Takeaway
STI rates are finally dropping—but congenital syphilis keeps climbing. Don't make assumptions about who's at risk and screen everyone who's sexually active. A brief, nonjudgmental conversation about syphilis in any clinical setting can prevent devastating outcomes.
Lifelong learning in clinical excellence | June 15, 2026 | 3 min read
By Zachary Lorenz, MD & Matthew Hamill, MBChB, PhD, MPH, Johns Hopkins Medicine
A woman in her 20s came to the emergency department for a fall. She had no symptoms that would make anyone think of a sexually transmitted infection, and on a busy night, no one would have thought to ask. But her hospital ran opt-out syphilis testing, and results were reactive. After staging, the patient was diagnosed with latent syphilis of unknown duration. She was surprised, as she didn’t consider herself “at risk” and had never been tested for syphilis. A few years ago, probably none of us would have.
K-shaped STI curves
There’s promising news in the CDC’s 2024 provisional surveillance data. Combined cases of chlamydia, gonorrhea, and syphilis fell about 9% from the prior year—the third straight annual decline—and primary and secondary syphilis dropped more than 20%. After years of inexorable increases, the curve may finally be starting to bend.
But these are early signs, not a victory, and the progress isn’t shared equally. Congenital syphilis—when the disease is passed to babies during pregnancy—rose again in 2024 for the 12th consecutive year to nearly 4,000 cases, roughly seven times the burden of a decade ago. The majority of those cases were preventable with timely testing and treatment, but posed devastating outcomes, such as stillbirth.
A disease that crossed over
In recent decades in the U.S., syphilis has been seen almost exclusively as a disease associated with men who have sex with men. It no longer is. Syphilis in the U.S. has moved into broader heterosexual networks and reached more women of reproductive age. Our patient in the ED represents the human face of this shift—a diagnosis no one expected in a setting other than a sexual health clinic.
Screening is everyone’s job
The uncomfortable truth is that we still screen less than half of the patients who, by guidelines, should be screened. Closing that gap requires near-patient screening and care linkage programs outside of a specialty clinic. Opt-out testing in the ED, during prenatal visits, at urgent care centers, and at primary care clinics are a start. At-home, self-testing programs may help reach the patients who fall through the cracks.
The doxyPEP gap
Doxycycline post-exposure prophylaxis (doxyPEP) is a real advance, with strong evidence for reducing syphilis and chlamydia among gay and bisexual men and transgender women. But the evidence doesn’t yet support its use in cisgender women—those at the center of the congenital syphilis epidemic. This gap is one of the central challenges ahead, and a reminder that prevention tools and screening aren’t interchangeable but are instead complementary.
What we can do:
1. Test more, assume less.
Offer opt-out syphilis and HIV screening wherever patients land, including the ED and primary care clinic.
2. Use your well-honed communication skills.
Take a brief, nonjudgmental sexual history, and screen for STIs by anatomic sites of sexual exposure and behavior rather than by who “seems” at risk.
3. Re-screen in pregnancy per guidelines.
Many congenital cases reflect infection acquired later in pregnancy and missed.
4. Lean on vetted resources.
The 2021 CDC STI Treatment Guidelines, the National STD Curriculum, and the STD/HIV Prevention Training Center at Johns Hopkins can help interpret testing results and provide expert recommendations.
The numbers are finally moving in the right direction. Whether that progress reaches every patient—including the ones we would never have thought to test—is up to us.
This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.