Daniel Reeders: New Perspectives In Syphilis Control


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An overview of syphilis prevention and testing campaigns given by Daniel Reeders from People Living With HIV/AIDS Victoria at AFAO's syphilis forum in May 2009.

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  • How widespread is the strategy?... of
    'B4 we have sex let's get tested 2GETHER
    for A VARIETY of STDs.'

    Do sexual health checkups reduce the ambiguity and can they be
    like anything else POTENTIAL sex partners do together?...

    If you needed surgery would you want the surgeon to wash
    before operating?...

    If you needed a blood transfusion would you want the blood tested
    before or after the transfusion?...

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Daniel Reeders: New Perspectives In Syphilis Control

  1. 1. Syphilis Campaign Strategy Daniel Reeders Campaign Coordinator People Living With HIV/AIDS Victoria [email_address]
  2. 2. Emergent Syphilis <ul><li>Urban epidemics among MSM, associated with leather scenes and SOPV use </li></ul><ul><li>Disproportionate representation of PLWHA in diagnoses </li></ul><ul><li>Younger doctors had been taught syphilis was a third world disease </li></ul><ul><li>International travel a key feature </li></ul>
  3. 3. American Syphilis <ul><li>Epidemics during the late 1980’s – 1990’s </li></ul><ul><li>Sustained by core group HSA transmitters </li></ul><ul><li>“ Spontaneously resolved” due to host immunity </li></ul><ul><li>Resolved before organised response scale-up </li></ul><ul><li>Oxman GL et al. Mathematical Modeling of Epidemic Syphilis Transmission: Implications for Syphilis Control Programs. Sexually Transmitted Diseases: Volume 23(1) Jan-Feb 1996 p30-39. </li></ul>
  4. 4. Our Core Group? <ul><li>Men who are highly sexually active (HSA) </li></ul><ul><li>Sexually adventurous men (SAM) </li></ul><ul><li>Inner North and Inner South East </li></ul><ul><li>Older and more likely to be positive – evidence of less immunity to reinfection </li></ul><ul><li>More likely to use amphetamines </li></ul>
  5. 5. Targeting Strategy Australian Campaigns
  6. 8. Join Me in October
  7. 10. HIV and its Others <ul><li>In our discourse about campaign strategy -- </li></ul><ul><li>HIV is the big one; </li></ul><ul><li>Everything else goes in “Other STI”, and </li></ul><ul><li>Message is “regular” testing & treatment </li></ul>
  8. 11. Supporting individual decision-making around appropriate testing frequency <ul><li>Gotest website screenshot </li></ul>
  9. 12. Risk Groups
  10. 13. Risk Groups (1989) <ul><li>“ Risk Discourse” in Paul Senziuk, Learning to Trust (2004) p148-155. </li></ul><ul><li>“ The term ‘high-risk group’ implies that you are at risk from AIDS because of who you are rather than what you do. ” (orig. emph.) </li></ul><ul><li>But the “AIDS as gay disease” myth proved resistant even to the Grim Reaper campaign about heterosexual vulnerability </li></ul>
  11. 14. Risk Practices <ul><li>Educational policy has emphasised the need to inform people about risk practices rather than identify ‘high-risk’ groups eg. </li></ul><ul><li>Low Risk  Medium Risk  High Risk </li></ul><ul><li>Examples </li></ul><ul><li>Traffic light reminder campaign (ACON) </li></ul><ul><li>Personal Risk Assessment Framework Toolkit (VAC/GMHC) </li></ul>
  12. 15. Risk Practices <ul><li>ACON “HIV Basics” Campaign (2008) </li></ul><ul><li>Explicit Poster </li></ul><ul><li>http://www.acon.org.au/assets/file_library/other/HIV%20Basics%20A1%20Poster%20Explicit.pdf </li></ul>
  13. 16. Risk Practices for Syphilis <ul><li>Syphilis is spread by skin contact with a person who is infected and currently symptomatic (rash or ulcer). </li></ul><ul><li>Take Home Point </li></ul><ul><li>Touch is a “risk practice” for onward transmission of syphilis. </li></ul>
  14. 17. Test & Treat <ul><li>Syphilis is an Other STI, for which we recommend “regular” testing and treatment, not prevention strategies. </li></ul>
