The Congenital Syphilis Prevention Cascade: Reimagining a Missed Prevention Opportunities Framework for Effective Intervention.

ABSTRACT: Congenital syphilis (CS) rates have risen in the United States since 2013. Prevention of CS requires testing and treatment of pregnant and pregnancy-capable persons at high risk for syphilis. We developed a CS Prevention Cascade to assess how effectively testing and treatment interventions reached pregnant persons with a CS outcome.

A Sore Subject? An Examination of National Case-Based Chancroid Surveillance.

BACKGROUND: Chancroid has been a nationally notifiable condition in the United States since 1944, with cases reported to Centers Disease Control and Prevention through the National Notifiable Diseases Surveillance System. Although frequently reported during the 1940s, <20 cases have been reported annually since 2011. We assessed the performance and utility of national case-based chancroid surveillance. METHODS: We reviewed the literature to contextualize chancroid surveillance through National Notifiable Diseases Surveillance System. We then assessed 4 system attributes, including data quality, sensitivity, usefulness, and representativeness: we reviewed chancroid cases reported during 2011-2020, conducted interviews with (a) sexually transmitted disease programs reporting ≥1 case in 2019 or 2020 (n = 9) and (b) Centers Disease Control and Prevention subject matter experts (n = 10), and reviewed published communicable disease reporting laws. RESULTS: Chancroid diagnostic testing is limited, which affects the surveillance case definition. National case-based surveillance has poor data quality; of the 2019 and preliminary 2020 cases (n = 14), only 3 were verified by jurisdictions as chancroid cases. Sexually transmitted disease programs report the system has low sensitivity given limited clinician knowledge and resources; experts report the system is not useful in guiding national control efforts. Review of reporting laws revealed it is not representative, as chancroid is not a reportable condition nationwide. CONCLUSIONS: Critical review of system attributes suggest that national case-based chancroid surveillance data have limited ability to help describe and monitor national trends, and chancroid's inclusion on the national notifiable list might need to be reconsidered. Alternative strategies might be needed to monitor national chancroid burden.

Vital Signs: Missed Opportunities for Preventing Congenital Syphilis - United States, 2022.

Introduction: Congenital syphilis cases in the United States increased 755% during 2012-2021. Syphilis during pregnancy can lead to stillbirth, miscarriage, infant death, and maternal and infant morbidity; these outcomes can be prevented through appropriate screening and treatment. Methods: A cascading framework was used to identify and classify missed opportunities to prevent congenital syphilis among cases reported to CDC in 2022 through the National Notifiable Diseases Surveillance System. Data on testing and treatment during pregnancy and clinical manifestations present in the newborn were used to identify missed opportunities to prevent congenital syphilis. Results: In 2022, a total of 3,761 cases of congenital syphilis in the United States were reported to CDC, including 231 (6%) stillbirths and 51 (1%) infant deaths. Lack of timely testing and adequate treatment during pregnancy contributed to 88% of cases of congenital syphilis. Testing and treatment gaps were present in the majority of cases across all races, ethnicities, and U.S. Census Bureau regions. Conclusions and implications for public health practice: Addressing missed opportunities for prevention, primarily timely testing and appropriate treatment of syphilis during pregnancy, is important for reversing congenital syphilis trends in the United States. Implementing tailored strategies addressing missed opportunities at the local and national levels could substantially reduce congenital syphilis.

Primary and Secondary Syphilis Among Men Who Have Sex With Men and Women, 2010 to 2019.

ABSTRACT: The relative proportion of cases of primary and secondary syphilis among men who have sex with men and women reported through national case report data from 2010 to 2019 seemed stable overall and were stratified by race/ethnicity, region, and age group, but case counts increased.

Predicting Emergence of Primary and Secondary Syphilis Among Women of Reproductive Age in US Counties.

BACKGROUND: Syphilis, a sexually transmitted infection that can cause severe congenital disease when not treated during pregnancy, is on the rise in the United States. Our objective was to identify US counties with elevated risk for emergence of primary and secondary (P&S) syphilis among women of reproductive age. METHODS: Using syphilis case reports, we identified counties with no cases of P&S syphilis among women of reproductive age in 2017 and 1 case or more in 2018. Using county-level syphilis and sociodemographic data, we developed a model to predict counties with emergence of P&S syphilis among women and a risk score to identify counties at elevated risk. RESULTS: Of 2451 counties with no cases of P&S syphilis among women of reproductive age in 2017, 345 counties (14.1%) had documented emergence of syphilis in 2018. Emergence was predicted by the county's P&S syphilis rate among men; violent crime rate; proportions of Black, White, Asian, and Hawaiian/Pacific Islander persons; urbanicity; presence of a metropolitan area; population size; and having a neighboring county with P&S syphilis among women. A risk score of 20 or more identified 75% of counties with emergence. CONCLUSIONS: Jurisdictions can identify counties at elevated risk for emergence of syphilis in women and tailor prevention efforts. Prevention of syphilis requires multidisciplinary collaboration to address underlying social factors.

