Syphilis cases have increased dramatically among people living with HIV/AIDS in Australia, a group of health educators, clinicians and HIV activists heard in Sydney at a meeting convened by the Australian Federation of AIDS Organisations (AFAO) in November.

The most troubling of the findings discussed during the day was the highly aggressive nature of syphilis infection amongst HIV-positive people, emphasising the importance of positive people taking steps to protect themselves against syphilis.

Syphilis outbreaks have appeared recently in other countries amongst HIV-positive people – in the UK, Europe and Canada and across the United States including New York, Seattle, Chicago, San Francisco, Los Angeles and Miami. In San Francisco, the number of cases has quadrupled in the past three years.

Australia is currently also recording very high levels of sexually transmitted infections including gonorrhoea, chlamydia, and syphilis, all of which not only affect the health of positive people but also increase the likelihood of transmitting HIV to others.

Dr Andrew Grulich, associate professor at the National Centre in HIV Epidemiology and Clinical Research, revealed at the meeting that comparative research between HIV-positive gay men and HIV-negative gay men in NSW in 2005 indicated that rates of recent syphilis infection (within the past year) were ten times higher among HIV-positive gay men. In 2004, more than 60 percent of new cases of syphilis in NSW were diagnosed amongst HIV-positive gay men.

The problem for people living with HIV/AIDS is that many STIs manifest differently, the treatment can be different and the impact of having both HIV and an STI is different. With syphilis, the problem becomes even more pronounced.

What is syphilis?

Syphilis is a bacterial infection that enters the body via mucous membranes or even via the skin. Using condoms reduces the risk of transmission of syphilis but transmission can still occur even when condoms are used.

Syphilis has three stages, the first which presents as an ulcer at the point of infection (the anus, penis, mouth or elsewhere). The second stage usually begins as a rash and can appear up to 12 weeks after infection – it is during the first two stages that the person is most infectious. However, most transmission occurs from people who have no visible signs of the disease and who may not be aware they have syphilis.

Treatment for syphilis during the first and second stages is normally a course of penicillin injections over the course of a number of weeks.

If treatment is not given during the first or second stage, the disease enters a latent or dormant stage, in which no symptoms may occur – sometimes lasting years or even decades.

By the third stage, syphilis can be devastating, profoundly affecting any number of body parts and organs – including the heart (cardiovascular syphilis) the brain (neurosyphilis) and the bones (known as benign tertiary syphilis which results in a deep, penetrating pain that is usually worse at night). At this stage treatment is limited and due to the aggressive nature of syphilis the damage is already done and cannot be reversed.

Syphilis and HIV

In people with HIV, progression to tertiary syphilis can be much faster than in negative people, can present with different symptoms and there is an increased risk of development of neurosyphilis. Clinical studies have shown that having syphilis can reduce CD4 counts and increase HIV viral load.

Many people do not realise that having syphilis (or a number of other STIs) not only makes it easier to acquire HIV it also means that transmitting HIV is much more likely and the likelihood of passing STIs between HIV positive people is increased due to a diminished immune response.

“In the case of syphilis we are seeing a much faster disease progression amongst HIV positive people with tertiary syphilis presenting within months as opposed to years,” said Dr Darren Russell, a sexual health physician based in Cairns and past president of AFAO. “HIV-positive guys with lower T-cell counts are both more likely to be infectious and to get more ulcers at the primary stage of infection with syphilis.”

The response

AFAO is in the process of developing a national strategic response to the issue of sexually transmitted infections among gay men. The organisation is meeting with stakeholders and conducting training programs for staff at AIDS councils and PLWHA organisations. In addition the organisation will be releasing an education campaign early in 2006 in conjunction with state and territory AIDS councils across Australia.

The Australasian Society for HIV Medicine (ASHM) is also involved. “Even though ASHM is not funded to do work specifically with regard to syphilis – we feel that this issue is so important to quality HIV care that we will be working closely with Australasian Chapter for Sexual Health Medicine to ensure that all HIV physicians across the region are kept up to date with the latest information with regard to early detection, diagnosis and effective management of syphilis in HIV positive patients,” said Levinia Crooks, the executive officer of ASHM.

Protecting yourself

The best advice comes from Dr Russell: “If you are a sexually active HIV-positive person, you may want to discuss regular syphilis testing with your doctor and perhaps consider having a syphilis test done when you have your regular blood tests for HIV. From one to four times a year is a good idea.” Syphilis is detected via a simple blood test which your doctor can request along with your regular HIV blood work.

What is important to remember is that syphilis affects HIV positive people much more aggressively and although you may have been cured of syphilis once, it does not mean that you are immune and you can be infected with syphilis again. The only way to stop the spread of syphilis is to be tested on a regular basis.

Brent Allan is a director of NAPWA.