Scaling Up Syphilis Testing in China: Implementation beyond the Clinic/ Etendre le Depistage De la Syphilis En Chine Au-Dela Des Dispensaires/ Expansion De Las Pruebas De la Sifilis Fuera del Ambito De Los Dispensarios En China

Introduction In 2008, China had 278 215 officially reported syphilis cases--a threefold rise in the number of reported cases compared to 2004 and a tenfold increase over the past decade) The majority of syphilis cases are in regions of China that also have a substantial burden of sexually transmitted HIV infection, highlighting the importance of effective syphilis control efforts. (1) Technical advances in syphilis diagnostics now permit onsite identification of syphilis cases using sensitive and specific treponemal tests, (2) thus enabling programmes to plan for syphilis testing outside traditional clinical settings. (3) Although validated point-of-care syphilis tests are available at prices negotiated by the World Health Organization (WHO), successful pilot programmes have been implemented in high burden areas, and policy latitude for screening and scale-up already exist, routine syphilis screening has not been widely implemented in China. (4) Public health authorities keep records of syphilis testing and treatment since syphilis cases cluster and re-infection rates are high. (5) Coordination of clinical and public health functions is no small task, and this is why developing rationale syphilis policy is very important. Syphilis case reporting to local public health departments allows partner notification and treatment, which are both centrally important in syphilis control programmes. This paper reviews the current Chinese syphilis policy and introduces a theoretical framework for syphilis screening based on high-risk times and places (i.e. spatiotemporal). The WHO syphilis programme shows how onsite rapid syphilis testing enhances syphilis control using this framework. Finally we propose a comprehensive plan to improve the quality of syphilis screening and control programmes in China. Current syphilis policy Since syphilis re-emerged in China as a major sexually transmitted infection, (1) the national response has focused on prompt and effective clinical services for high-risk patients. (6) Chinas national syphilis policy recommends screening for individuals who have multiple sex partners, unprotected sex or partners with a history of sexually transmitted infection (STI). This clinic-focused syphilis policy is similar to practice guidelines from Canada, (7) the Russian Federation, (8) the United Kingdom of Great Britain and Northern Ireland, (8) and the newly independent states of eastern Europe and central Asia. (9) Despite these recommendations, a large number of high-risk patients in many regions of the world fail to receive regular syphilis screening. Incomplete syphilis screening in China relates to two linked problems: (i) limitations of traditional STI clinical services in reaching high-risk groups, and (ii) a failure to implement effective interventions. Unsafe commercial sex and unsafe homosexual sex are major drivers of the resurgent syphilis epidemic, (10) but there is ample data suggesting that neither sex workers nor homosexual men attend clinics in great numbers. (11,12) When these high-risk individuals do attend public clinics in China, there is often no record of their detailed sexual history, which is not in line with official guidelines. (13) There is no tradition of secondary case finding or partner notification in China (or in many low-income nations), so all related infections remain untreated. In addition, the lack of laboratory facilities to perform standard diagnostic tests in some parts of China has led to the use of syndromic STI management, an approach with poor sensitivity for the detection of syphilis infection. (14) Several aspects of the Chinese syphilis epidemic make a spatiotemporal framework for screening particularly important. China has an estimated 4-6 million sex workers (15) and the commercial sex industry has rapidly expanded during the past 10 years. (16) A population-based study of sexual health in China suggested that commercial sex is more important than casual sex in spreading STIs. …

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