Diagnosing sexually transmitted infections in resource‐constrained settings: challenges and ways forward

Abstract

Introduction Sexually transmitted infections ( STI s) remain prevalent and are increasing in several populations. Appropriate STI diagnosis is crucial to prevent the transmission and sequelae of untreated infection. We reviewed the diagnostic accuracy of syndromic case management and existing point‐of‐care tests ( POCT s), including those in the pipeline, to diagnose STI s in resource‐constrained settings. Methods We prioritized updating the systematic review and meta‐analysis of the diagnostic accuracy of vaginal discharge from 2001 to 2015 to include studies until 2018. We calculated the absolute effects of different vaginal flowcharts and the diagnostic performance of POCT s on important outcomes. We searched the peer‐reviewed literature for previously conducted systematic reviews and articles from 1990 to 2018 on the diagnostic accuracy of syndromic management of vaginal and urethral discharge, genital ulcer and anorectal infections. We conducted literature reviews from 2000 to 2018 on the existing POCT s and those in the pipeline. Results and discussions The diagnostic accuracy of urethral discharge and genital ulcer disease syndromes is relatively adequate. Asymptomatic Chlamydia trachomatis ( CT ) and Neisseria gonorrhoeae ( NG ) infections limit the use of vaginal discharge and anorectal syndromes. The pooled diagnostic accuracy of vaginal syndromic case management for CT / NG is low, resulting in high numbers of overtreatment and missed treatment. The absolute effect of POCT s was reduced overtreatment and missed treatment. Findings of the reviews on syndromic case management underscored the need for low‐cost and accurate POCT s for the identification, first, of CT / NG , and, second, of Mycoplasma genitalium ( MG ) and Trichomonas vaginalis ( TV ) and NG and MG resistance/susceptibility testing. Near‐patient POCT molecular assays for CT / NG / TV are commercially available. The prices of these POCT s remain the barrier for uptake in resource‐constrained settings. This is driving the development of lower cost solutions. Conclusions The WHO syndromic case management guidelines should be updated to raise the quality of STI management through the integration of laboratory tests. STI screening strategies are needed to address asymptomatic STI s. POCT s that are accurate, rapid, simple and affordable are urgently needed in resource‐constrained settings to support the uptake of aetiological diagnosis and treatment.

Shown for reading. Its publisher allows quoting it, not republishing it.

References 126

1. 1.

   World Health Organization (WHO). Report on global sexually transmitted infection surveillance. Geneva: WHO; 2018 [cited 2019 Jan 8]. Available from: https://www.who.int/reproductivehealth/publications/stis-surveillance-2018/en

   Not in our library

2. 2.

   Wasserheit JN. Epidemiological synergy: interrelationships between human immunodeficiency virus infections and other sexually transmitted diseases. Sex Transm Dis. 1992;19:61–77.

   Not in our library

3. 3.

   Cohen MS, Hoffman I. Sexually transmitted diseases enhance transmission of HIV: no longer a hypothesis. Lancet. 1998;351:5–7.

   Not in our library10.1016/s0140-6736(98)90002-2

4. 4.

   Cohen M. Classical sexually transmitted diseases drive the spread of HIV‐1: back to the future. J Infect Dis. 2012;206:1–2.

   Not in our library10.1093/infdis/jis303

5. 5.

   Rowley J, Vander Hoorn S, Korenromp E, Low N, Unemo M, Abu‐Raddad LJ, et al. Global and regional estimates of the prevalence and incidence of four curable sexually transmitted infections in 2016. Bull World Health Organ. June 2019 Online first. https://www.who.int/bulletin/online_first/BLT.18.228486.pdf?ua=1

   Not in our library

6. 6.

   World Health Organization (WHO). Global health care sector strategy on sexually transmitted infection, 2016‐2021. Geneva: WHO; 2016 [cited 2019 Jan 8]. Available from: http://www.who.int/reproductivehealth/publications/rtis/ghss-stis/en/

   Not in our library

7. 7.

   Steen R, Wi T, Kamali A, Ndowa F. Control of sexually transmitted infections and prevention of HIV transmission: mending a fractured paradigm. Bull World Health Organ. 2009;87(11):858–65.

   Not in our library10.2471/blt.08.059212

8. 8.

   Mayaud P, Mabey D. Approaches to the control of sexually transmitted infections in developing countries: old problems and modern challenges. Sex Transm Infect. 2004;80(3):174–82.

   Not in our library10.1136/sti.2002.004101

9. 9.

   Unemo M, Bradshaw CS, Hocking JS, de Vries HJC, Francis SC, Mabey D, et al. Sexually transmitted infections: challenges ahead. Lancet Infect Dis. 2017;17(8):e235–79.

   Not in our library10.1016/s1473-3099(17)30310-9

10. 10.

