43. MEASURING TRENDS IN STI SYNDROME AETIOLOGIES AND ANTIBIOTIC RESISTANCE PATTERNS: THE SOUTH AFRICAN EXPERIENCE
Authors: Lewis D. A. 
Published: December 2007

The World Health Organization's Global strategy for the prevention and control of sexually transmitted infections (STIs): 2006-2015 highlighted the need for STI surveillance as a cornerstone for national programmes. Yet, in many countries of the world, little or no surveillance exists and, when it does, it is often clinical in nature. Much of the world's resource-poor areas use the syndromic management approach, which includes a recommendation for periodic surveillance of antimicrobial resistance in Neisseria gonorrhoeae. It is also important to perform aetiological surveillance, to assess the common causes of the main STI syndromes, such as genital ulceration (GUS), male urethritis syndrome (MUS) and the vaginal discharge syndrome (VDS). This allows observation of trends and ensures that the drugs used in the syndromic management flow chart as still valid.
South Africa started to build a national microbiological and clinical surveillance programme in 2004. Prior to that, microbiological data came from surveillance among particular core groups, such as miners, that could not be extrapolated to the general population. 30 sentinel sites (primary healthcare facilities) were set up in each of the country's nine provinces for the purpose of enhanced clinical surveillance. Data were collected on all the main syndromes in terms of episodes per year. At the same time, microbiological surveillance was initiated in the following provinces: the Northern Cape, Mpumalanga, the Western Cape and Gauteng. Plans are to conduct further surveillance in the Free State and possibly the Eastern Cape later in 2007.
Within each province, one primary health care facility was chosen on the criteria of a large STO caseload and proximity to the laboratory doing the initial culturing of N. gonorrhoeae. Consecutive patients were recruited using informed consent and anonymous specimens collected. Patients were treated syndromically in the normal manner according to national STI management guidelines. Gonococcal isolates, obtained from men with urethral discharge, were tested for ciprofloxacin and ceftriaxone resistance using E tests. In addition, swabs were collected from MUS patients and VDS patients for multiplex polymerase chain reaction (M-PCR) based testing for the following four pathogens: N. gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis and Mycoplasma genitalium. Ulcer swabs were also tested by M-PCR for herpes simplex virus (HSV), Haemophilus ducreyi and Treponema pallidum. A separate PCR was used to test the extracted DNA for C. trachomatis L1-L3. Serum was taken from all participants and tested for syphilis (RPR plus TPPA), HSV-2 and HIV antibodies.
Key findings have confirmed the decline of chancroid to below 1% of genital ulcers and the predominance of genital herpes as the major cause of genital ulceration in South Africa. Gonorrhoea continues to be the major cause of urethritis in men and prevalence far exceeds Chlamydial infection. Approximately 10% of men with MUS are also infected/colonized with T. vaginalis. Only about one third of VDS cases appear to be caused by sexually transmitted pathogens. HIV infection rates exceed those recorded in the annual antenatal surveys and are highest among genital ulcer patients (70%). RPR seropositivity in non-ulcer patients is around 5% and antibodies to HSV-2 occur in about 50!!60% of patients overall. The surveillance has also demonstrated alarming rises in the prevalence of ciprofloxacin resistant gonorrhoea since 2004.