Improved results demonstrated in the 2017 national audit of early syphilis management in the United Kingdom

Abstract

The revised British Association of Sexual Health and HIV UK guidelines on the management of syphilis were published in 2015 and this audit measures performance against those standards and recommendations. Although not included in the guideline recommendations, an exploratory question on clinics’ HIV testing policy was also included. The audit was conducted over a two-month period in 2017 in genitourinary medicine (GUM) clinics across the UK of cases presenting in 2016. A total of 161 GUM clinics participated, and data were collected for 3017 cases. The standard for adherence to recommended treatment was met (97%, standard: 97%) and almost met for documented pre-treatment syphilis serology (95%, standard: 97%). Even though only 74% of patients had a documented action in relation to informing sexual contacts (standard: 97%), the standard for contacts seen and tested per index case within four weeks was met (0.9, standard: 0.6). Finally, those clinics with a formal policy on HIV testing after a syphilis diagnosis were twice as likely to test after the HIV window period, compared to clinics without a policy; a concurrent HIV diagnosis was made in 75 (3%) patients. More work is required to standardize documented delivery of effective partner notification and a formal policy on HIV testing appears to be effective.

Keywords

Syphilis treatment adherence contact tracing partner notification clinical audit

Introduction

There has been a resurgence of syphilis diagnoses in the UK with 5840 cases reported in 2016, predominantly in men who have sex with men (MSM).¹ The effective management of syphilis is critical because secondary and tertiary stage manifestations of the infection have significant risk of morbidity and mortality.² In December 2015, the British Association of Sexual Health and HIV (BASHH) published national UK guidelines³ aimed at protecting individuals and public health by limiting syphilis infection progression and transmission to sexual contacts. One year following publication, the implementation of these guidelines into standard clinical practice in the UK remained unknown; therefore, the BASHH National Audit Group (NAG) initiated a UK-wide audit to measure performance against these standards.

Methods

Audit questions were designed and piloted by the BASHH NAG in January 2017 and data were collected via online survey forms⁴ to allow the return of data on clinic policy and clinical practice (the latter being pseudonymized). The clinic policies survey included questions on the availability of diagnostics, testing policies before and after treatment, and follow-up HIV testing for those who tested HIV-negative at the first visit. The audit of clinic practice was derived from case note reviews of the 40 most recent cases of patients aged 16 years and over in 2016 with early syphilis diagnostic codes (A1, A2, A3).⁵ The data were collected during February and March 2017.

Results

A total of 161 Level 3 genitourinary medicine clinics participated and 3017 case notes were reviewed. Table 1 shows the gender of index cases and their sexual contacts; the majority of cases were men (92%), of whom 83% were MSM. The reasons for testing for syphilis are shown in Table 2.

Table 1.

Gender of patients and their sexual contacts.

Gender	Number (%)	Gender of sexual contact(s)	Number (%)
Male	2767 (91.7)	Male	2305 (83.3)
		Male and female	150 (5.4)
		Female	280 (10.1)
		Trans^a	4 (0.1)
		Not stated	28 (1.0)
Female	199 (6.6)	Male	186 (93.5)
		Male and female	1 (0.5)
		Female	8 (4.0)
		Not stated	4 (2.0)
Trans^a	7 (0.2)	Male	7 (100.0)
Not stated	44 (1.5)	Male	33 (75.0)
		Male and female	4 (9.1)
		Female	3 (6.8)
		Not stated	4 (9.1)

^aAll trans index cases and contacts had been assigned male at birth.

Table 2.

Reasons for syphilis testing.

Reason for syphilis testing	Number (%)
Symptoms attributable to syphilis	1174 (38.9)
Routine sexually transmitted infection screening	713 (23.0)
Symptoms not attributable to syphilis	300 (9.9)
Sexual contacts of a syphilis index patient	241 (8.1)
Diagnosed with syphilis elsewhere	232 (7.7)
Routine monitoring in the HIV clinic	162 (5.4)
Sexual contacts of a non-syphilis index patient	62 (2.1)
At presentation for post-exposure prophylaxis following sexual exposure to HIV	21 (0.7)
Other reasons	130 (4.3)

The stages of early infectious syphilis (number [%]) were similarly distributed between primary (1045 [35]), secondary (774 [26] which included 63 patients where neurological or ophthalmic involvement was suspected) and early latent disease (887 [29]), while there were fewer cases of early asymptomatic/incubating syphilis (276 [9]); for a small number (35 [1]) there were no data.

Results are presented for each of the five audit standards in the 2015 guidelines on the management of syphilis.³

The percentage of confirmed syphilis cases having a record of a RPR or VDRL titre obtained pre-treatment (standard 97% confirmed syphilis cases)

A total of 2860 (95%) cases had quantitative RPR/VDRL assays performed on pre-treatment samples with half taken or repeated on the first day of treatment (1702 [56%]). This test was not done at either visit in 80 (3%) cases and the question was not answered for 77 (3%) patients. Thus, the standard was not met.

The percentage of confirmed syphilis cases having fully adhered to a recommended treatment (standard 97% confirmed syphilis cases)

There were 2905 (97%) confirmed syphilis cases documented as having received appropriate treatment with either a single dose of benzathine penicillin (2.4 mega units), or fully adhering to two weeks of doxycycline, thus the standard was met; Figure 1 shows the breakdown of treatment delivered.

Figure 1.

Treatment given to patients with confirmed syphilis. Suitable regimens are those recommended in the management of syphilis guidelines.³

The percentage of confirmed syphilis cases having a record of a RPR or VDRL titre obtained six months post-treatment (standard 65% of confirmed syphilis cases)

Due to the timing of the data collection, actual practice performance in obtaining a post-treatment RPR/VDRL was not measured because of insufficient time between case finding and data submission for those patients who presented in the latter part of 2016. This standard was therefore addressed within the clinic policy survey: 129 (80%) clinics had a formal policy to perform a quantitative RPR/VDLR assay at three and six months after treatment while the remaining clinics routinely recommending this practice.

