It was spring 2023, and Dr. Irene Stafford had been called to the ER for what should have been a routine delivery.
But Stafford, a maternal-fetal medicine physician at the University of Texas Health Sciences Center in Houston, quickly realized something was wrong: She couldn’t find a heartbeat. The unborn baby boy had already died in the womb.
Soon after, the mother’s syphilis test — given to all women before delivery — came back positive. The infection had been silently passed from mother to son.
It’s a death, Stafford said, that could’ve been prevented with early detection and a shot of penicillin.
Syphilis, a sexually transmitted infection, was nearly eliminated in the U.S. at the beginning of the 21st century but has made a dramatic comeback. In 2022, the Centers for Disease Control and Prevention reported more than 200,000 syphilis cases — the highest counts since 1950. Congenital syphilis has similarly increased tenfold over the past decade, the CDC says, even though 90% of cases are fully preventable.
The return of syphilis is the result, experts say, of poorly funded prevention programs over the past two decades and difficulties in diagnosis; syphilis is referred to as the “great imitator” because its symptoms can vary so widely. Most people don’t show symptoms or know they’re infected, and even if they do visit the doctor’s office, there’s no guarantee they’ll be properly diagnosed.
Stafford said her patient didn’t have the resources to seek prenatal care, and no doctor or public health worker had ever told her that she should get tested for syphilis. So, when the patient noticed a small rash on her belly, she didn’t think too much about it, Stafford added.
“There’s a lot of people who are seen in private practice, hospital ERs, or walk-in centers, and those clinicians are not necessarily thinking of syphilis, they’re not necessarily getting a sexual history,” said Dr. Kenneth Mayer, an infectious disease physician and medical research director of the Fenway Institute in Boston. With a generation of doctors who saw few, if any, syphilis cases during their training, Mayer said that “the issue is tests not being done in the first place.”
The all-encompassing nature of the Covid pandemic added fuel to this fire, as public health departments redirected STI resources toward fighting the coronavirus.
“The solutions for controlling syphilis are relatively straightforward. We’re not talking about high tech approaches or a novel therapeutic,” said Dr. Dave Chokshi, chair of the Common Health Coalition and a former New York City Commissioner of Health. “It simply revolves around closing gaps in testing and treatment.”
As syphilis cases surge, doctors and public health officials are starting to develop innovative and sometimes unconventional strategies to screen people for syphilis and curb the spread of the disease.
Most often, that comes down to figuring out how to get people tested, a task that’s far easier said than done.
Spreading the word about syphilis
Given these challenges, some public health departments have launched eye-popping awareness campaigns, trying to raise the alarm among both the public and health care providers.
A few years ago, Donna Fox, the HIV and STI manager at the Toledo-Lucas County Health Department in Ohio, noticed that about one-fifth of syphilis cases in the area were among people who reported paying for sex.
So, trying to be proactive — and a bit provocative — Fox and her team ran billboards across the county in 2022 saying, “Paying for Sex? Get Tested!”
“We had to go bold, and we had to get to the point,” she said. The pushback was inevitable — “you might have to say something to your 10-year-old who can read,” Fox conceded — but the impact was measurable. From 2021 through 2022, the number of syphilis appointments scheduled via the county health department jumped by almost 50%, and syphilis cases dropped by 12%, she said.
Of course, syphilis doesn’t just spread among sex workers, so last year, Fox’s team broadened the campaign, keeping the same look and feel but instead saying “Syphilis is Serious” with “Spreading Locally!” overlaid over the side.
Other billboard campaigns across the country have featured giant bloodshot, infected eyes with the blurry words “Eye Syphilis is Serious” and a black silhouette of a pregnant woman with a red belly saying “Syphilis Can Be Fatal to Your Baby.” While these billboards are factually true, Mayer describes how this kind of fear-based campaign, or “loss frame,” draws lots of attention but may not be particularly effective at motivating behavioral changes for STIs.
“We’re not telling anybody not to have sex,” Fox said. “We’re telling people to have safe sex,” and to get tested afterward.
The sex positivity message isn’t just for the public. The Toledo-Lucas health department also launched an educational campaign for clinicians, reminding them to take a sexual history of all patients — since the county saw syphilis in people ages 15 to 72 last year — and to order a blood test if they suspect an STI, since the standard “pee in a cup” test can’t detect syphilis.
“Many physicians haven’t seen syphilis, and they’ve got a million things to know,” Fox said. “If we don’t talk to the physicians, we’re not going to get the testing we need done.”
Stafford, the maternal-fetal medicine doctor in Houston, has taken a more hands-on approach. Texas mandates syphilis testing for pregnant women at three points — during their first prenatal visit, around the 28-week mark and before delivery — but in reality, these tests are often missed. So, last year, Stafford launched an alert in UTHealth’s electronic medical records, prompting providers to test their pregnant patients for syphilis at each of the prescribed times. The simple tweak helped increase screening rates from 2% to 47% at all three timepoints, while decreasing congenital syphilis cases by half.
Chokshi sees this as another good example of the public health and health care systems working hand-in-hand, with the former “setting the parameters of what standard of care should look like” and hospitals making it a reality.
