MSM Syphilis Prevention: Sexual Identity and Intersecting Social

Networks

FR Bloom, A Goodfellow, M Berry, and MM Hayes

Centers for Disease Control and Prevention

BackgroundMSM Syphilis in Los Angeles

• Initial reemergence of MSM syphilis in 2000• Recurrent MSM syphilis increases since 2002

through present• Common characteristics of syphilis increases

– Drug use– HIV positive – LA County Gay Men’s Lock-Up (K-11 Unit)– Transgender MTF

Background IITransgender MTF and STDs in LA

• Social Stress– Stigma and unemployment– Cost of hormone therapy and surgery– Unstable residence patterns– Depression

• Drug use

– Sex trade

Technical Assistance IRapid Ethnographic Assessment

• Conversation and Observation: June 2005– Public Health Investigators (PHI) & Staff (n=10)– K-11 Deputies (n=2)– MSM street intercept (n=12)

» STD mobile testing van

• Revisit: February 2006– Public Health Investigators (PHI) and

STD Program staff (n=12)

Technical Assistance II Syphilis Case Reports: Preliminary

Review• 47 Syphilis cases with history of incarceration

– January – June, 2005– 41 (88%) male cases– 31-38 (66% - 81%) MSM

– 15 (32%) HIV+ MSM

• 5 (11%)Transgender MTF identified by PHI narrative– 2 (4%) Transgender HIV +

• 1 heterosexual-identified male with Transgender partner

Findings IRapid Ethnographic Assessment

• Continuity of Services– LA County Health Department and County Jail– Service referrals (Medical, mental health, social)

• Determining Sexual Identity– PHI observation versus self identity– Biological determinates versus social

determinates

• Chasing Syphilis versus Syphilis prevention– Keeping up with technology– Staffing needs, time, effort, and results

Findings II: Syphilis Case ReportsThe Context of Incarceration

• 83% Drug use and addiction • 15% Homelessness or unstable residence• 68% Anonymous partners• 89% Unprotected penetrative sex• 34% Sexual risk while in jail• 6% Travel out of area• 35% Trading sex for drugs/money• -- Referral issues• -- Casewatch system deficits

» transgender or other MSM identity

Findings IIIIntersecting Social Networks

• MSM as an artificial category with limited use• Diversity and conflict: gender identity for

MSM• K-11 as milieu of intersecting social networks

– Gay-identified men– Bisexual-identified men– Transgender

• Bridging and intersecting networks– Place versus population

Recommendations IGender and Public Health

• Increase public health capacity to capture transgender and other MSM identities– Focus on identity beyond biology in interview– Enhance open-ended approach to data collection

• Increase capacity to capture field note data

• Improve understanding of gap between observer categories and client gender-identity– Gender identity is key to disclosing behaviors

and social networks

Recommendations IIResponse and Implementation

• Casewatch capacity and gender-identity– Transgender and other identities added to

program• Referral list distributed and referrals

increased• One of four open field FTEs filled

– 2 additional PHI temporarily added• Continued collaboration at LA County Jail

– STD testing and treatment

Implications ISyphilis Prevention for Transgender

MTF• Biological Facts versus Social Identities

– Social identities reveal networks– Social identities add context to behaviors– Social contexts

• Venues• Access to care• Communities• Cofactors (homelessness, unemployment)

Implications IISyphilis Prevention Sustainability

• Sustainable prevention for MSM – Based on gender identity

• Cross-cutting or targeted

– Recognition of instability of behavior change– Target social and health services to improve

sustainability• Change in services over change in end-user

– Use of collaboration to improve service access, treatment, and prevention