Review of Current Evidence and Comparison of Guidelines for ...

EUR/03/5045931
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current treatment is adequate. The difficulty in interpreting evidence in HIV positive patients is
compounded by the fact that many patients may currently be receiving anti-retroviral therapy,
thereby boosting their immune systems. However, it is not known what will happen to those
patients in the long term if they fail on their anti-retroviral treatments and have a reduction in
their CD4 counts.
This new evidence looking at HIV and syphilis co-infection has led to many of the conclusions
about treatment regimes in all stages of disease, both in HIV positive and negative patients. In
the main, the guidelines propose that treatment for syphilis in patients with HIV should be no
different from guidelines in HIV negative patients. Specific differences in treatment are as
follows; the CDC guidelines suggest a possible three dose of benzathine penicillin at day 1, day
8 and day 15 in early syphilis. Due to concern about higher levels of asymptomatic neurosyphilis
in HIV positive patients (Rolfs study found a higher level of CSF changes in the HIV positive
group) CDC recommends the examination of CSF in all HIV positive individuals with late
syphilis and consideration of this in early syphilis. United Kingdom guidelines propose treating
all HIV positive patients with treatment for neurosyphilis. CSF examination is advisable in all
HIV positive patients in the European guidelines; otherwise treatment is the same as for HIV
negative patients. There are no specific guidelines for the treatment of HIV/syphilis co-infected
patients in Russian Federation.
It is recommended in all guidelines that all patients who are diagnosed with syphilis should be
tested for HIV.
Syphilis in Pregnancy
To add to a complex situation in terms of pathogenesis and treatment of syphilis, the challenge in
pregnancy is finding treatment which will treat the mother adequately, while not harming the
fetus, and either treat or prevent infection in the fetus. A recent Cochrane review has looked at
the various regimes used (100). Singh and McCloskey have written a review article on syphilis
in pregnancy that also mentions Australian guidelines (101). As in other areas of syphilis
management there has been no comparison made about the relative efficacy of different
penicillins (5).
The CDC guidelines recommend using the same regimes as for the relevant stage of syphilis as
in non-pregnant patients but with a possible second dose at day 8 for BBP in early syphilis (5).
This is based on research showing that due to physiological changes in pregnancy a single IM
dose of 2.4 mu benzathine penicillin remains at treponemicidal levels (>0.018 µg/ml) in serum
for three times longer in non-pregnant than pregnant women (102). Watson-Jones et al.
completed a prospective cohort trial of 1688 pregnant women in Tanzania (103). A total of 382
women with positive syphilis serology were given a single dose of BBP (2.4mu IM). This
showed no increased risk of adverse pregnancy outcome for women with positive syphilis
serology treated with BBP compared with 950 seronegative women. Stillbirth rate was 2.3% in
seropositive treated women and 2.5% in seronegative women. Low-birth-weight live births were
6.3% in seropositive treated women and 9.2% in seronegative women. Alexander and colleagues
followed CDC guidelines (i.e. single dose BBP) in 448 pregnant women with early syphilis, with
a success rate of 98.2% in preventing congenital syphilis (104). However, a study in Africa
found if two doses of BBP one week apart were used in pregnant women with early syphilis
there were lower rates of congenital syphilis and infant mortality, with higher birth weights (25).
A PBP regime is recommended in the United Kingdom guidelines reflecting concern over