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Australia’s national screening program for syphilis shows progress
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A national syphilis screening program increased detection of asymptomatic infection and decreased the incidence of secondary syphilis among men who have sex with men in Australia, according to findings recently published in Clinical Infectious Diseases.
“Rates of syphilis among men who have sex with men (MSM) have been rising in many countries since the beginning of the 21st century and are now at the highest levels in decades in several regions,” Eric P.F. Chow, PhD, research fellow at the Melbourne Sexual Health Centre, and colleagues wrote. “In Australia, the National Syphilis in Gay Men Action Plan was released in 2009 and recommended frequent syphilis screening of higher risk HIV–negative as well as opt-out serological screening for syphilis with routine HIV monitoring in HIV–positive MSM. Australian guidelines recommended that all MSM be screened for syphilis at least once a year, with more frequent screening of higher risk men.”
The researchers performed serial cross-sectional analyses of 46 public sexual health clinics in Australia from 2007 to 2014, reviewing 359,313 visits. Approximately one-third of visits (32%) consisted of MSM with HIV.
During the study period, the proportion of MSM without HIV who were tested for syphilis increased from 7,677 to 19,179 (48%-91%; P < .0001), whereas the proportion of MSM with HIV rose from 1,664 to 3,273 (42%-77%; P < .0001), the researchers reported. Among those without HIV, the mean number of annual tests increased from 1.3 to 1.6 (P < .0001), and from 1.6 to 2.3 in those with HIV.
Overall, testing detected 2,799 early latent syphilis cases in HIV–negative men and 1,032 cases in HIV–positive men. Chow and colleagues wrote that the proportion of early latent detected syphilis infections in those without HIV rose from 27% to 44% (P < .0001), whereas the proportion of secondary cases decreased from 24% to 19% (P = .03). In MSM with HIV, the proportion of early latent infections rose from 23% to 45% (P < .0001), with the proportion of secondary cases falling from 45% to 26% (P = .0003).
Chow and colleagues reported a correlation between falling proportions of secondary syphilis and increasing testing coverage (r = -0.87; P = .005) or frequency (r = -0.93; P = .001) among MSM with HIV.
“The Australian study supports and extends previous research demonstrating that targeted, community-supported and adequately resourced campaigns are highly effective at increasing syphilis testing,” Jeffrey D. Klausner, MD, MPH, of the division of infectious diseases at the University of California, Los Angeles, wrote in an accompanying editorial.
“Currently, in the context of the syphilis epidemic in the United States, we are doing reasonably well at measuring the burden of disease but lack strong actors and clear communication regarding the impact of the disease, and we live within a political climate largely indifferent to the health of the most affected populations — men who have sex with men and, in the case of congenital syphilis, disadvantaged families. As infectious disease specialists, we must work to change that.” – by Andy Polhamus
Disclosure: Klausner reports grants from NIAID, NIH and NIMH. The researchers report no relevant financial disclosures.
Perspective
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Chow and colleagues show compelling evidence that a countrywide effort to increase the number of at-risk men tested for syphilis has reaped its rewards. Study outcomes extended beyond an increase in syphilis testing to an association with a decline in secondary syphilis. During this time, transmission of syphilis (and concomitant HIV in coinfected men) is most risky. The story began in 2009 when Australia’s National Syphilis in Gay Men Action Plan was rolled out. True to its name, “action” went beyond simply writing guidelines and issuing edicts. Rather, public health authorities were able to galvanize community support and obtain sufficient dollars to finance the program on a national basis. Once this was achieved, implementation of the testing recommendations in men attending outpatient clinics occurred by a clever combination of an opt-out approach and a linkage to HIV-1 viral load testing among those who were HIV–infected. The rest of the world can learn much from this Australian playbook. Ultimately, progress in breaking the epidemic can only occur with the right political will — a coordinated, well-resourced and prioritized national effort by progressive leaders.
But as rings true with HIV and other sexually transmitted infections, “getting to zero” requires much more. An intervention that targets men attending clinics would not reach the most vulnerable individuals who may not self-identify as being at-risk in the first place to obtain clinical services. Others may know of their infection risk but may be impeded by cost, discrimination and shame to seek medical services. The right political leadership is key, but unless stigma and social justice are addressed head-on, our progress will be limited.
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