Fighting Syphilis and HIV in Women and Children: Lessons from Uganda and Zambia

Global Health Magazine | December 15, 2011

December 15, 2011

Foundation staff – including Edward Bitarakwate, country director for Uganda, Jennifer Pollakusky, senior public policy officer, Tabitha Sripipatana, senior technical officer, and Susan Strasser, country director for Zambia –collaborated on this article for Global Health Magazine on the importance of rapid testing for syphilis in pregnant women. New point-of-care testing incorporated into antenatal and PMTCT services can decrease incidences of congenital syphilis and pediatric HIV, and ultimately reduce maternal and infant mortality.

Syphilis is often called a silent killer, because its symptoms frequently go undetected. But combined with HIV, it can be even deadlier – especially for women and children.
Approximately 12 million new cases of syphilis occur each year worldwide, and nearly 10 percent of all HIV-positive people are also infected with syphilis. In sub-Saharan Africa, co-infection of syphilis and HIV is a serious public health challenge, with women and young children among the most vulnerable groups.

Prevalence rates of syphilis among pregnant women can be as high as 17 percent. With no treatment, women are in danger of passing syphilis on to their infants. If mothers are also infected with HIV, a syphilis infection actually increases the risk of HIV transmission from mother-to-child. Pregnant women living with both HIV and syphilis are twice as likely to pass HIV on to their babies compared to a woman infected with HIV alone.

Like HIV, syphilis is a major cause of morbidity and mortality among women and children in resource-limited settings. Untreated syphilis during pregnancy is associated with a number of negative outcomes, such as stillbirth, premature delivery, low birth weight and infant death.

Syphilis, however, is curable with an affordable and accessible antibiotic medicine – penicillin. And both HIV and syphilis in infants and young children are almost entirely preventable by stopping mother-to-child transmission of the diseases.

Unfortunately, although HIV testing has become more accessible for pregnant women in sub-Saharan Africa as part of routine antenatal care, in many countries, including Uganda and Zambia, syphilis testing must still be accessed at separate sites.

Once tested for syphilis, many women have to wait until their next antenatal appointment to receive their test results – and since many do not return to the clinic, they never learn their diagnosis. Without proper diagnosis, most women never receive the medicines they need to treat syphilis, and unknowingly may pass syphilis on to their babies.

A recent study in Uganda and Zambia conducted by the Elizabeth Glaser Pediatric AIDS Foundation found that integrating new rapid syphilis screening with HIV testing for pregnant women can have a significant effect in preventing both transmission of syphilis and HIV from mother-to-child. The study also showed that screening of pregnant women for syphilis and HIV is feasible, cost-effective and an integral part of improving maternal and child health.

In partnership with the Ministries of Health in Uganda and Zambia, and the Centre for Infectious Disease Research in Zambia (CIDRZ), the study identified high rates of syphilis and HIV co-infection in pregnant women in both countries. In Uganda, 14.3 percent of syphilis-positive pregnant women also tested positive for HIV, and the rate was 24.2 percent in Zambia.

Although policies on syphilis screening of pregnant women have been in place in Uganda and Zambia for several years, these policies have not been widely implemented. This is, in part, due to logistical challenges with current testing methods, which require electricity, refrigeration and laboratory equipment. Testing supplies are often limited and unavailable at some health clinics, and few staff are trained to administer syphilis tests.

But newly devised rapid syphilis testing has made it easier to integrate syphilis screening into services provided at antenatal clinics to prevent mother-to-child transmission (PMTCT) of HIV. These simple and affordable tests make it possible to screen pregnant women for syphilis in a variety of urban and rural settings, without the need for special laboratory equipment or refrigeration.

The new rapid syphilis tests are simple to read and can be performed by many types of health care workers, increasing the number of pregnant women that can be tested for syphilis during routine antenatal visits. Results from the new tests are available within 20 minutes, allowing women to be diagnosed almost immediately, and if they test positive, receive treatment during the same visit. In addition, by combining rapid syphilis with HIV testing, women can receive these two important tests simultaneously.

A survey of health care workers conducted in Uganda and Zambia also showed that rapid syphilis testing could be incorporated into routine antenatal care and PMTCT services without any interruption or negative impact on service delivery or quality of care.

In Uganda, prior to rapid syphilis testing, laboratory technicians would perform syphilis testing for pregnant women. After rapid testing was introduced, it could be performed by a greater variety of health care practitioners, including midwives, who oversee the majority of antenatal care in most hospitals and rural health centers in Uganda. Shifting the responsibility of syphilis testing from lab technicians to midwives and nurses improved efficiency and uptake of syphilis testing, while decreasing the number of specialized staff needed to perform tests and improving the integration of syphilis and HIV services into routine antenatal care.

In Uganda and Zambia, integrated syphilis and HIV testing has also helped increase male involvement in the prevention and treatment of syphilis. As part of the introduction of rapid syphilis testing in Uganda, male partners were encouraged to attend the clinic for syphilis and HIV testing with their partners, and letters of invitation requesting men to get tested were sent home with women attending antenatal clinics. In many traditional African settings, male involvement is critical because gender roles dictate that men make decisions about their female partners’ health care, including whether women participate in PMTCT programs.

As a result of the invitation letters, there was a small but significant increase (from 9.8 percent to 12.5 percent) in men coming to the clinic with their partners for a package of care that included syphilis and HIV counseling and testing, syphilis treatment and referral for HIV care. In Zambia, partner notification letters were sent home with women who tested positive for syphilis to track the follow-up and treatment of male partners.

As a result of rapid syphilis testing, there has been swift and direct policy change in Uganda and Zambia to further the goal of eliminating congenital syphilis and pediatric HIV and AIDS. Findings from this study were presented to the Ministries of Health in Uganda and Zambia, which are now both incorporating rapid syphilis testing into their standard package of PMTCT services and antenatal care. In Zambia, the Ministry of Health, with support from the Elizabeth Glaser Pediatric AIDS Foundation, is procuring rapid syphilis test kits and supporting national trainers as part of a national rollout plan to support rapid syphilis testing of pregnant women across the country.

Providing a total package of maternal and newborn health care, including screening and treatment for HIV and syphilis, is important to improving the health of pregnant women and their children. Diagnosing pregnant women early and providing them with the proper treatment to prevent the transmission of syphilis and HIV to their infants may significantly reduce the number of miscarriages, stillbirths, preterm and low-birth-weight infants, early infant deaths, and AIDS in children.

At a global level, the World Health Organization (WHO) has called for the elimination of mother-to-child transmission of HIV and syphilis, and the U.S. Centers for Disease Control and Prevention (CDC) has declared that the scale-up of both PMTCT and the prevention of congenital syphilis is a winnable battle. The Americas and Africa are the focus of this strong, dual initiative to end both of these diseases in children.

Today, we have an important opportunity to ensure that syphilis and HIV do not continue to plague women, children, and families around the world. With the availability of treatment to prevent transmission of HIV and syphilis from mother-to-child, ending both diseases in children can soon be a reality.