2. Sexually transmitted infections in HIV

3. Session objectives At the end of the session, the participant should be able to –explain the concept of STD as a cofactor for HIV –discuss interventions to control STDs –list the approaches to management of STDs and the disadvantages of each approach –make a syndromic diagnosis based on the symptoms and write an appropriate prescription –explain to the patient regarding partner treatment and use of condoms

4. Session plan HIV and STI(5 minutes) Impact of STI s on HIV and vice versa (5 minutes) Role of STI treatment in HIV prevention (10 minutes) Approaches to STI diagnosis(5 minutes) Syndromic STI management(30 minutes)

5. Why STIs are important? HIV infection is primarily an STI in India-85% sexually transmitted STI s increase the spread of HIV Treatment of STIs reduce the transmission of HIV HIV care / STI care should be integrated HIV can alter the manifestations of STIs

6. For discussion Why is STI so worrying in the setting of HIV? Are interventions effective?

7. Biological evidence of STI as cofactor for HIV transmission presence of STD : increase viral load in genital secretion of HIV infected partner presence of STD : increase HIV susceptibility, disruption of epithelium cells, and increased inflammatory cells in HIV uninfected partner

8. Relative risk: STI as risk factor for HIV transmission Study populationSTIRelative risk Heterosexual men, Kenya Genital ulcer4.7 Heterosexual men, USASyphilis1.5-2.2 Heterosexual men, USAHerpes4.4 Heterosexual women, Zaire Gonorrhoea3.5 Chlamydia3.2 Trichomonas2.7 Heterosexual men, USAHerpes3.3-8.5 Syphilis8.4-8.5

9. Intervention studies: STD case finding strategies among CSW in Abidjan HIV incidence/100 py Before intervention 16.5 Basic strategy : monthly case finding 7.9 Intensive strategy : monthly case 5.5 finding using pelvic exam, and lab

10. Mwanza trial STD reference centre Syndromic approach Regular supply of effective STD drugs supervisory visits promote prompt attendance A 42% reduction in the incidence of HIV was noted in the intervention group as compared to the control group over 2 years of this intervention From Grosskurth et al., Lancet, 1995

11. Incidence of STDs in Thailand (1982-2001) First case of AIDS in 1984 100% condom initiated in 1989 100% condom completed in 1992

12. Where STD control is likely to have a maximum impact In settings with high prevalence of “relevant” STD (GUD, urethritis and cervicitis) Low quality of STD services At the earlier stages of the HIV epidemic It is NOT A MAGIC BULLET, but an essential component of a package of multiple HIV prevention strategies

13. Objectives of STI control To interrupt the transmission of STD (acquired infection) To prevent complication and sequelae To reduce HIV infection risk

14. Operational model of the role of health services in STD case management Population with STD Aware and worried Seeking care Correct diagnosis Correct treatment Cure Treatment completed

15. STRATEGIES IN COMMUNITY Sexual behavior change and condom promotion Education of the public regarding the s/s Improve the health seeking behavior Training of health workers to screen STI Training of GPs

16. Management of STIs Etiological approach Clinical diagnosis approach Syndromic approach

17. Problems with etiological management Delay in treatment Compliance with treatment Partner management Follow up Referral Maintenance of case records

18. Problems with etiological management Lab facility Interpretation of results Quality control Expensive (Chlamydia) Sophisticated tests

19. Operational model of the role of health services in STD case management Population with STD Aware and worried Seeking care Correct diagnosis Correct treatment Cure Treatment completed Promotion of health care seeking behaviour Improve quality of care Attitudes of personnel

20. Operational model of the role of health services in STD case management Population with STD Aware and worried Seeking care Correct diagnosis Correct treatment Cure Treatment completed Syndromic approach Include STD drugs in essential list Prescribe single dose Counsel about compliance

21. Clinical Diagnosis Approach Identify the STD causing symptoms based on clinical experience even experienced STD providers often misdiagnose STDs miss mixed infections difficult for surveillance

22. Clinical Diagnosis Approach Specialists!- (Holmes and Ryan) only 30% of chancroid and 10% mixed infections( Dangor 1990) 12/106 Syphilis misdiagnosed as Herpes

23. DiseaseAgentClinical features Chancroid Haemophilus ducreyi Multiple painful irregular, undermined edges, soft ulcer- Unilateral Bubo Donovanosis Calmeto bacterium granulomatis Painless progressive ulcer No regional adenopathy HerpesHSV 2&1Multiple painful grouped vescicles- ulcerate coalase Reccurence b/L adenopathy I primary LGV Chlamidia trachomatis L1 L2 L3 Transient ulcer Unilateral tender adenopathy, grove sign Syphilis Treponema pallidum Painless single ulcer, indurated clean base, Firm b/L adenopathy

24. Action action Symptom Decision Syndromic Diagnosis Approach Identify all possible STDs that could cause the syndrome and give recommended treatment based on epidemiological and laboratory data

25. Advantages V/S Disadvantages Treat at first visit Cost saving No loss to follow up Effective in mixed infection Minimal lab necessary Reduce HIV& STI spread Can be done by paramedics Over treatment False positive diagnosis Social problems due to over diagnosis Over treatment of partners

26. Syndromes Genital ulcer- syphilis, Chancroid, LGV, Herpes, Donovanosis Discharge- Gonococci, NGU Inguinal Bubo- LGV, Chancroid Vaginal discharge- Candidiasis, Trichomoniasis, BV, GC, Chlamydia Scrotal swelling- LGV, Gonorrhoea Lower abdominal pain- PID ( GC, Chlamydia) Ophthalmia neonatorum ( GC, Chlamydia)

