Guidance

Guidance on expedited syphilis testing and treatment for inclusion health groups

Published 26 August 2026

Applies to England

Introduction

Who is this guidance for? 

This guidance is intended to expedite the syphilis diagnosis and treatment pathways for inclusion health groups who are at high risk of loss to follow up in England. The guidance is intended to be used by healthcare professionals outside of specialist sexual health services in settings and contexts where traditional healthcare does not meet the need of some groups.

This guidance should be used alongside the syphilis clinical guidance set out by the British Association for Sexual Health and HIV (BASHH). It should complement the usual tailored support that is provided to help these groups with navigating the healthcare system. Following this guidance will provide an opportunity to increase both awareness of syphilis and access to comprehensive healthcare services, including local sexual health clinics and GP practices, among those at highest risk of loss to follow up.

The use of the expedited pathway as set out in this guidance should be conducted by trained healthcare professionals with experience of sexual health and working with inclusion health groups, with appropriate monitoring of possible cases by trained staff members.

Background

Syphilis is a sexually transmitted infection (STI) caused by the bacterium Treponema pallidum subsp pallidum, which in most cases is transmitted by direct contact with an infectious lesion. It is possible for syphilis to be acquired through the sharing of equipment such as sex toys and needles. Syphilis can also be transmitted from mother-to-child during pregnancy. It is estimated that around 1 in 3 sexual contacts of a syphilis case will develop the infection 1.

Syphilis is most infectious during the primary and secondary stages, which occur between 2 weeks to 3 months after infection. It can also be transmitted in the early latent stage and is generally considered infectious for up to 2 years after initial infection. If left untreated, about one-third of cases progress to serious complications, while others remain latent for life.

Rates of syphilis in England remain high. The number of infectious syphilis diagnoses has increased by 55.4% between 2015 (5,313) and 2025 (8,262) (see Sexually transmitted infections and screening for chlamydia in England: 2025 report).

Syphilis testing is usually performed in a laboratory and requires either capillary or venous blood. This can present challenges in some circumstances where affected individuals face inequalities in accessing healthcare. Further information regarding syphilis can be found in Appendix 1 and congenital syphilis in Appendix 2.

For the purposes of this guidance, loss to follow-up is defined as a breakdown in the planned processes for maintaining contact, treatment or monitoring within a defined care pathway, resulting in an interruption to clinical management. This may occur in secure settings, where individuals may be transferred or released before laboratory test results are available, or in outreach settings serving inclusion health groups, where service, communication and follow-up arrangements may be insufficient to support timely treatment and continuity of care.

This guidance is based on available evidence and has been developed through expert opinion and agreed by a multi-agency group established by the UK Health Security Agency (UKHSA). Partners who have supported the development of this guidance include NHS England, the BASHH prisons special interest group, representatives of the BASHH clinical effectiveness group, and specialist UKHSA health and justice, inclusion health, and sexual health teams.

BASHH guidelines provide information on the diagnosis and treatment of syphilis:

• BASHH UK guidelines for the management of syphilis 2024
• British Association of Sexual Health and HIV (BASHH) UK guidelines for the management of syphilis in pregnancy and children 2024
• Prison Standards BASHH

Further information, including specific information for prison healthcare teams and frequently asked questions (FAQs) for healthcare staff can be found in Appendix 3. Guidance on the use of point of care tests (POCTs) outside of level 3 services is available from the Medicines and Healthcare Products Regulatory Agency (MHRA).

Target populations

UKHSA have used the CORE20PLUS framework to define the populations to routinely consider in its work. The ‘PLUS’ element of the framework includes populations that experience extreme health protection inequalities, that is inclusion health groups. Inclusion health groups include:

• people experiencing homelessness
• people who use drugs
• sex workers
• people seeking asylum, refugees, and migrants in other vulnerable circumstances
• Gypsy, Roma and Traveller communities
• people who are in contact with the justice system
• people subject to modern slavery and/or trafficking

These groups can experience poor access to healthcare, negative experiences of stigma and discrimination when accessing healthcare, and can have multiple competing inequalities which can all contribute to high risk of loss to follow up. To reduce this risk, expert consensus has been reached on a rapid diagnostic and treatment pathway which balances the risk of both over-treatment and under-treatment in those at high risk of loss to follow up.

More information about prison populations can be found at Prison Standards BASHH as well as in Appendix 4.

More information about sex worker populations can be found at Clinical Standards for the Sexual Health Management of People Involved in Sex Work BASHH.

Key recommendations

This guidance recommends the use of point-of-care treponemal testing which offers a rapid treponemal result within approximately 15 minutes.

POCTs can be used by staff outside of the laboratory environment within a quality assured framework outlined at Management and use of IVD point of care test devices.

This pathway should only be used following a risk assessment. If any of the following - neurosyphilis, pregnancy, past syphilis diagnosis or treatment, symptoms or signs of tertiary syphilis (as described in Appendix 1) - are identified during risk assessment, this pathway should not be used and the BASHH UK guidelines for the management of syphilis 2024 should be used instead.

Where rapid diagnosis and treatment are needed, eligible patients who have undergone a risk assessment, can start treatment based on a reactive syphilis POCT.

