Melanie M. Taylor

Syphilis increases HIV viral load and decreases CD4 cell counts in HIV-infected patients with new syphilis infections.

Background: Syphilitic ulcers are known to facilitate the transmission of HIV infection, but the effect of syphilis infection on HIV viral loads and CD4 cell counts is poorly understood. Methods: We abstracted medical records for HIV-infected male syphilis patients seen at three clinics in San Francisco and Los Angeles from January 2001 to April 2003. We compared plasma HIV-RNA levels and CD4 cell counts during syphilis infection with those before syphilis infection and after syphilis treatment, using the Wilcoxon signed rank test. Results: Fifty-two HIV-infected men with primary or secondary syphilis had HIV viral load and CD4 cell count data available for analysis; 30 (58%) were receiving antiretroviral therapy. Viral loads were higher during syphilis compared with pre-syphilis levels by a mean of 0.22 RNA log10 copies/ml (P = 0.02) and were lower by a mean of −0.10 RNA log10 copies/ml (P = 0.52) after syphilis treatment. CD4 cell counts were lower during syphilis infection than before by a mean of −62 cells/mm3 (P = 0.04), and were higher by a mean of 33 cells/mm3 (P = 0.23) after syphilis treatment. Increases in the HIV viral load and reductions in the CD4 cell count were most substantial in men with secondary syphilis and those not receiving antiretroviral therapy. Conclusion: Syphilis infection was associated with significant increases in the HIV viral load and significant decreases in the CD4 cell count. The findings underscore the importance of preventing and promptly treating syphilis in HIV-infected individuals.

Risk Factors for Community-Associated Methicillin-Resistant Staphylococcus aureus Skin Infections among HIV-Positive Men Who Have Sex with Men

We investigated community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) skin infections among HIV-positive men who have sex with men. We performed a matched case-control study of 35 case patients and 76 control subjects. CA-MRSA skin infections were associated with high-risk sex and drug-using behaviors and with environmental exposures but not with immune status.

Detection of Acute HIV Infections in High-Risk Patients in California

Background: Given the strong relation between sexually transmitted diseases (STDs) and the spread of HIV infection, recent outbreaks of syphilis in the United States could lead to increased rates of new HIV infection. STD clinics serving persons at risk for syphilis would be logical sites to monitor rates of acute HIV infection. The detection of acute HIV infection, however, is not routine and requires the use of HIV RNA testing in combination with HIV antibody testing. Methods: To determine the rate of acute HIV infection, we performed HIV RNA testing on pooled HIV antibody-negative specimens from persons seeking care at San Francisco City Clinic (SFCC) and from men seeking care at 3 STD clinics in Los Angeles. We compared prevalence of acute HIV infection among those groups. Results: From October 2003 to July 2004, we tested 3075 specimens from persons at the SFCC, of which 105 (3%) were HIV antibody-positive and 11 were HIV RNA-positive/HIV antibody-negative, resulting in a prevalence of acute HIV infection of 36 per 10,000 (95% confidence interval [CI]: 26 to 50 per 10,000) and increasing by 10.5% the diagnostic yield of HIV RNA testing compared with standard testing. From February 2004 to April 2004, 1712 specimens were tested from men at 3 Los Angeles STD clinics, of which 14 (0.82%) were HIV-positive by enzyme immunoassay testing and 1 was HIV RNA-positive/HIV antibody-negative, resulting in a prevalence of 6 per 10,000 (95% CI: 3 to 13 per 10,000) and increasing the diagnostic yield for HIV infection by 7.1%. Conclusions: In our study, the addition of HIV RNA screening to routine HIV antibody testing in STD clinics identified a substantial increased proportion of HIV-infected persons at high risk for further HIV transmission, who would have been missed by routine HIV counseling and testing protocols. Further evaluation of the addition of HIV RNA screening to routine HIV antibody testing is warranted.

Correlates of Internet use to meet sex partners among men who have sex with men diagnosed with early syphilis in Los Angeles County.

Objective: The objective of this study was to evaluate use of the Internet to solicit sex partners by men who have sex with men (MSM) who were diagnosed with early syphilis infection. Study: Field interview records for syphilis patients were reviewed for factors associated with Internet use. Results: Internet users were more likely to be of white race (prevalence ratio [PR], 1.6; 95% confidence interval [CI], 1.4–1.8), to report anal insertive sex (PR, 1.1; 95% CI, 1.1–1.2), sex with anonymous partners (PR, 1.2; 95% CI, 1.1–1.3), intravenous drug use (PR, 2.7; 95% CI, 1.1–6.7), and nonintravenous drug use (PR, 1.4; 95% CI, 1.1–1.8). Controlling for race and sexual risk behaviors, white race (odds ratio [OR], 2.8; 95% CI, 1.8–4.6), having anonymous sex partners (OR, 3.4; 95% CI, 1.6–7.0), and nonintravenous drug use (OR, 1.6; 95% CI, 1.1–2.6) were associated with meeting sex partners through the Internet. Conclusions: Effective sexually transmitted disease risk reduction interventions using the Internet are needed to reach Internet-using, sex-seeking MSM populations engaging in high-risk behaviors.

