Is it okay to delay treatment for a 55-year-old male (M) patient with newly diagnosed syphilis and Human Immunodeficiency Virus (HIV) for one week to complete inpatient substance use disorder (SUD) treatment at an American Society of Addiction Medicine (ASAM) 3.5 level?

Management of Newly Diagnosed Syphilis and HIV in a Patient with Stimulant Use Disorder

The patient should complete the inpatient ASAM 3.5 treatment for stimulant use disorder before initiating treatment for newly diagnosed syphilis and HIV, as a one-week delay in treatment for these infections poses minimal immediate risk compared to the benefits of completing addiction treatment.

Rationale for Completing SUD Treatment First

Urgency Assessment for Syphilis Treatment

• While syphilis requires treatment, a one-week delay is not likely to significantly impact outcomes for most presentations:
  • Primary and secondary syphilis: Treatment within weeks of diagnosis is appropriate 1
  • Latent syphilis: Even longer treatment windows are acceptable 1
  • The CDC guidelines do not specify syphilis as requiring emergency treatment within hours or days 2, 1

Urgency Assessment for HIV Treatment

• While early HIV treatment is beneficial, a one-week delay before initiating antiretroviral therapy is unlikely to significantly impact long-term outcomes
• There is no guideline recommendation for emergency initiation of HIV treatment in asymptomatic, newly diagnosed patients

Benefits of Completing SUD Treatment

• Interrupting the ASAM 3.5 treatment program could significantly compromise the patient's recovery from stimulant use disorder
• Completing addiction treatment improves the likelihood of adherence to subsequent HIV and syphilis treatment regimens
• The patient is already halfway through the program, suggesting progress has been made

Management Plan

During Remaining Week of SUD Treatment

• Conduct baseline laboratory tests to prepare for subsequent treatment:
  • CD4 count and HIV viral load
  • Complete syphilis staging with RPR titer
  • Basic metabolic panel and liver function tests
  • Consider CSF examination if neurological symptoms are present 2, 1

Post-Discharge Treatment Plan (to be implemented immediately after completing SUD treatment)

1. Syphilis Treatment:

   • For primary/secondary syphilis: Benzathine penicillin G 2.4 million units IM in a single dose 1
   • For latent syphilis: Benzathine penicillin G 7.2 million units total, administered as 3 doses of 2.4 million units IM at 1-week intervals 1
   • For HIV-infected patients with syphilis, some experts recommend the 3-dose regimen regardless of stage 2

2. HIV Treatment:

   • Initiate antiretroviral therapy based on current guidelines
   • Ensure close follow-up with an HIV specialist

Special Considerations

HIV and Syphilis Co-infection

• HIV-infected patients with syphilis may have:
  • Higher rates of neurological complications 2, 3
  • Potentially higher rates of treatment failure 4
  • Need for more careful follow-up 2, 1

Follow-up Requirements

• Syphilis follow-up: Clinical and serologic evaluation at 3,6,9,12, and 24 months after treatment 1
• HIV follow-up: Regular monitoring of CD4 counts, viral load, and medication adherence
• Substance use disorder follow-up: Arrange outpatient addiction treatment continuation

Potential Pitfalls to Avoid

• Avoid discharging the patient early from addiction treatment, as this could compromise long-term recovery and adherence to HIV/syphilis treatment
• Avoid delaying treatment beyond one additional week, as longer delays may increase risk of complications
• Avoid treating only one condition (either HIV or syphilis) while neglecting the other
• Avoid failing to arrange comprehensive follow-up for all three conditions (SUD, HIV, and syphilis)

Conclusion for Care Team

The one-week delay to complete addiction treatment represents the optimal balance between addressing the patient's immediate substance use disorder needs while ensuring timely treatment of newly diagnosed infections. This approach maximizes the likelihood of successful outcomes for all three conditions.