20.STI and HIV

Sexually Transmitted Infections

Unit 15HIV Care and ART: A Course for Physicians

* Learning Objectives

Differentiate STI and STD Describe the epidemiology of STIs Describe syndromic management of STIs Illustrate: The impact of STI on HIV The impact of HIV on STI Demonstrate the importance of HIV testing and counseling in patients with STIs

* STI versus STD

STI – Infections acquired through sexual intercourse (may be symptomatic or asymptomatic)STD – Symptomatic disease acquired through sexual intercourseSTI is most commonly used because it applies to both symptomatic and asymptomatic infections

* Estimated New Cases of Curable* STIs Among Adults

* Prevalence and Incidence of STIs
Higher among urban residents, unmarried, and young adults Differs between countries and regions within countries Differences can be caused by social, cultural, and economic factors, or levels of access to care

* STIs in Ethiopia

No uniformity in reporting STI cases Only surveillance system is for HIV and syphilis among pregnant women All regions (except SNNPR) reported 451,686 cases of STIs between June 1998 and June 2002 This number reflects severe underreporting


* STI Dissemination
The rate of STI dissemination depends upon: Rate of exposure Efficiency of transmission per exposure Duration of infectiousness STI dissemination can be reduced by: Behavior modification: limiting partners, condom use Screening of risk groups, pregnant women, and their partners Treating all infections Health education and risk reduction counseling Partner notification

* Challenges to Prevention

Difficult to change human behavior Co-infection with multiple STIs is common Not all STIs are treatable Many STIs are asymptomatic Transmission can occur during asymptomatic viral shedding

* How Symptomatic are STIs?

Source: WHO HIV/AIDS/STI Initiative

* Impact of STIs

Considerable morbidityHigh rate of complicationsFacilitate HIV transmission and acquisitionMay cause infertilityTreatment can be a high financial burdenMay cause problems in relationships—divorce, abandonment, beatings

* Interaction Between HIV and STIs

Significant interaction exists between HIV and STIs Affect similar populations Have a similar route of transmission The interaction is bidirectional HIV influences conventional STIs STIs influence HIV

* Influence of HIV Infection on STIs

HIV alters the clinical features of STIs Syphilis: Neurosyphilis develops more frequently and rapidly HSV: Ulcers are more severe, chronic, and possibly disseminate throughout body Response to treatment may be reduced High rates of treatment failure for neurosyphilis Complications may increase and occur more quickly



* Influence of STI on HIV infection
Increased transmission of HIV A person with STI has greater chance of transmitting and acquiring HIV infection Implications of the interaction: Reduction in conventional STI could result in reduction of HIV incidence Effective STI prevention and control should be components of HIV prevention programs

STI Management

* Syndromic Approach to STI Management
Identification of clinical syndrome Giving treatment targeting all the locally known pathogens which can cause the syndrome

* Syndromic Approach to STI Management (2)

Advantages Simple, rapid and inexpensive Complete care offered at first visit Patients are treated for possible mixed infections Accessible to a broad range of health workers Avoids unnecessary referrals to hospitals Disadvantages Over-treatment Asymptomatic infections are missed

* Examination of the STI Patient

Physical examination should include: Examination of anogenital area Examination of any other symptomatic areas, e.g., skin, joints, neurological, etc. Additional examinations in females Speculum examination Bimanual pelvic examination

* History of the STI Patient

Presenting symptoms Previous diagnosis of STI Sexual history Symptoms and diagnosis in sexual partner Past general medical history Current medications Risk factors for the acquisition of HIV and STIs In females: obstetric, menstrual history, and use of contraceptives



* Talking about STIs with Patients
Important to understand the patient’s perspective on talking about sex EmbarrassedNervousGuiltyShame, fearPatients would like their medical provider to beNonjudgmentalRespectfulMaintain privacy and confidentiality

* Group Discussion:Patient-centered vs. Provider-centered Approach to Care

What are the key differences between the patient- and provider-centered approaches to care? What are the positive and negative aspects of each approach? How would these different approaches possibly impact patient outcomes?

