CDC Telebriefing Transcript

CDC Reports Latest U.S. Syphilis Trends

October 31, 2002

CDC MODERATOR: Good afternoon, everyone. Thank you for joining us today for this discussion on national syphilis trends. I'm with Dr. Ron Valdiserri. He's the Deputy Director of CDC's Program for HIV, STD and TB Prevention.

Let me spell his full name for you. It's Ronald O. Valdiserri. R-o-n-a-l-d, middle initial O, last name Valdiserri, V as in victor-A-l-d as in dog-i-s as in sam-e-r-r-i. He has a medical degree and a master's degree in public health. Dr. Valdiserri will now give a brief statement on today's MMWR article, and then we will take questions.

Dr. Valdiserri?

DR. VALDISERRI: Thank you, Kitty.

Thanks to all of you for being on the call.

Today I will be reviewing new CDC data on primary and secondary syphilis cases in the United States. These data are featured in a new report by CDC researcher, Dr. James Heffelfinger, and they will be published tomorrow in CDC's Morbidity and Mortality Weekly Report.

First I'll be discussing the overall progress towards CDC's national goal to eliminate syphilis, including continued declines among African-Americans and women, as well as new challenges to reaching that goal. And then I'd like to talk about what CDC is doing to meet these challenges. Afterwards I'd be happy to take your questions.

All of you should have received a press release detailing the data we are presenting today. Please note that the embargo on the data lifted at the start of this call. Now, if you did not receive the release or if you have any other questions, please feel free to call our press office at 404-639-8895. Let me repeat that: 404-639-8895. And we'd be glad to help you get whatever information you might need for your stories.

In 1998 CDC began its initial efforts to eliminate syphilis from the United States by aggressively targeting prevention efforts to regions and populations that were most affected by the disease, specifically African-Americans and individuals living in the Southeast. We defined "elimination" as the absence of sustained transmission in the U.S.

Now, since these efforts began, there has been major progress in beating syphilis in these areas where it hit the hardest. The positive trends continued in 2001 with syphilis rates declining further among African-Americans and people living in the South. But despite the consistent declines in these key populations, 2001 marks the first increase in the national syphilis rate since 1990. CDC's new data show that primary and secondary syphilis cases in the United States rose by 2 percent between 2000 and 2001, from 5,979 cases to 6,103 cases. As a result, the overall syphilis rate increase slightly from 2.1 cases per 100,000 people in 2000 to 2.2 cases per 100,000 people in 2001.

Now, in reviewing the overall national data it's very important to look at trend within specific populations. According to the new data, the slight national increase can be attributed to increased syphilis diagnoses among men. Between 2000 and 2001 the syphilis rate among men in the United States rose by 15 percent. This increase coincided with outbreaks of syphilis among gay and bisexual men of all races in several American cities.

Data specific to syphilis among gay and bisexual men is not available nationally. Therefore we have to look at the overall cases reported in men. Now, among white and Latino men the increases of syphilis cases were quite dramatic, 63 percent and 50 percent respectively. And while there is a 3.5 percent decline in cases among African-American men, it should be noted that this decline is much smaller than the 15 percent decline we saw among African-American men last year.

Again, these increases in men contrast with the continued progress, positive progress we've made towards syphilis elimination among African-Americans generally and individuals living in the South. Let me share some of those statistics with you.

Among African-American women in particular, syphilis cases fell by 18.1 percent between 2000 and 2001. And in the South, although this is the region that remains the most affected by syphilis, with 56 percent of all American syphilis cases, there was an 8 percent decline between 2000 and 2001.

DR. VALDISERRI: Also, it's important to note that among women overall, there was a 19.5 percent decline in syphilis cases. These data clearly show that a targeted, concerted national effort to eliminate syphilis can and will work, yet continued success will depend on our ability to target resources to those areas and populations most affected, including gay and bisexual men.

Syphilis outbreaks among gay and bisexual men, while a major concern in and of themselves, also signal the potential for a resurgence in HIV transmission.

Our challenge and the challenge for gay and bisexual communities across America is to underscore the connections between syphilis and HIV and to renew the kind of commitment that these communities brought to HIV prevention in the early years of the epidemic.

It's important to point out that there is no single or simple explanation for why syphilis outbreaks and increases in high-risk behavior are occurring among certain populations of gay and bisexual men, nor do we have all the answers.

It is likely, however, that these outbreaks are a symptom of broader challenges facing these communities and are related to the changing circumstances of the HIV epidemic.

We now face many new and complex prevention challenges, including HIV being viewed as a less serious disease in light of improved treatments, miscalculations or lack of understand of risk for HIV transmission, and difficulty reaching gay and bisexual men of color with effective prevention messages, particularly men who have sex with men but may not identify as gay.

So we must continue to search for solutions to these new and evolving challenges.

CDC is working aggressively to help meet these challenges. First of all, to better understand why gay and bisexual men, particularly, may be vulnerable to syphilis, CDC has conducted studies in several cities to identify factors that may be playing a key role in syphilis transmission.