27. Principles of treatment Medical treatment Follow up-return after 7 days if symptoms persists Partner notification Rule out other STDs - counsel HIV test Counseling & education –safe sex –risk reduction –behavior modification etc Condom promotion and provision

28. For discussion If this patient presented to you with history of painful urethral discharge, what would you do?

29. Urethral discharge Azithromycin 1g + Cefixime 400 mg orally as a single dose under supervision

30. For discussion If this patient were to present to you with, what would your approach?

31. Genital ulcer History of genital ulcer; History or findings of vesicles NO Look for ulcer YES Treat for syphilis, chancroid NO Educate, counsel YES Treat for herpes Educate, counsel Inj Benzathine penicillin 24 L IM stat for syphilis Plus azithromycin, 1g orally as a single dose for chancroid

32. For discussion This patient presents with a history of swelling in the inguinal region. Discuss your approach. © Dr Balasubramanian

33. Inguinal swelling/ bubo History of swelling in the groin Examine for genital ulcer NO Treat for LGV YES Use genital ulcer flow chart Doxycycline 100 mg bd for 21days

34. For discussion In a patient presenting with vaginal discharge, what is the approach? What is the difference is a speculum examination is possible?

35. Vaginal discharge (without speculum examination) Cervicitis Azithromycin 1g + cefixime 400mg orally as a single dose Vaginitis Metronidazole 2 g stat plus fluconazole 150 mg stat

36. Vaginal discharge (with speculum) History of vaginal discharge Abdominal pain? NO Endocervical discharge? YES Treat for cervicitis, vaginitis Symptoms persisting? Refer NO Risk factors? YES. Treat for vaginitis NO. Educate, counsel. Follow up YES Use lower abdominal pain flow chart

37. For discussion If a young lady presents lower abdominal pain, what is your approach?

38. Lower abdominal pain in women History of abdominal pain Check for missed delivery, recent abortion, guarding, tenderness NO Pain on moving cervix? Fever? NO Other illness? YES Manage accordingly NO Reassure and follow up YES. Treat for PID If not improving, refer YES Refer immediately Azithromycin 1g + cefixime 400mg stat and metronidazole 400 mg bd for 14 days

39. For discussion If this patient presents with pain in the scrotum, with swelling, how would you manage?

40. Scrotal swelling Painful scrotal swelling History of trauma? NO Scrotal swelling? NO- reassure YES, injury history\ Testis rotated/ retracted? YES. Refer immediately NO. Treat YES: Refer Cefixime 400mg orally bd, 7 days + doxycycline 100mg bd, 14 days

41. Ophthalmia neonatorum Take history and examine Bilateral or unilateral swollen eyelids with purulent discharge? ｷ Treat baby for gonococcal and chlamydial infections ｷ Treat mother and partner for gonococcal and chlamydial infections ｷ Counsel and educate parents ｷ Come back after 3 days Improved? Complete treatment Reassure mother Refer immediately to higher- level facility ｷ Reassure mothers ｷ Advise to return if symptoms persist Yes No

42. Treatment for Ophthalmia neonatorum Recommended regimen: 1.Inj ceftriaxone 50mg\kg IM single dose, up to maximum of 125mg (to treat gonococcal infection) plus 2. Erythromycin syrup 50mg\kg, orally, daily in 4 ddivided doses for 14 days (to treat chlamydial infection)

43. Steps for STD prevention and management-All patients Treatment Instructions for medication Education and counseling condoms Education and counseling Treat for cure Don't spread Help partners treated Come back for check up Stay cured with condoms Keep staying with 1 partner Protect from HIV Protect your baby-ANC

44. Remember 6 Cs for STIs management Cure with treatment Compliance to treatment Contact tracing for partner management Counseling & education Condom promotion & provision Come back for clinical follow up

45. Condom- Common errors Misconceptions not corrected Packet opened and applied before erection Unrolled before application Tip of condom not squeezed Penis not withdrawn immediately after ejaculation Reservoir tip not facing down ward while slipping Not disposed properly

46. What can doctor do? Doctor can Distribute Display Demonstrate Condoms-------- 4D

47. Do not use grease, oils, lotions or petroleum jelly (Vaseline) forget to Use a condom each time you have sex. forget to Use a condom once only forget to Store condom in cool, dry place use condom that may be old or damaged Do not use a condom if –the package is broken –the condom is brittle or dried out –the colour is uneven or changed –it is unusually sticky

48. Condom & ART Continue condom use even in concordant couples –Different strains –Viral resistance –STIs –Effective ART programs may lead to increase in STI prevalence

49. References 1.Sexually transmitted infections treatment guide lines - NACO 2.WHO guide lines for management of Sexually transmitted infections 3.Grosskurth H,Gray R et al.Controle of Sexually transmitted disease for HIV-! Prevention; undrstanding the implications of the Mwanza and Rakai Trials lancet 2002;355:1981-87 4.Susanne Abraham STIs RTIs and HIV-module8-HIV distance learning 2002 5.Quality STD Care Training module for private medical practitioners – APAC-VHS Chennai Dr. Anupong Chitwarakorn 6.Management of sexually transmitted infections Dr. Anupong Chitwarakorn Department of Disease Control 7.Flow Charts on the Syndromic Management of Sexually Transmitted Infections- www.naco.nic.in