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Lessons from the syphilis outbreak in homosexual men in east London
  1. M Hourihan,
  2. H Wheeler,
  3. R Houghton,
  4. B T Goh
  1. Ambrose King Centre, Barts and the London NHS Trust, Whitechapel, London E1 1BB, UK
  1. Correspondence to:
 M Hourihan
 Ambrose King Centre, Barts and the London NHS Trust, Whitechapel, London E1 1BB, UK;


Objectives: To describe the epidemiology, presentation, and diagnosis of early syphilis in 103 homosexual men in east London.

Methods: A retrospective study using data from KC60 returns, the Health Protection Agency (HPA) enhanced surveillance forms and case notes.

Results: 40 cases of primary (PS), 40 of secondary (SS) and 23 of early latent syphilis were identified, 33% co-infected with HIV. 41% had concurrent sexually transmitted infections (STIs). Pain featured in 35% of PS and itch in 13% of rashes. Dark ground microscopy (DGM), performed in 44 of the symptomatic cases, was positive in 37 (84%) allowing early management. Initial syphilis serology was negative in 15/40 (37%) cases of PS. 51% and 49% opted for parenteral and oral treatment, respectively. In 53/103 (51%) cases oral sex was the only risk factor. 86% of infections were UK acquired. Only 4% of contacts were seen.

Conclusion: This outbreak, reflecting the resurgence of syphilis across the United Kingdom, highlights several important points. Painful chancres and itchy rash are common presentations. DGM is a highly sensitive diagnostic tool. Initial negative serological screening tests are common in PS and sero-surveillance for 3 months is recommended. The high prevalence of concomitant STIs indicates ongoing unprotected sexual intercourse. Oral sex is a significant risk factor and is a distinctly “unsafe” practice. Conventional partner notification is ineffective. Other methods of screening of the at-risk homosexual population are warranted. Continued education is required to reduce STI acquisition in homosexual men.

  • DGM, dark ground microscopy
  • GUD, genital ulcerative disease
  • HPA, Health Protection Agency, PS, primary syphilis
  • pVL, plasma HIV-RNA viral load
  • SS, secondary syphilis
  • STI, sexually transmitted infections
  • UPAI, unprotected anal intercourse
  • UPOI, unprotected oral intercourse
  • syphilis
  • homosexual men
  • HIV
  • oral sex

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  • Funding: Nil.

  • Conflict of interest: None.