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CDC News Conference Transcript

New CDC Data Shows Increases in U.S. Syphilis Rates

November 20, 2003

MODERATOR: Today's call is being recorded, and at this time I'd like to turn the call over to Dr. Ron Valdiserri. Thank you, sir. You may begin.

DR. VALDISERRI: Thank you. Hello. Thanks for joining us today. My name is Dr. Ron Valdiserri and I'm the deputy director of the National Center for HIV, STD, and TB Prevention at the CDC in Atlanta.

I'm joined today by Dr. John Douglas who is the director of CDC's Division of STD Prevention and also with us is Dr. Susan Blank, who is the assistant commissioner for the Bureau of STD Control at New York City's Department of Health and Mental Hygiene.

During this call, Dr. Douglas and I will discuss new CDC data on syphilis in the United States. The data are published in the November 21st issue of CDC's Morbidity and Mortality Weekly Report, and are featured in CDC's 2002 STD Surveillance Report, which is also being released today.

Following our discussion of the new data, Dr. Blank will talk about the local response to syphilis in New York City, which is one of several cities in the United States where syphilis rates have increased substantially in 2002.

Then I'll briefly touch on new gonorrhea and chlamydia statistics that CDC is also releasing, and then finally, we'll open the call up to questions.

CDC has prepared a press release on the data being discussed today. If you haven't received the release or if you have any other questions following this briefing, please contact our Office of Communications at [404] 639-8895. Once again that number is [404] 639-8895.

I'll now turn the call over to Dr. Douglas who's going to discuss CDC's new syphilis statistics.

Dr. Douglas.

DR. DOUGLAS: Thank you, Dr. Valdiserri.

As Dr. Valdiserri indicated, CDC is releasing new data today on reported syphilis cases in the United States in 2002.

Overall, the syphilis rate in the U.S. role by 9.1 percent between 2001 and 2002. This represents the second consecutive increase following a decade-long decline and an all-time low in 2000.

The total number of reported syphilis cases in 2002 was 12.4 percent higher than in the previous year, 6,862 versus 6,103 cases.

But since many cases of syphilis go undiagnosed, the actual number is probably significantly higher.

As in 2001, the increase in syphilis rates occurred only among men. The number of reported cases among men increased 27.4 percent between 2001 and 2002. This included increases of 85.2 percent among white men, and 35.6 percent among Latino men, while African American men experienced a slight decline, 2.6 percent.

Although the new statistics don't include information about sexual orientation, we estimate that more than 40 percent of the reported cases in 2002 were among men who have sex with men, or MSM.

These cases account for much of the reported increase overall.

This determination is based on a mathematical model which compares the much higher male to female ratio in 2002 to the relatively stable ratio seen in the years prior to recent outbreaks among gay and bisexual men.

In contrast to the increases among gay and bisexual men, the new CDC data showed substantial progress at reducing syphilis cases among women and African Americans. Reported syphilis cases fell 10.3 percent among African Americans between 2001 and 2002.

Among black women, the decline was 21.7 percent, and among women overall cases fell by 19 percent.

These declines are likely the result of ongoing syphilis education and testing programs in these populations.

Although the syphilis rate was still 8.2 times higher among African Americans than whites, the continuing declines in reported cases clearly show that progress is possible in the groups that are most affected.

Before turning it back to Dr. Valdiserri, I'd like to talk a little bit more about the challenges posed by increases in syphilis among gay and bisexual men.

Although the CDC data do not indicate rates of HIV co-infection, previous research has suggested that a large percentage of gay men diagnosed with syphilis are also living with HIV.

In New York, for example HIV-positive gay men comprise 61 percent of syphilis cases in 2002 compared to 20 percent in 1999.

In other cities, an average of about 50 percent of recent syphilis cases were among people with HIV.

Syphilis and HIV are transmitted through similar means, mainly through unprotected sexual activity, including anal, vaginal and oral intercourse.

Also infection with one disease can affect the transmission and the progression of the other.

