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Sexually Transmitted Infections Unit 15 HIV Care and ART: A Course for Physicians.

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Presentation on theme: "Sexually Transmitted Infections Unit 15 HIV Care and ART: A Course for Physicians."— Presentation transcript:

1 Sexually Transmitted Infections Unit 15 HIV Care and ART: A Course for Physicians

2 2 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

3 3 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

4 4 Estimated New Cases of Curable* STIs Among Adults

5 5 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

6 6 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

7 7 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

8 8 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

9 9 How Symptomatic are STIs? Source: WHO HIV/AIDS/STI Initiative

10 10 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

11 11 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

12 12 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

13 13 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

14 STI Management

15 15 Syndromic Approach to STI Management  Identification of clinical syndrome  Giving treatment targeting all the locally known pathogens which can cause the syndrome

16 16 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

17 17 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

18 18 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

19 19 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

20 20 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?

21 21 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

22 22 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

23 23 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

24 STI Syndromes and Management

25 25 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

26 26 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.

27 27 Case Study: Tsegenet (2)

28 28 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?

29 29 Genital Ulcer Syndrome

30 30 Genital Ulcer Disease: Differential Diagnosis  Herpes simplex  Syphilis  Chancroid  Lymphogranuloma venereum  Granuloma inguinale  Others

31 31 Differential Diagnosis? Courtesy of the Division of STD Prevention/CDC

32 32 Differential Diagnosis? Courtesy of the Division of STD Prevention/CDC

33 33 Differential Diagnosis? Courtesy of the Cincinnati STD/ HIV Prevention Training Center

34 34 Differential Diagnosis?

35 35 Differential Diagnosis? Courtesy of Peter Katsufrakis, MD

36 36 Differential Diagnosis? Courtesy of Peter Katsufrakis, MD

37 37 Differential Diagnosis? Courtesy of the Public Health Image Library/CDC

38 38 Differential Diagnosis? Courtesy of the Public Health Image Library/CDC

39 39 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

40 40 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)

41 41 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

42 42 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

43 43 Extensive Herpes Simplex Ulcers Courtesy of HIV In Site,

44 44 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

45 45 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%

46 46 HSV vesicles Courtesy of CDC/ Susan Lindsley

47 47 HSV circumferential ulcer Courtesy of CDC/ Dr. M. F. Rein; Susan Lindsley

48 48 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

49 49 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

50 50 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.

51 51 Case Study: Abel (2) Courtesy of Peter Katsufrakis, MD

52 52 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?

53 53 Case Study: Abel (4) Courtesy of Peter Katsufrakis, MD

54 54 Differential Diagnosis  Chlamydia  Gonorrhea  Mycoplasma hominis  Ureaplasma urealyticum  Hemophilus & Parahemophilus spp.  Other bacteria

55 55 Urethral Discharge Syndrome

56 56 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

57 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 Yes Educate/counsel Promote and provide condoms Offer VCT No Yes No

58 58 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”.

59 59 Case Study: Aida (2) Courtesy of Peter Katsufrakis, MD

60 60 Condyloma accuminata Courtesy of Peter Katsufrakis, MD

61 61 Condyloma accuminata Courtesy of Peter Katsufrakis, MD

62 62 Chlamydial Cervicitis Courtesy of STD/HIV Prevention Training Center at the University of Washington/ Connie Celum and Walter Stamm

63 63 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

64 64 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.

65 65 Case Study: Redeit (cont.) A.Is this a sexually transmitted infection? B.What are the likely causative organisms?

66 66 Vaginal Discharge  Common causes: Neisseria gonorrhea Chlamydia trachomatis Trichomonas vaginalis Gardnerella vaginalis Candida albicans

67 67 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 No Yes Vaginal Discharge

68 68 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

69 69 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 CDC

70 70 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

71 71 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.

72 72 Case Study: Redeit (cont.) A.What is happening? B.What should be done now?

73 73 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

74 74 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 No Yes

75 75 Recommended Treatment for PID Out patientInpatient 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

76 76 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

77 77 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 Yes Review in 7 days Yes Refer for specialist opinion and management No

78 78 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.

79 79 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

80 80 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 No Yes No Yes No

81 81 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

82 82 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)

83 83 Inguinal Bubo Courtesy of CDC/ Susan Lindsley

84 84 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 Yes No

85 85 Inguinal Bubo  Recommended treatment: Ciprofloxacin 500mg PO BID for 14 days, and Erythromycin 500mg PO QID for 14 to 21 days

86 86 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

87 87 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

88 88 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

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