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. Transmission of Infectious Diseases: Biologic Requirements
Infectious Susceptibility
Inoculum (concentration) Hereditary resistance
Phenotypic factors Innate resistance
Acquired (immune)
resistance

4. 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

5. 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

6. 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

7. 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

8. 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
STIs and HIV are closely interrelated. The clinical findings of certain STIs are changed in the presence of HIV. Furthermore, STIs, both ulcerative and nonulcerative, increase the risk of HIV transmission 2-5 times. Genital ulcers disrupt the epithelial barrier, and STIs also increase the number of cells vulnerable to HIV in the genital tract, increasing susceptibility in uninfected individuals. Alternatively, HIV-infected persons with STIs have increased genital tract HIV viral load, which increases infectiousness. Treatment of these infections reduces the amount of virus in the genital tract. These findings suggest that screening and treating STIs can be another way to prevent HIV transmission. Indeed, in one clinical trial in Tanzania, enhanced syndromic management of STIs resulted in a 38% decrease in HIV seroconversion over two years.

9. STI Case Management AETIOLOGIC: CLINICAL ASSESSMENT: SYNDROMIC: MIXED:
Lab isolation of the causative organism
CLINICAL ASSESSMENT:
“Aetiology” based on clinical appearance
SYNDROMIC:
Syndromes – clinical symptoms, signs, risk assessment, rapid and cost-effective tests
MIXED:
All of the above; but which give immediate results for “point of first contact” management

10. STI – Aetiologic Case Management
ADVANTAGES:
Screening for asymptomatic infection
Definitive diagnosis to guide partner management and counseling
Epidemiologic research studies needed to guide syndromic management
Antimicrobial susceptibility testing

11. STI – Aetiologic Case Management
DISADVANTAGES:
Current tests often expensive and unreliable
Require sophisticated equipment and training
Often require clients to return days later
Return often not feasible: distance, fares, work, etc
Results in high default rates
Period of infectivity prolonged by Tx delay
Lab facilities unavailable at point needed

12. STI – Syndromic Case Management
ADVANTAGES:
Identifies and treats by signs & symptoms
Syndromes easily recognised clinically
Small number of clinical syndromes
Tx given for majority of organisms
Simple and cost-effective
Valid, feasible, immediate Tx
Risk assessment increases performance

13. STI – Syndromic Case Management
DISADVANTAGES:
Tendency to overtreat – justifiable in high prevalence settings (>20%)
Decreased specificity
Overuse of expensive drugs
Asymptomatic cases not fully addressed even with risk assessment
Management of cervical infections problematic
Vaginal discharge algorithm performs poorly in low prevalence settings e.g., ANC, FP

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

15. 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

16. Essential Steps In STI Care Management*
Syndrome
Assessment
Contact tracing
Compliance
Confidentiality
Condom use
Counseling
(diagnostic tools)
Diagnosis
Treatment
5Cs
An Integrated Approach to SCM begins with:
RA & SA [sexual behaviours, specific exposures, sociodemographic and other markers of high risk]. History of RH and past STIs.
Depending on Resources for Testing results may lead to:
Confirmatory diagnostic tests (in symptomatic patients).
Screening tests (in asymptomatic patients at high risk).
In most settings, Tx of symptomatic patients is started on a syndromic presumptive basis:
Industrialised countries: while waiting on test results.
Or on basis of rapid tests: Gram, WP, TRUST, etc.
After Tx, SCM concludes with the 4 Cs (5 if confidentiality is added).
THE RULE OF 5s:
See: 5 risk factors; 5 steps; 5 prevention messages; 5 PID referrals; 5 PID treatment indicators.
(screening tests)
Risk
Assessment
* Adapted from Holmes & Ryan

17. 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

18. 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)

19. 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

20. Programmatic Advantages to Syndromic Management of STIs
In busy clinics provides the best care possible in the most efficient manner
Used routinely by all STI clinicians will reduce waiting time and relieve congestion
Will simplify procedures and patient- flow within the clinic – thereby reducing environmental stress