Syphilis increases the risk of HIV transmission by two to five times, partly because HIV-positive individuals with syphilis tend to have a greater number of genital sores or chancres. These chancres serve as portals of entry for HIV.

Also HIV-infected individuals with syphilis can shed more HIV in their genital secretions than those without syphilis.

Syphilis doesn't just facilitate HIV transmission. It may actually increase the progression of HIV disease itself. A study presented at the 2003 National HIV Prevention Conference reported that HIV viral load increased during syphilis infection and then declined with syphilis treatment.

I should point out that the increases in reported syphilis cases among MSM in some areas may be due, in part, to community level efforts to increase screening.

In other words, the rises in syphilis among gay and bisexual men in these cities may partly signal the success of education and screening efforts.

While there's no data to support this conclusion on a national level, local data from some cities have demonstrated increasing syphilis screening rates.

For example, local health officials in San Francisco worked with CDC to respond to early signs of syphilis increases in the city's gay community and have seen increased awareness in screenings.

According to data from the San Francisco Department of Health, the number of annual syphilis tests performed in San Francisco increased 33 percent from 1999 to 2002.

Now back to Dr. Valdiserri.

DR. VALDISERRI: Thank you, Dr. Douglas.

As we just heard, the campaign against syphilis in the United States is now being waged on two fronts. On one front, we're working to sustain the progress made among populations that historically have been hardest hit by syphilis, including African Americans.

To do so we need to continue supporting intensive work at the community level to educate, encourage screening, and connect people to treatment.

On the second, newer front, we're combating the emerging challenge of rising syphilis incidents among gay and bisexual men.

Given the complex challenges that gay and bisexual men face, we don't expect to see immediate results from our efforts.

Challenges facing gay men include a low level of concern about other STDS, among those already infected with HIV, as well as a more relaxed attitude about safer sex since the introduction of highly effective anti-retroviral treatment.

Many gay and bisexual men are also dealing with a range of interconnected challenges including substance abuse, depression, homophobia, and sometimes partner violence.

For gay and bisexual men, efforts to increase knowledge of the health complications of syphilis infection, particularly for people with HIV, will be essential.

It is also important that we take prevention programs into emerging venues that facilitate unprotected sex, including the Internet.

We also must continue to alert the health care providers who serve gay and bisexual patients of the urgent need for routine STD screenings, particularly among their HIV-infected patients.

At the same time, we need to make sure people at risk know of the importance of STD screening.

The STD hotline, which can be reached at 1-800-227-8922, can provide callers with information on where to get tested for STDs in their area.

CDC is already working alongside our state and local community partners in cities that are most affected, to reverse the increasing toll of syphilis among gay and bisexual men.

To talk more about what is being done on the community level, I'd like to now turn it over to Dr. Sue Blank from New York City.

DR. BLANK: First I'm going to talk a little bit about syphilis incidence in New York City in 2002, as well as discuss a little bit of what's going on this year, and talk about some of our efforts here in New York in the face of our syphilis outbreak.

Between 2000 and 2002, there was a nearly three-fold increase in the number of reported primary and secondary syphilis cases. From 2001 to 2002 alone, the increase was 54 percent. New York City's 2002 case number of 434 cases was among the highest nationwide, but its case rate remains much lower than many other cities, namely, 5.4 cases per 100,000 population.

Men accounted for 96 percent of our cases. Most of the cases were being diagnosed in doctors' offices and not in public health clinics. The largest increases in cases have been among white men, and information on sexual behavior and HIV status is gleaned from case investigation. We interviewed almost two-thirds of male cases last year, and 83 percent of male cases interviewed reported sex with other men, and 61 percent of the men who had sex with men, or MSM, that we interviewed disclosed that they were also HIV-infected.

Another highlight from 2002 was the completion of a study in New York City comparing men who had sex with men, or MSM, with syphilis to MSM without syphilis. The study was done jointly by the Health Department, the Centers for Disease Control and Prevention, and Callen-Lorde Community Health Center, New York City's largest provider of care to the lesbian, gay, bisexual, and transgender community.

