Publications
Partners
- There's been a resurgence of sexually transmitted infections in South Africa and around the world.
- The Gauteng Department of Health recently reported an increase of newly acquired STIs, in particular gonorrhoea and chlamydia.
- This spike calls for management guidelines and awareness programmes to be reviewed, says at least one expert.
A rise in reported cases of sexually transmitted infections in Gauteng in 2023 is a wake-up call that control and management strategies are not keeping pace with the growing disease burden in South Africa's most populous province, reports Spotlight.
"The Gauteng information confirms the rise in STIs that we are seeing in South Africa and across the world, including in the United States and Canada," said Dr Nomathemba Chandiwana, a director and principal scientist at Ezintsha Research Centre at Wits University. She is also a co-author of the 2022 guidelines on the management of sexually transmitted infections produced by the Southern Africa HIV Clinicians Society.
Chandiwana said any increase in STIs should raise alarms because it means "we simply don't have control over the things we thought we had under control".
The World Health Organisation (WHO) in 2022 noted that countries reported low coverage for preventive, testing and treatment services related, because of Covid-19 lockdown restrictions.
The WHO confirmed that this had led to a "resurgence of STIs and the emergence of non-classical STIs [such as Shigella sonnei, hepatitis A, Neisseria meningitidis, Zika and Ebola] globally". It also reported that currently, more than one million new STIs were acquired around the world each day, "posing a significant global health challenge".
Since the middle of 2023, the WHO has pushed for low-cost point of care tests to be more readily available in low and middle income countries, saying this would improve screening and diagnosis, data collection and make STI services more effective.
South Africa has not made such tests accessible, still relying on a syndromic approach, which is clinical diagnosis made by assessing a patient's symptoms and other visible signs.
Chandiwana said a review of STI treatment and management guidelines was necessary because the rising numbers posed significant new public health threats.
New public health threats
Of particular concern, she said, was that having STIs pushed up a person's risk of contracting HIV, which was "a chronic and serious disease", as well as developing other long-term or irreversible medical risks, including reproductive complications.
Earlier in February, the Gauteng Department of Health reported that the incidence of Male Urethritis Syndrome (MUS) in men aged 15 to 49 in the province had increased from 12% in 2020 to 15% in 2023. The department did not provide actual figures for the comparison, which is also somewhat complicated by the fact that in 2020 there were strict Covid-19 lockdowns and restrictions in place.
The department's information from 2023 showed that 167 to 109 males aged 15 to 49 visited health facilities across the province from April to December. Of these patients, 67 400 (40% of the 167 109) were treated for MUS.
The diagnosis of MUS is an indicator of newly acquired STIs, in particular gonorrhoea and chlamydia, which, according to the Gauteng Department of Health, are the most prevalent STIs in South Africa.
Chandiwana said diagnosis of MUS in men and pelvic inflammatory disease (PID) among women, were made by assessing symptoms of pain, discomfort and genital discharge and sores. Conventionally, it's treated with broad range antibiotics.
She explained that South Africa's guidelines to treatment and management were to make clinical decisions based on a patient's symptoms and signs.
"While this standard approach has worked, we are calling for a move to targeted diagnosis and targeted treatment. It's because you want to know which STI someone has and to treat them for that particular disease," said Chandiwana.
Different STIs can also result in different complications. Syphilis for instance, she said, can result in women giving birth to children who are Deaf or blind or raises the risks for infertility. (Spotlight previously reported on congenital syphilis in South Africa in more depth here.)
READ | Increase in STI cases: 'I have slept with more than six girls this month alone'
"We also have STIs that are present but not visible, so asymptomatic STIs, including HPV (human papillomavirus), which is the leading cause of cervical cancer in black women in South Africa," Chandiwana said.
"Of course it's complicated in a public healthcare system where we might not have lab services everywhere, and where there may be lab testing there is a long turnaround for results."
What to do
It means a multi-pronged approach is still necessary. This, she said, had to include a shift from blaming and policing people's sexual behaviour. Her comments are in response to Gauteng Health and Wellness MEC Nomantu Nkomo-Ralehoko's remarks in the same Gauteng Department of Health press release in which the MEC drew a link between a higher number of women coming forward to be initiated on Pre-Exposure Prophylaxis (PrEP) - an antiretroviral drug prescribed for HIV-negative people to stop HIV infection - and the higher recorded number of STIs.
The MEC is quoted as saying:
Chandiwana dismissed the conclusion of a causal relationship. "PrEP is a very important tool because it’s something people can take to prevent HIV. But before we had PrEP it was not like people were using condoms – people were using nothing. So I disagree, the uptake of PrEP is not directly involved with the increase of STIs," she said.
What's needed instead, she said, was to ask why people were not using condoms more often and why South Africa was not creating STI friendly services that include differentiated care for key populations such as sex workers, men who have sex with men, or people who inject drugs.
There should also be more peer navigators, services that are quick, efficient and confidential, as well as investment and development of rapid testing kits, she added.
Preliminary findings from the Sixth South African National HIV Prevalence, Incidence, and Behaviour survey released by the Human Sciences Research Council in November indicated that condom use had dropped substantially among young people from 2017 to 2022.
It did prompt Nkomo-Ralehoko to call for more uptake of PrEP.
"We would like to encourage more males to get initiated on PrEP to protect themselves against STI. Additionally, both men and women who are on PrEP should use condoms to protect themselves against STIs, HIV and unwanted pregnancies," she was quoted as saying in the press release.
Role of medical male circumcision
Meanwhile, the NGO Right to Care is promoting voluntary medical male circumcision as another strategy to combat the rise in STI cases.
"Uncircumcised men are more susceptible to STIs than men who are circumcised, especially STIs that cause ulcers or wounds," said Dr Nelson Igaba, senior technical specialist for voluntary medical male circumcision at the NGO.
READ MORE | Gauteng launches campaign to protect girls against cervical cancer following STI surge
He described the Gauteng statistics as "worrying" and said it should be read as a prompt for more men to opt for circumcision. The NGO will connect men to their nearest public facility to have the procedure done for free. (They can be contacted at 082 808 6152.)
Dr Tendesayi Kufa-Chakezha, a senior epidemiologist at the Centre for HIV and STIs at the National Institute for Communicable Diseases (NICD), also homes in on the need for more awareness building.
ALSO READ | Stats show young people are ditching condoms
"As a country we are not talking about STIs enough, among ourselves or with our children. More healthcare workers are needed and more training can be made available. We also need a massive campaign to educate communities on the causes of STI syndromes, symptoms, where to get treatment, types of treatments, complications and to go back to facilities if they don’t get better," she said.
Kufa-Chakezha said South Africa's STI treatment guidelines do conform with existing WHO guidelines. She said the NICD regularly collects information and specimens from health facilities, which allows them to determine the most common causes associated with the symptoms that are most commonly seen.
The NICD uses these findings to inform the country's STI management and treatment strategies that are based on diagnosis and treatment of the most prevalent STIs.
"If as a country we are not able to get more people with or without STI symptoms screened and treated, we will continue to have people acquiring STIs, developing symptoms associated with them, becoming ill and developing complications from them," she added.
*This article was published by Spotlight – health journalism in the public interest. Sign up to the Spotlight newsletter.
