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Lessons Learned from Syphilis Elimination in Guilford County Caroline Moseley, Jo Valentine and Evelyn Foust Health Promot Pract 2002; 3; 188 DOI: 10.1177/152483990200300214 The online version of this article can be found at: http://hpp.sagepub.com/cgi/content/abstract/3/2/188

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HEALTH PROMOTION PRACTICE / April 2002

Lessons Learned From Syphilis Elimination in Guilford County Caroline Moseley, MEd, CHES Jo Valentine, MSW Evelyn Foust, MPH

Guilford County, North Carolina has had a syphilis epidemic since 1994. Cofactors include crack cocaine use and the exchange of sex for drugs or money. The Guilford County Department of Public Health, and community-based organizations The Centers for Disease Control and Prevention and the North Carolina HIV/STD Prevention and Care Branch formed a partnership in 1997 dedicated to creating long-term solutions to the syphilis epidemic in Guilford County. A Rapid Ethnographic Community Assessment Process was conducted to explore the behavioral reasons behind the epidemic. Recommendations were made and are being implemented. Short interventions in targeted populations do not provide lasting solutions to community STD problems. Guilford County’s epidemic is a complex network of behavioral, environmental, and social factors. However, long-term partnerships between federal, state, and local health departments, in conjunction with community-based organizations, provide an infrastructure in which to implement lasting interventions that lead to community change.

he United States has experienced a dramatic decline in the incidence of syphilis since 1990, when the last epidemic reached it peak (Centers for Disease Control and Prevention [CDC], 1999a, 1999b, 1999c). This decline presented a unique opportunity to eliminate syphilis on a nationwide basis. In June 1999, the CDC’s Division of Sexually Transmitted Diseases Prevention issued “The National Plan to Eliminate Syphilis from the United States,” in which it set the goal of reducing the number of cases in the country to 1,000 or fewer by the year 2005. Such a reduction would mean the absence of sustained transmission of syphilis within U.S. borders (CDC, 1999a, 1999b, 1999c). However, the key to elimination rested with 28 U.S. counties, mainly in the South, that were reporting more than 50% of infectious syphilis cases for the entire country (CDC, 1999a, 1999b, 1999c). Many of those communities were plagued by poverty and racism, two overarching social problems that are habitually linked to the spread of sexually transmitted diseases (STDs), and minorities were disproportionately affected (Aral, 1999; CDC, 1999a, 1999b, 1999c; Gabel et al., 1998; Gibson, Leverett, & Arvelo, 1996). In 1998, for example, the rate of syphilis was 34 times greater among non-Hispanic Blacks than among non-Hispanic Whites (CDC, 1999a, 1999b, 1999c). The CDC’s national plan outlined five strategies for achieving syphilis elimination, one of which was to strengthen community involvement and partnerships (CDC, 1999a, 1999b, 1999c).

T

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Moseley et al. / SYPHILIS ELIMINATION IN GUILFORD COUNTY

FIGURE 1 Syphilis Rates (cases per 100,000) From 1994 to 1999: Guilford County, North Carolina, and the United States 45 40 35 30 Guilford County

25

North Carolina

20

U.S.

