The Intersection of HIV and Syphilis: Update on the Key Considerations in Testing and Management

Acceptability and feasibility of pre-exposure prophylaxis for bacterial STIs: a systematic review

BACKGROUND

A recent resurgence of bacterial sexually transmitted infections (STIs) is placing a major burden on high-risk populations, physicians, and the healthcare system. Treatment in the form of antibiotic pre-exposure prophylaxis (STI PrEP) is a potential solution. However, little is known about the acceptability and feasibility of this approach in high-risk populations.

METHODS

A comprehensive search strategy was developed and executed in October 2024 across six databases adhering to PRISMA guidelines.

RESULTS

Eight studies met the inclusion criteria. These studies were all conducted in high-income countries, used various methods, and all focussed on sexual minority men. Findings consistently identified moderate to high levels of acceptability among GBMSM (54.3% - 67.5%). Factors such as engagement in perceived 'high risk' sexual encounters, and past diagnosis of STIs strengthened acceptability, while others (e.g., antimicrobial resistance concerns and stigma) act as barriers. Only one study included the perspectives of healthcare workers, indicating a moderate willingness to prescribe, which would increase under governing-body endorsement.

DISCUSSION

Overall, while there is some promise of STI PrEP acceptability among GBMSM, vast gaps in knowledge remain. Knowledge transfer and feasibility and, hence, the sustainability and capacity needed for the success of STI PrEP is yet to be examined and understood. However, for STI PrEP to be successfully adopted, it is essential not only to assess its acceptability and feasibility but also to focus on knowledge transfer. Knowledge transfer is a dynamic and iterative process, involving the synthesis, dissemination, exchange, and application of knowledge in an ethically sound manner. This process supports the improvement of health outcomes, strengthens healthcare systems, and ensures that healthcare interventions, such as STI PrEP, are effectively understood and implemented by both healthcare providers and at-risk populations. Similarly, the perspectives of populations beyond GBMSM have been omitted, and there is little understanding of the impact of their differing socio-cultural contexts around sex-related behaviour and Western pharmaceutical healthcare interventions on their acceptance and uptake.

CONCLUSION

Further research into acceptability, feasibility and knowledge transfer among diverse high-risk groups, healthcare professionals, and policymakers is necessary to create a strong foundation for implementing STI PrEP.

The Role of Traditional and Reverse Algorithms in the Diagnosis of Syphilis in HIV-Infected Individuals: A Case Study on Istanbul

Background/Objectives:T. pallidum subsp. pallidum is a spirochete that only causes disease in humans as the causative agent of syphilis. HIV and syphilis have common transmission routes. In the present study, our aim was to evaluate the presence of syphilis coinfection in people living with HIV using conventional and reverse algorithms and to investigate its effects on laboratory parameters. Methods: The traditional algorithm for syphilis begins testing with the non-treponemal test. If the non-treponemal test is reactive, a treponemal test is then used to confirm syphilis infection. The reverse algorithm for syphilis begins testing with the treponemal test. If this test is reactive, then a non-treponemal test is performed. When the non-treponemal test is non-reactive, a second treponemal test is performed. Results: A total of 200 patients were included in the study. While 22 patients were determined to be syphilis-positive using the traditional algorithm, 37 patients were determined to be syphilis-positive using the reverse algorithm. Most of the patients who had syphilis coinfection were homosexual. Conclusions: It was found that syphilis coinfection had no effects on CD4+ T-lymphocyte and CD8+ T-lymphocyte values, CD4/CD8 rates, and HIV RNA amounts. People living with HIV must be screened and followed up for syphilis and other sexually transmitted diseases at certain intervals.

Analysis of seroprevalence and risk factors for syphilis and HIV among female sex workers and transgender individuals in different cities of Sindh, Pakistan

INTRODUCTION

Co-infections of syphilis and HIV have been found to exacerbate the impact on sexual and reproductive health, especially among key population groups such as Female Sex Workers (FSWs) and Transgender Individuals (TGs). The data on the prevalence and determinants of syphilis and HIV in Pakistan, particularly in Sindh province, is limited. This prospective cross-sectional study aimed to determine the seroprevalence and risk factors for HIV and syphilis infections among FSWs and TGs in different cities of Sindh, Pakistan.

METHODS

A total of 1120 participants (531 FSWs and 589 TGs) were recruited from Karachi, Sukkur, Hyderabad, and Larkana. Community-based serological testing for HIV and syphilis was performed using Abbot Bioline HIV/syphilis Duo test kits, and sociodemographic and risk factor data were collected through questionnaires. Chi-square and logic regression were applied to determine variables associated significantly with syphilis in TGs and FSWs.

RESULTS

TGs exhibited higher rates of syphilis (16.29%) and syphilis-HIV (6.79%) as compared to FSWs (syphilis: 15.63%; syphilis-HIV: 0.75%). Inconsistent condom use was more common among FSWs (75.32%), and over half reported STI symptoms. Regression analysis showed that for TGs, having five years (adjusted OR: 0.52, p = 0.04) and graduate-level education (adjusted OR: 0.40, p = 0.04) was associated with a lower risk of syphilis, while an income between 30,000 and 50,000 Pakistani rupees (OR: 1.93, p = 0.028) and more than three years in profession (adjusted OR: 2.20, p = 0.04) was associated with a higher risk. For FSWs, five (OR: 0.34, p = 0.03) and ten (OR: 0.02, p = 0.02) years of education were associated with a lower risk of syphilis, whereas an income between 30,000 and 50,000 PKR (OR: 3.05, p < 0.01) and self-reported HIV-negative status (OR: 3.08, p = 0.01) were associated with a higher risk of syphilis mono-infection.

