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Question about Syphilis treatment for HIV positive male

was diagnosed being HIV + in 2016 and vegan treatment shortly after diagnosis. Transmission occurred most likely in 2013.  VL has been undetectable for every test since and CD4 was 900 last test.  After establishing care with ID doctor, I also tested positive for Syphilis. Titer at time of diagnosis  was 1:256. Doctor gave me 2 shots of penicillin at same time. Titer dropped to 1:64 a few months later. Then it jumped up to 1:128 but lab most likely made an error bc upon retest a few days later it was 1:64. Fast forward over the years and the Titer stayed the same until 2021 it went down to 1:4. 6 months later, it is now 1:16. I believe that it is a lab error in dilution assay but asked doctor to prescribe me doxycycline 100mgx2 day for 14 days. One day before starting doxycycline,  I took 3g of Azithromycin out of fear. My questions are this: 1.) Is it possible that the Titer decrease to 1:4 was an error as I had never been below 1:64 prior to that? I understand that a four fold decrease indicates positive treatment success but also a four fold increase indicates possible reinfection. 2.) is it possible that the 1:16 titer is in error if the 1:4 is valid? 3.) I have access to a large quantity of Azithromycin not expired or old. I find no drug interactions between doxycycline and Azithromycin so will it help eradicate the infection if I give a two combo punch similar to a two-three drug regimen that is available for HIV? Going to take doxycycline 200mg/total a day split into two doses and since I took 3g of Azithromycin already was going to take 500mg a day for 15 days. I just want to make sure I won’t be doing more harm than good. I don’t care about any possible liver damage or kidney problems bc short term goal is to get rid of this disease. I would like to point out that I have had zero symptoms that would indicate to me that I had reinfection. No chancre, no sore, no rash, no headaches, back pain, hearing loss, spots on soles of hands or feet, nothing. Also, sexual activity has been very restricted and very infrequent. Thank you In advance for your reply.
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207091 tn?1337709493
I'm concerned that you are treating without maybe having reliable labs.

The treatment for syphilis is the same for HIV+ patients, but there can be differences in the titers after treatment.


"The majority of reports have involved posttreatment serologic titers that were higher than expected (i.e., high serofast) or fluctuated, and false-negative serologic test results and delayed appearance of seroreactivity have also been reported (622)."

This seems to be what you are seeing - higher than expected titers, as in not going below 1:64, perhaps fluctuations.

If you haven't had any new exposures, I wouldn't keep treating. Are you working with an infectious disease specialist, preferably one very familiar with HIV and STIs?

Also, don't take azithromycin.


"However, because of T. pallidum chromosomal mutations associated with azithromycin and other macrolide resistance and documented treatment failures in multiple U.S. geographic areas, azithromycin should not be used as treatment for syphilis (606–608). "

I hope this helps. I'm not a doctor, and really hope you are working with one on this.
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Thank you for your input and reply. Yes I am working with an infectious disease doctor. I’m a 100% Disabled Veteran so my treatment is all done through the VA. My ID doctor has been doing it for over 30 years. Several studies I found showed that 2g oral Azithromycin in a single dose produced efficacy cure rates of 95% so that’s why I took it before speaking on the phone with my doctor and then started his recommendation of doxycycline for 14 days. My biggest concern is the reliability of the RPR Titer test. From my understanding it’s open to human interpretation in dilution. They recently changed labs from in house to LabCorp so could that be causing the discrepancy? Also, my Titer was never below 1:64 for years and then miraculously it drops to 1:4 only to increase back to 1:16 6-7 months later. I’d like to hear if from someone if taking Azithromycin with doxycycline will cause any loss of effectiveness or interactions as I can find none. They are two different types of bacteria medication with one being a tetracyclic antibiotic and the other being a macrolide antobiotic
Why are you taking zith and doxy and not penicillin? Are you allergic to penicillin? Penicillin is THE recommended treatment.

The RPR isn't the most reliable, which is why it should be confirmed with a treponemal test. (The RPR is a nontreponemal test.)

Absolutely the change in labs could be causing the change, too. Different labs, different systems, different people - absolutely.

