Antenatal syphilis in sub-Saharan Africa: missed opportunities for mortality reduction

Sero-prevalence of syphilis and associated factors among pregnant women in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Syphilis remained a major cause of reproductive morbidity and poor pregnancy outcomes in developing countries. Previously, studies showed inconsistent results and failed to show the actual picture of the diseases in Ethiopia. Thus, the aim of this meta-analysis was, first, to determine the updated pooled prevalence of syphilis among pregnant women in Ethiopia and, second, to assess its associated factors.

METHODS

A comprehensive search was made on PubMed, Google scholar, Science Direct, and African Journals Online databases to identify relevant articles. A random effects model was used to estimate pooled syphilis prevalence and odds ratio (OR) with the respective 95% confidence intervals (CIs) using STATA 14 statistical software. I² statistics and Egger's regression test in conjunction with funnel plot was used to determine heterogeneity and publication bias among included studies respectively.

RESULT

We identified 13 suitable studies in this analysis. Accordingly, the pooled prevalence of syphilis among pregnant women in Ethiopia was 2.32% (95% CI, 1.68-2.97). Specifically, syphilis prevalence was 2.53% (95% CI, 1.92-3.14%) and 1.90% (95% CI, 0.40-3.40%) as per the treponemal and non-ytreponemal diagnostic test, respectively. On the other hand, regional analysis indicated that 4.06% (95% CI, 2.86-5.26) in Southern Nations Nationalities and Peoples (SNNP), 2.16% (95% CI, 1.57-2.75) in Amhara and 1.46% (95% CI, 0.69-2.23) in Oromia region. Being married (OR, 0.37 (95% CI, 0.12-0.91%)) was less likely to develop syphilis. On the other hand, women with history of multiple sexual partner (OR, 2.98 (95% CI, 1.15-7.70)) and women with history of previous sexually transmitted infection (STI) (OR, 4.88 (95% CI, 1.35-17.62)) have higher risk to develop syphilis. Besides, the pooled syphilis-HIV coinfection was 0.80% (95% CI, 0.60-1.01%).

CONCLUSION

This study provides evidence of relatively high prevalence of syphilis among pregnant women in Ethiopia. Therefore, it is recommended to further ramping up of current intervention measures to prevent future generations.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020211650.

Factors associated with HIV and syphilis screenings among pregnant women at first antenatal visit in Lusaka, Zambia

OBJECTIVES

To identify characteristics associated with obtaining HIV and syphilis screenings of pregnant women attending a first antenatal visit in Lusaka, Zambia.

RESULTS

Among 18,231 participants from April 2015 to January 2016, 95% obtained HIV screening, 29% obtained syphilis screening, and 4% did not obtain antenatal HIV or syphilis screenings. Divorced/separated women were associated with a moderate decrease in prevalence of obtaining HIV (adjusted prevalence ratio (aPR) 0.88, 95% confidence interval (95% CI) 0.82, 0.95) and syphilis (aPR 0.51, 95% CI 0.27, 0.96) screenings compared to married women. Women with previous pregnancies were associated with a slight decrease in prevalence of obtaining HIV screening (aPR 0.97, 95% CI 0.95, 0.99) compared to women without previous pregnancy. Older women ≥ 35 years were associated with a slight decrease in prevalence of obtaining HIV screening (aPR 0.96, 95% CI 0.92, 0.99) compared to younger women. The statistically significant differences were not of clinical relevance as defined by a proportional difference of 10 percent. Findings of this study show that a vast majority of pregnant women are obtaining HIV screenings but not syphilis screenings during first antenatal visit. Provision of antenatal HIV and syphilis screening at first visit is only weakly related to patient level factors.

Framework for the implementation of advanced HIV disease diagnostics in sub-Saharan Africa: programmatic perspectives

Patients with advanced HIV disease have a high risk of mortality, mainly from tuberculosis and cryptococcal meningitis. The advanced HIV disease management package recommended by WHO, which includes diagnostics, therapeutics, and patient psychosocial support, is barely implemented in many different countries. Here, we present a framework for the implementation of advanced HIV disease diagnostics. Laboratory and point-of-care-based reflex testing, coupled with provider-initiated requested testing, for cryptococcal antigen and urinary Mycobacterium tuberculosis lipoarabinomannan antigen, should be done for all patients with CD4⁺ cell counts of 200 cells per μL or less. Implementation of the advanced HIV disease package should be encouraged within primary health-care facilities and task shifting of testing to lay cadres could facilitate access to rapid results. Implementation of differentiated antiretroviral therapy delivery models can allow clinicians enough time to focus on the management of patients with advanced HIV disease. Efficient up-referral and post-discharge systems, including the development of patient-centric advanced HIV disease literacy, are also crucial. Implementation of the advanced HIV disease package is feasible at all health-care levels, and it should be part of the core of the global response towards ending AIDS as a public health threat.

Prevalence and factors associated with HIV and syphilis infection among children aged 0-36 months in Kilimanjaro, Tanzania: a community-based cross-sectional study

Background

Childhood mortality is high in sub-Saharan Africa. Mother-to-child transmission (MTCT) of HIV and congenital syphilis are among significant causes. Dual elimination of these two infections is one of the international goals. Community-based studies on the burden of HIV and syphilis among children will contribute to fine-tuning the interventions to achieve the elimination goal. This study aims to describe the prevalence of HIV and syphilis among children aged 0–36 months and associated factors in northern Tanzania.

Methods

This was a community-based cross-sectional study, which was conducted in all the seven districts of Kilimanjaro region. Multistage sampling was used, and a total of 2452 children aged 0 to 36 months and their primary caretakers were enrolled. Interviews were conducted with the mother/caretaker, and dried blood samples were collected from the children and processed for laboratory diagnosis of HIV and syphilis. HIV ELISA was first performed on all the samples. Positive samples of children < 18 months were confirmed using PCR.

Results

The prevalence of HIV among 2452 children aged 0–36 months was 1.7% (n = 42). There was a significant difference in the distribution of HIV by age of the child, maternal antenatal attendance, and breastfeeding history.

The prevalence of syphilis was 0.4% (n = 10). Five of the children were more than 1 year old. All children with a positive test for syphilis were from Moshi rural district, and their mothers consumed alcohol. No child was co-infected with HIV and syphilis.

Conclusions

Though the prevalence of the two infections was low, detecting syphilis in children suggests a missed opportunity in screening women during pregnancy. The region may be on track with the goal to achieve dual elimination of mother-to-child transmitted HIV and syphilis. However, efforts are needed to reduce missed opportunities for screening women for syphilis and HIV early in pregnancy and retesting at 3rd trimester/delivery. Strategies to improve testing for HIV-exposed children are needed.

Brief Report: High Rates of Adverse Birth Outcomes in HIV and Syphilis Coinfected Women in Botswana

BACKGROUND

Little is known about the combined impact of HIV/syphilis coinfection on birth outcomes.

METHODS

Antenatal HIV and syphilis test results, obstetric history, and infant birth outcomes were collected from obstetric records in maternity wards in Botswana between 2008 and 2011 (5 sites) and 2014 and 2016 (8 sites). We used logistic regression to compare adverse birth outcomes by HIV and syphilis status. Outcomes included stillbirth, preterm delivery, low birth weight, and in-hospital neonatal death.

RESULTS

Of 76,466 women, 75,770 (99.1%) had HIV test results, and 20,520 (27.1%) were HIV positive. Syphilis test results were available for 67,290 (88.0%), and 697 (1.0%) had reactive rapid plasma reagin. Among 692 women with syphilis and an HIV test result, 261 (37.7%) were coinfected. HIV-infected women were more likely to be infected with syphilis than HIV-uninfected women [odds ratio (OR) = 1.68; 95% confidence interval (CI): 1.44 to 1.96]. From 2008-2011 to 2014-2016, the proportion of women with syphilis remained constant (1.1% vs. 1.0%, P = 0.41), but HIV/syphilis coinfection declined from 45% to 27% (P < 0.0001). Stillbirth occurred in 5.8% of coinfected women, compared with 1.9% with no HIV/syphilis (OR = 3.09; 95% CI: 1.83 to 5.23); 3.4% with HIV alone (OR = 1.75; 95% CI: 1.03 to 2.97), or 3.7% with syphilis alone (OR = 1.58; 95% CI: 0.77 to 3.25). Low birth weight occurred in 24.1% of coinfected women, compared with 12.1% with no HIV/syphilis (OR 2.31; 95% CI: 1.74 to 3.08; 20% with HIV alone (OR = 1.27; 95% CI: 0.96 to 1.69); or 14.6% with syphilis alone (OR = 1.85; 95% CI: 1.26 to 2.74).

CONCLUSIONS

Although HIV/syphilis coinfection in pregnancy has declined in the past decade, coinfection was associated with adverse birth outcomes.

Antibiotic treatment for newborns with congenital syphilis

BACKGROUND

Congenital syphilis continues to be a substantial public health problem in many parts of the world. Since the first use of penicillin for the treatment of syphilis in 1943, which was a notable early success, it has remained the preferred and standard treatment including for congenital syphilis. However, the treatment of congenital syphilis is largely based on clinical experience and there is extremely limited evidence on the optimal dose or duration of administration of penicillin or the use of other antibiotics.

OBJECTIVES

To assess the effectiveness and safety of antibiotic treatment for newborns with confirmed, highly probable and possible congenital syphilis.

