BACKGROUND:Extragenital testing for chlamydia and gonorrhea infections is now routine in many settings. We assessed temporal and demographic trends in extragenital testing and positivity in public health department clinics in Virginia. METHODS:We analyzed urogenital and extragenital chlamydia/gonorrhea laboratory results for clients aged 15 years or older who attended 116 health department clinics from 2018 to 2023. Test volume and positivity was stratified by anatomic site, year, sex, and age. RESULTS:There were 181,471 client visits with valid test results. The proportion of visits with any extragenital testing increased from 19% to 46% during this time. Male clients were twice as likely as females to receive pharyngeal testing (46% vs. 22%) and five times as likely to be tested rectally (15% vs. 3%). Rectal specimen positivity surpassed urogenital positivity for chlamydia (females and males) and gonorrhea (males only). Overall, one-quarter of clients diagnosed with gonorrhea infections were identified exclusively through extragenital testing, as were 9% of clients with positive chlamydia tests. These proportions increased over time and were greater for younger clients and for males relative to females. Two-thirds of extragenital infections would have been missed by urogenital testing alone, including 40% and 49% of females and 86% and 73% of males with extragenital chlamydia and gonorrhea infections respectively. CONCLUSIONS:The proportion of clients who received extragenital chlamydia/gonorrhea testing increased over time, extragenital test positivity was high, and it identified infections that would have been missed otherwise. The impact on sexually transmitted infection sequelae and transmission remains unclear.
INTRODUCTION:Concerns persist that HIV pre-exposure prophylaxis (PrEP) may be associated with increased sexually transmitted infections (STIs), but longitudinal data incorporating the pre-PrEP period and standardized screening remain limited. METHODS:We conducted a retrospective cohort study of individuals initiating oral emtricitabine/tenofovir disoproxil fumarate PrEP at two STI clinics in Milan, Italy (2018-2024). Participants underwent baseline and quarterly screening (pharyngeal, anal, vaginal swabs and urine NAATs) for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG). We estimated baseline prevalence and interval-specific conditional cumulative incidence (CCI) across 0-3, 3-6, 6-9, and 9-12 months intervals, and described symptomatic and recurrent diagnoses. Finally, we evaluated STI trends across three calendar periods: 2018-2019, 2020-2021, and 2022-2024. RESULTS:A total of 1,087 individuals were included (median age 35 years [IQR 30-41]); most were cisgender GBMSM (98.4%). At baseline, 15% (163/1,087) had at least one CT/NG infection. During follow-up, 516 new diagnoses occurred in 359 individuals (33%). Interval-specific CCIs for any CT/NG infection were 13.5%, 15.2%, 17.7%, and 12.7% across the four intervals. The majority of infections were asymptomatic.No substantial differences in STI trends were observed across the three calendar periods. CONCLUSIONS:In this real-world PrEP cohort undergoing quarterly NAAT screening, CT/NG diagnoses were common at baseline and maintained high but stable incidence during the first year after PrEP initiation, with no clear upward trend over time.
In June 2023, the Cook County Jail expanded opt-out gonorrhea and chlamydia testing to male detainees. In the 12 months before and after, testing among males increased from 7.2% to 23.5% of intakes, with cases rising threefold for both gonorrhea and chlamydia. Most infections were treated before release.
