SEXUALLY TRANSMITTED DISEASES (STI)

1. SEXUALLY TRANSMITTED DISEASES (STI) Dr. Esther Kyungu

2. Overview • Introduction • Pathology • Epidemiology • Clinical Features • Complications • Differential Diagnosis • Management • Contact notification & treatment • Counseling • Prevention

3. Introduction • A sexually transmitted disease (STD), also known as sexually transmitted infection (STI) or venereal disease (VD), is an illness that has a significant probability of transmission between humans or animals by means of sexual contact, including vaginal intercourse, oral sex, and anal sex. • While in the past, these illnesses have mostly been referred to as STDs or VD, in recent years the term sexually transmitted infection (STI) has been preferred, as it has a broader range of meaning; a person may be infected, and may potentially infect others, without showing signs of disease.

4. Introduction cont… • Some STIs can also be transmitted via use of an IV drug needle after its use by an infected person, as well as through childbirth or breastfeeding. • Most STIs affect both men and women, but in many cases the health problems they cause can be more severe for women. If a pregnant woman has an STI, it can cause serious health problems for the baby.

5. Types and their pathogenic causes Bacterial • Bacterial Vaginosis (BV) - not officially an STI but affected by sexual activity. • Chancroid (Haemophilus ducreyi) • Gonorrhea (Neisseria gonorrhoeae) • Lymphogranuloma venereum (LGV) (Chlamydia trachomatis serotypes L1, L2, L3.) • Syphilis (Treponema pallidum)

6. Viral • Viral hepatitis (Hepatitis B virus) • Herpes Simplex (Herpes simplex virus (1, 2) • HIV/ AIDS (Human Immunodeficiency Virus) • Genital warts - ("low risk" types of Human papillomavirus HPV) Fungal • Yeast Infection Protozoal • Trichomoniasis (Trichomonas vaginalis) Parasites • Pubic lice (Phthirius pubis)

7. Pathology • Many STIs are (more easily) transmitted through the mucous membranes of the penis, vulva, rectum, urinary tract and (less often - depending on type of infection) the mouth, throat, respiratory tract and eyes. • The visible membrane covering the head of the penis is a mucous membrane, though it produces no mucus (similar to the lips of the mouth). • Mucous membranes differ from skin in that they allow certain pathogens into the body. Pathogens are also able to pass through breaks or abrasions of the skin, even minute ones.

8. Pathology cont… • The shaft of the penis is particularly susceptible due to the friction caused during penetrative sex. • The primary sources of infection in ascending order are venereal fluids, saliva, mucosal or skin (particularly the penis), infections may also be transmitted from feces, urine and sweat. • The amount required to cause infection varies with each pathogen but is always less than you can see with the naked eye. • Some infections labeled as STIs can be transmitted by direct skin contact. Herpes simplex, pubic lice and HPV are both examples.

9. Epidemiology • STI incidence rates remain high in most of the world, despite diagnostic and therapeutic advances that can rapidly render patients with many STIs noninfectious and cure most. • Sexually active adolescent girls both with and without lower genital tract symptoms (Worldwide in 2006) include chlamydia trachomatis (10 to 25%), Neisseria gonorrhoeae (3 to 18%), syphilis (0 to 3%), Trichomonas vaginalis (8 to 16%), and herpes simplex virus (2 to 12%).

10. Epidemiology cont… • Among adolescent boys (Worldwide, 2006) with no symptoms of urethritis, isolation rates include C. trachomatis (9 to 11%) and N. gonorrhoeae (2 to 3%). • In 2006, WHO estimated that more than 1 million people were being infected daily. • About 60% of these infections occur in young people <25 years of age, and of these 30% are <20 years. • Between the ages of 14 and 19, STIs occur more frequently in girls than boys by a ratio of nearly 2:1; this equalizes by age 20.

11. Epidemiology cont… • An estimated 340 million new cases of syphilis, gonorrhea, chlamydia and trichomoniasis occurred throughout the world in 2006. In Tanzania • Between 10-20% of sexually active population contract STIs each year. • The surveillance of HIV and syphilis infections among antenatal clinic attendees in 2003/2004 showed an overall prevalence of syphilis & HIV to be 7.3% and 8.8% respectively.

