1
Definition
STIs are infectious diseases transmitted
by sexual activity & sometimes by blood
transfusion and from mother to child
2
Sexually transmitted
infections
Are important because of their
Magnitude
Potential complication (health social and
economic consequences)
Interaction with HIV and AIDS
Disproportionately involve women with
significant impact on reproductive potential
3
Epidemiology of STIs
STIs are major public health problems globally
Globally 340 million new cases of curable STIs occur
every year (69 million are in sub-Saharan Africa)
In many developing countries STIs are among
the top five disease
There is little information of STIs in Ethiopia
Adult prevalence of HIV(2.2%) & syphilis (1.5%)
Total of 451,686 cases reported between June 1988 &
June 2002 in Ethiopia
4
Distribution of STIs
Prevalence higher in urban than rural
Higher in unmarried & young adults
More frequent among females than males
between the ages of 14-19
After the age of 19, there is slight male
preponderance
5
STI statistics are
underestimated
Reasons for underestimation:
People with asymptomatic STIs do not seek
treatment
Poor access: health facilities offering treatment for
STIs may be too far away for many people
Missed opportunity: people seeking other health care
such as antenatal services may not be routinely
screened for STIs
Stigma: many patients perceive a stigma in attending
modern STIs services
Non-reporting facilities: large number of people visit
private & traditional care providers that are not
reporting
6
Factors Affecting Transmission
Behavioral Factors
Socio-economic
-Many partner -Poverty
-Change of partners -Religious Restrictions
-Not using condoms - Women’s position
- Casual sex Cultural
- Sex with CSW & partner
- Alcohol & substance use Biological & clinical
- Assymptomatic STIs
Personal factors - Age
- Delay in getting Rx - Sex
- Stigma being ashamed - Vulnerability, immunity
- Noncompliance to Rx
7
The link between STI &
HIV
STIs facilitate the transmission of HIV
The presence of HIV can make people more
susceptible to the acquisition of STIs
The presence of HIV increases the
severity of STIs and
their resistance to standard treatment
8
Clinical presentations of HIV
and STI co-infection
Atypical presentation of Syphilis rapid progression
to neurosyphilis
Atypical lesions of chancroid
Recurrent or persistent genital ulcers from HSV2
Severe genital herpes may require suppression of
recurrence with acyclovir
Human papilloma virus with exophytic genital warts
Risk of treatment failure with single injection of
Benzathine Penicillin in primary syphilis
Topical anti-fungals are less effective
9
Approaches to STI
diagnosis & Rx
Classical approaches
Etiologic diagnosis
Clinical diagnosis
Syndromic approach
10
Advantages of Syndromic Mx
Sensitive & does not miss mixed infections
Treats the patient at first visit
Can be implemented at 10 health care level
Uses flow charts with logical steps
Simple, rapid & inexpensive
Provides opportunity for education &
counseling
11
Limitations of syndromic Mx
Risk of over treatment
Asymptomatic infections are missed
Requires prior research to determine the common
causes & Rx of a syndrome
Needs training
12
SYNDROME COMMON CAUSE
Vaginal discharge Vaginitis (trichomoniasis, bacterial
vaginosis & Candida albicans)
Cervicitis (gonorrhea & Chlamydia)
Urethral discharge in men Gonorrhea & chlamydia
Genital ulcer Syphilis, chancroid & herpes
Lower abdominal pain Gonorrhea, chlamydia & mixed
anaerobes
Scrotal swelling Gonorrhea &chlamydia
Inguinal bubo LGV & Chancroid
Neonatal conjunctivitis Gonorrhea & Chlamydia
13
Steps in syndromic STI
management / Comprehensive
approach
Syndromic diagnosis and treatment,
History taking and examination
Use of flow charts
Education on risk reduction
Providers initiated HIV Counseling & testing/ PIHCT
Condom promotion and provision for safer sex
Partners notification and management
Follow up
Referral
14
URETHRAL DISCHARGE
Burning sensation on
urination Sexually Transmitted Infections
Urethral discharge Urethral discharge
Causes
[Link]
[Link]
[Link]( some times)
15
Recommended treatment for
urethral discharge
Ciprofloxacin 500 mg tablet po stat
Or
Spectinomycin 2 grams IM stat
PLUS
Doxycycline 100 mg po bid for 7 days
Or
Tetracycline 500 mg po qid for 7 days
Or
Erythromycin 500mg po qid for 7 days
16
GENITAL ULCER
17
Causes of genital ulcer
Vesicular
HSV2: Genital Herpes
Non-Vesicualr
T. Pallidum: Syphilis
H. Ducreyi: Chancroid
C. Trachomatis: L1-L3: LGV
[Link]: Granuloma ingunale
18
Syphilis
Primary Tertiary
Solitary non tender hard ulcer/ - Cardiovascular: aortitis
Chancre - Neuro-syphilis
Painless inguinal adenopathy
Secondary
- Skin rash
- Alopecia
- Mucosal ulcerations
- Condylomata lata
- Generalized lymphadenopathy
19
Syphilis
Chancre Rash
20
Chancroid
Painful Ulcer with soft
margins described as soft
chancre
Inguinal adenopathy that
becomes necrotic and
fluctuant (buboes)
High rates of HIV infection
among patients
Soft ulcer
21
Lymphogranuloma Venereum
(LGV)
Caused by C. trachomatis serovars L1, L2, or L3.
