Syphilis is a sexually transmitted infection caused by the bacterium Treponema pallidum. A major public health issue in developing countries, the condition develops over four stages and is potentially fatal if untreated. A pregnant woman with syphilis can transmit the infection to her baby, which may result in a severe condition in liveborn infants, stillbirth, or neonatal death. Syphilis infection can be transmitted by direct person-to-person contact via open sores on the lips, mouth, genitals and other areas, and during vaginal, anal or oral sexual intercourse. Open sores also increase the risk of human immunodeficiency virus (HIV) infection. Universal syphilis screening within an existing antenatal care program has been advocated as an effective way to reduce syphilis-associated adverse outcomes. However, despite decades of syphilis-testing programs and substantial advances in screening technology, successful prevention and treatment of syphilis have been limited. This is largely due to delays in the identification and treatment of infected women. Technical and logistical difficulties with testing, lack of antenatal care, and poor-quality services are possible contributing factors. It is therefore crucial to investigate available randomised controlled trials to determine which test strategies are most effective in developing countries.
Two included trials assessed point-of-care syphilis testing against conventional testing methods. The first trial was carried out in Mongolia and compared the rapid treponemal test with conventional testing. The point-of-care testing provided screening, test results and treatment within the same day. The trial reported a marked improvement in screening coverage, case detection and treatment, both at the first visit and in the third trimester, compared with conventional screening. The second trial was conducted at primary healthcare clinics in rural South Africa. On-site screening using the rapid plasma reagin (RPR) test was compared with conventional testing. Among women who tested positive for syphilis, no clear reduction in perinatal deaths was observed in those who had RPR testing compared with conventional testing, and technical and logistical difficulties were reported.
Both trials were mainly at high risk or unclear risk of bias. In one trial, in Mongolia, on-site screening was better at detecting syphilis cases. More trials are warranted, especially in regions where the disease burden is increasing and HIV co-infection is probable due to high HIV/AIDs prevalence.