  15. 18. How long is the piece of string? <ul><li>Victorian STI Strategy recommends 12 monthly testing for gay men </li></ul><ul><li>Drama Down Under campaign website talks about testing immediately if you discover symptoms (homepage) or every six months (one page in) </li></ul><ul><li>“ Test more often if you have a lot of sex” </li></ul><ul><li> Audience members are motivated to answer to avoid that recommendation! </li></ul>
  16. 19. Infectivity by Week Oxman et al 2004 (Fig. 2).
  17. 20. Quarterly Testing Jan Feb Mar Apr May June July Aug Sep Oct Nov Dec Primary Syphilis No chancre or missed it Secondary Syphilis Fever, malaise Up to 2 years if left untreated Quarterly Checkup Quarterly Checkup Quarterly Checkup Quarterly Checkup Window Period (EIA, TPHA, RPR)
  18. 21. Syphilis has intermittent infectivity <ul><li>Most of the infective period will be over by the time a person who tests every 12 months makes it to their GP for a checkup. </li></ul><ul><li>Not even 6 monthly frequency will reliably reduce the number of people currently in the highest infectivity period. </li></ul><ul><li>Reducing epidemic spread probably requires people to test every 3 months. </li></ul><ul><li>“ Doesn’t everybody?” (Beyond participant). </li></ul>
  19. 22. Purchase Analysis <ul><li>Can we ask gay men to test every 3 months? </li></ul><ul><li>Individual Cost/Benefit Analysis – </li></ul><ul><ul><li>Individual Cost/Benefit Analysis: Symptoms were the #1 reason why men fronted up for testing in Syphilis in Sydney Gay Men Survey, 2006. </li></ul></ul><ul><ul><li>“ Sexual health” is an abstract/tenuous benefit. </li></ul></ul><ul><li>Community-minded rationale </li></ul><ul><ul><li>Feeling cared-for? </li></ul></ul><ul><ul><li>Protecting sexual partners? </li></ul></ul><ul><ul><li>Bring syphilis under control? </li></ul></ul><ul><ul><li>Needs to be explicit </li></ul></ul>
  20. 23. Risk is the rationality of government <ul><li>Risk justifies regulation (Foucault) </li></ul><ul><li>Gay men understand this implicitly </li></ul><ul><li>HSA/SAM are especially skeptical </li></ul>
  21. 24. Risk Groups (2008) <ul><li>We don’t want to ask people who are at low risk of syphilis or HIV infection to front up for testing they don’t need. </li></ul><ul><li>How do we get the testing message to people who will benefit from increased testing frequency? (‘benefit groups’?) </li></ul><ul><ul><li>Targeting strategy (HSA) </li></ul></ul><ul><ul><li>Supporting individual elaboration </li></ul></ul>
  22. 25. HIV & Risk Groups (2008) <ul><li>Shaun Syms (Toronto) interviewing Edward White (Yale Centre for Interdisciplinary Research on AIDS) – </li></ul><ul><li>“ [F]ocus is shifting away from &quot;what you do&quot; to &quot;who you do it with.&quot; Can you elaborate on this idea, and how it may relate to HIV prevalence in specific communities? – Men who have sex with men have a greater prevalence of blood-borne infections than other populations, not simply because they have historically engaged in unprotected anal sex, [but] because they form a dense, highly-connected sexual network separate from other sexually-active people.” (pers.comm.) </li></ul>
  23. 26. HIV and Risk Groups? <ul><li>Ronald Stall (CROI 2008) – interviewed at </li></ul><ul><li>“ HIV risk isn't just about our own individual behavior. It's about the level of HIV prevalence out in the communities in which we find our sexual partners; and the proportion of partners in those sexual networks that are viremic, and efficient transmitters.” </li></ul><ul><li>http://www.thebody.com/content/confs/retro2008/art45012.html </li></ul>
  24. 27. Australian Application <ul><li>“ Dense, highly-connected sexual network separate from other sexually-active people” (Ted White) </li></ul><ul><li>“ Men whose sexual access is limited by n. and whose sexual networks have [a] high community viral load” (Ronald Stall) </li></ul><ul><li>Intensive sex partying? </li></ul><ul><li>Sexual adventurism? </li></ul>
