National Advisory Committee on Sexually Transmitted and Blood-Borne Infections statement: Syphilis screening recommendations for non-pregnant adults and adolescents
On this page
- Preamble
- Executive summary
- Introduction
- Methods
- Recommendations
- Dissemination, implementation, monitoring and evaluation
- Research priorities and implications
- List of abbreviations
- Acknowledgements
- Appendices
- References
Preamble
The National Advisory Committee on Sexually Transmitted and Blood-Borne Infections (NAC-STBBI) is an External Advisory Body that provides the Public Health Agency of Canada (PHAC) with ongoing scientific and public health advice and recommendations for the development of sexually transmitted and blood-borne infections (STBBI) guidance, in support of its mandate to prevent and control infectious diseases in Canada.
PHAC acknowledges that the advice and recommendations in this statement are based upon the best available scientific knowledge at the time of writing and is disseminating this document for information purposes to primary care providers and public health professionals. The NAC-STBBI statement may also assist policy makers or serve as the basis for adaptation by other guideline developers. NAC-STBBI members and liaison members conduct themselves within the context of PHAC's Policy on Conflict of Interest, including yearly declaration of interests and affiliations.
The recommendations in this statement do not supersede any provincial or territorial legislative, regulatory, policy and practice requirements or professional guidelines that govern the practice of health professionals in their respective jurisdictions, whose recommendations may differ due to local epidemiology or context. The recommendations in this statement may not reflect all the situations that may arise in professional practice and are not intended as a substitute for clinical judgment in consideration of individual circumstances and available resources.
Executive summary
Background
Syphilis is caused by the bacterium Treponema pallidum, and can cause serious health problems if left untreated, and in extreme cases, can result in severe complications like dementia or death. Syphilis progresses through stages with varying symptoms, including primary, secondary, latent, and tertiary stages. The World Health Organization (WHO) estimated 7.1 million new syphilis infections globally in 2020. Infectious (primary, secondary, and early latent stages) and congenital syphilis are also on the rise in Canada; all jurisdictions have declared increased rates of infection. The national rate of infectious syphilis increased from 5.1 per 100,000 population in 2011 to 24.7 per 100,000 in 2020.
Rationale for the guidelines
Sustained and significant increases in Canadian rates of syphilis prompted the National Advisory Committee on Sexually Transmitted and Blood-Borne Infections (NAC-STBBI) to prioritize the review and update of the Public Health Agency of Canada's (PHAC) existing screening recommendation for non-pregnant adults and adolescents.
Objectives
The objectives of this work are:
- to assess the evidence for syphilis screening in non-pregnant adults and adolescents to inform the development of evidence-based guidance; and
- to update, as required, the existing syphilis screening recommendation.
Methods
A working group composed of NAC-STBBI members was formed at the beginning of the project to undertake this work. These guidelines were developed following the methods outlined in the 2014 WHO handbookFootnote 1 for STI experts, clinicians, researchers, and program managers. The research question was "what is the clinical utility of syphilis screening using risk-based approaches versus population-wide approaches for adolescents and adults"? A methodologist and a team of systematic reviewers from the STBBI Guidance for Health Professionals team at the PHAC independently conducted a systematic review, an environmental scan of previously published syphilis screening guidelines and commissioned a rapid review in 2022 by the Canadian Agency for Drugs and Technologies in Health (CADTH)Footnote 2. The evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE)Footnote 3Footnote 4 approach and presented to the working group to inform development of the recommendations. Conflicts of interest were managed according to PHAC guidelines, and no conflicts were declared before the recommendations were discussed and finalized. Research implications were also developed by the working group. This statement has been endorsed by PHAC.
Summary recommendations
This statement provides two screening recommendations for adults and adolescents. Recommendation 1 includes syphilis screening for sexually active adults and adolescents and recommendation 2 includes syphilis screening for high prevalence groups/communities (such as gay, bisexual and other men who have sex with men; people living with HIV; people who are incarcerated; people who access addiction services; certain Indigenous or First Nation communities). Table 1 shows the summarized recommendations.
Recommendation 1: Syphilis screening for sexually active, non-pregnant adults and adolescents
The NAC-STBBI recommends syphilis screening in all sexually active persons with a new or multiple partners, and/or upon request of the individual.
The NAC-STBBI recommends screening every three (3) to six (6) months in individuals with multiple partners.
Strength of recommendation and quality of evidence:
Strong recommendation, moderate certainty of evidence
Recommendation 2: Syphilis screening for high prevalence groups/communities
The NAC-STBBI recommends that targeted "opt-out" screening programs should be considered as frequently as every three (3) months* when serving population groups and/or communities** experiencing high prevalence of syphilis (and other STBBI), such as:
- Gay, bisexual and other men who have sex with men;
- People living with HIV;
- Person who is or has been incarcerated;
- People who use substances and/or access addiction services;
- Some Indigenous communities
Strength of recommendation and quality of evidence:
Strong recommendation, moderate certainty of evidence
Notes:
* Consider aligning screening with other health services ("opportunistic screening") for individuals living with HIV and other individuals at increased risk accessing care services. Opportunistic screening is defined as offering screening when an individual is accessing non-emergency health services and has not undergone recent STBBI testing.
** Consider local epidemiology when determining which groups/communities to target, and for a specific individual, travel history and patient risk factors need to be considered.
Introduction
This statement focuses on syphilis screening for sexually active non-pregnant adults and adolescents. For the purpose of these recommendations, screening is defined as testing asymptomatic individuals. Sustained and significant increases in Canadian rates of syphilis prompted the National Advisory Committee on Sexually Transmitted and Blood-Borne Infections (NAC-STBBI) to prioritize the review and update, or validation, of the Public Health Agency of Canada's (PHAC) existing screening recommendation.
Public health importance in Canada
Syphilis is a sexually transmitted infection (STI) caused by the organism Treponema pallidum subspecies pallidum and can have significant morbidity if left untreated. In 2020, the World Health Organization (WHO) estimated that 7.1 million new syphilis infections occurred globally.Footnote 5 Infectious (primary, secondary, and early latent stages) and congenital syphilis are on the rise in Canada.Footnote 6 Other high-income countries, such as the United States of America (USA), Australia and the United Kingdom (UK) have reported similar trends.Footnote 7
Syphilis is a notifiable infection in Canada and cases are reported to the Canadian Notifiable Disease Surveillance System (CNDSS). It is the third most commonly reported STI in Canada, but over the past decade, rates have increased by 393.1%; compared to 33.1% and 181.7% increase in rates for chlamydia and gonorrhea respectively. The national rate of infectious syphilis increased from 5.1 per 100,000 population in 2011 to 24.7 per 100,000 in 2020. While rates have historically been higher in males than in females, reported rates of infectious syphilis have been increasing faster among females. Between 2010 and 2019, the female rate increased by 1,446.8% compared to a 287.9% increase in males. During this time, the male to female ratio has gone from 10.3:1.0 to 2.6:1.0; however, in 2019 males still accounted for 71.7% of all infectious syphilis cases.Footnote 7
As of January 2020, all jurisdictions have declared increased rates of infection. The majority of cases continue to be among gay, bisexual and other men who have sex with men (gbMSM), but an increase has been reported in the heterosexual population with the most significant increase being in women of childbearing age leading to increases in rates of congenital syphilis.Footnote 6Footnote 8 The outbreaks have been reported to be associated with behavioural risks such as anonymous or multiple partners, condomless sex and substance use (e.g., methamphetamine),Footnote 9 and also linked to social determinants of health (race, poverty, access to health services, and housing instability).
Screening and diagnostic testing
Syphilis is diagnosed using serology: some tests detect non-treponemal antibodies (non-treponemal tests, or NTT), and others detect treponemal antibodies (treponemal tests, or TT). Screening relies on a testing algorithm (with a combination of both types of serologic tests) for the diagnosis of syphilis. The "traditional algorithm" uses an initial NTT, followed by confirmatory treponemal testing. The "reverse algorithm" uses an initial TT, followed by confirmatory NTT. In the reverse algorithm, an additional TT may be done in some cases. Most provinces and territories in Canada use the reverse algorithm.
NTTs licensed for use in Canada include the rapid plasma reagin (RPR) and Venereal Disease Research Laboratory (VDRL). The VDRL is used primarily for the testing of cerebral spinal fluid (CSF).Footnote 10 All NTTs have similar performance and their sensitivity in primary syphilis is approximately 75%.Footnote 11 Acute false-positive results may be attributed to febrile illness, immunization, and pregnancy; chronic false-positives may be attributed to hepatitis C infection, connective tissue disease, intravenous drug use, malignancy, malaria, Chagas disease, tuberculosis, and leprosy.Footnote 1Footnote 12Footnote 13 False-positive results can occur in a small portion of the population and may be caused by other spirochetal infections as well as the infections/conditions that can cause false-positive NTT results.Footnote 14 The positive predictive value (PPV) of a syphilis test result is dependent on the prevalence of the infection in the population being tested.Footnote 15 A quantitative RPR is used to help stage syphilis infection, monitor response to treatment or detect re-infection.Footnote 10Footnote 16 An analysis of traditional and reverse algorithms found that outcomes such as the number of cases detected, adverse events prevented, and overtreatment rates would be similar.Footnote 17 A cross-sectional study found that the traditional algorithm had the highest negative likelihood ratio (0.24), a missed diagnosis rate of 24.2%, and only 75.8% sensitivity. However, the reverse algorithm had a higher diagnostic efficacy compared to the traditional algorithm with reported sensitivity, specificity, and accuracy all superior to 99%.Footnote 18
Syphilis treatment
The efficacy of treatment for syphilis has been well established and therefore, was not included in this recommendation report. The preferred treatment for infectious syphilis (primary, secondary or early latent) in non-pregnant adults is long-acting benzathine penicillin G (2.4 million units IM as a single dose).Footnote 19 This treatment has been shown to have a success rate of 90% to 100%.Footnote 20
Purpose/Rationale for new recommendations and approach to the updates of existing syphilis screening guidelines for adults and adolescents
An update to the syphilis screening recommendation for adults and adolescents was prioritized at the October 2019 National Advisory Committee on Sexually Transmitted and Blood-Borne Infections (NAC-STBBI) face-to-face meeting and work started on the project immediately with the formation of a working group and completion of a scoping exercise. The research question was "what is the clinical utility of syphilis screening using risk-based approaches versus population-wide approaches for adolescents and adults"? Based on the results of the 2019 scoping exercise and a review completed by the Canadian Agency for Drugs and Technologies in Health (CADTH, July 2022)Footnote 2 the working group determined that the existing syphilis screening recommendation remains valid (i.e., screening is recommended for anyone presenting with risk factors for syphilis to prevent complications, transmission and reinfection). This was further confirmed by the US Preventive Services Task Force's (USPSTF) review and validation of their 2016 syphilis screening recommendation.Footnote 21 The systematic review (SR) conducted by the USPSTF identified one relevant study examining the effectiveness of syphilis screening in reducing complications of the disease (Chow et al, 2017)Footnote 22; this study had been identified in the 2019 scoping exercise. Due to project delays resulting from the COVID pandemic and competing priorities, the working group decided to repeat the search performed as part of the 2019 scoping exercise with the goal of identifying new evidence that may have been published in the interim. This search was completed in January 2023 and used the same research question and criteria identified in 2019.
