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Syphilis treatment in the presence of HIV: the debate goes on

Lawrence, Davida; Cresswell, Fionaa; Whetham, Jennifera; Fisher, Martina,b

Current Opinion in Infectious Diseases: February 2015 - Volume 28 - Issue 1 - p 44–52
doi: 10.1097/QCO.0000000000000132

Purpose of review Benzathine Penicillin G has been used to treat syphilis for over 50 years; however, the precise regimen of penicillin for treatment of syphilis in HIV-positive individuals remains a hot topic of debate. Although international guidelines recommend the same treatment for syphilis, regardless of HIV status, there are inconsistencies in prescribing practices among clinicians.

Recent findings Two previous systematic reviews have found limited evidence for enhanced treatment of syphilis in the presence of HIV. However, a growing body of literature indicates that the rate of asymptomatic neurosyphilis may be higher in HIV, and that syphilis infection is associated with poorer long-term neurocognitive outcomes. A number of retrospective studies propose that serological response may be slower, or serological failure may be higher, among HIV-positive individuals, but these studies are limited by high loss to follow-up, high reinfection rates and a focus on serological rather than clinical response. Beyond penicillin, some evidence suggests equivalence of macrolides, cephalosporins and doxycycline, although macrolide resistance is an increasing concern.

Summary Until a prospective, randomized study is conducted, inconsistency with treatment will continue. We offer a pragmatic approach to recognizing patients who may require further investigation or neuropenetrative antibiotic treatment.

aThe Lawson Unit, Royal Sussex County Hospital, Brighton and Sussex University Hospitals NHS Trust

bBrighton and Sussex Medical School, University of Sussex, Brighton, East Sussex, UK

Correspondence to Martin Fisher, BSc, MBBS, FRCP, Brighton and Sussex University Hospitals, Brighton, East Sussex, BN1 9PX, UK. Tel: +44 1273 664718; e-mail:

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