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Syphilis cases are on the rise, and inconsistent screening in general practice is leaving people at risk.
Syphilis in Australia has re-emerged as a major public health threat. Notifications have more than doubled over the past decade, prompting its declaration as a Communicable Disease Incident of National Significance (CDINS) a designation reserved for conditions requiring a coordinated national response. Despite this, gaps in clinician awareness and practice persist.
Recent research by ASHM, surveying more than 819 Australian healthcare workers, highlights a concerning disconnect: 54% of healthcare professionals report low confidence in when to test or refer for syphilis, and only 38% believe itis their responsibility to raise sexual health with patients. While most clinicians are technically able to test, few are routinely initiating these conversations and the consequences are significant.
Syphilis can easily go unnoticed, with up to half of cases having no symptoms. When there are symptoms, they can easily be mistaken for other conditions, meaning a blood test is vital for detection. Left untreated, syphilis can lead to severe complications, including neurological and cardiovascular disease. In pregnancy, the stakes are even higher: congenital syphilis can result in miscarriage, stillbirth, or neonatal death. Since 2016, 33 infant deaths in Australia were attributed to this entirely preventable condition.
This is not a failure of diagnostics or treatment, but of detection.
Clinical insights and gaps
In general practice, we are seeing firsthand the consequences of inconsistent and incomplete STI screening. Patients frequently present having undergone partial testing, often limited to chlamydia and gonorrhoea, without inclusion of syphilis or HIV serology. This reflects a broader misunderstanding that persists among clinician that syphilis testing is either optional, risk dependent, or included in other forms of testing such as urine screens. It is not.
ASHM’s recent findings reinforce what many of us observe in practice. While 88% of healthcare workers report being equipped to test or refer for STIs, only 21% report regularly discussing sexual health with patients. This gap between capability and practice is critical. Without initiating conversations, opportunities for testing and therefore early diagnosis are missed.
Syphilis remains “the great imitator.” Its symptoms are highly variable and frequently absent. Even when present, lesions may be atypical or mistaken for other conditions. Relying on symptom-driven or risk-based testing alone is therefore insufficient. Blood testing is simple, accessible, and essential.
We need to move towards a model of routine, standardised STI screening, where syphilis and HIV serology are included in all appropriate testing — not selectively, but systematically. Opportunistic screening should be considered a core function of general practice, much like blood pressure measurement or cervical screening. This approach not only improves detection but also reduces stigma by removing assumptions about risk.
This is particularly urgent in pregnancy. While early antenatal screening is well established, repeat testing later in pregnancy is not always consistently implemented. Given the devastating but preventable consequences of congenital syphilis, adherence to repeat testing protocols must be prioritised. Every missed test represents a missed opportunity to prevent harm.
Importantly, syphilis is no longer confined to specific populations. Rising case numbers across diverse demographics reinforce that this is a whole population issue, requiring a whole healthcare system response.
Implications and next steps
Australia’s response to syphilis must now focus on implementation and coordinated efforts. The tools are already available: accurate testing, effective treatment, and clear guidelines. The challenge lies in ensuring these are applied consistently in everyday clinical practice, through culturally-safe models of care that address barriers.
ASHM’s National Syphilis Awareness Campaign is one critical step in addressing current gaps. The campaign aims to encourage professionals to move from risk-based testing to opportunistic and enhanced testing strategies to protect all communities. By equipping healthcare professionals with practical tools, education, and decision-support resources, it aims to improve confidence in testing and reinforce the importance of early detection. However, awareness alone is not enough. We must embed these practices into routine care across the entire healthcare system.
A shift is required from a risk-based model to a universal, normalised approach to STI screening. This includes:
- routinely including syphilis and HIV serology in all STI testing;
- increasing frequency of sexual health discussions in clinical encounters;
- leveraging opportunistic screening across all patient populations; and
- strengthening adherence to antenatal testing guidelines, including repeat screening.
System level support will be essential. Clinical software prompts, funding models that support preventive care, and ongoing professional education can all help translate knowledge into action.
There is also a need to address stigma, both perceived and real, which continues to act as a barrier for clinicians and patients alike. Normalising sexual health as part of routine care is key to overcoming this.
Ultimately, preventing further transmission and further avoidable infant deaths is a shared responsibility across the healthcare system. If we can make comprehensive STI screening as routine as checking blood pressure, we have a real opportunity to reverse the trajectory of this epidemic.
Dr George Forgan-Smith, Melbourne-based GP with a specialist focus on gay men’s health and sexual wellbeing.
Dr Karen Freilich is a GP and Sexual Medicine & Therapy Consultant at Monash Health.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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