**1. Introduction**

Sexually transmitted infection (STI) means organisms that lead to infection after sexual intercourse between two persons, while sexually transmitted disease (STD) simply means an obvious clinical disease that resulted from the STI [1]. Doctors and other health workers are the key stakeholders in the prevention and treatment of STIs [1]. The World Health Organization (WHO) estimates that approximately 340 million new cases of the four main curable STIs (gonorrhea, chlamydial infection, syphilis, and trichomoniasis) occur every year, and 75–85% of them in developing countries [2]. STIs impose an enormous burden of morbidity and mortality in developing countries, both directly through their impact on reproductive and child health, and indirectly through their role in facilitating the sexual transmission of

Human Immuno-deficiency Virus (HIV) infection [3]. The high prevalence of STIs has contributed to the disproportionately high HIV incidence and prevalence in most resource-limited settings [3]. The greatest impact is on women and infants [3]. The World Bank has estimated that STIs, excluding HIV, are the second commonest cause of healthy life years lost by women within the age range of 15–44 age in Africa. These bacterial STIs are also responsible for up to 17% of the total disease burden [4].

These underscore the need for appropriate diagnosis and treatment of STI to mitigate the person-to-person transmission and the associated morbidity and mortality associated with the untreated infection acquired sexually [3, 5, 6]. In resource-poor countries, diagnosis based on causative organisms of STIs remains very difficult as a result of the unavailability of laboratory diagnostics that will direct practitioners on the best treatment modality [3]. In the few centers with laboratory support, tests results for the detection of causative organisms for suspected STIs take days/weeks, to be made available to physicians and this makes early definitive/targeted treatment based on etiologic diagnosis difficult/impossible [3, 7].

To solve this problem of lack of etiologic diagnosis and associated difficulty in the treatment of STIs, the WHO brought out the syndromic case management approach in 1984 to guide the practitioners in effective and timely treatment of STIs [8]. This syndromic case management approach remains the approach to STI treatment adopted in many countries of the world, especially developing countries [8]. This syndromic case management approach is based on the identification of consistent groups of symptoms and easily recognizable signs and treatment that will deal with most, or the most serious, organisms responsible for producing the syndrome [9]. Introduction of additional parameters in the syndromic diagnosis of nonviral sexually transmitted infections in low-resource settings and hence improved management has been advocated but is still far-fetched [10].

Consequently, the highest levels of multidrug resistant bacterial STIs have been found in resource-limited countries [11–13]. The reasons are complex and include poor quality of health services, high burden of disease, and lack of accessible, accurate, and confirmed diagnostic assays, ineffective regulations, overuse of antibiotics, inappropriate dosing, and lack of knowledge about the risks of microbial resistance [13]. Not surprisingly, scholarly reviews on syndromic case management, underscored the need for low-cost and accurate Point-of-Care Tests (POCTs) for the identification, first, of *Chlamidia trachomatis* (CT)/*Neisseria gonorrhea* (NG), and, second, of *Mycoplasma genitalium* (MG)/*Trichomonas vaginalis* (TV) and NG/MG resistance/susceptibility testing [14]. Near-patient POCT molecular assays for CT/NG/TV are commercially available, but the cost and other limitations remain prohibitive, especially in resourceconstrained settings [7, 15, 16]. These challenges are driving the development of lower-cost solutions [14]. Also, advocacy and subsidization of available diagnostic, treatment, and prevention facilities or measures will immensely reduce the burden of these conditions in the resource-limited settings [14]. This chapter thus brings to the fore the challenges of treating bacterial sexually transmitted infections in resourcepoor settings and the current evidence on the topic for scholars, researchers, and practitioners.
