Repeat syphilis among men who have sex with men in California, 2002-2006: implications for syphilis elimination efforts

Messaging about very low nicotine cigarettes (VLNCs) to influence policy attitudes, harm perceptions and smoking motivations: a discrete choice experiment

BACKGROUND

To reduce smoking and the harms it causes, countries, including the USA, are considering policies to reduce nicotine in combustible tobacco to minimally addictive levels. Effective messages about very low nicotine cigarettes (VLNCs) and this policy are crucial in combating misperceptions threatening the policy's effectiveness.

DATA AND METHODS

A discrete choice experiment assessed messages about VLNCs. Participants were 590 adults who smoked exclusively, 379 adults who both smoked and used e-cigarettes, 443 adults who formerly smoked and 351 young adults who never smoked (total n=1763). Seven message attributes were varied systematically (source, harm, chemicals, nicotine, satisfaction, addictiveness and quitting efficacy). Outcomes were selection of messages that generated the most positive attitude towards reduced nicotine policy, the greatest perceived harmfulness of VLNCs, and most strongly motivated quitting and initiating behaviour for VLNCs.

RESULTS

Information about specific harms and chemicals of VLNCs had the largest effects on selection of messages as eliciting more negative attitudes towards VLNCs policy, increasing perceived VLNC harmfulness, increasing motivation to quit VLNCs and decreasing motivation to try VLNCs. Messages with information about quitting efficacy were selected as more motivating to quit among those who smoke, but also more motivating to try VLNCs among those who do not smoke.

CONCLUSION

Harm and chemical information can be prioritised to ensure VLNCs are not misperceived as less harmful than regular cigarettes. Messages about increased quitting efficacy and reduced addictiveness associated with VLNCs may backfire if presented to those who do not smoke.

Support for nicotine reduction in cigarettes: findings from the 2016 and 2020 ITC Four Country Smoking and Vaping Surveys

INTRODUCTION

The USA and New Zealand have sought to establish a product standard to set a maximum nicotine level for cigarettes to reduce their addictiveness. This study examined support for very low nicotine cigarettes (VLNCs) in Australia, Canada, England and the USA between 2016 and 2020.

METHODS

Repeated cross-sectional data were analysed from participants who currently smoke, formerly smoked or vaped and/or currently vape in the 2016 (n=11 150) and/or 2020 (n=5432) International Tobacco Control (ITC) Four Country Smoking and Vaping Survey. Respondents were asked if they would support a law that reduces the amount of nicotine in cigarettes to make them less addictive. Adjusted and weighted logistic regression analyses estimated the prevalence and predictors of support, such as country, age, sex, education, income, race and smoking/vaping status for VLNCs (support vs oppose/do not know).

RESULTS

A majority of respondents supported a VLNC law, with support highest in Canada (69%; 2016 and 2020 combined), followed by England (61%), Australia (60%) and the USA (58%). Overall, support decreased from 62% in 2016 to 59% in 2020 (p=0.004), which did not differ by country. Levels of support differed by smoking/vaping status, where those who exclusively smoked daily showed the lowest level of support (59%) and those who exclusively vaped non-daily had the highest level of support (72%).

CONCLUSION

More than half of respondents in all four countries-including those who smoked daily-supported a hypothetical VLNC standard to render cigarettes less addictive. It is important to examine if support is sustained after policies are implemented.

Reduced Risk of Syphilis Reinfection in Men Interviewed by Disease Intervention Specialists: A Pilot Study

Introduction

Syphilis is a highly transmissible sexually transmitted infection. Rising rates of infection and reinfection are of great concern to public health officials. In local health departments across the U.S., disease intervention specialists attempt to interview all people diagnosed with early syphilis, to elicit sexual partner information, and to trace and treat the partners. This method of interviewing and contact tracing is an evidence-based practice that reduces the spread of the disease in the community, but few studies address the relationship between the disease intervention specialists' interviews and index patient reinfections. We hypothesized that patients who were interviewed, patients who provided partner information, and patients with more treated partners would have a reduced risk of reinfection.

Methods

Our sample consisted of 82 men listed in the Suffolk County Department of Health Services syphilis log who were diagnosed with primary, secondary, or early latent syphilis. We determined whether and when the patients were reinfected during a set time period, from 2016 to 2020. Kaplan-Meier analyses with log-rank statistics and Cox hazard proportional models were used to calculate time to reinfection and hazard ratios.

Results

Although none of the models produced p<0.05, notable trends were observed. In subset analyses of interviewed patients, 23.8% of patients who named partners were reinfected during the study period, whereas 50% of those who did not name partners were reinfected during that time. In addition, the hazard ratio for index patients who named partners was 0.51 (95% CI=0.225, 1.170, p=0.113). When some or all the patients' partners were treated, 20% were reinfected by the end of the study, whereas 33.3% of cases with no partners treated were reinfected by the end of the study. The hazard ratio for patients with some or all partners treated was 0.48 (95% CI=0.136, 1.711, p=0.258).

Conclusions

Although none of the results was statistically significant, trends suggest that partner elicitation and partner treatment status could be associated with reduced risk of syphilis reinfection. Because this pilot study utilized a small convenience sample that was not tested for statistical power, we could not adequately address these trends. Future studies, with larger sample sizes, should address these relationships.

Incidence, risk factors, and clinical findings of syphilis among men living with HIV in Croatia during the COVID-19 pandemic

We conducted a nationwide longitudinal observational study to estimate the incidence of syphilis in a cohort of male persons living with HIV (MLWH) in Croatia in the pre-COVID-19 and COVID-19 years. Data were reviewed and extracted from the clinical database. We analyzed 1187 MLWH (≥ 18 years) in care in Croatia from 2018 to 2021 and used Poisson regression to calculate rates. We observed a 91.4% increase in incidence between 2019 and 2020; the overall rate was 6.0/100 person-years, and the annual rate ranged from 3.3/100 person-years in 2018 to 9.3/100 person-years in 2021. We found higher rates in men who have sex with men, MLWH with a baseline history of syphilis, MLWH with a more recent HIV diagnosis, and a lower rate in those who had clinical AIDS. The rate of syphilis serological testing was 3.5% lower in 2020 compared to 2019. Recurrent syphilis was more likely asymptomatic compared to the first episodes. In conclusion, during the COVID-19 epidemic years, there was a huge increase in syphilis. Results highlight the need for enhanced and novel prevention interventions.

Syphilis vaccine: challenges, controversies and opportunities

Syphilis is a sexually or vertically (mother to fetus) transmitted disease caused by the infection of Treponema pallidum subspecie pallidum (TPA). The incidence of syphilis has increased over the past years despite the fact that this bacterium is an obligate human pathogen, the infection route is well known, and the disease can be successfully treated with penicillin. As complementary measures to preventive campaigns and early treatment of infected individuals, development of a syphilis vaccine may be crucial for controlling disease spread and/or severity, particularly in countries where the effectiveness of the aforementioned measures is limited. In the last century, several vaccine prototypes have been tested in preclinical studies, mainly in rabbits. While none of them provided protection against infection, some prototypes prevented bacteria from disseminating to distal organs, attenuated lesion development, and accelerated their healing. In spite of these promising results, there is still some controversy regarding the identification of vaccine candidates and the characteristics of a syphilis-protective immune response. In this review, we describe what is known about TPA immune response, and the main mechanisms used by this pathogen to evade it. Moreover, we emphasize the importance of integrating this knowledge, in conjunction with the characterization of outer membrane proteins (OMPs), to expedite the development of a syphilis vaccine that can protect against TPA infection.

