6//26 Increase in syphilis testing and detection of early syphilis among men who have sex with men across Australia 27-24 Eric P.F. Chow,2, Denton Callander 3,4, Christopher K Fairley,2, Lei Zhang,2, Basil Donovan 3,5, Rebecca Guy 3, David A Lewis 6,7, Margaret Hellard 8,9, Phillip Read 3,, Alison Ward, Marcus Y Chen,2 on behalf of the ACCESS collaboration Melbourne Sexual Health Centre, 2 Central Clinical School, Monash University, 3 The Kirby Institute, UNSW Australia, 4 Centre for Social Research in Health, UNSW Australia 5 Sydney Sexual Health Centre, 6 Western Sydney Sexual Health Centre, 7 Marie Bashir Institute for Infectious Diseases and Biosecurity & Sydney Medical School-Westmead, University of Sydney, 8 Burnet Institute, 9 Infectious Disease Unit, Alfred Hospital, Kirketon Road Centre Clinic 275, Royal Adelaide Hospital Acknowledgments ACCESS steering committee, site investigators & data managers Christopher Fairley, Basil Donovan, Rebecca Guy, John Kaldor, Andrew Grulich, Margaret Hellard, Marcus Chen, Lewis Marshall, Catherine O Connor, David Wilson, Bridget Dickson, Denton Callander, Hammad Ali, Lucy Waters Smith, David Lewis, Eva Jackson, Darren Russell, Emanuel Vhalkis, Manoji Gunathilake, Alison Nikitas, Maree O Sullivan, Debbie Allen, Nathan Ryder, Katherine Brown, David Smith, Yoges Paramsothy, Cheryn Palmer, Stephen Davies, Catherine O Connor, Anna McNulty, Arun Menon, Angela Parker, and David Lewis Funding The ACCESS collaboration was funded by the Health Departments of the Australian Capital Territory, the Northern Territory, New South Wales, and Victoria. EPFC is supported by the NHMRC Early Career Fellowships and Australasian Sexual Health Conference Scholarship
6//26 Background Increase in syphilis among men who have sex with men (MSM) worldwide since the last decade o HIV serosorting, use of smart phone applications for meeting partners, drug use ( chemsex ), pre-exposure prophylaxis (PrEP) US Preventative Services Taskforce 2 o Syphilis screening of asymptomatic MSM o Benefits prevention of onward transmission and the more serious manifestations of syphilis Read P et al. Sex Health 25; 2(2): 55-63 2 Cantor AG et al. JAMA 26; 35(2): 2328-37 Australia s response Recommendations based on modelling o At least twice yearly syphilis screening of high risk HIV-negative MSM o Opt-out syphilis serological screening of HIV-positive MSM with routine HIV management and testing Wilson D, et al. Phase A of the National Gay Men s Syphilis Action Plan: Modelling evidence and research on acceptability of interventions for controlling syphilis in Australia Sydney: National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, 29. 2
6//26 Aim To examine trends in the rates of syphilis testing and detection among MSM in Australia using data from 46 sexual health clinics To examine the relationships between syphilis testing and detection of asymptomatic early syphilis Study population The Australian Collaboration for Coordinated Enhanced Sentinel Surveillance (ACCESS) o National network of sentinel sites for sexually transmitted infection (STI) surveillance 46 publicly-funded sexual health clinics participating in the ACCESS network from 27 to 24 Men who have sex with men (HIV-negative and HIV-positive) 3
6//26 Syphilis Diagnoses 3 stages Primary Secondary Early latent (within 2 years) Diagnoses were made by clinicians at the clinics based on Australian Department of Health definitions Australian Government Department of Health. Syphilis Laboratory Case Definition (LCD). 22. http://www.health.gov.au/internet/main/publishing.nsf/content/cda-phln-syphilis.htm Outcome measures Testing coverage per year o Proportion of MSM who were tested for syphilis at least once in a year Testing frequency per year o Mean number of syphilis tests per man per year Number and proportion of early syphilis diagnoses by stage Correlation between syphilis diagnoses and coverage/frequency Stratified by HIV serostatus, and year 4
