Accelerating the dual elimination of mother-to-child transmission of syphilis and HIV: Why now?

Congenital Syphilis-An Illustrative Review

Congenital syphilis is caused by the spirochete, Treponema pallidum, which can be transmitted from an infected mother to her fetus during pregnancy or by contact with a maternal lesion at the time of delivery. The incidence of congenital syphilis is rapidly increasing all over world with 700,000 to 1.5 million cases reported annually between 2016 and 2023. Despite the widespread availability of Penicillin, 2677 cases were reported in 2021 in the US. Clinical manifestations at birth can vary widely ranging from asymptomatic infection to stillbirth or neonatal death. Low birth weight, rash, hepatosplenomegaly, osteolytic bone lesions, pseudoparalysis, central nervous system infection, and long-term disabilities have been reported in newborns with congenital syphilis. Prevention of congenital syphilis is multifaceted and involves routine antenatal screening, timely treatment of perinatal syphilis with penicillin, partner tracing and treatment, and health education programs emphasizing safe sex practices and strategies to curb illicit drug use. Neonatal management includes risk stratification based on maternal syphilis history, evaluation (nontreponemal testing, complete blood counts, cerebrospinal fluid, and long-bone analysis), treatment with penicillin, and followup treponemal testing. Public health measures that enhance early detection during pregnancy and treatment with penicillin, especially in high-risk mothers, are urgently needed to prevent future cases of congenital syphilis.

Maternal HIV and syphilis are not syndemic in Brazil: Hot spot analysis of the two epidemics

While the annual incidence of HIV diagnosis in pregnancy in Brazil remains relatively stable, rates of maternal syphilis increased over six-fold in the past decade. We hypothesized that maternal HIV and syphilis are two distinct epidemics. Data on all cases of maternal HIV or syphilis detected in pregnancy between January 1, 2010 to December 31, 2018 were requested from the Brazilian Ministry of Health. In order to evaluate how the epidemics evolved over the time period, ArcGIS software was used to generate spatiotemporal maps of annual rates of detection of maternal HIV and syphilis in 2010 and 2018. We utilized Euclidean-distance hot spot analysis to identify state-specific clusters in 2010 and 2018. From 2010 to 2018, there were 66,631 cases of maternal HIV, 225,451 cases of maternal syphilis, and 150,414 cases of congenital syphilis in Brazil. The state of Rio Grande do Sul had the highest rate of maternal HIV detection in both 2010 and 2018. Hot spots of maternal HIV were identified in the three most Southern states in both 2010 and 2018 (99% confidence, z-score >2.58, p <0.01). While syphilis incidence >30 per 1,000 live births in 2018 in four states, only the two coastal states of Rio de Janeiro and Espirito Santo in Southeastern Brazil were significant hot spots (90% confidence, z-score 1.65-1.95, p <0.10). Contrary to the general assumption, HIV and syphilis epidemics in Brazil are not syndemic in pregnant women. There is a spatial cluster of maternal HIV in the South, while syphilis is increasing throughout the country, more recently on the coast. Focusing on maternal HIV hot spots in the Southern states is insufficient to curtail the maternal and congenital syphilis epidemics throughout the country. New strategies, including ongoing hot spot analysis, are urgently needed to monitor, identify and treat maternal syphilis.

The sexual reproductive health of women: Unfinished business in the Eastern Europe and Central Asia region

EBCOG and ESCRH are committed to work with UNFPA- EECA Region to reduce high maternal mortality, preventing unwanted pregnancies, improving adolescent health, reducing the burden of STDs including HIV, safeguarding and protecting sexual health and achieving gender equality to achieve the objectives of ICPD 25 as agreed in Nairobi on 12th November 2019. Both organisations will provide technical assistance to support the development of country level SRH strategies to achieve these objectives as outlined in this joint position statement. We advocate policies developments for knowledge transfer from west to the east to address the unmet need for effective contraceptive methods, to reduce the rates of teenage and adolescent pregnancy rates. All this can be achieved by developing a work force fit for purpose to support the implementation of national SRH strategies. We urge upon international and national funders to work with us to develop sustainable models of care in the Eastern Europe and Central Asian Region.

Syphilis among pregnant women in Northeast Brazil from 2008 to 2015: a trend analysis according to sociodemographic and clinical characteristics

INTRODUCTION

The number of syphilis cases among pregnant women in Brazil has increased. This study aimed to analyze the temporal trend of syphilis indicators among pregnant women in Northeast Brazil.

METHODS

A time-series study was performed.

RESULTS

We observed an increase in the detection rate of syphilis among pregnant women, those aged 15-19 years, and those of brown ethnicity. A strong correlation was observed between the detection rate of syphilis and family health strategy coverage.

CONCLUSIONS

Despite an increase in primary care coverage, The increase in cases of syphilis among pregnant women is still considered a challenge.

A systematic review and meta-analysis of studies evaluating the performance and operational characteristics of dual point-of-care tests for HIV and syphilis

BACKGROUND

Mother-to-child transmission (MTCT) of syphilis and HIV continue to be important yet preventable causes of perinatal and infant morbidity and mortality.

OBJECTIVES

To systematically review, critically appraise and perform a meta-analysis to evaluate the operational characteristics of dual rapid diagnostic tests (RDTs) for HIV/syphilis and evaluate whether they are cost effective, acceptable and easy to use.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

We searched seven electronic bibliographic databases from 2012 to December 2016 with no language restrictions. Search keywords included HIV, syphilis and diagnosis.

