Acceptability, feasibility and cost of point of care testing for sexually transmitted infections among South African adolescents where syndromic management is standard of care

The World Health Organization (WHO) identified the scale-up of interventions to tackle sexually transmitted infections (STIs) as a priority in their Global Health Sector Strategy for HIV, viral hepatitis and STIs 2016–2021 [1], highlighting the importance of providing STI prevention and care in primary health, sexual and reproductive health (SRH), and HIV services, with the goal of ending STI epidemics as a major public health concern by 2030.

The high prevalence of curable STIs amongst young people in sub-Saharan Africa (SSA), particularly young women, has been well described [2‐5]. A meta-analysis of 18 HIV prevention studies in SSA found Chlamydia trachomatis (CT) and Neisseria gonorrhoea (NG) prevalence ranging between 10–15% and 1.7–4.6% respectively in primary healthcare populations aged 15–24, with CT/NG prevalence particularly high amongst South African (SA) participants [6]. STI prevalence is higher still in some SA provinces, with over half of participants in an adolescent oral Pre-Exposure Prophylaxis (PrEP) study in Cape Town and Johannesburg testing positive for at least one STI at baseline [5]. The majority diagnosed with CT/NG were asymptomatic, further highlighting the poor sensitivity of syndromic STI management.

The effect of untreated STIs is substantial, both as a co-factor for HIV transmission, and for short- and long-term reproductive sequelae for women and men [7, 8]. Adolescents and young people are specifically vulnerable to both STIs and HIV [9], underlining the necessity for adolescent-responsive STI services. STIs in low-resource settings are largely managed syndromically, relying on patient-reported symptoms to provide treatment for a number of potential infections. While this approach offers an immediate and relatively low-cost pathway in resource-limited, high HIV burden settings, it is inadequate in treating and preventing STIs due to its inability to detect asymptomatic infections, leading to both over and under treatment of STIs and adding to the risk of antibiotic resistance [10‐12].

WHO guidance recommends moving towards aetiological diagnosis over syndromic management of STIs. Affordable and feasible diagnostic options are urgently required, this may include point-of-care (POC) diagnostics [1]. The integration of test and treat programmes into community-based HIV/SRH services has the potential to reduce STI-related morbidity and further STI and HIV transmission in communities where HIV is prevalent. In 2011, SA rolled out POC testing for tuberculosis (TB) in primary care clinics using GeneXpert (Cepheid, Sunnyvale, CA, USA), where they request patients to return within 1–2 days for results [13]. The same technology can be used to test for CT/NG, providing rapid diagnosis and increasing the potential for same day treatment. Although GeneXpert machines are generally located in nearby laboratories, their widespread availability presents an opportunity for STI management in SA. There are limited data evaluating POC STI testing in adolescent populations, a population at risk of both STI and HIV infection in South Africa [5]. The primary aim of this study was to evaluate the feasibility and acceptability of integration of POC STI testing into health services for young people (15–23 years) in low-income, high-burden environments. To inform implementation, a secondary aim was to assess the cost of offering POC STI testing versus the standard syndromic approach.

This pilot study demonstrated acceptability of POC STI testing and treatment among youth attending a youth centre and mobile SRH service in Cape Town, and the feasibility of same day testing. Participation was voluntary and without reimbursement, indicating that the positive feedback received was likely due to strong support for the service among users.

The prevalence of CT and NG amongst participants was high (50%), aligning with data from previous studies in this population [6, 25‐27]. Using POC diagnostics, STIs that would have gone undetected and untreated using syndromic algorithms were diagnosed. The potential sequelae of these untreated genital infections underline the importance of offering STI testing and treatment to populations at risk in high-burden settings. It is possible that STI testing as part of a SRH service for adolescents could present a valuable drawcard to encourage health-seeking behaviours such as HIV testing and prevention opportunities [28].

The proportion of adolescents willing to wait for results is an important factor to consider when designing STI testing interventions and modelling their effectiveness as adolescents often describe waiting times as one of the barriers to engaging in health services [8, 15, 25]. Despite the provision of WiFi, computer access and areas to socialise and play sports, only 25% of YC participants waited the full 90 min to receive their results. At the MC, where there was little provided to occupy the participants but where they were actively requested to stay, a similar proportion waited (27%) overall. In both settings, the wait was too long to retain a majority of adolescent participants.

A more notable difference was the extent of return, where the majority of YC participants returned and received their results (83%) compared to only 50% of MC participants. This is likely due to the fixed-site nature of the YC in the community, whereas the MC changed locations regularly, making return less convenient or possible.

Although same-day testing in this population was feasible, the difficulties providing contemporaneous in-person results and treatment highlights the pragmatic challenges associated with providing a same day service, which is of greater relevance when providing mobile versus fixed-site health services. These findings support the need for shorter waiting times or the possibility of results communicated by phone or text message, and a script for treatment potentially collected at a fixed venue or couriered. The latter option has shown success amongst men who have sex with men in the United Kingdom [29, 30], but is yet to be evaluated amongst youth in LMICs. There is thus scope for further research to explore the feasibility and acceptability of communicating results through mobile technology (phone calls and/or messaging applications) amongst this population. It remains unknown what waiting period would be acceptable and sufficient to retain most adolescents.

The perception of STI risk in this South African adolescent population was low despite reporting inconsistent condom use and half subsequently testing positive for at least one STI. Additionally, despite the high HIV burden in SA, nearly a third of YC participants declined a HIV test. It is possible that the perceived increased stigma of HIV over other STIs may have played a role. Given that adolescents appeared to be more enthusiastic about STI testing however, STI testing might be a useful hook to engage adolescents in SRH services generally.

The cost analysis unsurprisingly showed syndromic management to be the least costly option, as although it requires trained personnel, it requires minimal supplies, equipment, and medication. It is possible that the cost saving is offset by the poor performance of syndromic management, although this requires future assessment. This pilot study is one of the few POC STI testing implementation studies conducted in lower-income countries in an adolescent population. At least two African studies have found that specific POC diagnostics reduced over-treatment with antibiotics [31, 32]. Although POC technology used (GeneXpert) was more costly than syndromic management, and required extra space and electricity that may not be available in all settings, in countries that have already invested in GeneXpert laboratory-based testing platforms for TB,there may be an opportunity to integrate STI testing at lower cost.

This pilot study conducted under pragmatic conditions had some limitations. The study included a convenience sample of young people attending two well established adolescent SRH service distribution points known to be adolescent focused and friendly, which may not be generalisable to other primary care settings in South Africa. However, this did provide important feedback on whether POC diagnostic testing would be well received and how adolescents would view the waiting period. Although contact slips were given to participants testing positive for CT and/or NG, it is unknown whether disclosure took place or partners were successfully treated, and therefore re-infection may have occurred. This is the current standard of practice which is known to have limited efficacy [33, 34].

WHO has recommended aetiological testing as part of its 2016–2021 strategy for global STI control particularly among key populations [1]. The added cost of aetiological testing may be offset given the costs of managing the sequelae of untreated STIs, cost and harm of overtreatment with antibiotics and potential increased HIV risk. Larger implementation studies in LMICs should evaluate the feasibility of integrating STI test-and-treat programmes into existing HIV/SRH services. In particular, there is a need for research to understand how to integrate existing technologies into the most high-burden, vulnerable settings as well as to identify acceptable methods to support rapid results delivery and efficient targeted treatment for both patient and partner.

STIs are highly prevalent amongst young people in southern Africa, with potential significant sequelae, A robust public health approach is required to address this, including increased resource allocation towards the integration of aetiological testing and targeted treatment of STIs into adolescent-focused health services.