| What's going on Here
The Syphilis/HIV Connection
Syphilis/HIV and MSM
Process of Elimination
Collaboration is the Key Resources
and References
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It put Detroit in the spotlight in 2001 for having achieved the
notoriety of being the city with both the highest number and rate, of the
CDC selected cities, with populations over 200,000. To put this into
perspective, however, this media hype was over 351 cases of syphilis
within the City of Detroit.
“Syphilis is not a prevalent disease, it’s a prominent disease,” said
Carla Merritt, the MDCH epidemiologist who tracks syphilis at the Detroit
Health Department (DHD). It is the current STD poster child because the
national Centers for Disease Control and Prevention (CDC) is trying to
eliminate it. CDC sees this as a realistic goal because syphilis has such
low prevalence now, is easily diagnosed, and is treatable at every stage.
And elimination is worth the effort - syphilis aids the transmission of
HIV.
The CDC came out with its syphilis elimination plan in 1998 and began
targeted prevention efforts within African American populations and in the
southeastern states. CDC defines elimination as “absence of sustained
transmission.” This is not the same as eradication; the CDC is aiming for
1,000 or fewer cases in the US by 2005.
These efforts were paying off in the targeted populations. And then there
was a national increase in syphilis, over 2%, between 2000 and 2001, which
can be attributed to an increase among men. This coincided with outbreaks
within the (men who have sex with men) MSM population in several cities
around the nation, particularly on the coasts.
What’s Going On Here
As to the 2001 spotlight for Detroit, Deputy Director of CDC's National
Center for HIV, STD, and TB Prevention; Ronald O. Valdiserri, said in a
press conference (October 31, 2002), “We are turning that situation
around. Generally the transmission in Detroit has been heterosexual
transmission among socially and economically challenged populations.”
In 2002, 95% of syphilis reported in its infectious stages in Detroit* was
among blacks and the male to female ratio still showed a primarily
heterosexual transmission. However, MDCH surveillance indicates that while
the syphilis numbers are going down in Detroit, they are increasingly
being represented by MSM. And the smaller numbers of outstate cases are
more likely to be, white, male, and report MSM behavior.
Comparing Detroit statistics, 2001 to 2002, the total number of infectious
syphilis (primary and seconday) cases who reported MSM activity rose 62%.
The percent of all Detroit P&S cases reporting MSM activity rose 35% in
this time period. It is important to note that all early syphilis case
numbers are falling in 2003.
*Note: Detroit statistics include Detroit, Hamtramck, Harper Woods,
Highland Park and the Grosse Pointes. ‘Outstate’ refers to all of the
counties, including Wayne outside this area.
The Syphilis/HIV Connection
In an article published June 3 in the American Journal of Public Health,
the authors adapted a simplified model of the effect of infectious
syphilis on HIV transmission to estimate the number of new HIV cases among
African Americans attributable to syphilis in 2000. They estimated that
about 545 new cases of HIV among African Americans in 2000 could be
attributed to the facilitative effects of infectious syphilis on HIV
transmission. These 545 cases represent about 3 percent to 5 percent of
all new HIV cases among African Americans in 2000, assuming that there are
11,200 to 21,600 new HIV infections among African Americans each year.
(from CDC summary)
The Detroit Health Department and MDCH did a study to find out how many of
those with syphilis here were also HIV positive. “ We found 111 cases of
those with syphilis who also had HIV (in Detroit only),” said Kathryn
Macomber, the MDCH epidemiologist who is tracking syphilis/HIV
co-morbidity. “Of these 111 cases, 74 were diagnosed with syphilis
After
HIV….this also translates into 3.7% of all syphilis cases have HIV.”
“We were hoping not to see this since it pointed to continued unprotected
sex after an HIV diagnosis, not only sharing exposure to syphilis, but
also to HIV,” said Macomber. See the MDCH Surveillance report,
The
Prevalence of Syphilis Infections After an HIV Diagnosis.
Being infected with syphilis creates a 2 to 5 fold increased risk of
acquiring HIV due to genital lesions, which create an entry point for the
virus (HIV), according to Merritt.
Merritt and Macomber have been collaborating to cross match Detroit’s
syphilis database with the HIV database to find out where these two
epidemics coincide, and to characterize these populations in terms of
risk, behavior and demographics.
When the syphilis data were compared to the HIV data it was discovered
that among those with syphilis and HIV, most cases had been diagnosed with
HIV an average of 4.2 years before syphilis. This indicates continued
risky/unprotected sex after an HIV diagnosis.
Merritt said she recently learned at a WSU AIDS Research and Education
Center sponsored conference on syphilis* that if you are co-infected with
syphilis and HIV, Treponema pallidum (the organism that causes syphilis)
increases your HIV viral load. "T. pallidum induces increased reproduction
of the HIV virus in immune cells. This increases an individual's viral
load making the disease more easily transmitted," she said.
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Treponema pallidum
This is the Latin name for the organism which causes syphilis. There are a
number of stages of infection. During the primary and secondary (P & S)
stages, the infection can be passed sexually. MDCH surveillance follows
these first two and early latent as well. ” We track all the stages,” said
Merritt, “but do most of our analysis and interventions on primary,
secondary and early latent.” The early latent stage is important because,
while not infectious itself, it is important for locating sexual partners.
