Screening for Syphilis Infection: Recommendation Statement

U.S. Preventive Services Task Force

doi:10.1370/afm.215

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Screening for Syphilis Infection: Caveat for HIV-Infected Persons
Ronald H Goldschmidt, MD

Published on: 26 September 2004
When will common sense prevail
Michael W Kelber

Published on: 18 August 2004
A step in the right direction
Jerry Kennard

Published on: 18 August 2004
Syphilis screening in men who have sex with men
Daniel Knight, MD

Published on: 14 August 2004
New news or is it?
John C. Graves, MD, FAAFP

Published on: 13 August 2004

Published on: (26 September 2004)
Page navigation anchor for Screening for Syphilis Infection: Caveat for HIV-Infected Persons
Screening for Syphilis Infection: Caveat for HIV-Infected Persons
Ronald H Goldschmidt, MD, San Francisco, CA
The updated U.S. Preventive Services Task Force recommendations on screening for syphilis (1) are based not only on evidence, but on generally accepted approaches to STD screening in primary care.
An important caveat to the strong (classification A) recommendation that clinicians screen persons at increased risk for syphilis infection, however, concerns persons with human immunodeficiency virus (HIV) infection...
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The updated U.S. Preventive Services Task Force recommendations on screening for syphilis (1) are based not only on evidence, but on generally accepted approaches to STD screening in primary care.
An important caveat to the strong (classification A) recommendation that clinicians screen persons at increased risk for syphilis infection, however, concerns persons with human immunodeficiency virus (HIV) infection. The screening procedure of a standard initial nontreponemal test (VDRL of RPR) followed by a confirmatory treponemal test (FTA-ABS or TP-PA), although appropriate for HIV-infected persons, does not have the test sensitivities and specificities indicated in these recommendations. In fact, nontreponemal and treponemal test sensitivity and specificity data are not established for HIV-infected persons. Although standard tests usually are accurate and reliable for HIV-infected persons, numerous instances of false positive and false negative syphilis test serologies have been reported. The 2002 Sexually Transmitted Diseases Treatment Guidelines (2) point out that HIV-infected persons can have atypical serologic test results (i.e., unusually high, unusually low, or fluctuating titres). When serologic tests and clinical syndromes do not correspond with one another, use of other tests (e.g., biopsy and direct microscopy in the case of early syphilis) should be considered.
Clinicians who perform screening of patients at risk for syphilis need to be aware of possible HIV co-infection as well as the possibility that syphilis testing can be inaccurate in HIV-infected persons.
Reference
1. U.S. Preventive Services Task Force. Screening for syphilis infection: recommendation statement. Ann Fam Med 2004;2:362-5.
2. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2002. MMWR 2002;51(No. RR-6):1-77.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (18 August 2004)
Page navigation anchor for When will common sense prevail
When will common sense prevail
Michael W Kelber, Salem, OR, USA
the USPSTF recommends against routine screening of asymptomatic persons who are not at increased risk for syphilis infection. Yet they recommend screening all pregnant patients. In my practice, these two groups are the same. The recommendations are absurd, create unnecessary cost and make no sense.
Pregnant women who are at increased risk for syphillis should be screened. But WHY screen asymptomatic perso...
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the USPSTF recommends against routine screening of asymptomatic persons who are not at increased risk for syphilis infection. Yet they recommend screening all pregnant patients. In my practice, these two groups are the same. The recommendations are absurd, create unnecessary cost and make no sense.
Pregnant women who are at increased risk for syphillis should be screened. But WHY screen asymptomatic persons not at increased risk just because they got pregnant.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (18 August 2004)
Page navigation anchor for A step in the right direction
A step in the right direction
Jerry Kennard, UK
The incidence and pattern of STD's does point to the need for an intelligent screening protocol. This initiative provides a step in the right direction although I have some concerns over the lack of data and follow-up in cases where false positives are recorded, or the negative/ethical considerations involved with screening. While the number of false positives is not high in a relative sense, they represent a significan...
