Warning:

This document is being maintained for historical purposes, but is now out of date. To view current guidelines please visit:

• STD Treatment Guidelines   at http://www.cdc.gov/STD/treatment

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1993 Sexually Transmitted Diseases Treatment Guidelines

09/24/1993

SUGGESTED CITATION
Centers for Disease Control and Prevention. 1993 Sexually
transmitted diseases treatment guidelines. MMWR 1993;42(No. RR-14):
{inclusive page numbers}.

CIO Responsible for this publication:
National Center for Prevention Services,
Division of Sexually Transmitted Diseases and HIV Prevention

Syphilis Among HIV-Infected Patients

Diagnostic Considerations
     Unusual serologic responses have been observed among
HIV-infected persons who also have syphilis. Most reports involved
serologic titers that were higher than expected, but false-negative
serologic test results or delayed appearance of seroreactivity have
also been reported. Nevertheless, both treponemal and nontreponemal
serologic tests for syphilis are accurate for the majority of
patients with syphilis and HIV coinfection.

     When clinical findings suggest that syphilis is present, but
serologic tests are nonreactive or confusing, it may be helpful to
perform such alternative tests as biopsy of a lesion, darkfield
examination, or direct fluorescent antibody staining of lesion
material.

     Neurosyphilis should be considered in the differential
diagnosis of neurologic disease among HIV-infected persons.

Treatment
     Although adequate research-based evidence is not available,
published case reports and expert opinion suggest that HIV-infected
patients with early syphilis are at increased risk for neurologic
complications and have higher rates of treatment failure with
currently recommended regimens. The magnitude of these risks,
although not precisely defined, is probably small. No treatment
regimens have been demonstrated to be more effective in preventing
development of neurosyphilis than those recommended for patients
without HIV infection. Careful follow-up after therapy is
essential.

Primary and Secondary Syphilis Among HIV-Infected Patients

Treatment
     Treatment with benzathine penicillin G 2.4 million units IM,
as for patients without HIV infection, is recommended. Some experts
recommend additional treatments, such as multiple doses of
benzathine penicillin G as suggested for late syphilis, or other
supplemental antibiotics in addition to benzathine penicillin G 2.4
million units IM.

Other Management Considerations
     CSF abnormalities are common among HIV-infected patients who
have primary or secondary syphilis, but these abnormalities are of
unknown prognostic significance. Most HIV-infected patients respond
appropriately to currently recommended penicillin therapy; however,
some experts recommend CSF examination before therapy and
modification of treatment accordingly.

Follow-Up
     Patients should be evaluated clinically and serologically for
treatment failure at 1 month and at 2, 3, 6, 9, and 12 months after
therapy. Although of unproven benefit, some experts recommend
performing CSF examination after therapy (i.e., at 6 months).

     HIV-infected patients who meet the criteria for treatment
failure should undergo CSF examination and be retreated just as for
patients without HIV infection. CSF examination and re-treatment
also should be strongly considered for patients in whom the
suggested fourfold decrease in nontreponemal test titer does not
occur within 3 months for primary or secondary syphilis. Most
experts would re-treat patients with benzathine penicillin G 7.2
million units (as 3 weekly doses of 2.4 million units each) if the
CSF examination is normal.


Special Considerations

Penicillin Allergy -
     Penicillin regimens should be used to treat HIV-infected
patients in all stages of syphilis. Skin testing to confirm
penicillin allergy may be used (see Management of the Patient With
a History of Penicillin Allergy), but data on the utility of that
approach among immunocompromised patients are inadequate. Patients
may be desensitized, then treated with penicillin.

Latent Syphilis Among HIV-Infected Patients

Diagnostic Considerations
     Patients who have both latent syphilis (regardless of apparent
duration) and HIV infection should undergo CSF examination before
treatment.

Treatment
     A patient with latent syphilis, HIV infection, and a normal
CSF examination can be treated with benzathine penicillin G 7.2
million units (as 3 weekly doses of 2.4 million units each).

Special Considerations

Penicillin Allergy

     Penicillin regimens should be used to treat all stages of
syphilis among HIV- infected patients. Skin testing to confirm
penicillin allergy may be used (see Management of the Patient With
a History of Penicillin Allergy), but data on the utility of that
approach in immunocompromised patients are inadequate. Patients may
be desensitized, then treated with penicillin.

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