SEARCH METHODS

We searched the Cochrane STI Group Specialized Register, CENTRAL, MEDLINE, Embase, LILACS, WHO ICTRP, ClinicalTrials.gov and Web of Science to 23 May 2018. We also handsearched conference proceedings, contacted trial authors and reviewed the reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing antibiotic treatment (any concentration, frequency, duration and route) with no intervention or any other antibiotic treatment for neonates with confirmed, highly probable or possible congenital syphilis.

DATA COLLECTION AND ANALYSIS

All review authors independently assessed trials for inclusion, extracted data and assessed the risk of bias in the included studies. We resolved any disagreements through consensus. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

Two RCTs (191 participants) met our inclusion criteria and none of these trials was funded by the industry. One trial (22 participants) compared benzathine penicillin with no intervention for infants with possible congenital syphilis. Low-quality evidence suggested that benzathine penicillin administration may not have decreased the rate of neonatal death due to any cause (risk ratio (RR) 0.83, 95% confidence interval (CI) 0.06 to 11.70), and showed a possible reduction into the proportion of neonates with clinical manifestations of congenital syphilis (RR 0.12, 95% CI 0.01 to 2.09). Penicillin administration increased the serological cure at the third month (RR 2.13, 95% CI 1.06 to 4.27). These results should be taken with caution, because the trial was stopped early because there were four cases with clinical congenital syphilis in the no treatment group and none in the treatment group. Interim analysis suggested this difference was significant. This study did not report neonatal death due to congenital syphilis or the frequency of serious or minor adverse events after therapy. We downgraded the quality of evidence because of imprecision and risk of bias.One trial (169 participants) compared benzathine penicillin versus procaine benzylpenicillin. High- and moderate-quality evidence suggested that there were probably no differences between benzathine penicillin and procaine benzylpenicillin for the outcomes: absence of clinical manifestations of congenital syphilis (RR 1.00, 95% CI 0.97 to 1.03) and serological cure (RR 1.00, 95% CI 0.97 to 1.03). There were no cases of neonatal death due congenital syphilis; all 152 babies who followed up survived. This study did not report on the frequency of serious or minor adverse events after therapy. We downgraded the quality of evidence because of serious risk of bias.

AUTHORS' CONCLUSIONS

At present, the evidence on the effectiveness and safety of antibiotic treatment for newborns with confirmed, highly probable or possible congenital syphilis is sparse, implying that we are uncertain about the estimated effect. One trial compared benzathine penicillin with no intervention for infants with possible congenital syphilis. Low-quality evidence suggested penicillin administration possibly reduce the proportion of neonates with clinical manifestations of congenital syphilis, penicillin administration increased the serological cure at the third month. These findings support the clinical use of penicillin in neonates with confirmed, highly probable or possible congenital syphilis. High- and moderate-quality evidence suggests that there are probably no differences between benzathine penicillin and procaine benzylpenicillin administration for the outcomes of absence of clinical manifestations of syphilis or serological cure.

Integrated point-of-care testing (POCT) for HIV, syphilis, malaria and anaemia at antenatal facilities in western Kenya: a qualitative study exploring end-users' perspectives of appropriateness, acceptability and feasibility

Background

HIV, syphilis, malaria and anaemia are leading preventable causes of adverse pregnancy outcomes in sub-Saharan Africa yet testing coverage for conditions other than HIV is low. Availing point-of-care tests (POCTs) at rural antenatal health facilities (dispensaries) has the potential to improve access and timely treatment. Fundamental to the adoption of and adherence to new diagnostic approaches are healthcare workers’ and pregnant women’s (end-users) buy-in. A qualitative approach was used to capture end-users’ experiences of using POCTs for HIV, syphilis, malaria and anaemia to assess the appropriateness, acceptability and feasibility of integrated testing for ANC.

Methods

Seven dispensaries were purposively selected to implement integrated point-of-care testing for eight months in western Kenya. Semi-structured interviews were conducted with 18 healthcare workers (14 nurses, one clinical officer, two HIV testing counsellors, and one laboratory technician) who were trained, had experience doing integrated point-of-care testing, and were still working at the facilities 8–12 months after the intervention began. The interviews explored acceptability and relevance of POCTs to ANC, challenges with testing, training and supervision, and healthcare workers’ perspectives of client experiences. Twelve focus group discussions with 118 pregnant women who had attended a first ANC visit at the study facilities during the intervention were conducted to explore their knowledge of HIV, syphilis, malaria, and anaemia, experience of ANC point-of-care testing services, treatments received, relationships with healthcare workers, and experience of talking to partners about HIV and syphilis results.

Results

Healthcare workers reported that they enjoyed gaining new skills, were enthusiastic about using POCTs, and found them easy to use and appropriate to their practice. Initial concerns that performing additional testing would increase their workload in an already strained environment were resolved with experience and proficiency with the testing procedures. However, despite having the diagnostic tools, general health system challenges such as high client to healthcare worker volume ratio, stock-outs and poor working conditions challenged the delivery of adequate counselling and management of the four conditions. Pregnant women appreciated POCTs, but reported poor healthcare worker attitudes, drug stock-outs, and fear of HIV disclosure to their partners as shortcomings to their ANC experience in general.

Conclusion

This study provides insights on the acceptability, appropriateness, and feasibility of integrating POCTs into ANC services among end-users. While the innovation was desired and perceived as beneficial, future scale-up efforts would need to address health system weaknesses if integrated testing and subsequent effective management of the four conditions are to be achieved.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3844-9) contains supplementary material, which is available to authorized users.

Integrated point-of-care testing (POCT) of HIV, syphilis, malaria and anaemia in antenatal clinics in western Kenya: A longitudinal implementation study

Background

In sub-Saharan Africa, HIV, syphilis, malaria and anaemia are leading preventable causes of adverse pregnancy outcomes. In Kenya, policy states women should be tested for all four conditions (malaria only if febrile) at first antenatal care (ANC) visit. In practice, while HIV screening is conducted, coverage of screening for the others is suboptimal and early pregnancy management of illnesses is compromised. This is particularly evident at rural dispensaries that lack laboratories and have parallel programmes for HIV, reproductive health and malaria, resulting in fractured and inadequate care for women.

Methods

A longitudinal eight-month implementation study integrating point-of-care diagnostic tests for the four conditions into routine ANC was conducted in seven purposively selected dispensaries in western Kenya. Testing proficiency of healthcare workers was observed at initial training and at three monthly intervals thereafter. Adoption of testing was compared using ANC register data 8.5 months before and eight months during the intervention. Fidelity to clinical management guidelines was determined by client exit interviews with success defined as ≥90% adherence.

Findings

For first ANC visits at baseline (n = 529), testing rates were unavailable for malaria, low for syphilis (4.3%) and anaemia (27.8%), and near universal for HIV (99%). During intervention, over 95% of first attendees (n = 586) completed four tests and of those tested positive, 70.6% received penicillin or erythromycin for syphilis, 65.5% and 48.3% received cotrimoxazole and antiretrovirals respectively for HIV, and 76.4% received artemether/lumefantrine, quinine or dihydroartemisinin–piperaquine correctly for malaria. Iron and folic supplements were given to nearly 90% of women but often at incorrect doses.

Conclusions

Integrating point-of-care testing into ANC at dispensaries with established HIV testing programmes resulted in a significant increase in testing rates, without disturbing HIV testing rates. While more cases were detected and treated, treatment fidelity still requires strengthening and an integrated monitoring and evaluation system needs to be established.

Rollout of rapid point of care tests for antenatal syphilis screening in Ghana: healthcare provider perspectives and experiences

BACKGROUND

Effective implementation of rapid point of care tests (POCTs) for antenatal syphilis screening especially in settings where antenatal care attendance is high, can significantly increase screening coverage and treatment uptake. The operational challenges of introducing rapid syphilis POCTs at scale needs to be investigated. This study explores healthcare providers' experiences and challenges in antenatal syphilis screening following the national rollout of rapid syphilis POCTs in Ghana.

METHODS

Prior to the main study, we undertook a desk review of key syphilis policy documents, and conducted key stakeholder interviews and a baseline survey of syphilis screening practices. Antenatal syphilis screening had been poorly implemented mainly due to inadequate technical and logistic support, and lack of monitoring and supervision. For the main research, semi-structured interviews were conducted with 51 purposively selected healthcare staff involved in antenatal syphilis screening in 15 health facilities in three regions, representative of all levels of healthcare in Ghana and two regional programme coordinators, at least four months after the rollout. The interviews were supplemented with an audit of the conduct of antenatal care, syphilis-related supplies and other maternal and newborn interventions. Qualitative data were coded and analysed using Nvivo software.

RESULTS

Syphilis screening with rapid POCTs was integrated into antenatal care in almost all (13/15) the facilities surveyed. Testing and treatment were offered free of charge to pregnant women, their partners and babies. In most facilities, midwives were performing syphilis tests together with HIV tests. Operational challenges included: inadequate training and lack of refresher training, lack of clear testing guidelines, clear channels of communication, supervision, and guidance on treatment and referral procedures, frequent stockouts of, or expired test kits, staff overload, and poor documentation of test results and treatment.

CONCLUSION

Although syphilis screening with rapid syphilis POCTs was integrated into antenatal care, key challenges, particularly around supply chain and supervision, need to be addressed to improve and sustain such a programme.

