High rates of syphilis among STI patients are contributing to the spread of HIV-1 in India

Screening and diagnostic testing protocols for HIV and Syphilis infections in health care setting in Qatar: Evaluation and recommendations

BACKGROUND

HIV and Syphilis are common STIs, which have become a concern and burden on healthcare systems, as many infections go untreated and lead to potentially serious complications. HIV is usually diagnosed with Western blot, PCR, and p24 antigen testing. Whereas, Syphilis is mainly diagnosed through clinical findings and serologic testing. The Medical Commission Department (MC) under MOPH is responsible for screening all newcomers to Qatar, aiming to keep the country free from serious infectious diseases.

OBJECTIVE

We aimed to evaluate the diagnostic efficiency of the protocols used in the MC for screening HIV and Syphilis infections.

METHODS

We conducted a retrospective study of samples analyzed by 4th Generation ARCHITECT® HIV Ag/Ab Combo and Rapid Plasma Reagin (RPR) between January to December 2019. ARCHITECT® HIV Ag/Ab Combo positive samples were confirmed by INNO-LIA™ HIVI/II and RT-PCR. RPR-reactive samples were confirmed by ARCHITECT® Syphilis Treponema pallidium Antibody (Syphilis TPA) assay.

RESULTS

For HIV, data were collected from 585,587 individuals, of which 595 (0.1%) were positive by the ARCHITECT® HIV Ag/Ab Combo (Analyzer A). When all initially positive sera were re-tested on newly collected blood samples using different ARCHITECT® HIV Ag/Ab Combo analyzer (analyzer B), 99.8% (594/595) of samples were also positive, suggesting high reproducibility. The positive predictive value (PPV) between ARCHITECT® HIV Ag/Ab Combo and the INNO-LIA™ HIVI/II confirmatory assay was 31.8%. The PPV between ARCHITECT® HIV Ag/Ab Combo and HIV-PCR assay was 26.8%. Retrospective data for Syphilis were collected from a total of 97,298 individuals who visited the MC, of which 198 (0.20%) were initially positive by RPR. The PPV between RPR and Syphilis TPA confirmatory assay was 36.6%.

CONCLUSION

Despite the high rate of false positivity using ARCHITECT® HIV Ag/Ab Combo and RPR screening assays, both assays have proven to be highly effective as screening testing methods.

Prevalence trends and risk factors associated with HIV, syphilis, and hepatitis C virus among pregnant women in Southwest China, 2009–2018

Objective

This study investigated prevalence trends and identified the associated factors of HIV, syphilis and hepatitis C virus (HCV) among pregnant women in the Guangxi Zhuang Autonomous Region (Guangxi), Southwest China.

Methods

Serial cross-sectional surveys were performed annually among pregnant women in Guangxi from 2009 to 2018. Blood specimens were collected to test the prevalence of HIV, syphilis and HCV. Cochran–Armitage analysis was used to assess the trends of HIV, syphilis and HCV prevalence, as well as the sociodemographic and behavioural data. In this study, we used zero-inflated negative binomial (ZINB) regression models to identify factors associated with HIV, syphilis and HCV infection.

Results

A total of 23,879 pregnant women were included in the study. The prevalence of HIV, syphilis and HCV was 0.24%, 0.85% and 0.19%, respectively. There was a decrease in HIV prevalence from 0.54% to 0.10%, a decrease in HCV prevalence from 0.40% to 0.05% and a decrease in syphilis prevalence from 1.53% to 0.30%. The findings based on the ZINB model revealed that pregnant women who had a history of STI had significantly increased risks of HIV (OR 6.63; 95% CI 1.33–32.90) and syphilis (OR 9.06; 95% CI 3.85–21.30) infection, while pregnant women who were unmarried/widowed/divorced were more likely to have HIV (OR 2.81; 95% CI 1.20–6.54) and HCV (OR 58.12; 95% CI, 3.14–1076.99) infection. Furthermore, pregnant women whose husband had a history of STI (OR 5.62; 95% CI 1.24–25.38) or drug use (OR 7.36; 95% CI 1.25–43.43) showed an increased risk of HIV infection.

Conclusions

There was a relatively low prevalence of HIV, syphilis and HCV among pregnant women. Although decreasing trends in HIV, syphilis and HCV infections were observed, effort is needed to promote STI testing in both premarital medical check-ups and antenatal care, especially targeting couples with a history of STI or drug use.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12981-022-00450-7.

Quantifying Vulnerabilities of Single Women and Sexually Transmitted Infections in South Africa (2002-2016): Is It Getting Better (or Worse)?

Curable sexually transmitted infections (STIs) affect millions of people across the world. Besides unacceptably high HIV rates, South Africa also has the highest burden of STIs in the world. The aim of the study was to investigate temporal changes in STI incidence rates using the data from ~ 10,000 women who enrolled in several HIV prevention trials, KwaZulu-Natal, South Africa (2002-2016). We particularly focused on the changes in distribution of the most influential factors and their population-level impacts on STI incidence rates over time. Characteristics of the women were compared across the study periods: 2002-2004, 2005-2008, 2009-2011, and 2012-2016. Besides multivariable Cox regression models, population attributable risks were calculated for the significant factors. Despite the significant progress in prevention, testing, and treatment programs, infection rates increased substantially from 13.6 to 20.0 per 100 person-year over the study period. Our findings provided a compelling evidence for single/non-cohabiting South African women to be the most vulnerable population who consistently and substantially contributed to increasing STI rates during the 15 years of study duration (PAR%: 44%-47%). We also highlighted the impact of women's lack of knowledge related to their partner, using injectable contraceptives, less parity, and baseline STI positivity which were increased substantially over time. Our findings suggest that a significant proportion of STIs could be prevented by targeting single/non-cohabiting. These results may provide guidance in developing more effective STI prevention programs by targeting women at highest risk of infections and delivering more realistic messages.

The Most Frequent Neurological Complications in HIV Patients in Constanta and the Influence that Coinfections Have in the Onset of Such Conditions

Abstract: This paper shows the results of a retrospective observational analytical study that has enrolled 166 HIV positive patients diagnosed with a neurological complication between June 2012 and June 2020, in Clinical Infectious Diseases Hospital of Constanta. 119 patients (71,69%) were diagnosed with one of the three neurological complications: HIV associated dementia (HAD), Progressive Multifocal Leukoencephalopathy (PML) and CNS Toxoplasmosis (CT). We have noted CD4 levels, viral loads, and the presence/absence of other infections like: HBV, HCV, Treponema pallidum, Mycobacterium Tuberculosis.

The results show that PML and CT, in this order, are the main opportunistic infections with important neurological impact. Both, PML and CT are in direct correlation with the immune status, but also with other infections like the infection with HCV or with M. Tuberculosis. CD4 nadir <100 cells/mmc and viral load ≥100000copies/ml have a stronger association with PML (p<0,05). Patients known with HIV and T. pallidum infection are more likely, in case of new sudden neurological signs, to be diagnosed with Neurotoxoplasmosis versus PML, or HAD (p<0,05). Given the fact that HIV patients can have multiple alterations of neurological functions, and spectaculous but complicated neuro imagistic results, knowing the history of the patients, the lab results, and the statistical probability can help the physician, infectious disease specialist or neurologist, to make a faster and precise diagnosis.

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.

Estimating prevalence and incidence of sexually transmitted infections among South African women: Implications of combined impacts of risk factors

In addition to being the epicentre of the HIV epidemic, South Africa also has the highest burden of sexually transmitted infections (STIs) in the world. Therefore, understanding the most influential risk factors of STIs is a research priority. Using the data from 9948 women who resided in KwaZulu Natal, South Africa, we estimated the population attributable risk to quantify the combined impacts of the most influential factors on STI diagnosis. Overall STI prevalence was 20%, and STI incidence was 15 per 100 person-years. Four factors: age at sexual debut, single/not cohabiting, two or more sex partners and parity <3 were identified as the most influential risk factors for STI prevalence and incidence rates. However, these factors collectively associated with only 51% and 53% of the excess STI prevalence and incidence rates, respectively. These relatively modest impacts provide empirical evidence for the significant impacts of unmeasured factors on STIs. Culturally and socially appropriate prevention programs may be more effective to target those at highest risk of STIs.

