Barriers in Healthcare for People with Sexually Transmitted Infections in Sub-Saharan Africa; A Systematic Review of Qualitative Studies

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This paper presents an overview of how various socio-cultural, economic, and systemic barriers allow limited access to healthcare services leading to poor health and increased disease burden. Aim: This systematic review aims to explore and address the barriers to accessing effective healthcare for STIs in SSA, identifying key factors that hinder healthcare access and providing evidence-based recommendations for improvement. Methods: A systematic review method was used in this study following the Cochrane Handbook and other guidelines on reporting of systematic review. The review involved cross-sectional qualitative primary research studies in English language, conducted between 2014 and 2024, in Sub-Saharan Africa. The electronic sources used for the search include Google Scholar, CINAHL, and PubMed; the quality of the selected studies was assessed using the CASP check-list. Sixteen articles were chosen for this study to be analyzed in relation to the formulated themes. Results: The major challenges noted were cultural, economic and healthcare system factors that hinders an individual to access effective health care for STIs in SSA. Pregnancy and sexually transmitted infections such as HIV were largely related to stigma and shame which entailed that females, female sex workers, and young people shy off from seeking the necessary services. These challenges were worsened by the economic factors including transport hitches and lack of resources while structural factors like rigid health care polices and long waitlists also impounded enrollment and compliance to treatment. Conclusion: The research noted the factors that hinder the access and use of STI health care services in Sub-Saharan Africa and referred to certain approaches that need to be taken to eliminate stigma, increase health care awareness, and ensure availability of enhanced services. It is recommended to respond in the clients’ own language, prejudice in countenance, broadening the population to reach and making sure all the recurrences are available to sustain a welcoming healthcare setting. Sexually transmitted infections Healthcare access Barriers to care Sub-Saharan Africa Health disparities Qualitative research Public health Figures Figure 1 Introduction Adolescence to adulthood age has various reproductive health concerns as key milestones [1]. In the last two decades, STIs including chlamydia, gonorrhoea, syphilis, and HIV have been increasing and have become a threat to both developed and developing countries [2]. Sexually transmitted infections that result from sexual contact, such as vaginal, oral, and anal sex affect the sexual and reproductive health of men and women 15–49 years [3]. They are a significant worldwide cause of infertility, acute illness, long-term disability, and death with numerous medical and psychological impacts [4]. Research also established that STIs lead to other adverse health impacts such as HIV/AIDS, ectopic pregnancy, eye problems and pelvic inflammatory diseases [5]. This particular group of people in the society determines the economic future of a given nation. The World Health Organisation (WHO) pointed out that approximately 374 million new cases of STIs occur each year [6]. Sub-Saharan African nations have the greatest incidence of STIs, accounting for around 93 million cases annually [7]. In underdeveloped nations, insufficient access to technology, laboratory services, and qualified specialists hampers the identification of the etiological causes of STIs, hence exacerbating their prevalence [8]. Adolescent females and young women are a vulnerable demographic disproportionately impacted by sexually transmitted infections [9]. Numerous studies from Sub-Saharan Africa have identified women of reproductive age as being at elevated risk for STIs [10]. Worldwide, teenage girls and young women aged 15–24 are the most impacted, with being under 25 years old serving as the most significant predictor of STIs [11]. Socio-behavioral risk factors for STIs in this demographic including poor educational attainment, unmarried status, many sexual partners, substance abuse, and early initiation of sexual activity [12]. Furthermore, critical populations, like males who engage in sexual activities with other men, transgender people, and sex workers, face a heightened risk of acquiring STIs [13]. Additional risk factors encompass high-risk sexual conduct linked to alcohol and drug consumption, insufficient information regarding STIs, perceived peer norms, lack of condom usage, and intergenerational interactions [14]. Untreated STIs in developing countries contribute to approximately 17% of total economic losses and lead to medical complications, including cervical inflammation, genital and urinary infections, infant disabilities, ectopic pregnancies, infertility, cardiovascular disorders, and heightened risk of HIV transmission [15]. Timely identification and intervention of STIs can effectively halt the transmission cycle and prevent problems. Comprehending the determinants of STI transmission is crucial for the implementation of successful STI prevention programs, especially in regions with a high incidence of HIV [16]. In sub-Saharan Africa, these issues are never confronted, often leading to adverse reproductive outcomes, including sexually transmitted infections (STIs) and unintended births [17]. The incidence of postponed treatment for STIs in sub-Saharan Africa differs by country, with rates of 23.1% in Durban, South Africa; 42% in Laos; 64% in Ghana; 58% in Uganda; and 67% in Ethiopia [18, 19]. Adolescents may hesitate to obtain information from their parents owing to apprehension of being perceived as participating in forbidden activities [20]. Nonetheless, urbanisation and Western influence are swiftly altering sexual and reproductive norms, resulting in youngsters engaging in sexual activity at an earlier age [21]. There is an urgent necessity to eliminate obstacles that adolescents have in obtaining reproductive health information and treatments. Given the elevated incidence of illness and consequences from STIs in young women, it is crucial to identify and mitigate barriers to STI screening, as well as to devise focused therapies [20]. The WHO set a strategy towards elimination of the epidemic of STIs from 2016 to 2021 (Dadzie et al. , 2022). Many previous works have also revealed that there are many challenges, such as discrimination, economic issues, limited medical resources and facilities, and cultural expectations and attitudes, that prevent early diagnosis and treatment [3, 4]. According to Green, (1992) dependence on traditional healers was attributed to cultural belief while Agimas et al., (2024) pointed on delays in treatment due to economic and geographical disparities. Also, system gaps, such as the uneven quality of STI services in private clinics and the lack of policy for combined treatment limit the effectiveness of interventions [7, 9]. Nonetheless, there is still limited integrated knowledge that can articulate the multifaceted and interconnected challenges of the foregoing in different parts of Sub-Saharan Africa [14, 16]. The current review will identify the gaps in the existing literature through a synthesis of previous research findings, patterns and deficiencies in the current data and recommend ways of improving the management of STIs. Therefore, while the burden of STI related illnesses is well understood and prevention and treatment of the STIs is important to reduce this burden, there is limited information on the overall incidence and factors associated with delayed treatment for STIs in Sub-Saharan Africa, which is important for policy and program development. Hence, this systematic review set out to identify determinants as barriers to treatment for STIs in sub-Saharan Africa. Research Question The following PEO framework was used to develop a research question for this systematic review. Component Description Population Individuals with sexually transmitted infections (STIs) in Sub-Saharan Africa Exposure Barriers to accessing effective healthcare Outcome Difficulty in obtaining timely and adequate STI care What are the barriers to accessing effective healthcare for individuals with sexually transmitted infections (STIs) in Sub-Saharan Africa? Methods and Materials As previously stated, this systematic review adopts a qualitative research approach to identify and analyse the chosen topic. In doing so, it improves upon conventional literature collection by applying a systematic and more critical methodology. This review is grounded in a positivist paradigm, emphasising the study of reality through objective criteria. Accordingly, a structured process was followed that included locating, screening, and critically appraising relevant studies using predefined inclusion and exclusion criteria. Unlike primary research, systematic reviewers do not seek confidential or classified information but rely on publicly available evidence. For this review, a critical appraisal tool was employed to assess the validity and significance of selected studies, alongside carefully planned data extraction and analysis strategies to ensure reliable synthesis of findings. Registered with PROSPERO under the ID CRD420251123822, the review addresses the central research question within a robust ethical framework, adhering strictly to established guidelines to ensure methodological transparency and integrity. Research Design The systematic review approach has been chosen for this review due to its ability to combines strength of both quality data and was carried out using the following guidelines; the Cochrane handbook for systematic reviews for interventions and specific reporting items to guide systematic review [22]. It is possible to find all the bodies of literature related to the topic of study and make an assessment of the nature of findings without exposing the possibility of missing a study while providing a good coverage of the topic in a single attempt [23]. This type of method is more useful to be used in evaluating the previous works in respect with the present research area; and is known systematic review. The use of systematic review approach is expected to enhance the quality of the review and simplicity and credibility on the findings. These results are unlikely to directly inform public health decisions which rely on a systematic assessment of a rigorous and transparent process of selection and deception. A systematic review helps one to make a comprehensive evaluation of the existing literature with regards to a given current research question. In contrast, a systematic review creates a vast amount of evidence from numerous fields of sciences such as primary observational studies, case series, as well as randomised controlled trials, making the current picture and points more comprehensive [24]. With this approach, bias is reduced to the minimum, and no essential information is left unnoticed, and therefore evidence-based practise has a strong ground. Search strategy The researcher identified pertinent databases for the search, including Google Scholar, CINAHL, and PubMed, since they are especially tailored for healthcare and medical research studies [25]. Since these databases are often used for nursing and scientific research, they probably include pertinent information about the topic. By merging many phrases, the researcher created thorough search algorithms. These methods were customised to meet the specific requirements of each database and used the relevant Boolean operators to narrow down the search. Boolean operators are used to combine terms like "barriers" OR "obstacles" OR "challenges" AND "accessing treatment" OR "healthcare access" OR "treatment access" AND "effective treatment" OR "medical care" OR "health services" AND "sexually transmitted infections" OR "STIs" OR "sexually transmitted diseases" AND "Sub-Saharan Africa" OR "Africa south of the Sahara" OR "SSA", the search approaches made sure that finding research was thorough and targeted. Inclusion and Exclusion Criteria For this review, the inclusion criteria focused on primary research studies that employed qualitative methods to explore the research question in depth. Eligible studies had to be published in the English language between 2014 and 2024, ensuring the inclusion of recent and relevant literature. Only studies conducted within Sub-Saharan African countries were considered, as the review specifically targeted this geographic context. Furthermore, all included studies were required to be peer-reviewed to ensure methodological rigor and credibility. The exclusion criteria eliminated grey literature, conference abstracts, case series, blogs, and other non-peer-reviewed materials, as these sources often lack sufficient methodological detail and reliability. Studies published in languages other than English were excluded to maintain consistency in data interpretation and avoid translation bias. Additionally, research published before 2014 was excluded to ensure the findings reflected contemporary evidence. Finally, studies conducted outside the Sub-Saharan African region were not considered, as they fell outside the defined scope and focus of this review. Screening Process When the search was first conducted, a total of 1190 publications were found. After eliminating 485 studies that were identical to one another, there were 705 unique research articles that were left for more investigation. There were total of 376 studies that focused on the treatment of illnesses other than sexually transmitted infections. After going through the process of screening, there were a total of 329 studies that were still included in the pool. A total of 227 studies were disregarded because they were carried out in countries that were not in the SSA region. Due to the fact that they contained things like literature reviews, meta-analyses, case studies, editorial letters, procedures, and comments, 88 of the remaining 100 articles were disregarded. As a consequence, 16 studies were ultimately chosen for further analysis. There is a representation of the screening method in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram (Figure 1). Critical Appraisal The current study aims to provide a systematic review of the literature. The Critical Appraisal Skills Programme (CASP) approach was used to evaluate the quality of the included studies (Kilicoglu, 2018). The quality of the included studies was carefully assessed by the researcher (Table 1- Appendices). This required assessing the methodology's benefits and drawbacks, any biases, and the overall quality of the data provided in each study. A thorough assessment was carried out to guarantee the authenticity and dependability of the findings. The CASP tool was chosen because of its standardised methodology, which offers precise instructions and standards for a variety of research designs. To conduct the study, a methodological evaluation was required. These attributes include the size of the sample, the effectiveness of the study design, the clarity of the research question, the collection and processing of data, and the interpretation of the findings [22]. Liamputtong (2020) asserts that the user-friendly architecture of the CASP tool ensures a thorough assessment of study quality based on recommendations supported by data and recognised research standards. Data Extraction and Synthesis of Finding Analysis The data used in each of the included studies were appropriate and gathered and arranged in a very systematic manner. This information covered aspects of the study such as the design, sample size, characteristics, intervention, measures of outcome and findings (Table 2- Appendices). The extraction, summarising and analysing of data for systematic reviews were done with high accuracy and without skipping a detail. The data collected in this study consisted of excerpts, findings and principal topics which were analyzed thematically. The researcher will identify trends, themes and trends within the data identified. This is a process where data is sorted into themes and sub themes and then compared and contrasted across different research studies. Thus, by analysing the data, it is possible to reveal the patterns, ensure the data validity and estimate the overall determinants as barriers to treatment for STIs in sub-Saharan Africa. Ethical Consideration Ethical concerns related to the included studies were identified by this systematic review. Though this research relied on a literature review technique and did not directly involve any persons or organisations, it is prudent to evaluate the ethicality of materials so tested. Each was meticulously reviewed to make sure that all research reported met ethical standards, and that the research had been approved by the appropriate institutional review board or ethics committee. Research based on the empirical analysis examined whether ethical criteria that include consent, anonymity and participant protection were adhered to in the research [26]. The current evaluation excluded or revealed these studies if its writers found any investigations that had received limited ethical scrutiny, or if