June 27, 2016

Dear Colleague:

I am writing today to make you aware of significant increases in reported syphilis cases in Virginia and nationally and to assure you have the necessary information on testing, treatment and related resources.

Key Observations/Recommendations

  • Most syphilis is reported among men who have sex with other men (MSM); however, cases among women and congenital syphilis are increasing in Virginia and nationally.
  • In 2015, 43% of Virginia’s total early syphilis (TES) cases were co-infected with HIV, raising concerns of syndemic transmission.
  • Test persons diagnosed with any sexually transmitted disease (STD) for syphilis and HIV.
  • Test sexually active MSM for syphilis and HIV at least annually.

Syphilis Cases
Virginia rates of TES diagnoses, (which includes primary, secondary and early latent syphilis) increased by 40.5% in 2015 when compared to the 2011-2014 average annual rate.  The majority of TES cases were male (90%); of these, 75% were MSM.  The rate of TES among women increased 47% for the same period.  National rates of congenital syphilis increased 38% from 2012-2014.  Virginia had eight congenital syphilis diagnoses from 2013-2015 as compared to two cases diagnosed in 2010-2012 (Annual STD Surveillance Report-Total Early Syphilis).

HIV and syphilis co-infection raises concerns for further syndemic transmission.  In addition, patients co-infected with syphilis and HIV may be at increased risk for neurologic complications and serologic treatment failure.

Due to increases in ocular syphilis, the Centers for Disease Control and Prevention (CDC) recently released an updated advisory.  This clinical manifestation can occur at any stage of syphilis and may result in significant sequelae, including blindness.  The Virginia Department of Health (VDH) received reports of five cases in 2015 and three cases in 2016.


Timely identification of STDs is the foundation for effective prevention efforts.  The U.S. Preventive Services Task Force now recommends syphilis screening for at-risk asymptomatic adolescents and adults.  In addition:

  • Screen all pregnant women for HIV and syphilis at the first prenatal visit with repeated testing in areas with high prevalence and for women with increased risk.
  • Test sexually active MSM for HIV and syphilis at least annually.
  • Test persons diagnosed with any STD for HIV and syphilis.


The CDC’s 2015 STD Treatment Guidelines indicate that a one-time dose of penicillin G benzathine (Bicillin-LA®) 2.4 million units IM is recommended for primary, secondary and early latent syphilis.  Additional doses to treat early syphilis do not enhance efficacy, including in patients living with HIV infection.  Treat sexual partners of a person who receives a diagnosis of primary, secondary, or early latent syphilis within 90 days preceding the diagnosis presumptively for early syphilis, even if serologic test results are negative.  Although the CDC announced a national shortage of Bicillin-LA® in May 2016, more recently CDC indicates there is currently a sufficient supply to adequately treat syphilis cases.  If providers’ supply levels of Bicillin-LA® reach three weeks or less, notify the Pfizer Supply Continuity Team at 844-804-4677 for assistance.  Treat ocular syphilis with aqueous crystalline penicillin G IV or procaine penicillin IM with Probenecid for 10-14 days.

In closing, I appreciate your efforts to ensure identification and reporting of syphilis cases.  This will aid our collective efforts to effectively address this increase.  Please report syphilis to your local health department via a morbidity report form.  Report primary and secondary syphilis immediately by the most rapid means available.  Clinical consultation on syphilis management is available on-line at National Network of STD Clinical Prevention Training Centers (NNPTC) STD Clinical Consultation Network.  For additional information, contact Ashley Carter at or 8048648042 or visit the VDH-STD program or CDC-Division of STD Prevention websites.

Thank you for your continued efforts to improve and maintain the health of the people in Virginia.


Marissa J. Levine, MD, MPH, FAAFP

State Health Commissioner