CONCLUSION

In conclusion, the results of the study show higher rates of syphilis and HIV co-infection among TG compared to FSW from Sind. The study findings provide valuable insights for national health agencies and policymakers to devise data-driven strategies for preventing and controlling syphilis and HIV infections among FSW and TG populations in Sind.

A retrospective analysis of syphilis cases with a focus on otolaryngology at a university hospital

OBJECTIVES

In recent years, there has been a notable increase in syphilis cases in Japan and Western countries. Syphilis, a classic sexually transmitted disease caused by treponemas, presents diagnostic challenges due to its diverse clinical manifestations. This study explores the diagnosis of syphilis in patients treated at our hospital.

METHODS

We retrospectively reviewed patients who visited our hospital between April 2015 and March 2024. The review focused on the patients' clinical backgrounds, onset times, symptoms, diagnostic processes, and clinical courses.

RESULTS

Our hospital had 45 cases of syphilis. Forty-five cases of syphilis were diagnosed as syphilis in our hospital (13 cases were diagnosed in the Otolaryngology: ENT department). The median age was 40 years, with a significant male predominance (male-to-female ratio of 34:11). The median duration from the onset of subjective symptoms to syphilis diagnosis was 54 days. The timeframe from the initial clinic visit to diagnosis ranged from 1 to 57 days, with a median of nine days. Notably, 47.5% of the patients reported a history of employment or patronage in the sex industry. 73.3% of patients presented to local clinics with any kind of subjective symptoms, but syphilis was often missed in the differential diagnosis. Patients visiting the ENT department were referred to our hospital with a diagnosis of persistent oral ulcer, oropharyngeal carcinoma and neck lymphadenopathy. Histological and cytological evaluation was performed in 33% of patients, but the diagnosis was often difficult to make. Additionally, some patients initially denied using sex services at their first visit but later disclosed this during subsequent visits to the Department of Infectious Diseases, highlighting the critical role of thorough medical history assessments.

CONCLUSION

Diagnosing syphilis can be challenging unless the physician specifically suspects it. It is crucial to consider syphilis in cases of pharyngeal mucosal inflammation and neck lymphadenopathy. This study highlights the need for heightened awareness and education regarding the signs and symptoms of syphilis, particularly oropharyngeal and skin findings, to ensure timely diagnosis and treatment.

Analysis of Neurosyphilis Imaging Methods and Treatment: A Focused Review

Neurosyphilis, a severe complication of syphilis caused by Treponema pallidum, progresses through multiple stages, including asymptomatic, meningeal, meningovascular, and late parenchymal forms such as syphilitic paresis and tabes dorsalis. Neurosyphilis spreads through sexual contact and from mother to child. Symptoms of neurosyphilis include nausea, cranial nerve deficiencies, and seizures. Diagnosing this condition is particularly challenging due to its varied symptoms, which frequently overlap with other neurological disorders. Current diagnostic approaches primarily rely on cerebrospinal fluid (CSF) analysis and neuroimaging techniques like magnetic resonance imaging (MRI) and single-photon emission computed tomography (SPECT). The exploration of recent advances in neurosyphilis testing and the expanding role of imaging techniques in tracking treatment efficacy are seen. Penicillin G continues to be the primary treatment, with ceftriaxone serving as an alternative for patients with penicillin allergies. Even though ceftriaxone is less potent than penicillin G, it can still successfully eradicate neurosyphilis in patients. This review seeks to deepen the understanding of neurosyphilis pathophysiology, refine diagnostic accuracy, and inform evidence-based treatment approaches. This will ultimately contribute to improved patient outcomes.

Syphilitic Hepatitis: An Uncommon Manifestation of Secondary Syphilis

Syphilitic hepatitis is a rare manifestation of a sexually transmitted infection. Given its nonspecific presentation, it is important for clinicians to consider the diagnosis in sexually active patients presenting with elevated liver tests.  In this case, a 30-year-old man presented with an itchy rash and was diagnosed with an allergic reaction. He returned to the clinic one week later with a worsening rash. A sexual history was obtained, which led to sexually transmitted disease testing. Laboratory evaluation revealed a positive syphilis serology. A diagnosis of secondary syphilis was made, and he was treated with penicillin. The following day, he presented to the emergency department complaining of worsening rash, abdominal pain, and fever. Laboratory evaluation was significant for elevated transaminases. He received supportive care and was advised to follow up with his primary care provider. One month after his initial presentation, he presented to the clinic with resolution of the rash. Laboratory evaluation revealed a fourfold decrease in rapid plasma reagin titer and improvement in liver enzymes. The transaminitis work-up was unremarkable, and the liver tests ultimately normalized. A diagnosis of syphilitic hepatitis was made. A comprehensive detailed sexual history is important and key to the diagnosis of syphilitic hepatitis. Long-term sequelae are rare. Syphilitic hepatitis is a curable condition and should remain in the differential diagnosis in all sexually active persons presenting with abnormal liver enzymes.

Sociobehavioral Risk Factors and Clinical Implications of Late Presentation Among People Living with HIV in the Brazilian Amazon Region

This study aimed to analyze the prevalence, sociobehavioral factors and clinical-laboratory consequences of late presentation among people living with HIV (PLHIV) in the Brazilian Amazon region. In total, 402 HIV + individuals treated at reference units in Belém city (Pará, Brazil) between 2018 and 2019 were evaluated. Late presentation was defined as a first-collection LTCD4+ count below 350 cells/µL. Sociodemographic, behavioral and clinical data were obtained from questionnaires or medical records. Th1, Th2 and Th17 cytokine profiles were evaluated by flow cytometry. Longitudinal data on viral load, T lymphocytes, and antiretroviral therapy administration were obtained from control and logistic databases. Approximately 52.73% of the participants were late presenters and sought medical care 7-12 + months after their primary HIV diagnosis. Sociobehavioral factors associated with late presentation included illicit drug use for more than 5 years, polyamory, no alcohol consumption, homosexuality, and sexual inactiveness after HIV diagnosis. Clinically, late presentation was associated with coinfection rate; polysymptomatology; high IFN-ɣ, IL-6 and IL-10 levels; nonresponse to antiretroviral therapy; and virological failure- and tuberculosis coinfection-motivated changes to therapy. In summary, the prevalence of late presentation in Pará in the Brazilian Amazon region is high. Delays in seeking specialized care after a primary HIV diagnosis cause medium/long-term changes in the life expectancy and health of PLHIV.