15 10 5

99 19

97 19

95

0

19

One of the Southern counties especially hard hit by syphilis was Guilford County, North Carolina, which began an elimination strategy well before the national plan was launched. Guilford County is located in north central North Carolina, near the Virginia border. It is the third largest of the state’s 100 counties, with a population of 421,048 (U.S. Census Bureau, 2000). Greensboro, with a population of 223,891 (2000 Census), is the largest and most urban city within the county; High Point, with a population of 85,839 (2000 Census), is the second largest city. Guilford County began experiencing high rates of primary and secondary (P&S) syphilis (i.e., infectious syphilis) in 1994. Whereas North Carolina’s syphilis rate declined 57% between 1994 and 1997, the P&S syphilis rate for Guilford County increased 147% (Gabel et al., 1998). Although this rate dropped by approximately 34% between 1997 and 1999, the county remained among 13 U.S. counties with the highest P&S syphilis rates (CDC, 1999a, 1999b, 1999c; see Figure 1). In 1999, 94% of Guilford County’s syphilis cases were among minorities; 46% were among people in their 30s and 25% were among those in their 40s, with about equal percentages of men (51%) and women (49%) affected (Guilford County Department of Public Health [GCDPH], 1999). A number of factors may have contributed to the syphilis epidemic in Guilford County. The association between disadvantaged economic status and high syphilis rates is especially striking in the southeastern United States, where low economic status is also linked to inadequate access to primary health care and persistent patterns of substance abuse. A decade ago, the poverty rate for Guilford County was approximately 10%, making it the eighth wealthiest of North Carolinian counties (North Carolina Department of Commerce, 1998). Despite the county’s relative prosperity, however, there were considerable disparities in economic status between Whites and African Americans. In 1990, 20% of the African American population lived in poverty, as compared to only 6% of the White population (Guilford County, 1995). The link between drug use/abuse, including alcohol, and STDs has also been well documented (Aral, 1999; Gabel et al., 1998; Gibson et al., 1996). Between 1995 and 1997, 14% of syphilis-infected Greensboro residents and 7% of High Point residents with syphilis reported using crack cocaine. Such drug use, along with other behavioral factors like having multiple sex partners, appeared to be associated with the high incidence

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of syphilis (Sutton, 1997). As early as 1993, Greensboro was seeing a steady increase in the number of arrests for crack cocaine use and distribution (Greensboro Corrections Department, 1998). Simultaneously, there was a dramatic rise in the number of Greensboro syphilis cases (North Carolina Department of Health and Human Services HIV/STD Prevention and Care Branch, 1998). In 1997, 31% of persons with early syphilis and/or HIV/AIDS in Greensboro and 23% in High Point reported engaging in some form of exchange of sex for money or drugs (see Figure 2). It had become clear that the barter of sex for drugs—or for the money to purchase them—combined with social factors such as poverty and inadequate access to primary health care were contributing to the high syphilis rates in Guilford County (Sutton, 1997). This situation required an innovative intervention that addressed treatment and education. Given the social stigma associated with syphilis, as well as the controversial history of public health efforts to prevent and control this disease in African American communities, a strategy built on community partnerships was deemed crucial (Thomas & Quinn, 1991). In 1998, GCDPH, in partnership with the North Carolina HIV/STD Prevention and Care Branch (HIV/STD Branch), collaborated with the CDC to develop a community-based syphilis prevention and control intervention. The primary objectives were (a) to provide STD health education, (b) to increase access to effective STD screening and treatment, and (c) to establish a sustainable, community-involved public health


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FIGURE 2 Percentage of Syphilis and/or HIV Cases Admitting to the Exchange of Sex for Drugs or Money, Guilford County, 1993 to 1997 45 40 35 30 25 20 15 10 5 0

Sex for Drugs or Money

1993 1994 1995 1996 1997

response to the sexual health needs of Guilford County’s affected communities. BACKGROUND: ORGANIZING THE RESPONSE GCDPH had a long history of providing STD treatment in its clinics and of utilizing traditional control methods like contact tracing and partner notification. It had also offered STD education in many settings. However, in the decade of the 1990s these traditional programs were no longer adequate to control and prevent syphilis (or other STDs). GCDPH realized that it was time to look beyond its own walls and involve the community. The theoretical basis for involving the community in solving its own problems is rooted in basic community organizing principles (Alinsky, 1971; Freire, 1970). When members of the community are asked about their problems and needs and they suggest the means of solving or meeting them, the community is empowered to improve its own health. Fortunately, GCDPH had previously worked with several community coalitions in the county, so it was able to mobilize these existing alliances to address the syphilis epidemic. The HIV/STD Branch also saw the potential advantages of capitalizing on this local energy and commitment. It offered to (a) help organize a local syphilis prevention task force, (b) provide an immediate syphilis outbreak screening and treatment response, (c) conduct a social and behavioral assessment to guide the development of long-term syphilis interventions, and (d) develop a syphilis and general STD health education and awareness campaign. To assist in this local effort, the branch invited the CDC to provide expertise in the social and behavioral assessment as well as the

