Big changes are coming in South Africa’s fight against sexually transmitted infections, according to a draft of government's fifth HIV action plan, enabling free home tests for four common, and curable, STIs: gonorrhoea, chlamydia, syphilis and trichomoniasis.
Writing in Bhekisisa, Zano Kunene says the tests could soon be available at chronic medicine pick-up points countrywide, according to the draft of SA’s HIV, TB and STI action plan. Government clinics will also roll out same-day STI tests/results.
The new plan is being finalised after comments from the public and civil society, says Nelson Dlamini, communications manager at the South African National Aids Council. The final draft will be published on World TB Day on 24 March.
The updated strategy will run from 2023 to 2028.
Until now, the public health sector has not used tests as a standard means to diagnose these four STIs (apart from syphilis). Instead, people get treated only if they go to a facility displaying symptoms like genital sores or discharges.
This is called “syndromic management”, used by many low- and middle-income countries, including Tanzania and Mozambique.
The logic is that many facilities don’t have easy access to a laboratory, so it might take up to four days for people to get their results: then they might not return to the clinic for the news or the medicine anyway.
In South Africa’s private sector, however, using lab tests to diagnose STIs is commonplace.
The trouble with the syndromic method is twofold:
First, most people with these STIs are asymptomatic, meaning they don’t show any symptoms (that was the case for more than three-quarters of women in one local study). So, with the current approach in the public health system, it means they won’t be treated and will continue to spread the infection to others.
Additionally, the Health Department doesn’t consistently collect data on how many people have one of the four common STIs (gonorrhoea, chlamydia, syphilis and trichomoniasis) on a national level.
Instead, the department and the National Institute for Communicable Diseases run data collection drives every now and again, where samples are collected from people (who show symptoms) in all nine provinces and sent to the lab. The results are used to make predictions about how many of these infections are circulating, and the department then decides whether it’s buying the correct medicines.
This method of data collection makes it difficult to know whether the country reached the government’s previous HIV and STI plan’s (2017-22) goal to find 50% more symptomless cases of these four infections by the end of 2022, says Yogan Pillay, who heads the local arm of the Clinton Health Access Initiative.
When gonorrhoea, syphilis or chlamydia are not treated, they can cause infertility, increase the chance of contracting HIV or lead to stillbirth. People with HIV who are not on antiretroviral treatment can also spread the virus more easily when they have gonorrhoea.
The second problem is that people who do have symptoms (and who arrive at a clinic for help) will get an antibiotic that works against more than one infection, because health workers don’t know exactly what they are treating. This could result in some bugs becoming resistant to those medicines, something South Africa already struggles with.
In short: the public health system is potentially over-treating people with symptoms and under-treating those without, says Johan Hugo, a senior clinical adviser at the Anova Health Institute.
But the way South Africa approaches both these problems – through diagnostics and data – is changing. Here’s how.
Diagnostics: finding the patients
Testing people, like pregnant women, when they go to clinics could make a big difference, shows research published in the journal Infectious Diseases in Obstetrics and Gynaecology in 2018.
At three clinics in Tshwane, pregnant women used rapid tests for gonorrhoea, chlamydia and trichomoniasis. Nine out of 10 who tested positive for any of these infections could start treatment immediately, without having to wait longer for help.
However, these tests are not widely available in the public sector. State facilities have rapid tests for syphilis, commonly given to pregnant women and survivors of sexual violence, but they are not standard use or for the three other STIs.
Under the new STI plan, though, tests would be available to more people, including teenage girls and young women (between 15 and 24), sex workers, transgender people, men who have sex with men and survivors of gender-based violence.
In the private sector, rapid self-test kits for single STIs cost between R125 and R200 or R500 for a kit to screen for all four curable STIs.
Another option for the state could be to use the GeneXpert machines, already available for testing for TB, to detect a chlamydia and gonorrhoea infection, said Hugo.
With this machine, test results are available within 90 minutes when using the chlamydia and gonorrhoea cartridges. All health workers do is replace the TB or HIV test kit inside the machine with one that works for a specific STI.
