Syphilis in Australia: 2004-2009 Basil Donovan National Centre in HIV Epidemiology and Clinical Research; and Sydney Sexua...
Today 1. Global context 2. Australian trends in infectious syphilis 3. Enhanced surveillance for syphilis 4. Effects of sy...
Fabricius 1994: 25 Conrad Reitter , Prior of a Cistercian monastry,1508: Woodcut illustrating his ode:  ‘Mortilogus’  (‘ou...
Global epidemiology syphilis <ul><li>Global incidence >12m (WHO) </li></ul><ul><li>Mainly affects developing nations (up t...
Infectious syphilis notifications, by sex, USA 1981-2005 MSM proportion 1999 - 15% 2004 – 64%
Infectious syphilis notifications,  UK 1998-2007
Infectious syphilis in MSM in London, 2001-2008, by HIV status
 
Australian infectious* syphilis notifications   Source: National Notifiable Diseases Surveillance System *primary, seconda...
Australian infectious syphilis notifications, by year and sex Source: National Notifiable Diseases Surveillance System Per...
Relative risk of STIs for MSM in Australia Guy R, unpublished
Infectious syphilis notifications in Australian men, by state Source: National Notifiable Diseases Surveillance System Per...
Infectious syphilis notifications in  non-Indigenous urban men, by state Source: National Notifiable Diseases Surveillance...
Infectious syphilis notifications in urban MSM in WA, by quarter Source: National Notifiable Diseases Surveillance System
Infectious syphilis notifications in Australian men,  by age group Source: National Notifiable Diseases Surveillance Syste...
Median age at diagnosis for infectious syphilis, gonorrhoea and HIV infection in Australia Source: National Notifiable Dis...
Routine and enhanced surveillance <ul><li>Routine surveillance </li></ul><ul><li>Name, or code </li></ul><ul><li>Jurisdict...
Enhanced surveillance (1) Source: State / Territory Health Authorites * Jan – Sept 2008 only ** total notifications Charac...
Enhanced surveillance (2) Source: State / Territory Health Authorites * Jan – Sept 2008 only Characteristic VIC QLD WA SA ...
Sentinel surveillance, Victoria (1) <ul><li>Victorian Primary Care Network for sentinel surveillance of BBVs and STIs </li...
<ul><li>5,153 men completed questionnaires </li></ul><ul><li>106 men tested positive for infectious syphilis </li></ul><ul...
Risk factors for infectious syphilis  *Jin F et al.  MJA  2005 Study MSM Sex @ venues Internet UAI Oral Sex HIV+ Other STi...
Syphilis incidence in two MSM cohorts  in Sydney After adjusting for age, HR if HIV+ 9.20 (95% CI 3.63-23.31) UAI with HIV...
Effect of syphilis on HIV Changes greater with secondary syphilis or CD4 >500 Study (place) N= VL log CD4 Response Buchacz...
Effect of syphilis on HIV <ul><li>Consider syphilis if   VL or   CD4 in a stable patient.  Make syphilis serology routin...
Acknowledgements <ul><li>State and Territory Surveillance coordinators </li></ul><ul><ul><li>Kate Ward, Nasra Higgins, Cra...
The end ‘ Clinton lied.  A man might forget where he parks or where he lives, but he never forgets oral sex, no matter how...
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Basil Donovan: Syphilis epidemiology surveillance And HIV interactions

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Basil Donovan from NCHECR addresses the global context; Australian trends in infectious syphilis; enhanced surveillance for syphilis; and the effects of syphilis on HIV infection, at AFAO's syphilis forum in May 2009.

