Forward Thinking on Syphilis: An Information Exchange on Innovative Approaches to Syphilis, Focused on MSM

Executive Summary

Forward Thinking on Syphilis was an information exchange event focused on urban syphilis and men who have sex with men (MSM), hosted by the NCCID in September 2014, with participation from 32 partners. The purpose was to share information across sectors and jurisdictions about outbreaks of syphilis affecting MSM in several cities across Canada. Over thirty participants from across Canada met to exchange ideas on innovative, integrative and upstream strategies that might help public health and community-based partners in men’s health achieve greater gains in managing and preventing syphilis, often in ‘hard-to-reach’ populations. This was not a consensus building event, nor was the intention to build recommendations. This report offers practice-based knowledge and lessons shared. It represents only one event, and the views of a necessarily limited number of attendees. Although readers may find worthwhile lessons and ideas that are adaptable to their own context, the distinct epidemiological, social and demographic characteristics between regions should be kept well in mind.

A common theme among participants attending this event was a lack of evaluation research to support evidence-based practice. Practitioners sought answers to the same overarching question: What is a strategy that works in syphilis control for MSM and what is the evidence that it works? It’s this question that set the context for discussions of gaps, successes and what needs strengthening. The participants of the event continue to keep in touch, Forward Thinking on their public health syphilis prevention and management campaigns.

Background

The National Collaborating Centre for Infectious Diseases hosted a Knowledge Exchange event in Winnipeg in September 2014, as a response to requests made from public health colleagues across Canada for an opportunity to network and share information to help control recent outbreaks of syphilis in Canadian cities.

Working with a diverse Advisory Group of concerned public health personnel, NCCID developed a shared agenda and brought together public health practitioners from several health regions and jurisdictions, researchers and staff from community-based organizations. The goal was to provide an opportunity to share information and ideas on innovative, integrative and community-informed public health strategies with demonstrated or promising effectiveness in reducing the burden of syphilis, particularly among men who have sex with men (MSM). Specific objectives for the Knowledge Exchange event included:

1. Share current knowledge on syphilis outbreaks, highlighting what we know about the burden of syphilis and dynamics of transmission among MSM;
2. Share evidence-based, practice-based, and client-centred knowledge that can contribute to an understanding of features of effective public health interventions for MSM;
3. Identify opportunities to bridge disease-specific silos and sectors, to build more upstream, integrated and community-informed approaches to syphilis.
4. Strategize on ways to advance innovative strategies to control syphilis among MSM.

Response to the event was overwhelming: 32 people came to the event, and many more had to be declined. To accommodate travel and other considerations, the workshop began in the late afternoon of September 29 and continued through September 30, 2014. The meeting has served as an opening for many additional conversations and for changes in public health practice in the few short months since it was held.

This report is a brief summary of the event. Links to additional materials related to the planning and outcomes of the event are also provided.

Setting the Context

Building on the success of previous consultations and events, as well as the enthusiasm of the Advisory Group members, NCCID proposed a Virtual RoundTable to precede the Forward Thinking event. The intent was to share considerable knowledge ahead of time and to build on the networking generated by the national STBBI Network and the Advisory Group itself.

NCCID developed and issued a closed online survey which participants used prior to the workshop to input information about their current syphilis interventions or sexual health promotion work with MSM. Contributors shared information and stories about their innovative, integrative, community efforts, and described success, surprise or disappointment. The results were collated and summarized prior and following the event. (A final public version is being discussed by the group).

As part of the preparation and interest that was generated during the planning process, NCCID associates created a summary of evidence as background which was circulated to participants in advance of the event, Effectiveness of interventions for syphilis prevention and control in MSM: A summary of published research findings by Sarah-Amélie Mercure, M.D. and Noémie Savard, M.D.

Forward Thinking was held in Winnipeg, Manitoba on September 29 and 30, 2014. The final agenda for can be found in Appendix A. Participants at the event included representatives from Public Health Agency of Canada, CATIE, provincial ministries of health and public health agencies, regional and local public health jurisdictions, as well as community outreach agencies. For the complete list of participants, see Appendix B.

The first evening was used to set the context, with evidence of the epidemiology of syphilis, from a national perspective. Participants contributed other evidence from their locale, to describe the state of outbreaks with which they are coping. This was followed by a presentation on syndemic approaches to outreach and prevention.

