Barriers to Routine Antenatal Syphilis Screening in Uganda: Provider Perspectives and Practices

Abstract

Congenital syphilis is preventable through early detection and treatment during pregnancy. Although global syphilis rates have declined, the prevalence of undiagnosed and untreated infections remains high in low- and middle-income countries. In Uganda, national clinical guidelines recommend syphilis screening and treatment at the first antenatal care (ANC) visit, yet coverage remains suboptimal, contributing to ongoing perinatal transmission. As part of a multiple-method research project, this qualitative study explored provider perspectives on barriers to antenatal syphilis screening and treatment. We conducted in-depth interviews with 20 ANC providers at six public health facilities in two districts serving diverse communities. Using a descriptive qualitative approach and thematic analysis, we identified four interrelated barriers to effective service delivery: (1) stockouts of test kits and benzathine penicillin that disrupt care; (2) limited access to formal training and continuing education, reducing provider confidence in diagnosis and treatment; (3) misalignment between clinical guidelines and routine practice, leading to missed screening opportunities; and (4) low male partner engagement, increasing risk of reinfection. Addressing these barriers through health systems strengthening—including improved supply chain monitoring, universal provider training, supportive supervision, and community-informed strategies for partner engagement—is critical to reducing perinatal syphilis transmission and advancing Uganda’s progress toward congenital syphilis elimination.

Introduction

Perinatal HIV and syphilis transmission can significantly increase infant morbidity and mortality worldwide, particularly in low-and middle-income countries (LMICs) (Gloyd et al., 2001). More specifically, low-income countries account for 90% of perinatal syphilis transmissions, with 62% of global congenital syphilis cases occurring in Africa (Sankaran et al., 2023; Zhang et al., 2022).

Syphilis is a sexually transmitted infection (STI) treatable through the administration of penicillin, a relatively inexpensive, accessible, and highly effective antibiotic (Saloojee et al., 2004). Despite the availability of penicillin and the global initiative to end congenital syphilis initiated by the World Health Organization (WHO, 2007), maternal syphilis infection is still responsible for 70,000 cases of congenital syphilis each year (WHO, 2024). As part of this initiative, the WHO has outlined strategies for healthcare providers to follow when testing and treating pregnant women for syphilis through a three-pronged screening process. It is recommended that pregnant women undergo syphilis screening at their first antenatal care (ANC) visit, during the third trimester, and again at the time of delivery (Hakizimana et al., 2023; WHO, 2017). This comprehensive screening strategy facilitates early and ongoing detection of syphilis as well as timely treatment to decrease the likelihood of perinatal transmission.

Over the past 20 years, most regions of Africa have seen a decline in the prevalence of syphilis among pregnant women. However, this progress has not been uniform, and East Africa remains disproportionately affected (Hussen & Tadesse, 2019). It is estimated that, among pregnant women in East Africa, 3.2% are infected with syphilis, compared to sub-Saharan Africa, which has a prevalence of 2.9% (Hussen & Tadesse, 2019). Prevalence estimates from Uganda are even higher with 3.8% of newborns and 4.1% of mothers presenting at a large regional referral hospital for postnatal syphilis testing receiving a positive test result (Oloya et al., 2020; Saloojee et al., 2004).

Although more than 97% of pregnant women in Uganda attend at least one ANC visit, fewer than two-thirds (approximately 60%) complete the recommended four or more visits (Uganda Bureau of Statistics, 2023). ANC services are officially offered free of charge in public-sector facilities; however, many women still face out-of-pocket expenses for transport, medications, or laboratory services, particularly when supply chain interruptions lead to stockouts of test kits or treatments. Pregnant women seek ANC primarily at government health centers (Health Centre IIIs and IVs), regional referral hospitals, and private not-for-profit or for-profit clinics (Rutaremwa et al., 2015; Uganda Ministry of Health, 2016; WHO, 2014). Public-sector facilities are more likely to experience supply shortages, workforce constraints, and long wait times, particularly in rural settings (Tumwine et al., 2022). In contrast, private-sector facilities often provide more consistent access to medications and diagnostics but are frequently cost-prohibitive for lower-income women, limiting equitable access to comprehensive ANC services (Konde-Lule et al., 2010; Orach, 2009; Ssennyonjo et al., 2018). These facility-level and financial disparities can significantly influence the feasibility and timeliness of routine syphilis screening and treatment during pregnancy (Gloyd et al., 2001; Martin et al., 2022; Nakku-Joloba et al., 2019).

If syphilis is left untreated during pregnancy, the likelihood of perinatal transmission is estimated to be between 45% and 70% (Oloya et al., 2020). Similarly, HIV can also be transmitted perinatally if not properly managed (i.e., without correct and consistent maternal use of antiretroviral therapy during pregnancy). There are high prevalences of HIV and syphilis among pregnant women, particularly in sub-Saharan Africa. A meta-analysis found that 7.3% of people living with HIV in sub-Saharan Africa were also co-infected with syphilis (Mussa et al., 2024), and a global review indicated that co-infection of HIV and syphilis was a 9.5% among adults. (Hussen & Tadesse, 2019). Co-infected mothers are at a higher risk of transmitting both infections to their infants; for instance, mothers with both HIV and syphilis are twice as likely to transmit HIV to their babies compared to mothers living with HIV who do not have syphilis (Strasser et al., 2012).

