Sexually transmitted infections self-sampling among sexually active individuals in sub-Saharan Africa: a scoping review protocol

Abstract

Introduction

Sexually transmitted infections (STIs) pose a huge public health challenge in sub-Saharan Africa, where prevalence rates are among the highest globally. Barriers such as limited healthcare access, stigma and inadequate diagnostic facilities impede timely detection and treatment. Self-sampling for STI testing offers a potential solution to these challenges. This scoping review will systematically map the available evidence on self-sampling for STIs in sub-Saharan Africa, focusing on its feasibility, acceptability, implementation and outcomes.

Methods and analysis

The scoping review will be guided by the Arksey and O’Malley framework. The review will include a comprehensive search of peer-reviewed and grey literature from various repositories and databases. The following databases will be searched: PubMed, Scopus and Global Health. Studies that will be included will meet specific criteria. The results of the review will be reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols checklist.

Ethics and dissemination

The methodology used for this study is a scoping review of existing literature; therefore, ethical approval is not required. Findings of this study will be shared at national, regional and international conferences and published in a peer-reviewed journal.

Trial registration

We registered the protocol with the Open Science Framework.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• The scoping review will follow the Arksey and O’Malley framework, ensuring methodological rigour and robustness.

• Various electronic databases will be searched, including PubMed, Scopus and Global Health.

• The literature search will be complemented with a grey literature search to reduce publication bias.

• Two independent reviewers will conduct the selection of studies in a two-step process: screening of titles and abstracts and full-text screening.

• The limitation of the scoping review is that, due to limited financial resources to undertake translation of non-English studies, there is potential for the introduction of bias towards English studies.

Background

Sexually transmitted infections (STIs) are a huge public health challenge in sub-Saharan Africa.^{1 2} It is estimated that over a million people acquire STIs every day, and over 500 million new cases of curable STIs (gonorrhoea, chlamydia, syphilis and trichomoniasis) occur every year globally.^{3 4} STI testing is important for treating and preventing further transmission of infection.³ Despite surveillance, monitoring and multiple interventions to increase diagnosis and treatment, STIs remain a public health burden.⁴ If left undiagnosed and untreated, STIs have serious consequences, including premature death, infertility, ectopic pregnancies and chronic illness,5,7 among others. STIs can also facilitate the transmission of HIV, complicating efforts to fight the scourge. Untreated STIs in developing countries contribute to approximately 17% of economic losses due to loss of production time.⁸ Efforts are needed to expand access to STI services. Self-sampling, where individuals collect specimens themselves (be it at a health facility, home or elsewhere) and send them to laboratories for testing, offers prospects to expand access to STI services.^{5 9}

Regular screening, particularly among high-risk populations, is important for STI prevention and control. Hitherto, the common approach to management of STIs is the syndromic management approach,¹⁰ a clinical approach that involves diagnosing and treating STIs based on the symptoms (syndromes) presented by the patient.⁴ Despite the practicality of syndromic management of STIs, public health experts doubt its overall effect on the STI burden.⁵ The global surge in STIs^{3 10} casts doubts on the efficacy of syndromic management, and new approaches, including self-sampling, may be needed to deal with the burden of STIs.⁹ Previous research shows that clinic-based screening by clinicians captures a small number of people, as the majority are excluded by several barriers, including inaccessible health facilities, discomfort, embarrassment, lack of time and resources to access health facilities and perceived or real lack of privacy.¹¹ Technological advancement has made it possible to collect and test samples outside health facilities without the involvement of health workers/clinicians, and studies have demonstrated feasibility.¹² It is now possible to self-sample using urine, cervical brush and vaginal, urethral, oropharyngeal or rectal swabs. Evidence demonstrates that the sensitivity and specificity of self-samples are comparable to samples collected by health workers.12,14 In high-income countries, self-sampling for STIs is widely available as an alternative to health worker/clinician sampling.^{10 15}

