Syphilis is a sexually transmitted disease (STD) caused by the spirochete bacterium Treponema pallidum. This infection progresses through 4 stages, and clinical manifestations are often subtle with variable presentation.1 Failure to recognize and treat a syphilis infection introduces the risk of long-term neurological and cardiovascular complications, as well as disease propagation.
The Centers for Disease Control and Prevention (CDC) reported that the number of syphilis cases neared extinction in 2000, with an incidence rate of 2.1 per 100,000 persons. However, in 2017, the incidence rate of primary and secondary syphilis cases spiked to 9.5 per 100,000 persons nationally, with pockets reaching as high as 40.2 per 100,000 in Washington DC.2,3 Men contributed to 87.7% of all reported primary and secondary syphilis cases. Men who have sex with men accounted for 79.6% of these cases in 2017, whereas women accounted for 15%, representing a 9% increase among men and a 21.1% increase among women.2,3 The increase in syphilis incidence is a major public health concern, placing all populations at a higher risk of contracting and spreading human immunodeficiency virus (HIV), or contracting syphilis while pregnant, resulting in congenital syphilis (43.8% increase since 2016).2,3 These factors demonstrate the need for further focus and research by public health professionals as well as health care providers.
The CDC and The United States Preventative Services Task Force routinely publish Sexually Transmitted Disease guidelines. However, the only recommended screening for prevention and treatment of syphilis is in all pregnant women and high-risk patients. High-risk patients are vaguely defined as those who engage in high-risk sex, sex workers, and persons in correctional facilities.4,5
Previously published literature examining provider screening practices for STDs is sparse. The most recent study was completed in 2002, which examined chlamydia, gonorrhea, syphilis, and HIV. A national sample of 7300 physicians were included in this study, which documented that screening practices were well below recommended guidelines.6 In addition, no specific attention was placed on family practice providers. Family practice providers represent the largest preventative medicine force in the United States.7 Almost one third of family practice providers are nurse practitioners (NPs) and physician assistants (PAs).7 Because these providers are responsible for the majority of preventative care, a larger focus should have been placed on family practice providers.
The American Academy of Family Physicians recommends that family providers have a thorough understanding of syphilis, including its clinical manifestations, appropriate stage-specific diagnostic testing, and effective antibiotic treatments. As mentioned previously, there are no guidelines that recommend screening patients for syphilis, with the exception of pregnant women and high-risk populations.4 Understanding the current screening practices in place by providers is fundamental to aid in the assessment and implementation of advanced education and policy changes to increase syphilis-screening practices and, ultimately, decrease the spread of disease.
Because of the resurgence of syphilis across the United States and the lack of previous research examining primary care provider syphilis screening practices, further research is necessary. The proposed research examines whether family care physicians', NPs', and PAs' provider-patient contact time, and the willingness and comfort level of a provider to ask sexually related questions of their patient have an effect on syphilis-screening practices. By surveying family care NPs and PAs in addition to physicians, a wider breadth of knowledge and practices can be analyzed to capture the most complete picture concerning screening practices.
MATERIALS AND METHODS
This study was approved by the Institutional Review Board at Penn State College of Medicine, as well as the institutional review boards of the participating medical institutions. The target population of this study consisted of family medicine and walk-in clinics (the walk-in clinics are used by the hospital system as a means for providing same day acute care family practice appointments). The survey was electronically distributed to physicians, NPs, and PAs at 3 major health systems (n = 3121): Milton S. Hershey Medical Center, Reading Health System, and Pinnacle Health. These 3 health systems constitute the main primary care providers for the majority of urban, suburban, and rural communities in central Pennsylvania.
The survey instrument used in this study was developed by the investigators, validated by a small group of medical professionals from all fields represented, and was administered electronically via the Research Electronic Data Capture (REDCap)8 software program. The survey was distributed anonymously and confidentially through electronic listservs provided by each medical institution and took approximately 30 minutes for participants to complete. The survey consisted of 27 questions measuring on demographic information, provider-patient contact time, and comfort in asking sexual behavior questions of their patients. Questions assessing provider comfort querying about sexual health were adapted from the CDC's Five P's approach: partners, prevention of pregnancy, protection from STDs, practices, and past history of STDs.9 At completion and submission of the survey, participants were directed to a free online continuing education module about syphilis provided by the CDC.10
Three members of the research team coded the participant responses to the open-ended questions using thematic analysis. Quantitative data were analyzed via SAS 9.4 (SAS Institute Inc, Cary, NC). Descriptive statistics and multiway contingency tables along with χ2 tests were used to examine the primary care providers' belief about syphilis screening guidelines and practices.
The demographic characteristics of the respondents (N = 52) were varied. No participants were under the age of 20 years with the age groups of 26 to 30 years and 31 to 35 years holding the majority of respondents, at 17.3% each. A total of 14 participants also reported ages of 41 to 45 years and 56 to 60 years, with 7 in each category. Most of the respondents were female (63.5%), with 34.6% male, and 1 individual choosing other as the reported sex. Forty-five participants identified as White, with 94.2% of respondents identifying as not Hispanic or Latino (Table 1).
