STI and HIV Service Provision: Symptoms, Treatment, and Counseling

1. Family Planning Counseling and Service Provision,STI Evaluation and Treatment, and HIV Counseling and/or TestingModule 3 - Session 2STI and HIV Service ProvisionOPTIONAL SET

2. A Note about Slides for Training in STIs and HIV • The second component of the PAC model notes that If countries have STI or HIV prevalence and available human resources, STI evaluation and treatment and HIV counseling and testing or referral for testing should occur. This set of slides provides a summary of STI and HIV. Additional training time would be needed to provide full information on STI. A full set of slides for STI training is available as an optional slide set.

3. Module 3 - Session 2Objectives At the end of this session, participants will be able to: • Describe the symptoms and complications of common STIs and HIV/AIDS • List the essential information that all postabortion clients must have about STIs before they leave the health facility • Explain how to evaluate, treat and follow up clients with STIs using the syndromic approach • Provide counseling within the context of STI/HIV risk

4. Sexually Transmitted Infections/Reproductive Tract Infections • Sexually transmitted infection (STI) refers to an infection that is passed from person to person by sexual contact. • STIs are part of a broader group of infections known as reproductive tract infections (RTIs). • Not all RTIs are sexually transmitted; some may be the result of an overgrowth of the bacteria and other organisms that normally live in the vagina. • While some RTIs can cause only mild discomfort, others can be very serious.

5. STIs/RTIs and HIV • The presence of any infection that causes irritation of the skin in and around the vagina increases the possibility of infection with HIV. • Though HIV is technically an STI, it is not a reproductive tract infection. • Hepatitis B and C are other examples of STIs that are not RTIs.

6. Presenting Symptoms • When a PAC client reports reproductive tract symptoms (pain, itching, swelling, sores, discharge), remember that not all infections of the genitals or reproductive tract are the result of sexual contact. • Telling a client he or she has a sexually transmitted infection can have serious negative consequences for the client and his or her sexual partners. Before doing so, be sure of the diagnosis.

7. Common STIs • Common infections that can be spread by sexual contact include: • Gonorrhea • Syphilis • HIV • Chlamydia • Trichomoniasis • Herpes • Human papillomavirus (genital warts and cervical dysplasia)

8. Presenting Symptoms (2) • Often, people infected with STIs, especially women, have no symptoms. • A woman often becomes aware of the presence of an STI during routine screening or if her partner is diagnosed. • Having symptoms does not necessarily mean the presence of an STI, so a thorough evaluation is critical.

9. Presenting Symptoms (3)

10. Presenting Symptoms (4)

11. Cervical Infections • The cervix is the most common site of infection for gonorrhea and chlamydia. • Infections of the cervix are often asymptomatic. • Despite lack of symptoms, a cervical infection can be severe if it reaches the upper reproductive tract. • When cervical infection is suspected, treat for both gonorrhea and chlamydia.

12. Gonorrhea • The bacteria that causes gonorrhea, Neisseria gonorrhea, grows in the: • Urethra • Cervix • Rectum • Throat (throat infection can occur following oral-genital sex with an infected partner) • Symptoms: • Women: purulent vaginal discharge, or pain and burning on urination. About 50% have no noticeable signs or symptoms. • Men: cloudy or pus-like discharge from the penis, pain or burning with urination, or swollen and tender testicles. Some men have no symptoms. • Gonorrhea infections in the rectum often have no symptoms, but gonorrhea in the throat may cause a sore throat.

13. Gonorrhea Complications • Women: if untreated/inadequately treated—can spread into the pelvic area and infect the uterus, fallopian tubes and ovaries. • Men: can infect the epididymis (where sperm are stored). Epididymitis can lead to infertility. • In utero: can be passed from mother to baby during birth. Without prompt treatment, the infant’s eyes can be seriously damaged, even resulting in blindness.

