A case study of antenatal syphilis screening in South Africa: successes and challenges

Gaps in the prevention of mother-to-child transmission of syphilis: a review of reported cases, South Africa, January 2020-June 2022

INTRODUCTION

Congenital syphilis (CS) is preventable through timely antenatal care (ANC), syphilis screening and treatment among pregnant women. Robust CS surveillance can identify gaps in this prevention cascade. We reviewed CS cases reported to the South African notifiable medical conditions surveillance system (NMCSS) from January 2020 to June 2022.

METHODS

CS cases are reported using a case notification form (CNF) containing limited infant demographic and clinical characteristics. During January 2020-June 2022, healthcare workers supplemented CNFs with a case investigation form (CIF) containing maternal and infant testing and treatment information. We describe CS cases with/without a matching CIF and gaps in the CS prevention cascade among those with clinical information.

FINDINGS

During January 2020-June 2022, 938 CS cases were reported to the NMCSS with a median age of 1 day (interquartile range: 0-5). Nine percent were diagnosed based on clinical signs and symptoms only. During January 2020-June 2022, 667 CIFs were reported with 51% (343) successfully matched to a CNF. Only 57% of mothers of infants with a matching CIF had an ANC booking visit (entry into ANC). Overall, 87% of mothers were tested for syphilis increasing to 98% among mothers with an ANC booking visit. Median time between first syphilis test and delivery was 16 days overall increasing to 82 days among mothers with an ANC booking visit.

DISCUSSION

Only 37% of CS cases had accompanying clinical information to support evaluation of the prevention cascade. Mothers with an ANC booking visit had increased syphilis screening and time before delivery to allow for adequate treatment.

Exploring motivation to notify and barriers to partner notification of sexually transmitted infections in South Africa: a qualitative study

Background

This article will review qualitative data from intervention-based counselling sessions to explore barriers to partner notification (PN) for South African men and women who have contracted sexually transmitted infections (STIs). This qualitative study took place in a township where there is high STI and HIV prevalence. In addition to reviewing barriers to PN, the study will also identify participants’ perceptions about effective PN strategies that are presented during the intervention. Ultimately, the study will assess the intervention’s impact on participants’ motivation and skills to notify their partners about their STI status.

Methods

Relying on recorded counselling sessions from an intervention run by a parent study, this sub- study reviewed 30 transcripts from counselling sessions with 15 men and 15 women. The intervention was a 60 min interactive session where STI and HIV education, risk mitigation, and effective PN strategies were discussed. Participants were between 19 and 41 years old (mean age = 28.4) and lived within the catchment area of a South African township. Recordings were chosen based on verbal responsiveness of the participant and were manually coded for analysis. In addition, two programme counsellors were interviewed about their perceptions of the intervention and their experiences with participants to enhance rigour and reduce potential bias.

Results

By the conclusion of the intervention session, both male and female participants were motivated to notify their partners face-to-face about their positive STI status. Despite this, misperceptions about the etiology and transmission of STIs, as well as inadequate support from the clinical level and power imbalances amongst men and women emerged as major barriers for the prevention of future STIs.

Conclusions

While the intervention appears to be successful in facilitating partners’ intentions to notify, the data shows significant social and structural barriers that will create difficulties for the prevention of future STIs. Participants’ persistent concerns about acquiring HIV or their current positive status affect decision-making and therefore, could be a window of opportunity for health-care providers or lay counsellors to discuss STIs in high prevalence areas.

