1. Self and Partner Examination for Syphilis Symptoms among MSM Brandy Peterson, MPH, CHES Melanie Taylor, MD, MPH ADHS/STDP Statewide STD Meeting September 2, 2009

2. Behavioral Surveillance Project 2 HIV clinics with highest number of syphilis cases in Maricopa County (McDowell & Spectrum) Objective: To increase self and partner examination of oral, penile, and rectal areas for syphilis lesions among HIV-infected men who have sex with men though an educational intervention during HIV clinic visits.

3. Implementation February 2, 2008-January 31, 2009 All male HIV infected patients from two HIV clinics were provided educational pictures and messages Providers asked risk questions related to unprotected sexual encounters Patients completed questionnaire assessing likelihood of seeking medical evaluation, frequency of examining self or partner for symptoms, likelihood of taking precautions to reduce the risk of acquiring syphilis and usefulness of materials

5. Provider Risk Assessment In the last 3 months, how many times have you had unprotected: -oral sex with steady, casual, and anonymous partners -anal sex with steady, casual, and anonymous partners In the last 3 months, did you examine your mouth or rectum for Syphilis lesions? _Yes _No

6. Patient Education Messages There is an increase in syphilis among MSM in Maricopa County Syphilis can be transmitted through oral sex in addition to anal and vaginal sex Sores caused by syphilis are painless and can be found in the mouth, anus, rectum, and penis Use of illicit drugs can increase the likelihood that you will engage in unprotected sex

7. Patient Education Messages Syphilis can cause a decrease in CD4 count and increase in viral load Neurosyphilis is being diagnosed at an increased rate in Maricopa County among HIV infected males Neurosyphilis can cause blindness, hearing loss, cognitive decline, stroke, and chronic headaches

8. Patient Questionnaire Patient Demographics (age, gender, race/ethnicity, education) Likelihood of seeking medical evaluation Frequency of examining self or partner for symptoms Likelihood of taking precautions to reduce the risk of acquiring syphilis Usefulness of materials

9. Results-Patient Questionnaire A total of 1633 completed questionnaires were received from male patients (76% MSM) at one or more visits to the HIV clinics Data analyzed using SPSS

10. Results-Self Exam Between baseline and intervention completion, the number of patients that reported “never checking”: their mouth decreased from 46.3% to 17.2% (p = <0.001) their penis decreased from 30.5% to 7.3% (p = <0.001) their rectal area decreased from 49.3% to 18.4% (p = <0.001)

11. Results-Partner Exam Similarly, the number of patients that reported “never checking” : their partner’s mouth decreased from 62.4% to 26.6% (p = <0.001) their partner’s penis decreased from 47.2% to 13.3% (p = <0.001) their partner’s rectal area decreased from 52.2% to 17.8% (p = <0.001) Frequency of self and partner examination varied.

12. Results-Provider Risk Assessment 689 HIV-infected male patients received a sexual risk assessment and self examination questions by their medical provider at one or more visits. Data analyzed using SPSS

13. Results-Provider Risk Assessment Among all patients with data from three patient encounters (N = 224) self examination behaviors increased from 46% (Baseline) to 72% (p = <0.001). Among the men in the study, there was no change in number of unprotected sex acts with steady (p = 0.2), anonymous (p = 0.7), or casual partners (p = 1.0) over time Among those who reported having sex (N = 113), there was an increase in self-examination of the oral/rectal areas from 58% to 83% between the first and third visits (p = <0.001)

14. Conclusions Following review of syphilis educational photos fewer HIV- infected men at two HIV clinics reported not examining themselves or their partners for syphilis lesions. After seeing pictures of ulcers and talking with their HIV-providers about syphilis, more men reported checking their mouths and rectal areas for syphilis ulcers.

15. Implications for Practice Patient education regarding syphilis should include recommendations for self and partner examination to identify syphilis lesions and help prevent spread of the disease. Clinic and provider-delivered education to MSM regarding syphilis should include recommendations for self-examination to identify syphilis lesions.

16. Acknowledgments McDowell Healthcare Center -Dr. John Post Spectrum Medical Group, P.C. -Carol Williams, FNP; Dr. Thanes Vanig Alfonso Urquidi Dr. Michelle Winscott Clinic Patients CDC DSTDP