Systems Mapping of Sexually Transmitted Infection Services at Three Clinical Sentinel Surveillance Sites in South Africa: Opportunities for Integrated Care.

Sexually transmitted infection (STI) service delivery in the context of integrated care and the South African HIV epidemic is complex. We aimed to document STI care and HIV testing processes in public health clinics in South Africa, revealing bottlenecks to patient flow and identifying opportunities for improvement. Clinic mapping, with semi-structured interviews and clinic observation, was conducted with facility representatives at three clinical sentinel surveillance sites. Facility surveys assessed patient volume and staffing. Identified challenges were associated with staffing allocations, and disruptions in patient flow resulted from poor clinic layout, inadequate lighting, and limited allocation of space for HIV testing and physical examination. Recommendations include staffing adjustments, reorganization of space to allow for designated service and waiting areas, sufficient supplies, and improved lighting. The facility reorganization component of South Africa's Ideal Clinic initiative provides a key opportunity for enacting many of these recommendations.

Development of new malaria diagnostics: matching performance and need.

Despite advances in diagnostic technology, significant gaps remain in access to malaria diagnosis. Accurate diagnosis and misdiagnosis leads to unnecessary waste of resources, poor disease management, and contributes to a cycle of poverty in low-resourced communities. Despite much effort and investment, few new technologies have reached the field in the last 30 years aside from lateral flow assays. This suggests that much diagnostic development effort has been misdirected, and/or that there are fundamental blocks to introduction of new technologies. Malaria diagnosis is a difficult market; resources are broadly donor-dependent, health systems in endemic countries are frequently weak, and the epidemiology of malaria and priorities of malaria programmes and donors are evolving. Success in diagnostic development will require a good understanding of programme gaps, and the sustainability of markets to address them. Targeting assay development to such clearly defined market requirements will improve the outcomes of product development funding. Six market segments are identified: (1) case management in low-resourced countries, (2) parasite screening for low density infections in elimination programmes, (3) surveillance for evidence of continued transmission, (4) clinical research and therapeutic efficacy monitoring, (5) cross-checking for microscopy quality control, and (6) returned traveller markets distinguished primarily by resource availability. While each of these markets is potentially compelling from a public health standpoint, size and scale are highly variable and continue to evolve. Consequently, return on investment in research and development may be limited, highlighting the need for potentially significant donor involvement or the introduction of novel business models to overcome prohibitive economics. Given the rather specific applications, a well-defined set of stakeholders will need to be on board for the successful introduction and scaling of any new technology to these markets.