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Persons using assistive technology might not be able to fully access information in this file. During 2005--2006, CDC sought input from attendees at five national HIV and STD conferences.
Partner services can play an essential role in preventing and controlling HIV in the United States. HIV infection, DISs can provide additional prevention counseling or help them access more intensive risk-reduction interventions.
Well-implemented partner services balance the interests of infected persons, their partners, and the community. This report does not include a comprehensive discussion of all areas of law relevant to partner services. In addition, persons who believe that they are being coerced might lie or withhold information. At the state level, the legal concept of the duty to warn is complex; consultation with legal counsel is necessary. Legal counsel should also be consulted regarding specific cases in which duty to warn or privilege to warn might apply. Available evidence suggests that the majority of HIV-infected persons are not interviewed for HIV partner services.
Partner services are provided almost exclusively by health departments, often by STD program staff members. Partner services might be more difficult to provide for persons using anonymous testing than for those using confidential testing.
All persons with newly diagnosed or reported early syphilis infection should be offered partner services.
Penalties for unauthorized disclosure of information should exist for both surveillance and program staff members. All staff members should be informed of these penalties to ensure that data remain secure and confidential. Pregnant women are at risk for transmitting HIV and other types of STDs to their fetus both in utero and during delivery. The following categories of persons also are considered high-priority index patients for partner services for HIV.
Many program areas use a reactor grid to assist with determining investigative priorities for syphilis reactors. Interviewing index patients to elicit partner information is a cornerstone of partner services. Program managers should ensure that policies and procedures adequately address each of these elements. Criteria for prioritizing index patients vary somewhat according to the infection involved. SalazarI, II, IV IUniversity of Connecticut Graduate Program in Public Health, Farmington, Connecticut, United States of America. Data were analyzed by chi-square analysis, bivariate correlations, and two-tailed t-test for independent samples.
The estimated rate of congenital syphilis in the region was 767 per 100,000 live births. This prevalence combined with late entry into prenatal care contributes to adverse pregnancy outcomes and a high estimated rate of congenital syphilis.
More research is needed on congenital syphilis and prenatal-care-seeking practices of rural Haitian women in order to understand the impact of maternal syphilis in the region and improve pregnancy outcomes.
Los datos se analizaron mediante la prueba de la ji al cuadrado, correlaciones bifactoriales y la prueba de la t de dos colas para muestras independientes. Sub-Saharan Africa has the highest prevalence of gestational syphilis, with up to 17% of pregnant women testing positive for syphilis at antenatal clinics (2). Several Latin American and Caribbean countries, including Haiti, also have very high reported rates of the disease (3, 4). Congenital syphilis rates closely parallel rates of primary and secondary syphilis in women of child-bearing age (5).
Adverse pregnancy outcomes are known to occur in up to 80% of women with active syphilis during gestation (7). Congenital syphilis, particularly if untreated, usually causes deleterious consequences to the child-including deafness, blindness, and mental retardation. Given that 50% of infants with congenital syphilis are asymptomatic at birth (8), many such children born to women with unrecognized gestational syphilis could remain untreated.
Early prenatal screening for syphilis, and proper treatment of women during pregnancy, is therefore the most cost-effective approach to avoid prenatal complications and the high morbidity associated with congenital syphilis (9, 10). Both the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) strongly recommend that all pregnant women, regardless of where they live, be tested for syphilis in the early stages of pregnancy or on the first prenatal visit (11, 12).
It is also recommended that they receive timely and appropriate penicillin treatment in the event they have serologic evidence of syphilis. Available data from a CDC-sponsored syphilis seroprevalence study in 2003-2004 determined that the overall gestational syphilis rate in Haiti was 3.7% (13).

A more recent study showed that the rate has remained high (3.6%) and that in one particular region of Haiti, Jeremie, an even greater proportion (6%) of pregnant women have serologic evidence of syphilis (4).
Two of the very few studies done on gestational syphilis in rural Haiti include those performed in the north central Artibonite region of Haiti (14, 15). The studies show the gestational syphilis rates in that rural area of the island also to be close to 6% (14). How gestational syphilis adversely affects Haitian women and their offspring in rural regions of the country has not been properly studied. This investigation was therefore designed to measure the prevalence of gestational syphilis in a region of rural Haiti and, more precisely, to determine pregnancy outcomes for women who have serologic evidence of gestational syphilis.
