The Diagnosis and Management of Syphilis in the HIV-Infected Patient

Response of HIV-Infected Patients with Asymptomatic Syphilis to Intensive Intramuscular Therapy with Ceftriaxone or Procaine Penicillin

The objective of this prospective pilot study was to evaluate the response of HIV-infected patients with asymptomatic syphilis to one of two intensive antibiotic treatment regimens. Thirty-one HIV-infected patients with serum rapid plasma reagin titre ≥1:4 and no clinical findings of syphilis were randomized to receive daily intramuscular injections of ceftriaxone or procaine penicillin (plus oral probenecid) for 15 days; 24 returned for follow-up study. Seven of 10 (70%) procaine penicillin-treated patients and 10 of 14 (71%) ceftriaxone-treated patients had a ≥4-fold decline in RPR ( P=0.94); two penicillin-treated and one ceftriaxone-treated patient relapsed. Two patients failed ceftriaxone therapy. Three penicillin-treated, and two ceftriaxone-treated patients were serofast. Serological responses were similar in those patients with and without asymptomatic neurosyphilis. There was no difference in the serologic response to daily treatment with ceftriaxone vs that with procaine penicillin plus probenecid; both treatments were associated with comparatively high rates of serological non-response and relapse.

Syphilis and HIV: a dangerous duo

HIV and syphilis affect similar patient groups and coinfection is common. All patients presenting with syphilis should be offered HIV testing and vice versa. Syphilis can enhance the transmission of HIV. Detection and treatment of syphilis can probably help to reduce HIV transmission. Syphilis may present with atypical features in the HIV-positive patient, for example, there is a higher rate of asymptomatic primary syphilis, and proportionately more HIV-positive patients present with secondary disease. Secondary infection may be more aggressive and there is an increased rate of early neurologic and ophthalmic involvement. Diagnosis is generally made with serology, but the clinician should be aware of the potential for false-negative serology in both primary and, less commonly, in secondary syphilis. All HIV-positive patients should be treated with a penicillin-based regimen, and alternative therapies should be used with caution. All HIV-positive patients should be considered for the evaluation of neurosyphilis. Relapse is a real concern and careful follow up is required. This review will explore the differences in clinical manifestations in HIV-coinfected individuals, and will discuss data to warrant different management in HIV-coinfected individuals.