What is the issue?
Infectious syphilis is defined as infection less than two years duration and includes primary, secondary and early latent clinical presentations. A total of 1,125 cases of infectious syphilis were notified in Victoria in 2016, compared to 948 cases in 2015 and 631 cases in 2014, representing 20 per cent and 50 per cent increase respectively. In the first quarter of 2017 there were 252 cases notified, a 6 per cent increase compared with the same period in 2016. The large majority of notified cases are in MSM. Nearly half of the cases were in HIV positive MSM, and of these, a significant proportion are reinfections.
A total of 6,265 cases of gonorrhoea were notified in Victoria in 2016, compared to 4,864 cases in 2015 and 3273 cases in 2014 representing 29 per cent and 49 per cent increase respectively. There were a total of 2,105 cases notified in the first quarter of 2017, indicating that the increasing trend in notifications continues. Although this increase was seen for both men and women, the infection continues to occur primarily among MSM in urban settings.
The emergence of antimicrobial resistance to gonorrhoea is of great public health concern. In Victoria, decreased susceptibility to ceftriaxone has been reported with 10 isolates detected in the first quarter of 2017. Azithromycin low level resistance continues to increase with 107 isolates reported in the first quarter of 2017. Obtaining culture for gonorrhoea from swabs is crucial for monitoring antimicrobial resistance.
Syphilis and gonorrhoea can be transmitted by unprotected vaginal, anal and oral sex. Both infections are often asymptomatic. Syphilis can present atypically without the chancre characteristic of primary syphilis or the rash of secondary syphilis and early detection through screening can prevent complications and further transmission. Syphilis and gonorrhoea are of particular public health importance because they increase both susceptibility to acquiring HIV infection and transmissibility of HIV infection.
Screening of groups at risk is essential for syphilis and gonorrhoea control, along with partner notification and prevention education. Clinicians play a vital role in control and prevention through early detection and treatment of cases and their contacts.
Screen all MSM for syphilis and gonorrhoea at least annually for gonorrhoea and chlamydia using urine, pharyngeal and anal swabs, together with blood tests for syphilis and HIV. Guidelines on screening and testing are available on the New South Wales Sexually Transmissible Infections Programs Unit . Screen MSM more often (for example, every 3 months) if one or more of the following risk behaviours apply:
- any unprotected anal sex
- more than 10 sexual partners in the last 6 months
- participate in group sex
- use of recreational drugs during sex.
HIV-positive MSM should have a syphilis test every time (an opt-out strategy) they have blood tests for routine HIV monitoring (for example, HIV viral load or CD4 count). HIV positive MSM should also have regular screening for other STI including gonorrhoea.
For gonorrhoea, obtain specimens for both culture and nucleic acid amplification testing (NAAT) for all symptomatic patients at presentation (e.g. purulent urethral or anal discharge in MSM) prior to treatment.
For NAAT confirmed gonorrhoea (including pharyngeal, rectal and cervical infections), ensure a reflexive culture (culture following a positive result) is performed and antibiotic susceptibility testing conducted where possible prior to treatment.
Treatment of cases and contacts
Treat all cases of syphilis and gonorrhoea in accordance with the current . Test and treat all sexual contacts of syphilis and gonorrhoea cases without waiting for test results. Immediate treatment of contacts prevents re-infection of the index case and further transmission.
Ensure that all possible attempts are made to contact sexual partners of MSM with syphilis and gonorrhoea at the time of diagnosis. Innovative partner notification tools are now available to contact partners anonymously via SMS or email. You can undertake partner notification at the time of consultation or strongly encourage your patients to contact their partners themselves.
Partner notification tools are available at the Let them know website and the Drama Downunder website.
Partner notification officers (PNOs) from the Department of Health and Human Services are available to assist with partner notification. The PNOs can contact the sexual partners of a person diagnosed with a sexually transmissible infection (STI), provide advice and referral to testing. Any identifying information about your patients is kept confidential. PNOs can be contacted at +61 3 9096 3367.
Provide advice regarding prevention strategies, early symptom recognition and periodic screening to all MSM patients. Advise MSM that syphilis and gonorrhoea can be transmitted through oral and anal sex. Emphasise that safe sex practices (that is, condom use) greatly reduce the risk of transmission. All MSM should have regular STI testing at least annually. More frequent syphilis and gonorrhoea screening (for example, every 3 months) is recommended for men at higher risk. HIV-positive MSM should be tested for syphilis at each episode of HIV monitoring.
Advice on the diagnosis and management STIs can be obtained from Melbourne Sexual Health Centre through a doctor’s only information line: 1800 0009 903 (Mon-Fri 9:30-12:30, 1:30-5:00) or on the MSHC .
Syphilis factsheet for clinicians
Gonorrhoea factsheet for clinicians
Australian STI management guidelines for use in primary
Contact tracing for STIs: information for clinicians
Australasian contact tracing
Australian sexually transmitted infections and HIV testing guidelines for asymptomatic MSM
Melbourne Sexual Health
The Drama Down
Partner notification information
Department of Health and Human Services Communicable Disease Prevention and Control Unit
Telephone: 1300 651 160
Fax: (61 3) 9096 9174
Partner notification officers
Telephone: 9096 3367