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Behavioral Health is Essential to Health • Prevention Works • Treatment is Effective • People Recover

January 30, 2024 

Dear Colleague: 

On behalf of the Substance Abuse and Mental Health Services Administration (SAMHSA), I 

want to alert you to increased rates of syphilis and other sexually transmitted infections (STIs) 

and provide guidance on the use of grant funds and SAMHSA’s programmatic work to address 

this public health concern. 

Syphilis and congenital syphilis along with substance use disorder, mental illness, and other STIs 

such as HIV, gonorrhea, and chlamydia represents a syndemic. Syndemics happen when two or 

more health conditions cluster and interact within a population because of social and structural 

factors and inequities, leading to an excess burden of disease and continuing health disparities. 

Addressing the syphilis syndemic requires collaboration between substance use preventionists, 

substance use disorder treatment providers, sexual health service providers, and supportive 

services providers (e.g., housing). 

Screening, testing, and treating for STIs is part of SAMHSA’s whole person approach to 

behavioral health treatment and substance use prevention. The U.S. Preventive Services Task 

Force recommends providers screen early for syphilis in all pregnant women as well as screen 

asymptomatic, nonpregnant adolescents and adults who are at increased risk for syphilis 

infection. Data from the Centers for Disease Control and Prevention (CDC) show a 74% increase 

in syphilis diagnoses from 2017-2021, including 2,800 congenital, or mother-to-child, syphilis 

cases in 2021 leading to 220 infant deaths. STIs overall have increased by 7% from 2020, with 

more than 2.5 million cases reported in the United States during 2021. Substance use, 

particularly methamphetamine use, appears to be highly correlated with rising rates of syphilis 

and other STIs. Among pregnant women with syphilis, substance use is nearly twice as high

among those with a congenital syphilis outcome than those without transmission. Disparities also 

exist in syphilis rates across racial and ethnic groups. For example, among American Indian and 

Alaska Native (AI/AN) persons, the rate of new syphilis cases of nearly four times the rate of 

white persons in 2020. Syphilis is also increasing among gay, bisexual, and other men who have 

sex with men. However, we know that actions can be taken to reverse these trends and prevent 

transmission of syphilis and other STIs in these and other populations. 

Unless expressly stated in the Notice of Funding Opportunity (NOFO) through which a grant is 

funded, SAMHSA grant recipients are not permitted to directly use SAMHSA funds for syphilis 

treatment. However, SAMHSA grant recipients may use their grant funds to address the syphilis 

syndemic by providing syphilis and other STI screening, testing, and referral to treatment in 

conjunction with SAMHSA supported work. Additional allowable activities include, but are not 

limited to, training for staff, case management for people who test positive for STIs, service 

navigation for people served by SAMHSA funds to syphilis or other STI prevention resources 
Substance Abuse and Mental Health Services Administration

1-877-SAMHSA-7 (1-877-726-4727) • 1-800-487-4889 (TDD) • www.samhsa.gov

and mental health support, and the development of memoranda of understanding (MOUs) or 

other agreements with STI treatment providers. 

Additionally, some current SAMHSA grant programs include required or allowable activities 

that address the syphilis syndemic. Those grant programs are listed below, with additional 

information provided in Appendix 1. 

1. The SAMHSA Substance Use Prevention, Treatment, and Recovery Services Block 

Grant (SUBG).

2. Minority AIDS Initiative: Substance Use Disorder Treatment for Racial/Ethnic 

Minority Populations at High Risk for HIV/AIDS (Short title: MAI – High Risk 

Populations: fiscal year (FY) 2023 grant cohort only, TI-23-008.

3. Minority HIV/AIDS Fund (MHAF): Minority HIV/AIDS Fund: Integrated 

Behavioral Health and HIV Care for Unsheltered Populations Pilot Project (Short 

Title: Portable Clinical Care Pilot Project): TI-23-024.

4. Minority AIDS Initiative: The Substance Use and Human Immunodeficiency Virus 

Prevention Navigator Program for Racial/Ethnic Minorities (Short Title: Prevention 

Navigator): FY 2023 grant cohort only, SP-23-005.

5. Services Program for Residential Treatment for Pregnant and Postpartum Women

(Short Title: PPW): FY 2023 grant cohort only, TI-23-002. 

6. Building Communities of Recovery (Short Title: BCOR): FY 2022 and FY 2023 

grant cohorts only, TI-22-014.

7. Recovery Community Services Program (Short Title: RCSP): FY 2023 cohort only, 

TI-23-018.