High Incidence, Reinfections, and Active Syphilis in Populations Attending a Specialized HIV Clinic in Mexico, a Dynamic Cohort Study

Syphilis, a sexually transmitted infection, has reemerged in many vulnerable groups around the world. The objective of the current study was to determine the prevalence and incidence of syphilis among people who attended a specialized HIV clinic in Mexico from 2011 to 2015. Databases from the laboratory were analyzed, and the following four groups were formed: people seeking HIV-1 voluntary counseling and testing (VCT), people in prison (PPr), people living with HIV (PLWH), and patients from primary care clinics (others). The diagnosis of syphilis was made using the reverse algorithm; antibody titers were examined to determine the stage of infection. Baseline data were analyzed and, with follow-up information, a retrospective dynamic cohort was formed. Factors associated with the seroprevalence of syphilis and active syphilis were evaluated by the chi-square test. Moreover, risk factors for the incidence of syphilis were described. A total of 81,863 baseline individuals were analyzed. The seroprevalence of syphilis was 9.9% in the VCT group, 8.2% in the PPr group, 37.0% in the PLWH group, and 8.7% in the others group; the prevalence of active syphilis was 1.7-13.1%. A total of 11,124 people were followed up. The incidence (cases per 100 person-years) was 3.5 among the VCT group, 16.0 among the PLWH group, and < 0.1 among both the PPr and others groups, respectively; moreover, the frequency of reinfections was 11.1-24.4%. The high prevalence and incidence of syphilis, active syphilis, and reinfections among men, transgender people, individuals aged 20-39 years, and people with a history of HIV or hepatitis B suggest that it is critical to improve prevention, diagnosis, and treatment measures to stop the reemergence of syphilis. There are also new factors such as methamphetamine use, group sex, or contacting partners over the internet that are associated with syphilis. In addition, HIV preexposure prophylaxis could contribute to the increased incidence of syphilis by providing false security in the prevention of STIs, thereby increasing risky sexual behaviors.

Syphilis, the Great Imitator-Clinical and Dermoscopic Features of a Rare Presentation of Secondary Syphilis

Syphilis is characterized by a wide range of variable clinical symptoms; therefore, it is often referred to as "The Great Imitator". Here, we report the case of a 69-year-old hepatitis-C-positive MSM patient, who was admitted to our clinic due to a solitary firm painless erythematous maculopapular lesion with a central crater-like crust on the upper right thigh that occurred two months prior. The dermoscopy showed an erythematous, copper-colored, oval lesion with diffuse monomorphic dotted and glomerular vessels, central crust, and circular scaling (Biett's sign). The histological findings ruled out neoplasia and described a plasma cell infiltrate and endothelial swelling. Finally, the combination of the dermoscopic image, histological findings and the additionally acquired knowledge about the sexual history of the patient at the second visit led to the diagnosis, which was then confirmed with serological tests. Dermoscopy may become a supportive tool to facilitate the recognition of secondary syphilis; however, the reporting of these atypical cases is crucial to highlight the many faces of the disease so that clinicians consider syphilis as part of the differential diagnosis of non-specific lesions.

Syphilis: recommendations for dermatologists on a resurgent epidemic

Despite reaching historical lows in the early 2000s, cases of both primary and secondary syphilis and congenital syphilis have increased dramatically in the U.S. over the last decade. In the U.S., the current syphilis epidemic is disproportionately impacting communities that have been historically underserved in medicine. These include men who have sex with men, especially those infected with HIV; people of color; and reproductive-age women with poor access to prenatal care. With syphilis now being more commonly diagnosed in non-STI than STI clinics in all genders, and since primary and secondary syphilis and congenital syphilis present with characteristic mucocutaneous manifestations, dermatologists are in a position to help reduce the advance of this preventable epidemic, by actively considering this diagnosis and incorporating syphilis screening into their practice. Herein, we delineate strategies by which dermatologists can contribute to this critical effort in their roles as clinicians, public health advocates, and researchers. In particular, we discuss the rapidly changing demographics of syphilis, nuances in serologic testing and treatment, strategies to increase public healthcare access and equity in these underserved populations, and research gaps in this field.

Making smoking history: temporal changes in support for a future smoking ban and increasing taxes in the general population of Denmark

BACKGROUND

An end date for smoking has been adopted in several countries and is now being discussed by governments all over the world. However, little is known about temporal changes in citizens' support for a future smoking ban.

AIM

To examine temporal changes in support for a future smoking ban and for increasing taxes on tobacco in Denmark, and to explore whether these changes differ across sex, age, educational attainment, smoking status and between smokers with/without intention to quit.

METHOD

The study was based on two waves of 'The Danish Capital Region Health Survey' conducted in 2013 and 2017. The pooled study sample included 96 521 citizens aged ≥16 years old.

RESULTS

Public support for a future smoking ban increased from 30.6% in 2013 to 50.3% in 2017, whereas support for increasing tobacco taxes remained unchanged at 59%. Support for a future smoking ban increased significantly in almost all subgroups from 2013 to 2017: Support among daily smokers increased by 27% between 2013 and 2017. Support among never smokers was almost 2.63 times higher than among smokers in 2013 and increased further in 2017 (OR: 2013=2.63; 2017=5.13).

CONCLUSION

This study indicates a readiness to support a future smoking ban and increasing tobacco taxes. Support for a future smoking ban has increased from 2013 to 2017 among both young people and adults. By 2017, about half of the population supported a future smoking ban and increasing tobacco taxes. Findings may help inform policy-making related to endgame strategies.

An Updated Review of Recent Advances in Neurosyphilis

Neurosyphilis is caused by Treponema pallidum invading the central nervous system, of which the incidence is increasing worldwide. Due to its variable clinical manifestations, diagnosis of neurosyphilis remains challenging, especially the asymptomatic form. This review focuses on recent advances in neurosyphilis, including epidemiology, clinical manifestations, laboratory findings, comorbidities, diagnosis, treatment, prognosis, and basic research. The expansion of men who have sex with men and the infection of human immunodeficiency virus mainly accounted for the increasing incidence of neurosyphilis. The rate of some historically described forms of neurosyphilis in the pre-antibiotic era declined significantly; atypical features are more prevalent. Neurosyphilis, regarded as a great mimicker for neuro-ophthalmic, audio-vestibular, and psychiatric disorders, often presents concomitantly with other diseases, including metabolic disorders. Studies on long non-coding RNAs, miRNAs, chemokines, and metabolites in peripheral blood and cerebrospinal fluid may facilitate exploring the pathogenesis and identifying novel biomarkers of neurosyphilis. The drug resistance of Treponema pallidum to penicillin has not been reported; ceftriaxone was proposed to be more effective than penicillin, whereas few randomized controlled trials supported this view. This study may pave the way for further research, especially the diagnosis and treatment of neurosyphilis.

[Syphilis infection in the ENT area]

The number of reported cases of syphilis has been increasing for years. The sexually transmitted disease is caused by the spirochete Treponema pallidum subspecies pallidum and progresses in different stages. Symptoms in the ENT area can occur in all stages. This means that a syphilis infection should always be considered by the ENT doctor as a differential diagnosis if the symptoms are suitable. Thus, with increasing oral sexual intercourse, the primary effect/hard chancre is more often observed in the oral cavity. In addition, symptoms can occur not only in the oral cavity, but also in the ear, nose, larynx, cervical and facial regions. The diagnosis is confirmed by direct pathogen detection or by serological detection. The spirochete cannot be cultivated. The therapeutic gold standard is the administration of benzathine penicillin G or procaine penicillin G. Doxycycline, macrolides or ceftriaxone are available as alternatives. In case of inner ear or cranial nerve involvement, the additional administration of a glucocorticoid is recommended. Before antibiotic therapy is administered, the patient must be informed about the possibility of a Jarisch-Herxheimer reaction. In cases of a syphilis infection, a collegial cooperation with the venereologists is always recommended so that an effective and comprehensive diagnosis and therapy can be carried out.