Some of the findings, overall, from those assessments reveal a lack of knowledge about STDs among men who have sex with men, limited counseling and diagnostic screening for STDs offered by health care providers, and the need for a much more concentrated and comprehensive community response.

CDC has dispatched rapid response teams to aid local health departments around the country in response to these syphilis outbreaks when they've been detected.

And to prevent syphilis transmission among vulnerable populations, including gay and bisexual men, CDC is supporting a wide range of tailored educational and outreach efforts, including testing interventions, public health interventions delivered on the Internet, that would alert men to the dangers of syphilis and would hope to increase both HIV and syphilis testing.

Various community health campaigns ,other intensified HIV prevention efforts, working very closely with local health departments and community-based organizations, and making services more accessible by providing them on mobile vans so that syphilis testing can be brought out to the community to many high-risk populations.

CDC is also working to improve the national STD surveillance system, and when completed, these changes will ensure that our surveillance system includes more accurate information on risk behavior, including information on the gender of sexual partners.

These new challenges do not, however, change our goal of syphilis elimination. As the new CDC report shows, half of the syphilis cases in the U.S. occurred in only 20 counties and one independent city, and 80 percent of U.S. counties did not--I repeat--did not report a single case of primary or secondary syphilis in 2001.

The absence of syphilis cases in the vast majority of U.S. counties serves as a reminder that syphilis elimination is a realistic and achievable goal.

We cannot and should not accept an increase in syphilis cases in any population as inevitable. The new data do make it clear that our strategies need to evolve as patterns in disease do.

For gay and bisexual men, this means greater education about the role of STDs in HIV transmission, integrated HIV and STD testing and educational services as well as placement of STD and HIV information in bars, clubs, and other places where men gather.

Success will continue to require the commitment and involvement of local communities, health departments and community organizations throughout the country.

Eliminating this disease is certainly not something that CDC can do on its own, and with that I'd be glad to take questions that you might have.

AT&T MODERATOR: Certainly, sir, and ladies and gentlemen, if you do have any questions or comments, we ask that you would press the one on your touchtone phone at this time.

And once again, ladies and gentlemen, to queue up for a question, just press the one on your phone keypad, and first we go to the New York Times Cheryl Stolberg [ph]. Please go ahead.

QUESTION: Hi. I was wondering if you could talk about a couple of things, first, if you could tell us a little bit about which cities or counties had outbreaks where you sent these response teams, and also I was wondering about Robeson County, North Carolina.

I see here a fairly low number of cases, but a fairly high rate, and I don't know anything about that county and I just wondered by that seems to be such an outlier in the rate.

DR. VALDISERRI: Okay, Cheryl. Let me start with your second question.

I think that the rate that you're seeing there is so high just because that's essentially a rural population, so--

QUESTION: Yeah. I just wondered what's going on there, you know, in a rural--I see a lot of, you know, fairly high rates, say, in Baltimore, or in Memphis, Detroit, Atlanta, but, you know, in a small rural area, I just--it was just interesting to me and I wondered if you could explain a little further.

DR. VALDISERRI: I think, frankly, we'd need to get back to you about that. I don't have that level of detail.

QUESTION: Okay. So then if you could talk about the--

DR. VALDISERRI: I wanted to answer your first question. CDC has, over the past 18 months or so, and in response to requests for assistance from state and local health departments, has sent rapid response teams to a number of cities, including Miami, Chicago, San Francisco. We've also been involved in investigations in New York and Los Angeles and Miami as well.

So there have been a number of areas where we have provided both epidemiologic assistance and also part of what we're doing now with the national syphilis elimination efforts is providing more detailed ethnographic type of information in addition to doing sort of the typical case control studies, also involving ethnographers, and other researchers who can work with local communities to give us more insight into what some of the factors are contributing to these outbreaks.

They do tend to vary from city to city, and I did mention in my prepared remarks, I did mention some of the common themes relate to very poor knowledge of STDs, other than HIV, among men who have sex with men, noting that health care providers are typically not counseling or providing diagnostic services to their clients.

But there have been different issues in different communities.

QUESTION: Based on what you know, do you expect this national trend to continue?

DR. VALDISERRI: Well, you know, we're always reticent to talk about trends in outlying years. Let's say we're concerned about it, even though it's a relatively small number of cases. It's really only 124, 125 cases, and it is a slight increase, we are concerned about it in the context of other reports of unsafe behavior among men who have sex with men. So it is certainly a situation that will bear ongoing and close scrutiny and effort.

QUESTION: Thank you.

AT&T MODERATOR: And thank you, Ms. Stolberg. Next, with the Washington Times, we go to Cheryl Wetstein [ph]. Please go ahead.

QUESTION: Hi there. I wondered if you could explain a little bit more, in detail, what kind of media campaigns, brochures and outreach are you doing, and do you mention specifically the word syphilis?

