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Competing Interests: Conflict of Interest and Sources of Funding: The authors declare no conflicts of interest.

Competing Interests: No conflicts of interest.

Background: SARS-CoV-2 pandemic mitigation efforts resulted in reallocation of public health personnel, likely impacting provision of timely sexually transmitted infection partner services (PS). We describe PS outcomes before and during the pandemic in King County, WA., Methods: We examined PS outcomes for syphilis and gonorrhea cases diagnosed in 2019 and 3 periods in 2020 (pre-lockdown: January 1, 2020-March 23, 2020; lockdown: March 24, 2020-June 5, 2020; post-lockdown: June 6, 2020-December 31, 2020). We described changes over time in 3 PS outcomes: cases initiated, interviewed, and with named sex partners. We calculated adjusted prevalence ratios (aPRs) with Poisson regression comparing these outcomes in the 2020 periods with 2019., Results: Reported gonorrhea (4611 vs. 4179) and syphilis (665 vs. 586) cases declined from 2019 to 2020. In 2019, 60.7% of cases were initiated, compared with 42.1% before lockdown (aPR, 0.74; 95% confidence interval [CI], 0.70%-0.78%), 41.7% during lockdown (aPR, 0.79; 95% CI, 0.73-0.85), and 41.7% after lockdown (aPR, 0.81; 95% CI, 0.77-0.85). Among initiated cases, the proportion interviewed also seemed to drop in the 3 lockdown periods (52.4%, 41.0%, 44.1%) compared with 2019 (55.7%). However, in adjusted analyses, the prevalence of interview among case patients was only lower pre-lockdown (aPR, 0.91; 95% CI, 0.85-0.99), and higher during (aPR, 1.10; 95% CI, 1.01-1.20) and after (aPR, 1.12; 95% CI, 1.06-1.19). Interviewed patients named partners more often during (21.4%; aPR, 1.35; 95% CI, 1.05-1.74) and less often after lockdown (16.0%; aPR, 0.63; 95% CI, 0.51-0.79), compared with 2019 (26.6%)., Conclusions: These results underscore the need for a trained public health worker reserve, and plans for deployment of existing workers and prioritization of cases to continue essential sexually transmitted infection public health activities during public health crises., Competing Interests: Conflict of Interest and Sources of Funding: The study was funded by grant CDC/NCHHSTP 1 NH25PS005185-01-00, STD Surveillance Network, and the authors declare no conflicts of interest., (Copyright © 2024 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: The United States has seen a > 40% increase in syphilis cases since 2017. Early disease identification and treatment are crucial. This review sought to identify emergency department (ED) patients at risk for syphilis., Methods: A 30-day retrospective review was conducted of visits to a single ED. Patient visits were assessed for predetermined syphilis "flags" to include a history of sexually transmitted infection (STI), current chief complaint or reason for visit (RFV) keyword(s) suggestive of potential STI or a positive pregnancy test result. Flagged charts were assessed for STI testing results within 6 months of ED visit. Data were analyzed using χ2 ., Results: There were 5537 total patient encounters, resulting in 455 flagged visits from 408 (8.4%) unique individuals, majority of whom were female (282, 69.1%; P < 0.001), Black (251, 61.5%; P < 0.001), aged 15 to 44 years (308, 75.5%; P < 0.001). Chief complaint was the most frequent flag (65.3%), followed by RFV (37.4%), prior STI (31.0%), and pregnancy (12.3%). Syphilis testing data were available for 120 flagged patients; 29 (24.2%) screened positive, including 11 (2.7% of total flagged cohort) with evidence for active infection. Among those, most were Black (90.9%), male (72.7%), aged 25 to 34 years (63.6%), and 9 (81.8%) had concomitant HIV. In active infection, prior STI flag was most common (72.7%), followed by chief complaint (54.5%) and RFV (45.5%)., Conclusions: This review demonstrates the performance of an electronic medical record-based "syphilis risk flag" screener applied to ED patients. Sex- and race-based discrepancies exist in flag rates, which may be reflective of sex- and race-based epidemiologic discrepancies in STI incidence., Competing Interests: Conflict of Interest and Sources of Funding: None declared., (Copyright © 2024 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: Productivity costs of sexually transmitted infections (STIs) reflect the value of lost time due to STI morbidity and mortality, including time spent traveling to, waiting for, and receiving STI treatment. The purpose of this study was to provide updated estimates of the average lifetime productivity cost for chlamydia, gonorrhea, and syphilis, per incident infection., Methods: We adapted published decision tree models from recent studies of the lifetime medical costs of chlamydia, gonorrhea, and syphilis in the United States. For each possible outcome of infection, we applied productivity costs that we obtained based on published health economic studies. Productivity costs included the value of patient time spent to receive treatment for STIs and for related sequelae such as pelvic inflammatory disease in women. We used a human capital approach and included losses in market (paid) and nonmarket (unpaid) productivity. We conducted 1-way sensitivity analyses and probabilistic sensitivity analyses., Results: The average lifetime productivity cost per infection was $28 for chlamydia in men, $205 for chlamydia in women, $37 for gonorrhea in men, $212 for gonorrhea in women, and $411 for syphilis regardless of sex, in 2023 US dollars. The estimated lifetime productivity cost of these STIs acquired in the United States in 2018 was $795 million., Conclusions: These estimates of the lifetime productivity costs can help in quantifying the overall economic burden of STIs in the United States beyond just the medical cost burden and can inform cost-effectiveness analyses of STI prevention activities., Competing Interests: Conflict of Interest and Sources of Funding: None declared., (Copyright © 2024 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: Syphilis coinfection among pregnant people living with HIV (PLH) may worsen pregnancy outcomes. We evaluated the impact of syphilis coinfection on pregnancies in south Brazil., Methods: Data were extracted from hospital records between January 1, 2008, and December 31, 2018. Preterm birth (PTB), low birth weight (LBW <2500 g), and a composite adverse infant outcome (AIO: HIV vertical transmission, loss to follow-up before HIV diagnosis, stillbirth, congenital syphilis) were evaluated among pregnancies without HIV and syphilis (PWOH + S), PLH monoinfection, syphilis monoinfection (PLS), and PLH with syphilis (PLH + S)., Results: Among 48,685 deliveries where patients were tested for HIV and syphilis, 1353 (2.8%) occurred in PLH; of these, 181 (13.4%) were HIV/syphilis coinfected (PLH + S). Among PLH, 2.4% of infants acquired HIV and 13.1% were lost to follow-up before HIV diagnosis. Among all PLS, 70.5% of infants acquired congenital syphilis. Across the cohort, 1.2% stillbirths/neonatal deaths occurred. Thirty-seven percent of PLH + S did not initiate antiretroviral therapy versus 15.4% of PLH monoinfection ( P < 0.001). Less than half (37.6%) of PLH + S had VDRL titers ≥1:16 compared with 21.7% of PLS only ( P < 0.001). Among PLH, syphilis coinfection and unknown/high VDRL titers (≥1:16) increased AIO risk more (adjusted relative risk [aRR], 3.96; 95% confidence interval [CI], 3.33-4.70) compared with low VDRL titers (≤1:8; aRR, 3.51; 95% CI, 2.90-4.25). Unsuppressed viremia (≥50 copies/mL) was associated with risk of PTB (aRR, 1.43; 95% CI, 1.07-1.92) and AIO (aRR, 1.38; 95% CI, 1.11-1.70) but not LBW. Lack of prenatal care was significant in predicting PTB and LBW in all PLH and PLS monoinfection., Conclusions: Syphilis coinfection worsens AIOs in all women and compounds negative effects of HIV infection during pregnancy. Effective syphilis treatment and HIV viral load suppression are paramount for optimal obstetric care., Competing Interests: Conflict of Interest and Sources of Funding: The authors have no competing interests or conflicts to declare., (Copyright © 2024 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: We aimed to compare the clinical presentations (symptomatic vs. asymptomatic) with prior Treponema pallidum infection status (first infection vs. reinfection) among people with early syphilis., Methods: We used data from PICASSO, a cohort study in Peru that enrolled people with active syphilis from May 2019 to August 2021. Study participants had early syphilis and a prior syphilis serological test result within the prior 12 months to determine prior T. pallidum infection status. We calculated prevalence ratios (PRs) of symptomatic clinical presentation (primary or secondary syphilis) by prior T. pallidum infection status, stratified by HIV infection status. In addition, we explored the association of prior T. pallidum infection status and lesion presentation, stratified by primary and secondary syphilis cases, using the Fisher exact test., Results: We include 84 T. pallidum reinfection cases and 61 first infection cases. We found increased frequency of symptomatic clinical presentation among first-infection cases (39% vs. 20%; PR, 1.94; P = 0.014). This association was stronger among persons living without HIV infection (38% vs. 7%; adjusted PR, 6.63; P = 0.001) in comparison to those living with HIV infection (45% vs. 34%; adjusted PR, 1.38; P = 0.458). Among secondary syphilis cases, more participants from the reinfection group reported that their lesions improved 1 week after treatment (100% vs. 29%, P = 0.045) compared with those with a first infection. Among the primary syphilis cases, all participants reported that their lesions improved 1 week after treatment., Conclusions: Prior syphilis was associated with a decreased prevalence of symptomatic reinfection, especially among persons not living with HIV infection., Competing Interests: Conflict of Interest and Sources of Funding: The authors have declared that no conflict of interest exist. This study has been funded by the National Institute of Allergy and Infectious Diseases (grant number 1R01AI139265). The National Institute of Allergy and Infectious Diseases had no role in the study outside of grant approval and continuation., (Copyright © 2024 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: Syphilis in Florida increased 49% from 2016 to 2020. Moreover, many serological tests for syphilis (STS) do not indicate current infection. Traditionally, syphilis surveillance systems used reactor grids, a method for prioritizing STS for investigation based on age, nontreponemal titer, and/or sex. In 2022, Florida's sexually transmitted disease surveillance system implemented an automated method for processing electronically reported STS (eSTS), expanding upon the reactor grid, using an individual's current STS (treponemal and nontreponemal), treatment history, and historical STS results aiming for more efficiently processing eSTS. We compared the new method of processing eSTS results against the reactor grid and determined potential value in time/cost savings of this change., Methods: All eSTSs (n = 4144) from January 2, 2023 to January 8, 2023, were compared by how the logic-based method processed test results versus how the reactor grid processed test results. Each method was compared using measurements of accuracy (e.g., sensitivity/specificity). Time and cost savings in eSTS processing were estimated., Results: Using the surveillance case definition as reference, the accuracy of the logic-based method for processing eSTS was nearly double (82.3% vs. 43.6%), had greater specificity (79.0% vs. 33.0%), and increased positive predictive value (47.5% vs. 22.0%) when compared with the reactor grid method. Sensitivity (99.5% vs. 98.6%) and negative predictive value (99.9% vs. 99.2%) remained similar. The logic-based method is estimated to save 7783 hours annually (~$185,000)., Conclusions: Processing eSTS based on current and historical STS results is significantly more accurate than using a reactor grid. Moreover, these improvements save time and resources that can be better allocated to other program prevention activities., Competing Interests: Conflict of Interest and Sources of Funding: The authors report no known conflicts of interest. The authors report no dedicated funding for this project but are employees of state and federal government agencies., (Copyright © 2024 American Sexually Transmitted Diseases Association. All rights reserved.)

