Is It Time to Rethink Syphilis Control?

TO THE EDITOR—We read with interest the iPrEx substudy by Solomon et al electronically published in the journal on 13 June [1]. This demonstrated a strikingly increased human immunodeficiency virus (HIV) incidence associated with incident syphilis infection (2.8 cases per 100 person-years for no syphilis vs 8 cases per 100 person-years for incident syphilis (hazard ratio, 2.6; 95% confidence interval [CI], 1.2–4.1; P < .001). These data add substantial weight to the evidence base demonstrating the strong link between incident syphilis infection and HIV acquisition risk among gay and other men who have sex with men (GMSM) and raise the importance of prevention strategies focusing on all sexually transmitted infections (STIs) including HIV. Since the arrival of effective combination antiretroviral therapy (ART) in the mid-1990s, GMSM across the world have experienced growing epidemics of bacterial (STIs) including syphilis, chlamydia, and gonorrhea (Figure 1). The basis for these epidemics is related to engagement in sexual practices thought unlikely to transmit HIV infection (eg, oral sex) but through which other STIs may be readily transmitted, HIV “transmission optimism” regarding the impact of ART on the likelihood of HIV transmission, and increased sexual risk behavior in the context of “serosorting” among GMSM (ie, GMSM permitting unprotected anal intercourse with sexual partners of the same HIV infection status) [2–4]. It has been estimated that the rate of syphilis infections in GMSM in most highand middle-income countries is >1000 times the notification rate in the general community. In Australia in 2012, therewere >9500 gonorrhea notifications in men, a 68% increase since 2008. Considerable public health efforts in Australia have