Sexual Health Sexual Health Society
Publishing on sexual health from the widest perspective
EDITORIAL

Increasing syphilis rates among men who have sex with men and screening to detect asymptomatic infection

Marcus Chen A B D and Rebecca Guy C
+ Author Affiliations
- Author Affiliations

A Melbourne Sexual Health Centre, Alfred Health, 580 Swanston Street, Carlton, Vic. 3053, Australia.

B Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic. 3004, Australia.

C The Kirby Institute, University of New South Wales, Sydney, Kensington, NSW 2033, Australia.

D Corresponding author. Email: mchen@mshc.org.au

Sexual Health 14(4) 301-303 https://doi.org/10.1071/SH17037
Submitted: 23 February 2017  Accepted: 10 March 2017   Published: 9 May 2017

Abstract

With reports of increasing syphilis rates among men who have sex with men in various countries and complications such as ocular syphilis and neurosyphilis, greater efforts for promoting frequent syphilis screening of higher risk men are required. This should include serological testing for syphilis every time HIV testing is undertaken and each time HIV viral load testing is performed in HIV-positive men who have sex with men. Systems-based approaches tailored to particular contexts should be explored, evaluated and, if shown to be effective, implemented.

Recent reports from a growing number of countries indicate that syphilis rates among men who have sex with men (MSM) are on the rise and have, in some cases, reached levels not seen for more than 20 years.1 Syphilis cases are occurring in both HIV-negative and HIV-positive MSM, with repeat infections often overrepresented in the latter group. Worryingly, reports have appeared of cases of neurosyphilis as well as ocular syphilis, a condition that is potentially blinding. Between 2014 and 2015, 388 suspected ocular syphilis cases were identified from eight US jurisdictions, with 93% of cases in MSM, and 51% in HIV positive people.2 The rise in syphilis is also concerning given syphilis may facilitate HIV transmission, as highlighted by data from the iPrEx study, where syphilis infection was associated with subsequent HIV acquisition.3

What is driving these increases in syphilis rates? The factors are likely to be multiple. During the 2000s so-called ‘HIV treatment optimism’ was a term often used to explain apparent increases in sexual risk-taking among MSM and accompanying high rates of sexually transmissible infection (STI) in MSM. With the more recent emergence of evidence for HIV treatment as prevention, and incremental use of pre-exposure prophylaxis against HIV, could we be entering a period of ‘HIV transmission optimism’ that is contributing to further increases in sexual risk-taking and syphilis incidence? These biomedical prevention methods protect men against HIV, but not STIs. Has the proliferation in use of mobile phone apps that link men with other men for sex been a contributing factor? Although the use of mobile apps to meet sexual partners has increased in Australia, men who primarily rely on the internet or apps actually reported less sexual risk behaviour than men using multiple methods.4 Longitudinal surveillance on trends in sexual risk-taking reported by MSM has often focused on HIV risk and condomless anal sex. These may not provide a complete explanation for changes in the incidence of syphilis if sexual practices other than anal sex are also important in the transmission of syphilis between men.

Historically, the control of syphilis has largely been predicated on the principle of early identification and treatment of the infectious stages of syphilis in order to reduce the period of infectivity and stem further transmission. Although primary syphilis may result in lesions that prompt infected individuals to seek treatment, they may be atypical and misdiagnosed even by experienced sexual health physicians.5 Moreover, primary lesions in MSM can occur in relatively hidden locations such as the mouth and anus where they may be overlooked. The generalised rash of secondary syphilis has a propensity for mimicking more common dermatological conditions, and may also be misdiagnosed, resulting in delays to treatment.6

Serological screening for syphilis is central to the detection of infectious syphilis. In 2016 the US Preventive Services Taskforce published recommendations supporting syphilis screening based on a systematic review that found evidence that screening persons at increased risk provides substantial benefits by preventing late disease and further sexual transmission. In this issue of Sexual Health Pizzicato et al. present the results of a cross-sectional survey of MSM and transgender women in Peru and found 5% of individuals to have serological evidence of untreated syphilis.7 HIV-positive individuals were more likely to have undiagnosed syphilis. They rightly conclude that increased screening for syphilis is required in MSM, including those with HIV.