A Consequence of the Syphilis Epidemic Among Men Who Have Sex With Men (MSM) : Neurosyphilis in Los Angeles, 2001-2004

Objectives: To describe the epidemiology and clinical findings of neurosyphilis (NS) cases diagnosed during the current syphilis epidemic occurring predominantly among men who have sex with men. Methods: Syphilis cases reported to the health department were reviewed for diagnosis of NS, cerebrospinal fluid venereal disease research laboratory results, and/or treatment for NS. Results: During 2001–2004, 7083 cases of syphilis were diagnosed in Los Angeles. One hundred nine cases of confirmed or probable NS occurring among persons aged 19 to 65 years were identified during this period (1.5%). Symptomatic NS was present in 1.2% of reported syphilis cases (86 of 7083). NS cases were inclusive of 71 (65%) men who have sex with men. Forty-two (49%) of the symptomatic NS cases occurred during secondary (N = 28) or early latent (N = 14) syphilis. Sixty-eight percent (N = 74) of the NS cases were human immunodeficiency virus (HIV)-positive. The estimated incidence of symptomatic NS among HIV-infected persons with early syphilis was 2.1% as compared with 0.6% among HIV-negative persons. Conclusion: Providers should maintain a high index of suspicion for NS among patients with syphilis, particularly those with HIV infection.

Methamphetamine use and sexual risk behaviours among men who have sex with men diagnosed with early syphilis in Los Angeles County

Methamphetamine use has been associated with risky sexual behaviour and sexually transmitted disease (STD)/HIV transmission among men who have sex with men (MSM). Field interview records for MSM early syphilis (ES) patients were reviewed for factors associated with methamphetamine use during January 2001 through December 2004. There were a total of 2915 ES cases reported during the study period. Of these, 1904 (65%) were MSM. Of these MSM, 167 reported methamphetamine use. Methamphetamine use was associated with having multiple sex partners (prevalence ratios [PR] 1.8, 95% confidence interval [CI] 1.4–2.4), not using condoms (PR 2.0, 95% CI 1.3–2.5), having anonymous sex partners (PR 1.1 95% CI 1.03–1.2), history of recent incarceration (PR 5.4, 95% CI 3.3–8.7), and meeting sex partners via the Internet (PR 1.6, 95% CI 1.3–2.1), at bathhouses (PR 1.6, 95% CI 1.2–2.0) and on the streets (PR 2.6, 95% CI 1.7–4.0). In multivariate analysis having multiple sex partners, not using condoms, recent incarceration and meeting sex partners at bathhouses were significantly associated with methamphetamine use. In conclusion, effective STD risk reduction interventions targeting MSM methamphetamine users are needed to curb risky sexual behaviour.

Control of syphilis outbreaks in men who have sex with men: the role of screening in nonmedical settings.

Objective: To quantify the scope and yield of targeted syphilis screening in nonmedical settings in 7 US cities affected by recent syphilis outbreaks among men who have sex with men (MSM). Methods: Data were collected from syphilis screening activities targeting MSM between 1999 and 2004, conducted in bathhouses or other commercial sex venues, MSM-oriented bars, mobile vans, and other nonmedical settings by the public health departments of Chicago, Houston, Miami/Fort Lauderdale, Los Angeles, NY, and San Francisco. Results: Of 14,143 syphilis screening tests (STS) conducted during community outreach campaigns at a variety of MSM oriented venues, 132 (0.9%) new cases of syphilis were identified. One hundred five (0.8%) new cases of early syphilis were found, including 23 cases of symptomatic syphilis. Screening in jails produced the highest prevalence of early syphilis (1.3%, 51 cases/3853 STS), followed by sex venues, including bathhouses (1.2%, 29 cases/2511 STS). Conclusions: These data suggest that even nontraditional, highly targeted screening programs conducted during outbreak situations do not detect many persons with syphilis, even though many of the screening venues were locations where men with syphilis met their sex partners. The low prevalence of infectious syphilis identified during these screening events suggests that the direct impact of these programs on decreasing syphilis transmission may be negligible. However, the secondary benefits, such as increasing awareness of syphilis and prompting earlier treatment due to symptom recognition, may be substantial.