Psychosocial correlates of regular syphilis and HIV screening practices among female sex workers in Uganda: a cross-sectional survey

BACKGROUND

Limited data are available regarding correlates of regular sexually transmitted infections (STIs) and HIV screening among female sex workers (FSW) in Sub-Saharan Africa. In this study, we aimed to assess the frequency of regular syphilis and HIV screening and the psychosocial correlates associated with screening among FSW in Uganda.

METHODS

This cross-sectional correlational study was conducted among 441 FSW, aged 17-49 years. We enrolled FSW through peer referrals and ascertained self-reported data on number of serological tests for HIV, syphilis and other STIs in the prior 12 months using an interviewer-administered questionnaire. In addition, we assessed attitudes, norms, social influences and self-efficacy towards 3-monthly Syphilis and 6-monthly HIV testing. We estimated the correlates of regular STI and HIV testing using negative binomial regression.

RESULTS

Of the respondents 420 (95.2%) reported to have ever taken an HIV test with 297 (67.4%) testing two or more times in the prior 12 months. Over half of the respondents (59%) reported ever taking a syphilis test with only 62 (14.1%) reporting testing three or more times in the prior 12 months. After adjusting for socio-demographics, attitude and norms, high perceived self-efficacy was associated with a 33% increase in the likelihood of repeated HIV testing [prevalence ratio (PR), 1.33, 95% confidence interval (CI) 1.15-1.53] while low perceived confidence was associated with a 25% decrease in the likelihood of repeated HIV testing (PR, 0.75, 95% CI 0.63-0.89). Similarly low attitudes and norms were associated with a decrease of 52.6% (PR, 0.47, 95% CI 0.37-0.61) and 47% (PR, 0.53, 95% CI 0.41-0.69) in the likelihood of repeated syphilis testing respectively.

CONCLUSION

Compared to HIV, uptake of repeated syphilis testing was very low. Correlates of HIV testing include; perceived self-efficacy amidst barriers and perceived confidence for HIV and low attitudes and accepting norms for syphilis. Health campaigns should emphasize overcoming barriers to HIV testing while promoting attitudes and norms including integration of serological syphilis testing and other STIs into HIV services.

Syphilis and human immunodeficiency virus infections among pregnant women attending antenatal care clinic of Gondar family guidance association, Northwest Ethiopia: implication for prevention of mother to child transmission

BACKGROUND

Sexually transmitted infections constitute a major public health problem worldwide. Syphilis and HIV infections cause various adverse pregnancy outcomes. Therefore, the aim of this study was to determine the seroprevalence of HIV and syphilis infections among pregnant women at Gondar Family Guidance Association clinic, northwest Ethiopia.

METHODS

A retrospective study was conducted using sociodemographic and laboratory data obtained from registration books of Gondar Family Guidance Association clinic from January 2011 to April 2015. A binary logistic regression model was fit to identify factors associated with HIV and syphilis infections. Odds ratios with 95% confidence intervals were calculated to determine the strength of association between factors associated with HIV and syphilis infections. A p-value ≤0.05 was considered statistically significant.

RESULTS

A total of 3504 pregnant women were included in the study from January 2011 to April 2015. The seroprevalence of HIV, and syphilis were 145 (4.1%) and 66(1.9%), respectively. Twenty-three (0.66%) women were co-infected. Age group 20-29 years (AOR: 3.86; 95% CI: 1.36-10.89), age group ≥30 years (AOR: 6.08; 95% CI: 2.04-18.14) compared to age < 20 year, and HIV-infection (AOR: 14.6; 95% CI: 8.49-25.18) were significantly associated with syphilis infection. There was a decline in trend seroprevalence of HIV from 5.2% in 2011 to 2.1% in 2015; and decline in syphilis seroprevalence from 2.6% in 2011 to 1.6% in 2015 but not statistically significant.

CONCLUSION

The data showed that syphilis and HIV infections are still critical public health concerns among pregnant women. Screening of all pregnant women for these infections is valuable. Further community-based studies to identify risk factors are necessary.

High subsequent and recurrent sexually transmitted infection prevalence among newly diagnosed HIV-positive Thai men who have sex with men and transgender women in the Test and Treat cohort

We determined subsequent and recurrent sexually transmitted infections (STIs) among men who have sex with men (MSM) and transgender women (TGW) in the Test and Treat cohort. Thai MSM and TGW adults with previously unknown HIV status were enrolled and tested for HIV. Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and syphilis were tested at baseline, month 12, and month 24 to identify subsequent STIs (any STIs diagnosed after baseline) and recurrent STIs (any subsequent STIs diagnosed among those with positive baseline STIs). Among 448 participants, 17.8% were HIV-positive, the prevalence of subsequent STIs and recurrent STIs was 42% (HIV-positive versus HIV-negative: 66.3% versus 36.7%, p < 0.001) and 62.3% (81% versus 52.5%, p < 0.001), respectively. Common subsequent STIs by anatomical site were rectal CT infection (21.7%), rectal NG infection (13.8%), pharyngeal NG infection (13.1%), and syphilis (11.9%). HIV-positive status was associated with both subsequent STIs (adjusted hazard ratio [aHR] 2.38; 95%CI 1.64-3.45, p < 0.001) and recurrent STIs (aHR 1.83; 95%CI 1.16-2.87, p = 0.01). The results show that newly diagnosed HIV-positive MSM and TGW were at increased risk of STIs despite being in the healthcare system. STI educational counseling is necessary to improve STI outcomes among MSM and TGW in both HIV prevention and treatment programs.

Sexually Transmitted Infections Among HIV-Infected Individuals in the District of Columbia and Estimated HIV Transmission Risk: Data From the DC Cohort

Background

Washington, DC, has one of the highest rates of HIV infection in the United States. Sexual intercourse is the leading mode of HIV transmission, and sexually transmitted infections (STIs) are a risk factor for HIV acquisition and transmission.

Methods

We evaluated the incidence and demographic factors associated with chlamydia, gonorrhea, and syphilis among HIV-infected persons enrolled at 13 DC Cohort sites from 2011 to 2015. Using Poisson regression, we assessed covariates of risk for incident STIs. We also examined HIV viral loads (VLs) at the time of STI diagnosis as a proxy for HIV transmission risk.

Results

Six point seven percent (451/6672) developed an incident STI during a median follow-up of 32.5 months (4% chlamydia, 3% gonorrhea, 2% syphilis); 30% of participants had 2 or more STI episodes. The incidence rate of any STIs was 3.8 cases per 100 person-years (95% confidence interval [CI], 3.5-4.1); age 18-34 years, 10.8 (95% CI, 9.7-12.0); transgender women, 9.9 (95% CI, 6.9-14.0); Hispanics, 9.2 (95% CI, 7.2-11.8); and men who have sex with men (MSM), 7.7 (95% CI, 7.1-8.4). Multivariate Poisson regression showed younger age, Hispanic ethnicity, MSM risk, and higher nadir CD4 counts to be strongly associated with STIs. Among those with an STI, 41.8% had a detectable VL within 1 month of STI diagnosis, and 14.6% had a VL ≥1500 copies/mL.

Conclusions

STIs are highly prevalent among HIV-infected persons receiving care in DC. HIV transmission risk is considerable at the time of STI diagnosis. Interventions toward risk reduction, antiretroviral therapy adherence, and HIV virologic suppression are critical at the time of STI evaluation.

Risk behaviours and prevalences of HIV and sexually transmitted infections among female sex workers in various venues in Changzhou, China

Female sex workers (FSWs) play an important role in the heterosexual transmission of HIV and sexually transmitted infections (STIs) in China. We conducted a cross-sectional study of 609 FSWs from various venues in Changzhou to investigate risk behaviours and prevalences of HIV and STIs among FSW subgroups. Structured questionnaires were used in face-to-face interviews to collect information. Blood and cervical specimens were collected to test for HIV, syphilis, Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) infections. The overall prevalences of syphilis, NG and CT were 5.6, 2.3 and 17.0%, respectively. The highest prevalence of syphilis (13.8%, P < 0.001) was observed among FSWs in low-class (LC) venues. No case of HIV infection was found. Less than half of all FSWs (40.7%) reported consistent condom use with clients during the last month. A multivariate analysis revealed a 13-fold increased risk for FSWs with NG infection to be infected with syphilis and a four-fold increased risk for FSWs aged 30-39 years to have a CT infection relative to FSWs aged 15-20 years. The prevalences of STIs were high, and risky sexual behaviours were common, especially among FSWs in LC venues. More tailored and comprehensive prevention programmes should be developed for specific FSW subgroups.

