Low effectiveness of syndromic treatment services for curable sexually transmitted infections in rural South Africa
- R G White1,
- P Moodley2,3,
- N McGrath1,4,
- V Hosegood1,4,
- B Zaba1,
- K Herbst4,
- M Newell4,
- W A Sturm2,
- R J Hayes1
- 1Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
- 2Department of Medical Microbiology, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, South Africa
- 3Department of Infection Control, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, South Africa
- 4Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa
- Richard G White, Infectious Disease Epidemiology Unit, Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK;
- Accepted 22 July 2008
- Published Online First 15 August 2008
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.
Additional date are published online only at http://sti.bmj.com/content/vol84/issue7
Funding: The Africa Centre for Health and Population Studies is supported by grants from the Wellcome Trust (GR065377/Z/01/H,GR065377/Z/01/B). The funders had no involvement in the design, collection, analysis or interpretation of the data, in writing the report or in the decision to submit. RGW would like to thank the MRC (UK) and the Wellcome Trust for their financial support.
Competing interests: None.
Ethics approval: Ethics approval was obtained from the Nelson Mandela Medical School Research Ethics Committee, University of KwaZulu-Natal, South Africa.
Contributors: RGW designed the study with RJH, PM and AWS. RGW wrote the effectiveness model and analysed data. NMcG and VH carried out additional data analysis. RGW wrote the manuscript with contributions from all authors. All authors approved the final version of the manuscript.