Abstract: Among 8455 people engaged in HIV care in 4 US cities, 4925 (58%) had treponemal testing at care entry. Of the 4925 tested, 3795 (77%) had a nonreactive result and might benefit from the reverse algorithm for a future incident syphilis diagnosis. Furthermore, low-barrier treponemal testing as a first step in the reverse algorithm may increase syphilis screening and decrease time to treatment., Competing Interests: Conflict of Interest and Sources of Funding: The authors declare that they have no affiliations with or involvement in any organization or entity with any financial interest in the subject matter or materials discussed in this manuscript. The Center for AIDS Research Network of Integrated Clinical Systems is funded by NIH NIAID R24 AI067039., (Copyright © 2024 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: Syphilis and congenital syphilis rates have increased sharply in Colorado in the past 5 years. Congenital syphilis is passed during pregnancy in utero and can cause lifelong physical, developmental, and neurologic problems for the child, or can lead to miscarriage, stillbirth, or early infant death. Congenital syphilis is easily prevented if the mother receives timely testing, treatment, and prenatal care. Providers can play a key role in preventing congenital syphilis for women with social vulnerabilities, who have a higher likelihood of syphilis and/or congenital syphilis infection., Methods: We surveyed 23 and interviewed 4 health care providers in southern Colorado in 2022 to record their experiences in providing sexual health care services. We asked providers with direct care experience about perceived barriers in effectively treating syphilis., Results: The most significant barriers reported in the survey were the cost of treatment (26%) and the loss to follow-up (22%). Interviews revealed further challenges, including discretionary testing procedures, delays in screening results, treatment referral issues, and stigma around substance use and sexual activity., Conclusions: Elevated syphilis and congenital syphilis rates pose significant public health challenges. Coordinated interventions are necessary to effectively reduce the transmission of syphilis and congenital syphilis among women with upstream barriers. Potential care solutions include expanding rapid, point-of care testing and treatment options, supporting bicillin delivery or web-based inventory systems, offering anti-stigma training for providers, offering mental and behavioral health resources at providers' clinics, and expanding partnerships with syringe access programs., (Copyright © 2024 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: Syphilis incidence is increasing among reproductive-aged women, and previous sexually transmitted infections (STIs) are a risk factor for subsequent STIs. This study aimed to determine syphilis incidence after a chlamydia, gonorrhea, or HIV diagnosis, and identify characteristics associated with higher syphilis incidence rates among reproductive-aged women in 1 mid-Atlantic city., Methods: A retrospective cohort of 85,113 chlamydia, gonorrhea, and HIV diagnoses occurring between 2009 and 2021 and among women aged 13 to 50 years was constructed using public health surveillance data. Cumulative incidence curves were estimated to examine time to early syphilis (i.e., primary, secondary, or early latent) diagnosis, and multivariable analyses determined incidence rate ratios by age (<25 vs. ≥25 years) and number of prior STI diagnoses (0 vs. ≥1) during the study period, stratified by STI., Results: There were 85,113 reportable STI diagnoses and 646 syphilis diagnoses in the cohort. Approximately 1 of 150 chlamydia, 1 of 100 gonorrhea, and 1 of 50 HIV diagnoses were followed by a syphilis diagnosis within 5 years. Cumulative incidence of syphilis differed significantly by STI diagnosis ( P < 0.001). In multivariable analysis, syphilis incidence rates were higher among women diagnosed with ≥1 (vs. 0) prior STI regardless of STI type ( P < 0.05) and among women ≥25 (vs. <25) years old diagnosed with gonorrhea ( P < 0.05)., Conclusions: There were significant differences in syphilis incidence by prior STI type, number of STIs, and age. Our data support targeted screening for syphilis among women with a history of STIs, parwomen with ≥1 prior STI diagnosis, and older women diagnosed with gonorrhea., Competing Interests: Conflict of Interest and Sources of Funding: None declared., (Copyright © 2024 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: In South Africa, extragenital etiological sexually transmitted infection (STI) screening among men who have sex with men (MSM) is not routinely available. We aimed to determine the prevalence of STI pathogens at rectal and pharyngeal sites, syphilis seroprevalence, and associated risk factors among a selection of high-risk MSM without symptomatic urethritis attending a men's health clinic in Johannesburg, South Africa., Methods: A cross-sectional study was conducted in 2022. Enrolled clients self-reported demographic, sexual behavioral risks, and clinical information. Client or clinician-collected rectal and pharyngeal swabs were tested for Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium, and Trichomonas vaginalis. C. trachomatis-positive rectal samples were reflex tested for lymphogranuloma venereum. Blood specimens were screened for syphilis. Univariate and multivariate regression models were used to determine factors independently associated with the presence of an extragenital STI or syphilis., Results: Among the 97 participants (median age, 29 years), 24.7% had an extragenital STI and 9.4% had high nontreponemal antibody titers (rapid plasma reagin ≥1:16). Rectal STIs were detected in 26.4% participants: N. gonorrhoeae (14.3%), C. trachomatis (9.9%), and M. genitalium (5.5%). Pharyngeal STIs were less prevalent (4.1%). Overall, the prevalence of any STI was 41%. Sex under the influence of drugs (adjusted odds ratio, 4.94; 95% confidence interval, 1.56-15.69) and engaging in condomless receptive anal intercourse with a casual partner (adjusted odds ratio, 8.36; 95% confidence interval, 1.73-40.28) were independent risk factors for having an extragenital STI., Conclusions: The high burden of extragenital STIs and active syphilis in asymptomatic MSM underscores the importance of routine etiological screening in this key population, as the syndromic approach would not enable detection or treatment of these infections., Competing Interests: Conflict of Interest and Sources of Funding: The authors have no conflicts of interest to declare. This work was internally funded by the Centre of HIV & STIs at the National Institute for Communicable Diseases, a division of the National Health Laboratory Service, South Africa., (Copyright © 2024 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: The United States has seen a significant rise in syphilis over the past 20 years with a disparate impact on American Indian communities. We conducted a thorough review of the local epidemiology that guided an innovative response to curb the epidemic., Methods: We analyzed syphilis data from a hospital in rural Arizona that serves an American Indian population of more than 18,000. Testing data were extracted from 2017 to 2023 with detailed chart reviews of all reactive results since January 2022. Descriptive and comparative statistics were computed using parametric and nonparametric methods where appropriate., Results: Among 5888 tested persons, 555 (9.4%) had reactive results and 277 (4.7%) represented new infections. Among new cases, 151 (54.5%) were female and 55 (19.9%) were reinfections. The annualized incidence rate was 10.0 cases per 1000 persons with peak annualized incidence among women aged 30 to 34 years of 22.6 infections per 1000 persons. During the observation period and after the implementation of programmatic changes in June 2022, there were statistically significant reductions in median time to treatment (-80%), test positivity (-70%), infections (-60%), and no congenital syphilis cases during the observation period., Conclusions: We observed significantly elevated syphilis rates in American Indian/Alaska Native persons compared with the general population. Strategic implementation of new policies and practices led to a measurable and meaningful improvement in several epidemic variables, and our experience may serve as a model to other communities., Competing Interests: Conflict of Interest and Sources of Funding: None declared., (Copyright © 2023 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: As the incidence of syphilis continues to increase, examining benzathine penicillin G (BPG) treatment data provides valuable insight for public health strategies. This study analyzed the trends of where BPG is administered relative to the initial clinical site of syphilis diagnosis. Our findings are timely in the context of recent national BPG shortages., Methods: The analysis included persons diagnosed with any syphilis stage in Maricopa County, Arizona, from January 1, 2021, to December 31, 2021. The Arizona surveillance database (PRISM) was the source of demographic, testing, and treatment data., Results: Of a total of 4028 persons with syphilis, 3038 (75.4%) received at least 1 injection of BPG. Among persons who received an initial BPG injection, only 1719 (56.6%) were diagnosed and treated at the same clinical site type. The Maricopa County Sexually Transmitted Disease Clinic administered BPG to 48.8% (n = 1483) of persons with syphilis who received an initial injection., Conclusions: Our findings analyze trends in BPG administration that are likely due to treatment referral practices and medication cost. Administration of BPG is not guaranteed at the clinical site of diagnosis, highlighting concerns regarding access to BPG. A burden is placed on patients who are required to leave their diagnosing provider to seek syphilis treatment at other health facilities that administer BPG., Competing Interests: Conflict of Interest and Sources of Funding The authors declared no potential conflicts of interest with respect to the public health surveillance activities, authorship, and/or publication of this article. The authors received no financial support for the surveillance work, authorship, and/or publication of this article., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Sexually Transmitted Diseases Association.)

