SYSTEMATIC REVIEW

Introduction of rapid syphilis

testing in antenatal care: A
systematic review of the impact on
HIV and syphilis testing uptake and
coverage
by :
Taufik Setiawan
Rahmadonal M Iqhbal
Faiz Muhammad Al As’Ady
Zahira Rikiandraswida
Triyoga Sulistyaningsih
Abstract
Background:
• Global guidelines recommend universal syphilis and HIV screening for pregnantwomen.
Rapid syphilis testing (RST) may contribute toward achievement of universal screening.

Objectives:
• To examine the impact of RST on syphilis and HIV screening among pregnant women.

Search strategy
• We searched MEDLINE for Englishand non-English language articles published through
November, 2014.
Abstract
Selection criteria:

• We included studies that used a comparative design and reported on syphilis and
HIV test uptake among pregnant women in lowand middle-income countries (LMICs)
following introduction of RST.

Data collection and analysis:

• Data were extracted from six eligible articles presenting findings from Asia, Africa,
and Latin America.
Abstract
Main results:

• All studies reported substantial increases in antenatal syphilis testing following introduction of RST;
the latter did not appear to adversely impact antenatalHIV screening levels at sites already offering
rapidHIV testing andmay increase HIV screening among pregnant women in some settings.
Qualitative data revealed that women were highly satisfied with RST. Nevertheless, ensuring
adequate training for healthcare workers and supplies of commodities were cited as key
implementation barriers.

Conclusions:
• RST may increase antenatal syphilis and HIV screening and contribute to the
improvement of antenatal care in LMICs.
Backgrounds
syphilis and HIV
In 2008,1.4 million pregnant women had active 90 000
syphilis
neonatal deaths, 65
000 preterm or low
antenatal birth weight infants,
and 150
Given that screening is syphilis and HIV
a key step in the screening does not 000 infected newborns
prevention and care approach optimal
continuum, coverage in
most LMICs
Backgrounds
to conduct a systematic review of
primary objective the impact of RST on syphilis and
HIV screening among pregnant
women in ANC settings.

to describe the factors identified as

influencing the effective
secondary implementation of RST and RHT in
objective
ANC settings, as presented in eligible
studies.
Materials and Methods
This study performed a systematic review in accordance with the PRISMA
guidelines, searching PubMed using keyword :
“Rapid syphilis” and “HIV”
“point of care” and “syphilis” and “HIV”
“immunochromatographic” and “syphilis” and “HIV”
“infectious disease transmission, vertical prevention and control” and “HIV”’
and “syphilis”

Searches were limited to studies published after 1999 and last searched was
November 2014.
Eligibility criteria
Published in a peer-reviewed journal
Conducted in an LMIC
Conducted among pregnant women
Reporting on both HIV and syphilis test uptake
following introduction of RST
Employing a comparison design
RESULT
Table 2 summarizes antenatal syphilis and HIV
screening outcomes by study. Baseline levels of
antenatal syphilis screening varied. Four articles
evaluated the introduction of RST in settings where no
pregnant women or only 1% to 2% were tested for
syphilis at baseline. Baseline antenatal syphilis
screening was highest in Zambia, where 79.9% of first-
time ANC attendees were screened.
Table 2
Summary of testing coverage outcomes from studied included a systemic review to determine the impact of rapid syphilis testing on
antenatal syphilis and HIV testing uptake and coverage
Author, year Syphilis testing coverage outcomes HIV testing coverage outcomes

Mabey et al. 2012 [22] China Uganda

Data on syphilis screening was not available prior to the See Strasser et al. 2012 [21] Zambia
introduction of RST; testing was done by a laboratory, and See Strasser et al. 2012 [21]
testing services were not widely available in rural China.
Following the introduction of RST, 96.0% (5272/5489) of
pregnant women were screened
Peru
Increase in the proportion of pregnant women screened for
syphilis (58% to 82%) [14]
Tanzania
Increase in the proportion of pregnant women screened for
syphilis (17.8% [634/3561] to 100% [58 249/58 249])
Uganda
See Strasser et al. 2012 [21] Zambia
See Strasser et al. 2012 [21]

