The global prevalence of sexually transmitted infections (STIs) presents a major public health challenge. STIs are among the most common infectious diseases reported around the world [1]. Over one million STIs are acquired every day, and rates continue to rise in many regions [2]. Beyond the immense human impact, this incidence puts a significant burden on health systems ā particularly in low- and middle-income countries with limited resources [3, 4].
As the most common STIs are both preventable and curable, the predominant approach has long been a symptom-based diagnosis, known as syndromic management. This allows patients with suspected STIs to receive treatment sooner. However, faster does not equate to better. Syndromic management can lead to three key problems: overtreatment, incorrect treatment and missed diagnoses [5]. Each of these results may result in worse patient outcomes. [6]
Leading health bodies agree that laboratory testing is now the best way to accurately diagnose STIs ā especially in asymptomatic people. Testing methods like Nucleic Acid Amplification Tests (NAATs) support health professionals to make informed treatment decisions so patients receive the right care sooner. Crucially, they also address the rising threat of antimicrobial resistance (AMR).
The STI burden in Asia Pacific
There is a high incidence of STIs in the Asia Pacific region. In 2020 alone, there were approximately 86 million new cases of four STIs: Chlamydia trachomatis (chlamydia), Neisseria gonorrhoeae (gonorrhoea), Treponema pallidum (syphilis) and trichomoniasis [7]. The prevalence of these STIs in the region aligns with global trends [2].
In Asia Pacific, social, economic, and systemic factors inhibit access to STI testing. Chlamydia, gonorrhoea, syphilis and trichomoniasis are all curable infections with relatively non-invasive treatment pathways. However, for a person to receive the correct treatment, they must first be tested and accurately diagnosed. Many STI cases are asymptomatic [5]; combined with low health literacy, a lack of symptoms means people are less likely to understand their infection risk and, consequently, less likely to get tested. Significant social stigma, low perceived risk, and the inconvenience and lack of access to quality testing are other common barriers to STI testing [8].
Why STI testing matters
Testing is the key to avoiding substantial clinical and economic flow-on effects from STIs. An accurate diagnosis allows health professionals to prescribe the correct course of treatment in a timely manner. Not only does this improve patient outcomes and reduce the financial burden on health systems, but it also enables disclosure to sexual partners (via contact tracing), thereby interrupting the chain of infection transmission [9].
While syndromic management remains a critical pragmatic tool in resource-limited settings ā where providing immediate, symptom-based care is significantly better than providing no treatment at all ā relying purely on this approach is increasingly insufficient. The inherent limitations of syndromic management, such as the inability to detect asymptomatic infections and the risk of misdiagnosis, can lead to incorrect treatment and severe, lasting complications for patients. If left untreated, infections like chlamydia and gonorrhoea may result in reproductive health issues, including infertility and pelvic inflammatory disease [10, 11]. Later-stage syphilis can affect vital organs, causing neurological and cardiovascular conditions, and even death [12]. Improperly treated STIs can spread through mother-to-child transmission, causing adverse pregnancy outcomes, including congenital STIs in neonates [13]. Many STIs also increase the risk of contracting and spreading human immunodeficiency virus (HIV) [14].
The rising threat of antimicrobial resistance in STIs
Treating STIs syndromically without lab-confirmed diagnoses has critical public health implications. Above all else, it fuels antimicrobial resistance (AMR). AMR occurs when bacteria, viruses and other microorganisms evolve and stop responding to antimicrobial medicines designed to treat them [15].
For STIs, the threat of AMR is particularly acute ā especially with N. gonorrhoeae. This pathogen has developed resistance to a wide range of antibiotic classes, earning the moniker āsuper gonorrhoeaā [16, 17]. Ciprofloxacin- and penicillin-resistant strains of gonorrhoea are particularly prevalent throughout Asia Pacific [18]. The widespread misuse and overuse of broad-spectrum antibiotics ā often given empirically without confirmatory testing ā is the biggest contributor to this crisis [15].
Using accurate laboratory testing not only ensures that patients receive correct treatments, but it also provides essential surveillance data on resistance patterns. These data allow clinicians and policymakers to implement effective Antimicrobial Stewardship programs and preserve the efficacy of last-line drug therapies [15].
NAATs: the gold standard for STI testing
Nucleic Acid Amplification Tests (NAATs) are molecular-based diagnostic tests known for their sensitivity and specificity. They work by analysing a specimen sample for the genetic material of pathogens such as viruses and bacteria. If a NAAT finds the deoxyribonucleic acid (DNA) or ribonucleic acid (RNA) of a pathogen in the sample, it amplifies this genetic material ā often through polymerase chain reaction (PCR).
In recent years, NAATs have become the gold-standard testing method for C. trachomatis and N. gonorrhoeae, among other pathogens [19]. NAATs can often detect the genetic material of pathogens in a sample when only a small number are present [6, 20]. This high sensitivity and specificity ensures patients receive an accurate diagnosis and suitable treatment. It also makes NAATs an effective screening tool for asymptomatic infections that may otherwise have been missed.
