Free home tests for sexually transmitted infections could be coming to South Africa

Free home tests for four common – and curable – sexually transmitted infections (STIs) – gonorrhoea, chlamydia, syphilis and trichomoniasis – could soon be available at chronic medicine pick-up points around the country, according to a draft of South Africa’s fifth HIV, TB and STI action plan.  

Government clinics will also roll out STI tests that give results on the same day. 

The new plan is being finalised after comments from the public and civil society were added, says Nelson Dlamini, communications manager at the South African National Aids Council. The final draft will be published on World TB Day on 24 March.

The updated strategy will run from 2023 to 2028. 

Until now, South Africa’s public health sector hasn’t used tests as a standard to diagnose these four STIs (apart from syphilis). Instead, people get treated only if they show up to a facility with symptoms such as genital sores or discharge coming from their penis or vagina. 

This is called “syndromic management” and it’s used by many low- and middle-income countries, including Tanzania and Mozambique. The logic is that many facilities don’t have easy access to a laboratory, so it might take up to four days for people to get their results, and then they might not return to the clinic to get the news or the medicine anyway. 

In South Africa’s private sector, however, using lab tests to diagnose STIs is commonplace.  

The trouble with the syndromic method is twofold: 

First, most people with these STIs are asymptomatic, meaning they don’t show any symptoms (that was the case for more than three-quarters of women in one local study). So, with the current approach in the public health system, it means they won’t be treated and will continue to spread the infection to others.

What’s more, the Health Department doesn’t consistently collect data on how many people have one of the four common STIs (gonorrhoea, chlamydia, syphilis and trichomoniasis) on a national level. Instead, the department and the National Institute for Communicable Diseases run data collection drives every now and again, where samples are collected from people (who are showing symptoms) in all nine provinces and sent to the lab. The results are used to make predictions about how many of these infections are going around, and the department then decides whether it’s buying the correct medicines. 

Read in Daily Maverick: “One pill within three days of condomless sex could stop three sexually transmitted infections”

This type of data collection makes it difficult to know whether the country reached the government’s previous HIV and STI plan’s (2017-22) goal to find 50% more symptomless cases of these four infections by the end of 2022, says Yogan Pillay, who heads the local arm of the Clinton Health Access Initiative. 

When gonorrhoea, syphilis or chlamydia aren’t treated, they can cause infertility, increase the chance of contracting HIV or lead to stillbirth. People with HIV who aren’t on antiretroviral treatment can also spread the virus easier when they have gonorrhoea. 

The second problem is that people who do have symptoms (and who show up to a clinic for help) will get an antibiotic that works against more than one infection, because health workers don’t know exactly what they’re treating. This could result in some bugs becoming resistant to those medicines, something South Africa already struggles with.

In short: the public health system is potentially overtreating people with symptoms and undertreating those without, explains Johan Hugo, a senior clinical adviser at the Anova Health Institute. 

But the way South Africa approaches both these problems – through diagnostics and data – is changing. Here’s how. 

Diagnostics: finding the patients

A rapid screening test for syphilis. (Photo:  iStock)

Data: Getting the numbers