Transcript Sexually transmitted infections in HIV

Sexually transmitted
infections in HIV
Session objectives
At the end of the session, the participant
should be able to
– explain the concept of STD as a cofactor for HIV
– discuss interventions to control STDs
– list the approaches to management of STDs and
the disadvantages of each approach
– make a syndromic diagnosis based on the
symptoms and write an appropriate
prescription
– explain to the patient regarding partner
treatment and use of condoms
Session plan
• HIV and STI
(5 minutes)
• Impact of STI s on HIV and vice versa
(5 minutes)
• Role of STI treatment in HIV prevention
(10 minutes)
• Approaches to STI diagnosis (5 minutes)
• Syndromic STI management (30 minutes)
Why STIs are important?
• HIV infection is primarily an STI in
India-85% sexually transmitted
• STI s increase the spread of HIV
• Treatment of STIs reduce the
transmission of HIV
• HIV care / STI care should be integrated
• HIV can alter the manifestations of STIs
For discussion
Why is STI so worrying in the
setting of HIV? Are interventions
effective?
Biological evidence of STI as
cofactor for HIV transmission
• presence of STD :
increase viral
load in genital secretion of HIV infected
partner
• presence of STD :
increase HIV
susceptibility, disruption of epithelium
cells, and increased inflammatory cells in
HIV uninfected partner
Relative risk: STI as risk factor for
HIV transmission
Study population
Heterosexual men,
Kenya
Heterosexual men, USA
Heterosexual men, USA
Heterosexual women,
Zaire
STI
Genital ulcer
Syphilis
Herpes
Gonorrhoea
Chlamydia
Trichomonas
Heterosexual men, USA Herpes
Syphilis
Relative risk
4.7
1.5-2.2
4.4
3.5
3.2
2.7
3.3-8.5
8.4-8.5
Intervention studies: STD case finding
strategies among CSW in Abidjan
HIV incidence/100 py
Before intervention
16.5
Basic strategy : monthly case finding
7.9
Intensive strategy : monthly case
finding using pelvic exam, and lab
5.5
Mwanza trial
•
•
•
•
•
STD reference centre
Syndromic approach
Regular supply of effective STD drugs
supervisory visits
promote prompt attendance
A 42% reduction in the incidence of HIV was noted
in the intervention group as compared to the
control group over 2 years of this intervention
From Grosskurth et al., Lancet, 1995
Incidence of STDs in Thailand
(1982-2001)
5
4.5
4
3.5
3
First case of
AIDS in 1984
100% condom
initiated in 1989
gonorrhoea
N.S.U.
chancroid
LGV
syphilis
2.5
2
1.5
1
100% condom
completed in 1992
0.5
0
1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 2000 2001
Where STD control is likely to have
a maximum impact
• In settings with high prevalence of “relevant” STD
(GUD, urethritis and cervicitis)
• Low quality of STD services
• At the earlier stages of the HIV epidemic
It is NOT A MAGIC BULLET, but an essential
component
of a package of multiple HIV prevention strategies
Objectives of STI control
• To interrupt the transmission of STD
(acquired infection)
• To prevent complication and
sequelae
• To reduce HIV infection risk
Operational model of the role of health
services in STD case management
Population with STD
Aware and worried
Seeking care
Correct diagnosis
Correct treatment
Treatment completed
Cure
STRATEGIES IN COMMUNITY
• Sexual behavior change and condom
promotion
• Education of the public regarding the s/s
• Improve the health seeking behavior
• Training of health workers to screen STI
• Training of GPs
Management of STIs
• Etiological approach
• Clinical diagnosis approach
• Syndromic approach
Problems with etiological
management
• Delay in treatment
• Compliance with treatment
• Partner management
• Follow up
• Referral
• Maintenance of case records
Problems with etiological
management
• Lab facility
• Interpretation of results
• Quality control
• Expensive (Chlamydia)
• Sophisticated tests
Operational model of the role of health
services in STD case management
Population with STD
Aware and worried
Seeking care
Correct diagnosis
Correct treatment
Treatment completed
Cure
• Promotion of health
care seeking behaviour
• Improve quality of
care
• Attitudes of personnel
Operational model of the role of health
