Syphilis Testing Among Sexually Active Men Who Have Sex With Men and Who Are Receiving Medical Care for Human Immunodeficiency Virus in the United States: Medical Monitoring Project, 2013-2014

Performance of an Electronic Medical Record-Based "Syphilis Flag" in Identifying At-Risk Patients in an Emergency Department

BACKGROUND

The United States has seen a > 40% increase in syphilis cases since 2017. Early disease identification and treatment are crucial. This review sought to identify emergency department (ED) patients at risk for syphilis.

METHODS

A 30-day retrospective review was conducted of visits to a single ED. Patient visits were assessed for predetermined syphilis "flags" to include a history of sexually transmitted infection (STI), current chief complaint or reason for visit (RFV) keyword(s) suggestive of potential STI or a positive pregnancy test result. Flagged charts were assessed for STI testing results within 6 months of ED visit. Data were analyzed using χ2 .

RESULTS

There were 5537 total patient encounters, resulting in 455 flagged visits from 408 (8.4%) unique individuals, majority of whom were female (282, 69.1%; P < 0.001), Black (251, 61.5%; P < 0.001), aged 15 to 44 years (308, 75.5%; P < 0.001). Chief complaint was the most frequent flag (65.3%), followed by RFV (37.4%), prior STI (31.0%), and pregnancy (12.3%). Syphilis testing data were available for 120 flagged patients; 29 (24.2%) screened positive, including 11 (2.7% of total flagged cohort) with evidence for active infection. Among those, most were Black (90.9%), male (72.7%), aged 25 to 34 years (63.6%), and 9 (81.8%) had concomitant HIV. In active infection, prior STI flag was most common (72.7%), followed by chief complaint (54.5%) and RFV (45.5%).

CONCLUSIONS

This review demonstrates the performance of an electronic medical record-based "syphilis risk flag" screener applied to ED patients. Sex- and race-based discrepancies exist in flag rates, which may be reflective of sex- and race-based epidemiologic discrepancies in STI incidence.

HIV Infection Modifies the Role of Prior Treponema pallidum Infection in the Clinical Presentation of Early Syphilis Among Adult Patients From Sexually Transmitted Infection Clinics in Peru

BACKGROUND

We aimed to compare the clinical presentations (symptomatic vs. asymptomatic) with prior Treponema pallidum infection status (first infection vs. reinfection) among people with early syphilis.

METHODS

We used data from PICASSO, a cohort study in Peru that enrolled people with active syphilis from May 2019 to August 2021. Study participants had early syphilis and a prior syphilis serological test result within the prior 12 months to determine prior T. pallidum infection status. We calculated prevalence ratios (PRs) of symptomatic clinical presentation (primary or secondary syphilis) by prior T. pallidum infection status, stratified by HIV infection status. In addition, we explored the association of prior T. pallidum infection status and lesion presentation, stratified by primary and secondary syphilis cases, using the Fisher exact test.

RESULTS

We include 84 T. pallidum reinfection cases and 61 first infection cases. We found increased frequency of symptomatic clinical presentation among first-infection cases (39% vs. 20%; PR, 1.94; P = 0.014). This association was stronger among persons living without HIV infection (38% vs. 7%; adjusted PR, 6.63; P = 0.001) in comparison to those living with HIV infection (45% vs. 34%; adjusted PR, 1.38; P = 0.458). Among secondary syphilis cases, more participants from the reinfection group reported that their lesions improved 1 week after treatment (100% vs. 29%, P = 0.045) compared with those with a first infection. Among the primary syphilis cases, all participants reported that their lesions improved 1 week after treatment.

CONCLUSIONS

Prior syphilis was associated with a decreased prevalence of symptomatic reinfection, especially among persons not living with HIV infection.