Clinical manifestation
Tender inguinal & femoral lymphadenopathy
22
LGV
23
Granuloma inguinale
Chronically progressive ulcerative disease
Etiologic agent is Calymmatobacterium
granulomatis
24
GI
25
Genital herpes
Multiple painful
vesicular genital
ulcers
26
Genital ulcer
Take Hx, & examine patient
Educate on risk reduction
No Offer HCT
Is ulcer vesicular, No Solitary Promote & provide
Recurrent or Non recurrent condoms
More than three ?
Non vesicular ?
Yes
yes
Treat HSV2
Educate on risk reduction
Offer HCT Treat for syphilis Chancroid
Promote & provide condoms
Partner managment And HSV2
Ask patient to return in 7d
No
Ulcer Refer
Ulcer healed?
No Improvin
Yes g yes
Educate on risk reduction Continue Rx for 10
Offer HCT days 27
Promote & provide
Recommended treatment for
genitalpenicillin
Benzathine ulcer 2.4 million units IM stat
Or
Doxycycline 100 mg bid for 14 days
Plus
Ciprofloxacin 500mg bid orally for 3 days
Or
Erythromycin tablets 500 mg qid for 7 days
Plus
Acyclovir 400mg tid orally for 10 days (200mg five
times per day of 10 day)
28
VAGINAL DISCHARGE
29
Causes of vaginal discharge
Sexually transmitted
Neisseria gonorrhoeae
Chlamydia trachomatis
Trichomonas vaginalis
Endogenous infection
Gardnerella vaginalis/ Bacterial vaginosis
Candida albicans
Others
Foreign body
Neoplasia
30
Causes (Cont)
Gardnerella vaginalis/ Bacterial
vaginosis
Homogeneous, thin, grayish-white discharge
that smoothly coats the vaginal walls
Vaginal pH > 4.5
Positive whiff-amine test
Fishy odor when 10%KOH is added to a sample of
vaginal discharge
“Clue cells” on saline wet mount
31
Clue cells
32
Causes (Cont)
Candida albicans
Risk factors: immunosuppression, increased
estrogen, diabetes, antibiotics
C/F:
white curd-like/"cottage cheese-like” discharge
Itching / vulvar pruritus
Erythema of vulva
Lab:
Wet mount with 10% KOH
Yeast/ hyphae
Culture –
33
Hypha
e
34
Causes (Cont)
Trichomonas vaginalis
Purulent , malodorous, green-yellow frothy discharge
Burning, pruritus, dysuria & dyspareunia.
