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Objectives: To evaluate trends in syphilis prevalence among antenatal women in a high HIV prevalence setting in northern Botswana. Methods: Laboratory logbooks of antenatal syphilis testing for 1992-2003 in Francistown, Botswana's second largest city, were reviewed, and a consecutive sample of 750 women per year from 1992-2003 were analysed. VDRL result and age were recorded. A positive result was considered a case. Results: Overall syphilis prevalence (VDRL positive) among pregnant women in Francistown decreased from 12.4% in 1992 to 4.3% in 2003 (p ⩾ 0.001). The downward trend in overall syphilis prevalence began in 1997. There was no change in syphilis prevalence from 1992-6. Beginning in 1997, there has been a significant decrease in syphilis prevalence in all age groups. Conclusions: Syphilis in pregnant women in Francistown has been decreasing for the last 6 years, despite extremely high HIV prevalence (stable at ⩾40% since 1996) in the same population. Reasons contributing to the decline in syphilis rates may include nationwide implementation of syndromic management of sexually transmitted diseases (STDs) in 1992, improved access to health care, and less risky sexual behaviour. There is evidence from other sources indicating that risky sexual behaviour in Botswana has decreased during the HIV epidemic. [ABSTRACT FROM AUTHOR]