Managing Sexually Transmitted Infections in Vietnam

1. Sexually Transmitted Infections HAIVN Harvard Medical School AIDS Initiative in Vietnam

2. Learning Objectives By the end of this session, participants should be able to: • Identify the most common sexually transmitted infections (STIs) in Vietnam • Explain how to diagnose and treat these STIs • Describe the principles of syndromic management of STIs • Explain how STIs affect HIV infection

3. What is an STI? • Sexually Transmitted Infection • Infection spread from person to person through sexual contact

4. Key Principles About STIs (1) • STIs are an important public health concern • Complications of untreated STIs can be serious • E.g. cancer, infertility, increased HIV transmission • STIs can be diagnosed and treated based on the presenting symptoms or syndrome • However, many STIs can be asymptomatic; will only be detected by routine screening • When one STI is present, others are often present as well

5. Key Principles About STIs (2) • STIs are largely preventable • Prevention messages are easily given and reinforced, and include: • Education on safer sex and condom use • Provision of condoms (and lubricant) • Management of all sexual partners • Referral for HIV testing and counseling

6. Common STIs

7. What Are Some Common STIs? • Bacterial • Syphilis • Gonorrhea • Chlamydia • Protozoal • Trichomoniasis • Viral • Herpes • HIV • HPV/Genital Warts • Hepatitis B and C • Other • Pelvic Inflammatory Disease (PID) • Scabies

8. Common Symptoms of STIs by Gender • Females • Ulcers/sores • Vaginal discharge • Swelling/ growths/warts (groin/labia) • Burning on urination • Pain (low abdominal/back ache) • Males • Ulcers / sores • Discharge (urethral) • Swelling/growths –warts (groin / scrotum) • Pain / burning on urination

9. Chlamydia and Gonorrhea

10. Chlamydia: Chlamydia Trachomatis Cervix with purulent discharge • Common worldwide • 75% of women and 50% of men have no symptoms • Diagnosis • Urethral or cervical swab: PCR or ELISA • Urine PCR

11. Chlamydia: Treatment STI Treatment Guidelines, BVDL, HCMC, 2006 Recommended: Alternatives: Always treat for Gonorrhea as well!

12. Gonorrhea: NeisseriaGonorrhoeae Epidemiology: • Can cause urethritis, cervicitis, pharyngitis, proctitis Symptoms: • Males usually have symptoms of urethritis and purulent discharge • Females often have no symptoms

13. Gonorrhea: Diagnosis • Gram stained smears are 95-100% sensitive and 98% specific in male urethritis • Gram-negative intracellular diplococci • Culture –use special culture medium • Urine PCR

14. Gonorrhea: Treatment STI Treatment Guidelines, BVDL, HCMC, 2006 Treatment options: • Flouroquinolones not effective for treatment due to high levels of resistance Always treat Chlamydia as well!

15. Pelvic Inflammatory Disease (PID) (1) Infection of the endometrium and/or fallopian tubes Causes • N. Gonorrhoeae • C. trachomatis • Anaerobes • Mycoplasma Symptoms • Lower abdominal pain • Vaginal discharge • Bleeding • Fever • Dysuria • Dyspareunia • Nausea, vomiting

16. Pelvic Inflammatory Disease (PID) (2) • Examination, look for: • Fever • Tachycardia • Adnexal tenderness • Cervical motion tenderness

17. PID: Treatment • Consider hospital admission for: • Severe illness • Pregnancy • No improvement in 2-3 days

18. Epididymitis • Symptoms: pain and swelling of the epididymus and scrotum • Diagnosis: based on symptoms and clinical exam Treatment: 18

19. Vaginal Discharge

20. Vaginal Discharge • Diagnosis: wet-mount examination of vaginal discharge with saline +/- KOH • Causes: • Candida: thick, white discharge • Bacterial Vaginosis: gardnerellavaginalis • Discomfort and malodorous discharge • Trichomoniasis: Trichomonasvaginalis • Discomfort and discharge • Sexually transmitted - treat male partners