Increasing HIV Incidence among Men Who Have Sex with Men in Jiangsu Province, China: Results from Five Consecutive Surveys, 2011-2015

Epidemics of HIV among men who have sex with men (MSM) are major public health concerns in most parts of China. This study examined the trends in HIV incidence and associated factors among MSM in Jiangsu Province. Five consecutive cross-sectional surveys were conducted among MSM from 2011 to 2015 in eight cities throughout Jiangsu Province. Participants were recruited from MSM venues or via the internet. Demographic and behavioral data were collected through HIV bio-behavioral surveys. Blood specimens were collected to test for HIV and syphilis. HIV incidence was estimated by the IgG-capture BED-EIA (BED) method and a chi-square trend test was used to compare differences over the years. Multivariate logistic regression analysis was used to identify factors associated with recent infection. A total of 2433, 2678, 2591, 2610 and 2541 participants were enrolled in 2011, 2012, 2013, 2014 and 2015, respectively. HIV incidence increased from 5.10% in 2011 to 6.62% in 2015 (p = 0.025). MSM who had an education level of junior high school or less (aOR = 1.472, p = 0.018), engaged in condomless anal sex in the past 6 months (aOR = 2.389, p < 0.001), did not have an HIV test in the past 12 months (aOR = 3.215, p < 0.001), and were currently infected with syphilis (aOR = 2.025, p = 0.001) were likely to be recently infected with HIV. HIV incidence is increasing among MSM in Jiangsu Province, China. Condom usage and HIV testing promotion should be prioritized when attempting to reduce HIV transmission among MSM in China.

Epidemiological impact of a syphilis vaccine: a simulation study

Despite the availability of inexpensive antimicrobial treatment, syphilis remains prevalent worldwide, affecting millions of individuals. Furthermore, syphilis infection is suspected of increasing both susceptibility to, and tendency to transmit, HIV. Development of a syphilis vaccine would be a potentially promising step towards control, but the value of dedicating resources to vaccine development should be evaluated in the context of the anticipated benefits. Here, we use a detailed mathematical model to explore the potential impact of rolling out a hypothetical syphilis vaccine on morbidity from both syphilis and HIV and compare it to the impact of expanded ‘screen and treat’ programmes using existing treatments. Our results suggest that an efficacious vaccine has the potential to sharply reduce syphilis prevalence under a wide range of scenarios, while expanded treatment interventions are likely to be substantially less effective. Our modelled interventions in our simulated study populations are expected to have little effect on HIV, and in some scenarios lead to small increases in HIV incidence, suggesting that interventions against syphilis should be accompanied with interventions against other sexually transmitted infections to prevent the possibility that lower morbidity or lower perceived risk from syphilis could lead to increases in other sexually transmitted diseases.

Poor awareness of syphilis prevention and treatment knowledge among six different populations in south China

BACKGROUND

China is facing an emerging epidemic of syphilis, and the cities in south China are most affected. Knowledge is a key factor in the prevention of syphilis infection, however, little is reported about how much people know about syphilis. This study was aimed at assessing peoples' awareness status in a city located in south China.

METHODS

Six populations were recruited for this study, including urban residents, factory workers, college students, pregnant women, female sex workers (FSWs), and men who have sex with men (MSM). A questionnaire designed by the National Center for Disease Control and Prevention was used to assess participants' awareness of syphilis knowledge. About 5% of participants were randomly selected to conduct a telephone survey for confirming the validity of fieldwork.

RESULTS

The study recruited 3470 participants, and 61.2% of participants were assigned to the awareness group. College students had the smallest percentage of awareness at 51.7% (371/718), followed by FSWs at 53.9% (200/371), factory workers at 56.0% (381/679), urban residents at 65.4% (435/665), pregnant women at 66.0% (451/683), and MSM at 81.1% (287/354). Multivariate logistic regression analysis showed that MSM and FSWs-but not factory workers and pregnant women-had more awareness of syphilis knowledge when comparing with urban residents; however, college students presented less awareness of syphilis knowledge than urban residents. Participants of younger age, of female gender, with lower education levels and without Shenzhen hukou possessed less awareness of syphilis knowledge than those of older age, of male gender, with higher education levels and with Shenzhen hukou respectively.

CONCLUSIONS

The percentages of awareness on syphilis knowledge found in this study are far from the benchmark set in the national 10-year plan. Tailored interventions for different subgroups to increase syphilis awareness are urgently warranted.

Early syphilis affects markers of HIV infection

The objective of this study was to investigate if early syphilis infection affects markers of HIV infection; CD4 T cells and viral load (VL). A retrospective study was performed on 160 HIV-positive patients (111 receiving antiretroviral therapy [ART] and 49 without ART). Early syphilis diagnosis was made in HIV patients during their follow-up at the HIV/AIDS Unit at a Greek Dermatology and Venereology Unit. The patients' blood tests were available at the time of diagnosis, as well as before and 12 weeks after early syphilis diagnosis. CD4 T cell counts and VL levels were measured. It was found that syphilis infection had a negative impact on the CD4 T cell counts in both groups, with reduced CD4 T cell counts observed in 84.6% (99/111) and 79.5% (39/49) of patients receiving and not receiving ART, respectively. After treatment for syphilis, CD4 T cell counts returned to pre-treatment levels in most patients, especially those receiving ART. There was a slight and transient VL increase. Patients receiving ART had a 27% increase in VL, compared to 71.4% among patients not receiving ART. Although the VL increase was slight (41-14,000 copies/ml) in the group under treatment, 4-5% (5/111) patients did not return to pre-treatment levels. Moreover, viral mutations associated with treatment resistance were identified in these patients. Early syphilis accelerates and complicates the progression of HIV infection. Early diagnosis and treatment of syphilis may prevent infection-associated complications in most instances. Consequently, prevention of syphilis and other sexually transmitted infections is of great importance for patients infected with HIV.

The prevalence and correlates of syphilis and HIV among homosexual and bisexual men in Shijiazhuang, China

Bisexual men (men who have sex with men and women) are potential epidemiological bridges responsible for the spread of HIV and other sexually transmitted infections from men who have sex with men only to the heterosexual population. We aimed to estimate the prevalence of syphilis and HIV and the factors associated with syphilis infection among men who have sex with men and women and men who have sex with men only from Shijiazhuang, China. In 2011-2013, a cross-sectional cohort of 427 men who have sex with men was recruited by a snowball sampling method and tested for syphilis and HIV. Chi square and logistic regression were performed to identify syphilis risk factors. Among the 427 men who have sex with men, 71 (16.6%) cases were syphilis-positive and 16 cases (3.7%) were HIV-positive. The proportions of men who have sex with men and women and men who have sex with men only in the total sample were 31.4% and 68.6%, respectively. Men who have sex with men and women exhibited double the syphilis prevalence of men who have sex with men only and were more likely to practice insertive anal sex. Higher education level, being married, having more male partners, and both receptive and insertive anal sex roles were associated with syphilis among men who have sex with men and women. Residing in suburban areas, being married, being HIV positive, and an absence of desire to change sexual orientation were associated with syphilis among men who have sex with men only. Therefore, men who have sex with men and women represent an important sub-group in the syphilis epidemic and further interventions should be developed to reduce risk among different sub-sets of men who have sex with men.

Population and dyadic-based seroincidence of herpes simplex virus-2 and syphilis in southern India

Objectives

Herpes simplex virus-2 (HSV-2) and syphilis are associated with increased risk of HIV, highlighting the importance of understanding their transmission dynamics. In India, most studies of HSV-2 and syphilis incidence are in high-risk populations and may not accurately reflect infectious activity. In this study, we aim to define HSV-2/syphilis incidence and risk factors in a population sample.