12. Clinical Features • Vaginal itching and/or discharge • Intermenstrual bleeding • Penile discharge & scrotal pain and fullness • Urethral discharge • Painful sex or urination • Pelvic and abdominal pain • Chancre sores (painless/ painful) -genital area, anus, tongue and/or throat • Small blisters on the genital area • Soft, flesh-colored warts around the genital area

13. Clinical Features cont… • Swollen glands, fever and body aches • Unusual infections, unexplained fatigue, night sweats and weight loss • A scaly rash on the palms and the soles • Itching skin, pain or abnormal tingling sensation at the site of infection • Yellow eyes and skin, pruritus • Dysuria, urinary frequency and/or urgency • Hepatosplenomegaly

14. Complications Men • Urethritis, Epididymitis, Proctitis, Urethral strictures Women • Cervicitis, Pelvic Inflammatory Disease(PID) • Ectopic (tubal) pregnancy, Premature birth Both Sexes • Infertility, Urethral fistulas, Blindness • Genital Elephantiasis, Frozen Pelvis • Meningitis, Intestinal obstruction and/or perforation

15. Differential Diagnoses • Cystitis • Cervicitis, Vaginitis • Urethritis • Cancer of the cervix, prostate • Candidiasis • PID

16. Investigations

17. Investigations cont…

18. Investigations cont… • Blood for syphilis (RPR, TPHA, FTA-ABS) • HIV serology (Capillus, Biolin, CD4+ etc) • Urinalysis (dipstick) for blood, protein, glucose and bilirubin • Blood for hepatitis B and C serology (HBsAg, HBeAg, Anti-HBs) • Liver biopsy • Paps smear for HPV • FBP & ESR • LFT & RFT

19. Medical Treatment • Bacterial Vaginosis – Metronidazole/Clindamycin (oral/Vaginal) • Candidiasis (Oesophageal/ vulvovaginal) – Azoles (Clotrimazole, Fluconazole), Nystatin, Amphotericin B • Chancroid – Azithromycin/Ceftriaxone • Chlamydia – Azithromycin/Ceftriaxone or Doxycycline • Genital Herpes – Acyclovir • Gonorrhoea – Azithromycin/Ciprofloxacin/ Ceftriaxone + Doxycycline

20. Medical Treatment cont… • Lymphogranuloma Venereum – Doxycycline/Azithromycin/Erythromycin • Syphilis –Benzathine Penicilin G • Trichomoniasis-Metronidazole • HIV/AIDS-ARV for those eiligible • Hepatitis B –Interferon + Lamivudine • Pubic Lice –Malathion/Carbaryl • Genital Warts –Salicyclic acid or salicyclic+lactic acids combination • Psychotherapy

21. Surgical Treatment • Incision & drainage of abscesses and buboes • Repair of rectovaginal/ vesicovaginal fistulas • Dilatation of strictures

22. Contact Notification and Treatment • We define the STI client as index case and his/her sexual partners who could be the source of infection or who could have been infected by the index case as contacts. • The concept of contact notification and treatment is based on the following facts: • Each STI client must have been infected by a sexual partner who should also be treated. • Each STI client is a potential source of infection to sexual partner(s) until treatment is completed.

23. Contact Notification & Treatment cont… • A treated STI client is cured but not immune. This means that s/he can be re-infected if the sexual partners still have the STI, a reason why these partners should be treated according to equivalent syndrome of the index patient to break the chain of STI transmission and to reduce the chance of the client being re- infected.

24. Counseling on STI & HIV • Counseling is a more in-depth process than health education and requires more time, privacy and confidentiality. • Specialized counselors need to provide adapted messages relevant for each person or couple on the issues of risk behaviours, vulnerability, dangers of STI, and specific ways to protect themselves. • Identify barriers-What keeps someone from changing behaviour? Is it personal view, lack of information, partners pressure? Which of these can be changed and how?

25. Counseling cont… • Help people find the motivation to reduce their risk (behaviour change)-meeting someone who has HIV/AIDS, hearing about a family member or friend who is infertile due to STI or learning that a partner has an infection. • Offer real skills-negotiation skills, demonstrate how to use condoms, and conduct role-playing conversations. • People need to feel that they have choices and can make their own decisions. Discuss substitute behaviours that are less risky.

26. Prevention • Abstinence • Safe sex – condoms use • Counseling, active & prompt treatment of sexual partners • Health Education on STI • Vaccines against some viral STIs, such as Hepatitis B and some types of HPV. • Prudent antimicrobial use • Hygiene (genitals, hands)

27. Summary • STI’s can be transmitted sexually, transplacentally, blood transfusion and through skin contacts. • Genital and extragenital sites may be involved depending on sexual practice(s). It is possible to be an asymptomatic carrier of sexually transmitted diseases. • STI’s in women often cause the serious conditions of PID, stillbirth and infertility.

28. Summary cont… • Development and spread of drug-resistant bacteria (e.g., penicillin-resistant gonococci) makes some STIs harder to cure. • Concept of counselling, contact notification and treatment is of paramount importance in control and prevention of STI.

29. References • “Tanzania’s National Guidelines for Management of sexually transmitted and Reproductive Tract infections’’. First Edition, March 2007. • STD Statistics Worldwide • Workowski K, Berman S (2006). "Sexually transmitted diseases treatment guidelines, 2006”. Shukla N, Poles M (2004). "Hepatitis B virus infection: co-infection with hepatitis C virus, hepatitis D virus, and human immunodeficiency virus.". Clin Liver Dis8 (2): 445–60, viii.