Evidence shows that self-sampling improves the uptake of STI testing when compared with sampling done by health workers.¹⁴ Self-sampling is particularly beneficial in circumstances where access to health facilities for STI services is problematic and can be used to screen for STIs in remote areas.⁷ It is also particularly useful for the screening of asymptomatic STIs, where individuals may not have the motivation to visit health facilities for syndromic management.^{4 10} Self-sampling also potentially reduces pressure on health workers who are generally overburdened in most health systems in sub-Saharan Africa.¹⁶

Our scoping review seeks to explore the breadth of literature on the feasibility, acceptability and use of STI self-sampling in settings where it is offered to sexually active individuals in sub-Saharan Africa. We have deliberately excluded HIV and focused on other STIs, as evidence on HIV self-sampling/testing is already well developed in the literature. Few studies have examined the feasibility, acceptability and use of STI self-sampling among sexually active individuals in sub-Saharan Africa. This study will add context-specific evidence from sub-Saharan Africa, adding to previous reviews on the feasibility, acceptability and use of STI self-sampling, which were global, focused on high-income countries and specific to certain groups such as women and key populations.

Methods

A scoping review methodology will be adopted because of the broad intent of the review, which is to provide an overview of the feasibility, acceptability and use of STI self-sampling among sexually active individuals in sub-Saharan Africa. We will employ the methodological framework developed by Arksey and O’Malley,¹⁷ consisting of five stages: (1) identifying the research question; (2) identifying the relevant studies; (3) selecting studies; (4) charting the data and (5) collating, summarising and reporting the results. The stages will be iterative, and modifications will be undertaken as necessary. To enhance reporting quality and ensure procedural rigour, the review will be conducted following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocol guidelines.¹⁸ The scoping review protocol was registered with the Open Science Framework.

Identifying the research question

The research questions were developed in consultation with the research team undertaking this scoping review. The agreed research questions are considered adequate to map the range of literature on STI self-sampling in sub-Saharan Africa. The specific research questions of the review are as follows:

1. How feasible is STI self-sampling among sexually active individuals in sub-Saharan Africa?

2. How acceptable is STI self-sampling among sexually active individuals in sub-Saharan Africa?

3. What is the uptake of STI self-sampling among sexually active individuals in sub-Saharan Africa?

4. Does STI self-sampling lead to uptake of treatment for individuals who test positive?

The research questions were developed informed by the population-concept-context mnemonic:

Population

The population for the scoping review is sexually active individuals in sub-Saharan Africa from the age of 15 years and above. We settled for this age group to account for early sexual debut, which is prevalent in most sub-Saharan African countries. Early sexual debut is defined as any sexual activity that occurs below the age of 15 years.¹⁹

Concept

Self-sampling for STIs is an approach where individuals take their own samples and send them to laboratories for testing, with the results sent back to them.⁵ Self-sampling may involve individuals collecting samples and handing them over to health workers to complete the process of sample testing.⁹ The typologies of samples are diverse, including urine, swab-collected samples, blood, discharge, semen and lesion samples. Studies will be included in the review regardless of whether samples were self-collected at a health facility, at home or elsewhere.

Context

The scoping review will focus on studies in sub-Saharan African countries capturing STI self-sampling among sexually active individuals. Sub-Saharan Africa bears a significant burden of STIs, with an incidence rate of 241 per 1000 adults aged 15–49 years, which is among the highest in the world.²⁰

In developing this scoping review, we are interested in the following outcomes. We are interested in mapping evidence on acceptability and feasibility of STI self-sampling. We will also consolidate evidence on the uptake of self-sampling when offered to sexually active individuals, as well as the uptake of treatment among those testing positive following self-sampling.

Identifying relevant studies

Studies will be identified in three ways (1) searching of electronic academic databases (2) searching of grey literature database (3) scanning of bibliographies of eligible papers. Studies will be identified through searches in PubMed, Scopus and Global Health. Searches of the databases will be limited from January 2010, when self-testing was gaining prominence to date, to given current context in self-sampling. Databases will be searched using the strategy outlined in table 1, using search terms listed in table 2. However, before a comprehensive search, a trial run in PubMed will be conducted to gauge sensitivity of the search terms using indicator publications. The search terms will be modified until they are able to pick the indicator publications. Additionally, we will scan through bibliographies of selected full-text articles for potentially eligible studies. The quality of the studies will be assessed using Critical Appraisal Skills Programme checklists, Cochrane Risk of Bias 2 and Risk of Bias in Non-randomised Studies (ROBINS-I).^{16 21 22}

Table 1. Showing search strategy.

