Participant's Handout

(ii)
Sayan Chatterjee
Secretary & Director General
Department of AIDS Control, NACO, Ministry of Health and Family Welfare, Government of India

MESSAGE

The prevention, control and management of STI/RTI is a well recognized cost effective
strategy for controlling the spread of HIV/AIDS in the country as well as to reduce
reproductive morbidity among sexually active population. Individuals with STI/RTI have
a significantly higher chance of acquiring and transmitting HIV. Moreover STI/RTI are
also known ti cause use infertility and reproductive morbidity. Controlling STI/RTI helps
decrease HIV infection rates and provides a window of opportunity for counselling about
HIV prevention and reproductive health.

An operational framework for convergence between National AIDS Control Programme

Phase III and Reproductive and Child health Programme Phase II under National Rural
Health Mission has been developed. This will bring about uniformity in implementation
os STI/RTI prevention and control through the public health are delivery system Through
this, the availability and reach of standardized STI/RTI care at all levels of health facilities
will be ensured.

The NACP III Strategy and Implementation Plan (2007-2012) makes a strong reference to
expanding access to a package of STI management services both in the general population
as well as for high risk behavior groups.

For nation-wide training of health functionaries on STI/RTI management standardized

training modules and training aids/job-aids for various functionaries involved in provision
of STI/RTI care have been developed to train doctors ANMs/Nurses, and to technicians on
Syndromic Case Management of STI/RTI.

I am sure that these comprehensive operational guidelines will help towards ensuring the
provision of quality STI/RTI services across the country.

(Sayan Chatterjee)

6th Floor, Chandralok Building, 36 Janpath, New Delhi-110001, Phone: 011-23325331, Fax: 011-23731746
E-mail: nacoasdg@[Link]

Know Your HIV status, go to the nearest Government Hospital for free Voluntary Counselling and Testing

(iii)
(iv)
 Government of India
P.K. PRADHAN, I.A.S. Ministry of Health & Family Welfare
Additional Secretary & Nirman Bhavan, New Delhi-110108
Mission Director (NRHM)
Tele: 23061451 Fax: 23061975
E-mail: md-nrhm@[Link]

PREFACE

Sexually transmitted infections and reproductive tract infections (STIs/RTIs) are important
public health problems in India. Studies suggest that 6% of the adult population in India is
infected with one or more STIs/RTIs. Individuals with STIs/RTIs have a significantly higher
chance of acquiring and transmitting HIV. Moreover, STIs/RTIs are also known to cause
infertility and reproductive morbidity. Controlling STI/RTIs helps decrease HIV infection
rates and provides a window of opportunity for counseling about HIV prevention and
reproductive health.

The implementation framework of National Rural Health Mission (NRHM) provided the
directions for synergizing the strategies for prevention, control and management for STI/
RTI services under Phase II of Reproductive and Child Health Programme (RCH II) and
Phase III of National AIDS Control Programme (NACP III). While the RCH programme
advocates a strong reference "to include STI/RTI and HIV/AIDS preventions, screening
and management in maternal and child health services", the NACP includes services for
management of STIs as a major programme strategy for prevention of HIV.

These modules are intended as a resource document for the programme managers and
service providers in RCH II and NACP III and would enable the RCH service providers
and NACO service provider in organizing effective case management services for STI/RTI
through the public health care system.

(P.K. Pradhan)

(v)
(vi)
Aradhana Johri, IAS
Additional Seceratary

Department of AIDS Control, NACO, Ministry of Health and Family Welfare, Government of India

FOREWORD
Community based surveys have shown that about 6% of adult Indian population suffers from
sexually transmitted infections and reproductive tract infections. The prevalence of these
infections is considerably higher among high risk groups ranging from 20-30%. Considering
that the HIV epidemic in India is still largely concentrated in the core groups, prevention and
control of sexually transmitted infections can be an effective intervention to reverse the HIV
epidemic progress.
Syndromic Case Management (SCM) is the cornerstone of STI/RTI management, being a
comprehensive approach for STI/RTI control endorsed by the World Health Organization
(WHO). This approach classifies STI/RTI into syndromes, which are easily identifiable group
of symptoms and signs and provides treatment for the most common organisms causing the
syndrome. Treatment has been standardized through the use of pre-packaged colour coded
STI/RTI drug kits. SCM achieves high cure rates because it provides immediate treatment on
the first visit at little or no laboratory cost. However, it goes hand in hand with other important
components like counseling, partner treatment, condom promotion and referral for HIV
testing.
As per the convergence framework of NACO-NRHM for STI/RTI service delivery, uniform service
delivery protocols, operational guidelines, training packages & resources, jointly developed by
NRHM & NACO are to be followed for provision of STI/RTI services at all public health facilities
including CHC and PHC. As per joint implementation plan, NACO/SACS would provide training,
quality supervision and monitoring of STI/RTI services at all health facilities, thus overseeing
the implementation. For tracking access, quality, progress and bottlenecks in STI/RTI program
implementation, common information and monitoring system jointly developed by NACO and
NRHM would be followed.
As a step to take convergence forward, it is envisaged that a resource pool of trainers is created
at state and district level so as to enable roll out trainings for service providers in the public
health care delivery system using the jointly developed training material and through the
cascade models of trainings. The ultimate aim is to ensure high quality STI/RTI service delivery
at all facilities with best utilization of resources available with both NACP III and RCH II/NRHM.

(Aradhana Johri)

6th Floor, Chandralok Building, 36 Janpath, New Delhi-110001, Phone: 011-23325343, Fax: 011-23731746
E-mail: [Link]@[Link]

Know Your HIV status, go to the nearest Government Hospital for free Voluntary Counselling and Testing

(vii)
(viii)
 Government of India
Dr. Sunil D. Khaparde Ministry of Health & Family Welfare
Deputy Director General Department of AIDS Control
National AIDS Control Organisation
Tel: 91-11-23736851
Fax: 91-11-23731746 9th Floor, Chandralok Building,
E-mail: [Link]@[Link] 36 Janpath, New Delhi-110 001

ACKNOWLEDGMENT
Reproductive tract infections (RTIs) including sexually transmitted infections (STIs) present a huge
burden of disease and adversely impacts the reproductive health of people. The emergence of
HIV and identification of STIs as a co-factor have further lent a sense of urgency for formulating a
programmatic response to address this important public health problem.
The comprehensive training modules on the Prevention and Management of STI/RTI have come
through with the coordinated and concerted efforts of various organizations, individuals and
professional bodies, who have put in months of devoted inputs towards it.
The vision and constant encouragement of Ms K Sujatha Rao, IAS, Secretary Health and Family
welfare, Shri K Chandramouli, IAS, Secretary and Director General NACO, Ms Aradhana Johri, IAS,
Additional Secretary NACO and Shri Amit Mohan Prasad, IAS, Joint Secretary RCH, Ministry of Health
and Family Welfare is sincerely acknowledged, under whose able leadership these modules have
been developed.
The technical content has been jointly developed by STI division, Department of AIDS Control
(National AIDS Control Organization) and Maternal Health Division of MoHFW. The National Institute
for Research in Reproductive Health (NIRRH), Mumbai under ICMR initiated and lead the process
of reviewing the existing training material and developing updated training modules through the
organization of a number of meetings and workshops. The preparation and design of material also
involved the technical assistance, funding support and other related support provided by WHO,
UNFPA, FHI and many other experts in the field.
Thanks are due to Dr. Anjana Saxena, Deputy Commissioner, Maternal Health Division, Dr. Himanshu
Bhushan, Dr. Manisha Malhotra, and Dr. Dinesh Baswal, Assistant Commissioners Maternal Health
Division for their constant technical inputs, unstinted support and guidance throughout the process
of developing these guidelines. The hard work and contributions of Dr. Ajay Khera, then Assistant
Director-General, and NACO STI team comprising of Dr. Shobini Rajan, Deputy Director, Dr. Bhrigu
Kapuria, Technical Officer, Dr. TLN Prasad, and Dr. Aman Kumar Singh, Technical Experts and
Dr. Naveen Chharang, Assistant Director at NACO have been invaluable in shaping the document.
Sincere appreciation is due to Dr. Sanjay Chauhan, Deputy Director, NIRRH who coordinated the
whole process along with his team comprising Dr. Ragini Kulkarni, Research Officer and Dr. Beena
Joshi, Senior Research Officer at NIRRH. Special mention is made of contribution of Dr. Deoki Nandan,
Director, NIHFW, Delhi and for all those who coordinated the piloting of the module through State
Health Directorates and State AIDS Control Societies of Uttar Pradesh, Madhya Pradesh, Assam,
Kerala, West Bengal and Gujarat. I also thank to Public Health Foundation of India (PHFI) for providing
assistance to print these modules.

(Dr. Sunil D. Khaparde)

(ix)
(x)
 List of
Abbreviations
List of Abbreviations
 CONTENTS

Module No. Topic Page No.

Annexure 197-200
(xiv)
 MODULE NO. 1

INTRODUCTORY MODULE
PROGRAMME OBJECTIVES AND SCHEDULE

Sr. No. Topic Page No

PARTICIPANT’S HANDOUT 1
TRAINING OF MEDICAL OFFICERS TO DELIVER STI/RTI SERVICES

1. Objectives of the training programme

By the end of this programme, MOs will be able to:

●● Understand about the magnitude of STI/RTI problem in the community and country;
●● Understand about the seriousness of complications of common STI/RTI, if left untreated and
its long term implications on health, including reproductive health;
●● Perform history taking and clinical examination of clients for STI/RTI;
●● Diagnose and treat common STI/RTI by using given flowcharts based on the infrastructure,
facilities and availability of drugs at PHC;
●● Educate and counsel STI/RTI clients about prevention and complete treatment of STI/RTI;
●● Treat partners of clients diagnosed with STI/RTI;
●● Provide treatment and counseling for STI/RTI among special populations (sex workers, MSM,
etc) in a non-judgmental way.

2 PARTICIPANT’S HANDOUT
 TRAINING OF MEDICAL OFFICERS TO DELIVER STI/RTI SERVICES

2. Schedule of the 2 day workshop for Medical Officers

Days/
Module: Topic and Duration Contents
Timings
Day 1 (Morning)
9 00 hrs Module 1: Introductory module ●● Getting to know each other
(1 hr.) ●● Training objectives and outline of
training programme
●● Pre-test questionnaire
10 00 hrs Module 2: Public health importance of ●● Importance of STI/RTI as a public
STI/RTI health problem
(1 hr.) ●● Epidemiology of STI/RTI
●● Challenges in prevention and
management
11 00 hrs TEA BREAK
11 15 hrs Module 3: Common STI/RTI and their ●● Sites of occurrence of STI/RTI
complications ●● Signs and symptoms of common
( 45 mins) STI/RTI
●● Causative organisms and modes of
presentation
●● Classifications and complications of
STI/RTI
12 00 hrs Module 4: History taking and risk ●● Tips and steps
assessment in STI/RTI ●● Role play
( 30 mins)
●● Checklist
12 30 hrs Module 5: Clinical examination for STI/ ●● Anatomy of reproductive tract
RTI (Review)
(1 hr.) ●● Syndrome specific examination tips
●● Video display of clinical
examination.
13 30 hrs LUNCH BREAK
Day 1 (Afternoon)
14 30 hrs Module 6 & 7: Approaches for ●● Approaches for management of STI/
management of STI/RTI, syndromic case RTI
management for STI/RTI. ●● Syndromic Case Management
(2 hr.) based on flowcharts.
16 30 hrs TEA BREAK

PARTICIPANT’S HANDOUT 3
TRAINING OF MEDICAL OFFICERS TO DELIVER STI/RTI SERVICES

Days/
Module: Topic and Duration Contents
Timings
16 45 hrs Module 8: Partner management ●● Critical issues
(30 mins) ●● Approaches for Partner
management
Day 2 (Morning)
09 00 hrs Recap of Day 1
09 30 hrs Module 9: Laboratory tests for STI/RTI ●● Definition of common terms
(1 hr.) ●● Lab. tests and their usefulness for
management of STI/RTI.
10 30 hrs Module 10 & 11: Client education and ●● Communication
counseling & Condom ●● Client education
(1 hr.)
●● Counseling
●● Video on counseling
●● Condom demonstration
11 30 hrs TEA BREAK
11 45 hrs Module 12: Management of sexual ●● Health services and sexual violence
violence management
(30 mins)
12 15 hrs Module 13: Preventing STI/RTI among ●● Treatment strategies and services
High Risk Groups ●● Counseling on safer sex
(45 mins)
13 00 hrs LUNCH BREAK
Day 2 (Afternoon)
14 00 hrs Module 14 & 15 : Preventing STI/RTI ●● Adolescent and youth at risk
in adolescents & Male participation in ●● Youth-friendly activities on STI/RTI
prevention and control of STI/RTI in the community.
(1 hr.)
●● Strategies for involving men in STI/
RTI prevention
●● Challenges
15 00 hrs Module 16: Recording and reporting ●● Individual patient record and
( 1 hr 30 mins) monthly reporting format
●● Management of STI/RTI clinical data
●● Case studies
16 30 hrs TEA BREAK
16 45 hrs Post Test Assessment & Wrap Up ●● Administer Post test questionnaire
(30 mins)

4 PARTICIPANT’S HANDOUT
 MODULE NO. 2

PUBLIC HEALTH IMPORTANCE OF STI/RTI

Sr. No. Topic Page No

6

PARTICIPANT’S HANDOUT 5
TRAINING OF MEDICAL OFFICERS TO DELIVER STI/RTI SERVICES

1. Definition of STI/RTI

It is critical to understand or get familiarized with the key terms generally used while providing
reproductive and child health services, and communicating with clients having STI/RTI. So before
beginning the discussion on diagnosis and treatment of STI/RTI, we will first ensure to understand
some of the key terms and basic concepts in this area.

What are RTI?

Reproductive tract infection is a broad term that includes sexually transmitted infections as well
as other infections of the reproductive tract that are not transmitted through sexual intercourse.
In women, RTI includes infections of the outer genitals, vagina, cervix, uterus, tubes, or ovaries.
In men, RTI involves the penis, testes, scrotum, or prostate. RTI are caused by bacteria, viruses, or
protozoa that person gets either through sexual contact or by non-sexual route.

What are STD?

STD means sexually transmitted diseases caused by microbes that are passed from one person to
another through sexual contact. The terminology is used to describe the diseases that are acquired
through sexual contact. Sexually transmitted organisms may also be sometimes transmitted by
nonsexual modes of transmission.

What are STI?

The term “Sexually Transmitted Infections” (STI) is a newer term used to indicate that infections
caused by microbes may not manifest as symptoms and do not always result in a disease.

STI versus STD

Historically, the terminology used to describe infections and diseases acquired through sexual
contact has demonstrated the social stigma attached to these infections. As these terms became
laden with moral judgments and as medical and public health professionals began to see the need
for a more accurate, technical description, the term STI was approved by WHO and hence became
the standardized term.

6 PARTICIPANT’S HANDOUT
 TRAINING OF MEDICAL OFFICERS TO DELIVER STI/RTI SERVICES

What is HIV and AIDS?

HIV stands for Human Immunodeficiency Virus, a retrovirus transmitted from an infected person
through unprotected sexual intercourse, or by exchange of body fluids such as blood, or from an
infected mother to her infant. AIDS stands for Acquired Immunodeficiency Syndrome. AIDS is the
stage of HIV infection that develops some years after a person is infected with HIV. HIV is a STI and
is transmitted through the same behavior that transmits other STI. About 86% of the HIV infection
is transmitted through the sexual route, whenever there is risk of STI, there is risk of HIV infection
as well.

What is Prevalence?
Prevalence measures at a point of time how common a disease is in a population (usually expressed
as a percent). It includes total number of new as well as old cases of disease present in the
population (usually in one year). E.g. Total number of chlamydial infection detected (new as well as
old cases) among pregnant women in a year at one Primary Health Center are 12 and total number
of pregnant women examined in a year at Primary Health Center are 120. Then “10% of pregnant
women have chlamydial infection” = “10% prevalence of chlamydial infection among pregnant
women”.

What is Incidence?
Incidence means the number of new cases of disease occurring (usually each year) e.g. WHO
estimates that about 340 million curable STI/RTI occur globally each year.

RTIs
STIs ●● Disruption of normal
●● Gonorrhoea vaginal flora(e.g
HIV
●● Chlamydia candida)
●● Syphilis
●● Postpartum and posta-
●● Hapatitis B ●● Chancroid
●● Oral analSTI ●● HPV bortion infections
●● HSV ●● Infections following
procedure (e.g. IUD)

Figure 1: Reproductive tract Infections (RTI); Sexually Transmitted Infections (STI);

and HIV infection

PARTICIPANT’S HANDOUT 7
TRAINING OF MEDICAL OFFICERS TO DELIVER STI/RTI SERVICES

2. Epidemiology of STI/RTI

According to WHO, STI and their complications rank in the top five disease categories for which
adults in developing countries seek health care. The incidence and prevalence of STI in the
developing world are rising rapidly. Premature deaths and disabilities not only devastate families,
but also threaten the cultural and economic stability of communities, countries, and whole
continents.

Situation in world
In recent years, there is a growing concern regarding the prevalence and extent of STI/RTI among
women and men in developing countries. Further, the threat of AIDS has focused greater attention
on the importance of RTI including STI.
●● The World Health Organization (WHO) estimates (2006) that approximately 340 million
new cases of the four main curable STI (gonorrhoea, chlamydial infection, syphilis, and
trichomoniasis) occur every year, 75–85% of them in developing countries. This means about
10% of adults are newly infected with curable sexually transmitted disease (STI) each year.
●● WHO also estimates that out of these 340 million curable STI that occur globally each year
there are about 12 million new cases of syphilis, 62 million new cases of gonorrhoea, 90 million
new cases of chlamydial infection, 176 million new cases of trichomoniasis.

Thus STI/RTI impose an enormous burden of morbidity and mortality in developing countries,
both directly through their impact on reproductive and child health, and indirectly through their
role in facilitating the sexual transmission of HIV infection.

Situation in India
Many studies have been conducted to estimate the prevalence of STI/RTI in men and women in
India, which reveal that there is a huge burden of STI/RTI and they adversely impact reproductive
health of people.

According to National Family Health Survey (NFHS) –2 data, it is estimated that the prevalence of
symptoms suggestive of STI/RTI in women was in the range of 23% to 43%, while in men it is in the
range of 4% to 9%. The STI clinic based data indicates syphilis as the major prevalent STI among
men (12.6-57%) followed by chlamydia (20%-30%), chancroid (9.9%-34.7%), and gonnorhoea
(8.5%-25.9%). The hospital based studies reports a varied prevalence for HSV (3.0- 14.9%) and
HPV (4.9-14.3%) among men. The NACO data indicates that awareness about STI/RTI in men is
53% while in women is only 44%. It is estimated that about 6% of the adult population (15-49
years) have STI/RTI episode in a year which amounts to about 30 million episodes per year (ICMR
Study, 2002).

8 PARTICIPANT’S HANDOUT
 TRAINING OF MEDICAL OFFICERS TO DELIVER STI/RTI SERVICES

3. Factors contributing to the spread of STI/RTI

Though the STI are infectious diseases, however, more than with other infectious diseases, STI
transmission also depends mainly on sexual behavior. A person with many sexual partners is much
more likely to acquire a STI than a person with one partner. A person with many partners also has
more opportunity to infect others.

Factors contributing to high STI/RTI prevalence

There are many reasons for high prevalence of STI/RTI, which include lack of access to health care
and medicines, lack of awareness of STI, and in-out migration.
●● STI such as syphilis, gonorrhea and chancroid spread more rapidly in places where communities
are disrupted, migrant labour is common and commercial sex networks are active.
●● Iatrogenic infections are more commonly seen where the RTI in high prevalence, and where
health care providers do not have the training or supplies to perform procedures safely.
Postpartum and post abortion infections are more common where medical services and
follow-up care are not provided safely.
●● Endogenous infections, such as yeast infection and bacterial vaginosis, are common worldwide
and are influenced by environmental, hygienic, hormonal and other factors like co existent
diabetes and immune compromised states like AIDS.

Factors that increase the risk of transmission

It is not necessary that every act of unprotected sex will result in STI transmission. The possibility
of getting infected depends on biological and behavioral factors.

Biological factors: Certain biological factors influence the transmission of STI/RTI which includes
age, sex, immune status of the host and virulence of the organism:
●● Age: The vaginal mucosa and cervical tissue of young women is immature and makes them
vulnerable to STI than older women. Cervical ectopy describes the situation where cells that
more readily allow infections to occur are found on the outer intra-vaginal surface of the
cervix. This is normal for younger women and makes them more vulnerable to STI than older
women. Taking the contraceptive pill can increase the size of the ectopy.
●● Sex: Infection enters more easily through a mucosal surface such as vaginal mucosa. Thus the
woman has much larger mucosal surface than the man and is more prone to being infected if
she has sexual intercourse with a partner who has an STI. In case of men, uncircumcised men
are more likely to get an STI than circumcised men. It is more difficult for uncircumcised men
to protect the inside surface of their foreskin from contact with body fluids.

PARTICIPANT’S HANDOUT 9
TRAINING OF MEDICAL OFFICERS TO DELIVER STI/RTI SERVICES

●● Immune status: The immune status of the host and the virulence of the infection affect
transmission of STI. Certain STI increase the risk of HIV transmission. HIV, in turn facilitates
the transmission of many STI and worsens the complications of STI by weakening the immune
system.

Behavioral factors
Many behavioural factors affect the possibility of contracting STI. Such behaviors, known as risky
behaviors are as follows:
●● Personal sexual behaviors

ŠŠ not using condoms during penetrative vaginal or anal intercourse

ŠŠ frequent sexual partner exchange

ŠŠ having more than one sexual partner

ŠŠ having sex with casual partners, sex workers or their clients

ŠŠ previous history of STI

ŠŠ exchanging sex for money, goods or favors

ŠŠ exchanging sex for drugs or drugs for sex

●● Other personal behaviors (non-sexual) that are risky include:

ŠŠ skin piercing

ŠŠ alcohol or other drugs during or before sex

ŠŠ blood transfusion
●● Even if an individual has no risky behaviors, they may be at risk if their partner/s:

ŠŠ has sex with others

ŠŠ has STI

ŠŠ is HIV positive

ŠŠ injects drugs

ŠŠ has sex with other men (male)

Social factors
●● Number of social factors link sex and behavioral issues and may affect a person’s risk of
contracting STI:
●● In most cultures women have very little power over sexual practices and choices; such as use
of condoms

10 PARTICIPANT’S HANDOUT
 TRAINING OF MEDICAL OFFICERS TO DELIVER STI/RTI SERVICES

●● Women tend to economically dependent on their male partners and are therefore likely to
tolerate men’s risky behavior of multiple sexual partners, thus putting themselves at the risk
of contracting STI
●● Sexual violence tend to be directed more towards women by men, making it difficult for
women to discuss STI with their male partners
●● In some societies girl-child tends to be married off to an adult male at a young age, thus
exposing girls to the infections
●● In some societies permissive attitude is taken to allowing the men to have multiple sexual
partners.

Most STI transmission occurs within a small part of the population that has multiple sex partners.
This does not mean that the rest of the community is not at risk for STI infection. A woman who
has sex with only her husband can still get a STI if her husband has other partners.

Clinical services can contribute to STI control, but they are not enough. Often, those at highest risk
of STI infection are least likely to use services. For these reasons, control of STI in any community
requires effective strategies that reach those with the greatest number of sex partners.

Risk group
In most communities there are certain people who may be more vulnerable to STI. These may vary
in different communities, but they usually include:
●● Adolescent girls and boys who are sexually active and indulging in unsafe sex
●● Women who have several partners for earning money.
●● Female and male sex workers and their Clients
●● Men and women whose jobs force them to be away from their families or regular sexual
partners are away for long periods of time.
●● Men having sex with men (MSM) including transgenders.
●● Street children, prison inmates, etc.

Special concerns for STI/RTI in women

Although STI affect both women and men, research shows that women are more susceptible
to infection and are less likely to seek treatment than men. Though the rate of infection vary
tremendously among and within countries, World Bank reports indicate that STI are the second
most important cause of health life years lost in women of childbearing age (after pregnancy-
related problems). The potential complications of untreated RTI are more serious in women and
infections can be transmitted to the offspring of pregnant women as well.

PARTICIPANT’S HANDOUT 11
TRAINING OF MEDICAL OFFICERS TO DELIVER STI/RTI SERVICES

Why STI/RTI in women are different from that of men?

The women are more vulnerable to infection with STI and management may be more difficult in
them than it is for men. This can be explained in two ways:

Biological differences
Biological differences make male-to-female transmission easier than female-to-male transmission.
●● The lining of the vagina is a mucous membrane, which is more permeable to infection than the
skin on the outside of the penis.
●● Women’s genitals have more surface area through which infection can enter.
●● Women are the receptive partners during intercourse.
●● Lack of lubrication during intercourse or changes in the cervix during the menstrual cycle can
facilitate more efficient transmission of infection to women.
●● Semen (thus bacteria or viruses which may be present in semen) stays in contact with the
vagina for a longer time than vaginal fluids stay in contact with male genitals.
●● Younger women may be more susceptible biologically due to an immature genital tract.
Because of this, their cervical tissues may be more readily penetrated by organisms (e.g.,
chlamydia and gonococcus).
●● Older women are more likely to get small abrasions in the vagina during sexual activity because
of the thinning of the tissues and dryness that occur with age.
●● Symptoms are less reliable indicators of disease in women.
●● Women with STI are less likely to have symptoms (asymptomatic) than men with STI.
●● When women do have symptoms such as vaginal discharge, they are not necessarily due to
STI.
●● Women who already have an infection (particularly one that causes genital lesions) are more
likely to get or transmit HIV, since women are often asymptomatic when infected with an STI,
they are often not aware of this increased risk.
●● Complications in women are more frequent, numerous and severe because infection may
ascend to uterus, tubes, and ovaries (Pelvic Inflammatory Diseases).
●● Consequences include PID, infertility, ectopic pregnancy, spontaneous abortion, and cervical
cancer.

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 TRAINING OF MEDICAL OFFICERS TO DELIVER STI/RTI SERVICES

Sociocultural differences
Sociocultural norms for men

Accepted male behavior that is the norm in many countries puts women at risk of infection.
●● Older men often seek younger women as sex partners. Older men are more likely to have been
exposed to STI because over time, they have more partners and therefore more opportunities
to transmit infections such as HIV, HSV and HPV, which remain for life. While women more
often settle into more stable relationships by their mid-20s.
●● Younger men who are single, are more likely to have new or multiple partners, and are less
likely to know about or use condoms. Younger men may have more partners over a shorter
time period and thus are at increased risk of STI.

Sociocultural norms for women

Certain factors reduce women’s options for protection against STI.

●● Women can’t always insist on condom use.
●● Women lack power in family and community to influence male sexual behavior.
●● Women cannot always refuse unwanted sex.
●● Women may be forced into exchanging sex for money or favors out of financial need.
●● For women, stigma attached to genital tract infections can prevent health care seeking
behavior.
●● Social stigma resulting from STI and their consequences can prevent marriage, cause divorce,
and lead to domestic abuse.
●● Other risks for women include the use of vaginal douches (which increase the risk of PID)
and the influence of hormonal contraceptives on acquiring or transmitting STI, although this
relationship is not yet fully understood.

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4. Impact of STI/RTI and the need for their prevention

and management
Why reproductive health services should focus on STI/RTI?
The STI/RTI are not only becoming a rapidly growing problem throughout the world but in the
country too. As the transmission and prevalence of STI/RTI are influenced mainly by social and
economic factors as well as by biological and behavior pattern, therefore the burden of STI/RTI
varies greatly from region to region, and from community to community. Where STI/RTI are
common, their complications are also common and the impact of STI is serious.

Seriousness of complications
RTI often go undiagnosed and untreated, and they lead to serious complications. If left untreated
or if not diagnosed and treated in time, even curable STI can cause serious complications. Some of
these infections can cause pelvic inflammatory disease, premature labor and delivery, spontaneous
abortion, ectopic pregnancy, infertility, inflammation of the testes, cardiovascular or neurological
complications, cervical cancer or even death. Some infections can also lead to pneumonia,
respiratory infections, and eye infections in infants. Pelvic inflammatory disease arising from STI
poses a major public health problem and adversely affects the reproductive health of poor and
untreated women. In women of childbearing age, STI are second only to maternal factors as causes
of disease and death. By far, the greatest burden of STI is borne by women and adolescents.

Links to HIV/AIDS
Studies have shown that the spread of HIV and other STI are closely related, STI are identified as a
co-factor for the causation of HIV infection and promiscuous behavior puts people at risk for any
sexually transmitted infections as well as HIV infection (86%). A person with an STI has a much
higher risk of acquiring HIV from an infected partner. A person infected with both HIV and another
STI has a much higher risk of transmitting HIV to an uninfected Partner.

For example, a person who has chancroid, chlamydia, gonorrhoea, syphilis, or trichomonas
infection can have as much as four to ten times the risk of getting HIV from a sexual partner
as a person who is not infected with one of these STI. An ulcerative STI (such as genital herpes,
syphilis, or chancroid) increases the risk of HIV transmission per exposure significantly more than
a non-ulcerative STI (such as gonorrhoea or chlamydia) since HIV can pass more easily through
genital ulcers. But STI that do not cause ulcers also increase risk because they increase the number
of white blood cells (which have receptor sites for HIV) in the genital tract, and because genital
inflammation may result in damage that can allow HIV to enter the body more easily.

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In addition, HIV infection may complicate diagnosis and treatment of other STI because HIV may
change the patterns of disease or clinical manifestations of certain infections and may affect
laboratory tests. In people with HIV infection, STI symptoms may be more severe, the period of
infectivity may be increased, and normal treatments may not give good results.

Fortunately, prevention of STI involves much the same behavior as prevention of HIV, and
prevention works. In addition, since HIV spreads more easily when other STI are present, HIV
transmission can be reduced by improving the recognition and management of curable STI at the
primary health care level. Therefore in prevention campaigns to educate people about the link
between behavior and infection with STI and HIV are needed. Prevention of STI infection provides
windows of opportunity for preventing new HIV infection. Effective STI prevention is considered as
the most cost effective strategy in preventing HIV infection. So, STI treatment and prevention can
be an important tool in limiting the spread of HIV infection.

Future implications
STI are a major public health problem not only because they are among the most common causes
of illness in the world, but also because of the potentially serious complications of untreated
STI and because of the relationship between STI and increased HIV transmission. In women of
childbearing age, STI are second only to maternal factors as causes of disease and death. By far,
the greatest burden of STI is borne by women and adolescents.

In 2006-07, HIV surpassed tuberculosis as the world’s leading infectious cause of death among
adults. The social impact of HIV has been particularly pronounced in Sub-Saharan Africa, where an
estimated 70% of the 40 million people in the world are living with HIV/AIDS and where 14 million
children have been orphaned by AIDS. In some countries, more than 20% of the adult population
is infected. The effects of losing an entire generation have created economic and social dislocation
families have lost means of support; industry has lost workers; the health care system has been
overwhelmed.

To sum up
●● STI/RTI are increasing and constitute one of the major causes of ill health in our country.
●● STI/RTI infection increases the risk of HIV transmission.
●● STI/RTI cause serious complications in men and women, including infertility.
●● STI/RTI are responsible for reproductive loss: spontaneous abortion, ectopic pregnancy, still
birth, prematurity, neonatal infections.
●● If left unscreened and untreated one of the serious consequences is cervical cancer in women
in India.

