Increased Methamphetamine, Injection Drug, and Heroin Use Among Women and Heterosexual Men with Primary and Secondary Syphilis - United States, 2013-2017

Sexually Transmitted Infection and HIV Testing and Diagnosis Among 15- to 44-Year-Old Patients With and Without Opioid Use Disorder

BACKGROUND

The association between illicit opioid use and prescription opioid misuse and sexually transmitted infections (STIs) has not been examined recently. Our study aimed to explore differences in STI/HIV care, and delivery of recommended testing and diagnoses among patients with and without opioid use disorder (OUD).

METHODS

Using 2019 MarketScan commercial claims data, we identified 15- to 44-year-old male and female patients, to assess the percentages of STI/HIV diagnoses (using International Classification of Diseases, Tenth Revision, Clinical Modification ) and screening (using Current Procedure Terminology codes) among patients with or without OUD diagnoses codes. We further assessed STI/HIV testing and diagnoses by demographic factors.

RESULTS

We identified 24,724 patients with OUD codes among 7.31 million patients. Both STI/HIV testing and diagnoses were significantly ( P < 0.05) higher among patients with OUD codes versus without: testing percentages were 16.81% versus 12.93% for chlamydia, 22.31% versus 16.62% for gonorrhea, 15.26% versus 7.61% for syphilis, and 18.18% versus 7.60% for HIV; diagnoses were 0.80% versus 0.35% for chlamydia, 0.30% versus 0.11% for gonorrhea, 0.23% versus 0.07% for syphilis, and 0.74% versus 0.33% for HIV. Similarly, among 0.53 million 15- to 24-year-old females who received services suggestive of sexual activity, chlamydia testing was significantly ( P < 0.05) higher among patients with OUD codes versus without (59.78% vs. 55.66%).

CONCLUSIONS

Patients with OUD codes have higher percentages of STI/HIV testing and diagnoses codes compared with those without OUD codes. Clinicians may want to consider a comprehensive multidisciplinary (OUD and STI prevention) approach in patient care and provide recommended STI/HIV screening among patients with OUD if not performed.

Sexually transmitted and blood-borne infection risk reduction with methadone and buprenorphine/naloxone among people with prescription-type opioid use disorder: Findings from a Canadian pragmatic randomized trial

INTRODUCTION

People who use drugs are disproportionally affected by sexually transmitted and blood-borne infections (STBBIs). While the benefits of methadone in reducing injecting-risk behaviours are well documented, less is known on its impacts on sexual-related risks, as well as its comparative effectiveness to buprenorphine/naloxone, particularly in the context of highly potent opioids. The aim of this study was to estimate the relative effects of buprenorphine/naloxone and methadone on injecting and STBBI risks among people with prescription-type opioid use disorder (POUD).

METHODS

Secondary analysis of a pan-Canadian pragmatic 24-week randomized clinical trial comparing methadone and buprenorphine/naloxone models of care among 272 people with POUD (including licit or illicit opioid analgesics, fentanyl). The Risk Behaviour Survey was used to collect injecting and sexual risks at baseline, and weeks 12 and 24.

RESULTS

In total, 210 participants initiated treatment (103 buprenorphine/naloxone and 107 methadone). At baseline, 113/205 (55.1%) participants reported recently injecting drugs, 37/209 (17.7%) unsafe injection practices and 67/162 (41.4%) high-risk sex. Both methadone and buprenorphine/naloxone were associated with reductions in the prevalence of injection drug use and high-risk sex at weeks 12 and 24 with no interactions between treatment arm and time.

CONCLUSION

Methadone and buprenorphine/naloxone were similarly effective in reducing injecting and sexual risk behaviours among people with POUD.

CLINICAL TRIALS REGISTRATION

clinicaltrials.gov NCT03033732.

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

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

Syphilis in Hematopathology Practice: A Diagnostic Challenge

CONTEXT.—

Syphilis, a reemerging disease caused by the spirochete Treponema pallidum, is becoming more frequent in surgical pathology and hematopathology practices. Hematopathologists typically receive lymph node biopsies from patients with syphilis who have localized or diffuse lymphadenopathy. Occasionally, syphilis infection in the aerodigestive tract can show a prominent lymphoplasmacytic infiltrate and mimic lymphoma. Besides the varying and occasional atypical morphology, the fact that clinical suspicion tends to be low or absent when histologic evaluation is requested adds to the importance of making this diagnosis.

OBJECTIVE.—

To summarize histologic features of syphilitic lymphadenitis and syphilis lesions in the aerodigestive tract, and to review differential diagnosis and potential diagnostic pitfalls.

DATA SOURCES.—

Literature review via PubMed search.

CONCLUSIONS.—

Characteristic histologic findings in syphilitic lymphadenitis include thickened capsule with plasma cell-rich inflammatory infiltrate, reactive follicular and paracortical hyperplasia with prominent lymphoplasmacytic infiltrate, and vasculitis. Lymph nodes, however, can show a number of other nonspecific histologic features, which frequently makes the diagnosis quite challenging. In the aerodigestive tract, syphilis is characterized by plasma cell-rich infiltrates. Immunohistochemistry for T pallidum is the preferred method for detecting spirochetes; however, this immunohistochemical stain shows cross-reactivity with other treponemal and commensal spirochetes. Differential diagnosis of syphilis in lymph nodes and the aerodigestive tract is broad and includes reactive, infectious, and neoplastic entities. Pathologists should be aware of the histologic features of syphilis and keep this challenging entity in the differential diagnosis.

Could ceftriaxone be a viable alternative to penicillin for the treatment of ocular syphilis?

This study was conducted to compare the effectiveness of ceftriaxone with that of aqueous crystalline penicillin G in treating ocular syphilis. We conducted a retrospective study from 2010 to 2021. Syphilis patients were administered either ceftriaxone (2 g intravenously daily for 14 days) or aqueous crystalline penicillin G [4 million units (MU) intravenously every 4 h for 14 days] as therapeutic interventions. Subsequently, we utilized these two groups to assess the serological results, cerebrospinal fluid analysis, and visual acuity at time intervals spanning 3 to 6 months post-treatment. A total of 205 patients were included, with 34 assigned to the ceftriaxone group and 171 to the penicillin group. The median age of patients was 56 years, with an interquartile range of 49-62 years, and 137 of them (66.8%) were male. Between 3 and 6 months after treatment, 13 patients (38.2%) in the ceftriaxone group and 82 patients (48.0%) in the penicillin group demonstrated effective treatment based on the clinical and laboratory parameters. The crude odds ratio (OR) was 0.672 (95% confidence interval [CI]: 0.316-1.428, P = 0.301), indicating no significant difference in effectiveness between the two groups. Thirty patients (17.5%) in the penicillin group and six patients (17.6%) in the ceftriaxone group did not experience successful outcomes. Notably, no serious adverse effects were reported in both the groups. There was no significant difference in the effectiveness of ceftriaxone and aqueous crystalline penicillin G in treating ocular syphilis. The administration of ceftriaxone without requiring hospitalization presents a convenient and safe alternative treatment option for ocular syphilis.

Sudden hearing loss secondary to syphilis

BACKGROUND

Syphilis is a sexually transmitted disease caused by the spirochete Treponema pallidum, whose incidence has increased significantly in recent years. Some patients may develop sudden hearing loss (SHL) against the background of otosyphilis.

OBJECTIVES

The objective of our study was to determine whether routine lues serology is useful in patients presenting with sudden hearing loss.

METHODS

For this purpose, all cases of SHL treated in our hospital during a period of 6 years were propectively collected. The frequency of positivity for syphilis in these patients, the treatment received, and their evolution were determined.