But how can substantial increases in syphilis screening, sufficient to put a dent into the syphilis epidemic among MSM, be achieved in the real world? This of course depends on the barriers to testing that exist in any particular context and what strategies targeting both MSM and health care providers are feasible. The Australian National Gay Men’s Syphilis Action Plan and Australian guidelines governing STI screening of MSM have advocated frequent syphilis screening of higher risk MSM. This includes serological testing for syphilis every time HIV testing is undertaken and each time HIV viral load testing is performed in HIV-positive MSM. The latter intervention has been shown to improve the detection of asymptomatic infectious syphilis among HIV-positive MSM.8,9 Studies show opt-out syphilis testing with HIV monitoring has led to increases in screening at some clinics that manage MSM with HIV in Australia, but this has not been achieved uniformly across HIV services.10,11 Systems-based approaches tailored to particular contexts should be explored, evaluated and, if shown to be effective, implemented. For example, text message reminders to MSM to have 3-monthly STI screening and an electronic health record alert reminding clinicians to screen high-risk MSM for syphilis more frequently have been shown to improve detection of early, asymptomatic syphilis.12,13 How much screening is required? Data from a national network of sexual health clinics in Australia show that the coverage and frequency of syphilis screening have both increased substantially among HIV negative and HIV positive MSM with increased detection of asymptomatic early syphilis and a relative reduction in secondary syphilis. Despite this, notifications for syphilis in Australia have continued to climb, ostensibly because new infections have outstripped any downward effect of interventions such as screening.14 Mathematical modelling could help answer what level of screening is needed for better control but constructing models that accurately reflect what is happening in the real world is challenging.

Efforts to improve partner notification, although challenging where partners are anonymous, should not be forgotten, nor should empirical treatment of men reporting sex with syphilis-infected partners.15,16 With the increasing availability of pre-exposure prophylaxis against HIV in various countries, and the potential this has for putting further upward pressure on syphilis incidence,17 syphilis screening of high-risk MSM with sufficient coverage and frequency will remain as important as ever. Given the continued rise of syphilis among MSM internationally, other interventions aimed at curbing the syphilis epidemic should be considered. Evidence that post exposure prophylaxis using doxycycline is effective in reducing the incidence of syphilis will generate discussion on the role of antibiotic prophylaxis at a time when there are concerns about antibiotic resistance and calls for greater antimicrobial stewardship.18


Conflicts of interest

None declared.



References

[1]  Read P, Fairley CK, Chow EP. Increasing trends of syphilis among men who have sex with men in high income countries. Sex Health 2015; 12 155–63.
Increasing trends of syphilis among men who have sex with men in high income countries.CrossRef |

[2]  Oliver SE, Aubin M, Atwell L, et al. Ocular syphilis – eight jurisdictions, United States, 2014–2015. MMWR Morb Mortal Wkly Rep 2016; 65: 1185–88. 10.15585/mmwr.mm6543a2 [verified 30 March 2017].

[3]  Solomon MM, Mayer KH, Glidden DV, Liu AY, McMahan VM, Guanira JV, Chariyalertsak S, Fernandez T, Grant RM, iPrEx Study Team. Syphilis predicts HIV incidence among men and transgender women who have sex with men in a pre-exposure prophylaxis trial. Clin Infect Dis 2014; 59 1020–6.
Syphilis predicts HIV incidence among men and transgender women who have sex with men in a pre-exposure prophylaxis trial.CrossRef | 1:CAS:528:DC%2BC28XhvFWlsL7M&md5=3cb98e145f455a75d65b8fdc0301154bCAS |

[4]  Hull P, Mao L, Prestage G, Zablotska I, de Wit J, Holt M. The use of mobile phone apps to meet sex partners by Australian gay and bisexual men: an analysis of sex-seeking repertoires and risks for HIV and STIs using behavioural surveillance data. Sex Transm Infect 2016; 92 502–7.
The use of mobile phone apps to meet sex partners by Australian gay and bisexual men: an analysis of sex-seeking repertoires and risks for HIV and STIs using behavioural surveillance data.CrossRef |

[5]  Towns JM, Leslie DE, Denham I, Azzato F, Fairley CK, Chen M. Painful and multiple anogenital lesions are common in men with Treponema pallidum PCR-positive primary syphilis without herpes simplex virus coinfection: a cross-sectional clinic-based study. Sex Transm Infect 2016; 92 110–5.
Painful and multiple anogenital lesions are common in men with Treponema pallidum PCR-positive primary syphilis without herpes simplex virus coinfection: a cross-sectional clinic-based study.CrossRef |

[6]  Bissessor M, Fairley CK, De Guingand D, Bradshaw CS, Chen MY. Delay in the diagnosis of early syphilis among men who have sex with men: need for greater community and health provider education. Int J STD AIDS 2009; 20 52–3.
Delay in the diagnosis of early syphilis among men who have sex with men: need for greater community and health provider education.CrossRef | 1:STN:280:DC%2BD1M%2FksVejtA%3D%3D&md5=e6fb26447479a12a1ed4ed38cbec2f4cCAS |

[7]  Pizzicato LN, Vagenas P, Gonzales P, Lama JR, Pun M, Sanchez J, Altice FL. Active syphilis and its association with HIV and sexual risk behaviours in a multicity sample of men who have sex with men and transgender women in Peru. Sex Health 2017;
Active syphilis and its association with HIV and sexual risk behaviours in a multicity sample of men who have sex with men and transgender women in Peru.CrossRef |