This document outlines the evidence collected and assessed by the working group to inform the NAC-STBBI's validation of the existing syphilis screening recommendation. The statement also acknowledges the ongoing outbreaks of infectious and congenital syphilis in jurisdictions across Canada and highlights the importance of making regular screening of sexually active adults and adolescents an essential part of routine medical care.
Objectives
The objectives of these guidelines are:
- to update the syphilis screening evidence on non-pregnant adults and adolescents, and to provide evidence-based guidance on syphilis screening for non-pregnant adults and adolescents; and
- to determine whether the existing syphilis screening recommendation remains valid.
Target audience
This document is intended to be used by primary care providers (i.e., nurses, physicians), provincial/territorial sexual health programs, local public health agencies, sexual health clinics, professionals' association, and researchers.
Methods
Working group
These syphilis screening recommendations were developed following the methods outlined in the 2014 editionFootnote 1 of the WHO handbook for guideline development. The NAC-STBBI established a working group (WG) for guideline development comprising four (4) members of the NAC-STBBI and supported by the secretariat. The WG included STI experts, clinicians, researchers, and programme managers (see Acknowledgements for member lists). The WG identified and agreed on the key population, intervention, comparator, outcome (PICO) questions that formed the basis for the SR and the recommendations. Following this meeting, the WG members prioritized outcomes according to clinical relevance and importance. The WG participated in meetings and teleconferences to prioritize the questions to be addressed, discuss the evidence reviews and finalize the recommendations for presentation to the NAC-STBBI for final approval.
A methodologist and a team of systematic reviewers from the PHAC STBBI Guidance for Health Professionals Section (PHAC SR team) independently conducted a SR update of major studies on syphilis screening and scanned previously published syphilis screening guidelines using Google, the websites of international organizations, provincial/territorial organizations, and a SR in 2022 by CADTHFootnote 2. PHAC SR team included studies published between January 2010 and January 2023 on syphilis screening, patient values and preferences, equity, feasibility, acceptability, economic analyses, and health technology assessments. The evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE)Footnote 3 approach and presented to the WG. Conflicts of interest were managed according to PHAC guidelines and declared before the recommendations were discussed and finalized (see section 2.5 Management of conflict of interests). Research implications were also developed by the WG.
Questions and outcomes
In October 2019 the NAC-STBBI formulated the research question "what is the clinical utility of syphilis screening using risk-based approaches versus population-wide approaches for adolescents and adults"? The WG identified the key PICO question that formed the basis for the SR and the recommendations as follows:
- Population: Non-pregnant adolescents and adults
- Intervention: Risk-based screening (based on clinician assessment and opinion) for syphilis with serologic testing using traditional or reverse sequence algorithms
- Comparator: Population-wide screening, at any time interval (e.g., 3 months, 6 months, 12 months), for syphilis with serologic testing using traditional or reverse sequence algorithms
- Outcomes: Clinical utility (e.g., incidence of infectious/non-infectious syphilis, neurosyphilis, or congenital syphilis), proportion of participants who receive unnecessary or inadequate treatment (e.g., due to false-positive or false-negative test results), participant acceptability, safety (e.g., adverse events, psychosocial harms)
- Study designs: Health technology assessments, systematic reviews, randomized controlled trials, non-randomized studies
Reviews of the evidence
A hierarchical approach was used to search for evidence to update the recommendations. The environmental scan on existing syphilis screening recommendations of different organizations was conducted by PHAC SR team. The PHAC SR team also searched for SR, then primary studies when no SR were available. Evidence for outcomes, patient values and preferences, resources, acceptability, equity and feasibility were reviewed from published and unpublished literature. Comprehensive searches for previously conducted SR, randomized controlled trials and non-randomized studies were performed from September 2019 to January 2023 (Appendix 1). Additional searches were conducted to identify studies on patient values and preferences (e.g., qualitative research designs) and resources (e.g., cost of intervention, cost-benefits and cost-effectiveness studies). Two members (HB, SG) of the Systematic Review Team screened studies, extracted and analysed the data, and assessed the quality/certainty of the evidence using the GRADE approach.Footnote 3
The certainty of the evidence was assessed at four levels:Footnote 3Footnote 4
- High: We are very confident that the true effect lies close to that of the estimate of the effect.
- Moderate: We are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
- Low: Our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect.
- Very low: We have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of effect.
Details of evidence from different sources/types and evidence to decision (EtD) judgements are available in Appendix 2 and Appendix 3. A total of 11 guidelines on syphilis screening were published between 2014 and January 2023 (Appendix 4).Footnote 23Footnote 24Footnote 25Footnote 26Footnote 27Footnote 28Footnote 29Footnote 30Footnote 31Footnote 32Footnote 33 The most common screening intervals were every three to six months. The Appraisal of Guidelines Research and Evaluation (AGREE) II instrumentFootnote 34 was used to evaluate the methodological quality of the identified guidelines.
From the literature search with the Health Canada Librarian in 2019, two systematic reviewsFootnote 35Footnote 36 were identified and included. The updated literature search since November 6, 2019 to January 17, 2023, with the Health Canada librarian resulted in 220 records. After removal of duplicates, there was a total of 176 articles. WG members shared 4 articles and 1 article was found in an article reference list. After title and abstract screening, 31 records were included for full text screening. All 31 full text records were retrieved and a final total of 9 records were included (Appendix 3). There were no published SR on the effectiveness of risk-based screening or the comparison of risk-based screening with interval screening. However, one recent randomized control trial (RCT) was published.Footnote 37
There were two more updated SR findings included here. Updated SRs were from CADTHFootnote 2 and USPSTF.Footnote 21 Of the 1,032 search records found by CADTH, 31 potentially relevant articles were included for full text screening. Only one overview of reviews by Fernane & FowlerFootnote 38 met the pre-specified inclusion criteria. It was written by Canadian authors, based on a research question focusing on screening adult patients (16 years of age and older) at low risk for syphilis.Footnote 38 The updated search by the USPSTF included one study by Chow et al.Footnote 22 on screening effectiveness from 2,780 abstracts and 40 full-text articles. In addition, 10 studies were included from the librarian's search, hand search, and suggested citations from the WG members on "Risk-based screening vs. interval screening", "Comparison of annual, three month, and six month screening intervals", "Syphilis screening as part of HIV viral load testing", and "Opt-in vs. Opt-out approach".
Making recommendations
Between March 2023 to May 2023, the WG developed the recommendations in three meetings. The four members were present and reviewed the evidence to decision table presented by PHAC SR team. They also reviewed the evidence and additional references from their experiences and practice. During formulation of the recommendations, the WG considered and discussed both the desirable and undesirable outcomes of screening interventions, the values and preferences, feasibility, equity, resources, cost and cost effectiveness of the interventions. They also discussed the implementation of the recommendations and research gaps. The discussion was facilitated by a methodologist with the goal of reaching consensus across the WG.
The recommendations having been finalized by the WG were presented to the NAC-STBBI on June 29, 2023. The Committee reviewed the evidence and the working group's rationale for the recommendation. Consensus was obtained to approve the recommendations and send them to PHAC for endorsement. PHAC approval was provided by the Vice-President of the Infectious Diseases and Vaccination Programs Branch on August 24, 2023. The recommendations were subsequently added to PHAC's Syphilis Guide within the STBBI Guides for Health Professionals.
According to the GRADE approach, the strength of both recommendations were rated as moderate. Moderate recommendations are worded as "the NAC-STBBI guideline recommends....". The implication of moderate recommendation are:
- For patients: "most individuals in this situation would want the recommended course of action, and only a small proportion would not. Formal decision aids are not likely to be needed to help individuals make decisions consistent with their values and preferences".
- For clinicians: "most individuals should receive the recommended course of action. Adherence to this recommendation, according to the guidelines, could be used as a quality criterion or performance indicator"
- For policy makers: "the recommendation can be adopted as policy in most situations".
Management of conflicts of interest
Members of the NAC-STBBI are required to identify affiliations and conflicts of interest on an annual basis. The Secretariat reviews member affiliations to ensure there are no conflict of interests. Committee members are also asked to identify any new affiliations at the start of every meeting and teleconference. No conflicts were identified by the working group and NAC-STBBI members that would prevent them from participating in the discussion and voting on the committee recommendation.
Recommendations
Recommendations developed by the NAC-STBBI are made at the population level. It is important to note that they may not apply to specific individuals within those groups, particularly as it relates to groups and communities who may have higher rates of syphilis when compared to the general public. It is always essential to consider each case on an individual basis in the context of the risk behaviours and epidemiological factors outlined in the recommendation.
Syphilis screening for sexually active, non-pregnant adults and adolescents
The NAC-STBBI recommends syphilis screening in all sexually active persons with a new or multiple partners, and/or upon request of the individual. The NAC-STBBI recommends screening every three (3) to six (6) months in individuals with multiple partners.
