Study confirms the link between MSM and web

San Francisco officials use on-line interventions

When the number of early syphilis cases in San Francisco increased from 41 in 1998 to 495 in 2002, and more than two-thirds of these cases also were HIV-positive, health department officials decided that new prevention interventions were needed.

The syphilis outbreak also was notable in how it mainly involved men who have sex with men (MSM) by 2002. In 1998, only 22% of the early syphilis cases involved MSM, whereas in 2002, 88% involved MSM. 1

Investigators with the San Francisco Department of Public Health (SFDPH) discovered a common thread running through these cases — the Internet. It was reported as the meeting place for sexual partners by 32.6% of the people included in the surveillance report, compared with 20.6% who used bars, 13.3% who used bathhouses, and 12.6% who met partners at sex clubs.1

Public health officials had to develop new strategies for tracking down sexual partners of syphilis cases, including asking for on-line handles and e-mail addresses through which they could notify MSM that they may have been exposed to syphilis, says Jeffrey Klausner, MD, of STD Prevention and Control Services, SFDPH.

"We won’t disclose the source individual, and we won’t start communicating with the partner until we start confirming who that partner is," he says.

"Then we usually try to have a conversation over the phone or face to face with the goal of getting that partner evaluated and potentially treated for syphilis infection," he explains.

No-name reporting blocks investigation

Unfortunately for the health department, the same kind of outbreak investigation cannot be conducted for HIV cases because the state does not permit HIV reporting by name, Klausner notes.

"No-names reporting is a barrier to controlling public health risk of HIV," he says.

"Without a name, I can’t follow up with individuals to know where they met their partners and then to work with them to actively notify their partners about recent exposure, " Klausner continues.

However, the syphilis outbreak provided a good opportunity to step up interventions for HIV and other sexually transmitted diseases (STDs), and the SFDPH responded by developing interventions that used the Internet as a tool, as well as by promoting a more general educational effort called Healthy Penis 2003.

Reaching target audience through the web

This campaign includes a special web site (, newspaper ads, shelter posters, subway billboards, and 7-foot mascot characters who walk in parades and visit bars and clubs each month, Klausner says. The number of people tested for syphilis has increased since the campaign began, he adds.

Health department officials also have investigated the Internet sites most commonly sited as meeting spots for sexual partners and contacted the web hosts to seek assistance with prevention education, Klausner says.

"We go to that business and try to collaborate with them to do on-line prevention activities, such as banner ads, hot links to sexual health sites," he explains. "Some businesses have been a lot more cooperative like, and others like AOL have been obstructive and don’t want anything to do with educating members."

In between the two are Craig’s List and m4m4, with which the SFDPH has begun to form new collaborations, Klausner continues.

Once the collaboration and education begins, the results are apparent. For instance, two years ago the No. 1 web site used by MSM who have early syphilis was, he says. Now, is the fourth highest site on the list, and the most common site is, Klausner adds. "That’s why it’s important, and not just for San Francisco," he says. "We talk to people in New York and Miami, too."

The Centers of Disease Control and Prevention (CDC) has acknowledged how the Internet is becoming one of the biggest venues for at-risk sexual activity.

"There’s a lot of interest in the community on how we can work with Internet providers and elements of industry to use the Internet proactively to provide health information," explains Ronald O. Valdiserri, MD, MPH, deputy director of National Center or HIV, STD, and TB Prevention of the CDC.

"San Francisco is reporting on using the Internet as a way to facilitate partner notification activities," he says. "And a national coalition of STD directors and the CDC held a meeting in August in DC where we brought together members, researchers, community activists, program providers, and a lot of people affiliated with the business to talk about this broad topic of the Internet and what we can do about it."

The CDC is doing some Internet-specific research, but it is leaving the Internet prevention program work to the state and local health departments and community-based organizations (CBOs), Valdiserri says.

"We would consider that to be a potentially appropriate outreach site in the same way that we would consider a bathhouse or a public park where cruising and public sex is taking place," he points out.

However, SFDPH officials have found that there are national sexual networks in which syphilis is being transmitted, and the web sites are the basis for these networks.

This also is why federal funding is needed to promote Internet prevention work, Klausner says.

CBOs and other groups have been doing groundbreaking work on reaching at-risk MSM through the Internet, but they and local health departments lack the resources to handle the vast cyberspace and geographical web of on-line activity.

"There’s a national structure to the Internet, and a lot of travel and internationally-based service providers serve lots of people," Klausner says. "It’s a challenge for me to develop prevention programs for San Francisco and have a lot of non-San Francisco people involved."

For example, the SFDPH has a web site with a health education service called "Ask Dr. K." Main-taining the web site takes time and money out of the pocket of San Francisco taxpayers, and yet, fewer than 10% of the people who are served by the web site live in San Francisco, he says.

"Because of the cross-jurisdictional nature of the Internet, there really has to be federal funding," Klausner says.


1. Use and early syphilis infection among men who have sex with men — San Francisco, California, 1999-2003. MMWR 2003; 52(50):1,229-1,232.