Early Syphilis Among Men Who Have Sex with Men in the US Pacific Northwest, 2008-2013: Clinical Management and Implications for Prevention

Factors Associated With Increased Syphilis Screening Among People Living With Human Immunodeficiency Virus

BACKGROUND

Antiretroviral therapy effectively reduces the risk of human immunodeficiency virus transmission, but in the context of undetectable equals untransmittable and decreased condom use, rates of syphilis are increasing. In Oregon, syphilis has risen over 20-fold in the past decade, from less than 30 to approximately 600 cases annually during 2016 and 2017. Although many cases are among people living with human immunodeficiency virus infection (PLWH), screening for syphilis among PLWH is often lacking. The objective of this study was to estimate the prevalence of past-year syphilis testing among PLWH in Oregon to identify facility-level and individual-level factors associated with testing.

METHODS

We examined 2015 to 2016 Medical Monitoring Project interview and medical records data in Oregon and conducted supplemental interviews with participants' medical providers. We used generalized mixed effects models to identify factors associated with syphilis screening.

RESULTS

Sixty-nine percent of Medical Monitoring Project participants had past-year syphilis screening. Patients receiving care from facilities with written sexually transmitted infection screening policies were far more likely to be screened than those receiving care from facilities without written policies (94% vs. 43%, P < 0.001). Participants who identified as male were more likely to have been tested, even after adjusting for facility-level characteristics. Clustering within facility accounted for about 15% of the unexplained variability in the adjusted mixed effects models.

CONCLUSIONS

Written sexually transmitted infection screening policies at medical facilities appear to be an important tool for ensuring syphilis screening occurs as recommended to prevent the continued rise in syphilis.

As through a glass, darkly: the future of sexually transmissible infections among gay, bisexual and other men who have sex with men

The trajectory of sexually transmissible infection (STI) incidence among gay and other men who have sex with men (MSM) suggests that incidence will likely remain high in the near future. STIs were hyperendemic globally among MSM in the decades preceding the HIV epidemic. Significant changes among MSM as a response to the HIV epidemic, caused STI incidence to decline, reaching historical nadirs in the mid-1990s. With the advent of antiretroviral treatment (ART), HIV-related mortality and morbidity declined significantly in that decade. Concurrently, STI incidence resurged among MSM and increased in scope and geographic magnitude. By 2000, bacterial STIs were universally resurgent among MSM, reaching or exceeding pre-HIV levels. While the evidence base necessary for assessing the burden STIs among MSM, both across time and across regions, continues to be lacking, recent progress has been made in this respect. Current epidemiology indicates a continuing and increasing trajectory of STI incidence among MSM. Yet increased reported case incidence of gonorrhoea is likely confounded by additional screening and identification of an existing burden of infection. Conversely, more MSM may be diagnosed and treated in the context of HIV care or as part of routine management of pre-exposure prophylaxis (PrEP), potentially reducing transmission. Optimistically, uptake of human papillomavirus (HPV) vaccination may lead to a near-elimination of genital warts and reductions in HPV-related cancers. Moreover, structural changes are occurring with respect to sexual minorities in social and civic life that may offer new opportunities, as well as exacerbate existing challenges, for STI prevention among MSM.

Investigation of Early Syphilis Trends Among Men Who Have Sex With Men to Identify Gaps in Screening and Case-Finding in Baltimore City, Maryland

BACKGROUND

Syphilis incidence is increasing across the United States among men who have sex with men (MSM). Early latent (EL) versus primary and secondary (P&S) syphilis may be an indicator of delayed diagnosis and increased opportunity for transmission. To inform syphilis control strategies and identify potential gaps in case finding, we described recent syphilis trends among MSM and compared characteristics of syphilis cases by diagnosis stage.

METHODS

We used public health surveillance data on P&S and EL syphilis diagnoses reported to the Baltimore City Health Department between 2009 and 2015. Differences across diagnosis stage were assessed using Cochran-Armitage and χ tests.

RESULTS

Between 2009 and 2015, Baltimore City Health Department received 2436 reports of P&S and EL diagnoses. The majority (61%) of reports were among MSM, among whom 86% were black and 67% were human immunodeficiency virus (HIV)-infected. During this period, P&S and EL syphilis increased by 85% and 245%, respectively (P < 0.0001). MSM with EL versus P&S syphilis were similarly likely to be Black, more likely to be older (P < 0.05), HIV coinfected (P < 0.001), and diagnosed in private health care settings (P < 0.0001), but less likely to report multiple (P < 0.001) and anonymous sex partners (P < 0.001).

CONCLUSIONS

In Baltimore City, syphilis diagnoses, particularly EL diagnoses, are increasing rapidly and are concentrated among Black HIV-infected MSM. Significant gaps in identifying MSM with P&S syphilis may exist, specifically among HIV-infected MSM, and those diagnosed in private health care settings. Strategies to address these gaps may include local guidelines and provider education to screen MSM more frequently than CDC currently recommends and regardless of HIV status or risk.

Syphilis ascendant: a brief history and modern trends

To provide a miniature review of recent literature surrounding a brief history of syphilis, to discuss the recently increasing incidence of syphilis, to discuss recent United State Preventative Service Task Force recommendations for syphilis screening, and to discuss congenital syphilis. The literature review was conducting using PubMed with the following search terms: syphilis, congenital syphilis, MSM and syphilis, prenatal syphilis, neurosyphilis, and other related terms. Treponema pallidum has been a constant, and unwanted, companion of humankind since antiquity. This sexually transmitted infection (STI) has the potential to affect virtually every rung of society-young and old, rich and poor, but it has a proclivity for the most vulnerable groups among us. Since record high rates of infection in the World War II era, tremendous progress has been made in effectively controlling the infection, and this has been largely mediated by the efficacy of penicillin on the causative spirochete. However, 2014 data from the Centers for Disease Control and Prevention demonstrated a sharp increase in the rate of new cases of syphilis, predominantly in men who have sex with men. Additionally, the numbers of newly diagnosed cases of congenital syphilis are on the rise as well. In effect, a burgeoning crisis has come to the doorstep of the medical community. We are faced with changing attitudes regarding sexual interactions. The authors believe that geolocation dating and sex applications for smart phones increase the availability of sexual encounters. Pre-exposure prophylaxis may be leading to more laissez-faire attitudes toward unprotected intercourse, and with increased opportunities for sexual encounters, co-infected states with other diseases may be altering the landscape of STIs. In 2016, in response to increasing rates of newly diagnosed syphilis, the United States Preventative Health Services Task Force reaffirmed the need for syphilis screening in at-risk populations. However, primary care physicians and advanced practice providers may not always be aware of which patients fall into that category. Due to the highly personal nature of discussing sexuality, sexual behavior may not be explored at all. Numerous challenges lie ahead of the infectious diseases, primary care, and public health communities in attempting to bend the curve of the ascendant rise in syphilis. To adequately combat this infection, sufficient funding will need to be provided to public health departments, adequate access to health care resources will be needed to allow for the necessary screening of patients, and primary care practitioners will need thoroughly engage with their patients to understand their sexual practices and to offer the necessary interventions.