Methods

We conducted a longitudinal population-based survey in Andhra Pradesh, India, in two rounds: 2004–2005 and 2010–2011. Sociodemographic and behavioural data were collected, and dried blood spots tested for HSV-2 and Treponema pallidum IgG. After calculating sexually transmitted infection (STI) incidence, associated factors were assessed using modified Poisson regression and within-couple transmission rates modelled using seroconcordance/discordance data.

Results

12 617 adults participated at baseline with 8494 at follow-up. Incidence of HSV-2 and syphilis per 1000 person-years was 25.6 (95% CI 24.1 to 27.2) and 3.00 (95% CI 2.52 to 3.54). Incidence of HSV-2 was higher in women vs men (31.1 vs 20.2) and in rural vs urban residents (31.1 vs 19.0) (p<0.05 for both). STI seroincidence increased in a step-wise fashion with age and was associated with spousal seropositivity for both sexes (incidence rate ratio (IRR) 2.59 to 6.78). Within couples the rate of transmission per 1000 couple-years from men to women vs women to men was higher for HSV-2 (193.3 vs 119.0) compared with syphilis (27.6 vs 198.8), p<0.05 for both.

Conclusions

HSV-2 has higher incidence among subpopulations such as women, rural residents and older-aged individuals, suggesting a need for more generalised STI prevention approaches among populations traditionally considered low risk.

The increase of sexually transmitted infections calls for simultaneous preventive intervention for more effectively containing HIV epidemics in China

OBJECTIVE

To identify the priority public health challenges with respect to the development of multipurpose prevention technologies in China.

DESIGN

Review of published literature, databases of state and local disease control agencies and unpublished data relating to HIV and other sexually transmitted infections (STIs).

SETTING

China.

POPULATION

General and migrant populations.

METHODS

Review of published data, government reports and databases of China Disease Control agencies, and our unpublished studies.

MAIN OUTCOME MEASURES

Reported STI incidence, particularly HIV, syphilis, chlamydia and genital herpes, and the migrant population with respect to disease transmission.

RESULTS

We found that the reported STI incidence increases along with that of HIV and showed significant geographic overlap with HIV. Economic migrant workers may facilitate the spread of STIs, including HIV.

CONCLUSIONS

To more effectively contain the HIV epidemic, it is imperative to develop preventive measures to simultaneously target HIV and other STIs. We recommend that the development of multipurpose prevention technologies in China should target HIV and STIs.

Comparison of serological response to doxycycline versus benzathine penicillin G in the treatment of early syphilis in HIV-infected patients: a multi-center observational study

BACKGROUND

While doxycycline is recommended as an alternative treatment of syphilis in patients with penicillin allergy or intolerance, clinical studies to compare serological response to doxycycline versus benzathine penicillin in treatment of early syphilis among HIV-infected patients remain sparse.

METHODS

We retrospectively reviewed the medical records of HIV-infected patients with early syphilis who received doxycycline 100 mg twice daily for 14 days (doxycycline group) and those who received 1 dose of benzathine penicillin (2.4 million units) (penicillin group) between 2007 and 2013. Serological responses defined as a decline of rapid plasma reagin titer by 4-fold or greater at 6 and 12 months of treatment were compared between the two groups.

RESULTS

During the study period, 123 and 271 patients in the doxycycline and penicillin group, respectively, completed 6 months or longer follow-up. Ninety-one and 271 patients in the doxycycline and penicillin group, respectively, completed 12 months or longer follow-up. Clinical characteristics were similar between the two groups, except that, compared with penicillin group, doxycycline group had a lower proportion of patients with secondary syphilis (65.4% versus 41.5%, P<0.0001) and a higher proportion of patients with early latent syphilis (25.3% versus 49.6%, P<0.0001). No statistically significant differences were found in the serological response rates to doxycycline versus benzathine penicillin at 6 months (63.4% versus 72.3%, P = 0.075) and 12 months of treatment (65.9% versus 68.3%, P = 0.681). In multivariate analysis, secondary syphilis, but not treatment regimen, was consistently associated with serological response at 6 and 12 months of follow-up.

CONCLUSIONS

The serological response rates to a 14-day course of doxycycline and a single dose of benzathine penicillin were similar in HIV-infected patients with early syphilis at 6 and 12 months of follow-up. Patients with secondary syphilis were more likely to achieve serological response than those with other stages.

HIV incidence and risk factors in Chinese young men who have sex with men--a prospective cohort study

Objectives

To assess HIV incidence and its associated risk factors among young men who have sex with men (YMSM) in urban areas, China.

Design

The study used a prospective cohort study design and standard diagnostic tests.

Methods

A twelve-month prospective cohort study was conducted among YMSM (18–25 years old) in 8 large cities in China. The participants were recruited via snowball sampling. A total of 1102 HIV-negative YMSM completed baseline assessment, 878 YMSM participants completed 6-month follow-up, and 902 completed 12-month follow-up. HIV was screened by an enzyme-linked immunosorbent assay and confirmed with Western Blot. Syphilis was screened via rapid plasma reagent and confirmed by treponema pallidum particle agglutination assay.

Results

78 HIV seroconversions were identified within 1168.4 person-year observations yielding an incidence rate of 6.7 per 100 person-years. HIV seroconversion was associated with non-student status (RR = 2.61, 90% CI = 1.3–5.26), low HIV transmission knowledge (RR = 8.87, 90% CI = 2.16–36.43), and syphilis infection (RR = 5.04, 90% CI = 2.57–9.90).

Conclusions

Incidence of HIV among YMSM is high in urban areas of China. Interventions measures are required to contain the HIV epidemic within this population.

The oral mucosa immune environment and oral transmission of HIV/SIV

The global spread of human immunodeficiency virus (HIV) is dependent on the ability of this virus to efficiently cross from one host to the next by traversing a mucosal membrane. Unraveling how mucosal exposure of HIV results in systemic infection is critical for the development of effective therapeutic strategies. This review focuses on understanding the immune events associated with the oral route of transmission (via breastfeeding or sexual oral intercourse), which occurs across the oral and/or gastrointestinal mucosa. Studies in both humans and simian immunodeficiency virus (SIV) monkey models have identified viral changes and immune events associated with oral HIV/SIV exposure. This review covers our current knowledge of HIV oral transmission in both infants and adults, the use of SIV models in understanding early immune events, oral immune factors that modulate HIV/SIV susceptibility (including mucosal inflammation), and interventions that may impact oral HIV transmission rates. Understanding the factors that influence oral HIV transmission will provide the foundation for developing immune therapeutic and vaccine strategies that can protect both infants and adults from oral HIV transmission.

Prevalence and associated risk factors for syphilis in women with recurrent miscarriages

OBJECTIVE

A Cross Sectional population based serological studies was conducted to determine the prevalence and associated risk factors for syphilis women with recurrent miscarriages.

METHODS

Patient's 5ml whole blood was collected through venepuncture technique. Data were collected by all women answered a questionnaire and by investigating blood sample VDRL test and FTA-ABS test. The study was conducted in a confidential manner and numbers were used to identify the participant.

RESULTS

Total 256 women were included in the present study. Mean age of women was 29.4 years while range was 21 to 38 years (206/256). Out of the 256 samples, 05 (1.9%) were positive for active syphilis. Majority belonged to low socioeconomic group, uneducated and had previous congenital anomaly.

CONCLUSION

Active infection with Treponema pallidum (T.P) in women belonging to low socioeconomic level were disquieting. This is probably due to illiteracy and high proportion of unsafe sexual behavior. It is also suggestive that seropositive status is often discovered in routine serological studies during pregnancy.

HIV incidence and associated factors in a cohort of men who have sex with men in Nanjing, China

BACKGROUND

Many surveys conducted in recent years reported the increasing trend of HIV infection among men who have sex with men (MSM), but limited data exists on HIV incidence by cohort study in China.

METHODS

A 6-month prospective cohort study was conducted. A total of 397 MSM found HIV seronegative at baseline study were followed-up for 6 months starting from May 2007 and re-evaluated seroconversions of HIV at 6 months. Questionnaire interviews were conducted to collect information about risk behaviors.

