Abstract
Background: Sexually transmitted infections (STIs) are a serious public health, reproductive,
and sexual health burden in South Africa. There are insufficient interventions advocating for
STI prevention and control in primary healthcare (PHC) facilities, as a result, they remain
overlooked and unprioritized. The prevalence of symptomatic and asymptomatic STIs
continues to grow at an alarming rate among key and priority populations (KPP). Moreover,
the currently used syndromic case management approach in PHC facilities alone is
inadequate in controlling STIs. Most of the South African PHC facilities lack diagnostic testing
and capacity. Therefore, there is a need to identify factors that hinder effective STI
management and generate new evidence to strengthen the current prevention and control.
Aim: This study aimed to develop a roadmap for strengthening STI prevention and control
among KPP in selected PHC facilities in Limpopo Province.
Methods: A mixed-methods study design was employed to accomplish the four objectives of
the study.
Systematic review: A systematic review was conducted to explore existing STI control
methods among KPP in PHC facilities of Sub-Saharan Africa (SSA). The STI programme
opportunities, strengths, challenges, gaps, as well as factors contributing to the rise in STIs
among KPP were further explored. The systematic review followed the Preferred Reporting
Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was registered
in the International Prospective Register of Reviews (PROSPERO) (ID: CRD42023439416)
(Objective 1). In-depth interview: In-depth interviews involving a purposive sample of 18
key stakeholders (15 service providers and 3 policymakers) were carried out to explore their
views and roles on the STI programme scope, content, availability, accessibility, affordability,
and quality of STI services. In each facility, three professional nurses, including the facility
manager, were selected. Themes and subthemes were developed through Tech’s step
analysis and inductive analytical approach (Objective 2). Programme evaluation: An STI
programme evaluation in five PHC facilities was conducted to assess the facilities’ operations
and delivery services. In each facility, the facility manager completed the World Health
Organisation STI assessment checklist tool, where the appraisal rating scale was used to
gauge the facility's performance in relation to the WHO checklist tool. A descriptive statistic
displaying frequencies and proportions was analysed using STATA software version 18
(Objective 3). The key stakeholders aged 18 years/above with at least one year of STI
experience were evaluated and included (objectives 2 and 3). Evidence-based Roadmap:
An evidence-based roadmap for strengthening and advancing STI management systems in
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PHC facilities was developed by integrating findings obtained from objectives 1-3. The Logic
Model informed the development of the roadmap as well (Objective 4).
Results: Systematic review: The systematic review included 39 eligible studies from 14
SSA. Most of the studies were conducted in South Africa, followed by Kenya, and the fewest
were conducted in Nigeria, Malawi, and Ghana. Sixty-nine percent of the studies were
conducted in urban areas compared to three percent that were conducted in rural areas. The
primary method for STI management and prevention was the syndromic case management
approach. This approach was commonly offered with partner referral, condoms, doxycycline
pre-exposure prophylaxis and counselling. Syndromic management approach was effective
in treating STIs such as gonorrhea and syphilis, and its challenges were the possibility of
overtreatment, undertreatment of asymptomatic STIs, adverse birth effects and drug
resistance. A few of the studies were conducted on laboratory diagnostic methods such as
polymerase chain reaction, nucleic acid amplification, transcriptase and Gene Xpert. The
latter methods demonstrated higher diagnostic accuracy for asymptomatic STIs. However, a
loss of patient follow-up, shipping samples to other countries for further analysis, and routine
maintenance costs were associated barriers to these methods. In-depth interviews: The scope
of the STI programme in PHC facilities includes prevention, testing, screening, and treatment.
The study outlined opportunities to increase linkage to care, awareness, availability, and
accessibility to STI services to improve screening and testing coverage among KPP. These
include the extended PHC days and hours, social media, free services, and community
healthcare workers. Service providers improved healthcare services through peer in-services
training, and routine monitoring and reporting of captured data. Key barriers were staff
shortage, poor data storage management, and the absence of laboratory-based diagnostic
tests. Adequate supply of condoms and STI medication, as well as services integration within
PHC facilities. Programme evaluation: In the third trimester of pregnant women's ANC visits,
a drop in syphilis screening was observed in the five facilities. Facilities two, four, and five had
more males who screened for male urethritis than those who were treated. The findings
demonstrated a mismatch of STI data elements on the e-tick register, the clinic register and
patients' files. A few of the STI data elements reported by the facilities adhered to the reporting
data elements recommended by WHO. Sexually transmitted infections data disaggregation
by age and gender exists only for cervical cancer screening and male urethritis syndrome.
Conclusion: The study highlighted that the syndromic management approach remains the
standard STI control in PHC facilities. There is still a lack of diagnostic testing in PHC facilities
to improve and facilitate early diagnosis and treatment. The gaps and challenges associated
with the current STI control could be used to inform and direct policymakers and targeted
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interventions to up-scale and strengthen the current STI programme. There is a significant
need to enhance the reporting of data elements on the e-tick register so that it aligns with what
is reported on patients' files and the clinic register for better disease monitoring and
management within PHC facilities. Data disaggregation should be improved by gender and
age for all the KPPs. Syphilis screening and treatment in PHC facilities should be extended to
other KPPs to mitigate its alarming incidence. To contribute to realizing and achieving the
WHO's Vision 2030 and the National Strategic Plan 2023-2028, which is aligned with the
National Development Plan Vision 2030 of combating STIs as a public health challenge, there
is a great need to improve diagnostic testing within PHC facilities and encourage continuation
of services integration to accelerate uptake of services and improved healthcare outcomes.