All study procedures were reviewed and approved by the HHF Research Review Committee and the Institutional Review Board at the University of Connecticut Health Center. HHF began work in Jeremie in 1986 and has focused on providing high-quality maternal and child health care. HHF has clinics and a rural public health program, which have participated in sentinel CDC syphilis seroprevalence studies cited above. Primary services are provided by community health workers (CHWs or agents de santé). CHWs live in the villages, where they provide accessible preventive and curative care to 2000-3000 people.
PHACT maintains household and individual information, including information about each individual, family unit, and household with a unique numeric identifier. Information housed in the database includes demographic information, socioeconomic indicators, immunization status, maternal and child weights, pregnancy history, prenatal care, birth outcomes, and child spacing.
This test takes 10-15 minutes, so women who test positive are able to receive the first dose of intramuscular penicillin treatment on the day of testing. The Determine-TP rapid test (Inverness, Waltham, Massachusetts, United States of America) has been validated in several studies as an appropriate screening tool for low-resource areas (17-20).
Rapid point-of-care syphilis testing during pregnancy has been studied in Haiti and has been shown to be very cost-effective (10). The HHF treatment regimen at the time of this study was two doses of benzathine penicillin, 2.4 million units intramuscularly, given 8 days apart (see below for current treatment regimen). At the time of the second injection, affected women were asked to bring their partners for treatment to prevent reinfection.
These localities were chosen based on two criteria: length of time associated with HHF and number of pregnancies in 2004-2006. These criteria were used to provide a representative sample of women from the HHF service area.
According to a comparison with the PHACT database, approximately 10% of the paper prenatal records could not be found because they were lost or destroyed. Syphilis test dates, results, and treatment were entered into PHACT for the 507 prenatal records that were located.
Women with a known history of treated syphilis were to be excluded from the study; however, no women met this criterion. Additional verification was done by examining all available HHF death certificates and midwife reports for the study period.
In addition, community health agent interviews for the villages were used to verify miscarriages, stillbirths, and neonatal deaths. Congenital syphilis was defined according to CDC criteria (see Table 1) (21), which are based principally on maternal syphilis serologic status and whether the woman received appropriate treatment. Physical examination results were not available for infected infants because they are not routinely examined in the rural communities where they are delivered. A total of 507 women, ranging in age from 14 to 49 years, with a mean age of 28.6 years, were included in the study. Most women (72.3%) indicated they had a mari, a Kreyol word that may mean legal marriage but more commonly means cohabitation with a male partner. There was no significant difference in gestational syphilis prevalence rates by village.
Although 410 women were tested, clear documentation of the time during pregnancy when they were tested was available for only 350 (85% of those tested). All adverse outcomes were recorded as one variable in the data set and could not be separated for analysis.
All 3 infants were born to women who tested positive for syphilis and were either inadequately treated or received treatment within 30 days of delivery. One of the three infants died at delivery, most likely as a result of congenital syphilis. On the basis of these numbers, we estimate that the congenital syphilis rate for rural Jeremie is approximately 767 cases per 100000 live births.
This rate is no doubt very high but grossly underestimates the magnitude of the problem, as many offspring likely die in utero before delivery. The seroprevalence rate is significantly higher than the established rate previously determined for the entire country (4, 13). It is possible, but unlikely, that serologic evidence for syphilis represents infection with one of the nonvenereal endemic treponematoses, such as yaws.

This uncertainty is plausible because venereal syphilis and the endemic treponematoses are serologically indistinguishable (23). Although a global elimination campaign for yaws and other endemic treponematoses in the 1950s virtually eliminated the disease, there was a resurgence in some areas in the 1970s (24).
Endemic treponematoses, however, are not vertically transmitted (25); thus, one would not expect to see the relationship between adverse pregnancy outcomes and a positive treponemal assay found in this study if the high prevalence were due to one of the endemic treponematoses.
Further research is needed to help elucidate the social, cultural, and epidemiologic factors that may contribute to the regional variations in prevalence. It is possible that testing positive for syphilis may only be a marker for other factors that might influence pregnancy outcome, such as poor overall health, HIV status, and low socioeconomic status. Though treatment of gestational syphilis significantly decreases the risk of adverse pregnancy outcomes, women with syphilis during pregnancy are 2.5 times more likely to have adverse outcomes than women who were not infected at any time during pregnancy, even after treatment (26). A prospective cohort or case-control study controlling for variables such as HIV status and overall health might help to delineate this relationship more clearly.