(strong recommendation, moderate certainty of evidence)
Syphilis screening for high prevalence groups and communities
The NAC-STBBI recommends that targeted "opt-out" screening programs should be considered as frequently as every three (3) months* when serving population groups and/or communities** experiencing high prevalence of syphilis (and other STBBI), such as:
- Gay, bisexual and other men who have sex with men;
- People living with HIV;
- Person who is or has been incarcerated;
- People who use substances and/or access addiction services; and/or
- Some Indigenous communities
(strong recommendation, moderate certainty of evidence)
Note:
* Consider aligning screening with other health services ("opportunistic screening") for individuals living with HIV and other individuals at increased risk accessing care services. Opportunistic screening is defined as offering screening when an individual is accessing non-emergency health services and has not undergone recent STBBI testing.
** Consider local epidemiology when determining which groups/communities to target, and for a specific individual, travel history and patient risk factors need to be considered.
Factors associated with Syphilis infectionsFootnote 39Footnote 40Footnote 41Footnote 42
Behaviours/Activities
- Barrierless sexual activity involving contact with oral, genital or anal mucosa
- Multiple sexual partners
- Sexual contact with a known case of syphilis or other STBBI
- Substance use, including chemsex
Epidemiological
- Previous syphilis infection or other STBBI
- HIV infection
- High prevalence area/groups
- Housing instability/street involvement
Summary of the evidence
The certainty of the evidence for the screening for syphilis is moderate. The evidence review included three SRFootnote 35Footnote 36Footnote 38, and 11 studies: one 1 randomisedFootnote 37 and 10 non-randomized studies (including three cohort studiesFootnote 43Footnote 44Footnote 45, seven retrospective chart review, and cross-sectional studies)Footnote 22Footnote 46Footnote 47Footnote 48Footnote 49Footnote 50Footnote 51 on syphilis screening. In addition, there was an environmental scan of 11 guidelines on syphilis screening published between 2014 and January 2023.Footnote 23Footnote 24Footnote 25Footnote 26Footnote 27Footnote 28Footnote 29Footnote 30Footnote 31Footnote 32Footnote 33 All organizations recommend risk-based screening. Of the included guidelines, four organizations recommend screening for those at increased risk of infection at varying intervals – from annual screening to up to four times a year depending on risk behaviours. The most common intervals were every three to six months.
From the PHAC search results, one RCTFootnote 37 reported that in risk-based screening versus interval screening, the average annual number of syphilis tests per individual increased from 0.53 to 2.02 tests and the time-adjusted rate ratio, 2.03 (1.85–2.22).Footnote 37 With intervention, the annualized proportion of newly identified early syphilis increased from 0.009 to 0.032 and the odds of annual screening increased nearly 4-fold and the mean number of tests per year increased 2-fold.Footnote 37 Comparison of annual, 3-month, and 6-month screening intervals during routine serology taken as part of HIV monitoring resulted in a marked increase in the proportion of HIV-positive MSM diagnosed with asymptomatic syphilis.Footnote 22Footnote 43Footnote 46Footnote 47Footnote 51 Additional studies using modeling projected similar results.Footnote 52Footnote 53 These studies showed that increasing the frequency of syphilis screening to every 3 months was the most effective strategy for reducing infectious syphilis cases. Targeted screening was more effective than universal screening.
Enhanced screening of MSM with prior syphilis may efficiently reduce transmission, especially when identification of high-risk men via self-reported partner numbers or high-frequency screening is difficult to achieve. A 2010 study examining syphilis screening as part of HIV viral load testing found same day tests were highest in clinics with the opt-out strategy (87%; range: 84% - 91%), compared with opt-in (74%, p=0.121), and risk-based (22%; range: 20% - 24%, p<0.01).Footnote 44 Over 50.8% of incident syphilis cases were asymptomatic and were only identified through routine screening.Footnote 44 One observational study compared three strategies: risk-based screening, opt-in, and opt-out approach for HIV-positive gbMSM.Footnote 45 The opt-in approach was defined as offering syphilis testing to HIV-positive gbMSM during HIV viral load testing (which was recommended every three to six months) and testing those who agree; with opt-out screening, syphilis testing was done automatically unless the patient declined. Risk-based screening involved assessing risk and then offering a syphilis test accordingly. The authors found that the opt-in and opt-out approaches led to increased uptake of syphilis testing. Risk-based testing resulted in lower testing frequencies and potentially missed opportunities.Footnote 45 Reekie and othersFootnote 48 also examined the uptakes of opt-out vs opt-in screenings using a cross-sectional retrospective review in a remand (pretrial, presentence, or detention) facility in Alberta, Canada, between March 1, 2018, and February 28, 2020 among individuals ≤ 35 years. The same definitions for opt-in and opt-out were used in both instances. They found that opt-out screened more admissions among ≤ 25 years, even though total opt-out uptake was low (n=902/2906; 31.2%). Opt-out screening resulted in high levels of treatment completion (93.7%) while also capturing a high proportion (52.6%) of asymptomatic cases. Opt-in achieved significantly high positivity rates for syphilis. Opt-out screening resulted in higher STI positivity rates compare to other STIs (CT, GN) (29.5%), however, lower than opt-in screening (35.8%). However, opt-out screening diagnosed higher new syphilis cases (case-finding rate). Opt-out: 7.3% (150/2053 tests); opt-in 7.1% (150/1995 tests). Both found similar HIV positivity rates. There were no differences in the proportion of positive test results between testing programs across gender, age categories, or over time (p = 0.120).Footnote 48
Another study in USA, examined the prevalence of syphilis in the population to evaluate the routine, opt-out syphilis screening model.Footnote 49 They found a large number of missing cases while targeting screening to only those deemed "high-risk" by behavior or symptoms. Little more than 50% (7 of 13) of those testing positive did not present with complaints. Venegas et alFootnote 50 also found Opt-out screening using technology and risk factor identified 27 of the 59 patients with reactive syphilis tests considered newly diagnosed syphilis infection (no history of syphilis infection reported in the system) and require follow-up treatment.
A qualitative study reported on patient values and preferences, feasibility, and equity for syphilis screening in males (n=21) accessing HIV care.Footnote 54 A majority of males were in favour of routinely testing for syphilis as part of conventional HIV care. The routine method was thought to have a de-stigmatizing effect on syphilis testing. From the patient's point of view, HIV care clinics are easy locations to be tested for syphilis. Reekie et al reportedFootnote 48 the feasibility of opt-out screening in a short-term correctional facility for individuals ≤35 years in Alberta, Canada. They reported that opt-out screening at admission is feasible and can improve STI testing in high-risk individuals experiencing incarceration in Canada.Footnote 48
There was no other study on patient values and preferences, feasibility, and equity for syphilis screening in non-pregnant adults and adolescents in Canadian settings. Most studies focused on the acceptability and feasibility of treatment and point-of-care testing, which are not within the scope of the review. The WG also recognizes that some population groups face higher rates of stigma and discrimination, creating barriers to accessing care and unequal access to care services across jurisdictions and public health agencies (e.g., rural versus urban), as resource levels vary across provinces and territories. They considered and agreed that certain population groups have higher rates of mistrust in health care services making them less likely to seek care and previous negative experience with the health care system may result in individuals avoiding care.
Four cost-effectiveness modelling studies examining either risk-based screening or interval screening were included.Footnote 55Footnote 56Footnote 57Footnote 58 The modeling studies were based in Canada, the US, Germany, and Australia. The studies did not directly compare the cost-effectiveness of risk-based screening to interval screening for syphilis. Studies also focused primarily on high risk population groups, such as gbMSM, people living with HIV and sex workers. Generally, targeted screening at 3 or 6 month intervals were considered more cost-effective compared to universal annual screening in these populations.Footnote 55Footnote 56Footnote 57Footnote 58
Overall, the WG therefore agreed that syphilis screening should be offered to all sexually active persons with a new or multiple partners, and/or upon request of the individual. They agreed that screening should be offered every three (3) to six (6) months in individuals with multiple partners. They also agreed that targeted "opt-out" screening programs should be considered as frequently as every three (3) months for health services serving population groups and/or communities experiencing a high prevalence of syphilis (and other STBBI).
See Appendix 2 for the evidence to decision judgements, and Appendix 3 for the characteristics of included studies and summary of findings, including evidence profiles.
Dissemination, implementation, monitoring and evaluation
Dissemination
These recommendations have been incorporated within the Screening and Diagnostic Testing section of PHAC's Syphilis Guide. An advance copy of the statement will be provided to the provinces and territories via the Communicable and Infectious Diseases Steering Committee and the Council of Chief Medical Officers of Health.
Implementation
Canada is experiencing tremendous strain on the health care system due to a lack of trained professionals and extremely limited primary care capacity.Footnote 59 These challenges have been exacerbated by the COVID-19 pandemic. Syphilis and other STBBI screening are often considered based on individual risk factors for the person seeking care. Nurses and physicians must discuss these factors with the individual to determine their sexual health history and to identify the appropriate screening tests required. Due to stigma and prior negative experience with the healthcare system, individuals may not be fully transparent when discussing their sexual health, and often underestimate their own personal risk. Health care providers should consider implementing an "opt-out" approach to screening, removing the need for an in-depth discussion on the person's sexual history. These programs have experienced greater success compared to "opt-in" programs in certain settings. Applying opt-out programs normalize STBBI screening and can help reduce stigma related to sexual health.
Health care providers should consider offering screening when patients are accessing other non-emergency health care services. In some circumstances, such as with individuals living with HIV, STBBI screening is considered part of routine care. These patients will often undergo regular blood testing to ensure they are responding to treatment and maintaining a suppressed viral load. This provides an opportunity for screening for other STBBI. For individuals with limited or infrequent access to health services, health care providers should practice opportunistic screening for STBBI. Regardless of whether the individual is there for STBBI related care, health care providers should take the opportunity to determine when they last underwent STBBI screening and offer it if appropriate. For individuals who engage in behaviours that increase their risk level (such as multiple partners) or are part of a high prevalence population (for example people who use substances), screening can occur as frequently as every three months.
Many individuals are apprehensive when discussing factors associated with STBBI due to fears of potential or past stigma and/or discrimination. When individuals experience stigma and discrimination with the health care system, it can make them hesitant to seek care and share information related to factors associated with STBBI. Further normalizing and standardizing the offering of STBBI screening can help mitigate the perception of stigma.