Make syphilis testing convenient
Beyond greater awareness, access to testing and treatment needs to be quick, easy and convenient, Chokshi said.
Indian Country has led the way on this, partly by necessity: American Indian and Alaska Natives have the highest syphilis rates of any racial or ethnic group, almost seven times higher than white people.
As such, tribes across the U.S. have turned to incentives, giving people $10 gift cards if they come in for STI testing or treatment, said Jessica Leston, founder of the Raven Collective, an Indigenous public health organization.
“We’re just helping people pay for gas and child care and get food on their table,” Leston said. At Cass Lake Indian Hospital’s pharmacy in rural Minnesota, the strategy increased STI testing tenfold, according to one study, with over 70% of the patients who got a test not having a primary care provider.
In 2023, a coalition of tribal communities partnered with Johns Hopkins School of Medicine to ramp up a program called I Want the Kit, which sends at-home STI test kits in the mail. The tests come in unmarked envelopes with instructions on how to collect a sample and send back the test. Results come back in a week or two, and patients are linked to health care resources if the test comes back positive.
Even with these programs, syphilis testing can be overshadowed by more immediate concerns.
In California, for example, half of pregnant women with syphilis reported methamphetamine use, and a quarter were homeless. In the state’s rural Shasta County, near the Oregon border, almost 100% of pregnant woman with syphilis similarly have a substance use disorder and 90% are unhoused, said Trojan Carvajal, a supervising public health nurse in the county’s STI unit.
In April 2023, Shasta County launched the CommUNITY Mobile Care Clinic, an RV retrofitted with a reception area and two exam rooms, bringing STI tests and treatments to the county’s most vulnerable — from homeless camps to pop-ups with the local LBGTQ community center. Importantly, there’s no STI branding on the mobile clinic itself, allowing people to feel more comfortable walking in to get tested.
Last year, one-third of all syphilis tests performed by Shasta County were done through the mobile clinic, according to Jai Winchell, a community education specialist with the county’s public health department. These people would likely have never sought syphilis services otherwise, Winchell said, but with this mobile clinic crisscrossing the county and arriving at their doorsteps, they can get tested and treated in just 30 minutes.
Piggybacking syphilis services
Shasta County’s mobile clinic also offers other services, including test strips for deadly drugs like fentanyl and xylazine, naloxone to reverse overdoses and referrals to addiction counselors, as well as water, snacks and dental kits, Winchell said. The idea is to address overlapping concerns together, while also attracting those who wouldn’t have considered STI testing, if not for the package deal.
This approach also helps build trust, said Dr. Arlene Seña, an infectious diseases physician at the University of North Carolina Chapel Hill, showing how mobile clinic staff are invested in you as a person with various needs, rather than a singular problem to be solved. “It might be more costly, but it’s also much, much more effective and helpful to the community,” Seña said.
Syphilis services can also be integrated with general health care services. In March, Stafford launched a rapid testing program at two Houston hospitals aimed at all pregnant women admitted to the emergency department. The program, called Preg-Out, was set up on an opt-out basis, so everyone got tested unless they refused. It took about 15 minutes, and women were offered prenatal care regardless of the result.
“We noticed that pregnant patients, especially those that end up having a child with congenital syphilis, often frequent the ED and don’t get tested,” Stafford said. In the three-month pilot, Stafford said testing rates for pregnant women increased twelvefold, with about 35% of their partners wanting to get tested as well.
Other hospitals have implemented opt-out screening programs for all patients, including Grady Memorial Hospital in Atlanta in one of their urgent care centers and the University of Chicago in their emergency department. Not every hospital has the resources to test everyone, Seña said, so she believes prioritizing pregnant patients, as done in Houston, can be a high-impact first step.
“You can’t just rely on public health departments to do the brunt of the work for STI recognition and prevention,” she said. “You have to go hand in hand with other providers in the community.”
The future ahead
The U.S. got syphilis rates down before, but that was in the 1990s, when HIV was ravaging through America.
“What changed behavior then was lethal, hard-to-treat disease,” said Mayer, from Fenway Health. “Now, you have a generation of people who may be less informed,” leading to lower rates of condom use and STI screening rates.
However, it’s also a time of innovation. In June, the CDC recommended doxycycline post-exposure prophylaxis for high-risk groups — essentially, a morning after pill for STIs. If taken within 72 hours of condomless sex, so-called DoxyPEP reduces syphilis rates by over 70%, and Fenway Health, where half of patients are LGBTQ, has already begun ramping up distribution, Mayer said. Meanwhile, other researchers like Seña have been working on developing a syphilis vaccine, but that’s probably several years down the line.
“Our task right now is to arrest the growth in cases,” said Chokshi, from the Common Health Coalition, and he’s optimistic that these innovative awareness, testing and treatment campaigns can do that. But permanently bending the syphilis curve will require scaling these efforts nationally and promoting greater coordination between health care and public health.
“There’s no reason that the endgame can’t be, once again, trying to eliminate syphilis — this historic scourge that is completely preventable and treatable,” Chokshi said.
