Rwanda’s low coverage of syphilis testing among pregnant women is putting mothers and newborns at risk of severe complications – such as stillbirth, newborn death, and babies born with congenital syphilis – which could be prevented with early diagnosis and treatment, according to health officials.

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Fewer than 70 percent of pregnant women in Rwanda are currently tested for syphilis during antenatal care visits, said Dr Gallican Rwibasira, the Head of the National HIV, Sexually Transmitted Infections (STIs) and Hepatitis Programmes at Rwanda Biomedical Centre (RBC).

"This gap is mainly due to the country’s continued reliance on laboratory-based testing, which delays results and increases the risk of patients not returning for treatment,” said Dr Rwibasira.

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Dr Rwibasira noted that syphilis is often a silent infection, as many people have no visible symptoms. As a result, patients asked to return later for lab results may never come back, leaving infections undetected and untreated.

Syphilis is a bacterial infection spread primarily through vaginal, anal and oral sex. It can also be transmitted during pregnancy, leading to stillbirth, newborn death or congenital syphilis, a condition in which babies are born infected. The World Health Organization (WHO) estimates that most syphilis infections are asymptomatic or go unrecognized, increasing the danger of late diagnosis.

Globally, around eight million adults aged 15–49 acquired syphilis in 2022.

When untreated, treated late or treated with the incorrect antibiotic, syphilis in pregnancy results in adverse birth outcomes in 50 to 80 percent of cases, according to WHO.

The infection is preventable and curable, or can be treated effectively but the only challenge is identifying people in time, especially those without visible symptoms, Dr Rwibasira said.

For pregnant women, WHO recommends benzathine penicillin (BPG) injection as the first-line treatment. BPG is the only WHO-recommended option for treating syphilis during pregnancy. As second-line treatment, antibiotics like doxycycline, ceftriaxone or azithromycin may also be used.

Dr Rwibasira noted that testing is the crucial first step.

He said that Rwanda still relies largely on laboratory-based methods that require collecting blood samples and waiting for results. Introducing point-of-care testing – rapid tests that deliver results within minutes, he said, would allow healthcare providers to diagnose and treat syphilis immediately.

While the current rapid test panels in Rwanda have focused on HIV and hepatitis B, a new WHO prequalified rapid test panel makes it possible to screen for HIV, hepatitis B and syphilis at once during a single clinic visit.

"The scientific evidence is clear that it helps. However, the timeline for rolling out this rapid test panel in Rwanda depends partly on the availability of funds,” Dr Rwibasira said, noting that early diagnosis is important because standard antibiotic doses for adults do not always apply to newborns once the infection has been passed on, which is why it advisable to push for screening during antenatal care visits.

Why testing must be confidential, respectful

Syphilis also affects other vulnerable groups including gay men.

In Rwanda, targeted STI clinics and 12 health facilities now provide youth-friendly and key population services, screening for HIV and other STIs, even among patients who do not report symptoms, Dr Rwibasira noted.

"We ask about symptoms, but also test those who don’t have visible signs. People with multiple sexual partners, sex workers and other high-risk groups are vulnerable.”

Dr Rwibasira said that untreated syphilis can have serious consequences, including sterility (being unable to have children) in both men and women, heart disease and neurological damage. He advised that people who suspect they may have syphilis should speak to their health-care provider.

WHO advises that correct and consistent use of condoms can also reduce the risk of syphilis.

Dr Rwibasira noted that stigma is the main barrier to testing.

"If someone tests positive for HIV, hepatitis B or syphilis, people may judge their sexual behaviour, which is why testing must be confidential and respectful.”

In Rwanda, most public health campaigns have focused on HIV and, to some extent, hepatitis B, while syphilis and other sexually transmitted infections have received less attention.

Dr Rwibasira put emphasis on the need for the media and communities to help raise awareness about these infections.

RBC is now working to integrate awareness campaigns for HIV, hepatitis B and syphilis, explaining that these infections often share transmission methods and prevention strategies.

"The mode of transmission is the same, and the prevention methods are similar. If we promote condom use to prevent HIV, it also helps prevent syphilis.”

The consequences of missing an infection in pregnancy can be tragic and lifelong, he said. Perinatal syphilis is harder to treat after birth, and babies can be left with serious complications.