Syphilis is inexpensive to detect and treat, making it a possible “easy win” when it comes to cost, feasibility and speed of scale-up, according to the WHO. However, mother-to-child transmission of syphilis, a devastating and preventable silent threat that causes more child deaths globally than HIV, often goes overlooked. Many countries are experiencing rising congenital syphilis epidemics, including the US, which has seen a ten-fold increase over the past decade. The global syphilis/HIV screening and treatment disparity is particularly alarming considering that women with HIV and syphilis co-infection are 2.5 times more likely to transmit HIV to their children.
Addressing a missed opportunity
Effective diagnosis and treatment of syphilis in pregnant women can significantly reduce the risk of mother-to-child transmission and protect newborns. Despite the availability of simple and affordable solutions, maternal syphilis remains neglected. This results in a global tally of 200,000 stillbirths and neonatal deaths annually, and more than 100,000 cases of lifelong health complications including blindness, neurological issues, and hearing loss.
In September 2021, Evidence Action, a nonprofit dedicated to scaling up evidence-based interventions, collaborated with the Liberian National AIDS and STI Control Program to launch the Syphilis-Free Start program. This initiative aims to address the critical gap in syphilis screening and treatment by integrating dual HIV/syphilis rapid tests into existing antenatal care services.
According to Liberia’s DHIS2 facility-reported data, over 95% of pregnant women attending at least one antenatal care visit. While 80% were screened for HIV at the time, less than 8% were tested for syphilis. This is despite a low-cost test that can screen for syphilis at the same time as HIV – with no additional burden on the part of expectant mothers.
The Syphilis-Free Start program supports policy development, program management, and coordination for delivery of dual tests and drugs in Liberia. Additional support included supply chain management improvements, enhanced data collection and monitoring systems, and assistance with healthcare provider training and supervision. The partnership has also focused on identifying sustainable funding sources to help ensure the program’s long-term viability.
Liberia’s game-changing program
Monitoring and evaluation data, which was presented at the 2024 International AIDS Conference, showcases remarkable, accelerated success in Liberia. From January to August 2023, syphilis screening rates skyrocketed from 8% to 75% across hundreds of facilities nationwide. Of the 2.7% of women who tested positive, 88% received benzathine penicillin treatment. By next year, the country is on track to match the 80% HIV screening rate, proving how quickly dual testing has been integrated into healthcare programs. A recent survey revealed that 82% of facilities had dual tests in stock, 93% of providers knew proper testing procedures, and 99% of pregnant women accepted syphilis testing.
Over 320,000 pregnant women have been screened for syphilis, leading to treatment for over 5,400 women and preventing over 2,300 adverse birth outcomes, including saving over 1,300 lives. By integrating dual testing into routine prenatal care, Liberia has demonstrated the power of leveraging existing healthcare infrastructure to address multiple health challenges simultaneously. The results show how practical, evidence-based solutions can be transformative in improving health outcomes cost-effectively and at scale.
Blueprint for prenatal care
These findings show that dual tests are very effective in prenatal care and have been quickly adopted by both healthcare providers and pregnant women. Liberia’s success illustrates the importance of investing in training local health teams, as this helps them develop the skills necessary to implement and maintain new methods. By conducting nationwide testing, local healthcare teams have transformed prenatal care, providing expectant mothers with essential health information and timely treatments that greatly improve outcomes for both mothers and their babies.
The success of Liberia’s national rollout of dual HIV/syphilis rapid tests serves as a model for other countries seeking to address congenital syphilis. Strategic allocation of resources, particularly to county and district health teams, has been crucial in ensuring high-quality, comprehensive services. By building on existing healthcare structures, the program reduced redundant capacity building efforts.
Broad adoption of this practical, evidence-based approach can help make significant strides in preventing syphilis transmission and improving health outcomes for mothers and newborns. By integrating dual testing into antenatal care settings, countries can protect countless newborns from preventable diseases and significantly improve maternal and child health outcomes.
About the authors:
Dr. Jonathan Flomo is Program Manager for the National AIDS & STI Control Program in Liberia.
Emilie Efronson is Evidence Action’s country director in Liberia.
Competing interests: None
Handling Editor: Neha Faruqui