Background: Syphilis is a curable sexually transmitted infection that, untreated, is associated with significant morbidity and mortality. In people living with HIV (PLWH), syphilis carries greater risks of disease progression. We estimated syphilis prevalence among PLWH in the general population in sub-Saharan Africa and compared the prevalence among PLWH and without HIV., Methods: We searched for studies published January 1, 2011, to March 28, 2022, reporting syphilis prevalence among PLWH in sub-Saharan Africa (PROSPERO No. CRD42020167328). We excluded studies in high-risk subpopulations. We estimated pooled syphilis prevalence among PLWH using random-effects modeling and compared the prevalence with people without HIV when included in the same study. We examined influences of region, study setting, and test type in subgroup analyses., Results: We identified 926 studies; 53 were included in the meta-analysis. Pooled syphilis prevalence among PLWH was 7.3% (95% confidence interval [CI], 6.3%-8.5%). Prevalence differed by region: 3.1% (95% CI, 2.2%-4.0%) in Southern, 5.5% (95% CI, 2.3%-9.3%) in West/Central, and 10.5% (95% CI, 8.0%-13.1%) in Eastern Africa. Prevalence also differed by study setting: 13.8% (95% CI, 5.7%-23.0%) in sexual and reproductive health/sexually transmitted infection care, 8.7% (95% CI, 5.0%-12.8%) in HIV care, 7.1% (95% CI, 5.8%-8.5%) in antenatal care, and 3.8% (95% CI, 2.0%-5.8%) in household/community-based settings. Syphilis prevalence was higher among PLWH than without HIV (relative risk, 3.5; 95% CI, 2.8-4.5)., Conclusions: Syphilis is highly prevalent among PLWH in sub-Saharan Africa and is more common among PLWH than without HIV. Integration of syphilis screening and management into HIV care may reduce complications of HIV-syphilis coinfection among PLWH in sub-Saharan Africa., Competing Interests: Conflict of Interest and Sources of Funding: J.J. has received in-kind research support from binx health. All other authors declare no competing interests., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Sexually Transmitted Diseases Association.)

Background: Current US syphilis screening focuses on men who have sex with men (MSM), because of the increased risk of infection in their sexual networks, and on pregnant people, because of complications associated with congenital syphilis. However, screening for men who have sex with women (MSW) who are at increased risk of syphilis is also recommended. Factors associated with syphilis testing and positivity were assessed among young, Black MSW., Methods: Data from the Check It study-a seek, test, and treat study for chlamydia in New Orleans, LA, among Black MSW aged 15 to 26 years-were used. Survey data were used to elicit self-reported syphilis testing, self-reported testing results, and sociodemographic and behavioral factors associated with these 2 outcomes., Results: Per the Centers for Disease Control and Prevention, all men in the study were recommended for syphilis screening because of their age, race, and geographic location. Of the 1458 men included, 272 (18.7%) reported ever having been syphilis tested, 267 men reported their results, and 23 (8.6%) reported testing positive. In logistic regression, older age (odds ratio [OR], 1.21 per year older; P < 0.001), prior Chlamydia trachomatis , Neisseria gonorrhoeae , and/or HIV testing (OR, 50.32; P < 0.001), and younger age at sexual debut (0.90 per year older, P = 0.005) were significantly associated with prior syphilis testing. In addition, testing positive for C. trachomatis and/or N. gonorrhoeae during the study was significantly associated with a history of syphilis positivity (OR, 3.08; P = 0.031)., Conclusions: Although syphilis testing was associated with factors that might increase the risk of acquisition, only 19% of individuals meeting Centers for Disease Control and Prevention testing recommendations had ever been screened., Competing Interests: Conflict of Interest and Sources of Funding: The authors have no conflicts of interest to declare., (Copyright © 2023 American Sexually Transmitted Diseases Association. All rights reserved.)

