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.

'You can talk about condoms [with younger men] while older men beat you for that': Young women's perceptions of gender-based violence within intergenerational relationships in South Africa.

BACKGROUND: In South Africa (SA), HIV prevalence is significantly higher in young women than in young men. Intergenerational relationships and women's dependence on men are known HIV risks. OBJECTIVES: To qualitatively explore young women's perceptions and experiences of dating younger and older men and their perceived risks for gender-based violence. METHODS: From July to September 2011, we conducted eight focus group discussions (FGDs) and 20 in-depth interviews (IDIs) with young women aged 15 - 24 years. Women were recruited from two SA communities: one urban location in Gauteng Province and one rural location in Limpopo Province. All interviews were recorded, transcribed and translated from local languages into English. The study team then analysed the transcripts thematically, using an inductive approach, with ATLAS-ti (v6.2) software. RESULTS: In total, 110 young women participated, 20 of them in both the FGDs and the IDIs. Young men were viewed by the participants as immature, unable to provide financially and likely to be HIV-positive, although young women sought out young men for 'love', mutual understanding and intimacy. In contrast, older men were perceived as easy to respect, ready for marriage and able to provide for women's needs. Young women sought older men as providers, but acknowledged that older men were more likely to be violent and that discussing sexual and reproductive health and HIV with them was difficult. Young women expressed the belief that if a man was providing for them financially, he had 'the right' to use violence. CONCLUSIONS: The interviews highlighted young women's mixed views on the 'value' of older v. younger partners, and the perceived and real risks of violence in intergenerational relationships. There is a need for interventions addressing power dynamics in relationships, including healthy communication. However, to address young women's vulnerability to violence, ultimately young women and their families need access to economic opportunities that reduce dependence on transactional relationships.

Lessons learnt from the introduction of the contraceptive implant in South Africa

In 2014, South Africa (SA) introduced the subdermal contraceptive implant with the aim of expanding the contraceptive method mix and availability of long-acting reversible methods in the public sector. Three years on, concerns have been raised about the decline in uptake, early implant removals and challenges in service delivery. This article explores the lessons learnt from the introduction of contraceptive technologies elsewhere and applies these to the SA context. Drawing on the World Health Organization's conceptual framework for the introduction of new contraceptive methods, and subsequent literature on the topic, lessons are classified into six cross-cutting themes. Recommendations highlight the need for SA to review and explore strategies to strengthen current implant services, including the provision of improved provider training aimed at sensitive, client-centred approaches; increased community engagement; and improved systems for programmatic monitoring and evaluation. With implementation of these recommendations, worrying trends in the provision of implants could be reversed.