The Courage to Learn From Our Failures: Syphilis Control in Men Who Have Sex With Men

Enhancing the Control of Syphilis Among Men Who Have Sex With Men by Focusing on Acute Infectious Primary Syphilis and Core Transmission Groups

The syphilis epidemic among men who have sex with men (MSM) has been increasing steadily. Many syphilis control programs focus on assuring treatment of all persons diagnosed with early syphilis without prioritizing acute primary syphilis or specific subgroups. Acute primary syphilis is highly infectious and contributes to a high proportion of new cases. Surveillance data show that among MSM with incident syphilis (primary or secondary) only about 35% are identified in the primary stage, indicating that most primary cases are missed and untreated. Patients with primary syphilis and large numbers of sex partners may play a major role in maintaining syphilis transmission. Considering those issues, sexually transmitted disease (STD) programs should consider increasing their focus on primary syphilis by assigning primary cases the highest priority, expanding client and clinician health education, and increasing the detection of primary syphilis through increased serologic screening frequency among high-risk MSM. Furthermore, syphilis control programs should implement steps to identify asymptomatic high-probable occult primary cases based on low titer (≤1:8) and recent seroconversion. Finally, to address core transmission groups, programs should implement periodic risk assessment to identify persons with a high number of sex partners and offer these individuals risk-reduction counseling, case management, and selective syphilis preexposure or postexposure doxycycline chemoprophylaxis. Although reprioritizing prevention efforts might be challenging, the Centers for Disease Control and Prevention, community advocacy groups, university STD research centers, and national STD prevention training centers can assist by providing support for consensus discussions and direction in developing operational guidance, some of which may be best delivered through STD and human immunodeficiency virus program partnerships.

It's the network, stupid: a population's sexual network connectivity determines its STI prevalence

There is little consensus as to why sexually transmitted infections (STIs), including HIV and bacterial vaginosis (BV) are more prevalent in some populations than others. Using a broad definition of sexual network connectivity that includes both structural and conductivity-related factors, we argue that the available evidence suggests that high prevalence of traditional STIs, HIV and BV can be parsimoniously explained by these populations having more connected sexual networks. Positive feedback, whereby BV and various STIs enhance the spread of other STIs, then further accentuates the spread of BV, HIV and other STIs. We review evidence that support this hypothesis and end by suggesting study designs that could further evaluate the hypothesis, as well as implications of this hypothesis for the prevention and management of STIs.

It's the network, stupid: a population's sexual network connectivity determines its STI prevalence

There is little consensus as to why sexually transmitted infections (STIs), including HIV and bacterial vaginosis (BV) are more prevalent in some populations than others. Using a broad definition of sexual network connectivity that includes both structural and conductivity-related factors, we argue that the available evidence suggests that high prevalence of traditional STIs, HIV and BV can be parsimoniously explained by these populations having more connected sexual networks. Positive feedback, whereby BV and various STIs enhance the spread of other STIs, then further accentuates the spread of BV, HIV and other STIs. We review evidence that support this hypothesis and end by suggesting study designs that could further evaluate the hypothesis, as well as implications of this hypothesis for the prevention and management of STIs.

Déjà vu? A Comparison of Syphilis Outbreaks in Houston, Texas

BACKGROUND

After reaching an all-time low in 2000, syphilis incidence in the United States has increased as the burden shifted from heterosexuals to men who have sex with men (MSM). Houston, Texas, experienced 2 outbreaks of syphilis during this transformation in trends. Further evaluation is necessary to determine if these outbreaks occurred among the same subpopulations.

METHODS

Surveillance data collected on all reported infectious syphilis cases in Houston from 1971 to 2013 were analyzed. Trends in incidence among MSM and human immunodeficiency virus-positive Houston residents were examined. Peak syphilis years subsequent to 1999, years 2007 and 2012, were compared to determine if outbreaks arose in distinctive subpopulations. Categorical variables between these years were compared using chi-square and Fisher's exact tests, whereas further associations between the years were evaluated using multivariable logistic regression.

