1. Syphilis co-infection among persons living with HIV
infection in Shelby County, Tennessee:
Describing timing of diagnoses and at-risk populations.
Morrell, KR
Konnor, RY
Kmet, JM
Chapple-McGruder, TD
Shelby County Health Department, Memphis TN

2. Background
• HIV/STD co-infection cannot be assessed at the
national level through exact match methods.
• HIV/STD data not stored in the same surveillance
systems.
• No common identifiers for linkage.
• Co-infection can be assessed at the local level.
• Personal identifiers must be used.
Shelby County Health Department

3. Biological Significance
• HIV and syphilis co-facilitate transmission of
each other.
• HIV shedding
• Cellular recruitment of HIV susceptible cells
• Mucosal barriers breached
• Accelerated progression through the syphilitic
stages may occur among HIV+ individuals
• More likely to progress to clinical neurosyphilis
Shelby County Health Department

4. Public Health Significance
• Increased prevalence of HIV/syphilis co-
infection could represent:
• Increases in sexually risky behavior;
• Increased transmission of HIV in patients with
syphilis.
• May indicate need for expanded behavioral
interventions targeted to:
• Persons testing positive for STDs;
• Persons who know their HIV+ status.
Shelby County Health Department

5. Number of Syphilis and HIV Cases in
Shelby County, 2000-2009
1000
900
Number of Cases
800
700
600 HIV
500
Syphilis
400
300
200
100
0
Shelby County Health Department

6. Objectives
• Identify the number of persons recently
diagnosed (2006-2009) with syphilis/HIV co-
infection in Shelby County;
• Describe the timing of diagnosis;
• Identify populations at an increased risk.
Shelby County Health Department

7. Data Sources
• Enhanced HIV/AIDS Reporting System (EHARS)
• PLWHA (people living with HIV/AIDS) as of Dec. 31,
2009
• Sexually Transmitted Disease Management
Information System (STDMIS)
• Individuals diagnosed with syphilis between 2006-
2009
* Excluded cases <13 years at diagnosis
Shelby County Health Department

8. Data Linkage
PLWHA Syphilis cases
(as of Dec. 31 2009) diagnosed between
2006-2009
• Exact match in SAS by:
• Last name
• First name
• Date of birth
Shelby County Health Department

9. Defining Co-Infections by Timing of Diagnosis
Concurrent diagnosis:
< 3 months
Syphilis & HIV
HIV before Syphilis:
> 3 months
HIV Syphilis
Syphilis before HIV:
3 months - 1 year
Syphilis HIV
Shelby County Health Department

10. Regression Analysis
• Determine factors significantly associated with
syphilis co-infection among PLWHA
• chi-square analysis
• multivariate regression
• Variables of interest:
• Gender
• Race
• Age
• HIV risk transmission category
• Provider type at HIV diagnosis
Shelby County Health Department

11. Matching Results
6, 232 PLWHA 2,680 syphilis cases
(as of Dec. 31, 2009) (2006-2009)
377 records linked
Concurrent HIV before Syphilis
diagnosis: Syphilis: before HIV:
135 (36%) 218 (58%) 24 (6%)
Shelby County Health Department

12. Timing of Co-Infection Diagnoses
Concurrent HIV before Syphilis
diagnosis: Syphilis: before HIV:
135 (36%) 218 (58%) 24 (6%)
P&S: 66 (18%)
Early Latent: 64 (17%)
Late Stage: 88 (23%)
Shelby County Health Department

13. Co-infections by Demographics (n=377)
Gender Age Race/Ethnicity
3% 1%
12% 15% 10%
25%
50%
88% 96%
13 - 19 20 - 29
30 - 39 40+ Black, not Hispanic
Male Female
White, not Hispanic
Hispanic

14. Co-Infections by HIV Risk Transmission
Category (n=377)
Heterosexual 16%
17%
1%
MSM 1%
MSM/IDU
IDU 65%
No reported Risk
Shelby County Health Department

15. Co-Infections by Provider Type at HIV
Diagnosis (n=377)
Public Facility
1% 12%
5% Hospital
Private Facility
7% 49%
Correctional Facility
10%
Blood Services
16% Federal Facility
Unknown
Shelby County Health Department

16. Factors Significantly Associated with Co-Infection
Variable OR Estimates 95% CI
Gender
Male 2.5 (1.7, 3.7)
Race/Ethnicity (vs. White, not Hispanic)
Black, not Hispanic 5.6 (3.2, 9.9)
Age (vs. 40+)
13 - 19 years 2.4 (1.5, 3.7)
20 - 29 years 2.1 (1.5, 2.9)
Risk Transmission Category (vs. Heterosexual)
MSM 2.1 (1.5, 3.1)
Provider Type at HIV Diagnosis (vs. Private)
Correctional 3.8 (2.2, 6.6)
Public 1.9 (1.3, 2.8)
Shelby County Health Department

17. Conclusions
• Indication of continued risky sexual behaviors:
• 18% of linked records are HIV cases diagnosed at
least 3 months before P&S syphilis
• 6% of linked records are syphilis cases diagnosed
at least 3 months before HIV
• Need for interventions in the PLWHA population
that focus on:
• reinforcing consistent condom use;
• motivation to practice safer sex.
Shelby County Health Department

18. Conclusions
• Populations at increased risk for Syphilis co-
infection among PLWHA:
• Males;
• Black, not Hispanic individuals;
• MSM;
• 13-29 years;
• Diagnosed with HIV in public and correctional
facilities.
Shelby County Health Department

19. Conclusions
• Syphilis and HIV testing should be offered
concurrently.
• Both tests currently offered in Shelby Co. jails and
STD clinics.
• Other public clinics should be considered for
point-of-care testing.
Shelby County Health Department

20. Limitations
• Indication of continued risky sexual behavior
relies on assumption that:
• both tests are offered at initial diagnosis; or
• DIS staff locate, refer and link to care for
additional testing within 3 months.
• Limited risk exposure data
• Exact deterministic matching
Shelby County Health Department

21. Acknowledgements
• Shelby County HIV/STD Program
• DIS and surveillance staff
• Donna Freeman, Supervisor/Nurse Practitioner
• Tennessee Department of Health
• CDC National Center for HIV, STD, and TB
Prevention
Shelby County Health Department

22. References
1. Centers for Disease Control and Prevention. 1998. HIV prevention through early detection and treatment of other
sexually transmitted diseases - United States. MMWR 47(RR-12):1-24. Retrieved from:
http://www.cdc.gov/mmwr/preview/mmwrhtml/00054174.htm
2. Funnye A, Akhtar A, Ven D. 2003. Syphilis and Human Immunodeficiency Virus Co-Infection. Journal of the
National Medical Association 95(5): 363-382. Retrieved from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2594513/pdf/jnma00309-0060.pdf
3. Zetola N, Klausner J. (2006). Syphilis and HIV Infection: An Update. Clinical Infectious Diseases 44: 1222-8.
Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/17407043
4. Newman L, Samuel M, Stenger M, Gerber T, Macomber K, Stover J, Wise W. (2009). Practical Considerations for
Matching STD and HIV Surveillance Data with Data from Other Sources. National Center for HIV/AIDS, STD and
TB Prevention, Centers for Disease Control Public Health Reports. Retrieved from:
http://www.publichealthreports.org/issueopen.cfm?articleID=2356
Shelby County Health Department