RESULTS

Of the total number of patients evaluated during that period, 71 underwent serological screening for syphilis, of whom 2 (2.8 %) presented positive screening antibodies. In one of them, the RPR was normal and had been treated with lues a few years before. After treatment there was no improvement. The other patient, diagnosed with otosyphilis with unconfirmed suspected neurological disease, showed normalization of hearing after specific treatment.

CONCLUSIONS

Since it is a potentially curable disease, despite the low overall frequency of syphilis in patients with SHL it is advisable to perform serological screening for syphilis in high risk patients (e.g., incarceration, multiple recent sexual partners, men who have sex with men) or atypical clinical presentation (e.g., concurrent neuropathies).

The Intersection of Substance Use Disorders and Infectious Diseases in the Emergency Department

Substance use disorders (SUDs) intersect clinically with many infectious diseases, leading to significant morbidity and mortality if either condition is inadequately treated. In this article, we will describe commonly seen SUDs in the emergency department (ED) as well as their associated infectious diseases, discuss social drivers of patient outcomes, and introduce novel ED-based interventions for co-occurring conditions. Clinicians should come away from this article with prescriptions for both antimicrobial medications and pharmacotherapy for SUDs, as well as an appreciation for social barriers, to care for these patients.

Syphilis Diagnosis After a Chlamydia, Gonorrhea, or HIV Diagnosis Among Reproductive-Aged Women in Baltimore, MD

BACKGROUND

Syphilis incidence is increasing among reproductive-aged women, and previous sexually transmitted infections (STIs) are a risk factor for subsequent STIs. This study aimed to determine syphilis incidence after a chlamydia, gonorrhea, or HIV diagnosis, and identify characteristics associated with higher syphilis incidence rates among reproductive-aged women in 1 mid-Atlantic city.

METHODS

A retrospective cohort of 85,113 chlamydia, gonorrhea, and HIV diagnoses occurring between 2009 and 2021 and among women aged 13 to 50 years was constructed using public health surveillance data. Cumulative incidence curves were estimated to examine time to early syphilis (i.e., primary, secondary, or early latent) diagnosis, and multivariable analyses determined incidence rate ratios by age (<25 vs. ≥25 years) and number of prior STI diagnoses (0 vs. ≥1) during the study period, stratified by STI.

RESULTS

There were 85,113 reportable STI diagnoses and 646 syphilis diagnoses in the cohort. Approximately 1 of 150 chlamydia, 1 of 100 gonorrhea, and 1 of 50 HIV diagnoses were followed by a syphilis diagnosis within 5 years. Cumulative incidence of syphilis differed significantly by STI diagnosis ( P < 0.001). In multivariable analysis, syphilis incidence rates were higher among women diagnosed with ≥1 (vs. 0) prior STI regardless of STI type ( P < 0.05) and among women ≥25 (vs. <25) years old diagnosed with gonorrhea ( P < 0.05).

CONCLUSIONS

There were significant differences in syphilis incidence by prior STI type, number of STIs, and age. Our data support targeted screening for syphilis among women with a history of STIs, parwomen with ≥1 prior STI diagnosis, and older women diagnosed with gonorrhea.

Psychiatric manifestations of neurosyphilis over past two decades: Findings from a tertiary care neuropsychiatric hospital in south India

OBJECTIVE

To assess presentation of neurosyphilis with a focus on the psychiatric aspects.

METHOD

File review of the cases with a positive cerebrospinal fluid venereal disease research laboratory test between 1999 to 2020.

RESULTS

Medical records of 143 neurosyphilis patients were analysed. Hallucinations, delusions, and catatonia were the commonest psychiatric symptoms. Brain atrophy was the commonest neuroimaging finding. The number of neurosyphilis patients and the proportion with delirium or catatonia declined during the second decade (2010-2020).

CONCLUSION

Atypical presentation of psychiatric symptoms around the fifth decade, with associated neurological symptoms or brain imaging changes, should prompt evaluation for neurosyphilis.

Evaluation of self-directed specimen collection for chlamydia and gonorrhea testing among people who use drugs

Background: People who use drugs (PWUD) often have elevated sexually transmitted infection (STI) risk and unmet healthcare needs. Self-directed STI specimen collection (i.e., individuals collect the specimen and mail to the laboratory) may be valuable in addressing STI testing barriers among PWUD. Methods: Within a cohort study among PWUD in New York City, we conducted a cross-sectional substudy from November 2021-August 2022 assessing sexual health with a one-time online survey (n = 120); participants could opt-in to receive a self-collection kit. Participants who opted-in were mailed a kit containing collection materials (males: urine cup, females: vaginal swab), pre-paid return label, instructions, and educational information. Specimens were sent to the laboratory and tested for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC). We measured the number of kits requested, delivered, mailed to the lab, and CT/GC positive; and examined differences in requesting a kit by sociodemographic and behavioral characteristics. Results: Sixty-three total kits were requested by 44 unique participants. Of the 63 requested, 41 were delivered; one kit was undeliverable at the provided address and the rest were not sent due to no address provided or being duplicate requests. Of the 41 kits delivered, three participants returned the kit to the lab; of those, one was positive for CT and GC. The greatest differences in those who did and did not request a kit were observed by age, sexual orientation, past-year sex trade and casual partnerships, and experiences of relationship violence. Conclusions: Self-directed specimen collection may be desirable for PWUD, but research is needed to understand barriers to this testing approach for this population.

The Mortality of Congenital Syphilis

OBJECTIVES

To document the case-fatality rate (CFR) of congenital syphilis diagnosed by molecular tools and rabbit infectivity testing (RIT) of clinical specimens in addition to standard evaluation and to compare that with the CFR using the Centers for Disease Control and Prevention (CDC) surveillance case definition.

STUDY DESIGN

Prospective, single site, cohort study of all cases of syphilis among mothers and their infants from 1984 to 2002. The diagnosis of congenital syphilis was determined using IgM immunoblotting, polymerase chain reaction, and RIT of fetal or infant specimens in addition to clinical, laboratory, and radiographic criteria. Data were retrospectively reviewed to ascertain fetal and neonatal mortality.

RESULTS

During the 18-year study, there were 191 cases of congenital syphilis confirmed by abnormalities on clinical, laboratory, or radiographic evaluation and/or positive serum IgM immunoblot, blood polymerase chain reaction, or blood/cerebrospinal fluid RIT. Of the 191 cases, 59 died for a CFR of 31%. Of the 59 deaths, 53 (90%) were stillborn and 6 (10%) died in the neonatal period. The majority (74%, 39/53) of stillbirths occurred in the third trimester. The CDC surveillance case definition correctly identified all infants with congenital syphilis, but the CDC CFR was 10% which underestimated the CFR by more than 300%.

CONCLUSIONS

Our findings corroborate the high sensitivity of the CDC surveillance definition for congenital syphilis but highlight its poor estimation of its associated mortality. The CFR among infected progeny of pregnant women with syphilis was 31%, due mostly to demise in the third trimester and as such highlights the need for detection and appropriate treatment of syphilis during pregnancy.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Syphilis

Syphilis is a sexually and vertically transmitted bacterial infection caused by the bacterium Treponema pallidum. Its prevalence is high in low-income and middle-income countries, and its incidence has increased in high-income countries in the last few decades among men who have sex with men. Syphilis is a major cause of adverse pregnancy outcomes in low-income and middle-income countries. Clinical features include a primary chancre at the point of inoculation, followed weeks later by the rash of secondary syphilis, a latent period, and in some cases, involvement of the eyes, CNS, and cardiovascular systems. It is diagnosed serologically. A single intramuscular dose of long-acting benzathine penicillin is recommended for people who have had syphilis for less than 1 year and longer courses for people with late latent syphilis. Control strategies include screening and treatment of all pregnant women, and targeted interventions for groups at high risk. Vaccine development, research on antibiotic prophylaxis, and digital messaging as prevention strategies are ongoing.