The adverse outcomes for newborns exposed to untreated syphilis include increased risk of stillbirth, neonatal death, preterm birth, and congenital malformations (Saloojee et al., 2004; Zhang et al., 2022). Therefore, early and continued screening and treatment for both syphilis and HIV during pregnancy are essential to prevent perinatal transmission and to protect neonatal health (Strasser et al., 2012). Understanding the perspectives, knowledge, and attitudes of both patients and providers is crucial for identifying the reasons behind gaps in syphilis testing and treatment. A systematic review of barriers and facilitators to HIV and syphilis rapid diagnostic testing in ANC settings across LMICs highlights that attitudes and beliefs often influence care seeking practices and care provision. From the perspective of pregnant women, socio-cultural beliefs, gender roles (including those that influence male partner involvement in care seeking), and health knowledge significantly affect willingness to participate in rapid diagnostic testing (Zhang et al., 2022). There is a need for ongoing training, user-friendly tests, support from supervisors and communities, sufficient resources including staffing, and compensation to effectively offer care and rapid diagnostic testing (Zhang et al., 2022). However, there is limited research focusing specifically on provider perspectives, knowledge, and attitudes, which is critical to understanding the practical challenges and barriers to syphilis screening and treatment.

Syphilis screening is essential to comprehensive ANC, and integrated screening programs have been adopted broadly (WHO, 2017). However, implementation of routine syphilis screening during the antenatal period remains inconsistent due to persistent structural and socioeconomic barriers within health systems, particularly in low-resource settings (Gloyd et al., 2001; Nakku-Joloba et al., 2019). To address these gaps, this qualitative study explores ANC providers’ perspectives to better understand challenges in key service delivery. Specifically, we sought to answer the following research question: What are the key facility-level and systemic barriers perceived by ANC providers that impact the delivery of routine syphilis screening and treatment during pregnancy in Uganda? By identifying these barriers, we aim to inform evidence-based strategies to optimize syphilis screening and treatment programs and reduce the burden of congenital syphilis.

Methods

Study Design

The Feasibility of Antenatal Syphilis and HIV Point of Care Testing to Prevent Perinatal Transmission in Uganda (FASTOM) study was a multiple-methods project designed to assess gaps in knowledge and coverage of maternal syphilis, dual syphilis, and HIV infection testing and treatment in Uganda. This manuscript reports findings from the qualitative component, which explored provider perspectives on facility-level and systemic barriers to routine syphilis screening and treatment—complementing other components focused on patient experiences and implementation feasibility.

FASTOM was nested within the infrastructure of the Africa Medical and Behavioral Sciences Organization’s (AMBSO) Population Health Surveillance (APHS) Study, an ongoing longitudinal community-based open cohort study. APHS aims to generate insights on underexplored and emerging public health issues in Uganda, such as mental health, substance use, gender-based violence (GBV), violence against children, food insecurity, health behaviors, disability, and emerging diseases across all age groups. APHS’s methods have been described in detail previously (Mugamba et al., 2023). The cohort surveillance activities are conducted in six communities across two districts in Uganda: Hoima (in the mid-western region) and Wakiso (centrally located around the capital city of Kampala). These communities were selected for their collective representativeness of life in Uganda and include rural, urban and semi-urban communities’ in each of the two districts. Data collection for the APHS has been continuous since 2018, with each round taking approximately 12 months. When necessary to answer pertinent public health research questions, qualitative methods—like those included in the FASTOM study—are nested into data collection to support the in-depth exploration of such topics.

This qualitative inquiry was informed by Health Systems Strengthening (HSS) principles and frameworks addressing access to care in resource-limited settings. Specifically, we considered how interconnected factors—such as supply chain reliability, workforce capacity, provider training, and patient engagement—shape service delivery, consistent with the WHO’s health systems building blocks framework (Kruk et al., 2018; Peters et al., 2007; WHO, 2007).

FASTOM was integrated into the third round of APHS data collection. Data for the qualitative study was collected from September 2022 to July 2023, and included 10 focus group discussions with pregnant and postpartum women in the six study communities (there were 82 participants in total across the 10 groups) and in-depth interviews with ANC providers (n = 20) working in public health facilities that serve these communities. After analysis and team discussions, the work was split into two manuscripts. Qualitative findings from pregnant and postpartum women have been published elsewhere (Miller et al., 2025). The present analysis focuses on data gathered during in-depth interviews with ANC providers to understand their perspectives and practices around antenatal syphilis screening. Additional manuscripts presenting the quantitative findings are also forthcoming.

This study was approved by University of California Los Angeles Human Research Protection Program (IRB#22-000928), Clarke International University (CIUREC/059) and Uganda National Council for Science and Technology (SS4468). Informed consent was secured from all participants before participation in the study.

Recruitment Sites and Procedures

Healthcare facilities for participant recruitment were selected by AMBSO based on existing community relationships and recommendations from the local community advisory board members. ANC providers were purposively selected from these facilities based on the “department” or field of specialty they worked in. Both private and public facilities were included to capture the breadth of care options available. Potential participants were invited via phone or email to participate. Provider eligibility criteria included: (1) having worked as an ANC provider in either Wakiso or Hoima for at least 6 months; (2) Currently working directly with pregnant women (representing at least half of the patients they serve); (3) Having a phone or some other way of being contacted (e.g., current email account); and (4) Consenting to involvement in the study. These eligibility criteria were used to ensure that in depth interviews were conducted with individuals who have knowledge of the local setting and dynamics, and the challenges faced by pregnant women regarding perinatal transmission of syphilis and HIV, including current clinical practices related to syphilis and HIV screening and treatment. The following clinic types served as recruitment facilities: the public health facilities included hospitals, health center IVs and Health center IIIs (While Health center IVs perform all functions of Health Center IIIs, the major difference is that Health Center IVs can perform emergency surgeries and blood transfusions, while Health Center IIIs cannot). Health workers from private hospitals that provide ANC services were also interviewed.