The percentage of cases having the outcome of an agreed contact action(s), or the decision not to contact, documented for all contacts, within the appropriate look back interval (standard 97% confirmed syphilis cases)

The standard for this audit outcome was not met, being 23% below the national recommendation. Only 74% of index cases (2227/3003) had an agreed contact action(s), or decision not to contact, documented for all contacts. Documentation was not completed for all contacts in 18% (532/3003) of index patients and the outcomes were either uncertain or not documented for a further 9% (258/3003).

The ratio of contacts per index case of confirmed syphilis, with contact attendance at a Level 1, 2, or 3 sexual health service documented as (a) reported by the index case or by a healthcare worker (HCW) (b) confirmed by a HCW, within four weeks of the date of the first PN discussion (standard (a) 0.6 and (b) 0.4 contacts per index case within an agreed audit interval)

There were 0.94 contacts per index case seen and tested during the four-week period after the first PN interview as reported by the index case or a HCW (a) and 0.45 verified by a HCW (b) – both standards were achieved.

HIV testing policies and their impact on HIV testing after a new syphilis diagnosis

Patients diagnosed with syphilis are at risk of acquiring HIV and the HIV status of each of the syphilis cases in this audit was determined. The largest fraction (number [%]) tested HIV-negative at the start of the episode (2003 [66]) and this was followed by those known to be HIV-positive (877 [29]), a new HIV diagnosis at the time of the syphilis diagnosis (75 [3]), not tested for HIV at the syphilis diagnosis (54 [2]), and not answered (8 [<1]). Of the syphilis cases who were not already diagnosed with HIV, the majority had an HIV test (2078/2140 [97]).

The impact of a formal policy to provide repeat, follow-up HIV testing one month after an initial non-reactive HIV test result performed at the syphilis diagnosis was reviewed. The number (%) of patients who had a second HIV test in clinics with a formal policy [63 clinics], routinely recommended [84] and not routinely recommended [13], was 513/872 (59%), 396/891 (44%), and 50/160 (31%), respectively.

Discussion

This audit demonstrates that sexual health clinics in the UK meet two (recommended treatment and PN) of the four audited standards in the national guidelines.

The standard was met for the completion of a recommended treatment for early syphilis and was close to meeting the standards for pre-treatment testing. These results are comparable to those reported in Los Angeles (LA) county where 97% had confirmed treatment.⁵

In early syphilis the look-back period for PN is up to two years and BASHH have set a performance standard that 97% of index patients should have an agreed contact action documented⁶ and that 0.6 contacts per index case should be seen and tested within four weeks.⁷ In this audit, an agreed contact action was only documented in 74% of patients; however, the number of contacts seen and tested, either according to index patient or the HCW, exceeded the standard with 0.94 contacts per index seen and tested within four weeks.

The number of partners reported as seen and tested at one month in this audit is 50% higher than the figure reported by Public Health England (PHE) for England over a whole year⁸ and this disparity could be due to a number of reasons. One possibility is that we are inadvertently double counting partner attendance from index patient reporting and HCW verification, and consequently we overestimate the success of PN. Equally it is possible that the PHE data underestimate contact testing because the national code for a sexual contact of syphilis (PNS) is not captured at the time the contact presents for testing. There is clearly a need to improve documentation and reporting that contacts have been seen and tested. It is important to realize that even though the number of contacts per index case seen and tested in this audit is more than four times higher than that reported from LA county, 0.94 and 0.20 contacts per index case, respectively, this performance still likely represents a fraction of the total number of contactable contacts reported by the index patients with a new diagnosis of syphilis. Unfortunately it was not possible to accurately estimate the average number of contactable contacts per index case in this audit; however, the number of contactable contacts per index patient is likely to be at least two people, and consequently the current PN (contract tracing) strategies do not appear to be sufficient to control the syphilis epidemic.

Since this audit and the presentation at the BASHH Spring meeting in 2017, PHE have published data for 2017 and 2018 that show a continuing rise of syphilis in the UK. In response to the sustained syphilis epidemic, a PHE Action Plan has been initiated⁹ and its four pillars are as follows: (1) increase testing frequency of high-risk MSM and re-testing of syphilis cases after treatment, (2) deliver partner notification to BASHH standards, (3) maintain high antenatal screening coverage and vigilance for syphilis throughout antenatal care, and (4) sustain targeted health promotion.

Finally, it is known that patients diagnosed with syphilis are at risk of contracting HIV and in this audit nearly all patients (97%) had their HIV status assessed and this is a significant improvement on the 2006 audit when only 77% had an HIV test.¹⁰ A formal policy to test for HIV following a syphilis diagnosis was present in 40% of clinics and these services were nearly twice as likely to repeat HIV testing after the window period had elapsed than those clinics that make no recommendation. This result shows the impact of having a formal policy to encourage patients at high risk of contracting HIV to return for testing. A new HIV diagnosis was made in 3% of patients at the time of presentation; consequently, repeat HIV testing after four weeks in all those patients who initially tested HIV-negative at the time of their syphilis diagnosis is likely to be valuable to find new HIV infections and prevent onward transmission.

Recommendations

Agreed sexual contact actions should be documented for all patients diagnosed with syphilis

Improve coding of the attendance by a sexual contact of an index patient diagnosed with early syphilis

A formal policy should be in place to test all patients with a new syphilis diagnosis for HIV after the window period has elapsed

Footnotes

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

AS Menon-Johansson

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