they were indicative of possible ethical wrongdoing. This approach fits with the obligation to maintain the presumed rigour when applying ethical standards, and thus expand the scientifically synthesised body of the knowledge [27]. Results The findings of the systematic review are presented in this chapter, in an overview of the characteristics of the selected studies. An explorative summary of these studies based on predefined inclusion and exclusion criteria to provide a more contextualised view of the research landscape is presented. This chapter features a central thematic analysis, which involves the identification and critical analysis of recurring themes in order to synthesise insights from the literature. To introduce the various data in a comprehensive understanding of research question, the synthesis of findings approach was followed. Depth is given to each theme, each with a focus on major patterns and relationships that emerge from the data. Also, a data extraction table, summarising key information from each study, is included in the appendices for easier reference. All through this chapter they expose the analysis which will go through the top brains running those business ensuring a rigorous examination of the findings. Thematic Analysis Theme 1: Impact of Stigma on Healthcare-Seeking Behavior Total of nine studies [ 28 – 36 ] observed that stigma hinders PLHIVs from seeking healthcare services from facilities within the communities. Stigma related to the identification of being HIV positive because of frequent clinic visits or public consumption of medication hampers the motivation to seek early treatment. The study also elaborated how open spaces in the healthcare facilities where people take drugs freely abuse the rights of the patients and make the PLHIV feel embarrassed. This not only had the effect of dissuade people from seeking out healthcare in the first place but also encouraged feelings of shame and paranoia, which led people to seek out care in different areas of the region, so as not to be recognised. The harassment by authorities and especially for those with a history of substance use, added another level of difficulty to the situation through integration of legal and social exclusion with the health care barrier which was a multi-pronged barrier for proper adherence to treatment regimens. Countering this, analogy of ART to dehumanising metaphors like referring to pigs as ‘oil seed cakes’ was used to describe the exclusion language used for people living with AIDS. The psychological effects of such vices as public ridicule and embarrassment, which are social consequences of being a PLHIV, also reduced the willingness of the patients to follow the treatment regimens [ 36 ]. Similarly, Avuvika et al., (2017) noted that fear of stigma and judgement from health care workers and the community makes adolescent girls and young women avoid STI screening. Many people avoid seeking STI screening because they think that if they do, they will be branded as being sexually active. This fear is enhanced by the adverse consequences of partner notification processes which only serve to put the affected persons at the mercy of judgement and social shame [ 34 ]. In the same way, Jaya et al., (2024) found that young women are hindered by factors such as stigma, myths on STIs, and fear of being judged when seeking for STI healthcare services. The social stigma attached to STIs ensured that young women did not receive the medical attention they required because of fear. The cultural beliefs and the myths that surround STI transmission and cure compounded the problem therefore creating misinformation and wrong behavior. These barriers were compounded by fear of being judged by health care workers or peers, which made young women uncomfortable and unwelcome in such environment [ 28 ]. The studies highlighted a major failure in the health care system; youth friendly services that are confidential and non-discriminative are scarce, and many young women are therefore unable to access the right treatment from the right sources such as the clinics and turn to pharmacies and other unverified sources. This suggests that there is a need for the healthcare systems to embrace the non-stigmatising youth friendly model to encourage early and frequent STI testing [ 28 , 34 ]. Likewise, Nakanwagi et al., (2016) revealed that stigma and discrimination from healthcare workers were identified as key barriers for female sex workers (FSWs) in accessing HIV care. The stigma that is displayed by health professionals towards FSWs makes many of them flee from seeking the treatment services. Discrimination is quite explicit, and because sex workers are often afraid of being outed, the lack of trust prevails. This not only discourages the connection between prevention and care but also sustains the culture of prevention as friends are deterring potential patients from linking to the healthcare industry. Such structural bias worsens health inequalities because it further stigmatizes an already oppressed group, thus underlining the necessity of specific strategies to fight stigma in health settings and embrace diversity [ 35 ]. According to Wanyenze et al., (2017), stigma and structural barriers were major factors that influenced FSWs decision of seeking HIV testing and treatment. Shame and stigma, from fellow sex workers, family, and community, make many of them avoid seeking appropriate medical care. The view of HIV as a disease one gets by one’s own doing makes this situation worse, causing people to remain alone and not want to tell anyone about their status or job as a health worker. Furthermore, factors that include long waiting time and clash between clinic timing and the sex work shift work make it even more difficult to access health care services. In the same way, Muhindo et al., (2021) also established that a low perceived threat of Syphilis and internalised stigma were found to positively influence the frequency of testing among the FSWs. The participants had a Perception that Syphilis is less severe than HIV and therefore, few of them went for testing until they started experiencing symptoms. Stigma, together with fear of being seen at the clinics or spread of rumors, also plays a big role into delaying testing among FSWs. This stereotype not only affected their medical practices but also endangered their earning since they can lose customers [ 30 ]. According to Abuosi and Anaba (2019), societal stigma as well as labeling are other factors that affect the ability of adolescents to access healthcare at adolescent centers (ACs). The youths said that people in the community call them “bad” girls when they go to the clinic for checkup, family planning or abortion. Stigma-related to HIV/AIDS made many people refrain from visiting the health facilities in order not to be rejected by society. Also, peer and partners’ restrictions made it difficult to access healthcare as they revealed how social norms and relationships shape people’s behaviors in relation to their health [ 32 ]. Fear of parental punishment did not allow adolescents to turn to their parents for help in case of their need in health services, which proves that families provide insufficient support and communication on health issues of teenagers. The young people described feeling that their providers were dismissive and critical of them, especially the pregnant young people who experienced verbal belittlement. Discrimination between some adolescents and total rejection of others led to feelings of exclusion and deterrence from seeking further services [ 32 ]. Similarly, Martin et al., (2021) discovered that young people are discouraged from chlamydia and gonorrhoea testing because of expected stigma, and concerns over the confidentiality of their information. The feeling of being discriminated or rejected by the family and other people in the community makes people avoid the local healthcare centers and seek services from other distant or private clinics so as to conceal their status. This behaviour points to the effect that societal beliefs have on people’s approach to health, especially their Choices regarding STI testing and the need for healthcare systems to embrace confidentiality to foster non-stigmatised environments for STI testing [ 29 ]. Similarly, Ssekamatte et al., (2020) show that internalised stigma of trans-women sex workers affects their utilization of HIV/STI prevention and care services. This happens because many trans-women feel that if they go to a healthcare facility they will be discriminated against or even rejected by their healthcare providers and the rest of the community. This results in feelings of shame, or traumatization, which affect their willingness to discuss their health needs, especially in relation to their gender, and employment. It is therefore important to address this stigma in order to create a more accepting environment for trans-women in healthcare settings in order to seek the health care that they need [ 31 ]. On the other hand, Ssekamatte et al., (2020) also confirmed that the fear of violence and gossips from the community reduces the freedom and health seeking fifty of trans-women sex workers. Discrimination based on non-conforming dress code and behavior creates a hostile environment, that has forced many trans-women to limit their public appearances and engage in social activities mostly confined to night life. This social exclusion deprived them from both general and key population friendly health care facilities during normal business hours thus worsening inequity in health. Certain transwomen sex workers were labeled by healthcare providers and other key populations as ‘prostitute’ because of competition for clients as well as seeking for special consideration. These dynamics tension and deter some trans-women from seeking for health care services when their expectations were not met. There were also exclusion and invisibility in healthcare settings that greatly affect trans-women sex workers’ ability to seek sexual and reproductive health (SRH) services. Transwomen sex workers said they were discriminated, not only by clients but also by physicians who stigmatised them and called them abomination. This was also seen in their relations with other crucial demographic groups; trans women complained about being marginalised or disrespect within the frame of the LGBTIQ category. These experiences fostered negative healthcare environments, which deter trans women from using SRH services that they need [ 31 ]. Meanwhile, Tun et al., (2022) also highlighted the generalised prejudice and bigotry transgender persons encounter in the conventional HIV health care services, while documenting more encouraging findings in the transgender friendly CSO clinics. There was a tendency to generalise the concept of transgender people with other sexual minorities, including lesbians and men who have sex with men even among the healthcare workers who were trained on gender and sexual minorities. This conflation especially for the transgender women (TGW) with HIV leads to the assumption that TGW and MSM have similar health needs with the emphasis on anal sex (Tun et al., 2022). Deriving from such oversimplifications, this study shows that the specific HIV healthcare needs of transgender individuals are ignored and thus neglected. Patients who are transgenders and are living with HIV stated that they felt being insulted and disrespected during physical examination because of providers’ lack of sensitivity on gender issues. Stigma and fear of being discriminated made the majority of the transgenders to avoid seeking HIV services at mainstream facilities hence limited access to health care services [ 37 ]. Moreover, Moucheraud et al., (2019) also found the role of stigma as a critical determinant of adherence to STI treatment, as emphasised by healthcare providers. Stigma, whether internalised or experienced from the community, can deter patients from consistently taking their medication, fearing judgment or discrimination. Despite these challenges, patients generally recognize the health benefits of adhering to antiretroviral therapy (ART), including the suppression of the virus and the maintenance of a high CD4 count. Moucheraud et al., (2019) also identified being away from home due to employment or family obligations, such as funerals, as a significant barrier to adhering to STI treatment regimens. These higher-level social factors, often highlighted more by healthcare providers than patients, underscore the impact of mobility on treatment continuity. The frequent absence from home disrupts access to medication, leading to inconsistent adherence and compromised health outcomes [ 38 ]. Likewise, Okoror et al., (2016) noted that heterosexual HIV-positive men experience a significant emotional response to an HIV diagnosis especially if the diagnosis is made when the man is sick. The participants often expressed feelings of disbelief or astonishment that sometimes made them think of suicide, as well as fear of stigma and the costs of treatment. The study establishes that social context of diagnosis has an impact on the stigma faced by HIV positive men. The patients who were diagnosed after developing symptoms highlighted more severe enacted stigma such as being shunned by friends, family, and other members of the society. On the other hand, those with no symptoms at the time of diagnosis, who perhaps knew their status due to a family member’s diagnosis, had less immediate social sanctions. This variation shows that being visible or not visible differently affects the way society responds to illness. Changing stigma demands specific interventions which take into consideration the various routes that lead to diagnosis, public awareness campaigns to discourage people from avoiding patients [ 39 ]. On the other side, according to Cornelius et al., (2018), stigmatization in the health care System and spousal discord were found to hinder women with HIV from seeking care. Such women suffer from social stigma in both the health care institutions and from their families, which worsens the psychological burden of caring for their diabetes. Conflicts with spouses especially but not limited to polygamous relationships where disclosure of the dynamics of the relationship is not easy makes it even harder to get support and care. This conflict hampers women’s ability to get support from their spouses emotionally and financially, thus making it difficult for them to seek and follow treatment. To solve these issues, there should be efforts to eliminate prejudice in the health facilities and family care giver support programs to enhance effective interaction with family members [ 40 ]. Theme 2: Lack of Knowledge as a Barrier to Treatment of STIs Total of five studies [ 29 , 31 , 35 , 36 ] found this theme. So, Nakanwagi et al., (2016) described how the FSWs are still misinformed and are still using other forms of treatment which hinders their access to formal HIV care. FSWs used herbs or self-medication due to myths about ART and negative peer persuasion. The belief that ARVs are dangerous or require special handling discouraged some people from seeking the right medical care or even from taking the drugs at all. This perceived vulnerability to be weakened by ARVs and consequently affecting their ability to work shows a major health education and support service lacuna that is specific to the FSWs. Also, the low awareness of the physical whereabouts of the HIV clinics especially among the young FSWs worsened the situation and greatly called for intervention to address misconceptions and direct FSWs to the right services [ 35 ]. Likewise, Tomori et al., (2014) also identified the sociocultural misconceptions, and geographical barriers that greatly affect the HIV treatment. Myths regarding the effectiveness of treatment and the fear that the treatment is lethal indicated that there exists a major deficiency in community-level health awareness. These prejudices together with other difficulties of distance to go to a health facility made worse the situation of human beings [ 36 ]. Similarly, Wanyenze et al., (2017) establish that the FSWs have a general suspicion of HIV test outcomes and treatments as a hindrance to the utilization of HIV services. FSWs often have trouble coming to terms with negative results because the cultural understanding remained that every sex worker is bound to be HIV positive. This skepticism weakened the impact of HIV testing campaigns, and deterred people from purchasing into the idea of preventive health measures. Also, the perception of being injected by health workers with dangerous substances deters the FSWs from enrolling for or continuing with the ART [ 33 ]. In a similar manner, Martin et al., (2021) stipulated that self-rated STI preventive practices and testing misconceptions, including, for example, the notion that circumcision is protective, or HIV test includes other STIs, are a form of barrier to uptake. The lack of symptoms also affects people’s willingness to perform tests, which decreases the practice of prevention measures [ 29 ]. On the other hand, Ssekamatte et al., (2020) established that discrimination through breaches of confidentiality and limited awareness of gender identity among healthcare givers kept trans-women sex workers away from