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●● STI/RTI affect the larger community at national level:

ŠŠ Social impact of infertility

ŠŠ Mother-to-child transmission causing perinatal mortality, infant and child mortality and
morbidity such as disabilities and orphans

ŠŠ Maternal mortality.

ŠŠ Socio economic impact of AIDS

ŠŠ Increased cost to health systems

ŠŠ Cost to national productivity

ŠŠ Decreased life expectancy

Need for action

When diagnosed early, most STI/RTI can be treated easily and effectively. In addition, the earlier
a person seeks treatment for STI, the less likely it is that the infection will cause serious and
irreparable damage, be spread to others, or be passed to a baby. And now due to emergence
of HIV/AIDS problem and identification of STI as a co-factor for its causation, have further lent a
sense of urgency for formulating a programmatic response to address this important public health
problem.

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5. Challenges in prevention and management of STI/RTI

People are often too embarrassed or frightened to ask for help and information. Social stigma,
misinformation, fear, shame, cultural barriers, gender inequities and other factors can keep
individuals away from practicing safer sex behaviors, notifying partners, or receiving adequate
treatment.

In many countries, women find it particularly difficult to talk about STI and seek services for a
variety of reasons. Because of cultural and social factors, a woman may be more likely to blame
herself for her infection, fear abuse by her partner, and deny the presence of symptoms, or feel
too embarrassed to ask for care. Young people may also have particular difficulty in accessing
health care facilities because they may lack independent financial resources or fear that they will
be denied services or judged by health care workers and others. In some countries, men who have
sex with men– particularly those who do not consider themselves bisexual or homosexual– may
fail to seek treatment out of embarrassment, fear, or stigmatization.

Other common barriers to STI treatment for Clients include:

●● Lack of knowledge about STI, risks, symptoms, and complications
●● Misconceptions about causation of STI/RTI
●● Dependence on home remedies, quacks, faith healer especially in rural areas.
●● Absence of signs or symptoms of STI (especially in women)
●● Lack of knowledge about or access to treatment
●● Reluctance to discuss sexual matters
●● Fear that others will find out
●● Fear of a judgmental approach by the health care provider
●● Reluctance to undergo a genital examination (particularly by a provider of the opposite sex)
●● Laws and restrictions (such as laws restricting health care for minors)

It is important for health care providers to remember that STI affect men and women of all ages,
backgrounds, and socioeconomic levels. Providers of STI services and counseling must avoid
judgmental and moralistic attitudes that can deter clients from seeking treatment – especially
in the case of clients (who might be particularly susceptible to social stigma and bias, such as
adolescents, sex workers, unmarried women, and homosexuals).

The Piot and Fransen model of STI/RTI management graphically sums up the problems in the
treatment of RTI (Figure-1). The model illustrates some obstacles to STI/RTI control. The bottom
bar represents all women with STI/RTI in a community. The bars above shows how many people
are identified at each step, and the differences between the bars illustrate lost opportunities for
stopping STI/RTI transmission. Comparison of the small top bar with the bottom one shows the
proportion of all people with STI/RTI in the community who are identified and correctly managed
at health facilities. In the typical clinical approach to the control of STI/RTI, the contribution of
clinical services is small.

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Figure 1: Problems in management of RTI (Piot – Fransen model)

For example, suppose that 10 percent of the women in your community have STI/RTI. Of these
women, less than half are likely to have symptoms. Even among symptomatic women, however,
perhaps only half will seek or have access to care from a clinic. In this example, already less than
one-quarter of the women with STI/RTI are seeking care from a qualified health worker.

There are other obstacles. How many of the symptomatic women who come to your clinic
are accurately diagnosed? Even when diagnosed correctly, do the women leave with effective
medications and take all of them? Finally, do women treated for STI/RTI have their partners treated
successfully at the same time to ensure that they are not reinfected? These can be difficult steps
to achieve and are some of the things to consider when deciding whether your STI/RTI services will
make a difference in your community.

Improving STI/RTI case management at health centers expands the smallest bar, resulting in higher
cure rates among those who seek care. Still, it is apparent that improving services has its limits.
Clients do not usually come to health centers unless they have symptoms. Even among people with
symptoms, some choose to seek care from places other than clinics and hospitals. Self-treatment,
direct purchase of antibiotics from pharmacists or drug peddlers, and consultation with traditional
healers are among the many options available to someone with STI/RTI symptoms.

In order to convince people to use services, information about STI/RTI and the importance of
prompt treatment must be available at the community level.

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STI/RTI control strategies

There are two main elements of STI/RTI control:
●● Prevention is the primary strategy for controlling STI/RTI and HIV/AIDS. Prevention means
using community education and other strategies to prevent infection from occurring. In
order to raise community awareness, messages should be included about STI/RTI and their
consequences, reducing the number of sex partners, using condoms, and having safer sex. As
a strategy, prevention works.
●● Effective case management means correctly diagnosing and treating symptomatic and
asymptomatic patients, providing patient education for consistent condom use and partner
management to prevent reinfection and transmission to others.

Prevents
complications

Effective
management
of STIs
Decreases spread Opportunity for
and re-infection patient education

Effective case management strategy

Control strategies are often different for those who are at high risk and those at lower risk of
contracting and transmitting infection. Reaching those at high risk will provide the greatest overall
reduction of STI/RTI in the community.

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20 PARTICIPANT’S HANDOUT
 MODULE NO. 3

COMMON STI/RTI AND THEIR COMPLICATIONS

Sr. No. Topic Page No

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1. Body sites of STI/RTI occurrence in males and females

Anatomy of sexual and reproductive tract

An understanding of sexual and reproductive anatomy and physiology helps providers to educate
clients about their bodies and helps both clients and providers in a better way to discuss the sexual
and reproductive health issues.

When describing sexual anatomy to clients, the health care providers should be sure that they
should use language that the clients understand. Remember that many a times, clients may not
use medical terminology when discussing their genital structures; they might use slang, or might
even be too embarrassed to mention the names. To communicate effectively with clients, learn
their terminology as you share the technical names for body parts.

Male sexual and reproductive organs

External male genitals

The external male genitals consist of the penis and the

scrotum.

The penis is a cylindrical structure with the capacity to be

flaccid or erect. The penis provides passage for both urine
and semen. It can be a source of pleasure in response to
sexual stimulation and is the organ that penetrates the
mouth, vagina, or anus during penetrative sex. The head
of the penis, the glans penis, is the part of the penis that is most sensitive and has the most nerve
endings. The glans is covered by the foreskin, or prepuce, in men who are not circumcised.

The scrotum is a pouch of skin hanging directly under the penis that contains the testes. The
scrotum protects the testes and maintains the temperature necessary for the production of sperm.

Internal male genitals

The internal male genitals are: the testes, the epididymis, the vas deferens, the seminal vesicles,
the prostate gland, and the Cowper’s glands.

The testes, the paired, oval- shaped organs that produce sperm and male sex hormones
(testosterone), are located in the scrotum. They are highly innervated and sensitive to touch and
pressure. The testes produce testosterone, which is responsible for the development of male
sexual characteristics and sex drive (libido).

The epididymis are the two highly coiled tubes against the back side of the testes where sperm
mature and are stored until they are released during ejaculation.

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The vas deferens are the paired tubes that carry the
mature sperm from the epididymis to the urethra.

The seminal vesicles are a pair of glandular sacs that

secrete about 60% of the fluid that makes up the semen
in which sperm are transported. Seminal fluid provides
nourishment for sperm.

The prostate gland is a walnut-sized, glandular structure

that secretes about 30% of the fluid that makes up
semen. The alkaline quality of the fluid neutralizes the acidic environment of the male and female
reproductive tracts. A muscle at the bottom of the prostate gland keeps the sperm out of the
urethra until ejaculation begins. The prostate gland is very sensitive to stimulation and can be a
source of sexual pleasure for some men.

The Cowper’s glands are two pea-sized glands at the base of the penis under the prostate gland
that secrete a clear alkaline fluid into the urethra during sexual arousal and before orgasm and
ejaculation. These glands produce mucus-like, pre-ejaculatory fluid in the urethra that acts as a
lubricant for the sperm and the urethra as semen flows out of the penis.

Female sexual and reproductive organs

External female genitals

The external female genitals are: the mons pubis, the clitoris,
the labia majora, and the labia minora. Together, along with
the opening of the vagina, they are known as the vulva.

The mons pubis is a pad of fatty tissue over the pubic bone.
This structure, which becomes covered with hair during
puberty, protects the internal sexual and reproductive organs.

The clitoris is an erectile, hooded organ at the upper joining of the labia that contains a high
concentration of nerve endings and is very sensitive to stimulation.

The labia majora are two spongy folds of skin, one on either side of the vaginal opening, that cover
and protect the genital structures. The labia minora are the two erectile folds of skin between the
labia majora that extend from the clitoris on both sides of the urethral and vaginal openings. (The
area covered by the labia minora that includes the openings to the vagina and urethra, as well as
the Bartholin’s and Skene’s glands, is called the vestibule.)

The perineum is a network of muscles located between and surrounding the vagina and anus that
supports pelvic cavity and help keep pelvic organs in place.

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Internal female genitals

The internal female genitals are: the vagina, the cervix, the
uterus,the fallopian tubes, and the ovaries.

The vagina is a muscular, highly expandable, tubular cavity

leading from the vestibule to the uterus. The anterior vaginal
wall is more densely innervated and more highly sensitive to
stimulation than the posterior vaginal wall.

The Bartholin’s glands are two small, round structures, one on either side of the vaginal opening.
These glands secrete a mucus-like fluid during sexual arousal, providing vaginal lubrication.

The cervix (the lower part of the uterus that protrudes into the vaginal canal) has an orifice that
allows passage for menstrual flow from the uterus and passage of sperm into the uterus. During
vaginal intercourse, contact with this structure may provide sexual pleasure in some women.

The uterus is a hollow, thick-walled, pear-shaped, muscular organ located between the bladder
and rectum. It is the site for implantation of the fertilized ovum (egg), the location where the fetus
develops during pregnancy, and the structure that sheds its lining monthly during menstruation.
The upper portion of the uterus contracts during orgasm.

The fallopian tubes (oviducts) are a pair of tubes that extend from the upper uterus, extending
out toward the ovaries (but not touching them), through which ova (eggs) travel from the ovaries
toward the uterus and in which fertilization of the ovum takes place. The fallopian tubes contract
during orgasm.

The ovaries are two organs located at the end of each fallopian tube that produce ova (releasing
one per month from puberty to menopause). The ovaries produce estrogen and progesterone,
the hormones responsible for the development of sex characteristics. These hormones are also
responsible for elasticity of the genitalia, integrity of the vaginal lining, and lubrication of the
genitalia. Testosterone is also produced – although in smaller amounts than is produced in men –
and is responsible for sexual desire.

Where do STI/RTI occur?

STI/RTI in females
In women, RTI involve the outer genitals, vagina, cervix, and are referred to as lower reproductive
tract infections. Infections in the uterus, fallopian tubes, and ovaries are considered upper
reproductive tract infections.

Note: Infections of the cervix are considered more severe than vaginitis because they much more
commonly result in upper reproductive tract infection with its serious consequences. Unfortunately
they are also more difficult to detect, as they are frequently asymptomatic.

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STI/RTI in males
RTI generally begin in the lower reproductive tract (the urethra). If untreated, they may ascend
through the vas deferens (sperm tube) to the upper reproductive tract (which includes the
epididymis and testes). It also leads to prostatitis and epididymitis

Note: In general, RTI in men are easier to identify and treat, as they are more likely to be
symptomatic.

Sites of STI/RTI in females and males

Source: Adopted from “Integrating STI/RTI care for reproductive health, sexually transmitted and
other reproductive tract infections, A guide to essential practice-2005 WHO”

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2. Types of STI/RTI

Any individual can become infected with a sexually transmitted infection (STI) or reproductive
tract infection (RTI), regardless of age, background, or socioeconomic class.

RTI that are most common but may not always be sexually
transmitted are:
1. Bacterial vaginosis (BV)- A RTI in women that is caused by an imbalance in the vagina’s normal
environment and overgrowth of bacteria in the vagina.

2. Vaginal yeast infection- A RTI in women that occurs when the normal environment in the
vagina changes and there is overgrowth of yeast, commonly candida albicans.

There are over 20 STI. But the most common are:

1. Syphilis- A STI caused by Treponema Pallidum that initially causes painless sores that will heal
on their own but, if left untreated, can cause serious complications or even death.

2. Gonorrhoea- A STI due to infection by Neisseria gonorrhoea that can cause infertility in both
men and women. It includes ophthalmia neonatarum

3. Chlamydial infection- A STI due to infection by chlamydia trachomatis in both men and
women. It is often asymptomatic.

4. Trichomonas infection- A STI due to infection by Trichomonas vaginalis in both men and
women. It is often asymptomatic.

5. Chancroid- A STI due to infection by Haemophilus ducreyi, that causes lymph node swelling
and painful ulcers in the genital area.

6. Genital herpes- A STI due to Herpes simplex virus that causes painful genital ulcers.

7. Genital and cervical warts due to Human papilloma virus (HPV) - Growth or warts in the
genital area caused by some forms of HPV. Other forms of HPVs can lead to cervical cancer.

8. HIV infection - is caused by a retrovirus (Human immunodeficiency virus infection virus) that
weakens the immune system and causes AIDS.

9. Hepatitis B and hepatitis C infection- can cause liver damage, and possibly even liver failure.

10. Donovanosis- A STI due to infection by Calymmatobacterium granulomatis or Klebsiella

granulomatis that can cause serious ulcers at the site of infection. These ulcers can grow
together and cause permanent scarring and genital destruction.

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11. Lymphogranuloma venereum (LGV) - A STI due to a subtype of Chlamydia trachomatis that
causes inflammation of and prevents drainage of the lymph nodes in the genital area. LGV can
cause destruction and scarring of surrounding tissue.

12. Molluscum contagiosum -A STI due to a virus that causes relatively benign skin infections.
Molluscum contagiosum infection can lead to secondary bacterial infections.

13. Genital scabies- A STI in both men and women caused by itch mite, Sarcoptes scabiei.

14. Pubic lice- A STI in both men and women caused by pubic lice (Phthirus pubis).

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3. Signs and symptoms of common STI/RTI

The following list identifies signs and symptoms of the most common
STI/RTI:
In men:
●● Urethral discharge: chlamydia, gonorrhoea, trichomonas infection
●● Genital ulcer: treponema pallidum, H. ducreyi, Herpes Simplex infection
●● Genital itching: chlamydia, gonorrhoea, trichomonas infection
●● Swollen and/or painful testicles: chlamydia, gonorrhoea

In women:
●● Unusual vaginal discharge: BV, Chlamydia, gonorrhoea, trichomonas infection, vaginal yeast
infection
●● Genital itching: BV, trichomonas infection, vaginal yeast infection
●● Abnormal and/or heavy vaginal bleeding: chlamydia, gonorrhoea (Note: This symptom is often
caused by factors other than STI.)
●● Bleeding after intercourse: chlamydia, gonorrhoea, chancroid, genital herpes
●● Lower abdominal pain (pain below the belly button; pelvic pain): chlamydia, gonorrhea and
mixed anaerobic infection.
●● Persistent vaginal candidiasis: HIV/AIDS
●● Dyspareunia

In men or women:
●● Blisters or ulcers (sores) on the mouth, lips, genitals, anus, or surrounding areas: chancroid,
genital herpes, and syphilis
●● Burning or pain during urination: chlamydia, genital herpes, trichomonas infection, and
gonorrhoea
●● Itching or tingling in the genital area: genital herpes, candidiasis
●● Jaundice (yellowing of the eyes and skin) and/or fever, headache, muscle ache, dark urine:
hepatitis B, hepatitis C
●● Warts or bumps on the genitals, anus, or surrounding areas: HPV (genital warts)
●● Flu-like syndromes (fever, fatigue, headaches, muscle aches), mild liver inflammation: CMV
●● Small, dimpled bumps or lesions on the skin that usually do not hurt or itch and are flesh
colored, but can vary from white to yellow to pink: molluscum contagiosum
●● Small, red lesions or ulcers in the genital or anal area; lymph node swelling in the genital area;
chronic ulcers on the genitals or anus: LGV
●● Red nodules or bumps under the skin on the mouth, genitals, or anus that ulcerate, become
tender, and often bleed easily: donovanosis

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4. Classifications of STI/RTI

STI/RTI can be classified in several ways. They can be classified based on the actual infectious agent
or the type of agent causing the STI/RTI and mode (the combination of
symptoms a person experiences and clinical signs a provider sees on physical exam)

To successfully incorporate the management of RTI and STI into reproductive health services,
providers need to know what RTI and STI are, how they differ from one another, and how to
recognize the signs and symptoms that indicate that a client has an STI or RTI. However, providers
must also be aware that some RTI and STI are asymptomatic.

i. Classification of STI/RTI based on mode of transmission

Where do they come
How they spread Common examples
from
Endogenous Normally found in small Overgrowth can lead to Yeast infection,
infections numbers in vagina symptoms Bacterial vaginosis
Sexually Sex Partners Sexual contact Gonorrhoea,
transmitted Chlamydia.
infections (STI) Syphilis Chancroid,
Trichomoniasis, Genital
herpes, Genital warts,
HIV
Iatrogenic Inside or outside the Infection may be pushed Pelvic inflammatory
infections body: through the cervix disease (PID)
●● Endogenous into the upper genital following abortion or
tract and cause serious other transcervical
(vagina)
infections of the uterus, procedures. Also,
●● STI (cervix or fallopian tubes and other many infectious
vagina) pelvic organs. complications of
pregnancy and
●● Outside Contaminated needles or
postpartum period.
contamination other instruments may
also transmit infection if Transmission from
infection control is poor. patient to patient (or
healthcare provider)
of HIV, HBV, syphilis or
other infection.

Adopted from “Integrating STI/RTI care for reproductive health, sexually transmitted and other
reproductive tract infections: A guide to Essential practice-2005 WHO”

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ii. Classification of STI/RTI based on symptoms/syndromes

Clients suspected of having STI/RTI usually present with one or more of the following complaints.
These clinical entities may present as (i) vaginal or urethral discharge; (ii) vesicular and/or non-
vesicular genital ulcers; (iii) inguinal bubo; (iv) lower abdominal and/or scrotal pain; and (v) genital
skin conditions.

STI/RTI Causative organisms Symptoms/Signs

Presenting symptoms: Vaginal/Urethral discharge
Gonorrhoea “drip” Neisseria gonorrhoea Women
●● Purulent (containing mucopus) vaginal
discharge
●● Pain or burning on passing urine (dysuria)
●● Inflamed (red and tender) urethra
Men
●● Pain or burning on passing urine (dysuria)
●● Purulent (containing mucopus) urethral
discharge (drip)
●● Infection of the epididymis (coiled tube
leading from the testis to the spermatic cord)
●● Urethral abscess or narrowing (stricture)

Trichomoniasis Trichomonas vaginalis ●● May produce few symptoms in either sex

●● Women often will have a frothy (bubbly),
foul-smelling, greenish vaginal discharge
●●Men may have a urethral discharge
Chlamydia Chlamydia Women
trachomatis ●● Produces few symptoms, even with upper
genital tract infection (silent PID)
●● Purulent cervical discharge, frequently a
“beefy” red cervix which is friable (bleeds
easily)
Men
●● Most frequent cause of non-gonococcal
urethritis (NGU)
Bacterial vaginosis Overgrowth of ●● Not necessarily sexually transmitted
anaerobes (e.g., ●● Vaginal discharge with fishy odor, grayish in
Gardenella vaginalis)
color

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STI/RTI Causative organisms Symptoms/Signs

Candidiasis Candida albicans Women
●● Curd-like vaginal discharge, whitish in color
●● Moderate to intense vaginal or vulval itching
(pruritus)
Men
●● Itchy penile irritation (balanitis)
Presenting symptoms: Genital ulcers and buboes
Chancroid (Soft Haemophilus ducreyi ●● Painful, “dirty” ulcers located anywhere on
chancre) the external genitalia.
●● Development of painful enlarged lymph
nodes (bubo) in the groin.
Syphilis Treponema pallidum Occurs in 3 forms: primary and secondary and late
●● Primary syphilis
Initially, painless ulcer (chancre): in women
on the external genitalia (labia), in men on
the penis; in both sexes oral and anal ulcers
and enlarged nontender, nonsuppurative
rubbery lymph nodes
●● Secondary (disseminated) syphilis
Several weeks later non-itchy body rash
especially on palm and sole, headaches,
muscle aches, weight loss, low-grade fever.
The rashes may disappear spontaneously
●● Late syphilis
Develops in about 25% of untreated cases
and is often fatal due to involvement of the
heart, great blood vessels and brain.
Lymphogranuloma Chlamydia ●● Small, usually painless papules (like pimples)
venereum (LGV) trachomatis on the penis or vulva, followed by
(serovars L1, L2, L3)
●● Buboes in the groin which ultimately breaks
down forming many sinuses (draining
openings)
●● If untreated, the lymphatic system may
become blocked, producing elephantiasis
(swelling of the genitals or extremities)

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STI/RTI Causative organisms Symptoms/Signs

Granuloma Calymmatobacterium ●● An uncommon cause of ulcerative genital
inguinale granulomatis tract infection
(Donovanosis) or Kleibsella
●● Typically, the infected person develops lumps
granulomatis
under the skin which break down to form
“beefy” red, painless ulcers
Genital herpes Herpes simplex virus ●● Multiple painful vesicles later forming
shallow ulcers which clear in 2 to 4 weeks
(first attack) and may be accompanied by
watery vaginal discharge in women
●● Recurrent (multiple bouts) more than 50% of
the time.
Presenting symptoms: Lower abdominal pain
Pelvic ●● Neisseria ●● Lower abdominal pain, fever, vaginal
inflammatory gonorrhoea discharge
disease (PID)
●● Chlamydia ●● Menstrual irregularities like heavy irregular
trachomatis vaginal bleeding
●● Anaerobes ●● Dysmenorrhoea
●● Dyspareunia (pain during sexual intercourse)
●● Dysuria
●● Tenesmus
●● Low backache
●● Temperature> 390C
●● Vaginal/cervical discharge, congestion or
ulcers
●● Lower abdominal tenderness or guarding
Uterine/adnexal tenderness, cervical
●●
movement tenderness, presence of a pelvic
mass
Presenting symptoms: Acute scrotal pain and /or swollen scrotum
Epididymitis/ ●● Neisseria Acute: severe pain in one or both testes, sudden
Orchitis gonorrhoea swelling of the testes.
Chlamydia
●●
trachomatis
Presenting symptoms: Genital skin conditions
Genital warts Human papilloma ●● Single or multiple soft, painless, “cauliflower”
(Condyloma virus growth which appear around the anus, vulvo-
acuminata) vaginal area, penis, urethra and perineum

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STI/RTI Causative organisms Symptoms/Signs

Molluscum Pox virus ●● Multiple, smooth, glistening, globular papules
contagiosum of varying size from a pinhead to a split pea
can appear anywhere on the body. Sexually
transmitted lesions on or around genitals can
be seen. Not painful except when secondary
infection sets in.
Pediculosis pubis Phthirus pubis ●● There may be small red papules with a tiny
central clot caused by lice irritation.
General or local urticaria with skin thickening may
or may not be present.
Genital scabies Sarcoptes scabiei ●● Severe pruritis (itching) is experienced by the
client, which becomes worse at night.
The burrow is the diagnostic sign. It can be seen
as a slightly elevated grayish dotted line in the
skin, best seen in the soft part of the skin.

Based on the above table the seven major STI/RTI syndromes are incorporated in the National
Guidelines on Management of STI/RTI, they are:

1. Urethral discharge

2. Vaginal discharge

3. Genital ulcers

4. Inguinal buboes

5. Lower abdominal pain

6. Acute scrotal pain and /or scrotal swelling

7. Genital skin conditions

Please note that the STI/RTI are modified due to HIV infection. The clinical presentations of STI/RTI
are seen in an exaggerated form.

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5. Complications of STI/RTI

STI/RTI if left untreated can cause serious complications in males, females and neonates. Millions
of men, women, and children all over the world are affected by the long-term complications of RTI
and STI.

These infections can lead to numerous serious, long-term, and sometimes deadly complications,
particularly in women. Some STI/RTI can also cause pregnancy-related complications or congenital
infections. Unfortunately, symptoms and signs of many infections may not appear until it is too
late to prevent serious consequences and damage to the reproductive organs.

In addition, the complications of RTI and STI affect even more than an individual’s health. The
morbidity associated with them has a profoundly adverse effect on the quality of life and economic
productivity of many women and men, their families, and, consequently, entire communities.

Some of the most common complications of STI/RTI include:

●● Pelvic inflammatory disease (PID), which can lead to ectopic pregnancy, infertility, and chronic
pelvic pain
●● Increased susceptibility to opportunistic infections
●● Infertility, early labor and delivery, stillbirths, and spontaneous abortions
●● Neurological, cardiovascular, and other systemic conditions
●● Chronic pain and discomfort

Complications of STI/RTI in males

(i) Infertility
Infection of the upper reproductive tract can occasionally result in partial or complete blockage of
the sperm ducts, and disorders in sperm production. This can cause low sperm counts in semen or
abnormal sperm, which contribute to male infertility.

(ii) Carcinoma of the penis

Infection with Human papilloma virus (HPV) is associated with the development of penile cancer.

Complications of STI/RTI in females

(i) Pelvic inflammatory disease
Some of the most serious consequences of STI/RTI in women occur when an infection of the lower
genital tract (cervix or vagina) or outside organisms reach the upper genital tract (uterus, fallopian

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tubes, ovaries and surrounding structures). Infection may become generalized and life threatening,
and resulting tissue damage and scarring may cause infertility, chronic pelvic pain and increased
risk of ectopic pregnancy.

Untreated gonococcal and chlamydial infection in women results in pelvic inflammatory disease in
upto 40% of cases. One in 4 of these will result in infertility.

(ii) Adverse outcomes of pregnancy

STI such as chlamydia, gonorrhoea, syphilis, genital herpes etc. are responsible for the adverse
outcomes of pregnancy. In addition to ectopic pregnancy, other poor pregnancy outcomes that
are linked to STI include:
●● Fetal wastage - spontaneous abortion or stillbirth.
●● Low birth weight due to premature delivery or intra-uterine growth retardation.
●● Congenital or perinatal infections - eye infections causing blindness, infant pneumonias and
mental retardation.

(iii) Infertility
Infertility often follows after untreated pelvic inflammatory disease in women, and epididymitis
and urethral scarring in men. In fact, complications of STI are the most important preventable
causes of infertility in regions where childlessness is most common. Repeated spontaneous
abortion and stillbirth often due to STI such as syphilis are other important reasons why couples
are unable to have children.

(iv) Ectopic pregnancy

The tubal scarring and blockage that often follows PID may be total or partial. Fertilization can still
occur with partial tubal blockage but risk of implantation in the fallopian tubes or other site outside
the uterus (ectopic pregnancy) is high. Ruptured ectopic pregnancy, along with complications of
abortion and postpartum infection, is a common preventable cause of maternal death in places
with high prevalence of STI/RTI and PID.

(v) Cervical cancer

Infection with Human papilloma virus (HPV) appears to be strongly associated with the development
of cervi¬cal cancer. HPV causes about 5,00,000 cases of cervical cancer resulting in 2,40,000 deaths
mainly in the resource poor countries. It is the most common genital cancer among women in
India. Cervical cytological screening (Papanicolaou smears) facilities are still not available in the
primary health care facilities and therefore majority of diagnosed cases are detected in advanced
stages when treatment has lower successful outcome.

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Complications of STI/RTI in neonates

1. Perinatal and neo-natal infections
(i) Congenital syphilis
Congenital syphilis results from the transmission of Treponema pallidum infection from an
infected pregnant woman to her fetus. Maximum transmission (up to 100%) occurs if the
mother herself is in the primary or secondary stages of the disease and this transmission rate
drops to 10% to 30% if the mother is in the late latent stage. The symptoms and signs of the
congenital infection may not be evident till the infant is about 3 months old when hepato-
splenomegaly, conjugated hyperbilirubinemia, skeletal lesions, skin and mucus membrane
lesions and other features are detectable. If untreated, late manifestations appear in the
second year of life.

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(ii) Gonorrhoea
An untreated Neisseria gonorrhoea infection in pregnant woman results in its transmission to
her neonate. The neonate may present with only conjunctivitis, which usually appears within
the first four days of life and may progress to panophthalmitis unless treated. The newborn
may also have systemic disease, which may present as sepsis, arthritis or meningitis.

(iii) Chlamydia
Chlamydia trachomatis can be vertically transmitted from an infected pregnant woman to her
neonate and may cause only conjunctivitis or have systemic infection like pneumonitis.

Worldwide upto 4000 newborn babies become blind every year because of eye infection
attributable to untreated maternal gonnorhoea and chlamydial infections.

(iv) Human immunodeficiency virus (HIV)

Most of the HIV transmission takes place during delivery but it must be remembered that HIV
is also transmitted through breast milk (14%).

(v) Herpes simplex viruses 1 & 2 (HSV1 & HSV2)

The herpes simplex virus has a very high intrapartum transmission rate (75% to 90%) and can
lead to localized or central nervous system or disseminated disease in the affected neonates
with a very high rate of long-term residual sequelae.

(vi) Hepatitis B virus

Hepatitis B virus infection in the mother can be transmitted to the neonate. Neonatal infections
result in higher carrier rates with more chances of long term sequelae.

There are a number of other infections like cytomegalovirus, candida, trichomonas and other
organisms (TORCH infection) that are transmitted from the mother to the neonate and can
cause serious morbidity.

2. Prematurity
STI/RTI in pregnancy especially bacterial vaginosis and trichomoniasis may result in preterm
delivery, which can lead to prematurity and associated complications in the neonate.

3. Low birth weight

Low birth weight can be a result of prematurity or intrauterine growth retardation caused due to
associated STI/RTI in pregnancy.

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38 PARTICIPANT’S HANDOUT
 MODULE NO. 4

HISTORY TAKING AND RISK ASSESSMENT IN STI/RTI

Sr. No. Topic Page No

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1. Knowledge and skills necessary for STI/RTI history

taking

The most important aspects of STI/RTI case management are accurate diagnosis and effective
treatment. This needs time and skill in taking a detailed sexual history for both client and his/her
sexual contacts; carrying out a comprehensive physical examination and minimal investigations in
resource poor settings. To prevent the spread and complications, treatment must be effective, by
selecting the effective drugs for treating the infection, carefully monitoring its administration and
carrying out regular follow up. The sexual contact(s) must be traced so that they can be treated
thereby preventing the infection from spreading further. They should be educated on prevention
of STI/RTI as well.

The components of case management include:

●● History taking
●● Clinical examination
●● Early and correct diagnosis
●● Prompt and effective treatment
●● Advice on sexual behavior
●● Provision of condoms
●● Partner management
●● Case reporting
●● Clinical follow-up as appropriate.

Thus, effective case management consists not only of antimicrobial therapy to obtain cure and
reduce infectivity, but also comprehensive consideration and care of the Client’s reproductive
health.

How history taking helps in STI/RTI case management?

