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Sexually Transmitted Infections A predisposing factor for HIV transmission Syndromic Approach to Management . T. Hylton-Kong. Objectives. To review the facts: STIs enhances the acquisition and transmission of HIV To review the syndromic approach to management

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slide1

Sexually Transmitted Infections A predisposing factor for HIV transmission Syndromic Approach to Management

T. Hylton-Kong

objectives
Objectives
  • To review the facts: STIs enhances the acquisition and transmission of HIV
  • To review the syndromic approach to management
  • To demonstrate the use of the algorithms
stis and hiv epidemiological synergy
STIs and HIV:Epidemiological Synergy
  • Summarized by Wasserheit (STD 19:261; 1992)
  • Inflammatory STIs (e.g. GC) lead to 5 fold increased HIV acquisition
  • Genital ulcers lead to 12 fold increased HIV acquisition
how do stis increase hiv transmission
How do STIs increase HIV transmission?
  • Reducing physical/mechanical barriers (disruption of epithelium)
  • Increasing HIV in genital lesions, semen or both ( even if VL is undetectable)
  • Evoking a more infectious HIV variant
  • Increasing the number of receptor cells or the density of receptors per cell
increasing stis in plwhas
Increasing STIs in PLWHAs
  • Many studies have indicated increasing prevalence of STIs in PLWHAs (IJSTD 12:2, 2001)
  • HIV+ STDCAs were more likely to deny risky sexual behaviour
  • HIV+ STDCAs had higher prevalence of GC, syphilis or STI exposure
approach to sti case management
Approach to STI Case Management
  • STIs are common and serious especially to women and neonates
  • Effective case management is a cornerstone of control
  • Given at “point of first contact” it:
    • Decreases spread and prevents complications
    • Targets STI/HIV counseling and education to a receptive audience
  • In practice, STI control begins with the STI patient
stis and hiv
STIs and HIV
  • STI management one of few documented successful methods for prevention of HIV infection.
  • Enhanced syndromic treatment of STIs resulted in 38% decrease in HIV seroconversion over 2 years (Mwanza, Tanzania).
  • Proper condom use effective for most STIs incl. HIV
  • Future: role of microbicides
sti syndromic case management
STI – Syndromic Case Management

REQUIREMENTS:

  • Adequate medical history
  • Good sexual history
  • Complete STI clinical examination
  • Management guidelines
  • Good supply of effective drugs
syndromic flow charts for scm
Syndromic Flow Charts for SCM
  • Urethral discharge
  • Genital ulcer disease (M & F)
  • Vaginal discharge
  • Pelvic Inflammatory Disease (PID)
  • Scrotal swelling
  • Inguinal swelling
  • Ophthalmia neonatorum
  • Asymptomatic clients at high risk of infection
slide10

Essential Steps In STI Care Management*

Syndrome

Assessment

Contact tracing

Compliance

Confidentiality

Condom use

Counseling

(diagnostic tools)

5Cs

Diagnosis

Treatment

(screening tests)

Risk

Assessment

* Adapted from Holmes & Ryan

risk assessment include
Risk Assessment Include:
  • Sexual behaviours
  • Specific exposures
  • Sociodemographics/other high risk markers:
    • young age
    • marital status: not living with steady partner
    • partner problems
  • History of reproductive health
  • History of past STI
rapid laboratory tests
Rapid Laboratory Tests

May be used to narrow the spectrum of initial therapy. They include:

  • Wet mount (vaginal discharge)
  • Gram stain (UD, Cvx mucopus)
  • Darkfield (GUD/syphilis)
  • Rapid serologic tests e.g., (HIV/GUD/syphilis)
programmatic advantages to syndromic management of stis
Programmatic Advantages to Syndromic Management of STIs
  • Allows all STI clinicians to provide excellent care without referring
  • The most efficient system to realize a clinic’s dual responsibility – cure the patient and protect the community from STI
what is urethral discharge syndrome
What is Urethral Discharge Syndrome?
  • Discharge coming from the urethral meatus
  • May be frank pus, mucopurulent, or serous (clear)
  • Occasionally discharge will be white in colour

Gonococcal urethral discharge

Photo: Cincinnati STD/HIV Training Ctr

slide15

COMPLAINT OF URETHRAL DISCHARGE

Take History including Risk Factors.

Retract foreskin. Milk urethra if necessary

Discharge seen

No discharge seen

Counsel. Treat for

Gonorrhoea and Chlamydia

Re-evaluate patient after holding his

Urine for at least 4 hours

Follow-up 7 days after clinic visit if indicated

(e.g. if ceftriaxone for gonorrhoea was not prescribed)

Cured

Discharge persists. Treat for Trichomonas

Treatment regimen followed.

REFER

Treatment regimen

Not followed.

RE-TREAT

Complete any remaining

Treatments.

COUNSEL

genital ulcer disease
Genital Ulcer Disease

Wilkinson and Stone, 1995; Fig 8.46

J. Anderson, MD, ed.

Holmes, 1999; Plate 32

Syphilis

Chancroid

Herpes Simplex

genital ulcer disease18
Genital Ulcer Disease
  • Other Causes
    • Lymphogranuloma venereum
    • Granuloma inguinale (Donovanosis)
    • Neoplasm

There are many published studies on HIV transmission and GUD including HSV.