DR. VALDISERRI: Well, I'll start with the last question. Yes, it's in the brochures and posters, they definitely specifically mention syphilis.

I can give you more detail. I don't know that I can give you the level of detail you want, but let me give you a few examples, and it's important to point out in all of these efforts CDC is working very closely and at the invitation of the local health department and we also try to work very closely with nongovernmental organizations and community-based organizations representing the affected populations.

Let me talk in a little more detail about Chicago, for instance, what CDC did in some of its programmatic efforts there, working with the Department of Public Health. Essentially a coalition was formed that involved the Howard Brown Health Center, which is a community health center for gay men, an NGO, a nongovernmental organization that provided HIV/AIDS services to men of color. The local health department of course, and a number of other partners, all of whom were serving men who have sex with men.

Some of these were gay-identified men, some of them weren't, but they were all MSM populations. What they did in that campaign was to do, essentially to intensify outreach efforts and send community workers to bars and bathhouses that were frequented by high-risk men who have sex with men, to provide them with information about the syphilis outbreak, to make sure they understood the basics about how syphilis is diagnosed and how it's treated, and of course as part of that outreach effort, they would then share written information.

So that's an example of the kind of effort that's taking place in one city. Now, again, it does tend to vary from place to place, but typically there's a very strong involvement of community-based organizations and we are there at the invitation of the local and state health department, so we're working hand in hand with them.

QUESTION: Okay; thank you.

AT&T MODERATOR: Thank you, ma'am.

Representing Web MD, we'll go to Dan Denoon [ph]. Please go ahead.

QUESTION: Thank you. Is promotion of condom use a part of this campaign against syphilis, and if it is, could you comment on the disappearance of condom information from the CDC Web site.

DR. VALDISERRI: Let me start with your first question, that for sexually active men who have sex with men, who are high risk--and I make that distinction because we're typically not talking about a monogamous gay couple here. We're talking about individuals who have multiple partners.

They might have a main partner but they also have other partners. So there are a number of prevention messages. Certainly reducing the number of partners, certainly consistent and correct use of condoms, certainly as you likely know from our new published this year STD treatment guidelines, we have specific recommendations this year advising all health care providers who are taking care of gay and bisexual men, or MSM, to counsel and screen for STDs, at least on a yearly basis.

So to answer your first question, yes, consistent and correct use of condoms is one of the messages.

The condom factsheet that you refer to is off of the CDC Web site because it's currently under review. We're trying to add to it updated information that gives a more complete picture of what we know about condom effectiveness vis-a-vis specific STDs. So that's what's happening there.

QUESTION: Thank you.

AT&T MODERATOR: Thank you, sir.

With the Bay Area Reporter, Bob Roan [ph], please go ahead.

QUESTION: Thank you.

You make a special emphasis, a "big deal" about syphilis as opposed to other STDs, other than HIV. Could you explain to me why, from both a public health perspective and an individual medical perspective, why syphilis is different from--or how syphilis is different from other treatable STDs.

DR. VALDISERRI: Well, I mean it's different in a number of ways. Let me start--I don't know if this was the genesis of your question, but let me start and give you some background on why we think it's possible to eliminate syphilis. And so part of the big emphasis that the Agency had placed on syphilis is because we believe it's possible to eliminate, not eradicate, but eliminate syphilis, and that's basically defined as a lack of sustained transmission, and there are a number of specific goals that fall under that. They're repeated in the MMWR article, but we would expect to see at least 90 percent of U.S. counties syphilis free by 2005, and would aim for a thousand or fewer cases of syphilis nationally every year in America.

We think that's possible for a number of reasons. We're talking about, first of all we're talking about a disease that has been eliminated. Again, I don't--it's not eradication, it's elimination. About a disease that has been brought to those levels or lower in other industrialized nations of the world like Canada and Sweden for instance. Also we have very good diagnostic tests for syphilis. We also have curative treatments for syphilis that can be fairly easily administered. And we know a great deal about the natural history of this STD, unlike some of the other STDs that we're dealing with.

So when you go back and look at the information that CDC has put out around syphilis elimination, that's part of our exploration about why we think this is truly an attainable goal, and again, despite the slight increase in cases among men in 2001, we're still seeing tremendous progress.

There are obviously medical reasons why syphilis is still a big deal. There are long-term medical sequelae of untreated syphilis, and in the days prior to penicillin many people were chronically ill with tertiary syphilis, you know, had heart disease, had brain and central nervous system disease. So it's not an inconsequential infection.

And we also should remember that syphilis an be passed from a mother to her baby, and we still--congenital syphilis is still a situation of concern. There are a number of medical reasons also why syphilis is important.

Now, we also like to point out that in addition to all of those reasons for eliminating syphilis, that syphilis also likely contributes to the transmission of HIV. That's been clearly shown in other parts of the world, in other countries, that having syphilis, and quite frankly a number of other STDs as well, can increase the risk of transmitting or acquiring HIV. So there are a number of reasons why this still remains a serious problem.