21. 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
Urethral discharge is a very common STI symptom in males. A 2001 study found that 48% of men seeking STI-related treatment at clinics in Botswana presented with urethral discharge
Gonococcal urethral discharge
Photo: Cincinnati STD/HIV Training Ctr

22. 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

23. Let’s turn to our treatment checklist

24. Genital Ulcer Disease Syphilis Chancroid Herpes Simplex
Wilkinson and Stone, 1995; Fig 8.46
Genital ulcers are most commonly caused by syphilis, chancroid, or herpes simplex. These etiologies cannot be reliably distinguished from one another on clinical grounds and may coexist in the same individual. HIV-infected persons with syphilis may have abnormal serologic results, such as unusually high titers, false negatives, or delayed seroreactivity, although generally serologic tests can be interpreted in the usual manner. The clinical presentation of syphilis is variable at all stages, but atypical manifestations may be seen in the setting of HIV infection. Neurosyphilis should be considered in the differential diagnosis when HIV-infected individuals present with neurologic signs or symptoms. Therapy is not altered by the presence of HIV infection.
With chancroid, response to treatment may be diminished in the HIV-infected person; with use of single dose therapies, close follow-up is necessary since treatment failure may be more likely. Herpes simplex infections are chronic, involving relapsing infections that cannot be cured by current therapies, although infections can be controlled by suppressive or intermittent antiviral agents such as acyclovir. In the HIV-infected client with genital herpes, more frequent, prolonged, and/or severe episodes are common with progressive immunesuppression and lesions may be atypical in appearance or location.
J. Anderson, MD, ed.
Holmes, 1999; Plate 32
Syphilis
Chancroid
Herpes Simplex

25. 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
Other causes of genital ulcers include lymphogranuloma venereum and granuloma inguinale, which are caused by infections and may be more difficult to treat in individuals with HIV infection. With any genital ulcer that does not heal and does not respond to treatment, a malignant neoplasm must be considered.
In areas with limited resources for diagnosis, syndromic management is recommended and has been shown to be accurate and effective. With syndromic management, immediate treatment is given for all major causes of genital ulceration, based on local information about causes of ulcers and their drug susceptibility.

26. GENITAL ULCER SYNDROME
History, Risk Assessment, Examination.
Determine Number of Ulcers
Solitary Lesion
Multiple lesions
Recurrent at same site or with vesicles? No
Yes
Treat for Syphilis
& Chancroid
Treat for
Chancroid
& Syphilis
Treat for
Herpes
Review in 7 days
Review in 7 days
Ulcer Persists
Cured
Ulcer Persists
Cured
Refer
Refer

27. Let’s turn to our treatment checklist

28. Genital herpes vesicles

29. 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
Women with HIV have higher rates of HPV infection and longer persistence of HPV, a characteristic that has been linked to greater likelihood of progression to precancerous changes or cervical dysplasia. Women with HIV are also more likely to have infection with multiple HPV types and greater frequency of oncogenic or cancer-causing HPV types. Both the likelihood of HPV infection and its persistence increase with lower CD4 cell counts and higher viral loads.

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

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

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

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

34. 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
Another problem frequently seen in women with HIV infection is abnormal vaginal discharge. This can be caused by one or more vaginal infections, including bacterial vaginosis, candidiasis, or trichomoniasis. The first and most common type of vaginal infection, bacterial vaginosis or BV, is not caused by a single type of bacteria, but by an overgrowth of different pathogenic bacteria that alter the normal vaginal environment. BV has been associated with an increased risk of pelvic inflammatory disease and, in pregnant women, an increased risk of preterm labor and premature rupture of membranes. More recent information has shown that BV may enhance HIV transmission, both sexual transmission and mother-to-child transmission.
The second type of vaginal infection, candidiasis or yeast infection, may increase in frequency with progressive HIV disease, as the immune system becomes more suppressed. These infections are also common after antibiotic treatment in both HIV-infected and HIV-uninfected individuals. The third common type of vaginal infection is trichomoniasis, a protozoan infection that is transmitted sexually. Syndromic management of abnormal vaginal discharge, including treatment for these three types of infections, is recommended and is effective for the treatment of vaginal infections.

