1. Slide 1 Unit 3: Sexually Transmitted Infections (STIs)
Unit 3 should take approximately 1 hour and 15 minutes to implement:
Step 1: Introduction and Learning Objectives (Slides 1-2) – 2 minutes
Step 2: STD Overview (Slides 3-12) – 10 minutes
Step 3: Genital Ulcers & Syphilis (Slides 13-42) – 15 minutes
Step 4: Inguinal Buboes (Slides 43-47) – 5 minutes
Step 5: Male Urethral Discharge (Slides 48-50) – 5 minutes
Step 6: Scrotal Swelling (Slides 51-54) – 5 minutes
Step 7: Female vaginal discharge (Slides 55-63) – 5 minutes
Step 8: Lower Abdominal Pain and PID (Slides 64-69) – 5 minutes
Step 9: Men who have Sex with Men (Slides 70-71) – 5 minutes
Step 10: Safer Sex Counselling (Slides 72-74) – 5 minutes
Step 11: Key Points (Slide 75) – 3 minutes
Step 12: Question and Answer (No Slides) – 10 minutes
NOTE:
These facilitation notes provide information on timing, items to emphasize, and background information to help the facilitator understand and explain the slide content. These notes are not meant to be read aloud by the speaker.
It may be necessary to darken the lighting in the training room so that participants can see sufficient detail in the photographs contained in this unit.
Unit 3:
Sexually Transmitted Infections (STIs)

2. Objectives Participants will be able to:
Slide 2
Participants will be able to:
Describe the interaction of HIV with other STIs
Apply the Namibian Syndromic STI Management Guidelines
Support STI management and prevention as part of HIV care and prevention
Step 1: Introduction and Learning Objectives (Slides 1-2) – 2 minutes
This unit provides information on the interaction of HIV and STDs, and on the potential impact of STD treatment on HIV transmission. It emphasizes syndromic management of STDs using the format of the 1999 Namibian guidelines, with additional information on secondary and tertiary syphilis and a brief segment at the end on prevention counseling. In the past, some facilitators and participants wanted more details on individual STDs. This presentation limits such detail, because
(1) Syndromic treatment is more effective than treatment based on a clinical diagnosis
(2) Accurate laboratory testing for specific STDs is not accessible for most of Namibia, and
(3) There are time limitations for this unit within the OI course.
This unit is extremely important as it describes ways to reduce HIV transmission and to bring more persons with HIV into care.
Ask participants if they have any questions about the learning objectives before continuing.
Unit 3: Sexually Transmitted Infections (STIs)

3. Etiology of STI in Namibia, 1994
Slide 3
Male urethral discharge
Female vaginal discharge
Gonorrhea
69%
12%
Chlamydia
27%
46%
Trichomonas
17%
Candida
49%
Bacterial Vaginosis
55%
Syphilis
19%
HIV
24%
14%
Step 2: STD Overview (Slides 3-12) – 10 minutes
These data from Windhoek more than 10 years ago demonstrate what were the most prevalent causes of inflammatory STDs at that time.
Note that many patients had multiple infections (the percentages in the column for men and for women add to much more than 100%), so trying to treat based on a single clinical diagnosis will be ineffective.
Note the high rate of syphilis diagnosed by performing an RPR on persons with a discharge.
Note the high rate of HIV diagnosed by performing an HIV test on persons with a genital discharge, back in 1994.
Gonorrhea was diagnosed by gram stain or culture, chlamydia, syphilis and HIV by serology, and candida by culture.
Data from STD patients
NACOP/MOHSS, Windhoek, August 1994
Unit 3: Sexually Transmitted Infections (STIs)

4. Etiology of STI in Namibia, 1994 (2)
Slide 4
Chancroid
16%
Syphilis
22%
Herpes 5%
LGV 1%
Chancroid & syphilis
18%
Chancroid & Herpes 7%
Chancroid & syphilis & Herpes +/1 LGV 2%
Syphilis & LGV
Syphilis & Herpes
Unknown
35%
HIV
26%
These data, from 10 years ago in Windhoek, show a high prevalence of chancroid, syphilis, and also combinations of infections in persons with genital ulcer disease.
Over the last 15 years (and since this study was done), the worldwide prevalence of chancroid and syphilis have been decreasing, whereas the worldwide prevalence of Herpes simplex genital ulcers has increased dramatically (Connie Celum, HSV and Global HIV-1, presented at Conference on Retroviruses and Related Infections (CROI) Feb 11, 2004).
The frequency of multiple infections among persons with genital ulcers is extremely important, because it explains why it is difficult to make a specific etiologic diagnosis on clinical grounds and why it is very important to treat for the several pathogens likely to cause genital ulcers at the same time (syndromic management). 18% of patients needed treatment for both syphilis and chancroid. Treatment based on the syndromic approach is more effective than treatment based on a clinical diagnosis. Reliable methods for making a specific laboratory diagnosis of STDs are not widely available in Namibia (culture, antigen detection, PCR) and are too expensive for routine use in developing nations. Thus, the syndromic approach is extremely important in the treatment and control of STDs, and in the effort to reduce sexual HIV transmission.
Data from 91 genital ulcer patients
NACOP/MOHSS, Windhoek, August 1994
Unit 3: Sexually Transmitted Infections (STIs)

5. Clinical Management MOHSS 1999 WHO 2001 US CDC 2002
Slide 5
MOHSS 1999
Guidelines for the syndromic management of sexually transmitted diseases
WHO 2001
Guidelines for the management of sexually transmitted infections
US CDC 2002
Sexually transmitted diseases treatment guidelines
Data from the 1994 study led to the development and approval of Namibia’s STD treatment guidelines in This slide set describes treatment regimens and flowcharts from this document (see full reference below). MOHSS plans to perform a study on the etiology of STDs in 2006 and use the data to review and possibly update the guidelines. Additional recommendations in this slide set come from the WHO guidelines and the US guidelines (full references below). The slides clearly indicate when WHO or US CDC recommendations are included.
HIV testing, which was not part of the guidelines in 1999 because it was not very available, is now available and strongly recommended for all STD patients.
Republic of Namibia, Ministry of Health and Social Services (MoHSS). Guidelines for the Syndromic Management of Sexually Transmitted Diseases, April, As noted, these may be revised in 2006.
Alternative treatments from the World Health Organization (WHO). Guidelines for the Management of Sexually Transmitted Infections. Geneva, 2001 are sometimes included. Indications are noted on the sides that include treatment issues and information that go beyond the 1999 MOHSS STD Guidelines.
Another resource: Centers for Disease Control and Prevention (CDC). Sexually Transmitted Diseases Treatment Guidelines, Downloaded 13, Oct. 2005: These guidelines may also be revised in 2006 and will be available on the CDC website.
Unit 3: Sexually Transmitted Infections (STIs)

6. STIs and HIV Common modes of transmission
Slide 6
Common modes of transmission
Transmission of multiple STIs (including HIV) at same time is common
This highlights the importance of syndromic management for STIs
STIs increase HIV transmission during unprotected sex. A single infection increases HIV transmission by 4-8 times.
Persons infected simultaneously with HIV and STI are over 20x more infectious than persons with chronic HIV alone.
STDs are common among HIV infected persons because they may be transmitted together and are associated with the same sexual behaviors.
STDs, important in their own right, also increase transmission and acquisition of HIV.
Unit 3: Sexually Transmitted Infections (STIs)

7. STIs and HIV
Slide 7
HIV may change the appearance or response to therapy of STIs
Improved syndromic treatment of STIs reduced HIV transmission in Tanzania by 42%*
*Grosskurth H et al. Lancet 1995;346:530
HIV may alter the appearance, natural history, and response to treatment of some STDs.
Treatment of STDs has been shown in some studies to reduce HIV transmission. The Grosskurth randomized controlled trial of enhanced versus standard STD treatment in Tanzania showed a reduction in HIV transmission.
The Gray randomized controlled study of community scheduled STD mass treatment in Rakai Uganda (Warwer M et al., Lancet 1999) did not show a reduction in HIV transmission. Nevertheless, public policy supports use of improving STD diagnosis and treatment as part of HIV prevention.
New data suggest that in Rakai, Herpes simplex ulcers (which are not curable and were not treated in the study) were the STD contributing most to HIV transmission. Studies are underway to learn if chronic suppression of genital Herpes in African countries can reduce HIV transmission
Sources:
Grosskurth H, et al. Impact of improved treatment of sexually transmitted diseases on HIV infection in rural Tanzania: randomized controlled trial. Lancet, Vol. 346:530-6.
Grosskurth H, Gray R, Hayes R, Mabey D, and Wawer D. Control of sexually transmitted diseases for HIV-1 prevention: Understanding the implications of the Mwanza dn Rakai trials. Lancet, Vol. 355:
Orroth K. et al. Higher risk behavior and rates of sexually transmitted diseases in Mwanza compared to Uganda may help explain HIV-1 trial outcomes. AIDS, :
Warwer, M. Control of sexually transmitted diseases for AIDS prevention in Uganda: A randomized community trial. Lancet, Vol. 535:
Corey L, Wald A, Celum CL, Quinn TC. The effects of herpes simplex virus-2 on HIV-1 acquisition and transmission: a review of two overlapping epidemics. J Acquired Immune Def Syndrome 2005;35:
Unit 3: Sexually Transmitted Infections (STIs)

