Sexually Transmitted Infections Unit 15 HIV 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 2 STI versus STD  STI – Infections acquired through sexual intercourse (may be symptomatic or asymptomatic)  STD – Symptomatic disease acquired through sexual intercourse  STI is most commonly used because it applies to both symptomatic and asymptomatic infections 3 Estimated New Cases of Curable* STIs Among Adults 4 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 5 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 6 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 7 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 8 How Symptomatic are STIs? Source: WHO HIV/AIDS/STI Initiative 9 Impact of STIs       Considerable morbidity High rate of complications Facilitate HIV transmission and acquisition May cause infertility Treatment can be a high financial burden May cause problems in relationships—divorce, abandonment, beatings 10 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 11 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 12 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 13 STI Management Syndromic Approach to STI Management  Identification of clinical syndrome  Giving treatment targeting all the locally known pathogens which can cause the syndrome 15 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 16 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 17 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 18 Talking about STIs with Patients  Important to understand the patient’s perspective on talking about sex     Embarrassed Nervous Guilty Shame, fear  Patients would like their medical provider to be  Nonjudgmental  Respectful  Maintain privacy and confidentiality 19 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? 20 Principles of Patient-Centered Care  Communicate in a nonjudgmental manner  Explore the disease and the patient’s feelings and perceptions about their condition  Understand the patient as a whole person  Come to a mutual understanding with the patient regarding disease management 21 Building Rapport  Begin with a non-medical interaction  Create an atmosphere that is open and supportive  Practice “active listening”  Discuss a detailed agenda of what will occur  Answer questions using simple terms the patient can understand 22 Expert Communication Skills  Maintain good eye contact  Use active listening and watch the patient’s nonverbal cues  Have warm and accepting body language  Rely on open ended questions  Avoid interrupting  Use summaries and reflections 23 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 25 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. 26 Case Study: Tsegenet (2) 27 Case Study: Tsegenet (3) A. What additional information do you wish to know about this patient? B. Based on the history you have and the appearance of the lesion, what does your differential diagnosis include? 28 Genital Ulcer Syndrome Patient complains of genital ulcer Take history & examine Vesicles or recurrence Yes Treat for HSV, Treat for syphilis if indicated No Ulcers and sores No Yes •Educate and counsel •Promote and provide condoms •Offer VCT •Ask the patient to return in 7 days •Educate •Promote and provide condoms •Offer VCT Treat for syphilis, chancroid and HSV No Ulcers healed No Ulcers improving Refer Yes Educate and counsel Promote and provide condoms Offer VCT Partner management Yes Continue treatment for further 07 days 29 Genital Ulcer Disease: Differential Diagnosis       Herpes simplex Syphilis Chancroid Lymphogranuloma venereum Granuloma inguinale Others 30 Differential Diagnosis? 31 Courtesy of the Division of STD Prevention/CDC Differential Diagnosis? 32 Courtesy of the Division of STD Prevention/CDC Differential Diagnosis? 33 Courtesy of the Cincinnati STD/ HIV Prevention Training Center Differential Diagnosis? 34 Differential Diagnosis? 35 Courtesy of Peter Katsufrakis, MD Differential Diagnosis? 36 Courtesy of Peter Katsufrakis, MD Differential Diagnosis? 37 Courtesy of the Public Health Image Library/CDC Differential Diagnosis? 38 Courtesy of the Public Health Image Library/CDC 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 39 Herpes Viruses  8 human herpesviruses (HHVs)  α-herpesviruses include :  Herpes simplex virus (HSV)-1  Herpes simplex virus (HSV)-2  Varicella zoster virus  β-herpesviruses include:  Epstein-Barr virus  Kaposi’s sarcoma-associated herpes virus (KSHV or HHV-8) 40 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 41 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 42 Extensive Herpes Simplex Ulcers 43 Courtesy of HIV In Site, www.hivinsite.org 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 44 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% 45 HSV vesicles 46 Courtesy of CDC/ Susan Lindsley HSV circumferential ulcer 47 Courtesy of CDC/ Dr. M. F. Rein; Susan Lindsley HSV Diagnosis  Clinical – characteristic multiple vesicular lesions or ulcers  Staining of scrapings from base of lesions to demonstrate characteristic giant cells or intranuclear inclusions  Wright stain  Tzanck preparation  Papanicolaou smear 48 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 49 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. 50 Case Study: Abel (2) 51 Courtesy of Peter Katsufrakis, MD Case Study: Abel (3) A. What additional information do you wish to know about this patient? B. Based on the history you have and the appearance of the lesion, what does your differential diagnosis include? C. If the patient instead appeared as on the following slide, how would this affect your differential diagnosis and management? 