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      Diagnosing sexually transmitted infections in resource‐constrained settings: challenges and ways forward

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          Abstract

          Introduction

          Sexually transmitted infections ( STIs) remain prevalent and are increasing in several populations. Appropriate STI diagnosis is crucial to prevent the transmission and sequelae of untreated infection. We reviewed the diagnostic accuracy of syndromic case management and existing point‐of‐care tests ( POCTs), including those in the pipeline, to diagnose STIs in resource‐constrained settings.

          Methods

          We prioritized updating the systematic review and meta‐analysis of the diagnostic accuracy of vaginal discharge from 2001 to 2015 to include studies until 2018. We calculated the absolute effects of different vaginal flowcharts and the diagnostic performance of POCTs on important outcomes. We searched the peer‐reviewed literature for previously conducted systematic reviews and articles from 1990 to 2018 on the diagnostic accuracy of syndromic management of vaginal and urethral discharge, genital ulcer and anorectal infections. We conducted literature reviews from 2000 to 2018 on the existing POCTs and those in the pipeline.

          Results and discussions

          The diagnostic accuracy of urethral discharge and genital ulcer disease syndromes is relatively adequate. Asymptomatic Chlamydia trachomatis ( CT) and Neisseria gonorrhoeae ( NG) infections limit the use of vaginal discharge and anorectal syndromes. The pooled diagnostic accuracy of vaginal syndromic case management for CT/ NG is low, resulting in high numbers of overtreatment and missed treatment. The absolute effect of POCTs was reduced overtreatment and missed treatment. Findings of the reviews on syndromic case management underscored the need for low‐cost and accurate POCTs for the identification, first, of CT/ NG, and, second, of Mycoplasma genitalium ( MG) and Trichomonas vaginalis ( TV) and NG and MG resistance/susceptibility testing. Near‐patient POCT molecular assays for CT/ NG/ TV are commercially available. The prices of these POCTs remain the barrier for uptake in resource‐constrained settings. This is driving the development of lower cost solutions.

          Conclusions

          The WHO syndromic case management guidelines should be updated to raise the quality of STI management through the integration of laboratory tests. STI screening strategies are needed to address asymptomatic STIs. POCTs that are accurate, rapid, simple and affordable are urgently needed in resource‐constrained settings to support the uptake of aetiological diagnosis and treatment.

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          Most cited references107

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          Antimicrobial resistance in Neisseria gonorrhoeae: Global surveillance and a call for international collaborative action

          In a Policy Forum, Teodora Wi and colleagues discuss the challenges of antimicrobial resistance in gonococci.
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            Sexually transmitted infections: challenges ahead.

            WHO estimated that nearly 1 million people become infected every day with any of four curable sexually transmitted infections (STIs): chlamydia, gonorrhoea, syphilis, and trichomoniasis. Despite their high global incidence, STIs remain a neglected area of research. In this Commission, we have prioritised five areas that represent particular challenges in STI treatment and control. Chlamydia remains the most commonly diagnosed bacterial STI in high-income countries despite widespread testing recommendations, sensitive and specific non-invasive testing techniques, and cheap effective therapy. We discuss the challenges for chlamydia control and evidence to support a shift from the current focus on infection-based screening to improved management of diagnosed cases and of chlamydial morbidity, such as pelvic inflammatory disease. The emergence and spread of antimicrobial resistance in Neisseria gonorrhoeae is globally recognised. We review current and potential future control and treatment strategies, with a focus on novel antimicrobials. Bacterial vaginosis is the most common vaginal disorder in women, but current treatments are associated with frequent recurrence. Recurrence after treatment might relate to evidence that suggests sexual transmission is integral to the pathogenesis of bacterial vaginosis, which has substantial implications for the development of effective management approaches. STIs disproportionately affect low-income and middle-income countries. We review strategies for case management, focusing on point-of-care tests that hold considerable potential for improving STI control. Lastly, STIs in men who have sex with men have increased since the late 1990s. We discuss the contribution of new biomedical HIV prevention strategies and risk compensation. Overall, this Commission aims to enhance the understanding of some of the key challenges facing the field of STIs, and outlines new approaches to improve the clinical management of STIs and public health.
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              Point-of-Care Testing for Infectious Diseases: Diversity, Complexity, and Barriers in Low- And Middle-Income Countries

              Madhukar Pai and colleagues discuss a framework for envisioning how point-of-care testing can be applied to infectious diseases in low- and middle-income countries.
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                Author and article information

                Contributors
                wit@who.int
                Journal
                J Int AIDS Soc
                J Int AIDS Soc
                10.1002/(ISSN)1758-2652
                JIA2
                Journal of the International AIDS Society
                John Wiley and Sons Inc. (Hoboken )
                1758-2652
                30 August 2019
                August 2019
                : 22
                : Suppl Suppl 6 , Understanding and addressing the HIV and STI syndemics. Guest Editor: Kenneth H Mayer, Henry JC de Vries ( doiID: 10.1002/jia2.v22.s6 )
                Affiliations
                [ 1 ] Department of Reproductive Health and Research World Health Organization Geneva Switzerland
                [ 2 ] Skin & Genito‐Urinary Medicine Clinic Harare Zimbabwe
                [ 3 ] Department of Emerging Threat and AMR FIND Geneva Switzerland
                [ 4 ] Department of Clinical Epidemiology and Biostatistics McMaster University Ontario Canada
                [ 5 ] World Health Organization Collaborating Centre for Gonorrhoea and other STIs Department of Laboratory Medicine Faculty of Medicine and Health Örebro University Örebro Sweden
                Author notes
                [*] [* ] Corresponding author: Teodora EC Wi, 20 Avenue Appia, Geneva, 1211, Switzerland. Tel. +41 2279114575. ( wit@ 123456who.int )
                Article
                JIA225343
                10.1002/jia2.25343
                6715950
                31468679
                1f34e7aa-74ec-46bb-b0c5-ba46181f597b
                © 2019 World Health Organization; licensed by IAS.

                This is an open access article distributed under the terms of the Creative Commons Attribution IGO License https://creativecommons.org/licenses/by/3.0/igo/legalcode which permits unrestricted use, distribution and reproduction in any medium, provided that the original work is properly cited. In any reproduction of this article there should not be any suggestion that WHO or the article endorse any specific organization or products. The use of the WHO logo is not permitted. This notice should be preserved along with the article's URL.

                Page count
                Figures: 0, Tables: 5, Pages: 11, Words: 11624
                Product
                Funding
                Funded by: World Health Organization's Human Reproduction Programme
                Categories
                Review
                Review
                Custom metadata
                2.0
                jia225343
                August 2019
                Converter:WILEY_ML3GV2_TO_NLMPMC version:5.6.8 mode:remove_FC converted:30.08.2019

                Infectious disease & Microbiology
                diagnostics,std/sti,point of care,key and vulnerable populations,treatment

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