healthcare services. Lack of confidentiality in the gender identity of the patients made the patients lose confidence with the healthcare facilities especially when such incidents happen in both general and key population-friendly health facilities. Further, the lack of knowledge of the physicians especially in the special facilities proves that there is lack of awareness among the healthcare providers. These breaches and gaps played a role in the erasure of trans-women sex workers, all the more reason why confidentiality measures must be strict and training more extensive in order to raise awareness among the providers of the trans patient population [ 31 ]. Theme 3: Socioeconomic Barriers to Accessing and Retaining Treatment of STIs Total of four studies [ 30 – 32 , 36 ] found this theme. So, Tomori et al., (2014) described the significant factors that hindered the process of people living with HIV (PLHIV) to access and maintain treatment in Sub-Saharan Africa region. The research also pointed out that poverty is one of the main factors that prevent the population from visiting a doctor when an illness appears. The total costs on transportation and medical services thus posed a major challenge to many of the PLHIV. This study painted a picture of ‘free treatment’ where one is forced to ask how free it is when other expenses like transport and drugs are still a major financial burden to the needy population. This financial burden not only hindered the patient’s ability to begin treatment but also endangered his or her future ability to adhere to treatment, thereby worsening health inequity. The general public lost more confidence in the healthcare system because of its link with the black market, which is a major challenge in the fight against low treatment adherence (Tomori et al., 2014). Likewise, Ssekamatte et al., (2020) also found out that the reason for limited access to sexual and reproductive health (SRH) services for trans-women sex workers was the low socioeconomic status. Others had no other source of income other than sex work and this means they cannot afford transport and medical fees. This financial constraint was a major challenge since it hindered early utilization of both general and key population-friendly health facilities. It is necessary to introduce policies that can help the economically vulnerable trans-women sex workers access the financing and affordable health care services without which, they are likely to be denied their right to health services [ 31 ]. According to Muhindo et al., (2021), FSWs especially the elderly are discouraged from regular testing by factors such as availability of syphilis testing kits and anti-biotics because the two are often scarce. While HIV testing was done in many facilities and at relatively low cost due to competition from many testing centres, syphilis testing was limited and costly, especially in the private sector. This difference pointed to the problem within the system of how resources are distributed and to what extent STI testing services were valued. The fear of contracting STIs, the need to look and be strong enough to work hard and earn a living also push many to seek testing frequently. However, the economic burdens of sex work are a major challenge because, while condomless sex is more profitable, it raises the risk of HIV infection [ 30 ]. Abuosi and Anaba (2019) affirmed that lack of resources was a major challenge to the utilization of adolescent health care services especially in the management of STIs. The young people also complained of inadequate basic commodities like drugs and condoms, hence they access them from pharmacies, yet they are expensive due to unemployment. Moreover, there are few health information resources available to youth, and there are no recreational facilities available at ACs to enhance the services’ effectiveness. These resource constraints do not only limit effective treatment but also the chances that adolescents will seek health care services [ 32 ]. Theme 4: Structural Barriers and Challenges in Adherence to STIs Treatment Total of nine studies [ 28 , 30 , 31 , 33 , 34 , 40 – 43 ] found this theme. So, Wanyenze et al., (2017) found out that there are structural challenges, including transportation problems of FSWs and rigid healthcare system policies, as main factors that hindered the FSWS’s adherence to the continuous ART. The mobility of the sex work due to the search of clients in different places interferes with the clinic’s protocol that only allow the refill of drugs at certain places. This lack of flexibility thus leads to interrupted treatment which in turn leads to poor health and higher risk of HIV transmission. Also, the fact that these women are exposed to violence – including rape and assault – on a regular basis complicate matter even further. The low awareness of post-exposure prophylaxis (PEP) and how to acquire it compound vulnerability, underlining the need for mobile health care services and special initiatives that address the needs and challenges of FSWs due to their specific life style and risk [ 33 ]. Muhindo et al., (2021) also established other challenges that affected effective service delivery; lack of testing kits for syphilis, expensive charges, and unfriendly provider attitudes, which discouraged frequent testing. Such systemic gaps, therefore, make it difficult and uninviting for FSWs to seek and undergo testing [ 30 ]. Similarly, Mark et al., (2017) also reported important structural and monitoring problems in the HIV care for adolescents. Few facilities had separate adolescent services and there was inert tracking and follow-up of treatment indicators for adolescents. Although family planning and contraceptive commodity supply chain was well established, other key services including STI testing, cervical cancer screening, and prenatal care were poorly available. This limited scope of services is not in tandem with the overall health needs of adolescents especially the high-risk ones for sexual health problems. According to Mark et al., (2017), there was also no general counseling that limited adolescents’ access to crucial information and support thus, knowledge deficits and preventive care. The lack of coherence in the age indicator for adolescence and the insufficient differentiation of the treated subjects’ outcome indicated the problems of the medical care system. This was especially problematic in view of the fact that the study focused on adolescents living with HIV, who have special healthcare requirements and barriers. Mark et al., (2017) also observed the absence of targeted surveillance particularly in the West and Central Africa that hampered the evaluation of the effectiveness of the treatment regimens. It was uncommon for young mothers to be transferred back to adolescent clinics, and the message they got, for example, being told not to ‘mess up again,’ was rather stigmatising than supportive. The process of transition especially if one is a pregnant adolescent in this case may worsen feelings of isolation and being stigmatised hence discouraging the client from continued use of health care services [ 43 ]. On the other hand, Mark et al., (2017) showed that lack of adherence to ART regimen and non- disclosure of HIV status were key challenges associated with optimal treatment and care among adolescents in Sub-Saharan Africa. Non-adherence is a common problem, with many adolescents not adhering to the recommended treatment plan and regimen, and non-disclosure either by the adolescent or to the adolescent is also common. Such an approach does not facilitate the creation of a supportive context for adherence and, thereby, increases the probability of the treatment failure and the emergence of drug resistance. The work under consideration suggests that more specific psychological and social factors influencing adolescents’ adherence should be explained and not just general concepts [ 43 ]. In the same way, Jaya et al., (2024) also discussed structural factors including the problem of clinic hours that are inconvenient for school and denial and neglect by young women as major barriers to STI healthcare. Stiffness of the clinics’ timings hampered the young women and students to get the services they need, while carelessness and denial of symptoms delayed the help seeking process. This is because there are many logistical and psychological barriers which make it difficult for people to access the few available health facilities, let alone get the required services such as extended clinic hours and youth friendly facilities [ 28 ]. Similarly, Ondenge et al., (2017) also noted other organizational factors including burnout and workload challenge as main factors that hinder effective provision of quality care. Fatigue and burnout among the providers limited their capacity to give quality, empathetic, and comprehensive care with the result of the patients losing interest. This burden from the health system not only influenced the providers’ health but also the quality-of-service delivery as some patients complained that they were not being attended to sufficiently [ 42 ]. Even though some of the PLHIV can appreciate the exhaustion of the healthcare workers, this does not in any way improve the health of the PLHIV. On the hand, Ondenge et al., (2017) explained that the kind of relationship that exists between the provider and the patient has an impact on the participation of the PLHIV to the healthcare services. Reporting on positive interactions with perceptive and caring providers helped patients to start and continue care and promoted trust. However, the negative interaction which can be defined as harassment, neglect or care less communication contributes to disengagement from care. It also pointed towards the importance of practicing patient-centered communication with the healthcare providers so that no patient has to fall in the category of non-responders. The perception of patients as “good” or “bad” based on their adherence to rules further complicated the dynamic, as it fosters favoritism and alienation [ 42 ]. In contrast, Silumbwe et al., (2018) highlight how geographical barriers, particularly the long distances to healthcare facilities, significantly hinder the consistent utilization of family planning and contraceptive (FP/C) services in rural areas. The effort required to travel long distances demotivates many women, contributing to discontinuation and intermittent use of contraceptive methods. Furthermore, the rigid scheduling of FP/C services means that clients arriving late risk being turned away, exacerbating the challenge of access. Discriminatory behaviors, such as scolding or ignoring marginalised groups like adolescents and unmarried women, deter these groups from seeking necessary care. Additionally, the frequent stock-outs of preferred contraceptive methods and the lack of trained personnel for long-acting reversible contraceptives (LARCs) further restrict access. The absence of policies facilitating contraceptive services in schools compounds these issues, leaving adolescents particularly vulnerable to early pregnancies and limited reproductive health options [ 41 ]. Likewise, Ssekamatte et al., (2020) identified inadequate access to hormones and essential medical supplies, such as lubricants and STI drugs, as significant barriers for trans-women sex workers seeking comprehensive healthcare. The lack of proper access to hormones through healthcare facilities forces many to rely on private pharmacies without proper prescriptions or counseling, increased the risk of misuse and health complications. This inadequate support for transitioning dampened the motivation of trans-women sex workers to pursue gender-affirming care. Additionally, frequent stockouts of STI drugs and other medical supplies in key population-friendly healthcare facilities exacerbated the difficulty in accessing consistent, quality care [ 31 ]. Ssekamatte et al., (2020) also highlighted challenges in diagnosing and treating STIs for trans-women sex workers due to the lack of appropriate facilities, such as proctoscopy, in general healthcare settings. Many general facilities were catering primarily to heterosexual populations and were not equipped to handle STIs that affect the anal region, a common concern for trans-women sex workers. This gap in service provision led to inadequate diagnosis and management of STIs, further marginalised trans-women and compromising their health outcomes [ 31 ]. In addition, Avuvika et al., (2017) also identified structural barriers, such as the distance to STI testing facilities and the lack of youth-friendly centers, as significant obstacles. Adolescent girls and young women are reluctant to seek services that are either too far from their homes or too close, where they risk being seen by familiar faces. The absence of dedicated reproductive health centers that cater to the unique needs of youth exacerbates this issue. Furthermore, the study indicates that the lack of support from the broader community, particularly religious institutions, contributes to the silence and stigma surrounding adolescent sexual health [ 34 ]. Similarly, Cornelius et al., (2018) also highlighted systemic inefficiencies, such as long waiting times and unsatisfactory healthcare worker attitudes, which deter women from accessing HIV services. Participants expressed dissatisfaction with the responsiveness of healthcare services and emphasised the need for greater government involvement in improving service delivery. The discussion of an anti-stigma bill reflects the participants' recognition of the importance of policy-level interventions to combat HIV-related stigma [ 40 ]. Discussion This systematic review identified key socio-economic, structural, and cultural barriers to HIV and STI care across sub-Saharan Africa (SSA), as well as factors that could improve access, retention, and adherence. High treatment costs, long travel distances to facilities, lack of complementary services, and insufficient food supply emerged as significant socio-economic obstacles. These were compounded by strong HIV-related stigma, a barrier documented both within SSA and internationally [ 44 , 45 ]. In the Rufiji area of Tanzania, participation in antiretroviral therapy (ART) programmes was itself a source of stigma, as community members identified and openly targeted people living with HIV (PLHIV), sometimes through verbal abuse [ 46 ]. Agnarson et al. (2013) linked this to local beliefs that individuals on ART were more likely to spread HIV through unprotected sex. The review also highlighted reliance on traditional and alternative treatment systems over biomedical approaches as a major socio-cultural determinant of retention in care [ 28 , 30 , 31 ]. While similar overlaps between conventional and traditional care systems have been noted in Tanzania and elsewhere in SSA [ 47 , 48 ], the review underscored that traditional healers often play an important role for PLHIV because they are more accessible and affordable than distant biomedical specialists. Female sex workers (FSWs) in SSA, despite the wide geographical availability of HIV services [ 33 ], encountered multiple obstacles to access. At the individual level, these included internalised stigma, fear of a positive HIV result, lack of knowledge about available services, and misconceptions that sometimes led to rejecting negative results [ 40 – 42 ]. Social stigma was pervasive, originating from service providers, the general public, and even sex worker networks [ 49 ]. Structural barriers included discrimination in healthcare settings, confidentiality concerns, unfriendly services, inconvenient clinic hours, and procedural limitations such as strict refill policies that tied clients to a single facility. High mobility among FSWs and law enforcement interventions—including arrests—further disrupted continuity of treatment [ 50 , 51 ] Similar barriers were observed in STI screening for young women and adolescents. Lack of information about STIs, the cost of medical services, and the widespread belief that being asymptomatic meant being disease-free reduced testing uptake [ 52 , 53 ]. Facilitators included access to urine-based testing, well-equipped facilities, assurances of confidentiality, and services that were easy to reach [ 33 , 34 , 43 ]. Absence of symptoms was often wrongly taken as evidence of being STI-free [ 54 ]. The review noted that comprehensive sexual health education has been linked to more responsible sexual behaviour among teenagers, including delayed sexual debut, both of which reduce STI risk [ 55 ]. Poor adherence to treatment was identified by healthcare facilities as a significant obstacle [ 30 – 32 , 36 ]. In a recent survey, adolescents living with HIV reported multiple adherence barriers [ 56 ]. The review found that many facilities lacked clear procedures for detecting and managing loss to follow-up or non-adherence, and that counselling tools were underused (Stewart and Baeten, 2022). Young people aged 15–19 were at particularly high risk of disengaging from care [ 57 ]. Peer support was proposed as a solution, but supporting evidence was scarce. However, recent findings from Zimbabwe indicated that adolescent-led, community-based peer programmes could improve psychological wellbeing, adherence, retention, and linkage to care [ 58 – 60 ]. Negative provider attitudes also emerged as a major barrier to STI treatment [ 7 , 61 ]. Adolescents were more likely to seek and stay in care when they perceived providers as adolescent-friendly [ 62 ]. They were also more willing to share sensitive information with non-judgemental clinicians [ 9 ]. The review suggested that adolescent-friendly practices could be promoted through on-the-job training, reinforcement, and incentives [ 55 ]. Privacy was a valued aspect of care; insufficient space and lack of confidentiality deterred service use [ 63 , 64 ]. Other deterrents included long wait times, inconvenient working hours, and shortages of medicines and supplies. Improved resource availability was strongly correlated with increased STI treatment uptake [ 54 ]. Inadequate infrastructure also hindered access to STI information [ 30 , 31 ]. Testing behaviour was shaped by personal attitudes, confidence in self-testing, social influences, previous experiences, and perceived benefits. Motivators included concerns about health, ability to work, family responsibilities, and future aspirations [ 32 , 33 ]. Perceived risk was high for HIV but lower for syphilis, which was often seen as a minor concern unless symptoms appeared [ 53 ]. In Uganda, dual HIV/syphilis testing during pregnancy—driven by fears of infertility, HIV risk, and the desire for customer satisfaction—boosted syphilis testing [ 65 ]. Lack of sexual health education resources, insufficient parental support, and negative community attitudes further restricted access for adolescents [ 34 – 36 ]. Parental and societal disapproval could prevent adolescents from seeking reproductive health services, particularly where guardian consent is required [ 66 ]. The review suggested involving parents and community leaders in decisions on STI care to increase acceptance. Among trans-women sex workers, barriers included fear of disclosure, stigma, discrimination, and violence. Some avoided care altogether, especially in facilities lacking population-specific services. Fear of exposing gender identity or sex work status—due to possible shame, discrimination, or legal consequences—was a key deterrent [ 31 , 66 , 67 ]. Internalised stigma, low self-esteem, and anticipated breaches of confidentiality were also influential. Less than half of participants in one study had ever tested for HIV, with fear of violence and gossip being strong deterrents [ 29 , 68 ]. Some altered their clothing to conform to social norms and reduce risk when accessing care, a practice also seen in Malaysia and the US [ 69 ]. The review stressed the importance of inclusive, non-discriminatory SRH services and removing prejudice among providers and patients [ 70 , 71 ]. Men’s experiences were also addressed. Okoror et al. (2016) challenged stereotypes of hypersexual African men by showing that many altered their sexual behaviours after HIV diagnosis, including practising safer sex and reducing alcohol and extramarital activities. However, stigma persisted, with community members targeting men with chronic illness even before diagnosis. Illness undermined traditional masculine ideals of strength and self-reliance, making it harder for men to accept their HIV-positive status. These constructions of masculinity heteronormative and patriarchal remain influential in many ethnic groups in southwest Nigeria [ 45 , 52 ]. The review emphasised the need for accessible, acceptable delivery systems for STI diagnostic testing [ 21 ]. Sociocultural and structural barriers such as low health literacy, shame, stigma, judgemental provider attitudes, and guardian consent requirements limited young people’s access to SRH care. While many said they would seek care if symptomatic, confidentiality concerns made them reluctant to use school-based services. Community-based STI testing, often integrated with HIV and SRH services and co-designed with young people, was preferred for its accessibility and acceptability. The review noted that uptake is the main determinant of screening programme effectiveness [ 16 , 72 ], but achieving high coverage requires significant effort and service adaptation [ 13 ]. Partner notification, crucial for breaking transmission cycles, showed low yields. Less than 10% of partners in reviewed studies attended treatment after notification. In SSA, direct patient referral achieved a median 25% attendance, compared to 84% for accelerated partner therapy and 69% for provider referral [ 73 , 74 ]. Fear of violence, relationship breakdown, and accusations of infidelity were key deterrents, underscoring the importance of support and counselling for both index patients and partners [ 68 , 69 ]. Barriers to medication access included prejudice, stigma, poor provider–patient communication, drug shortages, and financial constraints [ 59 , 71 ]. In one Nigerian setting, over 40% of women reported poor adherence due to miscommunication or rushed providers. Stigma was cited by nearly 30% as a reason for non-adherence [ 75 ]. Before the introduction of standardised dispensing procedures, 25% of patients at a large Nigerian institution were not receiving adequate HIV medication; this fell to 3% afterward [ 60 ]. Concerns about the sustainability of foreign funding particularly from the U.S. President’s Emergency Plan for AIDS Relief were widespread, as withdrawal could worsen existing problems [ 57 ]. The review concludes that improving access, uptake, and adherence to HIV and STI services in SSA will require multi-level interventions. These include tackling stigma, ensuring consistent drug supply, improving provider attitudes, increasing privacy and confidentiality, involving community stakeholders, and expanding adolescent-friendly services. Evidence-based behavioural and structural strategies many already tested in high-burden east and southern African contexts can be adapted for Nigeria and other challenging environments across Africa and globally [ 44 , 46 ]. Limitations and Strengths One notable strength is the comprehensive approach taken in the research design, which utilizes qualitative methods to gather insights from various populations, including female sex workers, adolescents, and transgender individuals across multiple Sub-Saharan countries. This diversity in perspectives allows for a nuanced understanding of the socio-cultural, economic, and systemic factors that hinder access to STI healthcare. Additionally, the use of established guidelines from the Cochrane handbook and the CASP for evaluating the quality of the studies further bolsters the rigor of the review. However, the systematic review also has limitations that may affect the generalizability of its findings. The inclusion criteria restricted the analysis to studies published in English and within a specific timeframe (2014–2024), potentially excluding relevant research published in other languages or before this period. This could lead to a biased representation of the available literature, as significant insights from non-English studies may be overlooked. Implications of Findings The results of this systematic review demonstrated the complex barriers that people in SSA encounter in the search for health care for STIs. Stigma, economic factors, literacy, and structural barriers, including limited utilization of available services, deny those at high risk of HIV, especially female sex workers, adolescents, and transgenders from appropriate care. Such barriers did not only worsen the health inequity but also negatively impacted health and enhanced disease burden in the region. Stigma remains an ever-present issue, alongside poor healthcare systems, and socioeconomic factors, requires that more specific approaches and broader changes be made in the health-care systems to improve the care and situation of stigmatised populations. Conclusion The systematic review describes the major challenges to the healthcare seeking for STIs in Sub-Saharan Africa with the focus on the multifactorial interconnection between the stigma, lack of awareness, socio-economic barriers, and structural factors. A major theme that emerges is the wide spread of stigma related to STI and HIV which heavily influences the patient’s choice of care. The review suggests that more specific educational campaigns are needed to address these misconceptions and raise awareness of the existing healthcare options that can greatly improve preventive health behaviors. In addition, it identified socioeconomic status as a predictor variable that presented barriers, primarily, the costs associated with treatment. Some of the people said that the transportation costs and costs of seeking medical care made health care unaffordable even though there was free treatment. Additionally, structural barriers such as inflexible healthcare policies and inadequate service provision further hinder access to care. 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Chimoyi et al. , "Understanding factors influencing utilization of HIV prevention and treatment services among patients and providers in a heterogeneous setting: a qualitative study from South Africa," PLoS Global Public Health, vol. 2, no. 2, p. e0000132, 2022. S. Vargas et al. , "Point-of-care testing for sexually transmitted infections in low-resource settings," Clinical Microbiology and Infection, vol. 28, no. 7, pp. 946–951, 2022. A. Hazra and J. N. Cherabie, "Is mpox a sexually transmitted infection? Why narrowing the scope of this disease may be harmful," Clinical Infectious Diseases, vol. 76, no. 8, pp. 1504–1507, 2023. C. W. Spearman et al. , "A new approach to prevent, diagnose, and treat hepatitis B in Africa," BMC Global and Public Health, vol. 1, no. 1, p. 24, 2023. H. U. Okoye and E. Saewyc, "Influence of socio-contextual factors on the link between traditional and new media use, and young people’s sexual risk behaviour in Sub-Saharan Africa: a secondary data analysis," Reproductive health, vol. 21, no. 1, p. 138, 2024. X. Liang et al. , "The trend analysis of HIV and other sexually transmitted infections among the elderly aged 50 to 69 years from 1990 to 2030," Journal of Global Health, vol. 14, p. 04105, 2024. K. Siamisang, B. Nkomo, K. Kusi, D. Kanyenvu, and M. Molefi, "High-risk behaviors and factors for HIV and sexually transmitted infections among transgender people in Gaborone, Botswana: results from a national survey," Pan African Medical Journal, vol. 41, no. 1, 2022. K. L. Sarenje, O. Ngalamika, M. C. Maimbolwa, A. Siame, S. M. Munsaka, and G. Kwenda, "Antimicrobial resistance of Neisseria gonorrhoeae isolated from patients attending sexually transmitted infection clinics in Urban Hospitals, Lusaka, Zambia," BMC infectious diseases, vol. 22, no. 1, p. 688, 2022. S. Mulupi et al. , "What are the barriers to the diagnosis and management of chronic respiratory disease in sub-Saharan Africa? A qualitative study with healthcare workers, national and regional policy stakeholders in five countries," BMJ open, vol. 12, no. 7, p. e052105, 2022. N. Schmidt et al. , "Check It: A community-based chlamydia seek, test, and treat program for young Black men who have sex with women in New Orleans, Louisiana," Sexually Transmitted Diseases, vol. 49, no. 1, pp. 5–11, 2022. Y. Zhang et al. , "Barriers and facilitators to HIV and syphilis rapid diagnostic testing in antenatal care settings in low-income and middle-income countries: a systematic review," BMJ global health, vol. 7, no. 11, 2022. A. Afferri, H. Allen, A. Booth, S. Dierickx, A. Pacey, and J. Balen, "Barriers and facilitators for the inclusion of fertility care in reproductive health policies in Africa: a qualitative evidence synthesis," Human reproduction update, vol. 28, no. 2, pp. 190–199, 2022. H. Fogarty et al. , "Motivators and barriers to blood donation among potential donors of African and Caucasian ethnicity," Blood Transfusion, vol. 21, no. 1, p. 13, 2022. A. Medina-Marino et al. , "Sexually transmitted infection screening to prevent adverse birth and newborn outcomes: study protocol for a randomized-controlled hybrid-effectiveness trial," Trials, vol. 23, no. 1, p. 441, 2022. C. D. Chikwari et al. , "The impact of community-based integrated HIV and sexual and reproductive health services for youth on population-level HIV viral load and sexually transmitted infections in Zimbabwe: protocol for the CHIEDZA cluster-randomised trial," Wellcome Open Research, vol. 7, p. 54, 2023. H. D. Mazigo et al. , "“Female genital schistosomiasis is a sexually transmitted disease”: Gaps in healthcare workers’ knowledge about female genital schistosomiasis in Tanzania," PLOS Global Public Health, vol. 2, no. 3, p. e0000059, 2022. M. Harfouche, F. M. Abu-Hijleh, C. James, K. J. Looker, and L. J. Abu-Raddad, "Epidemiology of herpes simplex virus type 2 in sub-Saharan Africa: Systematic review, meta-analyses, and meta-regressions," EClinicalMedicine, vol. 35, 2021. M. T. Vallejo-Ortega, H. Gaitán Duarte, M. B. Mello, S. Caffe, and F. Perez, "A systematic review of the prevalence of selected sexually transmitted infections in young people in Latin America," Revista Panamericana de Salud Pública, vol. 46, p. e73, 2023. S. W. Mwaniki, P. M. Kaberia, P. M. Mugo, and T. Palanee-Phillips, "Prevalence of five curable sexually transmitted infections and associated risk factors among tertiary student men who have sex with men in Nairobi, Kenya: a respondent-driven sampling survey," Sexual Health, vol. 20, no. 2, pp. 105–117, 2023. Additional Declarations No competing interests reported. Supplementary Files Appendices.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 25 Aug, 2025 Editor assigned by journal 21 Aug, 2025 Submission checks completed at journal 21 Aug, 2025 First submitted to journal 13 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7361651","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":500435025,"identity":"03cff54a-35ac-4873-8340-e0a911cd1496","order_by":0,"name":"Rabail Fatima","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/ElEQVRIiWNgGAWjYFACHgaGhAI5CPtDBZBgZm4gQouBMYhiYJxxBqSFkQgtDFAtzLxtIBECWszbzx788MDAQN5eIjvxA++82mj+dqCWHxXbcGqROZOXLJFgYGDYI5G7WUJy2/HcGYcZGxh7ztzGqUWCIccAqOUPI1DLBgnDbcdyG4BamBnb8Gjhf2P8A2iLPciWH4lzjuXOJ6hFIscM5LBEoJZtEgcbanI3ENbyLs0CqCW558zbbZYNxw7kbgRqOYjXL/y5h2/+qDCwbW/P3Xz7T01d7rzzhw8++FGBWwsCCCSAyMNg9gEi1AMBP1hdHXGKR8EoGAWjYEQBAHprW/W4i/CUAAAAAElFTkSuQmCC","orcid":"","institution":"Riphah International University","correspondingAuthor":true,"prefix":"","firstName":"Rabail","middleName":"","lastName":"Fatima","suffix":""},{"id":500435026,"identity":"624832a1-706e-49c8-8d46-37611f8697bb","order_by":1,"name":"Amina Kone","email":"","orcid":"","institution":"University of Nottingham","correspondingAuthor":false,"prefix":"","firstName":"Amina","middleName":"","lastName":"Kone","suffix":""}],"badges":[],"createdAt":"2025-08-13 06:53:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7361651/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7361651/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89254715,"identity":"11aaa7f7-576e-4f15-be1f-0f33d905a659","added_by":"auto","created_at":"2025-08-18 05:08:35","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":154731,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA Flow Chart of Screening Process of Studies\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7361651/v1/a0754b26ccfa7701acf9a889.png"},{"id":89255693,"identity":"e6d22626-9e7a-451b-8a15-32be5cd5df8c","added_by":"auto","created_at":"2025-08-18 05:32:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":982194,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7361651/v1/36b74773-8e56-4ec8-b5b0-6d7adeb9914a.pdf"},{"id":89254743,"identity":"aecf9f61-eef5-48b2-b1e7-013a11dc8959","added_by":"auto","created_at":"2025-08-18 05:08:38","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":86925,"visible":true,"origin":"","legend":"","description":"","filename":"Appendices.docx","url":"https://assets-eu.researchsquare.com/files/rs-7361651/v1/50974ae5926b212520f523e0.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Barriers in Healthcare for People with Sexually Transmitted Infections in Sub-Saharan Africa; A Systematic Review of Qualitative Studies","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAdolescence to adulthood age has various reproductive health concerns as key milestones [1]. In the last two decades, STIs including chlamydia, gonorrhoea, syphilis, and HIV have been increasing and have become a threat to both developed and developing countries [2]. Sexually transmitted infections that result from sexual contact, such as vaginal, oral, and anal sex affect the sexual and reproductive health of men and women 15\u0026ndash;49 years [3]. They are a significant worldwide cause of infertility, acute illness, long-term disability, and death with numerous medical and psychological impacts [4]. Research also established that STIs lead to other adverse health impacts such as HIV/AIDS, ectopic pregnancy, eye problems and pelvic inflammatory diseases \u0026nbsp;[5]. This particular group of people in the society determines the economic future of a given nation. The World Health Organisation (WHO) pointed out that approximately 374 million new cases of STIs occur each year [6].