Syphilis during pregnancy: a preventable threat to maternal-fetal health

Syphilis remains the most common congenital infection worldwide and has tremendous consequences for the mother and her developing fetus if left untreated. Recently, there has been an increase in the number of congenital syphilis cases in the United States. Thus, recognition and appropriate treatment of reproductive-age women must be a priority. Testing should be performed at initiation of prenatal care and twice during the third trimester in high-risk patients. There are 2 diagnostic algorithms available and physicians should be aware of which algorithm is utilized by their testing laboratory. Women testing positive for syphilis should undergo a history and physical exam as well as testing for other sexually transmitted infections, including HIV. Serofast syphilis can occur in patients with previous adequate treatment but persistent low nontreponemal titers (<1:8). Syphilis can infect the fetus in all stages of the disease regardless of trimester and can sometimes be detected with ultrasound >20 weeks. The most common findings include hepatomegaly and placentomegaly, but also elevated peak systolic velocity in the middle cerebral artery (indicative of fetal anemia), ascites, and hydrops fetalis. Pregnancies with ultrasound abnormalities are at higher risk of compromise during syphilotherapy as well as fetal treatment failure. Thus, we recommend a pretreatment ultrasound in viable pregnancies when feasible. The only recommended treatment during pregnancy is benzathine penicillin G and it should be administered according to maternal stage of infection per Centers for Disease Control and Prevention guidelines. Women with a penicillin allergy should be desensitized and then treated with penicillin appropriate for their stage of syphilis. The Jarisch-Herxheimer reaction occurs in up to 44% of gravidas and can cause contractions, fetal heart rate abnormalities, and even stillbirth in the most severely affected pregnancies. We recommend all viable pregnancies receive the first dose of benzathine penicillin G in a labor and delivery department under continuous fetal monitoring for at least 24 hours. Thereafter, the remaining benzathine penicillin G doses can be given in an outpatient setting. The rate of maternal titer decline is not tied to pregnancy outcomes. Therefore, after adequate syphilotherapy, maternal titers should be checked monthly to ensure they are not increasing four-fold, as this may indicate reinfection or treatment failure.

Implementation of repeat HIV testing during pregnancy in Kenya: a qualitative study

BACKGROUND

Repeat HIV testing in late pregnancy has the potential to decrease rates of mother-to-child transmission of HIV by identifying mothers who seroconvert after having tested negative for HIV in early pregnancy. Despite being national policy in Kenya, the available data suggest that implementation rates are low.

METHODS

We conducted 20 in-depth semi-structured interviews with healthcare providers and managers to explore barriers and enablers to implementation of repeat HIV testing guidelines for pregnant women. Participants were from the Nyanza region of Kenya and were purposively selected to provide variation in socio-demographics and job characteristics. Interview transcripts were coded and analyzed in Dedoose software using a thematic analysis approach. Four themes were identified a priori using Ferlie and Shortell's Framework for Change and additional themes were allowed to emerge from the data.

RESULTS

Participants identified barriers and enablers at the client, provider, facility, and health system levels. Key barriers at the client level from the perspective of providers included late initial presentation to antenatal care and low proportions of women completing the recommended four antenatal visits. Barriers to offering repeat HIV testing for providers included heavy workloads, time limitations, and failing to remember to check for retest eligibility. At the facility level, inconsistent volume of clients and lack of space required for confidential HIV retesting were cited as barriers. Finally, at the health system level, there were challenges relating to the HIV test kit supply chain and the design of nationally standardized antenatal patient registers. Enablers to improving the implementation of repeat HIV testing included client dissemination of the benefits of antenatal care through word-of-mouth, provider cooperation and task shifting, and it was suggested that use of an electronic health record system could provide automatic reminders for retest eligibility.

CONCLUSIONS

This study highlights some important barriers to improving HIV retesting rates among pregnant women who attend antenatal clinics in the Nyanza region of Kenya at the client, provider, facility, and health system levels. To successfully implement Kenya's national repeat HIV testing guidelines during pregnancy, it is essential that these barriers be addressed and enablers capitalized on through a multi-faceted intervention program.

Partner Notification Among Peruvian Pregnant Women With Syphilis

INTRODUCTION

As part of an implementation research study on the feasibility of implementing point-of-care tests for syphilis in Peru, we collected information on partner treatment of syphilis-seropositive pregnant women and explored womens' and health providers' knowledge and practices regarding partner notification and treatment (PNT) for maternal syphilis.

METHODS

Mixed methods were used to collect information. Quantitative data were collected from consecutive pregnant women with a positive point-of-care test for syphilis. A subset participated in qualitative interviews. Health providers completed a survey on knowledge, attitudes, and behaviors about PNT.

RESULTS

Of the 144 seropositive women, 46 (31.9%) had concurrent patient-partner treatment. From the 98 seropositive women whose partner was not at the clinic, 33 partners (33.7%) received at least 1 dose of penicillin. The multivariate model showed that screening at the antenatal care clinic (prevalence ratio [PR], 3.84), first sex after age 16 years (PR, 0.55), and lifetime number of partners (PR, 0.55 for 2-4 partners; PR, 0.77 for >4 partners) were independently associated with treatment for the partner. Women identified the provider as key for the PNT, but less than half of the providers reported having been trained for counseling and recognize the need for defining the procedures and standardization for PNT. Providers and women both reported that men may not come for treatment once notified because of fear, distrust of the system, or barriers associated with the services.