Barriers and facilitators to the implementation of antenatal syphilis screening and treatment for the prevention of congenital syphilis in the Democratic Republic of Congo and Zambia: results of qualitative formative research

BACKGROUND

The impact of untreated syphilis during pregnancy on neonatal health remains a major public health threat worldwide. Given the high prevalence of syphilis during pregnancy in Zambia and Democratic Republic of Congo (DRC), the Preventive Congenital Syphilis Trial (PCS Trial), a cluster randomized trial, was proposed to increase same-day screening and treatment of syphilis during antenatal care visits. To design an accepted and feasible intervention, we conducted a qualitative  formative research. Our objective was to identify context-specific  barriers and facilitators to the implementation of antenatal screening and treatment during pregnancy.

METHODS

Qualitative research included in-depth semi-structured interviews with clinic administrators, group interviews with health care providers, and focus groups with pregnant women in primary care clinics (PCCs) in Kinshasa (DRC) and Lusaka (Zambia).

RESULTS

A total of 112 individuals participated in the interviews and focus groups. Barriers for the implementation of syphilis testing and treatment were identified at the a) system level: fragmentation of the health system, existence of ANC guidelines in conflict with proposed intervention, poor accessibility of clinics (geographical and functional), staff and product shortages at the PCCs; b) healthcare providers' level: lack of knowledge and training about evolving best practices, reservations regarding same-day screening and treatment; c) Pregnant women level: late enrollment in ANC, lack of knowledge about consequences and treatment of syphilis, and stigma. Based on these results, we developed recommendations for the design of the PCS Trial intervention.

CONCLUSION

This research allowed us to identify barriers and facilitators to improve the feasibility and acceptability of a behavioral intervention. Formative research is a critical step in designing appropriate and effective interventions by closing the "know-do gap".

Introducing onsite antenatal syphilis screening in Burkina Faso: implementation and evaluation of a feasibility intervention tailored to a local context

BACKGROUND

Although the advantages of introducing point of care testing for syphilis in antenatal care (ANC) are well documented, there is little evidence on how to address structural issues within health systems. A better understanding of how these interventions work in a range of settings and contexts is needed in order to overcome bottlenecks at health system level. To better understand the relationships between implementation and context we developed and implemented an intervention focused on integrating a rapid screening test for syphilis in ANC services in rural primary health care facilities in Burkina Faso. This manuscript describes the intervention and reports on feasibility and acceptability of the intervention, the facilitators and barriers to the implementation of this intervention and the likelihood that point of care test for syphilis will become routinely incorporated in practice.

METHODS

In Kaya Health and Demographic Surveillance System (Kaya HDSS), all 7 primary healthcare facilities were selected for intervention in 2013. A participatory approach was used to design and implement an antenatal syphilis screening intervention. The Normalization Process Model (NPM) proposed by May et al. was adapted in order to identify barriers and facilitators and to explore the likelihood to become routinely incorporated in practice. Registers, Observations (n = 14 ANC 1) of interactions between patients and health workers during ANC and interviews with health workers (n = 14) were our data sources.

RESULTS

An intervention that included onsite training, provision of supplies and medicines, quality control and supervision was implemented in 7 health facilities in 2013. Rapid syphilis test and treatment were delivered during ANC within the examination room with no specific additional mechanism regarding staff organization. The perceived barriers were lack of training of all staff, workload, stock-outs of consumables and lack of motivation of staff. Key facilitators included political environment, ease of use of test and acceptability to pregnant women.

CONCLUSIONS

Onsite testing for antenatal syphilis is a feasible and acceptable intervention in ANC at primary health facility in Burkina Faso. The point-of care test for syphilis is more likely to be acceptable by health workers as routine service and incorporated as a normal practice.

TRIAL REGISTRATION

The study was retrospectively registered on ClinicalTrials.gov under the Trial Registration Number NCT03156751 .

Implementation and Operational Research: Evaluation of a Public-Sector, Provider-Initiated Cryptococcal Antigen Screening and Treatment Program, Western Cape, South Africa

BACKGROUND

Screening for serum cryptococcal antigen (CrAg) may identify those at risk for disseminated cryptococcal disease (DCD), and preemptive fluconazole treatment may prevent progression to DCD. In August 2012, the Western Cape Province (WC), South Africa, adopted provider-initiated CrAg screening. We evaluated the implementation and effectiveness of this large-scale public-sector program during its first year, September 1, 2012-August 31, 2013.

METHODS

We used data from the South African National Health Laboratory Service, WC provincial HIV program, and nationwide surveillance data for DCD. We assessed the proportion of eligible patients screened for CrAg (CrAg test done within 30 days of CD4 date) and the prevalence of CrAg positivity. Incidence of DCD among those screened was compared with those not screened.

RESULTS

Of 4395 eligible patients, 26.6% (n = 1170) were screened. The proportion of patients screened increased from 15.9% in September 2012 to 36.6% in August 2013. The prevalence of positive serum CrAg was 2.1%. Treatment data were available for 13 of 24 CrAg-positive patients; 9 of 13 were treated with fluconazole. Nine (0.8%) incident cases of DCD occurred among the 1170 patients who were screened for CrAg vs. 49 (1.5%) incident cases among the 3225 patients not screened (P = 0.07).

CONCLUSIONS

Relatively few eligible patients were screened under the WC provider-initiated CrAg screening program. Unscreened patients were nearly twice as likely to develop DCD. CrAg screening can reduce the burden of DCD, but needs to be implemented well. To improve screening rates, countries should consider laboratory-based reflexive screening when possible.

Barriers to uptake of antenatal maternal screening tests in Senegal

Background

Evidence exists that selective antenatal maternal screening tests contribute to the reduction of maternal morbidity and mortality. However, data are lacking on coverage with the complete set of recommended tests. The study aimed to identify barriers to uptake of the complete set of tests recommended by the Ministry of Health in Senegal.

Methods

Data were collected in communities, antenatal care (ANC) clinics and the laboratories of 11 public health care facilities across Senegal. Mixed-methods included ethnography (observations and informal conversations), in-depth interviews and workshops at the health facilities; structured interviews with 283 women receiving antenatal tests (“women in the lab”); in-depth interviews with 81 women in communities who were pregnant or had recently delivered (“community women”).

Results

Only 13% of community women and 22% of women in the lab had received the complete set of tests. For various social, financial and antenatal care-related reasons 38% of community women who visited antenatal care facilities did not access a laboratory. The lowest test uptake was in women receiving antenatal care at health posts. Barriers at the laboratory level were the cost of the test, stock-outs of reagents, and broken equipment. Midwives were the main gatekeepers of the laboratory, not requesting (all) tests because of assumptions about women's financial problems and reliance on clinical symptoms.

Conclusion

In Senegal, recommended antenatal maternal screening tests are substantially underutilized. Efforts to increase test uptake should include accessible testing guidelines, reducing the cost of tests, raising awareness about the reasons for tests, and making the complete test set in point-of-care format accessible in peripheral health posts. National and international antenatal care policies and programs should facilitate access to maternal screening tests as a contribution to reducing maternal and infant morbidity and mortality.

•

Only 13% of pregnant women receive a complete set of antenatal maternal tests.

•

Financial problems and gender relations constrain women's access to laboratories.

•

Midwives as gatekeepers to the laboratory often request an incomplete test-set.

•

High price, reagent stock-out and faulty machines are barriers at the laboratory.

•

Understanding the multi-level barriers to test uptake should inform interventions.

Should All Pregnant Women be Screened for Syphilis?

In industrialized countries, the incidence of syphilis has decreased dramatically since the discovery of penicillin in the 1940s. However, syphilis and congenital syphilis are far from eradicated, especially in low- and middle-income countries. Syphilis in pregnant women is a cause of adverse pregnancy outcomes that can be prevented by screening for syphilis and early treatment in pregnancy. Several studies have found screening of pregnant women for syphilis to be a highly cost-effective intervention, even if the prevalence of syphilis is low. Obstacles to universal screening of pregnant women include low awareness of syphilis and low quality of antenatal care and healthcare in general in many low- and middle-income countries. For these settings, we need simpler and more reliable serological tests for syphilis, but we also need to strengthen health services in general to ensure sustainable antenatal care services to ensure sustainability of syphilis screening programmes.

Estimating the Public Health Burden Associated With Adverse Pregnancy Outcomes Resulting From Syphilis Infection Across 43 Countries in Sub-Saharan Africa

BACKGROUND

Untreated syphilis in pregnancy is associated with adverse clinical outcomes to the infant. The study aimed to estimate the public health burden resulting from adverse pregnancy outcomes due to syphilis infection among pregnant women not screened for syphilis in 43 countries in sub-Saharan Africa.

METHODS

Estimated country-specific incidence of syphilis was generated from annual number of live births, the proportion of women with at least 1 antenatal care (ANC) visit, the syphilis prevalence rate, and the proportion of women screened for syphilis during ANC.Adverse pregnancy outcome data (stillbirth, neonatal death, low birth weight, and congenital syphilis) were obtained from published sources. Disability-adjusted life-year (DALY) estimates were calculated using undiscounted local life expectancy, the neonatal standard loss function, and relevant disability weights. The model assessed the potential impact of raising ANC coverage to at least 95% and syphilis screening to at least 95% (World Health Organization targets).

