13.1. Challenges in STI surveillance and anticipated responses

The challenges in STI surveillance include:

• difficulty in conducting robust surveillance when laboratory testing is not available to detect STIs and understand the causes of STI syndromes;
• the asymptomatic nature of many STIs, resulting in a significant burden of infections being missed for lack of diagnostic testing; and
• limited linking of laboratory data to epidemiological data in many settings.

Ongoing STI surveillance at the country level therefore needs to be strengthened. The few data that are available should be used as stepping stones to improve surveillance by using the gaps for planning and programming to obtain more robust data. This should be done on continuously and not only periodically.

• Since the syndromic approach is widely used in STI country programmes, countries should keep on top of the causes of the STI syndromes emerging by regularly conducting etiological studies from sentinel sites using molecular assays, linked to other programmes, if necessary.
• STI surveillance should be an integral part of the syndromic approach, linked with periodic assessment of the antimicrobial resistance of key pathogens.
• The complications of STIs are another component that adds to the disease burden, and routine STI surveillance should incorporate monitoring of STI complications within STI management reporting systems.
• STI surveillance in key populations remains fundamental, since the STI prevalence in these populations remains a significant contributor to the STI epidemic. For this, the collaboration of NGOs should be sought and strengthened to harness these stakeholders as sources of data. Regular systematic STI surveillance and screening for STIs among key populations would be more relevant than occasional surveillance in providing information for effective interventions.
• Capacity-building is required for STI surveillance and monitoring. This requires strengthening laboratories by investing in human resources for laboratories and fostering the availability of and access to affordable STI diagnostic tests.
• Advocating for funding is essential for developing alternative approaches for managing people with STIs by using rapid point-of-care diagnostic tests.
• For syphilis, since there is routine maternal screening and trend estimation at the country level, modelling should be used more systematically and frequently to establish maternal syphilis trend estimates, together with the WHO congenital syphilis estimation tool to estimate the incidence of congenital syphilis as a basis for validating the elimination of mother-to-child transmission. These elements can be strengthened and scaled up, linked with STI workshops that are often conducted by UNAIDS for regional HIV estimation.

13.2. Research needs in STI case management

There are outstanding questions regarding the role of some organisms and their relevance and need for strategic control that require more research. Some of the key ones are the following.

• The role of overtreatment in developing or accelerating antimicrobial resistance, especially for N. gonorrhoeae and M. genitalium.
• M. genitalium: how important is this organism in pathogenicity and the need for control?

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  The role and impact on sexual and reproductive health, and need for effective control, of M. genitalium in urethritis among men, pelvic inflammatory disease among women and proctitis among women and men.

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  Research on best treatments for people with M. genitalium?

• H. ducreyi: this pathogen seems to have been controlled, but it is occasionally detected in some settings through infrequent etiological studies.

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  What mechanisms should be put in place to keep vigilance to ensure that the infection does not re-emerge, and if it does, how to detect it and prevent its spread?

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  What is the most feasible way of determining whether H. ducreyi has been eliminated?

• C. trachomatis genovar L1–L3: there seems to be a resurgence of lymphogranuloma venereum, especially among men who have sex with men, causing rectal infections.

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  Are there specific clinical manifestations that should alert the health-care provider to this infection?

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  What is the burden of this infection among men who have sex with men and people engaging in anal sex?

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  What are the long-term consequences of lymphogranuloma venereum if not treated?

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  How can the diagnosis of lymphogranuloma venereum be made more affordable and improved?

• Validation studies and cost–effectiveness studies of the various recommended flow charts, considering important outcomes, such as pelvic inflammatory disease and the development of antimicrobial resistance.
• Studies on the prevalence and effective treatment of people with anorectal and pharyngeal infections and the role of pooled sampling.

Overall, real rapid low-cost point-of-care tests for diagnosing N. gonorrhoeae and C. trachomatis need to be developed.