CONCLUSION

There is a need for better training of health providers, for clear and standardized processes for partner counseling, registration and follow-up, and an opportunity to introduce new technologies.

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.

Congenital syphilis: still a serious, under-diagnosed threat for children in resource-poor countries

BACKGROUND

With 700,000 to 1.5 million new cases annually, congenital syphilis remains a major infectious cause of morbidity and mortality in neonates, infants and children in resource-poor countries. We therefore analyzed the extent of congenital syphilis in the pediatric patient population at our rural hospital in Tanzania.

METHODS

For this retrospective analysis, from January 1, 1998 to August 31, 2000, all cases of congenital syphilis were collected from the medical records of the neonatal and pediatric department at Haydom Lutheran Hospital in rural northern Tanzania. Age, sex, weight, clinical signs and symptoms, venereal disease research laboratory (VDRL) results of mother and/or child, hemoglobin concentration, treatment, and outcome were recorded and analyzed.

RESULTS

Fourteen neonates and infants were included. The earlier the diagnosis, the more it rested on maternal data because the presentation of neonatal congenital syphilis resembled neonatal sepsis. Syphilitic skin lesions were only seen in the post-neonatal age group. VDRL results were positive in 11 of the 14 mothers, and in 4 of the infants. Anemia was common in older infants. No patient showed signs of central nervous system involvement. Two patients died, and the remaining were cured after standard treatment with procaine penicillin.

CONCLUSIONS

Highlighting the variable picture of congenital syphilis, this report demonstrates how difficult it is to make a correct diagnosis by solely history and clinical presentation in a resource-poor setting. Hence false-positive and false-negative diagnoses are common, and clinicians have to maintain a high index of suspicion in diagnosing congenital syphilis. Therefore, an important approach to control and finally eliminate congenital syphilis as a major public health problem will be universal on-site syphilis screening of all pregnant women at their first antenatal visit and immediate treatment for those who test positive.

Cost-effectiveness of rapid point-of-care prenatal syphilis screening in sub-Saharan Africa

BACKGROUND

Syphilis continues to be an important public health problem among pregnant women in sub-Saharan Africa with prevalence rates as high as 17%. Pregnant women are a critical population to screen to prevent the devastating consequences of infection to their unborn children. Although screening and appropriate treatment of infected pregnant women can prevent fetal and maternal complications, traditional screening algorithms requiring multiple tests have proven to be difficult to implement in resource-poor settings. We assess the cost-effectiveness of on-site prenatal syphilis screening with newly available rapid point-of-care screening tests in sub-Saharan Africa.

METHODS

Data from the literature were used to model the acquisition and subsequent natural history of syphilis in pregnant sub-Saharan African women over the course of their lifetime. We assessed the health and economic outcomes associated with screening strategies that differed by the initial test [rapid plasma reagin (RPR), immunochromographic strip (ICS)], need for confirmation with Treponema pallidum hemagglutination assay, and number of visits required. Model outcomes include adverse pregnancy outcomes (miscarriage, low birth weight, congenital syphilis, stillbirth, and neonatal death), life expectancy, lifetime costs (2004 US dollars), and incremental cost-effectiveness ratios.

RESULTS

With no screening, for a cohort of 1000 women with an average of 6 pregnancies in their lifetime, there were 256 cases of congenital syphilis, 583 low birth weight infants, and 170 stillbirths or neonatal deaths. The most effective and least costly strategy was one-visit rapid testing with ICS, which averted 178 cases of congenital syphilis, 43 low birth weight infants, and 37 perinatal deaths, and saved $170,030 per 1000 women compared with no screening. The choice between ICS and RPR was most influenced by test kit, labor and supply costs, and test sensitivity. RPR was preferred when the ICS cost more than doubled or ICS test sensitivity fell below 88%.

CONCLUSIONS

Universal prenatal syphilis screening using rapid point-of-care tests will improve both maternal and infant outcomes and is cost-effective.

Opportunities for treating sexually transmitted infections and reducing HIV risk in rural South Africa

AIM

This paper is a report of a study to determine the aetiological distribution of sexually transmitted infections and prevalence of human immunodeficiency virus infection in selected primary health care clinic attendees.