8. Medication-Assisted Treatment-Prescription Drug and Opioid Addiction (Short Title: 

MAT-PDOA): FY 2021 (TI-21-006), FY 2022 (TI-22-013), and FY 2023 (TI-23-001) 

grant cohorts.

9. Grants for the Benefit of Homeless Individuals (Short Title: GBHI): FY 2023 grant 

cohort only, TI-23-005. 

10. Targeted Capacity Expansion: Special Projects (Short Title: TCE – Special Projects): 

FY 2022 and FY 2023 grant cohorts, TI-22-002. 

Note that this list does not include any future grant programs; for grant programs FY 2024 and 

later, please refer to the grant NOFO and/or contact your Government Project Officer if you have 

additional questions about how SAMHSA-supported programs can help to address the syphilis 

syndemic. 

SAMHSA also oversees Opioid Treatment Programs (OTPs), which play an important role in 

addressing the syphilis syndemic. In addition to providing medications for opioid use disorder 

and other treatment and support services to address substance use and substance use disorders, 

OTPs are required by 42 Code of Federal Regulations (CFR) Part 8 Rules to “establish the risk 

of undiagnosed conditions such as Hepatitis C, the human immunodeficiency virus (HIV), 

sexually transmitted infections (STIs).” These requirements are important for assessing and 

providing whole-person care.

The rising rates of syphilis and other STIs in the United States, particularly among people who 

use substances, necessitate action across the healthcare field. For a list of resources to assist 
Substance Abuse and Mental Health Services Administration

1-877-SAMHSA-7 (1-877-726-4727) • 1-800-487-4889 (TDD) • www.samhsa.gov

clinicians in addressing the syphilis syndemic, see this link. By assessing the whole person 

needs of individuals with behavioral health conditions, we can make progress together. Thank 

you for your partnership in this effort. Please contact your Government Project Officer if you 

have any questions about your award or need additional information about STI prevention and 

substance use and how SAMHSA funding can be used to address the syphilis syndemic. 

Sincerely, 

Miriam E. Delphin-Rittmon, Ph.D. 

Assistant Secretary for Mental Health and Substance Use

/Miriam E. Delphin-Rittmon/
Substance Abuse and Mental Health Services Administration

1-877-SAMHSA-7 (1-877-726-4727) • 1-800-487-4889 (TDD) • www.samhsa.gov

Appendix 1: SAMHSA grant programs that include required or allowable activities that address 

the syphilis syndemic are listed below. 

1. The SAMHSA Substance Use Prevention, Treatment, and Recovery Services Block Grant 

(SUBG) Provides funding as a “payment of last resort” in very limited circumstances for 

syphilis screening, testing, prevention education, and medical treatment. Those three limited 

circumstances are:

I. For pregnant people in SUBG-funded SUD treatment programs and for people in 

SUD treatment with dependent children. Allowable services include providing an 

array of primary medical care for women and primary pediatric care for their 

children, including syphilis screening, testing, prevention education, and medical 

treatment for syphilis and congenital syphilis. 

II. For persons with HIV in SUBG-funded SUD treatment programs in CDC 

designated states. The SUBG requires the delivery of a defined array of HIV Early 

Intervention Services (EIS) in states with a prevalence of 10 or more cases of AIDS 

per 100,000 persons. The provision of EIS and post-test counseling includes 

screening and testing individuals with HIV and are engaged in SUD treatment for 

syphilis and referral to treatment. 

III. SUBG funds may also be used to address syphilis if a SUBG grant recipient has been 

approved by their assigned Center for Substance Abuse Treatment (CSAT) 

State Project Officer (SPO) to use grant funds for approved elements of a 

Syringe Service Program (SSP), with the important exception that SUBG grant 

funds may not be used for distribution of needles or syringes for purposes of injection 

drug use of illegal substances. In the circumstances in which SUBG funds have been 

approved by the CSAT SPO to fund approved elements of a Syringe Services 

Program, these approved elements may include screening and testing for HIV, HCV, 

TB, and STIs, including syphilis. 

Note: Aside from these three limited circumstances, the SUBG does not allow the 

use of general block grant funds for routine testing for infectious diseases for 

individuals who are engaged in SUD treatment. If you are a SUBG grant recipient 

and have additional questions, please reach out to your CSAT SPO directly. 

