Introduction South African guidelines recommend a syndromic approach (SA) to manage sexually transmitted infections (STIs). However, SA lacks specificity and may be particularly problematic for patients with persistent or recurrent genital STI symptoms (PRGS) with inability to adequately distinguish the two. The study objectives were to determine the prevalence and risk factors of PRGS.

Methods We conducted a cross-sectional study at 7 STI sentinel sites in 5 provinces. Demographic, clinical information and clinical specimens were collected. Multivariable logistic regression analysis was used. PRGS was defined as patients who self-reported non-resolution of genital symptoms in the preceding three months or previous treatment for the same genital STI symptoms in the preceding 12 months.

Results Of 1397 eligible patients, 28.9% reported PRGS. Among those with PRGS, recurrence was more common 90.1% than persistence 21.8% with 13.2% reporting both. The median age of those who reported PRGS was 28 years [IQR: 24–33], with 56.6% females. Among those with PRGS, 49.3% had vaginal discharge syndrome (VDS), 33.4% had male urethral syndrome (MUS) and 17.1% had genital ulcer syndrome (GUS). The most common pathogens identified among VDS, MUS and GUS patients with PRGS were bacterial vaginosis (60%), Neisseria gonorrhoea (81.5%), and herpes simplex virus 2 (57.5%), respectively. There were no pathogens detected in 19.8% patients. In multivariable analysis, being HIV-positive (adjusted odds ratio [aOR]=1.52, 95% CI 1.16–2.00), having VDS (aOR=1.66, 95% CI 1.23–2.25), being seen at a study site in Gauteng province (aOR=0.63, 95% CI 0.45–0.89) and age between 25–34 years (aOR=1.43, 95% CI 1.06–1.92) were significantly associated with having PRGS, after adjusting for potential covariates.

Conclusion We found high prevalence of PRGS, associated with HIV infection and VDS among young adults. We therefore recommend better integration of HIV and STI management, increasing HIV testing, and review of SA for VDS to include microbiological testing for pathogens associated with PRGS.