'Healthy Penis' campaign targets syphilis risk

What is your clinic doing to boost syphilis testing? An innovative social marketing campaign, "Healthy Penis," has been associated with an increase in syphilis tests in gay and bisexual men in San Francisco.1

While progress has been made in reducing the nationwide burden of syphilis, overall syphilis rates have been on the rise since 2001, largely due to increasing rates of syphilis among men who have sex with men (MSM), according to the Centers for Disease Control and Prevention. Between 2004 and 2005, the rate of primary and secondary syphilis increased 8.5% among men: from 4.7 cases to 5.1 cases per 100,000 men. During this same time, the rate increased among women from 0.8 to 0.9 cases per 100,000 women.2

San Francisco experienced a sharp increase in early syphilis, with the number of cases rising from 44 to 494 between 1999 and 2002, says Katherine Ahrens, MPH, an epidemiologist with the San Francisco Department of Public Health's (SFDPH) STD Prevention and Control division. More than 85% of these cases were among men who identified themselves as gay or bisexual, she notes.

In response to the rapidly expanding epidemic, SFDPH officials decided in late 2001 to initiate its Healthy Penis campaign, aimed at promoting syphilis testing in gay/bisexual men. The department hired a local advertising agency, Better World Advertising, to create the campaign, and launched it in June 2002.

Cartoons carry message

Syphilis is known as "the great imitator" because its symptoms — enlarged lymph glands, headaches, skin rashes, fever, sore throat, and swelling in joints — mimic those of many other diseases.3 The Healthy Penis campaign incorporated the use of humorous cartoon strips featuring Healthy Penis and Phil the Sore characters to promote syphilis testing; publicize the rise of syphilis among gay and bisexual men; provide information on syphilis transmission, symptoms, and prevention; and delineate the connection between syphilis and HIV.

The campaign was promoted in neighborhoods where the greatest concentration of gay or bisexual men lived and where there were businesses that catered to gay and bisexual men, says Ahrens. Cartoons were placed in a gay newspaper, and poster-sized reproductions were posted on the streets, on bus shelters, on gay web sites, and in gay bars. Media advertising also was developed in the form of a 30-second television commercial and banner advertising on Internet sites popular for meeting gay and bisexual sexual partners, she notes.

To tie in with the campaign, T-shirts and Healthy Penis and Phil the Sore stress grips were handed out at several gay pride events, which also included outreach activities conducted by health care workers wearing 7-foot Healthy Penis and Phil the Sore costumes. To facilitate syphilis testing, campaign materials also provided a web site, www.healthypenis.org, and a telephone hotline for people to get additional information, including hours and locations for testing and treatment sites in San Francisco, says Ahrens.

Message received

To evaluate the effectiveness of the program, Ahrens and fellow researchers conducted two surveys at six months and 2.5 years after campaign initiation. Researchers asked gay and bisexual men whether they were aware of the campaign and about their sexual health.

Survey findings indicate that gay and bisexual men who were aware of the campaign were more likely than those unaware to have tested recently for syphilis and to have greater knowledge about syphilis.1 This effect was sustained for almost three years.1

In 2005, incidence of early syphilis in San Francisco was lower than in the previous three years, with decreases in cases in gay/bisexual men accounting for the drop.1 The campaign was effective in augmenting syphilis testing and increasing syphilis awareness and knowledge in the San Francisco gay and bisexual community, and it may have contributed to the decrease, say authors.1

While the Healthy Penis campaign ended in San Francisco in 2005, its material has been adapted by other agencies for similar audiences. Elements from the campaign have been used by public health organizations in Seattle and Santa Clara, CA, Ahrens reports. Both campaigns were intentionally shorter than in San Francisco and involved cartoon strips and posters tailored to gay/bisexual men living in those locales, says Ahrens. Seattle employed the campaign in 2004, with Santa Clara using the campaign in 2006.

Santa Clara chose the campaign to combat rising syphilis rates, says Kevin Hutchcroft, local HIV/AIDS program director. It used one-time HIV education and prevention funds to fund its campaign.

To raise awareness about testing, Santa Clara placed posters in targeted areas, ran a several-month advertisement in a gay magazine, used penis costumes for Gay Pride Parade, and distributed stress grip novelties with testing site information, says Hutchcroft. The material was very well received by the target audience, he reports.

Start-up cost for the San Francisco program was $75,000 in 2002. The campaign continued through the end of 2005 at an additional cost of $295,000. Three-quarters of the campaign's first-year funds were spent on campaign development, with the remaining quarter spent on displaying campaign materials.1

Get tested, treated, stop syphilis

Why is it so important that gay and bisexual men be reached with a "Get Tested" message when it comes to syphilis? Getting tested and treated for syphilis is the main way to control its spread, as it is largely asymptomatic after the initial infection, Ahrens explains. Convenient, accurate, and inexpensive tests for the infection are widely available, she notes.

"Feedback from members of the gay/bisexual community in San Francisco emphasized that our syphilis prevention campaign be positive about sex, educational about syphilis, and not focus on changing sexual behavior to prevent syphilis transmission," says Ahrens. "They agreed that stressing 'Get Tested' would get the best response from gay/bisexual men in San Francisco."

References

  1. Ahrens K, Kent CK, Montoya JA, et al. Healthy penis: San Francisco's social marketing campaign to increase syphilis testing among gay and bisexual men. PLoS Med 2006; 3:e474.
  2. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2005. Atlanta: U.S. Department of Health and Human Services, November 2006.
  3. Centers for Disease Control and Prevention. Screening And Testing Men Who Have Sex With Men (MSM) For Syphilis. Atlanta: U.S. Department of Health and Human Services, 2006.

Resources

For more information on adapting the Healthy Penis campaign for your STD program, contact:

  • Jacqueline McCright, MPH, Community- based STD Services Manager, San Francisco Department of Public Health, STD Prevention & Control Services, 1360 Mission St., No. 401, San Francisco, CA 94103. Telephone: (415) 355-2015. E-mail: jacque.mccright@sfdph.org.