Universal screening for syphilis and other STBBIs among patients presenting for substance use-related care

Authors

Julia Kirsten MacIsaac MD, MPH, FRCPC (biography and disclosures) and Sofia Bartlett PhD (biography and disclosures)

Julia MacIsaac’s disclosures: Has received an honorarium from Gastrointestinal Research Institute (GIRI). GIRI is a non-profit with a mission to support clinical research and advance education in gastrointestinal diseases. Mitigating potential bias: Treatments or recommendations in this article are unrelated to products/services/treatments involved in disclosure statements.

Sofia Bartlett’s disclosures: Has spoken for, consulted for, and participated in medical advisory board programs with Gilead Sciences, AbbVie, and Cepheid (no personal payments accepted). Dr. Bartlett has received investigator-initiated research funding from Gilead Sciences, AbbVie, Pfizer, and TD Bank Group through unrestricted grants from the Pacific Public Health Foundation. Grant funding received from Pacific Public Health Foundation is provided directly to her institution (Provincial Health Services Authority). Mitigating potential bias: Recommendations are consistent with published guidelines. Editorial and content control is maintained in all speaking engagements, and only publicly available data are shared.

Preamble: The processes and recommendations presented in this article are most relevant for outpatient clinics serving a high volume of patients presenting for substance use care (e.g. opiate agonist treatment clinics, rapid access addiction clinics or family practice clinics caring for a large volume of patients with substance use disorders). Although the specific workflow changes may be less applicable to general family practice, general practitioners may nonetheless find this work relevant, as it supports routine opt-out STBBI screening for patients with substance use disorders in primary care.

This article will focus primarily on syphilis. While Hepatitis C virus will be mentioned briefly, a separate TCMP article dedicated specifically to Hepatitis C virus is forthcoming.

What I did before

Patients with substance use disorders who present for care are often at high risk of sexually transmitted and blood borne infections (STBBIs). Alcohol use—especially heavy drinking—increases sexual risk behaviours such as condomless sex or having multiple sexual partners, and is associated with sexually transmitted infection (STI) acquisition.¹ People who inject drugs (PWID) have an increased risk of blood borne infections, as globally, one in eight PWID are living with HIV, and 50% of PWID are living with hepatitis C (HCV).² In one study undertaken in Boston, USA, screening in 333 of 393 patients initiating care at a substance use clinic identified 61 new, active infections, including one HIV, three syphilis, four gonorrhea, three chlamydia, two Hepatitis B and 48 viremic HCV cases.³

At our low-barrier, high-volume outpatient addiction clinic in Vancouver, other staff and I would previously screen for STBBIs case-by-case. British Columbia Centre on Substance Use (BCCSU) guidelines recommend offering screening for HIV, HCV and STIs for all patients with opioid use disorder.⁴ The BC viral hepatitis testing guideline and HIV testing guideline also recommend offering HIV and HCV screening to anyone who has a history of injection drug use.^5,6 These guidelines do not provide guidance with respect to frequency of rescreening, or which specific tests to order.

Given time constraints while caring for this medically and socially complex patient population, we often did not ask the right questions to identify those at highest risk of infection. Those with risk factors such as engagement in transactional sex work or multiple sexual partners were often not identified and prioritized for screening. Even patients with known risk factors, like frequent injection substance use, were often not screened as they presented with competing health and social priorities, a trend supported by the literature.⁷ When screening was offered, our patients were given paper requisitions to bring to a nearby outpatient laboratory. At baseline, only 6% of new patients presenting for care completed any STBBI screening within the first 30 days.⁸ Our patient population faces STBBI screening barriers in other healthcare settings as well, including primary care, acute care and rural settings.

What changed my practice

An alarming increase in rates of STBBIs, which has disproportionately affected patients with substance use disorders, has made it imperative to integrate screening as a routine practice when presenting for care.^9-14  In addition, the availability of direct acting anti-virals (DAAs) to eliminate HCV is further reason to be proactive in screening for STBBIs in this population.

Syphilis rates in Canada have been increasing over the last decade.⁹ Following two cases of congenital syphilis in 2019, BC’s provincial health officer declared a syphilis outbreak,⁹ with rising cases among females of childbearing age. However, the majority of cases were still being diagnosed among gay, bisexual and other men who have sex with men (gbMSM).¹⁰ By 2022, there were more syphilis cases among heterosexual males and females, than among gbMSM.¹¹ BC Centre for Disease Control (BCCDC) data linked syphilis among heterosexual people to factors including substance use, street involvement, housing instability, transactional sex and mental illness.¹² Around this time, I began seeing this epidemiology shift in my practice, with more syphilis cases diagnosed among heterosexual people presenting for substance use-related care.