Number of individual MSM Number of individual MSM 6//26 Demographic characteristics 7,387 individual MSM (i.e. 359,33 clinic visits) o 97,895 (83%) HIV-negative men o 9,492 (7%) HIV-positive men Characteristics HIV -ve HIV +ve P value Age, median [IQR] 3 [25-4] 44 [36-52] <. Number of individual MSM 2, 8, 6, 4, HIV-negative MSM (N=97,895) 4, 3,5 3, HIV-positive MSM (N=9,492) 2, 2,5, 2, 8,,5 6, 4,, 2, 5 27 28 29 2 2 22 23 24 27 28 29 2 2 22 23 24 5
Mean number of syphilis tests Number of individual MSM Number of MSM individuals 6//26 Annual syphilis testing coverage 2, HIV-negative MSM 4, HIV-positive MSM 8, 6, 4, National Gay Men s Syphilis Action Plan 3,5 3, 2, 2,5, 8, 6, 4, 2, 48% 49% 49% 53% 82% 87% 9% 9% 2,,5, 5 42% 46% 48% 53% 67% 74% 77% 77% 27 28 29 2 2 22 23 24 27 28 29 2 2 22 23 24 Annual syphilis testing frequency 2.5 2..6.5..3 2.3 p trend <. p trend <..6.5. HIV-negative men HIV-positive men 27 28 29 2 2 22 23 24 6
Number of early syphilis cases Number of early syphilis cases 6//26 Implementation of opt-out or opt-in serological screening for syphilis with routine HIV viral load National Gay Men s Syphilis Action Plan Wilson D, et al. Phase A of the National Gay Men s Syphilis Action Plan: Modelling evidence and research on acceptability of interventions for controlling syphilis in Australia Sydney: National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, 29. Syphilis diagnosis 6 5 4 Early latent Secondary Primary (P trend <.) (P trend =.3) (P trend =.7) National Gay Men s Syphilis Action Plan HIV-negative MSM 37% 44% 25 2 5 Early latent (P trend =.3) Secondary (P trend <.) Primary (P trend =.735) HIV-positive MSM 42% 45% 3 2 36% 9% 3% 26% 27% 36% 37% 38% 24% 24% 27% 28% 24% 23% 38% 37% 49% 37% 4% 39% 39% 4% 27 28 29 2 2 22 23 24 5 4% 29% 26% 27% 23% 56% 34% 26% 45% 4% 52% 39% 23% 3% 29% 3% 34% 33% 3% 26% 2% 8% 27 28 29 2 2 22 23 24 7
6//26 How testing coverage and frequency influences syphilis diagnosis? Coverage & Diagnosis in HIV-positive men.9.8 r=.57 p=.4 Early latent.9.8 r=-.87 p=.5 Secondary.7.6.5.4.3.2 27 28 29 2 % of secondary diagnoses 2 24 22 23.7.6.5.4.3.2 27 28 29 2 2 22 24 23...4.5.6.7.8 % of testing coverage.4.5.6.7.8 % of testing coverage Similar trends in HIV-negative men but not statistically significant 8
6//26 Frequency & Diagnosis in HIV-positive men.9.8 r=-.72 p=.45 Early latent.9.8 r=-.93 p=. Secondary.7.6.5.4.3.2 27 28 29 2 % of secondary diagnoses 2 24 22 23.7.6.5.4.3.2 27 28 29 2 2 22 24 23...6.8 2 2.2 2.4 Frequency of syphilis tests.6.8 2 2.2 2.4 Frequency of syphilis tests Similar trends in HIV-negative men but not statistically significant Limitations. Testing & diagnoses were from publicly-funded sexual health clinics o Other health settings such as GPs and hospitals may differ 2. Behavioural data were not routinely collected at all clinics 9
6//26 Limitations 3. Not able to ascertain at what time point following infection early latent cases were detected Median RPR titres for syphilis cases at MSHC Primary :4 Secondary :28 Early latent :32 Chow EP et al. Epi & Inf. 26 Take home messages First study to demonstrate substantial increases in screening for syphilis in both HIV-positive and HIV-negative MSM were associated with o an increase in the detection of early latent syphilis AND o a decrease in secondary syphilis on a country level
6//26 Implications With the marked increase in syphilis cases among MSM, frequent syphilis screening of MSM should be widely implemented in order to identify and treat asymptomatic cases of infectious syphilis at an early stage to prevent progression and ongoing transmission. Rising Australian epidemic: Gonorrhoea and Syphilis what is the role of the General Practitioner? Jason Ong Hall L Tuesday 3:3-3:45pm