Syphilis demands that we take action now. This sexually transmitted infection (STI) isn’t just a relic of the past. It’s a present-day concern with serious consequences. Syphilis, if left unchecked, can cause serious problems to the brain and spinal cord. What’s more, it poses a significant risk to unborn babies if transmitted from an untreated pregnant person. This is known as congenital syphilis. Unfortunately, this isn’t a rare occurrence.
According to the Public Health Agency of Canada, reported cases of infectious syphilis have surged by a shocking 109% since 2018. There were nearly 14,000 cases documented in 2022 alone. Around one-third of cases were among females (as reported by Public Health Agency of Canada), with the highest rates in the Prairie provinces and neighbouring territories. In 2022, there were also 117 cases of confirmed congenital syphilis reported in Canada. This is a massive 599% increase since 2018. To put this into perspective, the number of congenital syphilis cases in Canada today should be zero. This is because all pregnant people getting prenatal care are routinely tested for syphilis. This makes the surge even more concerning. To add to these challenges, some areas and populations in Canada are seeing a rise in new HIV cases.
In 2019, Alberta reported rates of infectious syphilis not seen since the 1940s. Most transmissions, as reported by the Alberta government, were through heterosexual sex. The province has also reported a huge rise in congenital syphilis, about 20% of which have resulted in infant death. This is a result of many intersecting issues, including the epidemics of stimulant and opioid use, the effects of racism and colonization, unstable housing, poverty and incarceration. All can lead to stigma and mistrust of the healthcare system, resulting in reluctancy to use health services.
Given this catastrophic situation in Alberta, we decided to examine whether rapid point of care testing (RPOCT) for syphilis and HIV could help. RPOCT allows for someone to test and, if positive, get treatment for syphilis in a single visit. Immediate treatment prevents syphilis from getting worse. It also prevents transmission to sex partners and unborn children. Finally, it reduces the need to come back for more treatment. Our “Point of Care tests for syphilis and HIV” or “PoSH” study examined RPOCT in five locations: two emergency departments, a provincial correctional facility, a First Nations community and an STI clinic.
The study found 226 new cases of syphilis. It confirmed that we could test and treat syphilis in one visit. Of the 226 cases, our team diagnosed four new cases of HIV, 20 who were previously known to be positive. An HIV test meant that we could quickly link them to care to start or restart treatment. Fortunately, the treatment for syphilis is simple. It typically involves a single injection of penicillin, and has not changed in decades. Also, syphilis usually presents the same regardless of someone’s HIV status. Only a few people living with HIV will encounter severe complications.
After our study, Canadian health professionals got the green light to use the INSTI Multiplex RPOCT for syphilis and HIV. The approval in March 2022 marked a significant milestone. It lead to a wider adoption of testing across Alberta, which allowed nurses to offer RPOCT in the provincial STI program and STI clinics across the province.
A report from Alberta Health found that three quarters of congenital syphilis cases could have been prevented. These people had used health services while pregnant, usually in an acute care centre, but were not screened for syphilis. So, we decided to offer testing in hospitals that were seeing babies with congenital syphilis. To address this gap, we launched a new initiative called SHACC (Syphilis and HIV in Acute Care and Community settings). Its goal was to introduce RPOCT in several hospitals and community sites across Alberta. This would ensure that those at risk, including pregnant people, are offered syphilis and HIV testing when seeking care. Currently, six hospitals and 18 community sites in Alberta are using RPOCT as part of the SHACC initiative.
Looking ahead, with the support of two Canadian Institute for Health Research (CIHR) grants, we plan to advance testing in Alberta by including people with lived/living experience of HIV and syphilis in our health teams. We also plan to build an advisory committee with Indigenous Elders to ground our work in Indigenous ways of knowing.
Acknowledgments: The PoSH and SHACC study teams gratefully acknowledge all the participants in these initiatives and to our many funders and supporters including Sean Rourke and Kristin MacLennan (CIHR Centre for REACH), CIHR, Canadian Foundation for AIDS Research, Indigenous Services Canada, Alberta Health Services and Alberta Health.
Additional authors: Noel Ives, Jennifer Gratrix, Cari Egan, Petra Smyczek, Denise Lambert, Kevin Fonseca
Research roundup
Unprecedented Challenges Require Innovative Community Action
AllTogether4IDEAS,
University of Manitoba
Manitoba is grappling with alarming rates of syphilis and HIV. These rates are among the highest in the world. 2021 to 2023 saw the highest number of HIV cases ever recorded in Manitoba’s history. In 2022, Manitoba, Saskatchewan, and Alberta together had more than half of Canada’s infectious syphilis cases. They also had a significant portion of new HIV cases.
The AllTogether4IDEAS team is a collaborative partnership of programs and community-based organizations. We are committed to shedding light on HIV patterns in Manitoba compared to other provinces. Between 2018 and 2022, 773 people were referred to the Manitoba HIV Program. This is a drastic increase from previous years. This increase has redirected our efforts to focus on connections into community. It has forced us to adapt and apply existing tools to combat the current syphilis and HIV crisis. We are starting to build teams and put processes in place based on lessons from Alberta and Saskatchewan. These will test, treat and connect people to culturally appropriate care.
—Zulma Rueda & Yoav Keynan
Bringing Testing to Community in Saskatchewan
Saskatchewan Health
Authority, University of Saskatchewan
The SHIVER (Syphilis and HIV Early Response) study is led by Dr. Stuart Skinner at the Wellness Wheel Medical Clinic in Regina, Saskatchewan. It has been recruiting patients since February 2023. This study uses point of care tests for syphilis and HIV to improve access to testing, focusing on inner city, remote, rural and hard-to-reach populations across Saskatchewan. We are meeting people where they are at by going out into communities both on- and off-reserve, and offering HIV and syphilis testing. The SHIVER study offers people a choice to test for HIV, syphilis or both. The goal of the study is to recruit 1650 people. So far, we have reached over 800 patients, and the vast majority have chosen the dual HIV/syphilis multiplex test. The study runs in 12 clinic sites throughout Saskatchewan, including in eight First Nation communities, and we are adding new clinics and locations every day.
—Nikki Williamson & Cara Spence
The Power of Community
One Yukon Coalition
As syphilis and congenital syphilis cases rise across Canada, local community groups are stepping up to address the challenge. Recently, the One Yukon Coalition participated in The Ayaangwaamiziwin Initiative Summit in Winnipeg. This summit focused on building capacity and sharing knowledge. It showcased programs and research that emphasize the importance of community involvement and point-of-care testing initiatives to combat syphilis. In the Yukon, where the rate of infectious syphilis was 26 times higher in 2023 than in 2019, making testing and treatment more accessible is crucial. The summit showed the vital role of community organizations in reaching vulnerable populations. It served as an inspiration for all in attendance. Where there is community, there is power, and together we can work to create positive change.
—Justine Aman