Objectives: To evaluate the incidence of early syphilis based on time from initiation of highly active antiretroviral therapy (HAART) in human immunodeficiency virus (HIV)-infected patients.
Study Design: Five hundred thirty-nine HIV-positive patients undergoing HAART were followed up to 4 years to identify early (primary or secondary) syphilis. Incidence rate trends according to time from HAART initiation were evaluated by Poisson regression after adjustment for calendar year.
Results: With median follow-up of 2.9 years, 56 (10.4%) patients experienced early syphilis, 17 (3.2%) with primary syphilis, and 39 (7.2%) with secondary syphilis. The overall incidence rate of early syphilis for 4 years after the start of HAART was 4.57 per 100 person-years (95% confidence interval, 3.45–5.93). The incidence rate of early syphilis significantly increased in proportion to the years after the start of HAART (3.4–6.1 per 100 person-year, P for trend <0.001).
Conclusions: Early syphilis incidence in HIV-infected patients increased in proportion to HAART duration. The finding suggests that screening for syphilis in HIV-infected patients who initiate HAART should be encouraged with attention to the time passed since HAART initiation.
A study in a tertiary referral hospital in Republic of Korea found that early syphilis incidence in HIV patients increased with time after the start of HAART.
From the Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
This study was supported by the Medical Research Collaborating Center of Seoul National University Hospital, which provided statistical consultation.
Presented at 45th annual meeting of Infectious Diseases Society of America, San Diego, 2007.
Correspondence: Kang Won Choe, MD, PhD, Department of Internal Medicine, Seoul National University College of Medicine, 28 Yeongun-dong, Chongro-gu, Seoul, Republic of Korea 110–744. E-mail: firstname.lastname@example.org.
Received for publication June 19, 2007, and accepted September 9, 2007.
RECENT STUDIES HAVE REPORTED an increasing rate of syphilis among men having sex with men in an era in which highly active antiretroviral therapy (HAART) has become available in industrialized countries.1–3 This increase may be attributable to the decrease in mortality in human immunodeficiency virus (HIV)-infected patients associated with HAART,4 and to an increase in high-risk sexual behavior resulting from treatment-induced optimism.5,6 Furthermore, a study has demonstrated that virological and immunologic improvement with the use of HAART increased the level of unprotected sex among HIV-infected patients.7
However, there is little information about whether the duration of receiving HAART influences syphilis incidence or whether immunologic improvement through HAART is related to the incidence of syphilis in HIV patients.8 An understanding of the effect of HAART on the incidence of syphilis may have great implications for controlling HIV transmission as well as syphilis itself in HIV-infected patients; one reason is that syphilis may increase the risk of HIV transmission by causing genital ulcers.9
In this study, therefore, we aimed to evaluate the incidence of early syphilis as a function of the time after the start of HAART in HIV-infected patients.
The study included all HIV patients (>15 years old) who started HAART at Seoul National University Hospital (Seoul, Republic of Korea) from 1998 through 2006. The hospital is a 1600-bed, university-affiliated teaching hospital, and it is the largest referral center for HIV/acquired immune deficiency syndrome in South Korea; a quarter of all HIV patients in South Korea are seen at this hospital. HAART is defined as the use of at least 3 antiretroviral drugs, including protease inhibitors or nonnucleoside reverse transcriptase inhibitors, for at least 1 month.
In these patients, the first event of early (primary or secondary) syphilis was identified from 0 to 4 years after the start of HAART. Early syphilis was diagnosed with clinical symptoms and the reactive Venereal Disease Research Laboratory (VDRL) test and fluorescent treponemal antibody-absorption tests. Early latent syphilis was not included in the event of early syphilis because the patients did not receive regular monitoring for syphilis. Infections in patients with a history of previously treated syphilis were diagnosed when they showed a documented 4-fold or greater increase in VDRL test titers.
Baseline CD4 lymphocyte count and HIV RNA level were the test results obtained closest to the time of initiation of HAART (less than 90 days before initiation). CD4 cell counts and HIV RNA levels at the time of the syphilis diagnosis were taken as the averages of all measurements recorded within a window around the time of syphilis diagnosis ±2 months. Clinical categories were defined by the 1993 Centers for Disease Control and Prevention classification criteria.10
The confidence intervals (CIs) of the incidence rates of early syphilis were estimated by Poisson distribution 95% confidence limits, and trends of event rates according to the time after starting HAART were evaluated by Poisson regression after adjustment for the calendar year. Statistical analyses were performed with SPSS software (version 12.0) and SAS (version 9.1); the P value was considered significant at 0.05.
