The resurgence of infectious syphilis among men who have sex with men (MSM) in North America and Western Europe over the past decade is now well established and well characterized.1,2 The increases coincided with, or foreshadowed, rises in other common bacterial sexually transmitted diseases (STDs) including chlamydial and gonococcal infections; the reemergence of previously low-incidence STDs (e.g., lymphogranuloma venereum proctitis); and evidence of worsening trends in HIV incidence and prevalence, especially among young and minority MSM. 3–5 They have occurred on the heels of the advent of highly active antiretroviral therapy (HAART) in the late 1990s and within the context of resurgence of high-risk sexual behaviors, including increases in partner acquisition rates, partner concurrency, and practice of unsafe sex with known and unknown partners. 6–8 Wider societal and community-level determinants have also contributed to the increasing incidence, including the emergence and expansion of the Internet as a predominant venue for new partner acquisition; international travel and migration; and changes in sexual mixing patterns driven by expansions in male commercial sex work, circuit parties, and bathhouses.9,10 Stigma, discrimination, homophobia, recreational drug use, and mental ill health continue to play detrimental roles in the lives and sexual health decision making of homosexual men.1The complexity and dynamic interplay of these factors challenge public health practitioners and policy makers around the world.
In this issue of Sexually Transmitted Diseases, we are reminded of the unique challenges faced by local public health programs in their attempts to develop and implement effective interventions to control syphilis in MSM. Kerani et al.11 describe the limited impact of their attempts to reduce the incidence of syphilis in Seattle despite 3 years of local interventions and conclude that real limitations exist in the content and innovation of the prevention toolkit to address the sexual health of MSM. Similar failures to reduce rates of syphilis among MSM have been described in other Western industrialized settings, where rates have continued to rise since the beginning of this century, although a few jurisdictions have reported stabilization of rates (albeit at a higher incidence rate compared to the mid-‘90s) in recent years.12,13 Similar heterogeneity is also being observed within racial and ethnic subgroups in these settings, with some jurisdictions reporting increasing proportions of minority MSM being diagnosed with syphilis compared to white MSM.14
Why have efforts to control syphilis in MSM been so unrewarding? Arguably, any critical evaluation of the success of local prevention interventions should address 3 critical questions: Are we doing the right things, in the right combination, targeted to the right subpopulations to have an impact? Have we applied our interventions at a scale and intensity to change the epidemic trajectory? Are we measuring impact appropriately? Let's examine the Seattle experience through the lens of these questions in order to identify key principles for future public health efforts among MSM.
The “right” combination of interventions for the prevention and control of syphilis outbreaks in MSM is gradually being defined. In the absence of any experimental studies targeting biomedical outcomes, much of our understanding is driven by data derived from interventions aimed at increasing knowledge and awareness, reducing risk behaviors, and ensuring cultural competence by involving MSM in the development and implementation of prevention interventions. These have been incorporated into the recently revised National Plan to Eliminate Syphilis (NPES) in the United States,15 which highlights 9 focus areas for effective syphilis prevention and control including Surveillance, Clinical and Laboratory Services, Community Mobilization, Health Care Provider Mobilization; Tailoring of Interventions; Evidence-Based Action Planning, Monitoring and Evaluation; Training and Staff Development; and Research (http://www.cdc.gov/stopsyphilis/plan.htm) Specific interventions for preventing syphilis among MSM (Table 1) include strengthening local surveillance, implementing culturally competent health education and promotion, community mobilization, screening of high-risk groups, including HIV-positive MSM, and mobilizing health care practitioners.
In Seattle–King County, several of these NPES recommendations were addressed through expanded access to syphilis screening, enhanced partner services, improved surveillance, 3 public awareness campaigns, and the creation of an MSM Task Force of community leaders and CBO representatives. But the devil is always in the details, and those details are often constrained by “real-world” issues such as lack of local resources; limited surge capacity; and delays and inertia in the identification of, and response to, STD outbreaks compared to outbreaks of other infectious diseases (for example, food-borne illnesses).16 These problems frequently result in gaps in the comprehensiveness, timeliness, and phasing of intervention implementation.
The “right” intervention package must also be delivered to the “right” populations in a way that is appropriate to the phase of the STD and HIV epidemics that are occurring in these communities. For prevention of syphilis in MSM, this is often exceptionally challenging. In many jurisdictions with syphilis outbreaks, the initial epidemiologic profile of syphilis cases indicated that MSM who were at risk for syphilis were likely to be members of a particularly high-risk “core within the core” group of at-risk MSM, men who were likely to be HIV-positive, have high numbers of sexual partners, and be involved in high-risk sexual networks within which many partners are anonymous (e.g., the Internet, bath houses, sex parties, and circuit parties).17,18 They were also more likely to be users of recreational drugs including methamphetamine, cocaine, and ecstasy. Similar risk profiles observed in the recent resurgence of LGV in western Europe suggest that these men are not only at risk for syphilis but also for multiple STDs and other infections, including hepatitis C. Yet this is precisely the hardest subgroup to reach with prevention services. The tailored messages and intensive outreach that are required for this marginalized and often intentionally elusive group are usually very costly for prevention programs in terms of time and money. Unless interventions such as screening and partner notification can be deployed in innovative ways, they may have limited impact in these populations because of it is so difficult to find the MSM who most need these services. Simultaneously, identifying respected opinion leaders in these subgroups and building long-term working relationships with them is absolutely crucial but often also excruciatingly difficult. The Seattle-King County syphilis public awareness campaigns were primarily geared towards general MSM populations (e.g., those reading bus banners and gay newspapers) and may have failed to target the core of MSM at particularly high risk. Similarly, syphilis screening was instituted in STD clinics and some outreach sites; however, routine syphilis screening of HIV-infected MSM to identify asymptomatic or presymptomatic individuals attending HIV treatment centers was not implemented until 2003. While, in recent years, syphilis screening has yielded low detection rates in many subpopulations due to low disease incidence, focusing on HIV-positive MSM, especially those at high risk and in care, might also provide some access to this “core within the core” and be an entry point for targeted and intensive sexual health interventions.