BACKGROUND:Disease Intervention Specialists (DIS), essential implementers of HIV prevention efforts, have increasingly relied on learned empathy, rather than evidence-based strategies for client engagement. Given the mismatch between DIS demands and training, as well as demonstrated reductions in both client engagement and front-line implementer wellbeing, research is needed to identify and evaluate the communication strategies and skills that DIS currently employ, those they overlook, and those they would need additional support to utilize effectively. METHODS:With 18 semi-structured interviews, we identified the range of strategies currently used by DIS to engage clients in HIV prevention at a city health department. We also considered how strategies correspond to established behavioral science theory and research. RESULTS:We identified 26 distinct strategies within four clusters: Empathy, Emotion Regulation, Persuasion, and Partnership. The most commonly reported strategies were Cognitive and Compassionate Empathy and Logistical Support/Help, while the least utilized were Change Talk and Seeking Collaboration. Overall, we observed a disproportionate reliance on empathy and emotion-based strategies, but a relative underutilization of persuasion and partnership-based communication strategies with evidence-based impacts on client engagement and motivation for health behavior change. CONCLUSIONS:Staff underutilized client engagement approaches with strong empirical support (e.g., motivational interviewing), while overutilizing emotionally demanding strategies often linked to provider burnout. Although empathy-based communication is foundational to public health care, overreliance may compromise staff wellbeing and miss opportunities to optimize client behavior change. Systematically training DIS in evidence-based communication strategies represents a promising path to improve both client engagement and provider sustainability.
BACKGROUND:We examined the availability of HIV services offered in local jurisdictions' primary sources of safety-net STI services between 2018 and 2021. METHODS:We used data from the 2018 and 2021 Local Health Department STD Infrastructure Surveys. Survey questions included HIV services offered at the jurisdiction's primary safety-net clinic for STI services. Rao-Scott chi-square tests were used to compare HIV services offered by geographic characteristics and clinic type in 2018 and 2021. RESULTS:The provision of most HIV services was higher in 2021 than 2018 based on observed values. There was a significant increase in large jurisdictions that offered HIV PrEP initiation (23.6% in 2018 to 53.8% in 2021, p=0.015) and HIV nPEP (18.0% in 2018 to 48.3% in 2021, p=0.001). Differences were observed primarily in the South, with significant increases in HIV PrEP risk assessment and education (32.5% in 2018 to 68.9% in 2021, p<.0001) and HIV PrEP initiation (6.7% in 2018 to 19.3% in 2021, p=0.02). STI clinics significantly increased provision of HIV PrEP risk assessment and education (47.7% in 2018 to 76.6% in 2021, p=0.001), HIV PrEP initiation (12.7% in 2018 to 29.5% in 2021, p=0.008), and HIV PrEP referrals (54.1% in 2018 to 71.5% in 2021, p=0.047). There were no significant differences in HIV services offered among non-STI clinics. CONCLUSIONS:We identified progress in the availability of HIV services in STI clinics, large jurisdictions, and the South. STI clinics and other primary points of clinical care for STIs can be useful to provide HIV preventive services.
Nationally, the percentage of gonorrhea and chlamydia cases diagnosed in STD clinics dropped dramatically from 1989 through 2023 for men (gonorrhea: 74% to 7%; chlamydia: 47% to 6%) and women (gonorrhea: 57% to 4%; chlamydia: 26% to 3%). Careful consideration of where STDs are diagnosed is important for public health planning.
BACKGROUND:Sexually transmitted infections (STIs) remain a major public health concern among men who have sex with men (MSM). This study estimated STI prevalence and associated factors among MSM enrolled in Thailand's national pre-exposure prophylaxis (PrEP) registry under the Universal Health Coverage (UHC) program. METHODS:We conducted a cross-sectional analysis of MSM aged 15-49 years who underwent STI testing between January 2020 and August 2024 at enrolment in the PrEP registry program. STIs included syphilis, gonorrhoea, chlamydia and chancroids. Multivariable logistic regression was used to identify factors associated with STI and syphilis. RESULTS:Among 24,606 MSM, 1,974 (8.0%) were diagnosed with any STI, predominantly syphilis (n=1,911; 7.7%). STI prevalence was highest among MSM aged 20-24 years (8.6%) followed by 35-49 years (8.7%). STI prevalence was higher among those with prior PrEP use (9.7%) than among non-users (7.7%) and was markedly elevated among HCV-positive MSM (24.0%). In multivariable models, higher odds of STI diagnosis were observed among MSM aged 20-24 years (adjusted odds ratio [aOR] 1.21; 95% CI 1.08-1.36) and 35-49 years (aOR 1.14; 95% CI 1.01-1.29), those with prior PrEP use (aOR 1.26; 95% CI 1.11-1.45), and those with hepatitis C virus infection (aOR 3.17; 95% CI 1.95-5.13). CONCLUSIONS:STIs, particularly syphilis, remain common among MSM enrolled in Thai national PrEP program. These findings highlight the need to integrate STI and hepatitis screening into PrEP services and to strengthen targeted prevention strategies for MSM at increased risk.