Abstract: Congenital syphilis (CS) rates have risen in the United States since 2013. Prevention of CS requires testing and treatment of pregnant and pregnancy-capable persons at high risk for syphilis. We developed a CS Prevention Cascade to assess how effectively testing and treatment interventions reached pregnant persons with a CS outcome., Competing Interests: Conflict of Interest and Sources of Funding Sources: None declared., (Copyright © 2023 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: Congenital syphilis (CS) remains a major public health problem, and its incidence is increasing worldwide., Methods: Retrospective, observational, and descriptive study of cases with CS and their mothers at a tertiary-level hospital in Mexico from 2017 to 2022. Medical records of patients with CS and a structured collection of epidemiological, clinical, and laboratory data were analyzed and classified in the Centers for Disease Control scenarios as confirmed, probable, less probable, or unlikely., Results: One hundred eighty cases were diagnosed with a compatible definition of congenital syphilis, and we identified 43 (21.21%) confirmed proven. Among those proven cases, 15.6% had hematological, 13.3% skin, 12.2% liver, 6.7% pulmonary, 6.6% neurological, 5.8% eye, 5.6% bone, and 0.6% hearing involvements. According to the clinical stages of maternal syphilis, 119 (66.1%) were in the late latent phase, 49 (27.2%) in the early latent phase, 7 (3.9%) in the secondary stage, and 5 (2.8%) in the primary stage. Mothers with tertiary syphilis were not detected., Conclusion: Regardless of negative antenatal screening, health care workers should consider the diagnosis of congenital syphilis. Infants are still undiagnosed at birth, and only a tiny percentage exhibits symptoms. The wide range of clinical manifestations of this preventable infection can be misdiagnosed for various other diseases, causing diagnostic delays that can have serious consequences., Competing Interests: Conflict of Interest and Sources of Funding: None declared., (Copyright © 2023 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: Since 2000, there have been rising rates of syphilis infections nationally with higher incidence among minorities and persons living with human immunodeficiency virus (HIV) (PLWH). The purpose of this study was to determine syphilis treatment adequacy and factors associated with treatment delay., Methods: This was a retrospective academic-public health collaboration with the District of Columbia Department of Public Health reviewing surveillance data of all primary, secondary, and early latent syphilis cases diagnosed between January 1, 2015, and December 31, 2019. Data were analyzed using multivariable logistic regression to identify factors associated with delayed treatment >14 days from diagnosis., Results: Among 1852 individuals diagnosed with early syphilis, 93% (1730/1852) were male; 48% (893/1852) were coinfected with HIV; 43% (n = 796/1852) were African American/Black, 27% (n = 492/1852) were White, and race/ethnicity was unknown for 17% (n = 318/1852) of cases. Among 679 PLWH for whom viral load (VL) was known, 41% (278/679) had a VL < 20 copies/mL, and 18% (123/679) had VL >10,000 copies/mL. Treatment adequacy overall was 96.5%. Median time to syphilis treatment was 6 days (interquartile range = 4-7). Factors associated with delay of treatment included refused/unknown race (adjusted odds ratio [aOR], 1.95; 95% confidence interval [CI], 1.00-3.79), and HIV VL > 10,000 copies/mL (aOR, 1.97; 95% CI, 1.08-3.58)., Conclusions: The factors we identified associated with delayed treatment may reflect systemic factors contributing to the increased rates of infection among key populations. This highlights the importance of targeted public health efforts with the goal of reducing transmission of both HIV and syphilis., Competing Interests: Conflict of Interest and Sources of Funding: None declared., (Copyright © 2023 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: Gay, bisexual, and other men who have sex with men (GBM) are overrepresented in diagnoses of sexually transmitted infections (STIs) relative to their population size. This study assessed trends in STI testing and diagnoses among GBM in Australia., Methods: The Gay Community Periodic Surveys are repeated cross-sectional behavioral surveillance surveys of GBM. Participants reported the number of anal swabs, throat swabs, urine samples, and blood tests for syphilis they undertook in the last year. "Frequent comprehensive testing" was defined as ≥3 of each test in the previous year. Participants reported STI diagnoses of chlamydia, gonorrhea, syphilis, and other STIs in the last year. Trends in testing and diagnoses from 2017 to 2020 and 2020 to 2021 were assessed with logistic regression models., Results: We analyzed 24,488 survey responses from participants reporting casual sex in the last 6 months. Between 2017 and 2020, frequent comprehensive STI testing decreased among HIV-negative GBM on preexposure prophylaxis (PrEP) from 71.7% to 68.9% and declined further to 58.6% in 2021. Frequent comprehensive STI testing was stable during 2017-2020 among HIV-negative/untested GBM not on PrEP (17.4%-14.6%) and HIV-positive GBM (30.4%-35.1%) but declined in 2021 to 7.5% among non-PrEP-users and 25.7% among HIV-positive participants. There were minimal changes in STI diagnoses during 2017-2020, but diagnoses declined in 2021., Conclusions: Many GBM do not meet Australian STI testing guidelines that recommend quarterly testing. Further evaluation of whether this recommendation is realistic or necessary to reduce STIs among GBM is recommended., Competing Interests: Conflict of Interest and Sources of Funding: No conflicts of interests to declare. The Gay Community Periodic Surveys are supported by funds from state and territory health departments. The Centre for Social Research in Health and the Kirby Institute are supported by funding from the Australian Government Department of Health. This research was supported by an Australian Government Research Training Program Scholarship., (Copyright © 2023 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: Chlamydia, gonorrhea, and syphilis are common sexually transmitted infections that disproportionately affect specific groups in New Zealand (NZ). Predictors of reinfection are not well studied in NZ but could inform public health strategies to decrease sexually transmitted infection (STI) incidence., Methods: New Zealand-wide chlamydia, gonorrhea, and syphilis cases during 2019 were identified using nationally collected data. Cases were followed-up to identify reinfection with the same STI within 12 months of initial infections. Logistic regression models were used to identify predictors for each STI reinfection., Results: Determinants identified for increased odds of chlamydia reinfection were age groups 16-19 and 20-24 years, females, Māori and Pacific peoples, cases in the Northern region, and cases with at least one test before the initial infection. Age 40 years and older was associated with lower odds of gonorrhea reinfection, as was being of Asian ethnicity, living in Midland or Southern regions, and reporting heterosexual behavior. Region was the only statistically significant predictor for syphilis reinfection, with higher odds of reinfection for people living in the Central region., Conclusions: Our findings reflect disproportionate STI rates for some groups in NZ, with younger age groups, Māori and Pacific peoples, men who have sex with men, and people living in the Northern region experiencing higher odds of reinfection. Groups identified with higher odds for reinfection require increased access to culturally responsive health services to treat, understand, and prevent possible reinfection. Changes to current public health strategies could include culturally specific behavioral counseling, and improvements to and adherence to effective contract tracing., Competing Interests: Conflict of Interest and Sources of Funding: The authors declare no conflicts of interest. This work was supported by funds from the New Zealand Ministry of Health STI Surveillance. P.S. was supported by a Burnett Foundation Aotearoa Fellowship., (Copyright © 2023 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: Genital ulcer diseases (GUDs) are a common syndrome associated with sexually transmitted infections. Genital ulcer diseases increase the risk of HIV transmission, necessitating appropriate diagnosis and treatment. We provide an updated GUD etiology assessment in Malawi to guide diagnostic development and treatment algorithms., Methods: We enrolled patients 18 years or older presenting with GUD at a sexually transmitted infection clinic in Lilongwe, Malawi, between May and October 2021. We purposively sampled by HIV status. Swabs of ulcers were tested for Treponema pallidum, herpes simplex virus (HSV)-1 and HSV-2, Haemophilus ducreyi, and Chlamydia trachomatis using polymerase chain reaction. Blood was collected for syphilis and HSV-2 serologies and acute HIV testing. Participants were treated per Malawi guidelines. Ulcer resolution (size reduced by >50%) was evaluated 14 days later., Results: Fifty participants enrolled (30 without HIV, 2 with acute HIV infection, 18 with HIV seropositivity; 32 men, 18 women). Forty-six (92%) had an etiology identified. Syphilis was more common among those without HIV (22 of 30 [73%]) than participants with HIV (PWH; 8 of 20 [40%]; P = 0.04). Herpes simplex virus was more common among PWH (11 of 20 [55%]) than participants without (2 of 30 [7%]; P = 0.0002). One-fifth (9 of 50 [18%]) had H. ducreyi. Among those who returned for follow-up (n = 45), 9 (20%) had unresolved ulcers; persistent GUD was slightly more common in PWH (6 of 19 [32%]) than participants without (3 of 26 [12%]; P = 0.14)., Conclusions: We observed a dramatic increase in syphilis ulcer proportion in a population whose GUDs were previously HSV predominant. Observed differences in etiology and resolution by HIV status could play an important role in the ongoing transmission and treatment evaluation of GUD., Competing Interests: Conflict of Interest and Sources of Funding: None declared., (Copyright © 2023 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: Several large studies have demonstrated that syphilis carries a risk of future sexually transmitted infections (STI), such as human immunodeficiency virus. There are limited data on outcomes of syphilis infections that occur in populations that undergo universal syphilis screening, such as blood donors. Military trainees who donate blood can be followed through their military career to determine the future risk of STIs., Methods: Blood donor data were gathered from the Armed Services Blood Bank Center-San Antonio for those with positive Treponema pallidum antibodies between 2014 and 2021. The medical chart of each case was compared with 6 sex- and military accession date-matched controls with negative T. pallidum antibodies to determine the risk of STI in the 3 years after donation., Results: A total of 63,375 individuals donated blood during the study period. A total of 23 military trainees (0.36 per 1000 donors) had positive T. pallidum antibodies. A minority (n = 7; 30%) of cases were treated for early syphilis. Only 6 cases (26%) received a follow-up nontreponemal test within 1 year. Donors who tested positive had a significantly