UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Treatment and prevention of syphilis in the HIV-infected patient

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

INTRODUCTION

The approach to the treatment of syphilis in the HIV-infected patient is generally similar to the HIV-seronegative host, with some important caveats, as discussed below.

The treatment, monitoring, and prevention of syphilis in the HIV-infected patient are discussed here. The epidemiology, clinical features, and diagnosis of syphilis in the HIV-infected patient are discussed elsewhere. (See "Epidemiology, clinical presentation, and diagnosis of syphilis in the HIV-infected patient".)

TREATMENT

General principles — The HIV-infected patient with syphilis should be treated with the same regimens as recommended for HIV-seronegative patients [1-3]. The exact formulation varies with the stage of syphilis, but penicillin is the drug of choice.

Although alternative drugs have been utilized for the treatment of syphilis in HIV-seronegative patients, there are very limited data on the efficacy of these medications in the HIV-infected patient [4-8]. (See 'Primary and secondary syphilis' below.)

There are conflicting data as to whether HIV status has an impact on treatment outcomes or serologic responses. Several studies have suggested that serologically-defined treatment failures may be more common among HIV-infected patients [9,10]. The clinical import of this laboratory finding is unclear since this may be the result of slower declines in non-treponemal serologies rather than a lack of clinical response to treatment [10]. In contrast, in one prospective, multicenter, randomized trial of 541 patients, of whom 19 percent of whom were HIV-seropositive, no difference in clinical outcomes (resolution of rash or ulcers) was seen at one-year follow-up, regardless of HIV status [9].

                