The most important finding was that cases were much more likely to report HIV infection than controls. Cases were also more likely to report unprotected anal intercourse, attending private sex parties to meet partners, use of methamphetamine, poppers, and Viagra, drug use prior to sex, and annual incomes of greater than $30,000.

Another important couple of findings, however, was that both cases and controls reported on average 11 or more partners in the six months prior to participation, and that less than half of all partners discussed HIV prior to sex with these partners. Also, both cases and controls reported recruiting sex partners over the Internet.

In 2003, based on our data from the first three quarters of the year, we project the following for calendar year 2003: an increase in primary and secondary syphilis of about 10 percent, with men still accounting for over 90 percent--over 95 percent of the cases, and white men continuing to account for the largest proportion of cases. As was the case last year, most of the cases are residents of Manhattan, and between the interview data take longer to collect, it's premature to make projections for calendar year 2003.

New York City has taken a multi-pronged approach to syphilis which involves more than just the local health department. Despite a slow syphilis increase projected for 2003, it is still an increase, and we continue to monitor the situation closely and gather information to help us understand what's going on, who is affected, and where disease is occurring. We're working with neighborhood health departments, namely, in New Jersey, Long Island, upstate New York, and Connecticut, to prevent the spread of disease to other locales. We're increasing awareness among men who had sex with men, their community organizations, and their medical providers in terms of the presence of the outbreak, the risk factors, the recognition of signs and symptoms of disease, and the importance of screening, partner treatment, and disease reporting. This has occurred through the health department's direct outreach and, more importantly, through our community-based Syphilis Advisory Group.

We are encouraging the prevention of HIV and other STDs as the presence of one facilitates the transmission of the other, as was stated earlier by Dr. Douglas. This includes encouraging people to know their own STD and HIV status, to talk to their sex partners about that status, obtain appropriate vaccinations, limit numbers of sex partners and use barrier protection, and to seek help for depression, substance abuse, or domestic violence issues.

Lastly, we are integrating syphilis into a larger health agenda for men who have sex with men. New York City's Healthy Men's Night Out, also known at the Hotshot Program, is an innovative way to address syphilis as only one of the health issues concerning men who have sex with men. Our approach is based on: one, current case report data which help us geographically identify the target population; two, extensive community input to identify perceived needs; and, three, guidance from the health department's 2002 community health profiles, which highlight the key causes of preventable illness and premature death in our target neighborhoods.

We've packaged a variety of outreach activities with this information, and our community partners have helped us roll them out at pre-existing recreational venues. Activities include smoking cessation services, screening for blood pressure, cholesterol, chemical dependency, depression, and HIV/STD; vaccination for hepatitis A, B, pneumococcal pneumonia and influenza; and the venues include dance clubs, coffee shops, bingo games, bowling alleys, and movie theaters.

Our next steps here in New York include coordinating a community-based approach to engaging owners and staff of commercial sex venues.

Now I'll turn it back to Dr. Valdiserri.

DR. VALDISERRI: Thank you, Dr. Blank.

As I think we've demonstrated today, the job of eliminating syphilis in the United States is not done. Despite historic lows in some populations, recent increases among gay and bisexual men represent a major new challenge to both STD and HIV prevention efforts. Together with local partners, we have already taken the first steps toward addressing this new challenge.

Now, before taking questions, I'd like to briefly highlight some other new statistics that CDC will be releasing tomorrow, in this case related to gonorrhea. These data appear in the 2002 STD Surveillance Report and are highlighted in a fact sheet that was distributed with the press release.

The overall gonorrhea rate in the United States declined 2.7 percent between 2001 and 2002. At 125 cases per 100,000 population, the rate in 2002 was lower than any of the previous four years. However, despite this overall decline, cases of drug-resistant gonorrhea have continued to increase. The number of gonorrhea cases resistant to the antibiotic ciprofloxacin more than tripled between 2001 and 2002, from 38 to 116 cases. Most of these cases occurred in Hawaii and California.

Although gonorrhea remains highly treatable in most cases, the emerging resistance to ciprofloxacin warrants increased vigilance in diagnosing and treating this disease.