Syphilis Screening Among Young Black Men Who Have Sex With Women in New Orleans, LA

BACKGROUND

Current US syphilis screening focuses on men who have sex with men (MSM), because of the increased risk of infection in their sexual networks, and on pregnant people, because of complications associated with congenital syphilis. However, screening for men who have sex with women (MSW) who are at increased risk of syphilis is also recommended. Factors associated with syphilis testing and positivity were assessed among young, Black MSW.

METHODS

Data from the Check It study-a seek, test, and treat study for chlamydia in New Orleans, LA, among Black MSW aged 15 to 26 years-were used. Survey data were used to elicit self-reported syphilis testing, self-reported testing results, and sociodemographic and behavioral factors associated with these 2 outcomes.

RESULTS

Per the Centers for Disease Control and Prevention, all men in the study were recommended for syphilis screening because of their age, race, and geographic location. Of the 1458 men included, 272 (18.7%) reported ever having been syphilis tested, 267 men reported their results, and 23 (8.6%) reported testing positive. In logistic regression, older age (odds ratio [OR], 1.21 per year older; P < 0.001), prior Chlamydia trachomatis , Neisseria gonorrhoeae , and/or HIV testing (OR, 50.32; P < 0.001), and younger age at sexual debut (0.90 per year older, P = 0.005) were significantly associated with prior syphilis testing. In addition, testing positive for C. trachomatis and/or N. gonorrhoeae during the study was significantly associated with a history of syphilis positivity (OR, 3.08; P = 0.031).

CONCLUSIONS

Although syphilis testing was associated with factors that might increase the risk of acquisition, only 19% of individuals meeting Centers for Disease Control and Prevention testing recommendations had ever been screened.

Epidemiological analysis of syphilis surveillance among entry-exit population at Shanghai Port, China from 2014 to 2022

OBJECTIVE

To investigate the epidemiological characteristics of syphilis cases detected among entry-exit personnel at Shanghai ports from 2014 to 2022 and the changing trend of the syphilis epidemic in the region so as to provide data support for the scientific and effective prevention and control of syphilis at ports.

METHODS

From January 2014 to December 2022, the subjects of syphilis screening at Shanghai port were selected. Physical examination and serological testing were used to confirm syphilis. All the data used were downloaded from the HIS system of Shanghai International Travel Healthcare Center. Descriptive epidemiology was used to analyze the characteristics of the detected cases, and the linear trend Chi-square test was used to analyze the trend between groups.

RESULTS

From 2014 to 2022, a total of 918 cases of syphilis were detected among entry-exit personnel at Shanghai port, with a total detection rate of 154.68/100 000. The detection rate was the highest in 2015 and the lowest in 2022, showing a downward trend year by year since 2015. 54.36% of syphilis patients from East Asia were detected. Syphilis cases were reported in all age groups; most cases were under 39 years old, accounting for 36.06%. The syphilis detection rate in males was significantly higher than in females (79.63% vs. 20.4%). The main way of transmission was sexual transmission, accounting for 60.89%, among which male-to-male transmission was the primary way (22.36%).

CONCLUSION

The detection rate of syphilis among entry-exit personnel at Shanghai port has been decreasing continuously in recent years. Targeted health intervention should be carried out according to the monitoring results.

Management of Adult Syphilis: Key Questions to Inform the 2021 Centers for Disease Control and Prevention Sexually Transmitted Infections Treatment Guidelines

A panel of experts generated 5 "key questions" in the management of adult syphilis. A systematic literature review was conducted and tables of evidence were constructed to answer these questions. Available data suggest no clinical benefit to >1 dose of benzathine penicillin G for early syphilis in human immunodeficiency virus (HIV)-infected patients. While penicillin remains the drug of choice to treat syphilis, doxycycline to treat early and late latent syphilis is an acceptable alternate option if penicillin cannot be used. There are very limited data regarding the impact of additional antibiotic doses on serologic responses in serofast patients and no data on the impact of additional antibiotic courses on long-term clinical outcomes. In patients with isolated ocular or otic signs and symptoms, reactive syphilis serologic results, and confirmed ocular/otic abnormalities at examination, a diagnostic cerebrospinal fluid (CSF) examination is not necessary, because up to 40% and 90% of patients, respectively, would have no CSF abnormalities. Based on the results of 2 studies, repeated CSF examinations are not necessary for HIV-uninfected patients or HIV-infected patients on antiretroviral therapy who exhibit appropriate serologic and clinical responses after treatment for neurosyphilis. Finally, several important gaps were identified and should be a priority for future research.

