STI & HIV

1. STI & HIV DR.V.S.DORAIRAJ. DIRECTOR I/C & PROFESSOR INSTITUTE OF VENEREOLOGY MADRAS MEDICAL COLLEGE

2. STI & HIV STD previously called as VD, now called as STI, since some etiological agents, even though transmitted by sexual contact & also transmitted by other routes are included. (e.g.. CMV, HBV) More than 30 causative organisms are included in STI. HIV disease is one of the STI.

3. According to WHO, 330 million cases are reported every year, all over the world as STD. • India has high incidence of STD; and the annual incidence rate is 5% among the infectious diseases.

4. HIV infection and STD are bidirectionally synergic, though the route of transmission and target audience is the same. • HIV is present in all body fluids but more in vaginal fluid, semen and blood.

5. INTERACTION BETWEEN HIV INFECTION AND OTHER STD • 1.Potential for STD to increase the rate of both HIV Acquisition and Transmission • In patients with genital ulcers, the acquisition and transmission is increased by 10 folds due to raw area. • In patients with genital discharge it will be increased by 5 folds due to micro ulceration of mucosa.

6. INTERACTION BETWEEN HIV INFECTION AND OTHER STD 2.Potential for STD to accelerate the natural progression of HIV infection • Evidence suggest that HPV and HSV infection capable of accelerating HIV Disease through retroviral transactivation. • So, early diagnosis and treatment of these STD will prevent the spread of HIV.

7. STD in HIV Infection In HIV patients, STD will have, 1. Shorter incubation period 2. Clinical Features altered – Atypical and Florid 3. Serological parameters altered-in Secondary Syphilis 4. Complications will be preponed. 5. Refractory to treatment.

8. a. Syphilis Treponema pallidum b. Gonorrhea Neisseria gonorrhoeae c. Chancroid Haemophilus ducreyi d. Granuloma inguinale Calymmatobacterium granulomatis e. Lymphogranuloma venereum Chlamydia trachomatis (L1, L2, L3) f. Bacterial vaginosis Gardnerella vaginalis, Mobiluncus, Mycoplasma, Ureaplasma, Bacteroides, Peptococcus g.Non-gonococcal urethritis Chlamydia trachomatis (D to K) Mycoplasma, Ureaplasma, etc. h. Pelvic inflammatory disease N.gonorrhoeae, C.trachomatis, Mycoplasma, Ureaplasma, etc. i. Enteric disease Salmonella, Shigella, Campylobacter fetus, Branhamella catarrhalis. SEXUALLY TRANSMITTED DISEASES AND ASSOCIATED PATHOGENS 1. BACTERIAL

9. a. AIDS HIV – 1 & 2 b. Genital herpes HSV- 2 & 1 c. Hepatitis HAV, HBV, HCV, HDV, (? HEV, HGV, GBV-C) d. Genital warts Human papilloma virus (HPV) e. Molluscum contagiosum Molluscum contagiosum virus f. Mononucleosis Cytomegalovirus (CMV), EBV. 2. VIRAL

10. a. Candidiasis Candida albicans, C.tropicalis, etc. b. Tinea cruris Trichophyton, Epidermophyton a. Trichomoniasis Trichomonas vaginalis b. Giardiasis Giardia Lamblia c. Amebiasis, Amoebic ulcer Entamoeba histolytica 3. FUNGAL 4. PROTOZOA

11. a. Enterobiasis Enterobius vermicularis b. Trichuriasis Trichuris trichura c. Strongyloidiasis Strongyloides stercoralis a. Scabies Sarcoptes scabiei b. Phthiriasis pubis Pthirus pubis 5. HELMINTHS 6. ECTO PARASITES

12. After the emergence of HIV disease ,the incidence of syphilis ,viral infections like Herpes, genital warts ,protozoal infection like trichomoniasis & fungal infections like candidiasis are increased.

13. Genital Ulcer Diseases • Syphilis • Chancroid • Venereal Granuloma • Lymphogranuloma Venereum (LGV) • Herpes Genitalis

14. SYPHILIS HIV disease and Syphilis involves all system. Only difference is in syphilis, the causative organism, Treponema pallidum itself affects all system; whereas in HIV disease; because of immunedeficiency, the opportunistic organisms affect all the systems. Syphilis affects head to foot, hair to nail, does not spare any part of the body. Syphilologist – Stokes, says “ One who knows syphilis – knows medicine”. Incubation period : 9 - 90 days

16. Primary syphilis • Usually Single indurated painless hamcolour ulcer present with lymph nodes enlarged, discrete, painless and rubbery in consistencySero negative Phase Sero Positive Phase