Now, turning to chlamydia, which remains the most commonly reported STD in the United States, in 2002 834,555 chlamydia infections were reported to CDC. However, it's estimated that three million new cases of this largely asymptomatic infection occur in the U.S. every year.

Since case reports don't provide a complete account of the burden of chlamydia, researchers have to rely on studies of chlamydia in various groups to get a picture of where the disease is most common. You'll find more information about what states have the highest chlamydia burden in CDC's fact sheet.

As I mentioned at the start of the call, you can obtain the fact sheet or the press release by calling CDC's Office of Communications at 404-639-8895. That's 404-639-8895.

Now I'd like to open up the call to questions.

OPERATOR: Thank you. At this time we're ready to begin the question-and-answer session. If you would like to ask a question, please press star, one on your touch-tone phone. You will be announced prior to asking your question. To withdraw your question, you may press star, two.

Once again, if you would like to ask a question, please press star, one on your touch-tone phone. One moment for our first question.


OPERATOR: Our first question comes from Sabin Russell from the San Francisco Chronicle. Your line is open.

QUESTION: Yes, good morning. I was wondering if you had any information--I'm interested in the San Francisco statistics, whether or not San Francisco is now in first place, if I am interpreting this correctly, in terms of syphilis rates, if that is a new position for the city, and if so, who was in first place last year? I'm sure they're interested in that here.

DR. VALDISERRI: Dr. Douglas, would you like to answer that question?

DR. DOUGLAS: Yes, San Francisco is--would be considered to be in first place this year in terms of the rate among men. They also have the highest rate ratio of male to female, which is what we use as our best indicator of a preponderance of disease in gay men. They're not in first in terms of absolute number of cases.

I think your other question was who was in first place last year, and I'm going to have to get back to you about that. I actually don't have those numbers in front of me and don't want to misquote that.

DR. VALDISERRI: Okay. Thank you, Dr. Douglas.

Do we have another question?

OPERATOR: Thank you. Our next question comes from Steven Smith, the Boston Globe. Your line is open.

QUESTION: Good afternoon. I'm wondering if you could address what have been the specific strategies employed in the African American community that have led to decreasing rates. And what is your assessment of the transposability of those stratagems into the gay and bisexual community?

DR. VALDISERRI: Dr. Douglas, can you begin by talking about the specific elements of the syphilis elimination campaign that were targeted toward African Americans? And I'll take the second part of the question.

DR. DOUGLAS: Sure. The strategy that was used in the African American community addressed the issue that access to health care and public health infrastructure in many of the locales in which syphilis in African Americans was occurring was substandard. And so the focus was based in those areas on improvement to access to treatment, which involved increasing locales that treatment--diagnosis and treatment could take place.

It involved enhanced surveillance because actually monitoring how much syphilis was going on was uneven in some of those locales.

It involved developing responses to emerging outbreaks, so that when the surveillance system was able to detect that things were increasing, both the local health departments as well as response teams by CDC were able to be activated to respond--to respond to that.

Finally, and maybe most importantly, in many of the cities in which syphilis in African Americans was historically highest, there was less than optimal partnership between public health and community-based organizations. And I think a major strategy that began to turn that corner was engaging those organizations to recognize the importance of syphilis both as a unique biologic event as well as an indicator event, if you will, for substandard health care.

And those strategies taken into--as a group have been so far strikingly successful, as indicated by the falling rates in African Americans, and very specifically the falling rates in syphilis in the region in which that disease was most concentrated-- the South.

DR. VALDISERRI: Thank you, Dr. Douglas.

This is Dr. Valdiserri. To answer the second part of your question, I think it's very important to note that the prevention challenges that are facing gay and bisexual men tend to be very different from those facing women and African Americans where, as Dr. Douglas noted, we've seen major successes.

