1. The findings and conclusions in this presentation have not been formally disseminated by the Centers for Disease Control and Prevention and should not be construed to represent any agency determination or policy. Responding to the changing epidemiology of syphilis: Exploratory interviews of women with early syphilis—Chicago, 2005 Heather Lindstrom 1, Lora Branch 2, Gus Conda 2, Cassandra Davis 2, Thomas Peterman 1, Irina Tabidze 2, William Wong 2, Carol Ciesielski 2 1 Epidemiology and Surveillance Branch Division of STD Prevention National Center for HIV, STD, TB Prevention 2 Chicago Department of Public Health

2. Syphilis Sexually transmitted bacterial infection (Treponema pallidum) Curable

3. Stages of Untreated Syphilis Exposure (Incubation 2-6 wks) PrimarySecondary Early LatentLate Latent 6 months 12 months Infectious Period “Early Syphilis” 1-30+ Years 3 months

4. Primary and secondary (P&S) syphilis rates by sex: Chicago, 1999-2004 Males Females

5. Women with P&S syphilis: Chicago, 2004 Median age 22 years African-American, 87% Low-risk No common social or sexual networks Fewer than 10%: – Used illegal drugs – Exchanged of sex for money or drugs – Had history of incarceration

6. Reasons for concern Unexplained increases in P&S syphilis among women in 2004 Continued reporting of P&S cases among women in 2005 Cases occurred among young women of reproductive age

7. Objectives Describe context in which early syphilis transmission occurred Identify possible risk factors that could be studied further if necessary Generate ideas on future prevention strategies

8. Methods Identified 57 women with early syphilis Reported to the CDPH from January through October 10, 2005 Interviewed by disease intervention specialists (DIS) Data on reported cases was reviewed by CDPH epidemiologists Requested additional in-depth, exploratory interviews

9. Exploratory interviews Voluntary, no incentive provided Conducted with assistance from CDPH Disease Intervention Specialists (DIS) 30-60 minutes At home, in the car, or by phone Sexual behavior and prevention strategies Hypothesis generating, not hypothesis testing

10. Sample 14 interviewed (25%) 5 refused 57 early syphilis cases 2 not contacted 3 had non-working phone numbers 33 did not respond to requests for interviews

11. Context: n=14 women interviewed Stage of syphilis: secondary syphilis, 8 early latent syphilis, 6 African-American 13, Hispanic 1 Median age 22.5 years, range 17 – 43 years Pregnant at diagnosis, 5 High school graduates Impoverished

12. Risk factors: n=14 women interviewed Past sexually transmitted disease (STD), 6 Concurrent STD, 8 # of period sex partners: median = 2, range 1-6 Drug or alcohol abuse, 2 Exchanged sex for money or drugs, 0 History of incarceration, 0

13. Insights: sexual safety and prevention Women felt they picked “safe” partners Met within social network Monogamous Healthy appearance STD tested Strategies to prevent STDs Condoms used early in relationships STD testing Trust

14. Insights: experience with syphilis Emotional response to diagnosis Shame Stigma Fear Knowledge Knew about other STDs Limited knowledge of syphilis How to identify risky partners Incarceration history “Travelers” or men who like to “party”

15. Insights: ideas on future prevention Advice to other women Always use condoms No partner is a safe partner Get tested together Community interventions Information pamphlets and posters Radio or television spots Community outreach: teen clubs, field houses

16. Limitations Small number of interviews Limited generalizability

17. Conclusions Women were generally low risk No major risk factors identified Insights that could be used to inform future prevention interventions Educate women about syphilis Encourage women to use condoms longer in new relationships Consider the possibility that “no partner is a safe partner” in some settings

18. Acknowledgements Chicago Department of Public Health Illinois Department of Public Health CDC Colleagues: Stuart Berman Fred Bloom Dayne Collins Office of Workforce and Career Development

19. Age distribution of female P&S syphilis cases: US, 2004 vs. Chicago, 2005