Syphilis has seen the most dramatic rise in infection risk among my patients, but gonorrhea and chlamydia rates are also increasing in BC.¹³ Additionally, with the availability of DAAs, HCV has become curable for most patients.

To address these concerns, I led a quality improvement initiative to address gaps in screening and linkage to STBBI care.⁸

What I do now

In my practice, I now:

• Offer universal screening for HIV, HCV, HBV, gonorrhea, chlamydia and syphilis to all patients presenting for substance use-related care.
• Follow the screening guidelines our clinic adopted: we screen every six months, or more frequently, according to risk.
• Use a standardized order set including HCV Ab and HCV RNA PCR, so that infection can be confirmed with one blood draw.
• Offer treatment for syphilis, HCV, gonorrhea and chlamydia on site, and refer to the local clinic for HIV care.
• Facilitate pre-exposure prophylaxis (PrEP) for people at high risk of HIV infection.
• Offer onsite, low barrier phlebotomy with our part-time, in-house phlebotomist.

In our clinic, these changes substantially increased STBBI screening rates from a baseline of 6% to 33%.⁸

Addressing the gap in STBBI screening for patients presenting for care in other healthcare settings will need a tailored approach. A phlebotomist may not be practical in many settings and, even when available, patients still face barriers to having phlebotomy done, such as difficulty with venous access or fear of needles.

What creative solutions would be practical to implement in your practice to address these barriers? 

To provide additional options, we are in the process of implementing Dried Blood Spot (DBS) specimens for STBBI screening through a pilot with the BCCDC.¹⁵ The turnaround time to receive results back from DBS is not yet equivalent to standard of care tests sent to the lab, so this is not a perfect solution. However, the ability to offer more choices in how to get screened for STBBIs has been empowering both for clinicians and for patients. In BC, DBS is available in the Northern Health region through the Health Authority. Clinics or services in all other BC health regions may contact BCCDC Public Health Laboratory to inquire about accessing DBS.

We have long-acting penicillin G benzathine (Bicillin® L-A), the preferred antibiotic treatment for syphilis,¹⁶ stocked in the clinic to ensure treatment can be provided immediately to patients who are identified with syphilis. Although many of our physicians had limited experience in diagnosing and treating syphilis, consultation with the BCCDC Syphilis Desk (604-707-5607) provided the necessary guidance to deliver timely and appropriate care. Some clinics may be eligible to receive a supply of penicillin from the BCCDC, and can call the Syphilis Desk for information*.

We have a long way to go to optimize STBBI services for patients presenting with substance use-related care. Delivery needs to be tailored to patients’ needs which can be resource intensive. Increasing screening further from 33% to approach 100% will take a multifaceted approach. Since these changes have been implemented, however, we have seen an explosion in STBBI diagnosis and treatment in our clinic (16% of all patients screened are positive for at least one STBBI),⁸ which is both a positive step for patient-centred care, and an essential step in reducing the public health impacts of these infections.

^{*Approval for all clinical sites to stock Bicillin L-A supplied through the provincial formulary is considered on a case-by-case basis in collaboration between the regional health authority and BCCDC. Any sites wishing to stock Bicillin L-A should call the Provincial Syphilis Case Management line (604-707-5607) to request.}

Resources for patients

• BC Centre for Disease Control (BCCDC): Syphilis
• HealthLink BC: Syphilis
• Perinatal Services BC: Syphilis in Pregnancy: Information for Women and their Partners
• CATIE: Syphilis fact sheet
• Public Health Agency of Canada (PHAC): Syphilis fact sheet

Resources for health-care providers

View and download this handout you can use in practice. Download PDF.

Consultative services

• BC Centre for Disease Control (BCCDC) Syphilis Desk: 604-707-5607 for immediate clinical advice.

Dried blood spot information

• PHSA Laboratory Memo: Sexually Transmitted and Blood-Borne Infection testing performed on Dried Blood Spots: a primer on DBS pilot in BC
• Northern Health Authority – Clinical Practice Standard: Dried Blood Spots in Community Settings: a Clinical Practice Standard for healthcare providers in Northern Health Authority who wish to implement DBS into clinical practice.

