Background:
Early syphilis (primary, secondary and early latent) rates in Hawaii have been below 3 per 100,000 since 1990. Over the past 5 years, 96% of newly diagnosed primary and secondary cases have been males with a median age of 42 years. Over 80% of men were men who have sex with men. A recent case investigation of secondary syphilis in a young (27 year old) heterosexual Micronesian male and his 19 year old chlamydia and syphilis co-infected female partner provided a disease intervention challenge.

Objective:
To identify, test, and treat all locatable sexual contacts to syphilis, chlamydia and/or gonorrhea.

Method:
Through interviewing the index case and his partner, a large social network of Micronesians was uncovered. Living accommodations were transient, but a specific public park location served as a common gathering place. After gaining the trust of a key group member, disease intervention specialists from the state department of health were able to meet group members at the park and test for syphilis (serologically), and gonorrhea and chlamydia using urine-based nucleic acid amplification tests (NAATs).

Result:
Seven of 35 persons were serologically positive for syphilis (4 females and 3 males). Eight of 20 persons for whom urine-based NAATs were run, were positive for either gonorrhea, chlamydia, or both (3 chlamydia only, 1 gonorrhea only, 2 co-infected with gonorrhea and chlamydia, 2 co-infected with syphilis and chlamydia).

Conclusion:
Through establishing a relationship with a key social network member, the investigation process was greatly facilitated. Field testing ensured identification of sexually transmitted infections among hard to access persons.

Implications:
The importance of establishing rapport and trust with clients is paramount. Field investigations, including the field application of diagnostic techniques, may be necessary to identify infected persons who otherwise might not come to clinic.