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An overview of Sexually Transmitted Infections (S TIs) . Vanessa Hamilton Advanced Sexual Health Nurse , Nurse Educator Melbourne Sexual Health Centre. Important local points * Source: DHS Victoria vidb Jul 2007. HIV 91% HIV cases diagnosed in men, *

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an overview of sexually transmitted infections s tis

An overview ofSexually Transmitted Infections (STIs)

Vanessa Hamilton

Advanced Sexual Health Nurse,

Nurse Educator

Melbourne Sexual Health Centre

important local points source dhs victoria vidb jul 2007
Important local points *Source: DHS Victoria vidb Jul 2007
  • HIV 91% HIV cases diagnosed in men, *

81% of these men-who-have-sex-with-men (MSM)*

Decrease in number of diagnoses of AIDS since 94-95 (HAART)

12 cases heterosexual (1 born high prevalence country;6 reported sex in high prevalence country; 3 IDU; 2 – locally acquired?)*

  • Gonorrhoea 80% in MSM, *

nearly all amongst MSM; heterosexual – sex overseas*

increasing amongst MSM; Issue – antibiotic resistance

  • Syphilis 300% increase in infectious syphilis*

90% amongst MSM*

  • Chlamydia 4 fold increase in last decade in Australia

mostly impacting young women

        • :
chlamydia
Chlamydia
  • Most commonly reported bacterial infection in Australia
  • Increasing in all states
  • Significantly increased rates in Indigenous Australians in NT
  • Urgent public health situation– notified cases in Victoria almost tripled since 1990s
chlamydia by year and state territory
Chlamydia by year and State/Territory

Source: National Notifiable Diseases Surveillance System

chlamydia by year and age group
Chlamydia by year and age group

Source: National Notifiable Diseases Surveillance System

chlamydia1
Chlamydia

Sites

  • cervix, urethra,
  • can also infect the anus and less commonly eyes and throat

Transmission

  • vaginal, anal and less commonly oral sex
chlamydia2
Chlamydia
  • The highest burden of infection is in the 15- 29 year age group slightly more common in 20-29
  • Usually asymptomatic
  • Significant personal and public (financial) consequences if not detected
  • However it is relatively cheap and easy to diagnose
  • Relatively cheap and easy to treat
chlamydia symptoms in males
Chlamydia-symptoms in males
  • 50% or more of men with chlamydia urethritis are asymptomatic (30-60% quoted depending on study)
  • Symptomatic urethritis has an incubation period of usually 7-14 days
  • Symptoms are urethral dishcharge (white or grey), dysuria, discomfort, redness at urethral opening
chlamydia complications in males
Chlamydia complications in males
  • Epididymitis
  • Sexually reactive arthritis – inclduign Reiter’s syndrome
  • Transmission to others especially women
chlamydia symptoms in females
Chlamydia – symptoms in females
  • Cervical STIs are most often asymptomatic
  • Unusual vaginal discharge
  • dysuria
  • deep dyspareunia,
  • intermenstrual or Post coital bleeding
  • lower abdominal pain
  • cervix may appear inflamed with a mucopurulent discharge and contact bleeding. (MPC mucopurulent cervicitis)
chalamydia complications in women
Chalamydia complications in women
  • 50% will have endometritis
  • Between 10-40% of women infected with chlamydia develop PID
  • Tubo-ovarian abscess
  • Ectopic pregnancy; infertility
chlamydia diagnosis
Chlamydia Diagnosis
  • Nucleic Acid Amplification Tests (NAATs)

Detect Chlamydia trachomatis in swabs and urine

  • These DNA amplification tests include
    • PCR polymerase chain reaction
    • LCR ligase chain reaction
  • Check with your local lab as to which test they use
chlamydia diagnosis cont
Chlamydia Diagnosis cont…

Male

  • Urethral, urine
  • Rectum (MSM)

