Gourevitch and colleagues [1] have made a major contribution to our understanding of human immunodeficiency virus (HIV) infection and syphilis in intravenous drug users. Several case reports have suggested an increased incidence of neurosyphilis in the HIV era and that HIV infection or its associated immunosuppression may modify the presentation of syphilis, its rate of progression, and its response to standard treatment. Musher and coworkers [2] reviewed the literature and concluded that one dose of benzathine penicillin may not be adequate treatment for primary, secondary, and early latent syphilis in HIV-infected patients.

The authors suggest in their article [1] that clinical and serologic response to standard penicillin therapy did not differ by HIV serologic status. However, only 1 HIV-infected patient with secondary syphilis and one uninfected patient with early latent syphilis received standard therapy (that is, one dose of benzathine penicillin intramuscularly). On the other hand, 10 HIV-infected patients (2 with primary, 3 with secondary, and 5 with early latent syphilis) and 3 patients not infected with HIV (1 with primary and 2 with secondary syphilis) received higher than recommended doses of penicillin (two to four doses of benzathine penicillin). It appears that clinicians in their program were more likely to choose higher than recommended doses for their patients.

We caution readers that it may be premature to assume that standard therapy is effective in HIV-infected patients with primary, secondary, or early latent syphilis. Prospective, randomized studies are needed to identify the optimal regimen for the treatment of syphilis in HIV-infected patients.