Review
Syphilis and HIV: a dangerous combination

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Summary

HIV and syphilis affect similar patient groups and coinfection is common. All patients presenting with syphilis should be offered HIV testing and all HIV-positive patients should be regularly screened for syphilis. Syphilis agent may enhance the transmission of the other, probably through increased incidence of genital ulcers. Detection and treatment of syphilis can, therefore, help to reduce HIV transmission. Syphilis may present with non-typical features in the HIV-positive patient: there is a higher rate of symptomless primary syphilis and proportionately more HIV-positive patients present with secondary disease. Secondary infection may be more aggressive and there is an increased rate of early neurological and ophthalmic involvement. Diagnosis is generally made with serology but the clinician should be aware of the potential for false-negative serology in both primary and, less commonly, in secondary syphilis. All HIV-positive patients should be treated with a penicillinbased regimen that is adequate for the treatment of neurosyphilis. Relapse of infection is more likely in the HIV-positive patient and careful follow-up is required.

Section snippets

Epidemiology

WHO estimates that approximately 349 million people are actively infected with a treatable sexually transmitted disease.6 Of these, estimates from 1999 suggest an annual rate for syphilis of approximately 12 million active infections6 Almost two-thirds of these cases are in sub-Saharan Africa and south/southeast Asia. Recent outbreaks have been reported from many countries on all continents.7, 8, 9, 10 In sub-Saharan Africa between 2 and 17% of women test positive for syphilis in antenatal

Diagnosis

The key to syphilis recognition is a full examination by a skilled medical practitioner familiar with the protean manifestations of the infection. This examination should include all of the skin and mouth as well as the genital region. If syphilis is not suspected then the opportunity for early diagnosis and treatment and public-health intervention will be lost.

Clinical manifestations of syphilis in the HIV-positive patient

Typically syphilis occurs in three phases—namely primary, secondary, and tertiary disease. However, this is a gross oversimplification and the clinical presentation of syphilis is extremely variable over many years (figure 2).4 Several differences have been reported in the manifestations of syphilis in HIV-positive patients. In particular there seems to be a shift from presentation with primary to secondary disease and more aggressive disease progression. Furthermore, HIV itself or

Treatment of syphilis

Penicillin remains the mainstay of therapy for all stages and sites of syphilis and in all patient groups.105, 106, 137 Guidelines vary (table 2) but the general principle is one of maintaining prolonged serum treponemocidal concentrations. In HIV-negative patients with early syphilis (less than 2 years' duration) it is not necessary either to investigate for neurosyphilis or to use therapy that achieves treponemocidal concentrations of antibiotics in CSF (table 2).20, 105 For example, CDC

Future prospects

So what does the future hold? It is remarkable that penicillin remains the mainstay of therapy and there is little prospect that newer antibiotics will displace penicillin in the near future particularly following the emergence of macrolide resistance. An effective vaccine would offer great hope but insufficient research efforts have directed against syphilis. Despite some success143 our understanding of the determinants of protective immunity to T palllidum remain poor with little prospect for

Search strategy and selection criteria

Data for this review were identified by searches of Medline, Current Contents, and the Cochrane Database, and by reviewing the bibliographies of papers retrieved using this strategy. All articles published after 1966 were considered, as were articles in all languages. Search terms were “HIV”, “STD”, “STI” “syphilis”, “neurosyphilis”, “ocular”, “uveitis”, “retinitis”, “vitritis”, “cardiovascular”, “bone”, “skin”, “congenital”, and “malignant”. The websites of the World Health Organization,

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