Pai et al. 2012 [23] Increase in proportion of pregnant women screened for HIV, syphilis, and hepatitis B (9% [90/1002] to 96% [1002/1046])

Delvaux et al. 2011 [24] [24] Intervention areas: Coverage of syphilis testing among
the expected number of pregnant women increased in the Intervention areas: Coverage of HIV testing among the
total project area (0% to 77% [16 529/21 478]) and at each expected number of pregnant women increased in the total
demonstration area (0% to 50% in a demonstration project project area (55% [11 827/21 592] to 86% [18 394/21 478])
area comprised of one operational district, 0% to 88% in a and at each demonstration area (55% to 80% in a
demonstration project area comprised of four operational demonstration project area comprised of one operational
districts) Comparison area: No pregnant women were tested district, 55% to 88% in a demonstration project area
for syphilis at baseline or during the period RST was comprised of four operational districts) Comparison area:
implemented in the intervention areas Coverage of HIV testing among the expected number of
pregnant women increased (10% [427/4442] to 34%
[1512/4497])
 100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0% a b,c b b d d e
Peru Kenya Uganda Zambia Peru Tanzania Cambodia

Syphils Pre
Syphili
s Post HIV
Pre HIV
Post

Fig. 2. Proportion of pregnant women screened for syphilis and HIV prior to and following the introduction of rapid syphilis
testing. Note: Excludes data from China (data on syphilis screening prior to introduction of rapid syphilis testing (RST) not
available) and India (findings not disaggregated by test type). a Proportion of pregnant women screened who received
their results in less than 45 minutes. b Proportion of first-time antenatal care attendees screened. c HIV results are for
health facilities that did not experience stockouts of HIV test kits. d Proportion of pregnant women screened. No data on
HIV presented. e Proportion of expected number of pregnant women screened. Zero women were screened for syphilis
prior to introduction of RST.
Pai et al. reported that, in India, only 9% of the pregnant women
included in their study had been screened for HIV, syphilis, and
hepatitis B upon study entry  following a strategy of “triple
point-of-care testing,” 98% were screened for all three infections

In Peru, Flores et al. indicated that testing was conducted in the

hos-pital laboratory during the baseline period, leading to delays
in results reporting of up to 30 days and only 60% of pregnant
women screened receiving their HIV results in less than 45
minutes  Following the simul-taneous introduction of on-site
RST and RHT, 100% of women received their results in less than 45
minutes
Factors influencing effective
implementation
The simultaneous RST/RHT strategy reduced time burdens for pregnant women and significantly
shortened the time between testing and the provision of results
the simultaneous RST/RHT strategy required fewer staffing resources
RST was well accepted by healthcare workers, who found it easy to perform and were able to
test more people per day using RST
Discussion
This study systematically reviewed antenatal syphilis and HIV screen-ing uptake and coverage
following introduction of RST in ANC settings in LMICs
All studies and settings reported substantial increases in antenatal syphilis screening following
introduction of RST, whether in urban or rural settings, low-level health facilities, or tertiary
referral hospitals
Simultaneous introduction of RST and RHT may be a useful strategy for increasing both syphilis
and HIV screening coverage among pregnant women where neither is currently being conducted
a high syphilis testing coverage within ANC settings may still miss pregnant women who do not
attend ANC
R A P I D T E S T I N G A P P E A R E D A C C E P TA B L E T O
PREGNANT WOMEN. Q U A L I TAT I V E D ATA
R E V E A L E D T H AT P R E G N A N T W O M E N W E R E
H I G H LY S AT I S F I E D W I T H A N D P R E F E R R E D R A P I D
T E S T I N G . H I G H PAT I E N T S AT I S F A C T I O N M AY
H A V E B E E N D U E , AT L E A S T I N PA R T, T O
REDUCED TIME BURDENS SINCE RAPID TESTS
A L L O W S A M E - D AY R E S U LT S A N D T R E AT M E N T.

