Detecting asymptomatic syphilis

Syphilis is a bacterial sexually transmissible infection (STI) that is easily treatable if detected in the early stages of infection, but if untreated can have serious consequences. Advanced syphilis can cause severe neurological symptoms, and undetected infection during pregnancy can lead to miscarriage, stillbirth or significant morbidities for the child.1Hook E.W. Syphilis.Lancet. 2017; 389: 1550-1557Summary Full Text Full Text PDF PubMed Scopus (267) Google Scholar Worldwide, there were an estimated 7.1 million new syphilis infections among 15-49-year-olds in 2020 and 473 cases of congenital syphilis per 100,000 live births in 2016 (although congenital syphilis is underdiagnosed and underreported).2WHO Global progress report on HIV, viral hepatitis and sexually transmitted infections, 2021. Accountability for the global health sector strategies 201616d and effective.2021http://zotero.org/usealth OrganisationGoogle Scholar Global targets are for a 90% reduction in syphilis incidence and elimination of congenital syphilis by 2030.2WHO Global progress report on HIV, viral hepatitis and sexually transmitted infections, 2021. Accountability for the global health sector strategies 201616d and effective.2021http://zotero.org/usealth OrganisationGoogle Scholar However, despite some slow declines in congenital syphilis, progress in reducing the incidence of bacterial STIs has plateaued globally.2WHO Global progress report on HIV, viral hepatitis and sexually transmitted infections, 2021. Accountability for the global health sector strategies 201616d and effective.2021http://zotero.org/usealth OrganisationGoogle Scholar Furthermore, several high-income countries, including the United States and Australia, are currently experiencing resurgences of syphilis.3National Center for HIV, Viral Hepatitis, STD, and TB Prevention Sexually transmitted disease surveillance, 2021. Centers for Disease Control and Prevention, 2023https://www.cdc.gov/std/statistics/2021/default.htmGoogle Scholar,4King J. McManus H. Kwon A. Gray R. McGregor S. HIV, viral hepatitis and sexually transmissible infections in Australia: annual surveillance report 2022. The Kirby Institute, UNSW Sydney, Sydney, Australia2022http://handle.unsw.edu.au/1959.4/unsworks_81131Google Scholar In Australia, the infectious syphilis notification rate has increased from 6.7 cases per 100,000 people in 2012 to 22.7 cases per 100,000 people in 2021.4King J. McManus H. Kwon A. Gray R. McGregor S. HIV, viral hepatitis and sexually transmissible infections in Australia: annual surveillance report 2022. The Kirby Institute, UNSW Sydney, Sydney, Australia2022http://handle.unsw.edu.au/1959.4/unsworks_81131Google Scholar Most cases in Australia are transmitted via male-to-male sex; however, heterosexual transmission has increased in recent years. Surveillance data show pronounced increases for reproductive-aged women. For women aged 20–24, the infectious syphilis notification rate per 100,000 rose from 2.6 in 2012 to 26.6 in 2021; for women aged 25–29 the increase was from 4.9 to 22.7 per 100,000 over the same period.4King J. McManus H. Kwon A. Gray R. McGregor S. HIV, viral hepatitis and sexually transmissible infections in Australia: annual surveillance report 2022. The Kirby Institute, UNSW Sydney, Sydney, Australia2022http://handle.unsw.edu.au/1959.4/unsworks_81131Google Scholar Tragically this has been accompanied by re-emergence of congenital syphilis, with a total of 68 cases reported between 2012 and 2021, resulting in 17 infant deaths.4King J. McManus H. Kwon A. Gray R. McGregor S. HIV, viral hepatitis and sexually transmissible infections in Australia: annual surveillance report 2022. The Kirby Institute, UNSW Sydney, Sydney, Australia2022http://handle.unsw.edu.au/1959.4/unsworks_81131Google Scholar Aboriginal and Torres Strait Islanders (Australia's First Nations people) are disproportionately affected by syphilis, for whom infectious syphilis and congenital syphilis rates are 5.5 and 18 times higher, respectively, than for the general population.4King J. McManus H. Kwon A. Gray R. McGregor S. HIV, viral hepatitis and sexually transmissible infections in Australia: annual surveillance report 2022. The Kirby Institute, UNSW Sydney, Sydney, Australia2022http://handle.unsw.edu.au/1959.4/unsworks_81131Google Scholar There is currently an ongoing syphilis outbreak in remote and rural areas of northern Australia, where healthcare access is limited.4King J. McManus H. Kwon A. Gray R. McGregor S. HIV, viral hepatitis and sexually transmissible infections in Australia: annual surveillance report 2022. The Kirby Institute, UNSW Sydney, Sydney, Australia2022http://handle.unsw.edu.au/1959.4/unsworks_81131Google Scholar Changing syphilis epidemiology in Australia and other high-income countries has led to a renewed focus on testing and treatment along with updated guidelines. A range of initiatives and health promotion campaigns from Australian national and state governments have been