8. STI and HIV
Slide 8
There was a much higher rate of HIV among STD patients than among pregnant women in Namibia (as high as 61% in Katima Mulilo in 1998 and 65% in Oshakati in 2002). Overall HIV prevalence in STD patients was similar in 1998 and 2002, although there were considerable changes in individual sites. However, sample sizes were small, in particular in Differences per site are therefore difficult to interpret due to large confidence intervals. The lowest rate was 10% in Opuwo, which is similar to that found in pregnant women. However, 10% is still a high prevalence. HIV testing is urgent for persons presenting for treatment of an STD, as is counseling to reduce further STD exposure and STD/HIV transmission.
Source: MoHSS HIV sero-survey 2002
Unit 3: Sexually Transmitted Infections (STIs)

9. HIV in Semen of men with Gonorrhoea
Slide 9
In this study, 4 men with HIV and gonorrhea had high levels of HIV in their semen (top graph). HIV load in semen decreased dramatically with treatment (decrease in semen viral loads over time on top graph). However, the blood HIV viral loads did not change much from pre-treatment to after treatment of gonorrhea. With HSV, on the other hand, blood HIV viral load also decreases with treatment or resolution of the Herpes episode.
M C Atkins, E M Carlin, V C Emery, P D Griffiths, and F Boag Fluctuations of HIV load in semen of HIV positive patients with newly acquired sexually transmitted diseases BMJ, Aug 1996; 313:
Cohen M, Hoffman I, Royce RA et al. Reduction of concentration of HIV-1 in semen after treatment of urethritis: implications for prevention of sexual transmission of HIV-1. Lancet 1997; 349:
Schacker T, et al. Changes in Plasma Human Immunodeficiency Virus Type 1 RNA Associated with Herpes Simplex Virus Reactivation and Suppression J Infectious Disease 2002;186:
Unit 3: Sexually Transmitted Infections (STIs)

10. STIs and HIV Light colour – HIV in blood stream
Slide 10
Active STDs can raise both the amount of HIV in the bloodstream (the viral load shown in yellow) and the amount of HIV in the genital tract (shown in red). Times of high blood and genital viral loads are times when HIV transmission is highest. So a patient is most likely to transmit HIV when they are recently infected (first rise in the graph), when they have episodes of STDs (including Herpes recurrences – the 2nd and 3rd rises in the graph), and perhaps when they have advanced to AIDS (although persons who are quite ill may not be very sexually active). Treatment and counseling of persons during STDs is very important in reducing HIV transmission.
Source: Myron S. Cohen and Christopher D. Pilcher. Editorial Commentary. Journal of Infectious Disease. 2005:191 (1 May), 1391.
Light colour – HIV in blood stream
Dark colour – HIV in genital tract
Unit 3: Sexually Transmitted Infections (STIs)

11. STI Management Syndromic management
Slide 11
Syndromic management
Presumptive treatment of the most likely diagnoses
Addresses high rate of co-infections
Avoids unnecessary screening tests
Individual and public health benefit
Etiologic evaluation for complex cases after failure of syndromic management
Most STIs require treatment of partner even if asymptomatic
Always educate about transmission and promote condom use
HIV +/- RPR testing should be offered to all patients with STIs
If HIV negative, repeat in 3 months
Again, the main effort in STD treatment is the use of syndromic management.
Where sufficient laboratory testing is available, it can be applied to persons who do not respond to syndromic management.
Most patients with STDs will become reinfected unless their partner is also treated, so referral of partners for assessment and treatment is very important.
STD treatment provides an opportunity to educate patients about HIV and STD transmission, and to promote condom use and safer sex.
HIV and RPR testing should always be offered. Negative HIV tests should be repeated in 3 months, as the patient with a new STD may be in the ‘window period’ for HIV testing.
Unit 3: Sexually Transmitted Infections (STIs)

12. Topics Covered in this Unit
Slide 12
Genital ulcers
Syphilis
Inguinal buboes
Male urethral discharge
Scrotal swelling
Female vaginal discharge
Lower abdominal pain and Pelvic Inflammatory Disease
Men who have sex with men
Counselling about safer sex
Here are the STD syndromes covered in this unit, following the 1999 guidelines. Additional information (beyond that in the 1999 guidelines) is provided on syphilis, on men who have sex with men, and on counseling
Unit 3: Sexually Transmitted Infections (STIs)

13. Genital Ulcer Disease (GUD)
Slide 13
Each ulcer-causing condition has typical features, but patients often present with atypical features or multiple simultaneous conditions.
Without rigorous laboratory testing, we cannot be certain of the etiology.
Syndromic management is directed at the most common curable conditions.
This is a reminder that we treat genital ulcer disease using a syndromic approach.
Unit 3: Sexually Transmitted Infections (STIs)

14. Genital Ulcer Disease (GUD): Differential Diagnoses
Slide 14
Infectious
Syphilis*
Chancroid*
Lymphogranuloma venereum
Granuloma inguinale
Herpes simplex*
Pyoderma
Cutaneous amoeba
Non-infectious
Trauma
Fixed drug eruption
Erythema multiforme
Squamous cell cancer
Autoimmune ulcers
Bechet’s syndrome
Reiter’s syndrome
Here is a complete list of infectious and non-infectious causes of genital ulcers. This course focuses on the sexually transmitted infections.
STDs are in red: the five classical causes of genital ulcer disease, also squamous cell cancer which is usually a result of chronic infection with certain types of human papilloma virus, which is also sexually transmitted. Note that some genital tract diseases and infections are not sexually transmitted.
Cutaneous ameba may be seen in Rundu and Caprivi, but is rare elsewhere in Namibia. Autoimmune ulcers are difficult to diagnose (often used as diagnosis of exclusion).
STIs in red
*Most common in Namibia
Unit 3: Sexually Transmitted Infections (STIs)

15. Treatment of Genital Ulcers
Slide 15
Primary Syphilis (Treponema pallidum)
Benzathine penicillin 2.4 million units IM once
Chancroid (Haemophilus ducreyi)
Ceftriaxone 250 mg IM once
Alternatives*:
Erythromycin 500 mg po qd for 7 days (Preferred by some for HIV+ patients)
Ciprofloxacin 500 mg po bd for 3 days
Azithromycin 1.0 gram po once
Patient with genital ulcers should be treated for the 2 most common causes: primary syphilis treated with IM penicillin, and chancroid treated with IM ceftriaxone. The WHO and US CDC guidelines offer alternatives to ceftriaxone.
*The 1999 Namibian guidelines recommend only ceftriaxone
Unit 3: Sexually Transmitted Infections (STIs)

16. Genital Ulcer Yes No Blisters and recurrent blisters Genital ulcer
Slide 16
Blisters and recurrent blisters
Genital ulcer
Penicillin IM
Ceftriaxone IM
Health Ed
Partner Treatment
Condoms
HIV testing
No improvement?
Multiple blisters
Clean lesions
Secondary infection:
Cotrimoxazole
Reinfection?
Refer
Re-evaluate
Treat partner
Repeat protocol No
Yes
Step 3: Genital Ulcers & Syphilis (Slides 13-42) – 15 minutes
Refer to Handout 3.1 in the Participant Handbook or Section 4.4 (page 13) of the Republic of Namibia, MoHSS, Guidelines for the Syndromic Management of Sexually Transmitted Diseases, April 1999.
Single ulcers are treated for syphilis and chancroid. An RPR is not needed here because patients are treated for primary syphilis, but all patients should be offered HIV testing as well as health education, condoms, and a recommendation for their partner to come to clinic for examination and treatment.
This is the flowchart from the 1999 Namibia STD syndromic treatment guidelines.
Refer to Handout 3.1 or Section 4.4 (page 13) of the MoHSS Guidelines for the Syndromic Management of STDs.
Unit 3: Sexually Transmitted Infections (STIs)