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The incidence and pattern of STD's does point to the need for an intelligent screening protocol. This initiative provides a step in the right direction although I have some concerns over the lack of data and follow-up in cases where false positives are recorded, or the negative/ethical considerations involved with screening. While the number of false positives is not high in a relative sense, they represent a significant level of discomfort for a number of people in which interpersonal conflicts and personal anxiety could arise needlessly.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (14 August 2004)
Page navigation anchor for Syphilis screening in men who have sex with men
Syphilis screening in men who have sex with men
Daniel Knight, MD, Little Rock, AR, USA
In July 2004, The U.S. Preventive Services Task Force (USPSTF) updated its screening recommendations for syphilis. While no new evidence was obtained since 1996, new studies further supported the previous guidelines. These guidelines strongly recommend that clinicians screen persons at increased risk for syphilis infection and pregnant women.1 Persons “at risk” include men who have sex with men and engage in high- risk...
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In July 2004, The U.S. Preventive Services Task Force (USPSTF) updated its screening recommendations for syphilis. While no new evidence was obtained since 1996, new studies further supported the previous guidelines. These guidelines strongly recommend that clinicians screen persons at increased risk for syphilis infection and pregnant women.1 Persons “at risk” include men who have sex with men and engage in high- risk sexual behavior, commercial sex workers, persons who exchange sex for drugs, and those in adult correctional facilities.
These guidelines are particularly pertinent in men who have sex with men. Recent trends indicate resurgence in risky behaviors that expose men who have sex with men to HIV infection and other STD’s. The reported incidence of men engaging in unprotected anal intercourse increased from 37 percent in 1993-1994 to 50 percent in 1996-1997.2 While the rates of primary and secondary syphilis infection had been steadily decreasing during the 1990’s, in 2001, the rate increased for the first time in a decade. This increase was evident only in men and was associated in several urban areas among men who have sex with men, high reported rates of HIV co-infection, and high-risk sexual behavior.3
In light of these strong recommendations, it is imperative that clinicians screen men who have sex with men for risk of syphilis and offer testing to those at risk. Those men at risk would include men who have multiple or anonymous male sexual partners, are HIV-positive, have a history of illicit drug use or a history of an STD. Other organizations that recommend screening for syphilis include The American Academy of Family Practice, The Centers for Disease Control, the California STD Controllers Association and Public-Health-Seattle and King County.4 This population of men who have sex with men are particularly vulnerable and are present in all of our patient populations. These guidelines further emphasize that we should all be screening these patients, both for sexual practices and for risk of STD’s such as syphilis.
1. Screening for Syphilis Infection. In: U.S. Preventive Services Task Force. Guide to clinical preventive services: report of the U.S. Preventive Services Task Force. Guide to clinical preventive services: report of the U.S. Preventive services Task Force. 2d ed. Baltimore: Williams & Wilkins, 1996.
2. Anderson JE, Stall R. Increased reporting of male-to-male sexual activity in a national survey. Sex Transm Dis 2002; 29:643-6. 3. Primary and secondary syphilis among men who have sex with men—New York City, 2001. MMWR Morb Mortal Wkly Rep 2002; 51:853-6. 4. Knight DA. Health Care Screening for Men Who Have Sex with Men. Am Fam Phys 2004; 69:2149-2156.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (13 August 2004)
Page navigation anchor for New news or is it?
New news or is it?
John C. Graves, MD, FAAFP, Chattanooga, TN, USA
The USPSTF statement of Syphilis brings a little new news to an old subject. Most of the recommendation supports what we have all been doing for years: screening pregnant women and those with other STD's. I think the overall trend in the US supports that this is working for the population as a whole.
What this does highlight, which I am seeing throughout the STD literature, is the growing problem of old enem...
Show More

The USPSTF statement of Syphilis brings a little new news to an old subject. Most of the recommendation supports what we have all been doing for years: screening pregnant women and those with other STD's. I think the overall trend in the US supports that this is working for the population as a whole.
What this does highlight, which I am seeing throughout the STD literature, is the growing problem of old enemies showing up more in Men who have sex with Men, Commercial sex workers and drug abusers who trade sex for drugs. This is a difficult problem as many members of those populations are reluctant to discuss there behavior with healthcare worker if they actually see one and are unlikely to follow up regularly.
Competing interests: None declared
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Competing Interests: None declared.