Rising antimicrobial resistance in STIs being seen in India: experts

India is witnessing a steady rise in common sexually transmitted infections (STIs), particularly syphilis, while antimicrobial resistance (AMR), fragile drug supplies and gaps in testing and partner services threaten to outpace control efforts. Experts warn that this imbalance could hinder elimination goals and leave vulnerable populations at greater risk.

Globally, the World Health Organization (WHO) estimated about eight million new adult syphilis infections in 2022, including 1.1 million among pregnant women. These infections carry grave risks, contributing to stillbirths, neonatal deaths, prematurity and congenital syphilis. Newer data indicate a resurgence, with congenital syphilis rates, now reported at more than 500 cases per 100,000 live births. For many countries, syphilis control has once again become a public health priority.

Situation in India

Surveillance in India shows low but persistent syphilis among pregnant women, with significant State-level variations. Reports of rising gonorrhoea and resistant strains are emerging. The true incidence of congenital syphilis remains uncertain, largely because active surveillance is patchy. Under its elimination-of-vertical-transmission (EVT) commitments, India has promised to strengthen reporting, but progress has been uneven.

Clinicians describe the problem as one of daily gaps rather than distant targets. “If testing, drugs, and reporting fail at the first point of care, it is like treating patients with blindfolds on,” says S. Saradha, senior consultant, obstetrics, gynaecology and IVF, SIMS Hospital, Chennai. She highlights poor access to diagnostics in primary care, limited screening for asymptomatic infections such as chlamydia, weak partner notification services and inconsistent reporting. The absence of AMR tracking and unreliable supply chains for medicines further complicate evidence-based treatment, especially in syphilis during pregnancy.

Silent infections, missed cases

“Syndromic management remains a major blind spot. We are missing half the infections because people have no symptoms,” says Sapna Raina, senior consultant, Narayana Health City, Bengaluru. Chlamydia and gonorrhoea often present silently, yet lead to pelvic inflammatory disease and infertility when undetected.

She calls for rapid rollout of affordable point-of-care tests, starting with dual HIV–syphilis kits and extending to indigenous tests for chlamydia, gonorrhoea and trichomoniasis at district laboratories. She emphasises the need for sentinel AMR labs for gonorrhoea, pooled drug procurement, penicillin-allergy desensitisation protocols for pregnant women, and building buffer stocks.

R.K. Vidhya Lakshmi, senior consultant, obstetrics and gynaecology, SRM Global Hospitals, Chennai, also draws attention to the asymptomatic nature of most infections and the uneven availability of nucleic acid amplification tests (NAATs). “Domestic innovation is there, but without contracts and validation, manufacturers can’t scale, and clinics remain dependent on imports,” she notes. She stresses the need for national treatment guidance to be updated frequently in alignment with WHO’s Enhanced Gonococcal Antimicrobial Surveillance Programme (EGASP).

Stigma and barriers to care

Stigma remains one of the largest obstacles. “Women often come late or not at all; clinics rely on symptoms without tests; BPG (Benzathine penicillin G) is sometimes unavailable; and non-disclosure to partners keeps infections spreading, including those only found during antenatal screening,” says Girija Ashok Kumar, consultant gynaecologist and obstetrician, VS Hospitals, Chennai.

She calls for confidential partner management, mobile testing units, affordable domestic manufacturing of diagnostic kits, strict antibiotic stewardship, resistance tracking, and youth-focused education. “We lose patients at every step from walking into clinics, to telling partners, to even finding penicillin on the shelf,” she adds.

Dr. Saradha adds, “Community actions really make a difference. We must include expedited partner therapy, stigma reduction by normalising testing and universal antenatal screening integrated with HIV, TB and reproductive health services.”

Manju Goyal, senior consultant, Narayana Hospital, Jaipur, points to the need for flexibility in STI policy. She stresses that clinics must be prepared for emerging threats such as m-pox while ensuring that entrenched infections like chlamydia, gonorrhoea, syphilis and the resistant strains of these are not neglected.

The way forward

WHO recommends dual HIV–syphilis rapid tests in antenatal clinics as the most cost-effective method to prevent congenital syphilis. Benzathine penicillin G remains the recommended treatment for syphilis in pregnancy. But global shortages between 2023 and 2025, driven by rising demand and few suppliers, highlight the need for domestic production and secure procurement chains. WHO’s AMR surveillance also confirms increasing gonorrhoea resistance worldwide, underlining the urgency of culture-based and molecular testing.

According to experts, three priorities stand out for India :make dual HIV–syphilis rapid tests routine in antenatal care, pilot multiplex platforms for other STIs at district hubs, and enable same-day testing, counselling and treatment, build national and state-level buffer stocks of BPG and ceftriaxone, diversify suppliers, and monitor shortages through real-time dashboards, expand culture-based and molecular AMR testing and link it to regular national treatment advisories.