Between February and September 2022, we used purposive sampling to recruit providers with connections to the communities most impacted by increased syphilis rates among women. This sampling technique utilized surveillance data and family planning data for Pueblo County, Colorado to identify health care providers who offer either family planning, prenatal care, or sexual health services to women of reproductive age. Family planning data was obtained from the Colorado Department of Public Health Family Planning Program, which funds family planning clinics across the state. STI surveillance data from the Colorado Department of Public Health Office of STI/HIV/VH was utilized to identify all providers in Pueblo County who were screening women of reproductive age for STIs or HIV. These provider lists were combined, giving a list of 34 providers in the county who provide sexual health, family planning, or prenatal care services. This provider group was chosen because they have experience screening and treating the population of interest – women of reproductive age in Pueblo County.

All survey data were collected online, lasting 5–10 minutes, and included a $5 gift card. The surveys prompted providers to rate comfort with screening, staging, and treating syphilis and to identify barriers to those services. The survey questions were specific to providers’ experiences with their female-identifying patients. Four providers agreed to virtual, in-depth, semi-structured, audio-recorded interviews, which were transcribed verbatim. Saturation was not reached with the interview data, which is addressed in the discussion. Interviews took between 60–90 minutes; providers were offered a $50 gift card in appreciation for their time. In the interviews, providers were asked about barriers to providing screening and treatment of syphilis and CS; recommendations on reducing syphilis infection; and technical assistance they needed to support care provision.

Data collection occurred sequentially. The quantitative survey instrument was developed and administered prior to interviewing providers. The survey included free response, multiple choice, and Likert responses, and was designed to measure provider comfort with offering sexual health services and recording sexual health histories, and to better understand provider-reported barriers and concerns when offering syphilis testing and treatment to their female-identified clients. The survey was used to identify providers who were willing to be interviewed. Survey findings were also used to refine questions from an interview guide previously developed by one of the authors for a separate research project related to congenital syphilis.^ix The interview questions were designed to focused on provider experiences and barriers in offering syphilis screening, testing and treatment to women, including pregnant women and to identify barriers that were not identified when developing the survey.

Survey data were analyzed using SAS 9.4 to explore relationships between the provision of prenatal services and barriers to treatment. Qualitative data were thematically analyzed, first by extensively reviewing interview transcripts, using MS Word to uniformly format the transcripts, and then using MS Excel to summarize transcripts into a data table organized by interview question. Those summaries were then consolidated into a matrix that outlined domains, broad themes, sub-themes, and exemplar quotes. This thematic analysis was completed by three analysts, and domains and themes were identified through a consensus approach. The interview data augments and provides further clarity to the survey responses.

Out of a total of 34 providers contacted, 23 completed the survey for an overall response rate of 68%, exceeding the typical response rate among specialty care physicians.^xiv The three most common clinical settings of providers who responded to surveys were family planning clinics or reproductive medicine (n=7), local health departments (n=5) and primary care/family medicine (n=3). All of the providers eligible for 340B federally subsidized pharmacies (n=13) offered bicillin syphilis treatment. For the remaining providers who were not 340B eligible, just four offered bicillin syphilis treatment.

Of the four providers who completed interviews, three were in clinical coordination or management roles, and one provided direct care. The providers each practiced in a distinct setting: a private practice (obstetrics and gynecological), a crisis pregnancy center, a county public health family planning clinic, and a family medicine/general practice clinic that also offers recovery treatment and behavioral health services. Three provided testing for syphilis; only the respondent from the public health clinic offered both testing and treatment for syphilis.

The most common barriers providers reported in the survey are the cost of treatment (26%) and loss to follow up with clients (22%) (Table 1). Importantly, 30% of providers in the survey reported no barriers to syphilis treatment despite persistently increasing rates of syphilis and CS rates in the area. Thirteen percent reported a lack of provider education on providing treatment for syphilis. In qualitative interviews, providers perceived that women are at low risk for syphilis, as it is most commonly reported among men having sex with men or because of women’s reported stability and monogamy in their intimate relationships.

Overall, three main themes were identified, including: 1. Discretionary testing and delayed screening results, 2. Cost of treatment and treatment referral issues, and 3. Stigma around substance use and sexual activity.

We explored the systemic barriers that providers experience in delivering sexual health care in a medically underserved region of southern Colorado, with a special emphasis on the prevention of syphilis and CS among women of reproductive age. Interviews and survey results from healthcare providers identified three primary themes: 1) discretionary testing and delayed screening results; 2) the cost of treatment and treatment referral issues; and 3) stigma around substance use and sexual activity. Survey responses demonstrated a knowledge gap between the reality of rising syphilis rates and providers’ understanding of the need to routinely test women at increased risk of syphilis acquisition.

