Improving Antenatal Syphilis Screening and Treatment Coverage in Public Health Facilities in Kampala, Uganda: A Pre-Implementation and Implementation-Phase Study
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Introduction
Congenital syphilis (CS) remains a major cause of preventable adverse pregnancy outcomes globally, driven by poor antenatal care (ANC) quality, health-system barriers, and untreated maternal infection. In Uganda, syphilis screening and treatment coverage remains below national targets. We evaluated service-delivery impact of a multi-component syphilis testing and treatment intervention implemented across four public health facilities in Kampala, Uganda.
Methods
Guided by the Consolidated Framework for Implementation Research (CFIR), the intervention introduced same-day dual HIV/syphilis antibody testing, on-site treatment, and partner notification at three ANC facilities with women with serological evidence of syphilis or unknown syphilis status and infant follow-up at a tertiary referral hospital. Facility register data were compared between a pre-implementation period (January-December 2020) and the implementation period (June 2021-July 2022) using a modified Poisson regression model adjusting for site.
Results
Syphilis screening among women attending their first ANC visit increased from 55.2% to 88.3% (+33.6%; 95% CI 21.0-46.3; p<0.001); same-day treatment among those testing positive increased from 74% to 100% (difference 26.1; 95% CI 22.4-29.9; p<0.001). Partner testing increased nearly five-fold, from 11.8% to 62% (difference 51.9; 95% CI 46.8-57.0; p<0.001); 23.6% of tested partners were positive. Among the high-risk women, 62% tested positive for syphilis, nearly fifteen-fold higher than the general ANC population, and up to 46% of their infants met criteria for confirmed or possible CS; 41% of whom completed intravenous treatment.
Conclusions
A same-day rapid test-and-treat intervention substantially improved maternal syphilis screening and treatment coverage, even during the COVID-19 pandemic, but partner and infant treatment completion remained major gaps in the care cascade. Structural interventions, including integrated maternal-infant care pathways and targeting of high-risk mothers along with their male partners, are needed to close these gaps and advance progress toward the elimination of mother-to-child transmission of syphilis.
What is already known on this topic
Congenital syphilis (CS) is a major, preventable cause of stillbirth, neonatal death and adverse pregnancy outcomes, driven by missed or late screening, delayed treatment and untreated maternal infection. In Uganda, antenatal syphilis screening and treatment fall below national targets, and it is unclear whether health-system interventions can close these gaps in routine public facilities.
What this study adds
A multi-component intervention (same-day dual HIV/syphilis testing, on-site treatment and partner notification) substantially increased first-visit screening in Kampala public facilities, and all women who tested positive were treated the same day. Partner testing rose several-fold, and many tested partners were positive, revealing a large untreated reservoir. High-risk women had much higher syphilis positivity than the general antenatal population. Nearly half of their infants met criteria for confirmed or possible CS, yet fewer than half of these infants completed intravenous treatment.
How this study might affect research, practice or policy
Same-day test-and-treat is feasible in routine ANC and could be scaled nationally, with targeting of high-risk women and their male partners. Partner and infant treatment completion are the weakest points in the care cascade, so integrated maternal-infant care pathways are needed to advance elimination of mother-to-child transmission. Future research should test strategies to improve partner treatment and infant follow-up and assess the effect on CS incidence and cost-effectiveness.
