Antenatal syphilis screening in sub-Saharan Africa: lessons learned from Tanzania


Philippe Mayaud (corresponding author), Deborah Watson-Jones, Monique Oliff, David Mabey and Richard Hayes, Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK. Tel.: +44 207 927 2291; Fax: +44 207 637 4314; E-mail:, or, or,,
Fern Terris-Prestholt and Lilani Kumaranayake, Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK. Tel.: +44 207 612 7886; Fax: +44 207 637 5391; E-mail:,
John Changalucha, National Institute for Medical Research (NIMR), PO Box 1462, Mwanza, Tanzania. Tel.: +255 28 2500399; Fax: +255 28 2500654; E-mail:
Balthazar Gumodoka, Bugando Medical Centre, PO Box 1370, Mwanza, Tanzania. Tel.: +255-28-40610/5; Fax: +255-28-2500799
Ave-Maria Semakafu, Institute of Development Studies, Muhimbili University College of Health Sciences, PO Box 65454, United Nations Road, Dar es Salaam, Tanzania. E-mail:
Awene Gavyole, African Medical & Research Foundation (AMREF), PO Box 2773, Dar Es Salaam, Tanzania. Tel.: +255 22 2130860; Fax: +255 22 2115823; E-mail:


Objectives  To synthesise data from four recent studies in Tanzania examining maternal syphilis screening and its operational implementation in routine antenatal clinics (ANC), drawing lessons for strengthened antenatal services for the prevention of mother-to-child transmission (PMTCT) of HIV.

Methods  The impact of untreated maternal syphilis was examined in a retrospective cohort of 380 Tanzanian women. Effectiveness and cost-effectiveness of screening and single dose benzathine penicillin treatment were prospectively examined in 1688 pregnant women. Observation, interviews and facility audits were carried out in health facilities within nine districts to determine the operational reality of syphilis screening.

Results  Overall, 49% of women with untreated high titre syphilis experienced an adverse pregnancy outcome compared with 11% of uninfected women. Stillbirth and low birthweight rates among those treated for high- or low-titre syphilis were reduced to rates similar to those for uninfected women. The economic cost was $1.44 per woman screened and $10.56 per disability-adjusted life year saved. In the operational study, only 43% of 2256 ANC attenders observed were screened and only 61% of seroreactive women and 37% of their partners were treated. Adequate training, continuity of supplies, supervision and quality control are critical elements for strengthened antenatal services, but are frequently overlooked.

Conclusions  Maternal syphilis has a severe impact on pregnancy outcome. Same-day screening and treatment strategies are clinically effective and highly cost-effective, but there are significant challenges to implementing syphilis screening programmes in sub-Saharan Africa. Current PMTCT interventions present an opportunity to reinforce and improve syphilis screening. Increasing PMTCT coverage will involve similar operational challenges to those faced by syphilis screening programmes.