Search line	Category
1	STI search terms
2	Subject headings for STI for each database
3	1 OR 2
4	Self-sample collection search terms
5	Subject headings for self-sample collection for each database
6	4 OR 5
7	Sexually active individuals search terms
8	Subject headings for sexually active individuals term for each database
9	7 OR 8
10	Sub-Saharan Africa search terms
11	Subject headings for sub-Saharan Africa for each database
12	10 OR 11
13	3 AND 6 AND 9 AND 12

STI, sexually transmitted infections.

Table 2. Showing search terms.

Concept	Search terms
STIs	‘Chlamydia’ OR ‘Gonorrhoea’ OR ‘Gonorrhoea’ ‘Syphilis’ OR ‘Human Papillomavirus’ OR ‘Herpes Simplex Virus’ OR ‘Trichomoniasis’ OR ‘Hepatitis B’ OR ‘Hepatitis C’ OR ‘Cytomegalovirus’ OR ‘Bacterial Vaginosis’ OR ‘Lymphogranuloma Venereum’ OR ‘Mycoplasma genitalium’ OR ‘Sexually transmitted infection*’ OR ‘Sexually transmitted*’ OR ‘Reproductive tract infection*’ OR ‘Genital infection*’ OR ‘Chlamydia trachomatis’ OR ‘Neisseria gonorrhoeae’ OR ‘Treponema pallidum’ OR ‘Trichomonas vaginalis’
Self-sample collection	‘Sampling’ OR ‘Sample’ OR ‘Self sampling’ OR ‘Self-sample’ OR ‘STI testing’ OR ‘STI diagnosis’ OR ‘Sexually transmitted infections test’ OR ‘Self-collect’ OR ‘Sexually transmitted disease testing’
Sexually active individuals	‘15 years and older’ OR ‘Male’ OR ‘Female’ OR ‘Non-binary’ OR ‘Transgender’ OR ‘Teens’ OR ‘Young adults’ OR ‘Emerging adults’ OR ‘Youth’ OR ‘young person’ OR ‘Adults’ OR ‘Middle-aged adults’ OR ‘Older adults’
Sub-Saharan Africa	‘Angola’ OR ‘Benin’ OR ‘Botswana’ OR ‘Burkina Faso’ OR ‘Burundi’ OR ‘Cameroon’ OR ‘Cape Verde’ OR ‘Central African Republic’ OR ‘CHAD’ OR ‘Comoros’ OR ‘Congo’ OR ‘Congo Democratic Republic’ OR ‘Djibouti’ OR ‘Equatorial Guinea’ OR ‘Eritrea’ OR ‘Ethiopia’ OR ‘Gabon’ OR ‘Gambia’ OR ‘Ghana’ OR ‘Guinea’ OR ‘Guinea-Bissau’ OR ‘Cote d'Ivoire’ OR ‘Ivory Coast’ OR ‘Kenya’ OR ‘Lesotho’ OR ‘Liberia’ OR ‘Madagascar’ OR ‘Malawi’ OR ‘Mali’ OR ‘Mozambique’ OR ‘Namibia’ OR ‘Niger’ OR ‘Nigeria’ OR ‘Sao Tome and Principe’ OR ‘Rwanda’ OR ‘Senegal’ OR ‘Seychelles’ OR ‘Sierra Leone’ OR ‘Somalia’ OR ‘South Africa’ OR ‘South Sudan’ OR ‘Sudan’ OR ‘Swaziland’ OR ‘Tanzania’ OR ‘Togo’ OR ‘Uganda’ OR ‘Zambia’ OR ‘Zimbabwe’ OR ‘Africa, South of the Sahara’ OR ‘sub-Saharan Africa’

STI, sexually transmitted infection.