Data Collection

Local experienced qualitative data collectors conducted the interviews. Interview guide questions were developed collaboratively as a team, both asynchronously and through group discussion. All data collectors were fluent in English as well as the native languages of Luganda and Runyoro in Wakiso and Hoima districts respectively, and had received training in qualitative methods (generally and then with a refresher specific to this study). The data collectors also had valid certification in Human Subject Protection and Good Clinical Practice trainings at the time of data collection. Discussions were guided by a semi-structured interview guide (see Supplemental Material File 1) that explored topics related to knowledge of syphilis screening guidelines, perceived importance of syphilis screening, current screening practices in their clinic, and barriers to syphilis testing and treatment in their facility. All participants provided written informed consent before participating in the study and were compensated for their time with 10,000/= (Ten Thousand Ugandan shillings) [~$3USD]) and transport of 5,000/= (Five Thousand Ugandan Shillings) [~$1.50USD]). Interviews ran from 48 to 179 min (mean duration was 79 min). All interviews were audio-recorded with participant consent.

Data Analysis

Data collection and analysis were guided by an Interpretive Description approach, a qualitative methodology suited to applied health research that seeks to generate clinically relevant knowledge from experiential accounts (Thorne, 2016). This approach is grounded in a pragmatic epistemology, prioritizing the construction of meaning that is contextually situated, practice-informed, and applicable to policy and program development. Our analytic aim was to explore provider beliefs and practices surrounding syphilis screening and treatment in antenatal care (ANC), in order to identify modifiable systems-level and clinical barriers that could inform health system strengthening strategies in Uganda.

We used an interpretive thematic analysis process to identify patterns of shared meaning across provider narratives related to structural and systemic constraints. ANC providers were purposively sampled from facilities serving communities already participating in the larger APHS cohort, ensuring variation in geographic and health system context.

All interviews were translated into English and professionally transcribed. Transcripts were uploaded to Dedoose for analysis. Coding was conducted iteratively, combining inductive and deductive strategies. Initial deductive codes were informed by interview guide domains (e.g., provider knowledge, service delivery, patient engagement), while inductive codes were generated through close reading of transcripts. This dual strategy allowed for both conceptual alignment with research aims and flexibility to reflect provider-driven insights.

A subset of transcripts (n = 3, ~10%) was independently coded by two researchers (APM, NS) to refine the coding structure and support analytic depth. Divergences in coding were discussed not to reach consensus, but to expand interpretive perspectives—consistent with team-based analysis in interpretive methodologies. After finalizing the codebook, the remaining transcripts were coded independently. Themes were then constructed through collaborative interpretation of coded segments and reflected key barriers and potential solutions at the clinical, organizational, and health systems levels.

Themes in this context represent constructed patterns of meaning across participant accounts, rather than emergent topical summaries. Interpretive insights were refined through memoing and team discussion. Final interpretations were reviewed by a core analysis team (APM, NS, AW) and shared with the broader research team—including Ugandan co-investigators—to ensure contextual relevance and reduce interpretive bias.

To enhance trustworthiness, we adhered to Lincoln and Guba’s (1985) criteria: credibility, confirmability, dependability, and transferability. Credibility was enhanced through triangulation of provider perspectives with data from focus groups with pregnant women (see Discussion) and peer debriefs conducted by our Ugandan research team. Confirmability was promoted through a reflexive, team-based approach to analyzing the data, ensuring that interpretations were grounded in the data rather than researcher bias. While this does not replace the importance of member checking, the research team was comprised of qualitative researchers from the study communities promoting contextual and cultural understanding. Reliance on direct quotes to support themes highlighted throughout the paper also amplifies participant voice. Dependability was ensured by developing a systematic codebook and conducting parallel coding to maintain consistency. Transferability was supported using purposive sampling, open-ended questions, detailed field notes, and rich contextual description in the presentation of our findings. These strategies were used to ensure study setting and participant context are readily understood by the reader, which enhances the reader’s ability to map findings onto similar antenatal healthcare settings.

Results

A total of 20 providers were interviewed, 95% (n = 19) of whom were female (which is consistent with the typical makeup of health workers in Uganda, particularly in ANC settings) The cadres represented included midwives, nursing officers and gynecologists. Interviews were conducted in each district. Findings are presented below by thematic patterns that included; provider knowledge and syphilis literacy, access to health information, current clinical testing practices, engagement of male partners and clinical capacity and resource needs.

Provider Knowledge and Syphilis Literacy

Provider’s knowledge, attitudes and beliefs regarding the potential harms of congenital syphilis were heterogeneous. While recognition of signs and symptoms of syphilis infection and knowledge of appropriate syphilis treatment regimens were ubiquitous among providers, concerns around the harms of congenital syphilis, and in turn the sense of urgency assigned to timely testing and treatment during pregnancy was variable. Many providers were aware of the health consequences of undiagnosed and untreated maternal syphilis, including potential miscarriage and perinatal transmission and cited these risks as reasons to prioritize routine testing and timely treatment, as highlighted by this midwife from Hoima district.

Obviously, yes [we offer same day treatment] because we worry more about the unborn congenital syphilis, so if there is a lack of the required medicines at the facility, we have to prescribe medicines for her to go and buy from other pharmacies or clinics.—Midwife, 49 years old, Hoima District

Two alternative narratives also emerged. In the first, providers described serious harms that syphilis could cause while simultaneously asserting it was a low-risk disease due to the simplicity and accessibility of treatment (relative to other conditions such as HIV). In the second, more troubling narrative, highlighted below by a provider in Wakiso district, the harms of syphilis were downplayed and minimized, resulting in low overall concern and urgency around identification and treatment of cases.

