Dr  Alex  ParrBrighton  and  Sussex  Medical  School

Who  should  be  tested  for  syphilis?  Rationalising  syphilis  screening  in  

sexual  health  clinicsAlex  Parr1,  Nicolas  Pinto-‐Sander2,  Debbie  Williams2

&  Daniel  Richardson1,2

1.  Brighton  &  Sussex  Medical  School,  Brighton,  UK2.  Brighton  &  Sussex  University  Hospitals  NHS  Trust,  Brighton,  UK

Disclosure

No  conflicts  of  interest

Background

• Syphilis  diagnoses  increased  12%  from  2015  to  2016• >80%  of  cases  are  MSM

2138

4788

486 663256 301

3001

5920

0

1000

2000

3000

4000

5000

6000

7000

2012 2013 2014 2015 2016

Syphilis  d

iagnoses  (n)

Year  of  diagnosis

Figure  1:  Number  of  syphilis  diagnoses  in  MSM,  heterosexual  males  and  heterosexual  females,  England,  2012-‐2016    

Data  source:  PHE  Sexually  transmitted  infections  annual  data  tables

MSMHeterosexual  malesHeterosexual  femalesTotal

Public  Health  England:  Sexually  transmitted  infections  annual  data  tables

Background

£30M

C.  White. Sexual  health  services  on  the  brink    BMJ 2017; 359 :j5395doi: https://doi.org/10.1136/bmj.j5395The  King’s   Fund.  Local  government  public   health  budgets  for  2017/18.  https://www.kingsfund.org.uk/blog/2017/07/local-‐government-‐public-‐health-‐budgets-‐2017-‐18

• Many  clinics  perform  STS  for  all  attendees

• Significant  cost  implications  ~£5/test

• GUM  services  facing  budget  cuts  and  rising  demand

• Savings  and  efficiencies  need  to  be  found

Syphilis  testing  in  BrightonOver  5  years  between  June  2012  – June  2017

Number  of  tests  per  individualNon-‐MSM

n   £ people

1 22,430 112,150 22,430

2 9,704 48,520 4,852

3+ 11,581 57,905 2,935

n £

MSM 19,436 97,180

Non-‐MSM 43,715 218,575

Total 63,151 315,755

Unpublished   data,  Claude   Nichol   Centre  &  Lawson  Unit,   Brighton   2017

The  43,715  non-‐MSM  tests  resulted   in  only  116  positive  cases

Objective

To  assess  whether  we  can  we  reduce  the  number  of  syphilis  tests  we  perform

RISK  FACTORS

Men  who  have  sex  with  men

HIV  positive

Known  contact  of  syphilis

Endemicityof  patient  or  contact

Commercial  sex  work

Intravenous  drug  use

Sexual  assault

Kingston  M,  French  P,  Higgins  S,  McQuillian O,  Sukthankar A,  Stott  C,  et  al.  UK  national   guidelines  on  the  management  of  syphilis  2015.    BASHH.  Int J  STD  AIDS  0  (0)  1-‐26.

Methods

Data  team  provided  non-‐MSM  syphilis  diagnoses  in  previous  5  years  A1,  A2,  A3

Identified  and  excluded  those  with  risk  factors  using  electronic  record

Individual  case  analysis  –electronic  record  &  paper  records

ResultsNon-‐MSM  syphilis  cases  in  last  5  years

TotalNon-‐MSM  cases  from  data  team 116MSM/Trans  (coding  errors) 15Symptomatic 36Patient  from  endemic  area 35Contact  from  endemic  area 15Known  contact  of  syphilis 3Commercial  sex  worker 0Sexual  assault 0Intravenous  drug  use 0

No  apparent  risk 12

Analysis  of  final  12  revealed1 MSM  contact  documented   in  past

2 MSM  contact  documented   in  past

3 MSM  contact  documented   in  past

4 MSM  contact  documented   in  past

5 MSM  contact  documented   in  past

6 MSM  contact  documented   in  past

7 Male  with  previous  partners  from  African  countries

8 Female  who  had  lived  in  Latin  America

9 Male  with  symptomatic  penile  ulcer

10 Female  referred  by  blood   transfusion  services  with  genital  ulcer

11 Indian  female  diagnosed   at  antenatal  testing

12 Eastern  European  female  diagnosed   at  antenatal  testing

Conclusions

• Over  5  years  locally  we  didn’t  diagnose  any  non-‐MSM  with  syphilis  without  risk  factors  or  symptoms

• Must  ensure  sexual  histories  are  detailed  enough

• Targeted  repeat  testing  could  save  up  to  £20,000  per  year  in  Brighton

Recommendations  

All  new  patients  should  have  syphilis  serology

Only  repeat  if: MSM

Symptomatic  ulcer  /  rash

Endemic  patient  or  contacts

HIV  positive

Commercial  sex  worker

Sexual  assault

Consider  repeating  if: Other  STI  diagnosed

Intravenous  drug  use

Acknowledgments• Data  team  (Mr  Colin  Fitzpatrick)• Patients• Staff  at  Claude  Nicol  Centre  &  Lawson  Unit

Image  credit:  Daniel  Richardson,   Syphilis  infection   in  HIV+  patients,  August  2017