Countering the rise of syphilis: A role for doxycycline post-exposure prophylaxis?

Doxycycline post-exposure prophylaxis (PEP) holds the potential to mitigate increasing rates of syphilis among sexual minority men (SMM) in the US yet has received limited attention. Since evaluation of this intervention in actual populations is not currently feasible, we used agent-based models (ABM) to assess the population-level impact of this strategy. We adapted ABM of HIV and HPV transmission, representing a population of 10,230 SMM in Philadelphia, Pennsylvania, US. Parameter inputs were derived from the literature, and ABM outputs during the pre-intervention period were calibrated to local surveillance data. Intervention scenarios varied doxycycline uptake by 20, 40, 60, 80 and 100%, while assuming continued condom use and syphilis screening and treatment. Under each intervention scenario, we incorporated treatment adherence at the following levels: 0, 20, 40, 60, 80 and 100%. Long-term population impact of prophylactic doxycycline was measured using the cumulative incidence over the 10-year period and the percentage of infections prevented attributable to doxycycline at year 10. An uptake scenario of 20% with an adherence level of 80% would reduce the cumulative incidence of infections by 10% over the next decade, translating to 57 fewer cases per 1000 SMM. At year 10, under the same uptake and adherence level, 22% of infections would be prevented due to doxycycline PEP in the instances where condoms were not used or failed. Findings suggest that doxycycline PEP will have a modest impact on syphilis incidence when assuming a reasonable level of uptake and adherence. Doxycycline PEP may be most appropriate as a secondary prevention measure to condoms and enhanced syphilis screening for reducing infections among SMM.

Syphilis testing and diagnosis among people with HIV engaged in care at four United States clinical sites, 2014-2018

BACKGROUND

Despite rising rates of syphilis among people with HIV (PWH) in the United States, there is no optimal syphilis screening frequency or prioritization.

METHODS

We reviewed records of all PWH in care between January 1, 2014 and November 16, 2018 from four sites in the CFAR Network of Integrated Clinical Systems Cohort (CNICS; N=8455). We calculated rates of syphilis testing and incident syphilis and used Cox proportional hazards models modified for recurrent events to examine demographic and clinical predictors of testing and diagnosis.

RESULTS

Participants contributed 29568 person-years of follow-up. The rate of syphilis testing was 118 tests per 100 person-years (95%CI: 117-119). The rate of incident syphilis was 4.7 cases per 100 person-years (95%CI: 4.5-5.0). Syphilis diagnosis rates were highest among younger cisgender MSM and transgender women, Hispanic individuals, people who inject drugs, and those with detectable HIV RNA, rectal infections, and hepatitis C.

CONCLUSION

We identified PWH who may benefit from more frequent syphilis testing and interventions for syphilis prevention.

Sexually Transmitted Infections Treatment Guidelines, 2021

These guidelines for the treatment of persons who have or are at risk for sexually transmitted infections (STIs) were updated by CDC after consultation with professionals knowledgeable in the field of STIs who met in Atlanta, Georgia, June 11-14, 2019. The information in this report updates the 2015 guidelines. These guidelines discuss 1) updated recommendations for treatment of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis; 2) addition of metronidazole to the recommended treatment regimen for pelvic inflammatory disease; 3) alternative treatment options for bacterial vaginosis; 4) management of Mycoplasma genitalium; 5) human papillomavirus vaccine recommendations and counseling messages; 6) expanded risk factors for syphilis testing among pregnant women; 7) one-time testing for hepatitis C infection; 8) evaluation of men who have sex with men after sexual assault; and 9) two-step testing for serologic diagnosis of genital herpes simplex virus. Physicians and other health care providers can use these guidelines to assist in prevention and treatment of STIs.

