Sexually Transmitted Disease

Sexually Transmitted Disease 24th July 2002 Presented by Wong Kwok Tung

Viral • AIDS • Genital Herpes • Genital Warts • Molluscum contagiosum • Hepatitis

HIV Disease • HIV is a human retrovirus • 2 types - HIV-1 HIV-2 • HIV infection is characterized by a progressive depletion of CD4 lymphocytes

HIV Disease • Diagnosis- Screening assay (ELISA) and a confirmatory test (Western Blot) • Its sensitivity and specificity ~99% • False negative result during the window period • Sexual contacts accounts for 80% of all HIV infection

HIV Disease • Heterosexual 70%, Homosexual 10% • The presence of ulcer increase the risk of transmission, thus the risk is higher in those who have coexisting STD • The average length of time from HIV infection to development of AIDS in developed countries is about 10 year

HIV situation in 2001 in HK • Sex • male 1435 • female 320 • Exposure category • heterosexual 1001 • homosexual 336 • bisexual 84 • injecting drug user 44 • blood/blood product 68 • perinatal 14

HIV disease • Patient may present as fever, night sweat , myalgia, malaise, unexplained diarrhoea, weight lost, and persistent generalized lymphadenopathy.

Opportunistic infection • Candidiasis • TB, Mycobacterium avium intracelluare • CMV, Herpes • Pneumocystosis, Crytpcoccosis, Toxoplasmosis

Malignancies • Kaposi’s sarcoma • Non-Hodgkin lymphoma • Primary CNS Lymphoma • others- testicular CA, cervical CA

Poor Prognostic indicator • Low CD 4 count • Reversed CD4:CD8 ratio • Diminished cutanous cell- mediated immunity • Raised HIV p24 antigenaemia

Treatment • Medication - AZT azidothymidine, DdI Didanosine, ddC zalcitabine • Treat opportunistic infection • Contact tracing • Education to prevent further spread of disease • Psychosocial support

Genital Herpes • The most common form of genital ulceration in developed countries • Recurrent attacks are likely(~50%), and not necessarily related to sexual activity • In 1999 in the UK, 17456 people were diagnosed with a first episode of genital herpes and 14329 with recurrent herpes • Herpes can facilitate HIV transmission

Genital Herpes • Studies have confirmed the risk factors for the acquisition of herpes simplex virus type 2 including • age (infection is uncommon in children) • sex (women have higher rates than men) • increase no. of sexual partners • earlier age at first sexual intercourse • history of other STD • involvement in the commercial sex industry

Genital Herpes • Incubation period 2-10 days • primary infection may be asymptomatic • Women are generally severely affected than men • presents as groups of papules which may be pruritic or painful, vesicles, non indurated tender ulcer, crust

Genital Herpes • Can occur in genitalia, anus, month • Increasing evidence shows that many herpes infections are asymptomatic, thus stimulating discussion about how transmission can be reduced

Genital Herpes • Consistent use of condom • ?Continuous use of anti-herpes drugs would decrease the quantity of asymptomatic viral shedding • Considerable interest has been shown in the development of a vaccine to prevent acquisition of genital herpes

Diagnosis • Clinical • Tissue culture • Antigen detection test (ELISA, immunofluorescence, EM) • Type specific antibody assay ( antibody to HSV-2 )

Treatment • Topical treatment- Acyclovir • Oral treatment Acyclovir 200mg 5x /day x 7-10 days • Very frequenent recurrences may benefit from low dose Acyclovir for 6 months ( 200mg 2-3 times per day)

Advise • Warm salt bath • Hot/Ice pack • Painkiller • pass urine in warm bath • keep the sores dry • wear loose underwear, avoid tight jeans

Prevention • Use condom • Avoid sex during active lesion • wash genitals with soap and water immediately after sex

Genital warts • Warts are caused by HPV • Strong association between wart infection and cervical epithelial change which may progress to CIN and later invasive CA • HPV type 6,11.16,18 are particularly linked with genital warts • type 16 and 18 are high risk associate with CA cervix, while type 6 and 11 are low risk

Genital warts • In males, warts are found slightly more frequently in the uncircumcised • lesions most commonly adjacent to the fraenum,coronal sulcus, and inside the urinary meatus • can also occur in rectum, anus, perianal area

In female, warts are most commonly found at the fourchette, labia,perineum and perianal area • Pap smear is a essential part of examination • Recurrences are common

Treatment • Treatments were remains unsatisfactory, with all treatments having similar response rate (50-75%) • 0.5% podophyllotoxin paint BD for 3-7 days • Cryotherapy • ? Intralesional injection of alpha interferon • Imiquimod, a new topical immuno- therapeutic agent (lower relapse rate)

