STI/RTI basics
Chapter 3. Detecting STI/RTI

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Syphilis

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 STI/RTI.

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 assay�TPHA), if available, can be used to confirm non-treponemal test results (see Annex 3).
• 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

 

Recommendations

Syphilis testing should be done on-site where possible to maximize the number of patients who receive their results and are treated. Ideally:

• Patients should receive their test results before leaving the clinic.
• 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 antenatal visit

 

Treatment coverage =	Number of RPR-reactive women treated
	Number RPR-reactive

 

Box 3.2. Improving antenatal syphilis screening

Problem	What is supposed to happen, but does not	Possible solutions
Women in need not identified	Pregnant women are supposed to attend antenatal clinics early in pregnancy but do not�due to lack of confidence in the system and inadequate promotion.	Promote early attendance at antenatal clinic. Work to make services more acceptable and accessible. 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 not�because 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 supplies.
Test results not available	Laboratory technicians are supposed to conduct tests and communicate results to clinic staff but do not�because they think these tasks should not be part of their already heavy workload.	Improve coordination with laboratory. Develop on-site testing capacity.
Utilization poor	Women are supposed to appear at the next antenatal visit and receive test results but do not�because 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 not�because 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 supplies.

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.