Congenital Syphilis
This statement does not address prenatal screening, though a recommendation is available in the Syphilis Guide. It is important to be aware of the increasing rates of congenital syphilis across Canada. There were 96 cases of confirmed congenital syphilis in 2021, compared to only 7 cases in 2017, representing an increase of 1271%. Additionally, cases of infectious syphilis among females increased by 720% over that span.Footnote 60 Healthcare providers should be mindful of these trends when providing care to females of childbearing age (approximately ages 15 to 45). Care providers are reminded that universal screening is recommended in all pregnant people.
Monitoring and evaluation
PHAC and the NAC-STBBI continue to monitor syphilis activity in Canada for changes in the epidemiology of high prevalence populations and behaviours. Likewise, the publication of new evidence is monitored to respond to the latest developments. This screening recommendation will be revised if new evidence becomes available in the coming years, or the epidemiological situation changes to justify subsequent updates to the recommendation.
Limitations
Much of the evidence used to inform the development of these recommendations are based on an assessment of key populations or groups, such as gbMSM and people living with HIV. Considering that gbMSM populations continue to have higher rates of STBBI infections compared to the general public and individuals living with HIV are at increased risk of acquiring other STBBI, the recommendations may overestimate the frequency of screening needed in the public.
Research priorities and implications
Rapidly changing epidemiology has resulted in significant change to the incidence and prevalence of syphilis. This can cause certain studies to become quickly outdated when the population being assessed no longer reflects the population being impacted by the infection. Ongoing review and monitoring of the most recent surveillance data is integral to ensure individuals and populations with high infection prevalence are identified quickly.
STBBI research is primarily focused on specific key populations, such as people living with HIV and gbMSM. While the evidence for these groups is thorough, studies focused on the general population are lacking and can present a gap in the evidence. Extrapolating evidence from these groups to apply to the general population is not always feasible given significant differences in population groups. Prioritizing STBBI research on the general public should be considered.
List of abbreviations
- CADTH
- Canadian Agency for Drugs and Technologies in Health
- CIA
- Chemiluminescence immunoassay
- CSF
- Cerebral spinal fluid
- CUA
- Cost-utility analysis
- EIA
- Enzyme immunoassay
- EtD
- Evidence to decision
- FNIM
- First Nations, Inuit and Métis Peoples
- FTA-ABS
- Fluorescent treponemal antibody absorption assay
- gbMSM
- Gay, bisexual and other men who have sex with men
- GRADE
- Grading of Recommendations Assessment, Development and Evaluation
- ICER
- Incremental cost-effectiveness ratio
- NAC-STBBI
- National Advisory Committee on Sexually Transmitted and Blood-Borne Infections
- NTT
- Non-treponemal tests
- PHAC
- Public Health Agency of Canada
- PPV
- Positive predictive value
- QALY
- Quality adjusted life years
- RCT
- Randomized control trial
- RPR
- Rapid plasma reagin
- SR
- Systematic review
- STBBI
- Sexually transmitted and blood-borne infections
- STI
- Sexually transmitted infections
- TPHA
- T. pallidum hemaglutination assay
- TPPA
- T. pallidum particle agglutination assay
- TT
- Treponemal tests
- VDRL
- Venereal Disease Research Laboratory
- WG
- Working group
- WHO
- World Health Organization
Acknowledgements
Contributors to PHAC Syphilis screening guidelines for non-pregnant adults and adolescents:
NAC-STBBI Syphilis screening working group: J Bullard, J Gratrix, T Grennan, T Hatchette
NAC-STBBI members: I Gemmill (chair), T Grennan (vice-chair), J Bullard, W Fisher, J Gratrix, T Hatchette, AC Labbé, T Lau, G Ogilvie, M Steben, P Smyzcek, M. Yudin
NAC-STBBI Ex-Officio: I Martin
NAC-STBBI Secretariat (PHAC): H Begum, A Fleurant, S Gadient, S Ha, S Sabourin
Appendices
Appendix 1: Flow diagram of study selection on syphilis screening since 2019

Figure 1 - Text equivalent
The figure is a flow diagram outlining the steps for study selection. The diagram begins with the identification phase where 220 records from databases and 5 record from other sources were identified and 44 duplicate records were removed. It is followed by the screening phase where 181 records were screened, 150 records were excluded, 31 records were sought for retrieval. All records were assessed for eligibility, and 23 records were excluded. The diagram concludes with the included phase where 8 records were included in the review including original articles on out-patient screening, patient values, preferences and feasibility, cost-effectiveness of syphilis screening.
Appendix 2: Summary of evidence-to-decision framework judgements
Factor | Judgement |
---|---|
Problem |
The problem is a priority |
Desirable effects |
Desirable anticipated effects are moderate |
Undesirable effects |
Undesirable anticipated effects vary |
Certainty of evidence |
Certainty of evidence is considered low to moderate |
Values |
Possibly important uncertainty or variability |
Balance of effects |
Favors the intervention |
Resources required |
Moderate savings |
Certainty of evidence of required resources |
High |
Cost effectiveness |
No included studies for this factor |
Equity |
Equity impact is unknown |
Acceptability |
The acceptability of the intervention varies |
Feasibility |
The feasibility of the intervention varies |
Type of recommendation |
Strong recommendation for the intervention |
Interpretation of strong and conditional recommendations
The recommendations are labeled as "strong" or "conditional" according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. The words "the guideline panel recommends" are used for strong recommendations, and "the guideline panel suggests" for conditional recommendations. The table below provides GRADE's interpretation of strong and conditional recommendations by patients, clinicians, health care policy makers, and researchers.
Implications for: | Strong recommendation | Conditional recommendation |
---|---|---|
Patients |
Most individuals in this situation would want the recommended course of action, and only a small proportion would not. |
The majority of individuals in this situation would want the suggested course of action, but many would not. Decision aids may be useful in helping patients to make decisions consistent with their individual risks, values, and preferences. |
Clinicians |
Most individuals should follow the recommended course of action. Formal decision aids are not likely to be needed to help individual patients make decisions consistent with their values and preferences. |
Different choices will be appropriate for individual patients; clinicians must help each patient arrive at a management decision consistent with his or her values and preferences. Decision aids may be useful in helping individuals to make decisions consistent with their individual risks, values, and preferences. |
Policy makers |
The recommendation can be adopted as policy in most situations. Adherence to this recommendation according to the guideline could be used as a quality criterion or performance indicator. |
Policy-making will require substantial debate and involvement of various stakeholders. Performance measures should assess if decision-making is appropriate. |
Appendix 3: Characteristics of included studies and summary of findings
Table 3.1. Relevant systematic reviews on syphilis screening
Reference country | Objective(s) | Population | Methods | Outcome(s) | Main findings |
---|---|---|---|---|---|
Fernane & Fowler (2015) |
Is it efficacious to screen low risk clients? Intervention: Syphilis screening based on risk assessment (excluding prenatal testing, HIV testing, congenital syphilis) Comparator: Routine screening of population for syphilis |
general population ≥ 16 years of age |
Systematic literature search (January 2005 to March 11, 2015) Search for existing clinical guidelines |
Identification of syphilis cases |
Only findings from guidelines and expert opinions were included. Evidence-based guidelines are not relevant for this report and will not be described. The authors did not search for primary studies. The overview of reviews did not identify any relevant synthesized evidence studies for inclusion. For the purpose of this statement, guidelines identified in this study were not considered as this part of the process was focused on identifying relevant systematic literature reviews. A separate environmental scan for guidelines was completed. |
Informed USPSTF recommendation |
What is the effectiveness of screening for syphilis in reducing complications of the disease and transmission or acquisition of other STIs in asymptomatic, nonpregnant, sexually active adults and adolescents? What is the effectiveness of specific screening intervals and screening among population subgroups? |
Asymptomatic, sexually active men and nonpregnant women, including adolescents |
Systematic literature search (January 2004 to March 11, 2016) |
Reduced complications of syphilis infection Reduced transmission or acquisition of STIs |
No studies directly compared the effectiveness of syphilis screening in screened versus unscreened populations of non-pregnant adolescents and adults. Four observational studies evaluated the detection rates using specific screening intervals in MSM or HIV-positive populations outside the US. (3 studies in Australia and 1 in the UK) No studies on adolescents or other population subgroups. Results from these studies indicated that testing for syphilis every 3 months identified more new cases of infection compared with screening every 6 or 12 months in MSM or men living with HIV |
To identify clinic-based interventions efficacious at increasing screening and detection of GC, CT, and syphilis among MSM. |
MSM |
Systematic literature search (1990 to June 2011) |
Proportion of men screened Re-screening rates (proportion screened again) Detection rates (proportion diagnosed) |
Three studies on GC, CT, and syphilis Four studies on syphilis Reminder for clinicians to undertake 3-month syphilis testing of MSM with >=10 male partners in the prior 12 months. EMR improved syphilis retesting rates at 6 months from 64% to 81% (P=0.047) EMR alerts 3-month reminders for syphilis testing in higher-risk MSM increased the proportion screening from 77% to 89% (P<0.001). The proportion of early syphilis detected that was asymptomatic was from 16% to 53% (P<0.001) |