14. Gonorrhea Treatment Gonorrhea treatment (choose ONE) Treatment of choice: • Ceftriaxone, 125 mg IM injection as a single dose, OR • Cefixime, 400 mg by mouth as a single dose Alternative treatment: • Ciprofloxacin, 500 mg tablet by mouth as a single dose (Do NOT give to pregnant or breastfeeding women), OR • Spectinomycin, 2 g IM injection as a single dose If woman is pregnant, breastfeeding or <16 years of age: • Ceftriaxone, 125 mg IM injection as a single dose, OR • Cefixime, 400 mg by mouth as a single dose

15. Gonorrhea Treatment (2) • Treatments that may not be useful in countries where the disease is not commonly resistant to these medications are: • Kanamycin, 2 g intramuscular injection as a single dose • Trimethoprim, 80 mg/sulphamethoxazole, 400 mg; 10 tablets by mouth daily for 3 days (Do NOT give to pregnant or breastfeeding women.) Note: In most areas of the world, penicillin and tetracycline are no longer effective against gonorrhea: • Advise client to avoid sex until treatment is completed and symptoms are gone. Urge that sex partners(s) be treated.

16. Chlamydia • Caused by one of the most common STIs—especially among adolescents: • About 75% of women and up to 50% of men have no symptoms. • Left untreated, chlamydia can increase the risk of transmitting or acquiring HIV. • Symptoms: • Women: • Often have no symptoms of infection • Some notice an unusual vaginal discharge or bleeding after intercourse or between menstrual periods • Men: • Usually a clear discharge from the penis, and • Burning with urination, or • Swollen and tender testicles. • Many men have no symptoms

17. Lyphogranuloma Venereum • The same bacteria that cause symptoms of chlamydia can also cause another infection called LGV (lymphogranulomavenereum). • Symptoms in LGV: • Genital sores (ulcers) • Swollen lymph nodes (buboes)

18. Chlamydia Complications • Women: if untreated/inadequately treated, can spread into the pelvic area and infect the uterus, fallopian tubes and ovaries (PID). • Men: can affect the testicles and cause sterility. The symptoms of chlamydia are a discharge from the penis, pain or burning with urination, or swollen and tender testicles. Some men have no symptoms. • In utero: Chlamydia can pass from the mother to her baby during birth, infecting the baby’s eyes and possibly causing serious damage or even blindness.

19. Chlamydia Treatment Treatment of choice: • Azithromycin, 1 g by mouth as a single dose, OR • Doxycycline*, 100 mg by mouth 2 times daily for 7 days Alternative treatment: • Erythromycin 500 mg by mouth 4 times a day for 7 days, OR • Ofloxacin 300 mg by mouth twice a day for 7 days,OR • Tetracycline*, 500 mg by mouth 4 times daily for 7 days If woman is pregnant, breastfeeding or <16 years of age: • Erythromycin, 500 mg by mouth 4 times daily for 7 days, OR • Azithromycin, 1 g by mouth as a single dose, OR • Amoxicillin, 500 mg by mouth 3 times daily for 7 days * Do NOT give to pregnant or breastfeeding women.

20. Pelvic Inflammatory Disease (PID) • An infection of female internal organs, usually affecting the uterus, one or both fallopian tubes, the ovaries and surrounding pelvic tissues. These tissues become inflamed, irritated and swollen. • Causes of PID: • Several types of bacteria and other microorganisms • Chlamydia causes nearly half of all cases of PID; gonorrhea is the other cause of a large percentage of PID cases

21. Pelvic Inflammatory Disease (PID) Symptoms • The primary symptom is lower abdominal or pelvic pain, ranging from slight cramping (mild cases), to intense pain in severe cases. • Physical activity, especially sexual intercourse, may greatly increase the pain. • Abnormal vaginal bleeding (extremely heavy menstrual periods or bleeding or spotting between periods) is a very common symptom. • Abnormal vaginal discharge and fever may also be present.

22. Pelvic Inflammatory Disease (PID) Complications The complications of PID can be very serious. They include: Repeat PID: • Women who have had PID in the past are very likely to get it again if they are at risk of STIs. Pelvic abscess: • Local collection of pus in the pelvis formed by the breakdown of tissues; found in severe cases of PID and requires hospitalization, IV antibiotics and often, surgery. Chronic pelvic pain: • The scar tissue associated with PID may produce chronic pelvic pain or discomfort because of the distortion of the pelvic organs. Surgery may be required in severe cases.