higher risk of developing an STI within 3 years after blood donation compared with blood donors who tested negative (relative risk, 3.8; 95% confidence interval, 1.3-10.5; P = 0.01) including gonorrhea (9% vs. 0%, P = 0.02) and syphilis (9% vs. 0%, P = 0.02)., Conclusions: This study shows the presence of T. pallidum antibodies in blood donors was associated with an increased risk of future STIs. These cases support the need for close follow-up and broad STI testing in blood donors with positive T. pallidum antibodies., Competing Interests: Conflict of Interest and Sources of Funding: All authors agree with the submission of this manuscript and do not have known conflicts of interest., (Copyright © 2023 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: Incarcerated women experience high rates of HIV and sexually transmitted infections (STIs); few are offered HIV preexposure prophylaxis (PrEP). We aimed to examine HIV/STI screening rates in this population and identify PrEP eligibility., Methods: Results of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) urine and HIV/syphilis screening in cisgender women in the Dallas County Jail were compiled from January to October 2020. An electronic health record review was conducted for a subgroup in March 2020 to identify PrEP eligibility., Results: Overall, 4398 of 13,292 women were screened for CT and 4389 of 13,292 for GC, and among them, 479 (11%) screened for HIV and 562 (13%) for syphilis. Furthermore, 462 of 4398 (11%) were positive for CT, 323 of 4389 (7%) were positive for GC, 10 of 479 (2%) had positive HIV test results, of whom 6 (1.3%) were new diagnoses and 75 (13%) had a reactive rapid plasma reagin test. In March 2020, of 541 women screened, 90 tested positive for CT or GC. Of these 90, 70 (78%) did not receive HIV or syphilis screening, including women with these risk factors: 10 (14%) were homeless, 11 (16%) reported heroin use, and 10 (14%) reported methamphetamine use. Based on the presence of an acute bacterial STI, 17% (96 of 541) were PrEP eligible., Conclusions: Incarcerated women had high STI rates and other risk factors for HIV acquisition, although only 1 in 5 with acute STIs (11% overall) was also screened for HIV or syphilis. HIV prevention efforts should include comprehensive STI/HIV screening, linkage to treatment, and identification of PrEP candidates., Competing Interests: Conflict of Interest and Sources of Funding: A.E.N receives research funding from Gilead Sciences. D.K. conducts research on preexposure prophylaxis funded by grants from Merck and Gilead Sciences to Fenway Health; has received funding to develop educational content on preexposure prophylaxis from Virology Education and UpToDate, Inc.; and has been a consultant to Loma Linda U., UAB, and the University of North Texas Health Sciences Center., (Copyright © 2023 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: There is increased heterosexual transmission of syphilis in Australia, an infection with severe outcomes. Australian policy emphasizes increasing sexually transmissible infection knowledge/awareness. However, little is known about young Australians' perceptions and knowledge of syphilis., Methods: Our online sexual health survey was open May 2 to June 21, 2022, to 16- to 29-year-olds in Australia. We asked participants if they were aware of syphilis, their personal risk perception, and perceived severity of infection and compared with results for chlamydia/gonorrhea. Multivariable and multinomial logistic regressions were used to assess characteristics associated with outcomes. We measured sexually transmissible infection knowledge using 10 true/false statements (5 syphilis, 5 chlamydia/gonorrhea)., Results: Among 2018 participants (69.1% women, 48.9% heterosexual), 91.3% had heard of syphilis (vs. 97.2% for chlamydia and 93.3% for gonorrhea). Older (25-29 years; adjusted odds ratio [aOR], 2.4; 95% confidence interval [CI], 1.4-4.4) and gay/lesbian (aOR, 2.8; 95% CI, 1.4-5.3) respondents were more likely to have heard of syphilis, as were those who were non-Aboriginal, sexually active, and with a school-based sex education. Syphilis knowledge was lower than chlamydia/gonorrhea knowledge ( P < 0.001). More than half (59.7%) perceived syphilis to have serious health impacts (vs. 36.4% for chlamydia and 42.3% for gonorrhea). Older respondents were more likely (25-29 years; aOR 2.1; 95% CI, 1.6-2.8), and gay/lesbian respondents less likely (aOR, 0.7; 95% CI, 0.6-1.0) to perceive syphilis to have serious health impacts. One-fifth of sexually active participants were unsure of their risk of syphilis., Conclusions: Most young Australians are aware of syphilis, but few have comprehensive knowledge about the infection relative to chlamydia/gonorrhea. Considering increasing heterosexual transmission, syphilis health promotion campaigns should expand their focus., Competing Interests: Conflict of Interest and Sources of Funding: J.S.H. is recipient of an National Health and Medical Research Council fellowship grant. All other authors report no conflicts of interest., (Copyright © 2023 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: Syphilis notifications in Victoria, Australia, have been increasing over the past decade, with an increase in infectious syphilis (syphilis of less than 2 years in duration) cases in females of reproductive age and an associated reemergence of congenital syphilis (CS). Before 2017, there had been 2 CS cases in the preceding 26 years. This study describes the epidemiology of infectious syphilis among females of reproductive age and CS in Victoria., Methods: Routine surveillance data provided by mandatory Victorian syphilis case notifications were extracted and grouped into a descriptive analysis of infectious syphilis and CS incidence data from 2010 to 2020., Results: In 2020, infectious syphilis notifications in Victoria were approximately 5 times more than 2010 (n = 289 in 2010 to n = 1440 in 2020), with a more than 7-fold rise among females (n = 25 in 2010 to n = 186 in 2020). Females made up 29% (n = 60 of 209) of Aboriginal and Torres Strait Islander notifications occurring between 2010 and 2020. Between 2017 and 2020, 67% of notifications in females (n = 456 of 678) were diagnosed in low-caseload clinics, at least 13% (n = 87 of 678) of all female notifications were known to be pregnant at diagnosis, and there were 9 CS notifications., Conclusions: Cases of infectious syphilis in females of reproductive age and CS are on the rise in Victoria, necessitating sustained public health action. Increasing awareness among individuals and clinicians, and health system strengthening, particularly targeting primary care where most females are diagnosed before pregnancy, are required. Treating infections before or promptly during pregnancy and undertaking partner notification and treatment to reduce risk of reinfection are critical to reducing CS cases., Competing Interests: Conflict of Interest and Sources of Funding: All authors declare no conflicts of interest. No funding was received for this research., (Copyright © 2023 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: The COVID-19 pandemic has disrupted HIV and sexually transmitted infection (STI) testing accessibility. We sought to assess the longer-term impacts of COVID-19 on HIV and STI testing and diagnosis in Oregon., Methods: First, we examined HIV, Neisseria gonorrhoeae / Chlamydia trachomatis (CT), and syphilis tests conducted at the Oregon State Public Health Laboratory (public sector) and a large commercial laboratory (private sector) and HIV, N. gonorrhoeae , CT, and primary and secondary (P&S) syphilis diagnoses in Oregon from January 1, 2019, to December 31, 2021. We compared monthly testing and diagnosis rates in 5 prespecified periods: pre-COVID-19 (January 2019-February 2020), stay-at-home order (March 2020-May 2020), reopening (June 2020-December 2020), vaccine availability (January 2021-June 2021), and Delta/early Omicron spread (July 2021-December 2021). Second, we calculated the number of HIV and STI diagnoses per test in the public and private sectors. Finally, we used seasonal autoregressive integrated moving average models to predict expected HIV and STI diagnoses for comparison to those observed., Results: Both public and private sector HIV and bacterial STI testing fell to nadirs in April 2020 with incomplete recovery to 2019 levels by the close of 2021. Compared with pre-COVID-19, public sector and private sector testing was significantly lower in all subsequent periods. Compared with pre-COVID-19, P&S syphilis cases were 52%, 75%, and 124% greater in the reopening, vaccine availability, and Delta/early Omicron periods, respectively. From March 2020 to December 2021, we observed an excess of P&S syphilis cases (+37.1%; 95% confidence interval, 22.2% to 52.1%) and a deficit in CT cases (-10.7%; 95% confidence interval, -15.4% to -6.0%)., Conclusions: By December 2021, HIV/STI testing had not recovered to pre-COVID-19 levels, and HIV/STI continues to be underdiagnosed. Despite decreased testing, P&S syphilis cases have increased substantially., Competing Interests: Conflict of Interest and Sources of Funding: The authors declare that they have no affiliations with or involvement in any organization or entity with any financial interest in the subject matter or materials discussed in this article., (Copyright © 2023 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: Shifts in public health infrastructure to respond to one emerging health threat may have unanticipated consequences for preexisting diseases. Previous research evaluating the impact of COVID-19 on sexually transmitted infections (STIs) has been conducted nationally, with little exploration of the impact on a granular geospatial level. This ecological study seeks to quantify the association between COVID-19 cases or deaths and chlamydia, gonorrhea, and syphilis cases for all US counties in 2020., Methods: Separate, adjusted multivariable quasi-Poisson models with robust standard errors modeled the county-level association between 2020 COVID-19 cases and deaths per 100,000 and 2020 chlamydia, gonorrhea, or syphilis cases per 100,000. Models were adjusted for sociodemographic characteristics., Results: Every 1000 additional COVID-19 cases per 100,000 was associated with a 1.80% increase in the average number of chlamydia cases ( P < 0.001) and a 5.00% increase in the average number of gonorrhea cases ( P < 0.001). Every 1000 additional COVID-19 deaths per 100,000 was associated with a 57.9% increase in the average number gonorrhea cases ( P < 0.001) and a 74.2% decrease in the average number of syphilis cases ( P = 0.004)., Conclusions: Higher rates of COVID-19 cases and deaths were associated with increased rates of some STIs at the US county level. The underlying reasons for these associations could not be established by this study. The emergency response to an emerging threat may have unanticipated influence on preexisting diseases that varies by level of governance., Competing Interests: Conflict of Interest and Sources of Funding: The authors declare no conflict of interest. Research reported in this publication was supported by the National Institute of Biomedical Imaging and Bioengineering of the National Institutes of Health under Award Number U54EB007958. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Sexually Transmitted Diseases Association.)

