LAUSR

In 2016, the US Preventive Services Task Force (USPSTF) recommended, with an A recommendation, that asymptomatic, nonpregnant persons who are at increased risk for syphilis infection should be screened.1 Since that time, syphilis rates have continued to increase unabated, even with the barriers to testing and diagnoses imposed by the COVID-19 pandemic.2 In the new recommendation statement,3,4 USPSTF again provides an A recommendation to screen all asymptomatic, nonpregnant adults and adolescents persons at increased risk for syphilis, a well-timed reaffirmation to the current practices of sexual health clinicians.3,4 That said, wide gaps in syphilis testing and diagnoses remain, especially among clinicians who practice outside settings that emphasize sexually transmitted infection (STI) prevention services, including HIV care, sexual health, and prenatal clinics—even when screening is clearly indicated.5-7 Even at HIV clinics, many persons living with HIV do not receive the recommended screening despite their higher rates of syphilis and the unique factors associated with management and follow-up.8,9 The USPSTF’s updated 2022 recommendation3,4 cites new evidence in support of better outcomes with screening, improved risk identification, and identification of lower, manageable harms that screening might incur. In the evidence review,3 3 key points bolster the A recommendation4: the effectiveness of screening asymptomatic persons to reduce syphilis complications and transmission of both syphilis and other STIs (including HIV), availability and ability of risk assessment instruments to identify persons needing screening, and the harms of screening for syphilis. While the new evidence is welcome and clearly bolsters the updated recommendations,3,4 each study cited has nuances that should inform the discussion of future syphilis control efforts. First, to attest that screening asymptomatic persons for syphilis indeed improves outcomes, the USPSTF3,4 highlights a large, longitudinal Australian study demonstrating that screening asymptomatic men who have sex with men (MSM) was associated with increased detection of early latent syphilis and decreased incidence of secondary syphilis.10 In this case, both individual-level benefits (reduced likelihood of secondary syphilis) and population-level benefits (reduced transmission among MSM, a group with high syphilis incidence) were incurred. However, while syphilis testing increased considerably in both MSM living with HIV and those without HIV, at the end of the study, 91% of MSM without HIV received testing while only 77% of the MSM living with HIV did. Syphilis tests per individual increased from 1.3 to 1.6 among MSM without HIV and from 1.6 to 2.3 among MSM with HIV. Even though the mean number of tests increased more among MSM with HIV, a disparity remained among the proportion of MSM with HIV receiving syphilis testing compared with MSM without HIV. More recently, a stepped-wedge cluster-randomized clinical trial among men living with HIV in Canada (most of whom were MSM) showed that standing orders for syphilis screening at the time of routine HIV viral load measurements led to an increase in early syphilis detection.11 Many of these men did report at least 1 symptom, but an increase in syphilis detection was also observed among persons with no symptoms reported.11 The USPSTF3,4 expressly did not include studies among persons living with HIV, but with the increasing uptake of preexposure prophylaxis and better understanding of treatment as prevention, consideration of potential sex partners’ HIV status may not be a major consideration in partner choice; thus, syphilis may be transmitted efficiently throughout these networks.12 These studies demonstrate that increased efforts to screen for syphilis will yield higher rates of disease detection, at least among men with increased risk. It may be challenging to generalize these data to other persons, particularly cisgender + Related articles at jama.com, jamadermatology.com