Women in this study were found to enter prenatal care at an average of 23-25 weeks of gestation, which is much later than has been recommended by WHO (12). Possible reasons for this delay are lack of knowledge about the need for early prenatal care, social and financial costs of leaving marketing or agricultural work to attend visits, desire to keep pregnancy a secret in early stages, and lack of confirmation of pregnancy. Of even greater concern, 11% of women in this study were tested within only 30 days of delivery.
More research is needed to understand the prenatal-care-seeking practices of rural Haitian women, and increased efforts are needed to educate women about the importance of early prenatal care. The only congenital syphilis prevalence data available for rural Haiti are from studies in the Artibonite Valley, which showed a congenital syphilis rate of 550 cases per 100 000 (14, 15). On the basis of our current findings, we estimate a rate of 767 cases of congenital syphilis per 100 000 live births, which clearly indicates that the disease represents a critical public health problem that remains underrecognized and undertreated in this population.
As a result of this research, HHF has begun testing and treating all infants born to syphilis-positive mothers as recommended by the WHO congenital syphilis elimination program (1, 5).
Although the RPR assay likely yields many false positives (5), more specific treponemal tests generally have not been available in this low-resource setting. Treatment for syphilis-positive infants consists of a single intramuscular dose of penicillin per the WHO protocol (5), unless the child is symptomatic-in which case the infant is referred to the local hospital. Because of the well-known effects of syphilis in pregnancy combined with the high percentage of women affected in rural Haiti, both governmental and nongovernmental organizations working in rural Haiti should develop programs to help decrease the burden of syphilis.
Second, it is recognized that an important limitation of treponemal tests is that they can remain positive even after proper treatment for syphilis has been provided. Thus, someone previously treated for syphilis may be misdiagnosed as having a new, untreated case if only a treponemal test is used (16).
To address the latter, women in the HHF censused villages who have a positive Determine-TP rapid test are now being referred to Jeremie for confirmatory RPR and an HIV test. Changes in the HHF syphilis program already include the initiation of testing and treatment of neonates born to syphilis-positive mothers and changing the treatment protocol for gestational syphilis of unknown duration in pregnant women from two doses of penicillin to three to be consistent with CDC treatment recommendations (11).
In addition, HHF is placing greater emphasis on increasing the percentage of women who are screened for syphilis and providing education about the importance of early prenatal care and early syphilis screening. Specific recommendations being made to the Haitian MSPP include the following: (1) to make universal gestational syphilis screening and treatment more accessible in rural Haiti by providing rapid syphilis tests or laboratory supplies for the RPR to rural dispensaries and to ensure there is a continuous stock of penicillin at all rural and urban clinics, (2) to initiate universal testing and treatment of neonates born to syphilis-positive mothers as recommended by the WHO Congenital Syphilis Elimination Campaign, and (3) to undertake national education campaigns about the importance of early prenatal care.
This high prevalence combined with late entry into prenatal care results in poor pregnancy outcomes as well as a very high incidence of congenital syphilis. Clearly, maternal and congenital syphilis are underrecognized in this region of Haiti, and there is a need for increased program interventions and public education to reduce the burden of this preventable disease.
Future studies should be done on a larger number of villages, examining risk factors for gestational syphilis, documenting barriers to early prenatal care by using ethnographic methods, and having more in-depth documentation of congenital syphilis. Watson-Jones D, Oliff M, Terris-Prestholt F, Changalucha J, Gumodoka B, Mayaud P, et al. Cost-effectiveness of rapid point-of-care prenatal syphilis screening in sub-Saharan Africa.
Cost-effectiveness of rapid syphilis screening in prenatal HIV testing programs in Haiti.
Prevention of mother to child transmission of syphilis: integrated management of pregnancy and childbirth. Introduction of partner referral and treatment for control of sexually transmitted diseases in a poor Haitian community. Prospective, multi-center, clinic-based evaluation of four rapid diagnostic tests for syphilis. Evaluation of rapid diagnostic tests for the detection of human immunodeficiency viruses type 1 and 2, hepatitis B surface antigen, and syphilis in Ho Chi Minh City, Vietnam. Syphilis serology testing: a comparative study of Abbot Determine, rapid plasma reagin (RPR) card test and Venereal Disease Research Laboratory (VDRL) methods. A multi-centre evaluation of nine rapid, point-of-care syphilis tests using archived sera.

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