Table 3.2. Major studies on syphilis screening
Reference, country | Study design | Aim of study | Population (n) | Intervention and comparator | Outcomes | Findings |
---|---|---|---|---|---|---|
Risk-based screening vs. interval screening | ||||||
Ontario, Canada Protocol published results |
A Stepped Wedge Cluster Randomized Controlled Trial Setting: HIV outpatient clinics (Ottawa, Toronto) Study period: 1 February 2015 to 31 July 2017 |
To compare syphilis serological testing every 3 to 6 months to provider-initiated syphilis testing Ontario, Canada in 2017-2018 To determine the degree to which the intervention (1) increased the detection of early syphilis; (2) increased the proportion of men who undergo syphilis screening at least annually; and (3) increased screening frequency |
Among HIV-positive adult males; gbMSM |
Intervention: Opt-out standing orders for syphilis serology whenever men underwent routine HIV viral load tests Comparator: The usual syphilis testing practices prompted by signs or symptoms, exposure to active cases, patient disclosure of sexual risk behavior, patient request, and physicians experience-based knowledge of syphilis risk |
Screening coverage and frequency - Number of serological tests performed: Average annual number of syphilis tests per individual increased from 0.53 to 2.02 tests. Time-adjusted rate ratio, 2.03, 95% CI,1.85–2.22 Untreated early syphilis cases diagnosed New cases of syphilis were diagnosed, n=217 (control: 81; intervention: 136) (early syphilis cases 147 (68%) control: 61; intervention: 86). With intervention, the annualised proportion of newly identified early syphilis increased from 0.009 to 0.032; Annualized proportion of men with newly detected early syphilis: |
The syphilis serological testing with HIV viral loads resulted in a 25% increase in early syphilis The degree of benefit was inconclusive given the 95% CI of 0.71–2.20 and statistical non-significance. The odds of annual screening increased nearly 4-fold The mean number of tests per year increased 2-fold. The routine syphilis screening, annual coverage was 79.4% and men were tested on average twice per year. |
Comparison of annual, 3-month, and 6-month screening intervals | ||||||
Melbourne, Australia |
Observational study (retrospective) Setting: Sexual health centre Study period: July 2005 to December 2006 and January 2007 to June 2008. |
To determine whether the routine inclusion of syphilis serology with every blood test performed as part of HIV monitoring increases the detection of early, asymptomatic syphilis among HIV-positive MSM |
HIV-positive MSM (N=1031) Intervention (n=587) Control (n=444) |
Intervention: Offering syphilis screening every 3 months as part of HIV viral load monitoring from January 2007 to June 2008 Comparator: Annual syphilis screening during routine blood sample collection for HIV-positive MSM from July 2005 to December 2006 (control) Diagnosis of early syphilis in individuals with previous infection was completed using EIA and TPPA with 4-fold rise in RPR or a positive PCR |
Number of serological tests performed: Comparator: 1293 tests; with a median of 1 test per man per year Intervention: 2928 tests; with a median of 2 tests per man per year. Proportion of HIV-positive MSM diagnosed with early syphilis Comparator: 3.1% (14/444) Intervention: 8.1% (48/587) p=0.001 Proportion of latent syphilis diagnoses Comparator: 2.0% (9/444) Intervention: 4.2% (25/587) The proportion of syphilis cases diagnosed (excluding cases of unknown duration) Comparator: 60% Intervention: 66% |
The inclusion of routine syphilis serology taken as part of HIV monitoring resulted in a marked increase in the proportion of HIV-positive MSM diagnosed with asymptomatic syphilis. |
Victoria, Australia Included in USPSTF |
Observational study |
To assess the impact of a computer alert that reminded clinicians to test men who are at higher risk for syphilis on the rate of syphilis testing and diagnoses |
MSM High risk: >10 male partners within the prior 12 months Comparator: Total of 6789 consultations High risk MSM (n=2017 consultations) Low risk MSM (n=1885 consultations) Remaining consultations 42% were return visits for results Intervention: Total of 8036 consultations High risk MSM (n=1445 consultations) Low risk MSM (n=2448 consultations) 52% not classified due to missing risk data |
Intervention: Computer alerts appeared when MSM reported >10 partners within the prior 12 months, which recommended syphilis testing every 3 months (12 months after alerts were introduced in October 2008) Comparator: Standard care (12 months before October 2008) Algorithm not specified |
Proportion of syphilis tests in higher risk MSM Comparator: 77% (n=1559) Intervention: 89% (n=1282) p=0.001 Proportion of syphilis tests in lower risk MSM Comparator: 65% (n=1228/1885) Intervention: 68% (1667/2448) No difference (p=0.4) Proportion of diagnosed with early, asymptomatic syphilis in higher risk MSM Comparator: 16% (5/31) Intervention: 53% (31/58) p=0.001 Proportion of diagnosed early, asymptomatic syphilis in lower-risk MSM Comparator: 10% (1/10) Intervention: 19% (3/16) No difference (p=0.6) |
The proportion of syphilis tests administered increased significantly in higher risk MSM with the introduction of computer alerts. Proportion of higher-risk men who received a diagnosis of early syphilis and who were asymptomatic increased significantly with the computer alerts. |
Ontario, Canada This was a study protocol. Published as Burchell et al (2022) |
Cluster-randomized trial Setting: Hospital-based HIV outpatient clinics Study period: November 2014 to July 2017 |
To determine to what degree enhanced syphilis screening among HIV-positive men that incorporates opt-out syphilis testing during routine HIV laboratory evaluation increases detection rates of untreated syphilis, increases screening coverage, increases screening frequency, and reaches men at highest risk based on sexual behaviours. |
HIV-positive MSM |
Intervention: Opt-out syphilis serological test every 3-6 months with HIV laboratory evaluations Comparator: usual practice provider-initiated syphilis testing prompted by signs/symptoms, exposure to active cases, disclosure of sexual risk behaviours, physicians' knowledge and experience diagnosing syphilis Reverse algorithm: CLIA then RPR and TPPA if reactive; FTA-Abs if RPR and TPPA are non-reactive or indeterminate. *Note FTA-Abs is no longer used as of Oct. 2017 |
Detection rate of untreated syphilis (acute syphilis) Defined as seroconversion with prior negative syphilis serology within 12 months
Secondary outcomes: Proportion of men screened annually |
Published results |
Australia |
Observational study (Retrospective cross-sectional study) Setting: National sentinel network of 46 sexual health clinics Study period: January 2007 and December 2014 |
To examine trends in the rates of syphilis testing and diagnoses among MSM. To determine whether increases in screening occurred and whether increased screening was associated with greater detection of asymptomatic, early syphilis. |
MSM Total clinic visits: 359, 313 HIV-negative Median age = 31 years; IQR= 25 – 41 2007: n=7677 2014: n=19,179 HIV-positive Median age = 44 years; IQR = 36 – 52 2007: n=1664 2014: n=3273 |
Intervention: syphilis screening for MSM at least annually, with more frequent screening in higher risk men; and opt-out serological screening for syphilis in HIV monitoring of HIV-positive MSM Comparator: none Syphilis was diagnosed using Treponema pallidum immunoassay |
*Data presented from 2007 to 2014 Proportion tested at least once a year (coverage) HIV-negative Increase from 48% to 91% (p<0.0001) MSM aged ≤35 years: 50% to 92% MSM aged >35 years: 46% to 89% (p<0.0001) HIV-positive Increase from 42% to 77% (p<0.0001) MSM aged ≤35 years: 53% to 87% MSM aged > 35 years: 39% to 73% (p<0.0001) Mean number of syphilis tests per man per year (frequency) HIV-negative Increase from 1.3 tests to 1.6 tests (p<0.0001) Mean time between syphilis tests was 245 days (SD = 286 days). HIV-positive Increase from 1.6 tests to 2.3 tests (p<0.0001) Mean time between syphilis tests was 164 days (SD=188 days) Proportion of HIV viral load tests and syphilis tests Increased from 27% to 73% (p<0.0001) Annual diagnosis of primary syphilis HIV-negative: Decreased from 49% to 38% (p=0.017) HIV-positive: No change 33% to 29% (p=0.735) Annual diagnosis of secondary syphilis HIV-negative: Decreased from 24% to 19% (p=0.030) HIV-positive: Decreased from 45% to 26% (p=0.0003) Annual diagnosis of early latent syphilis HIV-negative: Increased from 27% to 44% (p<0.0001) HIV-positive: Increased from 23% to 45% (p<0.0001) |
n/a |
San Francisco, Miami, Washington, DC; US |
Observational study (Prospective study) Setting : STI clinics and community health centres Study period: October 2012 to January 2014 |
To assess the number and percent of gonorrhea and chlamydia infections that could be missed if extra-genital screening was not conducted and to determine the number and percent of patients infected with gonorrhea, chlamydia, and syphilis for whom treatment would have been delayed without screening every 3 months. |
PrEP users (HIV-negative gbMSM and transgendered women) (N=455) |
Intervention: screening for syphilis, gonorrhea, and chlamydia every 3 months (Patients were tested for tested for syphilis, gonorrhea, and chlamydia at weeks 12, 36, and 48 weeks) Comparator: CDC recommendation to screen PrEP users every 6 months Algorithm not specified |
% infections in which treatment would have been delayed had screening been conducted every 6 months instead of every 3 months Gonorrhea (n=181): % delayed treatment: 34.3 % detected: 65.7% Chlamydia (n=210): % delayed treatment: 40.0% % detected: 60.0% Syphilis (n=54): % delayed treatment: 20.4% % detected: 79.6% Total (N=445) % delayed treatment: 35.3% % detected: 64.7% % of missed infections without extra-genital screening (GC/CT only) Gonorrhea: 150/181 (82.9%) Chlamydia: 159/210 (75.7%) |
Significant proportion of syphilis, GC, and CT infections would be missed with screening every 6 months or if extra-genital screening had not been performed. Screening every 3 months followed by prompt treatment could prevent transmission in exposed partners (median of 3 sex partners/STI cases from being exposed from condomless anal sex). |
Melbourne, Australia |