Trends in Nationally Notifiable Sexually Transmitted Disease Case Reports During the US COVID-19 Pandemic, January to December 2020.

BACKGROUND: To describe changes in reported sexually transmitted diseases (STDs) during the US coronavirus disease 2019 pandemic, we compared the weekly number of reported nationally notifiable STDs in 2020 to 2019. METHODS: We reviewed cases of chlamydia, gonorrhea, and primary and secondary (P&S) syphilis reported to the US National Notifiable Disease Surveillance System in 2020. For each STD, we compare the number of 2020 cases reported for a given Morbidity and Mortality Weekly Report (MMWR) week to the number of 2019 cases reported in the same week, expressing 2020 cases as a percentage of 2019 cases. We also calculated the percent difference between 2020 and 2019 cumulative case totals as of MMWR week 50 (week of December 9). RESULTS: During MMWR weeks 1 to 11 (week of December 29, 2019-March 11, 2020), the weekly number of cases of STDs reported in 2020 as a percentage of the cases in the same week in 2019 was similar. However, 2020 numbers were much lower than 2019 numbers in week 15 (week of April 8; chlamydia, 49.8%; gonorrhea, 71.2%; and P&S syphilis, 63.7%). As of week 50, the 2020 cumulative totals compared with 2019 were 14.0% lower for chlamydia, 7.1% higher for gonorrhea, and 0.9% lower for P&S syphilis. CONCLUSIONS: During March-April 2020, national case reporting for STDs dramatically decreased compared with 2019. However, resurgence in reported gonorrhea and syphilis cases later in the year suggests STD reporting may have increased in 2020, underscoring the importance of continued STD prevention and care activities.

Increased Methamphetamine, Injection Drug, and Heroin Use Among Women and Heterosexual Men with Primary and Secondary Syphilis - United States, 2013-2017.

During 2013-2017, the national annual rate of reported primary and secondary (P&S) syphilis cases in the United States increased 72.7%, from 5.5 to 9.5 cases per 100,000 population (1). The highest rates of P&S syphilis are seen among gay, bisexual, and other men who have sex with men (collectively referred to as MSM) (2), and MSM continued to account for the majority of cases in 2017 (1). However, during 2013-2017, the P&S syphilis rate among women increased 155.6% (from 0.9 to 2.3 cases per 100,000 women), and the rate among all men increased 65.7% (from 10.2 to 16.9 cases per 100,000 men), indicating increasing transmission between men and women in addition to increasing transmission between men (1). To further understand these trends, CDC analyzed national P&S syphilis surveillance data for 2013-2017 and assessed the percentage of cases among women, men who have sex with women only (MSW), and MSM who reported drug-related risk behaviors during the past 12 months. Among women and MSW with P&S syphilis, reported use of methamphetamine, injection drugs, and heroin more than doubled during 2013-2017. In 2017, 16.6% of women with P&S syphilis used methamphetamine, 10.5% used injection drugs, and 5.8% used heroin during the preceding 12 months. Similar trends were seen among MSW, but not among MSM. These findings indicate that a substantial percentage of heterosexual syphilis transmission is occurring among persons who use these drugs, particularly methamphetamine. Collaboration between sexually transmitted disease (STD) control programs and partners that provide substance use disorder services will be important to address recent increases in heterosexual syphilis.

Developing a Topology of Syphilis in the United States.