development of an intervention program. Guilford County thus became the first community to conduct a Rapid Ethnographic Community Assessment Process (RECAP), the primary focus of which was to ask at-risk community members and service providers how best to prevent syphilis in their community. TOWARD AN INTERVENTION The Task Force and Outbreak Response The immediate outbreak response occurred during a 7-month period (June through December 1997). GCDPH, with assistance from the HIV/STD Branch, identified key service providers in the community whose clients were at high risk for syphilis (see Table 1 for a complete list of partner organizations). These organizations were enlisted to participate in solving the syphilis problem through the Guilford Health Action Project (GHAP). GHAP members organized a task force, or Rapid Intervention Outreach Team ([RIOT] Foust, 1994), to provide syphilis risk-reduction education and facilitate access to screening and treatment. The RIOT team used epidemiological mapping of reported syphilis cases to target basic syphilis education and screening in the high-morbidity neighborhoods of Greensboro and High Point. GHAP members sought and gained the support of key community leaders (identified through outreach) in these neighborhoods. RIOT team members provided information about syphilis and available health services, distributed condoms, and staffed temporary syphilis screening sites. In addition to these community outreach activities, GHAP organized a mass mailing about the epidemic to primary care physicians in Guilford County, who were encouraged to report all syphilis cases seen at their facilities. Another aspect of the campaign was to utilize the local media to reach the public. Local news reporters interviewed GHAP leaders about the syphilis epidemic and efforts to eliminate it on radio and television, and articles about the effort were published in newspapers. These media messages emphasized that syphilis was the whole community’s problem. The RECAP

Background A focused needs assessment that can be conducted relatively rapidly is an important component of most public health projects (Tashima, Crain, O’Reilly, & Elifson, 1996). In 1995, the “Innovations in Syphilis



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TABLE 1 Guilford Health Action Project (GHAP), Member Organizations GHAP Members, 1997

GHAP Members, 2000

Guilford County Department of Public Health (GCDPH) North Carolina HIV/STD Prevention and Care Branch (HIV/STD Branch) North Carolina Department of Health and Human Services, Region III Office Community Connection Outreach Center Triad Health Project Sickle Cell Disease Association of the Piedmont Prison Health Services Alcohol and Drug Services The Wright Focus Group

Guilford County Department of Public Health (GCDPH) North Carolina HIV/STD Prevention and Care Branch (HIV/STD Branch) North Carolina Department of Health and Human Services, Region III Office Community Connection Outreach Center Triad Health Project Sickle Cell Disease Association of the Piedmont Prison Health Services Alcohol and Drug Services The Wright Focus Group High Point Housing Authority Amistad de Guilford Greensboro Urban Ministries Rabbit Quarter Ministries Guilford Health Partnership Shipman Family Care Community Outreach Partnership Center Open Door Ministries Guilford School Health Alliance HealthServe Medical Center Greensboro Housing Authority Moses Cone Health System High Point Regional Health System Guilford County Sheriff’s Department Members of the affected community (e.g., pastors, community leaders, shop owners, etc.)

Prevention in the United States: Reconsidering the Epidemiology and Involving Communities” projects (ISP) adapted an approach known as Community Identification (CID) for use in five communities affected by syphilis in the southern United States. This approach allowed the ISPs to obtain information about values, beliefs, lifestyles, needs, and facilitators and barriers to health care services from the perspective of priority populations and the perspective of those who had substantial contact with priority populations. GCDPH, in collaboration with the CDC and the HIV/STD Branch, adopted a plan similar to that of the ISP projects. The specific objectives of the Guilford County assessment team were to (a) determine the best ways of reaching persons at high risk for syphilis, (b) choose prevention messages and strategies that would be appropriate and acceptable to the community, and (c) tailor sensitive outreach and screening efforts to the community in question. The assessment team included

the county community health educator from GCDPH, a regional disease intervention specialist and a state program consultant from the HIV/STD Branch, and two CDC staff persons.