Observational study Setting: STI clinic Study period: February 2009 and August 2010 |
To compare clinic visits, STI testing and detection rates over 12 month between men receiving reminders (reminder group) and men not offered the reminders (concurrent control group). |
MSM (N=4514) |
Reminders were sent every 3, 6, or 12 months for screening Intervention: Reminder group: reminders sent during Feb 2009 to Aug 2010 Comparator: Concurrent control group: after the reminders were implemented, but not offered reminders Historic control group: men who attended the clinic before the reminder system was implemented (July 2006 to Feb 2008) EIA and RPR together with EIA for HIV |
Clinic visits (return at least once during the 12 months) 3 month group: 89.5% (p<0.001) 6 month group: 87.7% (p<0.001) Control: 70.8% Proportion who received syphilis testing at least once 3 month group: 67% (393/656) p<0.001 6 month group: 51.9% (137/264) p<0.001 3, 6, or 12 group: 61.6% (545/997) p<0.001 Control: 39.3% (38/1382) % diagnosed with early syphilis 3 month group: 3.2% (19/656) p=0.025 6 month group: 1.9% (5/301) p=0.680 3, 6, or 12 group: 2.8% (25/997) p=0.060 Control: 1.5% (15/1382) % diagnosed with early latent syphilis 3 month group: 1.7% (10/656) p=0.008 6 month group: 0.8% (2/301) p=0.469 3, 6, or 12 group: 1.4% (12/997) p=0.028 Control: 0.4% (4/1382) |
n/a |
Opt-in vs. opt-out approach | ||||||
Alberta, Canada |
A cross-sectional, retrospective review March 2018 and February 2020 |
To evaluate the uptake of opt-out screening at admission. To determine reasons for screening noncompletion. To determine case-finding rates. To determine treatment |
Individuals ≤ 35 years in a remand facility (pretrial, presentence, or detention) in Alberta, Canada |
Opt-out screening at admission Opt-out and Opt-in testing in the correctional facility |
Opt-out versus Opt-In Opt-out screening resulted in higher STI positivity rates compare to other STIs (CT, GN) (29.5%), however, lower than Opt-In screening (35.8%) Opt-out screening diagnosed higher new syphilis cases (case-finding rate). Opt-out: 7.3% (150/2053 tests); Opt-in 7.1% (150/1995 tests) There were no differences in the proportion of positive test results between testing programs across gender, age categories, or over time (p = 0.120) Opt-out Total Opt-out uptake was low (n=902/2906; 31.2%). Treatment completion (93.7%) while capturing a high proportion (52.6%) of asymptomatic cases. |
Opt-out screened more admissions ≤ 25 years Opt-out achieved significantly high positivity rates for syphilis compared to CT and GN but lower compared to Opt-in. Both found similar HIV positivity rates. |
Chicago, USA |
A retrospective chart review Setting: Tertiary care centre's emergency department (ED) Study period: June 1, 2019 and December 31, 2019 |
To examine To evaluate the routine, opt-out syphilis screening |
Individual age 18 to 64 years |
A universal, Opt-out syphilis screening (Anyone age between 18 and 64, no documented diagnosis of HIV, and no record of HIV screening within the past 12 months. The alert continued to appear until the orders were placed or someone indicated the patient was not a candidate or had declined testing.) |
Prevalence of syphilis cases 1.1% (97 0f 9198) had presumed active syphilis infection (PAI) Only 18.6% of PAI presented with complaints related to sexually transmitted infections (STIs). |
A large number of missing cases while targeting screening to only those deemed "high-risk" by behavior or symptoms. Little more than 50% (7 of 13) of those testing positive did not present with complaints. |
Florida, USA |
A retrospective chart review Setting: Hospital record system) Study period: April 2018 to August 2019 |
To describe the development, implementation, and evaluation of the algorithm. Creation of smart syphilis screening algorithm based on patient risk |
Patients Screened by Syphilis Smart Algorithm |
Smart syphilis screening algorithm based on patient risk |
27of the 59 patients with reactive syphilis tests considered newly diagnosed syphilis infection (no history of syphilis infection in the health care system) |
The routine opt-out screening model, enhancing the Routine Screening Infrastructure |
Sydney and Melbourne, Australia |
Observational study (retrospective) Setting: Clinic specializing in gbMSM; HIV outpatient clinics Study period: 2006 to 2010 |
To describe the frequency of syphilis testing as part of routine HIV monitoring blood tests performed in HIV-positive MSM over a five-year period and differences by clinic testing policies. |
HIV-positive gbMSM N = 3131 to 3748 18 years and older with at least one HIV viral load test Median age: 44 to 45 years |
Interventions: Opt-out: syphilis testing done automatically on all HIV-positive MSM unless patient declines Opt-in: offering syphilis testing to HIV-positive MSM and conducting the test with those who agree Comparator: Risk-based: assessing risk and offering syphilis test accordingly *HIV viral load testing occurred every 3 to 6 months Algorithm not specified |
Syphilis testing frequency (tests/man) Number of syphilis tests per man increased from 1.3 in 2006 to 2.2 in 2007 (p<0.01) Number of syphilis tests remained stable at 2.1 from 2008-2010 Proportion of men with ≥ 3 syphilis tests per year Increased from 15% in 2006 to 36% in 2007 (p<0.01) Remained stable at 36% to 38% from 2008-2010 In 2010, the proportion of men having ≥ 3 syphilis tests in a year was highest in the clinics with the opt-out strategy (48%, range: 35% - 59%), compared to the opt-in (39%, p=0.12) and risk-based (8.4% range: 5.4% - 12%, p<0.01) Syphilis tests on the same day as HIV viral loads Proportion of same day HIV viral load testing increased from 37% in 2006 to 63% in 2007 (p<0.01). Remained stable at 68% to 69% in subsequent years. In 2010, same day tests was highest in clinics with the opt-out strategy (87%; range: 84% - 91%), compared with opt-in (74%, p=0.121), and risk-based (22%; range: 20% - 24%, p<0.01) |
The frequency of testing with risk-based strategy was significantly lower. From 2006 to 2010, the frequency of syphilis testing increased significantly. Higher syphilis testing rates were found in clinics with the opt-in and opt-out approach that integrate syphilis testing as part of HIV monitoring. Over 5 years, HIV-positive men undergoing syphilis testing was 5 to 6 times higher in clinics with opt-out and opt-in strategies compared with risk-based policies |
Syphilis screening as part of HIV viral load testing | ||||||
Alberta, Canada |
Retrospective study Setting: STI clinic Study period: January 1, 2006 and December 31, 2016 |
To characterise incident syphilis presentation, serological features, and treatment response in HIV-positive individuals. |
HIV-positive individuals (N=2448) Mean age at syphilis diagnosis was 47 years (range 21 to 72) Mean age at HIV diagnosis was 35 years (1 to 79) |
Syphilis testing with HIV viral load measures every 4 months Pre-2008: Non-RPR as a screening test 2008: EIA and then confirmed with non-RPR or FTA-ABS or INNO-LIA |
Number of syphilis tests On average, the average number of syphilis tests per patient was 180 days. The average number of syphilis screening tests that were done per patient per year over the 11-year period was 2.1. Screening rates were more frequent in high risk MSM with an average testing over 11 years being 2.4 tests/year. Over 50.8% of incident syphilis cases were asymptomatic and were only identified through routine screening. 28.5% (71/249) of the infections, syphilis occurred in individuals who had been previously treated for syphilis on one or more past occasions and were identified by a four-fold increase in RPR titre. |
Many asymptomatic syphilis episodes were identified and treated through routine screening of HIV-positive individuals. |
Additional studies: Modelling | ||||||
Toronto, Canada |
Mathematical modelling using a transmission model Data from reported case counts from 2006 and 2010 and modelled the population for a 10-year period beginning in 2011. |
To examine the marginal effect of increased frequency versus increased coverage of screening on syphilis incidence. |
MSM (n=2000) Assumption: Local prevalence of HIV-positivity: 20% |
Interventions: Increasing annual population coverage by 10% (Strategy B) Screen ever 6 or every 3 months (Strategy C) Screen a proportion of the population every 12 months such that the total number of tests performed is equivalent to strategy C (Strategy D) Comparator: Base case of annual screening at current coverage (Strategy A) |
Projected number of reported incident syphilis cases Over a 10-year intervention period, screening every 3 months was projected to avert approximately 650 incident syphilis cases, compared with 300 and 125 cases averted with screening every 6 month or expanded annual coverage, respectively. The proportion of cases averted, relative to the base case, were greater for the more frequent screened strategies than when the equivalent number of tests was applied to expanded coverage over the intervention period. |
Increasing the frequency of syphilis screening to every 3 months was the most effective strategy for reducing infectious syphilis cases. |
Winnipeg, Canada |
Mathematical modelling using a deterministic model of syphilis transmission using syphilis case data from 2011 to 2015 |
To determine the transmission impact of using prior syphilis infection to guide a focused syphilis screening intervention among MSM. |
MSM Assumed 30% screening of the entire population with additional screening tests from the scenarios |
Interventions: Strategy A: Focused screening every 3 months of men with prior reported infection Strategy B: Uniform screening every 3 months (i.e., uniform distribution of additional tests) Strategy C: Focused screening every 3 months of men in the high sexual activity group Comparator: Baseline scenario: 30% screened of the entire modelled population of MSM annually |
Baseline: At the end of the 10-year intervention period:
Enhanced screening strategies:
Strategy A:
Strategy B:
Strategy C:
|
Focused screening was more effective than universal screening. Enhanced screening of MSM with prior syphilis may efficiently reduce transmission, especially when identification of high-risk men via self-reported partner numbers or high-frequency screening is difficult to achieve. |
Table 3.3. Characteristics of patient values and preferences, cost-effectiveness studies on syphilis screening
Reference, country | Study design | Aim of study | Population | Intervention and comparator | Outcome | Findings |
---|---|---|---|---|---|---|
