Syphilis: A Need for Renewed Focus and Attention Across Health Systems

Syphilis, a sexually transmitted infection (STI) caused by the bacteria Treponema pallidum, has affected many individuals around the world over centuries, and is re-emerging as a global public health challenge (Tao et al. 2023). There is currently no vaccine available for syphilis. Although antibiotics are effective, disparities in access to diagnostic testing, antenatal screening, supply chain challenges, as well as treatment and partner management, increase the complexity of caring for people impacted by the infection (Nelson 2023). In addition, the risk of antimicrobial resistance is an emerging threat to syphilis management as well as many other STIs (Tien et al. 2020). Over history, the prevention and management of syphilis have been complicated by stigma, blame, misinformation and disinformation (Freyne et al. 2023). Many populations who live in vulnerable situations or are marginalised have been infected unknowingly, and congenital syphilis is a growing and vexing problem (Silverstein et al. 2025). Cultural factors which affect the autonomy of women in care-seeking as well as intimate partner violence are important to consider in the detection and management of syphilis (Sharps et al. 2021). Perhaps the most notable and shameful case in the history of syphilis is The Tuskegee Study of Untreated Syphilis in the Negro Male in the United States, undertaken from 1932 to 1972, which observed untreated syphilis in Black men without informed consent or treatment even after penicillin was available (Brawley 1998). From identifying Treponema pallidum under the microscope in 1905, to developing the Wasserman test and identifying the first antimicrobial, syphilis has moved from an enigma to a treatable condition. The discovery of penicillin in the 1940s was a game changer for the treatment of syphilis (Maatouk and Moutran 2014). In concert with strong public health strategies there was significant optimism that syphilis could be eradicated (Rosset et al. 2025). Sadly, this is not the case. Despite declining numbers in the late 20th century, syphilis has resurged across the globe affecting both high and low-income countries (Tao et al. 2023). For example, there have been significant increases in notifications across Australia in the past decade and continue to have cases ofcongenital syphilis and associated infant deaths (King et al. 2024). This crisis situation prompted the Australian Chief Medical Officer Michael Kidd to declare a Communicable Disease Incident of National Significance the first ever for syphilis in Australia in 2025. The fact that this situation could occur in a high-income country with a robust health system is a strong signal of both the high risk of exposure and the complexity of managing syphilis. Across the world, health care systems are facing similar challenges but the burden of syphilis is most pronounced in low-income countries, where only 25% of pregnant women are screened (Fatima et al. 2025). Ensuring all health professionals, particularly nurses and midwives, consider the screening and management of syphilis across the care continuum is critically important. Untreated syphilis can manifest in systemic complications across the life course (Zhou and Chanderraj 2023, 21). In this commentary, we outline the critical issues in the management of syphilis—some of which are historical but others that are emerging and becoming more complex in the context of geopolitical uncertainty and shifting social norms. The World Health Organization reports an estimated 8 million new syphilis cases among adults aged 15–49 in 2022, an increase from approximately 7.1 million in 2020 (World Health Organization 2024). The global congenital syphilis case rate increased to 523 per 100,000 live births in 2022, more than 10 times the WHO elimination of vertical (mother-to-child) transmission of syphilis threshold (50 per 100,000 live births) (World Health Organization 2024). In 2023, Australia recorded a record 6566 cases of infectious syphilis and 20 congenital syphilis cases, with 10 infant deaths and between 2014 and 2023, the infectious syphilis notification rate increased more than 200% from 8.8 to 24.4 per 100,000 (King et al. 2024). A national study reported that the number of infectious syphilis notifications for women of reproductive age increased in Australia during 2011–2021, as did the number of cases of congenital syphilis. During this time frame, 74 cases of congenital syphilis were notified: 40 in Aboriginal and Torres Strait Islander infants, 32 in non-Indigenous infants, and two in infants of unknown Indigenous status. Seventeen of the infants were stillborn; the mothers of 41 infants with congenital syphilis resided in major cities, and 32 had not received antenatal care (Bond and Chen 2024; Hengel et al. 2024). These numbers highlight the significant cause for concern. The number of syphilis cases is rising globally with a shift in the populations at risk. For example, in Australia, syphilis cases disproportionately affect men who have sex with men and populations in remote Aboriginal and Torres Strait Islander communities. During the past decade, the rising incidence of infectious syphilis among women of reproductive age and the preventable congenital cases has become a major concern (Bond and Chen 2024). Similar increases in syphilis cases in heterosexual populations and also in congenital syphilis have been reported internationally including high-income countries (Rosset et al. 2025). In men, the rising incidence of syphilis and other STIs has been linked to lower condom use, high rates of partner change, substance use during sex (chemsex) and co-infection with HIV. Across the world, poorly functioning health systems challenge effective treatment. Limited access to healthcare, poverty, stigma, and cultural barriers limit prevention and treatment particularly among priority populations, such as, men who have sex with men, sex workers, individuals living with HIV, victims of intimate partner violence, refugees and First Nations communities (Tao et al. 2023). There are many barriers in screening and treatment in many low and middle-income countries compounded by critical human resource shortages and supply chain issues. In some high-income countries, stigma associated with STIs and limited access to antenatal care are barriers to treatment and have led to rising