The second day consisted of presentations on current or recent syphilis interventions or sexual health promotion strategies with MSM, shared from Alberta Health Services, Vancouver Coastal Health, Winnipeg Regional Health Authority, Toronto Public House and Capital Region Health Authority in Nova Scotia. Presenters were asked to address five questions about their syphilis campaigns:

1. What led to the kind of campaign/intervention you did?
2. What worked, and why—what contributed to success? (E.g. who did you need to involve?)
3. What has been most innovative feature of your campaign? (E.g. breaking from past/standard approaches)
4. What have you learned about what does NOT work? Or: What obstacle remains?
5. What’s the most important ‘take away’ lesson that others may apply elsewhere?

All participants used these as context for full discussions about the implications for forward thinking about strategies and interventions at the local, regional and national levels.

This led to facilitated discussions to distill the lessons emerging to identify opportunities to collaborate, address upstream determinants and bridge silos. By the end of the event, participants identified future networking and knowledge exchange opportunities ahead.

Syphilis in Canada in 2014

Burden and Challenges

Infectious syphilis has been on the rise in Canada since 2002, during which time many urban jurisdictions also saw a shift toward highly disproportionate representation of MSM among newly identified cases. In 2012, males represented 98% of Toronto’s cases, among whom 91% reported ‘sex with same sex’ risk factor, or MSM. Despite increased efforts by public health to target the MSM population for prevention, syphilis case counts have remained high. Other sexually transmitted infections (e.g. Chlamydia and gonorrhea) have also seen a resurgence within this period. What public health authorities had identified as an ‘outbreak’ became more of an ongoing public health crisis in large urban jurisdictions. Recently, syphilis outbreaks have also been reported in less populous regions (PEI, Newfoundland, and Saskatchewan) and in populations among whom syphilis has not been of great concern in the past. In Quebec, more regions are affected than in the past, and fewer are free of syphilis. While syphilis spread, some large urban centres began to see some evidence of slowing or possibly improving rates. The rate of infectious syphilis in Toronto may have plateaued between 2009 and 2012, and showed indications of a decline in 2012. As well, rates of syphilis in Montreal seemed to stabilize by 2012, and a downward trend was seen in 2013 and 2014. However, the city also saw an increase in cases among younger men and women in 2011-2012, which is being monitored. Despite improvements, PH staff regard gains as tenuous and not yet significant. Challenges in conducting evaluations and quality data also affect their ability to confirm gains or identify successes in their approaches.

Risks are not uniform among gay and bisexual men. Generally, those with five or more sexual partners, or those infected with HIV have been differentiated as having greatest risk of infection. Closeted bi-sexual men present other challenges for the risks of passing syphilis to a woman in child bearing years with implications for her own health and potential for congenital syphilis in a child. A significant proportion of MSM with syphilis are co-infected with HIV and the implications of syphilis for the health of HIV+ men is of great concern. The consequence of more rapid progression of disease in HIV positive individuals is well recognized. Neurosyphilis or other complications such as cardiac involvement have been documented in such cases. A study of an HIV positive cohort in Ontario found that a quarter of HIV+ men had syphilis. As well, gay men with syphilis are commonly found to have an HIV infection, with rates varying across Canada. In Toronto, the public health authority has recorded a 50-60% prevalence of co-infection among MSM diagnosed with syphilis. In Montreal, nearly half of MSM infected with syphilis are HIV positive. In Alberta, provincial public health authorities estimate that one third of MSM infected with syphilis are co-infected with HIV. Public health personnel have observed a cyclical and pernicious problem in some urban centres where reinfection among a core population of MSM appears to be an important driver of the epidemic. Anecdotal reports from public health nurses describe situations where nurses come to recognize the names of those who repeatedly require follow-up and partner notification. Such reports suggest that a relatively small subset of individuals carry the major burden of syphilis.

By age, most cases of reported syphilis are concentrated in the 25-35 age range. However, the greatest relative increases over have been noted among young men aged 15-19 years (Gale-Rowe). In part, this is understood to reflect a change in gay men’s culture and perceptions of STIs and particularly of HIV. In Toronto, public health personnel describe seeing more young men who want to maintain their health, but also to enjoy their lifestyle, in which sex is a positive contributor to their wellbeing. Young men may have never known a world without HIV/AIDS, and unlike the generation before who witnessed the suffering and death of their peers, young men now see HIV to be a manageable chronic health condition. Thus, STBBIs, including syphilis, may be regarded as an acceptable risk for some. Participants from various regions described an awareness that high risk sexual activities (e.g. group sex, casual sex culture) appears to have seen resurgence, particularly among younger men. Social networking studies have shown bathhouses but also online sites to predominate as places MSM seek sexual partners. A Nova Scotian social networking analysis (De’angelo-scott) showed only 1 physical venue where MSM with syphilis infection met the partners, whereas other 5 were internet sites. Moreover, strategies used in the MSM community to lessen risk of HIV transmission have increased the popularity of oral sex, though this offers no protection for syphilis, which is more easily transmitted through oral sex. This trend is thought to be an important factor in syphilis transmission, although information is lacking from surveillance data on the primary site of infection.  Many HIV-positive men forgo using condoms by choosing to only partner with other HIV-positive men, a practice known as sero-sorting, thus increasing their risks for contracting STDs from their sex partners. HIV negative men using pre-exposure prophylaxis (PrEP, a once-a-day pill, to protect themselves from contracting HIV) who opt not to use condoms also put themselves at risk for syphilis.