52 Case Study: Abel (4) 53 Courtesy of Peter Katsufrakis, MD Differential Diagnosis       Chlamydia Gonorrhea Mycoplasma hominis Ureaplasma urealyticum Hemophilus & Parahemophilus spp. Other bacteria 54 Urethral Discharge Syndrome Patient complains of urethral discharge or dysuria Take history & do P/E; milk urethra if necessary Discharge confirmed No Other STIs present? yes •Treat for gonorrhea and chlamydia •Educate •Counsel •Promote and provide condoms •Offer VCT •Partner management •Advise to return in 7 days if discharge persists No •Educate and counsel •Offer VCT •Review if symptoms persist •Promote and provide condoms Yes Use appropriate flow chart 55 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 56 Patient complains of persistent/ recurrent urethral discharge or dysuria Take history and examine Discharge confirmed No Yes Persistent or Recurrent Urethral Discharge in Men •Educate/counsel Other STIs No •Promote and provide condoms present • Offer VCT Yes Does history confirm reinfection or poor compliance? Use appropriate flow chart No Yes Treat for trichomonas vaginalis •Educate/counsel •Promote and provide condoms •Return in 7 days Improved No Refer Yes Repeat urethral discharge treatment •Educate/counsel •Promote and provide condoms • Offer VCT 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”. 58 Case Study: Aida (2) 59 Courtesy of Peter Katsufrakis, MD Condyloma accuminata 60 Courtesy of Peter Katsufrakis, MD Condyloma accuminata 61 Courtesy of Peter Katsufrakis, MD Chlamydial Cervicitis Courtesy of STD/HIV Prevention Training Center at the University of Washington/ Connie Celum and Walter Stamm 62 Genital Wart Treatments  Internal     Bi- or tri-chloroacetic acid Cryotherapy Cautery Laser or other surgery  External       Podophyllin Imiquimod Bi- or tri-chloroacetic acid Cryotherapy Cautery Laser or other surgery 63 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. 64 Case Study: Redeit (cont.) A. Is this a sexually transmitted infection? B. What are the likely causative organisms? 65 Vaginal Discharge  Common causes:      Neisseria gonorrhea Chlamydia trachomatis Trichomonas vaginalis Gardnerella vaginalis Candida albicans 66 Patient complains of vaginal discharge or vulval itching/ burning Vaginal Discharge Take history, examine patient (external speculum and bimanual) and assess risk Abnormal discharge present No Yes Lower abdominal tenderness or cervical motion tenderness Educate Counsel Promote and provide condoms Offer VCT Yes Use flow chart for lower abdominal pain No Was risk assessment positive? Is discharge from the cervix? Yes Treat for chlamydia, gonorrhea, bacterial vaginosis and trichomoniasis No Treat for bacterial vaginosis and trichomoniasis Vulval edema/curd like discharge Erythema excoriation present No Educate Counsel Promote and provide condoms Offer VCT Yes Treat for candida albicans 67 Recommended Treatment for Vaginal Discharge Risk Assessment Positive for STI Risk Assessment Negative for STI Ciprofloxacin 500mg PO stat, or Spectinomycin 2gm IM stat plus Doxycycline 100mg PO BID for 7 days plus Metronidazole 500mg BID for 10 days Metronidazole 500mg PO BID for 7 days plus Clotrimazole vaginal tabs 200mg at bed time for 3 days 68 Prevention Counseling  Nature of the infection  Chlamydia is commonly asymptomatic in men & women  Gonorrhea is usually asymptomatic in women  Both easily transmitted during asymptomatic phase  Both have serious adverse effects on women’s reproductive health if untreated 69 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 70 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. 71 Case Study: Redeit (cont.) A. What is happening? B. What should be done now? 72 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 73 Patient complains of lower abdominal pain 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 No Is there cervical excitation tenderness Or lower abdominal tenderness And vaginal discharge Yes Patient has improved Before referral set up an IV line and resuscitate if required Yes Manage for PID Review in three days Yes Refer the patient for surgical or gynecological opinion and assessment No Any other illness found Manage appropriately No Refer patient Yes Continue treatment until completed •Educate and counsel •Offer VCT •Promote and provide condom •Ask patient to return if necessary 74 Recommended Treatment for PID Out patient Inpatient Ciprofloxacin 500mg PO bid Ceftriaxone 250mg IV BID, for 7 days, OR OR Spectinomycin 2gm IM stat Spectinomycin 2gm IM BID plus plus Doxycycline 100mg BID for 14 Doxycycline 100mg BID for 14 days days plus plus Metronidazole 500mg BID for Metronidazole 500mg BID for 14 days 14 days, OR Chloramphenicol 500mg IV QID 75 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 76 Neonatal Conjunctivitis Neonate presents with eye discharge Take history and examine child No Purulent conjunctivitis present? Signs of other illness present? No Yes Reassure mother, educate parents Review if symptoms persist Yes 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 Treat appropriately Review in 7 days Yes Eye infection cleared? Complete treatment course, reinforce education and counseling Review if necessary No Refer for specialist opinion and management 77 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. 78 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 79 Scrotal Swelling Patient complains of scrotal swelling or pain Take history, examine, offer HIV test Scrotal swelling or pain present? No Signs of other STI present? Treat according to appropriate flowchart No Yes Refer patient to hospital Reassure patient, educate, counsel, provide condoms. Review if symptoms persist Yes Yes History of trauma or testis elevated or rotated? or Diagnosis in doubt? No Treat for chlamydia and gonorrhea. Review in 7 days No Yes Patient has improved? Complete treatment course, reinforce education and counseling Review if symptoms persist 80 Scrotal Swelling Recommended 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 81 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) 82 Inguinal Bubo 83 Courtesy of CDC/ Susan Lindsley Patient complaining of inguinal swelling Inguinal Bubo Take history and examine Inguinal/femoral bubo present? No Any other STI present No •Educate •Counsel •Offer VCT •Promote and provide condoms Yes Use appropriate flow chart Ulcers present Yes Use genital ulcer flow chart No 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 84 Inguinal Bubo  Recommended treatment:  Ciprofloxacin 500mg PO BID for 14 days, and  Erythromycin 500mg PO QID for 14 to 21 days 85 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 86 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 87 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 88