cases of congenital syphilis (Freyne et al. 2023). The COVID-19 pandemic also disrupted syphilis screening, surveillance, and treatment. Reduced condom use, waning fear of HIV, declining testing rates and lack of investment in prevention strategies also contribute to rising numbers of cases (Nelson 2023). Syphilis is both a preventable and curable infection emphasising the importance of prevention and therapeutic initiatives. The increasing prevalence casts a spotlight on a failure in healthcare access, public health strategies and the poor uptake of screening (Silverstein et al. 2025). Fragmentation of health services can also be a deterrent and there is a need to strengthen coordination and continuity between primary care, maternity services and sexual health. Laboratories serve as a critical link in the treatment chain and need to be linked into health systems to allow timely diagnosis and the confidential treatment of data. Point of care testing also shows promise in opportunistic health interventions (Brandenburger and Ambrosino 2021). To address the current crisis of syphilis burden, we need a public and primary health response that promotes prevention, screening and contact tracing, appropriate follow-up and clear pathways of care as well as addressing structural and psychosocial barriers for access and engagement in care. For this to happen, an understanding of the epidemiology of syphilis and populations at risk within particular health systems is important (Almeida et al. 2022). There is a need to meet individuals where they are at through strengthening models of innovative care including point of care testing and outreach models, partnering with First Nations Peoples and those from culturally and linguistically diverse populations (Fatima et al. 2025). This is critical in addressing stigma and ensuring equitable access across communities. Embedding syphilis awareness in sexual health campaigns together with HIV and HPV, or settings where at-risk populations access care is important. Beyond public health strategies and increasing awareness in primary care there is also a need to foster research into vaccines and promote the responsible use of medications as frequent shortages in the supply of benzathine benzylpenicillin and potential antibiotic resistance to alternative treatment options especially in the context of increasing use of doxycycline post-exposure prophylaxis for STIs is another factor aggravating the effective management of syphilis (Nelson 2023). Strengthening prenatal screening and treatment, especially for underserved populations is critical. Many cases of congenital syphilis can be attributed to the late or absent antenatal care, with many diagnoses occurring too late in pregnancy to prevent transmission. There is a need for all models of antenatal care to be culturally appropriate and accessible and for women to receive midwifery continuity of care to build trust. In Australia, as in many countries, it is recommended to ‘universally offer and recommend syphilis testing at the first antenatal contact regardless of assessed risk’. Importantly, more than just this initial test, at least two other tests are recommended throughout the pregnancy for all women. This latest recommendation is to ‘Universally offer and recommend additional screening for syphilis at 26–28 weeks and at either 36 weeks or birth (whichever is earlier) regardless of assessed risk’. Multiple points of testing need midwives, obstetricians, general practitioners and other health care providers (in Australia, this would include Aboriginal Health Workers) to provide person-centred care, without judgement or stigma. The universality of testing means that this will be discussed with all women and decisions about risk status do not need to be made, thus reducing judgement and stigma. Antenatal care must also be accessible to women, provided in locations and times that suit the lives of women and families and preferably provided by the same caregivers to increase trust and provide ongoing support to women and families (Australian Government Department of Health, Department of Health, Disability and Ageing 2025). In many countries syphilis is a notifiable condition that needs to be reported to a public health authority. This has implications for clinicians and patients alike. If people who may have been exposed to syphilis are to feel confident undergoing screening, it is imperative that even anonymised results are not disclosed without good reason. But as well as protecting privacy it is important to encourage the appropriate use and disclosure of health information. In Australia, clinicians are legally required to report syphilis infection to the National Notifiable Diseases Surveillance System, to track and control outbreaks (Sohail et al. 2024). Some states maintain syphilis registers to manage treatments. Relevant State public health units will initiate contract tracing or partner notification, anonymously and with the consent of the patient. To maintain the reputation and maximise the effectiveness of the public health system, it is important to ensure patient confidentiality while taking threats to public health and third parties seriously. As we witness a rising lack of trust in health systems it is critical we observe principles of confidentiality and do all we can to ensure data integrity. The escalating burden of syphilis emphasises the importance of strong public health responses as well as prevention and vigilance across the healthcare continuum. Given the increase in the incidence of syphilis in pregnancy in high-income countries, elevated and often under-reported rates in low- and middle-income countries, a global approach to overcome diagnostic, therapeutic and implementation challenges is important. Tackling issues in health equity and addressing stigma are important considerations in responding to this challenging health problem that has been a ‘great imitator’ for centuries. This will require a multidisciplinary collaborative response that addresses the complex intersection of shame, stigma and risk as well as access to evidence-based diagnostics and therapies. Nurses and midwives are well positioned to lead this challenge through implementing evidence-based, person-centred, and culturally appropriate models of care. The authors declare no conflicts of interest. The authors have nothing to report.

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