Reflections from the 2025 STI & HIV Congress

In July this year, FGS was featured for the very first time at the HIV&STI World Congress – a biennial, interdisciplinary scientific meeting organised by the International Society for Sexually Transmitted Diseases Research. This included a workshop on FGS, co-organised by FIG and WHO and poster presentation on the multi-country burden assessment of FGS (MAP-FGS) led by COR-NTD. The main goal of the workshop was to engage new audiences – including clinicians, HIV and SRHR advocates and CSOs, policy makers, programme implementers and funders on FGS. While we encountered a significant lack of knowledge on FGS, with most participants unaware of this issue, we also saw much interest among those we engaged with; once people found out more about FGS, the potential links with their own work were evident. We also benefited greatly from WHO’s role in the session (with both the STI and NTD teams speaking at the session), and the support of the Congress President, Marc Steben, who has worked on FGS in Eswatini. 

Many of the challenges and themes discussed at the Congress felt familiar to us: 

• The funding crisis affecting global health was felt throughout, with many discussing the long-term implications of this, and of the backlash and reversal of hard-won gains in sexual and reproductive health rights. The effects of these trends are still unfolding, but are likely to affect improvements in health service delivery, particularly in low- and middle-income settings, for years to come. There is a clear need to reduce donor-dependency to limit the vulnerability of health systems to the politically-driven shifts in aid policy, alongside investments in core health system functions such as governance, information systems, and domestic financing.  
• The role of research in programme delivery was also discussed, highlighting challenges such as slow research-into-programme uptake, lack of operational research funding, lack of community engagement, and the need to embed learning and research into programme design. Additionally, survey methodologies can be improved to make results more informative and more useful for programme design – by assessing risk of exposure to disease and providing a better understanding of how health services are being used. 
• The need for strategic shifts – such as from increasing coverage of key interventions or treatment, to reducing incidence or prevalence of disease through a stronger focus on prevention (a shift already recognised in the NTD road map).  

At the same time, certain issues emerged that we felt should be more present in our own work on FGS, and that we could draw inspiration from: 

Co-creation and community-driven action, in which programme participants and service users play a fundamental role in the design of the services and interventions, have become common practice within HIV and STI programmes, and there is much that NTD programmes can learn from these experiences. The challenge is also not to limit co-creation to tokenistic ‘consultation activities’ at the community level, but to apply this approach also in guideline development, indicator setting, scaling up of services, and programme evaluation. Such an approach should be budgeted for, and in order to be effective should engage community members as experts in their own right, rather than as passive participants. Increasing community engagement will not only allow for more meaningful interventions, but will also increase the demand for FGS services at local health facilities. 

Challenging our assumptions on service delivery: Given the challenges with FGS diagnostics, one of our assumptions is that diagnosis (and treatment) in programme settings may need to be based on symptoms and presumptive treatment. However, at the Congress we noted that the STI community seems to be shifting away from syndromic diagnosis to more precise diagnostics, to ensure proper treatment and to collect more accurate data. Another assumption is the need to integrate FGS into screening programmes such as STI, HIV and cervical cancer. Discussions at the Congress provided helpful criteria for deciding whether or not screening is advisable, including availability of data on prevalence and incidence; information on frequency of exposure; availability of ASSURED (affordable, sensitive, specific, user-friendly, rapid and robust, equipment-free and deliverable) diagnostics; accessibility/safety of treatment; preventing re-infection; evidence that screening improves outcome for target population; readiness to implement programmes; feasibility and acceptability; and cost effectiveness of screening. When it comes to FGS, we are probably not there yet. 

Further discussion will be needed within the FGS community to enable us to call for specific actions to be taken by STI and HIV stakeholders. This includes coming to a consensus on appropriate targets and progress indicators, and providing a much clearer ‘business case’ for integration, which clearly sets out the return on investment, and the benefits of integration to the STI and HIV agendas. 

Overall, this forum provided us with a helpful entry point to a set of stakeholders and partners with whom we will need to engage further in future, in order to make FGS integration into service delivery, and the positive consequences it offers, a reality.