A patient history is taken to get the information needed to make an accurate assessment of the
problem and to provide appropriate treatment. It is one of the most important and sensitive parts
of the patient encounter, since we ask and probe about private sexual behaviors and concerns.
Risk assessment involves asking how likely it is that someone has been or will be exposed to a STI/
RTI. In this module we will cover the elements of history taking and risk assessment required to
counsel patients on STI/RTI prevention, and for syndromic management of STI/RTI. Counseling and
communication skills will be covered in further module on patient education.

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What are the goals of taking history?

●● To collect efficiently essential information that will help in diagnosis, treatment and prevention
of STI/RTI.
●● To establish the patient’s risk of contracting or transmitting a STI/RTI.
●● To determine if the patient has had any partners who may have been infected.

What information and skills are necessary for accurate history taking?
The most important part of history taking is to maintain its confidentiality and develop good
rapport with patient. The provider needs to establish good rapport with the patient from the start.

How to establish rapport with patient?

●● Smile and use welcoming tone of voice.
●● Use patient’s name during conversation.
●● Offer seat to the patient.
●● Stay close to the client, as culturally appropriate. Sometimes the desk or table creates barrier
so ask the patient sit on the stool near you rather than on the opposite side of the table.
●● Initiate talking only when you have privacy.
●● Make eye contact, if it is culturally appropriate.
●● Be respectful and understanding, especially if the client is hesitant.

The service provider should apply good interpersonal communication skills. While taking a history,
the provider must reassure the patient that confidentiality will be maintained and explain the
reason for asking certain questions. Patients are often embarrassed and may withhold important
information if they think that others will know what they say. An effective provider is able to apply
good interpersonal communication skills when taking a history, during an examination, and while
providing information and counseling. An effective provider:
●● Has a non-judgmental attitude
●● Empathizes with the patient
●● Listens actively
●● Uses language the patient understands
●● Poses questions clearly
●● Recognizes and correctly interprets nonverbal clues and body language
●● Paraphrases, interprets and summarizes patient’s comments and concerns
●● Offers praise and encouragement

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Key considerations for effective history taking

●● Always use the language, which the client understands well or is comfortable with.
●● Ensure auditory as well as visual privacy: The STI/RTI patients are always concerned about
hiding their identity and complaints. Therefore, unless privacy is ensured, the patient may not
open up. This may lead to getting insufficient or incomplete information and thereby incorrect
treatment.
●● Assure confidentiality: The patients are also worried if their information will be known to
others. Therefore, assure the patient that the information will remain between him and you
(the provider), none else will come to know about it.
●● Be non-judgmental.
●● Start the conversation by welcoming your client, taking them into confidence and encouraging
him/her to talk about their complaints. If a couple comes together, each of them also needs to
be interviewed and examined separately.
●● Be clear and confident in asking personal and sexuality related questions. Explain the patient
why it is important to ask these questions. Tell her/him that the information have bearing
on diagnosis and management of your problem. It has been observed that many health care
providers themselves are hesitant about asking sexuality related question which make the
patient also hesitant and uncomfortable.
●● Often, because the client feels uncomfortable talking about STI/RTI, individuals may come
to the clinic with other non-specific complaints or requesting a check-up, assuming that the
health care provider will notice anything abnormal that needs treatment. Therefore, health
care workers should maintain a high index of suspicion about STI/RTI.
●● Clients seeking antenatal care and family planning services should be viewed as opportunities
to provide general information about STI/RTI and should be asked about STI/RTI symptoms
and contraception.
●● One of the reasons why service providers hesitate to discuss STI/RTI with clients is that they
don’t want to start partner suspicion and partner conflict. One may assure that STI/RTI are not
necessarily acquired through sexual contact but they can also be acquired through unhygienic
conditions. For example, there is some evidence that HPV could be transmitted vertically from
mother to child. Hence whilst emphasizing that they should not suspect only the partners,
clearly indicate the possibility of sexual transmission and the need for both partners to be
treated simultaneously. This is absolutely essential to get partner confidence and co-operation.
●● The health care provider should be aware of the commonly used culturally appropriate STI/RTI
related terminology as well as those used for high-risk behavior.

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Information to be collected in history taking

General information:
●● Name,
●● Age,
●● Sex,
●● Address,
●● Employment,
●● Income,
●● Marital status,
●● Number of children,
●● Use of contraceptive method if any, and
●● Date of last menstrual period.

Present illness:
●● Symptoms and
●● Their duration
●● Any treatment taken

Medical history:
●● RTI and STI in the past,
●● Other illnesses,
●● Treatment taken
●● Drug allergies.

Sexual history:
●● Current sexual activity
●● Current partners,
●● New partner/s in last 3 months, and
●● Risky sexual and other behaviors.

Common problems which may be encountered when taking a history related

to STI/RTI are:
●● Enough time is not available;
●● The provider is uncomfortable talking about sex;
●● If there is a difference in social status between the patient and the provider and when the
provider is of opposite gender; and
●● Difficult to maintain enough privacy.

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2. History taking and risk assessment for STI/RTI

prevention

Risk assessment is a process of confidentially asking a patient particular questions to determine

his or her chance of contracting or transmitting a STI/RTI (e.g. many women may be at risk due to
the behavior of their husbands or partners). Health workers everywhere use risk assessment to
diagnose many kinds of problems.

It is important to assess men and women’s risk equally. Risk assessment is most effective when the
questions are developed in local language and according to local needs and conditions. Assessing
risk may be improved by tailoring questions to reflect local STI prevalence, making questions more
culturally appropriate and devising ways to help clients assess their own risk (self-assessment).
There is some evidence that self-risk assessment can provide information that is more accurate
because it avoids the difficulties of face-to-face questioning on sexual behavior. Self-assessment
of risk requires the health care worker to provide the client with sufficient information to allow the
client to decide whether s/he is at risk. Often people suspect they are at risk but are reluctant to
discuss their situations; and they need encouragement to ask any questions they may have.

Limitations of risk assessment:

●● It requires asking difficult, sensitive questions.
●● Clients may feel embarrassed about answering such questions, especially if the provider is of
opposite sex.
●● Clients may not understand the questions being asked since some of the scientific words/
sentences cannot be translated in local language/terms.
●● Information given may be inaccurate, poorly recalled, or untruthful.

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3. Demonstration of history taking and risk assessment

using a standardized Checklist
Framing statement
“In order to provide the best care for you and to understand your risk for certain infections, it is necessary for
us to talk about your sexual behavior.”

Screening questions
●● Have you recently developed any of these symptoms?

STI (Genital infections) symptoms checklist

For men
i. Discharge or pus (drip) from the penis
ii. Urinary burning or frequency
iii. Genital sores (ulcers) or rash or itching
iv. Scrotal swelling
v. Swelling in the groin
vi. Infertility
For women
i. Abnormal vaginal discharge (increased amount, abnormal odor, abnormal color, consistency)
ii. Genital sores (ulcers), rash or Itching
iii. Urinary burning or frequency
iv. Pain in lower abdomen
v. Dysmenorrhoea, menorrhagia, irregular menstrual cycles?
vi. Dyspareunia
vii. Infertility

High risk sexual behavior

●● For all adolescents: Have you begun having any kind of sex yet?
●● If sexually active do you use condom consistently?
●● Do you have any reason to think you might have a sexually transmitted disease? If so, what reason?
●● Have you had sex with any man, woman, with a gay or a bisexual?
●● Have you or your partner had sex with more than one partner?
●● Has your sex partner(s) had any genital infections? If so, which ones?
●● Do you indulge in high risk sexual activity like anal sex
●● Do you practice correct and consistent condom usage while having sex? If yes, whether every time or
sometimes?

STI history
●● In the past have you ever had any genital infections, which could have been sexually transmitted? If so, can
you describe?

STI treatment history

●● Have you been treated in the past for any genital symptoms? By whom? (qualified or unqualified person)
●● Did your partner receive treatment for the same at that time?
●● Has your partner been treated in the past for any genital symptoms? By whom? (qualified or unqualified
person)

Injection drug use

●● Have you had substance abuse? (If yes, have you ever shared needles or injection equipment?)
●● Have you ever had sex with anyone who had ever indulged in any form of substance abuse?

Menstrual and obstetric history in women and contraceptive history in both sexes should be asked

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46 PARTICIPANT’S HANDOUT
 MODULE NO. 5

CLINICAL EXAMINATION FOR STI/RTI

Sr. No. Topic Page No

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TRAINING OF MEDICAL OFFICERS TO DELIVER STI/RTI SERVICES

1. Clinical examination for STI/RTI

The purpose of clinical examination is:

●● To confirm any STI/RTI symptoms the client has described.
●● To look for signs the client may not have noticed if you think s/he is at risk

Elements of clinical examination for STI/RTI

●● General examination
●● Inspection of the external genitalia (male and female)
●● Abdominal examination (female)
●● Speculum examination (female)
●● Bimanual examination (female)

Remember: A normal finding on physical examination does not mean that the patient does not
have a STI/RTI.

What are pre-requisites for physical examination?

●● Clients should be examined in the same conditions of privacy as those in which history was
taken.
●● It is advisable to have an assistant of the same sex as the client present, during examination of
clients of sex opposite to the doctors.
●● Clients should be told about the examination with the help of diagrams and charts.
●● The examination should be done in a well-lit room while providing adequate comfort and
privacy. Before you start, keep the examination table with proper illumination ready as well
as sterilized speculums (for examination of female clients), collection swabs and labeled slides
for smears.
●● As far as possible, complete body examination of the client should be carried out so that none
of the skin lesions or lymph nodes is missed.

Ideal set up for conducting clinical examination

For Women
●● Privacy/separate room
●● Light source
●● Examination table for client to lie on

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●● Cusco’s Speculum
●● Allis’ forceps, Sponge holder
●● Tray with lid /cover to keep instruments.
●● Stainless steel bowls
●● Disposable and clean gloves that have been disinfected
●● Soap and sufficient water for hand washing and towel
●● Cotton
●● Cloth drape or undergarments or client’s clothing for female exam.
●● Lubricant or water for speculum exam
●● Savlon/Betadine/Sodium Hypochlorite solution/Bleaching powder
●● Sterilizer/Autoclave

For Men
●● Separate room with privacy
●● Light source
●● Examination table/stool
●● Soap and water for hand-washing
●● Disposable gloves
●● Time?

Physical examination of female clients

A. General examination
●● All examinations should begin with a general assessment, including vital signs and
inspection of the skin and mucous patches, to detect signs of systemic disease, some
examples given below.

Lesions of secondary syphilis Mucous patches in secondary syphilis

Fig Lesions of secondary syphilis

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B. Examination of the abdomen

Before you start, ask the patient to empty her bladder if she hasn’t done so in the last half hour.
●● Explain the procedure to her. Ask her to undress or to pull up her clothing so that you can see
her abdomen from just below her breasts down to her pubic hair.
●● Ask her to lie flat on her back on a firm bed or table with knees comfortably bent. Ask her to
relax her abdominal muscles as much as she can.
●● Listen for bowel sounds by putting a stethoscope on her abdomen. If you do not hear anything
for 2 minutes, this is a sign of danger.
●● Ask her to point to the area that hurts the most. Then begin pressing gently on the other side
to see where it hurts most.
●● As you press her abdomen, feel for lumps or masses, guarding, if her abdomen is soft or hard,
and if she can relax it under your hand.
●● To make sure she does not have a life threatening problem like appendicitis, an infection in her
gut, or PID, slowly but firmly press on her abdomen on the left side, then her right side, just
above where the leg joins the body (the groin).
●● Press until it hurts a little. Then quickly remove the hand. If a very sharp pain (rebound pain)
happens when the hand is removed, she may have a serious infection. Refer her immediately.
If she does not have rebound pain, complete the exam and move on to examine the genitals.

C. External genital examination

While examining a female client, a male doctor should ensure that a female attendant is present.
Genital examination in females must be performed with patient in lithotomy position.

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Some of the signs of various STI/RTI in women are shown as pictures in the following figures:

Vesicles of Genital Herpes Abrasions of Intertrigo

Herpetic ulcers Pus pouring out of endocervix in extensive

mucopurulent cervicitis due to chlamydia trachomatis
infection

Growth of genital warts Chancre of Syphilis

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a) Inspection

Staining of underclothes: Vaginal and urethral discharge, exudative ulcers

Inguinal region
●● Swelling, ulcer, lesions of fungal infections
●● Lymph nodes: look for enlargement, number, location (horizontal or vertical group), single or
multiple, scars and puckering, signs of inflammation on the surface and surrounding region
●● Abrasions due to scratching and lesions on inner aspect of thigh

Pubic area
●● Matting of hairs, pediculosis, folliculitis, or other skin lesions

Labia majora and minora

●● Separate the labia majora with both hands and look for erythema, edema, red formation
(lobulated fibrosed masses due to chronic lymphedema), fissuring, ulcers, warts or other skin
lesions

Ulcers
●● Location, number (single, multiple), superficial (erosions) or deep, edge (undermined/punched
out), margins (regular/irregular) and floor (presence of exudates, slough/granulation tissue)

Bartholin glands
●● Enlargement, ductal opening, discharge

Introitus
●● Discharge – colour, odour, profuse or scanty, curdy or thin, back drop of redness and
inflammation

Urethral meatus
●● Discharge (pressing under the urethra with one finger may show drops of discharge),
inflammation

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Perianal examination

Separate the buttocks with two hands for better visualization. Look for ulcer, macerated papules of
condyloma lata, warts, discharge, patulous anus, haemorrhoids, fissures, fistula

b) Palpation

Inguinal region
●● Lymphnodes: tenderness, increased warmth, superficial or deep, discrete or matted, free
mobility or fixed to deeper structures, consistency (firm or soft) and fluctuant.
●● Rule out hernia

Palpation of ulcer at any site

●● Tenderness, induration of the floor base and edges, bleeding on touch

D. Speculum examination
How to do speculum examination in women
●● Ask the woman to pass urine.
●● Wash your hands well with clean water and soap.
●● Ask her to loosen her clothing. Use a sheet or clothing to cover her.
●● Tell her to lie on her back, with her clean heels close to her bottom and her knees up.
●● Wear clean gloves in both hands.
●● Look at the outside genitals – using the gloved hand to gently look for lumps, swelling, unusual
discharge, sores, tears and scars around the genitals and in between the skin folds of the vulva.
●● Be sure that the speculum has been properly disinfected before you use it. Wet the speculum
with clean water before inserting it.
●● Put the first finger of your gloved hand in the woman’s vagina. As you put your finger in, push
gently downward on the muscle surrounding the vagina (work slowly, waiting for the woman
to relax her muscles).
●● With the other hand, hold the Cusco’s speculum blades together between the first and the
middle fingers. Turn the blades sideways and slip them into the vagina. (Be careful not to
press on the urethra or clitoris because these area are very sensitive). When the speculum is
halfway in, turn it so that the handle is down. Remove your gloved finger.
●● Gently open the blades a little and look for the cervix. Move the speculum slowly and gently
until you can see the cervix between the blades. Tighten the screw on the speculum so it will
stay in place.
●● Check the cervix, which should look pink, round and smooth. Notice if the opening is open
or closed, and whether there is any discharge or bleeding. If you are examining the woman

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because she is bleeding from the vagina after birth, abortion or miscarriage, look for tissue
fragments coming from the opening of the cervix.
●● Look for signs of cervical infection by checking for abnormal yellowish discharge, redness with
swelling, or easy bleeding when the cervix is touched with a swab. If the woman has been
leaking urine or stools gently turn the speculum to look at the walls of the vagina. Bring the
blades closer together to do this.
●● To remove the speculum, gently pull it towards yourself until the blades are clear of the cervix.
Then bring the blades together and gently pull back. Be sure to disinfect your speculum again.

E. Bimanual pelvic examination

1. Put the index finger of your gloved hand in the woman’s vagina. As you put your finger in,
push gently downward on the muscles surrounding the vagina. When the woman’s body
relaxes put the middle finger in also. Turn the palm of your hand up and advance gently until
you reach the cervix.

2. Feel the opening of the cervix to see if it is firm and round. Then put one finger on either side
of the cervix and move the cervix gently from side to side. It should move easily, without
causing pain. If it does cause pain, she may have an infection of the uterus, tubes, or ovaries.
If her cervix feels soft, she may be pregnant.

3. Feel the uterus by gently pushing on her lower abdomen with your outside hand– this moves
the uterus, tubes, and ovaries closer to your inside hand. The uterus may be tipped forward
or backward. If you do not feel it in front of the cervix, gently lift the cervix with your inside
hand and feel around it for the body of the uterus. If you feel the uterus under the cervix, it is
pointed to the back.

4. When you find the uterus, feel for its size and shape. Do this by moving your inside fingers to
the sides of the cervix. Then ‘walk’ the fingers of your outside hand around the uterus, feeling
the uterus between your two hands. It should feel firm, smooth, and smaller than an average
sized lemon.

If the uterus:
●● Feels soft and large, she is probably pregnant.
●● Feels lumpy and hard, she may have a fibroid or other growth.
●● Hurts when you touch it, she probably has an infection inside.
●● Does not move freely, she could have scars from an old PID infection.

5. Feel for the tubes and ovaries. If these are normal, they will not be felt. But if you feel any
lumps that are bigger than an almond or that cause severe pain, she could have an infection
or other emergency. If she has a painful lump and her period is late, she could have an ectopic
pregnancy.

6. Feel along the inside of the vagina for unusual lumps or sores.

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7. If anything feels abnormal and you don’t know what the problem is or how to treat it, refer the
patient.

8. On completion of the exam, record data regarding the presence or absence of findings relevant
to your diagnosis.

Physical examination of male clients

1. The male patient can be examined standing or lying down on an examination table.

2. Reassure him that you will be gentle and explain everything you are doing and what you find.

3. Ask him to lower his pants so that he is stripped from the chest down to the knees. Examine
the penis, noting any rashes or sores. Ask the patient to pull back the foreskin if present, and
look at the glans penis and the urethral meatus. Ask the patient to milk the urethra if not seen.

4. Palpate the inguinal region (groin), looking for enlarged lymph nodes and buboes.

5. Palpate the scrotum, feeling for individual parts of the anatomy (the testis, epididymis, and
spermatic cord on each side).

6. Have the patient turn his back to you and bend over while spreading his buttocks slightly. Look
at the anus for the presence of ulcers, warts, rashes, or discharge.

7. Record the presence or absence of ulcers, buboes, genital warts, and urethral discharge,
noting color and amount.

Signs to look for when examining men

a) Inspection

Staining of underclothes: due to urethral discharge, subprepucial discharge or from exudative

ulcers.

Inguinal region: swelling, ulcer, candidial intertrigo, tinea, enlarged lymph nodes: look for number,
location (horizontal or vertical group), single or multiple pointings, scars and puckering, signs of
inflammation on the surface and surrounding region

Pubic area: matting of hairs, pediculosis, folliculitis, or other skin lesions.

Scrotum: erythema, skin lesions (condyloma lata), asymmetry, scrotal swelling.

Penis: Size, oedema, deformity, phimosis, paraphimosis, autoamputation of genitals, foreign

bodies, old scars, circumcision, retraction of prepuce.

Inspection of ulcers: Number (single, multiple), superficial (erosions) or deep, edge (undermine/
punched out), margins (regular/irregular) and floor (presence of exudates, slough/granulation
tissue).

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Meatal examination: Erythema, discharge: thick, creamy or mucopurulent, wart, ulcer. If no

discharge then milk the penis (urethra) and look for discharge at the meatus.

Prepucial skin examination: Erosions, ulcer, warts, posthitis or other skin lesions.

Coronal sulcus: Ulcer, warts, pearly penile papules.

Glans penis examination: Erosions, ulcers, warts, balanitis (candidial, trichomonial).

Shaft of penis: papules, nodules, ulcers or other skin lesions, fibrosis.

Perianal examination: Separate the buttocks with two hands for better visualization. Look for
ulcer, macerated papules of condyloma lata, warts, discharge, patulous anus, haemorrhoids,
fissures, fistula.

b) Palpation

Inguinal region: Lymphnodes: tender or not, increased warmth, superficial or deep, discrete or
matted, free mobility or fixed to deeper structures, consistency: firm or soft and fluctuant. Rule
out hernia.

Palpation of spermatic cords: Tenderness, asymmetry, and thickening, varicocoeles.

Palpation of scrotum: Asymmetry, tenderness, consistency of testes and epididymis,

transillumination for hydrocoele. Rule out hernia.

Indicated if unprotected anal intercourse, rectal discharge.

Palpation of ulcer at any site: Tenderness, induration of the floor and edges, bleeding on
maneuvering.

c) Digital rectal examination

Performed if symptoms suggestive of prostatic disease. Should not be carried out if the client has
painful perianal disease such as herpetic ulcers, fissures, or haemorrhoids.

d) Proctoscopic examination

Indicated if unprotected anal intercourse, rectal discharge.

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Some of the signs of various STI/RTI in men are shown in the following figures:

Uretheral discharge in gonorrhea Herpes ulcers

Multiple grouped erosions over shaft of penis Chancre of glans in Syphilis

Chancre of coronal sulcus in Syphilis Ulcer of Donovanosis

Condyloma lata of Syphilis

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58 PARTICIPANT’S HANDOUT
 MODULE NO. 6

MANAGEMENT APPROACHES FOR STI/RTI

Sr. No. Topic Page No

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1. STI/RTI case management

The main objectives of STI/RTI management are:

●● To diagnose the infection at the earliest,
●● Provide correct and complete treatment,
●● Encourage change in risk behaviors, and
●● Ensure that sexual partners are appropriately treated.

Quality management of STI/RTI is important because it:

●● Prevents the development of long-term complications.
●● Reduces the length of time a person is infected and, therefore, reduces further spread of STI/
RTI including HIV.
●● Reduces the level of STI/RTI in the population that present an increased risk for sexual
transmission of HIV.
●● Allows for education and counseling on risk reduction and health-seeking behaviors.
●● Generally improves the quality of people’s lives.

Management of STI/RTI involves more than simply diagnosis and treatment of the infection.

The 7 steps of comprehensive STI/RTI case management are:

1. Take history.

2. Conduct physical examination.

3. Provide treatment.

4. Provide health education on prevention.

5. Provide condoms and demonstrate use.

6. Offer Partner treatment.

7. Follow up or refer as needed.

The above steps consists of the following critical components:

Counseling and education: Client-centered counseling helps prevent the spread of infection and
reduce clients’ risk for infection and reinfection. Counseling and health education also provide
clients with information on potential complications, as well as strategies to change risky sexual
behaviors.

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Condom promotion: Demonstration/instruction on correct use of condoms and access to an

adequate supply of condoms are essential parts of STI management. Programs should help clients
to understand the importance of consistent and correct use and the steps of proper condom use,
as well as help them develop skills for negotiating condom use.

Adherence with treatment: Providers must educate clients about the importance of following
and completing treatment regimens, even after all symptoms have disappeared. Providers should
explore ways that clients can successfully adhere to treatment regimens by identifying potential
barriers to adherence (e.g., costs, schedule, family or partner finding out) and strategize ways to
overcome these barriers.

Partner notification: When feasible, sexual partners of clients with STI should be notified and
encouraged to seek appropriate care however, strict confidentiality is critical, and issues of domestic
violence or potential harm to the client must also be addressed). Treating partners prevents the
further spread of the infection and reinfection of the client. There are three options for notifying
Partners: 1) clients can be counseled about talking to their partners on their own, 2) providers
can tell partners in conjunction with clients, and 3) if resources permit, providers or public health
workers can inform partners.

These seven components are sometimes referred to as the “Six C’s”:

1. Counseling and education of patient

2. Contact tracing

3. Condom promotion

4. Compliance with treatment

5. Come back for follow up

6. Cure the patient

The management of sexually transmitted infections (STI) and reproductive tract infections (RTI)
can be difficult because:
●● Many a times Lab Testing is often not available in low-resource primary health care settings, so
diagnosis must be made based on symptoms and signs.
●● Some infections are impossible to differentiate, even by highly trained providers, based solely
on their signs and symptoms.
●● Clients who seek treatment from multiple providers may present with symptoms altered by
previous treatments.

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2. Diagnosis and management of STI/RTI by different

approaches

The two main approaches to STI/RTI diagnosis and management:

●● The etiological approach
●● The syndromic approach

The etiological approach

The etiological approach, the most traditional of the two, is based on the results of laboratory
tests. These tests identify the specific infectious agent, which then determines the treatment to
be administered. Although this approach is often reliable for management of STI/RTI, it is often
not available to health providers in the developing world especially at the primary health care
level because it depends on trained laboratory technicians, availability of lab supplies, and in
some cases expensive, specialized equipment; there are limitation of the lab test to identify the
causative organism. Additionally, this method may require the client to return for a second visit in
order to collect laboratory results and receive treatment.

The syndromic approach

Because of the unavailability of laboratory tests in many low resource primary health care settings
and the potential for inaccuracy when providers rely on the clinical approach alone, syndromic
management is often the best approach.

In this approach, diagnosis is based on the identification of syndromes, which are combinations of
the symptoms the client reports and the signs the health care provider observes. The recommended
treatments are effective for all the diseases that could cause the identified syndrome.

Comparison between Etiologic and Syndromic approach

S. No. Etiologic approach Syndromic approach

1 Possible to get an exact diagnosis using Diagnosis may be wrong in certain cases
laboratory tests e.g. in case of vaginal discharge syndrome,
the approach is not effective to manage
gonorrhoea and chlamydia infection
2 Avoids over-treatment Over-treatment of patient as well as partner
may happen.
3 Patient must return for test results and The patient is diagnosed and treated in one
must wait for treatment till the lab visit
results comes.
4 More chances of lost to follow up No loss to follow up
5 Expensive as trained laboratory Relatively inexpensive as it avoids use of
technicians as well as infrastructure laboratory tests
and supplies are needed

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So looking at advantages and disadvantages of all 2 approaches, it shows that among 2 approaches,
the syndromic approach is having more advantages and seems to be an appropriate approach.

Syndromic management of STI/RTI

Syndromic management should be used only when a patient presents with a STI/RTI complaint; it
should not be used to screen for STI/RTI because it is not accurate in this situation.

Clients suspected of having STI/RTI usually present with one or more of the following complaints.
These clinical entities may present as (i) vaginal or urethral discharge; (ii) vesicular and/or non-
vesicular genital ulcers; (iii) inguinal bubo; (iv) lower abdominal and/or scrotal pain; and (v) genital
skin conditions.

Limitations of syndromic management

The flowcharts for urethral discharge and genital ulcers are very effective. However, syndromic
management cannot address the widespread problem of asymptomatic infections, in which
clients do not experience any symptoms at all. Some STI/RTI, such as chlamydia, gonorrhea,
human papilloma virus (HPV), hepatitis B, and genital herpes, often cause infections that are
asymptomatic. This means that the STI/RTI might never produce signs and symptoms, or that they
might not appear for a long time. For example, the majority of HPV infections in women and men
cannot be recognized clinically, and up to 75% of primary episodes of herpes are asymptomatic
or produce only mild or unrecognized symptoms. More than 75% of women with chlamydia are
symptom-free, yet this STI/RTI can lead to pelvic inflammatory disease (PID), which, in turn, can
lead to infertility and ectopic pregnancy.

The limitations of syndromic management for women with vaginal discharge

Syndromic management has been widely adopted and has proven useful for most syndromes.
However, syndromic management of vaginal discharge is an exception because vaginal discharge
is poorly correlated with the major causes of cervicitis, gonorrhoea and chlamydia.

Management of vaginal discharge has the following problems:

1. Vaginal discharge most often indicates vaginitis. A number of studies have shown that the
most common causes of vaginal discharge are bacterial vaginosis (BV), trichomonas vaginalis
(TV), and candidiasis. Of these, only TV can be sexually transmitted. Signs and symptoms
previously thought to be associated with STI such as yellow vaginal discharge are not specific
for STI and may be more common with non-sexually transmitted vaginitis.

2. Many women with cervicitis do not have vaginal discharge or lower abdominal pain.

3. Syndromic management of vaginal discharge has been misused as a screening tool. This
happens when women, who present to a health facility for other reasons, are asked if they
have vaginal discharge and then managed as if they came initially to complain of discharge.
We know that often vaginal discharge is either normal or related to vaginal infections. In many
settings, 40-50% of women will say, “yes” when asked if they have discharge. This can lead to
massive overtreatment of STI. Studies of the validity of syndromic management have shown
that vaginal discharge should not be used as a routine screening tool.

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4. The cervix is not easily accessible. There is some evidence that syndromic management of
vaginal discharge can be improved by examination of the cervix to determine whether there is
a cervical discharge or inflammation, but this requires training, tools, time, and supplies.

Overcoming problems in the syndromic management of vaginal discharge

1. We now know that vaginitis itself may have serious consequences. Bacterial vaginosis is
associated with PID. BV and trichomoniasis are associated with preterm labor and also with
an increase in HIV transmission. There is more benefit from treating vaginitis than previously
thought.

2. Assess the STI risk of anyone with vaginal discharge carefully. If you or she suspect high
risk based on prevalence of STI in your patient population, her occupation, or her partner’s
symptoms, occupation or behavior; treat her for cervicitis and vaginitis and try to ensure
partner treatment. The higher her risk, the greater the need to treat her immediately at the
first visit. If she is at high risk, you might also find ulcers or another STI.

3. Treat vaginal discharge as vaginitis only, unless you have convincing reasons to believe the
patient is at high risk for STI. This means not treating her partner initially. Treat with an
antifungal if she has evidence of candida.

4. Use every method you have to make a better, more specific diagnosis of STI in those women
who have symptoms but are lower risk. If you have the time and privacy to do an external
inspection for vaginal discharge and to palpate the abdomen, do so. If you have one glove and
can check for cervical motion tenderness and do a bimanual exam, do so. It may conserve your
resources to save speculum exams for women who return with persistent symptoms or whose
history is confusing. All of this may add to the accuracy (increased sensitivity, specificity, and
predictive value) of your diagnosis.

5. Tailor your approach to syndromic management of vaginal discharge according to your clinical
setting. Consider how high the risk to your population is (prevalence), how much of an exam you
are capable of doing well, and whether or not useful diagnostic tests and effective treatment
are available. Also consider the reason for a woman’s visit: does she have vaginal discharge or
has she come for another reason? Is she going to have a procedure (IUD or abortion), which
puts her at increased risk if she is infected with a STI?

6. One of the best ways to reach women at risk who are without symptoms is to target their
partners. Find ways to welcome men to your clinic, reach out to men in the community,
and make sure any men you treat for STI have their Partners treated and know how to use
condoms.

How to practice syndromic management

As we know that through this approach, symptoms and easily identified physical signs are used
to diagnose and treat patients for all possible STI/RTI that may cause this syndrome rather than
for specific STI/RTI. By using this knowledge decision making flowcharts are prepared to practice
syndromic management

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3. Use of flowcharts in management of STI/RTI

Steps in using flowcharts

●● Determine the clinical problem - ask for patient’s presenting symptom
●● Find the appropriate flowchart by looking at the clinical problem box at the top
●● Usually the flowchart will ask you to take a history and examine the patient
●● Use the results from the history and examination to make a decision - usually by choosing
“yes” or “no”
●● Depending on your decision, there may be more boxes to consider and more choices to make
●● Follow the arrows, proceeding one step at a time until you reach the end of a branch, or exit
path
●● Each of the exit paths leads to an action box. This is the box that tells you how to manage the
case.

The benefits of using flowcharts

●● They can be used in all types of health facilities
●● They suggest clear decisions
●● Standard treatment guidelines are given
●● Most cases can be treated at the health facility without referrals to higher levels

The main components of a flowchart

(Example from flowchart for genital ulcer)

1) The clinical problem—the patient’s presenting symptom, such as genital sores. The flowchart
always begins with this.

