Syphilis on the rise: A prolonged syphilis outbreak among HIV-infected patients in Northern Greece

Global Temporal Trends in Mother-to-Child Transmission Disease Incidence Among Women of Child-Bearing Age: An Analysis of Global Burden of Disease Study 2021 Data

Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS), syphilis, hepatitis B and hepatitis C are the four major Mother-to-child transmission (MTCT) diseases, represent a significant public health challenge worldwide. Understanding the disease burden among women of child-bearing age (WCBA) helps to implement effective screening and treatment programs to control the MTCT diseases globally. Data on HIV/AIDS, syphilis, hepatitis B, and hepatitis C was collected from the Global Burden of Disease (GBD) 2021 database spanning 1992-2021. We analyzed the temporal trends of four MTCT diseases with joinpoint regression and further evaluated age-period-cohort effects using the age-period-cohort model. The age-standardized incidence rates per 100,000 population for HIV/AIDS, syphilis, hepatitis B, and hepatitis C in 2021 were 34.73 (95% uncertainty interval [UI]: 30.03, 40.54), 279.19 (95% UI: 174.59, 459.54), 908.39 (95% UI: 494.99, 1640.44), and 77.44 (95% UI: 41.57, 126.12). Joinpoint regression revealed ongoing declines in HIV/AIDS and hepatitis B rates among WCBA, contrasting with increasing trends for hepatitis C and syphilis post-2012. Age effects for HIV/AIDS, syphilis, and hepatitis B peaked in the 15-29 age group, while hepatitis C peaked in the 45-49 age group. Period effects showed increased incidence rates for syphilis and hepatitis C since 2012, peaking between 2017-2021, while HIV/AIDS and hepatitis B showed a general decline. Cohort effects for all four diseases generally followed a fluctuating downward trend. For hepatitis B, the incidence rate is declining in all 21 GBD regions. At national level, only the United Kingdom and Greece have seen a slight increase in incidence rates compared to 30 years ago, but the increase is minimal. For other MTCT diseases, Eastern Europe has the highest increase in incidence rates of HIV/AIDS and hepatitis C among WCBA, which requires special attention. Tropical Latin America is the region with the greatest increase in syphilis incidence rates. Specifically, at the national level, the countries with the highest increase in incidence rates for HIV/AIDS, syphilis, and hepatitis C are Pakistan, Greece, and Ukraine, respectively. Globally, while HIV/AIDS and hepatitis B incidence in WCBA has decreased, negative age, period, and cohort effects persist in certain countries. Post-2012, hepatitis C and syphilis incidence in WCBA has risen, underscoring the need to refine management strategies against MTCT diseases.

Factors associated with HIV/syphilis co-infection initiating of antiretroviral therapy

OBJECTIVE

To evaluate the prevalence and factors associated with HIV/syphilis co-infection in people initiating antiretroviral therapy in Belo Horizonte, capital of the state of Minas Gerais.

METHODS

A sectional section of a prospective cohort study was carried out with people living with HIV, treatment-naive, initiating antiretroviral therapy, older than 16 years, and in follow-up treatment at specialized HIV/Aids care services in Belo Horizonte. Sociodemographic, behavioral, clinical, laboratory and pharmacological treatment-related data were obtained through interviews, medical records, and information systems for logistical control of antiretroviral medications and laboratory tests. The dependent variable was the first episode of active syphilis, recorded by the physician in clinical records, within 12 months after beginning of the antiretroviral therapy. Factors associated with HIV/syphilis co-infection were assessed using binary multiple logistic regression.

RESULTS

Among the 459 individuals included, a prevalence of 19.5% (n = 90) of sexually transmitted infections (STI) was observed, with syphilis (n = 49) being the most frequent STI in these individuals. The prevalence of HIV/syphilis co-infection was 10.6% (n = 49), and the associated independent factors were alcohol use (OR = 2.30; 95%CI: 1.01–5.26), and having a diagnosis of other sexually transmitted infections (OR = 3.33; 95%CI: 1.24–8.95).

CONCLUSIONS

There was a high prevalence of HIV/syphilis co-infection in people living with HIV initiating antiretroviral therapy in Belo Horizonte. HIV/syphilis co-infection was associated with behavioral and clinical factors, such as alcohol use and diagnosis of other sexually transmitted infections. Prior knowledge about the factors associated with this co-infection may support the decisions of health professionals engaged in the care to people living with HIV, with regard to timely diagnosis, guidance, follow-up and adequate treatment, both for syphilis and HIV.