I guess in conclusion I would say that many people have characterized syphilis as a 19th century disease, and are wondering why in the 21st century we're still dealing with it, so that's another reason why we think it's possible and why we really should continue our efforts around syphilis elimination.

QUESTION: Well, that really wasn't the question though. The question was to compare all of those impacts with other STDs, which to my mind, you know, many of them have many of the same impacts.

DR. VALDISERRI: I guess I'm not understanding your question. We are certainly--let me say for the record, syphilis and HIV are not the only two STDs that CDC is concerned about. We happen to be focusing on syphilis on this call because of the MMWR article that's going to be released tomorrow, that shows a slight increase in cases after over a decade's worth of decline, but that you should not take these comments to think that CDC is not concerned about other STDs, other viral STDs like HPV or herpes, et cetera. But that probably is a longer briefing.

AT&T MODERATOR: Did you have any follow-ups, Mr. Roane?

QUESTION: Better not.

AT&T MODERATOR: Okay. Thank you sir.

And let's move on then to the Chicago Tribune's John Carpenter. Please go ahead.

QUESTION: A quick question about Detroit. Among the cities that you listed where you sent rapid response teams, I didn't hear Detroit in that list and it's my understanding that there has been rapid response teams in Detroit. If you could just confirm that. But then I'm wondering if you're in a position generally to comment on Detroit. It looks like it's a fairly significant increase, and it is my understanding that that's continuing to increase. Any idea what's happening in Detroit?

DR. VALDISERRI: Let me say a few things about that. Yes, you are correct. I didn't state, or didn't cite Detroit, but we have sent technical experts there to work with the local and state health department. And I think what I can say generally about the situation is that there's been a lot of concerted effort in recently toward turning that situation around, and we're continuing to work really closely with our colleagues at the local health department to address that situation.

QUESTION: It's my understanding that in Detroit the cases are broad, in a broader demographic. They're not necessarily as limited to the high risk populations. Do you know anything about that?

DR. VALDISERRI: Yes. Let me speak generally to that. Yes, I think generally the transmission in Detroit, most of it has been heterosexual. That doesn't mean that there isn't any MSM transmission there, but typically it's been heterosexual transmission among socioeconomically challenged African-American communities. But I'd have to get back to you with more specifics about it, but it tends to be more of a heterosexual epidemic.

QUESTION: Okay, thank you.

AT&T MODERATOR: Thank you, Mr. Carpenter. Next we'll go to the line of Steven Smith with the Boston Globe. Please go ahead.

QUESTION: Hi, Dr. Valdiserri, good afternoon. I'm wondering really how sanguine you are about the prospects of taking the kind of model, the education model that you describe, going to bars, clubs, bath houses, because I know what I had heard from AIDS agencies both in Boston and elsewhere in the nation is really two things. One that oftentimes they are no longer even permitted to go into these venues for the reason that bar owners, bath house owners say they put a damper on things.

And second, I'm wondering if you could address how much of this is a generational issue. Are you seeing the transmission rates more significantly among younger MSMs, older MSMs and what that might portend?

DR. VALDISERRI: All right. Let me start with your first comment. I would say that CDC is in no way sanguine about current approaches to STDs generally and syphilis elimination specifically. I do really want to emphasize that we must as a nation continue to invest in research to improve our means and methods of preventing these infections. So we clearly don't have all the answers.

I think that your example about some of the difficulties of providing those kinds of outreach services is real. We've have--I think we haven't run into that problem, but I have no doubt that it exists. We've had very good cooperation, for instance, when our staff worked in San Francisco with health department staff there. There was a lot of outreach into bars and various sex clubs.

But the point that bears underscoring here is that the government, CDC, the public health community, we can't do this on our own. We must have the support of the communities at risk for and infected with syphilis to be able to do this, and that's why it's so important to form coalitions between the local health departments and the nongovernmental organizations to find out the best way to gain access to a community. I mean certainly just showing up a bar or at a club is--you know, fortunately we're beyond that level. We understand now how important it is to work with the community.

So I would say to answer your first part of the question, that's how I would answer it.

Now, remind me what the second question was?

QUESTION: Well, I'm just wondering in what sorts of age cohorts you're seeing transmission most significantly, and what kinds of generational issues that might bespeak?

DR. VALDISERRI: It is fairly complicated because it varies depending upon the organism, the organism one is talking about. I would say though that in the syphilis, the MSM outbreaks of syphilis have tended to be individuals who are in their 30s. Now, there's an age range there, but they have tended to not be adolescents, again, for the MSM outbreaks.

Now, this doesn't mean that young MSM don't get syphilis. It just means that in this particular series of outbreaks many of them have tended to occur among men in their 30s. And also a significant proportion of these men were co-infected with HIV.

AT&T MODERATOR: And, Mr. Smith, did you have any follow-up questions?

QUESTION: No, thank you.