BACKGROUND: In the United States, reported rates of syphilis continue to increase. Co-occurring epidemics of syphilis among men who have sex with men (MSM) and heterosexual populations create challenges for the prioritization of resources and the implementation of context-specific interventions. METHODS: State was the unit of analysis and was restricted to the 44 states with the most complete data of sex or sex partners for their reported adult syphilis cases. States were classified as high, medium, or low for reported congenital syphilis (CS) and MSM primary and secondary (P&S) syphilis rates. Average values of a range of ecologic state level variables were examined among the 9 categories created through the cross-tabulation of CS and MSM P&S syphilis rates. Patterns among ecologic factors were assessed across the 9 categories of states' syphilis rates. RESULTS: Among the 44 states categorized, 4 states had high rates of both CS and MSM P&S syphilis in 2015, whereas 12 states fell into the medium/medium category and 7 into the low category. Six states had high CS and medium MSM syphilis and 4 states had medium CS but high MSM syphilis. Several area-level factors, including violent crime, poverty, insurance status, household structure and income, showed qualitative patterns with higher rates of CS and MSM P&S syphilis. Higher proportions of urban population were found among states with higher CS rates; no trend was seen with respect to urbanity and MSM P&S syphilis. CONCLUSIONS: Several area-level factors were associated with CS and MSM P&S syphilis in similar ways, whereas other ecologic factors functioned differently with respect to the 2 epidemics. Explorations of community and area-level factors may shed light on novel opportunities for population specific prevention of syphilis.

Patterns of Racial/Ethnic Disparities and Prevalence in HIV and Syphilis Diagnoses Among Men Who Have Sex With Men, 2016: A Novel Data Visualization.

OBJECTIVES: To describe disparities in HIV infection and syphilis among gay, bisexual, and other men who have sex with men (MSM) in US states through ratio-based measures and graphical depictions of disparities. METHODS: We used state-level surveillance data of reported HIV and syphilis cases in 2015 and 2016, and estimates of MSM population sizes to estimate HIV and syphilis prevalence by race/ethnicity and rate ratios (RRs) and to visually display patterns of disparity and prevalence among US states. RESULTS: State-specific rates of new HIV diagnoses were higher for Black than for White MSM (RR range = 2.35 [Rhode Island] to 10.12 [Wisconsin]) and for Hispanic than for White MSM (RR range = 1.50 [Tennessee] to 5.78 [Pennsylvania]). Rates of syphilis diagnoses were higher for Black than for White MSM in 42 of 44 states (state RR range = 0.89 [Hawaii] to 17.11 [Alaska]). Scatterplots of HIV diagnosis rates by race showed heterogeneity in epidemic scenarios, even in states with similar ratio-based disparity measures. CONCLUSIONS: There is a widely disparate impact of HIV and syphilis among Black and Hispanic MSM compared with White MSM. Between-state variation suggests that states should tailor and focus their prevention responses to best address state data.

State-Specific Rates of Primary and Secondary Syphilis Among Men Who Have Sex with Men - United States, 2015.

In 2015, the rate of reported primary and secondary syphilis in the United States was 7.5 cases per 100,000 population, nearly four times the previous lowest documented rate of 2.1 in 2000 (1). In 2015, 81.7% of male primary and secondary syphilis cases with information on the sex of the sex partner were among gay, bisexual, and other men who have sex with men (collectively referred to as MSM) (1). These data suggest a disproportionate incidence of disease among MSM. However, attempts to quantify this disparity have been hindered by limited data on the size of the MSM population at the state level. To produce the first estimates of state-specific rates of primary and secondary syphilis among MSM, CDC used MSM population estimates based on a new methodology (2) and primary and secondary syphilis case counts reported in 2015 to the National Notifiable Diseases Surveillance System. Among 44 states reporting information on the sex of sex partners for ≥70% of male cases, the overall rate of primary and secondary syphilis among all men (aged ≥18 years) in the United States in 2015 was 17.5 per 100,000, compared with 309.0 among MSM and 2.9 among men who reported sex with women only. The overall rate of primary and secondary syphilis among MSM was 106.0 times the rate among men who have sex with women only and 167.5 times the rate among women.* These data highlight the disproportionate impact of syphilis among MSM and underscore the need for innovative and targeted syphilis prevention measures at the state and local level, especially among MSM. It is important that health care providers recognize the signs and symptoms of syphilis, screen sexually active MSM for syphilis at least annually, and provide timely treatment according to national sexually transmitted diseases treatment guidelines (3).

Racial Differences in Partnership Attributes, Typologies, and Risk Behaviors Among Men Who Have Sex With Men in Atlanta, Georgia.