Of the 539 patients who met the eligibility criteria, all except 6 patients were Korean, the median age was 38 years [interquartile range (IQR), 32–46], and 91% were men, 42% of whom were men having sex with men. Median follow-up duration per person was 2.9 years (IQR: 1.4–4.0). Among them, 56 (10.4%) patients were diagnosed with early syphilis, 17 (3.2%) with primary syphilis, 39 (7.2%) with secondary syphilis, and 9 (16.1%) had previous syphilis infections. The baseline characteristics of these patients at the start of HAART are shown in Table 1. Thirty-nine (69.6%) patients received protease inhibitors as their HAART regimen, and 17 (30.4%) received nonnucleoside reverse transcriptase inhibitor. The median titer of the VDRL tests at time of syphilis diagnosis was 1:64 (IQR, 1:32–1:128).
The overall incidence rate of early syphilis for 4 years after the start of HAART was 4.57 per 100 person-years (95% CI, 3.45–5.93). The period-specific incidence rate of early syphilis was 3.42 per 100 person-years (95% CI, 1.82–5.85) in the first year after starting HAART, 3.51 per 100 person-years (95% CI, 1.81–6.13) in the second year, 6.19 per 100 person-years (95% CI, 3.67–9.79) in the third year, and 6.10 per 100 person-years (95% CI, 3.25–10.43) in the fourth year. The incidence rate of early syphilis significantly increased in proportion to the years after the start of HAART after adjustment by the calendar year (P <0.001) (Fig. 1).
Median CD4 cell count was 165/mm3 (IQR, 70–250) at the start of HAART and 365/mm3 (IQR, 221–480) at the time of syphilis diagnosis (Table 1). The median increased level of CD4 cell counts from baseline at the time of syphilis diagnosis was 174/mm3 (IQR, 66–330).
In 33 (63%) of 52 patients with available data, HIV viral load was not detected (<400 copies/mL) at the time of syphilis diagnosis. Among patients with early syphilis, the proportion with undetected viral load at the time of syphilis was 69% in the first year after HAART initiation, 56% in the second year, 71% in the third year, and 54% in the fourth year.
Several previous studies have suggested an association between HAART and sexually transmitted diseases (STD) other than HIV infection.7,11–13 Some reported that the incidence of STD in HIV patients in the HAART era increased compared with the era preceding HAART introduction.7,13 However, the association between syphilis and HAART may just reflect the increased prevalence of syphilis in general population or men having sex with men. Therefore, we tried to minimize the effect of a secular trend in the population by adjusting the calendar year in Poisson regression model.
This study demonstrated that the incidence of new syphilis in HIV patients increased in proportion to the duration of HAART therapy even after adjustment by calendar year. This finding strongly supports the association between HAART and the increased incidence of syphilis in HIV patients.
The effect of HAART on the incidence of syphilis can be explained in both physical and psychological aspects. Successful HAART therapy results in a better physical condition, which may be related to increased sexual activity, including unprotected sexual behavior. Concurrently, HIV patients may believe that HAART reduces the risk of transmission and negates the need for safer sex practices.14 These physical and psychological changes may be factors in the increased incidence of syphilis.
Although baseline CD4 cell counts were diverse according to the time from start of HAART to early syphilis, CD4 cell counts at the time of syphilis diagnosis were over 200/mm3 in more than 80% patients. These findings suggest that CD4 cell count may be a useful marker for defining the risk group for syphilis during HAART. A previous study demonstrated that higher CD4 cell count at time of acquired immune deficiency syndrome diagnosis was associated with increased risk of acquiring a STD.11
The increase in the incidence of early syphilis after HAART initiation may raise concerns about HIV transmission because an increased syphilis incidence reflects a high rate of risky sexual behavior in HIV patients; in addition, syphilis may increase the risk of HIV transmission through genital ulcers.9,15 Our data showed that in about 40% of patients with early syphilis, HIV viral load was not fully suppressed. Although there are limited data regarding whether a syphilis outbreak among HIV patients increases HIV incidence,16 our findings draw special attention to HIV transmission from HIV patients receiving HAART.