All female patient should referred to specialised clinic for colposcopy

Mollusum contagiosum • Caused by pox virus which is transmitted by direct contact • Incubation period 2-7 weeks • presents as small,shiny, umbilicated, hemispherical, white papules, which may gradually enlarge, reaching a max diameter of 8-10mm

Molluscum may be found anywhere on the body, in genital area, it usually seen on the pubis or penis • Lesions are asymptomatic or slightly pruritic

Treatment • Usually resolve spontaneously • Deroofing aseptically with a needle and expressing the contents • 25% podophyllin in tinc benzoin co • destruction with electrocautery or diathermy

Protozoa • Tricomonas vaginalis

Trichomonas vaginalis • A protozoal parasite • It is a rounded or oval unicellular organism 15-30um with 4 flagella, lateral undulating membrane

Diagnosis • Easily recognised in fresh specimen under dark ground microscopy

Most common curable STD worldwide • most common form of vaginitis • associate with higher risk of gonorrhoea and HIV infection • Transmission can through sexual activity and contaminated instruments, eg toilet seat, towel, sex toy

Common symptoms • increase vaginal d/c • vulval sorenss • superficial dyspareunia • offensive odor • valval pruitis

Male • asymptomatic • urethral discharge • urethral pruitis

Treatment • Metronidazole 400mg BD x 1 week • Cure rate ~85% • if partner also treated spontaneously, cure rate -> 95%

Genital scabies • The mite Sarcoptes scabiei is frequently transmitted during sexual contact • The lesion are intensely pruritic and characteristically, pruritus is exacerbated at night or the patient is warm

Genital scabies • Classical lesion is a slightly raised sinuous burrow while excoriation, secondary infection or eczematous change may distort the appearance

Treatment • Lidane 1% lotion • Benzyl benzoate 25% left for 24 hour before wash off • boil underwear and linen

Pediculosis pubis • Commonly transmitted during sexual contact • but may also be transmitted from shed hair, clothing, towel • patient may be itching or noticing movement of the small (1-2mm) yellow brown or grey lice, or the minute black or dark brown nits attached to the base of a hair

Treatment • Lidane 1% lotion,apply thoroughly to wet hair and scalp of the affected and adjacent hairy area, allow to remain 4 minutes and then rinse thoroughly • Bed clothes and underwear washed in boil water • sexual contacts and family must be treated

Prevention of STDs • Education and counseling of persons at risk to adopt safer sexual behavior • Identification of asymptomatically infected persons and of symptomatic persons unlikely to seek Dx and Tx • effective Dx and Tx of infected persons • evaluation, treatment and counseling of sex partners of persons who are infected with STD

Prevention on STDs • Pre exposure vaccination of persons at risk for vaccine preventable STDs

Prevention of STDs • The most reliable way to avoid transmission of STD is to abstain from sexual intercourse (oral, vaginal, anal sex ) • Mutually monogamous relationship with uninfected partner • If a person chooses to have sex with a partner whose infection status is unknown or who is infected with HIV/STD, a new condom should be used for each act of insertive intercourse

Pre-exposure vaccination • It is one of most effective methods for preventing transmission of certain STD, such as Hepatitis B

Preventive methods • Condom • effective in preventing infections transmitted by fluids from mucosal surfaces (gonorrhoea, chamydia, trichomonas, and HIV) • less effective in preventing those transmitted by skin to skin contact (herpes simplex virus, HPV, syphilis, chancroid)

Preventive methods • In US, each latex condom are tested electronically for holes before packaging • ~2 broken per 100 condoms used • condom failure usually result from inconsistent or incorrect use

Recommendations on using condom • Use a new condom with each act of sexual intercourse • carefully handle the condom to avoid damaging it with fingernails, teeth, or other sharp objects • put the condom on after penis is erect and before any genital contact with the partner

Use only water-based lubricants (KY Jelly) with latex condom. Oil based lubricants (massage oil, body lotion, cooking oil) can weaken latex • Hold the condom firmly against the base of the penis during withdrawl, and withdraw while the penis is still erect to prevent slippage

Preventive methods • Spermicides are not recommended for STD prevention • Neither vaginal sponges nor diaphragms should be relied on • Condoms lubricated with spermicides are no more effective than other lubricated condoms in preventing against STDs

Preventive methods • Women who are not at risk for pregnancy might incorrectly perceive themselves to be at no risk for STDs • Those women who use hormonal contraception, IUCD, surgical sterilized and had hysterectomy should be counsel regarding the use of condoms

Sexually Transmitted Disease