Acceptability, feasibility and cost of point of care testing for sexually transmitted infections among South African adolescents where syndromic management is standard of care.

BACKGROUND: Young people (YP) in southern Africa are at substantial risk of HIV and sexually transmitted infections (STIs). Despite the epidemiological and biological link between STIs and HIV transmission and acquisition, infections such as Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) remain widely undiagnosed. Syndromic STI management is the standard of care in low- and middle-income countries (LMICs) despite a high prevalence of asymptomatic infections. We conducted an observational study to explore the acceptability, feasibility, and cost of a STI test-and-treat service for YP in Cape Town. METHODS: YP attending a mobile clinic (MC) and a youth centre clinic (YC) were offered STI screening. Urine testing for CT and NG using a 90-min molecular point-of-care (POC) test on the GeneXpert platform was conducted and treatment provided. Data were collated on demographics, sexual behaviour, presence of symptoms, uptake of same-day treatment, prevalence of CT/NG, and service acceptability. RESULTS: Three hundred sixty six participants were enrolled (median age 20, 83% female).57% (209/366) of participants tested positive for either CT (126/366, 34%) or NG (57/366, 16%) or co-infection (26/366, 7%). Clinical symptoms were a poor predictor of GeneXpert diagnosed CT or NG, with a sensitivity of 46.8% and 54.0% for CT and NG respectively. Although half of participants initially chose to receive same day results and treatment, only a third waited for results on the day. The majority of participants (91%) rated the service highly via a post-visit acceptability questionnaire. CONCLUSION: Curable STIs are highly prevalent in this population. STI screening using POC testing was feasible and acceptability was high. The study provides further impetus for moving policy beyond syndromic management of STIs in South Africa.

The costs and outcomes of paediatric tuberculosis treatment at primary healthcare clinics in Johannesburg, South Africa.

BACKGROUND: Little up-to-date information is available about the costs of providing drug-susceptible tuberculosis (DS-TB) treatment to paediatric patients in South Africa (SA), nor have actual costs incurred at clinics been compared with costs expected from guidelines. OBJECTIVES: To estimate actual and guideline treatment costs by means of a retrospective cohort analysis. METHODS: We report patient characteristics, outcomes and treatment costs from a retrospective cohort of paediatric and adolescent (<18 years) DS-TB patients registered for treatment from 1 April 2011 to 31 March 2013 at three primary healthcare clinics in Johannesburg, SA. Actual treatment costs in 2015 SA rands and US dollars were estimated from the provider perspective using a standard bottom-up microcosting approach and compared with an estimate of guideline costs. RESULTS: We enrolled 88 DS-TB patients (median age 4 years (interquartile range 1.0 - 9.5), 44.3% female, 22.7% HIV co-infected, 92.0% pulmonary TB). Treatment success was high (89.8%; 13.6% cured, 76.1% completed treatment), and the mean (standard deviation (SD)) cost per patient with treatment success was ZAR1 820/USD143 (ZAR593/USD46), comprising fixed costs (44.0%), outpatient visits (30.7%), medication (19.3%) and laboratory investigations (6.0%). This was 17% more than the mean (SD) cost estimated by applying treatment guidelines (ZAR1 553/USD122 (ZAR1 620/USD127)), with differences due mainly to higher laboratory costs and more outpatient visits taking place than were recommended in national guidelines. CONCLUSIONS: These results are the first reported estimates of paediatric DS-TB treatment costs in SA and show the potential cost savings of closer adherence to national treatment guidelines. The findings were robust in sensitivity analyses and are lower than previous cost estimates in adults.