23. Pelvic Inflammatory Disease (PID) Complications and Treatment Infertility: • When PID heals, scar tissue can form around the pelvic organs. • Scar tissue can cause blockage/distortion of the fallopian tubes. The result is that the egg cannot get through the tube and into the uterus. • After one episode of PID, a woman has an estimated 15% chance of infertility. After two episodes, the risk increases to approximately 35%, and after three, the risk is nearly 75%. Ectopic pregnancy: • An ectopic pregnancy occurs outside the uterus, most commonly in the fallopian tubes. Because PID can cause partial blocking of distortion of the fallopian tube, the chances of an ectopic pregnancy are greatly increased in a woman who has had PID. • An ectopic pregnancy is life-threatening and must be surgically removed. PID treatment: • Treat for gonorrhoea, chlamydia and trichomonas.

24. Recommended Outpatient Treatment for PID a When using these drugs, consider Neisseria gonorrhoeae resistance such as in some parts of Southeast Asia and Western Pacific. b Contraindicated for pregnant and breastfeeding women. c Patients taking metronidazole should avoid consuming alcohol; also avoid metronidazole during the first trimester of pregnancy.

25. Genital Ulcers • The most common genital ulcer diseases are: • Genital herpes • Chancroid • Syphilis • Differential diagnosis of genital ulcers using clinical features is often inaccurate, especially where several types of genital ulcer disease are common. • Clinical manifestations and patterns of genital ulcer disease may be different in people with HIV.

26. Genital Ulcers (2) • If the exam confirms the presence of genital ulcers, treat at the initial visit, if possible (per local guidelines): • For example, in areas where both syphilis and chancroid are prevalent, treat patients with genital ulcers for both conditions to ensure adequate therapy in case they do not return for follow-up. • Laboratory diagnosis of genital ulcer disease is rarely useful at the initial client visit and may even be misleading. • In areas of high prevalence of syphilis, a person may have a reactive serological test from a previous infection, even when chancroid or herpes is the cause of the present ulcer.

27. Syphilis • Caused by an organism called Treponemapallidum: • A curable infection • If not treated promptly or adequately, will progress through four stages with increasingly serious symptoms • A person infected with syphilis is also at a higher risk for transmitting or acquiring HIV • Symptoms: • Primary syphilis: • The first symptom is usually a small, painless sore in the area of sexual contact (penis, vagina, rectum or mouth) • Appears about 2–6 weeks after exposure and disappears within a few weeks • Because the sores are painless, many people do not realize they are infected

28. Secondary Syphilis Symptoms • Secondary syphilis: – After the sore of primary syphilis heals, symptoms of this phase appear. • The infected person can develop a non-itchy rash on the entire body, especially the palms of the hand or soles of the feet; flat warts (condylomatalata); swollen lymph nodes; fever; or tiredness. • These symptoms may last from 2–6 weeks and will eventually clear, even without treatment. • In the absence of treatment, the syphilis bacterium will remain and eventually enter the latent phase.

29. Latent and Tertiary Syphilis • Latent syphilis: • Is the period during which there are no visible signs or symptoms of the disease. • This period can last from 2–30 or more years after the client is infected. • A blood test (VDRL or RPR) is the only way to make a definite diagnosis during this period. • Tertiary syphilis: • Symptoms of this late stage of syphilis can occur from 2–30+ years after the initial infection. • Complications during this stage can include: • Gummas (small bumps or tumors on the skin, bones, liver or other organs) • Blindness • Insanity • Paralysis • If treated during this period, gummas will usually disappear • Though treatment at this phases will treat the disease and stop future damage, it cannot repair or reverse the damage that occurred before treatment.