First of all, we're talking about a population where in many--not all, but in many instances there is available access to health care. But we're talking about individuals who have high levels of HIV co-infection. Some of these persons have been hearing prevention messages for three decades now, and so we're dealing with issues of prevention burnout and skepticism. And we're certainly dealing with the issue of--as a result of improvements in HIV treatment, that there is not as much concern about maintaining safer sexual behaviors, in addition to the interconnected epidemics that were mentioned earlier.

So there are clearly some distinct and complex differences that we face when we're dealing with gay and bisexual men.

Now, having said that, it is important to underscore that better surveillance, community awareness campaigns, and improved access to testing and treatment are equally important in terms of addressing syphilis increases among gay and bisexual male communities.

OPERATOR: The next question comes from Rob Stein of the Washington Post. Your line is open.

QUESTION: Yeah. Hi. Thanks very much.

Well, you partially addressed what my question was. I was hoping you could talk a little bit more about what was driving this increase. It basically sounds like you think it's a combination of sort of epidemic fatigue and less of a concern about STDs and HIV because of improved treatment. But can you talk a little bit more about it. Is it because of new generation of young men coming of age? What do you think is going on here?

DR. VALDISERRI: This is Dr. Valdiserri.

The cause of these increases is multi-factorial. There is no single cause that we can pinpoint for increases among syphilis, among gay and bisexual men, and I should also point out that it's not just happening in the United States. Several other countries of the industrialized world, notably the United Kingdom, the Netherlands, Australia, several countries in Western Europe, have also reported increases in syphilis and other STDs among gay and bisexual men and have also reported that in many of these outbreaks there are high levels of HIV co-infection.

Clearly, the factors that I mentioned earlier play a role. The complacency that's developed because of improved HIV treatments, issues related, the ones I mentioned earlier I won't go through them again, but they are very important.

To answer your question about is it mainly younger people, no, that's not been our experience in the United States, and Dr. Douglas may wish to add to this, but, in terms of the national data that CDC has available, most of these men are in their 30s. So we're not talking about young adolescents who are becoming infected with syphilis.

John, would you like to add anything to that in terms of the age?

DR. DOUGLAS: I would just amplify what you said. It does appear that, in both national data, as well as data from specific outbreaks like New York City, I think the average age is often in the low to mid 30s. So it does not appear to be this new generational phenomenon.

Whether or not that is due to the fact that men in their 30s may be having sex with other men in their 30s, and there is an age-related difference in HIV prevalence, and that may translate into higher rates of exposure to syphilis, whether that's part of the phenomenon or not is unclear, but I would completely agree that this is not a phenomenon of adolescents or young 20s kind of men.

DR. VALDISERRI: The only additional comment, before we move on to the next question--this is Dr. Valdiserri--would be to say that, as a way of addressing this issue, it is vitally important to try to get the support and the muscle of the various gay communities behind this. This is clearly an issue that cannot be addressed fully by government.

And so part of what our strategy--as was mentioned earlier with African-American communities--part of our strategy is to, in fact, attempt to mobilize various organizations in the gay community and other communities that serve gay and bisexual men to get the word out about the important health consequences of undiagnosed and untreated syphilis.

Can we have the next question, please?

OPERATOR: Thank you. Our next question comes from Frank [inaudible] from the New York Post. Your line is open.

QUESTION: Thank you. This is a question for Dr. Blank. I don't know if you're still on.

DR. BLANK: Yes, I am.

QUESTION: Great. I was wondering if you could tell me the numbers that you mentioned for New York City, you said it among the highest nationwide, and I wonder if you could tell me where New York City falls. Since San Francisco is the first, if New York City is the second or the third or the fourth.

And if you could also go over those numbers again, and if you could tell me, if you know, since it's going down among blacks, specifically among gay black men in New York City, where do they fall?

DR. BLANK: Well, in answer to your first question, our case numbers for 2002, we had 434 cases of primary and secondary syphilis reported to us, which is a high number, but the case rate, in terms of cases per 100,000 population, is actually not very high. It's 5.4 cases per 100,000 population.