Syphilitic infection impairs immunity by inducing both apoptosis and pyroptosis of CD4+ and CD8+ T lymphocytes

Syphilis is an important health problem worldwide; however, few studies have probed the impact of syphilitic infection on T cell turnover. The mechanisms behind the frequency of T cell subset changes and the associations between these subsets during syphilitic infection remain unclear. Herein, we used a cell-staining method and flow cytometry to explore changes in T cell subpopulations and potential contribution of apoptosis and pyroptosis that triggered therein. We investigated caspase-1-mediated pyroptosis and caspase-3-mediated apoptosis of CD4⁺ and CD8⁺ T cells, the major effector lymphocytes with pivotal roles in the pathogenesis of infectious diseases. We found that the levels of caspase-1 and caspase-3 increased in both the circulation and intracellularly in CD4⁺ and CD8⁺ T cells. Caspase-1 showed a continual increase from early latent stage infection through to phase 2 disease, whereas caspase-3 increased through to phase 1 disease but declined during phase 2. In addition, serum levels and intracellular expression of caspase-1 and caspase-3 were positively correlated. Overall, this study increases our understanding of how syphilitic infection influences CD4⁺ and CD8⁺ T-cell turnover, which may help with designing novel and effective strategies to control syphilis infection and prevent its transmission.

Syphilis Testing among Men Who Have Had Rectal Gonorrhea and Chlamydia Tests, United States

The Centers for Disease Control and Prevention (CDC) recommends syphilis screening at least annually for sexually active men who have sex with men (MSM). The objective of this study is to assess the frequency of MSM testing for syphilis and how syphilis test results compared with results of rectal gonorrhea and chlamydia tests. In collaboration with a large US commercial laboratory, we identified men aged 15-60 years who had rectal chlamydia or gonorrhea tests during 09/01/2013-09/30/2015 as presumed MSM. We classified MSM as having current or past syphilis if during the study period they had (1) either a reactive qualitative non-treponemal test or at least a 1:1 quantitative non-treponemal test, and (2) they had a reactive treponemal test. Of 52,771 MSM, 14.3% had no syphilis testing, 4.8% had only treponemal testing (37.8% were reactive), 63.2% had only non-treponemal testing (2.0% were reactive), and 17.7% had both non-treponemal and treponemal testing (86.6% had current or past syphilis). Of those MSM who had reactive qualitative non-treponemal tests, at least 90% had no quantitative non-treponemal tests. Current or past syphilis was more common among MSM with positive rectal gonorrhea or chlamydia tests (24.1%) than MSM with negative rectal gonorrhea and chlamydia tests (13.0%, p < 0.005). Of MSM with any syphilis testing during 09/01/2013-09/30/2014, 64.8% also had annual repeat testing. Syphilis testing in general and repeat syphilis testing were frequent but suboptimal among MSM. It is important to continually monitor syphilis for MSM, especially for those MSM who had rectal chlamydia or gonorrhea infection.

Syphilis among adult males with a history of male-to-male sexual contact living with diagnosed HIV in New York State (excluding New York City): The challenge of intersecting epidemics

