HIV

High rates of syphilis among STI patients are contributing to the spread of HIV-1 in India

S J Reynolds^1,2, A R Risbud³, M E Shepherd¹, A M Rompalo¹, M V Ghate³, S V Godbole³, S N Joshi³, A D Divekar³, R R Gangakhedkar³, R C Bollinger¹ and S M Mehendale³

¹ Johns Hopkins University, Baltimore, MD, USA
² National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
³ National AIDS Research Institute, Pune, India

Correspondence to:
Correspondence to:
Steven J Reynolds
c/o American Embassy Kampala, PO Box 7007, Kampala, Uganda; sjr{at}jhmi.edu

Background: Recent syphilis outbreaks have raised concern regarding the potential enhancement of HIV transmission. The incidence of syphilis and its association with HIV-1 infection rates among a cohort of sexually transmitted infection (STI) clinic attendees was investigated.

Methods: 2732 HIV-1 seronegative patients attending three STI and one gynaecology clinic, were enrolled from 1993–2000 in an ongoing prospective cohort study of acute HIV-1 infection in Pune, India. At screening and quarterly follow up visits, participants underwent HIV-1 risk reduction counselling, risk behaviour assessment and HIV/STI screening that included testing for serological evidence of syphilis by RPR with TPHA confirmation. Patients with genital ulcers were screened with dark field microscopy.

Results: Among 2324 participants who were HIV-1 and RPR seronegative at baseline, 172 participants were found to have clinical or laboratory evidence of syphilis during follow up (5.4 per 100 person years, 95% CI 4.8 to 6.5 per 100 person years). Independent predictors of syphilis acquisition based on a Cox proportional hazards model included age less than 20 years, lack of formal education, earlier calendar year of follow up, and recent HIV-1 infection. Based on a median follow up time of 11 months, the incidence of HIV-1 was 5.8 per 100 person years (95% CI 5.0 to 6.6 per 100 person years). Using a Cox proportional hazards model to adjust for known HIV risk factors, the adjusted hazard ratio of HIV-1 infection associated with incident syphilis was 4.44 (95% CI 2.96 to 6.65; p<0.001).

Conclusions: A high incidence rate of syphilis was observed among STI clinic attendees. The elevated risk of HIV-1 infection that was observed among participants with incident syphilis supports the hypothesis that syphilis enhances the sexual transmission of HIV-1 and highlights the importance of early diagnosis and treatment of syphilis.

Abbreviations: ELISA, enzyme linked immunosorbent assay; GUD, genital ulcer disease; MSM, men who have sex with men; RPR, rapid plasma reagin; STI, sexually transmitted infections; TPHA, Treponema pallidum hemaglutination assay

Keywords: sexually transmitted infections; HIV; genital ulcer disease; syphilis

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