Abstract: Disease intervention specialists are often at the forefront of adoption of new technologies in support of sexually transmitted infection (STI) contact tracing efforts. Newer technology for detection of treatable STI includes point-of-care molecular tests for detection of chlamydia, gonorrhea, and trichomonas and syphilis serology point-of-care tests. Other additions to our case finding toolbox are the use of telemedicine and the proliferation of direct-to-consumer offerings, both of which rely on remote sample collection involving self-collection of specimens in nonclinical settings. Finally, on the near horizon are over-the-counter tests that will support self-testing without the involvement of a medical professional. Each of these new developments is discussed and contextualized in experiences resulting from the COVID-19 pandemic response. Many options are now available, or will be soon, for detection of STIs in nontraditional settings, and we need to consider the processes involved as we move toward adoption of these new tools., Competing Interests: Conflict of Interest and Sources of Funding: None declared., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Sexually Transmitted Diseases Association.)

Background: Public release of health data typically requires statistical disclosure limitation (SDL), but scant research demonstrates how real-world SDL affects data usability. Recent changes of federal data re-release policy allow a pseudo-counterfactual comparison of HIV and syphilis data suppression rules., Methods: Incident counts (2019) of HIV and syphilis infections by county for Black and White populations were downloaded from the US Centers for Disease Control and Prevention. We quantified and compared suppression status by disease and county between Black and White populations and calculated incident rate ratios for counties with statistically reliable counts., Results: Approximately 50% of US counties have incident HIV counts suppressed for Black and White populations compared with only 5% for syphilis, which has an alternative suppression strategy. The county population sizes protected by a numerator disclosure rule (<4) spans several orders of magnitude. Calculations of incident rate ratios, used as a measure of health disparity, were impossible in the 220 counties most susceptible to an HIV outbreak., Conclusions: Balancing tradeoffs between providing and protecting data are key to health initiatives worldwide. We encourage an increase in empirical research on the impact of SDL, especially in the context of health disparities, and recommend new approaches to avoid the "oppression of data suppression.", Competing Interests: Conflict of Interest and Sources of Funding: None declared., (Copyright © 2023 American Sexually Transmitted Diseases Association. All rights reserved.)

Abstract: Contact tracing is a core public health intervention for a range of communicable diseases, in which the primary goal is to interrupt disease transmission and decrease morbidity. In this article, we present lessons learned from COVID-19, HIV, and syphilis in San Francisco to illustrate factors that shape the effectiveness of contact tracing programs and to highlight the value of investing in a robust disease intervention workforce with capacity to pivot rapidly in response to a range of emerging disease trends and outbreak response needs., Competing Interests: Conflict of Interest and Sources of Funding: None declared., (Copyright © 2022 Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.)

Abstract: Disease intervention specialists (DIS) are the cornerstone of public health. However, the incremental gains of DIS-led interventions are difficult to detect at the population level. Health departments attempt to quantify the impact of key DIS activities through performance measures that assess how many and how quickly both patients are interviewed, and contacts are notified, tested, and treated. However, DIS work encompasses more than case finding and existing performance measures may not capture the full value DIS provide to health departments. In this article, we first describe how DIS investigations and contact tracing are conducted for sexually transmitted diseases and other communicable diseases to understand how the definition of effectiveness may vary by disease. Then, we examine the benefits and limitations of traditional performance measures using syphilis investigations as an example. Recognizing the limits of existing measures will improve our understanding of DIS impact and assist in the development of new measures of effectiveness that better represent the totality of DIS work., Competing Interests: Conflict of Interest and Sources of Funding: None declared., (Copyright © 2022 Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.)

Background: Manually performed nontreponemal assays, such as rapid plasma reagin (RPR), are labor intensive and time consuming. Recently, commercial automated RPR assays gained attention. The aim of this study was to compare the qualitative and quantitative performance of the AIX1000 (RPR-A; Gold Standard Diagnostics) to a manual RPR test (RPR-M; Becton Dickinson Macrovue) within a high-prevalence setting., Methods: A retrospective panel of 223 samples was selected for comparison between RPR-A and RPR-M, including 24 samples from patients with known syphilis stages and 57 samples from 11 patients in follow-up. In addition, 127 samples obtained during routine syphilis diagnosis with RPR-M were analyzed prospectively with AIX1000., Results: Overall qualitative concordance (percent agreement) between both assays was 92.0% in the retrospective and 89.0% in the prospective panel. Of 32 discordances, 28 were explained by a treated syphilis infection still positive in one assay and already negative in the other. One sample was false positive with RPR-A, 1 infection remained undetected by RPR-M, and 2 remained undetected by RPR-A. A hook effect was apparent on the AIX1000 at RPR-A titers from 1:32 onward; however, no infections were missed. Accepting a ±1 titer difference, quantitative concordance between both assays reached 73.1% and 98.4% for the retrospective and prospective panels, respectively, with an upper limit of reactivity for RPR-A at 1:256., Conclusions: The AIX1000 showed a similar performance to Macrovue RPR with the exception of a negative deviation for high-titer samples. Within the reverse algorithm used in our high-prevalence setting, AIX1000's main advantage is automation., Competing Interests: Conflict of Interest and Sources of Funding: The authors have no conflict of interest to disclose. The equipment and reagents for testing with AIX1000 were provided by Gold Standard Diagnostics and supplied by Selinion., (Copyright © 2023 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: The Centers for Disease Control and Prevention (CDC) recommends testing patients with chlamydia (CT)/gonorrhea (GC) for other sexually transmitted infections (STIs) and repeating CT/GC testing 3 to 12 months later. We assessed repeat CT/GC testing and testing for HIV/syphilis in accordance with CDC guidelines in the US Veterans Health Administration., Methods: Molecular laboratory testing for CT/GC during January 1, 2013-December 31, 2020 was retrieved from Veterans Health Administration data sources. Patients were evaluated for syphilis, HIV, and repeat CT/GC testing within 1 year after a positive CT/GC test result. Differences of CT/GC-positive patients associated with receiving recommended testing were assessed using χ2 /Fisher exact tests., Results: A total of 41,630 of 1,005,761 CT (4.1%) and 17,649 of 1,013,198 GC (1.7%) results were positive. Median ages of positive CT/GC patients were 29 and 36 years, respectively. Repeat testing rates for CT/GC within 90 to 119 days were 3.9% and 2.9%, and rates within 90 to 365 days were 32.8% and 34.7%, with 8.6% and 15% being positive again, respectively. Guideline-compatible repeat testing in known HIV-positive patients nearly doubled (75.7% for CT and 67.8% for GC). The CDC-recommended HIV testing was performed for 72.4% and 65.5% CT and GC first positives, respectively, whereas syphilis testing was completed for 66.5% and 60.5% CT and GC, respectively. Compared with 25- to 34-year-old patients with CT or GC, those younger than 25 years had higher odds of guideline-discordant repeat testing but had lower odds of not receiving HIV/syphilis testing., Conclusions: Nearly two-thirds of patients did not receive recommended repeat testing, and nearly one-third were not tested for HIV/syphilis. Veterans Health Administration providers may benefit from additional education on CDC-recommended sexually transmitted infection guidelines and testing recommendations., Competing Interests: Conflicts of Interest and Sources of Funding: The authors declare that they have no competing interests. This work was supported by intramural Veterans Health Administration funds., (Copyright © 2023 Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a "œwork of the United States Government"œ for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.)

Background: Many people vulnerable to HIV do not perceive themselves at risk or consider preexposure prophylaxis (PrEP). This study hypothesizes that syphilis diagnosis through universal, emergency department (ED) screening would increase PrEP uptake., Methods: This prospective cohort study enrolled patients tested for syphilis through ED screening between July 2019 and July 2021. Participants completed a survey about behaviors, HIV and PrEP knowledge, and opinions at the time of enrollment. All were offered PrEP if they met Centers for Disease Control and Prevention guidelines for PrEP use. Information about PrEP use and HIV status was collected 6 months later. Bivariate analysis was used to compare outcomes between groups testing positive versus negative for syphilis., Results: The study enrolled 97 participants, 49 with syphilis and 48 testing negative. Overall, 11 (11.3%) started PrEP, all in the syphilis group, despite 28 (58.3%) in the negative group having indications for PrEP. Participants with syphilis less frequently reported low perceived HIV risk than syphilis-negative participants who reported HIV transmission behaviors (83.7% vs. 92.9%). Participants reporting moderate to high HIV risk perception were significantly more likely to start PrEP (odds ratio, 10.5; 95% confidence interval, 1.41-78.1; P = 0.02). At 6 months, 3 participants remained on PrEP (follow-up data available for 63.5% of PrEP-eligible participants)., Conclusions: Syphilis diagnosis was associated with increased perception of HIV risk and increased PrEP initiation. Individuals who otherwise might not seek testing for syphilis because of perceived low risk may be identified through routine screening, thus providing an important opportunity to link more people to HIV prevention and PrEP services., Competing Interests: Conflict of Interest and Sources of Funding: None declared., (Copyright © 2023 American Sexually Transmitted Diseases Association. All rights reserved.)

