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Syphilis and gonorrhoea: resurgence of age-old problems

In the third part of our sexual health series, Dr Olwen Williams advises

who is at risk and how to manage general practice patients

There has been an unprecedented rise in the number of new cases of syphilis over the past five years. In 1997, a small outbreak associated with acquisition through heterosexual intercourse, commercial sex work and crack cocaine occurred in Bristol.

Subsequent outbreaks in Brighton, Manchester, Edinburgh, Glasgow and London have been mainly in men who have sex with men.

Over this period there has been a 1500 per cent rise, while in 2003 a total of 1,580 new diagnoses of primary and secondary infectious syphilis was reported to the Communicable Disease Surveillance Centres, in men who have sex with men (MSM).

In the London outbreak, homosexually-acquired syphilis made up 1,276/1,910 of the total number of cases, 44 per cent of the men were thought to have acquired their infection through oral sex and 53 per cent were also HIV positive.

The parallel rise in cases of gonorrhoea and, more worryingly, ciprofloxacin resistance, which now makes up 9 per cent of all cases of gonorrhoea in the UK, has also been witnessed. Some 22 per cent of all gonorrhoea diagnosis in 2003 was in MSM.

Sign of the times?

A rise in the number of cases of gonorrhoea is seen as a sign of changing sexual practices as its short incubation time and early symptoms reflect recent unsafe sexual practices.

Observers of this trend are worried that these markers for unsafe sex are a forerunner for an ongoing rise in HIV in the homosexually active population. Behavioural changes suggest an increase in rates of unprotected anal intercourse, especially among HIV discordant or unknown status partners.

Research suggests a combination of factors including 'safer sex fatigue', liberalisation of society and more 'venues' such as the internet to meet new sexual partners as being the underlying reasons behind this change.

Targeting advice

By nature of the fact that most gay men do not reveal their sexual orientation to their GP, they are an unknown/unseen quantity, and a challenge for primary care to identify the at-risk population who are registered in their practice. It is estimated that there were around 490,000 homosexually-active men in England in 2003. This is based on the supposition that 2.6 per cent of the male population over the age of 16 were gay.

The prevalence of diagnosed HIV in this group in the same year was estimated as 3 per cent. The average age of men diagnosed with homosexually-acquired HIV is 33. This group still remains the most at-risk group and primary care is well placed to address some of these issues.

It is well recognised that the psychosocial needs of homosexually-active men are not met in the current environment. Being aware that gay and bisexual men throughout their lives have a range of health and lifestyle issues that may affect their sexual health is imperative. 'Coming out' at any age may be a traumatic experience.

Isolation, failure to integrate in the workplace and bullying may lead to mental health problems. Recreational drug use may lead to dysinhibition and risk taking. They may not disclose their sexuality or sexual behaviour for fear of discrimination, stigma and homophobia when they present with these problems. Practices can promote a positive environment by removing these barriers through having the appropriate knowledge, skills and awareness.

Broaching the subject

Being skilled and able to introduce a sexual history into the consultation in a non-judgmental and non-moralistic way allows the individual to feel comfortable and confident that their sexuality/sexual preference will be respected. Assumption making can be disastrous ­ using the term 'partner/s' until the individual divulges the sex of their partner/s is a tactic that works.

Only inquiring later in the history if it's still ambiguous does one directly ask if they are male or female, or both. 'Sexual activity' can range from kissing to receptive or penetrative anal sex, and not everyone does everything! It is wise to clarify rather than make an assumption.

Specific services targeting gay and bisexual men in primary care should include information promoting safer sexual behaviour, leaflets on sexually transmitted infections, free condoms and lube and signposting to genitourinary medicine services. Availability of serological testing for HIV, hepatitis B and syphilis should be on display as well as hepatitis B vaccination for those found not to be immune.

Fast track referral for those newly diagnosed with HIV to specialist HIV services within two weeks of diagnosis. An awareness of local sexual health/ genitourinary medicine clinics' policies for post sexual exposure prophylaxis for HIV (PEPSI) is important as most centres advocate taking the combination antiretroviral therapy within 72 hours of exposure to HIV.

Diagnosis and management

In homosexually-active men diagnosis includes taking microbiological samples from all exposed sites (these will be identified from taking a good sexual history): rectal, urethral and pharyngeal.

Samples for gonorrhoea need to be placed in a charcoal transport medium and arrive at the laboratory on the same day, specifically labelled requesting gonococcal cultures. Standard therapy is currently ceftriaxone 250mg IM as a stat dose.

Guidelines also advocate the use of doxycycline 100mg orally for seven days to cover concomitant chlamydia infection, but this may inadvertently cover up undiagnosed syphilis without adequately treating it. As doxycycline will render syphilis serology negative, especially in the early stage, it is wise to perform syphilis serology prior to treating for chlamydia.

Syphilis ­ still known as the great mimicker ­ usually presents as a painless punched-out ulcer (single or multiple) anywhere on the body around nine to 90 days post infection. The chancre will heal without scarring within a few weeks but during this time a widespread maculopapular rash that desquamates on palms and sole, mouth lesions, lymphadenopathy and constitutional symptoms mimicking influenza may occur and persist for several months. This is secondary syphilis.

Individuals remain infectious for two years without therapy. Mainstay therapy remains procaine penicillin IM for a minimum of 10 days and maximum of 17 days if the individual is also HIV positive. Serological surveillance post treatment is necessary to ensure therapy has been adequate in all cases.

Other infections currently on the rise in MSM are lymphogranuloma venereum, giardiasis and hepatitis C.

Take-home points

·Assumption-making can be disastrous ­ using the term 'partner/s' until the individual divulges the sex of their partner/s is a tactic that works

·Behavioural changes suggest an increase in rates of unprotected anal intercourse, especially unknown status partners

·Doxycycline to cover concomitant chlamydia infection will render syphilis serology negative, especially in the early stage; it is wise to perform syphilis serology prior to treating

·Syphilis ­ individuals remain infectious for two years without therapy

Useful websites

www.tht.org.uk

www.sigmaresearch.org.uk

www.hpa.org.uk/infections/topics_az/hiv_and_sti

www.youchoose.org.uk

a website where gay men can increase their knowledge of HIV and can make an informed decision to undergo HIV testing

Clinical effectiveness group 2001. National guidelines in the management of gonorrhoea in adults. Available at

www.bashh.org

Olwen Williams, consultant genitourinary physician, Wrexham Maelor Hospital, and chair of the British Association for Sexual Health and HIV's adolescent and sexual health special interest group

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