Changes in the HIV Epidemic in Lower Silesia, Poland, Between 2010 and 2020: The Characteristics of the Key Populations

The HIV (Human Immunodeficiency Virus) epidemic remains a significant public health issue, requiring ongoing access to preventive methods. This study aimed to analyze the evolution of the HIV epidemic in Lower Silesia from 2010 to 2020, focusing on the key populations. A retrospective analysis of the medical records from newly diagnosed HIV patients at a major HIV clinic in Wroclaw was conducted, examining demographic data, infection routes, and laboratory results. An 84% increase in newly diagnosed HIV cases was observed over the decade, with the most common route of infection being sex between men (70% among those with a known infection route). These patients were generally in better clinical condition compared to their heterosexual counterparts, as indicated by a higher median CD4+ T cell count (465/μL vs. 250/μL). The changes in clinical status and infection routes were statistically significant. The HIV epidemic in Lower Silesia has shifted, with a notable rise in new infections among men who have sex with men. Heterosexual patients were often diagnosed at more advanced stages. Prevention strategies should adapt to these changing trends, with education and testing accessibility remaining priorities nationwide.

Sexually Transmitted Infections in People with Human Immunodeficiency Virus

Sexually transmitted infections (STIs) are more commonly seen in patients with human immunodeficiency virus (PWH). Routine sexual history taking and appropriate multisite screening practices support prompt identification and treatment of patients, which in turn reduces morbidity and spread of STIs including HIV. Nucleic acid amplification testing has high accuracy for diagnosing many of the major STIs. Diagnosis of syphilis remains complex, requiring 2 stage serologic testing, along with provider awareness of the myriad symptoms that can be attributable to this disease. Prevention through mechanisms such as vaccines and postexposure prophylaxis hold promise to reduce the burden of STIs in PWH.

Determinants of Late HIV Diagnosis and Advanced HIV Disease Among People Living with HIV in Tanzania

Background

About half of people infected with Human Immunodeficiency Virus (HIV) often present late for care, resulting in higher healthcare costs, undesired treatment outcomes, and ongoing HIV transmission. This study aimed to assess the prevalence and determinants of late HIV diagnosis and advanced HIV disease (AHD) in Tanzania.

Methods

Data were obtained from the 2016-17 Tanzania HIV impact survey. We included 677 newly diagnosed people living with HIV. Late HIV diagnosis and AHD were defined as having a CD4 cell count below 350 cells/µL or 200 cells/µL at diagnosis, respectively. Bivariate and multivariable logistic regression models were fitted to identify the determinants of late HIV diagnosis or AHD.

Results

The mean age of the participants was 37.8 years (SD, 12.4). About two-thirds were women (62.6%). The prevalence of late HIV diagnosis was 42.4%, whereas the prevalence of AHD was 17.7%. Factors associated with late HIV diagnosis included age 31-40 years (adjusted odds ratio [aOR] = 1.72, 95% confidence interval [CI]: 1.14-2.60), age ≥41 years (aOR = 1.79, 95% CI: 1.16-2.76), male sex (aOR = 1.88, 95% CI: 1.29-2.73), and active syphilis infection (aOR=2.63, 95% CI: 1.20-5.76). Factors associated with AHD were age 31-40 years (aOR = 2.12, 95% CI: 1.18-3.81), age ≥41 years (aOR = 2.42, 95% CI: 1.32-4.41), male sex (aOR = 1.77, 95% CI: 1.09-2.87), formal education (aOR = 0.49, 95% CI: 0.30-0.81) and active syphilis infection (aOR = 2.49, 95% CI: 1.07-5.77).

Conclusion

Late HIV diagnosis and AHD are prevalent among newly diagnosed people living with HIV in Tanzania. Specific subgroups are more likely to present late for HIV care, including middle-aged and older adults, men, illiterate individuals, and those with active syphilis and HIV co-infection. Therefore, we recommend expanding HIV testing services and implementing targeted interventions to improve early access and enrollment in HIV care.

Prevalence and Treatment Outcomes of Syphilis among People with Human Immunodeficiency Virus (HIV) Engaging in High-Risk Sexual Behavior: Real World Data from Northern Greece, 2019-2022

In this study, we aimed to assess the prevalence of syphilis among people with human immunodeficiency virus (HIV; PWH) engaging in high-risk sexual behavior, determine the stage of syphilis, and evaluate treatment efficacy. A retrospective single-center cohort study was conducted at the AHEPA University General Hospital of Thessaloniki, focusing on PWH at high risk for sexually transmitted infections (STIs) attending outpatient care from January 2019 to December 2022. Sociodemographic and clinical data were collected, incident syphilis rates were identified, associations with HIV-related characteristics were explored, and the treatment response was assessed. Among 991 participants, 94 PWH were diagnosed with syphilis, representing 9.4% of the cohort. Incident syphilis cases experienced a decrease in the early COVID-19 era compared to 2019, followed by a gradual increase leading up to 2022. The majority of syphilis cases were asymptomatic latent syphilis (71.1%). Men who have sex with men (MSM) and younger individuals exhibited higher rates of co-infection during the study period. No significant association was found between incident syphilis and HIV-related factors. Most syphilis cases (86%) were treated with benzathine penicillin G (BPG). Treatment with BPG and doxycycline showed an increased success rate (96.7% vs. 92.9%), with no statistically significant difference observed between them (p = 0.438). This study highlights the alarming incidence of syphilis among PWH engaging in high-risk sexual behavior, particularly among younger MSM. BPG remains effective, and alternative regimens like doxycycline show promise, especially in settings with penicillin shortages or patient allergies.