30. Syphilis Complications • Untreated or inadequately treated syphilis can: • Produce symptoms from about 2 weeks up to 30 years or more as it progresses from early to late stages • While curable with antibiotics, complications in later stages cannot be reversed with treatment • Congenital syphilis: • Syphilis can be passed from mother to infant before/during birth • An infected newborn may suffer from blindness, other severe organ damage or death • Syphilis may also cause abortion or premature delivery

31. Syphilis Treatment Syphilis treatment for early disease: primary, secondary, or latent syphilis of 2 years or less (choose ONE) For anyone without penicillin allergy: • Benzathine penicillin C, 2.4 million units total, in 2 intramuscular injections during 1 clinic visit; give 1 injection in each buttock • Aqueous procaine penicillin G, 1.2 million units in 1 intramuscular injection once daily for 10 days Allergic to penicillin * (men and non-pregnant women only): • Doxycycline 100 mg by mouth 2 times daily for 14 days • Tetracycline 500 mg by mouth 4 times daily for 14 days Allergic to penicillin (pregnant women only): • Erythromycin 500 mg by mouth 4 times daily for 14 days. This treatment may not be effective. Urge these women to bring their babies within 7 days after birth for treatment for congenital syphilis. Urge client to ensure that their sex partner(s) also get treated.

32. Syphilis Treatment (2) Late Latent Syphilisor Latent Syphilis of Unknown Duration For anyone without penicillin allergy: • Benzathine penicillin G, 7.2 million units total, administered as intramuscular injections in 3 doses of 2.4 million units each at 1-week intervals Allergic to penicillin (men and non-pregnant women only): • Same as for early disease but treat for 4 weeks rather than 14 days Allergic to penicillin (pregnant women only): • Same as for early disease but treat for 4 weeks rather than 14 days

33. Congenital Syphilis Treatment Congenital Syphilis Treatment (choose ONE) • Procaine penicillin G, 50,000 units per kg of body weight, as one intramuscular injection daily for 10 days • Aqueous crystalline penicillin C, 100,000 to 150,000 U per kg of body weight per day, given as 50,000 units/kg intravenously every 12 hours for the first 7 days of life and every 8 hours thereafter for the next 3 days If more than 1 day of treatment is missed, the entire course should be restarted.

34. Allergy to Penicillin • Symptoms: • Occur within 20 minutesafter penicillin injection • Treatment: • Maintain the airway • Give oxygen • Give epinephrine • Symptoms of true allergy to penicillin: • Symptoms of anaphylaxis, including severe facial swelling, widespread itching and hives • Difficulty breathing and swallowing • Sudden drop in blood pressure • Weak and rapid pulse • Nausea • Vomiting • Abdominal cramps • Diarrhea • Confusion • Dizziness • Possible loss of consciousness

35. Chancroid • Chancroid is an STI caused by Haemophilus ducreyi: • Also called “soft chancre” • Common in countries where HIV prevalence is high • Chancroid ulcers are often confused with those of syphilis or herpes, so treatment for both is often given • Symptoms: • In men and women: soft, painful blisters or sores (ulcers) on the mouth, lips, genitals, anus or surrounding areas

36. Chancroid Complications • Treatment cures the infection and complications are rare • Untreated chancroid may lead to: • Swollen lymph glands in the groin area (buboes) that can rupture and drain pus • Scarring and fibrosis • Recto-vaginal fistula

37. Chancroid Treatment Chancroid Treatment (choose ONE): • Azithromycin, 1g by mouth as a single dose • Ceftriaxone, 250 mg intramuscular, injection as a single dose • Erythromycin, 500 mg by mouth 4 times daily for 7 days • Ciprofloxin, 500 mg by mouth 2 times daily for 3 days: • Do NOT give to pregnant/breastfeeding women or people <age 18 • Trimethoprim, 80 mg/sulphamethoxazole, 400 mg; 2 tablets by mouth 2 times daily for 7 days. (Use only in area where it has been proved effective against chancroid and its effectiveness can be regularly monitored. (Do NOT give to pregnant or breastfeeding women.) • Re-examine in 3 to 7 days. Sex partner(s)—even those with no symptoms— should be treated if they had sex with patient within 10 days before patient’s symptoms started or since symptoms started.

38. Genital Herpes • Genital herpes (herpes simplex virus, type 2) is: • Transmitted through direct contact with the painful ulcers the infection causes • Can also be passed to a sexual partner even after the sores have healed or before an outbreak has occurred • Herpes can be transmitted between the genitals and the mouth during oral sex

39. Genital Herpes Symptoms • Herpes sores heal on their own after 1–2 weeks, but the virus stays in the body after the sores are healed, causing outbreaks (outbreaks are when the sores return after healing; they can happen weeks, months or even years apart). • Symptoms: • In men and women: blisters or ulcers (sores) on the mouth, lips, genitals, anus or surrounding areas • Burning or pain during urination • Itching or tingling in the genital area

40. Genital Herpes Complications • There is no cure for herpes, but there are ways to relieve pain caused by the sores. • Some people experience repeated (often painful) outbreaks. • Can be transmitted to a baby during pregnancy and delivery. If infected, the baby can become very sick and possibly die.