Responses to reduced nicotine cigarette marketing features: a systematic review

OBJECTIVE

To systematically review the literature regarding responses to commercial and public health marketing features for reduced nicotine cigarettes (RNCs) to anticipate potential industry and regulatory actions should an RNC product standard be issued.

DATA SOURCES

We searched PubMed for English-language articles using several keywords for reduced nicotine products, cigarettes and marketing features published through 2020.

STUDY SELECTION

Of 4092 records, 26 studies were retained for review that met criteria focusing on responses to RNC marketing features.

DATA EXTRACTION

Search terms created by the research team were used for review and included independent extraction and coding by two reviewers. Coding was categorised using study design terminology, commercial and public health features in tobacco regulatory science, and their association with individual responses outlined by several message processing outcomes.

DATA SYNTHESIS

Most studies focused on current cigarette smokers and were cross-sectional. Reactions to RNCs and attitudes and beliefs were the most common outcomes measured. For commercial features, articles generally studied RNC advertisements, products and/or descriptors. For public health features, articles studied counter-messaging (eg, warning labels) or general descriptors about nicotine or a reduced nicotine product standard. Commercial features were generally associated with favourable responses. Public health features offset favourable responses across most outcomes, though their efficacy was mixed. Contrasts in results by smoking status are discussed.

CONCLUSIONS

Commercial marketing of RNCs is appealing and may need stronger regulations or communication campaigns to accurately convey risks. Opportunities exist for future research within tobacco regulatory science.

Sexually Transmitted Infections Treatment Guidelines, 2021

These guidelines for the treatment of persons who have or are at risk for sexually transmitted infections (STIs) were updated by CDC after consultation with professionals knowledgeable in the field of STIs who met in Atlanta, Georgia, June 11-14, 2019. The information in this report updates the 2015 guidelines. These guidelines discuss 1) updated recommendations for treatment of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis; 2) addition of metronidazole to the recommended treatment regimen for pelvic inflammatory disease; 3) alternative treatment options for bacterial vaginosis; 4) management of Mycoplasma genitalium; 5) human papillomavirus vaccine recommendations and counseling messages; 6) expanded risk factors for syphilis testing among pregnant women; 7) one-time testing for hepatitis C infection; 8) evaluation of men who have sex with men after sexual assault; and 9) two-step testing for serologic diagnosis of genital herpes simplex virus. Physicians and other health care providers can use these guidelines to assist in prevention and treatment of STIs.

Clinical outcomes of syphilis in HIV-negative and HIV-positive MSM: occurrence of repeat syphilis episodes and non-treponemal serology responses

OBJECTIVES

HIV-positive men who have sex with men (MSM) may be at a higher risk of repeat syphilis, have different clinical manifestations and have a different serological response to treatment compared with HIV-negative MSM. The objective of this study was to assess whether HIV-negative and HIV-positive MSM with infectious syphilis (primary, secondary or early latent) differed in history of previous syphilis episodes, disease stage and non-treponemal titre of initial and repeat episodes, and the titre response 6 and 12 months after treatment. Furthermore, determinants associated with an inadequate titre response after treatment were explored.

METHODS

This retrospective analysis used data of five longitudinal studies (four cohorts; one randomised controlled trial) conducted at the STI clinic in Amsterdam, the Netherlands. Participants were tested for syphilis and completed questionnaires on sexual risk behaviour every 3-6 months. We included data of participants with ≥1 syphilis diagnosis in 2014-2019. Pearson's χ² test was used to compare HIV-negative and HIV-positive MSM in occurrence of previous syphilis episodes, disease stage of initial and repeat syphilis episode and non-treponemal titre treatment responses.

RESULTS

We included 355 participants with total 459 syphilis episodes. HIV-positive MSM were more likely to have a history of previous syphilis episodes compared with HIV-negative MSM (68/90 (75.6%) vs 96/265 (36.2%); p<0.001). Moreover, HIV-positive MSM with repeat syphilis were less often diagnosed with primary syphilis (7/73 (9.6%) vs 36/126 (28.6%)) and more often diagnosed with secondary syphilis (16/73 (21.9%) vs 17/126 (13.5%)) and early latent syphilis (50/73 (68.5%) vs 73/126 (57.9%)) (p=0.005). While not significantly different at 12 months, HIV-negative MSM were more likely to have an adequate titre response after 6 months compared with HIV-positive MSM (138/143 (96.5%) vs 66/74 (89.2%); p=0.032).

CONCLUSIONS

In repeat syphilis, HIV infection is associated with advanced syphilis stages and with higher non-treponemal titres. HIV infection affects the serological outcome after treatment, as an adequate titre response was observed earlier in HIV-negative MSM.

An Investigation of Early Syphilis Among Men Who have Sex with Men: Alaska, 2018: Findings from a 2018 Rapid Ethnographic Assessment

The state of Alaska had a sharp increase in cases of primary and secondary syphilis among gay, bisexual, and other men who have sex with men (GBMSM) in 2018, centered in Anchorage. A rapid ethnographic assessment was conducted in October 2018 to examine contextual factors contributing to local increases in syphilis. The assessment team conducted qualitative interviews with 64 (N=49 interviews) key informants in Anchorage and Matanuska-Susitna Valley identified through the STD/HIV program at the Alaska Department of Health and Social Services, Division of Public Health (ADPH):  ADPH staff (n = 11; 22%) Medical Providers (n = 18; 37%), Community-Based Organizations/Partners (n = 9; 18%), and GBMSM Community Members (n = 11; 22%). This project was deemed exempt from IRB review. Primary factors affecting syphilis transmission, care, and treatment among GBMSM were: (1) Low awareness about the current syphilis outbreak and ambivalence about syphilis and other STIs; (2) Aspects of sexual partnering such as travel, tourism, and the use of online sites and apps to facilitate anonymous sex and multiple (both sequential/concurrent) partnering; (3) The synergistic effects of substance use, homelessness, and transactional sex; (4) Choosing condomless sex; and (5) Challenges accessing healthcare, including the ability to find appropriate and culturally competent care. Syphilis increases may have been influenced by factors which spanned multiple sectors of the Anchorage community, including individual behavior, community-level risk and protective factors, and use of and interactions with resources offered by ADPH, community-based organizations, and medical providers.

Increased repeat syphilis among HIV-infected patients: A nationwide population-based cohort study in Taiwan

Among human immunodeficiency virus (HIV)-infected individuals, syphilis is an important sexually transmitted infection (STI), and repeat infections are common. Identifying risk factors for delineating the trends in repeat syphilis are essential for STI and HIV prevention.This study is to investigate the dynamic of the syphilis epidemic among HIV-infected patients and to identify the risk factors associated with repeat syphilis.A population-based cohort design was used to analyze claim data between January 2000 and December 2010 using the Taiwan National Health Insurance Research Database. The Poisson regression test was used to identify risk factors for repeat syphilis.Of 13,239 HIV-infected patients, annual syphilis screen tests have been performed in 4,907 (37.1%) of these patients. Syphilis has been diagnosed in 956 (19.5%) patients, and 524 (10.7%) had repeat syphilis. The annual trend in repeat syphilis showed a significant increase in the study period (β = 0.23, P < .001). Younger age (adjusted incidence rate ratio [aIRR] 1.43; 95% CI 1.11-1.86), male gender (aIRR 11.14, 95% CI 4.16-29.79), a history of STIs (aIRR 1.39, 95% CI 1.21-1.59) were independently associated with repeat syphilis. The retention in HIV care and adherence to antiretroviral therapy ≥85% ([aIRR] 0.77, 95% CI 0.61-0.98; P < .001) were associated with a reduced risk of repeat syphilis.The incidence of repeat syphilis increased during 11 years of follow-up. The screening of syphilis for early diagnosis and retention in HIV care with medication adherence should be encouraged to minimize the risk of repeat syphilis in the targeted population.