The early origin of syphilis remains debated; bone involvement was recognized in early clinical accounts and described with increasing precision as pediatric pathology and radiography developed in the late nineteenth and early twentieth centuries. Many such observations entered medical usage through eponymous labels, yet these have not been examined as a coherent group. We reviewed the origins and early clinical descriptions of eponymous osseous signs of congenital syphilis between 1871 and 1928 and to outline their present-day relevance. A documentary review was conducted using PubMed/MEDLINE and major digitized archives (Gallica, HathiTrust, Internet Archive, Wellcome Collection). Searches in English, French, and German were supplemented by citation tracing. Eponyms were included only when they appeared in at least two sources beyond the original report. Primary sources were analyzed for clinical features, anatomic site, date, and brief biographical context. Six eponyms met inclusion criteria: Parrot (1871), Fournier (1887), Fraenkel (1897), Wimberger (1925), Du Bois (1926), and Higoumenakis (1928). All were originally described in the context of congenital syphilis, primarily affecting infants and young children. Collectively, they illustrate patterns of cranial and clavicular hyperostosis, metaphyseal lucencies, and congenital digital anomalies. Although these signs no longer hold significant diagnostic value, they demonstrate how clinicians recognized skeletal involvement before serologic testing became widely available. These eponymous signs form a small but coherent historical record of how early clinicians interpreted the skeletal effects of congenital syphilis. While of primarily historical interest, they retain some value in prompting consideration of congenital infection when unexpected metaphyseal or hyperostotic changes are encountered in infants. Summary: This narrative review revisits six eponymous osseous signs of syphilis and imaging features that may help distinguish syphilitic bone disease from key mimics.
The effect of Tp0705 penicillin-binding protein polymorphisms on Treponema pallidum susceptibility to ceftriaxone and penicillin G was assessed in a recent study by Tantalo et al. While the study provides valuable phenotypic data from challenging in vitro cultures, its small sample size (N=3) and reliance on historical strains isolated over two decades ago may limit its immediate evolutionary generalizability to currently circulating lineages. Additionally, exploring the role of alternative penicillin-binding proteins and integrating in vivo pharmacokinetic parameters, such as serum protein binding, could provide a more comprehensive overview of susceptibility. Furthermore, the statistically significant variations observed at sub-inhibitory concentrations represent interesting physiological phenomena that warrant further exploration rather than being dismissed as experimental variations. To robustly delineate therapeutic efficacy, incorporating dynamic pharmacokinetic models alongside expanded prospective multi-locus genomic surveillance will be essential for future research.