Erythema of the vulva and vaginal mucosa
Punctate hemorrhages on the vagina and cervix ("strawberry
cervix“)
Motile Trichomonads on wet mount
35
Strawberry cervix Trichomonads
36
Causes (Cont)
Neisseria gonorrhoeae
vaginal pruritis & mucopurulent discharge
Discharge from the cervix
G-negative intracellular diplococci on G-stain
Culture: Thayer Martin medium
Chlamydia trachomatis
Mucopurulent cervical discharge
Investigations: PCR and Cell culture- expensive
37
Evaluation of patients with vaginal
discharge
Risk assessment: Risk factors for cervicitis
Age less than 25 years
Having multiple sexual partner in the last three
months
Having new partner in the last three months
Having ever traded for sex
Speculum examination to determine site of
infection
38
Vaginitis Vs Cervicitis
VAGINITIS CERVICITIS
Trichomoniasis, candidiasis, Gonorrhea & chlamydia
bacterial vaginosis
Most common cause of vaginal Less common cause of
discharge vaginal discharge
Less complications Major complications
Partner treatment unnecessary Partner treatment needed
Complication: PID, Premature rupture of membrane
Preterm labor, Infertility & Chronic pelvic pain
39
Vaginal discharge or vulval/Itching /Burning
Take Hx, examine patient (external,
speculum & bimanual) & assess risk
Educate on risk reduction
Abnormal discharge No
Offer HCT
present?
Promote & provide condoms
Yes
Yes
Lower abdominal tenderness /
Use LAP flowchart
cervical motion tenderness
No
Treat GC, CT, BV, TV
Yes
Is Risk assessment +?
No Treat for
Vulvar oedema/curd like Yes
Discharge, Erythema, Excoriations Candida A
Treat for BV present?
No
Educate, Offer HCT
40
Promote & provide condoms
Recommended treatment for
vaginal discharge
RISK ASSESMENT RISK ASSESMENT
POSITIVE NEGATIVE
Ciprofloxacin 500 mg po stat Metronidazole 500 mg bid for 7
or days
Spectinomycin 2 gm IM stat Plus
or Clotrimazole vaginal tabs 200
Ceftriaxone 125mg IM stat mg at bed time for 3 days
Plus
Doxycycline 100 mg po bid for 7 d
Plus
Metronidazole 500 mg bid for 7 d
41
Recommended treatment…
During pregnancy
Metronidazole, 250 mg orally, tid for 7 days
after 1st trimester or
Metronidazole 2g orally as a single dose
42
LOWER ABDOMINAL
PAIN
43
Indications for hospitalizations
Uncertain diagnosis
Acute abdomen can not be excluded
Pelvic or tuboovarian abscess is suspected
Severe illness precludes management on an
outpatient basis
Pregnancy
The patient is unable to follow or tolerate an
outpatient regimen
The patient has failed to respond to outpatient R x
44
45
Recommended treatment for
PIDOut patient In patent
Ciprofloxacin tablet 500 mg po Ceftriaxone 250 mg IV/IM daily
stat or
Ceftriaxone 250mg IM stat or Or
Spectinomycin 2 gm im bid
Spectinomycin 2 gm im stat Plus
Plus Doxycycline 100 mg bid for 14 days
Doxycycline tablet 100 mg po bid
for 14 days Plus
Plus Metronidazole 500 mg bid for 14 days
Metronidazole 500 mg bid for 14d or
Admit if there is no improvement Chloramphenicol 500 mg IV qid.
within 72 hours
46
INGUINAL BUBO
Painful, often fluctuant, swelling of the lymph
nodes in the inguinal region (groin)
Pathogens
C. trachomatis (serovar L1, L2, and L3)
H. ducreyi
C. granulomatis
T. pallidum( some times)
Treat Chancroid, LGV & GI
47
Recommended treatment for
inguinal bubo
Ciprofloxacin 500 mg bid orally for 3 days
Or
Erythromycin 500 mg po qid for 7 days
Plus
Doxycycline 100mg bid orally for 14 days
*If fluctuant aspirate through healthy skin
48
Scrotal Swelling
49
Scrotal swelling
Painful testis/ epididymis
< 25 years N. Gonorrhoea & [Link]
> 25 years other organisms, TB possible
(Other infectious causes are brucellosis, mumps,
onchocerciasis or W. babcrofti)
In pre-pubertal children is coliform,
pseudomonas or mumps virus
Mumps epidedimorchitis is usually noted within a
week of parotid enlargement
Other causes of scrotal swelling
testicular torsion; Trauma; Tumor
incarcerated inguinal hernia
50
Scrotal swelling
Take Hx, examine patient
no
Scrotal swelling No Reasure educate
Pain cnfirmed ? Analgesics Offer HCT
Promote & provide condoms
Yes
treat for GC/CT
Testis No Educate on risk reduction
rotated Offer HCT
Elevated Promote & provide condoms
paertener
Hx trauma
yes
Refer for
Surgical opinion
51
Recommended treatment
for scrotal swelling
Ciprofloxacin 500 mg po stat
Or
Spectinomycin 2 gm im stat
Plus
Doxycycline 100 mg PO bid for 7 days
Or
Tetracycline 500 mg PO bid for 7 days.
