Syphilis in HIV Positive and HIV Negative Individuals

1
Syphilis in HIV Positive and HIV Negative
Individuals

• Dr Patrick French
• Mortimer Market Centre

2
Syphilis in HIV Positive and Negative Individuals

• Introduction
• Why is the HIV/Syphilis interaction important?
• Epidemiology of HIV/Syphilis
• What is the natural history of syphilis in HIV
  positive individuals? ( serology and Rx response)

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Why is the HIV/Syphilis interaction important?-
Syphilis in the UK
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HIV/Syphilis Co-infection in the UK1997-2002

• MSM HIV ve
• Manchester 126/354 33
• Brighton 71/172 41
• London 389/829 47

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Syphilis in the UK Age/Gender

• Women/Early Syphilis
• 1995 32
• 2004 266
• 2005 405 (45 London)

6
Future Epidemiology? Syphilis/HIVLongitudinal
StudiesSyphilis and HIV Susceptibility(Rottingen
et al STDs 2001 579)
Rottingen et al. STD 200128579-597.
7
Crack Cocaine/Syphilis/HIV-Bahamas 1980s(Gomez
MP et al. STDs 2002 5)
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Bahamas Syphilis Incidence/HIV Prevalence
1982-1999

• HIV/Syphilis (HPA surveillance data)

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Differences between HIV positive/HIV negative
individuals with syphilis?

• Biological plausibility Cell mediated immunity
  probably important in immunological control of
  syphilis
• Case reports in the 1980s
• Seronegative syphilis(Hicks CB et al Ann Int Med
  1987 492)
• Atypical syphilis (Radolf JD et al J Am Ac Derm
  1988 423)
• Rapid progression (John DR et al NEJM 1987 1569)

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Evidence for the differences between HIV positive
and HIV negative syphilis co-infection
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The Syphilis and HIV Study (Rampalo AM et al
STDs 2001 158)

• Prospective
• Early Syphilis
• Multicentre (U.S.)
• 1991-1994
• 101 HIV Positive
• 440 HIV Negative
• ( Rampalo et al STDs 2001 228)

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Early Syphilis differences 1

• Large overlap between HIV positive / negative
• But If HIV positive
• ulcers more likely to be
• Larger
• Multiple
• Painful

• Pictures removed

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Early syphilis differences 2

• Genital Ulceration more likely as manifestation
  of 2 syphilis if HIV positive

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What about serologic diagnosis? Is it reliable?

• (EIA as screening test not assessed)
• But RPR/VDRL if HIV
• 1 tendency for lower titres
• 2 higher titres

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Late syphilis

• Case Reports
• ? More rapid progression to neurosyphilis
• ? Syphilitic uveitis (Zambrano W et al J Clin
  Ophthal 1987 1)
• ? Gummata (Hay PE et al Gen Med 1990 374)
• ?Higher risk of neurosyphilis if HIV positive
  (but LPs for individuals with early syphilis)
• (Marra CM et al CID 2004 189)
• No well conducted comparative studies

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Treatment in HIV positive and HIV negative
individuals for syphilis

• Rolfs RT et al NEJM 1997 307
• Goeman J et al Gen Med 1995 275
• Riedner G et al NEJM 2005 1236
• Probably response HIV pos HIV neg
• But possible increased risk of neurosyphilis if
  HIV report of Benzathine failure if HIV

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Summary

• Syphilis is an important co-factor in the
  transmission of HIV.
• HIV positive individuals should have regular
  screening for syphilis and all individuals for
  syphilis should have HIV testing.
• The natural history, serological response, and
  treatment response of syphilis in HIV individuals
  is similar to that in HIV negative individuals