Incidence Trends of Five Common Sexually Transmitted Infections Excluding HIV From 1990 to 2019 at the Global, Regional, and National Levels: Results From the Global Burden of Disease Study 2019

Objective

Sexually transmitted infections (STIs) are common worldwide and pose a challenge to public health. We conducted this study to assess the annual incidence of five common STIs, including syphilis, chlamydia, gonorrhea, trichomoniasis, and genital herpes at the global, regional, and national levels.

Materials and Methods

We obtained detailed data on STIs excluding HIV from 1990 to 2019 from the Global Burden of Disease (GBD) 2019 database. Estimated annual percentage change (EAPC) was calculated to quantify trends in age-standardized incidence rates (ASR) of STIs, stratified by gender, sociodemographic index (SDI) region, and pathogenic microorganism.

Results

Globally, incident cases of STIs increased by 58.15% from 486.77 million in 1990 to 769.85 million in 2019, but the annual change in ASR was only -0.04% (95% CI -0.09 to 0.01) per year. EAPC was 0.16 (0.06 to 0.26) for syphilis, 0.09 (0.05 to 0.13) for genital herpes, 0.06 (0.03 to 0.09) for trichomoniasis, -0.21 (-0.36 to -0.06) for chlamydia, and -0.14 (-0.19 to -0.08) for gonorrhea. High SDI regions reported significant increases in ASR of syphilis and chlamydia.

Conclusions

The burden of disease from STIs remains large, though control of STIs has contributed to the decreasing incidence in most regions, especially in the low-SDI regions. Globally, over the past 20 years, the ASR has remained stable for trichomoniasis and genital herpes decreased for chlamydia and gonorrhea, and increased for syphilis.

Resurgence of syphilis, the great imitator

Syphilis, one of the earliest diseases to be discovered in humans, still remains an enigma when it comes to its myriad manifestations and changing epidemiological profiles. There has been a surge in cases in the last few decades due to various factors. The human immunodeficiency virus (HIV) epidemics, global travel, increased incidence of male to male sexually transmitted diseases, online relationships culminating in casual sex are few of the important factors. Increased awareness could also be a factor for increased diagnosis. The multitude of clinical features especially when it comes to secondary syphilis and the rare tertiary manifestations, which can mimic various systemic disorders still pose a diagnostic challenge to the best of venereologists and physicians. This review aims to discuss the causes of resurgence in syphilis and few recent developments in pathogenesis, which could have led to this resurgence.

Consequences of HIV/Syphilis Co-Infection on HIV Viral Load and Immune Response to Antiretroviral Therapy

Introduction

Although syphilis is a frequent co-infection in patients with human immunodeficiency virus (HIV) infection, the influence of syphilis on immune response and virologic failure in HIV-infected patients following initiation of antiretroviral therapy (ART) is not well-defined.

Methods

A retrospective study was conducted at Tianjin Second People's Hospital to evaluate the prevalence of syphilis and immune status in 4171 ART-naïve patients. The study included patients who initiated ART between August 2009 and June 2019.

Results

The prevalence of syphilis was 40.1% in all ART-naïve patients and 42.5% in ART-naïve men who have sex with men. HIV/syphilis co-infection was associated with higher virologic failure (odds ratio (95% confidence interval): 1.30 (1.04, 1.63)). Patients with HIV/syphilis co-infection had lower median CD4⁺ T cell counts and CD4/CD8 ratios at baseline. After initiation of ART, patients co-infected with HIV/syphilis had smaller increases in CD4⁺ T cell counts and CD4/CD8 ratios than patients infected only with HIV. The rate of recurrence of syphilis or reinfection was 9% (n = 128) during seven years of ART.

Conclusion

HIV/syphilis co-infection had a negative impact on immune recovery and antiretroviral effectiveness. RPR titer and HIV viral load should be monitored in patients co-infected with HIV/syphilis, especially in patients with high RPR titers.

