Most STIs have no symptoms. Most STI care starts with one
South African public clinics treat sexually transmitted infections by symptom. Private practices can test, and often do. But in both, something has to send you there in the first place, and most infections send nothing.
The short answer. Between 53% and 61% of chlamydia, gonorrhoea and trichomonas infections in women produce no symptoms at all, and the proportion is highest in Africa. Any approach to sexually transmitted infections that starts when a symptom appears cannot reach them. In one South African programme, symptom screening flagged 9% of the women; laboratory testing of a subset found chlamydia in 25.7%.
In short
- Public clinics treat STIs by symptom. Private practices commonly test. In both, a symptom is usually what starts the process.
- At least half of all STI presentations in South Africa are managed in private general practice.
- Most infections in women produce no symptoms, so nothing prompts the visit or the test.
- Even when symptoms are present, matching them to a cause by flowchart is imprecise in both directions.
How South Africa manages STIs, in both sectors
The public system uses syndromic management. You arrive at a clinic with a symptom, a nurse matches it to a flowchart, and you are treated for the group of infections that symptom usually means. No sample is sent anywhere. You leave the same day, treated, at no cost. Laboratory tests are not widely available at state facilities beyond rapid syphilis tests, used mainly in pregnancy and after sexual violence.
It would be easy, and wrong, to be sniffy about that from a private laboratory. Syndromic management exists because testing at national scale is expensive and slow, and because someone standing in front of you with an infection needs treating today rather than next week. For symptomatic people it does its job. The government's current STI plan also moves in the other direction, proposing rapid tests and home kits for priority groups.
Private practice is a different picture, and this is where the assumption usually breaks. In South Africa's private sector, using laboratory tests to diagnose STIs is commonplace. If you see a private GP, testing is available and frequently used.
So if testing exists on the private side, where is the gap?
At least half of all STI presentations in South Africa are managed in private general practice, and general practitioners' knowledge and confidence in STI management varies. The Southern African HIV Clinicians Society's 2022 guideline covers both sectors, recommends diagnostic testing where resources allow, and sets out screening schedules for specific sexually active groups. In private practice the resources usually do allow.
The gap, in both sectors, sits upstream of the testing. Syndromic management is not only a treatment method: it is an entry point. Something has to make you seek care, and a symptom is what usually does it. An approach that begins when a symptom appears cannot reach an infection that never produces one, whether the practice at the end of it owns a laboratory account or not.
Most infections do not produce symptoms
This is the part that surprises people, and it is very well established. A 2024 systematic review pooling 48 studies across low- and middle-income countries measured how often these infections announce themselves in women.
60.7%
of chlamydia infections in women produced no symptoms
53.3%
of gonorrhoea infections produced no symptoms
56.9%
of trichomonas infections produced no symptoms
Pooled proportions from 48 studies in low- and middle-income countries. The proportion of women with asymptomatic infection was highest in Africa for all three pathogens.
South African data shows the same gap in a way that is harder to argue with, because both measurements were taken in the same programme. Between 2018 and 2021, a PrEP service screened 22,505 people for STI symptoms. Nine per cent of women and three per cent of men reported any. A subset was then tested in a laboratory.
Symptom screening flagged 9% of the women. Laboratory testing found chlamydia in 25.7% of them, and gonorrhoea in 14.1%. Among the men, symptoms flagged 3%, while testing found chlamydia in 20.0% and gonorrhoea in 18.6%. The study's own conclusion was that syndromic screening identifies symptomatic infections but misses asymptomatic ones.
None of those people were being neglected. They were screened, and the screening worked exactly as designed. It simply cannot see an infection that is not producing anything to see. A private GP with a laboratory account would have had the same problem, because nothing would have prompted the test.
The national picture is consistent with that. Modelled 2017 prevalence for South African adults aged 15 to 49 was 14.7% chlamydia in women and 6.0% in men, and 6.6% gonorrhoea in women and 3.5% in men. Syphilis declined steadily from 1990, but gonorrhoea and chlamydia showed no consistent trend, which the authors say highlights the need to extend STI services beyond clinic-based syndromic case management.
Even when there are symptoms, the flowchart is a blunt instrument
The second problem is precision. When a symptom is present it still has to be matched to a cause, and symptoms overlap heavily. A study of the vaginal discharge flowchart in Mozambique, using the same approach South Africa uses, measured how well that matching works.
