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Ocular Syphilis and Human Immunodeficiency Virus Coinfection Among Syphilis Patients in North Carolina, 2014–2016

Cope, Anna B., PhD*†; Mobley, Victoria L., MD; Oliver, Sara E., MD*; Larson, Mara, MPH; Dzialowy, Nicole, MSc; Maxwell, Jason, BS; Rinsky, Jessica L., PhD*†; Peterman, Thomas A., MD*; Fleischauer, Aaron, PhD*†; Samoff, Erika, PhD

doi: 10.1097/OLQ.0000000000000910
Original Studies

Background Ocular syphilis (OS) has been associated with human immunodeficiency virus (HIV) coinfection previously. We compared demographic and clinical characteristics of syphilis patients with and without HIV to identify risk factors for developing OS.

Methods We reviewed all syphilis cases (early and late) reported to the North Carolina Division of Public Health during 2014 to 2016 and categorized HIV status (positive, negative, unknown) and OS status based on report of ocular symptoms with no other defined etiology. We estimated prevalence ratios (PR) and 95% confidence intervals (CI) for OS by HIV status. Among syphilis patients with HIV, we compared viral loads and CD4 cell counts by OS status. We compared symptom resolution by HIV status for a subset of OS patients.

Results Among 7123 confirmed syphilis cases, 2846 (39.9%) were living with HIV, 109 (1.5%) had OS, and 59 (0.8%) had both. Ocular syphilis was more prevalent in syphilis patients with HIV compared to HIV-negative/unknown-status patients (PR, 1.8; 95% CI, 1.2–2.6). Compared with other patients with HIV, the prevalence of OS was higher in patients with viral loads greater than 200 copies/mL (1.7; 1.0–2.8) and in patients with a CD4 count of 200 cells/mL or less (PR, 2.3; 95% CI, 1.3–4.2). Among 11 patients with severe OS, 9 (81.8%) were HIV-positive. Among 39 interviewed OS patients, OS symptom resolution was similar for HIV-positive (70.0%) and HIV-negative/unknown-status (68.4%) patients.

Conclusions Syphilis patients with HIV were nearly twice as likely to report OS symptoms as were patients without documented HIV. Human immunodeficiency virus–related immunodeficiency possibly increases the risk of OS development in co-infected patients.

Ocular syphilis is more prevalent in syphilis patients with human immunodeficiency virus, particularly those with unsuppressed viral loads or low CD4 counts. Complaints of ocular symptoms may help detect previously undiagnosed human immunodeficiency virus.

From the *Centers for Disease Control and Prevention, Atlanta, GA; and

North Carolina Division of Public Health, Department of Health and Human Services, Raleigh, NC

Acknowledgements: The authors thank the Ocular Syphilis DIS Workgroup: Jason Hall, Victor Hough, Andre Ivey, Stephanie Hawks Sherard, Samantha Greene, Dishonda Taylor, Mike Mercurio, and Miraida Gipson. The authors also thank Evelyn Foust, Gui Liu, Charnetta Williams, Lauri Markowitz and the North Carolina Public Health Epidemiologists.

Sources of Funding: This work was supported jointly by the CDC and the North Carolina Division of Public Health.

Conflict of Interest: None declared.

Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Correspondence: Anna B. Cope, PhD, Division of Public Health, Department of Health and Human Services, 1902 Mail Service Center, Raleigh, NC 27699-1902. E-mail:

Received for publication July 3, 2018, and accepted August 23, 2018.

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© Copyright 2019 American Sexually Transmitted Diseases Association