Rectum and throat not validated

Female

  • Endocervical, high vaginal, urine
management
Management
  • Antibiotic Treatment
    • Azithromycin 1g orally once or
    • Doxycycline 100mg bd for 10 days or
    • Roxithromycin 300mg daily as a single dose (or 150mg bd) for 10 days
    • Recommended to avoid sex during and for seven days after treatment
chlamydia management continued
Chlamydia Management Continued
  • Contact Tracing
  • TORI – 3 months
gonorrhoea
Gonorrhoea
  • Bacterium Neisseria gonorrhoeae
  • Mucous membranes of the urethra, cervix, anus throat and eyes
  • Readily transmitted by anal, vaginal and oral sex
gonorrhoea1
Gonorrhoea
  • Rates going up more recently on NSW and VIC and SA – MSM
  • Rates much higher in NT and WA specifically due to rates in Indigenous Australian populations
gonorrhoea by year and state territory
Gonorrhoea by year and State/Territory

Source: National Notifiable Diseases Surveillance System

gonorrhoea by year and age group
Gonorrhoea by year and age group

Source: National Notifiable Diseases Surveillance System

gonorrhoea2
Gonorrhoea
  • Highest rates in 15-29 year age group
  • Different to CT as also somewhat higher rates in 30-35 year old due to higher incidence in MSM and Indigenous Australian populations
gonorrhoea diagnosis
Gonorrhoea - Diagnosis
  • Isolation of N. gonorrhoeae by culture is the diagnostic standard
  • DNA based tests
  • Advantages
    • Rapid results
    • Good for remote areas – transport
    • Urine or tampon
    • Sensitivity equal or better than culture
gonorrhoea3
Gonorrhoea
  • Ceftriaxone 250mg via IMI recommended treatment in Australia
  • Sensitivity tests in April 2003 of MSM showed 7% resistance to Ciprofloxacin
  • Gonorrhoea resistance not covered here.
  • Please refer to Venereology Society of Victoria, National Management Guidelines for STIs, 2002 or MSHC website
infectious syphilis by year and sex
Infectious syphilis by year and sex

Source: National Notifiable Diseases Surveillance System

syphilis1
Syphilis
  • A complex systemic illness with multiple clinical manifestations
  • Syphilis can be acquired:
    • Through sexual contact
    • By passage through the placenta
    • By kissing or other close contact with an infected lesion
    • By transfusion of fresh human blood
    • By accidental direct inoculation
serologic tests
Serologic Tests
  • Nonspecific nontreponemal tests
    • The RPR
    • Cheap, rapid
    • Convenient for screening large numbers of sera
    • Indicates disease activity
  • Specific antibody tests
    • TPHA, FTA-Abs
    • Establish the high likelihood of infection
    • Generally remain reactive over time, even after treatment
sypilis treatment
Sypilis treatment
  • Early Syphilis:

Benzathine penicillin 1.8 gm IM single dose

or Doxycycline 100mg twice daily for 14 days if allergic to penicillin

  • Late latent syphilis:

Benzathine penicillin 1.8 gm IM weekly for three weeks

the hiv epidemic in victoria
The HIV epidemic in Victoria

Cumulative figures to 31 December 2006

  • HIV diagnoses - 5,390
  • AIDS - 2,041
  • Deaths - 1,481
diagnoses of hiv infection and aids 1 in australia
Diagnoses of HIV infectionand AIDS1 in Australia

1. AIDS diagnoses adjusted for reporting delays.

Source: State and Territory health authorities

the hiv epidemic in australia
The HIV epidemic in Australia

Cumulative figures to 31 December 2006

  • HIV diagnoses - 26,267
  • AIDS - 10,125
  • Deaths - 6,723
global summary of the hiv aids pandemic as of december 2007
Global summary of the HIV/AIDS pandemic, as of December 2007

Number of people living with HIV/AIDS Total 33.2 million (30.6 – 36.1 million)Adults 30.8 million (28.2 – 33.6 million) Women 15.4 million (13.9 – 16.6 million) Children under 15 years 2.5 million (2.2 – 2.6 million)