BACKGROUND

South Africa has a high prevalence of human immunodeficiency virus and other sexually transmitted infections. Sexually transmitted infections are managed syndromically in the public sector as part of the essential nurse-driven primary care services provided at no cost to the client.

METHOD

This cross-sectional study was conducted in a rural community in South Africa between September and November 2002. A total of 277 consenting women were recruited. Vulvo-vaginal swabs were collected for screening for Neisseriae gonorrheae, Chlamydia trachomatis and Trichomonas vaginalis using DNA amplification methods and Gram stain with Nugent's score for the diagnosis of bacterial vaginosis. Seroprevalence of syphilis and human immunodeficiency virus infection were determined.

FINDINGS

The overall prevalence of human immunodeficiency virus in the study was 43.7% (95% confidence interval 37.6-50.0) with the prevalence in family planning clinic attendees 45.5% (95% confidence interval 38.9-52.3) and antenatal clinic attendees 33.3% (95% confidence interval 19.6-50.3). The prevalence of sexually transmitted infections amongst both the antenatal clinic and family planning attendees accounted for at least 70% of cases. Fifty per cent of women had one recognized sexually transmitted infection with 17.9% of the family planning and 14.5% of the antenatal clinic attendees having infections from two recognized pathogens. All infections were asymptomatic.

CONCLUSION

Nurse-driven antenatal and family planning services provide a useful opportunity for integrating reproductive health services, human immunodeficiency virus voluntary counselling and testing and treatment of sexually transmitted infections.

Onsite Rapid Antenatal Syphilis Screening With an Immunochromatographic Strip Improves Case Detection and Treatment in Rural South African Clinics

OBJECTIVES

Congenital syphilis is a significant cause of adverse pregnancy outcomes. In South Africa, rural clinics perform antenatal screening offsite, but unreliable transport and poor client follow up impede effective treatment. We compared 3 syphilis screening strategies at rural clinics: on-site rapid plasma reagin (RPR), on-site treponemal immunochromatographic strip (ICS) test, and the standard practice offsite RPR with Treponema pallidum hemagglutination assay (RPR/TPHA).

METHODS

Eight rural clinics performed the on-site RPR and ICS tests and provided immediate treatment. Results were compared with RPR/TPHA at a reference laboratory. Chart reviews at 8 standard practice clinics established diagnosis and treatment rates for offsite RPR/TPHA.

FINDINGS

Seventy-nine (6.3%) of 1,250 women screened on-site had active syphilis according to the reference laboratory. The on-site ICS resulted in the highest percentage of pregnant women correctly diagnosed and treated for syphilis (89.4% ICS, 63.9% on-site RPR, 60.8% offsite RPR/TPHA). The on-site RPR had low sensitivity (71.4% for high-titer syphilis). The offsite approach suffered from poor client return rates. One percent of women screened with the ICS may have received penicillin unnecessarily. There were no adverse treatment outcomes.

CONCLUSIONS

The on-site ICS test can reduce syphilis-related adverse outcomes of pregnancy through accurate diagnosis and immediate treatment of pregnant women with syphilis.

Correlates of syphilis seroreactivity among pregnant women: the HIVNET 024 Trial in Malawi, Tanzania, and Zambia

OBJECTIVES

The objectives of this cross-sectional study were to determine correlates of syphilis seroprevalence among HIV-infected and -uninfected antenatal attendees in an African multisite clinical trial, and to improve strategies for maternal syphilis prevention.

RESULTS

A total of 2,270 (86%) women were HIV-infected and 366 (14%) were HIV-uninfected. One hundred seventy-five (6.6%) were syphilis-seropositive (7.3% among HIV-infected and 2.6% HIV-uninfected women). Statistically significant correlates included geographic site (odds ratio [OR] = 4.5, Blantyre; OR = 3.2, Lilongwe; OR = 9.0, Lusaka vs. Dar es Salaam referent); HIV infection (OR = 3.3); age 20 to 24 years (OR = 2.5); being divorced, widowed, or separated (OR = 2.9); genital ulcer treatment in the last year (OR = 2.9); history of stillbirth (OR = 2.8, one stillbirth; OR = 4.3, 2-5 stillbirths); and history of preterm delivery (OR = 2.7, one preterm delivery).

