COMMENTARY

Syphilis Screening: Make It Routine in HIV Care

Shelley A. Gilroy, MD

Disclosures

April 25, 2018

HIV-Syphilis Coinfection

The Sexually Transmitted Infections Guidelines Committee of the New York State Department of Health AIDS Institute has recently released guidelines on the "Management of Syphilis in Patients with HIV." This guideline addresses transmission and prevention, screening, diagnosis, reporting and treatment, and posttreatment monitoring. The guideline aims to achieve the following goals:

  • Increase the number of people identified with HIV and syphilis coinfection and treat with effective interventions;

  • Reduce the case rate of primary and secondary syphilis by 10% and reduce disparities by specific populations that are disproportionally affected by syphilis infection[1,2];

  • Reduce the growing burden of morbidity and mortality associated with syphilis infection; and

  • Integrate current evidence-based clinical recommendations into the healthcare-related implementation strategies for the Ending the Epidemic initiative, which seeks to end the AIDS epidemic in New York State by the end of 2020.

This guideline recommends at least annual syphilis screening for all patients with HIV. Screening for syphilis and other sexually transmitted infections (STIs) should be performed every 3 months for persons at high risk, regardless of the frequency of their HIV monitoring visits.[1]

Cases of primary and secondary syphilis, the most infectious stages of the disease, have been increasing annually in the United States, especially in HIV-infected men who have sex with men (MSM).[3] In a Centers for Disease Control and Prevention analysis of 34 states, rates of primary and secondary syphilis were consistently higher among MSM who are diagnosed with HIV, compared with MSM who are not known to be HIV infected; however, the magnitude of the difference varied substantially across states.[4] Observed differences may be a result of increased incidence among HIV-positive MSM, as well as increased case detection through routine syphilis screening among MSM in HIV care.[5] The rate of reported primary and secondary syphilis cases in women increased by 36%, and the rate of congenital syphilis increased by 28% during 2015-2016.[3]

Get Comfortable Taking a Sexual History

Primary care providers and clinicians are often the first to see HIV-infected patients with STIs. Clinicians need to make taking a sexual history a priority and include it as a routine part of the history and physical examination. Most patients will discuss their concerns and sexual practices when the conversation is clinician initiated and performed in a comfortable and nonjudgmental setting. Focusing on sexual preference and practices while maintaining a nonjudgmental attitude is the key to patient disclosure about all sexual behaviors. Clinicians are advised to inform patients with HIV about the risk of acquiring syphilis through close physical contact involving the genital, rectal, or oral mucosa.[5]Genital secretions, infected by other pathogens, can also contain infectious amounts of HIV-1.[6] Syphilis and other ulcer-producing STIs are risk factors for acquiring or transmitting HIV infection.[7,8] Syphilis infection might indicate current sexual behaviors that place a person at increased risk for HIV infection. For clinicians who are uncomfortable discussing sexual behaviors and STI risk, the guideline provides helpful contact information as well as links to STI/HIV training sites and HIV-related educational resources.

Syphilis Screening, Diagnosis, and Treatment in HIV

Syphilis should be among the differential diagnosis when patients with HIV present with oral, genital, cervical, or anal lesions (chancres or warts); rash, vision, otic, neurologic, and or neuropsychiatric findings or complaints. Chancres are painless and can develop in less visible areas of the body, and thus are easily missed. Atypical presentations of syphilis in patients with HIV have been reported, and syphilis can mimic other infections, such as herpes or fungal rash, or noninfectious dermatologic conditions such as contact dermatitis or psoriasis. Photographic examples of secondary syphilis in HIV-infected patients are provided in the Appendix section of the guidelines.

Diagnosis and staging are determined by performing nontreponemal (RPR or VDRL) and treponemal (FTA-Abs, TP-PA) serologic testing and by the typical clinical appearance of ulcers and skin lesions. The nontreponemal tests are negative in approximately 20% of the cases presenting with a primary ulcer (chancre); therefore, both nontreponemal and treponemal testing are advised.[9] When there is clinical suspicion for syphilis but the nontreponemal test is negative, it is advised that clinicians communicate with the laboratory to confirm that the sample was retested after dilution (prozone effect).[10]Some laboratories use a reverse sequence screening algorithm with automated treponemal enzyme immunoassay or chemiluminescence immunoassays as the initial screening test, followed by confirmation with the nontreponemal RPR. This can be confusing, so the guideline includes a helpful syphilis screening algorithm to assist with interpretation of the laboratory results.

Treatment varies according to disease stage. The penicillin G recommended regimens are the same for patients with or without HIV. Patients with HIV who are diagnosed with syphilis should be monitored closely. Other treatment options for penicillin-allergic patients with HIV have not been well studied and should be used with caution. In pregnant women with syphilis who are penicillin allergic, desensitization therapy followed by treatment with penicillin is recommended due to high rates of congenital syphilis when other agents are used. This is also advised for patients with HIV rather than attempting other therapies if adherence to therapy or close follow-up cannot be ensured. Clinicians should perform a lumbar puncture in patients with neurologic, ophthalmologic, otic, or neuropsychiatric signs or symptoms that are not explained by another etiology, treatment failure, or tertiary syphilis. Long-term untreated infection can affect multiple organs, including the brain, nerves, eyes, heart, blood vessels, liver, bones, and joints, and can cause visual impairment, stroke, or death.[9]

If more people coinfected with syphilis and HIV are identified and treated early, the goals of reducing the rates of syphilis and HIV transmission will be achieved.

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