Ask the Doc: Syphilis and PrEP

In this installment of Ask the Doc, Dr. Howard Scheiner looks at the situation around high rates of gonorrhea and syphilis, especially ocular syphilis, in Los Angeles.

High rates have been driven by unprotected sex. But for now, the increase seems to be limited to the West Coast.

Dr. Scheiner also looks at PrEP and issues around nausea. Are there possible alternatives for those who do not accept Truvada?

Is There a Syphilis Outbreak?

Q: Dear Doc, I was in L.A. recently where there is a lot of concern about a syphilis outbreak. Is the situation the same here in New York City?

A: I certainly have been seeing more cases of syphilis and also gonorrhea in my practice here in NYC. If you live in Chelsea the rates of syphilis have been reported to be 6 times the city average and higher than the rates in San Francisco. The increase in the rates of syphilis has been driven by unprotected sex, according to the Department of Health. The vast majority of the cases are among men who have sex with men (MSM).

The failure to use condoms though is probably only one of the factors driving this increase, especially since condoms cannot guarantee prevention of syphilis. The lack of early detection and the presence of sexual networks may well contribute to the increased rates. Added to this is the fact that syphilis can be transmitted through oral sex, not just with intercourse.

The CDC has called what they are seeing as an "epidemic of syphilis among men who have sex with men." On the West Coast there is heightened concern about ocular syphilis.

Since December 2014, there have been at least 24 cases of ocular syphilis in Los Angeles, San Francisco and Washington State, and a number of those resulted in some level of blindness.

The majority of the confirmed cases have occurred in HIV-infected MSM. Ocular syphilis is a manifestation of neurosyphilis that can occur at any stage of syphilis. Some strains may be more likely to cause this condition.

There are four stages to syphilis. The first is a painless sore, known as a chancre. It may not be obvious that a sex partner has syphilis. These sores can be hidden in the anus, under the foreskin of the penis, in the mouth, or in the vagina, and easily missed. The second stage can present as a skin rash, often on the palms and soles. All of these symptoms will resolve even without treatment.

However, left untreated, latent syphilis can develop after the previous symptoms have disappeared on their own. The final stage is one of late complications affecting the cardiovascular or nervous systems that can develop ten to thirty years later.

If caught early on, a single shot of penicillin is usually curative.

Another concern is the increasing threat of gonorrhea and the worry of antibiotic-resistant gonorrhea developing, which the CDC has named as one of the top three "urgent threats" in the country.

All of this points to the importance of regular testing for STDs.

Being tested for HIV and other STDs every three months, which is the standard recommendation for those on PrEP, is probably a good idea for anyone who is sexually active with multiple partners.

Truvada Makes Me Sick; Is There an Alternative?

Q: I was unable to tolerate Truvada due to daily nausea which developed immediately after I started taking the medication. Is there any other alternative I can take as PrEP.

A: Unfortunately, at the present time there are no other approved PrEP medications. There are however several ongoing studies that may provide alternatives in the future.

There is the Next-PrEP study investigating Maraviroc (Selzentry) an HIV entry inhibitor, alone or in combination with the components of Truvada. There are also long acting injectables that are being studied. These drugs, delivered by injection can persist in the body for extended periods of time. Rilpivirine (Edurant), as a long-acting injectable and Cabotegravir an investigational integrase strand transfer inhibitor that can be administered every three months are being evaluated in small early trials.

Called "more than a doctor, a trusted friend" by his patients, Dr. Howard Scheiner is a true native New Yorker. He was born in the Bronx, he attended the esteemed Bronx High School of Science and City University of New York before receiving his medical education at The Mount Sinai School of Medicine. Truly a Renaissance man, in addition to his lifelong service to the medical profession, Dr. Scheiner is a published author, playwright and musical composer. Combining all his loves, he is perhaps most proud of founding "The Brent Varner Project, Inc." a charity that provides free HIV services to those in need through the Actors Fund of America.

This story is part of our special report: "Ask the Doc". Want to read more? Here's the full list.

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