Forum for Nordic Dermato-Venereology Nr 4, 2019

Lyudmyla Derevyanko – Progress Towards the Elimination of Mother to Child Transmission of Syphilis in Ukraine with suspicion of syphilis, due to the diagnostic requirements of performing confirmation tests in centralized laboratories. In addition, the current requirement for hospitalization of preg- nant women in dermato-venereological wards leads to a delay in treatment, especially for those who live in remote areas. In these cases, the WHO STI guideline suggests performing an on-site rapid syphilis test (RST) rather than the standard off- site laboratory-based screening and treatment strategy (10). In Ukraine, the rate of syphilis in pregnancy, as well as regis- tered cases of MTCT of syphilis, has been decreasing continu- ally for the last decade. Ukraine is currently approaching the target indicator for achieving elemination of MTCT of syphilis (case rate of congenital syphilis ≤50 per 100,000 live births). In addition to validating elimination of MTCT, countries must reach 3 process indicators: population-level antenatal cover- age (at least one visit) ≥95%; coverage of testing of pregnant women ≥95%; treatment coverage of syphilis-seropositive pregnant women ≥95% (5). A high level of antenatal cover- age and testing for syphilis during pregnancy was achieved in 2016–2018, although testing for syphilis has not reached the target of 95%. No country-level reporting on treatment in pregnant women diagnosed with syphilis is performed; hence this indicator is missing. The specific strategies in any particular country for dual elimi nation of MTCT of HIV and syphilis are greatly influenced by differences in HIV and syphilis epidemiology, service delivery models, coverage of health services, and available resources. In 2017 in Ukraine, the rate of syphilis in women was 4 times higher than the mean rate in EU/EEA countries (5.6 versus 1.4 cases per 100,000 population). It is also worth noting that, due to conflict with Russia, the figures for the 5 previous years do not include new infections in the non-government-controlled areas of Donetsk and Luhansk regions. Rates among women were also high (more than 3 cases per 100,000 population) in other EU/EEA countries, such as Bulgaria, Hungary, Iceland, Latvia, Lithuania, Romania and Slovakia. In addition, in EU/ EEA countries, the slight increase in rates of syphilis among women, which started in 2016, continued in 2017 (11). Ukraine has the second-largest HIV epidemic in Eastern Eu- rope and Central Asia and, moreover, between 2005 and 2014 the proportion of women who became HIV-positive through sexual transmission increased from 53% to 86% (12). This emphasizes that a dual strategy of elimination of MTCT of HIV and syphilis is substantiated. In addition, it is known that recent maternal syphilis infection is an independent risk factor for MTCT transmission of HIV (13). It is important to emphasize that measurement of the elimina- tion of MTCT of syphilis should not be limited only to those 124 D ermatology A broad women who attend clinics and who are in contact with the healthcare system. The indicators and targets are specifically set to be population-level indicators. Thus, they should be measured among the entire population of pregnant women and not just those who are part of a healthcare programme. There is no routinely collected information on prevention of MTCT of syphilis for women from key populations in Ukraine. Access to antenatal screening for vulnerable groups remains an issue in Ukraine as well in some EU/EEA countries (14, 15). The WHO and CDC treatment guidelines recommend the use of long-acting benzathine penicillin G for treatment of all form of syphilis during pregnancy, except neurosyphilis (15). In contrast, daily doses of short-acting aqueous benzylpeni- cillin preparations (intramuscular or intravenous) are usually prescribed for pregnant women, especially in the second half of pregnancy according to the national protocol in Ukraine. Meanwhile, there are major shortages of benzathine penicillin G in many countries, including Ukraine, which complicates the elimination of MTCT of syphilis according to the WHO strategy (16). Benzathine penicillin G is the only treatment recommended for prevention of MTCT of syphilis; other drugs are contraindicated, do not cross the placenta to treat the foetus, or are less effective. The global targets for elimination of MTCT of syphilis will not be met until the global shortage of benzathine penicillin G is taken into account, including the lack of knowledge con- cerning the efficiency of this low-cost medication, which has no documented risk of antibiotic resistance and is considered an essential medicine by the WHO (17, 18). Opportunities to improve global supply, demand, and use of benzathine pen- icillin G should be prioritized alongside efforts to eliminate MTCT of syphilis. Lyudmyla Derevyanko – Progress Towards the Elimination of Mother to Child Transmission of Syphilis in Ukraine the elimination of MTCT of syphilis, as well as for sharing knowledge about the prevention of this forgotten, but not eliminated, disease. R eferences 1. Korenromp EL, Rowley J, Alonso M, Mello MB, Wijesooriya NS, et al. Global burden of maternal and congenital syphilis and asso- ciated adverse birth outcomes – estimates for 2016 and progress since 2012. PLoS One 2019; 14: e0211720. 