Syphilis in heterosexual women: case characteristics and risk factors for recent syphilis infection in Tokyo, Japan, 2017-2018

In response to an increase in heterosexual syphilis notifications in Tokyo, we conducted a questionnaire-based case-control study among women aged ≥20 years and sexually active in the past six months who sought a syphilis test in Tokyo during 2017-2018. Cases were women diagnosed as recent syphilis infection based on serological tests. Controls were serologically non-reactive or those with only a past syphilis infection. We described cases and assessed for risk factors of recent syphilis using logistic regression. A total of 524 women (60 cases, 464 controls) were enrolled. Notably, among cases, 10 (16.7%) were students, 3 (5.0%) had a history of syphilis, and 14 (23.3%) had a single sex partner in the past six months. Female sex worker (FSW) status was strongly associated with syphilis (odds ratio [OR] = 3.40; 95% confidence interval [CI] = 1.96-5.90). In multivariable analysis, recent syphilis was associated with inconsistent condom use for vaginal/anal sex among FSWs (adjusted OR [aOR] = 3.42; 95%CI = 0.92-12.70) and among non-FSWs, with younger age (aOR = 0.36; 95%CI = 0.19-0.70; increase per category from 20-24, 25-29 to ≥30 years) and ≤high school education (aOR = 5.24; 95%CI = 1.95-14.10). A notable proportion of cases were those with first time infection and those with only a single partner. Moreover, risk factors differed between FSWs and non-FSWs, and a multi-pronged approach to prevent syphilis is required.

The resurgence of syphilis in high-income countries in the 2000s: a focus on Europe

Syphilis can cause severe complications and sequelae. Following a decrease in reported cases in European Union/European Economic Area (EU/EEA) and other high-income countries in the 1980s and 1990s as a result of the HIV epidemic and ensuing changes in sexual behaviour, trends started to increase in the 2000s in a number of EU/EEA Member States with higher rates among men and a large proportion of cases reported among men who have sex with men (MSM), particularly HIV-positive MSM. Trends in EU/EEA Member States vary however with some countries continuing to report decreases in the number of reported cases (mostly in the Eastern part of EU/EEA) whereas many Western European countries report increasing numbers of cases. Increasing rates among women, although still relatively low, have been observed in a number of countries leading to concerns around mother-to-child transmission of syphilis and congenital syphilis. Similar overall trends are observed in other high-income countries with the exception of Japan where rates among heterosexual men and women have been rising at alarming levels. Control of syphilis requires use of comprehensive, evidence-based strategies which take into account lessons learned from previous control efforts as well as consideration of biomedical interventions.

Current status of HIV/AIDS-syphilis co-infections: a retrospective multicentre study

OBJECTIVE

Treponema pallidum and HIV are transmitted frequently through sexual contact, these agents with epidemiological similarities co-infect the same host. The current number of HIV-infected cases in Turkey is increasing. For this reason, we aimed to reveal the characteristics of syphilis in HIV/AIDS cases.

METHODS

A retrospective longitudinal cohort study was performed, patients were followed up at 24 clinics in 16 cities from all seven regions of Turkey between January 2010 to April 2018. We examined the socio-demographic characteristics, laboratory parameters and neurosyphilis association in HIV/AIDS-syphilis co-infected cases.

RESULTS

Among 3,641 patients with HIV-1 infection, 291 (8%) patients were diagnosed with syphilis co-infection. Most patients were older than 25 years (92%), 96% were males, 74% were working, 23% unemployed, and 3% were students. The three highest prevalence of syphilis were in Black Sea (10.3%), Mediterranean (8.4%) and Marmara Regions (7.4%). As for sexual orientation, 46% were heterosexuals, 42% men who have sex with men (MSM), and no data available for 12%. Patients with the number of CD4+ ≤ 350 mm³ reached 46%, 17% of the patients received antiretroviral therapy and neurosyphilis association reached 9%.

CONCLUSION

Although HIV/AIDS-syphilis co-infection status appeared high in heterosexuals, MSM had a moderate level increase in cases. Our results suggested syphilis co-infection in HIV/AIDS cases should be integral part of monitoring in a national sexual transmitted diseases surveillance system. However, our data may provide base for HIV/syphilis prevention and treatment efforts in the future.

An Update on the Global Epidemiology of Syphilis

PURPOSE OF REVIEW

Syphilis continues to cause morbidity and mortality worldwide. While syphilis infection is easily identifiable and treatable, rates of syphilis infection continue to increase among select populations in high-income countries and remain at endemic levels in low- and middle-income counties.

RECENT FINDINGS

World Health Organization recommended strategies have led to the dual elimination of mother-to-child transmission of syphilis and HIV in several countries, however outbreaks among select populations need to be adequately addressed.

SUMMARY

Continued vigilance and investment is needed to address syphilis worldwide. The epidemiology of syphilis differs in high-income and low- and middle-income counties.