Current syphilis infection in virally suppressed people living with HIV: a cross-sectional study in eastern China

Background

Antiretroviral therapy (ART) has been shown to reduce human immunodeficiency virus (HIV) viral replication and ultimately achieve viral suppression and eliminate HIV transmission. However, little is known about the impact of viral suppression on high-risk behaviors and sexually transmitted infections (STIs).

Objective

This study aimed to assess the rates of current syphilis infection in virally suppressed people living with HIV (PLWH) and whether with the duration of ART can reduce the current syphilis infection in eastern China.

Method

We conducted a cross-sectional survey of PLWH in Zhejiang Province, China, in 2022. PLWH who were on ART >6 months and were virally suppressed (viral load <50 copies/mL) were included in the study. Data were collected from the National Epidemiological Database of Zhejiang Province and all participants were tested for viral load and current syphilis. Multivariable logistic regression was used to identify risk factors associated with current syphilis infection.

Result

A total of 30,744 participants were included in the analysis. 82.7% of participants were male, the mean age was 44.9 ± 14.1 years, 84.9% had received ART in a hospital setting, the mean time on ART was 5.9 ± 3.1 years and 5.6% of participants were infected with current syphilis. Multivariable logistic regression showed that being male [adjusted odds ratio (aOR): 2.12, 95% confidence interval (CI): 1.69-2.66], high level of education (aOR: 1.23, 95% CI: 1.02-1.49), homosexual route of HIV infection (aOR: 1.80, 95% CI: 1.60-2.04), non-local registered residence (aOR: 1.29, 95% CI: 1.11-1.51), had history of STIs before HIV diagnosis (aOR: 1.95, 95 % CI: 1.75-2.18) and treatment provided by a municipal hospital (aOR: 2.16, 95% CI: 1.31-3.55) were associated with increased risk of current syphilis infection. Being married (aOR: 0.67, 95% CI: 0.58-0.76) was associated with a decreased risk of current syphilis infection.

Conclusion

Our findings revealed a high rate of current syphilis infection among virally suppressed PLWH in eastern China. Duration of ART did not reduce the prevalence of current syphilis infection. Targeted interventions to reduce current syphilis infection should be prioritized for subgroups at higher risk.

Glutathione in HIV-Associated Neurocognitive Disorders

A large portion of patients with Human Immunodeficiency Virus (HIV) have neurologic sequelae. Those with better-controlled HIV via antiretroviral therapies generally have less severe neurologic symptoms. However, for many patients, antiretrovirals do not adequately resolve symptoms. Since much of the pathogenesis of HIV/AIDS (Autoimmune Deficiency Syndrome) involves oxidative stress either directly, through viral interaction, or indirectly, through inflammatory mechanisms, we have reviewed relevant trials of glutathione supplementation in each of the HIV-associated neurocognitive diseases and have found disease-specific results. For diseases for which trials have not been completed, predicted responses to glutathione supplementation are made based on relevant mechanisms seen in the literature. It is not sufficient to conclude that all HIV-associated neurocognitive disorders (HAND) will benefit from the antioxidant effects of glutathione supplementation. The potential effects of glutathione supplementation in patients with HAND are likely to differ based on the specific HIV-associated neurocognitive disease.

A Potential Screening Strategy to Identify Probable Syphilis Infections in the Urban Emergency Department Setting

Background

Syphilis diagnosis in the emergency department (ED) setting is often missed due to the lack of ED-specific testing strategies. We characterized ED patients with high-titer syphilis infections (HTSIs) with the goal of defining a screening strategy that most parsimoniously identifies undiagnosed, untreated syphilis infections.

Methods

Unlinked, de-identified remnant serum samples from patients attending an urban ED, between 10 January and 9 February 2022, were tested using a three-tier testing algorithm, and sociodemographic variables were extracted from ED administrative database prior to testing. Patients who tested positive for treponemal antibodies in the first tier and positive at high titer (≥1:8) for nontreponemal antibodies in the second tier were classified as HTSI. Human immunodeficiency virus (HIV) status was determined with Bio-Rad enzyme-linked immunosorbent assay and confirmatory assays. Exact logistic regression and classification and regression tree (CART) analyses were performed to determine factors associated with HTSI and derive screening strategies.

Results

Among 1951 unique patients tested, 23 (1.2% [95% confidence interval, .8%-1.8%]) had HTSI. Of those, 18 (78%) lacked a primary care physician, 5 (22%) were HIV positive, and 8 (35%) were women of reproductive age (18-49 years). CART analysis (area under the curve of 0.67) showed that using a screening strategy that measured syphilis antibodies in patients with HIV, without a primary care physician, and women of reproductive age would have identified most patients with HTSI (21/23 [91%]).

Conclusions

We show a high prevalence of HTSI in an urban ED and propose a feasible, novel screening strategy to curtail community transmission and prevent long-term complications.

