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Epidemiology, clinical presentation, and diagnosis of syphilis in the HIV-infected patient

Anne Rompalo, MD
Section Editor
Noreen A Hynes, MD, MPH, DTM&H
Deputy Editor
Jennifer Mitty, MD, MPH


Syphilis is a sexually acquired infection, which is characterized by episodes of active clinical disease interrupted by periods of latent infection, if left untreated. Studies suggest that HIV infection modulates the clinical presentation of syphilis with greater organ involvement, atypical and florid skin rashes, and more rapid progression to neurosyphilis. The results of serologic tests for syphilis may also be modified in HIV-infected patients. Furthermore, emerging data suggest that syphilis may have a negative impact on HIV viral load.

The clinical presentation of syphilis in the HIV-infected patient will be reviewed here. The diagnosis and treatment of the HIV-infected patient with syphilis and syphilis in immunocompetent patients and other hosts are discussed separately. (See "Syphilis: Epidemiology, pathophysiology, and clinical manifestations in HIV-uninfected patients" and "Syphilis: Treatment and monitoring" and "Syphilis: Screening and diagnostic testing" and "Treatment and prevention of syphilis in the HIV-infected patient".)


Syphilis is caused by the spirochete Treponema pallidum subspecies pallidum, a corkscrew-shaped, microaerophilic bacterium, which cannot be cultivated in the laboratory. (See "Syphilis: Epidemiology, pathophysiology, and clinical manifestations in HIV-uninfected patients", section on 'Microbiology'.)

Because of the inability to grow T. pallidum in culture, the diagnosis of syphilis depends upon the sexual exposure history, recognition of protean clinical signs and symptoms, and interpretation of diagnostic testing.


Although the rates of primary and secondary syphilis in the United States declined 90 percent from 1990 to 2000, the rates increased annually from 2001 to 2009. In 2013, the rate of reported primary and secondary syphilis in the United States was 5.3 cases per 100,000 population [1], more than double the lowest-ever rate of 2.1 in 2000 [2]. The largest increase in the number of syphilis cases has occurred among men who have sex with men (MSM). The increasing incidence of syphilis in this population is due in part to rising rates of risky sexual behaviors, such as anonymous sex, unprotected sex (oral and anal), sex with multiple partners, and/or sex under the influence of drugs, especially methamphetamine [3-9].


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Literature review current through: Sep 2016. | This topic last updated: Apr 23, 2015.
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