RESULTS

For all 43 sub-Saharan Africa countries, the estimated incidence of adverse pregnancy outcomes was 205,901 (95% confidence interval [CI], 113,256-383,051) per year, including stillbirth (88,376 [95% CI, 60,854-121,713]), neonatal death (34,959 [95% CI, 23,330-50,076]), low birth weight (22,483 [95% CI, 0-98,847]), and congenital syphilis (60,084 [95% CI, 29,073-112,414]), resulting in approximately 12.5 million DALYs. Countries with the greatest burden are (in DALYs, millions) Democratic Republic of the Congo (1.809), Nigeria (1.598), Ethiopia (1.466), and Tanzania (0.961). Attaining World Health Organization targets could reduce the burden by 8.5 million DALYs.

CONCLUSIONS

Substantial infant mortality and morbidity results from maternal syphilis infection concentrated in countries with low access to ANC or low rates of syphilis screening.

A study on usefulness of a set of known risk factors in predicting maternal syphilis infections in three districts of Western Province, Zambia

Introduction

Despite roll-out of cost-effective point-of-care tests, less than half antenatal attendees in rural western Zambia are screened for syphilis. This study formulated a clinical, risk-based assessment criteria and evaluated its usefulness as a non-biomedical alternative for identifying high-risk prenatal cases.

Methods

We conducted a cross-sectional survey of antenatal clinic attendees in Kaoma, Luampa and Nkeyema districts to collect data on exposure to nine pre-selected syphilis risk factors. These factors were classified into major and minor factors based on their observed pre-study association strengths to maternal syphilis. Clinical disease was defined as exposure to either two major factors, one major with two minor factors or three minor factors. Sensitivity, specificity and predictive values of the clinical protocol were then calculated in comparison to rapid plasmin reagin results.

Results

The observed syphilis prevalence was 9.3% (95% CI: 7.4 - 11.6%) and the overall sensitivity of the study criteria was 62.3% with positive predictive value of 72.9%. Sensitivities of individual case-defining categories were even lower; from 17.4% to 33.3%. Results confirmed that abortion history, still birth, multiple sexual partners, previous maternal syphilis infection, partner history of sexually transmitted infection and maternal co-morbid conditions of HIV and genital ulcer disease were significantly associated to maternal syphilis in study population as well.

Conclusion

The criteria was not as effective as biomedical tests in identifying maternal syphilis. However, it could be a useful adjunct/alternative in antenatal clinics when biomedical tests are either inadequate or unavailable.

Perceptions, attitude and uptake of rapid syphilis testing services in antenatal clinics in North-Western Tanzania

Infection with syphilis during pregnancy could cause spontaneous abortion, low birth weight and stillbirth. To prevent adverse pregnancy outcomes caused by syphilis, the World Health Organization (WHO) recommends syphilis screening and treatment of all pregnant women attending antenatal care (ANC) services. Rapid syphilis testing (RST) demonstration project was introduced at ANC clinics in Tanzania in 2009, to assess the feasibility, acceptability and its impact on uptake of syphilis screening service. Data collection was composed of in-depth interviews with health workers and pregnant women attending ANC. Additionally, from the health facility registers we extracted information on the uptake of antenatal care services, including number of pregnant women screened and treated for syphilis. Introduction of RST at health facilities was appreciated by pregnant women attending ANC and health workers. Following the introduction of RST services at ANC clinics, we observed a significant increase of the uptake of syphilis screening. Pregnant women appreciated RST service since it reduced the frequency of their visits to the health facilities and shortened the duration that they spent at the clinics. Moreover, the provision of same-day screening and treatment services helped women to save money that they would have to spend on transportation for the follow up visits. Health workers felt that RST simplified procedures to diagnose syphilis, and enabled the health workers to test and treat large numbers of clients in a shorter period of time. Our study demonstrates that, it is feasible to introduce RST service in antenatal clinics. The RST was appreciated by health workers and pregnant women, since it simplifies syphilis screening procedures, saves the time that pregnant women used to waste to wait for the results, and saves the cost that women would have to spend on transportation to come back for treatment.

The need for further integration of services to prevent mother-to-child transmission of HIV and syphilis in Mwanza City, Tanzania

OBJECTIVE

To assess the operational integration of maternal HIV testing and syphilis screening in Mwanza, Tanzania.

METHODS

Interviews were conducted with 76 health workers (HW) from three antenatal clinics (ANC) and three maternity wards in 2008-2009 and 1137 consecutive women admitted for delivery. Nine ANC health education sessions and client flow observations were observed.

RESULTS

Only 25.0% of HWs reported they had received training in both prevention of mother-to-child transmission (PMTCT) and syphilis screening. HIV and syphilis tests were sometimes performed in different rooms and results recorded in separate registers with different formats and the results were not always given by the same person. At delivery, most women had been tested for both HIV (79.4%) and syphilis (88.1%) during pregnancy. Of those not tested antenatally for each infection, 70.1% were tested for HIV at delivery but none for syphilis.

CONCLUSION

Integration of maternal HIV and syphilis screening was limited. Integrated care guidelines and related health worker training should address this gap.

Introduction of Syphilis Point-of-Care Tests, from Pilot Study to National Programme Implementation in Zambia: A Qualitative Study of Healthcare Workers' Perspectives on Testing, Training and Quality Assurance

Syphilis affects 1.4 million pregnant women globally each year. Maternal syphilis causes congenital syphilis in over half of affected pregnancies, leading to early foetal loss, pregnancy complications, stillbirth and neonatal death. Syphilis is under-diagnosed in pregnant women. Point-of-care rapid syphilis tests (RST) allow for same-day treatment and address logistical barriers to testing encountered with standard Rapid Plasma Reagin testing. Recent literature emphasises successful introduction of new health technologies requires healthcare worker (HCW) acceptance, effective training, quality monitoring and robust health systems. Following a successful pilot, the Zambian Ministry of Health (MoH) adopted RST into policy, integrating them into prevention of mother-to-child transmission of HIV clinics in four underserved Zambian districts. We compare HCW experiences, including challenges encountered in scaling up from a highly supported NGO-led pilot to a large-scale MoH-led national programme. Questionnaires were administered through structured interviews of 16 HCWs in two pilot districts and 24 HCWs in two different rollout districts. Supplementary data were gathered via stakeholder interviews, clinic registers and supervisory visits. Using a conceptual framework adapted from health technology literature, we explored RST acceptance and usability. Quantitative data were analysed using descriptive statistics. Key themes in qualitative data were explored using template analysis. Overall, HCWs accepted RST as learnable, suitable, effective tools to improve antenatal services, which were usable in diverse clinical settings. Changes in training, supervision and quality monitoring models between pilot and rollout may have influenced rollout HCW acceptance and compromised testing quality. While quality monitoring was integrated into national policy and training, implementation was limited during rollout despite financial support and mentorship. We illustrate that new health technology pilot research can rapidly translate into policy change and scale-up. However, training, supervision and quality assurance models should be reviewed and strengthened as rollout of the Zambian RST programme continues.

Antenatal syphilis screening using point-of-care testing in low- and middle-income countries in Asia and Latin America: a cost-effectiveness analysis

BACKGROUND

Untreated syphilis in pregnancy is associated with adverse clinical outcomes to the infant. In low- and middle-income countries in Asia and Latin America, 20%-30% of women are not tested for syphilis during pregnancy. We evaluated the cost-effectiveness of increasing the coverage for antenatal syphilis screening in 11 Asian and 20 Latin American countries, using a point-of-care immunochromatographic strip (ICS) test.

METHODS

The decision analytical cost-effectiveness models reported incremental costs per disability-adjusted life years (DALYs) averted from the perspectives of the national health care payer. Clinical outcomes were stillbirths, neonatal deaths, and congenital syphilis. DALYs were computed using WHO disability weights. Costs included the ICS test, three injections of benzathine penicillin, and nurse wages. Country-specific inputs included the antenatal prevalence of syphilis and the proportion of women in the antenatal care setting that are screened for syphilis infection as reported in the 2014 WHO baseline report on global sexually transmitted infection surveillance. Country-specific data on the annual number of live births, proportion of women with at least one antenatal care visit, and per capita gross national income were also included in the model.

RESULTS

The incremental cost/DALY averted of syphilis screening is US$53 (range: US$10-US$332; Prob<1*per capita GDP=99.71%) in Asia and US$60 (range: US$5-US$225; Prob<1*per capita GDP=99.77%) in Latin America. Universal screening may reduce the annual number of stillbirths by 20,344 and 4,270, neonatal deaths by 8,201 and 1,721, cases of congenital syphilis by 10,952 and 2,298, and avert 925,039 and 197,454 DALYs in the aggregate Asian and Latin American panel, respectively.

CONCLUSION

Antenatal syphilis screening is highly cost-effective in all the 11 Asian and 20 Latin American countries assessed. Our findings support the decision to expand syphilis screening in countries with currently low screening rates or continue national syphilis screening programs in countries with high rates.

