Bruce W. Furness

The resurgence of syphilis among men who have sex with men.

Purpose of review To identify recent progress and emerging problems in addressing syphilis among men who have sex with men. Recent findings A resurgence of syphilis has occurred among men who have sex with men in many developed countries. Infection has been associated with HIV coinfection, multiple partners, and recreational drug use. Unlike HIV, oral sex appears to be a common route of syphilis transmission. Many prevention approaches have shown, at best, modest success. Variable clinical presentation and potentially inconclusive lab tests make diagnosis confusing. Summary As the infection remains relatively rare, clinicians treating men who have sex with men should maintain a high index of suspicion for syphilis lesions, and should screen their sexually active patients for latent disease. Debates about syphilis control and treatment continue. The clinical manifestations, serologic responses, efficacy of treatment, and complications of syphilis have always been complicated. HIV coinfection adds to the confusion.

Evaluation of an Innovative Internet-based Partner Notification Program for Early Syphilis Case Management, Washington, DC, January 2007―June 2008

Background: The Internet has become a common venue for meeting sex partners and planning participation in risky sexual behavior. In this article, we evaluate the first 18 months of the Washington, DC, Department of Health Internet-based Partner Notification (IPN) program for early syphilis infections, using the standard Centers for Disease Control and Prevention (CDC) Disease Investigation Specialist (DIS) disposition codes, as well as Washington, DC, Department of Healths IPN-specific outcomes for pseudonymous partners. Methods: We analyzed DIS disposition codes and IPN-specific outcomes from all early syphilis investigations initiated January 2007–June 2008. Internet partners were defined as sex partners for whom syphilis exposure notification was initiated by e-mail because no other locating information existed. If the e-mails resulted in additional locating information, we used the standard CDC disposition codes. Alternatively, the following IPN-specific outcomes were used: Informed of Syphilis Exposure, Informed of General STD Exposure, Not Informed or Unable to Confirm Receipt of General STD Exposure. Results: From the 361 early syphilis patients, a total of 888 sex partners were investigated, of which 381 (43%) were via IPN. IPN led to an 8% increase in the overall number of syphilis patients with at least one treated sex partner, 26% more sex partners being medically examined and treated if necessary, and 83% more sex partners notified of their STD exposure. Conclusions: IPN augmented traditional syphilis case management and aided in the location, notification, testing, and treatment of partners. Conversely, without IPN, these 381 partners would not have been investigated.

Time to treatment for women with chlamydial or gonococcal infections: a comparative evaluation of sexually transmitted disease clinics in 3 US cities.

Background: Many women with positive screening tests for chlamydia or gonorrhea are not promptly treated and are at risk for complications and further disease transmission. Improved methods for notifying infected patients might increase timely treatment in this population. Goal: Describe notification procedures at STD clinics in Washington, DC; Los Angeles; and San Diego and compare timeliness of treatment during 2000 to 2002. Study: Interviews were conducted to determine methods for notifying infected patients. Data were abstracted from 327 medical records of women with chlamydia or gonorrhea who had not been treated presumptively. The interval between specimen collection and treatment (“time to treatment”) was calculated. Results: Each clinic had different procedures for notifying untreated infected women. Among those treated, the median time to treatment was 18 days in Washington, DC, and 8 days in Los Angeles. In San Diego, the median time to treatment was initially 14 days, which improved to 7 days after patient-notification procedures were changed. Conclusion: Simple changes in patient notification procedures can decrease time to treatment at STD clinics. STD programs should evaluate time to treatment and institute methods for efficient patient follow-up.

Misclassification of the stages of syphilis: implications for surveillance.

Short summary: Syphilis cases were reviewed to see if reported stages met the Centers for Disease Control and Prevention case definition. Classification was excellent for primary and secondary and good for late latent, but half of early latent and unknown duration were misclassified. New surveillance definitions are suggested, comments requested. Background: Uncertainty when staging latent syphilis should lead clinicians to call it late latent (requires more treatment) and disease investigators to call it early latent (priority for partner investigation). Accurate surveillance requires consistent case definitions. Objective: Assess validity of reported syphilis stages. Methods: Record reviews in 6 jurisdictions to determine if reported cases met the Centers for Disease Control and Prevention case definitions. Results: Nine hundred seventy-three records from 6 jurisdictions in 2002 showed excellent agreement for reported primary (94.0%) and secondary (95.4%), good agreement for late latent (80.2%), and poor agreement for early latent (48.4%) and unknown duration (49.7%). Unknown duration (age ≤35 and nontreponemal test titer ≥32) was often misinterpreted to mean “not known.” Early latent (within the past year, documented: seroconversion, fourfold titer increase, symptoms, or contact with an independently documented early syphilis case) was often misinterpreted to include patients with risky behavior, young age, or high nontreponemal test titers. Conclusions: The unknown duration stage should be dropped. Surveillance of latent syphilis would be more consistent if cases were reported as having high or low titers on nontreponemal test. Alternative approaches are solicited from readers.

Needle in a haystack: the yield of syphilis outreach screening at 5 US sites-2000 to 2007.