BACKGROUND:Group sex events (GSEs) have potential implications for transmission and acquisition of HIV and sexually transmitted infections (STI). METHODS:We analyzed survey data from Project DETECT, a Centers for Disease Control and Prevention-funded study evaluating point-of-care tests. Our analytical sample included cisgender gay, bisexual, and other men who have sex with men (cisGBMSM) seeking HIV/STI testing who reported at least one anal sex partner in the past three months. We defined recent GSE as a sexual encounter in the past three months involving more than two people. Poisson regression compared demographic characteristics and behaviors between participants and partners of participants who reported GSE participation vs. ≥2 sex partners but no recent GSEs. RESULTS:Recent GSE was reported at 707 (36%) of 1,991 study visits by 1,539 unique participants. Participants who reported bacterial STI diagnosis in the past three months (PR=1.31, 95%CI=1.16-1.49) and current pre-exposure prophylaxis (PrEP) use (PR=1.49, 95%CI=1.32-1.69) were more likely to report a GSE than to report ≥2 sex partners and no GSE. Partners recently diagnosed with an STI (PR=1.21, 95%CI=1.06-1.37) and partners with other concurrent partners (PR=1.91, 95%CI=1.62-2.26) were more likely to be partners of participants who reported GSE than participants with ≥2 partners but no GSE. CONCLUSIONS:GSE participation was common among cisGBMSM. While GSE participation was associated with some predictors of HIV infection, GSE participants were more likely to use PrEP. Healthcare for cisGBMSM should include assessing GSE participation and discussing strategies for HIV/STI prevention in the context of GSE.
A retrospective review of patients requiring outreach for syphilis results after emergency department (ED) screening showed that adding a chart flag to address results at return ED visits for patients otherwise unable to be contacted resulted in a 76.6% contact rate and 93.6% linkage to care among those needing treatment.
BACKGROUND:Sexually transmitted infections (STIs) remain a major public health concern with rising incidence worldwide. Dating applications have reshaped partner acquisition and sexual networking patterns, yet data on French users remain limited. This study aimed to describe sexual behaviors among dating app users in France and identify behavioral profiles. METHODS:We conducted a cross-sectional survey using an anonymous questionnaire distributed June-August 2024 through dating applications, social media, and community outreach. Participants reporting dating app use within the past 12 months were eligible. Descriptive analyses were performed, followed by multiple correspondence analysis (MCA) to identify behavioral profiles. RESULTS:A total of 230 participants completed the survey (44.3% men, 53.0% women, 2.6% non-binary), predominantly aged 18-30 years. Higher exposure patterns, including more frequent app use, higher partner turnover, and increased STI screening (71.4% within the past 6 months), were more common among men who have sex with men (MSM). Condom use was inconsistent across sexual practices, with more than 60% of participants reporting never using protection during oral sex. MCA revealed three behavioral profiles reflecting a gradient of exposure and prevention: a lower-exposure profile primarily involving men who have sex with women (MSW), a higher-exposure profile predominantly involving MSM, and an intermediate profile mainly involving women who have sex with men (WSM). CONCLUSIONS:Dating app users in France are not behaviorally homogeneous. Distinct profiles reveal misalignment between exposure, prevention, and screening engagement, highlighting the need for sexual health strategies beyond exposure-based assumptions.
BACKGROUND:While recent national increases in unknown duration or late syphilis (UDLS) have outpaced diagnoses of earlier stages of syphilis, causes and contributors remain unknown. We evaluated changes in the proportion of UDLS cases with high nontreponemal test titers in one jurisdiction to identify if UDLS cases, which often have lower titers compared with early syphilis cases, might increasingly be early syphilitic infections. METHODS:We identified UDLS cases with high titers (defined as rapid plasma reagin titers ≥1:32) reported to North Carolina during years 2015 and 2023. We evaluated changes in case counts and in the proportion of UDLS cases with high titers overall, by demographics, clinical factors, and incarceration history. RESULTS:When comparing years 2015 and 2023, UDLS case counts increased (628 vs. 2,498). The proportion of cases with high titers remained relatively stable between both years (51.3% vs. 50.2%), but increased among women (29.1% vs. 46.1%), women pregnant at the time of syphilis diagnosis (30.4% vs. 43.2%), men who have sex with women only (MSWO; 45.0% vs. 57.4%), and people who were recently incarcerated (41.7% vs. 52.9%). The proportion of cases with high titers decreased among men who have sex with men (66.4% vs. 58.1%), and men with HIV (68.0% vs 55.4%). CONCLUSIONS:The proportion of cases with high titers increased among women, MSWO, and people who were recently incarcerated, suggesting that an increasing proportion of UDLS cases in these populations might be early syphilitic infections. Future initiatives could identify methods of improving case staging to facilitate syphilis prevention and control.