Preliminary Taxonomies To begin the RECAP, the team constructed preliminary priority population taxonomies based on extant knowledge (see Figure 3). The taxonomies primarily described persons at greatest risk for syphilis as African American substance users who were involved in the exchange of sex for drugs, money, or shelter. As more data were collected, however, these early taxonomies evolved considerably (see Figures 4 and 5). Survey Instruments The RECAP team was able to use the survey instruments developed for the ISP projects, with minor modifications. The surveys were designed to explore the be-


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FIGURE 3 Initial Taxonomy: Persons at Risk for Syphilis Owing to Drug Use Male

FIGURE 5 Revised Taxonomy: Men at Risk for Syphilis Lower Socioeconomic Status High School Education

Female

Black Men

Drug Use

No Drug Use

Drugs for Sex

Money for Sex

Shelter for Sex

Sex for Drugs

Sex for Money

Sex for Shelter

High Risk Partner

Exchanging Sex

FIGURE 4 Revised Taxonomy: Women at Risk for Syphilis Lower Socioeconomic Status 20-40 Years High School Education

No Drug Use

Crack High-risk (Multiple Partners) Partner

Multiple Partners

Single/Widowed >45 Married (Younger)

Sex While High (Alcohol)

Alcohol & Marijuana

IVDU* (Steady Partner)

Drugs, Money, High-Risk or Shelter Partner for Sex

White Men

White/Black Females

Crack (Multiple Partners)

Alcohol & Marijuana

IVDU* (White, Early 20s, Steady Partner)

High-Risk Partner

Multiple Partners

Dealing

Sex While High (Crack or Alcohol)

Sex for Drugs, Money, or Shelter

High-Risk Partner

NOTE: IVDU = intravenous drug use.

havioral factors that put people at risk for syphilis—not to scrutinize the social, cultural, or environmental factors that may contribute to the spread of syphilis. In brief, the surveys focused on five principal domains related to syphilis prevention and control. These were (a) perceptions and knowledge of syphilis, (b) risk-taking behaviors and risk-reduction practices of persons at risk for syphilis, (c) health care–seeking behavior of persons at risk for syphilis, (d) utilization of health care services, and (e) intervention opportunities.

Training Traditionally, training for the community assessment process includes basic introductions to needs as-

Shelter for Sex

Money for Sex

NOTE: IVDU = intravenous drug use.

sessment, qualitative methods, and field interviewing. In January 1998, GCDPH and HIV/STD Branch staff participated in a 1-day training session that was conducted by the CDC members of the team.

Data Collection During the course of approximately 2 weeks, the team of four interviewers (three women and one man; two African Americans and two Whites) conducted a total of 64 interviews with relevant service providers and those at behavioral risk for syphilis. They also led one focus group. Provider Interviews For this component, the data collection team developed a list of organizations, agencies, and individuals that were service providers to the priority group. To ensure adequate representation of diverse perspectives, the providers were divided into relevant categories (such as mental health providers, financial assistance providers, religious affiliations, school-based contacts etc.).



