USPSTF Now Recommends Syphilis Screening in At-Risk Persons

Marcia Frellick

June 07, 2016

The US Preventive Services Task Force (USPSTF) has found A-level, high-certainty evidence that screening for syphilis in asymptomatic, nonpregnant persons at increased risk for infection provides substantial benefit.

The recommendation, which updates 2004 recommendations, appears in the June 7 issue of JAMA.

An evidence report that supports the new recommendation, also published in JAMA, found no direct evidence of harm in screening this population. Also, several available tests provide highly accurate detection, and antibiotics are highly effective in curing the infection, preventing late-stage disease and transmission.

Those at highest risk include men who have sex with men (MSM) and people living with HIV. Other risk factors include a history of incarceration or commercial sex work. Factors for consideration include geography, race/ethnicity, and being a male younger than 29 years old.

The evidence report, written by Amy G. Cantor, MD, MPH, from the Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland, and colleagues, notes that for HIV-positive men and MSM, screening every 3 months brought increased detection rates at various stages of syphilis, based on four observational studies from Australia and the United Kingdom. That schedule identified more new cases of infection compared with screening every 6 or 12 months.

Limitations include a wide variation in the number, quality, and applicability of studies used to make the recommendations and lack of studies conducted specifically with adolescents. Also, the studies focused on detection rates in MSM and HIV-positive patients, while other populations relevant to screening were lacking.

"[C]ontrol of syphilis in the United States seems quite possible, perhaps even easily achievable. Yet evidence from the last 15 years indicates quite the opposite to be true," write Meredith E. Clement, MD, Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina, and Charles B. Hicks, MD, Department of Medicine, University of California, San Diego, write in an accompanying editorial.

The number of cases of primary and secondary syphilis in the United States has been increasing since 2000 to approximately 20,000 cases in 2014.Dr Clement and Dr Hicks point to several changes that may be contributing to that increase.

One is that funding for public health over the past decade has not kept up with need. They point out that "the CDC's [Centers for Disease Control and Prevention's] budget has decreased significantly, from $7.07 billion in fiscal year 2005 to $5.98 billion in fiscal year 2013." State and local agencies have experienced similar cuts, including in sexually transmitted infection services.

In addition, focus on HIV has overshadowed attention to other sexually transmitted infections, they explained. And improvements in antiretroviral treatment have lessened the fear of AIDS and have significantly reduced safer-sex behaviors.

"The good news is that fixing what has gone wrong does not require huge capital investment, breakthrough technological advances, or massive restructuring of our health care system," they write.

Instead, the editorialists argue, the new analysis from USPSTF makes the case for much more widespread and comprehensive screening of groups at high risk for syphilis.

But first, heightened awareness is needed, particularly where patients at higher risk get follow-up.

"The syphilis demographic overlaps considerably with the HIV demographic," the editorialists write. "For example, in 2014, half of all MSM diagnosed with syphilis were also coinfected with HIV. Younger men (aged 20-29 years) have a prevalence rate nearly 3 times that of the national average for men, and persons of color are particularly at risk, with black individuals disproportionately affected in the United States."

Syphilis rates were 18.9 cases per 100,000 in blacks vs 3.5 per 100,000 in whites, they note.

They also urge healthcare providers to more thoroughly ask patients about sexual history and better identify those who need screening.

Several articles related to the USPSTF recommendation are available in JAMA specialty publications.

This research was funded by the Agency for Healthcare Research and Quality under a contract to support the USPSTF. Study authors have disclosed no relevant financial relationships. Dr Hicks reported having served on scientific advisory boards for Bristol-Myers Squibb, Gilead Sciences, Merck, Janssen Virology, and ViiV Healthcare and a data monitoring committee for AstraZeneca; having received royalties from UpToDate; and having served as an associate editor and author for NEJM Journal Watch. A coauthor reported having received royalties from UpToDate.

JAMA Published online June 7, 2016. USPSTF statement Evidence report Editorial


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