The latest guidelines on managing the spread of sexually transmitted infections (STI) focus on the importance of screening, a shift that has been welcomed by experts.

Published by the South African HIV Clinicians Society (SAHIVSOC) last month, the guidelines reflect its mission to move toward “evidence-based and expert endorsed best practice in STI care in Southern Africa”. Over 10 000 health workers with an interest in HIV belong to the organisation. 

South Africa has a high burden of STIs. Dr Alex de Voux,  from the Division of Epidemiology and Biostatistics at the University of Cape Town, said that there is limited availability of statistics in the country. This is because infections are not counted as individual cases. As a surveillance system in the country, within the public health system, they diagnose syndromes instead. 

This limits the understanding of the true burden of STIs because the information is only available through certain settings and from certain key populations.

“The estimates that we do get from certain research studies and surveillance settings indicate to us that adolescents are more disproportionately affected by STIs.”

Prevalence of certain STIs

De Voux, whose research focuses on curable STIs, said that chlamydia is more prevalent among women. This is usually because women tend to have a longer duration before presenting symptoms or how they are infected tends to last longer than men. 

De Voux also noted that the increasing rates of syphilis infections they are starting to see among pregnant women all over the country are a concern.  

“This is because syphilis can be transmitted to the unborn baby and result in stillbirth. And then, because we have a relatively high prevalence of HIV, reducing the increase of the STI burden amongst persons living with HIV and other key populations, such as commercial sex workers, remains important,” she said.

‘Nothing will change’

Dr Tendesayi Kufa-Chakezha, an epidemiologist at the National Institute for Communicable Diseases (NICD), explained that the guidelines released by the SAHIVSOC, represent expert-endorsed practice in STI care. However, they were not written by the National Department of Health (NDoH). This means the society’s guidelines are not binding on the state. 

Following the release of the 2015 STI management guidelines published by the NDOH, the guidelines authored by the department in 2018 included reviewed updates published in the Standard Treatment Guidelines and Essential Medicines list. 

De Voux said that the SAHIVSOC guidelines present key changes that address the limitations in the 2018 document.

Limitations of the existing guidelines 

The current guidelines rely on a syndromic management method. This method involves treating the many different causes of the symptoms that the patient presents with.

An example of this is a male patient presenting with urethral discharge. Based on the 2015 guidelines, they could have one of the following infections: gonorrhoea, chlamydia or mycoplasma genitalium. Whether or not they had any of these or none, they’d be treated for all of them, a common trend for all other infections.  

De Voux explained that the syndromic approach is dependent on the individual developing signs and symptoms once they are infected. She referred to research that has shown that you can be infected with a large proportion of different STIs that don’t represent signs and symptoms. She said it’s also possible that you might take longer to develop symptoms, which is often the case. 

Did you know that in 2017 there were 5.8 million cases of chlamydia just in South Africa?

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Danger of missing infections

“If you’re relying on an individual to first develop signs and symptoms and then also relying on that individual to present to care and share that information with a provider, you might be missing a lot of infections,” said de Voux.

She continued: “Those are the barriers to treating someone with those infections. This is the limitation of syndromic management.”

In addition, the treatment is also non-specific. This is because patients present with a syndrome and are treated for the most likely infection, as opposed to if they are diagnosed using a test and can directly be treated for the infection. 

Focus on screening 

De Voux said that one of the major differences with the new guidelines is the focus on screening and testing.

“This means you’re not waiting for someone to present with signs and symptoms before you test them for an STI. And it also recognises that other infections don’t have symptoms, and prompts individuals to be aware and screen regularly,” said de Voux.

De Voux added that stigma still plays a role in discouraging people from seeking healthcare. 

“The guidelines also emphasise that we can test for infections amongst asymptomatic people. This is important because several infections don’t have overt signs or symptoms, and several complications may come up as a result,” she said.

Lab vs symptom-only screening and testing

Unnoticed STIs that go untreated can lead to certain types of cancers, organ damage, or infertility. 

Kufa-Chakezha agreed that diagnostic testing of priority populations for STI prevention is one of the notable differences.

She also welcomed the inclusion of pathogen-directed treatment. This includes a list of medications that can be used as determined by diagnostic testing. 

This is the list of medications that can be used for the different STI causes as determined by the diagnostic testing.  

“In addition, syphilis testing for individuals with genital ulcers and the inclusion of expedited partner treatment is a key change. This is when individuals treated for STI also receive medications to take home for their partner,” said Kufa-Chakezha.

Bigger budget, more resources 

Kufa-Chakezha said that there is currently limited capacity to do diagnostic testing for STIs.

She said there would be a need to invest in:

• Laboratory equipment
• Clinic-level supplies for specimen collection
• Staff training at both clinic and laboratory levels
• Supply chains for medicines,
• STI prevention
• Treatment literacy material for the general public
• Data systems to allow the system to monitor and evaluate the impact of new guidelines.

De Voux added that more tests would be administered since those without symptoms would also test. This requires a larger budget to be allocated. 

Experts are working to develop the National Strategic Plan (NSP) on STIs and viral hepatitis. 

“This is an implementation plan to support these guidelines. We need to ensure that we have the budget to accommodate these recommendations,” said De Voux. – Health-e News