Testing and Case Rates of Gonorrhea, Chlamydia, Syphilis, and HIV among People with Substance Use Disorders in the Veterans Health Administration

BACKGROUND

Little is known about national patterns of sexually transmitted infection (STI) testing and infections among people with substance use disorders (SUDs).

METHODS

This study used a national retrospective analysis of people with SUDs receiving healthcare in the Veterans Health Administration in 2019 (N = 485,869). We describe testing rates, test positivity, and case rates for gonorrhea, chlamydia, syphilis, and HIV among individuals with alcohol, opioid, cocaine, and noncocaine stimulant use disorders in a national cohort of Veterans Health Administration patients.

RESULTS

Test and case rates for all STIs were highest among people with noncocaine stimulant use. People with alcohol use disorder had the lowest testing rates but intermediate incidence for all STIs. People with multiple SUDs had higher incidence of all STIs than those with single SUDs. Mental health diagnoses and houselessness were common. The HIV test positivity was 0.14% to 0.36% across SUD groups.

CONCLUSIONS

Sexually transmitted infection testing rates between SUD groups were discordant with their respective case rates. High STI rates in people with SUDs suggest a need for more comprehensive testing, particularly for those with noncocaine stimulant use and those with comorbid houselessness or mental health diagnoses.

Expanded prenatal syphilis screening in Manitoba, Canada: a direct short-term cost-avoidance analysis in an outbreak context

OBJECTIVE

The objective of this study is to provide a direct short-term cost-avoidance analysis of expanded three-time prenatal syphilis screening in the context of Manitoba's ongoing outbreak.

METHODS

A conservative modelling approach increased all financial costs of prenatal screening and minimized the direct costs of congenital syphilis treatment. The cost of syphilis screening was calculated using instrument, reagent and consumable costs as well as laboratory overhead and labour costs as documented by Cadham Provincial Laboratory. The short-term direct costs of treating congenital syphilis were calculated using hospital costs and doctor's billing fees. All costs were calculated in 2021 Canadian dollars. These numbers were applied to Manitoba's 2021 congenital syphilis statistics to provide a pragmatic cost-avoidance analysis.

RESULTS

The cost of applying three-time prenatal syphilis screening to all 16,800 yearly pregnancies in Manitoba equalled CAD $139,608.00 per year. The direct short-term cost of treating one uncomplicated case of congenital syphilis was $18,151.40. As 81 cases of congenital syphilis were treated in Manitoba in 2021, the short-term direct cost of treating congenital syphilis in Manitoba in 2021 was $1,470,263.40. Applying screening costs to the 125 adequately prevented cases of congenital syphilis in 2021, the screening program is associated with a cost-avoidance ratio of 16.25. If no prenatal syphilis program existed in Manitoba, an expanded screening program would be associated with a cost-avoidance ratio of 26.8.

CONCLUSION

Expanding prenatal syphilis screening is highly cost-avoidant in Manitoba. The 81 cases of congenital syphilis treated in Manitoba in 2021 highlight the need for novel community-based approaches to increase accessibility and engagement with prenatal care.

Cervical Syphilitic Lymphadenitis in a 29-Year-Old Female: A Case Report

Cervical lymphadenopathy is a common condition characterized by the enlargement of lymph nodes. It can have various causes, including infections, inflammatory conditions, and neoplastic processes. Syphilis, a sexually transmitted disease that progresses through multiple stages, can also be a rare cause of cervical lymphadenopathy, particularly in HIV-positive individuals. In this case report, we describe a patient presenting with throat pain, systemic symptoms, and cervical lymphadenopathy, initially clinically suggestive of lymphoma but ultimately determined to be caused by syphilis of unknown duration. This case highlights the importance of considering syphilis in the differential diagnosis of cervical lymphadenitis, particularly in patients with risk factors, such as intravenous drug use and HIV infection, and the need for a thorough evaluation of the patient's social and medical histories to diagnose and treat the condition accurately.

Heroin Use Is Associated With Vascular Inflammation in Human Immunodeficiency Virus

BACKGROUND

Heroin use may work synergistically with human immunodeficiency virus (HIV) infection to cause greater immune dysregulation than either factor alone. Unraveling how this affects end-organ disease is key as it may play a role in the excess mortality seen in people with HIV (PWH) who use heroin despite access to care and antiretroviral therapy.

METHODS

This is a prospectively enrolled, cross-sectional study of adults with and without HIV who use and do not use heroin using (18)F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) to compare tissue-specific inflammation including aortic (target-to-background ratio [TBR]), splenic, and bone marrow (standardized uptake value [SUV]).

RESULTS

A total of 120 participants were enrolled. The unadjusted mean difference in aortic TBR was 0.43 between HIV-positive [HIV+] heroin+ and HIV+ heroin-negative [heroin-] (P = .02); however, among HIV-, aortic TBR was similar regardless of heroin-use status. Further, HIV-by-heroin-use status interaction was significant (P = .02), indicating that the relationship between heroin use and higher aortic TBR depended on HIV status. On the other hand, both HIV (1.54 vs 1.68; P = .04, unadjusted estimated means for HIV+ vs HIV-) and heroin use were associated with lower bone marrow SUV, although the effect of heroin depended on sex (heroin-use-by-sex interaction, P = .03). HIV-by-heroin-use interaction was not significant for splenic or bone marrow SUV.

CONCLUSIONS

Aortic inflammation was greatest in PWH who use heroin, but paradoxically, bone marrow activity was the least in this group, suggesting complex and possibly divergent pathophysiology within these different end organs.

Substance Use Among Persons with Syphilis During Pregnancy - Arizona and Georgia, 2018-2021

Despite universal prenatal syphilis screening recommendations and availability of effective antibiotic treatment, syphilis prevalence during pregnancy and the incidence of congenital syphilis have continued to increase in the United States (1,2). Concurrent increases in methamphetamine, injection drug, and heroin use have been described in women with syphilis (3). CDC used data on births that occurred during January 1, 2018-December 31, 2021, from two states (Arizona and Georgia) that participate in the Surveillance for Emerging Threats to Pregnant People and Infants Network (SET-NET) to describe the prevalence of substance use among pregnant persons with syphilis by congenital syphilis pregnancy outcome (defined as delivery of a stillborn or live-born infant meeting the surveillance case definition for probable or confirmed congenital syphilis). The prevalence of substance use (e.g., tobacco, alcohol, cannabis, illicit use of opioids, and other illicit, nonprescription substances) in persons with a congenital syphilis pregnancy outcome (48.1%) was nearly double that among those with a noncongenital syphilis pregnancy outcome (24.6%). Persons with a congenital syphilis pregnancy outcome were six times as likely to report illicit use of opioids and four times as likely to report using other illicit, nonprescription substances during pregnancy than were persons with a noncongenital syphilis pregnancy outcome. Approximately one half of persons who used substances during pregnancy and had a congenital syphilis pregnancy outcome had late or no prenatal care. Tailored interventions should address barriers and facilitators to accessing screening and treatment for syphilis among persons who use substances. The need for syphilis screening and treatment should be addressed at any health care encounter during pregnancy, especially among persons who use substances.