services in STD case management
Population with STD
Aware and worried
Seeking care
Correct
diagnosis
Correct
treatment
Treatment
completed
Cure
• Syndromic approach
• Include STD drugs
in essential list
• Prescribe single dose
• Counsel about
compliance
Clinical Diagnosis Approach
Identify the STD causing symptoms
based on clinical experience
• even experienced STD providers
often misdiagnose STDs
• miss mixed infections
• difficult for surveillance
Clinical Diagnosis Approach
• Specialists!- (Holmes and Ryan)
• only 30% of chancroid and 10% mixed
infections( Dangor 1990)
• 12/106 Syphilis misdiagnosed as Herpes
Disease
Agent
Clinical features
Chancroid
Haemophilus
ducreyi
Multiple painful irregular,
undermined edges, soft ulcerUnilateral Bubo
Painless progressive ulcer
Donovanosis Calmeto
bacterium
granulomatis
Herpes
HSV 2&1
LGV
Chlamidia
trachomatis
L1 L2 L3
Treponema
pallidum
Syphilis
No regional adenopathy
Multiple painful grouped
vescicles- ulcerate coalase
Reccurence b/L adenopathy I
primary
Transient ulcer
Unilateral tender adenopathy,
grove sign
Painless single ulcer, indurated
clean base, Firm b/L adenopathy
Syndromic Diagnosis Approach
Symptom
Decision
Identify all possible STDs that could
cause the syndrome and give
recommended treatment based on
epidemiological and laboratory data
Action
action
action
action
Advantages V/S Disadvantages
•
•
•
•
Treat at first visit
Cost saving
No loss to follow up
Effective in mixed
infection
• Minimal lab
necessary
• Reduce HIV& STI
spread
• Can be done by
paramedics
• Over treatment
• False positive diagnosis
• Social problems due to
over diagnosis
• Over treatment of
partners
Syndromes
• Genital ulcer- syphilis, Chancroid, LGV, Herpes,
Donovanosis
• Discharge- Gonococci, NGU
• Inguinal Bubo- LGV, Chancroid
• Vaginal discharge- Candidiasis, Trichomoniasis,
BV, GC, Chlamydia
• Scrotal swelling- LGV , Gonorrhoea
• Lower abdominal pain- PID ( GC, Chlamydia)
• Ophthalmia neonatorum
( GC, Chlamydia)
Principles of treatment
• Medical treatment
• Follow up-return after 7 days if symptoms
persists
• Partner notification
• Rule out other STDs - counsel HIV test
• Counseling & education
– safe sex
– risk reduction
– behavior modification etc
• Condom promotion and provision
For discussion
If this patient presented to you
with history of painful urethral
discharge, what would you do?
Urethral discharge
Patient with urethral discharge
Discharge present
Treat for gonorrhoea and chlamydia
Review after 7 days
Discharge present?
No dischargeEvaluate for other STI
Present- treat as
per flow chart
Educate and counsel
Refer to VCCTC
YES- check compliance
Refer to higher institution
NO- educate and counsel
Refer to VCCTC
Azithromycin 1g +
Cefixime 400 mg orally as
a single dose under
supervision
For discussion
If this patient were to present to you
with, what would your approach?
Genital ulcer
History of genital ulcer;
History or findings of vesicles
NO
Look for ulcer
YES
Treat for syphilis, chancroid
YES
Treat for herpes
NO
Educate, counsel
Educate, counsel
•Inj Benzathine penicillin 24 L IM stat for
syphilis
•Plus azithromycin, 1g orally as a single dose
for chancroid
For discussion
© Dr Balasubramanian
This patient presents with a
history of swelling in the inguinal
region. Discuss your approach.
Inguinal swelling/ bubo
History of swelling in the groin
Examine for genital ulcer
NO
Treat for LGV
YES
Use genital ulcer flow chart
Doxycycline 100 mg bd for 21days
For discussion
In a patient presenting with vaginal discharge,
what is the approach? What is the difference is a
speculum examination is possible?
Vaginal discharge (without
speculum examination)
Patient with vaginal discharge
Lower abdominal pain?
NO
New/ symptomatic partner?
Multiple partners?
YES
Treat cervicitis, vaginitis
If persistent, refer
YES
Use lower abdominal
pain flow chart
NO
Educate, counsel
Follow up
Cervicitis Azithromycin 1g + cefixime 400mg orally
as a single dose
Vaginitis Metronidazole 2 g stat plus fluconazole
150 mg stat
Vaginal discharge (with speculum)
History of vaginal discharge
Abdominal pain?