That’s a valid question you pose auntie. The reason for not penicillin was strictly a personal choice to avoid that excruciatingly painful shot again. I asked my ID doctor for an alternative to the shot to which he prescribed doxycycline. I’m not allergic to penicillin. I took the Azithromycin on my own without doctor consult after reading that 2g orally in single dose was effective. So erring on the side of caution I took 3g. I’m a part time prepper and have stockpiles of meds, food, water, etc. so I had Azithromycin at my disposal. My question is still if combining the two will have any synergistic effect or if it has a negative effect on one or both. Or if it’s not going to affect one way or the other but still be effective.
It's not going to have a negative effect, as in cancel each other out.

Have you taken a treponemal test to see if you have an active infection? I'm not sure if you even need treatment. A confirmatory treponemal test will be able to tell you if you have an active infection that needs more treatment. Those are TPPA, FTA-ABS, TPHA - have you had any of those?

No I haven’t.  I’m going to Secure Message my Doc and request it.
Good, let us know.
Here’s a breakdown of all my tests over the years.
11/18/2016 - 1:64
12/29/2016 - 1:64
01/13/2017 - 1:32
03/03/2017 - 1:32
08/03/2017 - 1:32
10/03/2017 - 1:128 lab error
10/06/0217 - 1:32 confirmed lab error
04/03/2021 - 1:4 I believe this was an error also. It would be more feasible to have a drop to 1:16 than 1:4 imo
05/13/2022 - 1:16
Wouldn’t it make more sense that Titer at 4/03/2021 was also 1:16 and the 4/03 was an error bc now it’s back to 1:16. Also, TP-PA tests were conducted on all tests from 2016 through 2017. Only RPR quantitative was conducted after 2017.
It might be an error, but with HIV, you can have fluctuations, though I don't know if that holds as true when you are undetectable.

Also, we don't know if this is a new infection that is responding to treatment, or an old infection that is just fluctuating. It's really hard to know without the TPPA or TPHA.
I can’t thank you enough for your comments and input. With the test that showed a 1:128 Titer and then 3 days later back to 1:32, which freaked me out to say the least, I find it’s very possible that this is an error again. I’m going to continue the doxycycline for 14 days, and I see my ID doctor on 5/27/22 and will have a face to face conversation with him. My thinking is he prescribed me the meds to be on the safe side as I don’t think he thoroughly went through my test and Titer history to see what it was. If I have to, I’ll do a lumbar puncture to make sure it’s not latent Syphilis or neurological but like I said aside from the first time when I tested positive I have never had any symptoms of infection. The first time all I had was a small chancre that I thought was herpes but nothing ever since then.
Wait - are you doing all of this without a confirmation test? Why would you do that?

You won't get a penicillin shot, but you'll do a lumbar puncture? Get the confirmation. Seriously. There is no way to know if anything has been an error without that test.
I misrepresented that statement.  I was saying that if I had to I would get a lumbar puncture. Implying  that I’m desperate for  resolution of this is all. I’ll definitely have a conversation with ID doctor next week as it’s my appointment time. By that time I’ll have completed 10 of the 14 day doxycycline regimen and will ask him to proceed. In all reality I believe that this Titer test was an error or the 1:4 Titer result was one and actual Titer is 1:16 which is still a positive decrease from original Titer. It’s hard to know bc HIV poz patients have problems with accuracy of some test and fluctuations are possible. but like you said the only way to know is to do a treponema test.  Please forgive me for all this conversation. I suffer from anxiety and PTSD as it is, so this has only further exacerbated both. I thought I was through with this in 2016 when I got treatment the first time. Either way, I’ve committed myself to being sexually abstinent for the rest of my life. It’s just not important to me anymore.
You don't have to be abstinent. The proper testing, for you and your partner, can determine if you have active infections for any STI, and I'm sorry you haven't had proper testing. It's vital for you and others with HIV.

I'm sure this has exacerbated your anxiety and PTSD. If you have a therapist, or a treatment team, please reach out to them. Let me know what happens with the ID doc. Take care of you.
I don’t know who you are but you are so kind. Thank you for all your honesty and input. I’ll keep you apprised as to what happens next week. God Bless You
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