AT&T MODERATOR: You're very welcome, sir. Thank you.

And next we go to Knight-Ridder's Seth Borenstein. Please go ahead.

QUESTION: Yes. If you can go through, has there been any change in policy or educational efforts in any way between 2000 and 2001 in any direction that might be a cohort or that might explain some of this? Has there been less of an emphasis on condoms in 2001 than 2000? Any policy, funding change, has the funding for this changed at all in a year?

DR. VALDISERRI: Well, the short answer is no. In fact, what I would say is that from about, well, let's say from about the end of 1999 onward, CDC has been increasingly concerned about outbreaks of syphilis and other STDs in MSM and increasing reports of unsafe behavior. So we've actually been trying to focus more attention on that. Now, we have not seen substantial increases in funding for our domestic STD and HIV prevention programs. That much I can tell you. But I don't really believe, based on my best professional judgment, that what we're seeing is related to a policy change.

I do think that what we're seeing is very much related to a sea change in just communities' perceptions about sexual risk and sexual health, and it's a really difficult and challenging problem. And many of you have covered it, so you know what I'm talking about, this perception that HIV is no longer an issue, that practicing safer sex or reducing the number of partners is really no longer important because the disease has been licked. You know, unfortunately, that does contribute. It's not everything that's going on, but it certainly does contribute to part of what we're seeing here.

QUESTION: And just a follow up. Has there been any increase in abstinence education in the past year as part of this, or--

DR. VALDISERRI: In the past year, no. I mean, I think that with the Title V funding for abstinence only education, and I guess that's been going on for the past few years, there's been perhaps an increase in that, though those kinds of interventions are targeted primarily to school-age children and we're talking--again, I don't want to overgeneralize--but we're talking primarily about people who are out of school and young adults, and sexually active individuals.

QUESTION: All right. Thanks so much.

AT&T MODERATOR: And thank you, sir.

Next, we'll go to the line of Charles Ornstein with the Los Angeles Times. Please go ahead.

QUESTION: Hi, Dr. Valdiserri. I wanted to ask you two questions. First, I know we talked about six months ago or maybe a little longer, about the CDC's specific plan dealing with MSM, and back at that time you had mentioned that this was a high priority but I don't believe that it's come out since then.

So I'm wondering what the status of that is, and I'm also wondering about some 2002 numbers.

I know in Los Angeles and San Francisco and New York, and Detroit, that the numbers seem to be--you know, the growth between 2001 and 2002 seems to be a lot higher than the growth between 2000 and 2001, and so do you feel that--and I know that this is a question asked earlier, but given some of the numbers in some of these communities, do you think that the challenge ahead, that perhaps you'll have to shift resources away from the African American and the Southern areas, into the MSM areas.

DR. VALDISERRI: Let me answer your second question first, and generally say that part of the challenge that we continually face in public health, whether we're working in STDs or other communicable diseases, or chronic diseases, is the issue of making decisions about limited resource.

I mean, we certainly, as I mentioned earlier, have not had major increases in domestic STD or HIV funding in the recent past, and so people who work at the state and local level always have to make these kinds of decisions about shifting resources.

We typically don't do that kind of decision making at a federal level, but instead have urged our state and local health departments to continue to look very carefully at the epidemiology of transmission in their jurisdictions, and if it does, for instance, like they're seeing more and more syphilis transmission among MSM, and they don't have adequate services there, then they may have to shift resources.

But that's a case by case definition and it's obviously a tough one because there are many needs. We're not dealing with an either/or situation here.

On the first part of your question about the national syphilis elimination plan, I guess I'd like to answer that first by saying there is a difference between a written document and ongoing activities at CDC, and it's true that w have not published--at one point in time we had planned on publishing a supplement to the national syphilis elimination plan, that dealt specifically with MSM, but quite frankly, the further into that we got, the more it looked like it was turning out to be a fairly broad policy document without specific or highly-targeted technical information and a decision was made that we're rather spend the time of our technical experts, our scientists and our epidemiologists participating in these research, these rapid response teams, and some of the ethnographic assessments rather than writing policy documents.

But I can assure you that MSM is an extremely high--MSM issues remain a very high priority both for our Division of STD Prevention and also for our Divisions of HIV/AIDS prevention.

We are very, very concerned about what the future might hold if these trends continue to go in an upswing.

QUESTION: Do you feel that, you know, some of the prevention activities that have taken place in San Francisco and LA and in other communities, where they have devoted a lot more, you know, a lot of resources to awareness campaigns--do you think that those are working or do you think that perhaps they're not hitting the right tones in order to make a difference?

DR. VALDISERRI: It's so hard to answer a general question like that. I mean, I think that any time you ask someone in the public health community if an intervention is working, you know, we almost simultaneously want to answer it at multiple levels.

I mean, the first thing I want to know is what's the intervention, is it based on any kind of accurate epidemiologic and assessment information? Does it incorporate sound principles of behavioral science?

