What do the latest findings tell us about STIs and treatment in South Africa?
Sexually transmitted infections (STIs) are a group of infections passed from one person to another through sexual contact. Caused by more than 30 bacterial, viral, and parasitic pathogens, STIs can range from curable infections like gonorrhoea, chlamydia, and trichomoniasis, to lifelong conditions such as HIV and herpes. These infections are a major global health concern, affecting millions of people each year and contributing significantly to the burden of disease.
If left untreated, STIs can result in serious complications. These include pelvic inflammatory disease, infertility due to reproductive tract damage, adverse pregnancy outcomes, chronic pain, and increased risk of acquiring or transmitting HIV. Effective prevention and treatment strategies are essential not only to protect individuals but also to reduce transmission within communities.
In South Africa, the main approach to STI management has been syndromic treatment, in place since the 1990s. This strategy treats individuals based on the symptoms they report, without confirming the specific pathogen through lab testing. While this has allowed for timely treatment despite limited diagnostic capacity, it has also led to cases of both under-treatment and over-treatment, with implications for patient outcomes and antimicrobial resistance.
The following report examines the prevalence of STI-associated pathogens among symptomatic males and females attending sentinel STI services in South Africa between 1 January 2021 and 31 December 2024, providing key insights into aetiological surveillance and the effectiveness of syndromic management algorithms.
Materials and Methods
The STI Reference Laboratory at the National Institute for Communicable Diseases has conducted aetiological STI surveillance since 2005 at three primary healthcare clinics in Gauteng, KwaZulu-Natal, and Western Cape. Sites were chosen for patient volume, available workspace, and sample transport capacity.
DNA was extracted from the genital swabs and tested using a validated in-house real-time multiplex PCR assay on the RotorGene platform (Qiagen, Hilden, Germany) or QuantStudio™ 5 System (Applied Biosystems, Foster City, California, USA) to detect the presence of the following STI pathogens: NG, CT, TV, and Mycoplasma genitalium (MG) from urethral and endocervical swab specimens; and HSV-1 and HSV-2, TP, Haemophilus ducreyi (HD), CT, and L1, L2 and L3 serovars (LGV) from genital ulcer swab specimens.
Results
Between 2021 and 2024, 3,265 attendees enrolled in the STI surveillance, with 71.3% (2,329) male. The median age was 30 years (IQR 25–37), and 18.9% were under 25. Nearly all were Black African (98.7%) and self-identified as heterosexual (99.6%). Most participants came from Gauteng (42.5%) and KwaZulu-Natal (39.7%), with fewer from the Western Cape.
Among 2,113 male attendees with male urethritis syndrome, neisseria gonorrhoeae (83.1%) and Chlamydia trachomatis (21.1%) were the most common STIs detected. In women, chlamydia (17.8%), trichomonas vaginalis (13.9%), and gonorrhoea (13.5%) were most frequent, with bacterial vaginosis affecting 58% of those with vaginal discharge. Genital ulcers were mainly caused by HSV-2 (43.6%) and treponema pallidum (30.2%).
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