Screening and Testing Men Who Have Sex with Men (MSM)
for Syphilis


A Guide for Health Care Professionals


CDC Revision
                 September 10, 2004

Screening and Testing Men Who Have Sex with Men (MSM)
for Syphilis

A Guide for Health Care Professionals

Introduction

Primary and secondary syphilis rates (P&S) in the United States declined during the 1990s, and 2000 saw the lowest rates since reporting began in 1941. However, CDC data show that from 2000 to 2001, the number of cases of P&S syphilis increased 2.1 percent, and increased 12.4 percent between 2001 and 2002. Increases in syphilis cases during 2000 to 2002 were observed only among men. 

CDC figures show that nearly all counties with a high incidence of syphilis cases (more than 10/100,000 persons) are in the South or in large metropolitan areas with sizable MSM populations. 

The National Syphilis Elimination Effort (SEE) is a nationwide campaign bringing health-care providers and community leadership together to mobilize communities to drive down syphilis rates in the United States. SEE is a part of the Centers for Disease Control (CDC) National Plan to Eliminate Syphilis, which was launched in 1998. For more information on the plan, go to www.cdc.gov/std/see.

To help fight syphilis, SEE needs the support of health-care providers, members of community-based organizations (CBOs), religious leaders, policymakers and activists in order to:`
* increase detection and monitoring of syphilis cases;
* strengthen community involvement and partnerships to implement locally relevant syphilis elimination action plans;
* respond rapidly to outbreaks to interrupt transmission of the disease;
* enhance health promotion efforts to promote preventive sexual and health care behaviors to those at risk;
* and expand clinical and laboratory services to promote access to and use of high-quality care for people infected with or exposed to syphilis.

Syphilis outbreaks among gay and bisexual men in cities including Los Angeles, Seattle, San Francisco, New York City, Chicago, and Miami Beach have been characterized by high rates of HIV co-infection.  Syphilis increases the risk of contracting HIV two- to five-fold. 

Medical practices primarily serving MSM  and general practices with some MSM among their patients  need to address syphilis and its co-factor role in HIV transmission. Your practice is a logical venue to routinely screen for syphilis, HIV and other sexually transmitted diseases (STDs), which affect the population in general, not just MSM. However, in addition to syphilis and HIV, MSM are at high risk for multiple STDs including chlamydia, gonorrhea, and hepatitis A and B. When counseling patients about the need for regular testing for STDs, it is important that they know that abstinence is the only sure method to avoid contracting such infections. Condom use and monogamy, while offering some prevention, are not 100% effective against syphilis.

Current clinical services for MSM do not always include integrated services to prevent all STDs affecting this population. This booklet offers suggestions to help build trust and rapport with MSM so they will be forthcoming about their sexual history and behaviors. It also suggests possible approaches for encouraging them to be tested annually for syphilis, HIV, and other STDs. 

A CDC publication,  Sexually Transmitted Diseases Treatment Guidelines - 2002 recommends comprehensive STD prevention, screening, testing, treatment and clinical management services for sexually active MSM, including annual tests for HIV, syphilis, gonorrhea, chlamydia and vaccination against hepatitis A and B.  Please visit www.cdc.gov/std/treatment  to obtain Sexually Transmitted Diseases Treatment Guidelines  2002. Feel free to download these treatment guidelines from this web site to your Palm device.

SEE offers the following additional materials to assist you in diagnosing and treating syphilis and other STDs: Sexual History Discussion Form, A Guide to Taking a Sexual History, Physician Pocket Guide on Syphilis, and the STD Treatment Guidelines Pocket Guide. 

Quick facts about syphilis
 
Syphilis is a systemic STD caused by the Treponema pallidum bacterium, transmitted person to person via vaginal, anal, or oral sex through direct contact with a syphilis chancre. Rarely, it may be transmitted during foreplay, and it can also be transmitted to the fetus during pregnancy. It can be cured with penicillin or a substitute drug when the patient is allergic to penicillin. 

