Basil Donovan from NCHECR addresses the global context; Australian trends in infectious syphilis; enhanced surveillance for syphilis; and the effects of syphilis on HIV infection, at AFAO's syphilis forum in May 2009.

1. Syphilis in Australia: 2004-2009 Basil Donovan National Centre in HIV Epidemiology and Clinical Research; and Sydney Sexual Health Centre, Sydney Hospital Thanks particularly to: Melanie Middleton Rebecca Guy

2. Today 1. Global context 2. Australian trends in infectious syphilis 3. Enhanced surveillance for syphilis 4. Effects of syphilis on HIV infection

3. Fabricius 1994: 25 Conrad Reitter , Prior of a Cistercian monastry,1508: Woodcut illustrating his ode: ‘Mortilogus’ (‘our most gracious mistress Mary to preserve us from the French Disease’)

5. Infectious syphilis notifications, by sex, USA 1981-2005 MSM proportion 1999 - 15% 2004 – 64%

6. Infectious syphilis notifications, UK 1998-2007

7. Infectious syphilis in MSM in London, 2001-2008, by HIV status

9. Australian infectious* syphilis notifications Source: National Notifiable Diseases Surveillance System *primary, secondary, latent <2 years from infection Number by quarter

10. Australian infectious syphilis notifications, by year and sex Source: National Notifiable Diseases Surveillance System Per 100,000

11. Relative risk of STIs for MSM in Australia Guy R, unpublished

12. Infectious syphilis notifications in Australian men, by state Source: National Notifiable Diseases Surveillance System Per 100,000

13. Infectious syphilis notifications in non-Indigenous urban men, by state Source: National Notifiable Diseases Surveillance System Per 100,000

14. Infectious syphilis notifications in urban MSM in WA, by quarter Source: National Notifiable Diseases Surveillance System

15. Infectious syphilis notifications in Australian men, by age group Source: National Notifiable Diseases Surveillance System Per 100,000

16. Median age at diagnosis for infectious syphilis, gonorrhoea and HIV infection in Australia Source: National Notifiable Diseases Surveillance System years

18. Enhanced surveillance (1) Source: State / Territory Health Authorites * Jan – Sept 2008 only ** total notifications Characteristic VIC QLD WA SA Year 2008* 2008 2007 2008 Median age** 36 37 44 39 % total notifications 100 (n = 293) 52 (n = 96) 49 (n = 49) 100 (n = 50) Reason for test Symptomatic Screening Other / unknown 42% 47% 11% - 65% 22% 13% - Place of diagnosis STI Clinic GP Other / unknown - 33% 0% 66% 55% 24% 21% 42% 22% 36%

19. Enhanced surveillance (2) Source: State / Territory Health Authorites * Jan – Sept 2008 only Characteristic VIC QLD WA SA Year 2008* 2008 2007 2008 % male homosexual contact 80 82 76 64 Type of partner Casual Regular Other / unknown 68% 11% 21% - 57% 41% 2% - Mode of transmission (MSM) Oral and anal sex Oral sex Other / unknown - - 50% 37% 13% -

22. Risk factors for infectious syphilis *Jin F et al. MJA 2005 Study MSM Sex @ venues Internet UAI Oral Sex HIV+ Other STis Alcohol & Drug Use Other Taylor 2004 LA × × × × × × Peterman 2005 US × × × × × × × Viagra Income <30000 Klausner 2005 SF × × × × Anon sex. Viagra Righarts 2004 UK × × × × × Hetero contact with sex workers Jin 2005* Sydney × × × × × No. of partners

23. Syphilis incidence in two MSM cohorts in Sydney After adjusting for age, HR if HIV+ 9.20 (95% CI 3.63-23.31) UAI with HIV+ partner, HR 4.45 in HIM and 8.67 in pH Jin F et al, ASHM 2009 (submitted) HIM (HIV neg) pH (HIV pos) Incidence/100 person years 0.49 3.62 95% confidence interval 0.31-0.74 1.67-6.48

24. Effect of syphilis on HIV Changes greater with secondary syphilis or CD4 >500 Study (place) N= VL log CD4 Response Buchacz K et al. AIDS 2004 (SF/LA) 52 (58% HAART)  0.22  62 RPR not rep’d. VL recovery slow. Kofoed K et al STD 2006 (Copenhagen) 37 (83% HAART)  0.04  106 Pen = doxy. VL/CD4 better with doxy.

27. The end ‘ Clinton lied. A man might forget where he parks or where he lives, but he never forgets oral sex, no matter how bad it is’ Barbara Bush