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In their commentary on the resurgence of syphilis in England, Fenton et al1 cover issues surrounding controlling outbreaks of syphilis, quoting parallels in the United States, and identify the need for simple treatment, preferably with a single dose regimen. Two important differences between the two countries in management strategy that could be relevant to the current UK situation are, however, not discussed. Firstly, variation in penicillin treatment regimen: in the United States single dose benzathine penicillin is recommended for primary, secondary, and early latent syphilis,2 whereas in the United Kingdom, 10 days of procaine penicillin is the preferred regimen except when compliance is likely to be a problem.3 Secondly, epidemiological treatment of sexual contacts is a policy pursued actively in the United States but not in the United Kingdom.4
These differences have evolved as responses to the epidemiological patterns of syphilis in the two countries. In the United States outbreaks of syphilis are well recognised whereas in the United Kingdom they are a relatively new phenomenon. Given the success in managing outbreaks in the United States it might be relevant to review proved aspects of syphilis management using single dose benzathine penicillin, as in the United States, that could be applied in the United Kingdom. Adopting this treatment regimen would also open the way for other effective treatment strategies such as selective mass treatment and epidemiological therapy in high prevalence populations. The issue of compliance with protracted regimens of procaine penicillin, a problem that takes up considerable time of genitourinary medicine clinic staff, would also be solved. Although concerns about using a single dose of benzathine penicillin in HIV positive subjects with advanced immunosuppression have been raised, possible treatment failures are still at the case report stage. Furthermore, there are no documented treatment failures in Africa where the prevalence of syphilis and HIV is the highest. World Health Organization currently recommends that HIV infected patients with early syphilis are treated no differently from non-HIV infected patients and recommends single dose therapy.5
In trying to identify new interventions to improve STI control for limiting the spread HIV, the basic principles of STI control are, if anything, more relevant today compared with the past. Although the issues and arguments raised here have been discussed in depth previously,6 they bear repeating in the light of the recent increase in syphilis in the United Kingdom.
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