period”for syphilis infection. To assess the difference in risk behaviors between those who use the Internet for sexual encounters and those who do not. To identify the most common Internet sites for sexual encounters used by MSM with early syphilis diagnosis. Critical period:Primary syphilis - 90 days , Secondary syphilis - 6.5 months preceding the onset of symptoms; and Early latent – one year prior the date of treatment. LAC - DHS

6. Methods Between January 2001 and December 2003, demographic, behavioral and venue information were collected from 899MSM who were diagnosed with early syphilis(primary, secondary and early latent). Association between demographic and behavioral characteristics with Internet use for sexual encounter were assessed using chi-square and Fisher’s exact test . Independent predictors of Internet use and the odds of initiating sexual contact through the internet were calculated using logistic regression. The most frequent internet sites for initiating sexual encounter reported by MSM with syphilis diagnosis were also documented. LAC - DHS

7. Results • Demographic, behavioral, and venue information were collected for 899 MSM early syphilis cases during field interviews. • Of these, 205 (22%) met sex partners via the Internet. • 65% were HIV positive by self-report. LAC - DHS

8. Trends in Internet Use for Sexual Encounters by MSM with Syphilis Diagnosis, 2001 - 2003 LAC - DHS

9. Internet Use for Sexual Encounters Among MSM with Syphilis Diagnosis, By Age _____________________________________________________________________________________________ ** p-value < 0.05 LAC - DHS

10. Internet Use for Sexual Encounters Among MSM with Early Syphilis, By Race/Ethnicity and HIV Status * p-value < 0.05 LAC - DHS

11. Risk Behaviors Among MSM with Early Syphilis, By Internet Use for Sexual Encounters * p-value < 0.05 LAC - DHS

12. Risk Behaviors Among MSM with Early Syphilis, By Internet Use for Sexual Encounters Used the Internet for Sexual Encounter Risk BehaviorsTotal Yes N (%) No N (%) P - value Condom used0.60 Yes 252 62 (33.7) 190 (31.7) No 532 122 (66.3) 410 (68.3) Incarcerated past year 0.13 Yes 32 4 (2.2) 28 (4.7) No 744 180 (97.8) 564 (95.3) IV drug user 0.02* Yes 18 8 (4.1) 10 (1.5) No 852 188 (95.9) 664 (98.5) Non-IV drug user 0.01* Yes 252 73 (38.2) 179 (26.6) No 612 118 (61.8) 494 (73.4) LAC - DHS *p-value<0.05

13. Drug Use Among MSM with Early Syphilis, By Internet Use for Sexual Encounters *GHB: Gamma hydroxy butyrate LAC - DHS

14. Influence of Sociodemographics on Internet Use for Sexual Encounters Among MSM with Syphilis Diagnosis LAC - DHS * p<0.05

15. Reported Internet Sites Used for Sexual Encounters by MSM with Syphilis in Los Angeles LAC - DHS

16. Conclusion • Overall 22% MSM who were diagnosed with early syphilis infection met their sexual partners through the Internet • 65% were HIV positive • MSM with early syphilis who do use the Internet to meet their sexual partners were: • 2.6times more likely to be White • 3.8times more likely to have anonymous sex • 2.6times more likely to use injection drugs • Independent predictors of meeting sexual partners via the Internet among MSM with early syphilis were: • White race • Having anonymous sex partners LAC - DHS

17. Recommendations • The Internet is an important venue for conducting STD/HIV prevention and control. • Potential public health prevention and control efforts should include interventions like online outreach and automated behavioral risk reduction. LAC - DHS

18. Future Directions • Identify additional Internet sites used for sexual encounters among MSM early syphilis cases. • Explore the association between socio-economics and the ethnicity of persons using the internet as a sex venue. LAC - DHS