RESULTS

Incidence among MSM was 20.9 to 32.1 times higher than other men from 2005 to 2013. After adjusting for covariates, cases in 2012 were significantly more likely to be Hispanic (adjusted odds ratio [AOR] = 1.61; 95% confidence interval [95% CI], 1.03-2.53), reported meeting partners via the Internet (AOR, 1.74; 95% CI, 1.18-2.58), and engaged in anonymous sex (AOR, 1.92; 95% CI, 1.40-2.63) in comparison to cases in 2007.

CONCLUSIONS

We found marked disparities of syphilis by subpopulation in Houston. Herein, we present evidence that outbreaks have been distinct in a major southern city with a high burden of syphilis.

A double-edged sword: does highly active antiretroviral therapy contribute to syphilis incidence by impairing immunity to Treponema pallidum?

BACKGROUND AND HYPOTHESIS

Recently, the world has experienced a rapidly escalating outbreak of infectious syphilis primarily affecting men who have sex with men (MSM); many are taking highly active antiretroviral therapy (HAART) for HIV-1 infection. The prevailing hypothesis is that HAART availability and effectiveness have led to the perception among both individuals who are HIV-1 infected and those who are uninfected that HIV-1 transmission has become much less likely, and the effects of HIV-1 infection less deadly. This is expected to result in increased sexual risk-taking, especially unprotected anal intercourse, leading to more non-HIV-1 STDs, including gonorrhoea, chlamydia and syphilis. However, syphilis incidence has increased more rapidly than other STDs. We hypothesise that HAART downregulates the innate and acquired immune responses to Treponema pallidum and that this biological explanation plays an important role in the syphilis epidemic.

METHODS

We performed a literature search and developed a mathematical model of HIV-1 and T. pallidum confection in a population with two risk groups with assortative mixing to explore the consequence on syphilis prevalence of HAART-induced changes in behaviour versus HAART-induced biological effects.

CONCLUSIONS AND IMPLICATIONS

Since rising syphilis incidence appears to have outpaced gonorrhoea and chlamydia, predominantly affecting HIV-1 positive MSM, behavioural factors alone may be insufficient to explain the unique, sharp increase in syphilis incidence. HAART agents have the potential to alter the innate and acquired immune responses in ways that may enhance susceptibility to T. pallidum. This raises the possibility that therapeutic and preventative HAART may inadvertently increase the incidence of syphilis, a situation that would have significant and global public health implications. We propose that additional studies investigating the interplay between HAART and enhanced T. pallidum susceptibility are needed. If our hypothesis is correct, HAART should be combined with enhanced patient management including frequent monitoring for pathogens such as T. pallidum.

Infectious syphilis in women: what's old is new again?

The aim of this study was to examine trends in infectious syphilis epidemiology among women in Winnipeg, Canada. A descriptive study of syphilis among Winnipeg residents between 2003 and 30 June 2015 was undertaken. Adjusted rate ratios (ARR) and 95% confidence intervals (95%CI) from Poisson regression analyses are reported. Characteristics of men and women were compared using logistic regression, with adjusted odds ratios (AOR) reported. Between 2014 and 2015, the rate of syphilis was 1.7/100,000, representing a five-fold increase since 2006-2013. All cases have been heterosexual, 90% 20-39 years of age, and 59% living in Winnipeg's inner core. Approximately 24% were pregnant at diagnosis; no cases of congenital syphilis have been reported. Compared to men, women were more likely to report alcohol use (AOR: 3.8, 95% CI: 1.2-11.9) and co-infection with chlamydia (AOR: 5.0, 95% CI: 1.1-22.9). In conclusion, the rates of infectious syphilis are increasing among women. Prenatal screening and education for inner-core women and the health care providers serving them should be prioritized.