What Is Not Working, or of Uncertain Value?

Participants discussed the implications of the information on programs across the country. A number of key themes arose regarding where success is still elusive:

• Negative, shame or fear-based messaging about sex and gay men is not effective, and may do more harm. Education-based approaches that presume information will lead to changes in behaviour have limited impact.
• There is some concern that testing blitzes may have poor long-term effects, as a large population of recently tested and treated individuals builds a reservoir of susceptible individuals which can trigger a new flare up. Thus, there is concern that intense testing and treatment may cause more harm.
• Campaigns have short-lived success and need to be continually updated to gain attention of target populations.
• Varying levels of success are seen with some targeted approaches, particularly if target groups are not consulted and involved from the beginning.

Where are the Gaps?

• Meaningful evaluation of interventions is needed, including social media interventions and e-Health methods.
• Cooperation with primary care practitioners is needed. There is a need to increase awareness about syphilis screening in general medicine clinics. Primary care physicians still need information on the symptoms of syphilis and reminders to offer testing to clients who may be at risk.
• More and varied testing sites are needed to increase the likelihood that MSM are tested. The importance of convenient and accessible testing sites cannot be overstated.
• More gay-friendly primary care and testing sites are needed. Stigma about syphilis remains and cultural norms in health systems are difficult to change. Hetero-normative messages predominate in public health, which is understood to alienate those MSM at greatest risk for infection.
• Greater investment in outreach and community-based advocacy efforts – Gay men and other MSM need support for asking physicians that they be tested and for learning about the signs and symptoms of syphilis, long-term health implications and who is at risk.
  • Positive Living BC encourages individuals to talk to their care provider and request syphilis tests be added to routine blood work for ART. They educate and counsel people to foster personal empowerment in sexual health.
  • An outreach worker stated: “Guys need good language to dialogue about sexual activities with their doctors. Front line doctors do too.”
• Culturally-sensitive approach to syphilis – Compared to older men’s past experiences of HIV/AIDS, and to other concerns that face gay men (e.g. threats to personal health and safety from violence and homophobia), syphilis may not be perceived by gay men as serious. Patient education and advocacy is needed.
• Testing strategies in Canada need review and the most appropriate testing method must be advanced. Challenges and trade-offs are recognized for most methods.
• Optimal frequency of testing not known – We need to know how often to test to have the best outcome. The risk that recurrent infections occur when testing and treatment is carried out too often is of concern.
• Make use of gay men’s health knowledge/other assets – Approach syphilis testing like HPV or STI testing for women, that is, integrated and supportive so that it’s hard not to be tested.
• Address treatment gaps – Participants shared reports of treatments not being stocked by pharmacies, or the wrong treatment being dispensed. It is important for public health to work more closely with the pharmacists, and with community-based clinics that serve MSM.
• Do more to build political will and policy that safeguards gay men. The importance of gay men’s overall health and wellbeing, as well as sexual health, needs to be reflected in policy and integrated throughout public health practice.
• Social media use by public health raises confidentiality concerns, which are yet to be resolved. Interventions using technology are challenging in terms of procurement of services, rapid changes in technology and users’ preferences, and maintenance demands.

What Is Promising?

A number of successes were shared at the event, which participants discussed in detail and considered for their local situations. Primary among those success was the important point that No one strategy has been shown to be particularly effective. A combination of interventions and strategies are recognized as being needed.

Collaborations and Partnerships

• Cross-sector collaboration– Success has been attributed to knowledge transfer and collaboration across all sectors as well as across various levels of public health.
• Partnerships – Both public health and community-based agencies mentioned relationships and partnerships between these two sectors as a winning feature of interventions.
• Build relationships with media and with a government partner, in advance of launching a campaign. Seek allies in the media and develop relationships, though this is more difficult in major urban centres where there are large numbers of media outlets.