Prepare Your Practice

Its hard for me to talk about [syphilis]because you feel embarrassed that you will be judged. An MSM in LA

Although not all MSM have the same communication concerns regarding health-care providers, some key issues emerge. Research studies found that gay men may fear that they will receive poor treatment, be denied care, or be judged or made to feel unwelcome if they admit their homosexuality. Many gay men, therefore, are not forthcoming about their sexual history. The SEE Guide to Taking a Sexual History outlines questions designed to put patients at ease and elicit honest responses about their sexual practices.

As a health-care provider, you represent the first line of defense for syphilis elimination. Your involvement with the SEE community mobilization effort is crucial. You are often the only health information source for those at risk or in need of treatment for syphilis. Patients see you as a credible expert on what is important to the community in terms of medicine and diseases.

First you greet the person, how was your day? Then start talking about when was the last time you had sex, who are you having sex with and so on. MSM, NYC  You may want to take out this quote.  It is not one of the strongest ones.

If your practice primarily serves MSM, you are undoubtedly aware of health-related issues of particular concern to your patients, and have created a welcoming practice environment. In treating patients overall health, you may already be incorporating messages about the importance of regular testing for syphilis and other STDs as well as HIV. If you are not currently emphasizing the importance of testing for syphilis, please join SEEs effort and start testing and counseling for syphilis. Reporting the presumptive and confirmed cases of syphilis to your health department within one working day of the diagnosis  is also very important.  

If your practice does not primarily serve MSM, a few simple, low-key signals can help communicate that your office offers equal treatment regardless of sexual orientation.
Such signals can empower patients to be candid about their sexuality. Although a patients sexual orientation is only one factor to be considered in an overall approach to health, it is an important aspect as it relates to possible health risks.

Consider the following steps:
* In addition to other information and reading materials you provide for your patients, perhaps you could include posters and pamphlets with gay-friendly messages and a few gay-health oriented magazines in your reception or waiting area  if appropriate. 
* Or, think about setting up one gay-friendly examining room in your practice with gay-health oriented publications and posters. 
* Train administrative, nursing, and clinical staff on how to contribute to a welcoming practice environment. 
* Ensure that patients initial visit forms use appropriate language. For example, use relationship status and offer gender-neutral options to make it easier for the patient to provide truthful information. 

Remember: As a health-care provider, you are in a unique position to provide increased syphilis screening, testing, treatment, and reporting.  If you help improve syphilis testing, treatment, and reporting, it will be possible to more accurately assess the rates of syphilis in the community, and will provide treatment for more people infected and living with syphilis.. Participating in SEE may be a chance to claim your part in eliminating a disease in your community!


Prepare Yourself

Comfort level plays an important role in discussing sensitive matters both for the patient and for the physician.

If I didnt feel comfortable with my doctor, what benefit do I get in going to my doctor? I have to tell my doctor everything, so that he can give me the treatment I need. But if I go and tell him lies, or I dont tell him whats happening to me, he cant help me. An MSM in LA


Whether you primarily treat MSM or only a few MSM, the SEE materials and CDC guidelines offer a quick checklist for diagnosis and treatment of syphilis and other STDs, and may help health care professionals feel confident when providing these services.  Awareness of issues to be discussed and potential problems to be addressed ensures that you offer your patients excellent overall health care.

Clinicians providing health care to gay and bisexual men may not be aware of all the things that should be discussed during the visit, A New York City physician  who primarily sees gay and lesbian patients 

Screening for syphilis and other STDs is a critical component of early detection and treatment. MSM should be routinely screened for syphilis, especially in light of the fact that syphilis infection increases the risk of contracting HIV. 

A physician recently commented, Weve seen cases where someone has been seen by their [doctor] two or three times before the [doctor] realized [the patient had syphilis], thinking early syphilis rashes were a reaction to HIV antiviral medication.

