This evaluation of STI services across South Africa found gaps in the availability of medications, adherence to STI guidelines, condom provision and prevention messaging. Limited integration with HIV services for this high-risk population was a missed opportunity. Quality of STI care should continue to be monitored, and interventions to improve quality should be prioritised as part of national strategic HIV and primary healthcare agendas.

IntroductionThe South African National Department of Health sought to improve syndromic management of sexually transmitted infections (STIs). Continuing medical education on STIs was delivered at primary healthcare (PHC) clinics using one of three training methods: (1) lecture, (2) computer and (3) paper-based. Clinics with training were compared with control clinics.MethodsTen PHC clinics were randomly assigned to control and 10 to each training method arm. Clinicians participated in on-site training on six modules; two per week for three weeks. Each clinic was visited by three or four unannounced standardised patient (SP) actors pre-training and post-training. Male SPs reported symptoms of male urethritis syndrome and female SPs reported symptoms of vaginal discharge syndrome. Quality of healthcare was measured by whether or not clinicians completed five tasks: HIV test, genital exam, correct medications, condoms and partner notification.ResultsAn average of 31% of clinicians from each PHC attended each module. Quality of STI care was low. Pre-training (n=128) clinicians completed an average of 1.63 tasks. Post-training (n=114) they completed 1.73. There was no change in the number of STI tasks completed in the control arm and an 11% increase overall in the training arms relative to the control (ratio of relative risk (RRR)=1.11, 95% CI 0.67 to 1.84). Across training arms, there was a 26% increase (RRR=1.26, 95% CI 0.77 to 2.06) associated with lecture, 17% increase (RRR=1.17, 95% CI 0.59 to 2.28) with paper-based and 13% decrease (RRR=0.87, 95% CI 0.40 to 1.90) with computer arm relative to the control.ConclusionsFuture interventions should address increasing training attendance and computer-based training effectiveness.Trial registration numberAEARCTR-0000668.

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Sexually transmitted infection (STI) service delivery in the context of integrated care and the South African HIV epidemic is complex. We aimed to document STI care and HIV testing processes in public health clinics in South Africa, revealing bottlenecks to patient flow and identifying opportunities for improvement. Clinic mapping, with semi-structured interviews and clinic observation, was conducted with facility representatives at three clinical sentinel surveillance sites. Facility surveys assessed patient volume and staffing. Identified challenges were associated with staffing allocations, and disruptions in patient flow resulted from poor clinic layout, inadequate lighting, and limited allocation of space for HIV testing and physical examination. Recommendations include staffing adjustments, reorganization of space to allow for designated service and waiting areas, sufficient supplies, and improved lighting. The facility reorganization component of South Africa's Ideal Clinic initiative provides a key opportunity for enacting many of these recommendations.