For those with a reactive initial POCT result, laboratory testing should also be conducted as set out in the BASHH clinical guidance to inform future treatment and management alongside supporting the individual to continue to access ongoing care wherever possible. Further information on POCTs can be found in Appendix 5.

Appropriate treatment should be initiated where clinically necessary and completed by appropriately trained staff in line with the integrated sexual health service specification. Services which are not commissioned to treat syphilis (levels 1 and 2) may wish to consider developing a patient groups directive in order to do so.

Implementing treatment based on a POCT alone means there is a risk of over-treatment; however, the benefits of this pathway are felt to outweigh the negatives of over-treatment for syphilis among people in inclusion health groups who are at high risk of loss to follow up.

Implementing this new recommended rapid diagnostic screening and treatment pathway may increase uptake of some treatment for syphilis in those at high risk of loss to follow up, and may prevent serious tertiary complications, onward transmission and cases of congenital syphilis.

Expedited syphilis testing and treatment protocol  

Eligibility

All of the eligibility criteria set out below should be met before the expedited pathway is used:

1. The individual is part of an inclusion health group as described above.

2. The individual accessed syphilis POCT via testing in prison or via specific outreach initiatives such as:

   a. mobile clinics

   b. outreach to accommodation settings or other non-health settings used by inclusion health groups (such as daycentres)

   c. street-based care

   d. peer-led approaches

3. Where usual testing cannot be undertaken, for example because the individual declined venous blood testing, or they are expected to only engage with services for a short period of time before laboratory confirmed tests are available.

Exclusion criteria

A clinical risk assessment should be undertaken as part of the protocol to ensure that opportunities for further harm are mitigated.

Do not use this expedited pathway if you identify any of the following:

1. Neurosyphilis.
2. Pregnancy.
3. Past syphilis diagnosis or treatment.
4. Symptoms or signs of tertiary syphilis (as described in Appendix 1).

If any of the above are identified, the testing and treatment pathway set out by BASHH should be used instead, see BASHH UK guidelines for the management of syphilis 2024.

This expedited pathway could also be used by incident management teams (IMT) during incidents as an outbreak measure where eligibility for testing will be decided by the IMT chair.

Expedited testing and treatment pathway

 If the eligibility criteria described above are met, the following testing pathway can be used to expedite test results and treatment. 

1. Discuss the purpose of testing with patients with a translator if required. Supply easy read documents to support patients available in Appendix 6. Where possible, female healthcare staff should conduct testing for female patients. Further support for healthcare staff when discussing syphilis is available in Appendix 3.

2. Ensure patient is eligible based on the above inclusion and exclusion criteria.

3. Seek informed consent from the patient prior to testing.

4. Testing should be accompanied by signposting to appropriate wider support services if needed (for example mental health services, housing support) as well as appropriate counselling as to what a reactive POCT means.

5. Conduct a validated treponemal POCT, which detects the presence of antibodies against Treponema pallidum.

6. If the POCT is reactive:

   a. initiate appropriate treatment in line with BASHH clinical guidelines or refer to a level 3 sexual health service that can initiate treatment

   b. take a venous blood sample, for laboratory-based testing as per BASHH guidance

   c. provide information on syphilis and facilitate entry to substantive healthcare services, including direct referral where possible

   d. further lab testing on the venous blood sample will inform ongoing management for all people where possible in partnership with the local level 3 service provider or via services like RECONNECT (for secure settings) where possible.

7. If the POCT is non-reactive:

   a. consider taking a venous blood sample for laboratory testing or swabbing lesions for PCR testing if the individual is symptomatic (due to the potential for false negative POCT in early cases of syphilis)

   b. in those with lesions, consider another diagnosis such as mpox or herpes simplex virus (HSV).

Treatment  

Syphilis treatment should be delivered through, or in partnership with, a Level 3 (L3) sexual health service. For people who meet the risk assessment criteria, following a reactive POCT result treatment may be initiated with benzathine penicillin G, where clinically appropriate and in line with local pathways. Subsequent treatment decisions should be made by an L3 sexual health service in accordance with the BASHH UK Guidelines for the Management of Syphilis (2024)..

Healthcare teams in prisons, immigration removal centres (IRCs) and outreach settings should have local pathways in place to ensure that people with a reactive POCT result who meet the risk assessment criteria can access prompt treatment and timely referral to an L3 sexual health service for diagnostic confirmation, staging, and any further treatment required.

Safeguarding considerations

All staff using this guidance should remain alert to signs of abuse, exploitation, coercion, domestic abuse, trafficking, or unmanaged physical and mental health needs.

Staff involved should be aware of their local safeguarding policies and procedures and escalate any concerns in line with these processes to their local safeguarding teams (adult/child).

Patients must provide informed, voluntary consent, and staff involved should consider the impact of intoxication, mental health crises or cognitive impairment on capacity and follow the Mental Capacity Act 2005 where appropriate.

Confidentiality should be maintained, with information shared only when necessary for safeguarding, prevention of serious harm or required public health action. Documentation of all decision making is essential.

Reference

1. Denman J and others. ‘Infection risk in sexual contacts of syphilis: a systematic review and meta-analysis’ Journal of Infection 2022: volume 84, issue 6, pages 760 to 769