Scaling Down to Scale Up: A Health Economic Analysis of Integrating Point-of-Care Syphilis Testing into Antenatal Care in Zambia during Pilot and National Rollout Implementation

Maternal syphilis results in an estimated 500,000 stillbirths and neonatal deaths annually in Sub-Saharan Africa. Despite the existence of national guidelines for antenatal syphilis screening, syphilis testing is often limited by inadequate laboratory and staff services. Recent availability of inexpensive rapid point-of-care syphilis tests (RST) can improve access to antenatal syphilis screening. A 2010 pilot in Zambia explored the feasibility of integrating RST within prevention of mother-to-child-transmission of HIV services. Following successful demonstration, the Zambian Ministry of Health adopted RSTs into national policy in 2011. Cost data from the pilot and 2012 preliminary national rollout were extracted from project records, antenatal registers, clinic staff interviews, and facility observations, with the aim of assessing the cost and quality implications of scaling up a successful pilot into a national rollout. Start-up, capital, and recurrent cost inputs were collected, including costs of extensive supervision and quality monitoring during the pilot. Costs were analysed from a provider’s perspective, incremental to existing antenatal services. Total and unit costs were calculated and a multivariate sensitivity analysis was performed. Our accompanying qualitative study by Ansbro et al. (2015) elucidated quality assurance and supervisory system challenges experienced during rollout, which helped explain key cost drivers. The average unit cost per woman screened during rollout ($11.16) was more than triple the pilot unit cost ($3.19). While quality assurance costs were much lower during rollout, the increased unit costs can be attributed to several factors, including higher RST prices and lower RST coverage during rollout, which reduced economies of scale. Pilot and rollout cost drivers differed due to implementation decisions related to training, supervision, and quality assurance. This study explored the cost of integrating RST into antenatal care in pilot and national rollout settings, and highlighted important differences in costs that may be observed when moving from pilot to scale-up.

Estimating the uptake of maternal syphilis screening and other antenatal interventions before and after national rollout of syphilis point-of-care testing in Ghana

OBJECTIVE

To compare the uptake of maternal syphilis and HIV screening, intermittent preventive treatment for malaria, and tetanus toxoid administration in three regions of Ghana, before and after the rollout of syphilis point-of-care tests (POCTs).

METHODS

Antenatal register records were reviewed in 15 selected health facilities over an eight-month period, 16 months apart. Register records had been evaluated using the maternal record booklets as a gold standard in a separate prior survey.

RESULTS

In the evaluation study, the sensitivity of register data was low, ranging from 33.3% for tetanus toxoid administration to 53.8% for syphilis serology. In total, 8282 antenatal client records (4141 in each period) were reviewed. Less than a third of pregnant women received any single intervention at either period (ranging from 17.8% for tetanus toxoid to 29.8% for HIV testing). Overall, HIV screening had a marginal absolute increase of about 2% while the remaining interventions experienced non-significant absolute decreases of 4.1 to 11.1%. When adjusting for under-recording, syphilis screening uptake was 50% before and 33.6% after the introduction of POCTs.

CONCLUSION

Use of POCTs for syphilis did not result in increased uptake. Routine monitoring of antenatal interventions using the antenatal register may result in underestimation of their uptake.

Factors associated with syphilis screening uptake among pregnant women in health facilities in Brong Ahafo Region of Ghana

Background

Congenital syphilis is a consequence of undiagnosed, untreated, or inadequately treated maternal syphilis and results in serious adverse outcomes. It is easily diagnosed and in Ghana it is treated at points of care free; yet most pregnant women attending antenatal clinic (ANC) in Ghana are not screened. This study identified some factors influencing syphilis screening uptake at medical facilities during pregnancy in the Brong Ahafo Region of Ghana.

Method

A cross-sectional study was conducted in two districts in Brong Ahafo Region of Ghana. All the health facilities in the selected districts that run antenatal services were assessed on their preparedness to screen syphilis for pregnant women. Interviews were conducted among 390 pregnant women attending ANC at five hospitals in the two districts to identify individual and community level barriers to syphilis screening.

Results

In all 37 health facilities conducted antennal clinics in the two districts in 2013, 75.7% of the health facilities were public; Techiman had the higher number of health facilities (64.9%), test kits were available in only 29.7% of the health facilities and 43.2% of 37 health facilities were conducting syphilis screening. Majority of the pregnant women (57.7%) were within the age range of 20–29 years, 53.1% were in their third trimester, 32.6% in second trimester and 14.3% were in the first trimester. Syphilis screening was 52.4% among 37 health facilities. Among 390 pregnant women who participated in the study syphilis screening was 21.1%. At the health facility level, screening was significantly associated with the type of hospital (whether private or public), availability of test kits, and trained personnel, such as doctors/midwives and syphilis education. At the individual level, attending a public hospital (OR=5.49; 95% CI=1.71-17.65), willingness to request screening (OR=2.72; 95% CI=1.09-5.88), and being in the third trimester of pregnancy (OR=16.47; 95% CI=2.02-132.81) were significantly associated with syphilis screening uptake.

Conclusion

Despite government’s free screening policy for syphilis among pregnant women, the coverage of antenatal screening is still low. Training of lower level health workers and regular supply of logistics are crucial for the success of the syphilis prevention programme.

Factors associated with failure to screen for syphilis during antenatal care in Ghana: a case control study

Background

There is little data regarding the effect of ramping up new screening interventions on their uptake by target populations into routine care services in developing countries. This study aimed to determine patient-level factors associated with failure of pregnant women to get screened for syphilis during antenatal care, in the context of a national rollout of rapid syphilis point of care tests (POCTs) in Ghana.

Methods

An unmatched 1:2 case control study conducted among women admitted for delivery in two district hospitals in the Ashanti Region of Ghana from August to October 2010, 7 to 9 months after the introduction of POCTs in the region. Cases were women who had not been screened for syphilis during antenatal care and controls were women who had been screened. Patient-reported factors for being unscreened were examined using logistic regression to obtain odds ratios (ORs) and 95% confidence intervals (CIs).

Results

160 consecutive unscreened and 327 screened women were recruited. Most women had good knowledge of syphilis (58.7% among unscreened women vs. 64.2% among screened; P = 0.24). Factors associated with failure to get screened were: attending antenatal care in a private health facility (adjusted OR, 11.09; 95% CI 5.48-22.48), previous adverse pregnancy outcome (adjusted OR, 1.98; 95% CI 1.22-3.23) and not being screened for HIV during the current pregnancy (adjusted OR, 2.78; 95% CI 1.50-5.13). The odds of being unscreened also increased with decreasing doses of intermittent preventive treatment for malaria in pregnancy received (P trend < 0.001) and decreasing education level (P trend = 0.02).

Conclusion

Significant risk factors for not being screened, following the national rollout of syphilis POCTs, related to the type of health facility where antenatal care was received and some of the women’s personal characteristics. Targeting of private medical facilities to include syphilis POCTs and support other neglected public health interventions should be a priority.

Strategies of testing for syphilis during pregnancy

BACKGROUND

Each year about two million pregnant women are infected with preventable syphilis infection, mostly in developing countries. Despite the expansion of antenatal syphilis screening programmes over the past few decades, syphilis continues to be a major public health concern in developing countries. Point-of-care syphilis testing may be a useful strategy to substantially prevent syphilis-associated perinatal mortality and other negative consequences in resource-poor settings. However, the evidence on effectiveness has been generated mostly from observational study designs or has been reported as a mixed-intervention effect.

OBJECTIVES

To assess the effectiveness of antenatal syphilis screening in improving the uptake of screening tests and treatment, and reducing perinatal mortality.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2014) and the reference lists of retrieved studies.

SELECTION CRITERIA

Randomised (individual and cluster) controlled trials comparing different screening tests conducted during routine antenatal check-ups versus no screening test. Cross-over trials and quasi-randomised experimental study designs were not eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked for accuracy.

MAIN RESULTS

We included two cluster-randomised controlled trials (three reports). Both trials assessed point-of-care syphilis testing with conventional testing methods and together involved a total of 8493 pregnant women. Data from these trials were not amenable to meta-analysis as the measure of effectiveness was assessed in a non-comparable way.One trial randomised 14 antenatal clinics (including 7700 pregnant women) and was carried out at in Ulaanbaatar, Mongolia. The trial assessed one-stop syphilis testing using a rapid treponemal test, and was judged to have unclear methods of random sequence generation, allocation concealment, selective reporting, and other bias and low risk of bias for incomplete outcome data. Blinding was not reported and was assessed as high risk. The point-of-care testing provided screening, test results and treatment within the same day. The trial appears to have adjusted their results to account for clustering. We entered the data into RevMan using the generic inverse variance method. The incidence of congenital syphilis was lower in the clusters receiving on-site screening (adjusted odds ratio (AOR) 0.09, 95% confidence interval (CI) 0.01 to 0.71) and the proportion of women tested for syphilis was higher in the clusters receiving on-site screening at both the first antenatal visit and at the third trimester visit (OR 989.80, 95% CI 16.27 to 60233.05; OR 617.88, 95% CI 13.44 to 28399.01). Adequate treatment and partner treatment was higher with the on-site screening (AOR 10.44, 95% CI 1.00 to 108.99; AOR 18.17, 95% CI 3.23 to 101.20) and more syphilis cases were detected at first and third trimester visits with the on-site screening (AOR 2.45, 95% CI 1.44 to 4.18; AOR 6.27, 95% CI 1.47 to 26.69). Perinatal mortality, incidence of HIV/AIDS, obstacles in uptake of screening, any other adverse effects, or healthcare resource usage were not reported in this trial.The second trial divided clinics into seven matched pairs (including 7618 pregnant women, although results were only presented for the positive cases (793 women)), and within each pair one clinic was randomised to receive the on-site screening and the other to continue routine laboratory testing. The trial was conducted in primary healthcare clinics in KwaZulu-Natal, South Africa. Random sequence generation were judged to be at low risk of bias, but allocation concealment and incomplete outcome data were judged to be high risk. Other bias and selective reporting bias remain unclear. Blinding was not reported and was assessed as high risk of bias. This trial assessed the primary outcome of this review (perinatal mortality) and the secondary outcomes (adverse outcomes; adequate treatment; syphilis prevalence) in the subset of women (793 women) who tested positive for syphilis. Only one outcome, adequate treatment, was adjusted to account for cluster design. However, not enough information was provided to include this in an analysis using the generic inverse variance method. Where possible, results have therefore been presented in forest plots (perinatal mortality; adequate treatment), as if the data are from a parallel randomised controlled trial. These results should therefore be interpreted with caution.The trial reported on perinatal mortality in women with positive test results and showed that on-site screening using a rapid plasma reagin test had no clear evidence of an effect on perinatal mortality reduction (odds ratio (OR) 0.63; 95% CI 0.27 to 1.48; 18/549 (3.3%) versus 8/157 (5.1%)). After loss to follow up, 396/618 (64.1%) women with positive test results received adequate treatment (two or more doses of 2.4 mega units of benzathine penicillin) in the intervention cluster versus 120/175 (68.6%) in the control (OR 0.82; 95% CI 0.57 to 1.17). It was not possible to include any other data on reported outcomes in forest plots (adverse outcomes; syphilis prevalence). Incidence of congenital syphilis, proportion of women test for syphilis, incidence of HIV/AIDS, obstacles in uptake of screening, partner treatment, or healthcare resource usage were not reported in this trial.