initiated, including ‘Don't Fool Around with Syphilis' and ‘Young Deadly Free’.5Department of Health and Aged Care Young deadly free. Australian Government, Canberra2020https://youngdeadlyfree.org.au/about-us/the-syphilis-campaign/#:∼:text=Young%20Deadly%20Syphilis%20Free%20is,Queensland%2C%20including%20Torres%20Strait%20IslandsGoogle Scholar,6Department of Health and Aged Care Donon deadly free. Canberra: Australian government.https://www.health.gov.au/dont-fool-around-with-syphilisGoogle Scholar The Australian STI management guidelines have also recently been updated and now recommend syphilis serology as part of all asymptomatic STI screening.7Australian Sexual Health Alliance Australian STI management guidelines for use in primary care.2022https://sti.guidelines.org.au/Google Scholar Whilst there is high awareness and testing for syphilis among men who have sex with men, this is less so for heterosexual people who may not perceive themselves as at risk (or be aware of their risk status) and for whom understanding and awareness of syphilis is low compared with chlamydia or gonorrhoea.8Bittleston H. Goller J.L. Temple-Smith M. Coombe J. Hocking J.S. How much do young Australians know about syphilis compared with chlamydia and gonorrhoea? Findings from an online survey.Sex Transm Dis. 2023; 50 ([cited 2023 Aug 7];Publish Ahead of Print. Available from:): 575https://journals.lww.com/10.1097/OLQ.0000000000001834Crossref PubMed Scopus (0) Google Scholar Initiatives to increase syphilis testing and uptake are imperative. Gupta et al. report in this article on an opt-out syphilis testing strategy for women implemented in a large Australian metropolitan sexual health clinic in December 2017. The opt-out strategy involved the recommendation of a syphilis test for all female patients regardless of their risk and demographic characteristics. Prior to this, syphilis testing at the clinic was risk-based. They analysed data for 27,481 women attending between 2015 and 2020, finding that the switch from risk-based to opt-out testing resulted in an increase in syphilis testing from 52.8% to 67.4%. They also found no change in syphilis positivity rates between the two time periods, indicating that it is not redundant to expand testing those who would have been considered at lower risk. On the contrary, the authors found that testing more widely within the sexual health clinic setting resulted in the detection of a number of infections that may otherwise have gone undetected, allowing these cases to be treated and the prevention of potentially harmful sequelae. The authors noted a large proportion of asymptomatic diagnoses and an increase in the detection of cases of late-stage syphilis that would likely have otherwise been missed, demonstrating the impact of the opt-out approach. Previous studies in other contexts have demonstrated that opt-out approaches or routine testing offers are effective for increasing STI or HIV testing rates. For example, opt-out strategies have been shown to increase chlamydia and gonorrhoea testing among young people and nurse-led models involving a routine testing offer have led to increased HIV testing in primary care.9Leber W. Panovska-Griffiths J. Martin P. et al.Evaluating the impact of post-trial implementation of RHIVA nurse-led HIV screening on HIV testing, diagnosis and earlier diagnosis in general practice in London, UK.eClinicalMedicine. 2020; 19100229Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar,10Tomcho M.M. Lou Y. O'Leary S.C. et al.Ety gap: an intervention to improve Chlamydia and gonorrhea testing for adolescents and young adults in primary care.J Prim Care Community Health. 2022; 13215013192211313Crossref PubMed Scopus (2) Google Scholar Gupta et al. add to this body of research, confirming that opt-out approaches are also effective for expanding syphilis testing among women. Testing implementation studies such as these are important for optimising our response to STI outbreaks and ensuring public health responses are evidence-based and effective. To address recent rises in syphilis in Australia and elsewhere, opt-out strategies should be considered to increase testing among women and as an important part of preventing congenital syphilis. LB wrote initial draft, did referencing and formatting, and made final revisions. JG made edits to the draft and added statistics and literature. HB made edits to the draft and added statistics and literature. The authors declare no conflicts of interest. Increased syphilis testing and detection of late latent syphilis among women after switching from risk-based to opt-out testing strategy in an urban Australian sexual health clinic: a retrospective observational studyThe opt-out testing strategy increased syphilis testing among women with increased detection of asymptomatic late latent syphilis. The opt-out syphilis testing strategy is beneficial in sexual health services. Health education and awareness may be required to improve syphilis testing uptake. Full-Text PDF Open Access