2. Minority AIDS Initiative: Substance Use Disorder Treatment for Racial/Ethnic Minority 

Populations at High Risk for HIV/AIDS (Short title: MAI – High Risk Populations:), TI-23-

008: Recipients awarded from this NOFO in FY 2023 may use no more than 5 percent of the 

total award for staff training and screening and testing participants for HIV and other STIs, 

including test kits and required supplies, and referral to treatment services as appropriate. 

3. Minority HIV/AIDS Fund (MHAF): Minority HIV/AIDS Fund: Integrated Behavioral Health 

and HIV Care for Unsheltered Populations Pilot Project (Short Title: Portable Clinical Care 

Pilot Project): TI-23-024. 

I. Recipients awarded from this NOFO are required to provide the following activities: 

i. Screen clients and their drug-using and/or sexual partners on-site for HIV, 

viral hepatitis, STIs, mpox, and tuberculosis. 

ii. Provide case management and referral/linkage to treatment as necessary based 

on the client’s individual needs. Case management includes a comprehensive 

assessment of the client’s needs and the development of an individualized 
Substance Abuse and Mental Health Services Administration

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service plan, including infectious disease prevention and/or treatment services, 

as well as helping clients with funding for treatment, including HCV 

treatment, as necessary.

iii. Test participants for STIs (gonorrhea, chlamydia, and syphilis) and provide 

treatment on-site as needed.

II. As stated in the NOFO, no more than 15 percent of the total grant award may be used 

for the purchase of, among other expenses, STI screening, testing, and treatment 

medications (chlamydia, gonorrhea, and syphilis). 

4. Minority AIDS Initiative: The Substance Use and Human Immunodeficiency Virus 

Prevention Navigator Program for Racial/Ethnic Minorities (Short Title: Prevention 

Navigator): SP-23-005: Recipients awarded from this NOFO in FY 2023 may provide and/or 

refer individuals to supportive services that address social determinants of health and 

childhood adverse experiences to prevent the onset of mental health (MH)/SUD and reduce 

risk for HIV/viral hepatitis and STIs, including syphilis.

5. Services Program for Residential Treatment for Pregnant and Postpartum Women (Short 

Title: PPW): TI-23-002: Recipients awarded from this NOFO in FY 2023 are required to 

provide required supplemental services for women, including counseling on risk and testing 

for HIV, Hepatitis C, and other communicable diseases, including syphilis. 

6. Building Communities of Recovery (Short Title: BCOR). TI-22-014: Recipients awarded 

from this NOFO in FY 2022 and FY 2023 are allowed to provide education, screening, care 

coordination, risk reduction interventions, testing, and counseling for HIV/AIDS, hepatitis, 

and other infectious diseases, including syphilis, for individuals with SUD. 

7. Recovery Community Services Program (Short Title: RCSP): TI-23-018: Recipients awarded 

from this NOFO in FY 2023 are allowed to provide HIV/AIDS, viral hepatitis, and other 

infectious diseases education, including syphilis, screening, case management, and/or risk 

reduction interventions for individuals with Substance Use Disorder (SUD) or co-occurring 

substance use and mental disorders (COD), including those in recovery. 

8. Medication-Assisted Treatment-Prescription Drug and Opioid Addiction (Short Title: MATPDOA): FY21 (TI-21-006), FY22 (TI-22-013), and FY23 (TI-23-001) grant cohorts: 

Recipients awarded from the NOFOs in FY 2021, FY 2022, and FY 2023 are allowed to 

provide education, screening, including screening and confirmatory laboratory testing, care 

coordination, risk reduction interventions, and counseling for HIV, hepatitis C, and other 

infectious diseases for people with Opioid Use Disorder (OUD) who are receiving 

Medication for Opioid Use Disorder (MOUD), including syphilis. 

9. Grants for the Benefit of Homeless Individuals (Short Title: GBHI), TI-23-005: Recipients 

awarded in FY 2023 are allowed to provide training, screening, including laboratory 

screening and confirmatory testing, counseling, and treatment linkage as appropriate for 

Hepatitis C and other sexually transmitted infections, including syphilis. 
Substance Abuse and Mental Health Services Administration

1-877-SAMHSA-7 (1-877-726-4727) • 1-800-487-4889 (TDD) • www.samhsa.gov

10. Targeted Capacity Expansion: Special Projects (Short Title: TCE – Special Projects): FY22 

and FY23 grant cohorts only, TI-22-002: Recipients awarded from the NOFO in FY 2022 

and FY 2023 are allowed to provide education, screening, care coordination, risk reduction 

interventions, testing, and counseling for HIV/AIDS, hepatitis, and other infectious diseases, 

such as syphilis, for people with SUD who are receiving MOUD.