Management of sexually transmitted infections

1. Management of sexually transmitted infections Dr. Anupong Chitwarakorn Department of Disease Control Module 3 Sub module

2. Content Review of evidence of STD as co-factors in HIV transmissionIntervention studies : STD control reduce HIV incidence Principles and strategies of STD control program in developing countries

3. Review of evidence of STD as cofactors in HIV transmission presence of STD : increase viral load in genital secretionpresence of STD : increase HIV susceptibility, disrupture of epithelium cell Biological evidence

4. Association of STD and cervico – vaginal HIV shedding ( % ) of pt. with HIV shedding

5. Relationship between genital HIV shedding, presence of infections and clinical signs. no pus no pus pus

6. Median concentration of HIV – 1 RNA in semen among 104 men with and without urethritis (Malawi) X 104 copies / ml

7. STD increase HIV genital shedding Semen Urethritis genital ulcer - increased leucocytes N.gonorrhoea - Cervico-vaginal secretion muco – purulent cervicitis cervical ulcer vaginal ulcer increased leucocytes N.gonorrhoeae Chlamydia Review of evidence of STD as cofactors in HIV transmission.* Biological evidence

8. Hypothetical model of impact of STD on HIV genital shedding in men Antibiotic therapy 10 HIV RNA in blood plasma HIV RNA in semen 8 Log10 copies STD 6 4 2 Seroconversion Asymptomatic HIV progression AIDS From ISSTDR, Seville 1997; M. Cohen, plenary presentation

9. Relative risk : STD as risk factors for HIV transmission Study population STD RRHeterosexual men, Kenya genital ulcer 4.7Heterosexual men, U.S.A. syphilis 1.5 - 2.2Heterosexual men, U.S.A. herpes 4.4Heterosexual women, Zaire gonorrhoea 3.5 chlamydia 3.2 trichomonas 2.7Heterosexual men, U.S.A. herpes 3.3 - 8.5 syphilis 8.4 - 8.5

10. Intervention studies : STD case finding strategies among CSW in Abidjan HIV incidence/100 pyBefore intervention 16.5Basic strategy : monthly case finding 7.9Intensive strategy : monthly case 5.5 finding using pelvic exam, and lab

11. HIV incidence over 2 years in intervention and control communities in the Mwanza trial • Establishment of STD reference centre in Mwanza town • Training of HCW in syndromic approach,health education and condom promotion • Regular supply of effective STD drugs through a separate disbribution system • Regular supervisory visits to health centres • Periodic visits to the villages by health educators to promote prompt attendance to health centres for symptomatic STD

12. HIV incidence over 2 years in intervention and control communities in the Mwanza trial 4 HIV incidence: Overall reduction of HIV: 42 % intervention control 3 2 1 0 1 2 3 4 5 6 From Grosskurth et al., Lancet, 1995

13. Intervention studies : Mass treatment, Rakai, Uganda STD group (7,871) Control clusters (7,256)Azithromycin 1 gm Mebendazole 100 mg Ciprofloxacin 250 mg Iron – foliate tablet Metronidazole 2 gm Low dose MTV Both groups were screened and treated for syphilis Result: STD prevalence was significantly reduce in intervention group No impact on HIV incidence Mass treatment in 10 monthly intervals (15-59 yrs)

14. STD Control : Objectives • To interrupt the transmission of STD (acquired infection) • To prevent complication and sequelae • To reduce HIV infection risk

15. Incidence of STDs in Thailand(1982-2001) First case of AIDS in 1984 100% condom initiated in 1989 100% condom completed in 1992

16. STD prevention and control: before 1989 • Contact tracing • Health education • Control of CSW • Case finding • Case treatment • Case follow up

17. 1. Health promotion : safer sex practice, condom use2. Interventions among high risk behavioral groups3. Adequate, effective STD case management4. Integration between STD services and other programs : MCH, RH, ANC, etc5. Increase awareness and improve health care seeking behavior 6. Case screening and specific prophylaxis programs Effective STD control program :Principle

18. Number of STD cases and condom use rateamong male & CSW (1984-1998) percent thousands - 100 - 75 - 50 - 25 - 0 male prostitute Condom use rate

19. No. of Gonorrheae in two private clinic in Bangkok 1989 - 1998 Clinic A Clinic B

20. Effective STD Control program Adequate, effective STD case management STD care services: accessible, acceptable and effective   - Potential sources: public, private, informal sector  - Quality improvement : national guideline, syndromic approach; drugs/condom supplies training

21. Integration/collaboration between STD control program and other programs : ANC, MCH, FP, RH, dermatology and other existing programsTo enable early detection of STD and to provide more coverage STD service Effective STD Control program