The Value of Community Involvement

• Community Input – Input from community helps set the tone for campaigns and identify local and regional level actions needed. One agency had hosted a roundtable discussion with community-based agencies, care providers, and the health authority, and successfully synchronized their ideas and gained feedback from community and clients to ensure that actions taken reflected what was asked for.
• “Nothing about us, without us” Involve gay men at every stage of planning interventions. For example, hold focus groups on messages that are well accepted. Local leaders or spokespersons are recognized as factors in success of public health campaigns.
• Advance work with community – Outreach workers in public health are good liaisons, building relationships and working closely with CBOs and clients. Consider making connections with community partners a performance appraisal expectation for nurses.

Clinics and Program Strategies

• Address broad sexual health interests and concerns – Such strategies are favoured by community over ‘risk and avoidance of risk’ negativity common to more biomedical approaches.
• Specialized clinics for gay men and those most at risk are understood to be the most suitable sources of information on sexual health for gay men. We “need gay men talking to gay men” (e.g. Men’s Health Clinic established in Calgary).
• Risk-based screening recommendations – Many have screening services that target ‘at risk populations’. Other jurisdictions promote syphilis screening for all MSM.
• Meet gay men where they are – Provide convenient and accessible testing in community settings, social venues and widely available through local health centres and through outreach nurses in bathhouses, sex clubs, CBO’s facilities, male sex worker drop-in centre, strip clubs (as in Montreal). Remember that MSM are on-line too.
• Outreach workers speaking to MSM about the importance of partner notification is also important. Test and treat practice model for partner notification nurses is used in Alberta and has allowed expansion of outreach beyond major cities.
• Build capacity of MSM-serving clinics – TPH is piloting an educational project with a clinic which sees many MSM clients to improve knowledge of treatment, importance of rectal and pharyngeal swabs for tests of MSM.
• Down-loadable requisition forms have been tested. This eliminates the necessity of seeing a physician to order a test. But downloads have been few. Access to a printer may be a barrier. Bar coded electronic forms might be tried.
• Cultural competency – training health care providers and others on how to better work with the LGBT population / gay men and other MSM, as well as training on gender diversity, sexual orientation and sexual health (e.g. MSSS and INSPQ, TPH).
• Syndemics approach – consider more closely the social contexts of individuals and health, broadly defined.
• Stronger prevention management – VCH implemented (with partner agencies) a prevention case management program with a specific focus on gay men and MSM.
• Holistic gay men’s health – Integrate syphilis prevention within a broad strategy that promotes the health of gay men and other MSM. The message that ‘gay men’s health matters’ is an important statement to get across and can help counter the stigma that has intensified risks of STBBIs among this population. COCQ-SIDA’s syphilis campaign was integrated into a broader campaign “Prêt pour l’action” which aims to inform MSM about various aspects of sexual health.
• Reduce stigma. Get message out that syphilis is a concern and advise to get tested. E.g. the Hassle Free Clinic provides gay and bi men with information they need to make an informed decision on whether and when they need to be tested for HIV and syphilis; routine testing is encouraged.

The Value of Messaging that Will be Seen and Heard

• Straightforward messages – Using language that is plain and clear and reflects the language used by community people enhances uptake of public health messages. A community-based agency heard feedback that a “blunt” or straightforward message was appreciated. .
• Sex-positive messages – Sex-positive messages that reflect the benefit of sex for gay men is important. Sex contributes to gay men’s sense of well-being and health, and is fun. Agencies advocating for gay men advise that PH recognize the culture difference and work within the framework of gay men’s culture, where it is more common for individuals to not be in monogamous long-term relationships, but to have multiple partners, and to have a casual outlook on sex (e.g. Positive Living BC)
• Social marketing as awareness raising- Social marketing campaigns, despite difficulty establishing this in evaluation using incidence rates, have value for raising awareness. (AHS did find increase in awareness and a 17% increase in testing over a baseline). SIECCAN report has identified strategies that have had some success for syphilis. Montreal’s evaluation showed social marketing campaign of 2004-2005 increased uptake of syphilis testing by MSM—those exposed to campaign were more likely to consider that it was normal to be tested.
• Social media platforms – Online partner notification may be innovative. Use popular websites (Squirt.org), perhaps in collaboration with other public health units.
  • New media ways to reach clients – Montreal’s “Jacques & Jack” online survey with recommendations to MSM on when and where to be tested. TPH MSM committee exploring creation and promotion of a micro-website optimized for smart phones which will provide information on STIs (including syphilis), testing locations, and resources.
  • InSPOT – TPH education committee is re-invigorating the promotion of inSPOT. They have provided primary care practitioners with information on inSPOT.
• Enhanced surveillance – gather supplementary information on ‘risk markers’, locations where partners meet. Partnership with PH surveillance. Mapping allows follow-up of venue and network based contacts.