This study has some limitations. First, syphilis may present with nontypical features in HIV patients.17 Furthermore, we did not include latent syphilis in this study. Therefore, we might have underestimated the incidence of early syphilis in HIV patients. Second, recent studies reported that syphilis may decrease CD4 cell counts and increase HIV viral load.18,19 For this reason, values from the time of syphilis diagnosis might not exactly reflect the immunologic or virological state of the HIV patients. To minimize this discordance, we took CD4 counts and viral loads as averages of all measurements recorded within a window around the time of syphilis diagnosis. Third, incidence of STD may be influenced by risk-reduction counseling in clinics.20 The study hospital did not have a counseling program to prevent STD in HIV patients. The results in the HIV clinics with that situation might be different from ours.
In summary, this study demonstrated that the incidence of early syphilis in HIV patients increased in proportion to the time after the start of HAART. Our findings suggest that more intensive risk-reduction counseling and routine periodic screening for syphilis in HIV patients who initiate HAART should be encouraged with attention to the time passed since HAART initiation.
1. Dougan S, Evans BG, Elford J. Sexually transmitted infections in Western Europe among HIV-positive men who have sex with men. Sex Transm Dis 2007; 34:783–790.
2. Higgins SP, Sukthankar A, Mahto M, et al. Syphilis increases in Manchester, UK. Lancet 2000; 355:1466.
3. Centers for Disease Control and Prevention. Trends in primary and secondary syphilis and HIV infections in men who have sex with men—San Francisco and Los Angeles, California, 1998–2002. MMWR Morb Mortal Wkly Rep 2004; 53:575–578.
4. Chesson HW, Dee TS, Aral SO. AIDS mortality may have contributed to the decline in syphilis rates in the United States in the 1990s. Sex Transm Dis 2003; 30:419–424.
5. Van d V, Kippax S, Knox S, et al. HIV treatments optimism and sexual behaviour among gay men in Sydney and Melbourne. AIDS 1999; 13:2289–2294.
6. Dilley JW, Woods WJ, McFarland W. Are advances in treatment changing views about high-risk sex? N Engl J Med 1997; 337:501–502.
7. Dukers NH, Goudsmit J, de Wit JB, et al. Sexual risk behaviour relates to the virological and immunological improvements during highly active antiretroviral therapy in HIV-1 infection. AIDS 2001; 15:369–378.
8. Manavi K, Luo PL, McMillan A. The three-year positivity rate of sexually transmitted infections among a group of HIV-infected men attending the Department of Genitourinary Medicine, Edinburgh, UK. Int J STD AIDS 2005; 16:730–732.
9. Arora PN, Sastry CV. HIV infection and genital ulcer disease. Indian J Sex Transm Dis 1992; 13:71–73.
10. Center for Disease Control and Prevention. 1993 revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. MMWR Recomm Rep 1992; 41:1–19.
11. Scheer S, Chu PL, Klausner JD, et al. Effect of highly active antiretroviral therapy on diagnoses of sexually transmitted diseases in people with AIDS. Lancet 2001; 357:432–435.
12. Paz-Bailey G, Meyers A, Blank S, et al. A case-control study of syphilis among men who have sex with men in New York City: Association With HIV infection. Sex Transm Dis 2004; 31:581–587.
13. Stolte IG, Dukers NH, de Wit JB, et al. Increase in sexually transmitted infections among homosexual men in Amsterdam in relation to HAART. Sex Transm Infect 2001; 77:184–186.
14. Demmer C. Impact of improved treatments on perceptions about HIV and safer sex among inner-city HIV-infected men and women. J Community Health 2002; 27:63–73.
15. Fleming DT, Wasserheit JN. From epidemiological synergy to public health policy and practice: The contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sex Transm Infect 1999; 75:3–17.
16. Buchacz K, Greenberg A, Onorato I, et al. Syphilis epidemics and human immunodeficiency virus (HIV) incidence among men who have sex with men in the United States: Implications for HIV prevention. Sex Transm Dis 2005; 32:S73–S79.
17. Lynn WA, Lightman S. Syphilis and HIV: A dangerous combination. Lancet Infect Dis 2004; 4:456–466.
18. Buchacz K, Patel P, Taylor M, et al. Syphilis increases HIV viral load and decreases CD4 cell counts in HIV-infected patients with new syphilis infections. AIDS 2004; 18:2075–2079.
19. Kofoed K, Gerstoft J, Mathiesen LR, et al. Syphilis and human immunodeficiency virus (HIV)-1 coinfection: Influence on CD4 T-cell count, HIV-1 viral load, and treatment response. Sex Transm Dis 2006; 33:143–148.
20. Kamb ML, Fishbein M, Douglas JM Jr, et al. Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: a randomized controlled trial. Project RESPECT Study Group. JAMA 1998; 280:1161–1167.