Before NAAT technology, the predominant testing method for STIs like chlamydia and gonorrhoea was to take cell cultures [21, 22]. This was an invasive and resource-intensive process. Health professionals had to manually collect swab samples ā often from the cervix, urethra or rectum ā and send them to a lab using strict transport methods [22]. For higher-risk people without symptoms, the invasive nature of these tests could be a significant barrier [23]. NAATs, by comparison, are substantially less invasive. Testing for C. trachomatis and N. gonorrhoeae bacteria can be run using self-collected urine samples; for many patients, this eliminates the need for pelvic exams (women) or urethral swabs (men) [24]. For women, a self-collected vaginal swab is the preferred specimen due to its high sensitivity and ease of use, though first-catch urine remains a highly acceptable alternative when swabs are unavailable or not feasible [24, 28]. For men, first-catch urine has become the gold standard for non-invasive testing, providing a highly accurate result without the discomfort of a urethral swab [29]. By shifting toward these self-collection methods, healthcare providers can reduce the ābarrier to entryā for STI screening, encouraging more frequent testing among at-risk populations.
Leading public health organisations such as the World Health Organisation (WHO), the U.S. Centers for Disease Control and Prevention (CDC), the British Association for Sexual Health and HIV (BASHH), and the Australasian Society for HIV Medicine (ASHM) now recommend NAATs for many symptomatic and asymptomatic STIs [25, 26, 27, 28, 29].
Strategic placement of testing: centralised vs decentralised
While NAAT testing is the gold standard, its maximum public health impact is only realised when testing strategies align with local infrastructure, prevalence rates and patient access needs. To maximise the impact of NAATs across the geographically diverse Asia Pacific region, they must be strategically deployed to match local needs, leveraging their high sensitivity and flexibility. This convergence of technical superiority with operational reality leads directly to the core decision for policymakers and lab administrators: when to choose a high-throughput, cost-efficient centralised model and when to opt for the rapid, patient-centred decentralised (Point-of-Care or POC) approach. The choice is not mutually exclusive; it is complementary, designed to optimise the critical metrics of turnaround time and access.
Centralised laboratories are best for analysing non-urgent samples, such as annual screens, follow-ups or samples from asymptomatic people. Labs are generally equipped to process complex or multiplex panel tests for multiple pathogens and provide gold-standard quality assurance.
In an STI context, the centralised model is ideal for population screening of common infections like chlamydia and gonorrhoea as it is cheaper per test at high volume. It also allows for comprehensive public health surveillance. This is vital in countries where governments have classified certain STIs as notifiable infections, including Australia, China, Japan and several others across Asia Pacific [30, 31, 32].
Results from centralised testing tend to have a longer turnaround time. On average, STI test results are often delivered in a week [33, 34, 35]. However, prompt and timely intervention is incredibly vital for symptomatic patients. For this particular group, centralised testing is then less suitable for processing samples, as it can delay the commencement of appropriate treatment.
Decentralised POC testing facilitates faster access to diagnostic results. It is crucial for symptomatic patients and those in high-risk populations who require urgent diagnosis and care. POC testing generates rapid results, within the clinical visit, ensuring clinicians can initiate treatment sooner. It also eliminates the need for broad-spectrum antibiotics that may contribute to AMR.
Unlike centralised testing, POC testing does not require proximity to a central lab. Therefore, it is more accessible in remote and resource-limited clinical settings, and addresses one of the most notable barriers to STI testing in low- and middle-income countries: lack of health infrastructure [5].
As each test is run individually, decentralised POC testing has a higher cost per test. Further, those running tests must be highly trained in both the equipment and in quality control protocols to ensure results are accurate. Current POC testing technology is also limited in its capacity to run multiplexed panel testing or advanced AMR testing.
Transformational impact of optimised testing
The accurate and timely detection of STIs is critical to achieving better patient outcomes. Optimising the testing process and reducing the time to treatment addresses challenges associated with STIs, such as lowering infection transmission rates and reducing loss to follow-up. This ultimately lessens the burden of disease.
Beyond turnaround time, optimising STI testing is about selecting the most appropriate testing option for clinical needs. Decentralised testing is best for symptomatic patients, as it provides accurate results fast. Centralised testing, on the other hand, is particularly useful for annual screening, patient follow-ups, asymptomatic patient samples and epidemiological surveillance ā allowing governments to allocate resources according to real-time data and measure the success of intervention programmes.
The future of STI management: lab-informed care
The rising burden of STIs in the Asia Pacific region, coupled with the threat of AMR, requires a rapid and committed transition from traditional testing and management to laboratory-driven decisions and targeted treatments. Strategically phasing out testing methods like cell cultures and broad-spectrum treatments is the most effective way to interrupt STI transmission and protect public health.
Advanced testing methods like NAATs are highly sensitive and offer flexible sampling. Health systems must adopt updated guidelines that mandate NAAT use and promote the strategic deployment of suitable testing options. This means balancing the high-throughput efficiency of centralised laboratory NAATs for screening with the immediate, patient-centred benefits of POC testing in high-risk and remote settings. A lab-informed care approach will ultimately minimise patient loss to follow-up and safeguard antibiotic treatment efficacy.
These changes must be paired with targeted education and awareness campaigns aimed at high-risk populations. They should encourage people to be proactive in seeking regular screening and making positive health choices. Ultimately, this transformation is about more than technology; it is about changing practices and empowering communities to secure healthier futures.
References
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