Karla Schmitt

Reinfections during the Florida syphilis epidemic, 2000-2008.

Background: The last 3 syphilis epidemics in the United States peaked after 5 to 6 years, but rates have now increased for 8 years. We questioned whether persons with multiple syphilis diagnoses (repeaters) are fueling the epidemic. Methods: The Florida Department of Health database of all syphilis cases reported between 2000 and 2008 was used to examine demographics and disease presentation of repeaters and nonrepeaters using bivariate and multivariate analyses. Results: Of 26,070 persons diagnosed with syphilis, 643 (2.5%) were repeaters (range, 2–5 diagnoses): 82 women, 444 men who have sex with men (MSM), and 117 men identified as either heterosexual (n = 43) or unknown sexual orientation (n = 74). The mean time between first and second diagnosis was approximately 3 years. Median titer increase among those with a second diagnosis of early latent was 32-fold. In multivariate analysis, compared with nonrepeaters, repeaters were more likely to be MSM (odds ratio [OR], 5.3), human immunodeficiency virus (HIV)-infected (OR, 2.0), white (OR, 1.5), ages 35 to 39 (OR, 1.8), and to live in Miami-Dade or Broward Counties (OR, 1.7). Overall, the stage at diagnosis was similar for repeaters, whether it was their initial or subsequent diagnosis. However, HIV-infected MSM were more likely to be diagnosed with early latent at second diagnosis compared with initial diagnosis (P ≤ 0.01). Conclusions: Most syphilis diagnosed in the current Florida epidemic is among persons infected for the first time. Repeaters are mainly MSM who present with symptoms or large increases in titers. HIV-infected MSM may have higher rates of early asymptomatic disease because of more frequent screening. These are likely to be true new infections.

Risk for HIV following a diagnosis of syphilis, gonorrhoea or chlamydia: 328,456 women in Florida, 2000-2011.

Several effective interventions are available for preventing HIV in women. Targeting interventions requires understanding their risk of acquiring HIV. We used surveillance data to estimate risks of HIV acquisition for 13–59-year-old women following a diagnosis of syphilis, gonorrhoea or chlamydia in Florida during 2000–2009. We excluded women reported with HIV before their STI, and measured HIV reported subsequent to STI (through 2011). Rates were compared to women with no reported STI. A total of 328,456 women had: syphilis (3325), gonorrhoea (67,784) or chlamydia (257,347). During 2,221,944 person-years of follow-up, 2118 of them were diagnosed with HIV. For women with no STI reported, during 64,763,832 person-years, 19,531 were reported with HIV. The crude rate of subsequent HIV diagnosis (per 100,000 person-years) was higher for women diagnosed with syphilis (597.9), gonorrhoea (171.3) or chlamydia (66.3) than women with no STI (30.2). Annual rates of HIV decreased over-all by 61.8% between 2001 and 2011. Women with syphilis or gonorrhoea were at highest risk for HIV and therefore might benefit from intensive counselling. However, they represented only a small fraction of the women who acquired HIV. Most cases of HIV infection among women occurred among the large group of women who were not at highest risk.

Infectious syphilis among adolescent and young adult men: implications for human immunodeficiency virus transmission and public health interventions.

Background: In 2008, an increase in syphilis among young black men was noted in New York City (NYC), Miami-Fort Lauderdale, and Philadelphia. To explore this trend, we examined infectious syphilis cases from 2000 to 2008 among adolescent and young adult men in these areas. Methods: Descriptive analysis of male infectious syphilis cases reported to public health authorities in NYC, FL, and Philadelphia. Results: From 2000 to 2008, infectious syphilis cases among males increased in NYC (107–1027 cases), Miami-Fort Lauderdale (109–374), and Philadelphia (41–142). This increase was largely attributable to cases among men who have sex with men. Rates among black adolescent males (15–19 years) increased in NYC ([2.6–43.0]/100,000), Miami-Fort Lauderdale ([5.5–48.1]/100,000), and Philadelphia (]8.3–40.3]/100,000). Among males with infectious syphilis in 2008 in NYC, 9.1% of blacks and 6.6% of Hispanics were adolescents compared with 1.6% of whites (P < 0.001). In Miami-Fort Lauderdale, 12.2% of black males were adolescents compared to 2.0% of whites (P < 0.01) and 2.7% of Hispanics (P < 0.01). Black males dominated all age groups in Philadelphia, but were more likely to be <25 years of age than whites (P = 0.02). Human immunodeficiency virus coinfection rates were 14.8% among adolescent males in NYC, 15.4% in Philadelphia, and 25.0% in Miami-Fort Lauderdale. Conclusions: Very young black males have emerged as a risk group for syphilis in these 3 areas, as have young Hispanic males in NYC. Many are men who have sex with men and some are already human immunodeficiency virus-infected. Targeted risk reduction interventions for these populations are critical.

