Screening for syphilis


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Screening for syphilis as part of HIV monitoring increases detection of early, asymptomatic syphilis among HIV positive homosexual men. Presentation given by Marcus Chen at the AFAO National Syphilis Forum, 23 October 2009.

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Screening for syphilis

  1. 1. Screening for syphilis as part of HIV monitoring increases detection of early, asymptomatic syphilis among HIV positive homosexual men Bissessor M 1 , Fairley CK 1,2 , Leslie D 3 , Boyd K 1 , Chen MY 1,2 1. Melbourne Sexual Health Centre 2. The University of Melbourne, School of Population Health 3. Victorian Infectious Diseases Reference Laboratory
  2. 2. The intervention <ul><li>Change from annual syphilis screening of HIV positive MSM to routine syphilis serology with every blood sample for HIV monitoring (3 monthly) </li></ul><ul><li>Pre-formatted pathology request form </li></ul><ul><li>Advised patients about syphilis epidemic and routine screening </li></ul>
  3. 4. Aims <ul><li>Did the intervention increase the detection of early, asymptomatic syphilis compared with annual screening? </li></ul><ul><li>Did in reduce the likely duration of infectiousness? </li></ul>
  4. 5. Methods <ul><li>Comparison of 18 month periods: </li></ul><ul><ul><li>Pre-intervention: July 2005-December 2006 </li></ul></ul><ul><ul><li>Post-intervention: January 2007-June 2008 </li></ul></ul><ul><li>Proportion of HIV positive MSM with early, syphilis who were asymptomatic </li></ul><ul><li>Assumed infection occurred midway between the time of last negative serology and time of diagnosis (or from last baseline serology if previously infected) </li></ul>
  5. 6. Diagnosis of early syphilis <ul><li>Clinical features of primary or secondary syphilis with reactive serology or PCR or </li></ul><ul><li>Reactive syphilis serology within 12 months of previous negative serology or </li></ul><ul><li>4-fold rise in RPR titre within 12 months of baseline serology if previously infected </li></ul><ul><li>Late infections and those of uncertain duration excluded </li></ul>
  6. 8. 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
  7. 10. 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
  8. 11. Estimated Duration of infectivity Before After Days (range) 107 (9-362) 45 (23-325) p=0.018
  9. 12. It’s the frequency that counts <ul><li>Branger et al. (2008) </li></ul><ul><ul><li>HIV infected people attending Amsterdam clinic </li></ul></ul><ul><ul><li>2 syphilis tests 6 months apart </li></ul></ul><ul><ul><li>25-33% of syphilis asymptomatic </li></ul></ul><ul><li>Winston et al. (2005) </li></ul><ul><ul><li>HIV infected MSM attending London clinic </li></ul></ul><ul><ul><li>Syphilis screening as part of HIV care </li></ul></ul><ul><ul><li>2.5 syphilis tests per man per year </li></ul></ul><ul><ul><li>50-56% of syphilis asymptomatic </li></ul></ul><ul><li>This study </li></ul><ul><ul><li>3.3 syphilis tests per man per year </li></ul></ul><ul><ul><li>85% of syphilis asymptomatic </li></ul></ul>
  10. 13. Conclusion <ul><li>Simple and cheap intervention </li></ul><ul><li>Obviates need for sexual history </li></ul><ul><li>No complaints received </li></ul><ul><li>Pool of asymptomatic infection </li></ul><ul><li>Potential for impact on control: modeling </li></ul>
  11. 14. Acknowledgements <ul><li>Melanie Bissessor </li></ul><ul><li>Administration, nurse and IT staff at MSHC </li></ul><ul><li>Victorian Infectious Diseases Laboratory </li></ul>
  12. 15. Syphilis screening of HIV negative MSM <ul><li>How can we increase syphilis testing in HIV negative MSM? </li></ul><ul><li>Strategies implemented at the Melbourne Sexual Health Centre: </li></ul><ul><ul><li>Computer assisted self interview (CASI) </li></ul></ul><ul><ul><li>SMS/email reminders </li></ul></ul><ul><ul><li>Clinical decision support system </li></ul></ul>
  13. 16. Computer assisted self interview (CASI)
  14. 17. CASI sexual history
  15. 18. SMS reminders for STI checks
  16. 19. SMS reminders for STI checks <ul><li>SMS </li></ul><ul><li>=== </li></ul><ul><li>Your next check-up is now due. Ph 9341 6200 for appt or walk in. </li></ul><ul><li>To stop reminder, reply 'stop'. To change frequency, reply 'chg freq to' 3,6,9 mths </li></ul><ul><li>EMAIL </li></ul><ul><li>===== </li></ul><ul><li>Hi <Name> </li></ul><ul><li>Your next check-up is now due. Please phone 9341 6200 for an </li></ul><ul><li>appointment or just walk in to our clinic. </li></ul><ul><li>From Check-Up Reminder Service </li></ul><ul><li>To stop the reminder service, reply with 'stop'. To change </li></ul><ul><li>the frequency, reply with 'change frequency to' and then </li></ul><ul><li>indicate 3, 6 or 9 months. </li></ul>
  17. 20. Syphilis screening alert