BACKGROUND Screening for syphilis has been performed for decades, but it is unclear if the practice yields many cases at acceptable cost, and if so, at which venues. We attempted a retrospective study to determine the costs, yield, and feasibility of analyzing health department-funded syphilis outreach screening in 5 diverse US sites with significant disease burdens. METHODS Data (venue, costs, number of tests, reactive tests, new diagnoses) from 2000 to 2007 were collected for screening efforts funded by public health departments from Philadelphia; New York City; Washington, District of Columbia; Maricopa County, Arizona (Phoenix); and the state of Florida. Crude cost per new case was calculated. RESULTS Screening was conducted in multiple venues including jails, shelters, clubs, bars, and mobile vans. Over the study period, approximately 926 258 tests were performed and 4671 new syphilis cases were confirmed, of which 225 were primary and secondary, and 688 were early latent or high-titer late latent. Jail intake screening consistently identified the largest numbers of new cases (including 67.6% of early and high-titer late-latent cases) at a cost per case ranging from

Gonorrhea infections diagnosed among persons living with HIV/AIDS: identifying opportunities for integrated prevention services in New York City, Washington, DC, Miami/Dade County, and Arizona.

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Viral Loads Among HIV-Infected Persons Diagnosed With Primary and Secondary Syphilis in 4 US Cities: New York City, Philadelphia, PA, Washington, DC, and Phoenix, AZ.

3454. Data quality from other venues varied greatly between sites and was often poor. CONCLUSIONS Though the yield of jail intake screening was good, poor data quality, particularly cost data, precluded accurate cost/yield comparisons at other venues. Few cases of infectious syphilis were identified through outreach screening at any venue. Health departments should routinely collect all cost and testing data for screening efforts so that their yield can be evaluated.

Laboratory Capacity for Antimicrobial Susceptibility Surveillance of Neisseria gonorrhoeae-District of Columbia, 2007-2012.

Abstract:Persons living with HIV/AIDS who acquire new sexually transmitted diseases (STDs) pose a risk for enhanced transmission of both HIV and STDs. To describe the frequency of HIV coinfection among gonorrhea cases (GC), HIV and GC surveillance databases (2000–2008) were cross-matched in New York City (NYC), Washington, DC (DC), Miami/Dade County (MDC), and Arizona (AZ). During 2000–2008, 4.6% (9471/205,689) of reported GCs occurred among persons with previously diagnosed HIV: NYC (5.5%), DC (7.3%), MDC (4%), and AZ (2%). The overall HIV-GC coinfection rates increased over the study period in all 4 sites. Real-time data integration could allow for enhanced prevention among persons with HIV infection and acute STDs.

Public health interventions to control syphilis

Background:Incident syphilis among HIV-infected persons indicates the ongoing behavioral risk for HIV transmission. Detectable viral loads (VLs) among coinfected cases may amplify this risk. Methods:Primary and secondary cases reported during 2009–2010 from 4 US sites were crossmatched with local HIV surveillance registries to identify syphilis case-persons infected with HIV before or shortly after the syphilis diagnosis. We examined HIV VL and CD4 results collected within 6 months before or after syphilis diagnosis for the coinfected cases identified. Independent correlates of detectable VLs (≥200 copies/mL) were determined. Results:We identified 1675 cases of incident primary or secondary syphilis among persons with HIV. Median age was 37 years; 99.5% were men, 41.1% were African American, 24.5% were Hispanics, and 79.9% of the HIV diagnoses were made at least 1 year before syphilis diagnosis. Among those coinfected, there were no VL results reported for 188 (11.2%); of the 1487 (88.8%) with reported VL results, 809 (54.4%) had a detectable VL (median, 25,101 copies/mL; range, 206–3,590,000 copies/mL). Detectable VLs independently correlated with syphilis diagnosed at younger age, at an sexually transmitted disease clinic, and closer in time to HIV diagnosis. Conclusions:More than half of syphilis case-persons identified with HIV had a detectable VL collected within 6 months of the syphilis diagnosis. This suggests virologic and active behavioral risk for transmitting HIV.

Reactor Grids for Prioritizing Syphilis Investigations: Are Primary Syphilis Cases Being Missed?

Background In the District of Columbia (DC), Neisseria gonorrhoeae (gonorrhea) infections accounted for more than 25% of 9321 incident sexually transmitted infections reported in 2011; untreated infections can lead to reproductive complications and a higher risk for HIV transmission. In DC, limited capacity to measure the prevalence of antibiotic-resistant N. gonorrhoeae is available; culture-based antibiotic susceptibility testing (AST) is needed to monitor antimicrobial resistance. We examined the capacity of laboratories that report to the DC Department of Health to perform AST for ongoing surveillance of antibiotic-resistant N. gonorrhoeae and to identify suspected treatment failures. Methods We created a survey about diagnostic methods for gonorrhea testing and identified 33 laboratories that reported gonorrhea results to Department of Health in 2007 to 2012. Laboratories were assessed for use of bacterial culture or nucleic acid amplification testing (NAAT) for gonorrhea testing, prevalence of AST on gonorrhea-positive cultures, and types of antibiotics tested during AST. We estimated the prevalence of laboratory practices on the basis of self-report by staff. Results Nineteen (58%) laboratories completed the survey, representing 92% of the gonorrhea reporting. Seventeen (89%) of 19 laboratories conducted testing by culture; only 6 (35%) performed AST; 79% performed NAAT. Barriers to AST included longer completion times and limited number of provider requests for AST. Commercial laboratories (32%) were more likely to conduct both culture and NAAT, compared with health care facilities (11%). Conclusions We report a low prevalence of laboratories performing AST because of multiple barriers. State-specific strategies addressing these barriers are needed to improve detection of antibiotic-resistant gonorrhea stains circulating among the population.