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

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

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  1. Sexually Transmitted Infections A predisposing factor for HIV transmission Syndromic Approach to Management T. Hylton-Kong

  2. 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

  3. 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

  4. 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

  5. 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

  6. 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

  7. 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

  8. STI – Syndromic Case Management REQUIREMENTS: • Adequate medical history • Good sexual history • Complete STI clinical examination • Management guidelines • Good supply of effective drugs

  9. 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

  10. 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

  11. 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

  12. 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)

  13. 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

  14. 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

  15. 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

  16. Let’s turn to our treatment checklist

  17. Genital Ulcer Disease Wilkinson and Stone, 1995; Fig 8.46 J. Anderson, MD, ed. Holmes, 1999; Plate 32 Syphilis Chancroid Herpes Simplex

  18. 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

  19. 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

  20. Let’s turn to our treatment checklist

  21. Genital herpes vesicles

  22. 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

  23. Causes of Abnormal Vaginal Discharge • Candidiasis • May increase in frequency and/or severity with progressive HIV disease • Common after antibiotic treatment

  24. Typical vaginal discharge caused by trichomoniasis Source: Seattle STD/HIV Prevention Training Center at the University of Washington

  25. Causes of Abnormal Vaginal Discharge Trichomoniasis • Even though lesser degree of HIV transmission, its prevalence supersedes this • treatment of sex partner needed

  26. “Strawberry cervix” due to T. vaginalis Source: Claire E. Stevens/Seattle STD/HIV Prevention Training Center at the University of Washington

  27. 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

  28. Causes of Abnormal Vaginal Discharge • Cervicitis • Chlamydia • Gonorrhoea • Limitations of syndromic management • Use local prevalence data, if available • Risk assessment • Partner treatment

  29. Gonococcal Cervicitis Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides

  30. Vaginal Discharge: Risk Assessment

  31. 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

  32. 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

  33. 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

  34. Let’s turn to our treatment checklist

  35. Complaint of Vaginal Discharge Step 5 • Prevention Messages • Comply with Medication • Counsel re Risk Reduction • Condom use • Contacts (PN) • Confidentiality (assurance)

  36. 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

  37. Acute Salpingitis Source: Cincinnati STD/HIV Prevention Training Center

  38. 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

  39. 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).

  40. Let’s turn to our treatment checklist

  41. “Giving you the best that I got”…until… • Cheap • Non -Invasive • Test

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