2) The STI/RTI causing such presenting symptoms

3) The causative organisms for STI/RTI

4) The decision that needs to be made based on history, clinical examination and laboratory
tests.

5) The action that needs to be carried out based on the information given by the client such as
monogamous relationship or multiple Partners and in case of women whether she is pregnant
or not.

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Management approaches of STI/RTI by flowcharts

In the National Guidelines on Management of STI/RTI, the management of seven major STI/RTI
syndromes is incorporated in the form of flowchart. These flowcharts will help to guide health
care workers in the management of STI/RTI. The flowcharts describe the clinical syndrome, specific
STI/RTI under the syndrome and the causative organisms of the STI/RTI syndrome. Differential
diagnosis of the conditions is also mentioned wherever appropriate. The approach to the client with
specific points to be considered during history taking and examination is highlighted. If facilities
and skills are available, the laboratory tests, which need to be done, are also mentioned. The
treatment protocols to be followed at the primary health care system with appropriate referrals
where indicated is also given. Special emphasis is given on syndrome specific partner management
and management issues specific to pregnancy.

Important considerations for management of all Clients of STI/RTI

●● Educate and counsel client and sex partner(s) regarding STI/RTIs, genital cancers, safer sex
practices and importance of taking complete treatment
●● Treat partner(s) where ever indicated
●● Advise sexual abstinence during the course of treatment
●● Provide condoms, educate about correct and consistent use
●● Refer for voluntary counseling and testing for HIV, Syphilis and Hepatitis B
●● Consider immunization against Hepatitis B
●● Schedule return visit after 7 days to ensure treatment compliance as well as to see reports
of tests done.
●● If symptoms persist, assess whether it is due to treatment failure or re-infection and advise
prompt referral.

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SYNDROMIC CASE MANAGEMENT FOR MANAGING

STI/RTI

Sr. No. Topic Page No

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1. Flowcharts for Management of STI/RTI Syndromes

Flowchart 1: Management of Urethral Discharge/Burning Micturition
in Males

SYNDROME: URETHRAL DISCHARGE IN MALES

Causative organisms
●● Neisseria gonorrhoea
●● Chlamydia trachomatis
●● Trichomonas vaginalis

STI/RTIs: GONORRHOEA, CHLAMYDIAL

INFECTION, TRICHOMONIASIS

History of Examination Laboratory investigations

●● Urethral discharge (if available)
Look for
●● Pain or burning ●● Gram stain
●● The urethral meatus
while passing urine, examination of the
for redness and
increased frequency of urethral smear will
swelling
urination show gram-negative
●● If urethral discharge is intracellular diplococci
●● Sexual exposure not seen, then gently in case of gonorrhoea,
of either Partner massage the urethra
including high risk ●● In non-gonococcal
from the ventral part
practices like oro- urethritis more than
of the penis towards
genital sex 5 neutrophils per
the meatus and look
oil immersion field
for thick, creamy
(1000X) in the urethral
greenish-yellow or
smear or more than
mucoid discharge
10 neutrophils per
high power field in
the sediment of the
first void urine are
observed

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As dual infection is common, the treatment for urethral discharge should adequately cover
therapy for both, gonorrhoea and chlamydial infections.
Recommended regimen for uncomplicated gonorrhoea + chlamydia
Uncomplicated infections indicate that the disease is limited to the anogenital region (anterior
urethritis).
●● Tab. Cefixime 400 mg orally, single dose Plus
●● Tab Azithromycin 1 gram orally single dose under supervision
●● Advise the Client to return after 7 days of start of therapy
When symptoms persist after adequate treatment for gonorrhoea and chlamydia in the index
client and partner(s), they should be treated for Trichomonas vaginalis.
If discharge or only dysuria persists after 7 days
●● Tab. Secnidazole 2gm orally, single dose (to treat for T. vaginalis)
If the symptoms still persists
●● Refer to higher centre as early as possible

Syndrome specific guidelines for Management of pregnant Partner

Partner management Pregnant partners of male clients with urethral
●● Treat all recent Partners discharge should be examined by doing a per
●● Treat female partners (for speculum as well as per vaginal examination
gonorrhoea and chlamydia) and should be treated for gonococcal as well as
on same lines after ruling out chlamydial infections.
pregnancy and history of allergies ●● Cephalosporins to cover gonococcal infection
●● Advise sexual abstinence during the are safe and effective in pregnancy
course of treatment ●● Tab. Cefixime 400mg orally, single dose or
●● Provide condoms, educate about ●● Ceftriaxone 125mg by intramuscular injection
correct and consistent use +
●● Refer to ICTC for testing of HIV & ●● Tab. Erythromycin 500mg orally four times a
Syphilis day for seven days or
●● Schedule return visit after 7 days ●● Cap Amoxicillin 500mg orally, three times
a day for seven days to cover chlamydial
infection
●● Quinolones (like ofloxacin, ciprofloxacin),
doxycycline are contraindicated in pregnant
women.

Follow up
After seven days
●● To see symptomatic relief
●● To see reports of tests done for HIV & syphilis
●● If symptoms persist, to assess whether it is due re-infection
●● For prompt referral if required

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Flowchart 2: Management of Scrotal Swelling

SYNDROME: SCROTAL SWELLING

Causative organisms
●● Neisseria gonorrhoea
●● Chlamydia trachomatis

STI/RTIs: GONORRHOEA, CHLAMYDIAL

INFECTION

History of Examination Laboratory investigations

●● Swelling and pain in (if available)
Look for
scrotal region ●● Gram stain
●● Scrotal swelling
●● Pain or burning while examination of the
●● Redness and edema of urethral smear will
passing urine
the overlying skin show gram-negative
●● Systemic symptoms
●● Tenderness of the intracellular diplococci
like malaise, fever
epididymis and vas in case of complicated
●● Sexual exposure deferens gonococcal infection
including high risk
●● Associated urethral ●● In non-gonococcal
practices like oro-
discharge/genital urethritis more
genital sex
ulcer/inguinal lymph than 5 neutrophils
nodes and if present per oil immersion
refer to the respective field in the urethral
flowchart smear or more than
●● A transillumination 10 neutrophils per
test to rule out high power field in
hydrocoele should be the sediment of the
done. first void urine are
observed

Differential diagnosis (non STI/RTIs)

Infections causing scrotal swelling:
Tuberculosis, filariasis, coliforms, pseudomonas, mumps virus infection.
Non infectious causes:
Trauma, Hernia, Hydrocoele, Testicular torsion, and Testicular tumors

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Treatment
●● Treat for both gonococcal and chlamydial infections

ŠŠ Tab. Cefixime 400 mg orally, single dose Plus Tab Azithromycin

1 gram orally single dose under supervision, if patient does
not respond to the treatment refer to higher centre as early
as possible since complicated gonococcal infection may needs
parental and longer duration of treatment
●● Supportive therapy to reduce pain (bed rest, scrotal elevation with
T-bandage and analgesics)

Note
If quick and effective therapy is not given, damage and scarring of
testicular tissues may result causing sub fertility

Syndrome specific guidelines for Partner management

Partner needs to be treated for gonococci & chlamydia infections

Management protocol in case the Partner is pregnant

●● Depending on the clinical findings in the pregnant partner (whether
vaginal discharge or endocervical discharge or PID is present) the
drug regimens should be used.
●● Doxycycline is contraindicated in pregnancy
●● Erythromycin base/Amoxicillin can be used in pregnancy.

(Erythromycin estolate is contraindicated in pregnancy due to

hepatotoxicity. Erythromycin base or erythromycin ethyl succinate
should be given)

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Flowchart 3: Management of Inguinal Bubo

SYNDROME: INGUINAL BUBO Causative organisms

●● Chlamydia trachomatis serovars
L1, L2, L3, causative agent of
lympho granuloma venerum (LGV)
●● Haemophilus ducreyi causative
agent of chancroid
STI/RTIs: LGV, CHANCROID

History of Examination
●● Swelling in inguinal Look for
region which may be
●● Localized enlargement
painful
of lymph nodes in
●● Preceding history groin which may be
of genital ulcer or tender and fluctuant
Laboratory investigations
discharge
●● Inflammation of skin (if available)
ŠŠ Sexual exposure over the swelling
●● Diagnosis is on clinical
of either partner ●● Presence of multiple grounds
including high risk sinuses
practices like oro-
●● Edema of genitals and
genital sex etc
lower limbs
ŠŠ Systemic ●● Presence of genital
symptoms like ulcer or urethral
malaise, fever discharge and if
present refer to
respective flowchart

Differential diagnosis
●● Mycobacterium tuberculosis, filariasis
●● Any acute infection of skin of pubic area, genitals, buttocks, anus and lower limbs can also
cause inguinal swelling
If malignancy or tuberculosis is suspected refer to higher centre for biopsy.

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Treatment
●● Start Cap. Doxycycline 100mg orally twice daily for 21 days (to cover LGV) Plus
●● Tab Azithromycin 1g orally single dose OR
●● Tab. Ciprofloxacin 500mg orally, twice a day for three days to cover chancroid
●● Refer to higher centre as early as possible.

Note:
●● A bubo should never be incised and drained at the primary health centre, even if it is
fluctuant, as there is a high risk of a fistula formation and chronicity. If bubo becomes
fluctuant always refer for aspiration to higher centre.
●● In severe cases with vulval edema in females, surgical intervention in the form of
vulvectomy may be required for which they should be referred to higher centre.

Syndrome specific guidelines for Partner management

●● Treat all Partners who are in contact with Client in last 3 months
●● Partners should be treated for chancroid and LGV
●● Tab Azithromycin 1g orally single dose to cover chancroid
+
Cap Doxycycline 100mg orally, twice daily for 21 days to cover LGV
●● Advise sexual abstinence during the course of treatment
●● Provide condoms, educate on correct and consistent use
●● Refer to ICTC for HIV & syphilis testing
●● Schedule return visit after 7 days and 21 days

Management of pregnant Partner

●● Quinolones (like ofloxacin, ciprofloxacin), doxycycline, sulfonamides are contraindicated in
pregnant women.
●● Pregnant and lactating women should be treated with the erythromycin regimen, and
consideration should be given to the addition of a parenteral amino glycoside (e.g.,
gentamicin)

Tab. Erythromycin base, 500mg orally, 4 times daily for 21 days and refer to higher centre.

(Erythromycin estolate is contraindicated in pregnancy due to hepatotoxicity. Erythromycin

base or erythromycin ethyl succinate should be given)

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Flowchart 4: Genital Ulcers

SYNDROME: GENITAL ULCERS

STI/RTIs SYPHILIS CHANCROID GENITAL HERPES

Causative organisms
●● Treponema pallidum (syphilis)
●● Haemophilus ducreyi (chancroid)
●● Klebsiella granulomatis (granuloma inguinale)
●● Chlamydia trachomatis (lymphogranuloma venerum)
●● Herpes simplex (genital herpes)

History of Examination
●● Genital ulcer/vesicles/ ●● Presence of vesicles
Recurrence ●● Presence of genital ulcer- single or multiple
●● Burning sensation in ●● Associated inguinal lymph node swelling and if present
the genital region refer to respective flowchart
●● Sexual exposure
Ulcer characteristics:
of either partner
●● Painful vesicles/ulcers, single or multiple - Herpes
including high risk
simplex
practices like oro-
genital sex ●● Painless ulcer with shotty lymph node - Syphilis
●● Transient Ulcer with inguinal lymph nodes - LGV
●● Painful ulcer sometimes single giant ulcer associated
with painful bubo - Chancroid

Laboratory investigations
●● RPR test for syphilis
●● For further investigations refer to higher centre

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Treatment
●● If vesicles or multiple painful ulcers are present treat for herpes with Tab. Acyclovir 400mg orally, three times
a day for 7 days
●● If vesicles are not seen and only ulcer is seen, treat for syphilis and chancroid and counsel on herpes genitalis
To cover syphilis give Inj Benzathine penicillin 2.4 million IU IM after test dose in two divided doses (with emergency
tray ready) (In individuals allergic or intolerant to penicillin, Doxycycline 100mg orally, twice daily for 14 days)
+
Tab Azithromycin 1g orally single dose or
Tab. Ciprofloxacin 500mg orally, twice a day for three days to cover chancroid
Treatment should be extended beyond 7 days if ulcers have not epithelialized i.e. formed a new layer of skin over
the sore)
If both ulcers (GUD-NH) & blisters (GUD-H) are present or when the provider is not able to differentiate between
the two then treat for both GUD – NH and GUD herpetic infections.
Refer to higher centre
●● If not responding to treatment
●● Genital ulcers co-existent with HIV
●● Recurrent lesion

Syndrome specific guidelines for Partner management

●● Treat all Partners who are in contact with client in last 3 months
●● Partners should be treated for syphilis and chancroid
●● Advise sexual abstinence during the course of treatment
●● Provide condoms, educate about correct and consistent use
●● Refer to ICTC for HIV & Syphilis testing
●● Schedule return visit after 7 days

Management of Pregnant Women

●● Quinolones (like ofloxacin, ciprofloxacin), doxycycline, sulfonamides are contraindicated in pregnant women.
●● Pregnant women who test positive for RPR should be considered infected unless adequate treatment is
documented in the medical records and sequential serologic antibody titers have declined.
●● Inj Benzathine penicillin 2.4 million IU IM after test dose (with emergency tray ready)
●● A second dose of benzathine penicillin 2.4 million units IM should be administered 1 week after the initial dose
for women who have primary, secondary, or early latent syphilis.
●● Pregnant women who are allergic to penicillin should be treated with erythromycin and the neonate should
be treated for syphilis after delivery.
●● Tab. Erythromycin 500mg orally four times a day for 15 days
(Note: Erythromycin estolate is contraindicated in pregnancy because of drug related hepatotoxicity. Only
Erythromycin base or erythromycin ethyl succinate should be used in pregnancy)
●● All pregnant women should be asked history of genital herpes and examined carefully for herpetic lesions.
●● Women without symptoms or signs of genital herpes or its prodrome can deliver vaginally.
●● Women with genital herpetic lesions at the onset of labour should be delivered by caesarean section to
prevent neonatal herpes.
●● Acyclovir may be administered orally to pregnant women with first episode genital herpes or severe recurrent
herpes.

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Flowchart 5: Management of Vaginal Discharge in Females

SYNDROME: VAGINAL DISCHARGE

VAGINITIS TRICHOMONIASIS CERVICAL HERPES CERVICAL HERPES

Causative organisms Causative organisms

Vaginitis Cervicitis
●● Trichomonas vaginalis (TV) ●● Neisseria Gonorrhoea
●● Chlamydia trachomatis
●● Candida albicans
●● Trichomonas vaginalis
●● Gardnerella vaginalis, Mycoplasma ●● Herpes simplex virus

History Examination
●● Menstrual history to rule ●● Per speculum examination to differentiate between vaginitis
out pregnancy
and cervicitis.
●● Nature and type of
a) Vaginitis:
discharge (amount,
smell, color, consistency) Trichomoniasis - greenish frothy discharge
●● Genital itching Candidiasis - curdy white discharge
●● Burning while passing Bacterial vaginosis – adherent discharge
urine, increased Mixed infections may present with atypical discharge
frequency b) Cervicitis:
●● Presence of any ulcer, Cervical erosion /cervical ulcer/mucopurulent cervical discharge
swelling on the vulval or
inguinal region ●● Bimanual pelvic examination to rule out pelvic inflammatory
●● Genital complaints in disease
sexual Partners
●● If Speculum examination is not possible or Client is hesitant
●● Low backache treat both for vaginitis and cervicitis

Laboratory investigations (If available)

●● Wet mount microscopy of the discharge for Trichomonas vaginalis and clue cells
●● 10% KOH preparation for Candida albicans
●● Gram stain of vaginal smear for clue cells seen in bacterial vaginosis
●● Gram stain of endocervical smear to detect gonococci

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Treatment
Vaginitis (TV+BV+Candida)
●● Tab. Secnidazole 2gm orally, single dose or
Tab. Tinidazole 500mg orally, twice daily for 5 days
●● Tab. Metoclopropramide taken 30 minutes before Tab. Secnidazole, to prevent gastric intolerance
●● Treat for candidiasis with Tab Fluconazole 150mg orally single dose or local Clotrimazole 500mg
vaginal pessaries once
Treatment for cervical infection (chlamydia and gonorrhoea)
●● Tab cefixim 400 mg orally, single dose
●● Plus Azithromnycin 1 gram, 1 hour before lunch. If vomiting within 1 hour, give anti-emetic and
repeat
ŠŠ If vaginitis and cervicitis are present treat for both
ŠŠ Instruct client to avoid douching
ŠŠ Pregnancy, diabetes, HIV may also be influencing factors and should be considered in recurrent
infections
ŠŠ Follow-up after one week

Specific guidelines for Partner management

●● Cervicitis: Treat all Partners for gonorrhea and Chlamydia.
●● Vaginitis: Generally partner treatment is not required. If Partner is symptomatic, treat Partner for
the symptom.
●● Advise sexual abstinence during the course of treatment
●● Provide condoms, educate about correct and consistent use
●● Schedule return visit after 7 days

Management in pregnant women

Per speculum examination should be done to rule out pregnancy complications like abortion, premature
rupture of membranes
Treatment for vaginitis (TV+BV+Candida)
In first trimester of pregnancy
●● Local treatment with Clotrimazole vaginal pessary/cream only for candidiasis. Oral Flucanozole is
contraindicated in pregnancy.
●● Metronidazole pessaries or cream intravaginally if trichomoniasis or BV is suspected.
In second and third trimester oral metronidazole can be given
●● Tab. Secnidazole 2gm orally, single dose or
Tab. Tinidazole 500mg orally, twice daily for 5 days
●● Tab. Metoclopropramide taken 30 minutes before Tab. Metronidazole, to prevent gastric intolerance
Management of pregnant women with cervicitis
Pregnant women with cervical discharge should be examined by doing a per speculum as well as per
vaginal examination and should be treated for gonococcal as well as chlamydial infections.
●● Cephalosporins to cover gonococcal infection are safe and effective in pregnancy
ŠŠ Tab. Cefixime 400 mg orally, single dose or
ŠŠ Ceftriaxone 125 mg by intramuscular injection +
ŠŠ Tab. Erythromycin 500mg orally four times a day for seven days or
ŠŠ Cap Amoxicillin 500mg orally, three times a day for seven days to cover chlamydial infection
ŠŠ Quinolones (like ofloxacin, ciprofloxacin), doxycycline are contraindicated in pregnant women.

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Flowchart 6: Management of Lower Abdominal Pain in Females

SYNDROME: LOWER ABDOMINAL PAIN Causative organisms

●● Neisseria gonorrhoea
●● Chlamydia trachomatis
●● Mycoplasma,Gardnerella,
Anaerobic bacteria (Bacteroides
Pelvic inflammatory disease sp,gram positive cocci)

History Examination Laboratory investigations

●● Lower abdominal pain ●● General examination: (if available)
temperature, pulse, ●● Wet smear
●● Fever
blood pressure
examination
●● Vaginal discharge ●● Per speculum
examination: vaginal/ ●● Gram stain for
●● Menstrual
cervical discharge, gonorrhoea
irregularities like
heavy, irregular vaginal congestion or ulcers ●● Complete blood count
bleeding ●● Per abdominal and ESR
examination: lower
●● Dysmenorrhoea ●● Urine microscopy for
abdominal tenderness
pus cells
●● Dyspareunia or guarding
●● Dysuria, tenesmus ●● Pelvic examination:
Uterine/adnexal Differential diagnosis
●● Low backache tenderness,
●● Contraceptive use like cervical movement ●● Ectopic pregnancy
IUD tenderness, ●● Twisted ovarian cyst
Note: A urine pregnancy ●● Ovarian tumor
test should be done in
●● Appendicitis
all women suspected of
having PID to rule out ●● Abdominal
pregnancy. tuberculosis

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Treatment (Out Client treatment)

In mild or moderate PID (in the absence of tubo ovarian abscess), Out Client treatment can be given. Therapy is
required to cover Neisseria gonorrhoea, Chlamydia trachomatis and anaerobes.
●● Tab. Cefixim 400 mg orally Stat + Tab. Metronidazole 400mg orally, twice daily for 14 days
+
●● Doxycycline, 100mg orally, twice a day for 2 weeks (to treat Chlamydial infection)
●● Tab. Ibuprofen 400mg orally, three times a day for 3-5 days
●● Tab. Ranitidine 150mg orally , twice daily to prevent gastritis
●● Remove intra uterine device, if present, under antibiotic cover of 24-48 hours
●● Advise abstinence during the course of treatment and educate on correct and consistent use of condoms
●● Observe for 3 days. If no improvement (i.e. absence of fever, reduction in abdominal tenderness, reduction
in cervical movement, adnexal and uterine tenderness) or if symptoms worsen, refer for in Client treatment.
●● Schedule return visit after 3 days, 7 days & 14 days to insure compliance.

Caution: PID can be a serious condition. Refer the Client to the hospital if she does not respond to treatment within
3 days and even earlier if her condition worsens.

Hospitalization of Clients with acute PID should be seriously considered when:

●● The diagnosis is uncertain
●● Surgical emergencies e.g. appendicitis or ectopic pregnancy cannot be excluded
●● A pelvic abscess is suspected
●● Severe illness precludes management on an outpatient basis
●● The woman is pregnant
●● The Client is unable to follow or tolerate an out regimen
●● The Client has failed to respond to outpatient therapy
Note: All Clients requiring hospitalization should be referred to the district hospital

Syndrome specific guidelines for Partner management

●● Treat all Partners
●● Treat male Partners for urethral discharge (gonorrhoea and chlamydia)
●● Advise sexual abstinence during the course of treatment
●● Provide condoms, educate on correct and consistent use
●● Refer to ICTC for HIV & Syphilis testing
●● Inform about the complications if left untreated and sequelae

Management of pregnant women

Though PID is rare in pregnancy,
●● Any pregnant woman suspected to have PID should be referred to district hospital for hospitalization and
treated with a parenteral regimen which would be safe in pregnancy.
●● Doxycycline is contraindicated in pregnancy.
Note: Metronidazole is generally not recommended during the first three months of pregnancy. However, it should
not be withheld for a severely acute PID, which represents an emergency.

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Flowchart 7: Management of Oral and Anal STI

Causative organisms

SYNDROME: INGUINAL BUBO ●● Neisseria gonorrhoea

●● Chlamydia trachomatis
●● Treponema pallidum (syphilis)
●● Haemophilus ducreyi (chancroid)
●● Klebsiella granulomatis (granuloma
inguinale)
STI/RTIs: LGV, CHANCROID
●● Herpes simplex (genital herpes)

Examination

Look for

History ●● Oral ulceration,

redness, pharyngeal Laboratory investigations
●● Unprotected oral sex (if available)
inflammation
with pharyngitis.
●● Genital or anorectal ●● RPR/VDRL for syphilis
●● Unprotected anal sex
ulcers – single or ●● Gram stain
with anal discharge or
multiple examination of rectal
tenesmus, diarrhea,
●● Presence of vesicles swab will show gram
blood in stool,
negative intracellular
abdominal cramping, ●● Rectal pus
diplococcic in case of
nausea, bloating ●● Any other STI gonorrhoea.
syndrome
●● (Do proctoscopy for
rectal examination if
available)

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Pharyngitis with history of

unprotected oral sex

Or Genital or anorectal ulcers

seen Diarrhea, blood in stools,
Anal discharge, tenesmus
Or abdominal cramping,
bloating with history of
nausea, bloating with
unprotected anal sex Vesicles seen or history history of unprotected
Or of recurrent vesicular anal sex.
eruptions
Rectal pus or bloating with
history of unprotected
anal sex

Tab. Azithromycin 1 gm +
Tab. Cefixime 400 mg
Follow flowchart
Follow flowchart (Follow urethral discharge
urethral discharge syndrome flowchart)+
syndrome and treat genital ulcer syndrome
accordingly anti-diarrheal medicines as
needed &

Refer to higher facility

Any other STI syndrome Refer to relevant STI Syndromic flow chart

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8. Management of Anogenital warts

Causative organism
Virus: Human Papilloma Virus (HPV)

Clinical features
Single or multiple soft, painless, pink in color, “cauliflower” like growths which appear around the
anus, vulvo-vaginal area, penis, urethra and peri¬neum. Warts could appear in other forms such
as papules which may be keratinized.

Diagnosis
Presumptive diagnosis by history of exposure followed by signs and symptoms.

Differential diagnosis

i. Condyloma lata of syphilis

ii. Molluscum contagiousm

Treatment
Recommended regimens:

Penile and perianal warts

●● 20% Podophyllin in compound tincture of benzoin applied to the warts, while carefully
protecting the surrounding area with Vaseline, to be washed off after 3 hours. It should not be
used on extensive areas per session.
●● Treatment should be repeated weekly till the lesions resolve completely.

*Andt KA, Has JT.S. Manual of Dermatologic Therapeutic. ed 7th Lippincott William & Wilkins, New
Delhi 2007. Pg.236

Note: Podophyllin is contra-indicated in pregnancy. Treatment should be given under medical

supervision. Clients should be warned against self-medication.

Cervical warts
●● Podophyllin is contra-indicated.
●● Biopsy of warts to rule out malignant change.
●● Cryo cauterization is the treatment of choice. Cervical cytology should be periodically done in
the sexual Partner(s) of men with genital warts.

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Some of the pictures of Anogenital warts are shown below in Fig a to c

Fig a: Perivulval warts

Fig b: Penile warts

Fig c: Perianal warts

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9. Management of Molluscum contagiosum and Ectoparasitic infection

Fig d: Molluscum contagiosum

Causative Organism
Pox virus

Clinical features
Multiple, smooth, glistening, globular papules of varying size from a pinhead to a split pea can
appear anywhere on the body. Sexually transmitted lesions on or around genitals can be seen. The
lesions are not painful except when secondary infection sets in. When the lesions are squeezed, a
cheesy material comes out.

Diagnosis
Diagnosis is based on the above clinical features.

Treatment
●● Individual lesions usually regress without treatment in 9-12 months.
●● Each lesion should be thoroughly opened with a fine needle or scalpel. The contents should
be exposed and the inner wall touched with 25% phenol solution or 30% trichloracetic acid.

10. Pediculosis pubis

Causative organism
Lice - Phthirus pubis

Clinical features
There may be small red papules with a tiny central clot caused by lice irritation.

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General or local urticaria with skin thickening may or may not be present. Eczema and Impetigo
may be present.

Treatment
Recommended regimen:
●● Permethrin 1% creme rinse applied to affected areas and wash off after 10 minutes

Special instructions
●● Retreatment is indicated after 7 days if lice are found or eggs observed at the hair-skin junction.
●● Clothing or bed linen that may have been contaminated by the Client should be washed and
well dried or dry cleaned.
●● Sexual Partner must also be treated along the same lines.

11. Genital scabies

Causative organism: Mite - Sarcoptes scabiei.

Fig e: Genital Scabies

Clinical features
Severe pruritis (itching) is experienced by the Client, which becomes worse at night. Other
members of family also affected (apart from sexual transmission to the Partner, other members
may get infected through contact with infected clothes, linen or towels).

Complications
●● Eczematization with or without secondary infection
●● Urticaria
●● Glomerulonephritis
●● Contact dermatitis to antiscabetic drug

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Diagnosis
The burrow is the diagnostic sign. It can be seen as a slightly elevated grayish dotted line in the
skin, best seen in the soft part of the skin.

Treatment
Recommended regimens:
●● Permethrin cream (5%) applied to all areas of the body from the neck down and washed off
after 8--14 hours.
●● Benzyl benzoate 25% lotion, to be applied all over the body, below the neck, after a bath, for
two consecutive nights. Client should bathe in the morning, and have a change of clothing.
Bed linen is to be disinfected.

Special instructions
●● Clothing or bed linen that have been used by the Client should be thoroughly washed and well
dried or dry cleaned.
●● Sexual Partner must also be treated along the same lines at the same time.

Notes on the use of flowcharts

1. Urethral discharge syndrome
●● When a man complains of urethral discharge or burning on urination, go to the urethral
discharge flowchart.
●● Examine him. Burning may also be caused by genital ulcers or other problems. You should
be able to see a discharge, but even if you do not, he should be treated for genital discharge.
However, try milking the penis and observe the meatus for a discharge.
●● If he also has ulcers, go to the flowchart for ulcer management.

2. Genital ulcer disease (GUD)

●● When a man or woman complains of genital sores or ulcers, go to the “sore or ulcer” flowchart.
●● Syphilis and chancroid are the most common cause of curable ulcers in men and women in
most places in the world, so we treat for those unless lesions that look like herpes are present.
●● The grouped, vesicular, and painful lesions of herpes are usually distinctly different from the
lesions of syphilis and chancroid. If you are unsure, treat for syphilis and chancroid because
their consequences are more serious than herpes and they can be cured. Additionally treat
and counsel for herpes, as this may be the most symptomatic disease. It also promotes cervical
cancer.
●● If you find only genital warts, you do not need to treat for syphilis and chancroid. Treat the
warts if it is possible in your facility, or refer if necessary. Small genital wart infections may
resolve themselves without treatment, but they are contagious.

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3. Lower abdominal pain

●● Go to flowchart “Lower Abdominal Pain” (LAP) if a woman presents with LAP, or if she presents
with vaginal discharge, tells you she also has LAP and appears ill or feverish.
●● The history is important. Anyone with recent delivery, abortion, IUD insertion or other
intrauterine procedure within the last 3 weeks could have serious infection or sepsis and
should be referred. Anyone with a missed period or intermittent vaginal bleeding along with
LAP could have an ectopic pregnancy and should be referred immediately.
●● A temperature over 38°C, cervical motion tenderness, and vaginal discharge all indicate acute
PID and the patient should be managed as indicated on the flowchart. If the patient appears
extremely ill (fever of 40°C, cannot walk, vomiting, and cannot tolerate oral medication), then
she may need inpatient treatment and should be referred.
●● Otherwise, treat as an outpatient, but make sure she returns for follow up and refer if she
does not clearly improve on the medication.

4. Vaginal discharge
●● When a woman complains of vaginal discharge, go to the “ vaginal discharge “ flowchart.
●● Often vaginal discharge is either normal or related to vaginal infections(vaginitis). Common
causes of vaginal discharge are bacterial vaginosis (BV), trichomonas vaginalis (TV), and
candidiasis. All these three diseases are sexually transmissible. Most women with cervicitis do
not have vaginal discharge or lower abdominal pain.
●● Assess the STI/RTI risk of anyone with vaginal discharge carefully. If you or she suspects
high risk based on prevalence of STI/RTI in your patient population, her occupation, or her
partner’s symptoms, occupation or behavior, treat her for cervicitis and vaginitis and try to
ensure partner treatment.
●● Women with cervicitis will also present with vaginal discharge.
●● Many women with discharge may have GUD additionally and multiple symptoms or diseases
are common.

5. Inguinal bubo syndrome

●● When a man or woman complains of swelling in inguinal region, go to the “inguinal bubo“
flowchart.
●● Often swelling in inguinal region is either because of chancroid or LGV infection. Preceding
genital ulcer or discharge before swelling develops which may be painful.
●● Assess the STI/RTI risk of anyone with inguinal bubo carefully. If presence of genital ulcer or
discharge please refer to respective flowchart.

