1. Variation in Sexual “Marketplace” By Race/Ethnicity, Age and Sexual Orientation among Early Syphilis Case: Implication for Prevention Strategies Getahun Aynalem, MD, MPH; Lisa Smith, PhD; Peter Kerndt, MD, MPH Presented by Christine Wigen, MD Los Angeles County Department of Health Services STD Program

2. Introduction For prevention efforts, it is essential to understand the sexual “marketplace” or venues used to identify sexual partnership of those at risk of acquisition and/or transmission of STDs. In the past, sex venues have been associated with drug use, unprotected anal intercourse and anonymous sex. Little is known about the differences between the different race/ethnicity, ages, and sexual orientations who use these venues for sexual encounters.

3. Objectives To identify demographic and behavioral differences of those diagnosed with early syphilis that reported using different “sexual market places” for sexual encounters during the *critical period for infection. *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.

4. Methods Between January 2001 and December 2005, demographic, behavioral and venue use for sexual encounters were collected from 2426 of the 4029 reported early syphilis (primary, secondary and early latent) cases. Association between demographic and behavioral characteristics with the different venue use for sexual encounters were assessed using chi-square and Fisher’s exact test. The odds of initiating sexual contact through the different sexual marketplaces were calculated for each study group.

5. Study Setting Cases based on reportable STD registry in Los Angeles County which: u Comprise a geographic area of over 4,000 sq. miles u Home to ~10 million residents u Hispanic comprise the single largest racial/ethnic group (45%), followed by whites (31%) u 4029 early syphilis cases l 67% MSM, of whom 60% HIV-positive

6. Distribution of Early Syphilis Cases in Los Angeles County, 2001 – 2005

7. Results Of 4029 cases of early syphilis diagnosed between January 2001 and December 2005 in Los Angeles, 2426 reported venues for meeting sex partners. Of these 2426 early syphilis cases, the top 3 reported venues to meet partners were: u Commercial Sex Venues (CSVs) (18%) u Internet (21%) u Bars and clubs (35%)

8. Prevalence of “Sexual Marketplace” Use

9. Trends in Venue Use for Sexual encounter of Early Syphilis Cases

10. Association Of Venue Use for Sexual Encounter With Race/Ethnicity Sexual Marketplace/VenueTotal Used the Venue for Sexual encounter Yes N (%) No N (%) P - value CSV0.001 White938219 (23.4)719 (76.6) Non-White1372189 (13.8)1183 (86.2) Internet0.001 White922321 (34.8)601 (65.2) Non-White1346144 (10.7)1202 (89.3) Bars & Clubs0.0629 White930320 (34.4)610 (65.6) Non-White1362482 (35.4)880 (64.6)

11. Association Of Venue Use for Sexual Encounter With Race/Ethnicity Sexual Marketplace/VenueTotal Used the Venue for Sexual encounter Yes N (%) No N (%) P - value Dance Halls0.025 White9225 (0.5)917 (99.5) Non-White134721 (1.6)1326 (98.4) Parks0.003 White92220 (2.2)902 (97.8) Non-White134961 (4.5)1288 (95.5) Motels0.017 White92524 (2.6)901 (97.4) Non-White134461 (4.5)1283 (95.5)

12. Association Of Venue Use for Sexual Encounter With Sexual Orientation Sexual Marketplace/VenueTotal Used the Venue for Sexual encounter Yes N (%) No N (%) P - value CSV0.001 MSM1879432 (23.0)1447 (77.0) Heterosexual5483 (0.6)545 (99.4) Internet0.001 MSM1862517 (27.8)1345 (72.2) Heterosexual5474 (0.7)543 (99.3) Bars & Clubs0.001 MSM1943851 (43.8)1092 (56.2) Heterosexual57296 (16.8)476 (83.2)

13. Association Of Venue Use for Sexual Encounter With Sexual Orientation Sexual Marketplace/VenueTotal Used the Venue for Sexual encounter Yes N (%) No N (%) P - value Dance Halls0.074 MSM183819 (1.0)1819 (99.0) Heterosexual55011 (2.0)539 (98.0) Parks0.001 MSM184686 (4.7)1760 (95.3) Heterosexual5485 (0.9)543 (99.1) Motels0.001 MSM183953 (2.9)1786 (97.1) Heterosexual55141 (7.4)510 (92.6)

14. Association Of Venue Use for Sexual Encounter With Age Sexual Marketplace/VenueTotal Used the Venue for Sexual encounter Yes N (%) No N (%) P - value CSV0.001 < 3063970 (11.0)569 (89.0) 30 +1810366 (20.2)1444 (79.8) Internet0.012 < 30636114 (17.9)522 (82.1) 30 +1795407 (22.7)1388 (77.3) Bars & Clubs0.651 < 30667254 (38.1)413 (61.9) 30 +1871694 (37.1)1177 (62.9)