Miscellaneous ophthalmic conditions related to low CD4 cell count in HIV-positive patients

Introduction: Management of patients living with Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (AIDS) (PLWHA) still represents a challenge for doctors in various medical fields. The presence of co-infections, with different degrees of immune system impairment, raises the need for a multi-disciplinary approach to the PLWHA. Methods: In this paper, we present three cases of PLWHA with various ophthalmological conditions, who were admitted to "Prof. Dr. Matei Balș" National Institute for Infectious Diseases (INBIMB). Three of them were late presenters, recently diagnosed with AIDS. All three were in immuno-virological failure. The ophthalmic conditions were either related to the HIV infection, or the result of other complications. Discussion: The diversity and complexity of ocular involvement in PLWHA were deeply linked to the patient's immunological status at the ophthalmological evaluation moment. Thus, antiretroviral therapy (ART) played an important immune status recovery role. Encountered ocular conditions vary, some being directly caused by the presence of the virus, and the others were the result of opportunistic infections (cytomegalovirus, Varicella virus) or other co-infections (Treponema pallidum). Neurological conditions disturbing the natural defense mechanism, prolonged hospital stay, and exposure to multiple antibiotic regimens are risk factors for difficult-to-treat eye infections with multidrug-resistant bacteria. Some ocular conditions can be the reason that leads to HIV infection diagnosis, while others can appear during the time, especially in patients with low ART adherence. The prognostic is conditioned by the early recognition and correct management of the disease and the immunological status recovery under ART. Conclusions: Correct and early diagnosis of HIV-related eye conditions is mandatory to establish the most appropriate medical management to obtain an increase in the quality of life of the patient. Abbreviations: HIV = Human Immunodeficiency Virus, AIDS = Acquired Immunodeficiency Syndrome, ART = Antiretroviral Therapy.

Syphilis for dermatologists: Current concepts

Dermatologists are familiar with the classic aspects of syphilis. Our objective in this update is to display novel features of sexually acquired syphilis, its pathophysiology, natural history, atypical clinical variants, skin of color, clinical pearls, and prospects. Textbook knowledge, congenital syphilis, epidemiology, and historical data are excluded.

Clinical and immunological characteristics of HIV/syphilis co-infected patients following long-term antiretroviral treatment

Objective

This study aims to analyze the efficacy of anti-syphilis treatment and the impact of syphilis events on HIV virology and immunology in HIV/syphilis co-infected patients on long-term antiretroviral therapy (ART) and to investigate the incidence and factors of syphilis recurrence/re-infection/serofast state. The insights derived from this investigation can potentially guide strategies for preventing and managing syphilis and AIDS.

Methods

A retrospective case-control study was conducted at the AIDS clinic of Peking Union Medical College Hospital from January 2003 to December 2022. The study involved 86 HIV/syphilis co-infected patients and 86 HIV mono-infected patients matched based on age, baseline CD4 + T cell counts, and viral load. We examined the clinical characteristics of HIV/syphilis co-infected patients, evaluated the efficacy of anti-syphilis treatment, and analyzed the dynamic changes in HIV virology and immunology. The Generalized Estimating Equations (GEE) model investigated the factors associated with HIV/syphilis co-infection and syphilis recurrence/reinfection/serofast state.

Results

Syphilis serofast state was observed in 11.6% (10/86) of HIV/syphilis co-infected patients after treatment, and 33.7% (29/86) had syphilis recurrence or re-infection. The overall effectiveness of syphilis treatment stood at 76.8% (63/82). Notably, the effectiveness of syphilis treatment displayed a significant correlation with baseline syphilis titers exceeding 1:128 (p = 0.003). Over the 10-year follow-up period on ART, the HLA-DR + CD8+/CD8 + % levels in the HIV/syphilis co-infected group were markedly higher than those in the HIV mono-infected group (p < 0.05). However, no significant differences were observed between the two groups regarding HIV viral load, CD4+ T cell counts, CD8+ T cell counts, CD4/CD8 ratio, and CD38 + CD8+/CD8 + % (p > 0.05). GEE analysis model revealed that elevated HLA-DR + CD8+/CD8 + % levels were associated with HIV/syphilis co-infection (OR = 1.026, 95% CI = 1.007-1.046; p = 0.007) and syphilis recurrence/reinfection/serofast state (OR = 1.036, 95% CI = 1.008-1.065; p = 0.012).

Conclusion

While HIV/syphilis co-infected patients typically receive adequate treatment, the incidence of syphilis recurrence and reinfection remain notably elevated. A heightened HLA-DR + CD8+/CD8+ % is a notable risk factor for HIV/syphilis co-infection and syphilis recurrence/reinfection/serofast state. Therefore, it is advisable to reinforce health education efforts and ensure regular follow-ups for people living with HIV undergoing ART to monitor syphilis infection or increased risk of syphilis infection.

Neurosyphilis: insights into its pathogenesis, susceptibility, diagnosis, treatment, and prevention

Background and aim

Invasion of the central nervous system by Treponema pallidum can occur at any stage of syphilis. In the event that T. pallidum is not cleared promptly, certain individuals may experience progression to neurosyphilis, which manifests as cognitive and behavioral abnormalities, limb paralysis, and potentially fatal outcomes. Early identification or prevention of neurosyphilis is therefore crucial. The aim of this paper is to conduct a critical and narrative review of the latest information focusing exclusively to the pathogenesis and clinical management of neurosyphilis.

Methodology

To compile this review, we have conducted electronic literature searches from the PubMed database relating to neurosyphilis. Priority was given to studies published from the past 10 years (from 2013 to 2023) and other studies if they were of significant importance (from 1985 to 2012), including whole genome sequencing results, cell structure of T. pallidum, history of genotyping, and other related topics. These studies are classic or reflect a developmental process.