17. Primary Syphilis

18. Primary Syphilis

19. Primary Syphilis

20. Secondary syphilisOccurs 3 - 6 months after the appearance of primary syphilis in the case of untreated patients

21. Secondary Syphilis

22. Secondary Syphilis

23. Secondary Syphilis

24. Secondary Syphilis

25. Investigations • 1.Dark field microscopy • 2.RPR card test • 3.VDRL slide test • 4.TPHA assay • 5.FTA – ABS

26. Treatment • Early Acquired Syphilis ( <2 years from the date of contact • (Primary / Secondary / Early latent syphilis) • Inj.Benzathine Penicillin 24 Lakhs I.U I.M single dose (or) • Inj.Procaine Penicillin 12 Lakhs I.U I.M daily for 10 days

27. Treatment • Late Acquired Syphilis (>2 years from the date of contact) • Late Latent Syphilis • Inj.Benzathine Penicillin 24 Lakhs I.U I.M weekly for 4 weeks (or) • Inj.Procaine Penicillin 12 Lakhs I.U I.M daily for 3 weeks.

28. CHANCROID Causative agent : Haemophilus ducreyi Incubation period : 5-7 days Multiple Soft Painful easily bleeding ulcers with Bubo (Uni locular)

29. CHANCROID

30. CHANCROID

31. CHANCROID

32. Investigations1.Smear – Grams stain 2.Culture –Blood enriched mediaTreatmentT.Cotrimoxazole S.S 2 b.d for 10 –15days (or) T.Erythromycin 500 m.g q.i.d for 10 –15days

33. VENEREAL GRANULOMA Causative agent : Calymmatobacterium granulomatis Granulomatous Ulcer with Velvety appearance and wavy margin. Inguinal Lymph nodes not involved

34. VENEREAL GRANULOMA

35. VENEREAL GRANULOMA

36. Investigations Tissue smear – Leishman’s stain Giemsa stain Treatment T.Erythromycin 500 m.g q.i.d for 10 –14days (or) C.Doxycycline 100 m.g b.d for 10 –14days (or) C.Tetracycline 500 m.g q.i.d for 10 –14days

37. Herpes Genitalis Causative agent : Herpes simplex virus – 2 & 1 Incubation period : 2-7 days Grouped Vesicles Rupture and form Superficial, Erosive Ulcer with polycyclic border

38. Herpes Genitalis

39. Herpes Genitalis

40. Investigations Smear – Leishmans stain – multinucleated giant epithelial cells Treatment First clinical episode - T.Acyclovir 200 m.g 5 times daily for 7days Recurrence - T.Acyclovir 200 m.g 5 times daily for 5 days Acyclovir topical application

41. LYMPHOGRANULOMA VENEREUM (LGV) Causative agents : Chlamydia trachomatis (L1, L2, L3) Incubation period : 3 – 21 days Superficial, erosive, transient Ulcer. Usually patient may not notice the Ulcer, he will land in the stage of Bubo. (Multi Lacular)

42. LYMPHOGRANULOMA VENEREUM (LGV)

43. LYMPHOGRANULOMA VENEREUM (LGV)

44. Investigations 1.Antigen detection –a)Direct Fluorescent Antibody Technique b)ELISA 2.Antibody detection-a)Micro Immuno Fluorescence b)ELISA Treatment C.Doxycycline 100 m.g b.d for 10 –14days (or) C.Tetracycline 500 m.g q.i.d for 10 –14days Bubo must be aspirated through the normal skin

45. Genital Discharges Male Urethral discharge Physiological Pathological Gonococcal Urethritis Non Gonococcal Urethritis Non Specific Urethritis

46. Genital Discharges Female Vaginal Discharge Physiological Pathological Gonococcal Trichomoniasis Candidiasis Bacterial Vaginosis

47. GONOCOCCAL INFECTION Causative agent : Neisseria gonorrhoeae Incubation period : 2 – 5 days Sites : Can infect any columnar epithelium urethra, cervix, rectum, pharynx, conjunctiva ( NOT vagina)

48. Clinical features Men : Purulent urethral discharge, dysuria, In homo/bisexuals – Pharyngitis, proctitis. Women : Usually asymptomatic, but may have vaginal discharge, dysuria, proctitis. Pharyngeal disease – usually asymptomatic. Neonates : Neonatal conjunctivitis (Opthalmia neonatorum)

49. ACUTE GONOCOCCAL URETHRITIS

50. Investigations1.Smear – Grams stain 2.Culture – Modified Thayer Martin medium Treatment Inj.Procaine penicillin 48 lakhs I.U I.M single dose after test dose (or) Inj.Kanamycin 2 gram I.M single dose (or) Inj.Gentamycin 240 m.g I.M single dose(or) Inj.Ceftriaxone 250 m.g I.M single dose(or) T.Azithromycin 2 gram orally single dose