Even comprehensive interventions applied to the appropriate populations will fail if they are not implemented and sustained at sufficient scale or intensity to achieve public health impact. Limitations in our ability to scale up and sustain interventions have been an ongoing concern for HIV and STD prevention generally and for interventions among MSM in particular. Even when effective individual, group, or community-level interventions exist for changing risk behaviors,19,20 sufficient local resources for training and widespread implementation are rarely available. These effective behavioral interventions provide a useful adjunct to biomedical approaches to syphilis prevention and may help to achieve longer-term, sustained reductions in sexual risk behaviors, particularly among MSM at greatest risk. Other interventions that should be scaled up to achieve maximal effect include innovative partner notification activities; media campaigns; and Internet-based campaigns, especially those that have some impact on behavioral norms. Equally important, we have to measure and analyze implementation coverage levels in relation to prevention impact if we really want to understand why interventions succeed or fail. In Seattle–King County, as in most local health departments, limited data appeared to be available on coverage achieved by the nonclinical interventions, handicapping assessment of these interventions.
Finally, care must be taken in defining our measures of success since, even in the most ideal circumstances, knowing whether our efforts have had any impact on disease prevention can be difficult. Declining rates of diagnosed disease (as measured through case surveillance) remains the cornerstone of our outcome evaluation and may be an appropriate outcome measure where syphilis transmission is occurring within dense, isolated networks and where targeted prevention interventions can be applied. Increasingly, measures such as syphilis testing numbers, prevalence of reported screens, ratio of early/late syphilis cases, and partner notification outcomes have provided useful adjuncts to assess impact.
However, another marker of prevention success could include a slowing or stabilization of syphilis rates, especially within the context of increases in other bacterial STDs. Indeed, given the overlapping risk factors for STD transmission, it may be inappropriate to expect reductions in syphilis rates as an isolated indicator of our prevention successes, especially if the environmental contexts are driving global increases in risk behaviors and other bacterial STDs. In Seattle–King County, syphilis reports among MSM have continued to increase since 2000 along with reported cases of gonorrhea and chlamydial infections (Fig. 1). However, between 2004 and 2005, increases in all diagnoses of gonorrhea among MSM (71%) and symptomatic urethral gonorrhea among MSM (37%) exceeded that for syphilis (24%).21 While this may reflect changes in both testing practices and underlying disease incidence, evidence of such slowing or stabilization of syphilis incidence in the presence of rises in risk behaviors and the incidence of other bacterial STIs may reflect early or limited success in local syphilis prevention efforts, and more detailed evaluation will be required. Other markers such as syphilis diagnoses in HIV-positive MSM, MSM reporting high rates of partner change, and MSM reporting recreational drug use are often unavailable in current surveillance systems, and there is an ongoing need to ensure that more innovative, locally appropriate measures are used to improve our understanding of disease dynamics and to better evaluate the success of our prevention and policy efforts. The Centers for Disease Control and Prevention (CDC) and its partners are planning to capture some of these markers on a new STD interview form, due to be implemented shortly.
The recent resurgence of syphilis among MSM is a marker of underlying changes in attitudes, risk behaviors, and more general sexual health in many gay communities a quarter of a century into the AIDS epidemic and a decade into the era of HAART. It presents a profound challenge to MSM themselves and to public health. The synergistic increases in disease incidence across geographic regions suggest that similar social phenomena and contexts may be driving these changes. Consequently, successful control of syphilis and other STDs, including HIV infection, will likely require sustained, tailored interventions that are taken to scale and combine sound biomedical approaches with a more holistic approach to improving the sexual health of MSM: approaches in which culturally competent prevention and treatment services are provided within a context of efforts to address stigma, discrimination, mental health, and drug use and abuse for this population.
The public health approaches outlined in the original NPES produced dramatic reductions in syphilis especially among black heterosexuals, the priority population for which the plan was designed: Between 1991 and 2004, congenital syphilis cases declined by 92%.15 Rates of primary and secondary syphilis among women fell from 2.0 to 0.8 per 100,000 population, and rates in blacks fell from 14.3 to 8.9 per 100,000 population, with the black/white racial disparity falling from 44:1 in 1996 to 5:1 in 2005.15 Many of the core strategies that proved useful in achieving these gains—strengthening clinical and laboratory services, and surveillance in the context of intensive work with affected communities—remain relevant for tackling syphilis in MSM. The NPES, and years of experience with syphilis elimination, have also taught us that, although necessary, these interventions alone were not sufficient to achieve the observed gains among blacks. Targeted investment, innovation with evaluation, sustained local community mobilization, and understanding and tackling the social determinants of disease transmission in collaboration with community leaders were key contributors to local successes.19
Seattle–King County has long been one of the premier local health departments in the United States. Their critical analysis of their response to the local syphilis epidemic among MSM is an excellent reminder of how much we can learn from our failures and how important it is to have the courage to do so.
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