Enhancing the Control of Syphilis Among Men Who Have Sex With Men by Focusing on Acute Infectious Primary Syphilis and Core Transmission Groups

The syphilis epidemic among men who have sex with men (MSM) has been increasing steadily. Many syphilis control programs focus on assuring treatment of all persons diagnosed with early syphilis without prioritizing acute primary syphilis or specific subgroups. Acute primary syphilis is highly infectious and contributes to a high proportion of new cases. Surveillance data show that among MSM with incident syphilis (primary or secondary) only about 35% are identified in the primary stage, indicating that most primary cases are missed and untreated. Patients with primary syphilis and large numbers of sex partners may play a major role in maintaining syphilis transmission. Considering those issues, sexually transmitted disease (STD) programs should consider increasing their focus on primary syphilis by assigning primary cases the highest priority, expanding client and clinician health education, and increasing the detection of primary syphilis through increased serologic screening frequency among high-risk MSM. Furthermore, syphilis control programs should implement steps to identify asymptomatic high-probable occult primary cases based on low titer (≤1:8) and recent seroconversion. Finally, to address core transmission groups, programs should implement periodic risk assessment to identify persons with a high number of sex partners and offer these individuals risk-reduction counseling, case management, and selective syphilis preexposure or postexposure doxycycline chemoprophylaxis. Although reprioritizing prevention efforts might be challenging, the Centers for Disease Control and Prevention, community advocacy groups, university STD research centers, and national STD prevention training centers can assist by providing support for consensus discussions and direction in developing operational guidance, some of which may be best delivered through STD and human immunodeficiency virus program partnerships.

Comparative genomics and full-length Tprk profiling of Treponema pallidum subsp. pallidum reinfection

Developing a vaccine against Treponema pallidum subspecies pallidum, the causative agent of syphilis, remains a public health priority. Syphilis vaccine design efforts have been complicated by lack of an in vitro T. pallidum culture system, prolific antigenic variation in outer membrane protein TprK, and lack of functional annotation for nearly half of the genes. Understanding the genetic basis of T. pallidum reinfection can provide insights into variation among strains that escape cross-protective immunity. Here, we present comparative genomic sequencing and deep, full-length tprK profiling of two T. pallidum isolates from blood from the same patient that were collected six years apart. Notably, this patient was diagnosed with syphilis four times, with two of these episodes meeting the definition of neurosyphilis, during this interval. Outside of the highly variable tprK gene, we identified 14 coding changes in 13 genes. Nine of these genes putatively localized to the periplasmic or outer membrane spaces, consistent with a potential role in serological immunoevasion. Using a newly developed full-length tprK deep sequencing protocol, we profiled the diversity of this gene that far outpaces the rest of the genome. Intriguingly, we found that the reinfecting isolate demonstrated less diversity across each tprK variable region compared to the isolate from the first infection. Notably, the two isolates did not share any full-length TprK sequences. Our results are consistent with an immunodominant-evasion model in which the diversity of TprK explains the ability of T. pallidum to successfully reinfect individuals, even when they have been infected with the organism multiple times.

Characteristics of Persons With Repeat Syphilis-Idaho, 2011 to 2015

During 2011 through 2015 in Idaho, 14 (7%) of 193 persons with early syphilis had repeat syphilis. Persons with repeat infections were more likely to have had secondary or early latent syphilis (P = 0.037) and be infected with human immunodeficiency virus (P < 0.001) compared with those having 1 infection.

The development of an online risk calculator for the prediction of future syphilis among a high-risk cohort of men who have sex with men and transgender women in Lima, Peru

Background Syphilis incidence worldwide has rebounded since 2000, particularly among men who have sex with men (MSM). A predictive model for syphilis infection may inform prevention counselling and use of chemoprophylaxis.

METHODS

Data from a longitudinal cohort study of MSM and transgender women meeting high-risk criteria for syphilis who were followed quarterly for 2 years were analysed. Incidence was defined as a four-fold increase in rapid plasma reagin (RPR) titres or new RPR reactivity if two prior titres were non-reactive. Generalised estimating equations were used to calculate rate ratios (RR) and develop a predictive model for 70% of the dataset, which was then validated in the remaining 30%. An online risk calculator for the prediction of future syphilis was also developed.

RESULTS

Among 361 participants, 22.0% were transgender women and 34.6% were HIV-infected at baseline. Syphilis incidence was 19.9 cases per 100-person years (95% confidence interval (CI) 16.3-24.3). HIV infection (RR 2.22; 95% CI 1.54-3.21) and history of syphilis infection (RR 2.23; 95% 1.62-3.64) were significantly associated with incident infection. The final predictive model for syphilis incidence in the next 3 months included HIV infection, history of syphilis, number of male sex partners and sex role for anal sex in the past 3 months, and had an area under the curve of 69%. The online syphilis risk calculator based on those results is available at: www.syphrisk.net.

CONCLUSIONS

Using data from a longitudinal cohort study among a population at high risk for syphilis infection in Peru, we developed a predictive model and online risk calculator for future syphilis infection. The predictive model for future syphilis developed in this study has a moderate predictive accuracy and may serve as the foundation for future studies.

Sexually acquired syphilis: Historical aspects, microbiology, epidemiology, and clinical manifestations

Syphilis is caused by infection with the spirochetal bacterium Treponema pallidum subsp. pallidum. It was first recognized in the late 15th century. Since 2000, the incidence of sexually acquired syphilis has increased substantially in the developed world, with men who have sex with men and persons living with HIV infection disproportionately affected. Clinical manifestations of syphilis are protean and often include mucocutaneous manifestations. The first article in this continuing medical education series reviews historical aspects, microbiology, epidemiology, and clinical manifestations of sexually acquired syphilis.

Sexually acquired syphilis: Laboratory diagnosis, management, and prevention

The methods used for the laboratory diagnosis of syphilis include direct detection of Treponema pallidum subspecies pallidum and serologic testing. Serologic testing relies on both nontreponemal and treponemal tests. In newly developed reverse-sequence screening algorithms, treponemal tests are performed before nontreponemal tests. The management of syphilis requires appropriate staging, treatment, and follow-up of patients along with the prompt reporting of infections to public health authorities to assist with prevention and control efforts. Benzathine penicillin G remains the treatment of choice for all stages of syphilis. Screening of populations at higher risk for syphilis is recommended by the US Centers for Disease Control and Prevention, the US Preventive Services Task Force, and the World Health Organization. The second article in this continuing medical education series reviews the testing for and the management of sexually acquired syphilis.

Correlates of support for a nicotine-reduction policy in smokers with 6-week exposure to very low nicotine cigarettes

BACKGROUND

The US Food and Drug Administration recently issued an advanced notice of proposed rule-making for reducing the nicotine content in cigarettes to a minimally addictive level. Very little is known about whether use of very low nicotine content (VLNC) cigarettes affects support for a nicotine reduction policy.