Patient values and preferences, feasibility and equity | ||||||
Toronto and Ottawa, Canada |
Qualitative Hospital-based HIV outpatient clinics November 2017 to April 2018 |
To evaluate the enhanced syphilis screening among HIV-positive Men trial To measure patient acceptability which implemented an Opt-out, clinic-based intervention to routinise syphilis testing with HIV viral loads. |
Men living with HIV |
Intervention: standing orders for syphilis serology whenever men underwent venipuncture for routine HIV viral load tests |
Patient acceptability of Opt-out, clinic-based intervention to routinise syphilis testing with HIV viral loads |
The patients interviewed supported routine syphilis testing as part of standard HIV care and this was highly acceptable Most men expressed comfort attending a sexual health clinic, but for several reasons, preferred testing at their regular HIV care clinic (more comfortable, more trusting of staff to be knowledgeable and non-judgemental, already getting blood work done) Some men preferred, based on their self-assessment of syphilis risk, to opt out of testing. This was considered as a potential barrier to uptake of population-wide routinised syphilis testing. Still facing pervasive stigma despite receiving ongoing care |
Alberta, Canada |
A cross-sectional, retrospective review March 2018 and February 2020 |
To evaluate the uptake of opt-out screening at admission. To determine reasons for screening noncompletion. To determine case-finding rates. To determine treatment completion rates for those who tested positive. To compare testing outcomes between opt-out and opt-in testing in the facility. |
Individuals ≤ 35 years in a remand facility (pretrial, presentence, or detention) in Alberta, Canada |
Opt-out screening at admission -Opt-out and Opt-in testing in the correctional facility |
Total Opt-out uptake was low (n=902/2906; 31.2%). The main reason for not accepted was no perceived risk (p < 0.001) Acceptance rate was calculated by dividing the total number of individuals offered Opt-out testing by the number of patients consenting. |
Opt-out screening at admission is feasible and can improve STI testing in high-risk individuals experiencing incarceration in Canada. |
Cost and Cost-effectiveness | ||||||
Germany |
The model included gender- and age-stratified incident cases of syphilis (in-and outpatients) from 2010 to 2012. The annual direct and indirect economic burden was estimated based on the outcomes of this model |
To examine the possible impact of syphilis on the German healthcare system in order to support healthcare decision making |
Insured individuals of a German statutory health insurance company |
Age-distributed annual incidences were calculated Direct medical costs for inpatient and outpatient treatment, screening, and confirmatory testing, Indirect costs from loss of productivity for 1 year |
Reported incident syphilis cases In the insured population, an average incident cases of syphilis between 2010-2012= 4574/80,867,749 Incidence rate/100,000 person-years = 5.7 Cost analysis the average annual direct and indirect costs for syphilis in insurance population Direct cost Screening and confirmatory testing, outpatients (N = 1,006,727) Total screening and confirmatory testing, outpatients €5,787,886 Total direct costs € 7,540,312 Indirect costs (N = 3,534) €494,375 Productivity losses, outpatients (N = 3,074) € 217,623 Productivity losses, inpatients (N = 460) € 276,752 Total cost of syphilis 8,034,68 |
The total estimated economic burden of syphilis based on this model would amount to €20,292,110. In comparison to the average annual total healthcare costs from 2010 to 2012 as €29,730 From the societal point of view, the projected total indirect costs to be €681,285 |
US |
Exploratory Modelling study using two versions of the model (static and dynamic) |
To estimate the cost-effectiveness of syphilis screening among MSM compared to a strategy of no syphilis screening. |
HIV-positive and HIV-negative MSM aged 15 to 64 years |
Intervention: Syphilis screening over a 10-year timeframe (CDC recommends annual screening and every 3 and 6 months for MSM with risk factors) Comparator: No screening |
Cost of screening program Static model: US $3,800,300 Dynamic model: US $3,792,300 HIV treatment costs averted Syphilis medical costs averted Static model: US $1,539,800 Dynamic model: US $1,707,400 Incremental cost of screening Static model: US $481,600 Dynamic model: US - $9,307,900 Incremental number of QALYs gained Static model: 29.9 Dynamic model: 191.5 Cost-effectiveness ratio Static model: US $16,100 Dynamic model: US <$0 (cost-saving) Costs of screening program (test costs and treatment costs) In addition, HIV cases and costs averted through syphilis screening were also estimated. |
The cost per QALY gained by syphilis screening was < 0 US$ (cost-saving) in the dynamic version, but was high at 16,100 US$ in the static version of the model. Other finding: Syphilis screening resulted in a syphilis prevalence decline by 30% after a 10-year timeframe. |
Ontario, Canada |
Microsimulation study using Monte Carlo simulations on data from an observational cohort |
To evaluate the cost-effectiveness of increased frequency and coverage of syphilis screening strategies compared to standard of care in HIV-positive MSM |
HIV-positive MSM under HIV care |
Intervention: Frequent screening of 3- or 6-month screening and higher coverage of 100% Comparator: The standard annual screening of syphilis within HIV-positive MSM |
Cost (Undiscounted/ Discounted) Higher coverage, 6 months: $1661.30/$1019.51 Higher coverage, annual: $1834.26/$1059.74 Usual, 3 months: $1959.54/$1195.81 Usual, 6 months: $2003.24/$1148.20 Higher coverage, 3 months: $2225.39/$1408.94 Usual care: $2499.95$/1310.25 Incremental cost (Undiscounted/ Discounted) Higher coverage 6 months: -/- Higher coverage, annual: $172.96/$40.22 Usual, 3 months: $298.34/$176.30 Usual, 6 months: $341.94/$128.69 Higher coverage, 3 months: $564.08/$389.42 Usual care: $838.65/$290.73 Effectiveness (QALY)(Undiscounted/ Discounted) Higher coverage, 6 months: 29.129/13.3497 Higher coverage, annual: 29.1241/13.3468 Usual, 3 months: 29.1037/13.3448 Usual, 6 months: 29.1252/13.3466 Higher coverage, 3 months: 29.1314/13.3548 Usual care: 29.0968/13.3398 Incremental effectiveness (QALY)(Undiscounted/ Discounted) Higher coverage, 6 months: - /- Higher coverage, annual: -0.005/-0.0030 Usual, 3 months: -0.0253/-0.0049 Usual, 6 months: -0.0039/-0.0031 Higher coverage, 3 months: 0.0024/0.0050 Usual care: -0.0323/-0.0099 ICER ($/QALY)(Undiscounted/ Discounted) Higher coverage, 6 months: - /- Higher coverage, annual: dominated/dominated Usual, 3 months: dominated/dominated Usual, 6 months: dominated/dominated Higher coverage, 3 months: 239,539/77,516.35 Usual care: dominated/dominated A discount rate of 5% was applied to future costs and outcomes and is in CA$ |
The authors project that both increases in test frequency and coverage for MSM with HIV infection would increase effectiveness relative to current standard of care, and that all more-intense screening regimens (with the exception of higher coverage, 3-monthly screening) would decrease, rather than increase, net healthcare costs due to aversion of downstream sequelae of untreated syphilis infections. Annual screening (meaning the usual care) was more costly and less effective compared to the screening every 3-months and every 6 months Higher coverage and more frequent coverage would be more cost-effective in HIV-positive MSM compared to usual care. Compared to annual screening, higher (100%) coverage and screening every 3-months screening was projected to cost more (CA $98.69) and be more effective (0.015 QALY). All intermediate strategies cost less than the usual care strategy, but provided fewer QALY gains than higher coverage with 3 months screening interval. |
Victoria, Australia |
Mathematical transmission modelling study |
To analyse cost-effectiveness of testing policy vs health benefits from the prevention of syphilis (and HIV, CT, TV and GC) |
Female sex workers in Australia |
Intervention: Current standards of mandatory screening (Syphilis/HIV testing every 3 months -and CT, GC, TV every month) Comparator: Scenarios of increased risks due to less costs (≤ 50$ per QALY saved) |
Screening costs For 2000 female sex workers, it costed over $A 3,750,000 per year for HIV/syphilis screening every 3 months and GC/CT screening every month. QALY gained through HIV/syphilis screening, interval/weeks between screening test At a willingness-to-pay of $A 50 000 per QALY gained, HIV/Syphilis screening should not be conducted at < 40 weeks intervals. |
Increased screening frequency would result in a sharp increase in cost. Even if the testing was decreased to just once per year, if the incidence rate to sex workers remain unchanged, then less than 16 syphilis transmission (less than 1 HIV transmission) could be expected to male clients Mandatory syphilis and HIV screening of female sex workers at current frequencies (of every 3 months) is not cost-effective for the prevention in their male partners. If the incidence of STIs in sex workers remains low, there is a strong argument for relaxing regulations to less frequent testing. |
Melbourne, Australia *Included in USPSTF systematic review |
Observational study (retrospective) Setting: Sexual health centre Study period: July 2005 to December 2006 and January 2007 to June 2008. |
To determine whether the routine inclusion of syphilis serology with every blood test performed as part of HIV monitoring increases the detection of early, asymptomatic syphilis among HIV-positive MSM |
HIV-positive MSM (N=1031) Intervention (n=587) Control (n=444) |
Intervention: Offering syphilis screening every 3 months as part of HIV viral load monitoring from January 2007 to June 2008 Comparator: Annual syphilis screening during routine blood sample collection for HIV-positive MSM from July 2005 to December 2006 (control) Diagnosis of early syphilis in individuals with previous infection was completed using EIA and TPPA with 4-fold rise in RPR or a positive PCR |
Routine syphilis screening of HIV-positive MSM as part of their outpatient care is likely to be cost effective. In Australia the cost of syphilis screening per test was AUS$28.85 (RPR, EIA) or AUS$43.40 if TPPA was added (if RPR or EIA reactive) |
Table 3.4. Evidence profiles
Q1: Should [risk-based approaches] vs. [population wide/interval screening approaches] be used for [syphilis screening among sexually active adolescents and adults]?