Syphilis is often called the great imitator because its symptoms mimic those of many other diseases. Enlarged lymph glands, headaches, skin rashes, fever, sore throat and swelling in joints can indicate syphilis and numerous other conditions such as flu, bronchitis, measles, dermatitis or rheumatism, to name a few. Late-stage syphilis presents symptoms such as paralysis, numbness, difficulty coordinating muscle movements, fatigue, and dementia that may be mistaken for markers of such conditions as Alzheimers, cardiovascular disease, or neurological damage.

Syphilis may go undiagnosed and untreated for several reasons. 
* In the primary stage of syphilis, chancres may be in the rectum or in the mouth.  Patients may not notice them or may simply dismiss them as just another simple sore.  As a result, they may not consult a physician during this  phase.. 
*  Rashes that appear during the secondary phase of syphilis may also be faint and may go unnoticed by the patient.
*  Because patients may not be aware that they are infected due to symptoms being difficult to pinpoint, a thorough physical examination and taking the patients sexual history are very important for diagnosing syphilis. 
* SEEs Physician Pocket Guide on Syphilis offers a quick checklist of syphilis symptoms and the available treatment options.

Many doctors dont ask about sexual activity. An MSM in LA

In order to offer comprehensive health information .and services to MSM clients, make sure that you and your staff are up-to-date on important issues relevant to MSM such as depression, substance abuse, partner violence, HIV and STDs, discrimination, anal papilloma, prostate/testicular/colon cancer, and hepatitis immunization. Although raising sexual safety issues and encouraging periodic tests for HIV and other STDs can be time-consuming and difficult, it is crucial for the health and well-being of  at-risk MSM. 



* If it seems a patient may be holding something back, make statements and ask questions such as:

* If it seems a patient may be holding something back, make statements and ask questions such as:

o Im going to need you to be more explicit. Was the sexual contact genital, oral, or anal? With females or males or both?
o How many sexual partners are you talking about?
o How do drug and alcohol use relate to your sexual behavior, if at all?
o Have you ever been diagnosed with an STD?
o Do you know whether your partner(s) has ever been diagnosed and treated for an STD?
o When was the last time you were screened for HIV or other STDs?

 Please use A Guide to Taking a Sexual History to help you with this process.  Additionally, using the Sexual History Discussion Form for each patient and including it in their medical records will be an easy way for you to track changes in patients sexual health.

 Prepare Your Patients

The responses you get from a patient and the way he reacts throughout the discussion of syphilis and other STDs will guide you regarding the extent and type of education you might need  to provide for each patient. You may decide to introduce some of the  information below during different stages of an office visit as appropriate. 
* After10 years of decline, syphilis cases are on the rise among MSM. In New York, cases more than doubled from 2000 to 2001.
* There have been outbreaks among MSM in other cities, too. Just in the past few years, Seattle, Chicago, San Francisco, and Miami have had outbreaks. A lot of MSM with syphilis also have HIV. If you have syphilis, it makes your chances of contracting HIV two to five times greater.
* There is a rapid test for HIV. You can get preliminary results back in about 20 minutes.
* Getting tested for syphilis should be part of your routine medical care every year.




Get Involved

You and other health-care professionals are a vital part of the community mobilization effort to conquer syphilis.  You may want to cooperate with medical societies, community-based organizations, HIV prevention planners, and advocacy groups to strengthen linkages between prevention and clinical services. 



You can contribute to SEE efforts by:
* making  sexual history taking a part of your routine care (Sexual History Discussion Form, and A Guide to Taking a Sexual History are provided to make this a relatively easy process)
* using the SEE Physician Pocket Guide as a reference when screening
   patients for syphilis;
* reporting syphilis cases to local health departments
* hosting community screenings  either independently or in collaboration with other clinics or practices
* volunteering  to screen at community health fairs and MSM community events such as gay pride parades
* displaying SEE posters in your office waiting room
* joining a SEE community coalition of leaders and experts who cooperate on strategies to mobilize the community for syphilis elimination
* incorporating syphilis transmission, screening, and treatment information into HIV/AIDS or STD educational classes and one-on-one patient counseling
* developing a resource list so you and your staff can refer patients to:
      Local community centers
Counseling services such as support groups, mental health services, and health education facilities
      Legal resources
      Gay-friendly sub-specialists and other providers



Any visit to a health-care setting represents an opportunity to diagnose and treat syphilis and other STDs, thus a chance to decrease transmission of HIV. Test your patients for syphilis annually and whenever reported behaviors necessitate it. You will help eliminate a curable disease and contribute to your patients optimum health.


