Background: Syphilis cases increased nearly ten-fold from 2008-2013 among residents of Multnomah County, Oregon; the majority (94.2%, as of 2013) were among men who have sex with men (MSM). These increases persist despite intensified public health efforts.
Methods: During a one-week rapid ethnographic assessment, trained interviewers conducted semi-structured qualitative interviews with community members, health care providers, and persons representing agencies and businesses serving MSM. Informants discussed community awareness of syphilis, perceived reasons underlying syphilis increases, and recommendations for improving prevention efforts. Providers discussed syphilis screening, diagnosis, and treatment practices. Data were analyzed using NVivo10.
Results: Fifty-four interviews were conducted: 19 with MSM, 52.6% (10/19) were HIV positive and 36.8% (7/19) were treated for syphilis in the previous two years; 13 with HIV and primary care providers (PCPs), and 22 with agency and business representatives. Syphilis increases were attributed to lack of awareness and knowledge of syphilis symptoms, sequelae, and transmission routes. Several men experienced treatment delays due to misdiagnoses by PCPs, or difficulty obtaining bicillin. Syphilis is considered “treatable,” by many MSM and not a major concern while emphasis on condom use has declined, and serosorting by HIV status is common. Portland’s gay “community” is undergoing change and fragmentation with shifts in the way men socialize. Informants said that that social media sites contribute to syphilis by facilitating connections among persons participating in high-risk sexual activities; methamphetamine is considered a contributing factor.
Conclusions: Despite public health efforts, MSM in Portland still need basic information about syphilis. Primary care providers may benefit from training focused on syphilis diagnosis and treatment. More emphasis on primary STD prevention is warranted, but traditional outreach approaches may no longer be effective. Multi-channel syphilis awareness campaigns targeted towards multiple MSM sub-groups should be considered; more research is needed to determine effective strategies for reaching younger men.