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HIV and Syphilis Testing Among Men Who Have Sex With Men Attending Sex Clubs and Adult Bookstores - San Francisco, 2003
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JAIDS Journal of Acquired Immune Deficiency Syndromes: Volume 37(2) 1 October 2004
Letter To The Editor
Buchacz, Kate A PhD*†; Siller, Jacqueline E MPH‡; Bandy, David W MA‡; Birjukow, Nathaniel BA‡; Kent, Charlotte K PhD‡; Holmberg, Scott D MD, PhD*; Klausner, Jeffrey D MD, PhD‡§
*Division of HIV/AIDS Prevention, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA;
†Epidemic Intelligence Service, Division of Applied Public Health Training, Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, GA;
‡STD Prevention and Control Services, City and County of San Francisco, San Francisco, CA;
§Department of Medicine, University of California at San Francisco, San Francisco, CA
Supported by the Centers for Disease Control and Prevention as part of collaboration with the City and County of San Francisco Department of Public Health.
To the Editor:
From 1998 through 2002, the number of primary, secondary, and early-latent syphilis cases in San Francisco increased >10-fold from 41 to 495.1 In 2002, 88% of these early syphilis cases were in men who have sex with men (MSM), 66% of whom were HIV positive.1 In response to the outbreaks, the San Francisco Department of Public Health (SFDPH) launched a social marketing campaign2 in 2002 and expanded outreach and syphilis testing among MSM in San Francisco to increase early syphilis case finding and treatment and thereby limit the spread of syphilis and possibly HIV infection.3,4 As part of program evaluation efforts, we conducted a rapid brief survey in selected gay venues in San Francisco to assess the percentage of men who recently (past 6 months) tested for syphilis and HIV infection and reported HIV seropositivity status.
Owners and managers of 4 sex clubs (sites A-D, representing the 4 main gay sex clubs in San Francisco) and 2 adult bookstores (sites E and F) were invited to participate in the survey. All agreed to participate except for club D, which refused based on internal policies. Each participating site received 250 surveys for distribution in April or May 2003. The front desk staff at each venue was instructed to offer the survey with a small incentive (candy or personal lubricant) to consecutive men entering the venue until all 250 surveys were given out or for at least 7 days. The men were asked to complete the 7-question anonymous palm-sized survey and place it in a ballot box. The SFDPH approved the survey, which was exempt from review by the Institutional Review Board at the Centers for Disease Control and Prevention.
Analyses were performed on 676 (91%) of 743 surveys from men who identified as first-time respondents: 177 from site A, 220 from site B, 100 from site C, 77 from site E, and 102 from site F. The participants' median age was 35 years (interquartile range, 28-42 years); 61% were white, 17% were Latino/Hispanic, 8% were African American/black, 9% were Asian or Pacific Islander, and 5% were of other race or ethnicity (including Native American and multiracial).
Overall, 401 (60%) of 673 men reported having tested for syphilis in the past 6 months. Syphilis testing rates were the highest among men who were younger than 30 years of age, those of white, Latino/Hispanic, or other race or ethnicity, and those who had sex exclusively with men. Of HIV-positive men, 52% reported having recently tested for syphilis, compared with 64% of HIV-negative men.
Among 598 participants who reported their HIV status, the overall self-reported HIV seropositivity rate was 17%, ranging from 3% at sex club B to 48% at sex club C. The prevalence of HIV infection was lowest among younger age groups and Asians/Pacific Islanders; it was highest among men of other race or ethnicity and those who had sex only with men.
In the analyses limited to 572 men who had testing information and were not known to be HIV positive, 295 (52%) reported having tested for HIV in the past 6 months, 111 (19%) last tested >12 months ago, and only 44 (8%) reported never having tested for HIV. Recent HIV testing rates were highest among men who were younger, those who were white or Latino/Hispanic, and those who had sex only with men.
Recent HIV testing and syphilis testing rates declined significantly with increasing age, whereas HIV seroprevalence increased significantly with age. In multivariate models controlling for sociodemographic factors and site, younger age and having sex exclusively with men remained the key significant predictors of recent HIV and syphilis testing and HIV seropositivity (data not shown).
Although 〜60% of men surveyed tested for syphilis and 52% of men who were not known to be HIV positive tested for HIV in the past 6 months, the findings suggest that there remains a need for targeted innovative approaches to increase testing rates among sexually active, particularly older, MSM in San Francisco. Although most gay sex clubs in the city distribute condoms, lubricants, and HIV prevention information, none offer ongoing HIV or syphilis counseling and testing on-site5 (SFDPH unpublished findings). Interventions to offer ongoing HIV and syphilis screening at sex venues warrant systematic study. HIV and syphilis testing does provide an opportunity for risk-reduction counseling, education about symptoms, and linkage of infected persons to care and, thus, can play an important role in prevention efforts. Substantial HIV seroprevalence among respondents at some sites highlights the potential for HIV transmission at these venues.
Our findings should be interpreted with caution owing to a convenience sample of a hard-to-reach population and venues. Survey response rates could not be accurately estimated, because we could not document whether the venue staff followed the protocol of offering the survey to every male entrant. Due to a smaller than projected client base and estimated low response rates, some venues did not achieve a goal of surveying 250 men. Because of potential nonresponse bias, our estimates for HIV and syphilis testing rates and HIV seropositivity may not hold for all men visiting the 5 gay venues, but the estimates are generally consistent with results from other surveys of homosexual men in San Francisco and elsewhere.
This brief anonymous field survey has provided timely programmatic testing data to SFDPH during a syphilis outbreak affecting primarily HIV-infected MSM. On the basis of survey findings, the SFDPH has set a goal of achieving 6-month syphilis testing rates of 90% among MSM visiting sex venues in San Francisco. Once additional targeted programs to increase syphilis testing are implemented as part of syphilis control measures in San Francisco, resurvey may provide a useful tool for program evaluation purposes.
Kate A. Buchacz, PhD*†
Jacqueline E. Siller, MPH‡
David W. Bandy, MA‡
Nathaniel Birjukow, BA‡
Charlotte K. Kent, PhD‡
Scott D. Holmberg, MD, PhD*
Jeffrey D. Klausner, MD, PhD‡§
*Division of HIV/AIDS Prevention, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA;, †Epidemic Intelligence Service, Division of Applied Public Health Training, Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, GA;, ‡STD Prevention and Control Services, City and County of San Francisco, San Francisco, CA;, §Department of Medicine, University of California at San Francisco, San Francisco, CA
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