RESULTS

Of the 397 MSM who were found seronegative at the baseline study, 286 (72.0%) received the HIV antibody testing at month 6; 7 of them showed HIV seroconversions, yielding an incidence of 5.12 per 100 person-years. Significant predictors of seroconversion (Poisson regression analyses) included duration being MSM >10 years (relative risks [RR] = 3.08, 95% CI: 1.53-6.20), recruiting male sex partner mostly at saunas (RR = 2.35, 95% CI:1.09-5.08), positive syphilis diagnosis made at the baseline study (RR = 2.82, 95% CI: 1.31-6.09), having multiple male sex partners in the last 6 months (RR = 2.54, 95% CI: 1.18-5.49), having at least 1 casual male sex partner in the last 6 months (RR = 2.17, 95% CI: 1.00-4.70), and having unprotected anal sex with a regular male sex partner in the last 6 months (RR = 2.22, 95% CI: 1.10-4.49).

CONCLUSIONS

The incidence of HIV among MSM is very high; many new infections would hence occur in China. Effective interventions are warranted. The risk factors reported in this study give some insights for designing relevant prevention programs.

Screen more or screen more often? Using mathematical models to inform syphilis control strategies

Background

Syphilis incidence among men who have sex with men (MSM) continues to rise despite attempts to increase screening and treatment uptake. We examined the marginal effect of increased frequency versus increased coverage of screening on syphilis incidence in Toronto, Canada.

Methods

We developed an agent-based, network model of syphilis transmission, representing a core population of 2,000 high-risk MSM. Epidemiological and biological parameters were drawn from regional surveillance data and literature-derived estimates. The pre-intervention period of the model was calibrated using surveillance data to identify 1000 credible simulations per strategy. Evaluated strategies included: annual syphilis screening at baseline coverage, increased screening frequency at baseline coverage, and increased coverage of annual screening. Intervention impact was measured as annual prevalence of detected infectious cases and syphilis incidence per year over 10 years.

Results

Of the strategies evaluated, increasing the frequency of syphilis screening to every three months was most effective in reducing reported and incident syphilis infections. Increasing the fraction of individuals tested, without increasing test frequency, resulted a smaller decline in incidence, because reductions in infectious syphilis via treatment were counterbalanced by increased incident syphilis among individuals with prior latent syphilis. For an equivalent number of additional tests performed annually, increased test frequency was consistently more effective than improved coverage.

Conclusions

Strategies that focus on higher frequency of testing in smaller fractions of the population were more effective in reducing syphilis incidence in a simulated MSM population. The findings highlight how treatment-induced loss of immunity can create unexpected results in screening-based control strategies.

Syphilis treatment response among HIV-discordant couples in Zambia and Rwanda

BACKGROUND

Syphilis continues to be a common sexually transmitted infection, despite the availability of inexpensive and effective treatment. Infection in human immunodeficiency virus (HIV)-discordant couples is important because syphilis increases the risk of HIV acquisition. Current US treatment guidelines recommend 1 dose of benzathine penicillin for early syphilis, irrespective of HIV status, but data from coinfected patients are limited.

METHODS

Retrospective analysis of 1321 individuals in 2 African HIV-discordant couple cohorts was performed. Cox proportional hazards analysis and multivariable modeling were used to assess predictors of serologic response to treatment at 180 days and 400 days. Modeling was performed for all episodes of positive rapid plasma reagin (RPR) test results and on a subset with higher RPR titers (≥1:4).

RESULTS

A total of 1810 episodes of syphilis among 1321 individuals were treated with penicillin between 2002 and 2008. Although a positive RPR was more common in the HIV-infected partners, HIV infection did not impact the likelihood of serologic response to therapy (odds ratio [OR], 1.001; P = .995). By 400 days, 67% had responded to therapy, 27% were serofast, and 6.5% had documented reinfection. Prevalent infections were more likely to remain serofast than incident infections (33% vs 20% at 400 days).

CONCLUSIONS

In 2 HIV-serodiscordant couple cohorts in Africa, incident syphilis had a very good likelihood of response to penicillin therapy, irrespective of HIV infection. This supports current Centers for Disease Control and Prevention treatment guidelines. A high proportion of prevalent RPR-positive infections remain serofast despite treatment.

The impact of syphilis screening among female sex workers in China: a modelling study

BACKGROUND

In China, female sex workers (FSWs) are at high risk of syphilis infection, but are hard to reach for interventions. Point-of-care testing introduces opportunities for expanding syphilis control measures. Modelling is used to estimate the impact of using rapid tests to screen FSWs for syphilis. In other settings, modelling has predicted large rebounds in infectious syphilis following screening, which may undermine any impact achieved.

METHODS

A deterministic syphilis transmission model among FSWs and clients was fitted to data from Yunnan Province (FSW syphilis prevalence = 7.5%), and used to estimate the impact of rapid syphilis testing and treatment for FSWs. Impact projections were compared for different model structures that included risk heterogeneity amongst FSWs, incoming syphilis infections amongst new FSWs and clients and re-infection from FSWs' regular non-commercial partners. The rebound in syphilis prevalence after screening ceased was explored.

RESULTS

All model structures suggest yearly syphilis screening could substantially reduce (by 72-88%) syphilis prevalence amongst FSWs in this setting over five years. However, incoming syphilis infections amongst new FSWs and clients or re-infections from regular non-commercial partners of FSWs can considerably reduce (>30%) the proportion of infections averted. Including heterogeneity in risk amongst FSWs had little effect upon the proportion of infections averted. In this setting, the rebound in syphilis prevalence after screening ceased is predicted to be slight, but it could be large in high prevalence settings.

CONCLUSIONS

Rapid test screening could dramatically reduce syphilis prevalence amongst hard-to-reach groups, but strategies to reduce re-infection from regular non-commercial partners are needed to maximise impact.

Prevalence and epidemiological traits of HIV infections in populations with high-risk behaviours as revealed by genetic analysis of HBV

The prevalence and epidemiological traits of human immunodeficiency virus (HIV)/hepatitis B virus (HBV) infections in high-risk populations (HRPs) remained unclarified in Japan. We determined the prevalence of HIV, HBV and Treponema pallidum (TP) and the viral genotypes in HRPs who attended primary sexually transmitted infection (STI) clinics in Osaka province during 2006-2011. Of 7898 specimens, 133 (1·7%) were HIV positive, which was significantly higher than the figures reported by Japanese Red Cross (0·0019%) and public health centres (0·27%) in Japan. The frequency of HIV-1 subtype B was 88·7%, followed by CRF01_AE (2·3%) and C (0·8%), which were almost identical to the national trend. HBV seroprevalence was surprisingly high in the HIV-positive group (63·2%), which was significantly higher than that in the HIV-negative group (25·6%). By contrast, there was no statistical correlation between HIV and TP infection. Interestingly, the distinct HBV genotypes Ae and G were prevalent in the HIV-positive population (60·0% and 20·0%, respectively), although both were rarely detected during nationwide surveillance. The transmission of HIV and HBV appeared to occur largely within a closed community early in life. Of note, about one-quarter of HIV-positive cases would have remained untested if health professionals had not motivated individuals to undergo HIV testing. This is the first evidence-based assessment of HIV positivity and HIV/HBV co-infection in HRPs at primary STIs in Japan and the effect of the involvement of health professionals in the diagnosis of HIV infections in asymptomatic carriers. The genotyping of HBV provided valuable information for understanding HIV epidemical traits.

A systematic review and meta-analysis of risk factors for sexual transmission of HIV in India

Background

Approximately 2.4 million people are living with HIV in India. This large disease burden, and potential for epidemic spread in some areas, demands a full understanding of transmission in that country. We wished to quantify the effects of key sexual risk factors for HIV infection for each gender and among high- and low-HIV risk populations in India.

Methodology

We conducted a systematic review of sexual risk factors for HIV infection from 35 published studies. Risk factors analyzed were: male circumcision/religion, Herpes Simplex Virus 2, syphilis, gonorrhoea, genital ulcer, multiple sexual partners and commercial sex. Studies were included if they met predetermined criteria. Data were extracted and checked by two researchers and random-effects meta analysis of effects was conducted. Heterogeneity in effect estimates was examined by I² statistic. Publication bias was tested by Begg's test and funnel plots. Meta regression was used to assess effect modification by various study attributes.

