To the Editor —We would like to congratulate Asare et al [1] on their analysis of the outcomes of point-of-care testing for sexually transmitted infections (STIs) among women in South Africa during a human immunodeficiency virus (HIV) vaccine trial. They found that, in 1 clinic, 92% of women with a positive test result for Chlamydia trachomatis or Neisseria gonorrhoeae (Xpert CT/NG; Cepheid) received same-day treatment. We would like to highlight the variability in receipt of same-day STI treatment at primary healthcare (PHC) settings in South Africa.
We evaluated same-day STI treatment at the baseline visit in our ongoing implementation-effectiveness trial of STI diagnostic strategies in pregnancy in the Buffalo City Metropolitan Municipality in South Africa [2]. At 4 PHC clinics, we enrolled pregnant women attending their first antenatal care visit at <27 weeks of gestation. On-site testing with the Xpert CT/NG and TV (Trichomonas vaginalis) assays is conducted in 2 of 3 study arms; results are usually available within 90 minutes after sampling. Women are encouraged to wait for their results, and those who cannot wait are contacted by telephone. The study is approved by the Human Research Ethics Committee at the University of Cape Town (reference 676/2019).
We have enrolled 511 women in this analysis, with a median age of 28 years (interquartile range, 24–32 years). The prevalence of HIV is 29%, and the prevalence of syphilis, 2%. The overall baseline STI prevalence is 24% (125 of 511), with 83 women (16%) testing positive for C. trachomatis, 27 for N. gonorrhoeae (5%), and 31 for T. vaginalis (6%). In our cohort, 39% of women (49 of 125) with a diagnosed STI received same-day treatment. However, there was a large difference between the 4 clinics: 96% of women (26 of 27) received same-day treatment at 1 facility, compared with 7 of 25 (28%), 7 of 39 (18%), and 9 of 34 (26%) at the others. At these clinics, 66% (66 of 98) received treatment within 7 days of testing (Table 1).
Table 1.
Time to Treatment Initiation After Point-of-Care Sexually Transmitted Infection Testing at 4 Primary Healthcare Facilities in South Africa
| Timing of Treatment Initiation Relative to Testing | Women, No. (%) | ||||
|---|---|---|---|---|---|
| Facility A (n = 27) |
Facility B (n = 39) |
Facility C (n = 34) |
Facility D (n = 25) |
Total (n = 125) |
|
| Same day | 26 (96) | 7 (18) | 9 (26) | 7 (28) | 49 (39) |
| After 1–7 d | 0 | 19 (49) | 13 (38) | 11 (44) | 43 (34) |
| After >7 d | 0 | 10 (26) | 7 (21) | 4 (16) | 21 (16) |
| No return for treatment | 1 (4) | 3 (8) | 5 (15) | 3(12) | 12 (10) |
We agree that rapid STI diagnostics could improve STI management in settings where syndromic management is standard of care. The benefits of on-site STI testing, however, may depend on the setting and on test characteristics. We achieved >90% same-day STI treatment at 1 clinic (facility A), which has a designated waiting area. However, most women did not wait for their results at 3 other PHC clinics, which are crowded and do not have a designated waiting area. Nevertheless, most women received STI treatment within 7 days after telephone follow-up. This is faster than reported by Asare et al [1] for laboratory-based testing (8% treated within 7 days) but similar to results for clinic-based testing (98% treated within 7 days). In addition, Asare et al used an antigen test for T. vaginalis that gives results in 10–15 minutes, which might contribute to the high levels of same-day treatment in clinic-based testing.
In conclusion, our findings confirm that on-site STI testing can achieve high levels of same-day treatment, but further implementation research is needed to determine the settings, populations, contexts, and test characteristics that are needed to optimize same-day STI treatment at the PHC level.
Contributor Information
Mandisa M Mdingi, Research Unit, Foundation for Professional Development, East London, South Africa.
Remco P H Peters, Research Unit, Foundation for Professional Development, East London, South Africa; Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa; Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa.
Ranjana Gigi, Research Unit, Foundation for Professional Development, East London, South Africa; Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland; Graduate School for Health Sciences, University of Bern, Bern, Switzerland.
Chibuzor Babalola, Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA.
Christopher M Taylor, Department of Microbiology, Immunology & Parasitology, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA.
Christina A Muzny, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA.
Nicola Low, Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.
Andrew Medina-Marino, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Desmond Tutu Health Foundation, Cape Town, South Africa.
Jeffrey D Klausner, Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA.
Notes
Financial support. This work was supported by the National Institutes of Health (grant 5R01AI149339-02 to A. M. M. and J. D. K. [paid to the institution]), the Swiss National Science Foundation (project 197831 to R. P. H. P. and N. L. [paid to the institution]), and the Swiss National Science Foundation MD-PhD scholarship to R. G. (paid to the institution).
References
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