6. Scrotal pain and/or swelling

●● When a man complains of scrotal swelling and/or pain, go to the “scrotal swelling“ flowchart.
●● Often scrotal swelling and/or pain is either due to gonorrhoea or chlamydial infection. It may
be associated with pain or burning while passing urine or urethral discharge.

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●● Assess the STI/RTI risk of anyone with scrotal swelling and/or pain carefully. Treat the patient
for both the infection simultaneously.
●● Many men with discharge may have GUD additionally and multiple symptoms or diseases are
common.

7. Oral and anal STI

●● When a woman or man complains of oral or anal STI, go to the “ oral or anal STI “ flowchart.
●● Often oral or anal STI are either due to gonorrhoea, syphilis, chancroid, herpes simplex,
granuloma inguinale or chlamydial infection.
●● Assess the STI/RTI risk of anyone with oral or anal lesions carefully. Look for genital lesions and
accordingly follow the flowcharts and treat accordingly.

8. Ano- genital warts

●● When a woman or man complains of swelling or growth at ano-genital region, it could be
because of HPV infection, HSV infection or due to syphilis, go to the “ ano-genital wart “section
and treat according to signs specific for STI/RTI.

9. Genital skin conditions

●● When a woman or man complains of other genital skin conditions, go to the “ genital skin
conditions “ section.
●● Often the commonest genital skin condition is because of either scabies or pubic lice

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2. Drugs used in STI/RTI management

Different kinds of medications are used for each STI/RTI syndrome. Bacterial resistance to
antibiotics has become a major barrier to the effective control of some STI/RTI. Bacterial resistance
can be attributed to natural resistance and to the misuse of medicines, particularly not taking the
full recommended dose or giving wrong, insufficient, or expired medications.

Good counseling on the proper use of medications is just as important as prescribing the right
medication. Using ineffective medication, taking too low a dose or stopping treatment early
because of side effects can contribute to the spread of STI/RTI and may cause antibiotic resistance.
Programs that provide STI/RTI management need to keep an uninterrupted supply of antibiotics
on hand or to correctly prescribe low-cost, effective medications that patients can afford.

Drugs to be stocked at STI clinics

All clinics must maintain adequate stock of drugs required for treatment of STI as per the standard
protocol. Following is the inventory of essential STI treatment drugs. They should be stored in a
secure location and used before their expiry date.

1. Inj. Benzathene Penicillin – 24 lakhs unit vial

2. Inj. Ceftriaxone (250 mg & 1 gm)

3. Tab. Azithromycin (1g)

4. Tab. Cefixime (400mg)

5. Tab. Fluconazole (150 mg)

6. Tab. Secnidazole (500 mg)

7. [Tab Metronidazole (400 mg)] Tinidazole (500 mg) as per recommended on the syndrome
approach

8. Tab. Erythoromycin (500 mg) base/stearate

9. Cap. Doxycycline (100 mg)

10. Cap. Acyclovir (400 mg)

11. Clotrimazole Vaginal pessary (500 mg)

12. Podophyllin tincture 20%

13. Permethrin cream (5%) and (1%)

14. Benzyol benzoate lotion.

What is antibiotic resistance?

Antibiotic resistance is the ability of bacteria to adapt to changing environments in order to survive.
With increased use of antibiotics over the 50 years since their discovery, weaker, susceptible

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strains of bacteria have been killed off. This has led to the selection of the strongest, most resistant
strains. Such resistant strains are often very difficult to treat with more commonly used, low-cost
antibiotics.

There are many examples of resistance, such as multi-drug resistant tuberculosis (TB). Other
bacteria, such as Chlamydia trachomatis have remained extremely sensitive to drugs of the
tetracycline family, though this drug is often misused.

The principle causes of antibiotic resistance are:

●● Not completing the treatment regimen (i.e. stopping when feeling better, or sharing the
medication).
●● Self-medication with too low a dose or the wrong medication, using drugs sold on the street.
●● Use of antibiotics when they are not needed (for example, to treat viral infections such as
colds).
●● Misuse of antibiotics (using the wrong drug or the wrong dose).

How to prevent antibiotic resistance in the community

●● Use antibiotics appropriate for specific infections or syndromes.
●● Make sure you have prescribed the right drug for the right amount of time.
●● Always give clear instructions on how to take drugs and on the dangers of taking drugs
incorrectly. Emphasize the need to take the entire drug, even if the patient is feeling better.
Tell the patient not to save any of the drugs or give it to someone else.
●● Use supervised regimens (e.g. as used in DOTS) whenever possible
●● Be aware of changing resistance patterns by keeping in touch with the national STI control
program.

Screening for asymptomatic clients for STI/RTI

It is well known that most STI/RTI are asymptomatic, especially amongst the women. Therefore
screening asymptomatic clients for STI/RTI will provide great help in detection of more cases and
timely treatment of them along with their partner can control most of the STI/RTI. Antenatal
and family planning service setting could be the situation where asymptomatic women may be
screened. In this session we will see, which are the common laboratory screening tests used for
detection of STI/RTI and their role for control of STI/RTI.

Most common screening programmes worldwide are those for detecting syphilis in pregnant
women. Untreated syphilis in pregnant female is associated with number of adverse outcomes
such as pregnancy loss, stillbirths and congenital syphilis. Providers are recommended to follow
Government of India’s following guidelines while providing services to pregnant women:

1. Guidelines for Pregnancy Care and Management of common obstetric complications by

Medical Officers, 2005.

2. Guidelines for Antenatal Care and Skilled Attendance at birth by ANMs and LHVs, 2006.

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PARTNER MANAGEMENT

Sr. No. Topic Page No

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1. Purpose of timely partner management

What is Partner management?

Partner management is one of the most important parts in control and prevention of STI/RTI. Many
times partners do not seek services because of number of reasons like absence of symptoms,
lack of assurance of confidentiality, hence to motivate partner is a critical task. In such situations,
partner management is essential which is a process in which the partners of those identified as
having STI/RTI are identified, informed of their potential risk of infection, and offered treatment
and counseling services. In this module we will discuss the critical issues regarding partner
management.

Timely partner management serves following purpose:

●● Prevention of re-infection to index patients
●● Prevention of transmission from infected partners and
●● Help in detection of asymptomatic individuals, who do not seek treatment.

2. Critical issues on partner management

Confidentiality: Partners should be assured of confidentiality. Many times partners do not seek
services, as they perceive confidentiality as a serious problem. Respecting dignity of client and
ensuring confidentiality will promote partner management.

Voluntary reporting: Providers must not impose any pre-conditions giving treatment to the index
client. Providers may need to counsel client several times to emphasize the importance of client-
initiated referral of the partners.

Client initiated partner management: Providers should understand that because of prevailing
gender inequities a woman might not be in position always to communicate to her husband/
partner regarding need for partner management. Such client initiated partner management may
not work in some relationships and may also put women at the risk of violence. Hence alternative
approaches should be considered in such situations.

Availability of services: STI/RTI diagnostic and treatment services should be available to all
partners. This may mean finding ways to avoid long waiting times. This is important because many
asymptomatic partners are reluctant to wait for services when they feel healthy.

Ignorance: The partner has to know the importance of his treatment, which will prevent reinfection
to his/her regular or other casual partners and development of complications to himself/herself,
and free provision of treatment and other facilities like provision of condoms etc.

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3. Approaches for partner management

There are two approaches to partner management:

I. Referral by index client
In this approach, index client informs the partner/s of possible infection. This appears to be a
feasible approach, because it does not involve extra personnel, is inexpensive and does not require
any identification of partners. A partner notification card with relevant diagnostic code should
be given to each index client, where partner management is indicated. This approach may also
include use of client-initiated therapy for all contacts.

The index client might approach the partner treatment in the following ways:
●● By directly explain the partner/s about STI and the need for getting treated
●● By motivating and accompanying the partner/s to the treatment center/health care provider
●● Asking the partner/s to attend the clinic without specifying the reasons
●● Providing referral card to the partner/s and asking him/her to attend the clinic.

ii. Referral by providers

In this approach service provider contacts client’s partners through issuing appropriate partner
notification card and telephone calls if telephone number is available from the index case. The
information provided by client is used confidentially to trace and contact partners directly. This
approach needs extra staff and is expensive. Telephone call will be less expensive, does not require
extra staff.

Making client referral mechanism feasible

The possible steps in initiating client referral for STI/RTI are:
a. Making patient him/herself take STI/RTI treatment

b. Help him/her understand how to avoid re-infection

c. Help him/her understand importance of possible transmission that might have occurred and
further transmission

d. Helping him on how and what to communicate with partner/s

a. Making the client take STI/RTI treatment

The first and most important step in initiating partner treatment is help and encourage the patient
to initiate his own treatment, as prescribed by the doctor. This will take care of the infection in
index (or presenting) patient.

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b. Help client understand how to avoid re-infection

In addition to his/her own treatment, the patient needs counseling on how to prevent re-infection.
And, one of the important strategies for it is treatment of all the partners. As the person is
suffering from the infection and is worried about his/her health, the impact of health education
and counseling is much better as he/she is ready to receive any advice for getting well. Thus, the
patient more likely to listen to the messages attentively and act upon it, thereby increasing the
possibility of partner treatment, at least for his own sake (if not for partner/s).

c. Help client understand importance of possible transmission that might have occurred and
further transmission

The messages during counseling of client receiving the STI/RTI treatment should emphasize on
immediate impact as well as strategies for long term prevention. The messages for immediate
impact should include prevention of re-infection during treatment period, thereby increasing the
possibility of getting good results from the treatment. Emphasis should also be given on preventive
strategies such as condom use.

The long term prevention messages should include risk reduction strategies such as reducing
number of partners, condom use, safe sexual practices and immediate treatment seeking if
symptoms reappear.

d. Helping client on how and what to communicate with partner/s

The providers must understand how challenging and embarrassing it will be for the index patient
to convey the news of getting infected with STI/RTI, due to social stigma attached to these issues.
Therefore, the providers must help clients to build courage for taking the partners into confidence.
The providers must emphasize on how partner treatment is best for the good health of the index
client and his/her partner/s and overall family. They should also provide the client with the option
of conveying the news and treatment themselves (healthcare providers) and help them is resolving
the infection.

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e. Provide the index client a partner referral card as prescribed in the table below:

Syndrome of index patient Treatment for Partner/s

Urethral Discharge Treat for Gonorrhoea & Chlamydia
Genital Ulcer – Non Herpetic Treat for syphilis and Chancroid
Genital Ulcer –Herpetic Routine partner treatment not given unless partner is
symptomatic
Vaginal Discharge (Cervicitis) Treat for Gonorrhoea & Chlamydia
Vaginal Discharge (Vaginitis) Routine partner treatment not given unless partner is
symptomatic
Lower Abdominal Pain (PID) Treat for Gonorrhoea & Chlamydia
Scrotal Swelling Treat for Gonorrhoea & Chlamydia
Inguinal Bubo Treat for Lymphoagranuloma Venereum & Chancroid
Oral/Ano – rectal Discharge Treat for Gonorrhoea & Chlamydia
Neonatal Conjunctivitis Treat both parents for Gonorrhoea & Chlamydia

What if the client referral fails?

Two situations in this regards are possible:
1. Client refuses to refer partner/s

2. If the partner fails to come for treatment

1. Client refuses to refer partner/s: In spite of your gallant efforts, if the patient does not agree to
refer the partner/s to the clinic, the only option for the provider is to go for the “provider referred
partner treatment”.

However, it is worthwhile to attempt explore some other options such as providing the presumptive
treatment through index clients. Many providers do not agree with this option in the fear of
incomplete treatment or misuse of medicines provided. However, the providers may want to
consider this as sort of “last resort” for providing partner treatment. The provider will have to take
a call in such situations depending on how much he/she can trust the patient based on the short
interaction they had during client education session.

2. If the partner fails to come for treatment: The only option left with the provider is to go for the
“provider referral”.

Provider referral:
If the system is efficient to obtain the details of the partners including their coordinates, the
provider, through his/her field staff may want to get in touch with the partners of index client and
motivate them to take treatment.

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General principles for partner management

●● In general, partners should be treated for the same STI as the index client, whether or not they
have symptoms or signs of infection.
●● Health care providers should be as sure as possible about the presence of an STI before
informing and treating the partner, and should remember that other explanations are possible
for most RTI symptoms like vaginal discharge.
●● Special care is required in notifying partners of women with lower abdominal pain who are
being treated for possible pelvic inflammatory disease. Because of the serious potential
complications of PID (infertility, ectopic pregnancy), partners should be treated to prevent
possible re-infection. It should be recognized, however, that the diagnosis of PID on clinical
grounds is inaccurate, and the couple should be adequately counseled about this uncertainty.
It is usually better to offer treatment as a precaution to preserve future fertility than to mislabel
someone as having an STI when they may not have one.
●● It is important to explain to the couple that some of these infections are acquired through
unhygienic conditions like unclean toilets, fomites, swimming pools etc. However if one of
them has acquired the infection, it cannot be treated fully unless the partner is also treated, as
there is a definite chance of reinfection through sexual transmission. This ensures compliance
from both partners.

Follow-up visits
Follow up visits should be advised
1. To see reports of tests done for HIV, Syphilis and Hepatitis B.

2. Advise clients to come back for follow up after 7 days. In case of PID, follow up should be on
day 3, day 7 and day 14 and in case of LGV, followup is on day 7, 14 and after 21 days.

Two-step strategy for partner management

A two-step strategy can be used where clients are first asked to contact partners themselves. If no
response till one or two weeks, clinic or health department staff can attempt to trace the contact
for treatment.

Note: Efforts needed to diagnose and treat Partner but whether the Partner should be treated, the
choice to be rested with the patient

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Box: Sample Partner reporting card

Sample coupon for a free examination

Coupon for a free examination

Date:

Please attend following centers along with the card:

Stamp of the Facility:

Timings:

Diagnostic Code:

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 MODULE NO. 9

LABORATORY TESTS FOR STI/RTI

Sr. No. Topic Page No

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1. Definitions of common terms

Antigen: A molecule, which is recognized by the immune system and induce an immune reaction
(the organism itself)

Antibody: A class of serum proteins, which are induced in response to the immune reaction
following contact with antigen (an infectious organism)

False positives: Uninfected people diagnosed as positive

False negatives: Infected people diagnosed as negative (missed infections)

Sensitivity:
●● How good a test is at identifying people who are infected?
●● Higher the sensitivity, the lower the rate of false negatives (missed infections)
●● Example: if sensitivity of a test is 95% and 100 infected people are tested, 95 will have positive
test results and 5 will have negative test results (even though they are infected)
●● The minimum number of organisms needed in a sample for a test to be positive varies from
one type of test to another. The lower the number of organisms that can be detected, the
greater the sensitivity of the test. The new amplified DNA techniques [e.g., polymerase chain
reaction (PCR), ligase chain reaction (LCR)] are extremely sensitive and can detect between 1
and 50 organisms in the sample tested.

Specificity:
●● How good a test is at identifying people who are not infected?
●● Higher the specificity, the lower the rate of false positives
●● Example: if specificity of a test is 95% and 100 people who are not infected are tested, 95
will have negative test results and 5 will have positive test results (even though they are not
infected)

Sensitivity & specificity are used to give an indication of how good a diagnostic test is. Ideally one
would like a test that has 100% sensitivity (i.e. everyone who is infected tests positive) and 100%
specificity (i.e. everyone who is not infected tests negative).

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2. Role of the laboratory in STI/RTI control

1. Screening and detection of disease in those without symptoms who seek health care for other
reasons, e.g. antenatal women

2. Screening groups of people who may be at risk for a STI/RTI but have no symptoms.

3. Testing a sample of the population to see what percentage is infected (prevalence) and how
many new infections are occurring in a certain time period (incidence).

4. Conducting simple studies to check on the accuracy of syndromic management (validation).

5. Testing for antimicrobial resistance.

6. Sentinel surveillance of STI.

7. Making an etiologic diagnosis for patients who present with STI/RTI symptoms.

8. Simple laboratory tests improve the diagnostic sensitivity and specificity of syndromic approach
to symptomatic STI/RTI, particularly in women.

However, most labs in PHC have little or no capacity to test for gonorrhoea, chlamydia, herpes and
other STI/RTI. Even when they do such tests, the accuracy of diagnosis is likely to be poor.

3. Laboratory tests for STI/RTI

A. Microscopic examination: Directly visualizing the organism on vaginal/cervical smear under

the microscope. Examples: Wet mount for Trichomonas vaginalis, Candida (budding cells),
Bacterial vaginosis (BV), Gram staining for gonococcus, BV causing organism, Candida and
Dark field microscopy for Treponema pallidum

B. Detection of antigen (a specific molecule from the infecting organism itself): Example: Enzyme
immunoassay (EIA) for chlamydia, gonorrhoea and other infections.

C. Antibody tests: To measure the body’s response of producing antibodies to the infecting
organism. Examples: EIA used for Treponema pallidum or HIV antibodies.

D. Culture of different organisms (Growing the organism in the laboratory). Examples: Culturing
Trichomonas vaginalis, Candida albicans and other species, Chlamydia trachomatis and
[Link]

E. Detection of DNA of the organism using non-amplified techniques: Example: Nucleic acid
hybridization used for herpes.

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F. Detection of DNA of the organism using amplified techniques: Examples: PCR (polymerase
chain reaction), LCR (ligase chain reaction) and TMA (transcription mediated amplification)
used for chlamydial infection and HIV infection.

G. Other: Use of Vaginal pH for BV

1. What are the laboratory tests for detecting common STI/RTI and
how they are performed?
The pH of vaginal fluid should be measured using pH paper of appropriate range (3.8 to 6.0). The
vaginal fluid sample is collected with a swab from the lateral and posterior fornices of the vagina
and the swab is then touched directly on to the paper strip. Alternatively, the pH paper can be
touched to the tip of the speculum after it has been withdrawn from the vagina. Care must be
taken not to use any jelly (eg K.Y jelly) or disinfectant (eg. savlon) before doing pH test. Contact
with cervical mucus must be avoided since it has a higher pH. The normal vaginal pH is 4.0. In
bacterial vaginosis (BV), the pH is generally elevated to more than 4.5.

The vaginal pH test has the highest sensitivity (less false negativity) of the four characteristics
used for identification of BV, but the lowest specificity (more false positivity); an elevated pH is
also observed if the vaginal fluid is contaminated with menstrual blood, cervical mucus or semen,
and in women with a T. vaginalis infection. In simple words it means that if pH test is negative the
result can be taken as it is but if it is positive one has to rule out the other factors contaminating
the sample such as menstrual blood, cervical mucus or semen or presence of T. vaginalis infection

2. Wet mount microscopy

Wet mount microscopy is the direct microscopic examination of vaginal discharge for the diagnosis
of trichomoniasis, candidiasis and bacterial vaginosis (Box 1).

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Box 1 Wet mount microscopy examination of vaginal discharge

Collect specimen Take a specimen of discharge with a spatula from the sidewalls or deep in
the vagina where discharge accumulates.
Prepare slide Mix specimen with 1 or 2 drops of saline on a glass slide and cover with
a cover slip.
What to look for ●● Examine at 100X magnification and look for typical jerky movement
of motile trichomonads (ovoid, globular, pear-shaped flagellated
protozoan).
●● Examine at 400X magnification to look for yeast cells (round to ovoid
cells with typical budding) and trichomonads.
●● To make identification of yeast cells easier in wet mount slides, mix
the vaginal swab in another drop of saline and add a drop of 10%
potassium hydroxide to dissolve other cells. Note any fishy odour to
suggest BV.
●● Presence of clue cells (squamous epithelial cells covered with many
small coccobacillary organisms). Wet mount shows stippled granular
cells without clearly defined edges because of the large numbers of
adherent bacteria present and an apparent disintegration of the cells.
The adhering bacteria are predominantly G. vaginalis, sometimes
mixed with anaerobes).
Important Look for evidence of other vaginal or cervical infections as multiple
infections are common.

Mycelia

Budding Yeast

Fig 1: Potassium hydroxide preparation of vaginal fluid

showing budding yeast and mycelia

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Clue Cell

Fig 2: “Clue cells” in vaginal wet mount (x 400)

Trichomonas vaginalis

Fig 3 : Trichomonas vaginalis in a wet mount of

vaginal discharge (x 400)

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Box 2 Clinical criteria for Bacterial vaginosis (BV)

BV can be diagnosed using simple clinical criteria with or without the aid of a microscope
Collect specimen Take a specimen of discharge from the sidewalls or deep in the vagina
where discharge pools (or use discharge remaining on speculum). Note
color and consistency of discharge. Touch pH paper to discharge on swab
or speculum and note pH.
Prepare slide ●● Place specimen on a glass slide. Add a drop of 10% potassium
hydroxide (KOH) and note for any fishy smell.
●● Make a wet smear with 0.9% normal saline, cover with cover slip and
see under microscope for clue cells.
What to look for The diagnosis of BV is based on the presence of at least 3 of the 4 following
characteristics
●● Homogeneous white-grey discharge that sticks to the vaginal walls
●● Vaginal fluid pH >4.5
●● Release of fishy amine odour from the vaginal fluid when mixed with
10% potassium hydroxide (positive Whiff test)
●● “Clue cells” visible on microscopy on wet preparation
Important Look for evidence of other vaginal or cervical infections as multiple
infections are common.

3. Whiff test
Women with BV often complain of a foul vaginal smell. This odour is due to the release of amines,
produced by decarboxylation of the amino acids (lysine and arginine) by anaerobic bacteria. When
potassium hydroxide is added to the vaginal fluid, these amines immediately become volatile,
producing the typical fishy odour.

Place a drop of vaginal fluid on a glass slide and add a drop of 10% potassium hydroxide. Hold the
slide close to nose to detect the amine odour. After a positive reaction, upon standing the specimen
will quickly become odourless because the amines will be rapidly and completely volatilized.

4. Gram stain microscopy

A gram stain of a vaginal smear has a higher specificity (i.e lesser false positivity) for the diagnosis
of bacterial vaginosis (BV) than a wet mount preparation. Moreover, a Gram stain allows good
evaluation of the vaginal bacterial flora. Normal vaginal fluid contains predominantly lactobacillus
species and exceedingly low numbers of streptococci and coryneform bacteria. In BV, lactobacilli
are replaced by a mixed flora of anaerobic bacterial morphotypes and G. vaginalis. However, gram
stain microscopy has a very low sensitivity for detecting [Link] among women; culture
remains the method of choice.

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Box 3 Gram stain microscopy of vaginal smears

Collect specimen A Gram stain slide can be prepared at the same time as the wet mount by
rolling the spatula/swab on a separate slide.
Prepare slide 1. Heat fix.

2. Stain with crystal violet (60 seconds) and rinse.

3. Stain with iodine (60 seconds) and rinse.

4. Decolorize with acetone-ethanol for few seconds (until the liquid runs
clear).

5. Stain with safranin (30 seconds) and rinse.

6. Gently blot dry and examine under oil immersion (1000X) and count
each type of organisms.
What to look for 1. Lactobacilli (large Gram positive bacilli) only: Normal

2. Mixed flora, mainly lactobacilli with a few short rods (coccobacilli):

Considered normal

3. Presence of clue cells; mixed flora, mainly Gardnerella and anaerobic

bacteria with a few lactobacilli diagnose as BV

4. Presence of clue cells, mixed flora of Gram-positive, Gram-negative

and Gram-variable rods; no lactobacilli diagnose as BV
Important Look for evidence of other vaginal or cervical infections as multiple
infections are common.

*Nugent score

Scoring system (0 to 12) from Gram-stained vaginal smears

Total score Lactobacillus Gardnerella and Bacteriodes Mobilincus curved

morphotypes (large spp. morpho- types (small Gram- negative/
Gram positive bacilli) Gram negative/ Gram variable bacilli
variable bacilli)
0 0 + (>30/oif) 0 (0/oif) 0 (0/oif)
3 1 + (6-30/oif) 1 + (<1/oif) 1 + (</oif)
6 2 + (1-5/oif) 2 + (1-5/oif) 2 + (2-5/oif)
9 3 + (<1/oif) 3 + (6-30/oif) 3 + (6-30/oif)
12 4 (0/oif) 4 + (>30/oif) 4 + (.30/oif)

Morphotypes are scored as the average number seen per oil immersion field (oif). Note that less
weight is given to curved Gram negative/ variable rods. Total score = lactobacilli + G. vaginalis and
Bacteriodes spp. + curved rods.

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Interpretation of Nugent score

0-3 = normal, never treat

4-6 = intermediate, decide on symptoms for treatment

7-or more = BV infection, Treat

Lactobacilli

Fig 4: Gram stained vaginal smear showing a normal

flora of lactobacilli (x 1000)

Clue Cell

Fig 5 : Gram stained vaginal smear with typical “clue cell” (x 1000)

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Gram - negative rods

Fig 6 : Gram stained vaginal smear showing large Gram-

negative rods (Mobilincus mulieris) (x 1000)

Use of gram stain for diagnosis of cervical infection

1. The Gram stain method in female does not provide conclusive evidence of the presence of
gonococcal infection. Presence of intracellular gram negative diplococci indicates infection but
their absence does not rule out infection.

2. The costs associated with the method, including the cost of maintaining microscopes, outweigh
the benefits in terms of improved quality of care.

Use of gram stain for diagnosis of Urethral/Ano-rectal infection

1. For men, gram stain microscopy of urethral discharge smear will show pus cells and gram-
negative intracellular diplococci as well as extra cellular diplococci in case of gonorrhoea.

2. In case of non-gonococcal urethritis more than 5 neutrophils per oil immersion field (1000X)
in the urethral smear or more than 10 neutrophils per high power field (400X) in the sediment
of the first void urine, in the absence of N. gonorrhoea, is observed.

3. The Gram stain method in male provide conclusive evidence of the presence of gonococcal
infection.

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Fig 7: Gram stain Urethral discharge smear : Gram-negative diplococci of Neisseria gonorrhoea

5. Rapid plasma reagin (RPR) test for syphilis

The current non-treponemal tests for syphilis are Venereal Disease Research Laboratory Test
(VDRL Test) and Rapid Plasma Reagin (RPR) test. RPR test is most suitable for the primary health
care set-up.

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Procedure of RPR test

●● Seek consent
●● Use a sterile needle and syringe. Draw 5 ml of blood from a vein. Put in a plain test tube
●● Let the test tube stand for 20 minutes to allow serum to separate (or centrifuge 3–5 minutes
at 2000–3000 rpm). In the separated sample, serum will be on top.
●● Use sampling pipette to transfer the serum. Take care not to include any red blood cells from
the lower part of the separated sample.
●● Hold the pipette vertically over a test card circle. Squeeze teat to allow one drop (50 µl) of
serum to fall onto a circle. Spread the drop to fill the circle using a toothpick or other clean
spreader.

Important: Several samples may be done on one test card. Be careful not to contaminate the
remaining test circles. Use new tip and spreader for each sample. Carefully label each sample
with a patient name or number
●● Attach dispensing needle to a syringe. Shake antigen.* Draw up enough antigen for the
number of tests done (one drop per test).
●● Holding the syringe vertically, allow exactly one drop of antigen to fall onto each test sample.
Do not stir.
●● Rotate the test card smoothly on the palm of the hand for 8 minutes (or rotate on a
mechanical rotator.)

Interpreting results
After 8 minutes rotation, inspect the card in good light. Turn or tilt the card to see whether
there is clumping (reactive result). Test cards include negative and positive control circles for
comparison.
Interpretation of 1. Non-reactive (no clumping or only slight roughness): Non reactive for
test results syphilis

2. Reactive (highly visible clumping): Reactive for syphilis

3. Weakly reactive (minimal clumping): Reactive for syphilis

Note: Weakly reactive can also be more finely granulated and difficult to
see than this illustration
* Make sure antigen was refrigerated (not frozen) and has not expired.

Correlation and confirmation of test results

●● Tests for syphilis detect antibodies, which are evidence of current or past infection.
●● Non-treponemal tests (such as RPR test and VDRL test ) are the preferred tests for screening.
These tests detect almost all cases of early syphilis, but false positives are possible. RPR test
can be performed without a microscope.

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●● Quantitative RPR test titres can help evaluate the response to treatment.
●● Treponemal tests, such as Treponema pallidum haemagglutination test (TPHA), fluorescent
Treponema antibody absorption test (FTA-Abs), microhaemagglutination assay for antibodies
to Treponema pallidum (MHA-TP), if available, can be used to confirm non-treponemal test
results.

Quantitative RPR test titres can help evaluate the response to treatment.

RPR Quantitative Slide test

Additional Equipment and Reagent
1) Micropipette (1000ul) with blue plastic tips.
2) Normal Saline (0.9 %)
3) Test tubes or Cuvettes- 6 to 8 per reactive serum.
4) Rubber teats
Procedure:
A) Preparing sera in dilutions -
1) Take 6 test tubes (cuvette),label them from 1-6 and keep them in a rack.
2) Pipette 0.5 ml normal saline in each tube.
3) Pipette 0.5 ml of test serum in tube 1 and mix well. (Serum dilution = 1:2).
4) Take 0.5 ml of diluted serum from test tube 1 and add to tube 2. Mix well and transfer
0.5 ml to test tube 3, mix well and go on adding 0.5 ml of diluted serum to next tube till
tube 6 is reached. The dilution obtained in these 6 tubes are 1:2, 1:4, 1:8, 1:16, 1:32,
1:64 respectively.
5) Dilutions can be done up to 1: 1024 levels by following above described procedure.
B) Performing quantitative testing of diluted sera -
6) Take a RPR card and add 0.5 ml of serum from the sixth tube on one circle as shown in
figure 9.
7) Similarly add 0.05 ml of serum from the tube no 5, 4, 3, 2 and 1 in the remaining circles
respectively.
8) In circle 1 take 0.05 ml of neat, undiluted serum as for the qualitative test.
9) Positive and negative controls for each qualitative test should be incorporated.
10) Add 1 drop (1/60 ml) of RPR antigen to each circle with a 18 gauge needle and syringe.
11) Rotate the card on a RPR/VDRL rotator for 8 min or as oer manufacturers instruction
making a diameter of 3/4 inch and rotating at a speed of 180 RPM.
12) Observe the card immediately under 10 x magnification of light microscope.
13) Report the titer as the highest dilution of serum that shows a reactive result.

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Reporting:

Undiluted Serum Serum Dilution* Report

(1:1)* 1:2 1:4 1:8 1:16 1:32
R W N N N N Reactive undiluted only or 1 dil +
R R W N N N Reactive, 1:2 dilution, or 2 dils
R R R W N N Reactive, 1:4 dilution, or 4 dils
W W R R W N Reactive, 1:8 dilution, or 8 dils
N (ROUGH) W R R R N Reactive 1:16 dilution, or 16 dils
W N N N N N Weakly reactive, undiluted only or 0 dil
*R = Reactive W = Weakly Reactive N = Non-reactive
+ A titre of 1:1 means that the serum was reactive in a dilution of 1 to 1. This may also be termed as “1 dil”

The following table can be used to interpret syphilis test results.

Note: where additional tests are not available, all patients with reactive RPR or VDRL should be
treated.