Community Member Interviews and Focus Group The RECAP team conducted the majority of key participant (priority group) interviews outside the local health department. The team also organized and led one focus group involving six males in a correctional setting. Ethnographic Field Observations Because the interviews frequently took the data collection team to the streets, the interviewers were able to establish a sustained presence in the natural settings of persons who were at risk for syphilis (Valentine & DeAguerro, 1995). These ethnographic field observations contributed context and added depth to the data, informed the evolving taxonomies, and contributed to the determination of intervention access points. Data Analysis The CDC staff members analyzed the responses from the RECAP. Data from the provider interviews, community member interviews, and focus group were independently analyzed and coded across the five principal domains. The data were then summarized from the perspectives of the community members and the providers. A third level of analysis compared the responses from the two groups. Factors Facilitating the RECAP The assessment and preparation of the final report were accomplished in a relatively short time—approximately 10 weeks. The speed and effectiveness of the effort were highly dependent on several factors. These included the fact that four staff persons were able to devote full time to the project. Furthermore, the data collection team was experienced in STD health education, and each member was knowledgeable of the geography and demography of the neighborhoods. In addition, the team members possessed sound field interviewing skills and had histories of substantial contact with persons much like the key participant respondents. Finally, as noted above, the survey instruments the staff used had already been developed and tested and required limited modification. Findings From the Assessment The recommendations that providers offered for the control and prevention of syphilis included extending clinic hours, expanding outreach efforts, establishing community clinics, using mobile services, and increasing

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STD education. The most common recommendation from the community member respondents was to increase STD health education. Both respondent groups emphasized that STD education should be targeted at youth and adolescents and should begin in schools. Both groups also saw the need to expand STD education in low socioeconomic areas, housing projects, and on the streets. Several community members stressed that STD education materials should include graphic representations to facilitate recognition of early syphilis symptoms (e.g., chancres, rashes). Other community members said that there was a need for increased condom distribution. Finally, some providers recommended offering incentives to encourage persons at risk for syphilis to seek health care services. When asked about appropriate intervention access points, both groups identified the streets and community organizations and institutions where persons at risk for syphilis commonly congregated or sought services. Specifically, respondents mentioned “crack houses,” night clubs and bars, and schools as good places to reach those in need of STD and syphilis prevention services. The most frequently mentioned access points named by community members were public housing, shelters, and motels. Among sites most frequently named by the providers were jails, recreation centers, churches with outreach programs, gas stations, and convenience stores. Some notable differences in perspective between the community member respondents and the service provider respondents were found. Service providers spoke of the lack of trust that the at-risk community had for the public health department. The community respondents, on the other hand, said that GCDPH was the “STD expert” and they would go there for treatment if they thought they had an STD. More generally, though, there was a difference in perspective concerning the locus of control for the prevention of syphilis. Service providers considered the health system—including themselves—responsible for making services more accessible to the community. They argued that environmental (or external) factors such as lack of access to care, poverty, and racism were the main reasons for the syphilis epidemic and that expanding services in the affected community would go a long way toward solving the problem. Whereas the community respondents felt that access to care was important, they did not say that improving access was the primary solution. Rather, they felt an acute sense of personal (internal) responsibility for their own lives and said that decisions about


194


protecting their health were ultimately up to them. The subsequent intervention included some changes in external factors such as clinic times and location of services, but ultimately its focus was internal—emphasizing the responsibility of individuals to take control of their own health. DISCUSSION: TURNING ASSESSMENT INTO PRACTICE Guilford County was the first RECAP project to implement interventions based on recommendations that came directly from the at-risk community and its providers. Key components of the intervention plan were as follows. Increasing Syphilis Knowledge Within the Community

possible to reach through health education programs because they tend to be silent about their behavior. Media campaigns appeared to be the best way to reach this less accessible group. GCDPH collaborated with the health department of a neighboring county (Forsyth County) on a radio campaign to promote syphilis prevention. The radio messages ran on four different stations—hip-hop, R&B/ classic soul, country, and classic rock. The first two stations targeted the community members at highest risk for syphilis: African Americans in their 20s, 30s, and 40s. The syphilis prevention messages on the rock and country stations were directed toward those stations’ primary listeners: White males in the same age groups. Increasing Awareness of STD Services

I heard about it in the ’70s when Blacks came back from Vietnam. . . . It gets into the bones. . . . It is incurable.

More widely advertised health care services . . . basic cut and dry descriptions of services and how to get them . . . post the clinic times.