Selecting studies

Results from the initial search will be exported to EndNote for referencing and removal of duplicates. This will be followed by exporting into Covidence software for title and abstract screening and full-text screening. Title and abstract screening will be conducted by two independent reviewers, informed by the inclusion and exclusion criteria detailed below. Disagreements between the two will be resolved through discussion with the third author. Studies meeting the inclusion criteria will be subjected to full-text screening by two independent reviewers, with disagreements between the two reviewers resolved through discussion. Where full-text papers cannot be obtained, the authors of the papers may be contacted to provide the full text of the papers. Eligible studies will proceed to the stage of data extraction.

Inclusion criteria

• Studies reporting feasibility, acceptability and use of self-sampling among sexually active individuals in sub-Saharan Africa aged 15 years and above.

• Studies that are qualitative, quantitative, mixed methods or organisational reports reporting STI self-sampling.

Exclusion criteria

• Studies that are not in English.

• Studies reporting self-testing for HIV.

Charting the data

An Excel data charting tool developed beforehand will be used to extract data. Initially, two independent researchers will chart 10% of the selected papers, followed by a review of the consistency, usability and comprehensiveness of the charting tool. We anticipate the charting to be iterative, and the charting tool may be refined during the process of piloting and full-scale charting. Agreed changes will be added to the charting tool. Key information that will be extracted from the studies includes author(s), year of publication, location where the study was conducted, the goal of the study, research design, population and sampling, STI focus of the study, types of samples/sampling and key findings on feasibility, acceptability and use of self-sampling. At the end of data charting, we will compare the results of full-text data extraction done by the two independent researchers. Discrepancies will be resolved through team discussion.

Collating, summarising and reporting the results

The screening process will be visualised through a flowchart. Following Arksey and O’Malley’s methodological framework, results will be presented numerically and thematically.¹⁷ We will analyse the studies’ characteristics and summarise the findings using descriptive statistics presented in tables, charts and maps. Thematic analysis will be deployed to identify common ideas and patterns in the data. We will summarise narratively key findings on the feasibility, acceptability and use of STI self-sampling. Finally, we will discuss the interpretation of findings to inform implementers, policymakers and researchers.

Patient and public involvement statement

The design of this scoping review was without involvement of patients or the public.

Discussion

WHO has recommended self-sampling to expand STI services;¹⁰ however, evidence on the feasibility, acceptability and utility of self-sampling is still undeveloped, particularly in sub-Saharan Africa. This scoping review will present evidence on the acceptability, feasibility and use of STI self-sampling in sub-Saharan Africa. Such evidence is required by programme planners and policymakers to expand STI services beyond those provided by clinicians. Expanding STI services beyond clinician sampling can potentially address the workload for work health workers in Sub-Saharan Africa (SSA), who are usually overburdened.²³ This can allow health workers to focus on other critical demands.

STI services in SSA are predominantly provided in health facilities by clinicians or health workers. This excludes vulnerable groups who do not have access to health facilities,¹⁰ individuals uncomfortable with health workers’ attitudes²⁴ and individuals uncomfortable with health workers’ examinations³ from accessing STI services. It is important to generate evidence on feasibility, accessibility and uptake of STI self-sampling to inform the expansion of STI services beyond clinician sampling, which could increase access to STI services.

SSA has traditionally relied on syndromic management to diagnose and treat STIs. However, the use of syndromic management misses many asymptomatic STIs.¹⁰ Self-sampling is effective for screening of asymptomatic infections. Policymakers and programme planners need evidence supporting the feasibility, accessibility and uptake of STI self-sampling before widespread adoption of STI self-sampling.

We have identified the exclusion of non-English studies as a potential limitation of this scoping review. We are cognisant that this limitation potentially eliminates studies with valuable data on the feasibility, acceptability and use of self-sample collection for STIs. However, the English texts should be able to generate useful evidence on the utility of self-sampling for STIs in sub-Saharan Africa, where health systems are overburdened and there are many barriers to providing STI sampling services.

Ethics and dissemination

The study will not seek ethical approval, as it will be using already published secondary data and grey literature. The findings of the study will be published in a peer-reviewed scientific journal and disseminated at appropriate regional and international conferences.