You know, that's sort of the first round of questions we always ask. Then we want to look at how is it being implemented. Is it being targeted appropriately?

Is it really hitting the population that it's intended to reach?

Then the third question, which doesn't really come up as much domestically as it should, though you hear it all of the time in the international HIV realm, is the issue of scale.

That there is a correlation between the scale of efforts and the outcome in terms of safer behaviors, and it's not impossible, for instance, for an intervention to be scientifically sound and appropriately targeted, but it contributes so little, in quotes, compared to what's happening in that community, that maybe it's not having a communitywide effect.

So I can't really answer your question, but what I can say, Charlie, is that this is part and parcel of what folks who get public money, the kinds of questions that we have to continue to ask ourselves, because we are very--the one point we can agree to is that we are very concerned about what could be happening in various MSM populations in terms of increased syphilis and, as I mentioned earlier, the possibility for that to contribute to increased HIV transmission.

QUESTION: Thanks.

AT&T MODERATOR: And thank you, sir.

Representing the New York Times, we'll go to the line of Jo Napolitano. Please go ahead, sir.

QUESTION: Actually it's a woman. Thanks.

DR. VALDISERRI: Yeah, Jo. I knew you were a woman.

QUESTION: Yes; that's a very key element here. I know that you guys have had some written correspondence with Detroit, encouraging them to improve their handling of syphilis prevention and making other recommendations. In terms of the other cities that you visited, sending them a team to help them out in the situation, is it often the case that they're soliciting your help or you realize there's a problem in these cities and you send someone to them?

DR. VALDISERRI: We always go at the invitation of.

QUESTION: Do you ever just say they haven't invited us but they have such a serious problem, we're going anyway?

DR. VALDISERRI: No, we wouldn't do that, but we might say if there is a situation where perhaps--you know, these kinds of conversations take place at multiple levels.

QUESTION: Okay.

DR. VALDISERRI: It could be an epidemiologist in the city contacts a colleague here at CDC and says look, I'm picking up what appears to be an outbreak of syphilis and I'm very concerned. What do you guys think about it? Have you seen it elsewhere? What do you think I should do?

We might say in that circumstance, well, you know, maybe it's a good idea for you to ask us to come out and lend a hand.

So it might happen that way. But we really don't swoop in uninvited. We are there at the invitation of the state or local health department.

QUESTION: Okay. All right. Thank you.

AT&T MODERATOR: And thank you, ma'am.

Representing the STD Advisor, we go to the line of Skip Connet [ph]. Please go ahead.

QUESTION: Ron, I was looking at these numbers, and I was kind of concerned that a year ago we had this conference, and we were trying to figure out how much is attributed, of this increase, to MSM, and I think Dr. Kent [?] at that point said it's a small proportion, and so I'm kind of surprised that this increase is being attributed to MSM.

Can you tell us what, looking at non-MSM across the whole country, have the rates gone up or down?

DR. VALDISERRI: Well, part of the problem, Skip, is that--and I refer to this in my comments--when state and local health departments report syphilis information to us, the current situation is that the behavioral information provided is quite limited.

In fact we typically do not receive information about the gender of the sexual partner, and so, you know, just to be real specific about it, if they're reporting a case of urethral gonorrhea in a male, we don't know, because of the location in the urethra, we don't know whether that's a heterosexual male or a male who has sex with men only, or a male who has sex with men and women both.

So one of the things that we have done at the CDC is provide additional resource to expand the amount of behavioral data we get along with these case reports, and that's why when you read the MMWR, we were very scrupulous in the language we use, that what we're reporting is a slight increase nationally in cases in males, and as I said, I think that the actual increase is something like 124 cases.

So it's not a tremendous increase. But we do have information suggesting that many of these men may be men who have sex with men.

So we don't have complete information but the information that we have, along with well-documented outbreaks in a number of cities across the United States, and it leads us to kind of intensify our warning.

This is not the first time we've come out with this warning. We've been trying to sound this alarm for about 24 months, to try to get the communities more involved in this, to try to get the private medical sector more involved in this.

You know, we don't, as you well know because you report on STDs exclusively, we don't have the resources in the public sector to diagnose and treat all STDs in America. We have to rely on the private medical sector, which means we have to rely on their willingness and ability to counsel sexually active patients about the importance of risk reduction, of--

QUESTION: Right. Well, these outbreaks have been going on for more than four years now, and I'm just wondering why now, suddenly, it's MSM that you're kind of saying this is definitely, or, you know, most likely attributed to them.

DR. VALDISERRI: Well, as I said earlier, this is not the first time we've reported in the MMWR outbreaks of syphilis or other STDs among men who have sex with men.

In fact two or three weeks ago there was a report of what's happening to syphilis, primary and secondary syphilis in New York City, a very similar kind of situation where there's a great increase in the number of male cases, and again the information on sexual behavior is not complete, but a significant proportion of that increase can be attributable to MSM.

