Syphilis remains an increasing problem in Indianapolis and the country as a whole.  In the United States, the CDC surveillance report found that rates were at an all-time high since 2001 and that the increase had now spread to women as well as Men who have Sex with Men (MSM), who represent 10% of cases thus far in 2016. In addition, across the country there has been an increased number of cases of both ocular syphilis and congenital syphilis.

In Indianapolis, after a promising decrease in 2014, early syphilis began to surge once again beginning in April of last year. Ultimately, 2015 ended with 311 early syphilis cases up from 197 cases in 2014. The surge continues in 2016. The disease remains prevalent among MSM although cases among women are being increasingly reported. HIV-positive individuals account for approximately 45% of the total number of cases; several of these were newly diagnosed with HIV at the time of their syphilis diagnosis. Individuals are from all races, but disproportionately black (43%). And, two-thirds of those diagnosed are young (under 35).

Increasingly, individuals are refusing testing and treatment despite apparent exposure which is contributing to the observed increases. Substance abuse, particularly methamphetamines (involved in 10% of cases), and anonymous sex are also frequent risks named by patients. Many of those using methamphetamines are using them intravenously. Almost half of the cases mentioned at least one of a dozen online websites or apps such as Adam4Adam, Grindr, or Jack’d.

Some patients are refusing to talk to Disease Intervention Specialists (DIS) about their partners, putting them at risk for reinfection. In fact, one out of five early syphilis cases have a previous history of early syphilis infections with some having as many as four previous episodes. The environment is one of increased injection and non-injection drug use, overdoses, concomitant STDs and HIV transmission.

In order to address the ongoing outbreak, the Marion County Public Health Department established regular venue and street-based screening among those at highest risk, whether currently part of the outbreak or individuals considered a risk for rapidly increasing the number of cases (such as sex workers, IV drug users, etc.). These include night time screening at several gay bars and bathhouses; screening at two community-based organizations serving MSM; screening at a sex-worker project based out of a mobile unit outfitted for phlebotomy, counseling, and testing; a jail-based screening program; and of course, universal screening available on a walk-in basis at the STD clinic.

The department is also in the process of expanding internet outreach through the efforts of a team within the health department and a proposal to AmeriCorps. We also distributed a donation of 100,000 condoms by Trojan through NCSD in areas with high gonorrhea rates some of which overlapped with syphilis affected areas. Surveys of individuals receiving condoms showed that 28% had no other way to get them. Seventy two percent of recipients described themselves as highly likely to use condoms with their next partner.

One of the most successful interventions has been the screening of HIV-positive individuals at their HIV provider visits. The MCPHD STD Control Program recommends screening every three months for HIV positive individuals. At least one major provider has incorporated syphilis screening into its order set for routine visit lab work at HIV appointments. As a result of these efforts, HIV providers diagnosed at least 22% of early syphilis in 2015 compared to the STD clinic which diagnosed 30% of cases.

But controlling syphilis also means being out on the street since not all of those at risk are in care and DIS have had a lack of success in partner notification due to inadequate historical partner information from patients. This is thought to be the reason that, as mentioned earlier, in 2015, approximately 30% of all early syphilis cases had a history of syphilis in the previous five years, 20% of which occurred within that same calendar year.

To increase community awareness, public television and a radio station provided airtime to discuss syphilis. In 2015, DIS supervisors Kari Haecker and Lavida Joseph Brown and surveillance supervisor Justin Holderman noticed the trend of meth-using MSM with early syphilis. To address it, the Department developed an advertisement aimed at increasing the awareness of the relationship between syphilis and intravenous drugs.

Other efforts focused on a social network that DIS discovered through interviews. Of the 100 individuals in the network, 71 were infected with early syphilis often multiple times. From that social network, they identified 60 men as potential high risk transmitters based on how many people named them in the social network, the number of times they had had syphilis, and the lack of medical follow-up after their last syphilis treatment.  Instead of traditional calls and letters, DIS hit the road, meeting patients at their homes to in order to obtain field testing. DIS, working in pairs, focused on high priority individuals and their partners, as well as at-risk communities in two gay bars. While still ongoing, so far, efforts have found 2 early syphilis cases that would not have been otherwise found, one new HIV case, six cases of gonorrhea, and three chlamydia infections. One individual was successfully referred for PrEP.

From every success, DIS share not only the satisfaction of disease control and prevention, but the joy of outreach to those who might just find themselves healthier because of their hard work.