Syphilis: recommendations for dermatologists on a resurgent epidemic

Despite reaching historical lows in the early 2000s, cases of both primary and secondary syphilis and congenital syphilis have increased dramatically in the U.S. over the last decade. In the U.S., the current syphilis epidemic is disproportionately impacting communities that have been historically underserved in medicine. These include men who have sex with men, especially those infected with HIV; people of color; and reproductive-age women with poor access to prenatal care. With syphilis now being more commonly diagnosed in non-STI than STI clinics in all genders, and since primary and secondary syphilis and congenital syphilis present with characteristic mucocutaneous manifestations, dermatologists are in a position to help reduce the advance of this preventable epidemic, by actively considering this diagnosis and incorporating syphilis screening into their practice. Herein, we delineate strategies by which dermatologists can contribute to this critical effort in their roles as clinicians, public health advocates, and researchers. In particular, we discuss the rapidly changing demographics of syphilis, nuances in serologic testing and treatment, strategies to increase public healthcare access and equity in these underserved populations, and research gaps in this field.

Associations of Transactional Sex and Sexually Transmitted Infections Among Treatment-Seeking Individuals With Opioid Use Disorder

INTRODUCTION

Coinciding with the rise in opioid use across the U.S., the rates of sexually transmitted infections have reached historically high levels, underscoring the need to understand multiple pathways of disease spread. Although prevention is often focused on injection-related behaviors, this study sought to identify the prevalence and associations of a little understood pathway, transactional sex, among individuals with opioid use disorder, including associations of transactional sex with the prevalence of sexually transmitted infection diagnoses.

METHODS

Data were sourced from a nationwide opioid surveillance program of treatment-seeking individuals with opioid use disorder utilizing a serial, cross-sectional survey of 4,366 new entrants to 1 of 99 substance use treatment programs for opioid use disorder in 37 states from October 2018 to June 2021.

RESULTS

A quarter of the sample (24.9%) self-reported a lifetime history of transactional sex for drugs, with rates highest for sexual (56.6%) and gender (53.8%) minority, female (33.4%), Latinx (30.4%), and Black (29.6%) subgroupings. Lifetime diagnoses of all specific sexually transmitted infections analyzed were significantly higher (p<0.001) among those reporting transactional sex, particularly syphilis (14.3% vs 4.4%) and HIV (4.0 vs 0.9%). Financial hardship, trauma, and psychiatric disorder were significantly associated with transactional sex engagement.

CONCLUSIONS

Transactional sex is relatively common among patients with opioid use disorder, particularly among sexual/gender minorities, which was associated with a greater lifetime prevalence of all sexually transmitted infections assessed. Sexually transmitted infection testing remains at low levels within substance use treatment programs, occurring in just 26.3% of programs; sexual health screenings and sexually transmitted infection prevention/testing need to be prioritized and integrated into opioid use disorder patient care.

Syphilis in pregnancy: an ongoing public health threat

Syphilis is a treponemal infection that can be acquired sexually, hematogenously, or via vertical transmission from mother to infant. Despite evidence-based curative treatment options with penicillin, it remains a public health threat with increasing prevalence over recent years. Congenital syphilis, a condition where a fetus acquires the infection during pregnancy, can lead to stillbirth, miscarriage, preterm birth, birth defects, and lifelong physical or neurologic changes. Congenital syphilis rates in the United States increased by 261% from 2013 to 2018 and continue to increase in 2021. The only recommended treatment for syphilis in pregnancy is benzathine penicillin G because evidence of decreased risk of congenital syphilis with other modalities is lacking. Testing for syphilis is complex and includes either the reverse-sequence algorithm or the traditional algorithm. Determination of the clinical stage of syphilis includes incorporation of the previous treatment sequence and physical examination. The goal of this review was to discuss the current evidence about optimal treatment and testing during pregnancy to optimize maternal health and prevent congenital syphilis.

Amphetamine-type stimulants use and socio-economic factors associated with hepatitis C antibody positivity among border drug users in South of China

Background

Amphetamine-type stimulants (ATS) use has become popular in China. This study explored ATS use status and related risk factors of hepatitis C virus (HCV) infection among ATS users in Jinghong City, Xishuangbanna Prefecture, Yunnan Province, China.

Methods

A cross-sectional study was conducted by questionnaires from January to July 2021 in border area in Yunnan. Respondent driving sampling and consecutive sampling was carried out among border drug users, and blood samples were tested for HCV antibodies. HCV infection and related risk factors among ATS users were measured. Descriptive, univariate and multivariate analysis were conducted separately by Software SPSS 26.0.

Results

The ATS users accounted for 85.82% (345/402) among drug users, while anti-HCV antibody prevalence was 6.38% (22/345) among ATS users. The combined use of other types of drugs (OR = 7.29, 95%CI: 1.982-26.81, P = 0.003), injection drug use (OR = 6.823, 95%CI: 1.898-24.525, P = 0.003), average monthly income (OR = 4.825, 95%CI: 1.325-17.566, P = 0.017) might increase the risk of HCV infection among ATS users. ATS users with high school or above had higher HCV infection rates than those with primary school or below (OR = 5.718, 95%CI: 1.172-27.908, P = 0.031).

Conclusion

Taken together, among drug users using ATS in Jinghong City, Xishuangbanna Autonomous Prefecture, Yunnan Province, combined use of multiple drugs and intravenous drug use was the high risk factor for HCV infection. Therefore, corresponding education and intervention measures should be taken.

Screening for Syphilis Infection in Nonpregnant Adolescents and Adults: US Preventive Services Task Force Reaffirmation Recommendation Statement

IMPORTANCE

Syphilis is a sexually transmitted infection that can progress through different stages (primary, secondary, latent, and tertiary) and cause serious health problems if left untreated. Reported cases of primary and secondary syphilis in the US increased from a record low of 2.1 cases per 100 000 population in 2000 and 2001 to 11.9 cases per 100 000 population in 2019. Men account for the majority of cases (83% of primary and secondary syphilis cases in 2019), and rates among women nearly tripled from 2015 to 2019.

OBJECTIVE

To reaffirm its 2016 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a reaffirmation evidence update focusing on targeted key questions evaluating the performance of risk assessment tools and the benefits and harms of screening for syphilis in nonpregnant adolescents and adults.

POPULATION

Asymptomatic, nonpregnant adolescents and adults who have ever been sexually active and are at increased risk for syphilis infection.

EVIDENCE ASSESSMENT

Using a reaffirmation process, the USPSTF concludes with high certainty that there is a substantial net benefit of screening for syphilis infection in nonpregnant persons who are at increased risk for infection.

RECOMMENDATION

The USPSTF recommends screening for syphilis infection in persons who are at increased risk for infection. (A recommendation).

Primary syphilis without chancre – A case report of rare syphilitic balanitis of Follmann

Introduction

Syphilitic balanitis of Follmann (SBF) is a rare condition of primary syphilis which is characterized by any kind of balanitis with or without chancre on the penis combined with the presence of swollen inguinal lymph nodes confirmed by the finding of Treponema pallidum in the lesions or by the positive serological syphilitic testing. Timely identification of the SBF is very important in properly treating the disease stopping the spread of syphilis.

Case presentation

A 42year-old heterosexual male patient came to our clinic and complained of a painless, hard erythema nodule with a whitish scale in his coronal sulcus of the penis for about a week. The dermatologic examination revealed an infiltrative, hard erythematous lesion surrounding the coronal sulcus of the patient’s penis, with mild erosion and a small amount of exudation. There was a whitish pseudomembrane-like covering on the surface of the erythematous lesion in the coronal sulcus, which is mimicked as candidal balanitis. The result of the fungus microscopic examination was negative, while the laboratory findings showed positive results in serologic syphilitic testing. The patient was diagnosed with primary syphilis and intramuscularly treated with a dose of benzylpenicillin of 2.4 million units. The patient’s skin lesions disappeared completely 60 days after penicillin treatment.