17. Primary Syphilis in Men: Chancres
Slide 17
Source: ©Wellcome Trust, 2003
Primary syphilis causes an ulcer (chancre) usually on the genitals that is usually (but not always) single and painless. Here are examples on male genitalia.
Corona: The ridge below the glans of the penis
Coronal sulcus: The depression around the penis proximal to the coronal ridge
Frenulum: The undersurface of the penis, the bridge of tissue across the coronal sulcus
Prepuce: Foreskin
Image Source: ©Wellcome Trust. CD Rom: Topics in International Health – Sexually Transmitted Infections. The Trustee of the Wellcome Trust, London, Second Edition, ISBN
Frenulum
Source: ©Wellcome Trust, 2003
Coronal sulcus
Also shaft and inner side of prepuce (foreskin)
Source: ©Wellcome Trust, 2003
Unit 3: Sexually Transmitted Infections (STIs)
Corona

18. Primary Syphilis in Women
Slide 18
Primary syphilis is often asymptomatic in women
The most common sites of chancres are the labia, fourchette, and cervix.
Primary syphilis causes an ulcer (chancre) usually on the genitals that is usually (but not always) single and painless. Here are examples on female genitalia. The ulcer may be hidden within the folds of the labia and not be noticed by women.
Labia includes the large folds of skin around the vagina (labia majora) and the small folds within them defining the entry (labia minora).
The fourchette is the lower part of the vagina where the labia minora fuse.
The female prepuce is the hood over the clitoris where the labia minora fuse.
Image Source: ©Wellcome Trust. CD Rom: Topics in International Health – Sexually Transmitted Infections. The Trustee of the Wellcome Trust, London, Second Edition, ISBN
Source: ©Wellcome Trust, 2003
Labia
Unit 3: Sexually Transmitted Infections (STIs)

19. Uncommon Locations of Chancres
Slide 19
Mouth and lips
Anal area and buttocks
Fingers
Nipples of non-immune woman breast feeding an infant with congenital syphilis
Primary ulcers (chancres) of syphilis rarely occur in other locations, depending on the contact of the patient with the infection in their partner.
Unit 3: Sexually Transmitted Infections (STIs)

20. Syphilis Natural History
Slide 20
Characterized by episodes of active disease and periods of latent infection
Primary disease involves skin and mucosal surfaces
Secondary disease involves skin, mucous membranes, and many other organs
Latent disease has no signs or symptoms
Tertiary syphilis causes disease of the aorta or masses (gummas) in any organ
Neurosyphilis can occur at any stage
With this slide we leave the discussion of genital ulcer for a few minutes to complete the discussion of syphilis, then the presentation will return to genital ulcer disease.
Untreated syphilis may last for decades. It starts with the genital ulcer, then progresses to secondary disease. Without treatment, it becomes latent meaning the patient is infected but has no signs or symptoms of disease, only a positive blood test. Years later the patient can get tertiary syphilis. Neurosyphilis, once considered a part of late or tertiary syphilis, actually can occur during secondary syphilis or early latent syphilis also.
Unit 3: Sexually Transmitted Infections (STIs)

21. Secondary Syphilis Signs and Symptoms
Slide 21
Rash: often on palms and soles of feet, trunk
Malaise
Generalized lymphadenopathy
Mucous patches (oral cavity, pharynx, larynx, genitals)
Condylomata lata
Alopecia
Neurosyphilis
Secondary syphilis occurs within a few weeks of the untreated primary ulcer , and is a disseminated disease with some, but not necessarily all, of the signs and symptoms listed here.
Additional background for the facilitator:
Clinical Manifestations of Secondary Syphilis:
Rash (75-90%): macular, papular, squamous (scale), pustular (rare), combination; usually nonpruritic; may involve palms and soles in 60%. Any new onset macular, papular or squamous rash should be evaluated to rule out secondary syphilis.
Generalized lymphadenopathy (70-90%) .
Constitutional symptoms (50-80%), most commonly malaise.
Mucous patches (5-30%): flat patches involving oral cavity, pharynx, larynx, and genitals.
Condylomata lata (5-25%): moist, heaped, wart-like papules that occur in warm intertriginous areas (most commonly, gluteal folds, perineum, perianal); teeming with treponemes.
Alopecia (10-15%): patchy occipital and bitemporal, loss of lateral eyebrows.
Neurosyphilis (<2%): early forms of basilar meningitis or meningovascular.
Liver and kidney involvement, usually not clinically significant.
Note: Signs and symptoms of secondary syphilis often are the first observed clinical manifestation of syphilis in MSM and women.
Source: National Network of STD/HIV Prevention Training Centers - Syphilis, pg 8. January Downloaded 03 Oct. 2005:
Unit 3: Sexually Transmitted Infections (STIs)

22. Rash of Secondary Syphilis in a Pregnant Woman
Slide 22
Source: ©Wellcome Trust, 2003
Here is a photo of the rash of secondary syphilis on the abdomen and palms of a pregnant woman.
Additional background on syphilis in pregnancy for the facilitator – syphilis treatment including treatment in pregnancy is on slide 29.
Syphilis in Pregnancy:
Treat with penicillin according to stage of infection. Erythromycin is not an acceptable alternative drug in penicillin-allergic patients. Patients who are allergic to penicillin should be desensitized in the hospital and treated with penicillin.
Some experts recommend that a second dose of Benzathine penicillin G 2.4 million units IM be administered 1 week after the initial dose for women who have primary, secondary, or early latent infection.
In the second half of pregnancy, management and counselling may be facilitated by a sonographic fetal evaluation for congenital syphilis, but this should not delay therapy.
Image Source: ©Wellcome Trust. CD Rom: Topics in International Health – Sexually Transmitted Infections. The Trustee of the Wellcome Trust, London, 2nd Edition, ISBN
Unit 3: Sexually Transmitted Infections (STIs)

23. Condylomata Lata: Mucosal Lesions of Secondary Syphilis
Slide 23
Part of secondary syphilis are these painless, raised, flat lesions on moist skin called condylomata lata. They are very infectious and should be recognized and treated. They are flatter, broader, and more numerous than ordinary genital warts, and occur in the setting of secondary syphilis symptoms.
Image Source: ©Wellcome Trust. CD Rom: Topics in International Health – Sexually Transmitted Infections. The Trustee of the Wellcome Trust, London, Second Edition, ISBN
Source: ©Wellcome Trust, 2003
Painless warty lesions on moist skin
May have fever, adenopathy, rash
Teeming with spirochetes
Highly infectious
Unit 3: Sexually Transmitted Infections (STIs)

24. Syphilis Signs and Symptoms
Slide 24
Latent
No clinical manifestations
Only evidence is positive serologic test
Early Latent
<1 year duration
Late Latent
>1 year duration or unknown
Without treatment, the clinical illness of primary and secondary syphilis will resolve. Despite a lack of symptoms, the patient remains infected. Those with no symptoms but a positive syphilis test should be treated. (treatment is described later)
Latent Syphilis:
No clinical manifestations. Only evidence is positive serologic test for syphilis.
Categories:
early latent: <1 year duration
late latent: ≥1 year duration or of unknown duration.
Criteria for early latent syphilis:
Documented seroconversion in comparison with a serologic titer obtained within the year preceding the evaluation.
Unequivocal symptoms of primary or secondary syphilis reported by patient in past 12 months.
Contact to an infectious case of syphilis in the past 12 months.
A 4-fold increase in serologic titer in comparison with a titer within the past 12 months may represent a case of early latent syphilis or relapse of a previously treated case.
Relapses of secondary lesions in up to 25% of cases, usually within the first year.
Unit 3: Sexually Transmitted Infections (STIs)