OBJECTIVE

This study examined the effects of using VLNC versus usual brand (UB) cigarettes on support for a nicotine reduction policy and determined whether participant characteristics and responses to VLNC cigarettes were associated with policy support.

METHODS

Participants from a cigarette trial who were assigned to either 0.4 mg nicotine/g tobacco research cigarettes or their UB for 6 weeks were asked about their support for the policy. χ² tests were used to compare support for the policy between cigarette conditions and logistic regression analyses were conducted to assess covariates associated with policy support.

FINDINGS

Policy support did not differ by condition. After 6 weeks of using VLNC cigarettes, 50% of participants supported the policy, 26% opposed and 24% responded 'Don't Know'. Support was higher among those adherent to smoking only VLNC cigarettes (65%) compared with those who were non-adherent (44%). Older participants and those interested in quitting had increased odds of support. Cigarette satisfaction, perceived harm and perceived nicotine content were not significantly associated with support.

CONCLUSIONS

Smoking VLNC cigarettes did not affect support for a nicotine reduction policy. Understanding predictors of policy support and opposition will help public health officials to maximise the public health acceptance and impact of this policy (ClinicalTrials.gov Identifier: NCT01681875 Post-Results).

Old Pathogen, New Challenges: A Narrative Review of the Multilevel Drivers of Syphilis Increasing in American Men Who Have Sex With Men

Since the turn of the current century, syphilis incidence and prevalence have been increasing more rapidly among men who have sex with men (MSM) than any other US subpopulation, exceeding their previously high rates in the 1970s and 1980s, before the AIDS epidemic. The reasons for these trends are multifactorial and complex, involving individual behavioral, sociocultural, structural, and biological factors, which will be reviewed in this article. Men who have sex with men tend to have more sexual partners than heterosexuals, and engage in practices (e.g., anal sex) that are highly efficient for syphilis transmission and nondetection of primary chancres. In the era of highly active antiretroviral therapy rendering adherent patients noninfectious and the use of preexposure prophylaxis, there is substantially less concern about HIV transmission and acquisition among MSM, resulting in higher levels of condomless sex. The increased concentration of syphilis among black MSM is partially related to assortative mixing, that is, black MSM being more likely to have other black sex partners, as well as decreased access to preventive services and treatment due to economic marginalization, Societal rejection and discrimination may also potentiate factors that may increase sexual risks resulting in syphilis, for example, depression and substance use. The anticipation of experiencing homophobic discrimination in health care settings may lead many sexually active MSM to delay needed screening and treatment, thus being infectious to partners for longer periods than other populations. To effectively control the syphilis epidemic among MSM, scaling up a combination of programs, ranging from enhanced community education to training clinicians and health care systems to provide culturally competent care, will be necessary.

Social networks as drivers of syphilis and HIV infection among young men who have sex with men

OBJECTIVES

Syphilis and HIV epidemics overlap, yet little is known about combined network and behavioural factors that drive syphilis-HIV coinfection. Our study objective was to assess network contexts and sexual behaviours associated with syphilis-HIV co-infection and monoinfection among a particularly vulnerable subgroup: young Black men who have sex with men (YBMSM). To achieve this objective, we examined factors associated with coinfection by each subgroup as classified by syphilis-HIV infection status: (A) HIV monoinfected, (B) syphilis monoinfected and (C) neither syphilis infected nor HIV infected. In addition, we further identified the factors that are associated with HIV infection or syphilis monoinfection.

METHODS

Data were collected from a sample of 365 YBMSM, aged 16-29 years, recruited through respondent-driven sampling between 2014 and 2016, in two cities with large HIV epidemics: Houston, TX, and Chicago, IL. We conducted a series of multinomial logistic regression models to predict coinfection, HIV monoinfection and syphilis monoinfection as a function of network and sexual behavioural factors.

RESULTS

Coinfection was associated with having network members who are coinfected or HIV infected within one's social network. Syphilis monoinfection was associated with a higher number of social venues attended, and HIV monoinfection was associated with having more condomless top partners.

CONCLUSION

Public health interventions that address the diagnosis and treatment of syphilis infection and ensure that those with syphilis are being tested for HIV may be promising in limiting the synergy of syphilis-HIV infections in onward transmission. Advancing HIV and syphilis prevention efforts in high-prevalence networks may allow prioritisation of limited resources.

HIV infection and sex in sex-on-premises venues are associated with a higher risk of syphilis reinfection among men who have sex with men

Introduction

Recent outbreaks of syphilis occurred predominantly in men who have sex with men (MSM). A significant proportion of syphilis cases occur in MSM who had more than one episode of syphilis. This group may play an important role in syphilis transmission.

Aim

To identify factors associated with the risk of syphilis reinfection.

Material and methods

Forty-four MSM patients with the first episode of syphilis who were treated at the Department of Dermatology at the Jagiellonian University School of Medicine in Krakow, Poland were included in this study. After completing the treatment, the RPR testing was done every 3 months for 2 years in every patient. In the study period, we identified 12 (22%) cases of syphilis reinfection, eight of which were asymptomatic. Clinical, demographic and behavior data from patients with only one episode of syphilis were compared with those collected from repeaters.

Results

Individuals with syphilis reinfection had concomitant HIV infection more frequently, reported a higher number of sexual partners and had sex in sex on premises venues more frequently (p < 0.05). In the multivariate analysis, we found that being HIV-infected MSM and having sex in sex on premises venues independently correlated with a higher risk of syphilis reinfection (OR = 9.6, 95% CI: 2.2–42.5 and OR = 5.6, 95% CI: 1.4–22.5, respectively).

Conclusions

Results of our study highlight a strong need for frequent and repeated screening among MSM patients (especially those with concomitant HIV infection) with the first episode of syphilis and taking detailed patient’s history regarding also demographic and behavior data. We should also improve prevention policies to reduce risk behaviors in this population.

Smokers' support for tobacco endgame measures in Canada: findings from the 2016 International Tobacco Control Smoking and Vaping Survey

BACKGROUND

The Canadian government has committed to an endgame target of less than 5% tobacco use by 2035. The aims of this study were to assess baseline levels of support for potential endgame policies among Canadian smokers, by province/region, demographic characteristics and smoking-related correlates, and to identify predictors of support.

METHODS

We analyzed data for 3215 adult (age ≥ 18 yr) smokers from the Canadian arm of the 2016 International Tobacco Control Four Country Smoking and Vaping Survey. We estimated weighted percentages of support for endgame measures for 6 provinces/regions of the country. We used weighted logistic regression models to identify predictors of support for 14 endgame strategies.

RESULTS

Among cigarette endgame policies, support was highest for reducing nicotine content (70.2%), raising the legal age for purchase (69.8%), increasing access to alternative nicotine products (65.8%) and banning marketing (58.5%). Among e-cigarette policies, there was majority support for restricting youth access (86.1%), restricting nicotine content (64.9%), prohibiting use in smoke-free places (63.4%) and banning marketing (54.8%). The level of support for other endgame measures ranged from 28.9% to 45.2%. Support for cigarette and e-cigarette policies was generally higher among smokers with intentions to quit and those from Quebec. Support for e-cigarette policies was generally lower among smokers who also used e-cigarettes daily.

INTERPRETATION

There is considerable support among Canadian smokers for endgame policies that go beyond current approaches to tobacco control. Our findings provide a baseline for evaluating future trends in smokers' support for innovative measures to radically reduce smoking rates in Canada.