AUTHORS' CONCLUSIONS

This review included evidence from two cluster-randomised trials at high or unclear risk of bias for most of the 'Risk of bias' domains. Data were not combined in meta-analysis because the trials used non-comparable measures of effectiveness.Point-of-care syphilis testing showed some promising results for syphilis detection and treatment rates and for use in different settings. In Mongolia point-of-care testing was found to be effective in increasing the proportion of pregnant women tested for syphilis and treatment provided, reducing congenital syphilis, and improving access to treatment for both women and their partners. In contrast, in rural South Africa, among women with positive test results, there was no clear evidence of an effect of point-of-care syphilis testing in increasing adequate syphilis treatment rates, and reducing perinatal mortality, but point-of-care testing was found to reduce delay in seeking treatment.More trials are therefore warranted to determine the effectiveness of available testing strategies for improving syphilis-associated adverse outcomes in pregnant women and neonates, especially in high-risk regions.

Evaluation of the SD Bioline HIV/Syphilis Duo assay at a rural health center in Southwestern Uganda

Background

Point-of-care tests have the capacity to improve healthcare delivery by reducing costs and delay associated with care. A novel point-of-care immunochromatographic test for dual diagnosis of both HIV and syphilis by detecting IgG, IgM and IgA antibodies to HIV, and specific and recombinant Treponema pallidum antigens has recently been developed, but has not been evaluated in rural field settings. We evaluated the performance of the SD Bioline Syphilis/HIV Duo (Duo) assay at a healthcare center in rural Uganda.

Methods

A convenience sample of pregnant women attending Kinoni Health Centre IV from March to May, 2013 was enrolled. Venous blood was collected and centrifuged for plasma isolation. Samples were tested with the Duo assay and compared with the Treponema pallidum hemaglutination assay and paired HIV rapid antibody tests as the reference standards. The ease of use and time required for the Duo assay were also assessed by laboratory technicians.

Results

Two hundred twenty women were enrolled with a mean age of 25.00 years (SD 5.41). The sensitivity and specificity of the Duo assay were 100% (95% CI 79.0 – 100%) and 100% (95% CI 97.6 – 100.0) respectively, for syphilis, and, 100% (75.9 – 100%) and 99.5% (96.8 – 99.9%) respectively, for HIV. The duo kit was found to be faster and easier to use than the current HIV and syphilis testing techniques.

Conclusion

The sensitivity and specificity of the SD Bioline HIV/Syphilis Duo test were excellent in a field setting in Uganda. The Duo assay should be further evaluated in alternate populations and with point-of-care specimens (e.g. whole blood from finger stick specimens), but shows promise as a tool for improved HIV and syphilis surveillance, diagnosis, and treatment in field settings.

Reported estimates of adverse pregnancy outcomes among women with and without syphilis: a systematic review and meta-analysis

BACKGROUND

To estimate probability of adverse pregnancy outcomes (APOs) among women with and without syphilis through a systematic review of published literatures.

METHODOLOGY/PRINCIPAL FINDINGS

Chinese and English literatures were searched for studies assessing pregnancy outcomes in the presence of maternal syphilis through August 2013. The prevalence estimates were summarized and analyzed by meta-analysis. Fifty-four literatures involving 11398 syphilitic women and 43342 non-syphilitic women were included from 4187 records initially found. Among untreated mothers with syphilis, pooled estimates were 76.8% for all APOs, 36.0% for congenital syphilis, 23.2% for preterm, 23.4% for low birth weight, 26.4% for stillbirth or fetal loss, 14.9% for miscarriage and 16.2% for neonatal deaths. Among syphilitic mother receiving treatment only in the late trimester (>28 weeks), pooled estimates were 64.4% for APOs, 40.6% for congenital syphilis, 17.6% for preterm, 12.4% for low birth weight, and 21.3% for stillbirth or fetal loss. Among syphilitic mothers with high titers (≥1∶8), pooled estimates were 42.8% for all APOs, 25.8% for congenital syphilis, 15.1% for preterm, 9.4% for low birth weight, 14.6% for stillbirth or fetal loss and 16.0% for neonatal deaths. Among non-syphilitic mothers, the pooled estimates were 13.7% for all APOs, 7.2% for preterm birth, 4.5% for low birth weight, 3.7% for stillbirth or fetal loss, 2.3% for miscarriage and 2.0% for neonatal death. Begg's rank correlation test indicated little evidence of publication bias (P>0.10). Substantial heterogeneity was found across studies in the estimates of all adverse outcomes for both women with syphilis (I2 = 93.9%; P<0.0001) and women without syphilis (I2 = 94.8%; P<0.0001).

CONCLUSIONS/SIGNIFICANCE

Syphilis continues to be an important cause of substantial perinatal morbidity and mortality, which reminds that policy-makers charged with resource allocation that the elimination of mother-to-child transmission of syphilis is a public health priority.

Synthesized prevention and control of one decade for mother-to-child transmission of syphilis and determinants associated with congenital syphilis and adverse pregnancy outcomes in Shenzhen, South China

The purpose of this investigation was to assess the effectiveness of an intervention program on mother-to-child transmission (MTCT) of syphilis and investigate determinants of congenital syphilis (CS) and adverse pregnancy outcomes (APOs). The Shenzhen local government initiated an intervention program of MTCT of syphilis in 2001. Based on this program, maternal and paternal factors associated with CS and APOs among syphilitic women were investigated from 2007 to 2012 by a prospective cohort study. From 2002 to 2012, 2,441,237 pregnant women were screened and screening coverage reached 97.2 % in 2012. In the background of continuing growth of CS in China, CS in Shenzhen significantly decreased from 109.3 cases in 2002 to 9.9 cases in 2012 per 100,000 live births. Maternal education (adjusted odds ratio [aOR]CS = 0.65; aORAPOs = 0.79) and history of syphilis (aORCS = 0.28; aORAPOs = 0.61), as well as paternal age (aORCS = 0.62; aORAPOs = 0.86) and education (aORCS = 0.66; aORAPOs = 0.86) were negatively associated with CS and APOs, but maternal unmarried status (aORCS = 1.95; aORAPOs = 2.61), inadequate antenatal care (ANC) (aORCS = 3.61; aORAPOs = 1.79), more sexual partners (aORCS = 1.51; aORAPOs = 1.39), every week of delay in treatment (aORCS = 2.82; aORAPOs = 1.27), higher baseline titers of nontreponemal antibodies (aORCS = 5.65; aORAPOs = 1.47), early syphilis (aORCS = 23.24; aORAPOs = 26.95), and non-penicillin treatment (aORCS = 3.00; aORAPOs = 2.16), as well as paternal history of cocaine use (aORCS = 2.70; aORAPOs = 2.44) and positive (aORCS = 4.14; aORAPOs = 1.50) or unknown (aORCS = 2.37; aORAPOs = 2.06) status of syphilis increased the risk of CS and APOs. Condom use (aOR = 0.70) decreased MTCT of syphilis. A ten-year program consisting of screening and treatment, early ANC, health education, partners tracking, detection, and treatment, follow-up visits, and information management is an effective means to block MTCT of syphilis. Maternal and paternal factors constituted two separate profiles associated with MTCT of syphilis.

A three year retrospective study on seroprevalence of syphilis among pregnant women at Gondar University Teaching Hospital, Ethiopia

BACKGROUND

Sexually transmitted infections (STIs) are a serious public health problem in low income countries, including Ethiopia. Syphilis caused by Treponema pallidum remains a major cause of reproductive morbidity and poor pregnancy outcomes in low income countries. Stillbirth, perinatal death, serious neonatal infection and low-birth weight babies are common among seropositive mothers.