People newly infected with HIV in 2007 Total 2.5 million (1.8 – 4.1 million)Adults 2.1 million (1.4 – 3.6 million) Children under 15 years 420 000 (350 000 - 540 000)

AIDS deaths in 2007 Total 2.1 million (1.9 – 2.4 million)Adults 1.7 million (1.6 – 2.1 million) Children under 15 years 330 000 (310 000 - 380 000)

The ranges around the estimates in this table define the boundaries within which the actual numbers lie, based on the best available information.

post exposure prophylaxis
Post-exposure Prophylaxis
  • There is some evidence that antiretroviral therapy, given within 72 hours of exposure, may reduce the risk of infection
  • Treatment is given for four weeks
  • A risk-assessment must be performed, and weighed against the side-effects and possible development of drug resistance
  • balance between the amount of HIV produced each day and the amount of HIV cleared by the immune system
further reading
Further Reading
  • ASHM, HIV/Hepatitis: a guide for primary care, 2001
  • Holmes KK et al, Sexually Transmitted Diseases, 3rd edition, 1999, McGraw-Hill
trichomoniasis
Trichomoniasis
  • Trichomonas Vaginalis
  • Vaginal infection
  • Vaginal sex
trichomoniasis1
Trichomoniasis
  • Symptoms variable: thin, frothy, malodorous vaginal discharge
  • 50% women may be asymptomatic
  • 95% men asymptomatic (and ? self-limiting)
diagnosis
Diagnosis
  • Wet prep from posterior fornix of vagina
  • Culture
  • DNA testing – not widely available
management1
Management

Antibiotics

  • Tinidazole 2g orally stat or
  • Metronidazole 2g orally stat
  • Metronidazole 400mg bd for 5/7 or
  • Clotrimazole 1% PV daily for 6 days

Treat partner

bacterial vaginosis
BACTERIAL VAGINOSIS
  • What is it?
  • Not a Sexually Transmitted Infection
  • Syndrome of disordered vaginal ecology
typical presentation of bv
Typical presentation of BV
  • Malodour
  • Increased vaginal discharge, more noticeable after menstruation or coitus
  • But mostly asymptomatic
complications of bv
Complications of BV?
  • PID?
  • Premature rupture of membranes
  • LBW
  • Post-partum endometritis
herpes simplex virus
Herpes simplex Virus
  • Type 1 and Type 2

NEW KNOWLEDGE

  • HSV I is now a more common cause of genital herpes in some populations
  • Genital herpes can substantially facilitate the transmission of HIV infection
biology of herpes simplex biological differences between hsv 1 and 2
Biology of Herpes Simplex: Biological Differences Between HSV 1 and 2
  • Either type is equally adept at infecting sacral or trigeminal ganglia
    • HSV-1 establishes competent latencyin trigeminal ganglia
    • HSV-2 establishes competent latency in sacral ganglia
epidemiology hsv 1
Epidemiology: HSV-1
  • Age-specific variations in HSV-1 seroprevalence
    • 95% in the middle-aged and elderly
    • 70% in the 20-35 year age group, and about
    • 50% in adolescents
    • HSV-1 causes approximately 50% of primary genital herpes
epidemiology hsv 2
Epidemiology: HSV-2
  • ~15-20% of sexually active persons have acquired HSV-2 by age 30
making the diagnosis
Making the Diagnosis
  • Think herpes!
  • Always examine someone with genital symptoms
  • Any skin break in the genital area could be a herpes infection
  • All that itches is not thrush
  • Take a swab!
thrush and herpes
Thrush and Herpes
  • If you don’t look for herpes

you won’t find herpes!