25. Neurosyphilis Symptomatic neurosyphilis may present as:
Slide 25
Symptomatic neurosyphilis may present as:
Lymphocytic meningitis
Stroke syndromes
Seizure disorders
Progressive dementia
Psychosis
Spinal cord dysfunction (tabes dorsalis)
Central nervous system involvement with syphilis can present as early as during secondary syphilis, or after decades of infection. It can cause a wide variety of conditions. Treatment of early stages prevents brain damage, treatment in late stages can prevent progression but does not reverse the damage that has already occurred. Diagnosis and treatment of neurosyphilis will be presented after a few slides.
Neurosyphilis:
Central nervous system invasion occurs early in infection in 30-40% of patients; however most patients eventually clear this site of infection with conventional therapy.
Asymptomatic neurosyphilis can occur at any stage. Early forms of neurosyphilis usually occur a few months to a few years after infection. Clinical manifestations include acute syphilitic meningitis, a basilar meningitis that typically involves cranial nerves VI, VII and VIII, or meningovascular syphilis, an endarteritis that presents as a stuttering stroke-like syndrome and seizures.
Late forms of neurosyphilis usually occur decades after infection and are rarely seen. Clinical manifestations of parenchymatous involvement include general paresis and tabes dorsalis.
Ocular involvement can also be early or late. Uveitis may be the most common early presentation.
Source: National Network of STD/HIV Prevention Training Centers - Syphilis, pg 9. January Downloaded 03 Oct. 2005:
Unit 3: Sexually Transmitted Infections (STIs)

26. Tertiary Syphilis
Slide 26
Some untreated patients develop other effects of syphilis years or more after infection
Benign tertiary syphilis (gummas): liver masses, skin disorders, eye lesions, bone deterioration (6%)
Syphilis of the heart and great vessels (4%).
In about 14% of untreated infected persons syphilis remains chronically active. 4% may get neurosyphilis, others get the syndromes listed here. 4% may get late neurosyphilis, already described. The others may get gummas or aortitis.
After an average latent period of more than 15 to 25 years the following manifestations occur. These patients are not infectious.
Unit 3: Sexually Transmitted Infections (STIs)

27. Serologic Diagnosis of Syphilis
Slide 27
Non-Treponemal Antibody:
3 names, same test
RPR (rapid plasma reagen)
VDRL (venereal disease research laboratory)
WR (Wasserman reaction)
Detects the immune reaction, but not an antibody test
RPR may be negative in primary syphilis
Titre is high in secondary disease and drops over time and after treatment
Antibody Test: Treponema Pallidum Haemagglutination (THPA)
Done to confirm RPR (+) tests
Two types of tests exist: the more common non-treponemal antibody tests, and the specific tests for antibody to Treponema pallidum which is the cause of syphilis.
Although there are many different tests with different names, NIP performs the RPR but will do so even if a different name is used for the test. Please use the term RPR as that is the correct name of the test actually performed by NIP. VDRL is a different (although similar) test. WR is an old name referring to the original test devised by Dr. Wasserman and is no longer performed.
Treponema Pallidum Haemagglutination (THPA) is available at NIP and is being used as confirmation for RPR(+) tests.
Additional background for facilitator:
Specific treponemal antibody tests, done as a supplement to non-treponemal tests, are done in other countries. The specific treponemal tests remain positive for life, even after treatment. It is most reliable to check the level or the titre of the RPR test to confirm current positivity.
Non-treponemal tests:
Principles:
Measure IgM and IgG antibody directed against a cardiolipinlecithin-cholesterol antigen.
Not specific for T. pallidum.
Reaction may be microscopic (VDRL) or macroscopic (RPR).
VDRL and RPR titres are not equivalent. RPR titres tend to be higher and are not directly comparable to VDRL titres for monitoring response to therapy. RPR may be slightly more sensitive and the longer duration of infection, the wider divergence between the RPR and VDRL.
TRUST and USR are comparable to the VDRL.
Note: Ideally positive non-treponemal tests need to be confirmed with a treponemal test for initial diagnosis, but the specific treponema tests are not easily available nor widely used in Namibia
Advantages: (a) Rapid (RPR) and inexpensive. (b) Easy to perform and can be done in clinic or office (RPR). (c) Quantitative. (d) Used to follow response to therapy. (e) Can be used to evaluate possible reinfection.
Disadvantages: (a) May be insensitive in certain stages (particularly primary and late latent). (b) Biological false positive reactions. Febrile illnesses and recent immunizations. Chronic causes of false positives include injection drug use, autoimmune and chronic diseases. (c) Rarely, a phenomenon called “the prozone effect” may cause a false negative reaction. The prozone effect occurs when the reaction is overwhelmed by antibody excess and may happen in late primary or in secondary syphilis. If clinical suspicion of secondary syphilis is high, the lab should dilute the serum to at least a 1/16 dilution to rule out the prozone effect.
Unit 3: Sexually Transmitted Infections (STIs)

28. Diagnosis of Neurosyphilis
Slide 28
Positive serum RPR or treponemal antibody test
Abnormal CSF
increased WBC
increased protein
positive CSF VDRL (not RPR)
Many false-negative tests occur
In Namibia, patients with a positive serum RPR, a compatible clinical syndrome, and an abnormal CSF should be treated for neurosyphilis
The most specific test for neurosyphilis is a CSF VDRL. It can be ordered specifically from NIP. It can be used in cases of a positive RPR, a compatible clinical syndrome (the possibilities are very broad), and either an elevated CSF white blood cell count or an elevated CSF protein.
Many persons with HIV will have some brain disease, abnormal CSF, and even a positive RPR without really having neurosyphilis. It is very difficult to eliminate neurosyphilis as a possibility in these patients, and they should be treated for neurosyphilis.
Unit 3: Sexually Transmitted Infections (STIs)

29. Syphilis Treatment Primary, secondary, early latent:
Slide 29
Primary, secondary, early latent:
Benzathine penicillin 2.4 million units IM once
Latent or tertiary syphilis
Benzathine penicillin million units IM once weekly for 3 weeks (3 injections)
Neurosyphilis
Penicillin G 2-4 million units IV q4 hourly for days
Here are the basic treatment regimens for syphilis. A person with a positive RPR and no symptoms (latent syphilis) should be treated with 3 injections of benzathine penicillin, one week apart, although this is not regularly done in Namibia. Note that the treatment of neurosyphilis is complex, with a minimum of 10 days of high dose IV penicillin like treatment of meningitis.
Pregnant women with a positive RPR should receive one or more injections of penicillin to prevent syphilis transmission to the newborn.
This information supplements the treatment regimen for genital ulcer disease, already described.
Unit 3: Sexually Transmitted Infections (STIs)

30. Syphilis and HIV In general, manage as in HIV uninfected patients.
Slide 30
In general, manage as in HIV uninfected patients.
Primary syphilis may not have classical appearance
Unusual serologic responses may occur.
Neurologic complications in early syphilis more frequent
If symptoms, RPR + and CSF abnormal treat for neurosyphilis
The same treatment is used for syphilis in HIV+ as in HIV uninfected persons. Sometimes the lesions look unusual, and neurosyphilis may be more common.
Unit 3: Sexually Transmitted Infections (STIs)

31. Chancroid in Men Painful Soft edge Clean, sharp edges
Slide 31
Painful
Soft edge
Clean, sharp edges
Yellow exudate in base
Source: ©Wellcome Trust, 2003
Now we return to the discussion of genital ulcer disease. Remind participants to follow the flow diagramme for genital ulcer disease.
Classically chancroid causes one or more painful ‘soft’ ulcers. Lymphadenopathy can occur.
Top Image: Ulcer of inner aspect of prepuce. Small, superficial lesions, well defined edges, mild erythema of margins, yellow purulent exudate.
Bottom Image: Painful chancroid ulcer on coronal sulcus.
Image Source: ©Wellcome Trust. CD Rom: Topics in International Health – Sexually Transmitted Infections. The Trustee of the Wellcome Trust, London, Second Edition, ISBN
May be multiple
Most common locations: foreskin, corona, frenulum
Source: ©Wellcome Trust, 2003
Unit 3: Sexually Transmitted Infections (STIs)

32. Chancroid in Women Painful Soft edges Clean, sharp edges
Slide 32
Painful
Soft edges
Clean, sharp edges
Yellow exudate in base
Source: ©Wellcome Trust, 2003
Here are examples of chancroid ulcers in women and some of the typical locations. In women, the ulcer itself may not be easily visible so the patient may present with other symptoms including dysuria, vaginal pain, or bleeding. Lymphadenopathy can occur.
Image Source: ©Wellcome Trust. CD Rom: Topics in International Health – Sexually Transmitted Infections. The Trustee of the Wellcome Trust, London, Second Edition, ISBN
May be multiple
Most common locations:
Labia, fourchette, clitoris, introitus
Source: ©Wellcome Trust, 2003
Unit 3: Sexually Transmitted Infections (STIs)

