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The effectiveness of treatment for syphilis is evaluated by demonstrating declining titres of the non-treponemal antibody tests—for example, the rapid plasma reagin (RPR). The serological response in HIV co-infected individuals has been the subject of debate, with some studies reporting a similar serological response1,2 and others a delayed response in HIV positive patients.3,4
A resurgence of infectious syphilis has occurred in Manchester, United Kingdom, in recent years.5 From January 1999 to August 2002, 379 cases of early syphilis were reported and 28% were HIV co-infected (CDSC North West, personal communication). North Manchester General Hospital (NMGH) houses one of the city’s three genitourinary medicine clinics and the regional infectious diseases unit, providing care for approximately 1000 HIV positive individuals. Our aim was to evaluate the serological response to treatment for early syphilis in HIV positive and negative individuals treated at NMGH.
Between January 1999 and March 2002, 75 men (72 homosexual) and three women were diagnosed with early syphilis. Of the 78, 40/75 men were HIV positive. The RPR results 3, 6, and 12 months following treatment for early syphilis were collected by retrospective case note review. Exclusion criteria were syphilis re-infection during the study period (two patients), HIV status undetermined (six patients declined HIV testing), or lost to follow up (16 patients). Patients were divided into two groups—HIV positive and HIV negative individuals. From the sequential RPR results 3, 6, and 12 months following treatment the mean reduction in RPR titres in each group at these points was calculated, and statistical comparison made between the two groups using the Student’s t test.
The results are shown in table 1.
We found no significant difference in the reduction of RPR titres in the year following treatment between the HIV positive and negative groups.
Of the 31 HIV positive individuals in this study, 17 were taking highly active antiretroviral therapy at the time their syphilis was diagnosed. The average CD4 lymphocyte count in this group was 460×106/l (range 33–1000) and viral load 83 515 copies/ml (range <50–442 000).
Limitations of the study are that it was retrospective, patients in the HIV positive and negative groups were not matched individually for variables such as stage of syphilis or initial RPR titre, and the treatment regimens varied (all received at least 10 days intramuscular procaine penicillin or 14 days oral doxycycline, and HIV positive patients prolonged courses of treatment in accordance with the UK national guidelines for the treatment of early syphilis6). No account was taken of the patient’s CD4 lymphocyte count, or whether they were receiving antiretroviral therapy. However, the cohort represents a diverse group of HIV positive individuals and we consider them representative of those generally encountered in clinical practice.
We demonstrated that in clinical practice the RPR remains a valid way of assessing the response to treatment of syphilis in those co-infected with HIV. Larger prospective studies, with cases and controls matched for variables such as the stage of syphilis at diagnosis, the initial RPR titre, and treatment regimens are required.