OBJECTIVE

To assess the seroprevalence of syphilis and risk factor correlates of this infection at Gondar University Teaching Hospital, Ethiopia.

METHODS

The study was done on 2385 pregnant women attending the antenatal care clinic (ANC) from January 2009 to December 2011. Data was abstracted from the antenatal care clinic medical database. Chi-square test was used, using SPSS version 16 and significance level was chosen at 0.05 level with a two-tailed test.

RESULTS

Of the total, 69(2. 9%) of pregnant women were confirmed as seropositive for syphilis. Pregnant women with an age group of 21-25 years of old were the most seropositive (3.4%), followed by 26-30 years of old (3.1%). The prevalence of syphilis infection was 3.2% in urban and 2.2% in rural pregnant women. Relatively high prevalence of syphilis infection were identified among students (4.2%) followed by governmental employees (3.8%).

CONCLUSION

The seroprevalence of syphilis among pregnant women attending ANC is declining. However, syphilis is more prevalent in the young and urban pregnant women. Emphasis on education to young people on STI risk behavioral change and partner follow up and notification for exposure to syphilis and treatment should be given.

The cost and cost-effectiveness of scaling up screening and treatment of syphilis in pregnancy: a model

BACKGROUND

Syphilis in pregnancy imposes a significant global health and economic burden. More than half of cases result in serious adverse events, including infant mortality and infection. The annual global burden from mother-to-child transmission (MTCT) of syphilis is estimated at 3.6 million disability-adjusted life years (DALYs) and $309 million in medical costs. Syphilis screening and treatment is simple, effective, and affordable, yet, worldwide, most pregnant women do not receive these services. We assessed cost-effectiveness of scaling-up syphilis screening and treatment in existing antenatal care (ANC) programs in various programmatic, epidemiologic, and economic contexts.

METHODS AND FINDINGS

We modeled the cost, health impact, and cost-effectiveness of expanded syphilis screening and treatment in ANC, compared to current services, for 1,000,000 pregnancies per year over four years. We defined eight generic country scenarios by systematically varying three factors: current maternal syphilis testing and treatment coverage, syphilis prevalence in pregnant women, and the cost of healthcare. We calculated program and net costs, DALYs averted, and net costs per DALY averted over four years in each scenario. Program costs are estimated at $4,142,287 - $8,235,796 per million pregnant women (2010 USD). Net costs, adjusted for averted medical care and current services, range from net savings of $12,261,250 to net costs of $1,736,807. The program averts an estimated 5,754 - 93,484 DALYs, yielding net savings in four scenarios, and a cost per DALY averted of $24 - $111 in the four scenarios with net costs. Results were robust in sensitivity analyses.

CONCLUSIONS

Eliminating MTCT of syphilis through expanded screening and treatment in ANC is likely to be highly cost-effective by WHO-defined thresholds in a wide range of settings. Countries with high prevalence, low current service coverage, and high healthcare cost would benefit most. Future analyses can be tailored to countries using local epidemiologic and programmatic data.

Barriers to antenatal syphilis screening in Burkina Faso

INTRODUCTION

Despite advances in treatment and management, syphilis remains a major public health problem in Burkina Faso. Syphilis in pregnancy poses major health risks for the mother and the fetus and also increases the risk for HIV transmission. Despite its potential benefits, antenatal syphilis screening is often poorly implemented in many sub-Saharan African countries. The purpose of the study is to identify and understand barriers affecting health system performance for syphilis screening among pregnant women in Burkina Faso.

METHODS

We conducted in-depth interviews and observations in the Kaya health district, Burkina Faso. Participants were purposively selected to capture a range of perspectives across different actors with different roles and responsibilities. Seventy-five interviews were conducted with health providers, district managers, facility managers, traditional healers, pregnant women, community health workers, and Non-Governmental Organizations (NGO) managers. Interviews were transcribed and organized into codes and categories using NVivo software.

RESULTS

Participants identified multiple barriers at health providers and community levels. Key barriers at provider level included fragmentation of services, poor communication, low motivation for prescription, and low awareness of syphilis burden. Cost of testing, distance to laboratory and lack of knowledge about syphilis were identified as barriers at community level.

CONCLUSION

The study highlights barriers such as distance, cost of testing, and knowledge about syphilis. The introduction of point of care testing for syphilis could be an entry point for improving coverage of antenatal syphilis screening.

Rapid-Testing Technology and Systems Improvement for the Elimination of Congenital Syphilis in Haiti: Overcoming the "Technology to Systems Gap"

Background. Despite the availability of rapid diagnostic tests and inexpensive treatment for pregnant women, maternal-child syphilis transmission remains a leading cause of perinatal morbidity and mortality in developing countries. In Haiti, more than 3000 babies are born with congenital syphilis annually. Methods and Findings. From 2007 to 2011, we used a sequential time series, multi-intervention study design in fourteen clinics throughout Haiti to improve syphilis testing and treatment in pregnancy. The two primary interventions were the introduction of a rapid point-of-care syphilis test and systems strengthening based on quality improvement (QI) methods. Syphilis testing increased from 91.5% prediagnostic test to 95.9% after (P < 0.001) and further increased to 96.8% (P < 0.001) after the QI intervention. Despite high rates of testing across all time periods, syphilis treatment lagged behind and only increased from 70.3% to 74.7% after the introduction of rapid tests (P = 0.27), but it improved significantly from 70.2% to 84.3% (P < 0.001) after the systems strengthening QI intervention. Conclusion. Both point-of-care diagnostic testing and health systems-based quality improvement interventions can improve the delivery of specific evidence-based healthcare interventions to prevent congenital syphilis at scale in Haiti. Improved treatment rates for syphilis were seen only after the use of systems-based quality improvement approaches.

State of the art syphilis diagnostics: rapid point-of-care tests

Syphilis remains an important and entirely preventable cause of stillbirth and neonatal mortality. More than 1 million women with active syphilis become pregnant each year. Without treatment, 25% of them will deliver a stillborn baby, 33% will deliver a live 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. Until recently access to screening in low- and middle-income countries has been limited, since screening tests have been laboratory based, requiring equipment, electricity and trained laboratory staff. Now a number of rapid, cheap, simple and accurate screening tests are available and can give a result in 15-20 min, enabling those who require treatment to be treated at their first visit.

Antenatal syphilis screening using point-of-care testing in Sub-Saharan African countries: a cost-effectiveness analysis

BACKGROUND

Untreated syphilis in pregnancy is associated with adverse clinical outcomes for the infant. Most syphilis infections occur in sub-Saharan Africa (SSA), where coverage of antenatal screening for syphilis is inadequate. Recently introduced point-of-care syphilis tests have high accuracy and demonstrate potential to increase coverage of antenatal screening. However, country-specific cost-effectiveness data for these tests are limited. The objective of this analysis was to evaluate the cost-effectiveness and budget impact of antenatal syphilis screening for 43 countries in SSA and estimate the impact of universal screening on stillbirths, neonatal deaths, congenital syphilis, and disability-adjusted life years (DALYs) averted.

METHODS AND FINDINGS

The decision analytic model reflected the perspective of the national health care system and was based on the sensitivity (86%) and specificity (99%) reported for the immunochromatographic strip (ICS) test. Clinical outcomes of infants born to syphilis-infected mothers on the end points of stillbirth, neonatal death, and congenital syphilis were obtained from published sources. Treatment was assumed to consist of three injections of benzathine penicillin. Country-specific inputs included the antenatal prevalence of syphilis, annual number of live births, proportion of women with at least one antenatal care visit, per capita gross national income, and estimated hourly nurse wages. In all 43 sub-Saharan African countries analyzed, syphilis screening is highly cost-effective, with an average cost/DALY averted of US$11 (range: US$2-US$48). Screening remains highly cost-effective even if the average prevalence falls from the current rate of 3.1% (range: 0.6%-14.0%) to 0.038% (range: 0.002%-0.113%). Universal antenatal screening of pregnant women in clinics may reduce the annual number of stillbirths by up to 64,000, neonatal deaths by up to 25,000, and annual incidence of congenital syphilis by up to 32,000, and avert up to 2.6 million DALYs at an estimated annual direct medical cost of US$20.8 million.

CONCLUSIONS

Use of ICS tests for antenatal syphilis screening is highly cost-effective in SSA. Substantial reduction in DALYs can be achieved at a relatively modest budget impact. In SSA, antenatal programs should expand access to syphilis screening using the ICS test. Please see later in the article for the Editors' Summary.

The costs of accessible quality assured syphilis diagnostics: informing quality systems for rapid syphilis tests in a Tanzanian setting

OBJECTIVES

To determine the costs of Rapid Syphilis Test (RSTs) as compared with rapid plasma reagin (RPR) when implemented in a Tanzanian setting, and to determine the relative impact of a quality assurance (QA) system on the cost of RST implementation.

METHODS

The incremental costs for RPR and RST screening programmes in existing antenatal care settings in Geita District, Tanzania were collected for 9 months in subsequent years from nine health facilities that varied in size, remoteness and scope of antenatal services. The costs per woman tested and treated were estimated for each facility. A sensitivity analysis was constructed to determine the impact of parameter and model uncertainty.

FINDINGS

In surveyed facilities, a total of 6362 women were tested with RSTs compared with 224 tested with RPR. The range of unit costs was $1.76-$3.13 per woman screened and $12.88-$32.67 per woman treated. Unit costs for the QA system came to $0.51 per woman tested, of which 50% were attributed to salaries and transport for project personnel.