15. Association Of Venue Use for Sexual Encounter With Age Sexual Marketplace/VenueTotal Used the Venue for Sexual encounter Yes N (%) No N (%) P - value Dance Halls0.032 < 3063213 (2.1)619 (97.9) 30 +177817 (1.0)1761 (99.0) Parks0.071 < 3063632 (5.0)604 (95.0) 30 +178161 (3.4)1720 (96.6) Motels0.564 < 3063127 (4.3)604 (95.7) 30 +178167 (3.8)1714 (96.2)

16. Influence of Demographic and Behavioral Characteristics on Using Venues for Sexual Encounter Variables Odds ratio (95% CI) Univariate analysis Multivariate analysis CSV Age (y) 301.1 (1.1 – 1.2)*1.6 (1.2 – 2.1)* Race/ethnicity White vs. Non-white1.9 (1.5 – 2.4)*1.2 (1.1.9 - 1.5)* Sexual Orientation MSM vs. Heterosexual 54.2 (17.3 – 169.5)* 135 (18.9 – 965.8)* Internet Age (y) 301.1 (1.0 – 1.1)*0.7 (0.6 – 1.0) Race/ethnicity White vs. Non-white4.5 (3.6 – 5.6)*3.4 (2.7 – 4.3)* Sexual Orientation MSM vs. Heterosexual 52.2 (19.4 – 140.3)* 67.2 (16.6 – 271.6)* Bars & Clubs Age (y) 301.0 (0.9 – 1.1) 0.9 (0.7 – 1.1) Race/ethnicity White vs. Non-white0.9 (0.8 – 1.4) 0.7 (0.6 – 0.8)* Sexual Orientation MSM vs. Heterosexual 3.9 (3.1 – 4.9)* 4.7 (3.6 – 6.1)* * p<0.05

17. Influence of Demographic and Behavioral Characteristics on Using Venues for Sexual Encounter Variables Odds ratio (95% CI) Univariate analysis Multivariate analysis Motel Age (y) 301.0 (0.9 – 1.0)1.1 (0.7 – 1.7) Race/ethnicity White vs. Non-white0.6 (0.3 – 0.9)*0.8 (0.5 – 1.3) Sexual Orientation MSM vs. Heterosexual 0.4 (0.2 – 0.6)* Park Age (y) 300.9 (0.9 – 1.0)0.7 (0.4 – 1.1) Race/ethnicity White vs. Non-white0.5 (0.3 – 0.8)*0.4 (0.2 – 0.6)* Sexual Orientation MSM vs. Heterosexual 5.3 (2.1 – 13.1)*7.4 (2.9 – 18.5)* Dance Hall Age (y) 301.0 (0.9 – 1.0) 0.6 (0.3 – 1.3) Race/ethnicity White vs. Non-white0.4 (0.1 – 0.9)* 0.4 (0.1 – 1.0) Sexual Orientation MSM vs. Heterosexual 0.5 (0.2 – 1.1)* 0.8 (0.3 – 1.6) * p<0.05

18. Summary of Results Of early syphilis cases who reported venues to meet sexual partners, most met sexual partners through the Internet (21%), at CSVs (18%), and at bars/clubs (35%). Whites compared to Non-whites were… u more likely to initiate sexual encounters: l via the Internet (OR=4.4, 95% CI 3.6-5.6) l at CSVs (OR=1.9, 95% CI 1.5-2.4) u less likely to initiate sexual encounters l at parks (OR=0.5, 95% CI 0.3-0.8) l in motels (OR=0.6, 95% CI 0.3-0.9)

19. Summary of Results (cont.) MSM compared to heterosexuals were… more likely to initiate sexual encounters: at CSVs (OR=54.2, 95% CI 17.3-169.5) at bars and clubs (OR=3.9, 95% CI 3.1-4.9) through the Internet (OR=52.2, 95% CI 19.4-140.3) at parks (OR=5.3, 95% CI 2.1-13.1) less likely in motels (OR=0.4, 95% CI 0.2-0.6) Those who were less than 30 years of age were more likely to initiate sexual encounters at CSVs, and through the Internet (p<0.05).

20. Conclusion The sexual “marketplace” or venue to initiate sexual encounters for contacts of cases with early syphilis varies based on age, race/ethnicity, and sexual orientation.

21. Implications Findings from this study highlight the need for targeted HIV and STDs prevention interventions tailored to the difference in age, race/ethnicity and sexual orientation at the different sex “marketplaces.”