Substance use and sexual risk behaviors among american Indian and alaska native high school students.

BACKGROUND We describe the prevalence of behaviors that put American Indian and Alaska Native (AI/AN) high school students at risk for teen pregnancy and sexually transmitted infections (STIs) and the relationships among race/ethnicity and these behaviors. METHODS We analyzed merged 2007 and 2009 data from the national Youth Risk Behavior Survey, a biennial, self-administered, school-based survey of US students in grades 9-12 (N = 27,912). Prevalence estimates and logistic regression, controlling for sex and grade, were used to examine the associations between race/ethnicity, and substance use, and sexual risk behaviors. RESULTS Of the 26 variables studied, the adjusted odds ratios (AOR) were higher among AI/AN than White students for 18 variables (ranging from 1.4 to 2.3), higher among AI/AN than Black students for 13 variables (ranging from 1.4 to 4.2), and higher among AI/AN than Hispanic students for 5 variables (ranging from 1.4 to 1.5). Odds were lower among AI/AN than Black students for many of the sexual risk-related behaviors. CONCLUSIONS The data suggest it is necessary to develop targeted, adolescent-specific interventions aimed at reducing behaviors that put AI/AN high school students at risk for teen pregnancy, STI/HIV, and other health conditions.

Epidemiologic Investigation of a Cluster of Workplace HIV Infections in the Adult Film Industry: Los Angeles, California, 2004

BACKGROUND Adult film production is a legal, multibillion dollar industry in California. In response to reports of human immunodeficiency virus (HIV) transmission by an adult film worker, we sought to determine the extent of HIV infection among exposed workers and to identify means of improving worker safety. METHODS The Los Angeles County Department of Health Services initiated an outbreak investigation that included interviews of infected workers to elicit information about recent sex partners, review of the testing agencys medical records and laboratory results, molecular analysis of HIV isolates from the 4 infected workers, and a risk assessment of HIV transmission in the adult film industry. RESULTS Many adult film workers participate in a monthly program of screening for HIV infection by means of polymerase chain reaction-based technology to detect HIV DNA in blood. A male performer tested negative for HIV on 12 February 2004 and 17 March 2004, then tested positive for HIV on 9 April 2004. During the period between the negative test results, he experienced a flulike illness after performing unprotected vaginal and anal intercourse for an adult film produced outside the United States by a US company. After returning to California, he performed unprotected sex acts for adult films with 13 female partners who had all tested negative for HIV in the preceding 30 days; 3 subsequently tested positive for HIV (a 23% attack rate). Contact tracing identified no reasonable sources of infection other than the male index patient. CONCLUSION Although current testing methods may shorten the window period to diagnosis of new HIV infection, they fail to prevent occupational acquisition of HIV in this setting. A California Occupational Safety and Health Administration-approved written health and safety program that emphasizes primary prevention is needed for this industry.

Use of the serologic testing algorithm for recent HIV seroconversion (STARHS) to identify recently acquired HIV infections in men with early syphilis in Los Angeles county

Background:Syphilis outbreaks among men who have sex with men (MSM) in the United States, many of whom are HIV infected, have prompted increased concern for HIV transmission. Methods:To identify whether men are acquiring HIV concomitantly or within the critical period of syphilis infection, banked Treponema pallidum particle agglutination-positive serum specimens from men with early syphilis infection were screened for HIV-1 antibody. Samples that were positive for HIV antibody were then tested with a less sensitive (LS) HIV-1 antibody enzyme immunoassay (serologic testing algorithm for recent HIV seroconversion [STARHS]) to identify HIV infections that occurred on average within the previous 6 months. Results:Of the 212 specimens banked from men with early syphilis, 74 (35%) were HIV-positive. Of these, 15 tested non-reactive by the LS assay. Twelve of these 15 were considered to be recent infections by the LS assay and testing history. Eleven (92%) of the recent infections were among MSM. One man had primary syphilis, 6 (50%) had secondary syphilis, and 5 (42%) had early latent syphilis. Eight men (67%) reported sex with anonymous partners, and 3 (25%) reported consistent condom use. The estimated HIV incidence was 17% per year (95% confidence interval [CI]: 12%-22%) among all men with early syphilis, and it was 26% per year (95% CI: 91%-33%) among MSM. Conclusions:Syphilis epidemics in MSM may be contributing to HIV incidence in this population. The STARHS can be applied as a surveillance tool to assess HIV incidence in various at-risk populations, but further studies are necessary for validation.