Results

Neurosyphilis has garnered global attention, yet susceptibility to and the pathogenesis of this condition remain under investigation. Cerebrospinal fluid examination plays an important role in the diagnosis of neurosyphilis, but lacks the gold standard. Intravenous aqueous crystalline penicillin G continues to be the recommended therapeutic approach for neurosyphilis. Considering its sustained prominence, it is imperative to develop novel public health tactics in order to manage the resurgence of neurosyphilis.

Conclusion

This review gives an updated narrative description of neurosyphilis with special emphasis on its pathogenesis, susceptibility, diagnosis, treatment, and prevention.

Prevalence of syphilis among people living with HIV who attend a large urban antiretroviral therapy clinic in Panama: a cross-sectional epidemiological study

Background

Syphilis is a serious global public health challenge. Despite prior progress in syphilis control, incidence has been increasing in recent years. Syphilis is a common coinfection among people living with HIV (PLHIV). In Panama, few data describe syphilis prevalence among PLHIV. We describe syphilis antibody and high-titer (⩾1:8) active syphilis prevalence and associated factors among individuals who attended an antiretroviral clinic.

Methods

A cross-sectional study was undertaken during February-March 2022 and September-October 2022 for adults (⩾18 year) assigned male and female at birth, respectively. Participants provided peripheral blood samples and self-administered a questionnaire. Samples were screened using immunochromatography; antibody-positive samples were tested using rapid plasma regain to 1:512 dilutions. Logistic regression was used to identify factors associated with syphilis antibody and high-titer active syphilis.

Results

In all, 378 participants gave blood samples; 377 individuals participated in the questionnaire (216 self-reported male sex [males], 158 female [females], and three intersex individuals). Median age was 36 years (interquartile range: 28-45 years). Overall, syphilis antibody prevalence was 32.3% (122/378) (males, 50.7% [108/2013]; females, 5.7% [9/158]; intersex individuals, 100.0% (3/3)], p < 0.01. High-titer active syphilis was found among 24.6% (n = 30) of samples with positive antibody test (males 27.8% [n = 30], females 0.0% [0/9], intersex individuals 0.0% [0/3]). Antibody positivity was associated in the multivariable model with males (50.7%, AOR = 24.6, 95%CI: 1.57-384.53). High-titer active syphilis was associated with younger participant age (18-30 years, 13.2%, OR = 4.82, 95%CI: 1.17-19.83); 31-40 years, 7.8%, OR = 4.24, 95%CI: 1.04-17.21 versus 3.2% >40 years), homosexual identity (16.0% OR = 34.2, 95%CI: 4.50-259.27 versus 0.6% among heterosexual identity); in the multivariable model, associated with sexual identity (bisexual 19.1%, AOR = 10.89, 95%CI: 1.00-119.06) compared to heterosexual identity (0.6%) and weakly associated with concurrency (⩾1 ongoing sexual relationships, 15.9%, AOR = 3.09, 95%CI: 0.94-10.14).

Conclusion

This study found very high prevalence of syphilis antibodies and high-titer syphilis among PLHIV in Panama. Those most affected are males, younger in age, those who practice concurrent sexual relationships, and those who reported homosexual and bisexual identity. Targeted interventions should include repetitive testing and treatment, especially among individuals who may be at increased infection risk.

Exposure to Treponema pallidum Infection among Adolescent and Young Adult Women in Roraima, Amazon Region of Brazil

BACKGROUND

Syphilis is a chronic infectious disease, and its prevalence has been described since the 15th century. Because of the high prevalence of this infection in Brazil, this study aimed to evaluate the prevalence of syphilis and its associated factors among adolescent and young women living in the city of Boa Vista, Roraima, Brazil.

METHODS

The present study was cross-sectional, descriptive, analytical and quantitative. It involved 200 young and adolescent women. Laboratory tests were performed to diagnose syphilis, and a sociodemographic and epidemiological questionnaire was employed.

RESULTS

In the studied sample, 10 women had a positive result for syphilis, characterizing a prevalence of 5% for infection with Treponema pallidum. There was a statistically significant association between a monthly family income of less than 1 minimum wage and syphilis (p = 0.0449) and between illicit drug use and syphilis (p = 0.0234).

CONCLUSIONS

These results indicate the need for public health interventions, action plans, and the implementation of risk reduction strategies focused on this population.

Meningovascular Syphilis: A Case of a Young Man Presenting With Acute Stroke and Pulmonary Emboli

Syphilis is caused by the spirochete Treponema pallidum and classically progresses through a series of stages with increasing symptomatology if unrecognized and untreated. Importantly, central nervous system invasion can occur at any stage, which can lead to variable presentations of neurosyphilis. One such manifestation is meningovascular syphilis, which causes thrombosis of the cerebral vasculature, leading to stroke-like symptoms such as hemiplegia and aphasia. Young, healthy patients may present with these symptoms without any risk factors typically associated with the pathophysiology of cerebrovascular accidents. Further, patients living with HIV who present with stroke-like symptoms should have an even higher suspicion for neurosyphilis as a potential diagnosis. We present a case report of a 31-year-old male with sudden left-sided weakness and numbness who tested positive for both Treponema pallidum and human immunodeficiency virus (HIV).

Syphilis

Syphilis is a curable systemic infectious disease with a clear increase in incidence in recent years. The disease presents with a broad clinical spectrum and challenges clinicians due to the long incubation period and the sometimes complex interpretation of serological test results. Penicillin G remains the treatment of choice in all stages of syphilis.

