Low effectiveness of syndromic treatment services for curable sexually transmitted infections in rural South Africa

Abstract

Objectives:Syndromic sexually transmitted infection (STI) treatment remains a cost-saving HIV prevention intervention in many countries in Africa. We estimate the effectiveness of syndromic treatment for curable STIs in rural KwaZulu-Natal, South Africa, and the trend in STI prevalences before and after the introduction of syndromic treatment in 1995.Methods:Data were available from various clinical studies, surveys of public and private health providers, the general population and women attending antenatal, family planning and child immunisation clinics in rural northern KwaZulu-Natal between 1987 and 2004. Overall effectiveness was defined as the estimated proportion of the annual number of symptomatic curable STI episodes cured by syndromic treatment based on separate estimates for six curable STI aetiologies by gender.Results:Median overall effectiveness was 13.1% (95% CI 8.9 to 17.8%) of symptomatic curable STI episodes cured. Effectiveness increased to 25.0% (95% CI 17.3 to 33.8%), 47.6% (95% CI 44.5 to 50.8%) or 14.3% (95% CI 9.9 to 19.4%) if 100% treatment seeking, 100% correct treatment provision or 100% cure were assumed, respectively. Time-trends were difficult to assess formally but there was little evidence of decreasing STI prevalences. Including incurable but treatable herpes simplex virus (HSV)-2 ulcers in the effectiveness calculation would halve the proportion of ulcers cured or correctly treated, but this reduction could be entirely countered by including episodic antiviral treatment in the national guidelines.Conclusion:Overall effectiveness of syndromic treatment for curable STIs in rural KwaZulu-Natal remains low and there is little evidence of reduced curable STI prevalences. As syndromic treatment is likely to be a cost-saving HIV prevention intervention in South Africa, innovative strategies are urgently needed to increase rates of treatment seeking and correct treatment provision.

High Prevalence and Incidence of Asymptomatic Sexually Transmitted Infections During Pregnancy and Postdelivery in KwaZulu Natal, South Africa

“…Our findings and that of other recent studies, however, question the validity of this approach based on the large proportion of asymptomatic STIs prevalent in pregnant and other high-risk population groups. 15,[24][25][26][27] When extrapolating our findings to all primary health clinics using the syndromic approach to treating STIs in women, it would appear that an estimated 50% of pregnant women with 1 or more STIs and asymptomatic will go untreated if the syndromic approach is applied. Postdelivery, an estimated 80% of the women who are asymptomatic but infected with 1 or more STIs would be missed.…”

Antiretroviral treatment of primary HIV infection to reduce onward transmission

“…The mechanistic barriers to transmission are likely to be a result of complex interactions between host susceptibility and characteristics of the infecting viral strain [35]. Disruption of mucosal integrity caused by trauma or sexually transmitted infections may alter the transmission threshold, although disappointing results from large-scale randomized clinical trial (RCT) did not show that treatment of sexually transmitted infections significantly altered the risk of HIV transmission [36][37][38][39]40 ].…”

Advancing STI care in low/middle-income countries: has STI syndromic management reached its use-by date?

“…5 A study in rural KwaZulu-Natal (KZN), in the epicentre of the HIV epidemic, estimated that the overall effectiveness of syndromic STI services to successfully treat curable symptomatic episodes was only 13.1% (95% CI 8.9% to 17.8%), and that the prevalence of gonorrhoea and chlamydia has not fallen since the introduction of syndromic management. 6 Perhaps the most concerning aspect of ongoing STI syndromic management, is that this approach continues to be used in many HIV high-prevalence countries, despite the recognition of the strong epidemiological and biological links between STIs and HIV. 7 Furthermore, the overwhelming economic and service burden of HIV in some sub-Saharan countries has further exacerbated poor and inadequate STI care.…”