REVIEW METHODS

We included studies that evaluated the operational characteristics of dual HIV/syphilis RDTs. Outcomes included diagnostic test accuracy, cost effectiveness, ease of use and interpretation and acceptability. All studies were assessed against quality criteria and assessed for risk of bias.

RESULTS

Of 1914 identified papers, 18 were included for the meta-analysis of diagnostic accuracy for HIV and syphilis. All diagnostic accuracy evaluation studies showed a very high sensitivity and specificity for HIV and a lower, yet adequate, sensitivity and specificity for syphilis, with some variation among types of test. Dual screening for HIV and syphilis was more cost effective than single rapid tests for HIV and syphilis and prevented more adverse pregnancy outcomes. Qualitative data suggested dual RDTs were highly acceptable to clients, who cited time to result, cost and the requirement of a single finger prick as important characteristics of dual RDTs.

CONCLUSION

The results of this systematic review and meta-analysis can be used by policy-makers and national programme managers who are considering implementing dual RDTs for HIV and syphilis.

TRIAL REGISTRATION NUMBER

PROSPERO 2016:CRD42016049168.

ELIMINATION OF CONGENITAL SYPHILIS IN UKRAINE: ANALYSIS AND THE EMERGING ISSUES

The objective of this study is to analyze the indicators of the process of elimination of mother-to-child transmission of syphilis in Ukraine thus helping to prepare for elimination of this process according to the WHO targets and criteria. Epidemiological and clinical data of 237 women who had syphilis before or during pregnancy and babies born to them (238) from 1999 to 2007 years were presented. In addition were used statistical forms of the Public Health Center and Center for Medical Statistics of the Ministry of Health of Ukraine for the incidence of syphilis and HIV in women of reproductive age, pregnant women and children born to them, including those who were diagnosed with congenital syphilis (CS) and HIV infection. Analysis of the causes of СS suggests that the main risk factors in Ukraine were the lack of prenatal care in 44 % and treatment in 99 % of pregnant women with syphilis. Besides out-of-date normative base regulating STI diagnostic and care create delay in diagnostics and treatment of pregnant women and their newborns. In addition, the delay with prenatal diagnosis and treatment, late infection, quality of diagnostics, iatrogenic errors, refusal of women from current requirement for hospitalization, reinfection, and birth at home can be attributed to risk factors for CS. Despite the main target indicator of CS elimination has been achieved, process indicators of syphilis as coverage of syphilis testing and treatment of pregnant women as well as other additional requirements have not reached yet. On the way to the CS elimination Ukraine is facing a few challenges. There is an urgent need on further year the new strategy on STI/СS prevention with targets and targets indicators. In addition national protocols of the treatment of pregnant women should be adapted according to the European Guidelines as well as comprehensive data is required for surveillance and monitoring of CS elimination.

Management of syphilis in pregnancy: Knowledge and practices of health care providers and barriers to the control of disease in Teresina, Brazil

AIMS

The aim of the study is to verify the knowledge and practices of health professionals working in prenatal care (PNC) related with syphilis during pregnancy and to identify the main barriers to the implementation of protocols for the control of this disease.

METHODS

A cross-sectional study in Teresina, Brazil, from January to May 2015, was conducted with 366 physicians and nurses working in PNC, corresponding to 70% of eligible professionals. We evaluated 20 knowledge and practice criteria related to the diagnosis and treatment of syphilis during pregnancy with a 95% compliance standard. We performed descriptive analysis of the data and used χ² statistical test to verify differences according to professional category.

RESULTS

Only 2 criteria, "knowledge about mother to child transmission according to gestational age" and "counselling on infection," reached 95% compliance. Knowledge of the epidemiological profile of congenital syphilis and the goal of elimination of congenital syphilis and knowledge about serological tests had scores below 50%, while practices related with posttest counselling, cure control, and treatment of partners reached 60%. We identified organisational barriers related to the late initiation of PNC, to the delayed return of syphilis test results, to the application of benzathine penicillin in primary care units and to the treatment of partners.

CONCLUSIONS

Strategies for early initiation of PNC, implementation of rapid tests for syphilis, ensuring treatment of pregnant women with penicillin, adequate partner treatment, and continued education of health professionals on clinical management and counselling in sexually transmitted diseases are necessary to eliminate congenital syphilis.

The introduction of syphilis point of care tests in resource limited settings

INTRODUCTION

Syphilis remains an important and preventable cause of stillbirth and neonatal mortality. About 1 million women with active syphilis become pregnant each year. Without treatment, 25% of them will deliver a stillborn baby and 33% a low birth weight baby with an increased chance of dying in the first month of life. Adverse pregnancy outcomes due to syphilis can be prevented by screening pregnant women, and treating those who test positive with a single dose of penicillin before 28 weeks' gestation. Areas covered: This manuscript covers the impact of syphilis on pregnancy outcome, the diagnosis of syphilis, with a special focus on point of care (POC) tests, and challenges to the introduction of POC tests, and their potential impact on the control and prevention of syphilis in resource limited settings. Expert commentary: POC tests for syphilis are available which meet the ASSURED criteria, and could make syphilis screening accessible to all women anywhere in the world who attend an antenatal clinic. High quality dual POC tests for HIV and syphilis could ensure that well-funded programmes for the prevention of mother to child transmission of HIV can contribute towards increased coverage of antenatal syphilis screening, and prevent more than 300,000 adverse pregnancy outcomes due to syphilis annually. Alongside investment to increase availability of syphilis POC tests, operational research is needed to understand how best to improve screening of pregnant women and to translate test availability into improved pregnancy outcomes.