Who should be tested for syphilis? Rationalising syphilis screening in sexual health clinics

Dear Editor,

There has been an epidemic of syphilis among men who have sex with men (MSM) locally since 2000. ¹ Sexual health services are currently experiencing financial pressure and need to streamline all aspects of care. Rationalising the number of syphilis tests in low-risk patients could make significant savings.

Using our clinical database, we searched for patients diagnosed with early syphilis in the previous five years, and then using clinical coding and electronic patient records, we excluded the following cases: MSM, HIV-positive, people who inject drugs (PWID), known contacts of syphilis, non-EU citizens, sexual contacts from non-EU countries, sex workers (SWs) and victims of sexual assault.

We identified 116 cases of early syphilis in the time period of which 104 were MSM, leaving 12 non-MSM cases. Of these, eight were male and four female. Six men, although not coded MSM, had documented sexual contact with other men. Of the remaining six patients (four female and two male), all had identifiable risk factors including sexual exposure in high-prevalence countries in Latin America, sub-Saharan Africa, the Indian sub-continent and Eastern Europe, and one male had a symptomatic genital ulcer.

Of the 116 cases of early syphilis, all had identifiable risk factors from the clinical history. Testing patients for syphilis at each sexual health attendance is expensive and potentially unnecessary. Locally where the syphilis epidemic is almost exclusively occurring in MSM, we suggest that all new patients should be screened for syphilis at their initial presentation, but repeat screening in non-MSM could be rationalised to those who are symptomatic with ulcers or rashes or have identifiable risk factors on sexual history taking – endemic risk/partners, PWID, victims of sexual assault or SWs. All MSM should continue to be screened routinely. From these data, we cannot recommend limiting HIV testing in this low-risk population attending sexual health services, but this could be considered following careful evaluation. Reduced screening for syphilis in sexual health services has been adopted in some areas, but there is a paucity of published data, and further work is needed exploring the safety and cost effectiveness of this approach.