USPSTF Advises to Keep Screening for Syphilis as Cases Soar

Nonpregnant teens and adults who have ever been sexually active and are at increased risk for syphilis should still be screened for the sexually transmitted infection, the U.S. Preventive Services Task Force (USPSTF) said on Tuesday.

The final recommendations garnered an “A” grade, and are firmly in line with the draft guidance posted earlier this year and the Task Force’s 2016 recommendation on the matter, according to Carol Mangione, MD, MSPH, of the University of California Los Angeles, and other members of the USPSTF. (Pregnant women should continue to follow separate recommendations for syphilis screening most recently released in 2018.)

While the optimal screening frequency for teens and adults at increased risk for syphilis is not well established, Mangione and coauthors noted in JAMA, people living with HIV and men who have sex with men (MSM) may benefit from annual or more-frequent screening (every 3 or 6 months) if they continue to be at high risk.

Along with MSM and people with HIV, rates of syphilis are also higher in those who use illicit drugs and people with a history of incarceration, military service, or sex work, according to the guidance.

“Healthcare professionals should be knowledgeable about a patient’s risk for syphilis infection based on both an individual- and community-level assessment,” said Task Force Vice Chair Michael Barry, MD, of Massachusetts General Hospital in Boston, in a press release. “Risk is dependent on a combination of factors including how common syphilis infections are in the community, social factors affecting a patient’s ability to maintain sexual health, and individual risk factors such as sexual history.”

The new recommendations come at a time when a substantial uptick in syphilis infections in the U.S. has been reported. From 2000 to 2019, primary and secondary infections increased from 2.1 to 11.9 cases per 100,000 persons, according to data from the CDC.

Most of the cases in 2019 involved men (83%), with MSM comprising 57% of those infections. Black individuals had five times the case rates of white individuals, and rates of syphilis were also higher in Hispanic, Native American/Alaska Native, and Native Hawaiian/Pacific Islander populations.

To illustrate the benefit of annual screening in a MSM population, the USPSTF pointed to evidence from Australia. There, annual screening in a study of more than 100,000 MSM boosted the detection of latent infections from 27% to 44% in HIV-negative men and from 23% to 45% in HIV-positive men. Testing also reduced secondary infections from 24% to 19% in the HIV-positive group, and from 45% to 26% in the HIV-negative group.

“It is vital that people who are at increased risk for syphilis get screened so the infection can be treated before problems develop or worsen,” Task Force member Katrina Donahue, MD, MPH, of the University of North Carolina at Chapel Hill, said in a press release.

Undetected and untreated, syphilis can damage the brain, nerves, eyes, and cardiovascular system, leading to movement disorders, sensory deficits, dementia, and paralysis.

In an accompanying editorial, Susan Tuddenham, MD, MPH, and Khalil Ghanem, MD, PhD, both of Johns Hopkins University in Baltimore, said that while syphilis screening has been promoted for years, “uptake in key populations, such as people with HIV and MSM, has been poor, indicating the need for improvement.”

They made the case for the “modernization” of screening.

“Relying on existing approaches that depend on traditional clinician-driven, clinic-based testing will not curtail the epidemic,” the editorialists wrote. They suggested two approaches for achieving better screening rates: at-home sample collection and at-home rapid testing. These approaches would allow patients to order, self-collect, and submit the samples via mail or at a convenient drop-off location to a central laboratory for testing, they said. The lab would then contact the patient with results and further instruction.

“This approach has been used for gonorrhea and chlamydia testing using nucleic acid amplification tests and has proved feasible and acceptable to patients,” Tuddenham and Ghanem noted. “Failure to modernize screening strategies for syphilis will also mean failure to control this infection.”