Although long-term in vitro cultivation of the syphilis agent, Treponema pallidum subspecies pallidum, was introduced less than a decade ago, it has revolutionized and accelerated research with this difficult pathogen. Moreover, it is allowing for the exploration of topics that could not easily be pursued when propagation in the rabbit model was the only possible method for the expansion of treponemes. This report, based on talks presented at the Shanghai International Syphilis Symposium 2025, provides an overview of how in vitro cultivation is currently being applied to syphilis research.
Background: Syphilis diagnosis in resource-limited settings relies on syndromic management and treponemal-based antibody screening tests that cannot distinguish active infection from past-treated infection, both of which can lead to overtreatment. Point-of-care (POC) tests that detect active infection could reduce unnecessary treatment. Methods: We developed an agent-based model of co-transmitting syphilis and human immunodeficiency virus, calibrated to Zimbabwe using population-based survey data (ZIMPHIA) and UNAIDS estimates. We modeled five scenarios involving two hypothetical new POC diagnostic products introduced from 2027: (1) a test detecting Treponema pallidum DNA in genital ulcer specimens, and (2) a non-treponemal test identifying active infection following a treponemal-positive result, applied across antenatal care, key population, and human immunodeficiency virus care settings. We also conducted a threshold-based cost analysis to assess whether reductions in unnecessary treatment alone could be cost-saving. Results: Under the current standard of care, approximately 112,000 adult syphilis treatments are administered annually across all modeled detection and screening use cases, of which approximately 80% are unnecessary (i.e., administered to individuals who do not have an active syphilis infection). Combining both diagnostics reduces overtreatment to 24% (a 3.4-fold reduction). Across use cases, each test avoids approximately 0.4 to 0.8 unnecessary treatments, implying cost savings whenever the test price is less than 40% to 80% of the treatment cost. Conclusions: Even under the conservative assumption that current syndromic management and screening practices achieve high syphilis treatment rates among care-seeking individuals, introducing POC diagnostics for active syphilis could substantially reduce overtreatment while maintaining treatment of individuals with active infection. Reductions in unnecessary treatment alone may be cost-saving at low test prices, even without accounting for downstream health outcomes. This analysis does not model the impact of improved diagnostics on transmission dynamics, congenital syphilis burden, or other health outcomes; studies that quantify these additional benefits are needed to inform a full economic evaluation.
Background: Syphilis in pregnancy and congenital syphilis (CS) remain major public health challenges in Latin America despite long-standing elimination initiatives. CS incidence continues to rise, although diagnosis and treatment are available, reflecting persistent programmatic gaps. A systematic assessment of strengths, weaknesses, opportunities, and threats (SWOT) can help refine strategies and accelerate progress toward the elimination of mother-to-child transmission (EMTCT) of syphilis. Methods: We performed a qualitative SWOT analysis of public health policies addressing syphilis in pregnancy and CS in Latin American countries. Data sources included Pan-American Health Organization databases, global monitoring databases, national data, peer-reviewed literature, and programmatic reports. Evidence was synthesized using a standardized matrix to classify internal and external factors affecting syphilis control. Results: Regional strengths include political commitment, national guidelines aligned with Pan-American Health Organization/World Health Organization recommendations, high antenatal care coverage, use of rapid and HIV/syphilis tests, and established surveillance systems. Key weaknesses include late antenatal care initiation, gaps in timely testing and treatment, regulatory barriers to point-of-care testing and penicillin administration, benzathine penicillin shortages, data quality limitations, fragmented governance and care, and weak partner management. Opportunities include strengthening the EMTCT agenda via program integration, digital health expansion, regional collaboration, and innovative diagnostic strategies. Threats include rising syphilis incidence, competing public health emergencies, political and economic instability, poverty, exclusion and stigma, and loss-to-follow-up during and after pregnancy due to population mobility. Conclusions: Despite political commitment, Latin America remains far from achieving EMTCT of syphilis. Strengthening integrated services, supply chains, data systems, and partner management is needed to improve outcomes.