When researchers tested this method in 12 clinics in Australia, it worked just as well as laboratory tests, research shows, and much faster.
A study from Durban that used the GeneXpert machine to test for STIs gave similar results, and women who tested positive received medication and a pack of information, condoms and treatment for their sexual partners as soon as the results were out (within about two hours).
The cartridges are pricey, though – about R250 a shot to test for gonorrhoea. So, although the Durban study showed that this method could be good for diagnosing STIs fast, it didn’t look at whether it would be an affordable option.
But if people can get their STI results so fast in clinics, why would the government also roll out home tests?
It’s a way to get around stigma, the action plan says. Discrimination at clinics makes it hard for people to get the health services they need, especially those at a high risk of contracting STIs, like sex workers and transgender people.
Close to 40% of the practitioners involved in one study felt uncomfortable caring for patients from such high-risk groups, also called key populations.
In a Brazilian study, transgender women said they were far more comfortable collecting their own samples (from their anus, urethra or mouth) than having a health worker do it.
Pillay cautions, though, that sending out self-test kits could create another set of problems regarding keeping track of infections.
Health workers would not know whether people used the test, he said, and if they have, there was no guarantee they would come in for treatment.
Data: getting the numbers
There were more than 4.5m estimated new cases of gonorrhoea in South Africa in 2017; 5.8m new chlamydia infections, and 70 000 cases of syphilis, according to a 2018 modelling study.
But these figures are only educated guesses and could be inflated, the researchers caution, because there was not much data with which to work. That meant they had to do “crude” calculations based on figures from some smaller studies, which did not all have the same research method.
Under the new HIV and STI plan, the Health Department will conduct nationally representative studies to determine how many of these STIs are circulating among those most likely to be infected (sex workers and young women).
These data will make it easier to find and treat more people with STIs, without having to test everyone in the country.
In the meantime, health facilities will change how they collect data for people showing symptoms of STIs.
Currently, health workers record only information for male urethritis syndrome, a condition where a bacterial infection – which is sexually transmitted – causes inflammation in the urethra (the tube along which urine flows out from the bladder).
Some 311 000 men arrived at healthcare facilities with symptoms of this condition in 2017.
While men are likelier than women to show symptoms of infections like chlamydia and gonorrhoea, they are less likely to ask for help quickly. Pillay said they are likely to start recording cases of vaginal discharge syndrome in women and genital ulcer disease too, because these are underlying symptoms of STIs like chlamydia and herpes among this gender.
Tracking these two syndromes can help understand STI trends in women who show symptoms, so that it can pick up in which areas more intensive testing and treatment must happen.
To ensure the people who need treatment get it, the department also plans to add an STI section to the country’s tracking platform, Tier.Net, that helps monitor people on HIV and TB treatment.
This system keeps track of people on HIV medication, for example, so that health workers know to test their viral load whenever they go for check-ups at the clinic. The online platform doubles as a way to collect data and filter it to the government to help manage the country’s response to HIV infections. In the same way it could help track STI numbers.
But Tier.Net has had drawbacks, research shows. Health workers have battled to keep it updated alongside the paper records, which has resulted in mismatches between what’s on electronic sheets and what’s in a clinic’s books.
Until then, Pillay said, health workers should simply encourage more people to get screened for STIs while having other check-ups at a healthcare facility.
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Infectious Diseases in Obstetrics & Gynaecology article – Acceptability and Feasibility of Integrating Point-of-Care Diagnostic Testing of Sexually Transmitted Infections into a South African Antenatal Care Program for HIV-Infected Pregnant Women (Open access)
See more from MedicalBrief archives:
New STI guidelines emphasise screening
New TB testing strategy showing promising results in SA
Young rural SA women more vulnerable to STIs than young men
Meta-analysis of STI prevalence in sub-Saharan Africa
Dramatic increase in STIs in Gauteng
HIV treatment might boost susceptibility to syphilis