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

Substantial increases in syphilis during 2008-2013 were reported in the US Pacific Northwest state of Oregon, especially among men who have sex with men (MSM). The authors aimed to characterize the ongoing epidemic and identify possible gaps in clinical management of early syphilis (primary, secondary, and latent syphilis ≤1 year) among MSM in Multnomah County, Oregon to inform public health efforts. Administrative databases were used to examine trends in case characteristics during 2008-2013. Medical records were abstracted for cases occurring in 2013 to assess diagnosis, treatment, and screening practices. Early syphilis among MSM increased from 21 cases in 2008 to 229 in 2013. The majority of cases occurred in HIV-infected patients (range: 55.6%-69.2%) diagnosed with secondary syphilis (range: 36.2%-52.4%). In 2013, 119 (51.9%) cases were diagnosed in public sector medical settings and 110 (48.0%) in private sector settings. Over 80% of HIV-infected patients with syphilis were in HIV care. Although treatment was adequate and timely among all providers, management differed by provider type. Among HIV-infected patients, a larger proportion diagnosed by public HIV providers than private providers were tested for syphilis at least once in the previous 12 months (89.6% vs. 40.0%; p < 0.001). The characteristics of MSM diagnosed with early syphilis in Multnomah County remained largely unchanged during 2008-2013. Syphilis control measures were well established, but early syphilis among MSM continued to increase. The results suggest a need to improve syphilis screening among private clinics, but few gaps in clinical management were identified.

Syphilis Experiences and Risk Perceptions Among Repeatedly Infected Men Who Have Sex with Men

CONTEXT

In urban areas of the United States, syphilis is a major public health issue for men who have sex with men, despite widespread efforts to curtail a growing epidemic; repeated infections are not uncommon in this population. The ways that men who have sex with men experience and conceptualize syphilis, and how their attitudes and beliefs impact their risk for infection, are poorly understood.

METHODS

In-depth interviews were conducted in 2010-2011 with 19 Los Angeles County men aged 21-54 who reported having male sex partners and had had two or more early syphilis infections within the previous five years. Interview transcripts were analyzed inductively to uncover themes.

RESULTS

Participants had considerable knowledge about syphilis symptoms, transmission and consequences, and most felt that syphilis was a highly stigmatized disease. They had had 2-5 infections in the past five years, and the majority believed they were at risk for another infection because of their sexual risk behaviors. Many had a sense of fatalism about being infected again, and some expressed that this possibility was an acceptable part of being sexually active. Concern about syphilis often decreased as men experienced more infections. Most participants reported short-term sexual behavior changes after a syphilis diagnosis to prevent transmission; however, few were willing to make long-term behavior changes.

CONCLUSIONS

Additional qualitative studies of men who have sex with men should be conducted to better understand the continuing syphilis epidemic and to help identify the most promising intervention strategies.

Acceptable interventions to reduce syphilis transmission among high-risk men who have sex with men in Los Angeles

OBJECTIVES

We examined perceptions of and attitudes toward existing and potential syphilis interventions, including case management and Web-based programs, to increase syphilis testing among high-risk men who have sex with men (MSM).

METHODS

Between October 2010 and June 2011, we conducted in-depth interviews with 19 MSM in Los Angeles, California, with repeat early syphilis infections (primary, secondary, and early latent syphilis) within the previous 5 years. We analyzed the interviews inductively to determine the most acceptable potential interventions.

RESULTS

Experiences with health department and community-based standard of care case management were generally positive. The most popular interventions among respondents included a Web site providing information on syphilis and syphilis testing, automated Web reminders to test, being paid to test, free online home testing kits, and preexposure prophylactic medication. Respondents' beliefs that they would continue to practice high-risk sexual behaviors reinforced their reasons for wanting increased accessibility and convenient testing strategies.

CONCLUSIONS

Public health officials should consider participant responses to potential interventions for syphilis, which suggest that high-risk MSM would consider testing more often or using other interventions.