Primary Care and Clinical Treatment

• Awareness raising and testing focus – Participants commonly remarked that it is beneficial not to focus on promoting condom use alone, but on getting men to test for syphilis. (E.g. Test, treat, tell is Toronto Public Health’s approach.) Not pushing condoms at all costs, but recognizing and reinforcing the many strategies that MSM use to protect themselves” (COCQ-SIDA)This is a message that tends to win greater acceptance among gay men.
• Primary care AND clients – informing both doctors and patients (re what tests are needed) leads to better results. Primary care needs resources to remind them of the signs and symptoms.
• Capitalize on strong gay culture and the high capacity gay men have for managing sexual health risks developed as a consequence of the community’s history with HIV/AIDS. Gay men are astute managers of HIV risks. The capacity is an opportunity that public health can take better advantage of.
• Case management that prioritizes at risk MSM for testing and follow-up. Work with MSM individually, through case management to educate and advocate for clients at risk of re-infection.
• Prioritizing syphilis – Dedicating staff (epidemiologist, public health nurses, or Director position) can help prioritize syphilis relative to other STI demands. Dedicated website for all STIs.
• POC testing – (AHS example of success). Factors to consider in the success of POC: prevalence of syphilis in your community, access to traditional testing methods, and previous syphilis seropositive rate. (clarify with Colleen)
• Integrate HIV or STI and syphilis testing – Offer syphilis testing along with routine HIV testing and care. AHS used Gonorrhea focus in a campaign as a wedge to talk about STI and safer sex behaviours that have benefits for other STBBIs. Integration is furthered by using same staff to follow-up on both STIs and HIV, and consistent leadership from a director over all—a centralized program for all is helpful. HIM clinic nurses explain and offer syphilis testing with every HIV test. OHTN Cohort Study is evaluating an approach that incorporates standing orders for syphilis screening whenever viral loads ae ordered among men in HIV care.
• Guidelines on STI/syphilis testing and treatment (and in App form) – guidelines reduce the likelihood of omissions in care, and reduces the time to respond.
• Evaluation – can increase support for interventions in the future.
• Treatment – expediting treatment by couriering medications to physicians’ offices (TPH). Treatment access also improved by policies at STI clinics: g. require no appointment, accept those without health care cards, those using alias identification, and giving priority to syphilis patients (Alberta Health Service example). Test and Treat practice also reduces barriers to treatment.
• Presumptive treatment – BC provincial guidelines allow for presumptive treatment.
• Partner notification using social media / new media – has been piloted but there are no published evaluation results. Montreal public health has a profile on ManHunt used for PN.

What Happened Next

Of the 32 participants at the workshop, 29 completed the evaluation. They rated the event very favourably, with 93% rating the workshop is either good (36%) or excellent (57%). Respondents said they felt that all of the six objectives were at least partially met, but the strongest evaluation being those objectives about brokering knowledge. The objectives focused on providing opportunities to identify more integrated, upstream. Client and community-informed approaches received a slightly lower evaluation, which may, as one respondent noted, reflect the state of knowledge in terms of these approaches.

The majority of participants strongly agreed that there was the correct mix of participants, activities were appropriate, and their interest was sustained throughout the event. The majority of participants agreed that there was plenty of opportunity to connect with people for the purpose of future collaboration and that the virtual roundtable questionnaire was helpful.

When asked what was most valuable about the workshop many participants highlighted sharing information or knowledge exchange. Their comments included:

• opportunity to network with other practitioners
• learn about other initiatives across the country
• network to “break out of local tunnel vision and expand thoughts on interventions”
• “to hear themes come out across regions such as challenges, opportunities and the importance of community inclusion and partnership”
• valuable to hear “the diversity of points of views and perspectives”
• this is a very complex issue in this workshop provided an excellent opportunity to look at where issues are headed
• great to have the mix of public health and community agencies as each has different mandates

All those who completed an evaluation said that their knowledge of effective interventions/strategies for syphilis prevention and control had improved. Some (18%) said that their knowledge had improved a little, some (46%) said their knowledge was somewhat improved and others (36%) indicated their knowledge had improved a lot.

The media picked up on some work by WRHA and approached NCCID staff for interviews, information about the event, and for information on syphilis.  Some news articles were published, including an article in the Globe and Mail: “Old disease, modern problem: How hook-up culture is bringing syphilis back”, by Shane Dingman, Technology reporter.

The participants of the event continue to keep in touch, Forward Thinking on their public health syphilis prevention and management campaigns.