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Thu Jun 04 00:00:00 GMT+00:00 2015.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Workowski KA, Bolan GA, Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015; 64:1.
  2. http://www.cdc.gov/std/treatment/2010/default.htm.
  3. Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: Recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf (Accessed on September 06, 2016).
  4. Ghanem KG, Erbelding EJ, Cheng WW, Rompalo AM. Doxycycline compared with benzathine penicillin for the treatment of early syphilis. Clin Infect Dis 2006; 42:e45.
  5. Long CM, Klausner JD, Leon S, et al. Syphilis treatment and HIV infection in a population-based study of persons at high risk for sexually transmitted disease/HIV infection in Lima, Peru. Sex Transm Dis 2006; 33:151.
  6. Marra CM, Boutin P, McArthur JC, et al. A pilot study evaluating ceftriaxone and penicillin G as treatment agents for neurosyphilis in human immunodeficiency virus-infected individuals. Clin Infect Dis 2000; 30:540.
  7. Wong T, Singh AE, De P. Primary syphilis: serological treatment response to doxycycline/tetracycline versus benzathine penicillin. Am J Med 2008; 121:903.
  8. Gutierrez-Galhardo MC, do Valle GF, Sá FC, et al. Clinical characteristics and evolution of syphilis in 24 HIV+ individuals in Rio de Janeiro, Brazil. Rev Inst Med Trop Sao Paulo 2005; 47:153.
  9. Rolfs RT, Joesoef MR, Hendershot EF, et al. A randomized trial of enhanced therapy for early syphilis in patients with and without human immunodeficiency virus infection. The Syphilis and HIV Study Group. N Engl J Med 1997; 337:307.
  10. Ghanem KG, Erbelding EJ, Wiener ZS, Rompalo AM. Serological response to syphilis treatment in HIV-positive and HIV-negative patients attending sexually transmitted diseases clinics. Sex Transm Infect 2007; 83:97.
  11. Ghanem KG, Moore RD, Rompalo AM, et al. Neurosyphilis in a clinical cohort of HIV-1-infected patients. AIDS 2008; 22:1145.
  12. Marra CM, Maxwell CL, Tantalo LC, et al. Normalization of serum rapid plasma reagin titer predicts normalization of cerebrospinal fluid and clinical abnormalities after treatment of neurosyphilis. Clin Infect Dis 2008; 47:893.
  13. Ghanem KG, Moore RD, Rompalo AM, et al. Antiretroviral therapy is associated with reduced serologic failure rates for syphilis among HIV-infected patients. Clin Infect Dis 2008; 47:258.
  14. González-López JJ, Guerrero ML, Luján R, et al. Factors determining serologic response to treatment in patients with syphilis. Clin Infect Dis 2009; 49:1505.
  15. Ganesan A, Mesner O, Okulicz JF, et al. A single dose of benzathine penicillin G is as effective as multiple doses of benzathine penicillin G for the treatment of HIV-infected persons with early syphilis. Clin Infect Dis 2015; 60:653.
  16. Tittes J, Aichelburg MC, Antoniewicz L, Geusau A. Enhanced therapy for primary and secondary syphilis: a longitudinal retrospective analysis of cure rates and associated factors. Int J STD AIDS 2013; 24:703.
  17. Gaudio PA. Update on ocular syphilis. Curr Opin Ophthalmol 2006; 17:562.
  18. Gordon SM, Eaton ME, George R, et al. The response of symptomatic neurosyphilis to high-dose intravenous penicillin G in patients with human immunodeficiency virus infection. N Engl J Med 1994; 331:1469.
  19. Walter T, Lebouche B, Miailhes P, et al. Symptomatic relapse of neurologic syphilis after benzathine penicillin G therapy for primary or secondary syphilis in HIV-infected patients. Clin Infect Dis 2006; 43:787.
  20. Pound MW, May DB. Proposed mechanisms and preventative options of Jarisch-Herxheimer reactions. J Clin Pharm Ther 2005; 30:291.
  21. Yang CJ, Lee NY, Lin YH, et al. Jarisch-Herxheimer reaction after penicillin therapy among patients with syphilis in the era of the hiv infection epidemic: incidence and risk factors. Clin Infect Dis 2010; 51:976.
  22. Riedner G, Rusizoka M, Todd J, et al. Single-dose azithromycin versus penicillin G benzathine for the treatment of early syphilis. N Engl J Med 2005; 353:1236.
  23. Bai ZG, Yang KH, Liu YL, et al. Azithromycin vs. benzathine penicillin G for early syphilis: a meta-analysis of randomized clinical trials. Int J STD AIDS 2008; 19:217.
  24. Marra CM, Colina AP, Godornes C, et al. Antibiotic selection may contribute to increases in macrolide-resistant Treponema pallidum. J Infect Dis 2006; 194:1771.
  25. Mitchell SJ, Engelman J, Kent CK, et al. Azithromycin-resistant syphilis infection: San Francisco, California, 2000-2004. Clin Infect Dis 2006; 42:337.
  26. Lukehart SA, Godornes C, Molini BJ, et al. Macrolide resistance in Treponema pallidum in the United States and Ireland. N Engl J Med 2004; 351:154.
  27. Marra CM, Maxwell CL, Tantalo L, et al. Normalization of cerebrospinal fluid abnormalities after neurosyphilis therapy: does HIV status matter? Clin Infect Dis 2004; 38:1001.
  28. Musher DM. Neurosyphilis: diagnosis and response to treatment. Clin Infect Dis 2008; 47:900.
  29. Knaute DF, Graf N, Lautenschlager S, et al. Serological response to treatment of syphilis according to disease stage and HIV status. Clin Infect Dis 2012; 55:1615.
  30. Centers for Disease Control and Prevention (CDC), Health Resources and Services Administration, National Institutes of Health, HIV Medicine Association of the Infectious Diseases Society of America. Incorporating HIV prevention into the medical care of persons living with HIV. Recommendations of CDC, the Health Resources and Services Administration, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR Recomm Rep 2003; 52:1.
  31. Cohen CE, Winston A, Asboe D, et al. Increasing detection of asymptomatic syphilis in HIV patients. Sex Transm Infect 2005; 81:217.
  32. Centers for Disease Control and Prevention (CDC). Primary and secondary syphilis--United States, 2002. MMWR Morb Mortal Wkly Rep 2003; 52:1117.