John R. Su, MD, PhD, MPH; John F. Beltrami, MD, MPH&TM; Akbar A. Zaidi, PhD; Hillard S. Weinstock, MD, MPH
Acknowledgment: The authors thank the state and local health departments that collected and provided these data.
Financial Support: By the Centers for Disease Control and Prevention.
Potential Conflicts of Interest: None disclosed. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-2328.
Reproducible Research Statement:Study protocol: Not applicable. Statistical code: Available from Dr. Zaidi (e-mail, email@example.com). Data set: Limited data are available on request from Dr. Su (e-mail, firstname.lastname@example.org).
Requests for Single Reprints: John R. Su, MD, PhD, MPH, Division of STD Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road, MS-E02, Atlanta, GA 30333; e-mail, email@example.com.
Current Author Addresses: Drs. Su, Zaidi, and Weinstock: Division of STD Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road, MS-E02, Atlanta, GA 30333.
Dr. Beltrami: Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road, MS-E59, Atlanta, GA 30333.
Author Contributions: Conception and design: J.R. Su, J.F. Beltrami, H.S. Weinstock.
Analysis and interpretation of the data: J.R. Su, J.F. Beltrami, A.A. Zaidi, H.S. Weinstock.
Drafting of the article: J.R. Su, J.F. Beltrami, A.A. Zaidi.
Critical revision of the article for important intellectual content: J.R. Su, J.F. Beltrami, H.S. Weinstock.
Final approval of the article: J.R. Su, J.F. Beltrami, H.S. Weinstock.
Statistical expertise: A.A. Zaidi.
Administrative, technical, or logistic support: J.F. Beltrami.
Collection and assembly of data: J.R. Su.
Su J., Beltrami J., Zaidi A., Weinstock H.; Primary and Secondary Syphilis Among Black and Hispanic Men Who Have Sex With Men: Case Report Data From 27 States. Ann Intern Med. 2011;155:145-151. doi: 10.7326/0003-4819-155-3-201108020-00004
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Published: Ann Intern Med. 2011;155(3):145-151.
Until 2005, national-level data on the sex of sex partners that describe how primary and secondary syphilis affects men who have sex with men (MSM) of different races or ethnicities were not reported.
To present data from 27 states comparing trends in primary and secondary syphilis among MSM of different races or ethnicities.
Review of case report data and regression analysis.
Federal database of case reports in the National Electronic Telecommunications System for Surveillance.
Men reported to be MSM.
Cases of primary and secondary syphilis per 100 000 males of matching race or ethnicity (“rates”), determined by using population data from the National Center for Health Statistics as the denominator to compare age and racial and ethnic differences.
For each year during 2005 to 2008, 27 states from all U.S. census regions reported data on the sex of sex partners for 70% or more of male cases of primary and secondary syphilis. Regression analysis revealed significantly different trends in rates of primary and secondary syphilis: Absolute increases in rates among black MSM and Hispanic MSM were, respectively, 8.0 times and 2.4 times the absolute increase in rate among white MSM. By region, rates among MSM increased 30% in the Midwest, 48% in the South, 73% in the Northeast, and 77% in the West. By age group, the largest absolute increase in rates occurred among MSM aged 20 to 29 years.
Results from 27 states may not be generalizable to the United States as a whole.
Rates of primary and secondary syphilis disproportionately increased among black and Hispanic MSM (compared with white MSM) and among young MSM. Care providers should offer counseling about safer sexual practices and screening for syphilis and other sexually transmitted infections when caring for MSM.
Centers for Disease Control and Prevention.
Gregorio A. Millett
August 19, 2011
Sexual risk does not explain racial disparites in STIs among MSM
To the Editor: We read with great interest the recent publication by Su et al in the August 2nd edition of the Annals of Internal Medicine (Primary and Secondary Syphilis Among Black and Hispanic Men Who Have Sex With Men: Case Report Data From 27 States) (1). The authors presented an important analysis that found greater rates of syphilis among black and Latino MSM compared to white MSM across 27 states during 2005-2008 with disparities worsening over time.
Su and colleagues are correct that racial disparities in STD among MSM mirror observed racial disparities in HIV infection. However, although the authors acknowledge that various reasons may explain these disparities, we disagree with their assumption that these disparities are due to greater risk behaviors among black MSM. Disproportionate HIV/STD burden persist among black MSM even though black MSM engage in comparable or less risk behavior than white MSM (2). This dynamic was first reported in 1987 in a study published in JAMA (3) and observed in multiple subsequent studies including CDC's landmark Young Men's Survey with a sample of 3500 MSM across seven cities also published in JAMA, (4) and replicated in another important CDC study published in AIDS this year among 5100 MSM recruited across 21 cities for the National HIV Behavioral Surveillance System (5). Moreover, a meta-analysis published in AIDS in 2007 reported the same pattern of greater STD prevalence among black MSM despite comparable or less risk behavior across multiple scientific studies comprising over 25,000 MSM (2).
Some may suggest that black MSM are underreporting their risk behaviors relative to white MSM, but studies that have examined this issue find no evidence supporting differences in response bias by race. More importantly, greater disease burden among black MSM relative to white MSM in the absence of greater sexual or drug risks persists irrespective of study design, decade of data collection, region of the country, or demographics of the study sample (e.g., young MSM, HIV-positive MSM, substance users) (2).
