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Background  Since 2000, substantial increases in syphilis in men who have sex with men (MSM) have been reported in many cities. Condomless anal sex (CAS) is one of the factors, along with drugs for sex and sex in group. This study identified factors and clinical manifestations as well as  Treponema pallidum (T.pallidum)  strains that could be related to early syphilis in Barcelona.    Methods  This prospective study was conducted in a sexually transmitted infections unit in 2015. Epidemiological, behavioral, clinical and microbiological variables were collected in a structured form. Univariate and multivariate statistical analyses were performed focusing on HIV-positive patients.    Results  Overall, 274 cases were classified as having early syphilis (27.5% primary, 51.3% secondary, and 21.2% early latent syphilis). In all, 94% of participants were MSM and 36.3% were HIV-positive. The median number of sexual contacts in the last 12 months was 10; 72.5% practiced CAS, 50.6% had sex in group, and 54.7% consumed drugs. HIV-positive cases had more anonymous sex contacts ( p  = 0.041), CAS ( p  = 0.002), sex in group ( p  < 0.001) and drugs for sex ( p  < 0.001). In the multivariate analysis, previous syphilis (adjusted odds ratio [aOR] 4.81 [2.88–8.15]), previous  Neisseria gonorrhoeae  infection (aOR 3.8 [2.28–6.43]), and serosorting (aOR 20.4 [7.99–60.96]) were associated with having syphilis. Clinically, multiple chancres were present in 31% of cases with no differences on serostatus, but anal chancre was most common in HIV-positive patients ( p  = 0.049). Molecular typing did not conclusively explain clinical presentation in relation to specific  T.pallidum  strains.    Conclusion  Control of syphilis remains a challenge. Similar to prior studies, HIV-positive patients were found to engage more often in sexual behaviors associated with syphilis than HIV-negative patients. Clinical manifestations were rather similar in both groups, although anal chancre was most common in HIV-positive patients. Various strain types of syphilis were found, but no clinical associations were identified.

Early syphilis: risk factors and clinical manifestations focusing on HIV-positive patients