\u003c/p\u003e\n\u003cp\u003eSub-Saharan African nations have the greatest incidence of STIs, accounting for around 93 million cases annually [7]. In underdeveloped nations, insufficient access to technology, laboratory services, and qualified specialists hampers the identification of the etiological causes of STIs, hence exacerbating their prevalence [8]. Adolescent females and young women are a vulnerable demographic disproportionately impacted by sexually transmitted infections [9]. Numerous studies from Sub-Saharan Africa have identified women of reproductive age as being at elevated risk for STIs [10]. Worldwide, teenage girls and young women aged 15\u0026ndash;24 are the most impacted, with being under 25 years old serving as the most significant predictor of STIs [11]. Socio-behavioral risk factors for STIs in this demographic including poor educational attainment, unmarried status, many sexual partners, substance abuse, and early initiation of sexual activity [12].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFurthermore, critical populations, like males who engage in sexual activities with other men, transgender people, and sex workers, face a heightened risk of acquiring STIs [13]. Additional risk factors encompass high-risk sexual conduct linked to alcohol and drug consumption, insufficient information regarding STIs, perceived peer norms, lack of condom usage, and intergenerational interactions [14]. Untreated STIs in developing countries contribute to approximately 17% of total economic losses and lead to medical complications, including cervical inflammation, genital and urinary infections, infant disabilities, ectopic pregnancies, infertility, cardiovascular disorders, and heightened risk of HIV transmission [15]. Timely identification and intervention of STIs can effectively halt the transmission cycle and prevent problems. Comprehending the determinants of STI transmission is crucial for the implementation of successful STI prevention programs, especially in regions with a high incidence of HIV [16].\u003c/p\u003e\n\u003cp\u003eIn sub-Saharan Africa, these issues are never confronted, often leading to adverse reproductive outcomes, including sexually transmitted infections (STIs) and unintended births [17]. The incidence of postponed treatment for STIs in sub-Saharan Africa differs by country, with rates of 23.1% in Durban, South Africa; 42% in Laos; 64% in Ghana; 58% in Uganda; and 67% in Ethiopia [18, 19]. Adolescents may hesitate to obtain information from their parents owing to apprehension of being perceived as participating in forbidden activities [20]. Nonetheless, urbanisation and Western influence are swiftly altering sexual and reproductive norms, resulting in youngsters engaging in sexual activity at an earlier age [21]. There is an urgent necessity to eliminate obstacles that adolescents have in obtaining reproductive health information and treatments. Given the elevated incidence of illness and consequences from STIs in young women, it is crucial to identify and mitigate barriers to STI screening, as well as to devise focused therapies [20].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe WHO set a strategy towards elimination of the epidemic of STIs from 2016 to 2021 (Dadzie \u003cem\u003eet al.\u003c/em\u003e, 2022). Many previous works have also revealed that there are many challenges, such as discrimination, economic issues, limited medical resources and facilities, and cultural expectations and attitudes, that prevent early diagnosis and treatment [3, 4]. According to Green, (1992) dependence on traditional healers was attributed to cultural belief while Agimas et al., (2024) pointed on delays in treatment due to economic and geographical disparities. Also, system gaps, such as the uneven quality of STI services in private clinics and the lack of policy for combined treatment limit the effectiveness of interventions [7, 9]. Nonetheless, there is still limited integrated knowledge that can articulate the multifaceted and interconnected challenges of the foregoing in different parts of Sub-Saharan Africa [14, 16]. The current review will identify the gaps in the existing literature through a synthesis of previous research findings, patterns and deficiencies in the current data and recommend ways of improving the management of STIs. Therefore, while the burden of STI related illnesses is well understood and prevention and treatment of the STIs is important to reduce this burden, there is limited information on the overall incidence and factors associated with delayed treatment for STIs in Sub-Saharan Africa, which is important for policy and program development. Hence, this systematic review set out to identify determinants as barriers to treatment for STIs in sub-Saharan Africa.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eResearch Question\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe following PEO framework was used to develop a research question for this systematic review.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eComponent\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDescription\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePopulation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIndividuals with sexually transmitted infections (STIs) in Sub-Saharan Africa\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eExposure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBarriers to accessing effective healthcare\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcome\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDifficulty in obtaining timely and adequate STI care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cul\u003e\n \u003cli\u003eWhat are the barriers to accessing effective healthcare for individuals with sexually transmitted infections (STIs) in Sub-Saharan Africa?\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Methods and Materials ","content":"\u003cp\u003eAs previously stated, this systematic review adopts a qualitative research approach to identify and analyse the chosen topic. In doing so, it improves upon conventional literature collection by applying a systematic and more critical methodology. This review is grounded in a positivist paradigm, emphasising the study of reality through objective criteria. Accordingly, a structured process was followed that included locating, screening, and critically appraising relevant studies using predefined inclusion and exclusion criteria.\u003c/p\u003e\n\u003cp\u003eUnlike primary research, systematic reviewers do not seek confidential or classified information but rely on publicly available evidence. For this review, a critical appraisal tool was employed to assess the validity and significance of selected studies, alongside carefully planned data extraction and analysis strategies to ensure reliable synthesis of findings. Registered with PROSPERO under the ID CRD420251123822, the review addresses the central research question within a robust ethical framework, adhering strictly to established guidelines to ensure methodological transparency and integrity.\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eResearch Design\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eThe systematic review approach has been chosen for this review due to its ability to combines strength of both quality data and was carried out using the following guidelines; the Cochrane handbook for systematic reviews for interventions and specific reporting items to guide systematic review [22]. It is possible to find all the bodies of literature related to the topic of study and make an assessment of the nature of findings without exposing the possibility of missing a study while providing a good coverage of the topic in a single attempt [23]. This type of method is more useful to be used in evaluating the previous works in respect with the present research area; and is known systematic review. The use of systematic review approach is expected to enhance the quality of the review and simplicity and credibility on the findings. These results are unlikely to directly inform public health decisions which rely on a systematic assessment of a rigorous and transparent process of selection and deception. A systematic review helps one to make a comprehensive evaluation of the existing literature with regards to a given current research question. In contrast, a systematic review creates a vast amount of evidence from numerous fields of sciences such as primary observational studies, case series, as well as randomised controlled trials, making the current picture and points more comprehensive\u0026nbsp;[24]. With this approach, bias is reduced to the minimum, and no essential information is left unnoticed, and therefore evidence-based practise has a strong ground.\u003c/p\u003e\n\u003ch2 id=\"_Toc187255969\"\u003e\u003cem\u003eSearch strategy\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eThe researcher identified pertinent databases for the search, including Google Scholar, CINAHL, and PubMed, since they are especially tailored for healthcare and medical research studies [25]. Since these databases are often used for nursing and scientific research, they probably include pertinent information about the topic. By merging many phrases, the researcher created thorough search algorithms. These methods were customised to meet the specific requirements of each database and used the relevant Boolean operators to narrow down the search. Boolean operators are used to combine terms like \u0026quot;barriers\u0026quot; OR \u0026quot;obstacles\u0026quot; OR \u0026quot;challenges\u0026quot; AND \u0026quot;accessing treatment\u0026quot; OR \u0026quot;healthcare access\u0026quot; OR \u0026quot;treatment access\u0026quot; AND \u0026quot;effective treatment\u0026quot; OR \u0026quot;medical care\u0026quot; OR \u0026quot;health services\u0026quot; AND \u0026quot;sexually transmitted infections\u0026quot; OR \u0026quot;STIs\u0026quot; OR \u0026quot;sexually transmitted diseases\u0026quot; AND \u0026quot;Sub-Saharan Africa\u0026quot; OR \u0026quot;Africa south of the Sahara\u0026quot; OR \u0026quot;SSA\u0026quot;, the search approaches made sure that finding research was thorough and targeted.\u003c/p\u003e\n\u003cp id=\"_Toc187255970\"\u003e\u003cem\u003eInclusion and Exclusion Criteria\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFor this review, the inclusion criteria focused on primary research studies that employed qualitative methods to explore the research question in depth. Eligible studies had to be published in the English language between 2014 and 2024, ensuring the inclusion of recent and relevant literature. Only studies conducted within Sub-Saharan African countries were considered, as the review specifically targeted this geographic context. Furthermore, all included studies were required to be peer-reviewed to ensure methodological rigor and credibility.\u003c/p\u003e\n\u003cp\u003eThe exclusion criteria eliminated grey literature, conference abstracts, case series, blogs, and other non-peer-reviewed materials, as these sources often lack sufficient methodological detail and reliability. Studies published in languages other than English were excluded to maintain consistency in data interpretation and avoid translation bias. Additionally, research published before 2014 was excluded to ensure the findings reflected contemporary evidence. Finally, studies conducted outside the Sub-Saharan African region were not considered, as they fell outside the defined scope and focus of this review.\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eScreening Process\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eWhen the search was first conducted, a total of 1190 publications were found. After eliminating 485 studies that were identical to one another, there were 705 unique research articles that were left for more investigation. There were total of 376 studies that focused on the treatment of illnesses other than sexually transmitted infections. After going through the process of screening, there were a total of 329 studies that were still included in the pool. A total of 227 studies were disregarded because they were carried out in countries that were not in the SSA region. Due to the fact that they contained things like literature reviews, meta-analyses, case studies, editorial letters, procedures, and comments, 88 of the remaining 100 articles were disregarded. As a consequence, 16 studies were ultimately chosen for further analysis. There is a representation of the screening method in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram (Figure 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCritical Appraisal\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe current study aims to provide a systematic review of the literature. The Critical Appraisal Skills Programme (CASP) approach was used to evaluate the quality of the included studies (Kilicoglu, 2018). The quality of the included studies was carefully assessed by the researcher (Table 1- Appendices). This required assessing the methodology\u0026apos;s benefits and drawbacks, any biases, and the overall quality of the data provided in each study. A thorough assessment was carried out to guarantee the authenticity and dependability of the findings. The CASP tool was chosen because of its standardised methodology, which offers precise instructions and standards for a variety of research designs. To conduct the study, a methodological evaluation was required. These attributes include the size of the sample, the effectiveness of the study design, the clarity of the research question, the collection and processing of data, and the interpretation of the findings [22]. Liamputtong (2020) asserts that the user-friendly architecture of the CASP tool ensures a thorough assessment of study quality based on recommendations supported by data and recognised research standards.\u003c/p\u003e\n\u003ch2 id=\"_Toc187255972\"\u003e\u003cstrong\u003eData Extraction and Synthesis of Finding Analysis\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe data used in each of the included studies were appropriate and gathered and arranged in a very systematic manner. This information covered aspects of the study such as the design, sample size, characteristics, intervention, measures of outcome and findings (Table 2- Appendices). The extraction, summarising and analysing of data for systematic reviews were done with high accuracy and without skipping a detail. The data collected in this study consisted of excerpts, findings and principal topics which were analyzed thematically. The researcher will identify trends, themes and trends within the data identified. This is a process where data is sorted into themes and sub themes and then compared and contrasted across different research studies. Thus, by analysing the data, it is possible to reveal the patterns, ensure the data validity and estimate the overall determinants as barriers to treatment for STIs in sub-Saharan Africa.\u003c/p\u003e\n\u003ch2 id=\"_Toc187255973\"\u003e\u003cstrong\u003eEthical Consideration\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eEthical concerns related to the included studies were identified by this systematic review. Though this research relied on a literature review technique and did not directly involve any persons or organisations, it is prudent to evaluate the ethicality of materials so tested. Each was meticulously reviewed to make sure that all research reported met ethical standards, and that the research had been approved by the appropriate institutional review board or ethics committee. Research based on the empirical analysis examined whether ethical criteria that include consent, anonymity and participant protection were adhered to in the research [26]. The current evaluation excluded or revealed these studies if its writers found any investigations that had received limited ethical scrutiny, or if they were indicative of possible ethical wrongdoing. This approach fits with the obligation to maintain the presumed rigour when applying ethical standards, and thus expand the scientifically synthesised body of the knowledge [27].\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe findings of the systematic review are presented in this chapter, in an overview of the characteristics of the selected studies. An explorative summary of these studies based on predefined inclusion and exclusion criteria to provide a more contextualised view of the research landscape is presented. This chapter features a central thematic analysis, which involves the identification and critical analysis of recurring themes in order to synthesise insights from the literature. To introduce the various data in a comprehensive understanding of research question, the synthesis of findings approach was followed. Depth is given to each theme, each with a focus on major patterns and relationships that emerge from the data. Also, a data extraction table, summarising key information from each study, is included in the appendices for easier reference. All through this chapter they expose the analysis which will go through the top brains running those business ensuring a rigorous examination of the findings.