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Sexually Transmitted Diseases:
Letters to the Editor

Outbreak of Syphilis Among HIV-Infected Patients: Descriptive Data From a Parisian Hospital

Abraham, Bruno MD*†; Marih, Latifah MD*; Thevenet, Sandrine*; Marechal, Elisete Da Silva*; Verdet, Charlotte MD‡; Rozenbaum, Willy MD, PhD*; Pialoux, Gilles MD, PhD*

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*Service de Maladies Infectieuses et Tropicales, Hôpital Tenon, Paris, France, †Service de Médecine Interne, Centre Hospitalier, Brive, France, ‡Laboratoire de Bactériologie, Hôpital Tenon, Paris, France

Received for publication March 23, 2005, and accepted June 15, 2005.

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To the Editor:

A recent increase in syphilis incidence was observed in North America and Europe.1–3 Because Treponema pallidum's transmission pathways share the same route of HIV, then a rise in HIV coinfection might also be expected. In France, most of the cases have been reported from Paris.2 The aim of the study was to describe the recent syphilis cases as well as patients' characteristics in the context of an HIV infection.

We analyzed data from patients followed at Tenon Hospital Infectious Disease Service from January 2000 to December 2002. The analysis of clinical and serologic response was performed during the follow-up period. A decrease in Venereal Disease Research Laboratory (VDRL) titer dilution by 2 or more or changes to a nonreactive test were considered a satisfactory response.4

Of 3448 patients followed in our service, 71 (2%) had a new diagnosis of syphilis. The half-year incidence of syphilis among patients with HIV increased progressively from 0.8 per 1000 (first half-year of 2000) to 9.8 per 1000 (second half-year of 2002) (Fig.1). All were homo- or bisexual men with a median age of 36 years old (range, 28–56 years). HIV-positive serologic status was known before the syphilis diagnosis for a median of 8.8 years (range, 0–19 years), only 6 (8.5%) individuals receiving the diagnosis simultaneously. Forty-eight (67.6%) patients were taking antiretroviral (ARV) therapy; median time under ARV treatment was 4.6 years (range, 0–15.8 years). At time of syphilis seropositivity, median CD4+ cells count was 425/mm3 (range, 17–1753/mm3) and median plasmatic HIV-RNA virus load was 2.9 log/mL (range, <1.7–>5.7 log/mL). Secondary syphilis was more frequent (48%) than primary (25%), latent syphilis (20%), primary–secondary (4%), and symptomatic neurosyphilis (1%). After treatment, no clinical failure was observed. Satisfactory serologic response was observed in 34 of 39 (87.2%), 26 of 29 (89.7%), and 16 of 17 (94.1%) at 3, 6, and 9 months follow up, respectively.

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This study shows the dramatic increase of syphilis coinfection in homo- and bisexual HIV-positive men in Paris, suggesting a relapse in sexual risk behavior among this population. Since 1998, an increase in unsafe sex and sexually transmitted disease in HIV-positive individuals has been reported, but especially for men who have sex with men.5 Highly active antiretroviral therapy (HAART) has led to the decline in morbidity and mortality in HIV-1-infected patients,6 but despite this success, the widespread use of the ARV regimen has been associated with misunderstood concepts. HIV plasma VL undetectable or high CD4 cell count might be falsely reassuring factors for the risk of transmission.7 In fact, although undetectable in the plasma, HIV RNA has been found in semen fluids,8 suggesting a potential transmission of the virus. Moreover, the interrelation between genital syphilis and HIV is well known. Syphilis increases the risk of the rate of HIV acquisition (2- to 4-fold) and the risk for transmitting HIV (between 2- and 9-folds).9,10 Our findings, as well as other reports, must be considered a serious warning to reinforce the message of prevention on populations with risk behaviors for STD and HIV infection.11,12

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References

1.Primary and secondary Syphilis: United States, 2000–2001. MMWR Morb Mortal Wkly Rep 2002; 51:971–973.

2.Dupin N, Jdid R, N'Guyen YT, et al. Syphilis and gonorrhoea in Paris: The return. AIDS 2001; 15:814–815.

3.Hopkins S, Lyons F, Coleman C, Courtney G, Bergin C, Mulcahy F. Resurgence in infectious syphilis in Ireland: An epidemiological study. Sex Transm Dis 2004; 31:317–321.

4.Rolfs RT, Riduan JM, Hendershot EF, et al. A randomized trial of enhanced therapy for early syphilis in patients with and without human immunodeficiency virus infection. N Engl J Med 1997; 337:307–314.

5.Katz MH, Schwarcs MJ, Kellog TA, et al. Impact of highly active antiretroviral treatment on HIV seroincidence among men who have sex with men. San Francisco. Am J Public Health 2002; 92:1387–1388.

6.Pallela FJ Jr, Delaney MK, Moorman AC, et al. Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. Outpatients Study Investigators. N Engl J Med 1998; 338:853–860.

7.Suarez TP, Kelly JA, Pinkerton SD, et al. Influence of a partner's HIV serostatus, use of highly active antiretroviral therapy, and viral load on perception of sexual risk behavior in a community sample of men who have sex with men. J Acquir Immun Defic Syndr 2001; 28:471–477.

8.Zhang H, Dornadula G, Beumont M, et al. Human immunodeficiency virus type 1 in the semen of men receiving highly active antiretroviral therapy. N Engl J Med 1998; 339:1802–1809.

9.Greenblatt RM, Lukerhart SA, Plummer FA, et al. Genital ulceration as a risk factor for human immunodeficiency virus infection. AIDS 1988; 2:47–50.

10.Stamm WE, Handsfield HH, Rompalo AM, et al. The association between genital ulcer disease and acquisition of HIV infection in homosexual men. JAMA 1988; 260:1429–1433.

11.Golden MR, Marra CM, Holmes KK. Update on syphilis. Resurgence of an old problem. JAMA 2003; 290:1510–1514.

12.Hook EW 3rd, Peeling RW. Syphilis control: A continuing challenge. N Engl J Med 2004; 351:122–124.

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