Results

All risk factors were significantly associated with HIV status. The factor most strongly associated with HIV for both sexes was HSV-2 infection (OR_men: 5.87; 95%CI: 2.46–14.03; OR_women: 6.44; 95%CI: 3.22–12.86). The effect of multiple sexual partners was similar among men (OR = 2.46; 95%CI: 1.91–3.17,) and women (OR = 2.02; 95%CI: 1.43–2.87) and when further stratified by HIV-risk group. The association between HSV-2 and HIV prevalence was consistently stronger than other STIs or self-reported genital ulcer. If the strong associations between HSV-2 and HIV were interpreted causally, these results implied that approximately half of the HIV infections observed in our study population were attributable to HSV-2 infection.

Conclusions

The risk factors examined in our analysis should remain targets of HIV prevention programs. Our results confirm that sexual risk factors for HIV infection continue to be an important part of Indian HIV epidemic 26 years after it began.

Assessing and evaluating the combined impact of behavioural and biological risk factors for HIV seroconversion in a cohort of South African women

In this prospective study, we aimed to investigate and evaluate the impact of combinations of behavioural and biological risk factors on HIV acquisition in a cohort of women. Demographic, sexual and biologic risk factors including HIV seroconversion results from 1485 HIV negative women who were enrolled in a HIV prevention trial were used. First, Cox regression models were used to create a prediction model and weighted scoring system. Second, internal validation data-set was used to evaluate the performance characteristics of the model prospectively. In the prediction model, an increasing number of lifetime sexual partners, women who were classified as in a "high risk behavior" group, and those who were not cohabitating with their partners were consistently associated with increased risk of HIV acquisition. Among the baseline biological factors, genital epithelial disruption, genital signs and symptoms, genital discharge and detecting edema, erythma or warts in vulva were all associated with HIV seroconversion. High scores were associated with increased risk of HIV seroconversion. A cut-point score of 15 (out of 44) or higher distinguished an "increased risk" group with a sensitivity of 88%. This study presents reasonable robust analyses for investigating and evaluating epidemiological measures on HIV infection. Results from this study may be included as part of a health promotion to prompt those who are at increased risk of HIV infection which may potentially lead to increased uptake and frequency of testing.

Molecular subtyping of Treponema pallidum during a local syphilis epidemic in men who have sex with men in Melbourne, Australia

Treponema pallidum is the causative agent of syphilis, a sexually transmitted infection of significant public health importance. Since 2000 there has been a marked increase in the number of cases of syphilis infections notified in Victoria, Australia, with the majority of cases occurring in men who have sex with men (MSM) and the highest incidence being in HIV-infected MSM. The molecular subtyping method described by Pillay et al. (A. Pillay et al., Sex. Transm. Dis. 25:408-414, 1998) has been used in this study to determine the diversity of T. pallidum subtypes circulating locally and to look for any relationship between T. pallidum subtypes and HIV status over a 6-year period (2004 to 2009). Treponema pallidum DNA was detected in 303 patient specimens (n = 3,652), and full subtyping profiles were obtained from 90 of these (from 88 patients). A total of 11 T. pallidum subtypes were identified: types 14e (28, 31.1%), 14d (15, 16.7%), 14k (13, 14.4%), 14p (12, 13.3%), 14i (7, 7.8%) 14b (6, 6.7%), 14l (5, 5.6%), and 12i, 13b, 13i, and 13e (1 each, 1.1%). This study showed a similar level of variation among circulating T. pallidum strains compared with that in other studies using the same methodology. A different mix of strains and different predominating strains have been found at each geographical study location, with type 14e emerging as the predominant local strain in Victoria. There was no detectable trend between T. pallidum subtypes and the specimen collection site or stage of syphilis (where known), nor was there any relationship between particular strains and HIV status.

The increasing prevalence of serologic markers for syphilis among Chinese blood donors in 2008 through 2010 during a syphilis epidemic

BACKGROUND

In China, the growing syphilis epidemic parallels the spread of human immunodeficiency virus (HIV) in the general population. This study evaluated the prevalence and incidence of serologic markers for syphilis among donors at five Chinese blood centers.

STUDY DESIGN AND METHODS

We examined whole blood and apheresis donations collected from January 2008 through December 2010. Postdonation testing of syphilis was conducted using two different Treponema pallidum antibody enzyme-linked immunosorbent assay kits. The prevalence of serologic markers for syphilis (%), and the rate of coinfection with HIV-1/2, hepatitis B virus (HBV), and hepatitis C virus (HCV) were calculated. A multivariable logistic regression analysis was conducted examining donor characteristics associated with positive syphilis serology. Seroconversion rate and syphilis incidence were estimated.

RESULTS

Of 801,511 donations, 60% were from first-time donors and 40% were from repeat donors. There was a significant increase in syphilis serologic markers among first-time donors with 0.41, 0.45, and 0.57% positivity over 3 years (p < 0.001). Approximately 2.8, 0.8, and 0.5% of HIV-1/2-, HBV-, and HCV-positive donations also tested reactive for syphilis. Logistic regression results suggest that first-time donors were nine times more likely to be syphilis positive than repeat donors. Higher syphilis positivity was associated with donors older than 25 years and with less education. Estimated incidence among repeat donations was 33 (95% confidence interval, 29-39) per 100,000 person-years.

CONCLUSION

The increase in syphilis serologic prevalence reflected the syphilis epidemic in the general population. Without screening, most of these syphilis-positive donations would get into the blood supply. Thus, during a syphilis epidemic, continued syphilis screening of blood donations may be important to maintain blood safety and public health.

Introduction of rapid tests for large-scale syphilis screening among female, male, and transgender sex workers in Mumbai, India

BACKGROUND

Despite widespread availability of rapid plasma reagin (RPR) for syphilis screening at sex worker (SW)-dedicated project clinics, uptake of syphilis testing remains low and prevalence of syphilis remains high among SWs in Maharashtra, India. The primary reasons given for refusal of RPR were fear of venipuncture and long waiting times for results.

METHODS

Between December 2007 and February 2008, rapid point of contact diagnostic tests (Syphicheck-WB, Qualpro Diagnostics, India) using finger-prick samples were introduced for syphilis screening, with RPR confirmation test of positives.

RESULTS

Uptake of syphilis screening among clinic attenders increased to 63.1% compared with an average of 14.3% before the intervention. Among the 19,809 SWs who were screened, 598 tested positive (3% prevalence of lifetime infection). Of these, 395 (66.1%) accepted RPR confirmation test; 337 (88.3%) were seroreactive, 160 (40.5%) had titers ≥1:8 (active syphilis). The projected overall prevalence of active syphilis among all SWs screened was 1.2% but varied by site and typology of sex work (brothel-based, 2.4%; bar-based, 0.5%; street-based, 2.3%; male SWs, 0.2%; transgender, 11.3%; home-based, 0.6%).

CONCLUSIONS

The introduction of rapid tests dramatically increased the uptake of syphilis screening in this large-scale intervention among a high-risk population in India. However, only two-thirds of SWs with a positive rapid test accepted a confirmatory RPR test. The high proportion (40.5%) of active syphilis among those testing positive on the rapid screening test justifies treatment even if confirmatory testing is declined. A commercially available, simple, rapid nontreponemal test is needed to further strengthen syphilis screening.

The immunopathobiology of syphilis: the manifestations and course of syphilis are determined by the level of delayed-type hypersensitivity

Syphilis has plagued mankind for centuries and is currently resurgent in the Western hemisphere. Although there has been a significant reduction of tertiary disease and recognition of facilitative interactions with human immunodeficiency virus infection, the natural history of syphilis has remained largely unchanged; thus, new strategies are required to more effectively combat this pathogen. The immunopathologic features of experimental syphilis in the rabbit; the course, stages, and pathology of human syphilis; and a comparison of human syphilis with leprosy suggest that the clinical course of syphilis and its tissue manifestations are determined by the balance between delayed-type hypersensitivity (DTH) and humoral immunity to the causative agent, Treponema pallidum. A strong DTH response is associated with clearance of the infecting organisms in a well-developed chancre, whereas a cytotoxic T-cell response or strong humoral antibody response is associated with prolonged infection and progression to tertiary disease. Many of the protean symptoms/appearances of secondary and tertiary human syphilis are manifestations of immune reactions that fail to clear the organism, due to a lack of recruitment and, more importantly, activation of macrophages by sensitized CD4 T cells. The Bacillus Calmette-Guerin vaccination can enhance DTH and has been shown to produce a low, but measurable, beneficial effect in the prevention of leprosy, a disease that shows a disease spectrum with characteristics in common with syphilis. In the prevention of syphilis, a potential vaccine protective against syphilis should be designed to augment the DTH response.