No, I have never heard of a case [where a stillbirth was due to syphilis] in all my years of practice. When we investigate miscarriages, some people attribute them to what they call ‘nabuguuma’ — a kind of stomach burning or discomfort. Only in very rare cases do further tests confirm that syphilis was actually the cause.—Healthworker, 42 years old, Wakiso District

Providers detailed the necessity of preventive measures to avoid perinatal transmission of syphilis. The practice of counseling in the form of organized “health talks” (education sessions offered in group format to all women in the waiting area) and one-on-one informational sessions with healthcare providers during checkups were counseling approaches described by multiple providers. The primary purpose of these health talks, as described below, was to highlight the necessity of partner testing and the harms of congenital syphilis.

[At first ANC visit] we offer counseling, it even depends on the health education talk prepared in the morning for all mothers who come for antenatal. Sometimes they may talk about the investigations done on antenatal then the midwife enlightens mothers on the prevention of the infection. But still, even when we are taking blood to test them we counsel them about the infection and its prevention. —Midwife, 30 years old, Wakiso District

Providers demonstrated thorough knowledge of the signs and symptoms of syphilis in both mothers and children. Frequently noted symptoms included skin rash, vaginal sores, itchiness of the skin or vagina, recurrent abortions, abdominal pain, abnormal discharge, wearing away of the nails, and the possibility of asymptomatic positives. Abnormal discharge was noted by the majority of providers as the most common symptoms as confirmed by this Nursing officer from a clinic in Wakiso: “Sometimes they get a fever but, in most cases, they have abnormal discharges.”

Consistent with clinical guidelines, a series of Benzathine injections was recognized as the most efficient treatment for syphilis. However, the regimen was noted to have several drawbacks, including: (1) the need for providers to accurately determine the correct dosage based on the stage of syphilis (either a single injection or four), (2) significant pain at the injection site, which discouraged many from completing the treatment, and (3) frequent unpleasant side effects, such as nausea and vomiting, experienced by many. However, it was noted the alternative regimens which require frequent oral dosing are also burdensome.

Benzathine injections are very painful we put some vecuronium to paralyze but still it pains. [When prescribing the alternative treatment] women have a burden in taking pills so the other treatment a woman has to take pills every six hours.—Healthworker, 29 years old, Wakiso District

Additionally, side effects associated with oral regimens (e.g., azithromycin) were also reported. Other alternative treatments, such as cefixime and epinephrine, were mentioned but noted as being inaccessible and unaffordable due to the government’s exclusive provision of Benzathine injection therapy. These alternative treatments were described as relatively new, contributing to changes in treatment practices in recent years.

When a woman has a phobia of injections, the other option is to treat her with azithromycin tablets. Azithromycin has side effects among pregnant women. It causes nausea, stomach pain, and an urge to vomit. With those side effects, a woman is likely not to take the complete dose.—Nursing officer, 42 years old, Wakiso District

When needed, providers indicated that the series of three benzathine injections required to treat advanced latent syphilis was not ideal because completion of treatment was dependent on patients returning to the facility weekly for a month for administration, an often difficult task for pregnant women in rural Uganda. There also appeared to be some confusion over the number of shots required for a full course of treatment, with one midwife emphasizing the burden of four requires shots when the actual number required is three: “The syphilis injection is time-consuming and not user-friendly since it is given four times in four weeks.”

Access to Health Information

Providers indicated that they often relied on informal resources for knowledge on current syphilis guidelines including seeking advice from senior providers and using the Google search engine for ongoing medical education and resources. Many noted limited opportunities for formal continuing medical education forcing them to rely on medical training received during formal education in the medical training institutions, which for many was outdated. The clinical guidelines were noted as a useful official reference for practice guidelines. Google search was the most commonly mentioned informal source of health information. This resource was narrated as supplemental to clinical guidelines, which were not always up-to-date in the facilities. As one nursing officer in Wakiso district described, “I consult the clinical guidelines first. . ., the national clinical guidelines, the doctor, and then Google. If I cannot find a clear answer on Google, I give up.”

Providers also described utilizing the knowledge of superiors and colleagues to obtain health information. This communication can be facilitated via Internet platforms including WhatsApp and Zoom. Some participants, such as the provider below, indicated routine meetings for information sharing regarding healthcare and medical practices.

We normally have meetings to discuss more on testing syphilis every Tuesday and this is for all midwives [in] Hoima region, so we gain more on this platform. We also have our WhatsApp platform for Hoima regional referral where we discuss more syphilis testing.—Midwife, 39 years old, Hoima District

Providers expressed extensive knowledge regarding external organizations in their communities which offer STI prevention resources, education, and support for reproductive and perinatal health in Uganda. These organizations serve a variety of populations including adolescent mothers, families, traditional healers, pregnant women, women living with HIV, and the general population.

[S]ome organizations that reach out to pregnant women include; Reach a Hand Uganda which has ambassadors who are attached to Dwoli Health Centre III and also, we do have Baylor Uganda which is also attached to this facility [and] effectively engaging pregnant mothers and children [. . .]—Midwife, 39 years old, Hoima District

Providers expressed that organizations working directly with patients, village health teams, and health facilities to provide education are most effective in engaging the population. Organizations that failed to engage village health teams were viewed as less effective.

[Some organizations] are not 100% effective at engaging this population because in most cases, they leave out the Village Health Teams and yet these are people that help in mobilization and sensitization of the communities such as mobilizing mothers to attend early ANC.—Midwife, 31 years old, Hoima District

Current Clinical Testing Practices

Testing Procedures

Providers described routine HIV and syphilis testing, typically at the first ANC visit, and HIV every subsequent 3 months while the patient is pregnant, in accordance with Ministry of Health guidelines. Testing at the first appointment was described as mandatory by some, but not all providers. This provider from Wakiso described a variety of tests provided at first ANC visit.

