Syphilis incidence in men who have sex with men with human immunodeficiency virus comorbidity and the importance of integrating sexually transmitted infection prevention into HIV care

Abstract

Syphilis continues to be a growing epidemic among men who have sex with men (MSM), particularly for those living with the human immunodeficiency virus (HIV). In 2016, MSM accounted for 80% of primary and secondary syphilis diagnoses in men in the United States; almost half of who were also HIV-infected. The synergistic relationship between HIV and syphilis has significant implications not only for HIV patient management, but also for sexually transmitted infection (STI) control among MSM. Areas covered: We review the literature on STI screening and treatment barriers at the patient-, provider-, and health system-levels, and present strategies to incorporate STI prevention into HIV care settings. Expert commentary: Integration of STI prevention into HIV care is paramount to stop the epidemic of not only syphilis, but also other curable STIs like gonorrhea and chlamydia. Although guidelines have been established for STI testing in HIV-infected MSM, screening rates continue to be lower than desired. Gonorrhea and chlamydia screening is below 50% in HIV-infected MSM; interventions that improve testing of those two infections must be implemented. For syphilis control, other additional strategies such as chemoprophylaxis should be considered given syphilis screening is above 50% in HIV-infected MSM.

Patient Perspectives on the Implementation of Routinised Syphilis Screening With HIV Viral load Testing: Qualitative Process Evaluation of the Enhanced Syphilis Screening Among HIV-positive Men Trial

“…It's just routine…". While previous studies found that some men are hesitant around STI testing, and associate testing with shame and fear encountering homophobia (5,29,30), in our study men did not share these same fears. For this reason, we argue that routinising syphilis testing may circumvent the stigma experienced when patients ask for testing, or when providers recommend testing based on a patient's 'risk' pro le.…”

“…The men we interviewed noted that their HIV clinics and care providers produce a comforting atmosphere surrounding testing. Patient concerns regarding stigma, and healthcare provider fears of being perceived as judgemental or feeling uncomfortable discussing sexual practices, are documented barriers to STI care (5). Approaches that de-stigmatise STI testing are well understood, and include sensitivity training for clinicians and structural changes that normalise STI testing by, for example, displaying STI educational materials and offering testing in clinic settings beyond sexual health clinics, such as in HIV care settings and primary care (31).…”

“…In Ontario, Canada, most syphilis cases are reported among gbMSM, with 40% of these among HIV-positive gbMSM (3,4). Frequent testing and early treatment can prevent adverse health outcomes associated with untreated syphilis and reduce the risk of transmission to partners (5). International guidelines recommend syphilis screening for people with HIV at least once per year, with some advising more frequent testing at 3-6 month intervals (6)(7)(8)(9).…”

Incidence and Predictors of Serological Treatment Response in Early and Late Syphilis Among People Living With HIV

“…The high prevalence of syphilis in MSM living with HIV has been described [21] and is associated with a reduction in the awareness of sexually transmitted infections and high-risk sexual behaviors in this population [22]. With regards to these issues, in this study, 71% of the infections occurred in individuals with a history of syphilis (re-infections) and 34% of the subjects had more than 1 syphilis diagnosis during the follow-up period, indicating the recurrence of high-risk sexual behaviors in our patients.…”

Incidence of syphilis among HIV-infected men in Singapore, 2006–2017: temporal trends and associated risk factors

“…The interplay between HIV and syphilis infection has important implications for the prevention and treatment of HIV, as well as STI control via HIV-care based screening 4. HIV and Treponema pallidum , the causative agent of syphilis, share similar routes of transmission.…”