Field performance of a rapid point-of-care diagnostic test for antenatal syphilis screening in the Amazon region, Brazil

We evaluated an immunochromatographic point-of-care (POC) syphilis test in 712 pregnant women under field conditions in remote communities of the Amazon region (Brazil), and identified risk factors for syphilis. Women were screened by POC test using whole blood obtained by fingerprick, the fluorescent treponemal antibody absorption (FTA-Abs) test as the gold standard and the Venereal Diseases Research Laboratory (VDRL) test to determine test performance in active syphilis. Multivariate analysis was conducted to identify factors associated with syphilis infection. Among women, 2.2% had syphilis (positive FTA-Abs) and 0.8% active syphilis (FTA-Abs and VDRL positive). In all, 2.2% of samples were positive by the POC test. The sensitivity, specificity, positive and negative predictive values were 62.5% (95% confidence interval [CI]: 38.6-81.5), 99.1% (95% CI: 98.1-99.6), 62.5% (95% CI: 38.6-81.5) and 99.1% (95% CI: 98.1-99.6), respectively. The POC test identified 62.5% (10/16) of syphilis cases, 66.7% (4/6) of active syphilis cases and all high-titre syphilis cases (VDRL > 1:8). Older age was associated with syphilis infection. The rapid test performed moderately well as a screening tool for low-risk populations. This combined with on-site testing and same day treatment could expand antenatal syphilis screening programmes in distant communities characterized by difficult access to antenatal services and infrequent clinical follow-up visits.

Quantifying sexual exposure to HIV within an HIV-serodiscordant relationship: development of an algorithm

BACKGROUND

The risk of acquiring HIV from a single sexual contact varies enormously reflecting biological and behavioural characteristics of both infected and uninfected partners. Accurate information on HIV transmission risk is required to construct evidence-based risk reduction practices for individuals, to direct the provision of prevention strategies at the population level, and enable the definition, quantification and comparison of true exposure in individuals termed 'exposed uninfected' within clinical trials.

METHODS

Following a systematic review of current literature on HIV transmission estimates, an HIV risk score was developed, incorporating weighted risk factors into a Bernoulli mathematical model, allowing quantification of overall risk of HIV acquisition within HIV-serodiscordant partnerships.

RESULTS

The HIV risk score enumerates the relative risk of HIV acquisition from HIV-positive partners incorporating the type and frequency of specific sex acts, the index case HIV plasma viral load and stage of disease, and the presence of genital ulcer disease in either partner and pregnancy, HSV-2 seropositivity, and circumcision status (men only) in the HIV-negative partner.

CONCLUSION

Key determinants of HIV exposure risk can be incorporated into a mathematical model in order to quantify individual relative risks of HIV acquisition. Such a model can facilitate comparisons within clinical trials of exposed uninfected individuals and facilitate interventions to reduce HIV transmission.

A spatial analysis of county-level variation in syphilis and gonorrhea in Guangdong Province, China

Background

Sexually transmitted infections (STI) have made a resurgence in many rapidly developing regions of southern China, but there is little understanding of the social changes that contribute to this spatial distribution of STI. This study examines county-level socio-demographic characteristics associated with syphilis and gonorrhea in Guangdong Province.

Methods/Principal Findings

This study uses linear regression and spatial lag regression to determine county-level (n = 97) socio-demographic characteristics associated with a greater burden of syphilis, gonorrhea, and a combined syphilis/gonorrhea index. Data were obtained from the 2005 China Population Census and published public health data. A range of socio-demographic variables including gross domestic product, the Gender Empowerment Measure, standard of living, education level, migrant population and employment are examined. Reported syphilis and gonorrhea cases are disproportionately clustered in the Pearl River Delta, the central region of Guangdong Province. A higher fraction of employed men among the adult population, higher fraction of divorced men among the adult population, and higher standard of living (based on water availability and people per room) are significantly associated with higher STI cases across all three models. Gross domestic product and gender inequality measures are not significant predictors of reported STI in these models.

Conclusions/Significance

Although many ecological studies of STIs have found poverty to be associated with higher reported STI, this analysis found a greater number of reported syphilis cases in counties with a higher standard of living. Spatially targeted syphilis screening measures in regions with a higher standard of living may facilitate successful control efforts. This analysis also reinforces the importance of changing male sexual behaviors as part of a comprehensive response to syphilis control in China.

An overview of the relative risks of different sexual behaviours on HIV transmission

PURPOSE OF REVIEW

Sexual intercourse represents the majority of HIV transmission and is preventable. Overall, the risk of HIV transmission following a single sexual exposure is low especially in comparison with other sexually transmitted infections (STIs), with estimates of the average probability of male-to-female HIV transmission only 0.0005-0.0026 per coital act. The risk of acquiring HIV from a single contact varies enormously and is dependant upon the infectiousness of the HIV-positive individual and the susceptibility to HIV of their sexual partner.

RECENT FINDINGS

Of concern, unprotected sex among men who have sex with men (MSM) has increased in recent years and HIV incidence in both MSM and heterosexuals remains a considerable public health concern. Sexual practices and health optimism about HIV have changed, which have significantly impacted HIV risk behaviour.

SUMMARY

In this review article we summarize the current evidence regarding the observed relative risks of HIV transmission for each different types of sex act, relationship type and the strategies that have been tested to interrupt transmission.

Drug-related behaviors independently associated with syphilis infection among female sex workers in two Mexico-US border cities

AIMS

To identify correlates of active syphilis infection among female sex workers (FSWs) in Tijuana and Ciudad Juarez.

DESIGN

Cross-sectional analyses of baseline interview data. Correlates of active syphilis (antibody titers >1 : 8) were identified by logistic regression. Setting Tijuana and Ciudad Juarez, two Mexican cities on the US border that are situated on major drug trafficking routes and where prostitution is quasi-legal.

PARTICIPANTS

A total of 914 FSWs aged > or =18 years without known human immunodeficiency virus (HIV) infection who had had recent unprotected sex with clients.

MEASUREMENTS

Baseline interviews and testing for syphilis antibody using Treponema pallidum particle agglutination (TPPA) and rapid plasma reagin (RPR) tests.

FINDINGS

Median age and duration in sex work were 32 and 4 years, respectively. Overall, 18.0% had ever injected drugs, 14.2% often or always used illegal drugs before or during sex in the past month, 31.4% had clients in the last 6 months who injected drugs, and 68.6% reported having clients from the United States. Prevalence of HIV and active syphilis were 5.9% and 10.3%, respectively. Factors independently associated with active syphilis included injecting drugs (AOR: 2.39; 95% CI: 1.40, 4.08), using illegal drugs before or during sex (AOR: 2.06; 95% CI: 1.16, 3.65) and having any US clients (AOR: 2.85; 95% CI: 1.43, 5.70).

CONCLUSIONS

Among female sex workers in Tijuana and Ciudad Juarez, drug-using behaviors were associated more closely with active syphilis than were sexual behaviors, suggesting the possibility of parenteral transmission of T. pallidum. Syphilis eradication programs should consider distributing sterile syringes to drug injectors and assisting FSWs with safer-sex negotiation in the context of drug use.

Population-based seroprevalence of HSV-2 and syphilis in Andhra Pradesh state of India

BACKGROUND

Understanding the prevalence and risk factors for common causes of ulcerative genital disease in the general population would inform current STI syndromic management and HIV testing strategies in high HIV prevalence regions of India.

METHODS

Persons 15-49 years old from 32 rural and 34 urban clusters were sampled using a stratified random method to represent adults in the high HIV prevalence Guntur district in Andhra Pradesh state. Interviews were conducted and dry blood spots were collected on 12,617 study participants. Testing for HSV-2 and syphilis was performed.