Since 2009, syphilis has been increasing in New York State (NYS) excluding New York City (NYC) among men with a history of male-to-male sexual contact (MSM). Because MSM make up a disproportionate number of new HIV infections, this study aims to: 1) establish yearly rates of early syphilis diagnosis, 2) assess factors associated with early syphilis diagnosis, and 3) describe missed opportunities for earlier diagnosis of syphilis among MSM living with diagnosed HIV(MSMLWDH) in NYS, excluding NYC. A cohort of adult MSMLWDH alive in 2013 were followed through 2016 to identify individuals with at least one early syphilis diagnosis between July 2014 and December 2016. Early syphilis diagnosis rates were calculated for 2015 and 2016. Crude relative risks and 95% confidence intervals were calculated to determine associations between available covariates and both syphilis diagnosis and missed opportunities. Missed opportunities were defined as reports of an HIV-related laboratory test within a given window corresponding to syphilis staging where syphilis testing was not performed at the same time. Of 7,512 MSMLWDH, 50.0% were non-Hispanic white, 85.4% aged ≥35, and 320(4.3%) had an early syphilis diagnosis. Yearly rates were: 1,838/100,000, and 1,681/100,000 in 2015 and 2016, respectively. Persons who were non-Hispanic black, living with diagnosed HIV for less than three years, aged <45, and were always virally suppressed or always in HIV care were significantly more likely to have a syphilis diagnosis. Over half of individuals had evidence of a missed opportunity for earlier syphilis diagnosis. Syphilis stage at diagnosis, older age, and syphilis diagnosis not concurrent with an HIV-related laboratory test were associated with a higher likelihood of having a missed opportunity. This study supports high interrelatedness of the syphilis and HIV epidemics among MSM. Since syphilis can impact HIV viral load suppression status, efforts to end the HIV epidemic need to be coupled with syphilis elimination efforts.

Neurosyphilis: Old Disease, New Implications for Emergency Physicians

Recent epidemiologic data demonstrate increasing rates of neurosyphilis, particularly among those in the community of men who have sex with men and those coinfected with the human immunodeficiency virus (HIV). Here we discuss a case of early neurosyphilis and new HIV diagnosis in a 27-year-old previously-healthy trans woman presenting for the second time with progressive, ascending weakness and cranial nerve VI palsy. Emergency physicians should consider this rare but highly morbid diagnosis, given the rising prevalence of neurosyphilis among at-risk patients and those with new neurologic deficits.

Immunological Changes in Monocyte Subsets and Their Association With Foxp3+ Regulatory T Cells in HIV-1-Infected Individuals With Syphilis: A Brief Research Report

The incidence of syphilis has increased dramatically in men who have sex with men (MSM), especially those with HIV-1 infection. Treponema pallidum and HIV-1 are bidirectionally synergistic, accelerating disease progression reciprocally in co-infected individuals. We have shown that monocytes have different effects on T helper cells at different stages of HIV-1 infection. However, the immunological changes in the three monocyte subsets and in regulatory T cells (Tregs), and the associations between these cell types during syphilis infection among HIV-1-infected MSM remain unclear. Herein, we used cell staining methods to explore changes in monocyte subsets and Tregs and any associations between these cells. We found that the frequency of classical monocytes was higher in the rapid plasma reagin (RPR⁺) group than in the healthy controls (HCs) and the chronic HIV-1 infection (CHI) plus RPR⁺ (CHI&RPR⁺) group. The frequencies of Foxp3⁺CD25⁺CD45RA⁺ and Foxp3⁺Helios⁺CD45RA⁺ Tregs were significantly higher in the RPR⁺, CHI, and CHI&RPR⁺ groups than in HCs, whereas the frequency of CD45RA⁺ Tregs was lower in the CHI&RPR⁺ group than in CHI group. The frequencies of Foxp3⁺CD25⁺CD45RO⁺ and Foxp3⁺Helios⁺CD45RO⁺ Tregs were lower in the RPR⁺, CHI, and CHI&RPR⁺ groups than in HCs. The frequency of intermediate monocytes was inversely correlated with the frequency of CD45RA⁺ Tregs and positively correlated with the frequency of CD45RO⁺ Tregs. These results demonstrate for the first time that intermediate monocytes control the differentiation of Treg subsets in Treponema pallidum/HIV-1 co-infections. These findings provide new insights into an immunological mechanism involving monocytes/Tregs in HIV-infected individuals with syphilis.