Background The burden of sexually transmitted infections (STIs) in areas of sub-Saharan Africa with poor access to health care services is not well documented. In remote areas of South Africa, we investigated the prevalence of STIs and approaches to providing STI services through a mobile clinic. Methods We recruited 251 adult women visiting a mobile clinic that normally provides general health education and screening services, but not STI care. Clinical and sexual history was obtained and vaginal specimens were tested for Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, and Mycoplasma genitalium infection and for Candida albicans and bacterial vaginosis. Results Laboratory test was positive for 133 (53%) of 251 women for at least 1 STI: C. trachomatis was observed in 52 (21%) women, N. gonorrhoeae in 39 (16%) women, T. vaginalis in 81 (32%) women and M. genitalium in 21 (8%) women. Eighty-one (32%) women met the criteria for vaginal discharge syndrome, of which 58% (47/81) would have been treated accurately. Among asymptomatic women 84 (49%) of 170 were diagnosed with an STI but untreated under the syndromic approach. We could not identify factors associated with asymptomatic STI infection. Conclusions There is a high unmet need for STI care in rural South African settings with poor access to health care services. Provision of STI services in a mobile clinic using the syndromic management approach provides a useful approach, but would have to be enhanced by targeted diagnostics to successfully address the burden of infection.

BackgroundSexual behaviour is a core determinant of the HIV and sexually transmitted infection (STI) epidemics in women living in rural South Africa. Knowledge of sexual behaviour in these areas is limited, but constitutes essential information for a combination prevention approach of behavioural change and biomedical interventions.MethodsThis descriptive study was conducted in rural Mopani District, South Africa, as part of a larger study on STI. Women of reproductive age (18–49 years) who reported sexual activity were included regardless of the reason for visiting the facility. Questionnaires were administered to 570 women. We report sexual behaviour by age group, ethnic group and self-reported HIV status.ResultsYoung women (<25 years) were more likely to visit bars, practice fellatio, have concurrent sexual partners and report a circumcised partner than older women (>34 years); there was no difference for condom use during last sex act (36 % overall). Sotho women were more likely to report concurrent sexual partners whereas Shangaan women reported more frequent intravaginal cleansing and vaginal scarring practice in our analysis. HIV-infected women were older, had a higher number of lifetime sexual partners, reported more frequent condom use during the last sex act and were more likely to have a known HIV-infected partner than women without HIV infection; hormonal contraceptive use, fellatio, and a circumcised partner were less often reported.ConclusionsThis study provides insight into women’s sexual behaviour in a rural South African region. There are important differences in sexual behaviour by age group and ethnicity and HIV status; these should be taken into account when designing tailor-made prevention packages.

h We analyzed data of 263 women with at least one genital or anorectal sexually transmitted infection from a cross-sectional study conducted in rural South Africa. We provide new insights concerning the concurrence of Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, and Trichomonas vaginalis infections as well as the characteristics of bacterial loads. Chlamydia trachomatis and Neisseria gonorrhoeae are the most prevalent bacterial sexually transmitted infections (STI) in the world (1). The course of these infections is unpredictable and diverse (2-7). Most infections in women are asymptomatic and frequently remain unrecognized, which increases the risk for reproductive tract complications (6,(8)(9)(10). Insight into the mechanisms that drive the burden of these infections is essential for disease control. In addition to age, HIV infection, and behavioral factors, microbiological characteristics, including bacterial load, may play an important role in the risk of transmission, clinical presentation, and course of infection (6,(11)(12)(13)(14). Chlamydial load has been associated with clinical presentation, severity of infection, and transmissibility in animal models and in patients with ocular C. trachomatis infection (15-17). Gonorrheal loads have been shown to differ between anatomic locations and associated clinical presentations in men (18). Although real-time PCR and quantitation of DNA load have the potential of revealing new insights into the characteristics of infection, there is only limited literature about the relevance of bacterial load and frequency of concurrent STI in women (19,20). Knowledge about microbiological characteristics of infection could possibly help to improve understanding of the differences in STI prevalences at the population level. This study aimed to evaluate the concurrence and bacterial loads of genital and anorectal C. trachomatis and N. gonorrhoeae infections in South African women from a setting of high HIV prevalence.This study was a subanalysis of a previously described crosssectional study of 604 women in rural Mopani District, South Africa (21). In brief, consenting women 18 to 49 years of age who reported sexual activity during the previous 6 months were eligible. Questionnaires were completed and vaginal, anorectal and pharyngeal swabs (Copan Diagnostics, Brescia, Italy) were obtained by health care workers and stored at Ϫ20°C. Menses on the day of recruitment and refusal to have all three anatomic sites tested were exclusion criteria. Symptomatic women were treated the same day according to local treatment protocols, which include a notification slip for the partner. Asymptomatic women with an STI proven by molecular detection were called to return to the clinic for specific treatment. For the evaluation presented in this article, we selected all women (n ϭ 263) vaginally and/or anorectally infected with at least one of the following pathogens: C. trachomatis (n ϭ 107), N. gonorrhoeae (n ϭ 66), Mycoplasma genitalium (n ϭ 66), and Trichomonas vagina...

objectives To determine the unmet need for care and barriers for consulting sexually transmitted infection (STI) services at six primary healthcare (PHC) facilities in rural South Africa.methods Cross-sectional study using three community-based strategies to mobilise adult individuals with STI-associated symptoms to access care. Participants were mobilised through clinic posters and referral by community healthcare workers (CHWs) and traditional leaders after training. Men with male urethritis syndrome and women with vaginal discharge syndrome were mobilised to visit participating PHC facilities on two designated days when an expert team visited the facility. Questionnaires were completed and HIV rapid tests offered. The minimal unmet need for care of individuals with STI-associated symptoms was calculated by dividing the number of cases over the adult catchment population of each PHC facility.results We successfully mobilised 177 symptomatic individuals: 134 (76%) women and 43 (24%) men. The estimated minimal unmet need for STI care was 1:364 (95% CI 1:350-1:380) individuals in this region; the rate was higher in village than township facilities, and among women. Mobilisation through clinic posters (57%) and by CHWs (23%) was most successful. Three-quarters of individuals (132/177) reported symptoms that had been present for >30 days; 49% (87/177) had symptoms >6 months. In addition, we identified 14 individuals with untreated HIV infection amounting to a 7% HIV testing yield. Lack of awareness of symptoms (34%), and disappointment in care due to persistent (23%) or recurrent (15%) symptoms after previous treatment, or disappointment with health services in general during previous visit(s) for any reason (10%) was the most common reasons for not consulting health care.conclusions We demonstrate a high unmet need for care of individuals with STI-associated symptoms in rural South Africa that requires urgent attention. A multidisciplinary approach that creates service demand through community awareness and information provision by healthcare workers combined with strengthening the quality of STI services is required to improve reproductive health and prevent complications of untreated STIs in this population.keywords unmet need, sexually transmitted infections, community-based strategies, primary health care Tropical Medicine and International Health