Syphilis screening coverage and positivity by HIV treatment status among South African pregnant women enrolled in the 2019 antenatal HIV sentinel survey

We describe coverage of maternal syphilis screening, syphilis positivity, coverage of treatment and their association with maternal HIV infection and antiretroviral treatment (ART) status among pregnant women attending South African antenatal clinics. The 2019 antenatal care sentinel survey was a cross-sectional survey conducted from 1 October to 15 November 2019 at 1589 sentinel sites in all nine provinces of the country and aimed to enrol 36,000 pregnant women ages 15-49 years regardless of HIV, ART or syphilis status. Data collection procedures included obtaining written informed consent, a brief interview, medical record review and blood specimen collection. Completed data collection forms and specimens were sent to designated regional laboratories for data capture and HIV serology testing. Data analysis determined four outcomes i) syphilis screening coverage ii) syphilis positivity iii) coverage of any treatment and iv) with Benzathine penicillin G (BPG). Multivariable logistic regression models with or without interaction between HIV infection and ART status with province were used to determine factors associated with syphilis positivity. Of the 41 598 women enrolled, 35 900 were included in the analysis for syphilis screening coverage. The weighted syphilis screening coverage was 96.4% [95% Confidence Interval (CI) 95.9-96.7%] nationally and was lowest among HIV positive women not on ART at 93.5% (95% CI 92.2-94.5%). Syphilis positivity was 2.6% (95% CI 2.4-2.9%) nationally. Among those who were syphilis positive, 91.9% (95% CI 89.8-93.7%) had documentation of syphilis treatment status, of whom 92.0% (95% CI 89.8-93.9%) were treated, with the majority treated with one or more doses of BPG [92.2% (95% CI 89.8-94.3%)]. HIV-positive women, not on ART [adjusted odd ratio (aOR) 2.24 (95% 1.71-2.93)] and those on ART [aOR 2.25 (95% CI 1.91-2.64)] were more likely to be syphilis positive compared to those who were HIV negative. The national syphilis screening coverage met the global screening target of 95%. Syphilis positivity was higher among HIV positive women compared to negative women. Introduction of rapid syphilis testing and ensuring a universal supply of appropriate treatment for syphilis will reduce the likelihood of mother-to-child transmission of syphilis.

Delayed positivity of serological reactions in secondary syphilis against the background of severe HIV-induced immunosuppression

In recent decades, there has been an increase in syphilis associated with HIV infection cases, especially among men who have sex with men. The global prevalence of syphilitic infection among people living with HIV exceeds population rates. Concomitant HIV infection can affect not just the clinical course of syphilis, but also the production of antibodies to Treponema pallidum. In the presence of severe immunodeficiency in patients with HIV infection associated with secondary syphilis, the results of non-treponemal and/or treponemal tests may be false-negative or may become positive at a later date. Such cases are known, they occur infrequently and cause some diagnostic difficulties. The article presents a clinical observation of delayed positivity of serological reactions in secondary syphilis in a 23-year-old HIV-positive man from the authors' practice. The tactic of managing HIV-infected patients with clinical symptoms of syphilis and negative results of serological tests is discussed.

The Changing Trend of Syphilis: Is It a Sign of Impending Epidemic?

Background

Syphilis is a treatable bacterial infection caused by Treponema pallidum. There has been a change in incidence of syphilis in various nations over the years.

Aim

To study the epidemiological trends, demographic profile, high-risk behaviour, clinical pattern, and stage of syphilis over the last ten years in patients presenting to an STD clinic in a tertiary care hospital.

Material and Methods

This was a retrospective observational study over ten years. Records of all confirmed syphilis cases were analysed in relation to demography and clinical profile.

Results

There were a total of 3,110 STD patients among whom 31 cases (accounting for 0.99%) of confirmed syphilis were seen. There was a significant increase in cases in the last five years of study, especially in the last year. An increase in primary (PS) and secondary syphilis (SS) was observed. Males outnumbered females (3:1). Mean age of patients was 35.0 ± 11.53 years. Professionals were most common (22.6%) having syphilis followed by farmers (19.35%). A significant proportion (45.1%) of our patients were at least graduates. Unprotected sex was seen in all the patients followed by extramarital/premarital sex (71.35%). There were 16.12% of cases who had a history of paid sex and 9.7% were homosexuals. SS and latent syphilis were more common (38.7% each) than PS (19.35%). In PS single chancre and in SS truncal asymptomatic rash was the commonest clinical presentation. Limitation: Single-centre study, including only self-reported patients leading to a small sample size, is the major limitation of the study.

Conclusion

The increased trend of primary and secondary syphilis in recent years highlights that there is a risk of an impending epidemic.

Syphilis Infections, Reinfections and Serological Response in a Large Italian Sexually Transmitted Disease Centre: A Monocentric Retrospective Study

Background: Syphilis infection does not confer definitive and protective immunity against reinfection, and crucial aspects of repeated episodes of syphilis are far from being understood, especially among people living with HIV (PLWH). Methods: In order to explore the burden of syphilis in a large cohort of HIV-negative patients and PLWH, this retrospective study describes the demographics, clinical presentation and treatment outcome of patients with syphilis treated at our clinic from 2013 to 2021. Results: Within the study period, 1859 syphilis episodes (827, 44.5% first infections and 1032, 55.5% reinfections) were recorded. A total of 663 patients, of whom 347 (52%) had PLWH, were considered. Syphilis was mostly diagnosed in males (77%) and European (79%) patients. More than half of syphilis episodes were recorded during the late latent stage (64%) or during follow-up/screening visits for other diseases, while symptomatic stages led to a diagnosis in almost half of HIV-negative patients (p < 0.001). PLWH with syphilis infection were predominantly homo/bisexual (p < 0.001). A significantly higher rate of syphilis reinfection was observed in PLWH, who also demonstrated a higher range of subsequent episodes. The serofast state was found to be similar at the 6- and 12-month follow-up visits. The multivariate analysis carried out in the HIV-positive group showed that an RPR titre >1:16 was an independent predictor for serological non-response. Conclusions: Syphilis reinfections are predominantly diagnosed in HIV-positive MSM. The high rate of asymptomatic presentation among PLWH supports the role of periodical syphilis screening. In PLWH, the only baseline factor associated with an increased risk of non-response was an RPR titre >1:16, while assessment at 12 months after treatment increased the possibility of detecting a serological response, indicating that PLWH have a slower serological response to treatment.