Conclusion

To our knowledge, this is the first SBF case reported in China. Syphilitic balanitis of Follmann may have variable clinical appearances. We emphasize that when balanitis with risky sexual activities or with sexually transmitted diseases, the diagnosis of SBF should be kept in mind.

Exploring changes in maternal and congenital syphilis epidemiology to identify factors contributing to increases in congenital syphilis in Florida: a two time-period observational study (2013-2014 vs 2018-2019)

OBJECTIVES

As, cases of congenital syphilis (CS) and infectious syphilis among women more than doubled in Florida and across the nation during 2013-2019, we sought to understand what may be contributing to these increases in Florida.

DESIGN

A two time-period observational study.

SETTING

Pregnant women with reported syphilis infections and their pregnancy outcomes (2013-2014 and 2018-2019) in Florida.

PARTICIPANTS

1213 pregnant women with reported syphilis infections living in Florida and 341 infants meeting the CS case definition.

OUTCOME MEASURES

We assessed what proportion of the increase in CS was from increases in maternal syphilis infections. We examined maternal demographics, infection characteristics and timing of diagnoses that could explain the increase in CS. Finally, we reviewed if changes in presentation or severity of CS cases occurred.

RESULTS

During 2013-2014, 83 (21%) of 404 pregnant women with syphilis delivered babies with CS. During 2018-2019, 258 (32%) of 809 pregnant women with syphilis delivered babies with CS. Comparing CS prevention rates, it was determined that 65% of the increase in CS was due to the increases in maternal syphilis infections. The proportion of maternal cases staged as primary or secondary increased over time (7%-13%) (p<0.01) and reports of drug use became slightly more common (6%-10%) (p=0.02). During 2018-2019, women delivering CS infants were more likely to be reinfected during the same pregnancy (27 (10%) vs 5 (6%) p=0.23) and more had negative third trimester screening tests (43 (17%) vs 7 (8% p=0.07)). The percentage of infants with CS who had ≥1 sign or symptom increased from 35% to 40%, and the combined total of stillbirths and infant deaths increased from 5 to 26.

CONCLUSIONS

Recently, more pregnant women are being infected with syphilis and a higher per cent are not being treated to prevent CS. The reasons for this finding are unclear.

Retrospective Cohort Study Examining the Correlates of Reported Lifetime Stimulant Use in Persons Diagnosed With Infectious Syphilis in Alberta, Canada, 2018 to 2019

BACKGROUND

We sought to examine the correlates for stimulant use in persons diagnosed with infectious syphilis during an outbreak in Alberta to help guide public health interventions.

METHODS

Infectious syphilis data were extracted from the Communicable Disease and Outbreak Management database from January 1, 2018, to December 31, 2019. Behavioral, demographic, and lifetime reported stimulant use data were obtained. Descriptive analyses and logistic regression were performed for 3 subpopulations (gay, bisexual, and other men who have sex with men; men who have sex with women; and women).

RESULTS

Of 3627 individuals diagnosed with infectious syphilis, 23.9% (n = 867) cases were not interviewed for substance use and were removed from further analysis. Of the remaining 2759 people, 41.8% (n = 1153) self-reported lifetime stimulant use. Gay, bisexual, and other men who have sex with men reported stimulant use less often than women (24.6% vs. 44.1%; P < 0.0001) and men who have sex with women (24.6% vs. 46.2%; P < 0.0001). Multivariable analyses demonstrated that stimulant use was associated with persons who injected drugs, had correctional involvement, or reported multiple sex partners. Men who have sex with women were more likely to self-report First Nations ethnicity (adjusted odds ratio, 1.76 [95% confidence interval, 1.25-2.49]), and women were more likely to have a concurrent gonorrhea infection (adjusted odds ratio, 1.62 [95% confidence interval, 1.15-2.28]).

CONCLUSIONS

Nearly half of infectious syphilis cases in Alberta reported lifetime nonprescription stimulant use. Infectious syphilis cases with stimulant use were associated with injection drug use, multiple sex partners, and correctional involvement. Our observations highlight the need for integration of sexual health services into programs for people who use substances and those in corrections custody.

Understanding perinatal patient's health preferences and patient-provider relationships to prevent congenital syphilis in California and Louisiana

Background

Congenital syphilis (CS) has reemerged as a global maternal and child health crisis. Kern County, California and East Baton Rouge Parish, Louisiana are among the highest CS morbidity regions in the United States. We previously reported on social-ecological and structural barriers to prenatal care and maternal syphilis testing and treatment in these two regions. The aim of this study was to examine perinatal patient’s health preferences and perceptions of patient-provider relationships in the prenatal care clinic setting.

Methods

Between May 2018 and January 2019 we conducted 20 in-depth qualitative interviews with prenatal providers and 8 focus group discussions with pregnant and postpartum individuals in Kern County and East Baton Rouge Parish. We applied an adapted health services framework to analyze participants’ understanding of health disparities and vulnerable populations; perinatal patient’s health and prenatal care preferences; and participants’ perspectives of clinical encounters in the context of prenatal care and maternal syphilis testing and treatment.

Results

Site-specific determinants of syphilis infection emerged but participants from both locations felt CS prevention efforts should be prioritized among youth, racial/ethnic minority populations, people experiencing socioeconomic limitations and people with other commonly occurring health conditions. Although perinatal patients expressed clear health preferences, they reported inconsistent receipt of respectful, patient-centered care. Inconsistencies were connected with limited ethnic and cultural competence among providers, and implicit, negative attitudes toward patients using substances, experiencing homelessness, or engaging in sex work. Providers clearly aimed to offer high quality prenatal care. However, some clinic and health systems level factors were thought to reduce positive and communicative patient-provider relationships, contributing to gaps in use of prenatal care and syphilis testing and treatment.

Conclusions

Our findings suggest that interventions tailored to address setting-specific determinants (including clinic and health system factors) of disparities in CS risk could improve pregnant people’s access to prenatal care and ensure they and their sex partners receive timely syphilis screening and treatment. We recommend all prenatal care providers receive training on how to identify and mitigate implicit biases and provide competent and compassionate patient-centered care.

Syphilis in the era of re-emergence: A 6-year retrospective study from a tertiary care center in South India

Background

During the last several years, we have observed a rise in the number of patients with syphilis in our center.

Aims

To find out the trends in the presentation of syphilis to our clinic over a 6-year period and to analyze the clinicoepidemiological features of those patients.

Settings and Design

A retrospective chart review.

Subjects and Methods

We analyzed the case records of all cases of syphilis registered in our sexually transmitted infection (STI) clinic from October 1, 2012, to September 30, 2018. Syphilis was diagnosed based on clinical or serological evidence. We also evaluated these patients for any concomitant STI, including hepatitis B, hepatitis C, and HIV.

Statistical Analysis Used

The data were analyzed using SPSS software (version 20). Chi-square test was done for comparing categorical data, and P < 0.05 was considered statistically significant.

Results

During the study period, 215 patients with STI attended our clinic. Of these, 66 (31%) patients had acquired syphilis. Among them, 3 (4.5%) had primary syphilis, 23 (34.8%) had secondary syphilis, and 40 (60.6%) had latent syphilis. Fifteen (22.7%) patients had concomitant HIV infection. A statistically significant rise in the number of cases of syphilis compared with other STIs was noted in the latter half of the study period (P = 0.001). Among the 50 males with acquired syphilis, 29 (58%) were men having sex with men (MSM), including 19 bisexual persons. Among the five antenatal cases, two were detected very late in pregnancy.