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Basil Donovan: Syphilis epidemiology surveillance And HIV interactions

  1. 1. Syphilis in Australia: 2004-2009 Basil Donovan National Centre in HIV Epidemiology and Clinical Research; and Sydney Sexual Health Centre, Sydney Hospital Thanks particularly to: Melanie Middleton Rebecca Guy
  2. 2. Today 1. Global context 2. Australian trends in infectious syphilis 3. Enhanced surveillance for syphilis 4. Effects of syphilis on HIV infection
  3. 3. Fabricius 1994: 25 Conrad Reitter , Prior of a Cistercian monastry,1508: Woodcut illustrating his ode: ‘Mortilogus’ (‘our most gracious mistress Mary to preserve us from the French Disease’)
  4. 4. Global epidemiology syphilis <ul><li>Global incidence >12m (WHO) </li></ul><ul><li>Mainly affects developing nations (up to 10%) </li></ul><ul><li>Kills 1 million babies every year, 64 years after a single-dose cure (penicillin) </li></ul><ul><li>Endemic among Indigenous and ethnic minorities in wealthier nations </li></ul><ul><li>Resurgence among MSM in many western cities </li></ul>
  5. 5. Infectious syphilis notifications, by sex, USA 1981-2005 MSM proportion 1999 - 15% 2004 – 64%
  6. 6. Infectious syphilis notifications, UK 1998-2007
  7. 7. Infectious syphilis in MSM in London, 2001-2008, by HIV status
  8. 9. Australian infectious* syphilis notifications Source: National Notifiable Diseases Surveillance System *primary, secondary, latent <2 years from infection Number by quarter
  9. 10. Australian infectious syphilis notifications, by year and sex Source: National Notifiable Diseases Surveillance System Per 100,000
  10. 11. Relative risk of STIs for MSM in Australia Guy R, unpublished
  11. 12. Infectious syphilis notifications in Australian men, by state Source: National Notifiable Diseases Surveillance System Per 100,000
  12. 13. Infectious syphilis notifications in non-Indigenous urban men, by state Source: National Notifiable Diseases Surveillance System Per 100,000
  13. 14. Infectious syphilis notifications in urban MSM in WA, by quarter Source: National Notifiable Diseases Surveillance System
  14. 15. Infectious syphilis notifications in Australian men, by age group Source: National Notifiable Diseases Surveillance System Per 100,000
  15. 16. Median age at diagnosis for infectious syphilis, gonorrhoea and HIV infection in Australia Source: National Notifiable Diseases Surveillance System years
  16. 17. Routine and enhanced surveillance <ul><li>Routine surveillance </li></ul><ul><li>Name, or code </li></ul><ul><li>Jurisdiction, and postcode </li></ul><ul><li>Sex </li></ul><ul><li>Age </li></ul><ul><li>Stage (<2yrs or older/unknown, congenital) </li></ul><ul><li>Indigenous status </li></ul><ul><li>Enhanced surveillance </li></ul><ul><li>Routine, plus: </li></ul><ul><li>Health service type </li></ul><ul><li>Reasons for test </li></ul><ul><li>Symptoms, or not </li></ul><ul><li>Sex of partners </li></ul><ul><li>Transmission mode </li></ul><ul><li>HIV status </li></ul><ul><li>Acquired abroad? </li></ul>
  17. 18. Enhanced surveillance (1) Source: State / Territory Health Authorites * Jan – Sept 2008 only ** total notifications Characteristic VIC QLD WA SA Year 2008* 2008 2007 2008 Median age** 36 37 44 39 % total notifications 100 (n = 293) 52 (n = 96) 49 (n = 49) 100 (n = 50) Reason for test Symptomatic Screening Other / unknown 42% 47% 11% - 65% 22% 13% - Place of diagnosis STI Clinic GP Other / unknown - 33% 0% 66% 55% 24% 21% 42% 22% 36%
