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February 15, 2024
Dear Title X Family Planning Colleagues:
I am writing to provide an important update about rising cases of congenital syphilis and upcoming efforts by the Office of Population Affairs (OPA) to partner with you to address this trend. Title X clinics are a trusted source of sexual health in communities across the nation. OPA is committed to reducing the prevalence of syphilis, and I ask for your assistance in helping us achieve this goal.
The CDC recently published a report, Vital Signs: Missed Opportunities for Preventing Congenital Syphilis — United States, 2022, showing that congenital syphilis continues to be a significant epidemic in the U.S. Just in the past decade, cases rose by 10-fold; 9 out of 10 cases could have been prevented with timely testing and treatment. In almost 40% of cases, mothers received no prenatal care during pregnancy. We recognize the response to this public health challenge requires innovative ideas and new collaborations.
The report also highlights the importance of geography as a risk factor. For many sexually active people, the most significant risk factor for syphilis is living in a county with high rates of syphilis. Considering geographic risk can help reduce stigma and bias in syphilis screening. This improves access to syphilis testing and treatment for everyone.
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We want to be clear that Title X grant recipients have the flexibility to expend Title X funds to support testing, diagnosis, and treatment of sexually transmitted infections (STIs)—including syphilis—as part of Title X core services. We encourage all Title X grant recipients and service sites to offer syphilis testing to all sexually active people aged 15-44 years in counties with a rate of primary and secondary syphilis among women aged 15-44 that is greater than 4.6 per 100,000. In counties with a rate of primary and secondary syphilis lower than 4.6, providers should continue to assess individual risk factors to determine screening needs as outlined in existing CDC STI screening recommendations.
Here are additional actions Title X grant recipients can take to address the increase of congenital syphilis:
- Use AtlasPlus to assess the rates of primary and secondary syphilis in people of reproductive age (15-44) in the counties you serve.
- Screen at the earliest possible time in pregnancy. This can include pregnancy testing at Title X sites. Any pregnancy encounter is an opportunity to screen for syphilis.
- Ensure timely treatment once a positive syphilis test is identified. This can include pregnant patients and their partners per CDC STI Treatment Guidelines.
- When lost-to-follow-up is a concern, consider use of a rapid syphilis test to identify and immediately start syphilis treatment. Look for more information to be released soon.
- Consider point of care (rapid) and "opt-out" testing strategies to reduce barriers encountered with other screening methods and as a mechanism to normalize screening.
- Consider adoption of "Express STI Testing." Express STI services refer to triage-based STI testing without needing a full clinical exam. Research shows that express STI services increase clinic capacity and reduce the time to begin treatment.
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Set up injectable syphilis treatment delivery programs.
- Implement the use of Doxy PEP. Read guidance on the use of doxycycline post-exposure prophylaxis.
- Engage with State STI and Ryan White HIV/AIDS programs on efforts to address rising rates of syphilis (e.g., provider education, testing and treatment programs, and public awareness campaigns).
- Partner with organizations that provide care to pregnant women to make testing more accessible, expedite treatment, enhance case-tracking, and link people with necessary services.
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Collaborate with community programs that care for those who have medical, economic, or social vulnerabilities to reduce structural barriers to syphilis care. Racial and ethnic disparities in congenital syphilis rates reflect the need to make testing and treatment more accessible.
Thank you for your continued support and partnership in assisting us to combat the syphilis epidemic in your communities. Please distribute this widely so that we can all collectively work together to address this very serious issue.
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