33. Chancroid and HIV More likely to have multiple ulcers
Slide 33
More likely to have multiple ulcers
May respond more slowly to treatment
Ceftriaxone IM
Some recommend multiple dose treatment erythromycin for 7 days
Buboes require drainage
Chancroid increases HIV transmission
These are the known interactions of chancroid with HIV.
Unit 3: Sexually Transmitted Infections (STIs)

34. GUD Case Study
Slide 34
A 22 year old woman has 3 days of painful urination, vulvar pain, and fever.
She has recently become sexually active with a new partner.
Read the case study to the participants while they view the photograph of the vulva with multiple small blisters and ulcers.
Ask the participants to suggest a diagnosis.
Do not force participants to respond or wait too long for an answer.
Acknowledge any diagnoses offered; then simply proceed to the next slide and present the diagnosis. Use this approach with each slide that shows the image without the diagnosis listed.
Source: ©Wellcome Trust. CD Rom: Topics in International Health – Sexually Transmitted Infections. The Trustee of the Wellcome Trust, London, Second Edition, ISBN
Source: ©Wellcome Trust, 2003
She has had no prior episodes of this condition, and has otherwise been healthy.
Unit 3: Sexually Transmitted Infections (STIs)

35. Painful GUD: Differential
Slide 35
Clustered painful vesicles and ulcers are typical of Herpes Simplex Virus (HSV)
Recurrent clustered painful vesicles very typical of HSV
Other painful genital ulcers:
Chancroid: can be multiple especially with HIV co-infection
Bacterial super-infection of any other genital ulcer
Herpes usually presents with multiple, rather than single, ulcers.
Unit 3: Sexually Transmitted Infections (STIs)

36. Treatment of HSV Clean lesions and keep dry
Slide 36
Clean lesions and keep dry
Health Education/counselling
Condom promotion
HIV/RPR testing
For secondary infection
Cotrimoxazole 800/160 bd x 7 days
If severe and prolonged, consider
Acyclovir* 200 mg 5x day x 7 days or
Acyclovir* 400 mg 3x day for 7 days
*Acyclovir is not part of the 1999 Namibian guidelines
The only medication recommended in the 1999 Namibian guidelines for multiple ulcers (suggestive of Herpes simplex) is cotrimoxazole if super-infection of the ulcers is suspected.
For persistent or extensive ulcers, however, oral acyclovir is very effective. There is a suggestion to increase the availability of acyclovir into Namibia so that genital HSV could more often be treated, however, this has not been decided upon by MOHSS at this time.
Unit 3: Sexually Transmitted Infections (STIs)

37. HSV and HIV Very common co-infection
Slide 37
Very common co-infection
HIV causes HSV to be more severe, more prolonged, and sometimes very large persistent painful ulcers occur
HSV thought to be a very important factor in increasing HIV transmission
HSV can be transmitted even when no lesions are visible
Study in Kenya to learn if chronic suppressive therapy of HSV can reduce HIV transmission
HSV outbreaks in HIV-infected persons increase both genital tract HIV and plasma HIV viral loads, leading to increased HIV transmission. An HSV ulcer in an HIV negative person may increase their risk for acquiring HIV during unprotected sex. Acyclovir may also reduce the risk of HIV transmission associated with Herpes outbreaks, although studies are ongoing.
Sources:
Schacker T, et al. Changes in Plasma Human Immunodeficiency Virus Type 1 RNA Associated with Herpes Simplex Virus Reactivation and Suppression. Journal of Infectious Disease 2002;186:
Celum CL, Robinson N, Cohen M. Potential effect of HIV type 1 antiretroviral and Herpes simplex virus type 2 antiviral therapy on transmission and acquisition of HIV type 1 infection. Journal of Infectious Disease 2005;191:S
Unit 3: Sexually Transmitted Infections (STIs)

38. Painful Ulcers: Chancroid or HSV?
Slide 38
Ask participants to say if this is chancroid or HSV causing of multiple painful ulcers?
The answer is on the following slide.
Image Source: ©Wellcome Trust. CD Rom: Topics in International Health – Sexually Transmitted Infections. The Trustee of the Wellcome Trust, London, Second Edition, ISBN
Source: ©Wellcome Trust, 2003
Unit 3: Sexually Transmitted Infections (STIs)

39. Painful Ulcers: Chancroid or HSV?
Slide 39
Chancroid: multiple ulcers on foreskin with edema.
Oval, well defined, granular base, yellow exudate
This is Chancroid: multiple ulcers of the foreskin with preputial edema. These ulcers have typical chancroid features: round or oval, well defined,granular base, yellow purulent exudate. Such lesions are often confused with genital herpes. Both are painful, unlike the chancre of syphilis.
Note to facilitator: Under the 1999 guidelines, this would not be treated as chancroid because of the multiple ulcers. This diagnosis is very difficult to make without sophisticated laboratory testing, unavailable in Namibia.
Image Source: ©Wellcome Trust. CD Rom: Topics in International Health – Sexually Transmitted Infections. The Trustee of the Wellcome Trust, London, Second Edition, ISBN
Source: ©Wellcome Trust, 2003
Unit 3: Sexually Transmitted Infections (STIs)

40. Other Causes of Genital Ulcers
Slide 40
Other Causes of Genital Ulcers
Unit 3: Sexually Transmitted Infections (STIs)

41. Lymphogranuloma venereum (C. trachomatis L1, L2 or L3)
Slide 41
Starts as papule
May cause painless ulcer
Papule/ulcer often unapparent and heals spontaneously
Cause inguinal lymphadenopathy and buboes
Treatment 14 days doxycline or erythromicin
Lymphogranuloma venereum is a rare cause of painless ulcers in Namibia. It will be discussed further in the next section.
Unit 3: Sexually Transmitted Infections (STIs)

42. Granuloma Inguinale Caused by Calymmatobacterium granulomatis Uncommon
Slide 42
Caused by Calymmatobacterium granulomatis
Uncommon
Large chronic ulcers
Painless
Beefy red
Bleed easily
Granuloma inguinal is a rare cause of genital ulcer in Namibia. These are very large, chronic, but painless ulcers that can have heaped up tissue. Treatment is with a long course of doxycycline or erythromycin.
In summary, ask the participants to suggest a diagnosis for the case presented. Do not force participants to respond or wait too long for an answer. Acknowledge any diagnoses offered; then simply proceed to the following slides and present the diagnosis, treatment, and management
Image Source: ©Wellcome Trust. CD Rom: Topics in International Health – Sexually Transmitted Infections. The Trustee of the Wellcome Trust, London, Second Edition, ISBN
Treatment
21 days of
Doxycycline 100 mg bd OR
Erythromycin 500 mg 4x day
Source: ©Wellcome Trust, 2003
Unit 3: Sexually Transmitted Infections (STIs)

43. Inguinal Bubo Genital Ulcer present? Use flowchart for Genital Ulcer
Slide 43
Genital Ulcer present?
Use flowchart for
Genital Ulcer
Doxycycline 100 mg bd 14 days
Health ed/Partner treatment
HIV/RPR test
Aspirate bubo if needed
Condoms
Pregnancy: erythromycin 500 mg qid 14 days
Improvement in 7 days?
Continue treatment
Fluctuance?
Aspirate bubo
Yes No
Step 4: Inguinal Buboes (Slides 43-47) – 5 minutes
Refer to Handout 3.2 in the Participant Handbook or Section 4.6 (page 17) of the MoHSS Guidelines for the Syndromic Management of STDs, April This flow chart is has been modified from the flow chart in the Guidelines in an effort to minimize confusion.
Buboes without a genital ulcer are treated for lymphogranuloma venereum, and buboes with an ulcer are treated as for chancroid (GUD). Participants can follow the flow diagramme as the management of buboes is presented in the next few slides.
Refer to Handout 3.2 or Section 4.6 (page 17) of the MoHSS Guidelines for the Syndromic Management of STDs.
Unit 3: Sexually Transmitted Infections (STIs)

44. Inguinal Bubo (2) Swelling of lymph nodes in groin area
Slide 44
Swelling of lymph nodes in groin area
Painful or painless
Unilateral or bilateral
Often ‘bubo’ implies that the swollen nodes are filled with pus or are draining pus
Here is an explanation of inguinal adenopathy and buboes. Buboes usually involve suppuration (filling with pus) of lymph nodes of the groin.
Unit 3: Sexually Transmitted Infections (STIs)