So, first of all, you have to decide whether it's in terms of case numbers or case rates that you are interested in our standing compared to other places across the country, and I think that Dr. Douglas and the folks at CDC, and if you look in the surveillance report that's being released, you'll be able to find those comparisons. I cannot speak for other cities.

Your other question was about African- American men. We didn't, in what I discussed, was really in terms of the proportion of cases that we're seeing. Numbers of cases are increasing. From 2001 to 2002, however, the largest proportionate increase, in terms of the percent of cases among white men, that was where the largest increase was, not among African-American men.

DR. VALDISERRI: Thank you.

Dr. Douglas, would you like to comment on the relative standing of New York City in terms of other cities.

DR. DOUGLAS: Sure. As Dr. Blank mentioned, New York's absolute number of cases is tops in the country. Its rate per 100,000, which is adjusted for how many people live there, puts it 20th in the country. And then if one looks at the third way one can examine this, which is the male-to-female ratio, which is our best marker again for our proportion of cases among gay men, New York is second only to San Francisco. That rate ratio being 27.5.

Let me also, while I've got the mic, answer the earlier question from the San Francisco reporter about who was in first last year, and last year was Detroit, which had 351 cases, and not only the highest absolute number of cases, but the highest rate per 100,000 population.

DR. VALDISERRI: Thank you, Dr. Douglas.

The next question, please.

OPERATOR: Thank you. Once again, as a reminder, if you'd like to ask a question, please press star one on your touch tone phone.

Our next question comes from Lisa Richardson of the Los Angeles Times. Your line is open.

QUESTION: Yes. Thank you.

I wanted to know are those strategies that are effective with African Americans in general also effective with African American men who have sex with men, if we separate that group from the larger hole?

DR. VALDISERRI: This is Dr. Valdiserri. Again, let me perhaps address the first part of that question and then invite Dr. Douglas to comment.

It is important to understand that some of the basic strategies related to syphilis elimination, meaning doing a better job around surveillance for the disease so that we can detect outbreaks early on, increasing the availability of testing and treatment services. Those are equally important for all populations.

I think the point we're trying to make though is that the way that services are packaged for African American women, for instance, who live in the Southern U.S., might be very different from the way services are packaged for African American men, especially men who may be on the "down low," meaning that they have sex with other men, but they don't identify themselves as gay.

This is one of the reasons, for instance, why CDC is very interested and has taken some very important first steps to try to develop outreach and prevention strategies utilizing the Internet, which for many gay and bisexual men is an important venue where they hook up with sexual partners.

John, would you like to add anything?

DR. DOUGLAS: I would agree with what you said, Ron.

I think that it's taking the strategies that we know that have worked in one situation and modifying them and redirecting them toward another situation. I think there are likely to be differences between urban white MSM and urban African American MSM. There may be provider differences. There are clearly community network differences. There may be different community-based organizations that serve those individuals. There may be different levels of identification with the gay community, and I think those differences, certainly at the level of awareness and encouragement of health care seeking will probably require locale-specific tweaking, depending upon the proportion of the population that falls into those different groups.

DR. VALDISERRI: Thank you.

Next question.

OPERATOR: Thank you. Our next question comes from Diana Penner of the Indianapolis Star. Your line is open.

QUESTION: Hi. Thank you.

I haven't been sent the data yet, but I was told by the Public Affairs Office that Indianapolis in the current rankings dropped from 7th to 24th place or maybe it would be better to say improved from 7th to 24th place, and even before it was in 7th place, in '99, there was a fairly significant epidemic here that has steadily dropped off, and I wonder if you have looked specifically at Indianapolis or any other city where there's been improvement to analyze and tease out what was done, what worked, what strategies were effective.

DR. VALDISERRI: Dr. Douglas?

DR. DOUGLAS: Yeah, you're right about Indianapolis. It was 7th last year, and it's dropped down to 24th this year, and there's been a really dramatic reduction in total number of cases. It was 128 last year and 36 this year.

The county in which Indianapolis is located was one of three demonstration projects that CDC worked with to, if you will, implement a full-court press, in terms of responding to syphilis. And we have, in fact, in those three counties, seen among the largest decreases. That full-court press involved highly resourced versions of everything we talked about earlier--surveillance, access to treatment, outbreak evaluation, community partnering.

