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A national evaluation using standardised patient actors to assess STI services in public sector clinical sentinel surveillance facilities in South Africa
  1. Pamela K Kohler1,2,3,
  2. Eva Marumo4,
  3. Suzanne L Jed1,3,
  4. Gladys Mema3,
  5. Sean Galagan1,3,
  6. Kenneth Tapia1,
  7. Erushka Pillay3,
  8. Julia DeKadt3,
  9. Evasen Naidoo3,
  10. Julia C Dombrowski5,
  11. King K Holmes1,5,6
  1. 1Department of Global Health, University of Washington, Seattle, Washington, USA
  2. 2Department of Psychosocial and Community Health, University of Washington, Seattle, Washington, USA
  3. 3International Training and Education Center for Health, University of Washington, Pretoria South Africa
  4. 4National Department of Health, Pretoria South Africa Civitas Building, Pretoria, South Africa
  5. 5Department of Medicine, University of Washington, Seattle, Washington, USA
  6. 6Department of Epidemiology, University of Washington, Seattle, Washington, USA
  1. Correspondence to Dr Pamela K Kohler, University of Washington, 325 9th Ave, Box 359931, Seattle, WA 98104, USA; pkohler2{at}


Objectives Quality concerns in STI service delivery and missed opportunities for integration with HIV testing and prevention services in South Africa have been well documented. This national evaluation aimed to evaluate current utilisation and adherence to national STI guidelines, including partner notification and integration with HIV services, for diagnosis and management of STIs.

Methods Facility surveys assessed infrastructure and resource availability, and standardised patient (SP) assessments evaluated quality of STI care in 50 public clinics in nine provinces in South Africa. The primary outcome was the proportion of SPs receiving essential STI care, defined as: offered an HIV test, condoms, partner notification counselling and correct syndromic treatment. Weighted proportions were generated, and SP findings were compared by gender using χ2 tests with Rao-Scott correction.

Results More than 80% of facilities reported medications in stock, with the exceptions of oral cefixime (48.3%), oral erythromycin (75.1%) and paediatric syrups. Among 195 SP encounters, 18.7% (95% CI 10.7% to 30.5%) received all hypothesised essential STI services: offered HIV test (67.1%), offered condoms (31.4%), partner notification counselling (70.2%) and recommended syndromic treatment (60.7%). Men were more likely than women to be offered all services (25.1% vs 12.3%, p=0.023), recommended treatment (70.7% vs 50.9%, p=0.013) and partner notification counselling (79.9% vs 60.6%, p=0.020). Only 6.3% of providers discussed male circumcision with male SPs, and 26.3% discussed family planning with female SPs.

Conclusions This evaluation of STI services across South Africa found gaps in the availability of medications, adherence to STI guidelines, condom provision and prevention messaging. Limited integration with HIV services for this high-risk population was a missed opportunity. Quality of STI care should continue to be monitored, and interventions to improve quality should be prioritised as part of national strategic HIV and primary healthcare agendas.


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  • Meetings: Findings were presented in part at the International AIDS Society Meeting, Vancouver, Canada, 19–22 July 2015.

  • Handling editor Jackie A Cassell

  • Contributors PKK, KKH, EM, JCD and SLJ designed the study. SG, SLJ, EP, GM, EN and JD facilitated data collection and implementation. PKK, SG and KT conducted data analysis. PKK, KT and SG were responsible for manuscript development. All authors contributed significantly to the content and provided approval of the final manuscript. This article/manuscript was prepared while SLJ was employed at the University of Washington. The opinions expressed in this article/manuscript are the authors’ own and do not reflect the view of the Health Resources and Services Administration, the Department of Health and Human Services or the US government.

  • Funding Funding was received through the President's Emergency Plan for AIDS Relief (PEPFAR) via the HRSA grant to the International Training and Education Center for Health (I-TECH) U91 HA06801. Additional statistical support was provided by R01 AI029168 and the University of Washington Center for AIDS Research Biometrics Core (P30 AI027757).

  • Competing interests None declared.

  • Ethics approval South African Human Sciences Research Council.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Data are available on request by agreement of the principal investigator and the South Africa National Department of Health.