Diagnosis of a presumed sexually transmitted infection (STI) has traditionally been based on either clinical diagnosis, which is often inaccurate and incomplete, or laboratory diagnosis, which is complex, very expensive, and may delay treatment. As early as the 1970s, public health physicians, particularly those working in Africa, became interested in testing simple clinical tools for controlling and treating STIs.¹ This resulted in the design and promotion of “syndromic management” guidelines for STIs by the World Health Organization in 1991.² The syndromic approach does not require identification of the underlying aetiology. Instead, it is based on the identification of a syndrome—that is, a group of symptoms and easily recognised signs associated with a number of well defined aetiologies. Treatment is provided for the majority of the organisms locally responsible for the syndrome.

It rapidly became clear that the syndromic approach offered enormous advantages compared to the traditional approach, although more evidence was needed to rationalise and convince policy makers.³ Algorithms based on a syndromic approach were evaluated in many different settings, results of which were reported in the late 1990s—for example in a supplement of STI.⁴ In a study in South Africa, for instance, the syndromic management protocols provided adequate treatment for more than 90% of patients with genital ulcer syndrome (GUS).⁵ In another study …