Conclusions

We observed a marked increase in the number of cases of syphilis during the latter half of the study period. Primary and secondary syphilis were more frequent among MSM, suggesting a need to strengthen targeted intervention programs among them. More rigorous antenatal screening is necessary to prevent congenital syphilis.

Determinants of syphilis infection among pregnant women attending antenatal care in hospitals of Wolaita zone, Southern Ethiopia, 2020

Objective of the study

The objective of this study was to identify determinants of syphilis infection among pregnant women attending antenatal care in hospitals in the Wolaita zone, Southern Ethiopia,2020.

Methods

An unmatched facility-based case-control study was conducted among pregnant women who received antenatal care at four randomly selected hospitals from September 1 to October 30, 2020. A two-stage sampling technique was used in the selection of hospitals and study participants. The data were collected from the participants using a pre-tested structured questionnaire and analyzed using STATA Release 15. Bivariate and multivariate logistic regression analyses were used to determine syphilis infection determinants. Crude and adjusted odds ratios were used for each explanatory variable with a 95% confidence level. A statistically significant association was declared when a p-value was less than 0.05.

Results

A total of 296 (74 cases and 222 controls) pregnant women participated, with a recruitment rate of 97.4%. In multivariate logistic regression, the likelihood of developing a maternal syphilis infection was higher in pregnant women who had more than one-lifetime sexual partner [AOR = 3.59, 95% CI (1.09–11.71)]; a history of sexually transmitted infections [AOR = 3.46, 95%CI (1.32–9.08)] and used a substance [AOR = 3.39, 95%CI (1.31–8.77)].

Conclusion

Sexual-related factors continued to be a major determinant of syphilis in pregnant women. The results suggest that there is a need to promote safe sexual behavior, raise awareness about the risk of STIs, and early diagnosis and treatment of STIs to control syphilis infection, and necessary to make the antenatal care service comprehensive for pregnant women.

Impact of Heroin and HIV on Gut Integrity and Immune Activation

BACKGROUND

Altered gut integrity is central to HIV-related immune activation. Opioids may promote similar changes in gut permeability and/or increase systemic inflammation, potentially augmenting processes already occurring in people with HIV (PWH).

SETTING

Urban hospital systems in Cleveland, Ohio, and surrounding communities.

METHODS

This is a prospectively enrolled, cross-sectional study including people with and without HIV using heroin and people with and without HIV who have never used heroin, matched by age, sex, and CD4+ T-cell count (PWH only) to compare markers of gut integrity, microbial translocation, systemic inflammation, and immune activation.

RESULTS

A total of 100 participants were enrolled. Active heroin use was associated with higher concentrations of lipopolysaccharide-binding protein (LBP), beta-D-glucan (BDG), high-sensitivity C-reactive protein (hsCRP), soluble tumor necrosis factor-α-receptors I and II, soluble CD163, inflammatory monocytes, and activated CD4+ lymphocytes in adjusted models. HIV status tended to modify the effect between heroin use and LBP, BDG, hsCRP, patrolling monocytes, and activated CD4+ lymphocytes (P < 0.15 for interactions); however, it was not as expected. The effect of heroin on these markers (except patrolling monocytes) was greatest among those without HIV rather than among those with HIV.

CONCLUSIONS

Heroin use is associated with heightened microbial translocation, systemic inflammation, and immune activation. Concurrent HIV infection in virologically suppressed individuals does not seem to substantially worsen the effects heroin has on these markers.

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

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

Characteristics of the Audience Reached by the National Network of Sexually Transmitted Disease Clinical Prevention Training Centers and Correlation With Sexually Transmitted Infection Rates, 2015 to 2020

BACKGROUND

The National Network of Sexually Transmitted Disease Clinical Prevention Training Centers (NNPTC) trains clinical providers to diagnose and treat sexually transmitted infections (STIs) in the United States. The purpose of this study was to examine the demographics of clinical providers and to correlate the number of training episodes with STI rates at the county level.

METHODS

Registration data were collected between April 1, 2015, and March 31, 2020, in a custom Learning Management System from clinical providers taking NNPTC training. Using the 2018 STI surveillance data, counties were divided into quartiles based on reportable STI case rates and the number of county-level training events was compared per quartile. Univariate and multivariate analyses were conducted in IBM SPSS Statistics 23 (Armonk, NY) and SAS Enterprise Guide 7.1 (Cary, NC).

RESULTS

From 2015 to 2020, the NNPTC trained 21,327 individuals, predominantly in the nursing professions and working in a public health environment. In multivariate analysis, the number of training events was significantly associated with higher STI rates at the county level (P < 0.0001) and the state where a prevention training center is located (P < 0001).

CONCLUSIONS

The analysis suggests that NNPTC trainings are reaching the clinical providers working in geographic areas with higher STI rates.

Methamphetamine: burden, mechanism and impact on pregnancy, the fetus, and newborn

While the opioid epidemic has garnered worldwide attention, increasing methamphetamine use has drawn less scrutiny. Methamphetamine is a highly addictive psychostimulant affecting people from all backgrounds and regions. It is a potent vasoconstrictor, is associated with arrhythmias and dilated cardiomyopathy. Cardiovascular disease-related mortality is a leading cause of death in methamphetamine users. Women of childbearing age increasingly use methamphetamine and continue during pregnancy. In the short term, prenatal methamphetamine use is associated with fetal growth restriction and low birth weight in the newborn. Animal studies show reduction in uterine and umbilical blood flow following maternal methamphetamine administration. Based on currently available evidence, prenatal methamphetamine exposure has transient effects on gross motor development, no effect on language and cognition, and modest effects on behavior and executive functioning with poor inhibitory control, which may be attributable to early adversity. Further research is needed to evaluate long-term effects of prenatal methamphetamine exposure.

Predicting Emergence of Primary and Secondary Syphilis Among Women of Reproductive Age in US Counties

BACKGROUND

Syphilis, a sexually transmitted infection that can cause severe congenital disease when not treated during pregnancy, is on the rise in the United States. Our objective was to identify US counties with elevated risk for emergence of primary and secondary (P&S) syphilis among women of reproductive age.

METHODS

Using syphilis case reports, we identified counties with no cases of P&S syphilis among women of reproductive age in 2017 and 1 case or more in 2018. Using county-level syphilis and sociodemographic data, we developed a model to predict counties with emergence of P&S syphilis among women and a risk score to identify counties at elevated risk.

RESULTS

Of 2451 counties with no cases of P&S syphilis among women of reproductive age in 2017, 345 counties (14.1%) had documented emergence of syphilis in 2018. Emergence was predicted by the county's P&S syphilis rate among men; violent crime rate; proportions of Black, White, Asian, and Hawaiian/Pacific Islander persons; urbanicity; presence of a metropolitan area; population size; and having a neighboring county with P&S syphilis among women. A risk score of 20 or more identified 75% of counties with emergence.

CONCLUSIONS

Jurisdictions can identify counties at elevated risk for emergence of syphilis in women and tailor prevention efforts. Prevention of syphilis requires multidisciplinary collaboration to address underlying social factors.

Identification of United States Counties at Elevated Risk for Congenital Syphilis Using Predictive Modeling and a Risk Scoring System, 2018

BACKGROUND

The persistence of congenital syphilis (CS) remains an important concern in the United States. We use the 2018 data to refine a previous predictive model that identifies US counties at elevated risk for CS in 2018.

METHODS

Using county-level socioeconomic and health-related data from various sources, we developed a logistic regression predictive model to identify county-level factors associated with a county having had 1 or more CS case reported to the National Notifiable Diseases Surveillance System in 2018. We developed a risk scoring algorithm, identified the optimal risk score cutpoint to identify counties at elevated risk, and calculated the live birth to CS case ratio for counties by predicted risk level to compare counties at elevated risk with counties not at elevated risk.