45. Inguinal Adenopathy: Differential Diagnosis
Slide 45
Chancroid
Lymphogranuloma venereum
Leg infections
Hernia
Inguinal or femoral
Cancer
This is a list of causes of inguinal buboes and other conditions that might be mistaken for buboes.
Unit 3: Sexually Transmitted Infections (STIs)

46. Chancroid with Bubo Ulcer typical of chancroid
Slide 46
Ulcer typical of chancroid
30-50% have lymphadenopathy
10-30% have fluctuant or draining nodes
Treated like Chancroid:
Cetriaxone 250 mg IM
As mentioned earlier, chancroid can present with a bubo. When a genital ulcer is present, it is treated as chancroid, but the bubo may need to be aspirated to prevent rupture. As usual, offer an HIV test and RPR.
Image Source: ©Wellcome Trust. CD Rom: Topics in International Health – Sexually Transmitted Infections. The Trustee of the Wellcome Trust, London, Second Edition, ISBN
Aspirate bubo if needed.
HIV and
RPR tests.
Source: ©Wellcome Trust, 2003
Unit 3: Sexually Transmitted Infections (STIs)

47. Lymphogranuloma venereum
Slide 47
Aspirate bubo if needed.
HIV and
RPR tests.
Source: ©Wellcome Trust, 2003
Lymphogranuloma venereum causes unilateral or bilateral buboes. There may be a genital papule or ulcer associated with this, but often there is no genital lesion. It is treated with prolonged doxycyline or erythromycin, with aspiration of the buboes as needed. As usual, RPR and HIV tests are offered and prevention counseling, condom use, and referral of the partner are important.
Image Source: ©Wellcome Trust. CD Rom: Topics in International Health – Sexually Transmitted Infections. The Trustee of the Wellcome Trust, London, Second Edition, ISBN
No active papule or ulcer in this case
Bubo has ruptured
Doxycycline 100 mg bd x 14 days
OR (in pregnancy) Erythromycin 500 mg 4 times daily x 14 days
Sometimes longer treatment is needed
Unit 3: Sexually Transmitted Infections (STIs)

48. Male Urethral Discharge
Refer to Handout 3.3 or Section 4.2 (page 9) of the MoHSS Guidelines for the Syndromic Management of STDs.
Slide 48
Ciprofloxacin 500 mg po stat
Doxycycline 100 mg bd for 7 days
Health education
Partner treatment
Condoms
HIV testing
Return if symptoms persist
Re-infection?
Poor adherence?
Neither?
Repeat Protocol
Treat Partner
Extend doxycycline to 10 days
Symptoms persist?
Refer
Step 5: Urethral Discharge (Slides 48-50) – 5 minutes
Refer to Handout 3.3 in the Participant Handbook or Section 4.2 (page 9) of the MoHSS Guidelines for the Syndromic Management of STDs, April 1999.
Unit 3: Sexually Transmitted Infections (STIs)

49. Male Urethral Discharge (2)
Slide 49
Gonorrhea
Neisseria gonorrhea
Non-Gonococcal
Urethritis (NGU)
Chlamydia trachomatis
Mycoplasma genitalis
Ureaplasma urealiticum
Others
The urethral discharge is easy to see in these photos. It may be accompanied by ulcerative genital disease, including ulcers hiding under the foreskin. Milking the urethra may produce a discharge when it is not readily visible.
The common causes of a male urethral discharge are gonorrhea and non-gonococcal urethritis, usually caused by Chlamydia.
Image Source: ©Wellcome Trust. CD Rom: Topics in International Health – Sexually Transmitted Infections. The Trustee of the Wellcome Trust, London, Second Edition, ISBN
Source: ©Wellcome Trust, 2003
Source: ©Wellcome Trust, 2003
Unit 3: Sexually Transmitted Infections (STIs)

50. Male Urethral Discharge (3)
Slide 50
Ciprofloxacin 500 mg po stat
Treats gonorrhea
Doxycycline 100 mg bd for 7 days
Treats NGU, especially Chlamydia
Health education
Partner treatment
Condoms
HIV and RPR testing
Syndromic treatment of a male urethral discharge includes medications for both gonorrhea (single dose oral ciprofloxacin) and chlamydia (one week of twice daily doxycycline).
Other countries may use other regimens, depending on local susceptibility of gonococcus (sometimes IM ceftriaxone is required), and resources to purchase expensive single dose treatments for chlamydia (1 gram of oral azithromycin is effective but very expensive).
Health education, partner treatment, counseling on use of condoms, and both HIV and syphilis testing are part of the treatment.
Unit 3: Sexually Transmitted Infections (STIs)

51. Scrotal Swelling Acute onset of pain and / or swelling?
Slide 51
Acute onset of pain and / or swelling?
History of trauma?
Refer urgently
Ciprofloxacin 500mg po stat
Doxycycline 100mg bd for 10 days
Health education
Partner treatment
Condoms
HIV / RPR tests
Improved in 5 days?
Refer
Continue
treatment
Step 6: Scrotal Swelling (Slides 51-54) – 5 minutes
Refer to Handout 3.4 in the Participant Handbook or Section 4.5 (page 15) of the MoHSS Guidelines for the Syndromic Management of STDs, April 1999.
Note that if testicular torsion is possible, the patient must be referred immediately for a surgical assessment.
Refer to Handout 3.4 or Section 4.5 (page 15) of the MoHSS Guidelines for the Syndromic Management of STDs.
Unit 3: Sexually Transmitted Infections (STIs)

52. Scrotal Swelling: differential diagnosis
Slide 52
Acute Epididymo-orchitis
May have urethritis, also
Chronic Epididymo-orchitis
Testicular torsion
Acute severe pain, elevating testes may greatly reduce pain
Trauma
history
Hernia
Swelling originates in inguinal ring, bowel sounds?, reducible?
Scrotal swelling is discussed here because the causes of acute epididymitis are the same as the causes of urethritis.
However, not all scrotal swelling is epididymitis – review all the possible causes of scrotal swelling first.
Unit 3: Sexually Transmitted Infections (STIs)

53. Scrotal Swelling: differential diagnosis (2)
Slide 53
Acute Epididymo-orchitis < 35 years old
Neisseria gonorrhoea
Chlamydia trachomatis
Acute Epididymo-orchitis > 35 years old
May include enteric organisms from urinary tract
Chronic Epididymo-orchitis
Tuberculosis
These are the common bacterial causes of acute and chronic epididymitis.
Note that the causes of the acute syndrome vary by age, with the sexually transmitted pathogens considered more common among younger men.
However, recall that STDs are common among older Namibian men as well, so the sexually transmitted pathogens also cause disease in men more than 35 years old.
Unit 3: Sexually Transmitted Infections (STIs)

54. Treatment of Epididymo-Orchitis
Slide 54
Ciprofloxacin 500 mg po stat
Docycycline 100 mg po bd for 10 days
Health education
Partner treatment
Condoms
HIV test
RPR test
Since the etiologic bacteria are the same, one expects the treatment of epididymitis to be similar to that of urethritis. Note the longer course of doxycycline for epididymitis, 10 days rather than 7 days as in urethritis.
Unit 3: Sexually Transmitted Infections (STIs)

55. Vaginal Discharge Low risk for STD Treat for vaginitis only
Slide 55
Low risk for STD
Treat for vaginitis only
Metronidazole
Clotrimazole pessary
Treat for cervicitis & vaginitis
Ciprofloxacin
Doxycycline
Health education
Partner treatment
Condoms
HIV testing
Return if symptoms persist
Repeat Protocol
Treat Partner
Repeat
7 days
Clotrimazole pessary 500 mg stat
Re-infection?
Poor adherence
Good adherence
Symptoms persist
Refer
Yes No
Step 7: Vaginal discharge (Slides 55-63) – 5 minutes
Refer to Handout 3.5 in the Participant Handbook or Section 4.1 (page 7) of the MoHSS Guidelines for the Syndromic Management of STDs, April This slide is a slightly adapted version of the flow chart in the 1999 Guidelines.
Unit 3: Sexually Transmitted Infections (STIs)
Refer to Handout 3.5 or Section 4.1 (page 7) of the MoHSS Guidelines for the Syndromic Management of STDs.

