Free home tests for four common and curable sexually transmitted infections (STIs), namely gonorrhea, chlamydia, syphilis and trichomoniasis, may soon be available at chronic medication collection points across the country, according to a draft of South Africa’s fifth HIV report. , TB and STI action plan.
Government clinics will also perform STI tests that will return results the same day.
The new plan is being finalized after comments from the public and civil society were added, says Nelson Dlamini, communications manager for South Africa’s National AIDS Council. The final draft will be published on March 24, World Tuberculosis Day.
The updated strategy will run from 2023 to 2028.
Until now, the South African public health sector has not used standard tests to diagnose these four STIs (other than syphilis). Instead, people receive treatment only if they come to a center with symptoms such as genital sores or discharge from the penis or vagina.
This is called “syndromic management” and is used by many low- and middle-income countries, including Tanzania and Mozambique. The rationale is that many facilities do not have easy access to a lab, so it can take people up to 4 days to get their results and then they may not return to the clinic to get the results or medication anyway.
However, in the private sector in South Africa, the use of laboratory tests to diagnose STIs is commonplace.
The problem 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 a local study). So with the current focus on the public health system, it means that they will not receive treatment and will continue to spread the infection to others.
Also, the health department does not consistently collect data on how many people have one of the four common STIs (gonorrhea, chlamydia, syphilis, and trichomoniasis) nationwide.
Instead, the department and the National Institute of Communicable Diseases conduct data collection campaigns from time to time, where samples are collected from people showing symptoms in all nine provinces and sent to a laboratory. The results are used to make predictions about how many of these infections are occurring, and the health department then decides if they are buying the right drugs.
This type of data collection makes it difficult to know whether the country has met the government’s previous HIV and STI target (2017-2022) of finding 50% more asymptomatic cases of these four infections by the end of 2022, says Yogan Pillay, who runs the local arm of the Clinton Health Access Initiative.
When gonorrhea, syphilis, or chlamydia are not treated, they can cause infertility, increase someone’s chances of getting HIV, or, in the case of pregnant women, stillbirth. People with HIV who are not on antiretroviral treatment can also spread this virus more easily when they have gonorrhea.
The second problem is that people who have symptoms (and who go to a clinic for help) will be given an antibiotic that works against more than one infection, because health workers don’t know exactly what they are treating. This could lead to some microbes becoming resistant to those drugs, something South Africa already struggles with..
In short, the public health system is potentially over-treating people with symptoms and under-treating those without, explains Johan Hugo, a senior clinical adviser at the Anova Health Institute.
But the way South Africa addresses both issues, through diagnostics and data, is changing. That is how.
Diagnosis: finding the patients
Testing people, for example pregnant women, when they come to clinics could make a big difference, research published in the journal shows. Infectious Diseases in Obstetrics and Gynecology in 2018.
At three clinics in Tshwane, pregnant women used rapid tests for gonorrhea, chlamydia, and trichomoniasis. Nine out of 10 of those who tested positive for one of these infections could start treatment immediately, without having to wait any longer for help than they would have spent in line anyway.
However, these tests are not widely available in the South African public sector. State facilities have rapid tests for syphilis, which are commonly administered to pregnant women and survivors of sexual violence, but are not available as a standard or for the other three STIs.
However, under the new STI plan, testing would be available to many more people, including all adolescent girls and young women (ages 15-24); 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 a single STI cost between R125 and R200 or R500 for a kit that detects all four curable STIs.
Another option for the state could be to use GeneXpert machines, already available for TB testing, to detect if someone has a chlamydia and gonorrhea infection, Hugo says.
With this machine, test results are available in 90 minutes when using the chlamydia and gonorrhea cartridges. All health workers would have to 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 as well as research from lab tests shows, and it’s much faster.
A study in Durban using the GeneXpert machine to detect STIs found similar results. Women who tested positive received medicines, an information pack, condoms and treatment for their sexual partners as soon as the results were known. The patients told the researchers that this method worked for them because they got results quickly (in about two hours) and because they could help their partners.
However, the cartridges are expensive: it could cost around R250 for an injection to test for gonorrhea. So while the Durban study showed that this method might be good for diagnosing STIs quickly, it didn’t look at whether it would be an affordable option for South Africa.
But if people can get their STI results so quickly at clinics, why would the government implement home testing as well?
It’s a way to get around the stigma, says the action plan. Discrimination at clinics makes it difficult for people to get the health services they need, especially for people who are at high risk of contracting STIs, such as sex workers and transgender people.
About 40% of the doctors who participated in a study felt uncomfortable caring for patients who come from high-risk groups, also called key populations.
In a Brazilian study, transgender women said they felt much more comfortable collecting their own samples (from the anus, urethra, or mouth) than with a health worker.
However, Pillay cautions that shipping self-test kits could create another set of problems when it comes to keeping track of infections.
Health workers wouldn’t know if people used the test, he says, and if they did, there’s no guarantee they’d come for treatment.
Data: get the numbers
It is estimated that there were more than 4.5 million new cases of gonorrhea in South Africa in 2017, as well as 5.8 million new chlamydia infections and 70,000 syphilis cases, according to a 2018 modeling study.
But these numbers are just guesses and could be inflated, the researchers caution, because there wasn’t a lot of data to work with. That meant they had to make “raw” calculations based on numbers from smaller studies, which did not all use the same research methodology.
Under the new HIV and STI plan, the health department says it will carry out nationally representative studies to determine how many of these STIs are present in people most likely to be infected (such as sex workers and young women, for example). example).
This kind of data will make it easier for South Africa to find and treat more people with STIs, without having to test everyone in the country, says Pillay.
In the meantime, health facilities are going to change the way they collect data for people showing STI symptoms.
At the moment, health workers only record information for male urethritis syndrome. This is a condition in which a bacterial infection, which is sexually transmitted, causes inflammation in the urethra (the tube through which urine flows from the bladder). About 311,000 men presented to health centers with symptoms of this condition in 2017.
While men are more likely than women to show symptoms of infections like chlamydia and gonorrhea, they’re much less likely to call for help quickly, Pillay notes.
But, in the coming months, health care workers will probably start recording cases of vaginal discharge syndrome in women and genital ulcers, too, she says, because these are underlying symptoms of STIs like chlamydia and herpes.
Tracking these two syndromes can help the government understand STI trends in women showing symptoms, so they can spot which areas need more intensive testing and treatment, Pillay explains.
To help make sure people who need treatment get it, the health department also plans to add an STI section to the country’s tracking platform that tracks people on HIV and TB treatment, called Tier. .Net.
This system keeps track of people taking, for example, HIV drugs so health workers know to test their viral load (how much of the virus is in their blood) each time the patient comes to the clinic for a check. The online platform works 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 also help keep track of STI numbers.
But Tier.Net has had its downsides, research shows. Health workers have struggled to keep it up to date along with paper records, resulting in discrepancies between what’s on the spreadsheets and what’s on a clinic’s books.
Until then, Pillay says, health workers should simply encourage more people to get tested for STIs while other checkups are done at a health care facility.
This story was produced by the Bhekisisa Center for Health Journalism. Sign up for the Newsletter.