\u003c/p\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eThematic Analysis\u003c/h2\u003e\u003cdiv id=\"Sec13\" class=\"Section3\"\u003e\u003ch2\u003eTheme 1: Impact of Stigma on Healthcare-Seeking Behavior\u003c/h2\u003e\u003cp\u003eTotal of nine studies [\u003cspan additionalcitationids=\"CR29 CR30 CR31 CR32 CR33 CR34 CR35\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] observed that stigma hinders PLHIVs from seeking healthcare services from facilities within the communities. Stigma related to the identification of being HIV positive because of frequent clinic visits or public consumption of medication hampers the motivation to seek early treatment. The study also elaborated how open spaces in the healthcare facilities where people take drugs freely abuse the rights of the patients and make the PLHIV feel embarrassed. This not only had the effect of dissuade people from seeking out healthcare in the first place but also encouraged feelings of shame and paranoia, which led people to seek out care in different areas of the region, so as not to be recognised. The harassment by authorities and especially for those with a history of substance use, added another level of difficulty to the situation through integration of legal and social exclusion with the health care barrier which was a multi-pronged barrier for proper adherence to treatment regimens. Countering this, analogy of ART to dehumanising metaphors like referring to pigs as \u0026lsquo;oil seed cakes\u0026rsquo; was used to describe the exclusion language used for people living with AIDS. The psychological effects of such vices as public ridicule and embarrassment, which are social consequences of being a PLHIV, also reduced the willingness of the patients to follow the treatment regimens [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSimilarly, Avuvika et al., (2017) noted that fear of stigma and judgement from health care workers and the community makes adolescent girls and young women avoid STI screening. Many people avoid seeking STI screening because they think that if they do, they will be branded as being sexually active. This fear is enhanced by the adverse consequences of partner notification processes which only serve to put the affected persons at the mercy of judgement and social shame [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. In the same way, Jaya et al., (2024) found that young women are hindered by factors such as stigma, myths on STIs, and fear of being judged when seeking for STI healthcare services. The social stigma attached to STIs ensured that young women did not receive the medical attention they required because of fear. The cultural beliefs and the myths that surround STI transmission and cure compounded the problem therefore creating misinformation and wrong behavior. These barriers were compounded by fear of being judged by health care workers or peers, which made young women uncomfortable and unwelcome in such environment [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The studies highlighted a major failure in the health care system; youth friendly services that are confidential and non-discriminative are scarce, and many young women are therefore unable to access the right treatment from the right sources such as the clinics and turn to pharmacies and other unverified sources. This suggests that there is a need for the healthcare systems to embrace the non-stigmatising youth friendly model to encourage early and frequent STI testing [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eLikewise, Nakanwagi et al., (2016) revealed that stigma and discrimination from healthcare workers were identified as key barriers for female sex workers (FSWs) in accessing HIV care. The stigma that is displayed by health professionals towards FSWs makes many of them flee from seeking the treatment services. Discrimination is quite explicit, and because sex workers are often afraid of being outed, the lack of trust prevails. This not only discourages the connection between prevention and care but also sustains the culture of prevention as friends are deterring potential patients from linking to the healthcare industry. Such structural bias worsens health inequalities because it further stigmatizes an already oppressed group, thus underlining the necessity of specific strategies to fight stigma in health settings and embrace diversity [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAccording to Wanyenze et al., (2017), stigma and structural barriers were major factors that influenced FSWs decision of seeking HIV testing and treatment. Shame and stigma, from fellow sex workers, family, and community, make many of them avoid seeking appropriate medical care. The view of HIV as a disease one gets by one\u0026rsquo;s own doing makes this situation worse, causing people to remain alone and not want to tell anyone about their status or job as a health worker. Furthermore, factors that include long waiting time and clash between clinic timing and the sex work shift work make it even more difficult to access health care services. In the same way, Muhindo et al., (2021) also established that a low perceived threat of Syphilis and internalised stigma were found to positively influence the frequency of testing among the FSWs. The participants had a Perception that Syphilis is less severe than HIV and therefore, few of them went for testing until they started experiencing symptoms. Stigma, together with fear of being seen at the clinics or spread of rumors, also plays a big role into delaying testing among FSWs. This stereotype not only affected their medical practices but also endangered their earning since they can lose customers [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAccording to Abuosi and Anaba (2019), societal stigma as well as labeling are other factors that affect the ability of adolescents to access healthcare at adolescent centers (ACs). The youths said that people in the community call them \u0026ldquo;bad\u0026rdquo; girls when they go to the clinic for checkup, family planning or abortion. Stigma-related to HIV/AIDS made many people refrain from visiting the health facilities in order not to be rejected by society. Also, peer and partners\u0026rsquo; restrictions made it difficult to access healthcare as they revealed how social norms and relationships shape people\u0026rsquo;s behaviors in relation to their health [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Fear of parental punishment did not allow adolescents to turn to their parents for help in case of their need in health services, which proves that families provide insufficient support and communication on health issues of teenagers. The young people described feeling that their providers were dismissive and critical of them, especially the pregnant young people who experienced verbal belittlement. Discrimination between some adolescents and total rejection of others led to feelings of exclusion and deterrence from seeking further services [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSimilarly, Martin et al., (2021) discovered that young people are discouraged from chlamydia and gonorrhoea testing because of expected stigma, and concerns over the confidentiality of their information. The feeling of being discriminated or rejected by the family and other people in the community makes people avoid the local healthcare centers and seek services from other distant or private clinics so as to conceal their status. This behaviour points to the effect that societal beliefs have on people\u0026rsquo;s approach to health, especially their Choices regarding STI testing and the need for healthcare systems to embrace confidentiality to foster non-stigmatised environments for STI testing [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Similarly, Ssekamatte et al., (2020) show that internalised stigma of trans-women sex workers affects their utilization of HIV/STI prevention and care services. This happens because many trans-women feel that if they go to a healthcare facility they will be discriminated against or even rejected by their healthcare providers and the rest of the community. This results in feelings of shame, or traumatization, which affect their willingness to discuss their health needs, especially in relation to their gender, and employment. It is therefore important to address this stigma in order to create a more accepting environment for trans-women in healthcare settings in order to seek the health care that they need [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOn the other hand, Ssekamatte et al., (2020) also confirmed that the fear of violence and gossips from the community reduces the freedom and health seeking fifty of trans-women sex workers. Discrimination based on non-conforming dress code and behavior creates a hostile environment, that has forced many trans-women to limit their public appearances and engage in social activities mostly confined to night life. This social exclusion deprived them from both general and key population friendly health care facilities during normal business hours thus worsening inequity in health. Certain transwomen sex workers were labeled by healthcare providers and other key populations as \u0026lsquo;prostitute\u0026rsquo; because of competition for clients as well as seeking for special consideration. These dynamics tension and deter some trans-women from seeking for health care services when their expectations were not met. There were also exclusion and invisibility in healthcare settings that greatly affect trans-women sex workers\u0026rsquo; ability to seek sexual and reproductive health (SRH) services. Transwomen sex workers said they were discriminated, not only by clients but also by physicians who stigmatised them and called them abomination. This was also seen in their relations with other crucial demographic groups; trans women complained about being marginalised or disrespect within the frame of the LGBTIQ category. These experiences fostered negative healthcare environments, which deter trans women from using SRH services that they need [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMeanwhile, Tun et al., (2022) also highlighted the generalised prejudice and bigotry transgender persons encounter in the conventional HIV health care services, while documenting more encouraging findings in the transgender friendly CSO clinics. There was a tendency to generalise the concept of transgender people with other sexual minorities, including lesbians and men who have sex with men even among the healthcare workers who were trained on gender and sexual minorities. This conflation especially for the transgender women (TGW) with HIV leads to the assumption that TGW and MSM have similar health needs with the emphasis on anal sex (Tun et al., 2022). Deriving from such oversimplifications, this study shows that the specific HIV healthcare needs of transgender individuals are ignored and thus neglected. Patients who are transgenders and are living with HIV stated that they felt being insulted and disrespected during physical examination because of providers\u0026rsquo; lack of sensitivity on gender issues. Stigma and fear of being discriminated made the majority of the transgenders to avoid seeking HIV services at mainstream facilities hence limited access to health care services [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMoreover, Moucheraud et al., (2019) also found the role of stigma as a critical determinant of adherence to STI treatment, as emphasised by healthcare providers. Stigma, whether internalised or experienced from the community, can deter patients from consistently taking their medication, fearing judgment or discrimination. Despite these challenges, patients generally recognize the health benefits of adhering to antiretroviral therapy (ART), including the suppression of the virus and the maintenance of a high CD4 count. Moucheraud et al., (2019) also identified being away from home due to employment or family obligations, such as funerals, as a significant barrier to adhering to STI treatment regimens. These higher-level social factors, often highlighted more by healthcare providers than patients, underscore the impact of mobility on treatment continuity. The frequent absence from home disrupts access to medication, leading to inconsistent adherence and compromised health outcomes [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eLikewise, Okoror et al., (2016) noted that heterosexual HIV-positive men experience a significant emotional response to an HIV diagnosis especially if the diagnosis is made when the man is sick. The participants often expressed feelings of disbelief or astonishment that sometimes made them think of suicide, as well as fear of stigma and the costs of treatment. The study establishes that social context of diagnosis has an impact on the stigma faced by HIV positive men. The patients who were diagnosed after developing symptoms highlighted more severe enacted stigma such as being shunned by friends, family, and other members of the society. On the other hand, those with no symptoms at the time of diagnosis, who perhaps knew their status due to a family member\u0026rsquo;s diagnosis, had less immediate social sanctions. This variation shows that being visible or not visible differently affects the way society responds to illness. Changing stigma demands specific interventions which take into consideration the various routes that lead to diagnosis, public awareness campaigns to discourage people from avoiding patients [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOn the other side, according to Cornelius et al., (2018), stigmatization in the health care System and spousal discord were found to hinder women with HIV from seeking care. Such women suffer from social stigma in both the health care institutions and from their families, which worsens the psychological burden of caring for their diabetes. Conflicts with spouses especially but not limited to polygamous relationships where disclosure of the dynamics of the relationship is not easy makes it even harder to get support and care. This conflict hampers women\u0026rsquo;s ability to get support from their spouses emotionally and financially, thus making it difficult for them to seek and follow treatment. To solve these issues, there should be efforts to eliminate prejudice in the health facilities and family care giver support programs to enhance effective interaction with family members [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eTheme 2: Lack of Knowledge as a Barrier to Treatment of STIs\u003c/h2\u003e\u003cp\u003eTotal of five studies [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] found this theme. So, Nakanwagi et al., (2016) described how the FSWs are still misinformed and are still using other forms of treatment which hinders their access to formal HIV care. FSWs used herbs or self-medication due to myths about ART and negative peer persuasion. The belief that ARVs are dangerous or require special handling discouraged some people from seeking the right medical care or even from taking the drugs at all. This perceived vulnerability to be weakened by ARVs and consequently affecting their ability to work shows a major health education and support service lacuna that is specific to the FSWs. Also, the low awareness of the physical whereabouts of the HIV clinics especially among the young FSWs worsened the situation and greatly called for intervention to address misconceptions and direct FSWs to the right services [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Likewise, Tomori et al., (2014) also identified the sociocultural misconceptions, and geographical barriers that greatly affect the HIV treatment. Myths regarding the effectiveness of treatment and the fear that the treatment is lethal indicated that there exists a major deficiency in community-level health awareness. These prejudices together with other difficulties of distance to go to a health facility made worse the situation of human beings [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSimilarly, Wanyenze et al., (2017) establish that the FSWs have a general suspicion of HIV test outcomes and treatments as a hindrance to the utilization of HIV services. FSWs often have trouble coming to terms with negative results because the cultural understanding remained that every sex worker is bound to be HIV positive. This skepticism weakened the impact of HIV testing campaigns, and deterred people from purchasing into the idea of preventive health measures. Also, the perception of being injected by health workers with dangerous substances deters the FSWs from enrolling for or continuing with the ART [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. In a similar manner, Martin et al., (2021) stipulated that self-rated STI preventive practices and testing misconceptions, including, for example, the notion that circumcision is protective, or HIV test includes other STIs, are a form of barrier to uptake. The lack of symptoms also affects people\u0026rsquo;s willingness to perform tests, which decreases the practice of prevention measures [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOn the other hand, Ssekamatte et al., (2020) established that discrimination through breaches of confidentiality and limited awareness of gender identity among healthcare givers kept trans-women sex workers away from healthcare services. Lack of confidentiality in the gender identity of the patients made the patients lose confidence