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Research letter
UK Sexual health clinics may be missing atypical syphilis
  1. Bethany Harrison1,
  2. Rajul Patel2,3,
  3. Emily Clarke4
  4. on behalf of BASHH Herpes Special Interest Group
  1. 1 School of Medicine, University of Liverpool, Liverpool, UK
  2. 2 Department of Sexual Health, Solent NHS Trust, Southampton, UK
  3. 3 Faculty of Medicine, University of Southampton, Southampton, UK
  4. 4 Department of Sexual Health, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
  1. Correspondence to Dr Emily Clarke, Department of Sexual Health, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool L7 8XP, UK; emilyrclarke{at}

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The ‘atypical’ presentation of primary syphilis with multiple tender chancres has long been recognised.1 The significant increase in the prevalence of early infectious syphilis in England, especially in men who have sex with men, has resulted in the development of a national action plan.2 The aim of this UK-wide service evaluation was to determine whether clinics undertaking herpes simplex virus (HSV) swabs also have access to syphilis PCR testing on these swabs, which may reduce missed primary syphilis.

A paper questionnaire (and stamped addressed envelope) was sent to the lead clinician of every UK sexual health clinic listed on the BASHH website as of April 2019, of which 98 of 270 (36.3%) questionnaires were returned. Of these clinics, 94.9% (93/98) had access to type-specific HSV PCR swabs. When performing an HSV PCR swab for a patient with a clinical diagnosis of first-episode genital HSV, 16.7% (16/96) of clinics’ laboratories automatically test this genital ulcer swab for syphilis by PCR. In all clinics undertaking automatic testing for syphilis PCR, this was performed on all patients with no triage by patient group. Of the clinics, 86.7% (86/98) were able to specifically request syphilis PCR from ulcer swabs, of which 41.9% (36/86) were tested locally and 58.1% (50/86) at a reference laboratory.

While the majority of UK sexual health clinics have access to syphilis PCR testing on request, few clinics undertake a routine ‘genital ulcer swab’ testing automatically for both HSV and syphilis from genital ulcers. Patients who test negative for HSV from a genital ulcer may not return for repeat syphilis serology after the window period, and therefore primary syphilis may be missed. We recommend that clinics consider the introduction of routine syphilis PCR on their ulcer swabs to reduce this, given the rising prevalence of infectious syphilis in the UK.



  • Contributors Service evaluation design: BH, RP, EC. Data collection: BH. Data analysis: BH, EC. Letter writing: EC.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; internally peer reviewed.