RESULTS

We identified several county-level factors associated with a county having 1 or more CS case in 2018 (area under the curve, 88.6%; Bayesian information criterion, 1551.1). Using a risk score cutoff of 8 or higher (sensitivity, 83.2%; specificity, 79.4%), this model captured 94.7% (n = 1,253) of CS cases born in 2018 and identified 850 (27%) counties as being at elevated risk for CS. The live birth to CS case ratio was lower in counties identified as at elevated risk (2,482) compared with counties categorized as not at elevated risk (10,621).

CONCLUSIONS

Identifying which counties are at highest risk for CS can help target prevention efforts and interventions. The relatively low live birth to CS case ratio in elevated risk counties suggests that implementing routine 28-week screening among pregnant women in these counties may be an efficient way to target CS prevention efforts.

A descriptive study of syphilis testing in Manitoba, Canada, 2015-2019

Background

In 2018, Manitoba had the highest reported rate of infectious syphilis in Canada, at over three times the national average. Infectious syphilis in Manitoba is centred on young, marginalized heterosexual couples in Winnipeg's inner-city. Subsequently, a public health crisis involving congenital syphilis emerged in Manitoba, just prior to the coronavirus disease 2019 pandemic. Testing and screening (in the case of pregnancy) for syphilis is thought to be an effective measure to reduce the incidence of syphilis and its sequelae. The aim of this study is to describe syphilis testing practices in the general population and amongst pregnant women, during a period of shifting syphilis epidemiology.

Methods

We used population-based syphilis testing data from Cadham Provincial Laboratory (Winnipeg, Manitoba) for 2015 to 2019. Directly age-standardized rates are reported, and Poisson regression used to model the determinants of testing rates. Rates of prenatal screening are also reported.

Results

From 2015 to 2019, a total of 386,350 individuals were tested for syphilis. The rate increased annually, from 462 per 10,000 population in 2015 to 704 per 100,000 in 2019, while the female-to-male ratio decreased from 1.8 to 1.6. Prior to 2019, the majority of pregnant women (approximately 60%) were screened once, during the first trimester; however, 2019 saw more women having more than two tests during the course of their pregnancy.

Conclusion

An overall increase in the number of individuals tested was observed, reflecting the increased rate of syphilis in Manitoba. Prenatal screening patterns shifted in 2019, likely in response to rising congenital syphilis numbers.

Rising syphilis rates in Canada, 2011-2020

Background

Syphilis rates are of public health concern in Canada, with multiple jurisdictions reporting outbreaks over the past five years. The objective of this article is to describe trends in infectious and congenital syphilis in Canada 2011-2020.

Methods

Routine surveillance of syphilis is conducted through the Canadian Notifiable Disease Surveillance System (CNDSS). In response to rising rates of syphilis, all provinces and territories (P/Ts) have also submitted enhanced surveillance data on infectious syphilis to the Public Health Agency of Canada through the Syphilis Outbreak Investigation Coordinating Committee (SOICC) starting in 2018. Descriptive analyses of CNDSS and SOICC surveillance data 2011-2020 by age, sex, pregnancy status, male sexual orientation and P/Ts were performed.

Results

The national rate of infectious syphilis increased from 5.1 per 100,000 population in 2011 to 24.7 per 100,000 population in 2020.The rates increased in almost all P/Ts, with the Prairie provinces reporting the greatest relative increases from 2016 to 2020 (more than 400%). Rates in males were consistently higher than rates in females over the past 10 years; however, from 2016 to 2020, rates among females increased by 773%, compared with 73% among males. Although the proportion of cases who self-identify as gay, bisexual and other men who have sex with men decreased from 54% to 38% between 2018 and 2020, they still represent a high proportion of cases (according to data from eight P/Ts). From 2016 to 2020, rates of infectious syphilis increased in every age group, especially in females aged 15-39 years. Confirmed early congenital syphilis cases for 2020 increased considerably from prior years, with 50 cases reported in 2020, compared with 4 cases in 2016.

Conclusion

Infectious and congenital syphilis rates are a growing concern in Canada and the nature of the syphilis epidemics across Canada appears to be evolving, as evidenced by recent trends. More data and research are needed to better understand the drivers associated with the recent changes in the epidemiology of syphilis in Canada.

Characterizing female infectious syphilis cases in British Columbia to identify opportunities for optimization of care

Introduction

The rate of infectious syphilis continues to increase among females in British Columbia (BC) and Canada, raising concerns of increased incidence of congenital syphilis. We characterized syphilis cases among females in BC to identify opportunities to prevent syphilis and optimize its care.

Methods

All cases of infectious syphilis diagnosed in BC between March 13, 2018 and December 31, 2020 and reported as female gender were reviewed. Demographics, risk factors and concurrent conditions were collected from a provincial surveillance system. Subgroup analyses comparing cases with and without housing instability, substance use, mental illness and a recent sexually transmitted infection (STI) were conducted to understand differences between these subgroups. Statistical associations were calculated using chi-square or t-tests.

Results

There were 226 reported cases of female infectious syphilis in BC during this period: 38 (16.8%) in 2018; 74 (32.7%) in 2019; and 114 (50.4%) in 2020. Mean age was 32 years (range 15-75 years). Of those who reported concurrent conditions, most cases had experiences with housing instability (71.1%), substance use (68.2%) and mental illness (83.9%), while 42.9% had a recent STI. Cases who reported housing instability or substance use were significantly more likely to have experiences with a recent STI, street involvement, transactional sex, mental illness and income assistance (all p<0.01).

Conclusion

Our findings highlight the importance of fostering an enabling environment for syphilis care. Concurrent services to support individuals with syphilis as well as housing instability, substance use and mental illness, may help prevent syphilis and improve wellbeing.

Lessons from management of syphilis in Nunavut, Canada, 2012-2020

Background

Nunavut, part of Inuit Nunangat, is a geographically vast territory in northern Canada, with a population of over 38,000 people. Most (85%) of the population identify as Inuit. Nunavut has experienced a significant rise in heterosexual infectious syphilis cases since 2012. Management of communicable diseases, including syphilis, is challenging due to high staff turnover and long delays in specimen transport times. Social determinants of health are also an important contributor. The aim of this study is to describe the epidemiology and program elements for infectious syphilis from 2012-2020 and to highlight beneficial interventions.

Methods

Syphilis is a notifiable disease in Nunavut with all cases reported to the Territorial Department of Health. Cases were staged by a medical consultant. Data were analyzed and released in public reports as part of the public health program.

Results

From 2012 to 2020, 655 infectious syphilis cases were reported, with 53% of reported cases among females. Infection rates were highest in 20 to 39-year-olds. There was significant variability in reported cases over this time period by geographic region, with the majority of infectious cases reported from the Kivalliq region. Despite 48 reported cases in pregnancy, no confirmed congenital syphilis cases were identified. Program staff identified strengths of the response as well as ongoing needs, such as plain language resources available in multiple languages.

Conclusion

Despite the logistical challenges with syphilis management in the territory, the overall outcomes have been positive, with no confirmed congenital cases identified. We attribute this to a coordinated effort by multiple partners including key actions by public health nurses and community health representatives.

Prevalence and Types of Drugs Used Among Hepatitis A Patients During Outbreaks Associated with Person-to-Person Transmission, Kentucky, Michigan, and West Virginia, 2016-2019

Background

People who use drugs are at increased risk for hepatitis A virus infection. Since 1996, the Advisory Committee on Immunization Practices has recommended hepatitis A vaccination for people who use drugs. Since 2016, the U.S. has experienced widespread hepatitis A outbreaks associated with person-to-person transmission.