The flowchart caught between 73.0% and 82.5% of infections. Its specificity was 14% to 15%. In practical terms: 19.2% of symptomatic women who did have chlamydia, trichomoniasis or gonorrhoea would not have been identified and treated for it, and 70.0% of the women would have been treated despite having none of the three.
Both halves matter. Being missed means an untreated infection. Being treated when you are not infected means the real cause of your symptoms goes unfound, and it means treatment used where it was not needed, which is not a small thing in a country that has had to change its first-line gonorrhoea regimen twice since 2008.
What to do with that
Nothing here is an argument against going to a clinic. If you have symptoms and cannot wait, a public clinic will see and treat you today at no cost, and that is the right thing to do.
The argument is about the other situation: no symptoms, no reason anyone would think to test you, and a real chance of an infection anyway. That is the case for testing because you decided to, rather than because something forced you to. It matters before a new relationship, when stopping barrier protection, after a partner's diagnosis, in pregnancy planning, and simply as a routine you set for yourself.
If you want the technical side, we have written separately on why PCR is accurate for STI testing. And because most testing here is built around four infections, it is worth knowing what a four-infection panel leaves out.
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Frequently Asked Questions
Can you have an STI with no symptoms?
Yes, and it is the norm rather than the exception. A 2024 meta-analysis of 48 studies across low- and middle-income countries found that 60.7% of chlamydia infections, 53.3% of gonorrhoea infections and 56.9% of trichomonas infections in women produced no symptoms, with the proportion highest in Africa for all three. A South African PrEP programme found symptoms in 9% of the women it screened, while laboratory testing of a subset found chlamydia in 25.7% of them.
What is syndromic management of STIs?
Treating a sexually transmitted infection on the basis of symptoms, without a laboratory test to identify which organism is present. It is the standard approach in South African public clinics, and it exists for good reasons: it is free, it works on the day, and it does not depend on laboratory capacity. In the private sector laboratory testing is commonplace, so the limitation there is different: an approach that begins when a symptom appears still cannot reach an infection that never produces one.
If I have a private doctor, am I already being tested?
Not necessarily. Laboratory testing is commonplace in South Africa's private sector, so the tests are available to your GP. But something has to prompt one, and that is usually a symptom or a specific request. At least half of all STI presentations in South Africa are managed in private general practice, and practitioners' confidence in STI management varies. The Southern African HIV Clinicians Society's 2022 guideline, which applies to both sectors, recommends diagnostic testing where resources allow and sets out screening schedules for specific sexually active groups. If you have no symptoms and nobody has raised it, the sensible move is to ask.
Will my medical aid pay for an STI test?
It depends on whether the test counts as diagnosis or screening. A test ordered because you have symptoms is diagnostic. A panel you book yourself because you want to know is screening, and schemes generally treat the two differently. Epicentre does not bill medical schemes for these tests at all, so a panel booked directly with us is a cash purchase. What we do give you is the correct paperwork, carrying our practice number and the test codes, so you can claim back yourself. Claiming generally needs a referring doctor's details.
Should I still go to a clinic if I have symptoms?
Yes. If you have symptoms and cannot wait, a public clinic will treat you the same day and at no cost, and that is the right thing to do. Testing and syndromic treatment are not alternatives to each other: a test tells you what you actually have, which matters for your partner, for retesting, and for anything that has not resolved. Epicentre is a laboratory and does not diagnose or treat.
References
- Fortas C, et al. Asymptomatic infections with Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis among women in low- and middle-income countries. PLOS Global Public Health 2024;4(5):e0003226. Read it
- Comparing the integration of syndromic versus etiological management of STIs into HIV pre-exposure prophylaxis services, South Africa. Journal of Adolescent Health 2023. PMID 37953011
- Adult gonorrhea, chlamydia and syphilis prevalence, incidence, treatment and syndromic case reporting in South Africa, 1990-2017. PLOS One 2018. Read it
- Prevalence of STIs and assessment of the syndromic management of vaginal discharge in women with urogenital complaints in Mozambique. Frontiers in Reproductive Health 2024. Read it
- Peters RPH, et al. Southern African HIV Clinicians Society 2022 guideline for the management of sexually transmitted infections. Read it
- Sexually transmissible infections: current approaches to management. South African General Practitioner 2022. Read it
This article is general health information and not medical advice. Epicentre is a diagnostic laboratory: we provide testing and reporting, and we do not diagnose, prescribe or treat. Nothing here is a criticism of public sector care, and if you have symptoms and cannot wait, a public clinic will see and treat you today at no cost.