Interpreting serological test results

RPR RPR titre TPHA

Active infection + >1:8 +
Latent syphilis + Often <1:4 +
False positive + Usually <1:4 -
Successful treatment + or - 2 titres decrease (e.g. from 1:16 to 1:4) +

Card with specimens

Fig 8: Test serum is mixed with antigen and the card is

placed on appropriate rotator

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Fig 9: Reading RPR test results for 10 undiluted sera showing reactive (1,2,3,5, 4: Borderline)
and non-reactive samples (6 – 10). The presence of small to large flocculated clumps indicates
reactivity, whereas no clumping or a very slight roughness indicates non-reactivity

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4. Laboratory tests for STI/RTI at various levels of

health care

The laboratory tests can be done at 3 tier level:

(i) Primary health care level:
At PHC following tests can be offered -
●● Microscopic examination of fresh and stained samples of urethral and cervical discharges
●● Wet mounts for examination of vaginal discharge.
●● Collect cervical samples such as Pap smears and send them to more sophisticated laboratories
for reading
●● RPR testing for syphilis can easily be done at the PHCs
●● In case of 24x 7 PHCs (ICTC centers) they may be able to do gonorrhoea cultures, confirmatory
tests for syphilis and HIV antibody testing.

(ii) Secondary health care level:

●● At CHC level laboratories are usually larger than at the PHC level
●● May have more skilled workers
●● More reliable infrastructure
●● They may be able to do gonorrhoea cultures, confirmatory tests for syphilis, HIV antibody
testing
●● If there is a cytotechnician, Pap (cervical) smears could be done and read.

(iii) Tertiary health care level:

●● These laboratories are usually located in a District hospital or teaching hospital
●● They have the highest level of services
●● Most of the above tests are done at these facilities

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CLIENT EDUCATION AND COUNSELING

Sr. No. Topic Page No

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1. Definitions of key terms used in Client education

Client education: For STI, giving relevant information based on public health needs. This includes
information on infections, transmission, recommended treatment, prevention, risk reduction,
behavior change, and partner referral. This information can be communicated one-on-one, in
group settings in the clinic; and via posters, videos, and brochures. It should involve all possible
staff. Client education requires teaching and group facilitation skills.

Interpersonal communication: The face- to-face process of giving and receiving information
between two or more people. This involves both verbal and non-verbal communication.

Verbal communication: The way we talk with clients, the words we use, and their meanings.

Non-verbal communication: The way we behave with clients, including actions, behaviors,
gestures, and facial expressions.

Behavior change communication: The process of developing and providing simple messages
based on proven information that suggests realistic ways to change risky behavior. This includes
exploration of life situation and risk, consideration of options, and skill building, practice, and
support to implement and sustain the behavior change

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2. Communicating with Clients on STI/RTI

Adult education principles

Acknowledge that adults learn:
●● 20% of what they hear.
●● 40% of what they hear and see.
●● 80% of what they do or discover for themselves.

Therefore, teaching clients to increase their awareness of STI/RTI, risk reduction, behavior change,
etc. must involve three things to be effective: action, feelings, and ideas. These correspond to the
areas of skills, attitudes, and knowledge in this training.

Types of communication
●● Interpersonal communication
●● Verbal communication
●● Non-verbal communication
●● Behavior change communication

Interpersonal communication
The face-to- face process of giving and receiving information between two or more people, involves
both verbal and non-verbal communication.

Verbal communication
●● Refers to words and their meanings.
●● Begins and ends with what we say and how we say it.
●● Is largely conscious and controlled by the speaker.

Verbal communication skills

●● Facilitation: Encouraging, summarizing, and checking with the Client to be sure you understand
her/his concerns.
●● Reassurance: Showing your support.
●● Direction: Guiding a Client back to the reason for the visit.
●● Empathy: A critical skill acknowledging feelings and showing you care.
●● Partnership: Offering your commitment to help.
●● Asking questions: Use open and closed- ended questions to get the information you need.

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ŠŠ Open questions: Invite the Client to give a long answer. (“Tell me more about your back
pain.” “What else is troubling you?”).

ŠŠ Closed questions: Require only a “yes” or “no” or very short answer. (“Is your back painful?”
“How old are you?”).

Non-verbal communication
●● Refers to actions, gestures, behaviors, and facial expressions that express how we feel in
addition to speaking.
●● Is often complex and largely unconscious.
●● Often reveals the real feelings or messages being conveyed.
●● Can involve all of the senses.

Behavior change communication

The process of developing and providing simple messages based on proven information that
suggests realistic ways to change risky behavior. This includes exploration of life situation and risk,
consideration of options, and skill building, practice, and support to implement and sustain the
behavior change

How to communicate with clients having STI/RTI

We all attach strong emotions, values, and attitudes to sex. Sometimes we are judgmental or
disrespectful toward clients who do not share our views. This leads to a client feeling attacked or
judged, a situation that makes learning difficult, and to poor understanding and compliance with
treatment.

Most of us, including health care providers, respond emotionally to words that relate to the sexual
organs and sexual activity.

Such words often make us uncomfortable. This is communicated to clients who then feel even
more uncomfortable bringing up their problems. Providers often use medical terms that clients do
not understand to cover up their own embarrassment about sex.

Be comfortable with the real words your clients use to communicate about sexual matters and use
them yourself when appropriate in order to:
●● Put clients at ease.
●● Make what you are saying understandable.
●● Make compliance with treatment and behavior change more likely.

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3. Client education on STI/RTI

Goals of client education

●● Primary prevention or preventing infection in uninfected clients. This is the most effective
strategy to reduce the spread of STI/RTI and can be easily integrated into all health care
settings.
●● Curing the current infection.
●● Secondary prevention, which prevents further transmission of that infection in the community
and prevents complications and re- infection in the client.

Where to find the opportunities for client education?

Client education does not happen only one-to-one. A friendly and supportive atmosphere clinic-
wide promotes client confidence and use of services. Important messages on prevention and
treatment can be reinforced everywhere in the clinic. The attitudes of all clinic staff, from cleaning
to administrative and laboratory personnel, may contribute significantly to the success of a STI/
RTI prevention and management program. To foster positive and welcoming behavior towards
clients with STI/RTI, it may be helpful to sensitize all clinic staff so that they are comfortable giving
out condoms, medications, and information on prevention and treatment. Positive, helpful staff
behavior can be encouraged by:
●● Holding staff training sessions on the importance of STI/RTI prevention and management.
●● Conducting values clarification exercises.
●● Staff participation in decision making around addition of new services.
●● Staff participation in the development of educational materials.

Prevention and quality of care can be promoted at various places around the clinic:

Waiting room – health talks, posters, pamphlets, videos, condom demonstrations.

Registration desk– friendly clerk, confidential ways to identify clients’ complaints (such as choosing
your problem from a list of pictures), brochures, condoms.

Laboratory – posters, information about condoms, condoms to take.

Client Examination area – friendly providers, written material, educational posters on the wall,
condom demonstration by provider, pictorial list of where to get STI/RTI and HIV testing and
services.

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What the client needs to know?

Prevention of STI/RTI
●● Risk reduction
●● Using condoms, correctly and consistently, availability of condoms
●● Limiting the number of partners
●● Alternatives to penetrative sex
●● Negotiating skills

Information about STI/RTI

●● How they are spread between people
●● Consequences of STI/RTI
●● Links between STI/RTI and HIV
●● STI/RTI Symptoms - what to look for and what symptoms mean

STI/RTI treatment
●● How to take medications
●● Signs that call for a return visit to the clinic
●● Importance of partner referral and treatment
●● Acknowledge gender inequalities, which may impact male Partners coming forward to seek
services

Risky behaviors
We know that certain behaviors increase the risk of STI/RTI transmission. Most of these behaviors
involve sexual activity and are called unsafe sex.

What is safer sex?

Safer sex is sex with a partner who is uninfected or any sexual activity that reduces the risk of
passing STI and HIV from one person to another.

Some safer sex practices

●● Mutually faithful relationship between two uninfected partners
●● Reducing the number of sex partners
●● Using a barrier such as a condom for all types of intercourse
●● Non-penetrative sexual practices such as kissing, hugging, rubbing, and masturbating
●● Avoiding sex when either partner has signs of a STI
●● Abstinence

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Some practices that make sex risky

●● Unprotected vaginal sex if you don’t know whether your partner is infected.
●● Sex with a partner who has signs of a STI.
●● Sex with a partner who has other partners.
●● Unprotected anal sex.
●● Unprotected oral sex.
●● Use of alcohol or drugs with sex.
●● Sex with an intravenous drug user.
●● Multiple partners.
●● Casual sex or sex with strangers.
●● Frequent change of partners.
●● Douching.
●● Use of vaginal drying agents

Principles of effective Client education

●● Shows respect and concern for the safety of clients through body language, telling clients you
are concerned, being attentive to and acknowledging clients’ feelings, and taking sufficient
time with them.
●● Is client-centered. Provides messages that are tailored for each individual –different message
for married men, women, and adolescents.
●● Involves 3 kinds of learning: through ideas, actions, and feelings (cognitive, psycho-motor, and
affective).
●● Uses multiple channels (eyes, ears and face-to-face/visual, auditory, interpersonal).
●● Delivers messages via the eyes, ears, and face-to-face communication.

Principles of behavior change for prevention

●● Give good information- Give clients clear and accurate information on risky behaviors, the
dangers of STI, and specific ways to protect themselves. Identify behaviors that put particular
clients at risk.
●● People need motivation to change a behavior- People change behavior as a result of a
personal experience or crisis. Meeting someone who has HIV/AIDS, hearing statistics about
HIV/AIDS, hearing about a family member or friend who is infertile due to a STI, hearing about
the children of someone who died of AIDS, or learning that a partner is HIV-positive are all
experiences that might motivate someone to change.
●● Identify barriers to behavior change- What keeps someone from changing behavior? Is it
personal views, lack of information, or social restraints such as the need to please a husband?

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●● Establish goals for behavior change - Set up short- and long-term goals that Client and provider
can agree upon.
●● Offer real skills -Teach negotiation skills for women, demonstrate how to use a condom, and
conduct role- playing conversations.
●● Offer choices- Clients need to feel that they have choices and can make their own decisions.
Offer substitute behaviors that are less risky.
●● Plan for setbacks- Rehearse how the client can deal with a situation that temporarily worsens
(for example, the husband becomes angry, or refuses to use condoms).

4. Counseling on STI/RTI

Counseling: Face-to-face, personal, confidential communication in which one person helps

another to make decisions and then to act on them. Good counseling has two major elements:
mutual trust between client and provider and the giving and receiving of relevant, accurate, and
complete information that enables the client to make a decision. It requires conversational and
listening skills

Client counseling on STI/RTI

During counseling session, provider should talk about causation, transmission, recommended
treatment, prevention, risk reduction, behavior change, and partner referral. Clinics can have take
away information brochures in simple local languages with illustrations to reinforce messages.

Guidelines for counseling

●● Welcome your client warmly by name and introduce yourself.
●● Sit closely enough so that you can talk comfortably and privately.
●● Make eye contact and look at the client as s/he speaks.
●● Use language that the client understands.
●● Listen and take note of the client’s body language (posture, facial expression, looking away,
etc.).
●● Seek to understand feelings, experiences and points of view.
●● Be encouraging. (Nod or say, “Tell me more about that.”)
●● Use open-ended questions.
●● Provide relevant information.

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●● Try to identify the client’s real concerns.

●● Provide various options for the client.
●● Respect the client’s choices.
●● Always verify that the client has understood what has been discussed by having the client
repeat back the most important messages or instructions.

Barriers to good counseling

●● Lack of privacy.
●● Not greeting or not looking at the client.
●● Appearing to be distracted (for example, by looking at your watch or reading papers while s/
he is talking).
●● Using a harsh tone of voice or making angry gestures.
●● Sitting while the client stands or sitting far away from the client.
●● Allowing interruptions during the consultation.
●● Being critical, judgmental, sarcastic, or rude.
●● Interrupting the client.
●● Making the client wait for a long time.
●● Not allowing enough time for the visit.

Guidelines for communicating with clients

Safer sex rules
●● Use protection (condom or other barriers) every time you have sex unless you have sex with
only one faithful partner who is uninfected.
●● Keep away from unsafe practices like “dry sex” that may break the skin—the vagina should be
wet inside when you have intercourse.
●● Do not have sex in the anus, but if you must, always use a condom with lubrication because
the skin there can tear easily and allow HIV to pass.
●● Try massage, rubbing, touching, dry kissing, hugging, or masturbation instead of intercourse.
●● Have oral sex with a male or female condom if this is acceptable to you.
●● DO NOT have sex when either partner has sores on the genitals or when there is a discharge
from the penis.

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Guidelines to teach the Client negotiation skills for safer sex

●● How to make sex safer

Have sex that does not let semen into the vagina, mouth, anus, or an open sore. Safer sex
can be real sex, and not just “eating a sweet with the wrapper on.” Couples can talk about
sex together to learn to please each other. Bargain for safer sex. Safer sex can be more
pleasurable for both partners because it is less likely to cause worry, discomfort, or disease.
Instead of intercourse, try outer course, which is having sex without putting the penis into the
vagina.

●● Use condoms

Male condoms are the most effective way to prevent transmission of all STI/RTI (including
HIV), during sexual intercourse. If the man will not use condoms, the woman can use one of
the other barrier methods that might help protect her.

These methods include

1. The female condom

2. The diaphragm or cervical cap

3. Spermicide cream, jelly, film, foam, or foaming tablets

4. Vaginal sponge

These methods have been shown to be somewhat effective against bacterial STI/RTI, but not
HIV. Frequent use of spermicides, in fact, may increase the risk of becoming infected because
it irritates the vaginal lining, which makes it easier for HIV, and probably STI/RTI, to enter the
body. No method works perfectly all the time to prevent HIV/AIDS. But if you use male condoms
correctly every time you have sex, you will be 90% protected.

●● Negotiating for safer sex

Negotiating for safer sex is similar to negotiating for other things that we need. Thinking about
how to negotiate successfully in other areas will help. A way to begin is for someone to decide
what s/he wants, and what s/he is willing to offer in return.

●● Focus on safety

In bargaining for safer sex, the focus should be on safety, not lack of trust, blame, or punishment.
It is easier to reach agreement around safety because both people benefit from it.

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●● Use other people’s as examples

Knowledge that others are practicing safer sex can make it easier to start.

●● Ask for help if you need it

Inviting another trusted person to help discuss safer sex with a Partner may make it easier.

Summary table for client education and counseling

Health education
As a part of STI/RTI Counseling
To raise awareness For prevention
management
Talk about STI/RTI and Promote correct and Emphasize Discuss risk and
its complications consistent condom compliance with vulnerability
use treatment
Explain about Encourage fewer Promote condom Examine barriers to
symptoms and how to sexual partners use (including during prevention
recognize them treatment to avoid
re-infection)
Promote early use of Support delay in Encourage referral Discuss solutions and
services starting sex (for young of partners for build skills for safe sex
individuals) treatment
Make a plan and
follow up

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5. Integrated counseling and testing centers (ICTC) and

their role in STI prevention and management

Clients with STI have shown high-risk sexual behaviour. Based on this high-risk behavior, the health
care worker should inform the client about the links between STI and HIV and should encourage all
clients to undergo an HIV test, as the risk of HIV among STI is upto 10 times higher. In order to get
HIV test, Integrated Counseling and Testing Centers (ICTC) have been established. Each ICTC has
counselor(s) and a laboratory technician. As of November 2009, there are 5330 counseling centers
and more are being established. ICTCs are located in the medical colleges, district hospitals in
all states and in addition in selected CHCs and PHCs especially in the high prevalence states. It is
envisaged to establish ICTCs at all CHC and additional at selected PHCs in all states.

In Integrated Counseling and Testing Centers the STI Client will receive comprehensive and
accurate information on HIV/AIDS and HIV counseling to facilitate an informed choice regarding
an HIV test. The integrated centers serve as single window system by pooling all counselors and
laboratory technicians working in ICTC, PPTCT, blood safety, STI, ART/OIs and HIV - TB together to
offer round the clock counseling and testing services. This common facility will remove fear, stigma
and discrimination among the clients, PLHAs and the referrals.

The ICTC have common television and video based health education materials that are screened
continuously in the clients waiting area. The information related to preventive, promotive and
curative health care along with information regarding HIV/AIDS, and various services provided by
the hospital is provided to all the clients.

Opt-out strategy – In this, the counselor “assumes” that the client has come to get an HIV test
(implied consent). The HIV test will be done unless the client actively denies the test.

Opt-in strategy – In this, the counselor specifically asks the client, whether s/he would like to
undergo the HIV test. The client has to actively agree to the HIV test.

As per the National AIDS Prevention and Control Policy, all HIV tests are voluntary, based on the
clients consent, accompanied by counseling and confidentiality of the results.

Aims of pre-test counseling

●● To ensure that any decision to take the test is fully informed & voluntary
●● To prepare the client for any type of result, whether negative or positive or indeterminate
●● To provide client risk reduction information & strategies irrespective of whether testing
proceeds

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The clients are advised about preventive measures and use of condoms.
If the client declines to take the test, he/she leaves the ICTC. Some clients return to the ICTC after
a few days for the test. If the client agrees to undergo the test, he/she proceeds to the attached
laboratory for blood collection. After the blood sample is taken, the client either waits for the
results or is asked to return on assigned date with Patient Identification Digit (PID) number

The tests are performed by using the rapid test kits. If the test is negative and the client has
history of high risk factors, he/she is advised to repeat the test after 3 months as he/she may be in
the window period. If the result is positive the test is repeated with kits using a different method
of antibody detection. The result is considered positive if all three tests are positive. Before the
results are revealed to the client, post counseling is done.

Aims of post- test counseling aims to:

●● Help client understand and cope with the HIV test results
●● Provide the client with any further information required
●● Help clients decide what to do about disclosing their test result to partners and others
●● Help clients reduce their risk of HIV/ AIDS and take action to prevent infection to others including
condom, avoiding multiple partners and other high-risk behavior (Positive prevention).
●● Help clients access the medical and social care and support they need
●● Establish link with PLHA groups, if needed

In STI settings, the following is recommended

●● HIV testing should be recommended for all STI clients after pre-test counseling and informed
consent. There should be guarantee for confidentiality. Clients should be referred to the
nearest ICTC.
●● In some cases of STI in the presence of HIV infection, larger doses and longer treatment
duration of the drugs listed under the different STI may be required. These clients should be
followed up regularly for longer duration.
●● Excessive use of anti-microbials should be avoided, as it is likely to lead to more rapid
development of antibiotic resistance.
●● Although counseling of individual clients on risk reduction, and prevention of STI transmission
to the partners should be done in all clients of STI, this is of vital importance for those infected
with HIV.

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6. Glossary of STI/RTI related terminology

S. No Terms Meaning
1. Sexual Aberration A sexual activity, which differs from those generally,
practised, or considered ‘right’ or ‘moral’; also called
deviation, paraphilia or perversion
2. Adultery Sexual intercourse between a married person and an
individual other than his or her legal spouse
3. AIDS Acquired Immune Deficiency Syndrome; a fatal viral disease
that impairs the body’s ability to fight infections and cancers;
while the disease may be treated, the underlying immune
deficiency cannot up to now be cured by any means.
4.
5. Anal intercourse Sexual intercourse in which the penis is inserted into the
partner’s anus; sometimes termed sodomy or buggery
6. Anilingus The act of using the mouth or tongue in erotic stimulation
of the anus (the rim)
7. Aphrodisiac or Zoophilia Anything, such as drug or perfume, that is believed to
stimulate sexual desire
8. Bestiality Sexual relations between a human and an animal
9. Bisexual a. Having a sexual interest in, or sexual relation with, both
sexes (‘AC-DC’)

b. Literally, having sex organs of both sexes, as in

hermaphrodites
10. Celibacy a. The state of being unmarried, usually implying sexual
abstinence

b. Abstaining from sexual intercourse

11. Clap A layman’s expression for gonorrhoea
12. Coitus / Copulation Sexual intercourse between a male and a female, in which
(To engage in coitus, to the penis is inserted into the vagina
bang, to fuck, to lay, to
screw, to climb on)
13. Coitus interruptus The practice of withdrawing the penis from the vagina just
(premature withdrawal, before ejaculation;
pulling out)

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S. No Terms Meaning
14. Condom (French letter A contraceptive commonly used by males and recently
or FL, rubber sheath, introduced for females. For males it consists of a rubber or
Nirodh) In females the gut sheath that is drawn over the erect penis before sexual
condom is placed in the intercourse
vagina.
15. Fellatio (penilingus) The act of taking the penis into the mouth and sucking it for
(a blow job; to blow, to go sexual pleasure
down on, to eat, to suck)
16. Fidelity Being faithful to one’s chosen or given sexual Partner(s) and
having sexual intercourse only with that / those partner(s)
17. Fondling Touching or stroking lovingly; caressing
18. Foreskin (Prepuce) The skin covering the tip of the penis or the clitoris
19. French kissing (deep Use of the tongue in kissing; thrusting of the tongue into the
kissing or wet kissing) partner’s mouth during a kiss
20. Gay Another term for male homosexual
21. Glans The head of the clitoris or the penis; comes from the Latin
term for acorn
22. High-risk behaviour Term used to describe certain activities which increase the
risk of transmitting an STI; includes frequent change of
sex partners, anal and vaginal intercourse without using a
condom, oral-anal contact, semen or urine in the mouth,
sharing intravenous needles or syringes, intimate blood
contact and sharing of sex toys contaminated by body fluids;
often referred to as ‘unsafe ‘activities
23. HIV Human immunodeficiency virus which renders the human
immune (defense) system deficient and unable to resist
opportunistic infections and the development of specific
cancers
24. HIV – sero negative When HIV antibodies are not detected in the body
25. HIV- sero positive When HIV antibodies are detected in the body
26. IDU Injecting drug users
27. Impotence (Erectile Inability of a man to have sexual intercourse; usually refers
dysfunction) to inadequacy of penile erection
28. Incest Sexual intercourse between close relatives, such as father
and daughter, mother and son, or brother and sister
29. Labia majora The major or outer lips of the vulva
30. Labia minora The minor or inner lips of the vulva
31. Lecherous Being very lustful
32. Lesbian A female homosexual
33. Libido Sexual drive, interest or urge

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S. No Terms Meaning
34. Masturbation (Hand Self stimulation of the genitals through manipulation;
practice, playing with autoeroticism; self gratification
oneself)
35. Missionary position Face to face coital position with the male on top of the
female
36. Monogamy A marital arrangement in which a person has only one
spouse
37. Nymphomania The constant, extreme and irrepressible desire of a woman
for sexual satisfaction
38. Oral –genital sex Application of the mouth or tongue of one partner to the
genitals of the other
39. Oral-sex (head job, come Sexual activity which involves mouth contact with another
down on, eat each other) person’s genitals or anus; contact may include kissing,
sucking or licking of the sexual organs
40. Orgasm (The big O, to The peak or climax of sexual excitement in sexual activity
experience orgasm, to
come)
41. Paedophile An adult who engage in or desires sexual activity with a child
42. Partner exchange The planned exchange of sexual partners between four or
(Swinging, swapping) more individuals
43. Pederasty 1. Male sexual relations with boy, often- anal intercourse

2. Sexual relations via the anus

44. Petting (Making out, Sexual contact that excludes coitus
necking, dry fuck, dry lay)
45. Polyandry The form of marriage in which a woman has several
husbands
46. Polygamy A marital arrangement in which a person has more than one
spouse
47. Polygyny The form of marriage in which a man has several wives
48. Pornography The explicit description or exhibition of sexual activity in
literature, photographs, films, etc, intended to stimulate
erotic rather than emotional feelings
49. Promiscuous Engaging in sexual intercourse with many persons; engaging
in causal sexual relations
50. Prostitute A person who engages in sexual relationships for payment
(hooker, streetwalker, whore, pros); nowadays referred to
as a commercial sex worker to avoid a negative bias
51. Prostitution Engaging in sexual activity for money
52. Sadism The achievement of sexual gratification by inflicting physical
or psychological pain upon the sexual partner

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S. No Terms Meaning
53. Sado-masochism A form of behaviour in which sex and pain become
pathologically attached bondage, discipline
54. Safe- sex Term used currently to describe sexual activities mostly to
reduce the risk of transmission of STI; includes always using
a condom during sexual intercourse, mutual masturbation,
dry kissing, massage, fantasy, touching; opposed to unsafe
sex practices
55. Vaginal lubrication A clear fluid (like sweat) that appears on the walls of the
vagina within a few seconds after the onset of sexual
stimulation
56. Virgin A woman or girl who has never had sexual intercourse

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CONDOM AND IT’S PROPER USAGE TECHNIQUE

Sr. No. Topic Page No

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1. Condoms for STI/RTI prevention

Condom is one of the barrier methods of contraception. They are made by using either latex or
polyurethane, which cannot be penetrated by sperm, STI or HIV organism, so it provides dual
protection, helps in avoiding unwanted pregnancies and gives protection against STI. Therefore
promotion of the use of condoms and ready accessibility of condoms is important for the control
of STI and HIV. Management of STI includes counseling on preventive measures and use of
condoms. All health facilities providing STI services must always have in stock the essential drugs
and condoms. The necessity of using condoms must be explained to the clients along with the
advice on the treatment schedule and important for compliance of the full course of medicines
prescribed.

General Instructions for condom use

Remember:
The condom does not include spermicide. If you want additional protection, you must add your
own spermicide.

Use a new condom each time you have sex.

Use a condom only once.

For best results, store condoms in a cool, dry place.

Do not use a 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 color is uneven or has changed.

The condom is unusually sticky.

Male Condom
Most male condoms are made of latex, while some are made of polyurethane. Male condoms are
of two types: Non lubricated and lubricated.

Female condom
Female condoms are made of polyurethane. One advantage of it over the male condom is that its
size and shape enable it to cover the wider surface area including some of the external genitalia,
thus it may offer additional protection against infections that can be transmitted by contact with
skin normally not covered by a male condom. However, the female condom is expensive. It is
freely available in open market but not yet included in the National Family Welfare program.

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2. How to use a condom

How to use a male condom

Step 1: Open package

●● Use a new condom each time you have sex
●● Check that it has not expired and that the packaging has no holes by
pressing the pack between your fingers
●● Push condom to one side of package to allow room to tear open other
side
●● Remove condom carefully
●● DO NOT use finger nails, teeth or sharp objects to open package or
remove condom
Step 2: Put it on
●● Squeeze closed top end of condom to make sure no air is inside (can
make it break)
●● Place condom over top of erect penis
●● With other hand, unroll condom gently down the full length of your
penis (one hand still squeezing top end)
Step 3: During sex
●● Make sure condom stays in place
●● If it comes off, withdraw your penis and put on a new condom before
intercourse continues
●● Once sperm has been released into condom (ejaculation), withdraw
the erect penis and HOLD the condom in place on penis
Step 4: Dispose of condom
●● Remove condom ONLY when penis is fully withdrawn
●● Keep both penis and condom clear from contact with your Partners
body
●● Knot the end of the used condom

●● Place in tissue or bag before throwing it in dustbin

●● DO NOT flush condoms down the toilet. It will block the system.

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3. How to use a female condom

Before intercourse
Step 1 : Open package
●● Remove the female condom from the package, and rub it between
two fingers to be sure the lubricant is evenly spread inside the
sheath. If you need more lubrication, squeeze two drops of the extra
lubricant included in the package into the condom sheath.
Step 2 : Put it in
●● The closed end of the female condom will go inside your vagina.
Squeeze the inner ring between your thumb and middle finger.

Step 3 : Assure right position

●● Insert the ring into your vagina. Using your index finger, push the
sheath all the way into your vagina as far as it will go. It is in the right
place when you cannot feel it. Do not worry, it can't go too far.
Note: The lubrication on the female condom will make it slippery, so take
your time to insert it.
During sex
Step 4 :
●● The ring at the open end of the female condom should stay outside
your vagina and rest against your labia (the outer lip of the vagina).
Be sure the condom is not twisted.
●● Once you begin to engage in intercourse, you may have to guide
the penis into the female condom. If you do not, be aware that the
penis could enter the vagina outside of the condom's sheath. If this
happens, you will not be protected.
After intercourse
Step 5: Dispose of condom
●● You can safely remove the female condom at any time after
intercourse. If you are lying down, remove the condom before you
stand to avoid spillage.
●● Throw the female condom away. Do not reuse it.

During intercourse remember to remove and insert a new female condom if: Condom rips or tears
during insertion or tears during insertion or use, the outer ring is pushed inside, the penis enters
outside the pouch, the condom bunches inside the vagina, or you have sex again.

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 MODULE NO. 12

MANAGEMENT OF SEXUAL VIOLENCE

Sr. No. Topic Page No

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1. Health services and sexual violence

Sexual violence is defined as “any sexual act, attempt to obtain a sexual act,
unwanted sexual comments or advances, or acts to traffic women’s sexuality, using
coercion, threats of harm or physical force, by any person regardless of relationship
to the victim, in any setting, including but not limited to home and work”.
Often, because the victims feel uncomfortable talking about sexual violence, they
may come to the clinic with other non-specific complaints or requesting a check-
up, assuming that the health care provider will notice anything abnormal that
needs treatment. Therefore, health care workers should maintain a high index of
suspicion and ask about experience of sexual violence or abuse.

What services should be made available for a victim of Sexual violence?

The following services should be available, on-site or through referral, for Clients
who have experienced sexual violence:

1. Visual inspection
Before proceeding for examination consent of the victim or the legal guardian in
case of minors (less than 18 years) must be taken. Counseling of the victim must
be done. Examination of clothes, injuries and genital must be carried out. Look
for injury, erosions, scratch marks, bleeding, discharge, odour, irritation, warts and
ulcerative lesions.

2. Collection of Medicolegal evidence

Medicolegal examination should be available to document evidence if the person
chooses to take legal action. Staff should be trained in how to take forensic
specimens, or referral links should be made. Forensic examination must include
physical and genital examination. (Refer to the State-specific guidelines for forensic
examination).

3. Collection of samples for detecting STI/RTI

If facilities permit, swabs must be collected from various sites for wet mount
examination or culture of a number of causative organisms. Blood could be
collected for VDRL/RPR, HIV and HbsAg tests. If facilities are not available, sample
collection not to be done and refer the victim where appropriate health care facility
is available.

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4. Essential medical care for injuries and health problems

Medical management includes:
●● Care of injuries
●● Prevention of pregnancy by offering emergency contraception
●● STI prophylaxis

Note: It is important to obtain informed consent for any examination, treatment or

referral in a case of a victim of sexual assault.

2. Medical management of sexual violence

Medical management includes:

●● Prevention of pregnancy by offering emergency contraception
●● STI chemoprophylaxis
●● Care of injuries

Post exposure prophylaxis against pregnancy

Emergency contraception (EC) to prevent unwanted pregnancy should be given
within 72 hrs of unprotected sexual intercourse.

Post exposure prophylaxis with Emergency contraceptives

Type of Emergency contraception Dose and schedule
Levonorgestrel-only pills (contains 0.75 Levonorgestrel to be taken in 2 doses
mg of levonorgestrel per pill)
First dose- to be taken within 72 hours
after unprotected intercourse
Second dose- same dose to be taken
after 12 hrs of first dose

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Post exposure prophylaxis of STI

STI prophylaxis should be started as early as possible, although the doses should be spread out
(and taken with food) to reduce side effects such as nausea.

A. Post exposure prophylaxis of STI for adults and older children and adolescents weighing more
than 45 kg.

1. For protection against chancroid, gonorrhoea and chlamydia

●● Tab. Azithromycin 1gm orally on empty stomach, single dose under supervision
+
●● Tab. Cefixine 400mg orally after food single dose

2. For protection against T. Vaginalis and B. vaginosis

●● Tab Metronidazole 2gm orally after food single dose

OR
●● Tab Tinidazole 2gm orally after food single dose

B. Post exposure prophylaxis of STI for adult, adolescents & children weighing under 45 kg.

1. For protection against chancroid and chlamydia

●● Azythromycin 20 mg/kg of body weight in empty stomach single dose orally.

