POLICY AND PRACTICE
COMMENTARY
Controlling congenital syphilis in the era of HIV/AIDS
Saiqa MullickI,1; Nathalie BroutetII; Ye HtunIII; Marleen TemmermanIV; Francis NdowaII
IProgramme Associate, Population Council, P.O. Box 411744, Craighall, Johannesburg 2024, South Africa (email: smullick@pcjoburg.org.za)
IIMedical Officer, Controlling Sexually Transmitted and Reproductive Tract Infections, Department of Reproductive Health & Research, World Health Organization, Geneva, Switzerland
IIIFormerly Medical Officer, Department of Reproductive Health and Research, World Health Organization, 1211 Geneva 27, Switzerland
IVInternational Centre for Reproductive Health, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
Syphilis is a complex disease with potentially serious outcomes for pregnant women and their infants. The prevalence of syphilis in pregnant women and in children is difficult to evaluate: diagnostic tests have limitations; diagnosis can be complex, particularly in infants; and outcomes of infection in pregnancy are not always easily attributable to syphilis. As a consequence, the monitoring of programmes to prevent maternal and congenital syphilis is often poor or does not occur, and evaluations of programmes often require special studies to be undertaken because information is not readily available. Published information on prevalence lacks homogeneity, continuity and representative coverage, and it cannot be relied upon as a sole source for monitoring or evaluation purposes. Congenital syphilis remains a global public health problem. There is a need for improved surveillance of syphilis and its adverse outcomes. There may be synergies that could be identified for the mutual benefit of both antenatal screening programmes and strategies to prevent mother-tochild transmission.
Despite the long-standing existence of policies for the universal screening and treatment of women in pregnancy there remain challenges with both the diagnosis (1) of the disease and implementation of the programmes (2). Furthermore, if untreated or inadequately treated women progress to delivery, the nonspecific nature of the symptoms of congenital syphilis and the poor diagnostic tools available make diagnosis difficult (1).
Problems with data
The lack of suitable diagnostic tests has resulted in limited comparability of data and has also limited the interpretation of data. To add to this, data on the prevalence of syphilis in pregnancy have been biased towards urban populations who may have better access to health care. In addition, the data lack geographical coverage, are often published long after collection, and estimates are highly variable. In many cases, local data have been generalized to represent national prevalence figures. Information on trends is often not available at all. This means that the quality of information obtained from the monitoring and evaluation of antenatal screening programmes for syphilis is poor. Basic information on the proportion of women tested, found positive and treated is not readily available, and often case studies have had to be conducted to evaluate programmes (2). The lack of convincing evidence of antenatal syphilis as a public health problem may be one of the reasons that Saloojee et al. state that "congenital syphilis still lacks the high priority status it deserves" (1). This disease, which can be treated with inexpensive drugs, continues to cause significant morbidity and mortality (1).
Lessons learnt from HIV programmes
In contrast, the high level of politicization and priority given to human immunodeficiency virus (HIV) has led to the rapid roll-out of vertical programmes to prevent mother-to-child transmission; these programmes are much more complex to implement than are syphilis screening and treatment programmes. What lessons can be learnt from the advent of HIV and the implementation of programmes to prevent mother-to-child transmission?
Programmes to prevent the transmission of HIV from mother to child have been implemented rapidly, and they have brought significant resources into antenatal care. These programmes already have effective diagnostic tests for adults and infants (including rapid tests that can be used in primary care), counselling materials aimed at preventing HIV infection, guidelines and protocols for the care of mothers and infants, and routine surveillance has been implemented in many parts of the world.
The parallels between these two sexually transmitted infections HIV and syphilis are striking. Both syphilis and HIV are important public health problems that share many adverse pregnancy outcomes (310). There is a need to use resources effectively to reduce maternal and infant morbidity and mortality. There are opportunities to provide counselling, screening and surveillance for both HIV and syphilis together, and these should not be missed. In addition, programmes to prevent HIV could provide the catalyst required to focus not only on congenital syphilis but they could also be used to prevent other diseases, such as hepatitis B and neonatal tetanus.
The need for better tests for syphilis, for data on effective alternative drug regimens, and the need to improve access to testing through the use of on-site tests remain challenges, and progress has been slow. Perhaps these issues could be addressed if programmes to prevent syphilis were linked with programmes to prevent mother-to-child transmission of HIV; these combined programmes could build on the extraordinary political will that HIV prevention programmes have benefited from.
Screening for syphilis in pregnancy has achieved a relatively high level of integration into antenatal care programmes and high, although not universal, coverage of testing. However, programmes to prevent the transmission of HIV from mother to child are new, work vertically, and are still struggling with the need to improve the uptake of testing. In some countries, such as South Africa, syphilis testing has been included as part of annual antenatal HIV surveillance and has given researchers representative and current data on trends in syphilis (11). It may one day be possible for a rapid finger-prick test for both HIV and syphilis to be used during an antenatal appointment.
Programme managers and policy-makers need to identify synergies between programmes, evaluate the feasibility and cost-effectiveness of integrated approaches, and ensure that the lessons learnt are fed into the development of antenatal care policies and guidelines for the mutual benefit of both syphilis screening and programmes to prevent mother-to-child transmission. The potential positive public health impact of syphilis screening and treatment programmes to prevent mother-to-child transmission of HIV is huge and must not be ignored. 
References
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11. South African Department of Health. National reports on annual antenatal HIV and syphilis surveillance 19902002. Pretoria: South African Department of Health; 2002.
(Submitted: 1 May 2004 - Accepted: 3 May 2004)
1 Correspondence should be sent to this author.