So we think it's a useful model of what one can do if one identifies a locale in which there are rising problems, and then you attack it aggressively.

DR. VALDISERRI: Thank you.

Next question.

OPERATOR: Thank you. Our next question comes from Andrew Hawkins of the Blue Sheet. Your line is open.

MR. HAWKINS: --syphilis prevention awareness campaigns, et cetera, in 2004.

DR. VALDISERRI: Dr. Douglas?

DR. DOUGLAS: We have a categorical syphilis elimination program that is embedded with our national STD control program, and the funds that support that are in the range of approximately 28- to 30 million. That is for the upcoming fiscal year, which is at approximately the same level as it was last year.

Those monies are largely used in our project areas in states and cities around the country to--in a variety of different ways. So when you ask the question about awareness programs, it'll vary tremendously, locale by locale, and I'm not sure I could actually give you an estimate about what part of that approximate number was going for that kind of approach.

I don't know if Dr. Blank has any insights from New York City but that's the national picture.

DR. BLANK: Well, here, in New York City, I can say that we have received support from CDC for our syphilis efforts as well as support from New York City and New York State.

DR. VALDISERRI: This is Dr. Valdiserri.

The other general comment I would like to make is that CDC has awarded $4 million in supplemental funds to the eight American cities with the highest number of cases of syphilis among men who have sex with men, New York City is one of those, and those funds are being used for a variety of efforts but many--and we've met with providers from those cities and I can tell you that many of those efforts do include a very pronounced yet targeted campaign to raise awareness about the dangers of syphilis, to raise that awareness among gay and bisexual men.

DR. DOUGLAS: You know, if I could point out one more thing. We have recently completed here, and expect to be making available to programs in the field, what we've called the syphilis elimination tool kit, which is a packaged set of strategies that local and state health departments can use to sort of orchestrate syphilis prevention responses, with a large emphasis on awareness.

So that's another tool that we expect to be rolling out within the next six months or so, specifically in the area that we're talking about.

DR. VALDISERRI: Thank you.

Next question.

MODERATOR: Thank you. Our next question comes from Steve Mitchell of UPI. Your line is open.

QUESTION: Hi. Thanks for taking my question. This follows the increase last year, so I was wanting to find out if we are seeing corresponding increases in HIV rates yet or if that'll take some years before that starts rolling in?

DR. VALDISERRI: Thank you. This is Dr. Valdiserri.

We reported at our National HIV Prevention Conference in end of July, this past year, increased rates of HIV diagnoses among men who have sex with men, up 17 percent. When we reported--now those are diagnoses, so they don't necessarily represent new infections. But we were very concerned about that increase in diagnoses. It wasn't observed in other risk groups, and we continue to be concerned about the potential for increases in HIV incidents overall.

We do not yet have a national or nationwide way to measure new HIV infections though we do have a pilot program in place that we expect by the end of 2005 will begin to give us very sound estimates of HIV incidence.

So the answer to your question is that we have not observed or have not made the statement that HIV incidence meaning new HIV infections among MSM, are increasing nationally, but we are extremely concerned about that possibility when you look at these outbreaks, and also combine that with other important information like the increased rate of HIV diagnoses among men who have sex with men.

Susan, Dr. Blank, would you like to say anything about that from New York City's perspective?

DR. BLANK: I think it's similar in New York. We, as of 2000, have begun tracking HIV diagnoses here in the city, and certainly the concern for us is that this syphilis outbreak is going to be heralding, in the next couple of years, increases in HIV locally. Thank you.

DR. VALDISERRI: Thank you. Next question.

MODERATOR: Our next question comes from Zack Dendis [ph] of the Willamette Weekly, and the line is open.

QUESTION: Thank you.

In Portland, we haven't seen anything like the numbers that have been reported elsewhere, we are a smaller metropolitan area, but the numbers do seem to indicate a dramatic acceleration in the rate over the last year and particularly over the last six months.