O N LY F L E M I N G E T A L . D O C U M E N T E D PAT I E N T
C O N C E R N S , S P E C I F I C A L LY I N R E L AT I O N T O A
L A C K O F I N F O R M AT I O N R E G A R D I N G R A P I D
TESTS, WHICH THE AUTHORS SUGGESTED
C O U L D B E A D D R E S S E D B Y E N S U R I N G H E A LT H
WORKERS ARE A D E Q U AT E LY TRAINED OR
THROUGH STRONGER COMMUNITY OUTREACH
CONCERNING TESTING. BENEFITS OF RAPID
T E S T I N G F O R H E A LT H C A R E P R O V I D E R S W E R E
ALSO D O CUMENTED, INCLUD ING INCREASED
E F F I C I E N C Y A N D J O B S AT I S F A C T I O N

C H A L L E N G E S T O E F F E C T I V E I M P L E M E N TAT I O N
I N C L U D E D E N S U R I N G A D E Q U AT E T R A I N I N G A N D
SUPPLIES OF HIGH-QUALITY COMMODITIES.
F R E Q U E N T S TA F F T R A N S F E R S , T E S T Q U A L I T Y,
AND HIGHER-LEVEL S U P P LY MANAGEMENT
I S S U E S A D V E R S E LY I M PA C T E D I M P L E M E N TAT I O N
O F R A P I D T E S T I N G . T H E S E A R E C O M M O N LY
CITED BARRIERS TO QUALITY CLINICAL CARE
A N D S C A L E - U P O F H E A LT H P R O G R A M S I N
RESOURCELIMITED SETTINGS
Strengths and limitations
The present study is subject to several limitations. Due to the restricted number of eligible
studies and reporting differences, we were unable to conduct a meta-analysis, although this
would have more accurately addressed the issue discussed.
The study is also subject to limitations inherent to reviewstudies.
Additionally, testing coverage outcomes may not be directly attributable to RST. For example,
RSTwas evaluated in the context of larger interventions in some studies
Finally, the present study did not examine the quality of testing, gestational age at testing,
outcomes related to timely and appropriate treatment, or impact on rates of MTCT of syphilis
and HIV—the ultimate measure of program success.
Nevertheless, the study possesses particular strengths. The original studies are geographically
varied and represent data from high- and lower-burden countries. In addition, some studies
reported on large samples of pregnant women (greater than 10 000) and included data from
entire districts
Implications
The findings suggest that RST can quickly yield large increases in antenatal syphilis screening
In some sites, RST may serve as a tool for improving implementation of RHT and antenatal HIV
screening coverage. Simultaneous introduction of RST and RHT, as well as other rapid tests (e.g.
hepatitis B), appears feasible and may increase screening for each infection.
RST may contribute to the EMTCT of both syphilis and HIV and serve as an opportunity to
strengthen ANC and health systems in LMICs.
Future efforts and evaluations will be necessary to ensure that pregnant women who screen
positive receive timely and appropriate interventions to prevent MTCT of syphilis and HIV.
Acknowledgments
◦ Andrea Swartzendruber was supported by the National Institute on Alcohol Abuse and Alcoholism
(grant number F32 AA022058).

Conflict of interest
◦ The authors declare that they have no conflicts of interest.
 DOES THIS REVIEW ADDRESS A CLEAR
QUESTION?

Yes, the review address a clearly focused issue. The focused

issue in this review is about impact on HIV and syphilis
testing uptake and coverage. There was enough information
on the population studied in this review.
 Did the authors look for the appropriate
sort of papers?

Yes, a standard form was used to extract information about

study design and setting, evaluation methods, HIV and
syphilis testing coverage outcomes, and factors influencing
implementation from each eligible study. The study design
of the studies in this reviews are pre/post time series design
and a prospective cross-sectional design
 ARE THE RESULTS OF THIS REVIEW VALID?
Yes, the results of this review are valid. This review includes
important and relevant studies about the focused issue. The
studies obtained from PubMed (MEDLINE) using keyword
combination that explained in materials and methods
paragraph. There were no language restriction. The authors
screened the titles, abstracts and full articles to identify
eligible studies and using a standard form. The results of all
the included studies are clearly displayed in table 2.
 WILL THE RESULTS HELP LOCALLY?

Yes, the results may contribute to the Elimination of Mother

To Child Transmission of both syphilis and HIV and serve as
an opportunity to strengthen Ante Natal Care and health
systems in Low and Middle Income Countries.