2. For protection against gonorrhoea

●● Cefixime 8 mg/kg of body weight as a single dose,
OR
●● Ceftriaxone 125 mg by intramuscular injection, single dose

3. For protection against T. Vaginalis

●● Metronidazole 15 mg/kg of body weight orally 3 times a day for 7 days

Post sexual exposure prophylaxis of HIV

Refer to district hospital and follow NACO guidelines for the same.

* Sexually transmitted disease, 4th edition, King K Homes

Post sexual exposure prophylaxis against hepatitis B

If not vaccinated earlier, it is recommended. If vaccine is not available, refer to the centre where
Hepatitis B vaccination facilities are available.
An evaluation of the person’s personal safety should be made by a protective services agency or
shelter, if available, and arrangements made for protection if needed.

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Psychosocial support (both at time of crisis and long-term)

sychosocial management includes counseling and supportive services, which should be available
on-site or by referral. Women or children who have been sexually abused may need shelter and
legal protection. Adolescents in particular may need crisis support, as they may not be able or
willing to disclose the assault to parents or care takers.

Follow-up services for all of the above

It is essential to explain the importance of follow-up appointments and services during the first visit
itself. The woman should be clearly told whom to contact if she has other questions or subsequent
physical or emotional problems related to the incident.

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 MODULE NO. 13

MEN HAVING SEX WITH MEN AND TRANSGENDER AND

INJECTING DRUG USERS

Sr. No. Topic Page No

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1. High Risk Group (HRG) population and their role in

prevention and control of STI/RTI

Preventing transmission of STI/RTI among people, who have multiple partners, is the single most
effective strategy to reduce the number of new infections within the general population.

Women and men, who exchange sex for money, services or favors on a regular basis are most at
risk, exposed to and can transmit infections at a higher rate than others in the population. Like all
sexually active women and men of reproductive age, these women and men have reproductive
health needs and may come to PHC to avail family planning services. A provider needs skills to
help these women and men who are at high risk, to welcome them non-judgmentally, and to
treat them with the same care like their other clients. Because of their high potential to transmit
infections to others, the most at risk population especially sex worker needs effective treatment
whenever and wherever they present for care, as well as knowledge and skills to promote condom
use with their regular partners and customers.

Who are the people whom we can say as High Risk Group?
High risk group population comprises the people who sells sex for money or favors ( the female sex
workers), men having sex with men (MSMs), and intravenous drug users (IDUs).

What all HRG have in common is that their work puts them at high risk for STI/RTI. As health
workers, it is important to be able to identify these HRG individuals at risk and give them the care
they need in a non- judgmental and compassionate way.

HRG and STI/RTI

Not everyone in the population has the same probability of becoming infected with STI/RTI or
transmitting them to others. Female sex workers, MSMs, IDUs have the highest rates of transmission
of HIV. The reasons for the high rates of infection and transmission for sex workers include their
high number of sexual contacts, as well as co-factors such as the presence of other STI, concurrent
substance abuse and/or poor health status and lack of access to health services.

It has been observed that in some communities, as many as 6 out of 10 sex workers are infected
with HIV. Providing services to sex workers such as distributing free condoms, STI treatment and
enabling them to adopt safer behavior can have the greatest impact on slowing STI transmission
in the larger community.

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Barriers to services
●● Because of the mindset of community, there is a stigma for HRG population and therefore they
are not always welcome by general population.
●● Though women and transgenders who trade sex are often at the highest risk for STI/RTI, they
are often the least likely to seek STI/RTI services.
●● The female sex workers also has the same kind of barriers to care for themselves that affect
all women
●● HRG often find that services may be highly stigmatized. The providers may judge her harshly
as immoral and may treat her badly.

Possible solutions
Integration or linkage of STI/RTI services with the RCH services where a sex worker comes for family
planning may solve some of the problems of stigmatization, cost, and accessibility. Taking services
to communities or workplaces of sex workers such as target interventions that visits workplaces of
sex workers may help in reaching out to a large number of sex workers

2. STI/RTI services and treatment strategies for HRG

Providing care for HRG

●● You can make a big difference in the life of HRG by helping them get the care they needs and
prevent transmission of STI to the wider population.
●● Give the same respectful care to HRG as you gives to others.
●● Learn which medications provide the most up-to-date, effective, and affordable treatment;
make sure to keep a supply available.
●● Find a regular and adequate supply of free or cheap condoms.
●● Link up with organizations doing social marketing of condoms to make them available at clinics,
shops, bars, cafes, and from outreach workers.

Presumptive treatment
●● The presumptive treatment is advised ONLY for female sex workers and Men having sex with
men including transgenders.
●● Presumptive treatment is NOT offered to IDUs.

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●● The advantage of presumptive treatment is that high-risk individuals who may not have
symptoms are treated.
●● Presumptive treatment (the provider presumes that FSWs and MSM & TGs has been exposed
to infection because of their work and inability to use condoms with every customer) can be
effective.
●● Presumptive treatment, prevention education, and condoms if provided to FSW and MSM
then rates of all STI will decline among them.
●● While presumptive treatment strategy can have a significant effect on prevalence of STI/RTI
both in FSW and MSM and their partners, it cannot stand on its own. Community interventions,
which emphasize prevention, condom use in men, and the use of improved STI/RTI services,
should also be part of an integrated strategy.
●● Tab Azithromycin 1 gm and Tab Cefixime 400 mg are given under observation at clinic under
the guidance of MO as Presumptive treatment to FSW and MSM, when they visit the STI clinic
without any symptom or sign for first time and after six consecutive months from the last visit
to the clinic.

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Flowchart: Management of STI during routine visit by female sex workers

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Flowchart: Flowchart for routine visit by male and transgender sex workers
in clinics

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 MODULE NO. 14

PREVENTING STI/RTI IN ADOLESCENTS

Sr. No. Topic Page No

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1. STI/RTI among Adolescents and Youth

WHO has defined adolescents as those between the age group of 11 to 19 whereas youth between
the age group of 15-24.

Many PHCs do not offer services to unmarried adolescents. Services such as family planning for
women under age 18 or for those who are unmarried are many a time denied. At the same
time pregnancy, abortion, and STI rates in young women are high, accounting for a large part of
maternal morbidity and mortality.

Adolescent girls are particularly vulnerable to STI since they are less likely to have access to health
services and to recognize symptoms. Health services for adolescent boys are also extremely limited.

Lack of education about sexual health for both boys and girls leaves them ill equipped to make
important choices to protect themselves against unwanted sex, pregnancy, and STI. The AIDS
epidemic gives a new urgency to STI prevention and is also an opportunity to protect new
generations from the devastating effects of AIDS by making information and services available.

The magnitude of STI/RTI among Adolescent and Youth

●● Adolescents and youth in the age group 10-24 years contribute to about 30% of our population.
According to Census 2001, there are 225 million adolescents comprising nearly one fifth (22%)
of India’s total population, out of which 12% belong to the 10-14 yrs age group & nearly 10%
are in the 15-19 yrs age group.
●● The data from various Indian studies reveal that adolescents indulge in pre-marital sex more
frequently and at an early age.
●● More than half of the currently married illiterate females are married below the legal age of
marriage. Nearly 20% of the 1.5 million girls married under the age of 15 are already mothers.
Nearly 27% of married females adolescents have reported unmet need for contraception.
●● STI, including HIV, are most common among young people aged 15-24 years and more so in
young women. Over 35% of all reported HIV infections in India occur among young people in
the age group of 15-24 yrs indicating that young people are highly vulnerable. The majority
of them are infected through unprotected sex. An estimated 1 in 20 youths contracts STI/RTI
each year and one-third of all STI occur among 13–20-year-olds (110 million STI/year).
●● Mortality due to pregnancy and its outcomes in married female adolescents of 15-19 yrs is
higher than adult females who are in the reproductive age group. 35% of women hospitalized
for septic abortion are under age 20.

These statistics document the extent of unprotected sexual activity among youth and the
clear need to protect young women against both STI/RTI and pregnancy. We have to seek
the opportunity to educate, prevent, and treat STI/RTI, when young women already come for
abortion and care of pregnancy, in PHC setting.

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Protection against infection and pregnancy involve the same strategies and services used for
adults.

Young men can be involved in both family planning and STI/RTI prevention if their need for
information and treatment is addressed.

Why Adolescent and Youth are at risk STI/RTI?

●● The female genital tract is not mature and is more susceptible to infection (a biological risk for
girls).
●● Young men often have a need to prove sexual powers.
●● Adolescent and youth lack in negotiation skills and females have submissive attitudes towards
men.
●● Young men may have their first sexual experiences with sex workers.
●● Young women may have their first sexual experiences with older men.
●● Youth lack accurate knowledge about the body, sexuality, sexual health and STI.
●● There is a lack of political will to educate youth: no health/sexuality education, poor
communication between youth and elders, lack of materials directed at youth on the subject.
●● Youth lack control over their sexuality and are subject to early marriage, forced sex, and
poverty. In other words sex in exchange for social security.
●● Changing partners is more common among youth than among older men or women who may
be in stable relationships.

Therefore there is an urgent need for improving the accessibility of adolescents to preventive and
curative services including information and counseling.

Clinical presentation of STI/RTI in adolescents

The presenting symptoms of adolescents are very peculiar as very often they present with symptoms
other than those of STI/RTI. Therefore risk assessment plays a crucial role. The increasing tendency
of homosexual behavior as reported by some studies must also be kept in mind and ano-genital
lesions must be looked for.

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Girls Boys
In general among adolescent females, an RTI While among adolescent males STI is the main
rather than an STI, is the main cause of vaginal cause of urethral discharge.
discharge e.g. endogenous vaginitis.
Gonorrhoea among boys presents as proctitis,
Approximately 85% of gonococcal infection in urethral discharge, symptomatic pyuria, penile
females is asymptomatic. edema, epididyimitis and testicular swelling.
Disseminated gonorrhoea presents with
However, there may be vulval itching, minor
multiple systemic manifestations.
discharge, urethritis or proctitis.

In pre-pubescent girls, a purulent vulvo-

vaginitis may occur.
Similarly, Chlamydia trachomatis infection is While Chlamydia trachomatis infection in
also asymptomatic in the majority of cases. adolescent males presents as urethritis
Symptoms that may occur in the adolescent are
inter-menstrual bleeding, postcoital bleeding
and an increase in vaginal secretions
Candida albicans is uncommon in adolescents While in adolescent males infection due
prior to puberty. If present, the adolescent may to Candida albicans is causing urethritis
have a discharge, vulval itching, dyspareunia, uncommon
peri-anal soreness or a fissuring at the introitus.
Attacks of candida vulvitis may be cyclical in
nature and corresponds to menstruation.
The signs of acquired syphilis in children While in adolescent males, signs of acquired
present with small chancres or mucocutaneous syphilis is same as that of adult males
moist lesions either on the vulva or anus.
Presentation of syphilis is the same in
adolescents and adults
Bacterial vaginosis does not produce vulvitis
and the adolescent will not complain of itching
or soreness.

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2. Addressing STI/RTI among Adolescents and Youth

Barriers to information and services for youth

●● Lack of services: little access to family planning or services for treatment or prevention of STI
●● Lack of access to condoms
●● Provider, parent, teacher, and community attitudes about youth and sexuality
●● False belief that young people are not sexually active, and that information will increase sexual
activity
●● Lack of messages targeted to youth
●● Lack of providers trained to deal with youth

Overview of the Adolescent Reproductive and Sexual Health Strategy

(ARSH)
The Govt. of India has realized that the health situation of adolescent and youth will be central
in determining India’s health, mortality, morbidity and population growth scenario. Investment
in adolescent reproductive and sexual health will yield dividends in terms of delaying age at
marriage, reducing incidence of STI and reducing the proportion of HIV positive cases in 10-19 age
group. This will also help India in realizing its demographic bonus, as healthy adolescents are an
important resource for the economy.

The 10th five year plan recognizes adolescents as a distinct group for policy and programme
attention. The national population policy 2000 identifies adolescents as an undeserved group for
which health specifically reproductive and sexual health interventions are to be designed. The
national youth policy 2003 recognizes 13-19 yrs as a distinct age group, which is to be covered in
progammes of all sectors including health, education, science and technology etc. In this regard
the youth ministry has devised special programmes for adolescent health and empowerment.

Accordingly a national strategy for adolescent reproductive and sexual health (ARSH) has been
developed and in the National Rural Health Mission (NRHM) ARSH strategy has been approved
as a part of the Reproductive and Child Health Phase II (RCH II). Various States as a part of their
State and District RCH II plans have adopted this national strategy. This strategy is now to be
implemented in the districts in the primary health care setting.

ARSH strategy in National RCH II PIP?

The goals of the Govt. of India’s RCH II are reduction in IMR, MMR and TFR. In order to achieve these
goals the RCH lists out four technical strategies. One of the technical strategies is for adolescent
health.

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A strategy for ARSH has been approved as part of the national RCH II programme implementation
plan (PIP). This strategy focuses on reorgansing the existing public health system in order to meet
the service needs of adolescent. Steps are to be taken to ensure improved service delivery to
adolescent during routine checkups at sub centers clinics and to ensure service availability on fixed
days and timings at the PHC and CHC levels. This is to being tune with the outreach activities.

A core package of services would include preventive, promotive, curative and counseling services.
The framework of services in the RCH II ARSH strategy in the National PIP is presented below. This
describes the intended beneficiaries of the adolescent friendly reproductive and sexual health
services (target group) the health problems/issues to be addressed (service package) and the
health facilities and service providers to be involved.

Such friendly services are to be made available for all adolescent married and unmarried girls and
boys during the clinic sessions but not denied services during routine hours. Focus is to be given
to vulnerable and marginalized sub groups. A plan of service provision as per level of care may be
developed based on the RCH II service delivery plan.

ARSH strategy in State RCH II

The National RCH II ARSH Strategy has been adapted in several State RCH II PIPs. By and large,
most states have incorporated a strategy for adolescent health. The variation in them across
the states can be explained in terms of the scope of demand generation activities and service
provision. Some states have stressed more on knowledge/awareness generation and environment
building activities through involvement of NGOs and other departments such as Women and Child
Development, Youth and Education. Other states have proposed adolescent clinics and counseling
through NGOs. Most stated articulate a service delivery strategy for adolescent through the public
health system at the PHC and CHC levels. Some have proposed linkages with the adolescent-
related work already initiated at the tertiary level through district hospitals. While some states
have proposed selective coverage of PHCs and CHCs in a phased manner, others have proposed
full coverage of all districts for ARSH interventions. In the RCH II, district programme mangers are
expected to identify PHCs and CHCs based on certain key criteria. The RCH II programme proposes
additional inputs for strengthening RCH services in 50 per cent PHCs as 24 –hour functional centers.
These facilities will have additional nursing staff for organizing services. It is recommended to
select only such facilities in the first phase of implementing the RCH II ARSH Strategy. The available
physical infrastructure is to be kept in mind while selecting these facilities.

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Youth friendly STI/RTI services

The key “friendly” characteristics of services for adolescents are at the levels of the user, provider,
and health system. Health services must be:

(i) Accessible - ready access to services is provided

(ii) Acceptable - that is, healthcare meets the expectations of adolescents who use the services.
e.g. Convenient and confidential services, special hours (after school, evenings, weekends,
drop-ins) and comfortable for young men and young couples.

From the provider’s and manager’s perspective, services must be:

(i) Appropriate-required care is provided and unnecessary and harmful care is avoided

(ii) Comprehensive-care provision covers aspects from prevention through to counseling and
treatment with emphasis on communication skills for young people.

(iii) Effective-healthcare produces positive change in the health status of the adolescents. The
health system must focus on efficiency in service delivery that is high quality care is provided
at the lowest possible cost. Providers who want to work with youth, have special training, and
are non- judgmental and provides privacy during examination.

(iv) Equitable- that is, services are provided to all adolescents who need them, the poor, vulnerable,
marginalized and difficult-to-reach groups/areas.

Services are to be made available for all adolescents, married and unmarried girls and boys. Focus
is to be given to the vulnerable and marginalized sub-groups. The package of services is to include
promotive, curative and referral services.

Facilities must be in a position to provide the following core package of

services:
(i) Promotive services
●● Counseling and provision for emergency contraceptive pills
●● Counseling and provision for reversible contraceptives
●● Information/advice on SRH issues

(ii) Preventive services

●● Provision of condoms

(iii) Curative services

●● Treatment of common STI/RTI
●● Treatment and counseling for sexual concerns of male and female adolescents.
●● Management of sexual abuse among girls.

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(iv) Referral services

●● Voluntary Counseling and Testing Center
●● Prevention of Parent to Child Transmission.

(v) Outreach services

●● Periodic health check -ups and community camps.
●● Periodic health education activities.
●● Co-curricular activities.

Outreach strategy could focus on School-based/Peer education programs, target out-of-school and
married youth, use entertainment to gather youth and disseminate health messages (concerts,
movies, theatre, etc.) and encourage clinic attendance and Organize or link with sports programs
and Red Ribbon club.

Involvement of Adolescents in prevention of STI/RTI

Young people should have information about and be encouraged to:
●● Delay onset of sexual activity. Abstain from sexual activity until married.
●● Learn how to use condoms.
●● Use condoms. These may be discontinued when pregnancy is desired.
●● Limit the number of Partners. Avoid multiple partners and stick with one Partner.
●● Avoid high-risk partners.
●● Recognize symptoms of STI/RTI. If burning with urination and/or discharge from the penis, or
there are genital sores, young men and their partners should not have sex, but both should
come to the clinic for treatment.

Lessons learned from Youth Programs

We have learned some lessons from those who have started successful programs that target youth.
●● Do need assessment.
●● Involve communities.
●● Talk to community leaders.
●● Involve youth from the beginning. Ask them about their needs.
●● Involve parents from the beginning if possible, although this can be tricky.
●● Train peer educators.
●● Target message and ways of reaching specific groups, such as in-school or out-of-school youth,
married or unmarried youth.

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Reasons to provide Clinic Services for Youth include

●● High STI/RTI rates among youth.
●● STI/RTI diagnosis and treatment are not available outside a clinic.
●● Few contraceptive options are available to young women or men outside the clinic setting.
●● Young women already come for care because of pregnancy and abortion.
●● Prevention can be offered alongside care.

Strategies to attract Youth to Clinic Services

●● Make services friendly towards youth.
●● Providers who want to work with youth, have special training, and are non- judgmental.
●● Convenient and confidential services.
●● Special hours (after school, evenings, weekends, drop-ins).
●● Comfortable for young men and young couples.
●● Private exam and consultation rooms.
●● Array of contraceptive choices.
●● Emphasize barrier methods with emergency contraceptive pills (ECPs) for backup against
pregnancy.
●● Emphasis on communication skills for young people.

Outreach strategy
●● School-based education programs.
●● Peer education programs.
●● Target out-of-school youth.
●● Target married youth.
●● Word-of-mouth about where to find clinic services.
●● Use entertainment to gather youth and disseminate health messages (concerts, movies,
theatre, etc.) and encourage clinic attendance.
●● Organize or link with sports programs.

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 MODULE NO. 15

MALE PARTICIPATION IN PREVENTION AND CONTROL

OF STI/RTI

Sr. No. Topic Page No

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1. Strategies for involving men in STI/RTI prevention

Often men are the bridging group who acquire infection from and transmit STI/RTI to high-risk
partners such as sex workers and who then carry it home to their regular partners. In this way, STI/
RTI spread even to women who have only one partner. Reaching men with prevention messages
and condoms and treating their STI/RTI early and correctly are very effective ways to prevent the
spread of STI/RTI in their regular partners. A key strategy is getting men with STI/RTI to refer or
bring their regular partners for treatment, thus reaching the many women who may appear to be
low risk and have no symptoms.

Why should FP and STI/RTI services include men?

Men may have access to services for STI/RTI treatment through STI clinics and PHCs, but they are
mostly less informed than women about basic issues of sexual health and disease prevention.
It is clear from new research studies that men are eager for more information about their own
reproductive health and that of their partners. Men and women alike suffer from the fear of shame
and embarrassment attached to seeking treatment for STI/RTI and need sensitive treatment from
providers.

FP and STI/RTI services should include men:

●● To provide opportunities for increased access to information.
●● To enable men to support their partners.
●● To increase effectiveness of partner referral for STI/RTI treatment.
●● To improve partner communication skills.
●● To increase the use of condoms with casual partners.
●● To increase the use of condoms with regular partner if any one of the partner is infected or has
unprotected sex outside of it.

Two important reasons why men should be involved in STI/RTI prevention

program:
1. To encourage men with STI/RTI to bring or refer their partners for treatment. Since STI/RTI are
more often symptomatic in men than in women, partner management is an important way to
identify asymptomatic women who need treatment

2. To reach men with information about prevention, especially use of condoms in casual and
commercial sex encounters. This will reduce the chance that they will take STI/RTI home.

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Ways to involve Men in awareness, prevention, and treatment

There are many ways to involve men in the awareness, prevention, and treatment of STI/RTI. The
following are only a few examples:
●● Public information campaign on STI/RTI directed to men receiving early treatment and
informing their partners of the need for treatment.
●● Condom promotion for men with casual partners in addition to primary partners if not
practicing safer sex outside of the primary relationships.
●● Posters in local bars, pan shops where men gather that address STI/RTI and the need for men
to protect their families.
●● Drug treatment packets/kits with information on STI/RTI for female partners.
●● Partner referral cards for a man to give to his primary partner.
●● Linking FP/MCH services with STI/RTI services for partner referral.
●● Public information campaign on syphilis and HIV that addresses how men can protect both
their wives and newborns by decreasing the number of casual partners and using condoms.
●● Advertising ANC services that promote male partnership in pregnancy and birth.
●● Trained peer educators in the workplace.

Men may be more receptive to STI prevention messages if they

understand that STIs threaten their health and fertility, and may
endanger the lives of their wives, girlfriends and children.

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2. Challenges of Reaching Men and how to address

these challenges

Challenges How to address

●● Men may not feel comfortable using ●● Establish men only clinic or have
services mainly used by women. dedicated hours for men services
●● Ensure privacy and confidentiality
●● Men may feel shame or embarrassment ●● Create general public awareness
about seeking information or treatment ●● Provide better experiences to those
for STI/RTI. attending the clinic so they recommend
others to seek services
●● Provide adequate information to those
attending the clinic which might help
in spreading the word in the peers and
community
●● There is a lack of confidentiality for men if ●● Have proper arrangements for privacy to
their partners are with them. men and women in the clinic
●● Assure then and maintain confidentiality
Try couple counseling rather than
●●
individuals
●● Treating men may take time and resources ●● Assign adequate time to men as well as
away from women. women
●● Make available enough resources and
manpower for handling the load of STI/RTI
clinic/RH clinics
●● Treating men requires new skills from ●● Train providers to respond to STI/RTI
providers. management needs of both men as well
as women
●● Treating men may require different ●● Establish men only clinic or have
facilities and more male providers dedicated hours for men services

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 MODULE NO. 16

RECORDING AND REPORTING

Sr. No. Topic Page No

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1. Recording and Reporting Formats for Designated clinic

Good reporting practices help clinics monitor their services and permit meaningful data generation
to enable regular evaluation of the programmes. Minimal reporting records that should be
maintained by each of the designated STI/RTI clinic are given in table below:

Records and Reports of Designated STI/RTI clinic.

1 Patient Wise Card

2 STI/RTI Register

3 Counsellors Diary

4 Indent Form

5 Stock Register

6 Referral Form

7 STI/RTI Monthly Reporting Format

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The details of filling of these formats is described

1. Patient Wise Card

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Guidelines for Filling the STI/RTI Patient Wise Card

(To be used by all STI/RTI service providers)

General Instructions
Write the name of the service provider, Name and unique ID number of clinic (list of unique ID
numbers allotted to each STI/RTI clinic is available with M&E division of SACS)

1. SACS may print the name and unique ID number of STI/RTI clinic on cards before dispatching
them to individual clinics.

2. Write the name of service provider.

3. Write the patient ID number.

a. Write the patient ID number starting from 00001 and write consecutive numbers from
April to March.

b. Repeat the same for each financial year.

4. Write the patient general outpatient number (wherever applicable/available).

Who should fill the cards?

The STI/RTI patient wise card should be filled by STI/RTI service providers for each new STI/RTI
episode treated. The cards should be stored securely. All the cards of individual clients should be
kept stapled.

The monthly reporting format should be filled by using the consolidated data from these cards.
The filled cards should be available at clinic during supervisory visits.

The STI/RTI service providers include.

a) Providers at all designated STI/RTI and ObGyn clinics (health care facilities located at area/
district hospitals, teaching hospitals attached to medical colleges etc).

b) Providers with targeted interventions providing STI/RTI services for high risk groups.

Specific instructions
What should be written?
1. Write the date of visit under date column
2. Check the patient details-
a. Check the box for-Male or Female or Transgender accordingly.
b. Age-Write the completed years as told by patient.
c. Check “yes” if the patient is a New client i.e. attending that particular STI/RTI clinic for first
time or with fresh episode.
d. Check “No” if the patient has visited that particular STI/RTI clinic previously.

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Type of visit
e. Check the type of visit ONLY after examination is completed.

f. Check type of visit as “New STI/RTI” if the patient is attending with a fresh episode of STI/RTI.
●● Patients present with STI/RTI symptoms, and confirmed to have STI/RTI on physical and
internal examination.
●● STI/RTI signs are elicited by internal examinations, and/or
●● STI/RTI etiology diagnosed using laboratory method, and/or
●● If a known herpes patients visits with recurrent infection, check this box

g. Check type of visit as “Repeat visit” if the patient repeated the visit for the previously
documented complaints. This includes STI/RTI follow up (when the visit happens within 14
days following treatment).

3. a. Check the “Referred by” if the patient is referred by some other facility (such as ICTC/
PPTCT/ART centre/other OPDs in the institute where the clinic is located/NGOs/STI clinic with
targeted interventions/Peer Educator/Outreach worker etc).

b. Check the “Direct walk in” if the patient attended the clinic directly.

4. STI/RTI risk assessment

a) Check the box after taking detailed “Medical history” from the patient.

b) Check the box after taking detailed “Sexual history” from the patient

c) Check the box after conducting detailed “Physical examination” of the patient

d) Check the box after conducting detailed “Internal examination” of the patient

e) Write the key points of significance from history in the box provided.

5. STI/RTI syndrome diagnosis

a. Check the appropriate box as per the diagnosis made.
b. While making the syndrome diagnosis, the standardized definitions given ONLY to be
followed.
c. Should be filled in even if the diagnosis is made on clinical or etiological basis.
d. If the patients have more than one syndrome or condition, check all the appropriate
syndromes and/or conditions diagnosed.

1. Vaginal/Cervical Discharge (VCD): Includes a) Woman with symptomatic vaginal discharge

b) Asymptomatic patient with vaginal discharge seen on speculum examination.
c) Cervical discharge seen on speculum examination (All syndromic, etiological and clinical
STI/RTI diagnosis relating to vaginal or cervical discharge should be included here).

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2. Genital ulcer disease-non-herpetic (GUD-NH): Female or male or transgender with

genital or ano-rectal ulceration and with NO blisters (vesicles). (All STI syndromic, clinical
or etiological diagnosis relating to genial ulcers caused by Treponema Pallidum (syphilis),
Haemophilus Ducreyi (Chancroid), Granuloma Inguinale and Lymphogranuloma Venereum
(LGV) except herpes simplex virus type 2 should be included here).

3. Genital ulcer disease-herpetic (GUD-H): Female or male or transgender with genital or

ano-rectal blisters (vesicles) with ulcers or recurrence primarily caused by herpes simplex
virus type 2.

Note: If both ulcers and blisters are present, tick on both GUD and GUD herpetic or when
the provider is not able to differentiate between the two.

4. Lower abdominal pain (LAP): Female with Lower Abdominal Pain or tenderness, or
Cervical motion tenderness.

5. Urethral discharge (UD): Male or transgender with intact genitalia with Urethral Discharge
with or without dysuria or other symptoms with a history of unprotected sexual intercourse
in recent past.

6. Ano-rectal discharge (ARD): Male, female or transgender with symptoms of tenesmus or

if ano-rectal discharge seen on examination.

7. Inguinal bubo (IB): Individuals with inguinal bubo and NO genital ulcer. (Syndromic or
Clinical diagnosis of LGV should be included here).

8. Painful scrotal swelling (PSS): Male or transgender (with intact genitalia) with painful
scrotal swelling (primarily caused by infection of Gonococci and Chlamydia).

9. Genital warts: Individuals with anal or genital warts.

10. Genital scabies: Tick if patient is diagnosed as having genital scabies.

11. Genital Pediculosis: Tick if patient is diagnosed as having genital pediculosis.

12. Genital molluscum: Check the box if the patient is suffering with molluscum lesions over
the genitalia.

13. Asymptomatic (Serological Syphilis)-this box to be checked if the patient is found

serological syphilis.

14. Presumptive Treatment (PT)-All asymptomatic sex workers (male and female) attending
the clinic for the first time should be provided with presumptive treatment. Presumptive
treatment is also to be provided in case the sex worker presents asymptomatically after
not attending any clinical service for six consecutive months or more.

15. Other (specify): Individuals attending with any other STI/RTI related condition.

5. Examination findings
Summarize the salient findings of physical including internal examination in the box provided.

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6. Laboratory Tests Performed

RPR/VDRL test

a) Check if Rapid Plasma Reagin (RPR)/VDRL test is conducted and found reactive.

b) Write the highest titers reactive.

Gram stain

a) Check the box for “ICDC” if urethral and endo cervical smears demonstrates >5 PMN/hpf and
intracellular gram-negative diplococci inside polymorph nuclear cells.

b) Check the box for “WBC” if urethral and endo cervical smears demonstrates >5 PMN/hpf and
no intracellular gram-negative diplococci inside polymorph nuclear cells.

c) Check the box for “None” if urethral smears demonstrates <5 PMN/hpf and no intracellular
gram-negative diplococci inside polymorph nuclear cells.

d) Check the box for “None” if endo cervical smears demonstrates <10 PMN/hpf and no
intracellular gram-negative diplococci inside polymorph nuclear cells.

e) Check the box for “Nugent’s score Positive”-if the score is between 7 and 10 of vaginal
discharge smear (refer the National guidelines for managing reproductive tract infections
including sexually transmitted infections, August 2007).

KOH

a) Check the box for “Whiff test”-If a drop of 10% potassium hydroxide on vaginal secretion on a
glass slide releases fishy odours of amines.

b) Check the box for “Pseudohyphae”-If budding yeast/hyphae is seen under light microscope

c) Check the box “None”-if negative for whiff test and pseudohyphae.

Wet mount

a) Check the box for “Trichomonads”-if Motile trichomonads seen under light microscope (10x).

b) Check the box for “Clue cells”-if Clue cells comprise more than 20% of all epithelial cells in any
view under light microscope.