Purpose

To describe the prevalence of drug use, route of use, and drugs used among hepatitis A outbreak-associated patients.

Methods

State outbreak and medical records were reviewed to describe the prevalence, type, and route of drug use among a random sample of 812 adult outbreak-associated hepatitis A patients from Kentucky, Michigan, and West Virginia during 2016-2019. Differences in drug-use status were analyzed by demographic and risk-factor characteristics using the X ² test.

Results

Among all patients, residents of Kentucky (55.6%), Michigan (51.1%), and West Virginia (60.1%) reported any drug use, respectively. Among patients that reported any drug use, methamphetamine was the most frequently reported drug used in Kentucky (42.3%) and West Virginia (42.1%); however, opioids were the most frequently reported drug used in Michigan (46.8%). Hepatitis A patients with documented drug use were more likely (p<0.05) to be experiencing homelessness/unstable housing, have been currently or recently incarcerated, and be aged 18-39 years compared to those patients without documented drug use.

Implications

Drug use was prevalent among person-to-person hepatitis A outbreak-associated patients, and more likely among younger patients and patients experiencing homelessness or incarceration. Increased hepatitis A vaccination coverage is critical to prevent similar outbreaks in the future.

Sexual Risk Behaviors Among Persons Diagnosed With Primary and Secondary Syphilis Who Reported High-Risk Substance Use: Data From the National Notifiable Diseases Surveillance System, 2018

BACKGROUND

Recent increases in high-risk substance use (HRSU; i.e., injection drug use, heroin, methamphetamine, crack/cocaine) have coincided with rising primary and secondary (P&S) syphilis rates. To further understand these trends, we examined sexual risk behaviors among women, men who have sex with women only (MSW), and men who have sex with men (MSM) who were diagnosed with P&S syphilis in 2018 and reported HRSU.

METHODS

Data on HRSU and sexual risk behaviors among persons with P&S syphilis were drawn from syphilis case reports in 2018 from the National Notifiable Diseases Surveillance System. Persons with P&S syphilis were asked about sexual risk behaviors in the past 12 months including exchange sex for drugs/money, sex while intoxicated and/or high on drugs, sex with a person who injects drugs (PWID), sex with an anonymous partner, and number of sex partners. We describe percentages and adjusted prevalence ratios (aPRs) for women, MSW, and MSM reporting these behaviors by age, race/Hispanic ethnicity, type of drug used, and incarceration history (both in the past 12 months).

RESULTS

Among 19,634 persons diagnosed with P&S syphilis in 2018 with information on HRSU, 29.3% of women, 22.7% of MSW, and 12.4% of MSM reported HRSU. Among those reporting HRSU, percentages reporting exchange sex ranged from 17% to 35% (highest for women), whereas reports of anonymous sex ranged from 44% to 71% (highest for MSM). In this population, sexual risk behaviors were more commonly reported among those with a recent incarceration history than those without such history. Among those reporting injection drug use or heroin use, percentages reporting sex with a PWID ranged from 51% to 77%. In adjusted models, HRSU was significantly associated with one or more sexual risk behaviors for women (aPR, 2.63 [95% confidence interval {CI}, 2.39-2.90]; MSW: aPR, 1.38 [95% CI, 1.31-1.46]; and MSM: aPR, 1.30 [95% CI, 1.26-1.34]).

CONCLUSIONS

Collaborative partnerships across the US public health system could help address barriers to timely clinical care among persons diagnosed with P&S syphilis who report HRSU.

Challenges of sexually transmitted infections and sexual health among people who inject drugs

PURPOSE OF REVIEW

This review provides a summary of recently published research on sexually transmitted infections (STI) and related behaviors among people who inject drugs (PWID), covering three major areas: sexual behavior and its role in STI transmission among PWID, multilevel factors associated with STI risk, and strategies addressing sexual health of PWID. This review is timely given the growing priority of combination prevention approaches and integrated care for PWID.

RECENT FINDINGS

Modern research improves the understanding that PWID have an increased risk of STI, which varies by gender, setting, type of substance used, and presence of mental disorders. Major socioeconomic and structural factors, specific and nonspecific to PWID, facilitate inequality and sexual risk behavior. Sexual transmission continues to contribute substantially to the spread of bloodborne infections among PWID, accounting for at least 10% of new HIV cases according to epidemiological modeling. Despite the substantial evidence that behavioral interventions can improve sexual health and reduce sex-related risks among PWID, there is a research-practice gap, reflected in the scarcity of implementation studies published recently.

SUMMARY

Integration of sexual health into prevention programs for PWID is essential to curb transmission of STI, including HIV, among PWID and their sexual partners.

Predictors of Seronegative Conversion After Centralized Management of Syphilis Patients in Shenzhen, China

Objective: The aim of this study was to explore the seronegative conversion status of syphilis patients after centralized management and to analyze potential determinants.

Materials and Methods: A retrospective population-based cohort study was conducted, and data for individuals who had been diagnosed with syphilis between 2011 and 2019 were retrieved from the Shenzhen Nanshan Center for Chronic Disease Control. Seroconversion statuses were summarized as percentages. Univariable and multiple Cox proportional hazard regression models were used to analyze the factors associated with seronegative conversion among syphilis patients.

Results: During the study period, 1,545 patients with syphilis participated in the syphilis convergence case management program on a voluntary basis, of whom 290 were excluded due to missing follow-up data. A total of 27.6% (346/1255) of patients with syphilis showed seronegative conversion. Multivariable analysis revealed that the following significantly determined syphilis seroconversion from positive to negative: younger age (15–19 years vs. ≥30 years: HR = 2.18), male gender (HR = 1.45), lower baseline toluidine red unheated serum test (TRUST) titer of ≤ 1:8 (HR = 2.23), and different disease stages, including latent syphilis (HR = 1.98), primary syphilis (HR = 7.67), and secondary syphilis (HR = 4.83).

Conclusions: Few patients with syphilis tested negative after treatment at the end of the study. Seronegative conversion in the patients was associated with age, sex, baseline TRUST titer, and syphilis stage.

Sexually Transmitted Infection Epidemiology and Care in Rural Areas: A Narrative Review

BACKGROUND

Although rural areas contain approximately 19% of the US population, little research has explored sexually transmitted infection (STI) risk and how urban-developed interventions may be suitable in more population-thin areas. Although STI rates vary across rural areas, these areas share diminishing access to screening and limited rural-specific testing of STI interventions.

METHODS

This narrative review uses a political ecology model of health and explores 4 domains influencing STI risk and screening: epidemiology, health services, political and economic, and social. Articles describing aspects of rural STI epidemiology, screening access and use, and intervention utility within these domains were found by a search of PubMed.

RESULTS

Epidemiology contributes to risk via multiple means, such as the presence of increased-risk populations and the at-times disproportionate impact of the opioid/drug use epidemic. Rural health services are diminishing in quantity, often have lesser accessibility, and may be stigmatizing to those needing services. Local political and economic influences include funding decisions, variable enforcement of laws/statutes, and systemic prevention of harm reduction services. Social norms such as stigma and discrimination can prevent individuals from seeking appropriate care, and also lessen individual self-efficacy to reduce personal risk.

CONCLUSIONS

Sexually transmitted infection in rural areas is significant in scope and facing diminished prevention opportunities and resources. Although many STI interventions have been developed and piloted, few have been tested to scale or operationalized in rural areas. By considering rural STI risk reduction within a holistic model, purposeful exploration of interventions tailored to rural environments may be explored.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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