Factors associated with repeat diagnosis of syphilis in genitourinary medicine (GUM) clinic attendees in the North East of England, 2002-2014

This study aimed to identify factors associated with repeat syphilis infection in North East England, in order to inform local prevention and control opportunities. We undertook a case-case study comparing individuals diagnosed with single or multiple episodes of syphilis infection within genitourinary medicine (GUM) clinics in NE England (12 clinics serving a population of 2.5 million). Study cases were verified as having had true re-infection by a GUM clinician (using serological and/or clinical parameters) and control cases (3 per case) frequency matched to cases by age and year of presentation. The odds of exposure to sexual behavioural and clinical factors were compared for cases and control cases using stepwise multivariable logistic regression. We included 66 cases and 235 control cases. The majority of cases (62/66) and control cases (165/235) were men who had sex with men (MSM). Data were missing for 0-64% of cases across different variables. Following multivariable analysis HIV seropositivity (OR 23.3, 95% CI 4.32-125.9), failure to attend follow-up (OR 4.63, 95% CI 1.11-19.31), stage of infection and deprivation were associated with re-infection ( p < 0.001). In this study, HIV seropositivity and failure to attend follow-up were associated with re-infection with syphilis. Actions targeted at these groups may help to reduce ongoing transmission.

Repeat syphilis has a different immune response compared with initial syphilis: an analysis of biomarker kinetics in two cohorts

OBJECTIVE

We aimed to asses if there are differences in the clinical presentation and immune response of repeat as compared with initial syphilis.

METHODS

Prospective study: we prospectively recruited all patients with a new diagnosis of syphilis and tested their plasma for a range of cytochemokines and rapid plasma reagin (RPR) at baseline pretreatment and 6 months following therapy. Retrospective study: we compared RPR assay response kinetics between initial and repeat syphilis in persons attending our HIV/STI clinic from 1993 to 2016.

RESULTS

Prospective study: a total of 91 individuals, 36 with initial syphilis and 55 with repeat syphilis, were included in the study. At baseline visit, those with initial syphilis were more likely to be symptomatic and have higher levels of interleukin-10 than repeaters. At baseline, median RPR titres were higher in the repeat than the initial infection groups. Repeaters were less likely than those with initial infections to serorevert to a negative RPR and be serofast (<4-fold RPR titre decline) at 6 months.Retrospective study: syphilis was diagnosed in 1027/43 870 individuals tested. At diagnosis, repeaters had higher RPR titres and a stepwise increase in RPR titre with number of syphilis episodes. They had a different RPR test response kinetic: they were less likely to be serofast and to serorevert than initial syphilis at 6 and 12 months. No individuals with four or more previous episodes of syphilis seroreverted.

CONCLUSION

Repeat syphilis has a different clinical presentation and immunological response to initial infection.

Factors associated with syphilis treatment failure and reinfection: a longitudinal cohort study in Shenzhen, China

Background

The treatment failure and reinfection rates among syphilis patients are high, and relevant studies in China are limited. The aim of this study was to detect the rates of treatment failure and reinfection after syphilis treatment and to explore the potential associated factors.

Methods

We conducted a longitudinal cohort study in a sexually transmitted disease clinic, the Department of Dermatology and Venereology in Nanshan Center for Chronic Disease Control. Serological testing was performed at baseline and throughout the 2-year follow-up for syphilis patients. To identify potential predictors of treatment outcomes, multivariate logistics analyses were utilized to compare the demographic and clinical characteristics of patients with serological failure/reinfection to those with serological cure/serofast.

Results

From June 2011 to June 2016, a total of 1133 patients were screened for syphilis. Among the 770 patients who completed the 2-year follow-up, 510 first-diagnosed patients were included in the final analysis. Multivariate logistics analysis revealed the stage of syphilis (secondary syphilis VS. primary syphilis: adjusted odds ratio, 3.50; 95% confidence interval, 1.11-15.47; p = 0.04), HIV status (positive VS. negative: adjusted odds ratio, 3.06; 95% confidence interval, 1.15-8.04; p = 0.02) and frequency of condom use (always use VS. never use: adjusted odds ratio, 0.28; 95% confidence interval 0.08-0.75; p = 0.02) were significantly associated with the serological outcome.

Conclusions

The clinical implications of our findings suggest that it is very important to perform regular clinical and serologic evaluations after treatment. Health counseling and safety education on sex activity should be intensified among HIV-infected patients and secondary syphilis patients after treatment.

Can enhanced screening of men with a history of prior syphilis infection stem the epidemic in men who have sex with men? A mathematical modelling study

OBJECTIVES

The aim of this study is to determine the transmission impact of using prior syphilis infection to guide a focused syphilis screening intervention among men who have sex with men (MSM).

METHODS

We parameterised a deterministic model of syphilis transmission in MSM to reflect the 2011-2015 syphilis outbreak in Winnipeg, Canada. Enhanced screening of 75% of men with prior syphilis every 3 months (A) was compared with distributing equivalent number tests to all MSM (B) or those with the highest partner number (C). We compared early syphilis incidence, diagnoses and prevalence after 10 years, relative to a base case of 30% of MSM screened annually.

RESULTS

Strategy A was expected to avert 52% of incident infections, 44% of diagnosed cases and reduce early syphilis prevalence by 89%. Strategy B had the least impact. Strategy C was most effective, averting 59% of incident cases. When screening frequency was semiannual or annual, strategy A was the most effective.

CONCLUSIONS

Enhanced screening of MSM with prior syphilis may efficiently reduce transmission, especially when identification of high-risk men via self-reported partner numbers or high-frequency screening is difficult to achieve.

Rates and Correlates of Syphilis Reinfection in Men Who Have Sex with Men

PURPOSE

This study examined rates and correlates of syphilis reinfection in men who have sex with men (MSM).

METHODS

From 2012 to 2015, time to reinfection was assessed in 323 MSM receiving initial treatment for syphilis in San Francisco.

RESULTS

One in five men was reinfected (71/323; 22%). The rate of syphilis reinfection was greater among HIV-infected men (adjusted hazard ratio [aHR] = 1.96; 95% confidence interval [95% CI] = 1.16-3.31) and ketamine users (aHR = 2.76; 95% CI = 1.09-7.00).

CONCLUSION

Expanded prevention efforts are needed with HIV-infected and substance-using MSM to reduce the burden of reinfection in this population.

A mathematical model of syphilis transmission in an MSM population

Syphilis is caused by the bacterium Treponema pallidum subspecies pallidum, and is a sexually transmitted disease with multiple stages. A model of transmission of syphilis in an MSM population (there has recently been a resurgence of syphilis in such populations) that includes infection stages and treatment is formulated as a system of ordinary differential equations. The control reproduction number is calculated, and it is proved that if this threshold parameter is below one, syphilis dies out; otherwise, if it is greater than one, it is shown that there exists a unique endemic equilibrium and that for certain special cases, this equilibrium is globally asymptotically stable. Using data from the literature on MSM populations, numerical methods are used to determine the variation and robustness of the control reproduction number with respect to the model parameters, and to determine adequate treatment rates for syphilis eradication. By assuming a closed population and no return to susceptibility, an epidemic model is obtained. Final outbreak sizes are numerically determined for various parameter values, and its variation and robustness to parameter value changes is also investigated. Results quantify the importance of early treatment for syphilis control.

