A Review of the Evidence: The Experience and Impact of Integrating Congenital Syphilis (CS) Elimination and Prevention of Mother to Child HIV Transmission (PMTCT) in Low- and Middle-Income Countries

Background:  Numerous policies and commentaries recommend integrating CS and PMTCT efforts but provide little practical guidance and potential risks and benefits. 

Objectives: To review the literature on integrated PMTCT and CS efforts and identify outstanding research needs.

Methods:  We identified evaluations of interventions linking PMTCT and CS efforts by searching MEDLINE using the keywords “HIV” AND “Syphilis” AND (“Mothers” OR “Pregnancy”) and manually searching conference abstracts and included articles.

Results: Fifteen peer-reviewed articles and fifteen abstracts were included. Five studies assessed introduction of HIV testing with “routine” antenatal testing, including syphilis screening; all showed high HIV test acceptance (87-100%). Five additional studies reported integrating HIV and syphilis counseling and testing protocols was effective.  Three studies assessed introduction of HIV services into primary care; all showed significant increases in antenatal syphilis screening.  A South African study concluded that differences in HIV-free survival of HIV-exposed infants were partially due to differences in quality of antenatal care, measured, in part, by syphilis screening. Two studies evaluated rapid syphilis screening at facilities implementing PMTCT; both reported significant increases in syphilis test uptake (>95%) and treatment (>95%). Studies in Haiti reported that integrating rapid syphilis testing with antenatal HIV testing was cost-effective (US$7-$10/DALY).  Four studies reported that combined syphilis and HIV services improved HIV testing among men.  The remaining eight studies reported benefits and no risks of integrated efforts.

Conclusions: The limited number of evaluations of integrated PMTCT and CS efforts are overwhelmingly positive. PMTCT outcomes may be compromised without quality antenatal services, including syphilis testing.  Syphilis screening drastically lags HIV testing in many areas. PMTCT represents an opportunity to contribute to CS elimination at a relatively low cost.

Implications for Programs, Policy, and Research: Integrating PMTCT and CS increases uptake of these services. Further evaluations on practical aspects of integration would be useful.