QUESTION: Well, can you tell us in your project areas, of the thirty-two you have, last year eleven of those had increases. How about now? Has it changed at all?

DR. VALDISERRI: I don't have that number at the top of my head. We'd have to get back to you with that or have you call into the press office.

QUESTION: Okay. One last question.

What about the funding for syphilis elimination? Is it going to be flat, increased, decreased this year? Or next year?

DR. VALDISERRI: What can I say? I can tell you that the most recent increase we had--the most recent funding we had in 2001 was about $32 million.

QUESTION: And that's an increase or a decrease?

DR. VALDISERRI: I can't comment on that.

QUESTION: Okay.

AT&T MODERATOR: Any follow-ups Mr. Connet?

QUESTION: Well, how about the HIV rate, Ron? I mean, you've been saying that it's probably going to lead to HIV increases in MSM. Do you have any handle on that yet?

DR. VALDISERRI: Well, I think you may have seen, Skip, that CDC reported in Barcelona on HIV data on the 25 states in America where we have HIV reporting and have it for a long enough period of time, that we could talk about trends just in those 25 states.

The problem is that we are not yet in a situation where every state has HIV reporting.

Most of them now do but some of them have just come on board fairly recently. Part of the reason--and it's a very important activity that CDC has undertaken. Part of what we're doing is we are currently pilot testing an HIV incidence surveillance system that would enable us to estimate HIV incidents nationally.

QUESTION: Right.

DR. VALDISERRI: We expect to go online with this next year.

So we hope to be able to answer that question and because of the detuned [?] assay, we can now do that. It's not an easy thing to do because it's still an estimate, but the feeling is that it will be far superior to the estimate of 40,000 annual cases that we've been using for the past several years.

QUESTION: Just one last question.

Can you give us an estimate of the number of MSM with syphilis that are contributing to this overall six thousand cases. I mean, is it 5 percent, 2 percent--

DR. VALDISERRI: I don't know because I don't think the number of MSM in America have ever been delineated.

QUESTION: Well, with your new surveillance data that you're going to be collecting, will you know that a year from now? Two years? Or I mean, when are we going to have this information on gender-specific?

DR. VALDISERRI: We will have gender-specific information I guess as early as next year. Now it's still not every city in the United States but we're moving toward that. I guess I misunderstood your question about what proportion of the MSM population are contributing.

We don't know the number of MSM. There's been a lot of controversy, as you well know, about the number of MSM in the United States.

We're going to--I'm going to have to end soon here. So there may be another reporter that wants to ask a question because I have a 1:00 o'clock.

AT&T MODERATOR: Okay. I understand, Doctor. We actually have 12 reporters that are still in queue for questions. However, next in queue, we'll take Mike Stalby with the Charlotte Observer. Please go ahead.

DR. VALDISERRI: Mike, before you ask your question, let me say that I'm going to have to limit it to one question. I can't--if there are 12 people, I really want to try to talk to everyone, but I'm chairing a meeting at 1:00, so let's try to do this quickly.

QUESTION: Okay. Parochially, why the South? Why has there been a traditional concentration of syphilis cases in the South?

DR. VALDISERRI: People explain that in different ways. I think that the--a general way to explain that is that it's a reflection of a disproportionate burden of disease and illness among populations that have typically been denied access to adequate public health and medical services. So it's very much tied in to socioeconomic circumstances.

QUESTION: Okay.

AT&T MODERATOR: And thank you, sir.

If time allows, Doctor, we do have Julie Gage with the Miami Herald.

DR. VALDISERRI: Keep going.

AT&T MODERATOR: Okay, very good.

QUESTION: Hi. I was just wondering if you could tell me why there is such a high rate of syphilis here in the Miami area, if there's any information about which populations are most at risk?

DR. VALDISERRI: Well, the epidemic, the syphilis epidemic in Miami does have a very prominent MSM component to it. I think if you wanted more specifics about that, probably the best thing to do would be to contact the health department in Miami, or we could help facilitate that here. If you wanted to ask questions about why and what was happening.

QUESTION: Okay.

AT&T MODERATOR: And thank you, Ms. Gage.

We'll go to Bob Lemondola with the Sun Sentinel. Please go ahead.

QUESTION: Thanks for taking the question. I'm just curious, Doctor. You mentioned before that you've been kind of sounding the alarm for about 24 months now, and I'm just wondering do you think that the local and state officials are not getting the message, or is it a matter of they're just not--they're not mobilizing enough? What do you think is happening there?

DR. VALDISERRI: I think it's complicated. I mean certainly many jurisdictions have gotten the message, but these same jurisdictions are dealing with a number of other health issues as well. I would say that generally issues related to syphilis and even issues related to HIV have tended to fall off the radar screen in recent months for a number of reasons.

So I think it's--there has been some very positive response, but we certainly have a ways to go.

QUESTION: Thank you.

AT&T MODERATOR: Thank you, sir.

And next let's go to the line of Jocelyn Kaiser with the Science Magazine. Please go ahead.