Syphilis Experiences and Risk Perceptions Among Repeatedly Infected Men Who Have Sex with Men

CONTEXT

In urban areas of the United States, syphilis is a major public health issue for men who have sex with men, despite widespread efforts to curtail a growing epidemic; repeated infections are not uncommon in this population. The ways that men who have sex with men experience and conceptualize syphilis, and how their attitudes and beliefs impact their risk for infection, are poorly understood.

METHODS

In-depth interviews were conducted in 2010-2011 with 19 Los Angeles County men aged 21-54 who reported having male sex partners and had had two or more early syphilis infections within the previous five years. Interview transcripts were analyzed inductively to uncover themes.

RESULTS

Participants had considerable knowledge about syphilis symptoms, transmission and consequences, and most felt that syphilis was a highly stigmatized disease. They had had 2-5 infections in the past five years, and the majority believed they were at risk for another infection because of their sexual risk behaviors. Many had a sense of fatalism about being infected again, and some expressed that this possibility was an acceptable part of being sexually active. Concern about syphilis often decreased as men experienced more infections. Most participants reported short-term sexual behavior changes after a syphilis diagnosis to prevent transmission; however, few were willing to make long-term behavior changes.

CONCLUSIONS

Additional qualitative studies of men who have sex with men should be conducted to better understand the continuing syphilis epidemic and to help identify the most promising intervention strategies.

Emerging trends and persistent challenges in the management of adult syphilis

There are an estimated 10.6 million incident cases of syphilis worldwide each year. We highlight some persistent challenges and emerging trends in the clinical management of syphilis with a particular focus on therapy, serology, diagnostics, and prevention. Decades after the introduction of penicillin, the optimal management of early syphilis continues to be a controversial topic, particularly in the setting of HIV co-infection. Similarly, the need for routine lumbar puncture in HIV co-infected asymptomatic persons is an unanswered question. Despite advances in both automation and point-of-care diagnostics, we continue to rely on indirect measures of disease activity to manage this infection. As syphilis rates in some populations continue to rise, novel and effective prevention strategies are needed.

Sexually transmitted diseases treatment guidelines, 2015

These guidelines for the treatment of persons who have or are at risk for sexually transmitted diseases (STDs) were updated by CDC after consultation with a group of professionals knowledgeable in the field of STDs who met in Atlanta on April 30-May 2, 2013. The information in this report updates the Sexually Transmitted Diseases Treatment Guidelines, 2010 (MMWR Recomm Rep 2010;59 [No. RR-12]). These updated guidelines discuss 1) alternative treatment regimens for Neisseria gonorrhoeae; 2) the use of nucleic acid amplification tests for the diagnosis of trichomoniasis; 3) alternative treatment options for genital warts; 4) the role of Mycoplasma genitalium in urethritis/cervicitis and treatment-related implications; 5) updated HPV vaccine recommendations and counseling messages; 6) the management of persons who are transgender; 7) annual testing for hepatitis C in persons with HIV infection; 8) updated recommendations for diagnostic evaluation of urethritis; and 9) retesting to detect repeat infection. Physicians and other health-care providers can use these guidelines to assist in the prevention and treatment of STDs.

Go big or go home: impact of screening coverage on syphilis infection dynamics

OBJECTIVES

Syphilis outbreaks in urban men who have sex with men (MSM) are an ongoing public health challenge in many high-income countries, despite intensification of efforts to screen and treat at-risk individuals. We sought to understand how population-level coverage of asymptomatic screening impacts the ability to control syphilis transmission.

METHODS

We developed a risk-structured deterministic compartmental mathematical model of syphilis transmission in a population of sexually active MSM. We assumed a baseline level of treatment of syphilis cases due to seeking medical care in all scenarios. We evaluated the impact of sustained annual population-wide screening coverage ranging from 0% to 90% on syphilis incidence over the short term (20 years) and at endemic equilibrium.

RESULTS

The relationship between screening coverage and equilibrium syphilis incidence displayed an inverted U-shape relationship, with peak equilibrium incidence occurring with 20-30% annual screening coverage. Annual screening of 62% of the population was required for local elimination (incidence <1 case per 100 000 population). Results were qualitatively similar in the face of differing programmatic, behavioural and natural history assumptions, although the screening thresholds for local elimination differed. With 6-monthly or 3-monthly screening, the population coverage required to achieve local elimination was reduced to 39% or 23%, respectively.

CONCLUSIONS

Although screening has the potential to control syphilis outbreaks, suboptimal coverage may paradoxically lead to a higher equilibrium infection incidence than that observed in the absence of intervention. Suboptimal screening programme design should be considered as a possible contributor to unsuccessful syphilis control programmes in the context of the current epidemic.

[Epidemiological developments of selected sexually transmitted infections in Germany]

The number of people living with HIV infection has been increasing since the mid 1990s and is expected to rise further in the coming years. The HIV epidemic in Germany is still most affected by developments in the group of men who have sex with men (MSM). In this group, the number of newly diagnosed HIV infections has increased in recent years especially in large cities. Despite increased efforts to motivate HIV-infected people, who were not previously diagnosed, to be tested as early as possible and to seek medical treatment, the number of undiagnosed HIV-infected persons has increased. There are more people infected with HIV than those who have been tested positive for HIV and subsequently receive antiretroviral treatment. However, early testing and treatment alone are not sufficient to effectively contain the infection. Increased efforts are required to more effectively prevent new HIV infections by combining all the available options. In Germany as in all other developed countries, a stronger increase in the number of syphilis infections among MSM is reported, which is primarily due to a higher willingness to risk unprotected contacts, whereby the risk of HIV infection is also increased. The public prevention messages available for HIV are only partially effective against syphilis. More frequent examinations and optimized therapy management are necessary in addition to the use of condoms to prevent the spread of syphilis, gonorrhea, and Chlamydia trachomatis. Sustainable containment of new HIV infections must, therefore, be accompanied by both containment of sexually transmitted infections (STI) and use of public prevention messages for HIV/STI.

Clinical Aspects of Syphilis Reinfection in HIV-Infected Patients

BACKGROUND

The incidence of HIV-syphilis co-infection has risen since 2000, especially among men having sex with men (MSM). Syphilis reinfection can occur, but the clinical features of such events remain poorly characterized.

OBJECTIVE

To compare the cutaneous lesions seen with syphilis reinfections with those of first episodes in HIV-infected patients.

METHODS

In a cohort of HIV-infected patients, syphilis reinfection was established both clinically and biologically by evaluating changes in Venereal Disease Research Laboratory titers. Photographs and medical records were studied in order to determine the type of skin lesions and their quantification.

RESULTS

Among 533 HIV-infected patients, 42 (8%) experienced a first syphilis infection. Thirteen episodes of reinfection occurred in 12/42 (28%) patients, all MSM. In 78% of cases, reinfections were less symptomatic than first episodes. All patients presented classical syphilis lesions.

CONCLUSIONS

We observed a high rate of reinfection, but with less severe skin manifestations during reinfection episodes.

Acceptable interventions to reduce syphilis transmission among high-risk men who have sex with men in Los Angeles

OBJECTIVES

We examined perceptions of and attitudes toward existing and potential syphilis interventions, including case management and Web-based programs, to increase syphilis testing among high-risk men who have sex with men (MSM).

METHODS

Between October 2010 and June 2011, we conducted in-depth interviews with 19 MSM in Los Angeles, California, with repeat early syphilis infections (primary, secondary, and early latent syphilis) within the previous 5 years. We analyzed the interviews inductively to determine the most acceptable potential interventions.