Most of the participants identified as medical doctors (44.2%), followed closely with 40.4% of participants identified as NPs. When providers were asked to classify their patient population as primarily rural, suburban, or urban, 67.3% of providers chose suburban, with only 7.7% classified as rural. The majority of providers (38.5%) had been in practice for 0 to 5 years (Table 1).
Providers discussed sexual behaviors and screened patients as necessary or when patients complained of symptoms. When providers did discuss sexual behavior and screening, it was most often discussed in the context of the well-women visits with minimal to no discussion of screening men for STDs. These themes can be identified from the following quotes, which were open-ended responses to questions related to asking sexual behavior questions and asking about sexual partners:
“As indicated based on their condition/complaints.”
“When pertinent to the visit.”
“I only screen for syphilis in the context of dementia.”
“If a patient brings it up, or during the annual well-women exam.”
“If they are being seen for gyn (gynecological) issues.”
Thirty-one providers (67%) reported that they had a common spoken phrase, whereas 15 (33%) reported that they do not have a common phrase. Providers who reported a common phrase often reported gender-neutral statements similar to the CDC recommendations for taking a sexual history. The phrases included the following:
“Do you sleep with men, women or both?”
“Are you sexually active?”
“Do you have any sexual concerns?”
Not all phrases were gender neutral; several phrases listed included statements that could be perceived as bias and would discriminate against patients who are gay, lesbian, bisexual, or transgender, and these phrases often included statements presuming sexuality. Selected phrases are shown below:
“Are you and your wife/husband sexually active?”
“Are you happy with how sex is going for you and your spouse?”
Providers who reported no common phrases had few comments that were unbiased:
“I will ask if they are having sex with their partner and are they any problems, are they content.”
“I am matter of fact and ask if they have any issues with sexual dysfunction or difficulties. If they are shy or appear uncomfortable, I will start by saying something like...’Many people with chronic conditions have sexual issues or problems, have you encountered any such issues?’”
However, several comments represented a lack of discussion of the topic with patients or were considered biased and would discriminate against sexual minorities:
“Never really had to.”
“When interviewing before doing a PAP smear. I ask questions about partners, dyspareunia, vaginal discharge.”
“I only screen patients in the context of a dementia work-up.”
A quantitative analysis was performed using Fisher exact test, and it was reported that providers who had a common phrase were more likely to screen for syphilis than their counterparts who did not have a spoken phrase (P = 0.07).
Factors Affecting Screening
χ2 and t tests were used to determine if statistically significant relationships existed between any category and syphilis screening rate.
Demographic characteristics, patient-provider contact time, and provider type did not have a statistically significant relationship with syphilis screening rate (all P values, >0.1).
The outcomes of this study have important implications for medicine and public health practice. Although the results were unable to demonstrate an association between provider behaviors and syphilis screening, important information came to light about provider habits and potential provider bias when discussing sexual behaviors with patients.
The screening rate results of this survey are consistent with previous research. A 2002 study by Lawrence et al6 reported that fewer than one third of the physicians included in the study routinely screened men or women for STDs. A 2013 effort by the CDC, entitled the Syphilis Elimination Effort produced provider responses that were similar to the results from this survey.11 A majority of the providers interviewed in the Syphilis Elimination Effort program reported that they believed that many of their colleagues do not view syphilis as an important public health issue.11
Results from our survey indicate sizable diversity in how providers approach the topic of sexual behavior with their patients, specifically regarding syphilis screening. It was unanticipated to receive a number of responses indicating that providers only broach the topic of syphilis at women's health checkups, which would exclude a large number of the patient population. However, this was consistent with results from the Lawrence et al6 study, which found that physicians who saw male patients rarely screened for syphilis, HIV, gonorrhea, or chlamydia, even though these diseases are most often asymptomatic in males and on the rise in men who have sex with men. It was also unexpected to receive responses that providers only screened for syphilis when the disease had progressed to the point of manifesting as neurological symptoms. These results demonstrate the need for providers to receive further education in regards to syphilis screening and prevention.
Provider habits are also important to consider in prevention and screening of patients, and although no results were significant, qualitative evidence demonstrated pertinent trends. Providers without standard spoken phrases appeared less likely to screen patients, and if screening did occur, they only screened women or patients with neurological problems. Providers with standard spoken phrases appeared less likely to use biased statements and more likely to report screening for syphilis, although some statements could have some perceived bias (Are you and your wife/husband sexually active?). Although this study was limited in its scope and number of respondents, provider habits represent an important area for future research.
This study has important limitations that must be noted. Because this study relied on self-reported data, the answers reported by providers are subject to recall bias. Furthermore, providers with a higher frequency of sexually transmitted infections among patients may have been more likely to complete the survey, resulting in sample bias. The sample size of the study was small (N = 52), which may be owing to providers' already limited schedules. The results of this study may not be generalizable to the national population, as the survey sample population was limited to central Pennsylvania.
The results from this study demonstrate a need for increased provider education on the topic of sexual health, specifically regarding syphilis. It is important that public health professionals and providers address this issue because syphilis rates continue to rise in the United States.