Syphilis knowledge among at-risk persons, as well as among some key providers, was found to be low— and often inaccurate. Frequently, community members cited the common symptoms of gonorrhea as the symptoms of syphilis. Others described it as being incurable or an early form of HIV infection. Poor hygiene was frequently cited as a means of syphilis transmission. To increase syphilis knowledge among a large group of at-risk persons, GCDPH and other GHAP agencies began offering frank education in detention centers, drug treatment centers, and shelters for the homeless. To augment awareness in the general community, GCDPH maintains an ongoing media campaign. Public service messages like “Syphilis Is Back: Get Tested Now” are displayed on the backs of city buses. Syphilis prevention messages also appear in local newspapers, including a paper for the Latino community. As previously noted, the initial epidemiological data available to Guilford County public health professionals suggested that syphilis affected the African American community almost exclusively. Epidemiological data, however, are only as good as the system that reports them. Health care providers, for example, may delay their reporting of syphilis cases or not report them at all. The interviewers gained a new perspective on the epidemic from members of the at-risk community who described their sex partners. In particular, they spoke of White men who bought sex and drugs in high morbidity areas (see Figures 4 and 5). These men are almost im-

Given that syphilis is readily treatable and completely curable in the early stages, health care services need to be widely offered and accessible. To that end, Guilford County began publicizing local STD services, GCDPH extended its clinics’ hours and added alternative screening locations, and community-based syphilis education programs began providing information about local screening and treatment. Increasing Community-Level and Street Outreach Go to home, front door service, because it tells them how much you want them to get the information. People may be uncomfortable getting out of their environments.

GCDPH partnered with other GHAP organizations to provide HIV and syphilis testing outside of its main clinics. One community-based organization began offering screening in a local bar that caters to men who have sex with men. Community-based screening services are also provided at shelters, in churches, and on street corners. Although such outreach efforts initially got off to a slow start, community members have enthusiastically supported the services that are offered in some of the county’s most disadvantaged neighborhoods. It is common for community members to approach outreach workers, greet them by name, and ask them for condoms. Presumably because of the high level of rapport that has been established, outreach



FIGURE 6 Decline in Syphilis Cases in Guilford County, 1996 to 1999

workers often get requests for HIV and syphilis testing on the streets; many workers now carry screening kits. Facilitating Access to Treatment for Drug Abuse If they weren’t in need of the drug they wouldn’t engage in the behavior.

Priority group respondents spoke not only of bartering sex for drugs or money for drugs, but many said their drug use impaired their judgment, leading them to sexual risk-taking behaviors. Although drug and alcohol abuse treatment was determined to be an important strategy for controlling syphilis, the substance abuse treatment options in Guilford County did not begin to meet the overwhelming need. As a result of some of the partnerships that were established during the RECAP, however, some progress has been made toward establishing a more solid referral relationship between GCDPH and the local drug treatment community. For example, one of the county’s nonprofit drug treatment agencies screens all clients for syphilis and offers them an HIV test; it also employs a part-time health educator to provide HIV prevention counseling and general sexual health education. The health education staff at GCDPH conducts weekly risk-reduction sessions for clients enrolled in the agency’s detoxification program. After undergoing medically supervised detoxification, clients are transferred to a variety of other in-patient or outpatient settings, or they return home. Unfortunately, though, many leave the treatment setting only to return to their former environments, where they are at substantial risk for relapse into drug use, thereby increasing their chances of acquiring STDs. Providing Essential Services Through Mutually Supportive Partnerships Some people won’t take a chance. They are willing to say let’s try something else, but no one wants to give up what they’ve created—even if it’s not working.

As mentioned previously, GCDPH expanded its STD services in a variety of settings through partnerships with a variety of community-based organizations. These groups are often able to build trust among affected community members in ways that government-run agencies cannot. Through its partnerships with Prison Health Services and the Guilford County Detention Centers, GCDPH began offering educational programs and STD screening in the local jails. It also

195

180 160 140 120 100 80 60 40 20 0

number of P & S syphilis cases

1996 1997 1998 1999 2000

NOTE: P&S = primary and secondary.

