1. Risk Factors for Early Syphilis Among Men Who Have Sex With Men Seen in an STD Clinic – San Francisco, 2002-2003 STD Prevention Conference: March 10, 2004 William Wong MD Medical Director, City Clinic San Francisco Department of Public Health

2. Early Syphilis Cases – San Francisco, 1998-2003

3. Background  In 2003, 93% of early syphilis cases in San Francisco occurred among men who have sex with men (MSM)  36% of early syphilis cases in San Francisco were diagnosed at the municipal STD clinic (City Clinic)  45% of patient visits to City Clinic in 2003 were by MSM

4. Objective  To identify risk factors for early syphilis infection among MSM attending City Clinic

5. Methods  Convenience sample of self-identified gay and bisexual men attending City Clinic from November 2002 – March 2003  Confidential self-administered survey of demographic information, self-reported HIV status, and recent drug use and sexual behavior  Clinical and laboratory data obtained from electronic medical record

6. Gay Community Affiliation Index  Five items assessing:  Identification with the gay community and with other gay or bisexual men  Membership in gay community organizations  Reading gay community publications  High affiliation: 21 – 25 points  Low affiliation: 1 – 20 points

7. Analyses  Univariate, bivariate, stratified, and multivariate logistic regression analyses conducted using SAS version 8e  Multivariate analysis included:  Univariate factors associated with early syphilis at P values  0.2  Known confounders

8. Study Sample  2,107 MSM during study period  1,318 (63%) completed the survey Characteristic Median age, years (range) 36 (18-74) Sexual orientation: gay or bisexual 100% College education 60% Income  $30,000/ year 45% Reside in SF  2 years 74% Mean no. of sex partners in last 4 weeks 5.3

9. Selected Demographics, Reported HIV Status, and Risk for Early Syphilis among MSM – San Francisco City Clinic, 2002-2003 Characteristic Non-cases CasesOR95% CI n (%) n (%) Total 1265 (96) 53 (4) White Race 766 (64) 32 (60) 0.9(0.5-1.6) (n=1206) Positive HIV Status 190 (17) 27 (52) 5.3(2.9-9.6) (n=1166) High Community Affiliation 551 (48) 37 (70)2.5(1.3-4.7) (n=1192) No. of Partners  2 781 (62) 37 (70) 1.2 (0.6-2.2) (n=1225)

10. Reported Substance Use and Risk for Early Syphilis among MSM – San Francisco City Clinic, 2002-2003 Characteristic Non-cases CasesOR95% CI Use in last monthn (%) n (%) Methamphetamine 177 (16) 26 (50)5.4(2.9-9.8) (n=1181) Viagra ® 197 (18) 18 (50)2.6(1.4-9.8) (n=1176) Other Drugs* 363 (31) 26 (49)2.2(1.2-3.9) (n=1225) Alcohol 847 (74) 32 (60)0.5(0.3-1.0) (n=1197) * Other drugs include: cocaine, poppers, GHB, ecstasy, and ketamine

11. Selected Sex Venues Used to Meet Recent Sex Partners and Risk for Early Syphilis among MSM – San Francisco City Clinic, 2002-2003 Characteristic Non-cases CasesOR95% CI Use in last monthn (%) n (%) Internet 370 (32) 29 (55)2.61.5-4.7 (n=1225) Phone Sex Lines 114 (10) 11 (21)2.41.1-5.0 (n=1225) * Adult bookstores, bars/clubs, circuit parties, sex clubs, bathhouses, parks and other public places were not significant

12. Independent Correlates* for Early Syphilis among MSM – San Francisco City Clinic, 2002-2003 Characteristic aOR 95% CI Non-White Race/Ethnicity 2.21.1 – 4.4 Positive HIV Status 3.92.0 – 7.7 Meth and Viagra ® Use** 6.22.6 – 14.8 Meth Use Only** 3.21.3 – 7.6 Viagra ® Use Only** 0.90.3 – 2.9 Internet Use** 2.11.0 – 4.3 High Community Affiliation 2.31.2 – 4.6 * Adjusted for age and number of sex partners ** In the last 4 weeks

13. Limitations  Cross-sectional design limits inferences on causality  Findings may not be generalizable to all MSM  Self-reported behavior is subject to bias

14. Conclusions  Increased risk for early syphilis infection was associated with:  Non-White race/ethnicity  HIV infection  Methamphetamine use, especially with Viagra ®  Meeting recent sex partners on the Internet  Stronger gay community affiliation

15. Recommendations  Syphilis prevention efforts in San Francisco should target HIV infected persons and HIV care providers  Integrate substance abuse prevention efforts into broader STD and HIV control strategies  Continue Internet-based health promotion and disease prevention for MSM  Collaborate with gay community organizations and media outlets, inclusive of communities of color

16. Co-Authors San Francisco Department of Public Health Janice Chaw, MPH Charlotte Kent, MPH Jeffrey Klausner, MD MPH University of California, San Francisco Leila Alpers, MD

17. Acknowledgements San Francisco Department of Public Health STD Prevention and Control Services Toni Butler Robert Kohn, MPH Armando Litiatco Kate Scott, MPH Wendy Wolf, MPA Registration Team City Clinic Clinicians Syphilis Elimination Team

18. Contact information: William Wong, MD Medical Director San Francisco City Clinic 356 Seventh Street San Francisco, CA 94103 Phone: 415-487-5535 Fax: 415-437-9231 Email: will.wong@sfdph.org

19. Gay Community Affiliation Index  I feel like I am part of the San Francisco gay community (1-5 pts)  I feel a bond with other men who are gay or bisexual (1-5 pts)  I feel that any problems faced by the gay community are also my problems (1-5 pts)  Do you currently belong to any gay or GLBT community organizations or clubs? (1 or 5 pts)  Have you read any local or GLBT community publications during the last four weeks? (1 or 5 pts) Low affiliation: <20; High affiliation:  21 pts