52
Neonatal Conjunctivitis
53
Neonatal Conjuctivitis
It is a purulent conjuctivitis occurring in
a baby less than one month of age.
Sight-threatening condition
Common presentation are Redness, swelling of
the eye lid & discharge from the eye (sticky
eye)
The most important causes are gonorrhoea (20-
75%) & chlamydia (15-35%)
If caused by gonorrhoea, blindness often
follows
For babies older than one month, the cause is
unlikely to be an STI
54
Eye discharge
Take Hx, examine patient
Bilateral unilateral No Reassure mother
swollen eye ? advice to return
If necessary
Yes
Treat for
GC/CT
Treat mother partner (s)
Educate on risk reduction
Offer HCT
Promote & provide condoms
revist
Improved
yes
no refer
Continue RX till completed
55
Management
Prevention
As soon as the baby is born, carefully wipe both
eyes with dry, clean cotton wool;
Then apply 1% silver nitrate solution or 1%
tetracycline eye ointment into the infant’s eyes;
other options: 0.5% Erythromycin ointment or
2.5% povidone iodine solution;
Treatment
Ceftriaxon 125mg IM stat (max 50mg/kg) or
Spectinomycin 25mg/kg IM stat (max 75mg) plus
Erythromycin 50 mg/kg PO in four divided doses
for 14 days
56
PARTNER
MANAGEMENT
57
Advantages of Partner
Notification
Break cycle of infection
Eliminate asymptomatic infection
Prevent re-infection
Prevent complication by early
detection
Education & risk reduction
counseling
58
Two Approaches to Partner
Management
[Link] referral (passive contact
tracing)
[Link] referral (active contact
tracing)
59
Patient referral could be done in
several ways
By directly explaining about the STI &
the need for treatment
Asking the partner to attend a health
center with out specifying the purpose
of the visit
By giving a partner a card to attend
the center
60
Provider Referral
Possible if index patients are prepared to
disclose full contact information
It is resource intensive
The success depends on health care
providers communication skills
Can be used when
Patients refuse to refer partner
Patient has agreed to refer partners but they have
not come for treatment
61
Partner management
INDEX PATIENT TREATMENT OF PARTNER
Urethral discharge Treat for gonorrhea & Chlamydia
Vaginitis & Cervicitis Treat for gonorrhea & Chlamydia
Vaginitis No partner treatment needed
PID Treat for gonorrhea & Chlamydia
Scrotal swelling Treat for gonorrhea & Chlamydia
Inguinal bubo Treat for LGV
Neonatal conjunctivitis Treat for gonorrhea & Chlamydia
Genital ulcer Treat for syphilis & chancroid
62
GYNECOLOGIC
MANIFESTATIONS OF
HIV/AIDS
For many women, gynecologic complaints are the
initial manifestation of HIV/AIDS.
These conditions, which also exist in uninfected
women, can occur with higher frequency and
severity in women with HIV.
Candida vaginitis and bacterial vaginosis
Abnormal cervical cytology
Vulvar and perianal pathology
Pelvic inflammatory disease
Genital ulcer disease (eg, HSV, chancroid, syphilis,
idiopathic)
Menstrual disorders and ammenorrhea
PRIMARY CARE OF HIV
INFECTED WOMEN
HIV therapy
Health maintenance
Medical care must include routine medical
screening (mammograms, breast self-
examination, nutritional counseling for
osteoporosis, smoking cessation, etc) and a
recognition that not all complaints are
necessarily HIV-related.
CHOICE OF CONTRACEPTION
FOR A WOMAN WITH HIV
Specific contraceptives and their efficacy in
preventing pregnancy
Prevention of transmission of HIV and other
sexually transmitted diseases
Drug interactions between certain
antiretroviral agents and hormonal
contraceptives