* Principles of Patient-Centered Care

Communicate in a nonjudgmental mannerExplore the disease and the patient’s feelings and perceptions about their condition Understand the patient as a whole personCome to a mutual understanding with the patient regarding disease management

* Building Rapport

Begin with a non-medical interactionCreate an atmosphere that is open and supportivePractice “active listening”Discuss a detailed agenda of what will occur Answer questions using simple terms the patient can understand

* Expert Communication Skills

Maintain good eye contactUse active listening and watch the patient’s nonverbal cuesHave warm and accepting body language Rely on open ended questionsAvoid interrupting Use summaries and reflections

STI Syndromes and Management

* Common STI Syndromes
Urethral discharge or burning on urination in men Vaginal discharge Genital ulcer in men and women Lower abdominal pain in women Scrotal swelling Inguinal bubo

* Case Study: Tsegenet

Tsegenet is a 48 year-old woman who presents with a new genital lesion noted 4 days ago by her sex partner. The lesions is essentially asymptomatic except occasional mild pruritus. She reports a new male sex partner starting 2 months ago.

* Case Study: Tsegenet (3)

What additional information do you wish to know about this patient? Based on the history you have and the appearance of the lesion, what does your differential diagnosis include?

* Genital Ulcer Syndrome

* Genital Ulcer Disease:Differential Diagnosis
Herpes simplex Syphilis Chancroid Lymphogranuloma venereum Granuloma inguinale Others

* Genital Ulcer Disease Treatment

Recommended treatment for non-vesicular genital ulcer Benzanthine penicilline 2.4 million units IM stat or Doxycycline 100 mg bid for 15 days and Ciprofloxacin 500mg, po, bid for 3 days, or Erythromycin 500 mg, po, QID for 7 days Recommended treatment for vesicular or recurrent genital ulcer Acyclovir 200 mg five times per day for 10 days, or Acyclovir 400 mg TID for 10 days

* Herpes Viruses

8 human herpesviruses (HHVs)α-herpesviruses include : Herpes simplex virus (HSV)-1Herpes simplex virus (HSV)-2Varicella zoster virusβ-herpesviruses include:Epstein-Barr virusKaposi’s sarcoma-associated herpes virus (KSHV or HHV-8)


* HSV Spectrum of Disease
Persistent ulcerative HSV infections are very common in AIDS Candida and HSV often occur in association Oral-facial Primary: gingivostomatitis & pharyngitis Reactivation: herpes labialis Asymptomatic shedding is common Thus, patients are potentially infectious even when lesions are absent

* HSV Spectrum of Disease:Primary genital infection

Fever, malaise, myalgia, HA, pain, itching, dysuria, vaginal and urethral discharge Tender inguinal adenopathy, widely-spaced bilateral extra-genital lesions Cervix and urethra involved in 80% of women If a pregnant woman has active lesions, C-section is indicated to prevent herpes neonatorum in infant Occasionally: endometritis, proctitis & prostatitis Extensive perianal disease, proctitis, or both are common among HIV patients

* HSV in the Immunocompromised Host

High frequency of reactivation Increased severity Widespread local extension Higher incidence of dissemination Viremic spread to visceral organs, which is rare but can be life threatening

* HSV Epidemiology

By age 50, >90% people have HSV-1 antibodies Prevalence correlates with socioeconomic status HSV-2 appears at puberty and correlates with sexual activity Average world prevalence is about 25%

* HSV Diagnosis

Clinical – characteristic multiple vesicular lesions or ulcersStaining of scrapings from base of lesions to demonstrate characteristic giant cells or intranuclear inclusionsWright stainTzanck preparationPapanicolaou smear

* Treatment

Primary infection Acyclovir 200 mg PO 5x/day for 7-14 days, or Acyclovir 400mg PO tid for 7-14 days, or Famciclovir 500 mg PO bid for 7-14 days, or Valacyclovir 1 gm PO bid 7-14 days Recurrences treated with same dosage, but may need only 5-10 days therapy Suppressive therapy may be indicated for patients with frequent recurrences, BUT Continued treatment risks developing resistant HSV

* Case Study: Abel

Abel is a 26 year-old man who presents with tingling that has progressed to frank burning with urination, beginning 3 days ago. He also reports copious purulent urethral discharge. When asked, he admits to unprotected intercourse last weekend with a new partner.

* Case Study: Abel (3)

What additional information do you wish to know about this patient? Based on the history you have and the appearance of the lesion, what does your differential diagnosis include? If the patient instead appeared as on the following slide, how would this affect your differential diagnosis and management?