For any woman who walks into our hospital for her first visit, we carry out all the investigations; like Hepatitis b, blood levels or HB levels, HIV, syphilis, fasting blood sugar levels, UTI (Urinary tract infection) blood grouping and malaria. And when a mother comes in and it is not her first visit, and she claims she did a particular test minus any recording from somewhere else I have to redo that test to be sure of the results. So, it’s not only syphilis and HIV that we test.—Nursing Officer, 40 years old, Wakiso District

The majority of providers indicated their facility was already conducting dual HIV/syphilis testing with follow-up confirmatory testing for either infection as warranted. Rapid tests are frequently conducted by midwives while other tests are performed in the lab by a technician. Narratives from several providers detailed how the use of dual tests and compliance with the 3-month HIV testing rule had indirectly resulted in increased syphilis screening.

So according to the HIV guidelines, we should do a retest after three months. But because we are using a dual testing kit, we end up also testing for syphilis. So, it is not that when a mother tests positive for syphilis we retest them after treatment. We do the retesting for syphilis because we are also testing for HIV using one kit.—Midwife, 38 years old, Hoima District

A few providers reported that their facility exclusively used dual tests and as a result, would not test women living with HIV for syphilis so as not to “waste” the test.

When a mother initiating prenatal care is on ART [Antiretroviral Therapy] treatment and opens to us, we do not test for syphilis. In the process of not retesting for HIV, we do not test for syphilis.—Health worker, 42 years old, Wakiso District

Follow-Up and Post-Diagnosis Care

Nearly all providers reported that the primary mode of patient follow-up is via phone call. When asked for strategies to optimize communication with pregnant women, most participants suggested further investment in outreach to promote community education and sensitization.

I think the best way for improving patient communication is to cooperate with the women who help us in the villages. They are called the VHTs [Village Health Teams]. And the other measure is reaching out to the District Health Officer and also the assistant district health officer.—Nursing officer, 29 years old, Wakiso District

Engagement of Male Partners

Many providers reported encouraging women to walk-in with their partners for ANC visits to receive syphilis testing, counseling, and treatment as a couple, with several indicating that women who came with their partners were given priority as a way to incentivize male partner involvement.

It is mainly lack of time, women say their husbands are always busy at work and have no time to come to the hospitals that’s why we put up a policy that every woman that comes with her husband during pregnancy visits, they don’t go through a long cue/line, they’re treated as very important persons (VIPs) to encourage/motivate every woman to convince their husbands to come for testing as we test women as well.—Nursing Officer, 43 years old, Wakiso District

Consistent with clinical guidelines, providers described routine partner testing practices which typically involved an education component where the index patient (pregnant woman) is first educated about the importance of partner treatment to prevent reinfection and contraction of congenital syphilis. If the partner accompanies the index patient for treatment, they may be treated on the same visit. If the partner is not at the visit, alternative strategies for reaching the male partner for treatment are engaged as described here by a midwife in Hoima district.

Also, we have partner notification where we always give the information to the mother to deliver to their partner, and in case she is fine with sharing the phone number of the partner with us, we get that number and [. . .] we can call the partner and inform him about the importance of testing and some of the partners do come however some say that they are busy.—Midwife, 35 years old, Hoima District

Attending appointments and getting tested as a partner during ANC was described as an entry point to care for men who may not be accessing healthcare on their own. One provider described how if male partners do not want to come to the clinic to receive testing and treatment during ANC, providers will seek to provide him treatment during delivery because men are more likely to attend the birth than ANC visits:

We always encourage our mothers to come with their partners for ANC but if they fail, we wait for them during delivery it’s when we test them since most of them bring their wives for delivery. . .. we don’t call them, we only encourage mothers to bring their partners for testing during health education and post-test counseling.—Midwife, 35 years old, Hoima District

Many providers reported that despite receiving counseling, most partners do not seek or accept syphilis treatment. As one midwife from Wakiso described, “Very few accept treatment even after counseling them.” However, a few providers indicated that partners of women served by their facility were willing to receive treatment as described below.

[M]ost times most of these mothers come with their husbands. . . We give them information and those that have not come with their husbands, we let them know to come for treatment. . . I have not had challenges. For the patients I know personally, even those that are new to me, when I find one positive for syphilis, the husband comes by himself.—Gynecologist, 35 years old, Wakiso District

Several barriers to partner treatment were identified by providers including that men may experience fear of being tested (particularly for HIV), having to take time off work to attend the clinic (which was frequently opened during the same hours they were required to be a work), feeling that it isn’t a good use of their time to wait at the hospital for testing/treatment, and yet some have multiple sexual partners (who might not be aware of one another). Fear of the pain of treatment was again, noted by many providers.

But you know the treatment for syphilis is very painful, but we always try to convince them to accept to get treated. Usually, we use lignocaine to reduce the pain, but the truth is the drug is so painful. We explain to them that the drug is so painful but that they suffer the pain once a week.—Midwife, 38 years old, Hoima District

Although providers indicated that many women would like their partners to attend visits but were unable to get them to do so, several providers also noted that some may choose not to bring their partners if they fear violence.

Most people know syphilis is sexually transmitted so when the husband is told she has syphilis some of them are not well informed that they may also contract the infection. So instead of sitting down to find a solution, they end up fighting. But we try and inform these mothers that if he is not listening to you tell him to come to the facility. But still, very few turn up for treatment of sexually transmitted infections.—Midwife, 45 years old, Wakiso District

When asked for solutions to close the partner testing gap, availability of syphilis self-test kits was described as one discrete and convenient way to overcome barriers in getting male partners to attend ANC.