  25. 28. Risk Groups in Practice <ul><li>1980’s </li></ul><ul><li>Use condoms / don’t ask, don’t tell </li></ul><ul><li>2009+ </li></ul><ul><li>Targeting strategy to deliver messages to groups according to salience and benefit </li></ul>
  26. 29. Stigma <ul><li>Kippax (2007) </li></ul><ul><li>Stigma and discrimination are natural if unintended consequences of this ‘modern’ public health – particularly in the context of the epidemiological naming of ‘risk groups’. Stigma and discrim-ination are reinforced by the epidemiological categories developed in order to respond effectively to a virus, a virus that is continuing to spread along societies’ fault-lines of race, gender, sexuality and class. </li></ul>
  27. 30. Stigma ( Link & Phelan 2001) Social Power Social Power Discrimination Status Loss Separation Stereotyping Labelling STIGMA
  28. 31. Epidemiologic Synergy <ul><li>Fleming & Wasserheit (1999) </li></ul><ul><li>All three studies that were conducted among homosexual men relied on self reported history of syphilis, which is neither sensitive nor specific for detection of the disease. Nevertheless, two of these studies reported unadjusted odds ratios of 2.3 and 3.5 which remained significant in multivariate analysis. </li></ul><ul><li>Strong evidence that syphilis facilitates HIV transmission is also provided by the remaining study of over 5100 patients who were tested twice for HIV at four Miami STD clinics. Patients who were diagnosed with syphilis between the two HIV tests were almost three times as likely to HIV seroconvert as those who were diagnosed with syphilis before the first HIV test. These patients, in turn, were almost one and a half times as likely to seroconvert as those in whom syphilis was never diagnosed. The first of these analyses included only patients who had had syphilis at some point, and who shared behavioural risk factors for syphilis. Assuming that these risk factors remained stable over time, the ratio of HIV incidences in the two groups represents a measure of the additional risk of acquiring HIV incurred by having syphilis during an HIV exposure. Uniquely, this study also adjusted for the higher prevalence in Miami of HIV infection among syphilis patients than among patients with other STDs. This factor contributes importantly to the true population attributable risk of syphilis, but it may upwardly bias the estimate of the facilitating effect of syphilis on HIV transmission. </li></ul>
  29. 32. Epidemiologic Synergy <ul><li>The biology is beside the point </li></ul><ul><li>Shouldn’t think Syphilis via HIVX risk </li></ul><ul><li>Syphilis is a cultural marker of HSA/SAM </li></ul><ul><li>Challenge for clinical & educational practice – we’ve been out of touch </li></ul>
  30. 33. Outcomes <ul><li>Advertising Campaign </li></ul><ul><li>String Measuring Tool </li></ul><ul><li>Capacity Development </li></ul><ul><li>Community Engagement </li></ul>
  31. 34. Sexually Adventurous Men <ul><li>PLWHA Victoria requested priority on “Intensive Sex Partying” during agenda-setting in Victoria </li></ul><ul><li>Funding stream “Community development for Sexually Adventurous Men” </li></ul><ul><li>PLWHA Victoria received funding to develop community media channels for sexually adventurous MSM </li></ul><ul><li>Community engagement </li></ul>
  32. 35. References <ul><li>Kippax, S. 2007. “Reflections of a social scientist on doing HIV social research” HIV Australia 5(3). </li></ul><ul><li>Oxman GL et al. 1996. Mathematical Modeling of Epidemic Syphilis Transmission: Implications for Syphilis Control Programs. Sexually Transmitted Diseases: Volume 23(1) Jan-Feb 1996 p30-39. </li></ul><ul><li>Stall R, Friedman M, Marshal M, Wisniewski S. What's driving the US epidemic in men who have sex with men . In: Program and abstracts of the 15th Conference on Retroviruses and Opportunistic Infections; February 3-6, 2008; Boston, Mass. Abstract 53. </li></ul>