Competing Interests: Conflict of Interest: None declared.

Background: Partner Notification (PN) is a key public health service to alert the partners of patients diagnosed with a sexually transmitted infection and then support these individuals to test. Partner Notification is a challenge to deliver because of the personal nature of this communication and the time it requires to deliver effectively. Digital tools have been developed to support patients to inform their partners; unfortunately, it has not been possible to measure engagement with-and the impact of-these solutions. A digital PN tool (dPNt) was developed for use by the health care provider to (1) deliver anonymous PN, (2) support the partner to locate and test at an appropriate local service, and (3) track real-time outcome metrics. To assess the usefulness of this tool we analyzed dPNt adoption and performance in the delivery of PN services., Method: A dPNt engagement for 5715 patients diagnosed by 23 health care providers with either gonorrhea or syphilis in 2019 was analyzed to determine what factors were associated with the use of this tool. The PN performance and a sub analysis of the patients who used dPNt was compared with the adjusted aggregate PN performance reported by Public Health England., Results: Overall, dPNt engagement was 21% and 27% for patients with gonorrhea and syphilis, respectively. Male gender patients with gonorrhea and younger patients with either diagnosis were more likely to engage with dPNt. Nonengagement with dPNt was associated with a significantly higher number of partners reported as already seen and tested at the time that PN was initiated. The overall number of partners seen and tested per index patient increased in the clinics using dPNt from 0.43 to 0.84 for gonorrhea and 0.71 to 0.94 for syphilis, relative to Public Health England baseline results. Half of all prospective partner testing verification was done automatically by dPNt and no interaction was demonstrated between dPNt and standard methods., Conclusion: Digital PN tool engagement increased when more partners needed to be informed of their risk of infection. Future work is planned to improve the use of and engagement with dPNt to alert and test more partners or their risk and improve public health., Competing Interests: Conflict of Interest: A.S.M.-J. is the Founder & Director of SXT Health CIC, a community interest company limited by guarantee (UK company number: 07130130). TF declares no conflicts of interest., (Copyright © 2022 American Sexually Transmitted Diseases Association. All rights reserved.)

Abstract: We evaluated changes in rates of testing and diagnoses of sexually transmitted infections during the 2017-2020 period at Kaiser Permanente Southern California. During the COVID-19 pandemic period, we observed profound reductions in testing and fewer diagnoses of chlamydia, gonorrhea, and HIV compared with prepandemic periods, but syphilis diagnoses rates increased by 32%., Competing Interests: Conflict of Interest and Sources of Funding: J.J.C. and Q.C. have no conflicts of interest to declare. R.C.H. has received funding from Gilead for unrelated research. J.D.-O. has funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development for unrelated research. K.J.B. has received funding from Gilead, Dynavax, GlaxoSmithKline, Moderna, and Pfizer for unrelated research., (Copyright © 2022 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: Men who have sex with men (MSM) are a priority population for preexposure prophylaxis (PrEP) for HIV prevention. We summarized the surveillance data from the studies of MSM taking PrEP versus before taking PrEP to investigate the possible increased risk of sexually transmitted infections (STIs)., Methods: Two researchers independently searched 5 databases from January 2012 to April 2022 to identify relevant studies reporting the incidence density of syphilis, gonorrhea, and chlamydia infection. Subgroup analyses based on the type and location of research were conducted. The publication bias was detected by Egger's publication bias plot., Results: Twenty studies met the inclusion criteria for the meta-analysis. The pooled estimate of incidence density of syphilis was 9.53 per 100 person-years (PY), whereas 36.48 per 100 PY for chlamydial infection and 34.79 per 100 PY for gonorrhea, higher than the MSM before taking PrEP. The results of the subgroup analysis showed that the incidence density tended to be lower in prospective studies than in retrospective studies and lower in North American studies than in other regions' studies., Conclusions: The high incidence of STIs in the MSM taking PrEP needs to be increasingly appreciated, and more effective prevention method for STIs is valuable among MSM alongside HIV prevention uptake., Competing Interests: Conflict of Interest and Sources of Funding: The authors declare that there is no conflict of interest regarding the publication of this article., (Copyright © 2022 American Sexually Transmitted Diseases Association. All rights reserved.)

Abstract: The relative proportion of cases of primary and secondary syphilis among men who have sex with men and women reported through national case report data from 2010 to 2019 seemed stable overall and were stratified by race/ethnicity, region, and age group, but case counts increased., Competing Interests: Conflict of Interest and Sources of Funding: None declared., (Copyright © 2022 American Sexually Transmitted Diseases Association. All rights reserved.)

Abstract: Of 39 pregnant women at ≥20 weeks' gestation treated with benzathine penicillin G for infectious syphilis, we identified only 2 mild Jarisch-Herxheimer reactions. There were no immediate fetal sequelae. Data from our study do not support the recommendation for routine admission for the treatment of infectious syphilis in late pregnancy., Competing Interests: Conflict of Interest and Sources of Funding: None declared., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Sexually Transmitted Diseases Association.)