  18. 19. Enhanced surveillance (2) Source: State / Territory Health Authorites * Jan – Sept 2008 only Characteristic VIC QLD WA SA Year 2008* 2008 2007 2008 % male homosexual contact 80 82 76 64 Type of partner Casual Regular Other / unknown 68% 11% 21% - 57% 41% 2% - Mode of transmission (MSM) Oral and anal sex Oral sex Other / unknown - - 50% 37% 13% -
  19. 20. Sentinel surveillance, Victoria (1) <ul><li>Victorian Primary Care Network for sentinel surveillance of BBVs and STIs </li></ul><ul><ul><li>5 sites with high case loads of MSM </li></ul></ul><ul><ul><li>data collected March 2006 - July 2007 </li></ul></ul><ul><ul><li>self-completed questionnaires </li></ul></ul>Victorian Infectious Diseases Bulletin, 2008
  20. 21. <ul><li>5,153 men completed questionnaires </li></ul><ul><li>106 men tested positive for infectious syphilis </li></ul><ul><li>overall prevalence was 2.1% </li></ul><ul><ul><li>increased from 1.6%, Apr-Dec 2006, to 2.7%, Jan-Jul 2007 </li></ul></ul><ul><li>prevalence highest in: </li></ul><ul><ul><li>those over 40 </li></ul></ul><ul><ul><li>HIV positive men, 7.1% in Jan-July 2007 </li></ul></ul>Sentinel surveillance, Victoria (2) Victorian Infectious Diseases Bulletin, 2008
  21. 22. Risk factors for infectious syphilis *Jin F et al. MJA 2005 Study MSM Sex @ venues Internet UAI Oral Sex HIV+ Other STis Alcohol & Drug Use Other Taylor 2004 LA × × × × × × Peterman 2005 US × × × × × × × Viagra Income <30000 Klausner 2005 SF × × × × Anon sex. Viagra Righarts 2004 UK × × × × × Hetero contact with sex workers Jin 2005* Sydney × × × × × No. of partners
  22. 23. Syphilis incidence in two MSM cohorts in Sydney After adjusting for age, HR if HIV+ 9.20 (95% CI 3.63-23.31) UAI with HIV+ partner, HR 4.45 in HIM and 8.67 in pH Jin F et al, ASHM 2009 (submitted) HIM (HIV neg) pH (HIV pos) Incidence/100 person years 0.49 3.62 95% confidence interval 0.31-0.74 1.67-6.48
  23. 24. Effect of syphilis on HIV Changes greater with secondary syphilis or CD4 >500 Study (place) N= VL log CD4 Response Buchacz K et al. AIDS 2004 (SF/LA) 52 (58% HAART)  0.22  62 RPR not rep’d. VL recovery slow. Kofoed K et al STD 2006 (Copenhagen) 37 (83% HAART)  0.04  106 Pen = doxy. VL/CD4 better with doxy.
  24. 25. Effect of syphilis on HIV <ul><li>Consider syphilis if  VL or  CD4 in a stable patient. Make syphilis serology routine. </li></ul><ul><li>Interpret VL and CD4 with caution in syphilis </li></ul><ul><li>Neurosyphilis more likely in HIV if CD4<350 and RPR > 32 </li></ul><ul><li>Probably add to HIV infectivity and susceptibility </li></ul><ul><li>No new clinical syndromes </li></ul><ul><li>Long-term consequences? </li></ul>
  25. 26. Acknowledgements <ul><li>State and Territory Surveillance coordinators </li></ul><ul><ul><li>Kate Ward, Nasra Higgins, Craig Davis, Tess Davey, Caroline Giele, Riemke Kampen and Jiunn-yih Su </li></ul></ul><ul><li>Surveillance Systems and Policy Section, Australian Government Department of Health and Ageing </li></ul><ul><ul><li>Kate Robinson and Stefan Stirzaker </li></ul></ul><ul><li>NCHECR is funded by Australian Government Department of Health and Ageing and is affiliated with the faculty of Medicine, UNSW </li></ul>
  26. 27. The end ‘ Clinton lied. A man might forget where he parks or where he lives, but he never forgets oral sex, no matter how bad it is’ Barbara Bush

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