Florida's multifaceted response for increases in syphilis among MSM: the Miami-Ft. Lauderdale initiative.

After many years of declining rates, it became apparent in 1999 that syphilis cases were on the rise in Florida. Data analysis identified that the outbreak was predominately contained in Miami and Ft. Lauderdale and among men who have sex with men. An in-depth investigation was undertaken to identify the risk factors, the best way to attack the outbreak, and how to build sustainability into implemented strategies. After thorough review of the data and extensive dialogue with local public health and community participants, the Bureau of STD Prevention & Control developed initiatives that focused public awareness through print, radio, and television media resources; expanded access to men’s health services; and enhanced education/training for public and private health care providers, STD program field staff, and community representatives. This initiative has resulted in unprecedented community involvement in syphilis control efforts.

High Risk for HIV Following Syphilis Diagnosis Among Men in Florida, 2000-2011

Objective. Multiple interventions have been shown to reduce the risk of HIV acquisition, including preexposure prophylaxis with antiretroviral medications, but high costs require targeting interventions to people at the highest risk. We identified the risk of HIV following a syphilis diagnosis for men in Florida. Methods. We analyzed surveillance records of 13- to 59-year-old men in Florida who were reported as having syphilis from January 1, 2000, to December 31, 2009. We excluded men who had HIV infection reported before their syphilis diagnosis (and within 60 days after), then searched the database to see if the remaining men were reported as having HIV infection by December 31, 2011. Results. Of the 9,512 men with syphilis we followed, 1,323 were subsequently diagnosed as having HIV infection 60–3,753 days after their syphilis diagnosis. The risk of a subsequent diagnosis of HIV infection was 3.6% in the first year after syphilis was diagnosed and reached 17.5% 10 years after a syphilis diagnosis. The risk of HIV was higher for non-Hispanic white men (3.4% per year) than for non-Hispanic black men (1.8% per year). The likelihood of developing HIV was slightly lower for men diagnosed with syphilis in 2000 and 2001 compared with subsequent years. Of men diagnosed with syphilis in 2003, 21.5% were reported as having a new HIV diagnosis by December 31, 2011. Conclusion. Men who acquire syphilis are at very high risk of HIV infection.

Increasing knowledge of sexually transmitted infection risk.

exually transmitted infections (STIs) are a major threat to public health. Without intervention,experts predict dramatic increases in cases. Research on both knowledge and perceived risk of STIs among women of childbearing age is very limited. Because of the rising number of human immunodeficiency virus (HIV) infections and other STIs among this patient population, health directives should include behavioral interventions with the aim of empowering women with increased knowledge as well as an increased perception of risk of STIs. Positive behavior changes are plausible with STI prevention messages and services for at-risk women by means of nurse-directed interventions with the intention of enhancing perceived risk as well as increasing knowledge of STIs in women. The purpose of this study was to test the effects of an educational/behavioral intervention on knowledge and perceived risk of STIs in women of childbearing age.

Use of a Business Approach to Improve Disease Surveillance Data Management Systems and Information Technology Process in Florida's Bureau of STD Prevention and Control

The business of sexually transmitted disease (STD) prevention and control demands technology that is capable of supporting a wide array of program activities—from the processing of laboratory test results to the complex and confidential process involved in contact investigation. The need for a tool that enables public health officials to successfully manage the complex operations encountered in an STD prevention and control program, and the need to operate in an increasingly poor resource environment, led the Florida Bureau of STD to develop the Patient Reporting Investigation Surveillance Manager. Its unique approach, technical architecture, and sociotechnical philosophy have made this business application successful in real-time monitoring of disease burden for local communities, identification of emerging outbreaks, monitoring and assurance of appropriate treatments, improving access to laboratory data, and improving the quality of data for epidemiologic analysis. Additionally, the effort attempted to create and release a product that promoted the Centers for Disease Control and Preventions ideas for integration of programs and processes.