YES
Use lower abdominal
pain flow chart
NO
Endocervical discharge?
YES
Treat for cervicitis, vaginitis
Symptoms persisting?
Refer
NO
Risk factors?
YES. Treat for vaginitis
NO. Educate, counsel. Follow up
For discussion
If a young lady presents lower
abdominal pain, what is your approach?
Lower abdominal pain in women
History of abdominal pain
Check for missed delivery,
recent abortion, guarding, tenderness
NO
Pain on moving cervix?
Fever?
NO
Other illness?
YES
Refer immediately
YES. Treat for PID
If not improving, refer
YES Manage accordingly
NO Reassure and follow up
Azithromycin 1g +
cefixime 400mg stat
and metronidazole 400
mg bd for 14 days
For discussion
If this patient presents with pain
in the scrotum, with swelling,
how would you manage?
Scrotal swelling
Painful scrotal swelling
History of trauma?
NO
Scrotal swelling?
NO- reassure
YES: Refer
YES, injury history\ Testis
rotated/ retracted?
YES. Refer immediately
NO. Treat
Cefixime 400mg orally bd, 7 days + doxycycline 100mg bd,
14 days
Ophthalmia neonatorum
Take history and examine
No
Bilateral or unilateral swollen eyelids with purulent
discharge?
ｷReassure mothers
ｷAdvise to return if symptoms
persist
Yes
ｷTreat baby for gonococcal and chlamydial infections
ｷTreat mother and partner for gonococcal and chlamydial infections
ｷCounsel and educate parents
ｷCome back after 3 days
No
Refer immediately to higher- level
facility
Improved?
Yes
Complete treatment
Reassure mother
Treatment for Ophthalmia
neonatorum
• Recommended regimen:
1. Inj ceftriaxone 50mg\kg IM single dose,
up to maximum of 125mg (to treat
gonococcal infection)
plus
2. Erythromycin syrup 50mg\kg, orally, daily
in 4 ddivided doses for 14 days (to treat
chlamydial infection)
Steps for STD prevention and
management-All patients
• Treatment
• Instructions for
medication
• Education and
counseling
• condoms
• Education and
counseling
• Treat for cure
• Don't spread
• Help partners treated
• Come back for check up
• Stay cured with condoms
• Keep staying with 1
partner
• Protect from HIV
• Protect your baby-ANC
Remember 6 Cs for STIs
management
• Cure with treatment
• Compliance to treatment
• Contact tracing for partner management
• Counseling & education
• Condom promotion & provision
• Come back for clinical follow up
Condom- Common errors
Misconceptions not corrected
• Packet opened and applied before erection
• Unrolled before application
• Tip of condom not squeezed
• Penis not withdrawn immediately after
ejaculation
• Reservoir tip not facing down ward while
slipping
• Not disposed properly
What can doctor do?
•Doctor can
• Distribute
• Display
4D
• Demonstrate Condoms--------
Do not
•
•
use grease, oils, lotions or petroleum jelly (Vaseline)
forget to Use a condom each time you have sex.
forget to Use a condom once only
•
forget to Store condom in cool, dry place
•
use condom that may be old or damaged
•
Do not use a condom if
–
–
–
–
the package is broken
the condom is brittle or dried out
the colour is uneven or changed
it is unusually sticky
Condom & ART
• Continue condom use even in concordant
couples
–
–
–
–
Different strains
Viral resistance
STIs
Effective ART programs may lead to increase
in STI prevalence
References
1.
Sexually transmitted infections treatment guide lines - NACO
2.
WHO guide lines for management of Sexually transmitted
infections
3.
Grosskurth H,Gray R et al.Controle of Sexually transmitted
disease for HIV-! Prevention; undrstanding the implications
of the Mwanza and Rakai Trials lancet 2002;355:1981-87
Susanne Abraham STIs RTIs and HIV-module8-HIV distance
learning 2002
Quality STD Care Training module for private medical
practitioners –APAC-VHS Chennai
Management of sexually transmitted infections Dr. Anupong
Chitwarakorn Department of Disease Control
4.
5.
6.
7.
Flow Charts on the Syndromic Management of Sexually
Transmitted Infections- www.naco.nic.in