Management of syphilis in HIV-positive individuals

Abstract

Since the turn of the millennium a sustained outbreak of syphilis among men who have sex with men continues, approximately 20-50% of whom have concurrent HIV infection. In this paper we aim to explore the controversies that exist around the management of syphilis in HIV-positive individuals. Not only do HIV-positive people have different clinical manifestations of syphilis they have higher rates of asymptomatic neurological involvement, slower serological response to treatment and higher serological failure than HIV-negative individuals in most studies. Whether long-term clinical outcomes are different or affected by the antibiotic regimen selected remains to be established. The optimal antimicrobial regimen to treat syphilis in HIV is unknown due to a dearth of randomised controlled trial data. International guidelines state that the antibiotic management of syphilis is the same regardless of HIV status, with early syphilis treated with a single dose of benzathine penicillin G 2.4mU intrmuscularly. In practice, however, the majority of surveyed clinicians do treat HIV-positive people with more intensive antibiotics suggesting a lack of faith in guidelines. Factors which appear to affect the likelihood of developing neurological disease include CD4(+) count of <350 cells/μL, absence of antiretroviral therapy, rapid plasma regain (RPR) or venereal diseases reference laboratory titre (VDRL) >1:32, late-latent disease or lack of response to standard antibiotic treatment. We recommend a low-threshold for offering antibiotic treatment effective against neurosyphilis in HIV-positive people with syphilis, especially if they exhibit any of the above factors.

A single dose of benzathine penicillin G as an effective treatment for malignant syphilis in an HIV-positive patient: a case report

“…However, a survey indicated that physicians in the United States and Europe opted for a more intensive regimen of antibiotics for HIV co-infected individuals. Major concerns lie in the dierence in clinical features in HIV, impaired host immunity, a higher rate of asymptomatic neurological involvement, and slower serological response (4). There was no notable serological difference in treatment of single-dose versus three-dose BPG in HIV co-infected individuals, suggesting that the international recommendation of a single dose of BPG is sucient in acute infection Benzathine penicillin G for malignant syphilis in HIV (10).…”

“…To date, there is no specic recommended treatment for MS (3). Although the most commonly used treatment regimen is three consecutive weekly intramuscular injections of 2,400,000-unit benzathine penicillin G (BPG), a single dose of BPG, which follows the recommendation of secondary syphilis treatment, may be adequate to treat MS (3,4). JHR is a transient reaction following antibiotic treatment, which may result from a high serology titer in MS (3).…”

Syphilis: a fresh look at an old foe

“…Tipple summarises published reports on how syphilis may present differently in HIV-positive patients, while Cresswell and Fisher tackle the controversial question as to whether syphilis ought to be treated differently in patients with HIV. 17,18 Ho and Spudich delve into the complex area of neurosyphilis and critically review its diagnosis and management in the context of HIV, including the thorny issue of when lumbar punctures are indicated. 19 Turning to the biology of T. pallidum, Ma et al detail the typing methods that have been used to characterise different strains and make a case for the development of more discriminatory genotyping methods.…”