Syphilis reinfections pose problems for syphilis diagnosis in Antwerp, Belgium - 1992 to 2012

Persons with multiple syphilis reinfections may play an important role in syphilis transmission. We analysed all syphilis tests carried out for people attending the HIV/sexually transmitted infection (STI) clinic at the Institute of Tropical Medicine, Antwerp, Belgium, from 1992 to 2012 to evaluate the extent to which syphilis reinfections were contributing to the syphilis epidemic in Antwerp. We then characterised the features of the syphilis infections in individuals with five or more episodes of syphilis. A total of 729 syphilis episodes were diagnosed in 454 persons. The majority of syphilis episodes occurred in people who had more than one episode of syphilis (445/729; 61%). A total of 10 individuals had five or more episodes of syphilis diagnosed over this period. All were men who have sex with men, HIV positive and on antiretroviral therapy. They had a total of 52 episodes of syphilis diagnosed and treated. In 38/42 of the episodes of repeat syphilis in these 10 individuals, they presented without any signs or symptoms of syphilis. Given that the majority of cases of incident syphilis in our clinic were persons with reinfections and that they frequently presented without signs of symptoms of syphilis, there is a strong case for frequent and repeated screening in all persons with a diagnosis of syphilis.

Men who have sex with men, infectious syphilis and HIV coinfection in inner Sydney: results of enhanced surveillance

Background The resurgence of infectious syphilis in men who have sex with men (MSM) has been documented worldwide; however, HIV coinfection and syphilis reinfections in MSM in inner Sydney have not been published. Methods: For all laboratory syphilis notifications assessed as a newly notified case or reinfection, a questionnaire was sent to the requesting physician seeking demographic data and disease classification. Sex of partner and HIV status were collected for all infectious syphilis notifications in men received from 1 April 2006 to March 2011. Results: From April 2001 to March 2011, 3664 new notifications were received, 2278 (62%) were classified as infectious syphilis. Infectious syphilis notifications increased 12-fold from 25 to 303 in the first and last year respectively, and almost all notifications were in men (2220, 97.5%). During April 2006 to March 2011, 1562 infectious syphilis notifications in males were received and 765 (49%) of these men were HIV-positive and 1351 (86%) reported a male sex partner. Reinfections increased over time from 17 (9%) to 56 (19%) in the last year of the study and were significantly more likely to be in HIV-positive individuals (χ2 = 140.92, degrees of freedom= 1, P = <0.001). Conclusion: Inner Sydney is experiencing an epidemic of infectious syphilis in MSM and about half of these cases are in HIV-positive patients. Reinfections are increasing and occur predominantly in HIV-positive men. Accurate surveillance information is needed to inform effective prevention programs, and community and clinician education needs to continue until a sustained reduction is achieved.

Protocols for detection and typing of Treponema pallidum using PCR methods

Syphilis, caused by Treponema pallidum, is a sexually transmitted disease which was epidemic in Europe between the 15th and 20th century. From 2000 onwards it is worldwide mostly encountered among men who have sex with men but also among women in resource poor setting. Syphilis can easily be treated with penicillin but can become chronic, if left untreated. The disease develops in several stages with ulcerative lesions in the primary stage, and systemic spread to organs via the blood in later stages. Taking swab samples from these ulcerative lesions gives the best options for detection by PCR of T. palillidum. Alternatively blood samples can be analyzed in later stages. If tested positive in screening PCR assays, T. pallidum can also be typed by molecular methods, enabling molecular epidemiology. Different protocols are discussed in this chapter, that include all steps from sample collection, nucleic acid extraction, PCR, and detection. The combination of all steps together determine the final sensitivity and specificity of T. pallidum PCR.