with the healthcare facilities especially when such incidents happen in both general and key population-friendly health facilities. Further, the lack of knowledge of the physicians especially in the special facilities proves that there is lack of awareness among the healthcare providers. These breaches and gaps played a role in the erasure of trans-women sex workers, all the more reason why confidentiality measures must be strict and training more extensive in order to raise awareness among the providers of the trans patient population [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eTheme 3: Socioeconomic Barriers to Accessing and Retaining Treatment of STIs\u003c/h2\u003e\u003cp\u003eTotal of four studies [\u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] found this theme. So, Tomori et al., (2014) described the significant factors that hindered the process of people living with HIV (PLHIV) to access and maintain treatment in Sub-Saharan Africa region. The research also pointed out that poverty is one of the main factors that prevent the population from visiting a doctor when an illness appears. The total costs on transportation and medical services thus posed a major challenge to many of the PLHIV. This study painted a picture of \u0026lsquo;free treatment\u0026rsquo; where one is forced to ask how free it is when other expenses like transport and drugs are still a major financial burden to the needy population. This financial burden not only hindered the patient\u0026rsquo;s ability to begin treatment but also endangered his or her future ability to adhere to treatment, thereby worsening health inequity. The general public lost more confidence in the healthcare system because of its link with the black market, which is a major challenge in the fight against low treatment adherence (Tomori et al., 2014). Likewise, Ssekamatte et al., (2020) also found out that the reason for limited access to sexual and reproductive health (SRH) services for trans-women sex workers was the low socioeconomic status. Others had no other source of income other than sex work and this means they cannot afford transport and medical fees. This financial constraint was a major challenge since it hindered early utilization of both general and key population-friendly health facilities. It is necessary to introduce policies that can help the economically vulnerable trans-women sex workers access the financing and affordable health care services without which, they are likely to be denied their right to health services [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAccording to Muhindo et al., (2021), FSWs especially the elderly are discouraged from regular testing by factors such as availability of syphilis testing kits and anti-biotics because the two are often scarce. While HIV testing was done in many facilities and at relatively low cost due to competition from many testing centres, syphilis testing was limited and costly, especially in the private sector. This difference pointed to the problem within the system of how resources are distributed and to what extent STI testing services were valued. The fear of contracting STIs, the need to look and be strong enough to work hard and earn a living also push many to seek testing frequently. However, the economic burdens of sex work are a major challenge because, while condomless sex is more profitable, it raises the risk of HIV infection [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAbuosi and Anaba (2019) affirmed that lack of resources was a major challenge to the utilization of adolescent health care services especially in the management of STIs. The young people also complained of inadequate basic commodities like drugs and condoms, hence they access them from pharmacies, yet they are expensive due to unemployment. Moreover, there are few health information resources available to youth, and there are no recreational facilities available at ACs to enhance the services\u0026rsquo; effectiveness. These resource constraints do not only limit effective treatment but also the chances that adolescents will seek health care services [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eTheme 4: Structural Barriers and Challenges in Adherence to STIs Treatment\u003c/h2\u003e\u003cp\u003eTotal of nine studies [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan additionalcitationids=\"CR41 CR42\" citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e] found this theme. So, Wanyenze et al., (2017) found out that there are structural challenges, including transportation problems of FSWs and rigid healthcare system policies, as main factors that hindered the FSWS\u0026rsquo;s adherence to the continuous ART. The mobility of the sex work due to the search of clients in different places interferes with the clinic\u0026rsquo;s protocol that only allow the refill of drugs at certain places. This lack of flexibility thus leads to interrupted treatment which in turn leads to poor health and higher risk of HIV transmission. Also, the fact that these women are exposed to violence \u0026ndash; including rape and assault \u0026ndash; on a regular basis complicate matter even further. The low awareness of post-exposure prophylaxis (PEP) and how to acquire it compound vulnerability, underlining the need for mobile health care services and special initiatives that address the needs and challenges of FSWs due to their specific life style and risk [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Muhindo et al., (2021) also established other challenges that affected effective service delivery; lack of testing kits for syphilis, expensive charges, and unfriendly provider attitudes, which discouraged frequent testing. Such systemic gaps, therefore, make it difficult and uninviting for FSWs to seek and undergo testing [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSimilarly, Mark et al., (2017) also reported important structural and monitoring problems in the HIV care for adolescents. Few facilities had separate adolescent services and there was inert tracking and follow-up of treatment indicators for adolescents. Although family planning and contraceptive commodity supply chain was well established, other key services including STI testing, cervical cancer screening, and prenatal care were poorly available. This limited scope of services is not in tandem with the overall health needs of adolescents especially the high-risk ones for sexual health problems.\u003c/p\u003e\u003cp\u003eAccording to Mark et al., (2017), there was also no general counseling that limited adolescents\u0026rsquo; access to crucial information and support thus, knowledge deficits and preventive care. The lack of coherence in the age indicator for adolescence and the insufficient differentiation of the treated subjects\u0026rsquo; outcome indicated the problems of the medical care system. This was especially problematic in view of the fact that the study focused on adolescents living with HIV, who have special healthcare requirements and barriers. Mark et al., (2017) also observed the absence of targeted surveillance particularly in the West and Central Africa that hampered the evaluation of the effectiveness of the treatment regimens. It was uncommon for young mothers to be transferred back to adolescent clinics, and the message they got, for example, being told not to \u0026lsquo;mess up again,\u0026rsquo; was rather stigmatising than supportive. The process of transition especially if one is a pregnant adolescent in this case may worsen feelings of isolation and being stigmatised hence discouraging the client from continued use of health care services [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOn the other hand, Mark et al., (2017) showed that lack of adherence to ART regimen and non- disclosure of HIV status were key challenges associated with optimal treatment and care among adolescents in Sub-Saharan Africa. Non-adherence is a common problem, with many adolescents not adhering to the recommended treatment plan and regimen, and non-disclosure either by the adolescent or to the adolescent is also common. Such an approach does not facilitate the creation of a supportive context for adherence and, thereby, increases the probability of the treatment failure and the emergence of drug resistance. The work under consideration suggests that more specific psychological and social factors influencing adolescents\u0026rsquo; adherence should be explained and not just general concepts [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn the same way, Jaya et al., (2024) also discussed structural factors including the problem of clinic hours that are inconvenient for school and denial and neglect by young women as major barriers to STI healthcare. Stiffness of the clinics\u0026rsquo; timings hampered the young women and students to get the services they need, while carelessness and denial of symptoms delayed the help seeking process. This is because there are many logistical and psychological barriers which make it difficult for people to access the few available health facilities, let alone get the required services such as extended clinic hours and youth friendly facilities [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSimilarly, Ondenge et al., (2017) also noted other organizational factors including burnout and workload challenge as main factors that hinder effective provision of quality care. Fatigue and burnout among the providers limited their capacity to give quality, empathetic, and comprehensive care with the result of the patients losing interest. This burden from the health system not only influenced the providers\u0026rsquo; health but also the quality-of-service delivery as some patients complained that they were not being attended to sufficiently [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eEven though some of the PLHIV can appreciate the exhaustion of the healthcare workers, this does not in any way improve the health of the PLHIV. On the hand, Ondenge et al., (2017) explained that the kind of relationship that exists between the provider and the patient has an impact on the participation of the PLHIV to the healthcare services. Reporting on positive interactions with perceptive and caring providers helped patients to start and continue care and promoted trust. However, the negative interaction which can be defined as harassment, neglect or care less communication contributes to disengagement from care. It also pointed towards the importance of practicing patient-centered communication with the healthcare providers so that no patient has to fall in the category of non-responders. The perception of patients as \u0026ldquo;good\u0026rdquo; or \u0026ldquo;bad\u0026rdquo; based on their adherence to rules further complicated the dynamic, as it fosters favoritism and alienation [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn contrast, Silumbwe et al., (2018) highlight how geographical barriers, particularly the long distances to healthcare facilities, significantly hinder the consistent utilization of family planning and contraceptive (FP/C) services in rural areas. The effort required to travel long distances demotivates many women, contributing to discontinuation and intermittent use of contraceptive methods. Furthermore, the rigid scheduling of FP/C services means that clients arriving late risk being turned away, exacerbating the challenge of access. Discriminatory behaviors, such as scolding or ignoring marginalised groups like adolescents and unmarried women, deter these groups from seeking necessary care. Additionally, the frequent stock-outs of preferred contraceptive methods and the lack of trained personnel for long-acting reversible contraceptives (LARCs) further restrict access. The absence of policies facilitating contraceptive services in schools compounds these issues, leaving adolescents particularly vulnerable to early pregnancies and limited reproductive health options [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eLikewise, Ssekamatte et al., (2020) identified inadequate access to hormones and essential medical supplies, such as lubricants and STI drugs, as significant barriers for trans-women sex workers seeking comprehensive healthcare. The lack of proper access to hormones through healthcare facilities forces many to rely on private pharmacies without proper prescriptions or counseling, increased the risk of misuse and health complications. This inadequate support for transitioning dampened the motivation of trans-women sex workers to pursue gender-affirming care. Additionally, frequent stockouts of STI drugs and other medical supplies in key population-friendly healthcare facilities exacerbated the difficulty in accessing consistent, quality care [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Ssekamatte et al., (2020) also highlighted challenges in diagnosing and treating STIs for trans-women sex workers due to the lack of appropriate facilities, such as proctoscopy, in general healthcare settings. Many general facilities were catering primarily to heterosexual populations and were not equipped to handle STIs that affect the anal region, a common concern for trans-women sex workers. This gap in service provision led to inadequate diagnosis and management of STIs, further marginalised trans-women and compromising their health outcomes [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn addition, Avuvika et al., (2017) also identified structural barriers, such as the distance to STI testing facilities and the lack of youth-friendly centers, as significant obstacles. Adolescent girls and young women are reluctant to seek services that are either too far from their homes or too close, where they risk being seen by familiar faces. The absence of dedicated reproductive health centers that cater to the unique needs of youth exacerbates this issue. Furthermore, the study indicates that the lack of support from the broader community, particularly religious institutions, contributes to the silence and stigma surrounding adolescent sexual health [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSimilarly, Cornelius et al., (2018) also highlighted systemic inefficiencies, such as long waiting times and unsatisfactory healthcare worker attitudes, which deter women from accessing HIV services. Participants expressed dissatisfaction with the responsiveness of healthcare services and emphasised the need for greater government involvement in improving service delivery. The discussion of an anti-stigma bill reflects the participants' recognition of the importance of policy-level interventions to combat HIV-related stigma [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis systematic review identified key socio-economic, structural, and cultural barriers to HIV and STI care across sub-Saharan Africa (SSA), as well as factors that could improve access, retention, and adherence. High treatment costs, long travel distances to facilities, lack of complementary services, and insufficient food supply emerged as significant socio-economic obstacles. These were compounded by strong HIV-related stigma, a barrier documented both within SSA and internationally [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. In the Rufiji area of Tanzania, participation in antiretroviral therapy (ART) programmes was itself a source of stigma, as community members identified and openly targeted people living with HIV (PLHIV), sometimes through verbal abuse [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Agnarson et al. (2013) linked this to local beliefs that individuals on ART were more likely to spread HIV through unprotected sex.\u003c/p\u003e\u003cp\u003eThe review also highlighted reliance on traditional and alternative treatment systems over biomedical approaches as a major socio-cultural determinant of retention in care [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. While similar overlaps between conventional and traditional care systems have been noted in Tanzania and elsewhere in SSA [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e], the review underscored that traditional healers often play an important role for PLHIV because they are more accessible and affordable than distant biomedical specialists.