provides condom packets for inmates on their release. GCDPH has also had successful partnerships with representatives from the local housing authority, the school system, hospitals, and a group that helps Latinos link to needed STD health services, among others. CONCLUSIONS Given the context in which the syphilis epidemic broke out in Guilford County, it was unreasonable to expect traditional prevention and control methods (like contact tracing and partner notification) to provide a sustainable reduction in syphilis cases. The history of syphilis control in African American communities underscores the importance of involving communities in the development and implementation of their own syphilis elimination projects (Thomas & Quinn, 1991). It took a unified effort among many Guilford County service providers to deliver the type of interventions needed to reduce the rate of syphilis infection among Guilford County citizens. This ongoing unified effort is the cornerstone of Guilford County’s progress toward syphilis elimination (see Figure 6). There are, of course, challenges that still need to be met. One of these is to sustain the high level of community involvement. Task force members will inevitably experience burnout; thus, the outreach teams will need to find fresh blood to maintain the momentum of the elimination campaign. Community needs will necessarily change because the intervention efforts are changing the environments in which syphilis formerly spread. Thus, GHAP was exploring ways to reassess community attitudes and needs on a regular basis without having to repeat the RECAP. It is this cycle of listening and responding that leads to lasting community


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change. As one RECAP respondent said, “Let us be part of the reforms.”

North Carolina Department of Commerce. (1998, February 16). County ranking profiles. Retrieved from http://www.ospl.state.nc.us/osplbin/ crpmain.cgi/response

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Sutton, M. (1997). EPI-AID #97-80 trip report: Outbreak of early syphilis, Guilford County, NC, 1996-1997. Available from Epidemiology and Surveillance Branch, Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA 30333.

Centers for Disease Control and Prevention. (1999a, June). The national plan to eliminate syphilis from the United States. Atlanta, GA: Division of STD Prevention, Centers for Disease Control and Prevention.

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Centers for Disease Control and Prevention. (1999b, September). Sexually transmitted disease surveillance, 1998. Atlanta, GA: Division of STD Prevention, Centers for Disease Control and Prevention.

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Centers for Disease Control and Prevention. (1999c, December). Syphilis elimination report (SESR-52-Revision.0001). Atlanta, GA: Division of STD Prevention, Centers for Disease Control and Prevention. Foust, E. (1994). North Carolina’s rapid intervention outbreak team. North Carolina Department of Health and Human Services Newsletter, 94, 7.

Valentine, S. & DeAguerro, L. (1995). Defining the components of street outreach for HIV prevention: The contact and the encounter. Public Health Reports, 3, (Supp 1), 69-74. U.S. Census Bureau. (2000). U.S. Census 2000 population estimates for North Carolina. Available thorugh www.census.gov.

Freire, P. (1970). Pedagogy of the oppressed. New York: Heder and Heder. Gabel, H., Foust, E., Ogburn, D., Engel, N., Owen-O’Dowd, J., & Howerton-Privott, A. (1998). Outbreak of primary and secondary syphilis— Guilford County, North Carolina, 1996-1997. Morbidity and Mortality Weekly Report, 47(49), 1070-1073. Gibson, J., Leverett, W., & Arvelo, M. (1996). Providers of syphilis care in the southern United States. Sexually Transmitted Disease, 23(1), 40-44. Greensboro Corrections Department. (1998). Monthly crime reports. Available from Greensboro Police Department, 401 West Sycamore St., Greensboro, NC 27401. Guilford County. (1995). Health status of Guilford County: Data book. Available from the Health Surveillance and Analysis Unit, Guilford County Department of Public Health, 301 North Eugene St., Greensboro, NC 27401.

Caroline Moseley, MEd, CHES, is at the Guilford County Department of Public Health, Greensboro, North Carolina. Jo Valentine, MSW, is at the Division of STD Prevention, Centers for Disease Control and Prevention. Evelyn Foust, MPH, is at the HIV/STD Prevention and Care Branch, North Carolina Department of Health and Human Services.

Guilford County Department of Public Health. (1999). Guilford County health data book. Available through the Guilford County Department of Public Health.