Background: Syphilis can cause neurologic, ocular, or otic manifestations, possibly resulting in permanent disability or death. In 2018, the Centers for Disease Control and Prevention began collecting syphilis clinical manifestation data via the National Notifiable Diseases Surveillance System. We present the first reported US syphilis neurologic, ocular, and otic manifestation prevalence estimates., Methods: We reviewed 2019 National Notifiable Diseases Surveillance System data to identify jurisdictions reporting 70% or greater of syphilis cases 15 years or older with clinical manifestation data (considered "complete reporting"). Among these jurisdictions, we determined reported neurologic, ocular, and otic manifestation prevalence, stratified by demographic, behavioral, and clinical characteristics., Results: Among 41,187 syphilis cases in 16 jurisdictions with complete reporting, clinical manifestations were infrequently reported overall: neurologic (n = 445, 1.1%), ocular (n = 461, 1.1%), otic (n = 166, 0.4%), any (n = 807, 2.0%). Reported clinical manifestation prevalence was highest among cases 65 years or older (neurologic, 5.1%; ocular, 3.5%; otic, 1.2%) and those reporting injection drug use (neurologic: 2.8%; ocular: 3.4%; otic: 1.6%). Although reported neurologic and ocular manifestation prevalence was slightly higher among human immunodeficiency virus (HIV)-infected versus HIV-negative persons, approximately 40% of cases with manifestations were HIV-negative. Reported otic manifestation prevalence was similar regardless of HIV status. When stratifying by HIV status and syphilis stage, reported prevalence was highest among HIV-infected persons with unknown duration/late syphilis (neurologic, 3.0%; ocular, 2.3%; otic, 0.7%)., Conclusions: Reported neurologic, ocular, and otic manifestation prevalence was low among syphilis cases, but these data are likely an underestimate given potential underreporting. Reported clinical manifestation frequency, including among HIV-negative persons, emphasizes the importance of evaluating all syphilis cases for signs/symptoms of neurosyphilis, ocular syphilis, and otosyphilis., Competing Interests: Conflict of Interest and Sources of Funding: None declared., (Copyright © 2022 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: Human immunodeficiency virus (HIV) preexposure prophylaxis (PrEP) reduces HIV acquisition. We used a PrEP continuum of care to measure impact of field epidemiologist-facilitated referrals for PrEP-naive infectious syphilis cases across multiple clinical and pharmacy sites of care., Methods: Retrospective analysis of 2017 to 2018 primary and secondary syphilis cases, medical charts, and pharmacy data to identify PrEP education, referral offer, referral acceptance, first visit, prescription pickup (PrEP initiation) and 2 to 3 months (PrEP persistence). The HIV seroconversion was determined using database match at syphilis diagnosis date and at 12 months. χ 2 or Fisher's exact tests were used to compare demographic characteristics associated with steps with lower progression rates., Results: Of 1077 syphilis cases, partner services engaged 662 of 787 (84%) HIV-negative cases; 490 were PrEP-naive, 266 received education, 166 were offered referral, 67 accepted referral, 30 attended an initial appointment, and 22 were prescribed PrEP. Of 16 with pharmacy data, 14 obtained medication, and 8 persisted on PrEP at 2 to 3 months. Continuum progression was lowest from (1) PrEP-naïve to receiving PrEP education, (2) offered referral to referral acceptance, and (3) referral acceptance to initial PrEP appointment. Men with male partners were more likely to receive PrEP education or accept a referral. Higher social vulnerability was associated with increased PrEP referral acceptance., Conclusions: Few individuals accepted PrEP referrals and persisted on PrEP. Field and clinic data capture were inconsistent, possibly underestimating referral volume and impact of field engagement. Efforts aimed at increasing referral acceptance and clinic attendance may improve PrEP uptake especially among women and heterosexual men with syphilis., Competing Interests: Conflicts of Interest and Sources of Funding: None declared., (Copyright © 2022 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: Herpes simplex virus (HSV) has been the leading cause of genital ulcer syndrome (GUS) in South Africa for more than a decade, and acyclovir therapy is incorporated into syndromic management guidelines. We conducted surveillance at 3 sentinel sites to define the common sexually transmitted etiologies of GUS and to determine whether current syndromic management is appropriate. Secondary objectives of surveillance were to determine the seroprevalence of coinfections (HIV, syphilis, HSV-2) in persons presenting with GUS., Methods: Consecutive, consenting adult men and women presenting with visible genital ulceration were enrolled between January 1, 2019, and December 31, 2020. Genital ulcer swab and blood specimens were collected and transported to a central sexually transmitted infection reference laboratory in Johannesburg., Results: Among 190 participants with GUS, HSV-2 was the most frequently detected ulcer pathogen (49.0%; 95% confidence interval [CI], 41.9%-56.1%). The relative prevalence of the second most common ulcer-derived pathogen, Treponema pallidum, was 26.3% (95% CI, 20.5%-33.1%), with 90% of primary syphilis cases having a positive rapid plasma reagin (RPR) titer. Male sex was independently associated with primary syphilis compared with herpetic ulcers, after adjusting for the effect of casual sex partners and other exposures (adjusted odds ratio, 3.53; 95% CI, 1.35-9.21; P = 0.010). The overall HIV prevalence among participants was 41.3% (78 of 189; 95% CI, 34.2%-48.6%)., Conclusions: Herpes simplex virus 2 remains the predominant cause of GUS, justifying the continued use of acyclovir in syndromic guidelines. Adequate supplies of benzathine penicillin G for syphilis treatment are essential at primary health care level, in addition to the provision of syphilis and HIV risk reduction services., Competing Interests: Conflict of Interest and Source of Funding: All authors have no conflicts of interest to declare. Funding for this work was obtained from the operational cost center of the Centre for HIV & STI at the National Institute for Communicable Diseases, Johannesburg, South Africa., (Copyright © 2022 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: This study aimed to examine variations in the incidence rates of sexually transmitted infections (STIs; i.e., chlamydia, gonorrhea, and syphilis) across the urban-rural and area-deprivation continua from January of 2013 to December of 2018 in Yakima County, Washington. The rates of STIs has been increasing in the United States in the past decade. Historically, Yakima County has higher rates of STIs than state and national rates. In addition, Yakima County contains rural areas and areas with greater deprivation that face gaps in access to care., Methods: The Washington State Department of Health Database Surveillance System was used to conduct the study. The data set included diagnosed cases of chlamydia, gonorrhea, and syphilis with positive laboratory test results for the duration of the study period. Incidence rates of STIs were calculated and statistically analyzed across the urban-rural and area-deprivation continua using rural-urban commuting area codes and the area deprivation index., Results: The incidence rates of STIs increased from January of 2013 to December of 2018. Rates of STI did not differ in micropolitan, small town, and rural block groups compared with the metropolitan block groups. Most-deprived block groups had significantly higher STI rates compared with less deprived block groups., Conclusions: There is a need for increased STI intervention in higher deprivation areas including STI education. Public health officials and health care providers should be aware of these risk factors and tailor interventions to the neighborhood they serve., Competing Interests: Conflict of Interest and Sources of Funding: None declared., (Copyright © 2022 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: We sought to examine the correlates for stimulant use in persons diagnosed with infectious syphilis during an outbreak in Alberta to help guide public health interventions., Methods: Infectious syphilis data were extracted from the Communicable Disease and Outbreak Management database from January 1, 2018, to December 31, 2019. Behavioral, demographic, and lifetime reported stimulant use data were obtained. Descriptive analyses and logistic regression were performed for 3 subpopulations (gay, bisexual, and other men who have sex with men; men who have sex with women; and women)., Results: Of 3627 individuals diagnosed with infectious syphilis, 23.9% (n = 867) cases were not interviewed for substance use and were removed from further analysis. Of the remaining 2759 people, 41.8% (n = 1153) self-reported lifetime stimulant use. Gay, bisexual, and other men who have sex with men reported stimulant use less often than women (24.6% vs. 44.1%; P < 0.0001) and men who have sex with women (24.6% vs. 46.2%; P < 0.0001). Multivariable analyses demonstrated that stimulant use was associated with persons who injected drugs, had correctional involvement, or reported multiple sex partners. Men who have sex with women were more likely to self-report First Nations ethnicity (adjusted odds ratio, 1.76 [95% confidence interval, 1.25-2.49]), and women were more likely to have a concurrent gonorrhea infection (adjusted odds ratio, 1.62 [95% confidence interval, 1.15-2.28])., Conclusions: Nearly half of infectious syphilis cases in Alberta reported lifetime nonprescription stimulant use. Infectious syphilis cases with stimulant use were associated with injection drug use, multiple sex partners, and correctional involvement. Our observations highlight the need for integration of sexual health services into programs for people who use substances and those in corrections custody., Competing Interests: Conflict of Interest and Sources of Funding: None declared., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Sexually Transmitted Diseases Association.)

Background: In South Africa, male urethritis syndrome (MUS) is the most common sexually transmitted infection (STI) syndrome in men. We determined the distribution of STI etiologies and the susceptibility profiles of Neisseria gonorrhoeae isolates from men presenting with MUS to 3 sentinel surveillance health care facilities. Secondary objectives were to determine the seroprevalence of coinfections (HIV, syphilis, herpes simplex virus 2)., Methods: Consecutive, consenting men with symptomatic urethral discharge were enrolled between January 1, 2019, and December 31, 2020. Genital discharge swab and blood specimens were collected and transported to a central STI reference laboratory in Johannesburg, South Africa., Results: Among 769 men enrolled, N. gonorrhoeae was the commonest cause of MUS (674 [87.8%]; 95% confidence interval [CI], 85.2%-89.9%), followed by Chlamydia trachomatis (161 [21.0%]; 95% CI, 18.2%-24.0%). Of 542 cultivable N. gonorrhoeae isolates, all were susceptible to ceftriaxone (modal minimum inhibitory concentration, 0.004 mg/L) and azithromycin (modal minimum inhibitory concentration, 0.128 mg/L). Seroprevalence rates of HIV, syphilis, and HSV-2 were 21.4% (95% CI, 18.5%-24.5%), 2.3%, and 50.1%, respectively. Condom use at last sexual encounter was reported by only 7%, less than 50% had been medically circumcised, and only 66.7% (58 of 87) who self-reported an HIV-positive status were adherent on antiretroviral drugs., Conclusions: Neisseria gonorrhoeae and C. trachomatis were the predominant causes of MUS. Currently recommended dual ceftriaxone and azithromycin therapy are appropriate for MUS syndromic management; however, surveillance must be maintained to timeously detect emerging and increasing gonococcal resistance. Clinic-based interventions must be intensified in men seeing sexual health care to reduce the community transmission and burden of STI and HIV., Competing Interests: Conflict of Interest and Source of Funding: All authors have no conflicts of interest to declare. Funding for this work was obtained from the operational cost center of the Centre for HIV & STI at the National Institute for Communicable Diseases, Johannesburg, South Africa., (Copyright © 2022 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: The Centers for Disease Control and Prevention (CDC) and US Preventive Services Task Force (USPSTF) guidelines recommend screening for human immunodeficiency virus (HIV) in patients aged 15 to 65 years, as well as those at increased risk. Patients screened in the emergency department (ED) for gonorrhea (GC) and/or chlamydia represent an increased-risk population. Our aim was to assess compliance with CDC and USPSTF guidelines for HIV testing in a national sample of EDs., Methods: We examined data from the 2010 to 2018 Nationwide Emergency Department Sample, which can be used to create national estimates of ED care to query tests for GC, chlamydia, HIV, and syphilis testing. Weighted proportions and 95% confidence intervals (CIs) were reported, and Rao-Scott χ 2 tests were used., Results: We identified 13,443,831 (weighted n = 3,094,214) high-risk encounters in which GC/chlamydia testing was performed. HIV screening was performed in 3.9% (95% CI, 3.4-4.3) of such visits, and syphilis testing was performed in 2.9% (95% CI, 2.7-3.2). Only 1.5% of patients with increased risk encounters received both HIV and syphilis cotesting., Conclusions: Despite CDC and USPSTF recommendations for HIV and syphilis screening in patients undergoing STI evaluation, only a small proportion of patients are being tested. Further studies exploring the barriers to HIV screening in patients undergoing STI assessment in the ED may help inform future projects aimed at increasing guidance compliance., Competing Interests: Conflict of Interest and Sources of Funding: The authors all report no conflicts of interest to disclose. This study was unfunded., (Copyright © 2022 American Sexually Transmitted Diseases Association. All rights reserved.)