title: Rising Syphilis Infection among Rural HIV-Infected Men who Routinely Received Risk-Reduction Counseling: New Challenges to HIV Prevention in Clinical Care.
abstract: OBJECTIVE
  Syphilis incidence has been steadily increasing among HIV-infected men in the United States, representing an important public health challenge to HIV prevention. Clinic-based HIV prevention interventions are available but may need to be revisited in response to syphilis epidemic. We wanted to better understand the current epidemiology of syphilis in rural HIV-infected men who routinely received HIV risk-reduction counseling in order to plan more effective HIV prevention strategies in clinical care.
  
  
  METHODS
  We conducted a retrospective cohort study to examine factors associated with syphilis infections in rural HIV-infected men who received sexually transmitted disease screening and HIV risk-reduction counseling during HIV primary care from January 2008 to June 2013. We assessed patients' demographic, clinical, behavioral and psychosocial characteristics and performed a multivariable exact logistic regression to identify factors related to syphilis.
  
  
  RESULTS
  Despite routine risk screening and HIV risk-reduction counseling, a total of 51 syphilis infections were diagnosed among 702 HIV-infected men (5 patients were diagnosed ≥ 2 episodes). The majority of the study participants was sexually active and reported at least one unsafe sexual behavior, mainly inconsistent condom use. Younger age (<35 years, adjusted odds ratio (aOR)=3.09), higher educational attainment (some college or above, aOR=3.72), and perception that the partner may have sex with other people (aOR=3.10) were significantly associated with syphilis infection. Non-injection drug use was related to syphilis in HIV-infected men who have sex with men (aOR=2.86).
  
  
  CONCLUSIONS
  Some HIV-infected men, especially young, educated men, or those who perceived that their partners may have sex with other people, continue to have high-risk behaviors that increase their own risks of acquiring syphilis and may also facilitate HIV transmission. New strategies need to be developed for HIV primary care providers to help HIV-infected patients maintain safer sex practices.
authors.affiliation: Department of Medicine, Penn State Hershey College of Medicine, Hershey, PA, 17033, USA.
authors.forename: Poonam
authors.initials: P
authors.lastname: Mathur
authors.affiliation: Department of Medicine, Penn State Hershey College of Medicine, Hershey, PA, 17033, USA.
authors.forename: John
authors.initials: J
authors.lastname: Zurlo
authors.affiliation: Department of Medicine, Penn State Hershey College of Medicine, Hershey, PA, 17033, USA.
authors.forename: Patsi
authors.initials: P
authors.lastname: Albright
authors.affiliation: Department of Medicine, Penn State Hershey College of Medicine, Hershey, PA, 17033, USA.
authors.forename: Tonya
authors.initials: T
authors.lastname: Crook
authors.affiliation: Department of Medicine, Penn State Hershey College of Medicine, Hershey, PA, 17033, USA.
authors.forename: Cynthia
authors.initials: C
authors.lastname: Whitener
authors.affiliation: Department of Public Health Sciences, Penn State Hershey College of Medicine, Hershey, PA, 17033, USA.
authors.forename: Ping
authors.initials: P
authors.lastname: Du
keywords: Clinic-based HIV prevention; HIV risk-reduction counseling; HIV-infected men; Men who have sex with men; Rural HIV population; Syphilis