If the patient is in this stage his partners could still be in the early
stages and be able to transmit to others. Both primary and secondary
syphilis have symptoms. Primary syphilis is characterized by a painless
lesion or chancre at the point of entry, and secondary syphilis has a
symptomatic rash.
Though 99% of infected individuals are symptomatic, there are a couple of
problems. Since the chancre is painless, women may remain unaware of an
internal lesion. And a physician who is not looking for syphilis can
easily misdiagnose the rash. “Syphilis is called “the great imitator”
because it can look like almost anything including dermatitis or chicken
pox.
*Note: if left untreated, a mother can transmit Treponema pallidum at any
stage of disease/pregnancy to an unborn child. There were 23 cases of
congenital syphilis reported in Detroit in 2002.
Syphilis/HIV and MSM
From, 2002 data, in DETROIT 65% of those dual diagnosed with syphilis and
HIV are MSM. For the outstate cases this is 81%.
While the actual numbers of these co-infections are low here in Michigan,
MDCH – both the Surveillance Section and the Division of HIV/AIDS and STD
(DHAS) – officials looked at the trend in Michigan co-morbidity, and the
syphilis outbreaks that have been occurring nationally among MSM, and have
taken proactive measures. “We are working with gatekeepers and
community-based organizations with access to MSM populations, to
piggy-back the syphilis prevention and management on the existing HIV
vehicle," said DHAS Director Loretta Davis-Satterla.
DHAS sponsored a comprehensive training on MSM and syphilis for Detroit
and Oakland County agencies currently funded to provide prevention and
care for MSM this past spring. Merritt gave a syphilis epidemiology
presentation to this group. The Midwest AIDS Prevention Project (MAPP)
collaborated with DHAS and Detroit CBOs to provide a syphilis training and
prevention outreach program for MSM. See Men at Work article.
Process of Elimination
The history of syphilis resembles the tale of Sisyphus (that fellow of
Greek mythology “condemned to ceaselessly roll a rock to the top of a
mountain, whence the stone would fall back of its own weight.”) The bar
chart of syphilis - case numbers across the years since 1947 - is a roller
coaster ride. Just when it looks like it might be gone, there is another
surge of infection. The surge in 2001 that received all of the press was
actually not nearly as high as one in the early 90s, when the Michigan
cases peaked at 1,300.
But when the numbers decrease to almost nil, there is a theoretical “Core
Group” who maintains transmission, even in these times of low prevalence
according to Merritt. This core group, she said, is characterized by four
behaviors: 1) hardcore drug use; 2) exchange of money for sex or drugs; 3)
having four or more partners in the past year or 4) having unknown
partners in the past year.
Merritt said, “The numbers of cases have been declining drastically in
2003.” Elimination of syphilis in Detroit is a very achievable goal she
said. “With maintenance and targeting of effort, the goal is achievable,
and will result in improved health for Detroit’s citizens,” said DHAS STD
Section Manager Mark Miller.
Collaboration is the key
In Detroit, ER doctors have been trained to spot syphilis and now account
for many of the reported cases. Dawn Jackson, the syphilis elimination
coordinator goes out to Detroit area CBOs to provide syphilis training, so
outreach workers can get the prevention message out. For the statewide
DHAS sponsored “On The Frontlines: Referrals and Linkages Conference” this
summer in Novi, DHD did a presentation on local health departments and
CBOs partnering in the fight against syphilis, and Macomber presented on
Syphilis and HIV Co-Morbidity at the conference. So, statewide workers on
the frontlines, caseworkers, outreach workers, and clinicians are all
working together towards syphilis elimination.
Resources and References
Carla Merritt’s MDCH slide presentation, including information on all
stages of syphilis with graphic images, is available on the web site:
http://www.mihivnews.com/stats/HIVMSMTraining_rev.pdf
*"Managing the Syphilis Epidemic: Symptoms, Diagnosis, Case Management and
the Impact of HIV and Other Common Co-Morbid Disorders," U o D Mercy on
May 3, 2003. Dr. Jack D Sobel, Wayne State University School of Medicine, said that Treponema
pallidum induces HIV-1 gene expression in human monocytes. (Thues et al.
JID 1998; 177: 941-950) and that it promotes the expression of the
monocyte beta-chemokine receptor CCR5- a co-receptor of HIV transmission (Sellati
TJ et al. JID 2000; 181: 283-293).
“HIV Infections and Associated Costs Attributable to Syphilis Co-
infection Among African Americans”
American Journal of Public Health (06.03) Vol. 93; No. 6: P. 943-948
“Recommendations for Public Health Surveillance of Syphilis in US”
http://www.cdc.gov/std/SyphSurvReco.pdf Expert consultants included Dara
Gonoczy MDCH; and Bruce Nowak DHD
"The Practitioner's Handbook for the
Management of Sexually Transmitted Disease"
3rd Edition" by Connie L. Celum, MD, MPH, Jeanne Marrazzo, MD, MPH,
Negusse Ocbamichael, PA-C, Anne Meegan and Walter Stamm, MD, available
online (complete with downloadable color slides) at
http://www.STDhandbook.org
See the latest news on this issue:
"Health Officials: Detroit Syphilis Cases Declining" - and how this
reflects MSM cases - See Syphilis.
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