[8]  Bissessor M, Fairley CK, Leslie D, Howley K, Chen MY. Frequent screening for syphilis as part of HIV monitoring increases the detection of early asymptomatic syphilis among HIV-positive homosexual men. J Acquir Immune Defic Syndr 2010; 55 211–6.
Frequent screening for syphilis as part of HIV monitoring increases the detection of early asymptomatic syphilis among HIV-positive homosexual men.CrossRef |

[9]  Cohen CE, Winston A, Asboe D, Boag F, Mandalia S, Azadian B, Hawkins DA. Increasing detection of asymptomatic syphilis in HIV patients. Sex Transm Infect 2005; 81 217–9.
Increasing detection of asymptomatic syphilis in HIV patients.CrossRef | 1:STN:280:DC%2BD2MzgvFKrtg%3D%3D&md5=31f14c1fa4c0fffa3074d92cd17b5dd3CAS |

[10]  Guy R, El-Hayek C, Fairley CK, Wand H, Carr A, McNulty A, Hoy J, Bourne C, McAllister J, Tee BK, Baker D, Roth N, Stoove M, Chen M. Opt-out and opt-in testing increases syphilis screening of HIV-positive men who have sex with men in Australia. PLoS One 2013; 8 e71436
Opt-out and opt-in testing increases syphilis screening of HIV-positive men who have sex with men in Australia.CrossRef | 1:CAS:528:DC%2BC3sXhtl2iu7jF&md5=5ca2887fb9dd3269bcf4d213148aba76CAS |

[11]  Callander D, Baker D, Chen MY, Guy R. Including syphilis testing as part of standard HIV management checks and improved syphilis screening in primary care. Sex Transm Dis 2013; 40 338–40.
Including syphilis testing as part of standard HIV management checks and improved syphilis screening in primary care.CrossRef |

[12]  Zou H, Fairley CK, Guy R, Bilardi J, Bradshaw CS, Garland SM, Sze JK, Afrizal A, Chen MY. Automated, computer generated reminders and increased detection of gonorrhoea, chlamydia and syphilis in men who have sex with men. PLoS One 2013; 8 e61972
Automated, computer generated reminders and increased detection of gonorrhoea, chlamydia and syphilis in men who have sex with men.CrossRef | 1:CAS:528:DC%2BC3sXmvVCktrc%3D&md5=8bf69162c24ec64abad916870c1c98c4CAS |

[13]  Bissessor M, Fairley CK, Leslie D, Chen MY. Use of a computer alert increases detection of early, asymptomatic syphilis among higher-risk men who have sex with men. Clin Infect Dis 2011; 53 57–8.
Use of a computer alert increases detection of early, asymptomatic syphilis among higher-risk men who have sex with men.CrossRef |

[14]  Chow EPF, Callander D, Fairley CK, Zhang L, Donovan B, Guy R, Lewis DA, Hellard M, Read P, Ward A, Chen M. Increased syphilis testing of men who have sex with men: greater detection of asymptomatic early syphilis and relative reduction in secondary syphilis. Clin Infect Dis 2017; in press.

[15]  Tan WS, Chen M, Ivan M, Stone K, Rane V, Fairley CK, Ong JJ. Partner notification outcomes for men who have sex with men diagnosed with syphilis referred to partner notification officers, Melbourne, Australia. Sex Transm Dis 2016; 43 685–9.
Partner notification outcomes for men who have sex with men diagnosed with syphilis referred to partner notification officers, Melbourne, Australia.CrossRef |

[16]  Weerakoon AP, Fairley CK, Read T, Bradshaw C, Forrester C, Bissessor M, Denham I, Chen MY. Syphilis infection among homosexual men reporting contact with syphilis: a case control study. BMJ Open 2012; 2 e001339
Syphilis infection among homosexual men reporting contact with syphilis: a case control study.CrossRef |

[17]  Liu AY, Cohen SE, Vittinghoff E, Anderson PL, Doblecki-Lewis S, Bacon O, Chenge W, Postle BS, Mathseon T, Amico KR, Liegler T, Rawlings MK, Trainor N, Blue RW, Estrada Y, Coleman ME, Cardenas G, Feaster DJ, Grant R, Philip SS, Elion R, Buchbinder S, Kolber MA. Preexposure prophylaxis for HIV infection integrated with municipal- and community-based sexual health services. JAMA Intern Med 2016; 176 75–84.
Preexposure prophylaxis for HIV infection integrated with municipal- and community-based sexual health services.CrossRef |

[18]  Molina J-M, Charreau I, Chidiac C, Pialoux G, Cua E, Delaugerre C, Capitant C, Rojas-Castro D, Meyer L. On demand post exposure prophylaxis with doxycycline for MSM enrolled in a PrEP trial. Conference on retroviruses and opportunistic infections; February 13–16 2017; Seattle, Washington.


Abstract PDF (77 KB) Export Citation

View Altmetrics