[The pregnant women] finish the treatment. The only problem they face is their husbands or partners who don’t want to visit health facilities for both checkups and treatment. [. . .] it is so unfortunate that the government introduced self-testing kits for only HIV but not syphilis, so if they don’t visit, there is no way they can test themselves.—Midwife, 43 years old, Wakiso District

Clinical Capacity and Resource Needs

Training Gaps and Needs

As noted above, providers shared ranging experience and training in syphilis treatment and testing. Some providers reported engaging in routine continuing education events to supplement knowledge surrounding syphilis testing and treatment while other indicated that they had not been presented with opportunities to update their training as described by one health worker, “I have never got any formal training about syphilis since I left school.”

Among those who had received training since graduating, these opportunities sometimes occurred a long time ago, as noted by one nursing officer in Wakiso district who talked about her continuing medical education (CME), “Yes, I have [received CME training] but that was some time back, like 10 years back.” The most common format reported for training opportunities were workshops, conducted online or in person. A portion of these opportunities were CME within the workplace, with sessions ranging from 1 day to 2 weeks. These CME’s covered a broad range of health topics, including syphilis testing and treatment. Multiple providers expressed having received CME training many years prior, including those conducted by public health community outreach programs, organized and supported by the local implementing partners such as Baylor—Uganda.

The overwhelming majority of providers reported a desire for refresher training regarding the administration of syphilis testing and treatment. Providers expressed confusion regarding changing administering practices of treatment, including, the number of treatment doses, and updates to clinical guidelines. Clarification is needed regarding clinical diagnosis, specifically the ability to detect false negatives due to the presence of symptoms.

Yes, we need new information because the treatments have changed a lot [. . .] before we used to treat syphilis with PPF, and benzathine injection but now they introduced ceftriaxone in the treatment of syphilis. And the old treatment was very effective but now people do not want to be given those injections instead they prefer ceftriaxone injections. But treatments have been changing for some time. . . Now we can give ceftriaxone one gram for 7 days.—Midwife, 45 years old, Wakiso District

Several providers expressed a desire for specific training in antenatal syphilis case management, including information for partner testing and recurrent reinfection of pregnant women and how to educate them about risk. For example, a midwife (age 35) from Hoima said “The topic I would need is on the treatment, also on the recurrent re-infection because some mothers who test positive for syphilis, you treat and the dose gets finished, but your retest still turns positive.”

Additionally, there were requests for further training on managing and treating neonatal syphilis cases resulting from perinatal transmission. Several providers noted that it is often difficult to treat neonatal syphilis as many women do not give birth in the hospital or return for treatment post-delivery, underscoring the need for training in prevention counseling.

Well, information and training related to neonatal syphilis would be more helpful to me because we know how to treat the mothers but after delivery, most of them tend to disappear, so, we lack information about the management and treatment of neonatal syphilis. Therefore, if this is included, we can at least reduce the number of infections.—Midwife, 31 years old, Hoima District

Resource Availability and Constraints

Providers described varying accessibility to essential syphilis treatment. While many indicated that testing and treatment is provided on-site at their health care facility, they also noted that access was sometimes disrupted by stockouts, affecting the consistent availability of essential supplies. These stockouts create a resource barrier for pregnant women who must either (1) travel to a different clinic (which may be far) or (2) pay out of pocket for medication at a pharmacy that would typically be free in the clinic. One provider described how in the communities served by their clinic, asking a pregnant woman to pay for medication often meant diversion of funds that would otherwise be set aside for food.

Hmm, the last I knew a benzathine injection is around four thousand shillings. Then erythromycin tablets each tablet can cost around two hundred shillings. So, if you prescribe two tablets three times a day, those are 30 tablets. . .the benzathine a total of ten thousand shillings. To her, instead of looking for money for medicine, she will look for money for food.—Midwife, 40 years old, Wakiso District

Similar transportation and financial barriers were described by providers working in facilities that did not have the capacity or resources to offer on-site testing and treatment.

It happens once where we don’t have kits for testing, and we don’t feel good to refer these mothers because the regional health facility is located at a far distance, and they cannot afford transport and it is like a missed opportunity to provide services to them.—Midwife, 45 years old, Hoima District

These accessibility challenges are compounded when stockouts affect multiple neighboring facilities in the same region, forcing patients to make do with the treatment options available which aren’t typically free.

Some women tell us that even after referral to another facility, they still find when the treatment is out of stock and not there, so, they tend to come back to us when they have not received the treatment from where they were referred, and we provide it to them at a low cost. However, some mothers complete the treatment when they are referred.—Midwife, 31 years old, Hoima District

Discussion

Congenital syphilis remains a major global public health concern. Although rates are increasing in high-income countries (Moseley et al., 2024), the burden of disease remains significantly higher in LMICs, such as Uganda. This disparity is particularly concerning in settings with generalized HIV epidemics, due to the synergistic relationship between the two infections and the elevated risk of perinatal HIV transmission associated with syphilis co-infection (Lee et al., 1998; Wu et al., 2021). To address these persistent gaps in syphilis screening and treatment—which hinder progress toward WHO congenital syphilis elimination targets—this study qualitatively explored healthcare provider perspectives on barriers to routine syphilis screening and treatment during antenatal care (ANC). Providers identified multiple obstacles to service delivery, along with opportunities for intervention. These included stockouts of essential supplies, inadequate training opportunities, misalignment between clinical guidelines and actual practice, and limited male partner engagement in care.