QUESTION: This question concerns, goes back to the condom fact sheet and another thing mentioned in the Waxman letter. Do you know what I'm talking about?

DR. VALDISERRI: I believe you're referring to a congressional inquiry that was sent to Secretary Thompson?

QUESTION: Right. The other thing I guess they discussed, it's the Programs That Work page. Do you know what I'm talking about there?

DR. VALDISERRI: Yes. That's a program that are Division of Adolescent and School Health supported in the past.

QUESTION: Can you answer a question concerning that, or--

DR. VALDISERRI: It depends on what it is. Probably not if it's very specific.

QUESTION: Well, the question is I don't--I know the CDC response on this at least to one publication, the Blue Sheet on programs that work, was that something about there are reservations about the appropriateness of these activities. And I know that at least one of those programs was funded by NIH, that researchers are the [inaudible], looking at abstinence versus sex education to prevent I guess STD transmission. And I'm just wondering what is wrong with those programs and why it is felt that that needs to be reviewed?

DR. VALDISERRI: My general response is I don't believe that anything was deemed to be, quote, "wrong with those programs." But I think what we need to do is those programs are run out of another part of CDC, the Division of Adolescent and School Health. And if you give Kitty Bina a call--

QUESTION: Kitty Bine?

DR. VALDISERRI: B-i-n-a, Bina, at the number I stated early in our discussion, she can put you in touch with someone who can answer that question.

QUESTION: And on the condom fact sheet, was that triggered by anything particular? I know there was a recent report from some kind of institute in Texas, reviewing the recent study on condom effectiveness.

DR. VALDISERRI: No. It was, basically it was to update the fact sheet so that it could include more current scientific studies on condom effectiveness.

QUESTION: But I mean was there any kind of review or anything like that that triggered your decision to take it down at this point?

DR. VALDISERRI: No, other than a major source of information would have been the scientific review that the National Institutes of Health held, I guess it was a year ago this past summer, where they reviewed all the information. That sort of started us looking at what kind of messages were we giving about condoms, and were we making distinctions about what we know in other STDs. I mean we do know clearly that for HIV that if condoms are used consistently and correctly, they are highly effective. There are other STDs where that is not known because either the data don't exist and/or the way the sexual pathogen is transmitted, the condom may not be effective.

But to answer your question, no.

QUESTION: So it had nothing to do with this--I don't even know if you know about this report I'm mentioning. Do you know when the condom sheet came down, fact sheet?

DR. VALDISERRI: No, I don't.

QUESTION: Okay. And--

DR. VALDISERRI: I thought it was one question. I really have to get off the line in about 2 minutes.

QUESTION: Okay. Well, just the last question is, was that decision made by your office? At what level was the decision made to take down the fact sheet?

DR. VALDISERRI: It was a CDC DHHS decision.

AT&T MODERATOR: And thank you, Ms. Kaiser.

Our final question today comes from the San Francisco Chronicle's Chris Heridia. Please go ahead.

QUESTION: Hi, Dr. Valdiserri. In San Francisco clinics are having trouble meeting the demand for services. As you're well aware, Dr. Krauzner [ph] has raised quite a bit of awareness around syphilis in the MSM community, and now clinics are being bombarded with requests for services, and one of his chief complaints is that there aren't enough resources coming from federal sources, and I'm just wondering will there be more resources coming to these cities that are hardest hit?

DR. VALDISERRI: Well, you know, our resources come to us from Congress, so that's probably a question that you want to direct at a congressional level. We at CDC have been frank about the fact that there remain a number of important unmet needs related to STD prevention and control. And I believe in the Institute of Medicine report that is now about 3 or 4 years old, "The Hidden Epidemic," there was some discussion there also about the need to look at resource. So I don't deny that. I think that's a broader societal question about why, at what level do we support the prevention of sexually transmissible diseases.

You'd find a lot of support for that at CDC because we think it's very important to interrupt transmission.

QUESTION: Why are the syphilis elimination programs working among African-American communities and among women and not among gay and bisexual men?

DR. VALDISERRI: Well, I don't think it's that simple of a question. First of all, we're talking about national trends, and I think the most important point to underscore is that when we officially launched the syphilis effort most of the focus was targeted toward heterosexuals, African-Americans and people living in the Southeastern part of the United States because that's where most of the syphilis was occurring.

And the good news is that in response to that, we have seen the trends continue to go in a very positive direction. Now, what we're dealing with is a number of outbreaks in various MSM communities among all racial and ethnic groups, among all levels of men, whether they're gay identified or not, and what we're saying is that we're going to have to refocus and make sure that we address this burgeoning need as well.

And with that, I really am going to have to apologize, but I have to go. Thank you all very much.

AT&T MODERATOR: And ladies and gentlemen, that does conclude the press telebriefing for today. Thank you very much for your participation as well as for using AT&T's Executive Teleconference Service. You may now disconnect.

[End of telebriefing.]

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