HIV

a) Check the box for “Reactive”-if an HIV test is performed as per national HIV testing guidelines
and declared as reactive

b) Check the box for “Non Reactive”-if an HIV test is performed as per national HIV testing
guidelines and declared as non reactive

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Details of STI/RTI Treatment Given

This section has ‘four’ components

●● Pre specified colour coded kits starting from No 1 to 7
●● Check the box against the kit administered to the patient
●● If more than one kit is given to same patient due to multiple syndromes then check the relevant
boxes
●● General medicines administered to the patient
●● Check the relevant box, if any of these medicines were administered
●● If drugs for anaphylaxis are checked, detail the entire management of anaphylaxis including
the outcome on a separate sheet and append to the card.
●● All drug allergies, idiosyncratic reactions to be marked with “red ink” on the card
●● If kits are not in supply or in addition to kits loose drugs were prescribed/administered then
check the relevant boxes. Treatment regimens should be in accordance to National Technical
Guidelines for Managing RTI including STI, August 2007.
●● Write any other drug administered or prescribed to patient which doesn’t fall in any of the
above mentioned categories.

Other Services Provided

This section has four components and basically concerned with what additional value added
services provided to patient.

Patient education: check the relevant box if individual patient is provided with STI counseling on:
●● Partner/s treatment
●● Condom usage and disposal
●● Other risk reduction communication

Partner treatment: check the relevant box if individual patient is provided with
●● Prescription written
●● Medications given

Condoms: check the relevant box if individual patient is provided with

●● Condom given free
●● Sold (Social marketed)
●● Prescribed
●● Demonstrated (all clinics should have a penis model for demonstration purpose)

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Referrals: Check all the relevant boxes

●● ICTC: check the box if STI/RTI patient referred to the ICTC.
●● PPTCT: check the box if a pregnant STI/RTI patient referred to PPTCT.
●● DMC: check the box if STI/RTI patient who has suspected to be chest symptomatic referred to
DMC.
●● Care and support centre: check this box if a referral is done (List of care and support centres
with contact details should be available at all clinics and displayed at waiting hall).
●● ART centre: check this box if a referral is done (List of ART centres with contact details should
be available at all clinics and displayed at waiting hall. All individuals who are tested reactive
for HIV are to be referred for nearest ART centre, for registration and subsequent follow up.
This ART registration number should be written over the card for future references).
●● PLHA networks: check this box if a referral is done (List of PLHA net works with contact details
should be available at all clinics and displayed at waiting hall).
●● Others (specify): if a referral other than those mentioned above is done then specify the
place/centre to which patient is referred.
●● All ways provider should get the feedback of referral and document them in the card. As there
is no name over the card, the information will remain confidential and this fact should be
emphasized to PLHAs and HRG individuals.
●● IEC material given: check this box if take home IEC material is provided to attendee (the clinic
should keep a stock of simple hand bills on STI/RTIs for patient self education. SACS should
ensure availability of such IEC material at all STI/RTI clinics).
●● Append with results if any other tests performed: check this box if any other additional tests
performed. Append the copies of test/s performed along with their results .

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2. STI/RTI Register

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3. Counselors Diary

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4. Indent Form

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5. Stock Register

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6. STI/RTI Referral Form

STI/RTI Referral Form

(To be filled and handed to the client by STI/RTI Counselor/Nurse)

Referral to
ICTC/Chest & TB/Laboratory_______________________________________________

The patient with the following details is being referred to your center.

Name:_____________________________________ Age______________ Sex:______

STI/RTI-PID No:__________________________________________

Kindly do the needful

Referring Provider
Name:_____________________________________ Designation:_________________

Contact Phone:_____________________________Date of referral:______________

--------------------------------------------------------------------------------------------------------------
(To be filled and retained at referral site so as to be collected by
STI/RTI counselor/Nurse weekly)

The above patient referred has been provided ICTC/TB/RPR/VDRL/___________________

services and the patient has been tested/diagnosed/treated
for__________________________

The test/results of RPR/VDRL/is/are__________________________

Signature of the Medical Officer/Counselor/Lab In-charge

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7. STI/RTI Monthly Report

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NOTE: The medical officer in-charge, staff nurse and STI counselor at designated STI/RTI clinic should
ensure maintenance of all records and generate the monthly report which should be submitted to
SACS by the 5th of every month.

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Guidelines for filling Monthly Report Format for STI/RTI Clinics

(all public health facilities supported by NACO and TI NGOs)

Who should fill this?

This reporting format should be filled by all STI/RTI service providers and sent to the corresponding
reporting authority by the 5th of next month through SIMS. The STI/RTI service providers include:
●● Providers at all designated STI/RTI clinics (located in area/district hospitals, teaching hospitals
attached to medical colleges etc)
●● Targeted Interventions providing STI/RTI services for High Risk Behaviour Groups

What are the different sections of STI format?

The format is divided into eight sections as follows.

Section 1: Number of Patients availed STI/RTI services in this month

Section 2: STI/RTI syndrome and other STI/RTI diagnosed

Section 3: Details of other services provided to patients attending STI/RTI clinics in this month

Section 4: STI/RTI service for HRGs in this month

Section 5: ANC Syphilis screening in this month

Section 6: Laboratory diagnosis of STI/RTI

Section 7: Drugs & Consumables

Section 8: Details of Staff at the STI/RTI clinics

What should be reported?

●● Section 1, 2, 3, 5, 7 and 8 should be reported by all NACO designated STI/RTI clinics
●● Section 1, 2, 3, 4 and 7 should be filled by all Targeted Interventions
●● Additional Section 6 should be filled up by NACO designated STI/RTI clinics also having
laboratory services (Laboratory may be located in the STI/RTI clinic or through linkage with
existing laboratory in the hospital).

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General information

Sl No. Indicators Explanation

1 Unique ID Unique ID provided to STI/RTI Clinic/Gynaecology
OPD/TI NGO by respective SACS
2 Name of the STI/RTI Clinic/Gynae Name of the institution where STI/RTI Clinic/
OPD/TI NGO Gynaecology OPD is located

Name of the TI NGO

3 Address of STI/Gynae Address of STI clinic including state, city, district,
Block/Mandal and pin code
4 Reporting period Reporting month and year in the form of MM and
YYYY. Example: the data for the month January,
2011 would be reported in February 2011. So the
reporting month is 01 and year is 2011.
5 Name and phone number of the Name of the medical officer who is in charge of
Officer in-charge STI Clinic
6 Phone number of the Officer in- Phone number of the officer who is in charge of
charge STI Clinic

Section 1: No. of Patients availed STI/RTI services in this month

●● Should be reported by all STI/RTI service providers
●● One individual should be entered once in a month in this section in any row
●● Fill the number of individuals who have availed STI/RTI services under appropriate age and sex
category
●● Fill in the total number of STI/RTI visits under the specific category as per description below

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Sl No. Indicator Definition/Explanation

1 Clinic visit with STI/RTI complaints Fill the number of individuals visited with any
and were diagnosed with STI/RTI STI/RTI complaints as per STI/RTI patient wise
card and was treated for the same. This indicates
fresh STI/RTI episodes.
2 Clinic visit with STI/RTI complaint Fill the number of individuals visited for
but were NOT diagnosed with an complaints of STI/RTI, but were not diagnosed
STI/RTI with STI/RTI as per patient wise card.

Include the patients who came for syphilis

screening to Designated STI/RTI clinics. Do not
Clinic visit for syphilis screening
include ANC attendees.
(Exclude ANC)
Only for TI-NGOs, fill all those HRG (without
diagnosed STI/RTI) attending the STI clinic
For TI-NGOs-RMC, PT, Syphilis for Regular Medical Check-up, Presumptive
Screening (whichever applicable) Treatment and Syphilis screening *

*1. If any HRG attending for RMC or syphilis

screening or PT is found to be having STI/RTI,
they should be entered in row 1 only.

2. If any HRG availing more than 1 service (eg

RMC + Syphilis screening, PT + syphilis screening,
Symptomatic STI + Syphilis screening) should be
entered only once in one row based on his/her
having an STI/RTI or not.
3 Follow up visits for the STI/RTI Fill the number of patients who have come
complaint for a follow up visit (within 14 days of availing
treatment) out of patients counted in row 1
(clinic visit with STI/RTI and were diagnosed with
STI/RTI)
4 Age group and Sex Fill the number of individual availed STI/RTI
services under appropriate age (<20, 20-24, 25-
44, >44) and sex category.
5 Total no. of visits This is auto calculated in software. The total gives
total attendance of individuals at STI/RTI clinic.

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Section 2: STI/RTI Syndromic Diagnosis

●● Should be reported by all STI/RTI service providers
●● Should be filled for clinic visit with STI/RTI complaints and were diagnosed with STI/RTI only
(Section 1 Row 1)
●● Diagnosis could be reached on syndromic/clinical/etiological basis
●● Fill up consolidated number of STI/RTI patients diagnosed with following syndromes

Sl No Indicator Definition/Explanation
1 Vaginal/Cervical Discharge a) Woman with symptomatic vaginal discharge
(VCD) b) Asymptomatic patient with vaginal discharge seen
on speculum examination
c) Cervical discharge seen on speculum examination
(All syndromic, etiological and clinical STI/RTI
diagnosis relating to vaginal or cervical discharge
should be included here)
2 Genital Ulcer Disease (GUD)- Female or male or transgender with genital or ano-
Non Herpetic rectal ulceration and with NO blisters (vesicles).

(All STI syndromic, clinical or etiological diagnosis

relating to genial ulcers caused by Treponema
Pallidum (syphilis), Haemophilus Ducreyi (Chancroid),
Granuloma Inguinale and Lymphogranuloma
Venereum (LGV) except herpes simplex virus type 2
should be included here)
3 Genital Ulcer Disease (GUD)- Female or male or transgender with genital or ano-
Herpetic rectal blisters (vesicles) with ulcers or recurrence
primarily caused by herpes simplex virus type 2.
4 Lower Abdominal Pain (LAP) Female with Lower Abdominal Pain or tenderness, or
Cervical motion tenderness
5 Urethral Discharge (UD) Male or transgender with intact genitalia with
Urethral Discharge with or without dysuria or other
symptoms
6 Ano-rectal Discharge (ARD) Male, female or transgender with symptoms of
tenesmus or if ano-rectal discharge seen on exam
7 Inguinal Bubo (IB) Individuals with inguinal bubo and NO genital ulcer.
(Syndromic or Clinical diagnosis of LGV should be
included here)
8 Painful Scrotal Swelling (SS) Male or transgender (with intact genitalia) with
painful scrotal swelling (primarily caused by infection
of Gonococci and Chlamydia)
9 Genital warts Individuals with anal or genital warts.

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Sl No Indicator Definition/Explanation
10 Other STIs Individuals attending with any other STI/RTI related
condition (e.g. Genital Scabies, pubic lice, and
Genital Molluscum Contagiosum etc).
11 Serologically +ve for syphilis Individuals treated for serological reactive for
Syphilis.
Total number of episodes These counts the total number of episodes of STI/
RTI diagnosis made during the month. This is auto
calculated in the software.
People living with HIV attended with People living with HIV attended/treated for STI/RTI
STI/RTI complaints

Section 3: Details of Other Services provided to patients attending STI/RTI

clinics in this month
●● Should be reported by all STI/RTI service providers
●● Should be filled with details of other services like counselling, condom distribution, referrals
provided to STI/RTI clinic attendees as per Section 1.

Sl No Indicator Definition/Explanation
1 Number of patients counseled Fill total number of STI/RTI clinic attendees provided
with STI/RTI counseling.
2 Number of condoms provided Fill total number of condoms provided to all STI/RTI
clinic attendees.
3 Number of RPR/VDRL tests Fill total number of RPR/VDRL tests conducted for
conducted STI/RTI clinic attendees.
4 Number of patients found Fill the number detected reactive for RPR/VDRL test
reactive of the above.
5 Number of partner notification Fill the total number of partner notifications
undertaken undertaken of index STI/RTI patients treated.
6 Number of partners managed Fill the total number of partners of index STI/RTI
patients attended the clinic and managed.
7 Number of patients referred to Fill the number of STI/RTI clinic attendees referred to
ICTC ICTC.
8 Number of patients found HIV- Fill the number detected as HIV reactive, of the above.
infected (of above)
9 Number of patients referred to Fill in the number of STI/RTI clinic attendees
other services referred for any other services like care and support,
tuberculosis screening etc.

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Section 4: STI/RTI Service for HRGs

●● Should be filled by TI-NGO providing services to high risk behavior group (HRG).

Sl No. Indicator Definition/Explanation

1 Number of new individuals Fill in total number of new High Risk Behaviour Group
visited the clinic individuals visiting the clinic for the first time for any clinical
services.

This would include both symptomatic and asymptomatic

HRGs. It has no relationship with what package of services
is being availed.

This number can be arrived by summing up “new clients”

checked as “Yes” in patient wise card. Definition of “new”
HRG individual is as per TI guidelines
2 Number of presumptive Fill in total number of HRG individuals (FSW, MSM including
treatment (PT) provided TS/TG) who attended the clinic for STI/RTI services without
for Gonococcus and being symptomatic and were provided with treatment for
Chlamydia Gonococcus and Chlamydia as per NACO STI/RTI technical
guidelines August 2007.
3 Number of regular Fill in the number of HRG individuals (FSW, MSM including
STI check-ups (RMC) TS/TG) who attended the clinic for STI/RTI services without
conducted being symptomatic and received RMC. RMC means medical
check up including internal examination of HRG to be
done once in a quarter, which may include speculum or
proctoscope examination; and found to be not having STI/
RTI. Exclude the numbers of HRG receiving presumptive
treatment in this row.

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Section 5: ANC Syphilis Screening in this Month

●● Should be filled by all NACO designated STI/RTI clinics
●● Data should be drawn from the records of ANC clinic in the hospital
●● Should fill information for women making first visit for ANC only

Sl No. Indicator Definition/Explanation

1 Number of ANC first visits Write the number of pregnant women registered for first
in the month (Registration) time with the ANC clinic during the month.
2 Number of RPR/VDRL tests Write the number of registered pregnant women
performed undergone RPR/VDRL test during the month*
3 Number of RPR/VDRL tests Write the number of pregnant women found reactive for
reactive (qualitative) RPR/VDRL test*, of the above
4 Number of RPR/VDRL Write the number of pregnant women whose RPR/VDRL
tests reactive >= 1:8 test* titre is >=1:8, of the above
(quantitative)
5 Number of pregnant Write the number of pregnant women diagnosed having
women treated for syphilis syphilis undergone treatment

Section 6: Laboratory Diagnosis of STI/RTI

●● Should be filled by all NACO designated STI/RTI clinics
●● Do not include ANC syphilis screening data in this section

Sl No. Indicator Definition/Explanation

1 Total RPR/VDRL test Fill in the total number of RPR or VDRL qualitative tests
performed conducted among men, women, and others during the
reporting month (write the same number as recorded in
row 3 under section 3)
RPR test reactive >= 1:8 Fill in the number of RPR/VDRL tests reactive at or above
1:8 titres among men, women and others*, of the above
2 Total Gram stain Fill in total number of gram stain performed among men
performed (urethral smear) and women (endo-cervical smear and
vaginal discharge smear)*
Number of Smears +ve for Fill in number of gram stained smears positive for
Gonococcus gonococcus
Criteria for urethral smear >5 PMN/hpf and intracellular gram negative diplococci
inside poly morphonuclear cells
Criteria for endocervical Numerous PMN/hpf and intracellular gram negative
smear diplococci inside poly morphonuclear cells

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Sl No. Indicator Definition/Explanation

Non Gonococcal Fill in number of gram stained smears positive for non
Urethritis/cervicitis-Pus gonococcal urethritis/cervicitis
cells +
Criteria for urethral smear > 5 PMN/hpf and NO intracellular gram negative
diplococci inside poly morphonuclear cells
Criteria for endocervical >10 PMN/hpf and NO gram negative diplococci inside
smears poly morphonuclear cells
None Fill in number of gram stained smears negative for both
Criteria for urethral smear < 5PMN/hpf and NO intracellular gram negative
diplococci inside poly morphonuclear cells
Criteria for endocervical <10 PMN/hpf and NO gram negative diplococci inside
smear poly morphonuclear cells
Number of smears +ve for Fill in the number of smears +ve for Nugent’s score.
Nugent’s score Nugent’s score is +ve when the score is between 7 to 10
3 Wet mount tests Fill in the total number of wet mounts performed among
performed women
Motile trichomonads + Fill in the number of wet mounts demonstrated Motile
trichomonads seen under light microscope (10x)
Clues cells + Fill in the number of wet mounts demonstrated Clue
cells in more than 20% of all epithelial cells in any view
under light microscope
Whiff test + Fill in the number of wet mounts released fishy odours
of amines, when a drop of 10% potassium hydroxide is
placed on vaginal secretion on a glass slide
None None of the above tests are positive
4 KOH test performed Fill in total number of KOH tests performed among
women
Candidiasis+ Fill in the number of KOH slides demonstrated budding
yeast/hyphae under light microscope
None Fill in the number of KOH slides not demonstrated
budding yeast/hype under light microscope
5 Availability of Check yes or no for availability of the STI/RTI colour
consumables, functional coded drug kits, functional computers and its AMC.
computers and AMC of
Computers
* The information on number of test conducted and/or results may or may not be available
with facility providing clinical services. The providers are to ensure collection of the laboratory
data from the concerned providers/departments/or facilities (microbiology/pathology/
general lab).

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Section 7: Drugs and Consumables

●● Should be filled by all service providers at STI/RTI clinic
●● Provide details of stock of RPR test, TPHA tests kits, Per-packed STI kit 1, kit 2, kit 3, kit 4, kit
5, kit 6 and kit 7, condom pieces, reagents for gram stain, wet mount and KOH test and others
if any

Sl No. Indicator Definition/Explanation

1 Opening Stock This is auto calculated in software. This gives number of
STI/RTI drug kits/reagent/RPR, TPHA test kits available on
the first day of the month.
2 Number received in this Write the number of STI/RTI drug kits/reagent/RPR,
month TPHA test kits received during the month.
3 Number consumed Write the number of STI/RTI drug kits/reagent/RPR,
TPHA test kits utilised or distributed during the month.
4 Damage/Wastage Write the number of STI/RTI drug kits/reagent/RPR,
TPHA test kits wasted or damaged during the month.
5 Closing stock This is auto calculated in software. This gives the number
of STI/RTI drug kits/reagent/RPR, TPHA test kits available
on the last day of the month.
6 Stock sufficient for This is auto calculated in software. (Closing stock/drugs
approximate month consumed plus damaged/wasted)
Every clinic to ensure one quarter (3 months) drug/
testing kits/reagent supply for the clinic.
7 Earliest expiry date Write the expiry date of the drug kit, condom or reagent
in a lot of the closing stock having the earliest expiry date
in MM/YEAR
8 Quantity Write the quantity of the drug kit, condom and reagent
kit having earliest expiry date

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Section 8: Details of Staff at the STI/RTI clinics

●● Should be filled by all STI/RTI clinics
●● Contains human resource details at STI/RTI clinics

Sl No. Indicator Definition/Explanation

1 Medical Officer/s Number of doctors posts sanctioned, Number in place

Number of the doctors trained in STI as per National

guidelines (Induction/Refresher/Other) during the month
2 Staff Nurse Number of Staff Nurse posts sanctioned, Number in place

Number of the staff nurse trained in STI as per National

guidelines (Induction/Refresher/Other) during the month
3 Lab Technician Number of Lab Technician posts sanctioned, Number in
place

Number of the Lab Technician trained in STI as per National

guidelines (Induction/Refresher/Other) during the month
4 Counsellor Number of Counsellor posts sanctioned, Number in place

Number of the Counsellor trained in STI as per National

guidelines (Induction/Refresher/Other) during the month

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2. RECORDING AND REPORTING FORMATS AT SUB-

DISTRICT HEALTH FACILITIES (PHC/CHC/Block PHC,
Sub-divisional hospital, urban Health centre etc)

Minimal reporting records that should be maintained by each of the sub-district health facilities
(PHC/CHC/Block PHC/Sub-divisional Hospital/urban Health centre) are given in below in table:

Records to be maintained at NRHM facility

(PHC/CHC/Block PHC, Sub-divisional Hospital, Urban Health etc).
1 OPD Register

2 Drug Register

3 Laboratory Register

4 Referral Form

5 Monthly STI/RTI Monthly Reporting Format for NRHM

1. Patient OPD Register:

Patient Register for STI/RTI Services
S. No. Date Name Age Sex Diagnosis
1
2
3
4
5
6
7
8
9
10

The OPD register and other existing record maintained in PHC/CHC/Block PHC etc should be
utilised for maintaining records pertaining to STI/RTI. The physician should indicate the syndromic
diagnosis in the OPD register.

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2. Drug Stock Register:

Drug Stock Record Format
Number Closing stock
Opening stock
Drugs received Consumed (last day of every
(1st of every month)
this month month)
Prepacked STI Kit 1
Prepacked STI Kit 2
Prepacked STI Kit 3
Prepacked STI Kit 4
Prepacked STI Kit 5
Prepacked STI Kit 6
Prepacked STI Kit 7

3. Laboratory Register:
Syphilis screening of pregnant women or STI/RTI patients
Patient details Syphilis Test
S. No. Date Name Age Sex (STI patient or test: results for
ANC Mother) RPR/VDRL syphilis
1
2
3
4
5
6
7
8
9
10

The existing drug maintenance register and laboratory register used in the PHC/CHC/Block PHC
etc should be used for recording purpose. Only relevant column/page should be added to the
pharmacy and laboratory records so as to collect data pertaining to drug stock and laboratory
testing.

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4. STI/RTI Referral Form

STI/RTI Referral Form

(To be filled and handed to the client by STI/RTI Counselor/Nurse)

Referral to
ICTC/Chest & TB/Laboratory_______________________________________________

The patient with the following details is being referred to your center.

Name:_____________________________________ Age______________ Sex:______

STI/RTI-PID No:__________________________________________

Kindly do the needful

Referring Provider
Name:_____________________________________ Designation:_________________

Contact Phone:_____________________________Date of referral:______________

------------------------------------------------------------------------------------------------------------
(To be filled and retained at referral site so as to be collected by
STI/RTI counselor/Nurse weekly)

The above patient referred has been provided ICTC/TB/RPR/VDRL/_________________

services and the patient has been tested/diagnosed/treated
for__________________________

The test/results of RPR/VDRL/is/are__________________________

Signature of the Medical Officer/Counselor/Lab In-charge

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5. Monthly STI/RTI Monthly Reporting Format for NRHM:

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Guidelines for filling Monthly Reporting Format from NRHM facilities

(all public health facilities not supported by NACO)

Who should fill this?

Hard copies of this reporting format should be filled and submitted to the corresponding reporting
authority (District RCH officer or any other corresponding reporting authority) by the 5th of next
month by all NRHM facilities NOT supported by NACO (PHC/CHC/Urban Health Posts and Other
sub-district health facilities) under STI/RTI control and prevention program. These individual
reports are to be consolidated at district level and submitted as one report to SACS and State
Mission Director every month by the 7th of the month.

Note: All facilities supported by NACO need to report on the three page STI/RTI format only

What are the different sections of STI format?

The STI format is divided into 4 sections as follows:

Section 1: Number of Patients availed STI/RTI services in this month

Section 2: Syndromic diagnosis and investigation details

Section 3: Details of syphilis screening of pregnant women

Section 4: Status of Drugs & test kits

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General Information
Sl. No. Indicators Explanation
1 Unique ID of District Write the Unique ID of District which will be provided to
District by respective SACS
2 Name of the District/ Write the Name of the District or CHC or PHC or other facilities
CHC/PHC/Other sending the report.
facilities
3 Number of NRHM Write the number of NRHM facilities to report in the district.
facilities to report in
the district*
4 Number of Units Write the number of NRHM facilities reported in this month, of
reported in this the above
month*
5 Reporting period Reporting month and year in the form of MM and YYYY.
Example: the data for the month January, 2010 would be
reported in Feb 2010. So the reporting month is 01 and year is
2010.
6 Name of the Officer Name of the medical officer who is in charge of STI Clinic
in-charge
7 Phone number of the Phone number of the officer who is in charge of STI Clinic
Officer in-charge

* This information is only to be provided by the District.

Section 1: No. of Patients Availed STI/RTI services in this month

●● Fill the number of individuals who have availed STI/RTI services under appropriate sex category

Sl. No. Indicator Definition/Explanation

1 No. of patients diagnosed Fill the number of individuals visited with any STI/RTI
and treated for various STI/ complaints and was treated for the same.
RTI

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Section 2: Syndromic diagnosis and investigation details

●● Diagnosis could be reached on syndromic/clinical/etiological basis

Sl. No. Indicator Definition/Explanation

Diagnosis Fill up consolidated number of STI/RTI patients
diagnosed
with following syndromes
1 VCD - Vaginal/Cervical a) Woman with symptomatic vaginal discharge
Discharge b) Asymptomatic patient with vaginal discharge seen on
speculum examination
c) Cervical discharge seen on speculum examination
(All syndromic, etiological and clinical STI/RTI diagnosis
relating to vaginal or cervical discharge should be
included here)
2 GUD - Non Herpetic - Female or male or transgender with genital or ano- rectal
Genital ulcer disease- ulceration and with NO blisters (vesicles).
Non Herpetic (All STI syndromic, clinical or etiological diagnosis relating
to genial ulcers caused by Treponema Pallidum (syphilis),
Haemophilus Ducreyi (Chancroid), Granuloma Inguinale
and Lymphogranuloma Venereum (LGV) except herpes
simplex virus type 2 should be included here)
3 GUD - Herpetic - Genital Female or male or transgender with genital or ano- rectal
Ulcer Disease – Herpetic blisters (vesicles) with ulcers or recurrence primarily
caused by herpes simplex virus type 2.
4 LAP - Lower Abdominal Female with Lower Abdominal Pain or tenderness, or
Pain Cervical motion tenderness
5. UD - Urethral Discharge Male or transgender with intact genitalia with Urethral
Discharge with or without dysuria or other symptoms
6 ARD - Ano-Rectal Male, female or transgender with symptoms of tenesmus
Discharge or if ano-rectal discharge seen on exam
7 IB - Inguinal Bubo Individuals with inguinal bubo and NO genital ulcer.
(Syndromic or Clinical diagnosis of LGV should be
included here)
8 SS - Painful Scrotal Male or transgender (with intact genitalia) with painful
Swelling scrotal swelling (primarily caused by infection of
Gonococci and Chlamydia)
9 Genital Warts Individuals with anal or genital warts.
10 Other STI’s Individuals attending with any other STI/RTI related
condition (e.g. Genital Scabies, pubic lice, and Genital
Molluscum Contagiosum etc).

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Sl. No. Indicator Definition/Explanation

11 Serologically Positive for Individuals treated for serological reactive for Syphilis.
Syphilis
Investigation details
12 Number of STI/RTI Fill total number of RPR/VDRL tests conducted
patients tested for syphilis
(RPR/VDRL)
13 Of Above, Number of STI/ Fill the number found reactive for RPR/VDRL test
RTI patients found reactive
for syphilis
14 Number of STI/RTI Fill the number of STI/RTI clinic attendees referred to
patients referred for HIV ICTC
testing
15 Of above, Number of STI/ Fill the number detected as HIV reactive, of the referred
RTI patients found HIV- individuals
infected
16 Number of STI/RTI patient Fill in the number of STI/RTI clinic attendees tested with
tested for wet mount wet mount

Section 3: Details of syphilis screening of Pregnant women

●● Data should be drawn from the records of ANC clinic in the facility

Sl. No. Indicator Definition/Explanation

1 Number of Pregnant Write the number of pregnant women undergone RPR/
women screened for VDRL test for syphilis during the month
syphilis(VRDL/RPR)
2 Of above, Number of Write the number of pregnant women found reactive for
Pregnant women found RPR/VDRL test
reactive

Section 4: Status of Drugs & test kits

●● Provide details of stock status of RPR/VDRL test kits and Pre-packed STI kit 1 to 7
Sl. No. Indicator Definition/Explanation
1 Drugs & test kits available Fill in the numbers of RPR/VDRL test kits and Per-
packed STI kit 1, kit 2, kit 3, kit 4, kit 5, kit 6 and kit 7 kits
available

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 ANNEXURE - I

REFERENCES AND SOURCE

Source Year

PARTICIPANT’S HANDOUT 197

 ANNEXURE - II

CORE GROUP MEMBERS

Dr. Anjana Saxena

198 PARTICIPANT’S HANDOUT

 ANNEXURE - III

*LIST OF CONTRIBUTORS
(Other than Co-ordinating unit and Core-group members)

Dr. H.K. Kar

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21. Dr. Jayanti Mania

Assistant Director, National Institute for Research in Reproductive Health, (ICMR), Parel, Mumbai
22. Dr. (Mrs) Meenakshi Mathur
Prof and Head, Department of Microbiology, LTMC & LTM General Hospital, Sion, Mumbai
23. Dr. Poonam Mathur
Associate Professor, Gynaecology and Obs., MGM Medical College, Indore
24. Dr. M.M. Misro
Reader, Dept. of Reproductive Bio Medicine, NIHFW, Munirka, New Delhi
25. Dr. Shyama Mitra
Associate Professor, Dept. of Community Medicine, Medical College & Hospital, Kolkata
26. Dr. Amit Mistery
Assistant Professor, Skin and VD, B. J. Medical College, Ahmedabad
27. Dr. Preeti Mehta
Prof. and Head, Microbiology Dept., Seth G. S. Medical College & K.E.M Hospital, Mumbai
28. Dr. Deoki Nandan
Director, National Institute of Health and Family Welfare, NIHFW, Munirka, New Delhi
29. Dr. Gyandeep Nath
Assistant Professor, Dept. of Obstetric & Gynecology, Medical College, Guwahati
30. Dr. C. Nirmala
Associate Professor, Obs. & Gynaec. SAT Hospital, Medical College, Trivandrum
31. Dr. (Mrs.) Jyotika Ojah
Associate Professor, Community Medicine Medical College, Guwahati
32. Dr. Mitesh Patel
Assistant Professor, Dept. of Microbiology, B. J. Medical College, Ahmedabad
33. Dr. Chimanjita Phukan
Asst. Professor, Dept of Microbiology, Medical College, Guwahati
34. Dr. Chander Puri
National Institute for Research in Reproductive Health, (ICMR), Parel, Mumbai
35. Dr. Krishna Ray
Consultant Microbiologist, Prof and Head Microbiology Department, Manav Rachna College Foundation,
New Delhi
36. Dr. Raja Roy
Associate Professor, Dept. of Microbiology, Medical College & Hospital, Kolkata
37. Dr. Sarada Devi. K. L
Associate Professor, Microbiology Medical College, Trivandrum
38. Dr. (Mrs.) Padmaja Saikia
Assistant Professor, Dermatology Medical College, Guwahati
39. Dr. Atul Trivedi
Assistant Professor, PSM Dept., B. J. Medical College, Ahmedabad
40. Dr. Jayanti Shastri
Professor, Deptt. of Microbiology, TNMC & BYL Nair Hospital, Mumbai Central, Mumbai
41. Dr. V. K. Sharma
Professor and Head, Department of Dermatology and Venerology, AIIMS, New Delhi
42. Dr. Renu Shahrawat
Lecturer, National Institute of Health and Family Welfare, Munirka, New Delhi
43. Dr. S. Suprakasan
Professor, Dermatology & Venereology Medical College, Trivandrum
44. Dr. Teodora Elvira Wi
Director, STI Capacity Training, Family Health International, Mumbai
45. Dr. Sanjay Zodpey
Prof & Head, Dept of Preventive & Social Medicine, Govt. Medical College, Nagpur

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NOTE

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