Our analysis was guided by principles of Health Systems Strengthening and informed by access-to-care frameworks relevant to resource-limited settings. We examined how supply chain reliability, provider training, adherence to clinical guidelines, and community engagement intersect to influence service delivery, using the WHO’s health systems building blocks framework as an interpretive lens (Kruk et al., 2018; WHO, 2007). Informed by this systems perspective, we identified several actionable targets for improving syphilis screening and treatment in Uganda.

In theory, the Ugandan government provides both syphilis testing and treatment free of charge to pregnant women as part of routine prenatal care. However, providers across participating health facilities described frequent supply chain breakdowns that undermined these efforts. Stockouts of testing kits and medications disrupted care continuity and prevented providers from adhering to clinical protocols. These resource shortages triggered a cascade of challenges: when supplies were unavailable onsite, patients were often referred to external facilities or pharmacies, incurring additional transportation and prescription costs. Such barriers limited access to timely testing and treatment. This finding aligns with prior research in similar contexts. For example, during Ghana’s national rollout of dual HIV/syphilis testing kits, over half of the participating facilities experienced supply shortages that halted testing for 1 to 3 months (Dassah et al., 2018). These disruptions were attributed to poor communication, inadequate program monitoring, and failure to restock supplies in a timely manner. Similarly, providers and program coordinators often shifted blame onto one another, highlighting how communication failures compounded supply chain issues (Dassah et al., 2018). Our findings also echo a broader body of evidence from LMICs, where stockouts remain a common barrier to point-of-care testing and quality maternal care (Martin et al., 2022).

To address this challenge, several evidence-based strategies are available. At the facility level, incorporating stock management and supply chain procedures into routine staff training could help address communication breakdowns. At the national level, electronic surveillance systems—like those implemented in South Africa—have enhanced transparency and provided early warnings of impending stockouts (Falco et al., 2023; Martin et al., 2022). These systems, which offer end-to-end visibility across the supply chain, have proven acceptable to providers and have reduced medication shortages. Uganda’s transition from paper-based inventory systems to digital platforms is a promising step toward this goal. Lessons from COVID-19 response efforts in LMICs also underscore the value of warehouse reserves, coordinated supply chains, and digital tools (including blockchain) for improving test availability (Kumar et al., 2024).

Beyond supply availability, strengthening the health workforce is another essential component of syphilis control. Providers in our study reported limited access to formal training on syphilis testing and treatment, with many relying on peers or internet searches for guidance. These findings reveal important gaps in continuous professional development. HSS strategies recommend routine CME and supportive supervision to bolster provider capacity and service quality. In East Africa, structured CME programs have improved midwife knowledge and adherence to maternal health protocols (Isangula et al., 2018; Nabirye et al., 2014). A broader review of LMIC health systems confirms that training interventions consistently enhance provider performance (Rowe et al., 2018). Based on this evidence, we recommend institutionalizing CME focused on syphilis screening and treatment across public-sector facilities. These programs should emphasize test administration, result interpretation, and proper treatment procedures, with refresher trainings to mitigate the effects of staff turnover. High-quality, regularly updated training programs help ensure continuity of care, build confidence, and promote evidence-based practice (Zhang et al., 2022). Routine supervision and real-time monitoring can further support adherence to clinical protocols and improve care quality (Martin et al., 2022).

Further evidence of this need comes from a large cluster randomized trial in the Democratic Republic of Congo and Zambia. The study found that pairing a behavioral intervention—including training and supportive supervision—with adequate supplies significantly improved syphilis treatment uptake compared to providing supplies alone (Althabe et al., 2019). These findings underscore the necessity of combining workforce development with infrastructure improvements.

Our study also revealed inconsistencies between clinical guidelines and their implementation. Although Uganda’s Ministry of Health recommends the use of dual HIV/syphilis test kits at first ANC visits (Ministry of Health, Republic of Uganda, 2023), provider practices did not always align with these recommendations. For instance, some providers avoided testing HIV-positive patients for syphilis due to concerns about wasting the HIV portion of the dual test kit. This practice, while technically aligned with the guideline’s algorithm, resulted in missed screening opportunities for a population at elevated risk of syphilis infection. Our findings suggest the need for clearer guidance and improved monitoring to ensure that clinical guidelines are not only disseminated but also appropriately applied in practice.

Discrepancies between policy and practice were also evident in related qualitative work with pregnant women in Uganda (Miller et al., 2025). Women reported being charged for “mama kits” meant to be free and described instances where providers required partner presence before administering treatment. While intended to encourage male partner engagement, such requirements were seen as barriers to care and negatively impacted women’s health-seeking behaviors. These findings reinforce the importance of monitoring provider behavior and aligning practice with policy intentions through ongoing training and oversight.

Partner non-engagement in syphilis and HIV testing and treatment emerged as another critical challenge. Providers noted that many male partners were reluctant to seek testing due to financial constraints, long clinic wait times, and social stigma—findings that mirror previous research in Uganda and other LMICs (Nakku-Joloba et al., 2019). Since untreated male partners can reinfect their pregnant partners, effective prevention of congenital syphilis requires improved strategies for male partner engagement. One promising approach is the secondary distribution of self-testing kits. Evidence from sub-Saharan Africa indicates that HIV self-testing is both acceptable and cost-effective, especially when kits are distributed by pregnant women to their partners (Bulterys et al., 2020; Eshun-Wilson et al., 2021; Hamilton et al., 2021). This model can be adapted to syphilis, particularly as dual HIV/syphilis self-test kits become more widely available. A recent review reported that 88% of those who received syphilis self-test kits actually used them, supporting the feasibility of this strategy (Towns et al., 2023). However, additional research is needed to strengthen linkage-to-care strategies following positive self-tests.