CONCLUSIONS

Our results suggest that rapid syphilis diagnostics are very inexpensive in this setting and can overcome some critical barriers to ensuring universal access to syphilis testing and treatment. The additional costs for implementation of a quality system were found to be relatively small, and could be reduced through alterations to the programme design. Given the potential for a quality system to improve quality of diagnosis and care, we recommend that QA activities be incorporated into RST roll-out.

Antenatal care services in rural Uganda: missed opportunities for good-quality care

Experience from countries that have achieved low maternal mortality suggests that access to good-quality maternity services is critical to improve maternal health. In this article we appraise the quality of antenatal care (ANC) services in a rural district of Uganda. We used a mixed methods approach, relying on a combination of semistructured interviews with both clients and providers, structured observations of provider-patient interactions, and infrastructure assessment of selected health facilities. We found several bottlenecks in health service delivery, including ineffective organization of educational sessions; selective omission of certain services; lack of explanation of important clinical and laboratory procedures; failure to link the performed procedures with preventive information; and occasional lack of respect for clients. The policy implications of these findings are discussed in relation to the need to (a) ensure an adequate supply of medical equipment and drugs, (b) enhance health workers' compliance with ANC guidelines, and (c) combine medical procedures with educational messages.

The tale of two serologic tests to screen for syphilis--treponemal and nontreponemal: does the order matter?

BACKGROUND

Standard syphilis screening involves an initial screening with a nontreponemal test and confirmation of positives with a treponemal test. However, some laboratories have reversed the order. There is no detailed quantitative and qualitative evaluation for the order of testing. In this study, we analyzed the health and economic outcomes of the order of testing for the 2 serologic tests used in syphilis screening under pure screening settings.

METHODS

We used a cohort decision analysis to examine the health and economic outcomes of the screening algorithms for low and high prevalence settings. The 2-step algorithms were nontreponemal followed by treponemal (Nontrep-First) and treponemal followed by nontreponemal (Trep-First). We included the 1-step algorithms (treponemal only [Trep-Only] and an on-site nontreponemal only [Nontrep-Only]) for comparison. We estimated overtreatment rates and the number of confirmatory tests required for each algorithm.

RESULTS

For a cohort of 10,000 individuals, our results indicated that the overtreatment rates were substantially higher (more than 3 times) for the 1-step algorithms, although they treated a higher number of cases (over 15%). The 2-step algorithms detected and treated the same number of individuals. Among the 2-step algorithms, the Nontrep-First was more cost-effective in the low prevalence setting ($1400 vs. $1500 per adverse outcome prevented) and more cost-saving ($102,000 vs. $84,000) in the high prevalence setting.

CONCLUSIONS

The difference in cost was largely due to the substantially higher number of confirmatory tests required for the Trep-First algorithm, although the number of cases detected and treated was the same.

National, regional, and global trends in infertility prevalence since 1990: a systematic analysis of 277 health surveys

BACKGROUND

Global, regional, and national estimates of prevalence of and tends in infertility are needed to target prevention and treatment efforts. By applying a consistent algorithm to demographic and reproductive surveys available from developed and developing countries, we estimate infertility prevalence and trends, 1990 to 2010, by country and region.

METHODS AND FINDINGS

We accessed and analyzed household survey data from 277 demographic and reproductive health surveys using a consistent algorithm to calculate infertility. We used a demographic infertility measure with live birth as the outcome and a 5-y exposure period based on union status, contraceptive use, and desire for a child. We corrected for biases arising from the use of incomplete information on past union status and contraceptive use. We used a Bayesian hierarchical model to estimate prevalence of and trends in infertility in 190 countries and territories. In 2010, among women 20-44 y of age who were exposed to the risk of pregnancy, 1.9% (95% uncertainty interval 1.7%, 2.2%) were unable to attain a live birth (primary infertility). Out of women who had had at least one live birth and were exposed to the risk of pregnancy, 10.5% (9.5%, 11.7%) were unable to have another child (secondary infertility). Infertility prevalence was highest in South Asia, Sub-Saharan Africa, North Africa/Middle East, and Central/Eastern Europe and Central Asia. Levels of infertility in 2010 were similar to those in 1990 in most world regions, apart from declines in primary and secondary infertility in Sub-Saharan Africa and primary infertility in South Asia (posterior probability [pp] ≥0.99). Although there were no statistically significant changes in the prevalence of infertility in most regions amongst women who were exposed to the risk of pregnancy, reduced child-seeking behavior resulted in a reduction of primary infertility among all women from 1.6% to 1.5% (pp=0.90) and a reduction of secondary infertility among all women from 3.9% to 3.0% (pp>0.99) from 1990 to 2010. Due to population growth, however, the absolute number of couples affected by infertility increased from 42.0 million (39.6 million, 44.8 million) in 1990 to 48.5 million (45.0 million, 52.6 million) in 2010. Limitations of the study include gaps in survey data for some countries and the use of proxies to determine exposure to pregnancy.

CONCLUSIONS

We analyzed demographic and reproductive household survey data to reveal global patterns and trends in infertility. Independent from population growth and worldwide declines in the preferred number of children, we found little evidence of changes in infertility over two decades, apart from in the regions of Sub-Saharan Africa and South Asia. Further research is needed to identify the etiological causes of these patterns and trends.

Point-of-care tests to strengthen health systems and save newborn lives: the case of syphilis

Rosanna Peeling and colleagues describe their experience of introducing point-of-care testing to screen for syphilis in pregnant women living in low- and middle-income countries.

Compliance with focused antenatal care services: do health workers in rural Burkina Faso, Uganda and Tanzania perform all ANC procedures?

OBJECTIVE

To assess health workers' compliance with the procedures set in the focused antenatal care (ANC) guidelines in rural Uganda, Tanzania and Burkina Faso; to compare the compliance within and among the three study sites; and to appraise the logistic and supply of the respective health facilities (HF).

METHODS

The cross-sectional study was conducted in the rural HF in three African countries. This descriptive observational study took place in HF in Nouna, Burkina Faso (5), Iganga, Uganda (6) and Rufiji, Tanzania (7). In total, 788 ANC sessions and service provisions were observed, the duration of each ANC service provision was calculated, and the infrastructures of the respective HF were assessed.

RESULTS

Health workers in all HF performed most of the procedures but also omitted certain practices stipulated in the focused ANC guidelines. There was a substantial variation in provision of ANC services among HF within and among the country sites. The findings also revealed that the duration of first visits was <15 min and health workers spent even less time in subsequent visits in all three sites. Reagents for laboratory tests and drugs as outlined in the focus ANC guidelines were often out of stock in most facilities.

CONCLUSION

Health workers in all three country sites failed to perform all procedures stipulated in the focused ANC guideline; this could not be always explained by the lack of supplies. It is crucial to point out the necessity of the core procedures of ANC repeatedly.

Improving antenatal care to prevent adverse pregnancy outcomes caused by syphilis

Evaluation of: Hawkes S, Matin N, Broutet N, Low N. Effectiveness of interventions to improve screening for syphilis in pregnancy: a systematic review and meta-analysis. Lancet Infect. Dis. 11(9), 684–691 (2011). Untreated maternal syphilis continues to be an important risk factor for adverse pregnancy outcomes in many developing countries, resulting in spontaneous abortion, stillbirth, premature delivery or perinatal death. In this systematic review and meta-analysis, Hawkes et al. review the effectiveness of interventions to increase the uptake of syphilis screening and treatment in pregnancy. The ten studies they review, published between 1986 and 2008, have a total sample size of more than 41,000. Overall, they showed that interventions to improve the uptake of antenatal screening for syphilis in pregnancy could reduce the syphilis-attributable incidence of stillbirth and perinatal death by 50%. As prevention of congenital syphilis costs less than US$1.50 per woman screened, the investment to scale up antenatal screening programs would be cost effective, would significantly improve pregnancy outcomes and reduce neonatal mortality.

Syphilis test availability and uptake at medical facilities in southern China

OBJECTIVE

To examine syphilis testing capacity, screening coverage rates and types of syphilis tests used in medical facilities in southern China.

METHODS

Eleven of the 14 municipalities in Guangdong province participated. Data on syphilis testing capacity, screening coverage and types of syphilis tests used were collected from all types of public medical facilities offering prenatal care (n = 109). A total of 494 680 women who delivered during 2004-2008 were studied.

FINDINGS

In 2008, 54 196 pregnant women (43.1%) were not screened for syphilis. Among such women, 32 863 (60.6%) attended clinics without any syphilis testing capacity and 21 333 (39.4%) attended clinics that performed testing but were not screened. The likelihood of not having syphilis test capacity was much higher for hygiene stations (odds ratio, OR: 10; 95% confidence interval, CI: 4-25), services at the township level (OR: 33; 95% CI: 10-100) and services with ≤ 1000 deliveries per year (OR: 1.002; 95% CI: 1.001-1.003). These same service characteristics correlated with lower screening coverage rates (P < 0.01). Only one antenatal clinic had the capacity to conduct both treponemal and non-treponemal tests for diagnosing syphilis.

CONCLUSION

Syphilis screening is available in very few of the basic medical facilities offering prenatal care where most neonates in southern China are delivered. In light of this and of the increasing incidence of syphilis in the area, expanding point-of-care rapid syphilis testing is a priority.