56. Vaginal Discharge (2) Vaginitis Cervicitis Urethritis Candida GC*
Slide 56
Vaginitis
Cervicitis
Urethritis
Candida
GC*
Bacterial vaginosis
Chlamydia*
Chlamydia
(NGU)*
Trichomonas*
(HSV*)
(Syphilis*)
Infection at three different anatomical locations within the female genital tract all may produce a vaginal discharge: the vagina, the cervix, and the urethra.
Vaginitis may be caused by candida and bacterial vaginosis (BV), neither of which are sexually transmitted, and do not require treatment of the partner. BV is associated with sexual activity, however. Vaginitis may also be caused by trichomonas, which is sexually transmitted. Trichomonas can infect the cervix as well as the vagina.
Cervictis and urethritis are usually caused by Gonorrhea and chlamydia, as well as the agents of non-non-gonoccocal urethritis. As usual, we treat for the most common conditions at once.
HSV, especially first episodes, and also syphilis, may affect the cervix.
The conditions that are sexually transmitted can recur if the partner is not treated, and of course without treatment the partner may transmit to others.
*Sexually transmitted infections
*Partner should be treated
Unit 3: Sexually Transmitted Infections (STIs)

57. Treatment of Vaginal Discharge
Slide 57
Low Risk Women:
Treat for vaginitis
Candidiasis
Bacterial vaginosis
High Risk Women
Trichomoniasis
Treat for cervicitis and urethritis
Gonorrhoea
Chlamydia
The 1999 Guidelines recommend that women at low risk for STD be treated for candida and bacterial vaginosis.
The Guidelines recommend that women at high risk for STD be treated for bacterial vaginosis, trichomonas, gonorrhea and chlamydia. The next few slides go over these conditions and their treatment
High risk factors are described on slide 60.
Unit 3: Sexually Transmitted Infections (STIs)

58. Vulvovaginal Candidiasis
Slide 58
Vulvovaginal candidiasis is very common among all women, and even more common among HIV-infected women. It usually is associated with itching but there is no pain or odour.
Standard treatment in the 1999 guidelines is with a single intravaginal clotrimazole pessary. For some women this is not sufficient. A single dose of fluconazole, 200 mg, can work very well. For women with severe recurrent vaginal candidiasis, a longer course of fluconazole – 200 mg given 3 times in the first week then once weekly – is very helpful. May be able to d/c prophylaxis when immunity improves with HAART.
Left Image Source: ©Wellcome Trust. CD Rom: Topics in International Health – Sexually Transmitted Infections. The Trustee of the Wellcome Trust, London, Second Edition, 2003.
Right Image Source: Mandell, Douglas & Bennett’s Principles and Practice of Infectious Diseases, Sixth Edition, ©2005 by Elsevier, Inc.
Source: ©Wellcome Trust, 2003
Clotrimazole 500 mg intra-vaginal pessary once
Severe recurrence:
oral fluconazole 200 mg
3 doses in first week then once weekly
Unit 3: Sexually Transmitted Infections (STIs)

59. Bacterial Vaginosis (BV)
Slide 59
Bacterial vaginosis is also very common, in some studies up to 50% of African women with and without HIV have BV. It causes a discharge and sometimes an odor. It is associated with sexual activity but is not transmitted through sex. It is caused by a marked overgrowth (1000 times) of anaerobic and other bacteria in the vagina. The most effective treatment is with a week of twice daily metronidazole. A high single dose of metronidazole (as used for Trichomonas) has some effect. It often recurs.
Image Source: Mandell, Douglas & Bennett’s Principles and Practice of Infectious Diseases, Sixth Edition, ©2005 by Elsevier, Inc.
Metronidazole
400 mg bd x 7 days most effective
400 mg 5 tabs once (same as Trichomoniasis therapy)
Unit 3: Sexually Transmitted Infections (STIs)

60. Treatment of Women at risk for STD
Slide 60
All women with
Age < 25 years
Sexual partner with STD symptoms
New sexual partner in last 3 months
Sexual partner had other partners in last 3 months
The 1999 guidelines use these criteria, obtained by history, to classify women with a vaginal discharge as being at high risk for an STD and requiring the treatment described in the next few slides.
These factors certainly raise the risk that a woman has an STD, however, some women without these criteria may also have an STD.
Unit 3: Sexually Transmitted Infections (STIs)

61. Trichomoniasis Metronidazole 400 mg 5 tabs once 400 mg bd x 7 days OR
Slide 61
Trichomonas, a sexually transmitted parasite, causes a thin discharge and may infect the cervix as well (“strawberry cervix). A single large dose (2000 mg) of metronidazole cures the infection, as does the week long treatment used for BV.
Image Source: ©Wellcome Trust. CD Rom: Topics in International Health – Sexually Transmitted Infections. The Trustee of the Wellcome Trust, London, Second Edition, ISBN
Source: ©Wellcome Trust, 2003
Source: ©Wellcome Trust, 2003
Metronidazole
400 mg 5 tabs once OR
400 mg bd x 7 days
Unit 3: Sexually Transmitted Infections (STIs)

62. Gonorrhoea and NGU Same organisms as in male urethritis
Slide 62
Same organisms as in male urethritis
Ciprofloxacin 500 mg po once
and Doxycycline 100 mg bd x 7 days
Gonorrhea, Chlamydia, and the other agents of non-gonococcal urethritis of men also infect the cervix and urethra of women. The same treatment is effective as for male urethral discharge: a single dose of oral ciprofloxacin 500 mg and one week of oral doxycycline 100 mg twice daily.
Image Source: ©Wellcome Trust. CD Rom: Topics in International Health – Sexually Transmitted Infections. The Trustee of the Wellcome Trust, London, Second Edition, ISBN
Source: ©Wellcome Trust, 2003
Unit 3: Sexually Transmitted Infections (STIs)

63. Vaginal Discharge in Pregnancy
Slide 63
Substitute
With
Doxycycline
Erythromycin 500mg 4x daily for 7 days
Ciprofloxacin
Ceftriaxone 250mg IM stat
Metronidazole
Clotrimazole pessary 500 mg once
May give metronidazole 400 mg bd x 7 days for persistent symptoms after first trimester
Many of the standard drugs used to treat a vaginal discharge in are unsafe pregnancy. This slide shows the substitutions that should be made:
For Chlamydia, doxycycline is not used and one week of oral erythromycin is used instead
For Gonorrhoea, ciprofloxacin is not used and a single IM injection of ceftriaxone is used instead.
For vagintis, metronidazole is not used and a clotrimazole pessary for Candida is tried. IF symptoms persist despite the pessary, metronidazole can be given after the first trimester of pregnancy.
*Pregnant women should have an RPR checked as well.
*Not in 1999 MOHSS guidelines
Unit 3: Sexually Transmitted Infections (STIs)

64. Lower Abdominal Pain in Women
Slide 64
Rebound tenderness?
Guarding?
Overdue menses?
Abnormal vaginal bleeding?
Recent delivery/labour?
Suprapubic tenderness?
Vaginal discharge?
Fever?
PID risk factor?
Treat according to history and other clinical findings
Refer
Ciprofloxacin
500mg stat
Doxycycline
100 mg bd x 10 d
Metronidazole
400 mg tds x 7 d
Health education
Condoms
Partner treatment
HIV testing
Improved in 2 days?
Continue Treatment
Yes No
Step 8: Lower Abdominal Pain and PID (Slides 64-69) – 5 minutes
Refer to Handout 3.6 in the Participant Handbook or Section 4.3 (page 11) of the MoHSS Guidelines for the Syndromic Management of STDs, April 1999.
Risk factors for PID are outlined in slide 66.
Refer to Handout 3.6 or Section 4.3 (page117) of the MoHSS Guidelines for the Syndromic Management of STDs.
Unit 3: Sexually Transmitted Infections (STIs)

65. Lower Abdominal Pain: Differential Diagnosis
Slide 65
Pelvic inflammatory disease
Salpingitis
Endometritis
Tubo-ovarian abscess
Pelvic peritonitis
Ovarian cyst
Ectopic pregnancy
Septic abortion
Appendicitis
Cystitis and pyelonephritis
Mesenteric adenitis
Many very different illnesses can cause lower abdominal pain in women, so the examiner must decide if it is reasonable to treat for PID or if evaluation for another condition, perhaps a surgical emergency, is necessary.
Unit 3: Sexually Transmitted Infections (STIs)