Based on what has been seen in other cities, what can people expect here?

DR. VALDISERRI: Dr. Douglas, would you like to comment on that?

DR. DOUGLAS: It's a really good question.

I think it in part depends upon how quick a jump Portland public health can get on this. Your city reported 20 cases of primary and secondary syphilis in 2002, with a male-female rate ratio, 3.8, which suggests that those cases are largely occurring among men who have sex with men.

In cities such as New York, you heard from Dr. Blank, San Francisco, Los Angeles, Miami, which have a large number of cases, and MSM went from double-digit sorts of numbers like Portland, to triple digits, several hundreds, within a matter of two to three years. Now Portland's a smaller city, so you may not get that high. But it is possible to see increases that abruptly within that period of time.

Having said that, I am hopeful that the lessons that we're learning in these other cities--again, to reiterate the information we're getting from these eight cities we're working with closely in the U.S. now to find out what is working and what can be replicated, can be used in places like Portland to prevent that kind a increase from happening.

So I think it is in part based on risk behavior in the community, in part based on the aggressiveness of the public health coupled with community response.

DR. VALDISERRI: Thank you. Next question.

MODERATOR: Thank you. Our final question, which is a follow-up, is from Sabin Russell of the San Francisco Chronicle. Your line is open.

QUESTION: Oh, thank you, thank you for opening up a question for me again.

I have a question regarding the issue of, as you said, needing to kind of tweak the prevention messages to different locales.

I'm wondering if anybody could address the question of the political environment we're in right now, where there is considerable pressure against programs that are very specifically addressing sort of sexual practices in the gay community. The Stop AIDS Project, for instance, is under pressure from the CDC itself regarding the appropriateness of some of its programs that are targeted to the gay community there, and I'm wondering if you could just, in general, comment on the, whether the political climate is amenable to these local prevention messages that you feel are important to get, to address specific epidemics in specific communities.

DR. VALDISERRI: This is Dr. Valdiserri. I'll take that question from a national perspective.

I think stating the obvious, that issues related to syphilis and sexually-transmissible disease, and sexual behaviors of all kinds, and certainly sexual behaviors of sexual minorities like two men having sex, continue to be difficult for many Americans to deal with. That is not something that is unique to this place and time. It's a controversial issue that all of us who work in this field have dealt with because of the area where we work.

Having said that, let me also say that we continue to fund Stop AIDS, and CDC continues to fund community-based organizations who serve at-risk gay and bisexual men, and other persons who are sexually active.

We do have specific requirements that are put on us by Congress related to these funding activities. One of them has to do with the fact that we're not permitted, by act of Congress, to fund any kinds of activities that directly promote sexual activity, and so there are, you know, that is an issue, that that's not new, that's been in place since the late, mid to late '80s.

But to summarize, it's always--I think dealing with these issues is always controversial. There are clearly limits to what government can do, and that's why it's so important for us to build coalitions at the community level with community-based organizations, with other organizational entities, foundations, et cetera, so that all of us can work together to promote these efforts.

Do we have any other questions?

MODERATOR: Not at this time.

DR. VALDISERRI: Well, let me--

DR. BLANK: Can I--this is Sue Blank in New York City.

DR. VALDISERRI: Oh, of course; go ahead, Susan.

DR. BLANK: You know, about the question earlier about increases in HIV relative, you know, in the footprints of the increases in syphilis that we've discussed this morning, I think one of the really important pieces of the puzzle here is that there are thousands of people who are HIV-infected who don't even know it, and so even the best surveillance system can't identify what's going on in terms of rates of disease, and I think one of the really important pieces in being able to see, as the months and years progress, what happens, is that people need to get tested and they need to know their HIV status.

Thank you.

DR. VALDISERRI: Good point, Dr. Blank.

Well, with that, let me first of all thank Dr. Douglas and Dr. Blank for taking their time to share this information with all of us, and I also want to thank all of the journalists on the line for your ongoing interest in STD prevention and control, and that I believe concludes our call.

Thank you.

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