Advancing novel HIV prevention intervention research with MSM--meeting report

HIV continues to exact an enormous toll on society and to disproportionately affect gay and bisexual men and other men who have sex with men (MSM). Innovative prevention interventions are needed to reverse this trend. In August 2009, the U.S. National Institute of Mental Health and the Centers for Disease Control and Prevention convened a meeting of scientists, community representatives, advocates, and federal partners to discuss innovative prevention-intervention science. The meeting was structured to maximize discussion of (1) healthy sex interventions, (2) community and structural interventions, (3) integrated biomedical and behavioral interventions, and (4) interventions to improve uptake of HIV testing. Presentations and discussion focused on research gaps in designing risk-reducing and sexual health-promoting interventions for MSM, including interventions to address mental health, substance use, disclosure, and stigma. This article summarizes the meeting proceedings, highlights key points, and outlines future directions.

Endemic early syphilis among young newly diagnosed HIV-positive men in a southeastern U.S. state

An epidemic of HIV infections among college students who are primarily men who have sex with men (MSM) have been reported from North Carolina, a state with one of the highest syphilis rates in the southeastern United States. We assessed the proportion of early syphilis coinfections among young HIV-infected individuals statewide and associated risk factors. From January 2002 to July 2006, chart abstractions were performed from North Carolina surveillance records for newly diagnosed HIV-positive men 18-30 years of age reported between 2000-2005, and a subset of women in the same age group. Bivariable and multivariable analyses were conducted to assess early syphilis risk factors among HIV-infected persons. During the 6-year period, there were 1460 HIV-positive men aged 18-30 years reported in North Carolina; 90 (6.2%) were coinfected with early syphilis without a significant change over time. Data were available for 551 HIV-positive women diagnosed from 2002-2005; only 6 (1.1%) were coinfected. Fifty-five percent of coinfected men were diagnosed with both infections on the same date of evaluation. Young HIV-infected men who are black (adjusted odds ratio [aOR] 2.3; 95% confidence interval [CI], 1.3, 4.1), MSM (aOR 3.8; 95% CI, 1.8, 7.8), or reported sex with both genders (aOR 5.1; 95% CI, 2.2, 11.5), or anonymous sex (aOR 2.1; 95% CI, 1.3, 3.3) were more likely to have early syphilis. Although male coinfections have not increased over time, early syphilis has become endemic among young HIV-positive men statewide, emphasizing the need to provide screening for both infections among high-risk individuals.

Factors associated with newly diagnosed HIV among persons with concomitant sexually transmitted diseases

OBJECTIVE

We evaluated Illinois and Chicago Departments of Public Health surveillance databases to determine risk factors associated with newly diagnosed HIV among persons with bacterial sexually transmitted diseases (STDs).

METHODS

Test results for Chlamydia, gonorrhea, early syphilis (primary, secondary, and early latent), and HIV from public health clinics in Illinois in 2002 were merged with demographic and behavioral survey data collected during patient visits. STD was defined as any positive non-HIV result.

RESULTS

Among 43,517 patient encounters, 5814 (13.4%) had positive STD test results. There were 308 (0.7%) positive new HIV test results, of which 71 (23.1%) had concomitant infection with an STD. Compared with STD-positive, HIV-negative cases, age >30 years (OR = 1.9, 95% CI, 1.0,4.4), men who have sex with men (MSM) (OR = 22.2, 95% CI 11.3-43.7), and bisexual male (OR = 22.4, 95% CI 7.8-64.8) were independently associated with STD and HIV coinfections. Among distinct STDs, syphilis (n = 438) was the least frequent (7.5%), but was reported in the highest proportion (10.1%) of all new HIV infections and conferred the greatest risk (OR = 11.0, 95% CI 7.7-15.8) for newly diagnosed HIV.

CONCLUSIONS

MSM were at increased risk for newly diagnosed HIV with STD coinfection. Persons with a concomitant STD and HIV were older than US populations that generally constitute the greatest proportion of STD cases. These results highlight the role in particular of syphilis among populations at high risk for HIV transmission. Public health interventions targeting MSM and older adults for effective testing and prevention strategies are critically needed within high-risk networks for cotransmission of STDs and HIV.