66. Pelvic Inflammatory Disease (PID)
Slide 66
Risk Factors
Intra-uterine contraceptive devise (IUCD)
Sexual partner with STD
HIV infection
These factors are considered risks for PID in the flow diagram. However, women can have PID without an IUCD, and without knowledge of an STD in their partner or knowledge of their HIV status. Several studies have shown an increased seroprevalence of HIV in hospitalized PID patients (Hoegsberg 1990; Sperling 1991).
Source: A Guide to the Clinical Care of Women with HIV; Jean Anderson, M.D, ed.; HRSA page 175.
Unit 3: Sexually Transmitted Infections (STIs)

67. Factors Suggestive of PID
Slide 67
Suspect with findings on gyn exam:
Uterine or adnexal tenderness
Cervical motion tenderness
Clinical features
Fever ≥ 38.3°C
Cervical or vaginal mucopurulent discharge
WBCs on microscopic exam of saline preparation of vaginal fluid
Elevated ESR or CRP
Laboratory documentation of N. gonorrhea or C. trachomatis
Negative pregnancy test
Clinical diagnosis of symptomatic PID is correct only 65-90% of the time. "Salpingitis was identified at laparoscopy in 65% of those with a clinical diagnosis of PID, but some of the remaining women without salpingitis had lower genital tract infection" 
Features that help make the diagnosis are:
Uterine, adnexal, or cervical motion tenderness
Fever
A mucopurulent vaginal or cervical discharge
Laboratory studies if available such as white cells seen on the discharge, elevated ESR, or other evidence of GC or chlamydia (not generally available in Namibia)
Since ectopic pregnancy is in the differential, it is important to check a pregnancy test and be sure the patient is not pregnant.
Source: Westrom L and Wschenbach D, Pelvic Inlfammatory Disease, in Holmes KK et al, eds, Sexually Transmitted Diseases, Third Edition.1999 McGraw Hill, New York. pp
Unit 3: Sexually Transmitted Infections (STIs)

68. Pelvic Inflammatory Disease (PID)
Slide 68
Treatment for GC, chlamydia, anaerobes also covers gram negative enteric bacteria
Oral therapy of suspected mild-moderate PID
Ciprofloxacin 500 mg po stat
Doxycycline 100 mg po bd for 10 days
Metronidazole 400 mg po tds for 7 days
Case of severe illness or inability to take pills
Ceftriaxone 250mg IM stat and refer immediately
The treatment of PID aims at many of the same organisms as the treatment of cervicitis (gonorrhea, chlamydia) and also gram negative intestinal bacteria and anaerobic bacteria.
Outpatient treatment of PID uses the same medications as treatment of vaginal discharge. Note the prolonged course of doxycycline and both the increased daily dose of and 7 day duration of metronidazole
For persons too ill for outpatient treatment, they are given an IM dose of ceftriaxone and referred to hospital.
Unit 3: Sexually Transmitted Infections (STIs)

69. Severe PID is Treated in the Hospital with IV/IM Antibiotics
Slide 69
IV/IM meds until patient improves hours
Ceftriaxone IV/IM or
Cefoxitin IV
Doxycycline po +/- metronidazole po
Starts in hospital and continues after release
14 day total course of parenteral and oral antibiotics
Surgical drainage of abscesses as needed
Here are some regimens used to treat PID in the hospital, according to WHO and US CDC guidelines. Inpatient treatment of PID is not in the 1999 MOHSS guidelines
Note that it is difficult to prove that a patient has PID, and that seriously ill women should have additional tests, such as an ultrasound, or culdocentesis, and perhaps even a laparoscopy or laparotomy, to distinguish PID from appendicitis, ruptured ovarian cyst, ectopic pregnancy, or to drain a tubo-ovarian abscess.
Unit 3: Sexually Transmitted Infections (STIs)

70. Men who have Sex with Men (MSM)
Slide 70
Certainly exists in Namibia although rarely discussed
In many countries, MSM are the most likely to have HIV infection
Anal receptive intercourse
Practiced by MSM
Also sometimes practiced by women
Highest risk of HIV transmission of all sex practices
Step 9: Men who have Sex with Men (Slides 70-71) – 5 minutes
Almost all training materials about HIV in Namibia address heterosexual persons. However, in Namibia there are also men who have sex with men, and they have as high risk of HIV as in other parts of the world.
These patients may need appropriate medical care as well, including for any STD or HIV infection if present.
Many men who have sex with men, and some women, practice anal receptive intercourse. This has the highest risk of HIV transmission of any sex practice, and also can lead to unusual presentations of STDs.
Unit 3: Sexually Transmitted Infections (STIs)

71. STDs Associated with Anal Intercourse
Slide 71
Proctitis
GC and chlamydia most common
Treat like epidydimitis
Perianal HSV and warts more common
Urethritis with enteric organisms
Treat like cystitis
Some of the STDs associated with anal intercourse are listed here.
Persons receiving anal penetration may get gonorrhoea or chlamydia proctitis, which is treated like epididymitis.
Perianal herpes ulcers and warts are common (although persons can get perianal lesions of this type without anal intercourse as well).
Some persons who perform anal intercourse acquire urethral infection with intestinal organisms and should be treated as if they have cystitis (the symptoms are similar).
Unit 3: Sexually Transmitted Infections (STIs)

72. Counselling Source: ©Wellcome Trust, 2003 Slide 72
Step 10: Safer Sex Counselling (Slides 72-74) – 5 minutes
Counseling on modes of STD transmission, need for partner treatment, and behavior change to avoid future STDs is necessary.
Testing for HIV and, unless already treated, for syphilis, is important.
Cards are available that a patient can give to his/her sex partner informing them of the need to present to the health center for treatment (and HIV/RPR testing).
Image Source: ©Wellcome Trust. CD Rom: Topics in International Health – HIV/AIDS. The Trustee of the Wellcome Trust, London, Revised Edition, 2003.
Source: ©Wellcome Trust, 2003
Unit 3: Sexually Transmitted Infections (STIs)

73. Male Condom Source: ©Wellcome Trust, 2003 Slide 73
Explain use of the male condom, or ask a participants to describe how to use a male condom as they would with a patient/client.
Image Source: ©Wellcome Trust. CD Rom: Topics in International Health – Sexually Transmitted Infections. The Trustee of the Wellcome Trust, London, Second Edition, ISBN
Source: ©Wellcome Trust, 2003
Unit 3: Sexually Transmitted Infections (STIs)

74. Female Condom Source: ©Wellcome Trust, 2003 Slide 74
Explain use of the female condom, or ask a participants to describe how to use a female condom as they would with a patient/client.
Image Source: ©Wellcome Trust. CD Rom: Topics in International Health – HIV/AIDS. The Trustee of the Wellcome Trust, London, Revised Edition, 2003.
Source: ©Wellcome Trust, 2003
Unit 3: Sexually Transmitted Infections (STIs)

75. Key Points
Slide 75
Use syndromic approach to STIs in primary care and initial visits
Further evaluation and other therapy appropriate when patients do not respond to syndromic therapy
Persons with STIs should have HIV testing
Improvement in STI diagnosis and treatment can reduce HIV transmission
Step 11: Key Points (Slide 75) – 3 minutes
Key Points serve as a tool for summarizing and reviewing the main ideas that were discussed in the unit. Summarize the presentation and review the Key Points.
Tell participants about the three supplemental handouts located in the Participant Handbook for future reference: HO 3.7 – Signs, Symptoms, & Common Aetiologies of STD Syndrome, HO 3.8 – Laboratory Tests Available for Diagnosis of STDs, and HO 3.9 – Clinical Features of Common Genital Ulcers.
Remind participants that this unit was not meant to teach everything about STDs, but to emphasize the role of STD care in HIV prevention, and to provide guidelines on implementing syndromic treatment of STDs.
Step 12: Question and Answer (No Slides) – 10 minutes
Spend 10 minutes answering participant questions about the syndromic treatment of STDs.
Collect the questions first, and then answer the most important, avoid repetition, and postpone questions referring to topics to be covered later in the course.
Questions that cannot be answered at the time, or are not immediately relevant, should be written on flip chart paper and answered later (this is often called the ‘parking lot’).
If there are more questions than time allows, remind participants that questions can be asked informally of faculty throughout the day, at breaks, or during the daily review sessions.
Unit 3: Sexually Transmitted Infections (STIs)