Syphilis rates have risen significantly in recent years, with a disproportionate impact observed in Black communities. “In Mississippi, there has been an 80 percent increase in recent cases and a 1000 percent increase in congenital syphilis in the last six years,” according to the University of Alabama at Birmingham.  

Because syphilis is a preventable and treatable disease, this dramatic increase points to larger, systemic issues regarding healthcare access, routine screening availability, and inadequate prenatal care. To reverse this trend, clinicians must improve early detection through proactive screening, recognize varied clinical presentations, and initiate timely treatment. Addressing barriers to care is essential to protecting the most vulnerable among us. 

By understanding updated testing protocols and treatment pathways, providers can emphasize prevention and continuity of care to mitigate this public health crisis. 

What is the Epidemiology of Syphilis?

Syphilis is a systemic sexually transmitted infection (STI) caused by the bacterium Treponema pallidum. Over the past decade, the United States has experienced an incredible surge in infections, reversing years of public health progress. This resurgence isn’t just at home, but also abroad. The World Health Organization (WHO) estimated that, globally, 8 million adults between 15 and 49 years old acquired syphilis in 2022. The most alarming aspect of this epidemic is the sharp rise in congenital syphilis, which occurs when the infection is passed from an infected mother to her fetus during pregnancy. 

“There has been an incredible increase in syphilis in the United States over the last ten years,” says Ayesha Bryant, MD, MSPH, the Clinical Advisor of Alpas Wellness in Maryland. She refers to preliminary data from the Centers for Disease Control and Prevention (CDC), which reported that congenital syphilis has increased by almost 700 percent since 2012. “Historically disadvantaged groups, such as Black communities, have experienced this disproportionate burden of disease. This represents larger issues with accessing healthcare, receiving screenings, having adequate insurance, and obtaining prenatal care.”

In America, the lingering memory of the infamous Tuskegee Syphilis Study creates both stigma about the disease itself and distrust of medical institutions meant to treat it. Consequently, addressing syphilis requires providers to address those historic realities head-on, as well as acknowledge the barriers to care common for today’s patients. 

Recognizing the Varying and Deceptive Clinical Presentations

Syphilis has historically been referred to as the “Great Imitator” because its symptoms mimic so many different diseases.

It is notoriously difficult to diagnose based on visual presentation alone. The infection progresses through distinct clinical stages, often presenting with mild or completely unnoticeable symptoms that do not seem related to a sexually transmitted disease at all. 

“When a person contracts syphilis in the early stages, they will likely experience a single, painless lesion which then heals on its own.” Dr. Bryant says. “In late-stage syphilis, the individual may begin experiencing rash, neurological symptoms, visual impairment, and/or cardiovascular-related complications. As such, clinicians require a very low threshold for performing syphilis screens on all sexually active individuals, pregnant women, and those who report having either one or multiple sex partners.”

Because many cases of syphilis are asymptomatic or go unreported, clinicians should obtain comprehensive sexual histories from their patients.

Improving Early Detection and Prenatal Screening Protocols

To combat rising infection rates, clinicians should consider more aggressive gestational screening. Ideally, there would be a very low threshold for performing syphilis screenings on all sexually active individuals, pregnant women, and patients with multiple sexual partners. Providers ask for comprehensive sexual histories from their patients to gauge risk accurately. Yet, self-reporting about sexual experiences can be unreliable, especially when behaviors are considered illegal, risky, or socially aberrant. 

Instead, providers should turn to modern diagnostic protocols that utilize both treponemal and non-treponemal tests. Treponemal tests detect antibodies against Treponema pallidum to determine whether a patient has a history of infection. Non-treponemal testing measures biomarkers and proteins associated with cellular inflammation due to active infection, allowing clinicians to monitor treatment progress. 

Universal screening is especially critical during pregnancy because congenital syphilis is completely preventable if the mother is diagnosed and treated before delivery. If left untreated, gestational syphilis can lead to miscarriage, stillbirth, premature birth, blindness, deafness, and permanent neurological damage. 

The American College of Obstetricians and Gynecologists (ACOG) recommends universal screening at the first prenatal visit, in the third trimester, and at delivery, regardless of risk, given the rising incidence of congenital syphilis. Early detection is the definitive way to protect both maternal and neonatal health. 

Stigma and Structural Barriers to Care

Even though highly effective diagnostic tools exist, deep social and structural barriers prevent patients from receiving timely care. Stigma surrounding sexually transmitted infections remains a primary obstacle. 

In many Black communities, people fear being judged by providers and are reluctant to disclose a complete sexual history. Additionally, some people fear that their symptoms are too far gone for treatment. Yet, early diagnosis may require just one dose of intramuscular antibiotics, while late-stage symptoms could require multiple weekly doses or consistent daily doses for 10-14 days.

To overcome these issues and the structural barriers to care, clinicians must intentionally build trust and create a neutral, non-judgmental environment during clinical encounters. It is imperative that physicians not rely on patient self-reporting as their primary tool.

What Patients Should Expect Following a Diagnosis

Once a syphilis diagnosis is confirmed, patients can be assured that the disease is fully curable regardless of how long they have carried the infection. The gold standard of care for all stages of syphilis is antibiotic therapy with penicillin. Patients can expect their healthcare team to administer the appropriate dosage of penicillin based on the specific stage and duration of their infection. 

According to the CDC, doxycycline/tetracycline is used to treat non-pregnant people with penicillin allergies. If the patient is pregnant, penicillin is the only recommended treatment. Pregnant patients with penicillin allergies must be desensitized, and doxycycline/tetracycline is contraindicated in the second and third trimesters.

However, the damage that late-stage syphilis can cause may not be reversible. This means that the longer a person waits to get care, the more likely it is that possible organ, heart, or brain damage will be permanent. This is why it is important to stop syphilis in its tracks — well before it causes blindness, dementia, or other debilitating conditions.

Following the initial treatment, continuity of care is vital to confirm complete resolution of the infection. The care team will schedule mandatory follow-up blood tests — specifically non-treponemal antibody titers — to verify that cellular inflammation is decreasing and that the treatment is successful. 

Also, the care team can help provide confidential assistance with partner notification and contact testing to prevent reinfection and stop the cycle of transmission. 

Clinicians can support patients by providing clear communication about results, explicit instructions on avoiding sexual contact until the infection is cleared, and ongoing support to ensure long-term wellness. 

Key Clinical Takeaways

• Clinicians must actively screen all sexually active individuals, pregnant women, and patients with multiple partners for syphilis. For a variety of cultural or personal reasons, patients may not be willing to divulge accurate self-reported sexual histories. 
• To prevent congenital syphilis, ACOG guidelines recommend universal screening at the first, second, and third trimesters, and at delivery. 
• Diagnosis requires both treponemal testing to confirm a history of Treponema pallidum infection and non-treponemal testing to monitor the success of penicillin therapy.

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