Facilitators and barriers to point-of-care testing for sexually transmitted infections in low- and middle-income countries: a scoping review

Abstract

Background Sexually transmitted infections (STIs) in low- and middle-income countries (LMICs) are predominantly managed by syndromic management. However, most STIs are asymptomatic. These untreated STIs cause individual morbidity, and lead to high STI prevalences. There is increasing interest in the use of point-of-care tests (POCTs) for STIs in LMICs, which could facilitate same day testing and treatment. To best utilise these tests, we must understand the facilitators and barriers to their implementation. The aim of this review is to explore how point-of-care testing for STIs has been implemented into healthcare systems in LMIC and the facilitators and barriers to doing so. Methods A scoping review was conducted by searching MEDLINE, Embase, Emcare, CINAHL, Scopus, LILACS, the Cochrane Library, and ProQuest Dissertations and Theses for studies published between 1st January 1998 and 5th June 2020. Abstracts and full articles were screened independently by two reviewers. Studies were considered for inclusion if they assessed the acceptability, feasibility, facilitators, or barriers to implementation of point-of-care testing for chlamydia, gonorrhoea, trichomoniasis or syphilis in LMICs. Thematic analysis was used to analyse and present the facilitators and barriers to point-of-care STI testing. Results The literature search revealed 82 articles suitable for inclusion; 44 (53.7%) from sub-Saharan Africa; 21 (25.6%) from Latin American and the Caribbean; 10 (12.2%) from East Asia and the Pacific; 6 (7.3%) from South Asia; and one (1.2%) multi-regional study. Thematic analysis revealed seven overarching themes related to the implementation of POCTs in LMICs, namely (i) Ideal test characteristics, (ii) Client factors, (iii) Healthcare provision factors, (iv) Policy, infrastructure and health system factors, (v) Training, audit, and feedback, (vi) Reaching new testing environments, and (vii) Dual testing. Conclusion Implementation of POCTs in LMICs is complex, with many of the barriers due to wider health system weakness. In addition to pressing for broader structural change to facilitate basic healthcare delivery, these themes may also be used as a basis on which to develop future interventions. The literature was heavily skewed towards syphilis testing, and so more research needs to be conducted assessing chlamydia, gonorrhoea, and trichomoniasis testing, as well as home or self-testing.

Shifting the power: scale-up of access to point-of-care and self-testing for sexually transmitted infections in low-income and middle-income settings

“…The acceptability of POC testing for STIs is good amongst for both healthcare providers and patients in LMICs [2 ▪ ,19,20], with the favourability of use being influenced by a prospective user's experience in using POCs, their age, and their level of education [21–24]. Important barriers to POC testing by patients include the cost of tests, time taken to attend a clinic, low perceived risk, stigma, lack of partner notification, and lack of trust in healthcare providers [25–27].…”

“…vaginal discharge), followed by presumptive treatment with antibiotics. Although this approach enables immediate treatment, the majority of infections are asymptomatic and are, therefore, left untreated [2 ▪ ]. Syndromic management also lacks specificity, leading to overtreatment, which is a concern given the growing global problem of antibiotic resistance.…”

“…The WHO estimates that annually 374 million individuals contract infections with Chlamydia trachomatis , Neisseria gonorrhoea , Trichomonas vaginalis , or Treponema pallidum (syphilis): all of which are both sexually transmitted and curable [1]. Many of these sexually transmitted infections (STIs) remain untreated, however, because they occur in low-income and middle-income settings (LMICs) [1], where access to healthcare is limited, affordable diagnostics are unavailable, and sociocultural issues stigmatize those seeking treatment [2 ▪ ].…”

“…In addition to increasing risks of HIV infection and transmission from mother to child [3–5], these common curable STIs are direct causes of significant mortality and morbidity, with associated sequalae including pelvic inflammatory disease, infertility, miscarriage, still birth, preterm birth and low-birth-weight infants [1,6–8]. Accordingly, a wide range of etiological diagnostics have been developed for these STIs; although none of these are widely available in LMICs [2 ▪ ,9]. Similarly, while home-testing or self-testing for these STIs is being adopted in high-income countries (HICs), with clear evidence of impact, rollout of self-testing in LMICs has been limited.…”

Advances and challenges in sexually transmitted infections prevention among men who have sex with men in Asia

“…The second challenge is weak health systems. In low- and middle-income countries, weaknesses in health systems, such as inadequate infrastructure, inadequate documentation, heavy workloads, inadequate funding and quality assurance, are main barriers to the development of POCTs [ 47 ▪ ]. The third challenge is financial and policy support.…”