21. Vaginal Discharge: Treatment Candida Infection: Bacterial Vaginosis or Trichomonas :

22. Human Papilloma Virus (HPV)

23. HPV (1) There are many types of HPV • Some cause genital warts on the penis, anus, rectum, vagina, or cervix • Some cause cervical cancer and anal cancer

24. HPV (2)

25. HPV Treatment • Treatment (several weeks usually needed):

26. A B Identify the STI D C

27. STIs That Cause Ulcers

28. STIs that Cause Ulcers • The most common causes of genital ulcers in Vietnam are: • Herpes Simplex Virus (HSV) • Syphilis • Less common STIs that cause ulcers include: • Chancroid • Granuloma inguinale • Lymphogranuloma inguinale

29. Herpes Simplex Virus (HSV) • Common in many countries • 30-33% among female sex workers in S. Vietnam* • Lifelong and causes recurrent outbreaks • Two types of HSV: • HSV-1: usually causes oral infection • HSV-2: usually causes genital infection • Transmission increases during HSV outbreaks, but also occurs when there are no symptoms due to persistent viral shedding * O’Farrel, Int J STD AIDS, 2006

30. HSV: Symptoms • “Prodrome”: pain, tingling, numbness or itching at the site of the outbreak • Typical outbreaks are clusters of vesicles with pain, redness and swelling • HIV patients may have atypical symptoms: large, chronic ulcers

31. Chronic HSV Ulcers with HIV

32. HSV: Diagnosis Diagnostic Tests: • PCR of lesions • Serologic tests for HSV-1, HSV-2 • Viral culture

33. Genital HSV Treatment Sources: STI Treatment Guidelines, BVDL, HCMC, 2006 WHO STI Guidelines, 2003

34. Recurrent Episodes of HSV: Daily Suppressive Therapy • Daily suppressive therapy is for patients with multiple recurrences (> 5- 6/year) • Can reduce frequency of recurrences by >75% • No significant resistance • Dose: Acyclovir 400 mg 2x/day indefinitely

35. Syphilis

36. Syphilis: Treponema pallidum

37. Primary Chancre of Syphilis

38. Syphilitic Rash

39. Secondary Syphilis: condyloma lata

40. Syphilitic Rash Syphilis is one of the few skin conditions that can cause rash on the palms and soles

41. Syphilis Diagnosis (1) Nontreponemal “Screening” Tests: • VDRL or RPR • Initial screening test • Positive results should be confirmed Treponemal Serologic “Specific” Tests: • FTA-abs or MHA-TP • More expensive • Used to confirm a positive RPR or VDRL

42. Syphilis Diagnosis (2) Only patients positive for both the screening test and treponemal test need treatment

43. Syphilis Treatment Primary, secondary or early latent Syphilis (< 1 year) Late latent syphilis ( >1year) or unknown duration

44. Neurosyphilis Diagnosis: • Increased risk in PLHIV with CD4 < 350* • Evaluate any patient with syphilis and neurologic symptoms with CSF exam • CSF-VDRL (+) = neurosyphilis • May also have  WBC,  protein Treatment (Neurosyphilis or Ocular syphilis) • Penicillin G 4 MU IV q 4 h x 14 days * Source: JID, 2004

45. Genital Ulcer: Overall Treatment / Follow-Up

46. A B Identify the STI D C

47. Questions: How do STIs affect HIV? How do they Interact?

48. Effects of STIs on HIV Infection (1) • STIs increase transmission risk of HIV: • Ulcerative STIs (syphilis, chancroid, herpes) increase HIV risk 5 – 11 fold • Non-ulcerative STIs (gonorrhea, Chlamydia) increase risk 2 – 5 fold (perhaps higher for trichomonas)

49. Effects of STIs on HIV Infection (2) • Implications of the interaction: • Reduction in other STIs could result in reduction of HIV incidence • Effective STI prevention and control should be components of HIV prevention programs • All patients with STI should be offered counseling and testing for HIV

50. Syndromic Management • Treatment of STI symptoms based on the most likely etiologies in that location • Useful where diagnostic testing is not available or is too expensive • The WHO and Vietnam MOH have developed syndromic management guidelines for: • Urethral Discharge • Genital Ulcer • Vaginal Discharge • Lower abdominal pain in women