Screening for syphilis as part of HIV monitoring increases detection of early,

asymptomatic syphilis among HIV positive homosexual men

Bissessor M1, Fairley CK1,2, Leslie D3, Boyd K1, Chen MY1,2

1. Melbourne Sexual Health Centre2. The University of Melbourne, School of Population Health

3. Victorian Infectious Diseases Reference Laboratory

The intervention

Change from annual syphilis screening of HIV positive MSM to routine syphilis serology with every blood sample for HIV monitoring (3 monthly)

Pre-formatted pathology request form

Advised patients about syphilis epidemic and routine screening

Aims

Did the intervention increase the detection of early, asymptomatic syphilis compared with annual screening?

Did in reduce the likely duration of infectiousness?

Methods

Comparison of 18 month periods:Pre-intervention: July 2005-December 2006 Post-intervention: January 2007-June 2008

Proportion of HIV positive MSM with early, syphilis who were asymptomatic

Assumed infection occurred midway between the time of last negative serology and time of diagnosis (or from last baseline serology if previously infected)

Diagnosis of early syphilis

Clinical features of primary or secondary syphilis with reactive serology or PCR or

Reactive syphilis serology within 12 months of previous negative serology or

4-fold rise in RPR titre within 12 months of baseline serology if previously infected

Late infections and those of uncertain duration excluded

Frequency of syphilis testing

No. HIV+ MSM Total no. syphilis

tests Mean no. syphilis tests/man/year

Before 444 862 2.0

After 587 1952 3.3

Proportion with early, asymptomatic syphilis

Before After Difference in proportion (95%CI)

% MSM with early syphilis

3.1%

(14/444)

8.1%

(48/587)

5%

(2% to 7%)

(p=0.001)

% early syphilis asymptomatic

21%

(3/14)

85%

(41/48)

64%

(31%- 81%)

p=0.006

Estimated Duration of infectivity

Before After

Days

(range)

107

(9-362)

45

(23-325)p=0.018

It’s the frequency that counts

Branger et al. (2008)HIV infected people attending Amsterdam clinic2 syphilis tests 6 months apart25-33% of syphilis asymptomatic

Winston et al. (2005)HIV infected MSM attending London clinicSyphilis screening as part of HIV care2.5 syphilis tests per man per year 50-56% of syphilis asymptomatic

This study 3.3 syphilis tests per man per year 85% of syphilis asymptomatic

Conclusion

Simple and cheap intervention

Obviates need for sexual history

No complaints received

Pool of asymptomatic infection

Potential for impact on control: modeling

Acknowledgements

Melanie Bissessor

Administration, nurse and IT staff at MSHC

Victorian Infectious Diseases Laboratory

Syphilis screening of HIV negative MSM

• How can we increase syphilis testing in HIV negative MSM?

• Strategies implemented at the Melbourne Sexual Health Centre:

– Computer assisted self interview (CASI)

– SMS/email reminders– Clinical decision support system

Computer assisted self interview (CASI)

CASI sexual history

SMS reminders for STI checks

SMS reminders for STI checks

SMS===

Your next check-up is now due. Ph 9341 6200 for appt or walk in.To stop reminder, reply 'stop'. To change frequency, reply 'chg freq to' 3,6,9 mths

EMAIL=====Hi <Name>Your next check-up is now due. Please phone 9341 6200 for anappointment or just walk in to our clinic.From Check-Up Reminder ServiceTo stop the reminder service, reply with 'stop'. To change the frequency, reply with 'change frequency to' and then indicate 3, 6 or 9 months.

Syphilis screening alert