What is the recommended treatment for a patient with HIV (Human Immunodeficiency Virus) who tests positive for VDRL (Venereal Disease Research Laboratory)?

Treatment of HIV-Positive Patient with Positive VDRL

An HIV-infected patient with a positive VDRL should be treated with benzathine penicillin G 2.4 million units IM as a single dose for early syphilis (primary, secondary, or early latent), or 2.4 million units IM weekly for three consecutive weeks for late latent syphilis or syphilis of unknown duration. 1, 2

Initial Evaluation and Staging

Before initiating treatment, you must determine the stage of syphilis infection:

• Obtain a quantitative nontreponemal titer (VDRL or RPR) to establish a baseline for monitoring treatment response 2, 3
• Confirm with a treponemal test (FTA-ABS or TP-PA) to distinguish true infection from biological false-positive VDRL 2
• Perform a thorough clinical examination looking for chancre (primary), rash or mucocutaneous lesions (secondary), or absence of symptoms (latent) 2, 3
• Assess for neurologic symptoms (headache, vision changes, hearing loss, confusion) or ocular manifestations (uveitis, neuroretinitis) that would indicate neurosyphilis 1, 2

CSF Examination Indications

HIV-infected patients require a lower threshold for lumbar puncture compared to HIV-negative patients. Perform CSF examination if: 1, 2

• Any neurologic or ocular symptoms are present 1, 2
• Late latent syphilis or syphilis of unknown duration is diagnosed 1, 2
• Serum VDRL titer is >1:32 with CD4 count <350 cells/mm³ 2
• Treatment failure occurs (persistent symptoms or inadequate serologic response) 1

Treatment Regimens by Stage

Early Syphilis (Primary, Secondary, or Early Latent <1 Year)

Benzathine penicillin G 2.4 million units IM as a single dose 1, 2, 3

• Some specialists recommend a second dose one week later for HIV-infected patients due to concerns about treatment failure, though evidence is mixed 1, 4
• Alternative for penicillin allergy: Doxycycline 100 mg orally twice daily for 14 days (non-pregnant patients only) 2, 3

Late Latent Syphilis or Unknown Duration

Benzathine penicillin G 2.4 million units IM once weekly for three consecutive weeks 1, 2

• Some specialists add a neurosyphilis regimen in this setting for HIV-infected patients, though data are limited 1

Neurosyphilis (Confirmed by CSF Examination)

Aqueous crystalline penicillin G 18-24 million units per day IV (administered as 3-4 million units every 4 hours or continuous infusion) for 10-14 days 1, 2, 3

• Alternative: Procaine penicillin 2.4 million units IM daily plus probenecid 500 mg orally four times daily, both for 10-14 days 1
• Some specialists follow with benzathine penicillin G 2.4 million units IM weekly for three weeks after completing the neurosyphilis regimen 1
• Penicillin desensitization is mandatory for penicillin-allergic patients with neurosyphilis, as no proven alternatives exist 1, 2, 3

Enhanced Monitoring for HIV-Infected Patients

HIV-infected patients require more frequent follow-up than HIV-negative patients due to higher risk of treatment failure and atypical serologic responses: 1, 2

For Early Syphilis

• Clinical and serologic evaluation at 3,6,9,12, and 24 months (compared to 6 and 12 months for HIV-negative patients) 1, 2

For Late Latent Syphilis

• Serologic evaluation at 3,6,12,18, and 24 months 2

Treatment Success Criteria

• Fourfold decline in nontreponemal titer within 6-12 months for early syphilis 1, 2, 3
• Fourfold decline within 12-24 months for late latent syphilis 1, 2

Management of Treatment Failure

Treatment failure should be suspected if: 1

• Sustained fourfold increase in nontreponemal titer after initial decline 1
• Persistent or recurring clinical signs or symptoms 1
• Failure to achieve fourfold decline in titer within the expected timeframe 1

Retreatment Algorithm

1. Perform CSF examination to rule out neurosyphilis 1
2. If CSF is normal: Retreat with benzathine penicillin G 2.4 million units IM weekly for three weeks 1
3. If neurosyphilis is confirmed: Treat with IV aqueous penicillin G regimen 1

Critical Pitfalls to Avoid

• Never use treponemal test titers to monitor treatment response - they remain positive for life regardless of cure 2, 3
• Do not compare VDRL and RPR titers directly - use the same test method throughout follow-up, preferably at the same laboratory 1, 2
• Do not assume persistent low titers (<1:8) indicate treatment failure - 15-20% of patients remain "serofast" with stable low titers despite adequate treatment 1, 2
• Do not delay treatment waiting for darkfield microscopy results if clinical suspicion is high 3
• Be aware that HIV-infected patients may have atypical serologic responses with unusually high, low, or fluctuating titers 1, 2

Special Considerations

Jarisch-Herxheimer Reaction

• Warn patients about possible acute febrile reaction within 24 hours of treatment, characterized by fever, headache, and myalgia 3
• This reaction is common in early syphilis and does not indicate treatment failure 3

Partner Management

• Evaluate and treat all sexual contacts within the past 90 days for primary syphilis presumptively 3

Concurrent ART

• No immune reconstitution inflammatory syndrome (IRIS) has been described with syphilis treatment in HIV-infected patients 1
• Treatment response may be slower in HIV-infected patients, but standard regimens remain appropriate 1, 4