Training and education

• Overview of Syphilis for Healthcare Providers in BC: online course suitable for clinicians who may be involved in case management or follow up of syphilis cases or contacts
• TCMP article: Managing syphilis during pregnancy
• TCMP article: Interpretation of syphilis serology

Syphilis testing and treatment resources

• Sexually Transmitted Infection Drug Order Request Form: form to obtain Bicillin for syphilis treatment free of cost in BC or the Yukon
• Syphilis Treatment Form: form to report treatment of syphilis cases
• Syphilis Treatment (Bicillin L-A) Quick Tips: one page reference on first-line treatment of syphilis
• Non-certified Decision Support Tool for Syphilis: outline of the clinical management of syphilis with links to additional resources
• Standard Education for Sexually Transmitted Infections and Blood-Borne Infections (STBBI): overview of client education regarding STBBIs with links to additional resources

Syphilis surveillance data

• Syphilis Surveillance Reports: updates around syphilis epidemiology and trends in BC

References

1. Llamosas-Falcón L, Hasan OS, Shuper PA, Rehm J. A systematic review on the impact of alcohol use on sexually transmitted infections. Int J Alcohol Drug Res. 2023;11(1):3-12. doi:10.7895/ijadr.381 (View)
2. World drug report 2024. United Nations Office on Drugs and Crime. Published 2024. Accessed June 20, 2025. (View on unodc.org)
3. Harvey L, Taylor JL, Assoumou SA, et al. Sexually transmitted and blood-borne infections among patients presenting to a low-barrier substance use disorder medication clinic. J Addict Med. 2021;15(6):461-467. doi:10.1097/ADM.0000000000000801 (View)
4. A guideline for the clinical management of opioid use disorder. British Columbia Centre on Substance Use; BC Ministry of Health; BC Ministry of Mental Health and Addictions. Published November 2023. (View on bccsu.ca)
5. Viral hepatitis testing guideline. British Columbia (BC) Guidelines and Protocols Advisory Committee; BC Agency for Pathology and Laboratory Medicine; BC Medical Services Commission. Published May 2021. (View on gov.bc.ca)
6. HIV testing guidelines for the province of British Columbia. British Columbia Office of the Provincial Health Officer. Published 2015. (View PDF)
7. Goodyear T, Ti L, Carrieri P, Small W, Knight R. “Everybody living with a chronic disease is entitled to be cured”: Challenges and opportunities in scaling up access to direct-acting antiviral hepatitis C virus treatment among people who inject drugs. Int J Drug Policy. 2020;81:102766. doi:10.1016/j.drugpo.2020.102766 (View)
8. Kerkerian G, Fernandez Ruiz E, Stanley C, Funaro R, Mitchell EJT, MacIsaac JK. Improving screening rates for sexually transmitted and blood-borne infections among patients initiating care in a low-barrier addiction medicine clinic: a quality improvement project. BMJ Open Qual. 2025;14(1):e003088. Published 2025 Mar 12. doi:10.1136/bmjoq-2024-003088 (View)
9. BC experiencing highest rates of infectious syphilis in the last 30 years. British Columbia Centre for Disease Control. Published October 2019 (View on bccdc.ca)
10. Syphilis indicators report 2024 Q1. British Columbia Centre for Disease Control. Accessed July 17, 2024. (View on bccdc.ca)
11. Wong J., et al. The changing epidemiology of syphilis in BC. BCMJ. Published December 2022. (View on bcmj.org)
12. Willemsma K, et al. Distinguishing female infectious syphilis in British Columbia. Canada Communicable Disease Report. Published March 2022. (View on canada.ca)
13. Clinical prevention services sexually transmitted and blood‑borne infection and tuberculosis surveillance report. British Columbia Centre for Disease Control. Accessed July 17, 2024. (View on bccdc.ca)
14. Guidance for country validation of viral hepatitis elimination and path to elimination: technical report. World Health Organization. Geneva: World Health Organization; 2023. Licence: CC BY-NC-SA 3.0 IGO. Accessed June 25, 2025. (View on who.int)
15. Sexually transmitted and blood-borne inection testing performed on dried blood spots. PHSA Laboratories. Accessed July 17, 2024. (View on bccdc.ca)
16. Penicillin G benzathine (Bicillin® L‑A) for treatment of syphilis. British Columbia Centre for Disease Control. Accessed July 17, 2024. (View on bccdc.ca)

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Universal screening for syphilis and other STBBIs among patients presenting for substance use-related care

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