\u003c/p\u003e\u003cp\u003eFemale sex workers (FSWs) in SSA, despite the wide geographical availability of HIV services [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], encountered multiple obstacles to access. At the individual level, these included internalised stigma, fear of a positive HIV result, lack of knowledge about available services, and misconceptions that sometimes led to rejecting negative results [\u003cspan additionalcitationids=\"CR41\" citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Social stigma was pervasive, originating from service providers, the general public, and even sex worker networks [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Structural barriers included discrimination in healthcare settings, confidentiality concerns, unfriendly services, inconvenient clinic hours, and procedural limitations such as strict refill policies that tied clients to a single facility. High mobility among FSWs and law enforcement interventions\u0026mdash;including arrests\u0026mdash;further disrupted continuity of treatment [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eSimilar barriers were observed in STI screening for young women and adolescents. Lack of information about STIs, the cost of medical services, and the widespread belief that being asymptomatic meant being disease-free reduced testing uptake [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Facilitators included access to urine-based testing, well-equipped facilities, assurances of confidentiality, and services that were easy to reach [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Absence of symptoms was often wrongly taken as evidence of being STI-free [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. The review noted that comprehensive sexual health education has been linked to more responsible sexual behaviour among teenagers, including delayed sexual debut, both of which reduce STI risk [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePoor adherence to treatment was identified by healthcare facilities as a significant obstacle [\u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. In a recent survey, adolescents living with HIV reported multiple adherence barriers [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. The review found that many facilities lacked clear procedures for detecting and managing loss to follow-up or non-adherence, and that counselling tools were underused (Stewart and Baeten, 2022). Young people aged 15\u0026ndash;19 were at particularly high risk of disengaging from care [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. Peer support was proposed as a solution, but supporting evidence was scarce. However, recent findings from Zimbabwe indicated that adolescent-led, community-based peer programmes could improve psychological wellbeing, adherence, retention, and linkage to care [\u003cspan additionalcitationids=\"CR59\" citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eNegative provider attitudes also emerged as a major barrier to STI treatment [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]. Adolescents were more likely to seek and stay in care when they perceived providers as adolescent-friendly [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. They were also more willing to share sensitive information with non-judgemental clinicians [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The review suggested that adolescent-friendly practices could be promoted through on-the-job training, reinforcement, and incentives [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. Privacy was a valued aspect of care; insufficient space and lack of confidentiality deterred service use [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e]. Other deterrents included long wait times, inconvenient working hours, and shortages of medicines and supplies. Improved resource availability was strongly correlated with increased STI treatment uptake [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eInadequate infrastructure also hindered access to STI information [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Testing behaviour was shaped by personal attitudes, confidence in self-testing, social influences, previous experiences, and perceived benefits. Motivators included concerns about health, ability to work, family responsibilities, and future aspirations [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Perceived risk was high for HIV but lower for syphilis, which was often seen as a minor concern unless symptoms appeared [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. In Uganda, dual HIV/syphilis testing during pregnancy\u0026mdash;driven by fears of infertility, HIV risk, and the desire for customer satisfaction\u0026mdash;boosted syphilis testing [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eLack of sexual health education resources, insufficient parental support, and negative community attitudes further restricted access for adolescents [\u003cspan additionalcitationids=\"CR35\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Parental and societal disapproval could prevent adolescents from seeking reproductive health services, particularly where guardian consent is required [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. The review suggested involving parents and community leaders in decisions on STI care to increase acceptance.\u003c/p\u003e\u003cp\u003eAmong trans-women sex workers, barriers included fear of disclosure, stigma, discrimination, and violence. Some avoided care altogether, especially in facilities lacking population-specific services. Fear of exposing gender identity or sex work status\u0026mdash;due to possible shame, discrimination, or legal consequences\u0026mdash;was a key deterrent [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e]. Internalised stigma, low self-esteem, and anticipated breaches of confidentiality were also influential. Less than half of participants in one study had ever tested for HIV, with fear of violence and gossip being strong deterrents [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]. Some altered their clothing to conform to social norms and reduce risk when accessing care, a practice also seen in Malaysia and the US [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e]. The review stressed the importance of inclusive, non-discriminatory SRH services and removing prejudice among providers and patients [\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e, \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMen\u0026rsquo;s experiences were also addressed. Okoror et al. (2016) challenged stereotypes of hypersexual African men by showing that many altered their sexual behaviours after HIV diagnosis, including practising safer sex and reducing alcohol and extramarital activities. However, stigma persisted, with community members targeting men with chronic illness even before diagnosis. Illness undermined traditional masculine ideals of strength and self-reliance, making it harder for men to accept their HIV-positive status. These constructions of masculinity heteronormative and patriarchal remain influential in many ethnic groups in southwest Nigeria [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe review emphasised the need for accessible, acceptable delivery systems for STI diagnostic testing [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Sociocultural and structural barriers such as low health literacy, shame, stigma, judgemental provider attitudes, and guardian consent requirements limited young people\u0026rsquo;s access to SRH care. While many said they would seek care if symptomatic, confidentiality concerns made them reluctant to use school-based services. Community-based STI testing, often integrated with HIV and SRH services and co-designed with young people, was preferred for its accessibility and acceptability. The review noted that uptake is the main determinant of screening programme effectiveness [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e], but achieving high coverage requires significant effort and service adaptation [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePartner notification, crucial for breaking transmission cycles, showed low yields. Less than 10% of partners in reviewed studies attended treatment after notification. In SSA, direct patient referral achieved a median 25% attendance, compared to 84% for accelerated partner therapy and 69% for provider referral [\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e]. Fear of violence, relationship breakdown, and accusations of infidelity were key deterrents, underscoring the importance of support and counselling for both index patients and partners [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eBarriers to medication access included prejudice, stigma, poor provider\u0026ndash;patient communication, drug shortages, and financial constraints [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e, \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e]. In one Nigerian setting, over 40% of women reported poor adherence due to miscommunication or rushed providers. Stigma was cited by nearly 30% as a reason for non-adherence [\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e]. Before the introduction of standardised dispensing procedures, 25% of patients at a large Nigerian institution were not receiving adequate HIV medication; this fell to 3% afterward [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. Concerns about the sustainability of foreign funding particularly from the U.S. President\u0026rsquo;s Emergency Plan for AIDS Relief were widespread, as withdrawal could worsen existing problems [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe review concludes that improving access, uptake, and adherence to HIV and STI services in SSA will require multi-level interventions. These include tackling stigma, ensuring consistent drug supply, improving provider attitudes, increasing privacy and confidentiality, involving community stakeholders, and expanding adolescent-friendly services. Evidence-based behavioural and structural strategies many already tested in high-burden east and southern African contexts can be adapted for Nigeria and other challenging environments across Africa and globally [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e].\u003c/p\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eLimitations and Strengths\u003c/h2\u003e\u003cp\u003eOne notable strength is the comprehensive approach taken in the research design, which utilizes qualitative methods to gather insights from various populations, including female sex workers, adolescents, and transgender individuals across multiple Sub-Saharan countries. This diversity in perspectives allows for a nuanced understanding of the socio-cultural, economic, and systemic factors that hinder access to STI healthcare. Additionally, the use of established guidelines from the Cochrane handbook and the CASP for evaluating the quality of the studies further bolsters the rigor of the review. However, the systematic review also has limitations that may affect the generalizability of its findings. The inclusion criteria restricted the analysis to studies published in English and within a specific timeframe (2014\u0026ndash;2024), potentially excluding relevant research published in other languages or before this period. This could lead to a biased representation of the available literature, as significant insights from non-English studies may be overlooked.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eImplications of Findings\u003c/h2\u003e\u003cp\u003eThe results of this systematic review demonstrated the complex barriers that people in SSA encounter in the search for health care for STIs. Stigma, economic factors, literacy, and structural barriers, including limited utilization of available services, deny those at high risk of HIV, especially female sex workers, adolescents, and transgenders from appropriate care. Such barriers did not only worsen the health inequity but also negatively impacted health and enhanced disease burden in the region. Stigma remains an ever-present issue, alongside poor healthcare systems, and socioeconomic factors, requires that more specific approaches and broader changes be made in the health-care systems to improve the care and situation of stigmatised populations.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe systematic review describes the major challenges to the healthcare seeking for STIs in Sub-Saharan Africa with the focus on the multifactorial interconnection between the stigma, lack of awareness, socio-economic barriers, and structural factors. A major theme that emerges is the wide spread of stigma related to STI and HIV which heavily influences the patient\u0026rsquo;s choice of care. The review suggests that more specific educational campaigns are needed to address these misconceptions and raise awareness of the existing healthcare options that can greatly improve preventive health behaviors. In addition, it identified socioeconomic status as a predictor variable that presented barriers, primarily, the costs associated with treatment. Some of the people said that the transportation costs and costs of seeking medical care made health care unaffordable even though there was free treatment. Additionally, structural barriers such as inflexible healthcare policies and inadequate service provision further hinder access to care. The review calls for policies that address these socioeconomic and structural disparities, including improved resource allocation, mobile healthcare services, and the development of youth-friendly healthcare environments that accommodate the unique needs of various populations.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eR.F. conceived the study, conducted the literature review, performed the data extraction and analysis, and wrote the full manuscript. A.K. reviewed and provided critical feedback on the manuscript drafts. All authors reviewed and approved the final version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eA. S. Keuroghlian, A. Mujugira, and K. H. 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Palanee-Phillips, \u0026quot;Prevalence of five curable sexually transmitted infections and associated risk factors among tertiary student men who have sex with men in Nairobi, Kenya: a respondent-driven sampling survey,\u0026quot; \u003cem\u003eSexual Health,\u0026nbsp;\u003c/em\u003evol. 20, no. 2, pp. 105\u0026ndash;117, 2023.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Sexually transmitted infections, Healthcare access, Barriers to care, Sub-Saharan Africa, Health disparities, Qualitative research, Public health","lastPublishedDoi":"10.21203/rs.3.rs-7361651/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7361651/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Sexually transmitted infections (STIs) are important public health issues in Sub-Saharan Africa (SSA) affecting vulnerable population groups including female sex workers, youths and transgender persons. This paper presents an overview of how various socio-cultural, economic, and systemic barriers allow limited access to healthcare services leading to poor health and increased disease burden.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAim:\u003c/strong\u003e This systematic review aims to explore and address the barriers to accessing effective healthcare for STIs in SSA, identifying key factors that hinder healthcare access and providing evidence-based recommendations for improvement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A systematic review method was used in this study following the Cochrane Handbook and other guidelines on reporting of systematic review. The review involved cross-sectional qualitative primary research studies in English language, conducted between 2014 and 2024, in Sub-Saharan Africa. The electronic sources used for the search include Google Scholar, CINAHL, and PubMed; the quality of the selected studies was assessed using the CASP check-list. Sixteen articles were chosen for this study to be analyzed in relation to the formulated themes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The major challenges noted were cultural, economic and healthcare system factors that hinders an individual to access effective health care for STIs in SSA. Pregnancy and sexually transmitted infections such as HIV were largely related to stigma and shame which entailed that females, female sex workers, and young people shy off from seeking the necessary services. These challenges were worsened by the economic factors including transport hitches and lack of resources while structural factors like rigid health care polices and long waitlists also impounded enrollment and compliance to treatment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e The research noted the factors that hinder the access and use of STI health care services in Sub-Saharan Africa and referred to certain approaches that need to be taken to eliminate stigma, increase health care awareness, and ensure availability of enhanced services. It is recommended to respond in the clients’ own language, prejudice in countenance, broadening the population to reach and making sure all the recurrences are available to sustain a welcoming healthcare setting.\u003c/p\u003e","manuscriptTitle":"Barriers in Healthcare for People with Sexually Transmitted Infections in Sub-Saharan Africa; A Systematic Review of Qualitative Studies","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-18 05:08:15","doi":"10.21203/rs.3.rs-7361651/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-25T10:08:03+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-21T11:50:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-21T11:49:34+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Public Health","date":"2025-08-13T06:46:01+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7c83842d-9ed9-43ab-87fd-554771764874","owner":[],"postedDate":"August 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-26T09:58:04+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-18 05:08:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7361651","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7361651","identity":"rs-7361651","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}