* Differential Diagnosis

Chlamydia Gonorrhea Mycoplasma hominis Ureaplasma urealyticum Hemophilus & Parahemophilus spp. Other bacteria

* Urethral Discharge Syndrome

* Recommended Treatment for Urethral Discharge and Burning on Urination
Ciprofloxacin 500 mg po stat, or Spectinomycin 2g IM stat Plus Doxycycline 100 mg po BID for 7 days, or Tetracycline 500 mg po QID for 7 days, or Erythromycin 500 mg po QID for 7 days if the patient has contraindications for Tetracyclines

Persistent or Recurrent Urethral Discharge in Men

Take history and examine
Does history confirm reinfection or poor compliance?
Treat for trichomonas vaginalis Educate/counsel Promote and provide condoms Return in 7 days
Improved
Discharge confirmed
Patient complains of persistent/ recurrent urethral discharge or dysuria
Other STIs present
Use appropriate flow chart
Repeat urethral discharge treatment
Refer
Educate/counsel Promote and provide condoms Offer VCT
Yes
No
No
Yes
Yes
Educate/counsel Promote and  provide condoms Offer VCT
No
Yes
No

* Case Study: Aida

Aida, a 34 year-old woman, presents with a 2 month history of increasing, painless lesions she calls “hemorrhoids”.She also notes frequent, minimal bright red blood following bowel movements, and complains of perianal itching, and feeling “wet”.

* Case Study: Redeit

Redeit is a 26 year-old woman in a steady relationship with her boyfriend of 1 year. She presents complaining of a vaginal discharge for the past week. She describes increased discharge, change in color, and a foul odor.

* Case Study: Redeit (cont.)

Is this a sexually transmitted infection? What are the likely causative organisms?

* Vaginal Discharge

Common causes: Neisseria gonorrhea Chlamydia trachomatis Trichomonas vaginalis Gardnerella vaginalis Candida albicans

* Patient complains of vaginal discharge or vulval itching/ burning

Abnormal discharge present
Take history, examine patient (external speculum and bimanual) and assess risk
Lower abdominal tenderness or cervical motion tenderness
Was risk assessment positive? Is discharge from the cervix?
Vulval edema/curd like discharge Erythema excoriation present
Treat for bacterial vaginosis and trichomoniasis
Treat for chlamydia, gonorrhea, bacterial vaginosis and trichomoniasis
Use flow chart for lower abdominal pain
Educate Counsel Promote and provide condoms Offer VCT
Educate Counsel Promote and provide condoms Offer VCT
Treat for candida albicans
No
Yes
Yes
Yes
No
No
No
Yes
Vaginal Discharge

* Recommended Treatment for Vaginal Discharge

Metronidazole 500mg PO BID for 7 days plus Clotrimazole vaginal tabs 200mg at bed time for 3 days
Ciprofloxacin 500mg PO stat, or Spectinomycin 2gm IM stat plus Doxycycline 100mg PO BID for 7 days plus Metronidazole 500mg BID for 10 days
Risk Assessment Negative for STI
Risk Assessment Positive for STI

* Prevention Counseling

Nature of the infection Chlamydia is commonly asymptomatic in men & womenGonorrhea is usually asymptomatic in womenBoth easily transmitted during asymptomatic phaseBoth have serious adverse effects on women’s reproductive health if untreated CDC

* Prevention Counseling (2)

Transmission issues Effective treatment of chlamydia and/or gonorrhea may reduce HIV transmission Abstain from sexual intercourse until both partners are treated and for seven days after single dose therapy or until completion of a seven day regimen

* Case Study: Redeit (cont.)

Redeit leaves the OPD following evaluation for her vaginal discharge, but on the way home she loses the medication she was given. She does not return for additional medication out of embarrassment, but now two weeks later returns complaining of 3 days history of increasing pelvic pain and fever.

* Case Study: Redeit (cont.)

What is happening? What should be done now?

* Lower Abdominal Pain Due to PID (Pelvic Inflammatory Disease)

PID is ascending infection of the upper genital tract (uterus, tubes, etc) from the cervix and/or vagina Common etiologies: Sexually transmitted: Neisseria gonorrhea, Chlamydia trachomatis, Mycoplasma hominis Others (non-STI): streptococci, E. coli, etc Vaginal discharge is often present

* Lower Abdominal Pain

Patient complains of lower abdominal pain
Take history including gynecological And examine (abdominal and vaginal)
Any of the following present Missed overdue period Recent delivery/ abortion Miscarriage Abdominal guarding And/or rebound tenderness Abdominal mass Abnormal vaginal bleeding
Refer the patient for surgical or gynecological opinion and assessment Before referral set up an IV line and resuscitate if required
Is there cervical excitation tenderness Or lower abdominal tenderness And vaginal discharge
Manage for PID Review in three days
Continue treatment until completed Educate and counsel Offer VCT Promote and provide condom Ask patient to return if necessary
Patient has improved
Refer patient
Manage appropriately
Any other illness found
Yes
No
Yes
Yes
No
No
Yes