new diagnosis
New Diagnosis
  • PCR (polymerase chain reaction) is now the gold standard and has supplanted viral culture
  • PCR is quicker, cheaper and has fewer false-negative results
  • It is performed at VIDRL (Victorian Infectious Diseases Service)
  • “Multiplex PCR” = HSVI, HSVII, CMV & ZVZ
serological detection of hsv antibody
Serological Detection of HSV Antibody
  • Nonspecific tests are of little clinical use
  • Western Blot type-specific serology is useful in:
    • discordant couples
    • staging first presentations
    • typing culture -ve primary herpes
    • confirming atypical HSV-2 infection
    • excluding HSV-2 infection?
    • screening?
infectivity
Infectivity
  • High titres of virus particles are shed from obvious lesions
  • Episodes of viral shedding occur in asymptomatic individuals, and between overt recurrences
  • About 70% of cases of first-episode genital herpes are acquired from asymptomatic partners
barry
Barry
  • 26 yo single male
  • 18 mo recurrent post-coital “thrush”
  • Responds to topical antifungals
  • Examination: fissuring of prepuce
barry1
Barry
  • HSV-2 DNA detected by PCR
  • Asymptomatic on suppressive valaciclovir
louisa
Louisa
  • 18 yo HSC student
  • Asymptomatic partner
  • No penetrative sex
  • Acute vulvitis; HSV-1 detected
hsv asymptomatic shedding
HSV – Asymptomatic shedding
  • Transmissions mainly occur during transmissions of asymptomatic shedding
  • Most HSV –2 infections are acquired from a person with no history of GH
  • In HSV –2 pos individuals who have a history of recurrent GH. Most transmissions occur when lesions are not present
transmission of gh
Transmission of GH

The risk of heterosexual transmission of HSV-2 is estimated to be on average 10% over a 1-year period

1. Wald et al. N Engl J Med 1995; 333: 770–5.

prevention of transmission
Prevention of Transmission
  • Condoms
  • Suppressive antiviral therapy
  • Sexual practices/recognition of sx
  • Vaccines?
further information
Further Information…
  • Australian Herpes Management Forum
    • www.ahmf.com.au
  • Melbourne Herpes Self-Help Group
    • www.home.vicnet.net.au/~mhshg
  • Sydney Herpes Support Group
    • www.geocities.com/sydneygroup
slide66

Figure 1.9

Population and diagrammaticrepresentation of the core group concept

Non core Group – Fewer partners; more sex acts per partner

[Serial Monogamy]

Bridge Group

Core Group – More partners; less sex acts per partner.

[Concurrent partnerships]

Snapshot of Sex and Relationships

how do you control stis
How do you control STIs?

R0[t] = βcD(χ)

R0 Reproductive Rate [t]=time

β Transmission probability per partnership

C Rate of partner change

D Duration of Infection

priority group gay or other homosexually active men
Priority Group: Gay or other homosexually active men

R0 = βcD

β– Good degree condoms use; co-infection with another STI

c – high rate of partner change

D – access to screening

  • Male sexuality – sex drive etc.
  • Heterosexism
  • Homophobia
sti hiv prevention
STI / HIV Prevention
  • condoms for vaginal, anal and oral sex
  • non-penetrative contact
  • partner notification and treatment
  • raised awareness and education about STI’s
  • regular screening and treatment with antibiotics if detected
  • early detection may prevent complications and transmission of the STI to other sexual partners
  • regular screening encouraged amongst MSM
resources and supports
Resources and Supports

MSHC Services – WITS (Walk-In Triage Service)

  • On site clinical services

General Clinic

Green Room

Special Clinics (Thai, Korean, Chinese Sex Workers; Vulval, Dermatology Clinic) – and MSM Clinics (Thursday Evening)

Results and Information Line

(9347 0244 and follow prompts)

  • Outreach

Sex-On Premises Venue

Street based Sex workers (RhED)

VACCHO and CALD Projects

Prisons Project

  • Partner Notification Officers (DHS) –
  • Ph: 9347 1899
mshc resources and support www mshc org au
MSHC Resources and Supportwww.mshc.org.au
  • Web-based Patient Information ‘Check Your Risk’

http://checkyourrisk.org.au/

  • Web-based GP resources

www.mshc.org.au/gpassist

  • Sexual Health Physician Advice Line:

1800 009 903 (Toll Free)

Hours available:

Monday – Friday

09.00 -12.30 and

13.30 - 17.00