Without batting an eye, she scribbled on her notepad and I proceeded to tell her more. By the end of our conversation, she had the same reaction that most people do when told that Oregon is in the middle of a syphilis epidemic.

“I had no idea it was such a problem,” she said.

 Like many other states, Oregon has experienced a resurgence of syphilis. From 2007 to 2015, rates of primary and secondary syphilis increased over 1,500% across the state, with the majority occurring in the Portland-Metropolitan area and among Men who have Sex with Men (MSM). In 2013 the STD Program at the Oregon Public Health Division and the Multnomah County Health Department, which encompasses Portland, requested Epi-Aid assistance from the CDC. By January 2014, behavioral and social scientists from Atlanta had come to Portland to conduct a variety of projects including a Rapid Ethnographic Assessment for which they interviewed key stakeholders and members of the community to gain a greater understanding of why syphilis was continuing to increase.

The finding showed, among other things, that despite great work being done by local partners like area health departments and a local AIDS service organization, there were still men who were unaware that syphilis was a serious problem or who believed it was no big deal. Men also expressed confusion about signs and symptoms of syphilis (mistaking them for other STDs such as herpes or gonorrhea), as well as confusion about what a test for syphilis involved.

In their list of recommendations for future action, CDC scientists suggested we consider a multi-level social marketing campaign to inform MSM that syphilis was an issue and to make them aware of signs, symptoms, and testing options.

We considered a variety of options to inform the public and medical providers about the syphilis epidemic. The idea of a transit campaign was one of many being tossed around. The Portland area has the enviable reputation of having an excellent and widely used transit system of buses and light rail. What if we were to advertise on the sides and backs of buses and trains with some ads on the ceiling thrown in for good measure?

We knew that focusing the campaign solely around MSM would only have partial impact. While the epidemic was concentrated in MSM in the Portland-Metro area, we were continuing to see a number of other cases statewide, and disconcertingly our syphilis rates among women had been doubling year to year with a handful of congenital cases as well. If the ads were solely about MSM, they would be too easy for many people to tune out, thinking “that doesn’t impact me.” As our HIV/STD Prevention Program Manager, Ruth Helsley would put it “we want a campaign that’s not just going to target gay men, but also their grandmothers and other people that care about them.” We also knew that we wanted to target medical providers and they ride mass transit or drive and see buses all the time just like everyone else.

Thus the SyphAware campaign began to take off. We message tested a variety of slogans with partners and our statewide HIV/STD/Viral Hepatitis Integrated Planning Group and arrived at the following winning message:

This message seemed to resonate most because it was both surprising and thought-provoking. It contrasted many of the things most positively associated with the Portland area including our health-conscious level of fitness with the knowledge that according to the CDC from 2009–2013 the Portland/Vancouver/Hillsboro area was tied for fifth nationally in primary and secondary syphilis among the fifty most populous metropolitan statistical areas.

Lamar Advertising then took our slogans along with a diverse array of stock image models and created a variety of ads that appeared on buses and train cars. Over 115 ads ran beginning in November 2015 and some of them are still up today due to Lamar’s commitment to keeping the campaign running as long as possible based on the availability of space.

To make sure that people had access to concise and accurate information in an eye catching way, we worked with designers to create the www.SyphAware.org website. The site has basic information on preventing syphilis, signs and symptoms of the disease, and testing options. It even has an interactive quiz where folks can test their syphilis knowledge and learn if more routine screening is right for them. Since the site launched in November, it has had 2,300 visitors and has proven to be a useful tool for health departments around the state in promoting syphilis awareness and the need for screening among impacted populations.

We also took the launch of the campaign as an opportunity to do broad provider outreach. We disseminated a “Dear Colleague” letter to providers across the state explaining updates to our syphilis screening recommendations,  including a revised recommendation that pregnant women be screened for syphilis not just in the first trimester but also in the third trimester and at delivery.

Time will tell whether the SyphAware campaign has had any sort of measurable impact. We are currently working on evaluation activities to see if screening patterns among medical providers and the public have shifted. It was a relatively small campaign given our limited resources but it garnered a great deal of media attention and has inspired conversations in the community, and on that point alone it can be considered a success.

Silence, discomfort, and a lack of conversation around sexual health and STDs like syphilis only continue to contribute to their spread. Who knows? Maybe the campaign inspired a few grandmothers to talk to their grandkids about that ad they saw on the side of the bus.