2. World Health Organization (WHO). The global elimination of con- genital syphilis: rationale and strategy for action. Geneva: WHO; 2007 (cited 2017 Nov 20). Available from: http://apps.who.int/iris/ bitstream/10665/43782/1/9789241595858_eng.pdf. 3. World Health Organization (WHO). The investment case for eliminating mother-to-child transmission of syphilis: promoting better maternal and child health and stronger health systems (2012). Geneva: WHO, 30. Available from: http://www.who.int/ reproductivehealth/publications/rtis/9789241504348/en/. 4. World Health Organization (WHO). Global guidance on criteria and processes for validation: elimination of mother-to-child transmission of HIV and syphilis (2014). Geneva: WHO, 32. Avail- able from: http://www.who.int/reproductivehealth/publicaons/ emtct-hiv-syphilis/9789241505888/en/. 5. World Health Organization (WHO). Global guidance on criteria and processes for validation: elimination of mother-to-child transmission of HIV and syphilis, 2nd edition (2017). Geneva: WHO, 39. Available from: http://www.who.int/reproductivehealth/ publications/emtct-hiv-syphilis/9789241513272/en/. 6. CDC. Sexually transmitted disease surveillance in 2017. Available from: https://www.cdc.gov/std/stats17/2017-STD-Surveillance-Re- port_CDC-clearance-9.10.18.pdf. 7. European Centre for Disease Prevention and Control. Syphilis and congenital syphilis in Europe – a review of epidemiological trends (2007–2018) and options for response. Stockholm: ECDC; 2019. Available from: https://ecdc.europa.eu/sites/portal/files/ documents/Syphilis-and-congenital-syphilis-in-Europe.pdf. 8. European STD guidelines. Available from: https://www.iusti.org/ sti-information/pdf/guidelines.pdf. 9. World Health Organization Guidelines for the management of sexually transmitted infections. Available from: https://www.who. int/hiv/pub/sti/pub6/en/. 10. World Health Organization (WHO). WHO guideline on syphilis screening and treatment for pregnant women. Geneva: WHO; 2017. Available from: https://www.who.int/reproductivehealth/ publications/rtis/syphilis-ANC-screenandtreat-guidelines/en/. 11. European Centre for Disease Prevention and Control. Syphilis – annual epidemiological report for 2017. Available from: https:// ecdc.europa.eu/sites/portal/files/documents/syphilis-annual-epi- demiological-report-2017.pdf. 12. UNAIDS (2017) ‘Ending AIDS: Progress towards the 90-90-90 targets. Available from: http://www.unaids.org/sites/default/files/ media_asset/Global_AIDS_update_2017_en.pdf. 13. Kinikar A, Gupte N, Bhat J, Kulkarni V, Bhosale R, McIntire KN, et al. Maternal syphilis: an independent risk factor for mother to infant human immunodeficiency virus transmission. Sex Transm Dis 2017; 44: 371–375. 14. European Centre for Disease Prevention and Control. Antenatal screening for HIV, hepatitis B, syphilis, and rubella susceptibility in the EU/EEA. Stockholm: ECDC; 2016. Available from: https:// ecdc.europa.eu/sites/portal/files/media/en/publications/Publica- tions/antenatal-screening-HIV-hepatitis-B-syphilis-rubella-EU.pdf . 15. European Centre for Disease Prevention and Control. Antenatal screening for HIV, hepatitis B, syphilis, and rubella susceptibility in the EU/EEA – addressing the vulnerable population. Stock- holm: ECDC; 2016. Available from: https://ecdc.europa.eu/sites/ portal/files/media/en/publications/Publications/antenatal-screen- ing-sci-advice-2017.pdf. 16. World Health Organization (WHO). WHO guidelines for the treat- ment of Treponema pallidum (syphilis). Geneva: WHO; 2016 (cited 2017 Nov 20). Available from: http://apps.who.int/iris/bitstream/ 10665/249572/1/9789241549806-eng.pdf. 17. Nurse-Findlay S, Taylor MM, Savage M, Mello MB, Saliyou S, et al. Shortages of benzathine penicillin for prevention of mother-to- child transmission of syphilis: an evaluation from multi-country surveys and stakeholder interviews. PLOS Med 2017; 14: e1002473. 18. World Health Organization (WHO). WHO model list of essential medicines: 20th list. Geneva: WHO; 2017 (cited 2017 Nov 22). Available from: http://www.who.int/medicines/publications/essen- tialmedicines/20th_EML2017_FINAL_amendedAug2017.pdf?ua=1. In order to increase the rate of elimination of MTCT of syphilis in Ukraine, it will be critical to strengthen collaborations be- tween obstetricians, dermatovenereologists and paediatricians, as well as between academicians and public-health workers. As a result of recommendations generated by this evaluation, a national road-map for the elimination of MTCT of syphilis in Ukraine was created. C onclusion • The elimination of MTCT of syphilis as a public health threat by 2030 is an achievable goal, although Ukraine and other countries face critical challenges. • Taking into account the global goal of the dual elimination of MTCT of HIV and syphilis, as well as migration flows between Eastern and Western countries, better interna- tional collaboration is needed to improve measures for Forum for Nord Derm Ven 2019, Vol. 24, No. 4 Forum for Nord Derm Ven 2019, Vol. 24, No. 4 D ermatology A broad 125

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