Letters to the Editor

Management of Syphilis in People with HIV Infection


Am Fam Physician. 2021 Oct ;104(4):335.

Original Article: HIV Infection in Adults: Initial Management

Issue Date: April 1, 2021

Available at: https://www.aafp.org/afp/2021/0401/p407.html

To the Editor: The article by Drs. Goldschmidt and Chu comprehensively covered the initial management of adults with HIV infection. There is a difference in the management of syphilis in people with HIV infection that may be beneficial for readers to note. The number of primary and secondary syphilis cases reported in the United States has been increasing, reaching 35,063 cases (10.8 cases per 100,000 population) in 2018, which is a 71% increase from 2014.1 The recommended treatment for primary and secondary syphilis is a single dose of intramuscular penicillin G benzathine, 2.4 million units, regardless of HIV infection. Clinical and serologic responses to treatment are similar except for a slower serologic response in people with HIV infection.2 However, follow-up management of syphilis in people with HIV infection differs from that in people without HIV infection.3

The Centers for Disease Control and Prevention (CDC), the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America issued a clinical practice guideline for opportunistic infections and sexually transmitted infections, including syphilis.4 The guideline recommends that clinicians clinically and serologically reevaluate people with HIV infection at three, six, nine, 12, and 24 months after treatment for primary or secondary syphilis instead of at follow-up evaluations at six and 12 months after therapy in those without HIV infection.

Author disclosure: No relevant financial affiliations.


show all references

1. Centers for Disease Control and Prevention. Sexually transmitted disease surveillance 2018. October 2019. Accessed August 7, 2021. https://www.cdc.gov/std/stats18/STDSurveillance2018-full-report.pdf...

2. 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(5):307–314.

3. Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015 [published correction appears in MMWR Recomm Rep. 2015;64(33):924]. MMWR Recomm Rep. 2015;64(RR-03):1–137.

4. Panel on Opportunistic Infections in Adults and Adolescents with HIV. Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV: 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. Accessed August 7, 2021. https://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/Adult_OI.pdf

In Reply: We appreciate Dr. Sonoda's important reminder about follow-up testing intervals for primary and secondary syphilis in people with HIV. Our article focused on initial management and did not go in-depth on follow-up protocols for the range of co-occurring conditions and infections that can be identified with a baseline evaluation of people newly diagnosed with HIV. The 2021 updated CDC Sexually Transmitted Infections Treatment Guidelines have been released.1 These guidelines provide HIV-specific screening, diagnosis, treatment, and follow-up recommendations, which can differ for people with HIV. The section on “Syphilis Among Persons with HIV Infection” lists the follow-up intervals for primary or secondary syphilis as noted by Dr. Sonoda.

Author disclosure: No relevant financial affiliations.


1. Workowski KA, Bachmann LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1–187.

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