In Ja. HIV prevalence was 22% in STICA with GUD vs 7% in general STICA

slide19

GENITAL ULCER SYNDROME

History, Risk Assessment, Examination.

Determine Number of Ulcers

Solitary Lesion

Multiple lesions

Recurrent at same site or with vesicles?

No

Yes

Treatfor Syphilis

& Chancroid

Treatfor

Chancroid

& Syphilis

Treat for

Herpes

Review in 7 days

Review in 7 days

Ulcer Persists

Cured

Ulcer Persists

Cured

Refer

Refer

hpv infection and hiv
HPV Infection and HIV
  • HIV-infected women have
    • Higher prevalence of HPV, longer persistence
    • Higher likelihood of multiple HPV subtypes
    • Greater prevalence of oncogenic subtypes
  • Prevalence and persistence of HPV increase with declining immune function.
  • Rates of cervical dysplasia 10-11x greater than those observed in HIV-negative women
causes of abnormal vaginal discharge
Causes of Abnormal Vaginal Discharge
  • Candidiasis
  • May increase in frequency and/or severity with progressive HIV disease
  • Common after antibiotic treatment
typical vaginal discharge caused by trichomoniasis
Typical vaginal discharge caused by trichomoniasis

Source: Seattle STD/HIV Prevention Training Center at the University of Washington

causes of abnormal vaginal discharge25
Causes of Abnormal Vaginal Discharge

Trichomoniasis

  • Even though lesser degree of HIV transmission, its prevalence supersedes this
  • treatment of sex partner needed
strawberry cervix due to t vaginalis
“Strawberry cervix” due to T. vaginalis

Source: Claire E. Stevens/Seattle STD/HIV Prevention Training Center at the University of Washington

causes of abnormal vaginal discharge27
Causes of Abnormal Vaginal Discharge

Bacterial vaginosis

  • Overgrowth of anaerobic/facultative anaerobic flora
  • Associated with increased risk of PID, preterm labor, PROM
  • May enhance HIV transmission
causes of abnormal vaginal discharge28
Causes of Abnormal Vaginal Discharge
  • Cervicitis
    • Chlamydia
    • Gonorrhoea
    • Limitations of syndromic management
      • Use local prevalence data, if available
      • Risk assessment
      • Partner treatment
gonococcal cervicitis
Gonococcal Cervicitis

Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides

slide31

Complaint of Vaginal Discharge

Step 1

Take History (esp. sexual). Determine Risk Score

Step 2

Do Bimanual Pelvic Exam, Pass speculum

Step 3

Clean and Inspect Cervix

Step 4

Observe nature of Vaginal Discharge

Give Prevention Messages

Step 5

slide32

Complaint of Vaginal Discharge

Step 3

Clean and Inspect Cervix

Mucopus, Erosion or Friability:

Treat for GC, CT & TV

No Mucopus etc., but

Risk Score > 2:

Tx for GC, CT, TV

No Mucopus, Normal/No

Discharge, Risk Score <2:

No Tx but Counsel

slide33

Complaint of Vaginal Discharge

Step 4

Observe Nature

of

Vaginal Discharge

Runny, profuse or malodorous:

Treat for TV and BV.

White and curdlike: Treat fo Candida

slide35

Complaint of Vaginal Discharge

Step 5

  • Prevention Messages
  • Comply with Medication
  • Counsel re Risk Reduction
  • Condom use
  • Contacts (PN)
  • Confidentiality (assurance)
pelvic inflammatory disease
Pelvic Inflammatory Disease
  • Minimal criteria for diagnosis
  • Simple supporting signs
    • Fever >38.3°C
    • Abnormal discharge
  • In presence of HIV infection, PID may be more common and more severe
acute salpingitis
Acute Salpingitis

Source: Cincinnati STD/HIV Prevention Training Center

slide39

Complaint of Lower

Abdominal Pain (LAP)

Take History and Assess Risk. Do Exam:

Abdominal, pelvic, bimanual, speculum

  • Bowel or urinary symptoms?
  • Missed/overdue period; pregnant?
  • Recent childbirth or abortion?
  • Rebound tenderness; guarding?
  • Vaginal bleeding or pelvic mass?

Immediate

Referral to

Surgical or

OBGYN

yes

to

any

no to all

slide40

Complaint of Lower

Abdominal Pain (LAP)

Treat for PID.

If IUD present:

Remove after 2-4 dys.

Examine and treat partner(s).

[40% may be asymptomatic].

Counsel re 4 Cs.

  • Either:
  • Temperature > 38oC
  • Dyspareunia or previous PID
  • Vaginal discharge
  • Mucopurulent cervicitis
  • Risk assessment positive
  • With:
  • Pain on moving cervix/adnexa

Re-evaluate 3 days. Improved – complete Tx 10-14 days.

Not improved – refer hospital, (esp. if temperature elevated).