CONCLUSION

Many women without identified risk factors were syphilis-seropositive. Younger HIV-infected women were at highest risk. Universal integrated antenatal HIV and syphilis screening and treatment is essential in sub-Saharan African settings.

Treatment for syphilis in antenatal care: compliance with the three dose standard treatment regimen

BACKGROUND

In South Africa, three doses of benzathine penicillin 2.4 MU at weekly intervals are recommended for treating syphilis in pregnancy. Limited information is available on compliance with the recommended regimen, in terms of time to starting treatment, number of doses, and timing of treatment.

METHODS

The study was conducted to establish the degree of compliance with treatment for syphilis. Timing of treatment and the titres of the rapid plasma reagin (RPR) positive women were recorded. A retrospective record review was conducted of 18,128 antenatal records. These were records of women attending antenatal care clinics in a tertiary hospital catchment area in KwaZulu Natal between February 2001 and January 2002.

RESULTS

Treatment patterns showed that 15.9% received no treatment, 13.2% one dose, 5.8% received two doses, and 64.8% received three doses. In total, 188 women (1.03%) were found to be RPR positive. Of these 36% were found to be high titre positives (titre > or = 1:8).

CONCLUSION

Completed treatment was significantly associated with age of gestation at first visit (p = 0.029), with women attending later in pregnancy less likely to receive all three doses of treatment.

Treatment of maternal syphilis in rural South Africa: effect of multiple doses of benzathine penicillin on pregnancy loss

OBJECTIVES

Despite few data, the treatment of syphilis in pregnant women using a single dose of benzathine penicillin is the standard of care in many resource-poor settings. We examined the effect of various doses of benzathine penicillin on pregnancy loss among women with a positive Rapid Plasma Reagin (RPR) test result in a rural South African district.

METHODS

All pregnant women making their first antenatal care visit during pregnancy were screened for syphilis using the RPR test. Those testing positive were counselled to receive three weekly doses of benzathine penicillin, and received a partner notification card. Pregnancy outcomes were determined from facility records or home visits where necessary.

RESULTS

Of 8917 women screened, 1043 (12%) had reactive syphilis serology; of those with titre data available, 30% had titres of 1:8 or greater. While 41% (n = 430) of women received all three doses as counselled, 30% (n = 312) received only one dose, and 20% (n = 207) did not return to the clinic to receive treatment. Among the 947 women with pregnancy outcome data available, there were 17 miscarriages and 48 perinatal deaths observed. There was a strong trend towards reduced risk of pregnancy loss among women receiving multiple doses of penicillin (adjusted OR for perinatal mortality for each additional dose received, 0.63; 95% CI, 0.48-0.84).

CONCLUSIONS

While this association requires further investigation, these results suggest that there may be substantial benefit to providing multiple doses of benzathine penicillin to treat maternal syphilis in this setting.

Contribution of sexually transmitted diseases and socioeconomic factors to perinatal mortality in rural Ghana

BACKGROUND

The infant mortality rate is higher in sub-Saharan Africa than in other developing regions. The purpose of this study was to evaluate the association of sexually transmitted diseases (STDs) and socioeconomic and obstetric factors with perinatal mortality in rural Ghana.

METHODS

Perinatal mortality data were collected from 154 patient records of the outpatient and inpatient gynecology department of a rural Ghanaian setting in 1997. All women attended the antenatal care unit of the hospital at least once before delivery, where they were screened for common STDs, including syphilis, gonorrhea, and trichomoniasis. Patients' socioeconomic characteristics and previous obstetric complications were recorded.

RESULTS

The rate of perinatal mortality at the Holy Family Hospital in the Berekum district of Ghana was 13.7% in 1997 (154 of 1123 documented births). Characteristics of mothers whose infants died in the perinatal period and who had attended antenatal care at least once were as follows: prior obstetric complications, 108 patients (70.1%); average age, 25 years (range: 16-42 years); average number of previous sexual partners, three; prevalence of STDs, including gonorrhea, trichomoniasis, or syphilis, 83 patients (53.8%); history of other chronic diseases, 13 patients (8.5%); and illiteracy, 66 patients (42.8%). The number of previous sexual partners and illiteracy were higher in the STD-positive women.

CONCLUSIONS

Sexually transmitted diseases and previous obstetric complications seemed to contribute considerably to perinatal mortality in rural Ghana.