41. Genital Herpes (HSV-2) Treatment • There is no cure available. The client should keep the infected area clean and try not to touch the sores. Antibiotic ointments may help. • Clients should not have sex when blisters are present—not even with a condom. Herpes can be spread even when no blisters are present, but a condom may provide some protection. • Duration of symptoms can be shortened if treatment begins early in an outbreak. If not started early, treatment may be ineffective. • Urge that sex partners be evaluated and counseled and, if they have symptoms, treated.

42. Genital Herpes (HSV-2) Treatment (2) • For first outbreak: • Give acyclovir, 200 mg by mouth 5 times a day for 7 days, OR • 400 mg 3 times a day for 7 days. • For recurrences of blisters: • Give acyclovir, 200 mg by mouth 5 times a day for 5 days. • If client has outbreaks > 6 times a year, treat with acyclovir, 400 mg by mouth 2 times a day for 1 year and then reassess.

43. Viral Infections: Human Papillomavirus • Human papillomavirus (HPV): • Is the most prevalent sexually transmitted infection in the world, occurring at some point in up to 75% of sexually active women • Are a group of more than 100 viruses • Are called papillomaviruses because certain types may cause warts, or papillomas, which are benign tumors • Some types of HPV are associated with certain types of cervical cancer

44. Human Papillomavirus (2) • Sexual contact with a person infected with some types of HPV may cause warts to appear on or around the genitals or anus. • Genital warts (condylomata acuminata) are most commonly associated with two HPV types, HPV–6 and HPV–11. • Warts may appear within several weeks after sexual contact with an HPV-infected person; or they may take months or years to appear, or may never appear.

45. Human Papillomavirus (3) Symptoms: • Men and women: genital and/or anal warts (HPV-6, HPV-11). • Many HPV infections do not cause any symptoms. Complications: • Some types cause abnormal changes in the cells of the cervix, which, if left untreated, can lead to cervical cancer. • The types of HPV that cause genital warts are different than the types that cause cancer.

46. HPV Treatment • Currently there is no treatment for HPV infection. • HPV can stay in the body even after genital warts are removed. • Once infected, a person is most likely infected for life. • An active infection is controlled by the immune system and with time becomes dormant. • It is not possible to predict whether or when the virus will become active again. • HPV can be transmitted to others if the virus is active (i.e., the warts re-appear).

47. HPV Treatment (2) Treatment for anogenital warts (choose ONE): • Podophyllin 10–25% in compound tincture of benzoin: • Apply carefully to the warts, avoiding normal tissue. • External genital and perianal warts should be washed thoroughly 1–4 hours after application of podophyllin. • Allow treatment to dry before the speculum is removed. • Repeat treatment at weekly intervals. DO NOT use during pregnancy. • Trichloracetic acid (TCA) (80–90%): • Apply carefully to the warts, avoiding normal tissue. • Follow by powdering of the treated area with talc or sodium bicarbonate to remove un-reacted acid. • Repeat application at weekly intervals.

48. HPV Treatment (3) • Genital warts can also be treated by cryotherapy, electro- surgery or surgical removal. • Selection of removal method will depend on the methods available and the anatomical location of the warts. • Advise all patients that warts often reappear even after treatment.

49. HPV and Cervical Cancer • HPVs are now recognized as the major cause of cervical cancer. • Nearly all cervical cancers are directly linked to previous infection with one or more types of HPV. • Cervical cancer strikes nearly half a million women each year worldwide, claiming a 250,000 lives. • When possible, screen all women for cervical cancer.

50. Vaginal Infections • Vaginal infections (trichomoniasis, bacterial vaginosis and candidiasis): • Are very common in women of reproductive age • Are nearly always symptomatic • Rarely cause complications