RESULTS

Adjusted HSV-2 and syphilis seroprevalence rates were 4.70% and 2.08% for men and 7.07% and 1.42% for women. For men, tattooing, >3 lifetime sex partners, tobacco use, and sex with men in the past 6 months were associated with HSV-2 or syphilis (ORs, 1.66-2.95, p < 0.05). Male circumcision was positively associated with HSV-2 infection (OR, 1.37, p = 0.028) though this could be due to residual confounding. In women, greater than one lifetime partner remained significantly associated with HSV-2 in multivariate analysis (OR, 2.61; 95% CI, 1.39-4.87). Among all behavioral risk factors and other covariates in women and men, HIV infection exhibited the strongest association with HSV-2 and syphilis (ORs, 8.2-14.2, p < 0.001). The proportion of individuals with HSV-2 who were HIV infected was less than the proportion with syphilis who were HIV infected (11.8% vs. 22.7%; p = 0.001).

CONCLUSIONS

Nearly one in four persons surveyed in this population-based study that were seroprevalent for syphilis, were also HIV infected. Common population risk factors for syphilis, HSV-2 and HIV and high rates of co-seroprevalence suggest that HIV testing, STI testing and service strategies for these would benefit from direct linkage in India.

Integrated syphilis/HIV screening in China: a qualitative analysis

Background

The last decade has seen enormous advances in HIV treatment and care, but how to implement scaled up HIV testing, prevention, and treatment in low-income areas still presents a formidable public health challenge. South China faces expanding syphilis and sexually transmitted HIV epidemics, but health systems characteristics important for scaling up syphilis and HIV testing have not been defined.

Methods

A purposive sample to ensure public, private, and public-private hybrid STI clinic inclusion was selected in a South China city. Eight key informant interviews were conducted with the STI clinic manager, followed by eight focus group discussions with physicians. Data collection relied on a semi-structured format that included questions in each of the following domains: 1) clinical facilities; 2) laboratory capacity with a focus on syphilis/HIV diagnosis; 3) clinic personnel; 4) physical space with a focus on locations to disclose confidential results; 5) financial support.

Results

Public STI clinics had free syphilis testing/treatment and laboratory facilities to perform essential syphilis and HIV tests. However, despite serving a large number of STI patients, private STI clinics lacked nontreponemal syphilis testing, HIV testing, and had fewer connections to the public health infrastructure. Formally trained assistant physicians were 2.5 times as common as physicians at STI clinics. Only one of the 8 sites had onsite voluntary counseling and testing (VCT) services available.

Conclusion

These STI case studies reveal the potential for expanding integrated syphilis/HIV services at public STI clinics in China. More health services research is needed to guide scale-up of syphilis/HIV testing in China.

Incarcerated sex workers and HIV prevention in China: social suffering and social justice countermeasures

Sex workers in China are routinely coercively detained through administrative mechanisms outside of legal procedures, but very little is known about the anthropologic and public health context of these policies. This biosocial analysis of female Chinese sex worker detention uses ethnographic, legal, and public health data to describe social suffering and countervailing social justice responses among incarcerated sex workers (ISW) in China. Compared to sex workers not detained in China, ISW face substantive inequalities inscribed in physical and psychological suffering. Chinese sex worker detention camp practices may not only systematically increase HIV/syphilis risk among ISW, but also work to narrow women's social spheres of influence, a particularly cruel tragedy in a Chinese social system that highly values social and personal connections. A limited empiric analysis of Guangxi Province STI clinic data shows that cities detaining sex workers have higher mean HIV prevalence compared to cities that do not detain sex workers. While incipient medical and legal movements in China have generated momentum for expanding ISW services and resources, there is still substantial variation in the implementation of laws that ensure basic life-saving medical treatments. Post-incarceration social justice programs for sex workers linking women to essential STI/HIV resources, reconnecting broken social lives, and helping restore interpersonal relationships are urgently needed.

Prevalence and correlates of HIV and syphilis infections among men who have sex with men in Chongqing Municipality, China

OBJECTIVE

To examine the prevalence and correlates of HIV/syphilis infections and sexually transmitted diseases (STDs) among men who have sex with men (MSM) in Chongqing, China.

METHOD

Cross-sectional surveys were conducted to provide information, including sociodemographics, sexual and drug use behaviors, HIV knowledge, and HIV-related services in 2006 and 2007, respectively. Multiple methods, including venue-based recruitment, community outreach, Internet advertisements, and peer referral, were used to identify men in Chongqing willing to participate in this study.

RESULTS

Of the 1692 participants, 10.8% were HIV-infected (range by district: 7.0%-15.0%), 8.6% were syphilis-infected, and 15.3% self-reported STD-related symptoms. HIV infection was associated with older age, recruitment from bathhouses/saunas, less education, more male sex partners, sex with a woman in the past 6 months, syphilis infection, and STD-related symptoms. Syphilis infection was associated with older age, less education, inconsistent condom use with a man, STD-related symptoms, and HIV infection. STD-related symptoms were associated with older age, being of nonlocal residency, inconsistent condom use with a humans, having ever paid for sex with a humans, HIV infection, and being from District 1.

CONCLUSIONS

HIV and syphilis infections have reached alarmingly high rates in Chongqing's MSM population. Better targeted, in-depth and comprehensive intervention strategies are needed urgently, including education, condom promotion and distribution, STD control, drug use-related intervention, and advocacy for HIV counseling and testing with bridges to HIV prevention and care services. Widespread testing for HIV, syphilis, and other major STDs in this risk group should be considered as measures for control.

Evaluation of two human plasma pools as candidate international standard preparations for syphilitic antibodies

A collaborative study was designed to asses two freeze-dried human plasma preparations containing anti-Treponema pallidum antibodies, 05/132 and 05/122, for their suitability as international reference reagents for syphilis serology. Both preparations are intended as replacements of the first international standard (IS) for syphilitic serum antibodies (HS). Samples were tested by eight laboratories using the T. pallidum passive particle agglutination assay (TPPA), the venereal disease research laboratory test (VDRL) and the rapid plasma reagin test (RPR). In addition a range of immunoassays was also used. The outcome of the collaborative study revealed that candidate standard 05/132 contains T. pallidum-specific IgG and IgM and is reactive in VDRL or RPR, and that 05/122 contains T. pallidum-specific IgG but is not reactive in either the VDRL or RPR test. Both 05/132 and 05/122 are reactive in the TPPA. On the basis of these results the Expert Committee on Biological Standardization of the World Health Organization designated 05/132 as the 1st IS for human syphilitic plasma IgG and IgM with a unitage of 3 IU per ampoule relative to HS and 05/122 as the 1st IS for human syphilitic plasma IgG with a unitage of 300 mIU per ampoule relative to 05/132.

Burden of syphilis infections in Shenzhen, China: a preliminary estimation

Information on the prevalence and incidence of sexually transmitted infections is important for developing prevention and control strategies and allocating human and financial resources. However, there are no available estimates of such information for many areas in China. In this study, we used the existing data to make a preliminary estimation of syphilis infections in Shenzhen city, in south-eastern China. Data on prevalence rates of syphilis infections among different populations were obtained from the local HIV/sexually transmitted disease second-generation surveillance programme, and the sizes of different populations were estimated based on the most recently available figures. It was estimated that 83,760 (range 77,490–90,020) people are currently infected with syphilis, giving a prevalence of 0.71–0.82% (0.76% on average) in Shenzhen. Around 18% of these syphilis infections occur among men who have sex with men and another 15.8% and 8.7% occur among female sex workers and their clients, respectively. These estimates suggest that a combination of unprotected paid sex and sex between men may be sustaining the epidemic of syphilis in the study area. The preliminary estimates will assist the government in planning and improving its comprehensive intervention programmes for the future control and prevention of syphilis.

Syphilis and HIV co-infection

Syphilis is a complex disease, which is sexually transmitted. The incidence of syphilis is rising all over the world, partly due to the increased transmission in HIV patients and other high risk groups such as men who have sex with men. Interestingly syphilis itself facilitates HIV infection in several ways. Great importance exists in recognition of both diseases and their complex interactions. This article will review the manifestations of syphilis in the context of HIV infected patients, and the challenging diagnosis and management of these patients.