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Screening for syphilis in HIV-positive men who have sex with men (MSM)

Sir: We read with interest the recent clinical audit from Sydney looking at adherence to screening guidelines for men who have sex with men (MSM) by Ryder et al. Sexually transmitted infection (STI) testing guidelines for MSM have been endorsed by the Australasian College of Sexual Health Physicians, and suggest at least annual screening for syphilis in patients who have had sex with another man in the previous year. National Data from Australia demonstrate increasing numbers of infectious syphilis diagnoses, particularly in men. Given the continued outbreaks of syphilis across the globe in MSM, we were surprised the authors found that HIV-positive MSM were significantly less likely to be tested for syphilis in 2002, following the implementation of screening guidelines, but for other tests, no significant differences were found. In the light of the UK syphilis epidemic, where the bulk of new diagnoses have been seen in MSM, many of whom are co-infected with HIV, we find this concerning. Our recent publication demonstrated increasing detection of asymptomatic syphilis in HIV-positive patients who are routinely tested with their HIV follow-up bloods. In all, 38 of 40 asymptomatic cases in a one-year screening period were in MSM, consistent with our expectations. Likewise, during the study period, 63% of all early syphilis diagnoses within our genitourinary medicine centre were found in known HIV-positive individuals. This routine screening method was introduced in our unit in 2001 and has continued since. We also routinely offer syphilis screening to MSM within our sexual health service at each visit, even if they decline HIV testing. We would recommend that MSM groups within genitourinary medicine services and primary care in Australia, should be specifically targeted with regard to syphilis screening, particularly if co-infected with HIV where the issues of increased HIV transmission are also important. Annual screening alone in MSM (regardless of HIV status) is insufficient. By introducing a similar initiative to our own of routine screening at every visit, many co-infected MSM could be identified at an earlier stage of infection which would help in controlling the Australian syphilis outbreak.