Crystal methamphetamine is the driving force behind increased cases of syphilis in gay men, even while the disease is declining among other populations in the United States, according to data presented at the 2004 National STD Prevention Conference in Philadelphia.
'Estimates are that men who have sex with men (MSM) probably account for more than 60% of all current syphilis cases in the U.S.,' said Ronald O. Valdiserri, deputy director of the National Center for HIV, STD and TB Prevention at the Centers for Disease Control and Prevention (CDC). Five years ago MSM constituted only 5% of all syphilis cases.
'Combined with high rates of HIV infection among MSM diagnosed with syphilis, the data are cause for concern about increased sexual risk behavior among some groups of MSM.' He tied it to data linking these new infections to use of crystal meth.
Among 388 MSM in San Francisco, 16% used crystal and 6% used Viagra during their most recent encounter of anal sex, said the CDC's Gordon Mansergh. He conducted that study with the San Francisco Department of Public Health.
'Those who used Viagra were 6.5 times more likely to report unprotective insertive anal sex during the encounter,' but Viagra was not associated with bottoming. 'Men who reported using crystal during the encounter were twice as likely to report unprotected receptive anal sex,' but the drug was not linked to topping.
Another San Francisco study found that crystal users were nearly four times more likely to have syphilis, and more than three times as likely to be HIV-positive than their peers. It was based on a survey of 1,263 MSM visiting a public STD clinic. Men who used crystal and Viagra together were 6.1 times as likely to have syphilis as those who used neither drug.
Internet chat rooms have become a major facilitator for the transmission of STDs. A Los Angeles study found that 22% of MSM diagnosed with early syphilis had met sexual partners on the Internet around the time they most likely became infected.
Valdiserri pointed to new data from San Diego showing that 'MSM with syphilis were 45% less likely than heterosexual men to be diagnosed during the primary stage of their infection. As a result, they remained infectious for longer periods of time.'
'These suggest that traditional syphilis control strategies, which rely upon prompt diagnosis and treatment for both patients and their partners, may not be as effective for MSM as for other groups.' He said, 'People living with HIV need a lifetime of support to maintain safe behaviors and to protect both their health and their partners' health.'
Kenneth Mayer traced the rising arc of syphilis cases at Fenway Community Health, the large LGBT health provider in Boston. From a low of two cases in 1997, syphilis increased to 30 cases in 2002, and 51 cases in 2003. Over that same five-year period, gonorrhea cases increased from 41 to 98 cases.
About 15% of Fenway's patient population is infected with HIV, and that was the 'strongest single predictor of having a new case of syphilis.' Mayer said that mirrored what was found among MSM who came in for testing at STD clinics in eight cities—Chicago, Denver, Houston, Long Beach, Philadelphia, San Francisco, Seattle, and Washington, DC.
That same eight-city study showed that HIV-positive MSM were nearly twice as likely to have an STD as their HIV-negative peers.
Mayer called development of a rapid test to screen for syphilis infections 'the next frontier.' Work on that test is progressing rapidly. It will allow community organizations such as Fenway to use vans and other outreach measures for 'one stop shopping' to screen for both HIV and syphilis at bars, bathhouses, and other venues. Identifying and treating those infections will help reduce their spread to others.
Valdiserri said that two-thirds of those who are HIV-positive are sexually active, often with more than one partner. He stressed the importance for physicians to talk about STDs with their patients and screen them for infections.
Mayer cautioned not to focus too much on a core group of people at the center of this increase in STDs, because that group can change over time. Research has found that gay men often limit their sexual partners when in a relationship, and can go through a period of increased risky behavior when a relationship comes apart.
He urged tailoring prevention messages and interventions to differing age and interest groups. He emphasized the importance of 'inculcating a sense of responsibility within the community for people to talk about these issues without demonizing people, but also saying that there are consequences to people's behavior.'
'We are pretty good at getting out the message of how HIV is transmitted, but some of the sexually transmitted diseases are more easily transmitted,' said Mayer. Oral sex is a good example. It is extremely difficult to transmit HIV through oral sex, but other STDs readily transmit via that route.
Supporters of 'abstinence only' programs for reducing the spread of STDs found no solace in data presented at the conference. A majority of teenagers who pledged to not have sex before they were married did not live up to their vows, though they did delay intercourse an average of 18 months longer.
More importantly, when they did begin having sex, they were less likely to use condoms. As a result, they were just as likely to become infected with a STD as were their non-pledging peers. And through their ignorance, they were less likely to realize that they might be infected, and thus were more likely to transmit the STD to a subsequent sexual partner. Another area of concern is the growing incidence of drug-resistant gonorrhea. Ciprofloxacin (Cipro) is the drug of choice in treating this STD. But in Seattle/King County, the number of drug-resistant cases went from zero in the first quarter of 2003, to 3.8% in the third quarter, and 16.5% in the fourth quarter. Those cases were almost entirely (90%) in MSM. The alternative treatment generally is an injection.
'HIV is more easily transmitted by a person with a sexually transmitted disease, so STD prevention is HIV prevention,' said Terje Anderson, executive director of the National Association of People With AIDS (NAPWA). He was encouraged by the spate of research demonstrating the success STD prevention and education campaigns.
'Behavior change is complicated, messy, and takes time. All of that takes time and costs money,' said Mayer. 'Right now we are in an era when there is not a substantial investment in public health at the federal level.' He called for increased spending on public health as being more cost-effective in the long run.