    World Health Organization (WHO). Progress report on the implementation of the global strategy for the prevention and control of sexually transmitted infections; 2006‐2015. Geneva: WHO; 2015 [cited 2019 Jan 8]. Available from: http://www.who.int/reproductivehealth/publications/rtis/STI-progress.pdf

    Not in our library

11. 11.

    World Health Organization (WHO). Sexually transmitted and other reproductive tract infections: a guide to essential practice. Geneva: WHO; 2005 [cited 2019 Jan 8]. Available from: https://www.who.int/reproductivehealth/publications/rtis/9241592656/en/

    Not in our library

12. 12.

    Grosskurth H, Todd J, Mwijarubi E, Mayaud P, Nicoll A, ka‐Gina G, et al. Impact of improved treatment of sexually transmitted diseases on HIV infection in rural Tanzania: randomised controlled trial. Lancet. 1995;346(8974):530–6.

    Not in our library10.1016/s0140-6736(95)91380-7

13. 13.

    Johnson L, Dorrington R, Bradshaw D, Coetzee D. The effect of syndromic management interventions on the prevalence of sexually transmitted infections in South Africa. Sex Reprod Healthcare. 2011;2(1):13–20.

    Not in our library10.1016/j.srhc.2010.08.006

14. 14.

    Makasa M, Buve A, Sandøy I. Etiologic pattern of genital ulcers in Lusaka, Zambia: has chancroid been eliminated? Sex Transm Dis. 2012;39(10):787–91.

    Not in our library10.1097/olq.0b013e31826ae97d

15. 15.

    Mlisana K, Naicker N, Werner L, Roberts L, van Loggerenberg F, Baxter C, et al. Symptomatic vaginal discharge is a poor predictor of sexually transmitted infections and genital tract inflammation in high‐risk women in South Africa. J Infect Dis. 2012;206(1):6–14.

    Not in our library10.1093/infdis/jis298

16. 16.

    Detels R, Green AM, Klausner JD, Katzenstein D, Gaydos C, Handsfield H, et al. The incidence and correlates of symptomatic and asymptomatic Chlamydia trachomatis and Neisseria gonorrhoeae infections in selected populations in five countries. Sex Transm Dis. 2011;38(6):503–9.

    Not in our library

17. 17.

    Paz‐Bailey G, Rahman M, Chen C, Ballard R, Moffat HJ, Kenyon T, et al. Changes in the etiology of sexually transmitted diseases in Botswana between 1993 and 2002: implications for the clinical management of genital ulcer disease. Clin Infect Dis. 2005;41:1304–12.

    Not in our library10.1086/496979

18. 18.
    A high burden of asymptomatic genital tract infections undermines the syndromic management approach among adolescents and young adults in South Africa: implications for HIV prevention efforts · 2018

    Not checked
19. 19.
    Gonorrhea and chlamydia prevalence in different anatomical sites among men who have sex with men: a cross-sectional study in Guangzhou, China · 2018

    Not checked
20. 20.
    Antimicrobial resistance in Neisseria gonorrhoeae: Global surveillance and a call for international collaborative action · 2017

    No notice
21. 21.

    Unemo M, Jensen JS. Antimicrobial‐resistant sexually transmitted infections: gonorrhoea and Mycoplasma genitalium. Nat Rev Urol. 2017;14(3):139.

    Not in our library10.1038/nrurol.2016.268

22. 22.

    Peeling R, Holmes K, Mabey D, Ronald A. Rapid tests for sexually transmitted infections (STIs): the way forward. Sex Transm Infect. 2006;82 Suppl 5:V1–6.

    Not in our library10.1136/sti.2006.024265

23. 23.
    Point-of-Care Testing for Infectious Diseases: Diversity, Complexity, and Barriers in Low- And Middle-Income Countries · 2012

    No notice
24. 24.

    Zemouri C, Wi TE, Kiarie J, Seuc A, Mogasale V, Latif A, et al. The performance of the vaginal discharge syndromic management in treating vaginal and cervical infection: a systematic review and meta‐analysis. PLoS ONE. 2016;11(10):e0163365.

    Not in our library10.1371/journal.pone.0163365

25. 25.

    Banneheke H, Fernandopulle R, Gunasekara U, Barua A, Fernando N, Wickremasinghe R. Can trichomonas immunochromatographic test increase the validity and reliability of WHO syndromic algorithm for vaginal discharge as a screening tool for trichomoniasis? Ann Trop Med Public Health. 2016;9:43–7.

    Not in our library

26. 26.

    Barry MS, Ba Diallo A, Diadhiou M, Mall I, Gassama O, Ndiaye Gueye MD, et al. Accuracy of syndromic management in targeting vaginal and cervical infections among symptomatic women of reproductive age attending primary care clinics in Dakar, Senegal. Trop Med Internat Health. 2018;23(5):541–8.

    Not in our library10.1111/tmi.13046

27. 27.