35. Causes of Abnormal Vaginal Discharge
Cervicitis
Chlamydia
Gonorrhoea
Limitations of syndromic management
Use local prevalence data, if available
Risk assessment
Partner treatment
Another major cause of abnormal vaginal discharge is infection of the cervix or cervicitis. The two most common causes of cervicitis are gonorrhea and chlamydia, both of which are sexually transmitted. Unfortunately, syndromic management for abnormal vaginal discharge is less accurate in the diagnosis and management of cervicitis. If specific testing for gonorrhea and chlamydia is not available, other information should be used to make decisions about treatment, including personal risk assessment, local information about how frequently these infections are found, and other symptoms or signs, such as a cervical swab showing a purulent discharge. Sex partners should also be treated if a diagnosis of cervicitis is made.

36. Gonococcal Cervicitis
Mucopurulent cervical discharge is present in this patient. This sign may also be seen in chlamydial cervical infection as well.
Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides

37. Vaginal Discharge: Risk Assessment
Risk Factor
Score
Partner has urethral discharge 2
New partner in last 3 months 1
More than 1 partner last 3 months
Not living with steady partner
Age less than 21 years
[If risk score 2 and over, treat for cervicitis]

38. Complaint of Vaginal Discharge Give Prevention Messages
Step 1
Take History (esp. sexual). Determine Risk Score
Step 2
Do Bimanual Pelvic Exam, Pass speculum
Step 3
Clean and Inspect Cervix
There are 5 essential steps in the vaginal discharge algorithm:
Step 1: We have just seen how the Risk Score is determined.
Step 2 speaks for itself.
Progress after steps 3 to 4 depends on clinical findings.
Step 5: The prevention messages have already been outlined under STI Care Management, and will be summarised later.
Step 4
Observe nature of Vaginal Discharge
Give Prevention Messages
Step 5

39. 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

40. 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

41. Let’s turn to our treatment checklist

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

44. 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
Both gonorrhea and chlamydia are major causes of pelvic inflammatory disease or PID, which is an upper genital tract infection involving the endometrial cavity, fallopian tubes, ovaries, and the peritoneal cavity. Most women with PID present complaining of lower abdominal pain. On physical examination, the presence of lower abdominal tenderness, adnexal tenderness, and cervical motion tenderness form the basis for clinical diagnosis. The presence of other simple findings, such as fever and abnormal discharge increase the accuracy of diagnosis. If available, pregnancy testing should be performed, since ectopic pregnancy may present with similar findings. In women with HIV infection, PID may be both more common and more severe. Treatment with antibiotics to cover gonorrhea, chlamydia, and other aerobic and anaerobic bacteria is indicated. Hospitalization for intravenous therapy should be considered with severe PID and in women who have symptomatic HIV.

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

46. 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
Pregnancy Status:
In the 1994 vaginal discharge study:
Women who knew they were pregnant were 95/748 (13%)
Women who did not know were 67/748 (9%) to
any
no to all

47. 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
STI – J. D. C. Ross 78 (1): 18
The diagnosis of PID remains problematic.
Sensitivity and Specificity of a Clinical Diagnosis is about 50%.
Magnetic Resonance in severe cases (sens=95%; spec=89%); superior to Transvaginal Ultrasound (TVU).
Using “power Doppler” to improve TVU gave a PPV=91%., and was of particular value in milder cases seen in OPD.
PEACH randomised controlled study recruiting over 1500 OPD cases treated with cefoxitin and doxycycline. Preliminary data:
Adnexal tenderness = 96% sens, 4% spec.
LAT + AT + CMT = 83% sens, 22% spec.
Best predictor of endometritis was: pos GC/CT test + temp and WBC .
Doubts raised re protective value of OCs.
A meta-analysis (Gareen, 2000) found RR 0f 3.3 symptomatic PID in IUD.
Risk with IUD limited to first few weeks after insertion. Reflects introduction of bacteria to UGT. Therefore depends on prevalence of NG/CT in the population.
Re-evaluate 3 days. Improved – complete Tx days.
Not improved – refer hospital, (esp. if temperature elevated).

48. Let’s turn to our treatment checklist

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