Abstract
Sir: We read with interest the response of Hopkins et al. 1 to our previous article 2 and welcome the ongoing debate over the optimal treatment of syphilis in individuals with HIV infection. While it is reassuring that the Dublin group, as other groups, 3 describes the successful use of simplified penicillin regimens, we do not believe that the debate is yet over.
The literature is clear that HIV infection does alter response to syphilis treatment. 4–6 We and many others continue to have concerns that simplified courses may give inadequate central nervous system coverage. While the approach of the Dublin group to this issue is to screen for neurosyphilis in certain subgroups, we believe that this may be more complex (i.e. requiring head scanning and lumbar punctures) than extended treatment with penicillin for all those with HIV co-infection, and is likely to show high rates of cerebrospinal fluid abnormalities making extended treatment a requirement for a significant proportion 7,8 anyway.
Given the different strategies recommended by the Centers For Disease Control And Prevention and the British Association for Sexual Health & HIV 9,10 and the different protocols used in centres of current outbreaks such as Dublin and Brighton, we continue to believe that a randomized study should be pursued to clarify which treatment approach is optimal.