BACKGROUND:Congenital syphilis (CS) remains a major cause of stillbirth and neonatal morbidity, with an estimated 700,000 cases and 390,000 adverse birth outcomes annually. We evaluated the diagnostic utility of combined treponemal (TT) and nontreponemal (NTT) rapid point-of-care test and Treponema pallidum polymerase chain reaction (PCR) for detecting active maternal syphilis, CS, and treatment response in a high-prevalence, low-resource setting. METHODS:Secondary analyses were conducted from a prospective case-control study at Queen Elizabeth Central Hospital, Malawi. Women were recruited ≤48 h postpartum. Maternal and infant sera underwent testing with the DPP® Syphilis Screen and Confirm (Dual rapid diagnostic test [RDT]) and T. pallidum PCR (maternal vaginal swabs and infant nasopharyngeal swabs), with predefined clinical-serological reference standards based on qualitative rapid plasma reagin (RPR). RESULTS:Among 504 of 510 women with complete data, Dual RDT identified 110 seropositive cases at delivery, including 86 new maternal syphilis diagnoses. The NTT band showed good performance in mothers versus RPR (sensitivity: 84.8% [95% confidence interval: 77.4%-92.1%]; specificity 92.7% [95% confidence interval: 90.3%-95.1%]) but reduced sensitivity in infants, increasing from 51.9% to 80.0% with RPR titer. Laboratory visual and microreader interpretation showed high concordance (99.5%), while bedside visual accuracy was lower (77.4%). Any Dual RDT positivity identified 19 high-risk infants, of whom 7 of 19 (36.8%) were NTT positive. PCR detected maternal infection in 11 of 504 (2.2%), including 3 serology-negative cases. CONCLUSIONS:Dual RDT improves detection over TT alone. The NTT band without quantitation is insufficient for treatment monitoring or infant diagnosis. Combining Dual RDT with PCR may enhance detection of active maternal infection and CS in high-burden settings.
Background: Congenital syphilis remains a major global health challenge, driven partly by maternal reinfection during pregnancy. Partner notification (PN) is critical to prevent reinfection and reduce mother-to-child transmission, yet evidence on its uptake and effectiveness is limited. We aimed to assess PN coverage, outcomes, and barriers among pregnant women with syphilis in Blantyre, Malawi. Methods: We conducted a mixed-methods study at 4 primary health centers (Mpemba, Zingwangwa, South Lunzu, and Bangwe). A cross-sectional survey at delivery enrolled women with documented syphilis in the current pregnancy (positive treponemal rapid diagnostic test). PN was defined as informing partners of potential exposure and the need for testing; appropriate partner management was defined as partner testing and treatment according to results. Semistructured interviews with women and healthcare workers were analyzed using reflexive thematic analysis. Results: Among 131 women, 117/131 (89.3%) reported notifying partners; however, only 76/131 (58.0%) partners were tested, and a similar but nonidentical 76/131 (58.0%) received treatment. Appropriate partner management was completed in 40/131 (30.5%). Partner treatment was associated with being married or cohabiting (74/76, 97.4% vs 43/55, 78.2%; P = 0.0005), but not with age, HIV status, education, or adverse birth outcomes. Qualitative findings identified predominantly patient-led PN, with barriers, including fear of partner reaction, stigma, misinformation, and partner reluctance to access care; facilitators included community sensitization and healthcare worker involvement. Conclusions: Substantial attrition occurs between notification and partner management, highlighting critical gaps in the cascade. These findings support the need for standardized PN metrics and context-specific, multicomponent interventions addressing health system barriers.