    Molaei B, Mohmmadian F, Tadayon P, Gholami H, Kiani M, Rashtchi V. Comparative evaluation of accuracy and compatibility level of different diagnostic methods for bacterial vaginosis. Kuwait Med J. 2018;50(2):205–12.

    Not in our library

28. 28.

    Vallely LM, Toliman P, Ryan C, Rai G, Wapling J, Gabuzzi J, et al. Performance of syndromic management for the detection and treatment of genital Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis among women attending antenatal, well woman and sexual health clinics in Papua New Guinea: a cross‐sectional study. BMJ Open. 2017;7(12):e018630.

    Not in our library10.1136/bmjopen-2017-018630

29. 29.

    Tabrizi SN, Unemo M, Golparian D, Twin J, Limnios AE, Lahra M, et al. Analytical evaluation of GeneXpert CT/NG, the first genetic point‐of‐care assay for simultaneous detection of Neisseria gonorrhoeae and Chlamydia trachomatis. J Clin Microbiol. 2013;51(6):1945–7.

    Not in our library10.1128/jcm.00806-13

30. 30.

    Gaydos CA, Van Der Pol B, Jett‐Goheen M, Barnes M, Quinn N, Clark C, et al. Performance of the Cepheid CT/NG Xpert rapid PCR test for detection of Chlamydia trachomatis and Neisseria gonorrhoeae. J Clin Microbiol. 2013;51(6):1666–72.

    Not in our library10.1128/jcm.03461-12

31. 31.

    Pettifor A, Walsh J, Wilkins V, Raghunathan P. How effective is syndromic management of STDs? A review of current studies. Sex Transm Dis. 2000;27(7):371–85.

    Not in our library10.1097/00007435-200008000-00002

32. 32.

    Liu H, Jamison D, Li X, Ma E, Yin Y, Detels R. Is syndromic management better than the current approach for treatment of STDs in China? Evaluation of the cost‐effectiveness of syndromic management for male STD patients. Sex Transm Dis. 2003;30(4):327–30.

    Not in our library10.1097/00007435-200304000-00010

33. 33.

    Tsai C, Lee T, Chang H, Tang L, Chiang C, Chen K. The cost‐effectiveness of syndromic management for male sexually transmitted disease patients with urethral discharge symptoms and genital ulcer disease in Taiwan. Sex Transm Dis. 2008;84(5):400–4.

    Not in our library10.1136/sti.2007.028829

34. 34.

    Menezes Filho JR, Sardinha JCG, Galbán E, Saraceni V, Talhari C. Effectiveness of syndromic management for male patients with urethral discharge symptoms in Amazonas, Brazil. An Bras Dermatol. 2017;92(6):779–84.

    Not in our library10.1590/abd1806-4841.20175453

35. 35.

    Morency P, Dubois MJ, Grésenguet G, Frost E, Mâsse B, Deslandes S, et al. Aetiology of urethral discharge in Bangui, Central African Republic. Sex Transm Infect. 2001;77(2):125–9.

    Not in our library10.1136/sti.77.2.125

36. 36.

    Pépin J, Sobéla F, Deslandes S, Alary M, Wegner K, Khonde N, et al. Etiology of urethral discharge in West Africa: the role of Mycoplasma genitalium and Trichomonas vaginalis. Bull World Health Organ. 2001;79(2):118–26.

    Not in our library

37. 37.

    Rietmeijer CA, Mungati M, Machiha A, Mugurungi O, Kupara V, Rodgers L, et al. The etiology of male urethral discharge in Zimbabwe: results from the Zimbabwe STI etiology study. Sex Transm Dis. 2018;45(1):56–60.

    Not in our library10.1097/olq.0000000000000696

38. 38.
    Etiology of genital ulcer disease in a sexually transmitted infection reference center in Manaus, Brazilian Amazon. · 2013

    Not checked
39. 39.

    Becker M, Stephen J, Moses S, Washington R, Maclean I, Cheang M, et al. Etiology and determinants of sexually transmitted infections in Karnataka state, South India. Sex Transm Dis. 2010;37:159–64.

    Not in our library10.1097/olq.0b013e3181bd1007

40. 40.

    Mungati M, Machiha A, Mugurungi O, Tshimanga M, Kilmarx PH, Nyakura J, et al. The etiology of genital ulcer disease and coinfections with Chlamydia trachomatis and Neisseria gonorrhoeae in Zimbabwe: results from the Zimbabwe STI etiology study. Sex Transm Dis. 2018;45(1):61–8.

    Not in our library10.1097/olq.0000000000000694

Cited by papers we hold 2

• A Survey of Preclinical Studies Evaluating Nanoparticle-Based Vaccines Against Non-Viral Sexually Transmitted Infections · 2021
  Not checked
• The relevance of target product profiles for manufacturers, experiences from the World Health Organization initiative for point-of-care testing for sexually transmitted infections · 2021
  Not checked

Reads

A person counts once a day per paper. We keep no cookie and no address: a reader is a hash that changes every day. Any month under five reads shows no number.