RESULTS

Experiences with health department and community-based standard of care case management were generally positive. The most popular interventions among respondents included a Web site providing information on syphilis and syphilis testing, automated Web reminders to test, being paid to test, free online home testing kits, and preexposure prophylactic medication. Respondents' beliefs that they would continue to practice high-risk sexual behaviors reinforced their reasons for wanting increased accessibility and convenient testing strategies.

CONCLUSIONS

Public health officials should consider participant responses to potential interventions for syphilis, which suggest that high-risk MSM would consider testing more often or using other interventions.

Syphilis in the United States: on the rise?

Syphilis rates and trends vary by population subgroup. Among men who have sex with men (MSM), rates of primary and secondary (P&S) syphilis are high throughout the USA (228.8 per 100,000 in 2013). P&S syphilis among women is much less common (0.9 per 100,000 in 2013) and occurs in isolated outbreaks plus in a few counties with persistent low levels of infection. Congenital syphilis trends closely follow P&S trends among women. These trends have implications for prevention. Routine screening among MSM can prevent tertiary syphilis, but despite interventions, rates of infection continue to rise among MSM and will soon approach those last seen in 1982 (estimate: 340.7 per 100,000). Control of syphilis among women is possible and important because it often leads to congenital syphilis. Outbreaks among heterosexuals can be halted by intensive screening, treatment and partner notification.

Evolution of the syphilis epidemic among men who have sex with men

Syphilis has existed for millenni, but its epidemiology was only recently linked to men who have sex with men (MSM) after the introduction of penicillin in the 1940s; the syphilis epidemic became concentrated within the MSM community in subsequent decades. The HIV/AIDS epidemic in the 1980s led to a surge of new syphilis cases and revealed the potentiation between HIV and syphilis, as evidenced by a shift in the natural history of neurosyphilis. In response, MSM revolutionised their sexual behaviour by implementing community-driven seroadaptive strategies to stem HIV transmission. The Centers for Disease Control in the US called for the elimination of syphilis in the late 1990s since the rates had fallen sharply but this effort was overtaken by a resurgence of global outbreaks among MSM in the 2000s, many of which were linked to methamphetamine use and sexual networking websites. Syphilis remains highly prevalent today, especially among MSM and individuals infected with HIV, and it continues to present a significant public health conundrum. Innovative syphilis prevention strategies are warranted. MSM engaging in high-risk behaviour such as condomless anal receptive intercourse, sex with multiple partners or recreational drug use should be routinely screened for syphilis infection; they should also be counselled about the limits of seroadaptive behaviours and HIV pre-exposure prophylaxis as they relate to syphilis transmission.

Syphilis transmission: a review of the current evidence

Syphilis remains widespread worldwide, with increasing rates among men who have sex with men. This paper reviews available evidence regarding syphilis transmission, including data on: sexual transmission (transmission probability per sexual partnership), vertical transmission, transmission via blood products and organ donation, and other rare modes of transmission. In addition, host susceptibility to syphilis infection is discussed. Syphilis screening and treatment, condoms and risk-reduction counselling and how they modify syphilis transmission dynamics are considered.

Syphilis in the United States

Syphilis gained notoriety in the 1500s, when it became widespread throughout Europe. While the origins of syphilis are not certain, recent data have shown that it may have originated in the Americas from a close relative that causes Yaws (Treponema pallidum pertenue).(1) For the past 500years, the disease has shown its various faces all over the world. The 19th century saw an entire medical subspecialty-syphilology (sometimes known as syphilography)-devoted to the study of the great disease, then known as "the great imitator." Syphilis has an entire textbook of presentations and can mimic many other infections and immune-mediated processes. At the beginning of the 20th century, the many faces of the disease led to Sir William Osler's well-known aphorism, "The physician who knows syphilis knows medicine."(2) When penicillin was discovered, and used to treat syphilis in 1943, some thought that syphilis would go by the wayside, but syphilis continued what it has been doing for so many years . . . inconspicuously infecting humans. The United States has seen the incidence of syphilis increase numerous times throughout the past 70years. Every decrease in the incidence of syphilis is followed shortly by an increase. A marked shift in the epidemiology occurred from 1990 to 2000. In the 1990s, syphilis primarily occurred in heterosexual minority groups. In the new millennium, a majority of cases of syphilis are now transmitted among men who have sex with men (MSM).(3) This contribution discusses the incidence of syphilis in the United States and the reasons these trends continue.

Are Meaningful Use Stage 2 certified EHRs ready for interoperability? Findings from the SMART C-CDA Collaborative

BACKGROUND AND OBJECTIVE

Upgrades to electronic health record (EHR) systems scheduled to be introduced in the USA in 2014 will advance document interoperability between care providers. Specifically, the second stage of the federal incentive program for EHR adoption, known as Meaningful Use, requires use of the Consolidated Clinical Document Architecture (C-CDA) for document exchange. In an effort to examine and improve C-CDA based exchange, the SMART (Substitutable Medical Applications and Reusable Technology) C-CDA Collaborative brought together a group of certified EHR and other health information technology vendors.

MATERIALS AND METHODS

We examined the machine-readable content of collected samples for semantic correctness and consistency. This included parsing with the open-source BlueButton.js tool, testing with a validator used in EHR certification, scoring with an automated open-source tool, and manual inspection. We also conducted group and individual review sessions with participating vendors to understand their interpretation of C-CDA specifications and requirements.

RESULTS

We contacted 107 health information technology organizations and collected 91 C-CDA sample documents from 21 distinct technologies. Manual and automated document inspection led to 615 observations of errors and data expression variation across represented technologies. Based upon our analysis and vendor discussions, we identified 11 specific areas that represent relevant barriers to the interoperability of C-CDA documents.

CONCLUSIONS

We identified errors and permissible heterogeneity in C-CDA documents that will limit semantic interoperability. Our findings also point to several practical opportunities to improve C-CDA document quality and exchange in the coming years.

[Syphilis and human immunodeficiency virus infection: an endemic infection in men who have sex with men]

OBJECTIVE

to analyse epidemiological, clinical, and analytical features of HIV-infected men who have sex with men (MSM) diagnosed with syphilis in the Infectious Diseases Unit (Hospital Virgen de la Victoria, Málaga, Spain) during 2004-2013.

PATIENTS AND METHODS

An observational study was conducted on 196 syphilis episodes in 167 MSM infected with HIV (2004-2013). Epidemiological, clinical, and analytical data were collected. Annual syphilis incidence among HIV-MSM is calculated as the number of syphilis episodes among MSM in one year divided by the number of MSM followed up in that year.

RESULTS

Incidence ranged from 1.2% (2007) to 7.8% (2012). There were asymptomatic episodes in 42.8% cases, and an HIV-syphilis coincident diagnosis in 28.5%.

CONCLUSIONS

The annual incidence of syphilis has increased within HIV infected MSM. One third of the syphilis episodes were simultaneous to HIV diagnosis and near half of them were asymptomatic.

Syphilis in the modern era: an update for physicians

Syphilis is a complex, systemic disease caused by the spirochete Treponema pallidum. Syphilis is most commonly transmitted sexually or congenitally and can involve nearly every organ system. Its clinical progression involves several well-characterized stages: an incubation period, a primary stage, a secondary stage, a latent stage, and a late or tertiary stage. Syphilis during pregnancy is a leading cause of perinatal mortality in sub-Saharan Africa and can cause spontaneous abortion, stillbirth, prematurity, low birth weight, or congenital syphilis. Penicillin is highly effective against syphilis and remains the treatment of choice. This article reviews the epidemiology, clinical features, diagnostic approach, treatment, and prevention of syphilis.