* Recommended Treatment for PID

Out patient
Inpatient
Ciprofloxacin 500mg PO bid for 7 days, OR Spectinomycin 2gm IM stat plus Doxycycline 100mg BID for 14 days plus Metronidazole 500mg BID for 14 days
Ceftriaxone 250mg IV BID, OR Spectinomycin 2gm IM BID plus Doxycycline 100mg BID for 14 days plus Metronidazole 500mg BID for 14 days, OR Chloramphenicol 500mg IV QID

* Neonatal Conjunctivitis

Infection of the eyes of the neonate as a result of genital infection of the mother, transmitted during birth Causes: Neisseria gonorrhea Chlamydia trachomatis Treatment: Spectinomycin 50mg/kg IM stat or ceftriaxone 125mg IM stat plus Erythromycin 50mg/kg PO in 4 divided doses for 10 days May lead to blindness if not treated properly

* Neonatal Conjunctivitis

Neonate presents with eye discharge
Take history and examine child
Purulent conjunctivitis present?
Complete treatment course, reinforce education and counseling Review if necessary
Treat baby for gonococcal and chlamydial opthalmia AND Treat mother and partner for gonorrhoea and chlamydia Educate and counsel Review baby in 7 days or sooner if symptoms worsen
Signs of other illness present?
Treat appropriately
Reassure mother, educate parents Review if symptoms persist
Eye infection cleared?
No
No
Yes
Yes
Review in 7 days
Yes
Refer for specialist opinion and management
No

* Case Study: Yiman

Yiman is a 17 year-old boy who presents complaining of three days of increasing pain and swelling of his right scrotum. Symptoms began gradually, and he does not recall any trauma. He denies sexual activity.

* Scrotal Swelling

Common STI causes of scrotal swelling are similar to those of urethral discharge Neisseria gonorrhea Chlamydia trachomatis Exclude non-STI causes of scrotal swelling: TB Inguinal hernia Testicular torsion, etc

* Scrotal Swelling

Patient complains of scrotal swelling or pain
Take history, examine, offer HIV test
Scrotal swelling or pain present?
History of trauma or testis elevated or rotated? or Diagnosis in doubt?
Refer patient to hospital
Signs of other STI present?
Reassure patient, educate, counsel, provide condoms. Review if symptoms persist
Treat according to appropriate flowchart
Treat for chlamydia and gonorrhea. Review in 7 days
Patient has improved?
Complete treatment course, reinforce education and counseling Review if symptoms persist
Yes
Yes
No
Yes
No
No
Yes
No

* Scrotal SwellingRecommended Therapy

Ciprofloxacin 500mg PO stat, or Spectinomycin 2gm IM stat plus Doxycycline 100mg PO BID for 7 days, or Tetracycline 500mg BID for 7 days

* Inguinal Bubo

Swelling of inguinal lymph nodes as a result of STIs (or other causes) Common causes: Treponema pallidum (syphilis) Chlamydia trachomatis (LGV) Hemophylus ducreyi (chancroid) Calymatobacterium granulomatis (granuloma inguinale)

* Inguinal Bubo

Patient complaining of inguinal swelling
Take history and examine
Inguinal/femoral bubo present?
Ulcers present
Treat for LGV, GI and chancroid Aspirate if fluctuant Educate on treatment compliance Counsel on risk reduction Promote and provide condoms Partner management Offer VCT if available Advise to return in 07 days Refer if no improvement
Any other STI present
Use appropriate flow chart
Educate Counsel Offer VCT Promote and provide condoms
Use genital ulcer flow chart
No
No
Yes
Yes
No

* Inguinal Bubo

Recommended treatment: Ciprofloxacin 500mg PO BID for 14 days, and Erythromycin 500mg PO QID for 14 to 21 days

* Key Points

STIs are among the most common causes of illness in the world Emergence and spread of HIV infection and AIDS has major impact on the management and control of STIs STIs increase the acquisition and transmission of HIV HIV infection alters the clinical features and response to therapy of STIs

* Key Points (2)

The syndromic approach to STIs management is recommended by WHO Syndromic management is simple, rapid and inexpensive However, the syndromic approach leads to unnecessary over-treatment

* Key Points (3)

Partner notification and treatment are vital to interrupting STI spread Risk reduction education is key to preventing recurrence Every STD (or genital symptom) provides an occasion for patient education Cultural and interpersonal factors provide some of the greatest barriers to STD treatment and eradication