The role of main partnerships in shaping HIV transmission dynamics among men who have sex with men (MSM) has gained recognition in recent studies, but there is little evidence that existing definitions of partnership type are accurate or have consistent meaning for all men. Using data collected from 2011 to 2013 on 693 partnerships described by 193 Black and White MSM in Atlanta, GA, partnership attributes and risk behaviors were examined and compared by race, stratified in two ways: (1) by commonly used definitions of partnerships as "main" or "casual" and (2) by a new data-driven partnership typology identified through latent class analysis (LCA). Racial differences were analyzed using chi-square, Fisher's exact, and Wilcoxon-Mann-Whitney tests. Black participants were less likely to report condomless anal sex (CAS) within partnerships they labeled as main, yet they were also less likely to describe these partnerships as "primary" on a parallel question. In contrast, within strata defined by the LCA-derived typology, most partnership attributes were comparable and the likelihood of CAS was equivalent by race. These findings suggest that classification of partnerships as main or casual does not accurately capture the partnership patterns of MSM, resulting in differential misclassification by race. Future studies and interventions should refine and utilize more evidence-based typologies.

Concordance of Demographic Characteristics, Sexual Behaviors, and Relationship Attributes Among Sex Dyads of Black and White Men Who Have Sex with Men.

Differences in individual behaviors have failed to explain racial disparities between Black and White men who have sex with men (MSM). However, reporting of behaviors and partner characteristics are assumed to be non-differentially reported by race. From 314 participants, this study used the two-sided data-where sexual partners provide information on each other and their relationship-of 127 dyads of Black and White MSM from Atlanta, GA, to assess the reliability of partner-reported demographic characteristics and the concordance of sexual behaviors and partnership attributes by race. We compared proportions of concordance by race using a modified kappa (K m) to assess chance-corrected agreement. The median difference in age between self- and partner-reports was 0 (0-1) years. Compared to self-reports, 97 % of the partners of Black participants and 96 % of the partners of White participants correctly classified their race. We observed poor agreement on pre-sexual discussion (K m = 0.18) and being in an ongoing relationship (K m = 0.13), with no differences by race (p = 0.11). Although not statistically significant, Black MSM dyads had lower levels of concordance for unprotected anal intercourse in the previous 12 months (68 %) compared to White dyads (90 %), with fair agreement among Black dyads (K m = 0.26). Measures of partner-reported age and race are likely accurate; however, certain self-reported sexual behaviors and partnership attributes may be unreliable and differentially reported by race. Our findings highlight the need to assess the validity of measures used to estimate HIV transmission and inform racial disparities research.

Heterogeneity of HIV Prevalence Among the Sexual Networks of Black and White Men Who Have Sex With Men in Atlanta: Illuminating a Mechanism for Increased HIV Risk for Young Black Men Who Have Sex With Men.

BACKGROUND: Studying the heterogeneity and correlates of HIV risk in the sexual networks of black and white men who have sex with men (MSM) may help explain racial disparities in HIV-infection. METHODS: Black and white MSM were recruited as seeds using venue-based time sampling and provided data regarding their recent sex partners. We used chain referral methods to enroll seeds' recent sex partners; newly enrolled partners in turn provided data on their recent sex partners, some of whom later enrolled. Data about unenrolled recent sex partners obtained from seeds and enrolled participants were also analyzed. We estimated the prevalence of HIV in sexual networks of MSM and assessed differential patterns of network HIV risk by the race of the seed. RESULTS: The mean network prevalence of HIV in sexual networks of black MSM (n = 117) was 36% compared with 4% in networks of white MSM (n = 78; P < 0.0001). Sexual networks of unemployed black MSM had a higher prevalence of HIV than their employed counterparts (51% vs. 29%, P = 0.007). The networks of HIV-negative black MSM seeds aged 18 to 24 years had a network prevalence of 9% compared with 2% among those aged 30 years or older. In networks originating from a black HIV-positive seed, the prevalence ranged from 63% among those aged 18 to 24 years to 80% among those 30 years or older. CONCLUSIONS: The high prevalence of HIV in the networks of HIV-negative young black MSM demonstrates a mechanism for the increased HIV incidence observed in this age group. More research is needed into how age and socioeconomic factors shape sexual networks and HIV risk.

An updated protocol to detect invalid entries in an online survey of men who have sex with men (MSM): how do valid and invalid submissions compare?

Researchers use protocols to screen for suspicious survey submissions in online studies. We evaluated how well a de-duplication and cross-validation process detected invalid entries. Data were from the Sexually Explicit Media Study, an Internet-based HIV prevention survey of men who have sex with men. Using our protocol, 146 (11.6 %) of 1254 entries were identified as invalid. Most indicated changes to the screening questionnaire to gain entry (n = 109, 74.7 %), matched other submissions' payment profiles (n = 56, 41.8 %), or featured an IP address that was recorded previously (n = 43, 29.5 %). We found few demographic or behavioral differences between valid and invalid samples, however. Invalid submissions had lower odds of reporting HIV testing in the past year (OR 0.63), and higher odds of requesting no payment compared to check payments (OR 2.75). Thus, rates of HIV testing would have been underestimated if invalid submissions had not been removed, and payment may not be the only incentive for invalid participation.