Prevalence and Vulnerability Factors Associated with HIV and Syphilis in Older People from Subnormal Agglomerate, Brazilian Amazon

Background: This study aimed to estimate the prevalence of HIV and syphilis and associated factors among elderly people from subnormal agglomerations in a city in the Brazilian Amazon. Methods: An observational, cross-sectional study was carried out in a subnormal agglomerate from the Brazilian Amazon. Data collection was conducted from August 2021 to February 2022, using a structured questionnaire. Whole blood samples were collected to perform a rapid test for HIV and syphilis. People aged 50 and over were included in the study, and the sample consisted of 213 participants. The odds ratio was calculated by multiple logistic regression. Results: A total of 203 participants with a mean age of 63.5 years were considered (95% CI: 62.4; 64.6; standard deviation: 8.1; minimum age: 50 years and maximum age: 94 years). The prevalence of either HIV or syphilis was 16.4% (35/213; 95% CI: 0.11; 0.21); syphilis was 15.5% (33/213) and HIV was 1.40% (3/213). One coinfection (0.46%; 1/213) was registered. In the final multiple logistic regression, the elderly with an education level of illiterate/elementary were two times more likely to have a positive rapid test result for HIV or syphilis. Conclusions: Testing for HIV and syphilis identified that STI represented a burden on populations affected by socioeconomic inequality.

Cerebrospinal Fluid Changes and Clinical Features of Neurosyphilis Compared with Latent Syphilis Infection in the Central Nervous System: A Cross-Sectional Study

Purpose

At present, there is no gold standard or unified standard for the diagnosis of neurosyphilis, and the rate of misdiagnosis is high. The diagnosis of neurosyphilis is still challenging. This study compared the clinical indicators between neurosyphilis and latent syphilis infection in the central nervous system. The purpose of this study was to provide evidence for the differential diagnosis and prognosis of patients with neurosyphilis and latent syphilis infection of the central nervous system.

Methods

The clinical data of 59 patients with neurosyphilis and 30 patients with latent syphilis infection in the nervous system from 2008 to 2021 were analyzed. The cerebrospinal fluid and serum biochemical markers were evaluated for all patients.

Results

CSF-nucleated cells, CSF-TRUST, CSF-totalprotein and CSF-IgG (P<0.001) were significantly different between neurosyphilis and latent syphilis infection in the central nervous system. CSF-TRUST titer was positively correlated with D-D concentration (r = 0.274, P < 0.05), sodion (r =0.251, P < 0.05), respectively. Glucose concentration is the most unreliable in the diagnosis of neurosyphilis (AUC=0.445, P=0.395), and TRUST combined with nucleated cells and total protein is the most accurate in the diagnosis of neurosyphilis (AUC=0.989, P<0.001).

Conclusion

The combination of TRUST, nucleated cell count and totalprotein detection in CSF can distinguish the patients with neurosyphilis and latent syphilis infection in the central nervous system, which has a significant diagnostic value.

Tertiary Syphilis Masquerading as Oropharyngeal Cancer

Syphilis is re-emerging in the United States. Treponema pallidum, the spirochete bacterium responsible for syphilis, has immunoevasive properties that facilitate pathogenesis and widespread tissue involvement. Host immune status, particularly the presence of HIV/AIDS, can influence the presentation and severity of the disease. Patients co-infected with HIV and syphilis may develop atypical lesions, including those involving the oropharynx. Any immunocompromised patient with tongue lesions and lymphadenopathy is presumed to have a wide differential diagnosis, and tissue sampling with histopathologic analysis is indicated. We present a patient with gumma of the tongue as the initial manifestation of tertiary syphilis.

Point-of-Care Diagnostics for Diagnosis of Active Syphilis Infection: Needs, Challenges and the Way Forward

Syphilis, a curable sexually transmitted infection, has re-emerged as a global public health threat with an estimated 5.6 million new cases every year. Pregnant women and men who have sex with men are key target populations for syphilis control and prevention programs. Frequent syphilis testing for timely and accurate diagnosis of active infections for appropriate clinical management is a key strategy to effectively prevent disease transmission. However, there are persistent challenges in the diagnostic landscape and service delivery/testing models that hinder global syphilis control efforts. In this commentary, we summarise the current trends and challenges in diagnosis of active syphilis infection and identify the data gaps and key areas for research and development of novel point-of-care diagnostics which could help to overcome the present technological, individual and structural barriers in access to syphilis testing. We present expert opinion on future research which will be required to accelerate the validation and implementation of new point-of-care diagnostics in real-world settings.

A 2021 Update on Syphilis: Taking Stock from Pathogenesis to Vaccines

In 2021 the scientific community's efforts have been focused on solving the back-breaking challenge of the COVID-19 pandemic, but sexually transmitted infections (STI) are still one of the most common global health problems. Syphilis is a systemic disease caused by the spirochaete Treponema pallidum (TP) and is one of the oldest known diseases. Its incidence has increased in the last few years and syphilis still remains a contemporary plague that continues to afflict millions of people worldwide. Despite research improvements, syphilis pathogenesis is not completely clear; clinical presentation is very heterogeneous and the diagnosis can sometimes be difficult. Furthermore, few therapeutic options are available, and a vaccine has not been found yet. In this review, we describe the most recent evidence concerning the clinical manifestation, diagnosis, treatment and vaccine prospectives for this disease.