Many of the women of reproductive age who are at risk for syphilis acquisition experience several upstream issues which complicate their ability to seek and receive healthcare. Even among women who do receive care, however, loss to follow up is a significant barrier cited by providers in ensuring adequate treatment for syphilis and CS among women at risk. EDs are heavily utilized by medically underserved women and may provide an opportunity to provide testing or screening for women who might not otherwise be seen by a healthcare provider.^xvii However, if the ED cannot offer point-of-care testing and initiate treatment at the first visit, or even in the first week, the patient may be lost to follow up. This missed opportunity for treatment initiation contributes to ongoing transmission in the community and poor outcomes for women as syphilis or CS infection progresses.

Point-of-care, rapid tests for syphilis can yield results in minutes and may be a useful testing option for under-resourced settings. These tests, however, may yield a false-positive for anyone with a prior syphilis infection, qualitatively detecting Treponema pallidum (syphilis) antibodies, but unable to distinguish between an active infection and a previously treated infection. The survey found that just a few providers (n=4) were uncomfortable with the reverse algorithm testing used to rule out false positive results. Given the serious consequences of syphilis and CS, some experts have concluded that “the risk of over-treatment due to false positives which are not syphilis in origin is more acceptable than the risk of non-treatment of syphilis.”^xviii,xix Bicillin is the only recommended treatment for pregnant women infected with syphilis, and yet increasing costs and shortages continue to be a barrier. Several public health agencies across the U.S. advise prioritizing bicillin treatment for pregnant people and babies with congenital syphilis, since non-pregnant people can receive alternative treatment for syphilis infection.^xx Providing rapid point-of-care and confirmatory syphilis testing in EDs would facilitate providing the first round of treatment prior to leaving to women who test positive. Implementation models for point-of-care testing in EDs suggests that pulling a confirmatory laboratory sample in conjunction with a rapid test can minimize workloads for providers, and increase provider buy-in, because the lab would then handle public health reporting and additional follow up with the client.^xxi

The most common barrier cited by providers was the high cost of bicillin. Providers have long been resistant to ordering and stocking bicillin in their clinics because of the high cost and cold storage requirements for the drug.^ix Bicillin access relies heavily on 340B federally subsidized pharmacies and STD clinics to distribute the drug,^xxii prompting many providers to refer patients elsewhere for treatment. Referral creates an increased burden on patients who have limited access to transportation, childcare, or other restrictions to visit another clinic to access treatment and creates a gap in continuity of care. States and counties across the U.S. have implemented programs to have bicillin delivered directly to health care providers to coordinate care with patients at routine follow up visits. More information on public health departmental websites is needed to assist providers on finding clinics with bicillin doses available, such as expanding on the Bicillin Inventory Tool, developed by the National Coalition of STD Directors.^xxiii

Finally, ongoing stigma around substance use negatively affects interactions between providers and patients.^xxiv Some providers may have adverse attitudes or implicit biases towards people with substance use disorders (SUD), particularly for those with multiple SUDs or co-occurring disorders. Populations who experience labeling, stereotyping, or discrimination in health care settings report higher levels of disempowerment, poor quality care, and are deterred from seeking medical services.^xxv,xxvi Pregnant women who use substances may also be deterred by the threat of involvement from child protective services, which they fear may take the child away if they test positive for substances during pregnancy.

Educating providers on addiction is incredibly helpful in establishing a deeper understanding of addiction as a disease and public health concern.^xxvii State agencies and behavioral health programs could provide this key service by offering education and training to health care facilities and groups of providers. Contact with people in recovery has a particularly strong effect in changing provider attitudes, when coupled with education.^xxviii The most effective stigma reduction efforts among providers include components that dispel myths about addiction, use people-first language, and demonstrate that recovery from SUDs and successful living are viable.^xxix

Given the intersecting upstream issues experienced by many women of reproductive age at high-risk for syphilis, health care providers, including staff, nurses, and doctors at health care facilities, should integrate mental health and trauma-informed components into their practice to deliver more effective solutions for their patients.^xxix Hiring mental health and behavioral health specialists, ideally with lived experience or connections to the community, and co-locating these navigators and peer support services in clinical settings, can assist in connecting patients to resources and/or provide support as they navigate the complicated and fragmented healthcare system. This creates a climate in which substance use and mental health issues are destigmatized and regarded as health concerns, rather than moral failings.

This study presents healthcare providers’ perspectives of the challenges of effectively screening, testing, and treating for syphilis and congenital syphilis in a medically underserved region. A limitation of this study was that the small sample size for the interviews did not reach data saturation. The research goal was to interview providers from diverse practice settings, yet we were unable to recruit providers who work in correctional settings or providers who work in urgent care and emergency care settings. We had hoped to recruit more, but in the post-COVID environment, providers are working under limited capacity due to shortages of nursing and other allied health staff and the response rate was low.

Recent increases in syphilis and congenital syphilis are a challenge of significant public health concern and can overwhelm limited resources for medically underserved populations. Insights from providers with direct care experience illustrate gaps in services. Listening to provider perspectives and challenges can help public health entities develop practice-based recommendations that can help to mitigate the spread of syphilis.