Rather than individual risk behavior, numerous studies in the scientific literature report that greater background HIV/STI prevalence, high rates of unrecognized HIV infection, greater intraracial sexual mixing and other factors are responsible for the disproportionate HIV/STD rates among black MSM. We commend Su and colleagues for their groundbreaking contribution to the literature, but believe that we owe it to racial minority MSM and their providers to accurately pinpoint how and why these disparities exist in order to meaningfully address this issue.
Gregorio A. Millett, MPH, Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention
John L. Peterson, PhD, Department of Psychology, Georgia State University
Stephen A. Flores, PhD, Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention
Alexandra Oster, MD, Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention
1. Su JR, Beltrami, JF, Zaidii AA, Weinstock HS. Primary and Secondary Syphilis Among Black and Hispanic Men Who Have Sex With Men: Case Report Data From 27 States. Ann Intern Med 2011; 155:145-151.
2. Millett GA, Flores SA, Peterson JP, et al. Explaining disparities in HIV infection among black and white men who have sex with men: a meta- analysis of HIV risk behaviors. AIDS 2007;21:2083-2091
3. Samuel M, Winkelstein W Jr. Prevalence of human immunodeficiency virus infection in ethnic minority homosexual/bisexual men. JAMA. 1987;257: 1901-1902.
4.Valleroy LA, MacKellar DA, Karon JM, Rosen D, McFarland W, Shehan DA, et al. HIV prevalence and associated risks in young men who have sex with men. JAMA 2000; 284:198-204.
5. Oster AM, Wiegand RE, Sionean C, et al. Understanding disparities in HIV infection between black and white MSM in the United States. AIDS 25:1103-12.
Chris R Kenyon
University of Cape Town
August 24, 2011
Resurgence of syphilis in the United States: should we consider self-testing for sexual transmitted infections?
Resurgence of syphilis in the United States: should we consider self- testing for sexual transmitted infections?
To the Editor:
Hu and colleagues provide compelling and actionable information about the significant increases in the rates syphilis among men who have sex with men (MSM) in 27 States in the USA from 2005 to 2008 (1). We agree whole- heartedly with the authors, and Mayer and Mimiaga in the accompanying editorial, that imaginative solutions need to be sought. One such intervention they do not mention, however, is that of self-testing. We believe that this could be an intervention with great potential as it removes significant barriers to persons being more responsible for their sexual health and that of their sex-partner/s. A good case can be made for couple testing for various Sexually Transmitted Infections (STIs) before new couples engage in unprotected sex. Self-testing enables individuals and couples to do this in a way which does not involve an often stigmatizing, financially costly and time consuming trip to a health facility. Effective self-testing strategies that include a linkage to treatment have the potential to detect persons with STIs at earlier stages and therefore reduce the risk of STI transmission.
There is however so far only one FDA approved "home" test for an STI - a home collection system which is then sent to a laboratory for testing for HIV/Hepatitis B or C (2). This is despite the (admittedly limited) research that has been done having found home tests for HIV to be very accurate and considerably more convenient to clients than facility-based testing (3,4,5). Self-tests for syphilis, chlamydia, gonorrhoea are commercially available and being sold via the internet, (6) but it is unclear how reliable these tests are in self-testing settings. The currently available test for syphilis, for example, is an antibody-based test6 whose disadvantages include false positives in previously treated cases. As these tests could be used to increase linkages to care this is not necessarily a terminal problem as the false-positives would be picked up at this stage.
Much however still remains to be learnt about how best to utilize self-testing technologies. So far health authorities and many STI/HIV researchers have been reluctant to consider self-testing as a tool for HIV prevention. We hope that given our failure to control the STI epidemics this attitude will change and that at least more research in this domain will be stimulated.
1. Su JR, Beltrami JF, Zaidi AA, Weinstock HS. Primary and secondary syphilis among black and Hispanic men who have sex with men: case report data from 27 states. Ann Intern Med. 2011;155:145-51.
2. US Food and Drug Administration. http://www.fda.gov/forconsumers/byaudience/forpatientadvocates/hivandaidsactivities/ucm124919.htm (accessed on 22 August 2011).
3. Choko A, Desmond N, Webb E, Chavula K, Mavedzenge S, Makombe S, Squire B, French N, Mwapasa V, Corbett E. Feasibility, accuracy, and acceptability of using oral HIV test kits for supervised community-level self-testing in a resource-poor high-HIV prevalence setting: Blantyre, Malawi. 18th Conference on Retroviruses and Opportunistic Infections, Boston, abstract 42, 2011.
4. MiraTes Europe BV. HIV Home testing, the key to reaching high risk groups. 2008. Available at: http://www.aidsactioneurope.org/uploads/tx_windpublications/1167-0.pdf (accessed on 22 August 2011).
5. Corbett EL. Health worker access to HIV/TB prevention, treatment and care services in Africa: situational analysis and mapping of routine and current best practices . London, London School of Hygiene and Tropical Medicine, WHO/HIV department, WHO/TB department, Global Health Workforce Alliance, 2007.
6. Oral HIV Tests. http://oral-aids-test.com/ (accessed on 21 August 2011).
We are considering engaging in self-testing research for the early diagnosis of STIs.
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