Advancing STI care in low/middle-income countries: has STI syndromic management reached its use-by date?

Syndromic management of sexually transmitted infections (STIs) using algorithms based on the patient's presenting symptoms has been the cornerstone of STI care in many low/middle-income nations for over three decades; usually because of limited resources and lack of adequate laboratory services and also to deliver care as quickly as possible. The shortcomings of this approach have been well documented and include the inability to detect asymptomatic STIs,1 the lack of antibiotic susceptibility testing, the poor positive predictive value (PPV) of syndromic treatment resulting in the overuse of antibiotics (of particular concern in relation to antibiotic resistance to gonorrhoea)2 and limited opportunities for surveillance and partner notification. Of the three main STI syndromes (vaginal discharge, urethral discharge in men and genital ulceration), vaginal discharge has the lowest PPV for a laboratory diagnosable STI. Without adequate partner notification and treatment, the source partner is often rapidly reinfected. At a population level, asymptomatic STIs constitute the majority of those infected3 and the inability to test and treat these individuals means that most infected individuals remain untreated, resulting in long-term clinical complications and ongoing transmission. As an example, South Africa introduced STI syndromic management in 1995 and has followed WHO guidance including the recommendation that national guidelines should be regularly evaluated with periodic aetiological and antimicrobial resistance surveys and antibiotic treatment adjusted accordingly.4 However, training and implementation are often poor.5 A study in rural KwaZulu-Natal (KZN), in the epicentre of the HIV epidemic, estimated that the overall effectiveness of syndromic STI services to successfully treat curable symptomatic episodes …