EXECUTIVE SUMMARY
After a review of available evidence, the U.S. Preventive Services Task Force has issued new guidance stating that screening for syphilis infection in asymptomatic, nonpregnant persons at increased risk for infection provides substantial benefits.
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The number of cases of primary and secondary syphilis has been increasing since 2000. In 2014, 19,999 cases (6.3 cases per 100,000 persons) of primary and secondary syphilis were reported in the United States.
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Treatment of syphilis is vital because, if left untreated, syphilis can cause damage to the nervous system, the heart, and other organs.
Statistics are troubling: The number of cases of primary and secondary syphilis has been increasing since 2000. In 2014, 19,999 cases (6.3 cases per 100,000 persons) of primary and secondary syphilis were reported in the United States.1 What can clinicians do to reverse the trend?
After a review of available evidence, the U.S. Preventive Services Task Force has issued new guidance stating that screening for syphilis infection in asymptomatic, nonpregnant persons at increased risk for infection provides substantial benefit.2 The new guidance updates previous recommendations issued in 2004. The Task Force issued separate recommendations on testing in pregnant women in 2009.3 That guidance reaffirmed the call for screening all pregnant women for syphilis infection.
Treatment of syphilis is vital because, if left untreated, syphilis can cause damage to the nervous system, the heart, and other organs, notes Task Force member Ann Kurth, PhD, RN, MSN, MPH. Kurth is dean of the Yale School of Nursing in Orange, CT, and an adjunct professor in the New York University College of Nursing and the College of Global Public Health in New York City, as well as an affiliate faculty member in the University of Washington’s Department of Global Health and School of Nursing in Seattle.
“Of course, the first step toward treatment is screening for the condition, and the Task Force believes this increased prevalence reinforces the importance of screening for syphilis,” states Kurth.
Who Is at Increased Risk?
Who may be considered at increased risk for syphilis? According to the evidence reviewed by the Task Force, men who have sex with men (MSM) and people living with HIV are at highest risk for syphilis infection. In 2014, men accounted for 91% of all primary and secondary syphilis cases, and MSM accounted for 61% of cases.1 (Contraceptive Technology Update reported on the data. See the February 2016 article “Chlamydia, gonorrhea and syphilis cases are up for first time since 2006,” available at http://bit.ly/1Nis7zm.)
Additional factors associated with increased syphilis prevalence that clinicians should consider when deciding who to screen include certain races/ethnicities, certain geographic locations, and history of incarceration or sex work. Men younger than 29 also have higher rates of syphilis. Data from 2014 indicated men in this age group had the highest prevalence rate, which was nearly three times higher than that in the average U.S. male population.1
The optimal screening frequency for people who are at increased risk for syphilis infection is not well-established, the Task Force notes. MSM or persons living with HIV may benefit from more frequent screening. Studies suggest that detection of syphilis infection in MSM or persons living with HIV improves when screening is performed every three months compared with annual testing.4
In implementing the Task Force’s guidance, clinicians will want to ensure that they have implemented a screening approach that allows for open and honest conversations to identify those at high risk and encourage them to get screened in a safe setting without stigma, says Kurth. (Clinicians can download a free patient education handout on syphilis testing from the Journal of the American Medical Association website online at http://bit.ly/1rgPq9e.)
“Clinicians should also consider other relevant factors — including local infection rates, the patient’s sexual network, and the patient’s sexual risk behaviors — when deciding whether to screen for syphilis,” states Kurth. “We hope that this recommendation stresses the importance of screening for those at increased risk for syphilis infection and leads to more people receiving the care and prevention services that they need.”
An editorial adjoining the Task Force’s recommendations stated that practitioners need to improve their skills in taking a sexual history and applying recommended screening approaches to the persons for whom they provide care.5 The editorial was written by Meredith Clement, MD, a fellow in the Division of Infectious Diseases at Duke University Medical Center in Durham, NC, and Charles Hicks, MD, AIDS/HIV specialist and professor of clinical medicine in the Department of Medicine at University of California, San Diego.
“Misplaced concerns about patient objections to sensitive questions raise the likelihood of failure to identify high risk patients and result in missed screening opportunities,” the editorial states.
REFERENCES
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Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2014. Atlanta: Department of Health and Human Services; 2015.
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U.S. Preventive Services Task Force (USPSTF). Screening for syphilis infection in nonpregnant adults and adolescents: U.S. Preventive Services Task Force Recommendation Statement. JAMA 2016; 315(21):2321-2327.
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U.S. Preventive Services Task Force. Screening for syphilis infection in pregnancy: U.S. Preventive Services Task Force reaffirmation recommendation statement. Ann Intern Med 2009; 150(10):705-709.
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Cantor A, Nelson HD, Daeges M, et al. Screening for Syphilis in Nonpregnant Adolescents and Adults: Systematic Review to Update the 2004 U.S. Preventive Services Task Force Recommendation: Evidence Synthesis No. 136. Rockville, MD: Agency for Healthcare Research and Quality; 2016.
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Clement ME, Hicks CB. Syphilis on the rise: What went wrong? JAMA 2016; 315(21):2281-2283.