22. Effective STD Control program National / local media campaignsEducation for youth in / out of schoolCommunity initiatives (e.g. peer education/ clubs)Education in health facility waiting area Education as part of STD serviceWork place education programs Increase awareness and improve health care seeking behavior

23. Effective STD Control program Case screening and specific prophylaxis programs • syphilis screening in pregnancy • prophylaxis of opthalmia neonatorum

24. Supporting components STD surveillance system Training of health staffs Monitoring, evaluation and supervision Effective STD Control program

25. Effective STD control program :Principle 1. Health promotion : safer sex practice, condom use2. Interventions among high risk behavioral groups3. Adequate, effective STD case management4. Integration between STD services and other programs : MCH, RH, ANC, etc5. Increase awareness and improve health care seeking behavior 6. Case screening and specific prophylaxis programs

26. Operational model of the role of health services in STD case management Population with STD Aware and worried Seeking care Correct diagnosis Correct treatment Treatment completed Cure

27. Operational model of the role of health services in STD case management Population with STD Aware and worried Seeking care Correct diagnosis • Promotion of health care seeking behaviour • Improve quality of care • Attitudes of personnel Correct treatment Treatment completed Cure

28. Operational model of the role of health services in STD case management Population with STD Aware and worried Seeking care • Syndromic approach • Include STD drugs in essential list • Prescribe single dose • Counsel about compliance Correct diagnosis Correct treatment Treatment completed Cure

29. Clinical Diagnosis Approach Identify the STD causing symptoms based on clinical experience • even experienced STD providers • often misdiagnose STDs • miss mixed infections • difficult for surveillance

30. Etiologic Diagnosis Approach Identify the organism causing the symptoms with laboratory tests and microscopy • tests can be time consuming and expensive • e.g. cultures cost $12 - $40 & take up to six days • even rapid tests (RPR) require equipment to obtain • and separate venous blood • dependent technician & lab accuracy

31. Syndromic Diagnosis Approach Identify all possible STDs that could cause syndrome and give recommended treatment based on epidemiologic and laboratory data Symptom • Immediate treatment • decrease transmission • decrease complications • Can do syndrome surveillance • Need to weigh the ability to treat as many • infected as possible (sensitivity) with the risks of overtreatment (specificity) • resistance & stigma Decision Action action action action

32. THE SUPPOSED TO … APPROACH Oops! I was supposed to . . . RPR

33. No Urethral discharge Patient complains of urethral discharge or dysuria Take history and Examine. Milk urethra if necessary • Educate and counsel • Promote and provide condoms • Depending on counselling capabilities offer HIV testing Ulcer(s)present? Discharge confirmed? No Yes Yes • Treat for gonorrhoea and chlamydia • Educate • Counsel if needed • Promote and provide condoms • Depending on counselling capabilities offer HIV testing • Partner management • Advise to return in 7 days if symptoms persist Use appropriate flow chart Figure 1

34. Genital ulcers Patient complains of genital sore or ulcer Take history and examine • Educate and counsel • Promote and provide condoms • Depending on counselling capabilities offer HIV testing Sore/Ulcer/Vesicle present? No Yes • Management of herpes • Educate • Counsel on risk reduction • Promote and provide condoms • Depending on counselling capabilities offer HIV testing Vesicles or small ulcers with history of recurrent vesicles? Yes No • Treat for syphilis andchancroid • Educate • Counsel on risk reduction • Promote and /provide condoms • Depending on counselling capabilities offer HIV testing • Partner management • Advise to return in 7 days Yes Clinical deterioration, or no improvement after one week? : Needs adaptation to local epidemiological situation Figure 3

35. What proportion of STD is asymptomatic? • Incidence studies • 2% of incident infections with gonorrhoea remained asymptomatic for at least 2 weeks (Harrison et al., New England Journal of Medicine, 1979) • Prevalence studies • Screening pregnant women (GC/CT) 40% • Screening FP clinic attenders (GC) 80% • Male contact of clinical cases (GC) 29% • Male contacts of cases detected 76% through screening (GC)

36. Operational model of the role of health services in STD case management Population with STD Aware and worried asymptomatic STD Seeking care Correct diagnosis • Partner notification • Case finding • Screening • Selective mass treatment Correct treatment Treatment completed Cure

37. Where STD control is likely to have a maximum impact • In settings with high prevalence of “relevant” STD (GUD, urethritis and cervicitis) • Low quality of STD services • At the earlier stages of the HIV epidemic It is NOT A MAGIC BULLET, but an essential component of a package of multiple HIV prevention strategies

38. STI.PAC The 5 elements Assess The epidemic and the response Evaluate interventions Advocate for STD inclusion in the health care agenda Integrate STD prevention and care Strengthen STD activities

39. Thank you See you in BangkokWord AIDS Conference 11-16 July,2004