Examining the relationship between use of sexually explicit media and sexual risk behavior in a sample of men who have sex with men in Norway.

The purpose of this study was to investigate consumption patterns of gay-oriented sexually explicit media (SEM) among men who have sex with men (MSM) in Norway, with a particular emphasis on a possible relationship between gay SEM consumption and HIV risk behavior. Participants included 529 MSM living in Norway recruited online to complete a SEM consumption and sexual risk survey. Of the 507 participants who responded to the all items measuring exposure to SEM, 19% reported unprotected anal intercourse with a casual partner (UAI) in last 90 days, and 14% reported having had sero-discordant UAI. Among those with UAI experience, 23% reported receptive anal intercourse (R-UAI) and 37% reported insertive anal intercourse (I-UAI). SEM consumption was found to be significantly associated with sexual risk behaviors. Participants with increased consumption of bareback SEM reported higher odds of UAI and I-UAI after adjusting for other factors using multivariable statistics. MSM who started using SEM at a later age reported lower odds of UAI and I-UAI than MSM who started earlier. Future research should aim at understanding how MSM develop and maintain SEM preferences and the relationship between developmental and maintenance factors and HIV sexual risk behavior.

Recruitment Strategies of Methamphetamine-Using Men Who Have Sex with Men into an Online Survey.

Recruiting hidden populations into online research remains challenging. In this manuscript, we report lessons learned from our efforts to recruit methamphetamine-using men who have sex with men. Between July and October 2012, we implemented a four-phase recruitment strategy to enroll a total of 343 methamphetamine-using MSM into an online survey about recent substance use, sexual behavior, and various psychosocial measures. The four phases were implemented sequentially. During phase one, we placed advertisements on mobile applications, and during phase two, we placed advertisements on traditional websites formatted for browsers. During phase three, we used e-mail to initiate snowball recruitment, and during phase four, we used social media for snowball recruitment. Advertisements on mobile devices and websites formatted for browsers proved to be expensive options and resulted in few eligible participants. Our attempts to initiate a snowball through e-mail also proved unsuccessful. The majority (n=320) of observations in our final dataset came from our use of social media. However, participant fraud was a concern, requiring us to implement a strong participant verification protocol. For maximum recruitment and cost-effectiveness, researchers should use social media for recruitment provided they employ strong participant verification protocols.

Recommendations for internet-based qualitative health research with hard-to-reach populations.

Researchers new to online qualitative health research frequently have questions about how to transfer knowledge of offline data collection to an online environment. In this article, we present best-practice guidelines derived from the literature and our experience to help researchers determine if an online qualitative study design is appropriate for their research project and, if so, when to begin data collection with a hard-to-reach population. Researchers should reflect on administrative, population, and data collection considerations when deciding between online and offline data collection. Decisions must be made regarding whether to conduct interviews or focus groups, to collect data using asynchronous or synchronous methods, and to use only text or to incorporate visual media. Researchers should also reflect on human subjects, recruitment, research instrumentation, additional data collection, and public relations considerations when writing protocols to guide the research team's response to various situations. Our recommendations direct researchers' reflection on these considerations.

The effects of gay sexually explicit media on the HIV risk behavior of men who have sex with men.

This study sought to study consumption patterns of gay-oriented sexually explicit media (SEM) by men who have sex with men (MSM); and to investigate a hypothesized relationship between gay SEM consumption and HIV risk behavior. Participants were 1,391 MSM living in the US, recruited online to complete a SEM consumption and sexual risk survey. Almost all (98.5 %) reported some gay SEM exposure over the last 90 days. While 41 % reported a preference to watch actors perform anal sex without condoms (termed "bareback SEM"), 17 % preferred to actors perform anal sex with condoms (termed "safer sex SEM") and 42 % reported no preference. Overall SEM consumption was not associated with HIV risk; however participants who watched more bareback SEM reported significantly greater odds of engaging in risk behavior. The results suggest that a preference for bareback SEM is associated with engaging in risk behavior. More research to understand how MSM develop and maintain preferences in viewing SEM, and to identify new ways to use SEM in HIV prevention, is recommended.