Chapter 3. Detecting STI/RTI
Some people with an STI/RTI have symptoms and seek treatment, while
others do not (Figure 3.1). Promoting symptom recognition and early use
of health care services is an important way of reducing the burden of
Many women and men with an STI/RTI do not have symptoms, however, or
have minimal symptoms and do not realize that anything is wrong. They
may visit a clinic for other reasons or not at all. Yet identifying and
treating such patients prevent the development of complications for the
individual patient and help reduce transmission in the community.
Indications and opportunities for screening
- Pregnancy. Screening for syphilis should be done at the first
antenatal visit, as early as possible in pregnancy. It can
be repeated in the third trimester if resources permit, to detect
infection acquired during the pregnancy.
- Women who do not attend antenatal clinic should be tested at
delivery. Although this will not prevent congenital syphilis, it
permits early diagnosis and treatment of newborns.
- Women who have had a spontaneous abortion (miscarriage) or
stillbirth should also be screened for syphilis; in many areas,
identification and treatment of syphilis remove a major cause of
adverse pregnancy outcome.
- Men and women with STI syndromes other than genital ulcer should
be screened for syphilis. Screening is unnecessary for patients with
ulcers who should be treated syndromically for both syphilis and
chancroid without testing.
- Sex workers should be screened every 6 months.
Because of the serious complications of syphilis in pregnancy, the
first priority should be to ensure universal antenatal screening.
Available screening tools
- Non-treponemal tests, such as rapid plasma reagin (RPR) and
venereal disease research laboratory (VDRL) tests, are the preferred
tests for syphilis screening. RPR can be performed without a
microscope (see Annex 3). These tests detect almost all cases of early
syphilis but false positives are possible (Table 3.2).
- Treponemal tests (e.g. Treponema pallidum haemagglutination assayóTPHA),
if available, can be used to confirm non-treponemal test results (see
- Quantitative (RPR) titres can help evaluate the response to
treatment (see Annex 3).
Note: where additional tests are not available, all patients
with reactive RPR or VDRL should be treated
Syphilis testing should be done on-site where possible to maximize
the number of patients who receive their results and are treated.
- Patients should receive their test results before leaving the
- Patients with reactive (positive) results should be treated
immediately (see treatment table 5 in Chapter 8).
- All patients must be asked for a history of allergy to penicillin
(see treatment table 5 in Chapter 8 for effective substitutes).
- Sex partners should also be treated.
Syphilis screening in pregnancy is based on a blood test at the first
antenatal visit (repeated if possible in the third trimester). Partner
counselling should stress the importance of treatment and STI/RTI
prevention in maintaining a healthy pregnancy. Same-day, on-site
syphilis screening and treatment has been shown to greatly increase the
number of women effectively treated and to reduce the incidence of
congenital syphilis (Box 3.1).
Box 3.1. Benefits of improved antenatal syphilis screening
|In Zambia, despite high rates of congenital
syphilis and over 90% attendance by pregnant women at antenatal
clinics, less than 30% were screened for syphilis. Of those tested
and found to be seropositive, less than a third were treated.
Similar problems were documented in Nairobi, Kenya. Services in both
places were then improved to provide same-day testing and treatment.
As a result, the proportion of syphilis-reactive women who received
treatment in Nairobi increased to 92%, and 50% of partners were also
treated. In Zambia, the prevention programme reduced the rate of
complications of syphilis in pregnancy by two-thirds.
If syphilis screening is already established in antenatal clinics,
it should be evaluated regularly to estimate the proportion of women who
are tested, diagnosed and effectively treated. Two simple indicators can
be easily calculated each month from clinic records:
Screening coverage =
Number of pregnant women treated
Number of women at first
Treatment coverage =
Number of RPR-reactive women treated
Box 3.2. Improving antenatal syphilis screening
What is supposed to happen,
but does not
Women in need not identified
Pregnant women are supposed to attend
antenatal clinics early in pregnancy but do notódue to lack of
confidence in the system and inadequate promotion.
Promote early attendance at antenatal clinic.
Work to make services more acceptable and
Inform and empower women in community to ask for
services and screening.
Intervention not available
Clinic staff members are supposed to take
blood samples and send them to a laboratory but do notóbecause of
poor supervision, poorly organized systems to transport blood, lack
of needles, or other obstacles.
Improve training, supervision and motivation of
health care providers.
Improve stock management and reordering of needed
Test results not available
Laboratory technicians are supposed to
conduct tests and communicate results to clinic staff but do
notóbecause they think these tasks should not be part of their
already heavy workload.
Improve coordination with laboratory.
Develop on-site testing capacity.
Women are supposed to appear at the next
antenatal visit and receive test results but do notóbecause clinic
record systems are poorly managed and organized.
Improve antenatal care systems.
Urge pregnant women to attend antenatal clinic early
and return when advised.
Poor staff compliance
Clinic staff members are supposed to provide
syphilis treatment and education on prevention and partner
notification but do notóbecause the drug supply is irregular, they
consider talking about sexuality taboo and they have little time to
spend with each client because of their heavy workload.
Train providers in STI/RTI and sexuality.
Improve clinic staffing to meet workload.
Improve stock management and reordering of needed
Adapted from: Dallabetta G, Laga M, Lamptey P. Control of sexually
transmitted diseases: a handbook for the design and management of
programs. Arlington,VA, Family Health International, 1996.