Free home tests for four common – and treatable – sexually transmitted infections (STIs), namely gonorrhea, chlamydia, syphilis and trichomoniasis, may be available at chronic drug pick-up points across the country, according to South Africa’s fifth HIV plan. , TB and STI action plan.
Government clinics will also launch STI tests that provide same-day results.
The new plan was finalized after comments from the public and civil society were added, said Nelson Dlamini, communications manager at the South African National Aid Council. The final draft will be published on World TB Day on March 24.
The updated strategy will run from 2023 to 2028.
To date, the public health sector in South Africa has not used the test as a standard for the diagnosis of these four STIs (besides syphilis). However, people can be treated only if they come to the facility with symptoms such as genital pain or discharge from the penis or scrotum.
This is called “syndrome management” and is used by many low- and middle-income countries, including Tanzania and Mozambique. The logic is that many facilities do not have easy access to the laboratory, so it can take up to 4 days for people to get their results back and people cannot return to the clinic to get results or medicine.
However, in the South African private sector, the use of laboratory tests to diagnose STIs is common.
The problem with the syndromic method is twofold.
First, most people with STIs are asymptomatic, meaning they don’t show symptoms (like more than three-quarters of women in a local study). So, with the current approach in the public health system, it means that it will not be treated and will continue to spread the infection to others.
In addition, the health department does not consistently collect data on the number of people with one of the four common STIs (gonorrhea, chlamydia, syphilis and trichomoniasis) at the national level.
However, the department and the National Institute for Infectious Diseases conduct data collection every now and then, where samples are collected from people with symptoms in nine provinces and sent to laboratories. The results are used to make predictions about the number of infections and the health department then decides whether they are buying the right medicine.
The collection of this type of data makes it difficult to know whether the country has reached the HIV and STI target before the government (2017-2022) to find 50% more cases without symptoms of the four infections by the end of 2022, said Yogan Pillay, who is the head. the local arm of the Clinton Health Access Initiative.
When gonorrhea, syphilis or chlamydia are left untreated, they can cause infertility, increase a person’s chances of contracting HIV or, in the case of pregnant women, cause stillbirth. People with HIV who are not treated with antiretrovirals can also spread the virus more easily when they get gonorrhea.
The second problem is that people with symptoms (and those who come to the clinic for help) will get antibiotics that can fight more than one infection, because the health workers do not know exactly what they are treating. This can cause some bugs to become resistant to these drugs, which South Africa has done.
In short, the public health system has the potential to treat people with symptoms and not treat those who do not, explains Johan Hugo, senior clinical advisor at the Anova Health Institute.
But the way South Africa approaches the problem – through diagnostics and data – is changing. Here’s how.
Diagnostics – finding patients
Testing people, such as pregnant women, when they come to the clinic can make a big difference, suggests research published in the journal. Infectious Diseases in Obstetrics and Gynecology in 2018.
At three clinics in Tshwane, pregnant women use rapid tests for gonorrhea, chlamydia and trichomoniasis. Nine out of 10 people who test positive for the infection can start treatment immediately, without having to wait longer for help than those who have to wait in a queue.
However, the test is not available in the public sector in South Africa. State facilities have a rapid test for syphilis, which is usually given to pregnant women and survivors of sexual violence, but it is not available as a standard or for the other three STIs.
But under the new STI plan, testing will be available to more people, including all adolescent girls and young women (between 15 and 24 years); sex workers; transgender people; people who have sex with men and survivors of gender-based violence.
In the private sector, a rapid self-test kit for a single STI costs between R125 and R200 or R500 for a kit that screens for all four treatable STIs.
Another option for the state could be to use the GeneXpert machine, which is already available for TB testing, to pick up if someone is infected with chlamydia and gonorrhea, Hugo said.
With this machine, test results are available within 90 minutes when using chlamydia and gonorrhea cartridges. All health workers have to do is replace the TB or HIV test kit in the machine with one that can be used for a specific STI.
When researchers tested this method in 12 clinics in Australia, it worked just as well as laboratory test research had shown – and faster.
A study in Durban using the GeneXpert machine to test for STIs gave similar results. Women who test positive get medicine, information packs, condoms and treatment for sexual partners when the results come out. The patient told the researchers that this method worked for him because he got results quickly (about two hours) and because he could help his partner.
However, the cartridges are expensive – they cost around R250 to test for gonorrhea. So, although the Durban study suggests that this method may be good for rapid diagnosis of STIs, it cannot be seen that it will be an affordable option for South Africans.
But if people can get STI results quickly at clinics, why does the government also make home tests possible?
This is a way to overcome stigma, the action plan says. Discrimination in clinics makes it difficult for people to get the health services they need – especially for people at high risk of contracting STIs, such as sex workers and transgender people.
Nearly 40% of practitioners who participated in a study felt uncomfortable caring for patients from high-risk groups, also called key populations.
In a Brazilian study, transgender women said they were more comfortable collecting their own samples (from the anus, urethra or mouth) than having a health worker.
Pillay cautioned, however, that sending self-testing kits could create more problems when it comes to tracking infections.
Health workers won’t know whether people have used the test, he said, and if they have, there’s no guarantee they’ll enter treatment.
Data – take numbers
There were more than 4.5 million estimated cases of gonorrhea in South Africa in 2017, as well as 5.8 million new chlamydia infections and 70 000 cases of syphilis, according to a 2018 model study.
But those numbers are just educated guesses and can be exaggerated, the researchers warn, because there isn’t much data to go with it. That means they have to do “raw” calculations based on numbers from smaller studies, which don’t all use the same research methodology.
In the new HIV and STI plan, the health department said it will conduct a nationally representative study to determine the number of these STIs in people most likely to be infected (such as sex workers and young women, for example).
Data like this would make it easier for South Africa to find and treat more people with STIs, without having to test everyone in the country, Pillay said.
In the meantime, health facilities will change the way they collect data on people who show symptoms of STIs.
At the moment, health workers only record information for male urethritis syndrome. This is a condition where a bacterial infection – which is transmitted sexually – causes inflammation of the urethra (the tube along which urine flows out of the bladder). Close to 311 000 men came to health facilities with symptoms of this disease in 2017.
When men are more likely than women to show symptoms of infections such as chlamydia and gonorrhea, they are more likely to seek help quickly, Pillay said.
However, in the next few months, health workers may start recording cases of vaginal discharge syndrome in women and genital ulcer disease as well, he said, because these are symptoms of STIs like chlamydia and herpes.
Tracking both syndromes can help governments understand STI trends in women who show symptoms, so they can choose areas for more intensive testing and treatment, Pillay said.
To ensure that people who need treatment are treated, the health department also plans to add an STI section to the country’s tracking platform that monitors people on HIV and TB treatment, called Tier.Net.
This system tracks people who are on active, for example, HIV medication so that health workers know to test the viral load (how much virus is in the blood) every time a patient comes to check up at the clinic. The online platform is a way to collect data and filter it to the government to help manage the country’s response to HIV infection. In the same way, it may help to track STI numbers.
But Tier.Net has its drawbacks, research shows. Health workers have struggled to keep up-to-date with paper records, leading to mismatches between what’s on the electronic sheet and what’s in the clinic’s book.
Until now, Pillay said, health workers should only encourage more people to get screened for STIs while doing other checks at health facilities.
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