Community-based approaches such as mobile testing or home-based testing—both of which have shown high acceptability among men in sub-Saharan Africa—could further extend the reach of syphilis screening (Mark et al., 2017; Sharma et al., 2015). Facility-based solutions, including flexible testing hours, proactive partner notification by providers, and counseling to mitigate fear of disclosure and intimate partner violence, could also increase male participation (Nakku-Joloba et al., 2019). These interventions should be co-developed with communities to ensure cultural relevance, sustainability, and acceptability, in line with HSS principles emphasizing equity and responsiveness.

Overall, our findings highlight the importance of a systems-oriented approach to congenital syphilis prevention. Improving supply chains, provider training, guideline adherence, and community engagement will require integrated, scalable, and contextually appropriate interventions. Only through comprehensive health systems strengthening can Uganda make sustained progress toward eliminating congenital syphilis.

This study has limitations. Interviews were conducted in only two of Uganda’s 135 districts, which may limit generalizability. However, purposive sampling of diverse clinics and providers enhances the transferability of findings. Qualitative interpretation is inherently subjective, and our analysis may reflect research team perspectives. We mitigated this through reflexivity, team discussions, and inclusion of both Ugandan and non-Ugandan researchers familiar with the local context. Despite these limitations, the study offers valuable insights. Syphilis remains a significant but addressable public health concern in Uganda, and provider perspectives can inform practical, policy-relevant improvements in ANC service delivery.

Conclusion

Although efforts to address congenital syphilis in Uganda have made progress—such as expanding access to dual test kits—important barriers persist. These include stockouts, inconsistent guideline adherence, workforce training needs, and limited partner engagement. To address these gaps, we recommend enhancing supply chain monitoring, institutionalizing CME, improving guideline implementation through supervision, and scaling up community and partner-based testing strategies. Together, these solutions can strengthen Uganda’s syphilis response and support progress toward global elimination goals.

Author Biographies

Natalie Saham is a 3rd-year undergraduate student studying History at UCLA. She is a Research Assistant in the Wagman Lab within the UCLA Fielding School of Public Health.

Amanda P. Miller, PhD, MS, is public health researcher and an Assistant Professor at San Diego State University.

Stephen Mugamba is a public health researcher with experience in epidemiology, clinical trials, and public health program management. He is currently the Deputy Program Director at Africa Medical and Behavioral Sciences Organization (AMBSO) in Uganda, where he has made significant contributions to the field of HIV prevention science.

Taylor Thomas, MPH, MA, is the Research Coordinator for the Wagman Lab in the Department of Community Health Sciences at the UCLA Fielding School of Public Health. She also works closely with the Global College Campus Violence Prevention Network (GCVP), coordinating with international institutions to advance global violence prevention efforts.

Bashir Magada is a medical doctor with 4 years of experience in epidemiologic studies, HIV care and HIV clinical trials. He coordinated the field study activities during the implementation of this study.

Adriane Wynn, PhD, is an Assistant Professor in the Division of Infectious Diseases and Global Public Health at UC San Diego and a Research Associate at the Botswana Sexual and Reproductive Health Initiative. Her research focuses on diagnosis and management of sexually transmitted infections during pregnancy and the intersection between alcohol use and HIV, with an emphasis on evaluating the costs, benefits, and cost-effectiveness of interventions and strategies.

William Ddaaki is a Supervisor of Social and Behavior Sciences at the Rakai Health Sciences Program (RHSP) in Uganda, with over two decades of experience in public health research. With a background in Global Health and Development, William’s expertise encompasses cognitive research, social determinants of health, and utilizing research evidence to improve health behaviors.

Emmanuel Kyasanku holds an MPH from Uganda Martyrs University. He heads the Epidemiological and Behavioral studies and coordination of HIV Prevention Programs for AMBSO. He is a co-investigator on the AMBSO Population Health Surveillance for which he is in charge of the field investigation roles. He is currently pursuing his PhD in global public Health at Karolinska Institute in Stockholm-Sweden.

Robert Bulamba, MPH, is a statistician and public health specialist with AMBSO.

Vitalis O. Olwa is a medical officer with special interest in public health. He works as a study coordinator at AMBSO.

James Nkale is a Public Health Specialist with AMBSO.

Godfrey Kigozi, MBChB, MPH, PhD, received his medical training and doctoral training in Epidemiology at Makerere University and earned his master’s from the Department of Population and Family Health at Johns Hopkins University. He currently serves as a consultant and a member of the executive management at AMBSO and is also a co-Investigator for the APHS Study.

Fred Nalugoda, MHSc, PhD, is co-investigator of the APHS Study and the director of grants and training at Rakai Health Sciences Program. He earned his PhD in Epidemiology and Biostatistics from Makerere University and holds a master’s degree from Johns Hopkins Bloomberg School of Public Health.

Grace N. Kigozi, MPH, earned her master’s from Johns Hopkins University and is a co-founder and investigator at the Africa Medical and Behavioral Sciences Organization. She is in charge of regulatory and ethical observance of the minimum research guidelines for the APHS Study.

Alex Daama is an Epidemiologist working with AMBSO.

Gertrude Nakigozi, MBChB, PhD, MPH, earned her master’s from the Johns Hopkins Bloomberg School of Public Health and holds a PhD in Epidemiology from Makerere University in Uganda. She is a co-Investigator on the APHS Study.

Jennifer A. Wagman, PhD, MHS, is Associate Professor in the Department of Community Health Sciences at the UCLA Fielding School of Public Health. She is Co-Director of the UC Global Health Institute’s Center on Gender and Health Justice.