Your involvement is crucial to the success of SEE.

If you have specific questions about SEE that are not addressed in this guide or you would like to know how to become a member of SEE, visit the CDC Web site at www.cdc.gov/std/see or call your local health department.



 FREQUENTLY ASKED QUESTIONS


Suppose patients refuse to answer questions about their sexual history and practices?
Acknowledge your patients feelings and emphasize that respect for patients privacy is part of your practices policy. Try to put the patient at ease by asking questions about his life in general, such as, What do you do for fun? and Where do you like to go when you go out? and  Are you involved in a relationship or dating? As the patient feels more comfortable and begins to open up, ask a general question related to sex such as, How would you rate your sex life on a scale of 1 to 10? Follow up with, What would it take to bring it up to 10? 
 
How do I encourage MSM engaging in risky sex to change their behavior?
Statements like, I get a sense that youre not too worried about the risk of getting HIV, syphilis, and other STDs. What would it take to make regular condom use part of your sexual life? demonstrate empathy and show the patient that you are willing to help.
Emphasize the patients choice and control with statements such as Only you can decide to guard your sexual health. If you suspect the patient might be depressed, be using drugs and alcohol to excess, or has a partner violence problem, try a statement such as, Im sure you know the possible consequences of unprotected sex, and I wonder if other issues such as depression might be preventing you from protecting yourself. Could we explore that?  Follow up with, I know a colleague that might be able to help you with this issue, and refer him for additional services.

How do I overcome a patients resistance to being tested?
Warn the patient that syphilis can often go undetected, and that its long-term consequences can include blindness, neurological damage, and death. Tell him that syphilis is cured with a simple treatment regimen. More importantly, emphasize the fact that syphilis increases a persons chances of contracting and transmitting HIV.

How do I answer a patient who objects to having his name reported should he test positive?
Explain to the patient that reporting syphilis cases is a matter of law. However, since syphilis is a curable disease, having his name in the public record is not serious cause for concern. Reassure him that such records are confidential.




References


Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report (MMWR). Primary and Secondary Syphilis Among Men Who Have Sex with Men.  Sept 27, 2002;51(30);853-856. www.cdc.gov/mmwr/PDF/wk/mm5138.pdf 

Centers for Disease Control and Prevention. MMWR. Primary and Secondary Syphilis  United States, 2000-2001. Nov 1, 2002;51(43);971-973. www.cdc.gov/mmwr/PDF/wk/mm5143.pdf 


Columbia Presbyterian Medical Center. Guide to Clinical Preventive Services, Second Edition, Infectious Diseases: Screening for Syphilis. http://cpmcnet.columbia.edu/texts/gcps/gcps0036.html 

Elliott, Victoria Stagg. Latest CDC Treatment Guidelines Try to Rein in STDs. amednews.com. June 3, 2002. www.ama-assn.org/amednews/2002/06/03/hlsb0603.htm 


Gay and Lesbian Medical Association. Creating a Safe Clinical Environment for Men Who Have Sex with Men.  May 9, 2002. http://ce54.citysoft.com/_data/n_0001/resources/live/GLMA%20guidelines%202006%20FINAL.pdf 

Gay and Lesbian Medical Association. Ten Things Gay Men Should Discuss with Their Health-care Providers.
July 17, 2002. www.glma.org

Gay Mens Health Wiltshire and Swindon. Small Effort, Big Change: A General Practice Guide to Working with Gay and Bisexual Men. http://www.gmhp.demon.co.uk/health/gp/smalleffort.html  

MDAdvice.com. Syphilis: General Information. http://mdadvice.com/topics/std/info/7.htm