Risk-based versus interval screening | |
---|---|
Outcome | Evidence |
Syphilis Screening Number of serological tests performed (1 RCT)Table 6 Footnote d |
Average annual number of syphilis tests per individual increased from 0.53 to 2.02 tests Time-adjusted rate ratio, 2.03 (1.85–2.22) |
Untreated early syphilis cases diagnosed (1 RCT)Table 6 Footnote d |
With intervention, the annualised proportion of newly identified early syphilis increased from 0.009 to 0.032; |
Annual screening (1 RCT)Table 6 Footnote d |
The odds of annual screening increased nearly 4-fold |
Certainty of evidence |
MODERATE Imprecision |
Comparison of annual, 3-month, and 6-month screening intervals | |
Number/Proportion of serological tests performed (5 observational studies)Table 6 Footnote e,Table 6 Footnote f,Table 6 Footnote g,Table 6 Footnote h,Table 6 Footnote i |
The inclusion of routine syphilis serology taken as part of HIV monitoring resulted in a marked increase in the proportion of HIV-positive MSM diagnosed with asymptomatic syphilis. |
Certainty of evidence |
⨁⨁⨁◯ MODERATETable 6 Footnote b,Table 6 Footnote c Risk of bias |
Projected number of reported incident syphilis cases from studies using ModellingTable 6 Footnote j,Table 6 Footnote k |
Increasing the frequency of syphilis screening to every 3 months was the most effective strategy for reducing infectious syphilis cases. Focused screening was more effective than universal screening. Enhanced screening of MSM with prior syphilis may efficiently reduce transmission, especially when identification of high-risk men via self-reported partner numbers or high-frequency screening is difficult to achieve. |
Opt-in versus opt-out approach | |
Diagnosed higher new syphilis cases (4 observational studies)Table 6 Footnote l,Table 6 Footnote m,Table 6 Footnote n,Table 6 Footnote o |
Opt-out screening: Diagnosed higher new syphilis cases (case-finding rate). Opt-out: 7.3% (150/2053 tests); Opt-in 7.1% (150/1995 tests) Number of syphilis tests per man increased from 1.3 in 2006 to 2.2 in 2007 (p<0.01) In 2010, the proportion of men having ≥ 3 syphilis tests in a year was highest in the clinics with the opt-out strategy (48%, range: 35% - 59%), compared to the opt-in (39%, p=0.12) and risk-based (8.4% range: 5.4% - 12%, p<0.01) |
Certainty of evidence |
⨁⨁⨁◯ MODERATETable 6 Footnote b,Table 6 Footnote c Risk of bias |
Syphilis screening as part of HIV viral load testing |
|
Syphilis tests on the same day as HIV viral loads (1 observational study)Table 6 Footnote p |
In 2010, same day tests was highest in clinics with the opt-out strategy (87%; range: 84% - 91%), compared with opt-in (74%, p=0.121), and risk-based (22%; range: 20% - 24%, p<0.01) |
Certainty of evidence |
⨁⨁◯◯ LOWTable 6 Footnote a,Table 6 Footnote b,Table 6 Footnote c Risk of bias, Imprecision |
Number of syphilis tests (1 observational study)Table 6 Footnote p |
Over 50.8% of incident syphilis cases were asymptomatic and were only identified through routine screening. |
Certainty of evidence |
⨁⨁◯◯ LOWTable 6 Footnote a,Table 6 Footnote b,Table 6 Footnote c Risk of bias, Imprecision |
Appendix 4: Environmental scan of guidelines
Organization | Recommendation | Critical appraisal of guidelines Type of evidence considered, Stakeholder engagement Evidence gaps identified in guideline AGREE II Appraisal Footnote 34 |
Health equity considerations PROGRESS-Plus factors identified Footnote 61Footnote 62 |
---|---|---|---|
All STI testing should include both HIV and syphilis testing For men who have sex with men (MSM): at least annually, up to 4 times a year (every 3 months). Even men in monogamous relationships or who are not sexually active are encouraged to undergo at least annual testing For HIV positive MSM, up to 4 times per year or at least on each occasion of CD4/viral load monitoring Routine antenatal testing (repeat in late pregnancy if at risk of infection or reinfection e.g. Aboriginal populations in context of current outbreak). Routine immigration testing A sexual contact of a person with syphilis Presence of any signs and symptoms of infectious syphilis Congenital syphilis Routinely offer/recommend screening at first antenatal visit Recommend repeat testing early in the third trimester (28 to 32 weeks) For high-risk individuals, further testing at 6 weeks post-partum is recommended |
Evidence used: Published guidelines (WHO, 2021; BASHH 2022, CDC 2021), expert opinion. Stakeholder engagement: Yes Gaps identified: None identified Overall quality: 4 Many AGREE II items are not reported. The following domains cannot be assessed completely, or at all: Domain 2, 3,4,5,6 No scheme for grading statements is provided. |
PROGRESS-Plus factors identified: MSM, Aboriginal populations, Immigrants |
|
UK national guidelines on the management of syphilis 2015 updated 2019 |
Repeat screening is recommended at 6 and 12 weeks after a single 'high risk' exposure (unprotected oral, anal or vaginal intercourse with MSM, multiple partners, anonymous sex in saunas and other venues, commercial sex worker or sex partner linked with a country where the prevalence of syphilis is known to be high). Individuals at ongoing risk due to frequent 'high risk' exposures. Screening as part of routine sexual health check-ups for all STIs including HIV and others is recommended, usually every 3 months and informed by sexual history. Two weeks after presentation in those with dark field or PCR negative ulcerative lesions that could be due to syphilis. |
Evidence used: UK and US guidelines, Literature reviews using Medline, Cochrane library and Embase and expert opinion Stakeholder engagement: Yes Gaps identified: None identified Overall quality: 4 Many AGREE II items are not reported. The following domains cannot be assessed completely, or at all: Domain 2, 3,4,5,6 GRADE was used to report graded recommendations and the quality of evidence |
Not reported. However, discussed health promotion principles needed for the effective management of syphilis |
Sexually Transmitted Infections Treatment Guidelines, 2021 CDC 2015 version |
Syphilis serologic testing is indicated to establish whether persons with reactive tests have untreated syphilis, have partially treated syphilis, or are manifesting a slow or inadequate serologic response to recommended previous therapy. Persons in correctional facilities Opt-out screening for incarcerated persons should be conducted on the basis of the local area and institutional prevalence of early (primary, secondary, or early latent) infectious syphilis. Correctional facilities should stay apprised of local syphilis prevalence. In short-term facilities, screening at entry might be indicated. STI screening of persons with HIV Infection in HIV care settings More frequent screening for syphilis, gonorrhea, and chlamydia (e.g., every 3 or 6 months) should be tailored to individual risk and the local prevalence of specific STIs. MSM Syphilis serologic testing is indicated to establish whether persons with reactive tests have untreated syphilis, have partially treated syphilis, or are manifesting a slow or inadequate serologic response to recommended previous therapy. |
Evidence used: Literature reviews, expert opinion Stakeholder engagement: Yes Gaps identified: None identified Overall quality: 5 Evidence-to-decision tables are not included. |
Prisons and other closed settings Occupation: Sex workers Gender: transgender people Sexual orientation: gbMSM Age: adolescents, young adults Other vulnerable and socially excluded groups |
European Management Syphilis guideline 2020 2014 version |
Populations at risk of syphilis infection MSM HIV-positive MSM The screening of ethnic minorities, marginalized populations, sex workers and people who inject drugs (PWID) should be informed by local syphilis epidemiology Routine tests for syphilis should be taken in:
|
Types of evidence considered: Systematic review, expert opinion Stakeholder engagement: Yes Gaps identified: None identified Overall quality: 4 Evidence-to-decision tables are not included. No grading scheme is used. Stakeholder engagement: Not specified. |
Covers PROGRESS-Plus factors |
Syphilis testing for:
|
Types of evidence considered: Guidelines, Systematic review, and health technology reports, expert opinion Stakeholder engagement: Yes Gaps identified: None identified Overall quality: 6 Evidence-to-decision tables are included. GRADE was used to report graded recommendations and the quality of evidence Stakeholder engagement: Yes |
PROGRESS-Plus factors identified: MSM, Sex workers, Immigrants |
|
MSM (at least annually, but ideally with every sexual health check) HIV positive (at least annually, but ideally with every sexual health check) Routine antenatal screen; consider rescreening in later pregnancy if:
|
Types of evidence considered: Not mentioned Stakeholder engagement: Yes Gaps identified: None identified Overall quality: 3 Many AGREE II items are not reported. The following domains cannot be assessed completely, or at all: Domain 2, 3,4,5,6 Evidence-to-decision tables are not included. No grading scheme is used. Stakeholder engagement: Not specified. |
Included young people, men who have sex with men (MSM) and Māori and Pacific people. Used a "cultural safety" approach to overcome Inequities in health care |
|
Société Française de Dermatologie et de pathologie sexuellement transmissible (2016) |
Screening for syphilis is suggested for:
|
Types of evidence considered: expert opinion Stakeholder engagement: unclear Gaps identified: None identified Overall quality: 2 Many AGREE II items are not reported. The following domains cannot be assessed completely, or at all: Domain 2, 3,4,5,6 Evidence-to-decision tables are not included. No grading scheme is used. Stakeholder engagement: Not specified. |
Covered MSM, Pregnancy, migrant workers, Drug users |
The USPSTF recommends screening for syphilis infection in persons who are at increased risk for infection. MSM Persons living with HIV Other factors associated with syphilis infection:
"The optimal screening frequency for persons who are at increased risk for syphilis infection is not well established. Men who have sex with men or persons living with HIV may benefit from more frequent screening. Initial studies suggest that detection of syphilis infection in MSM or persons living with HIV improves when screening is performed every 3 months compared with annually." This recommendation is consistent with the 2016 USPSTF recommendation. |
Types of evidence considered: Systematic review, expert opinion Stakeholder engagement: Yes Gaps identified: None identified Overall quality: 6 Evidence-to-decision tables are not included. GRADE was not used to report graded recommendations and the quality of evidence Stakeholder engagement: Yes. |
Covered sex and gender, race and ethnicity inclusive of all persons at increased risk for syphilis. |
|
Provincial/Territorial guidelines | |||
Routine screening is recommended for people with risk factors for syphilis. A diagnosis of syphilis should be considered in anyone with signs or symptoms compatible with syphilis and also in the individuals at risk for sexually transmitted infections, such as:
|
Types of evidence considered: Adapted from the Canadian Guidelines on Sexually Transmitted Infections for provincial use with permission from the Public Health Agency of Canada |
n/a |
|
British Columbia Centre for Disease Control (BCCDC) (2016) Updated |
Syphilis screening is needed if:
Additionally, BCCDC has included predisposing factors rather than high-risk groups; those predisposing factors are:
|
Types of evidence considered: Adapted from the Canadian Guidelines on Sexually Transmitted Infections for provincial use with permission from the Public Health Agency of Canada |
n/a |
INESSS Pharmacological treatment STBBI – Syphilis (March 2016) |
Routine screening is recommended for people with risk factors for syphilis. In addition to completing diagnostic laboratory analyses for all individuals exhibiting signs and symptoms consistent with syphilis, the following individuals should also be screened for syphilis: Any asymptomatic person presenting risk factors (see the tool titled Tableau sur les ITSS à rechercher selon les facteurs de risque décelés at the following URL: www.msss.gouv.qc.ca/itss, Documentation section, under Professionnels/outils [French only]) |
Not clear |
n/a |
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