Sexually Transmitted Infections …. STI / STD : Sexually Transmitted Infections …. STI / STD Daisy Dharmaraj
ACS Medical college Slide 2: Definition:
A group of communicable diseases that are transmitted by sexual contact
Ectoparasites Slide 3: VD Venereal diseases …X
5 classical types to 20 or more now
Second generation STDs
HIV AIDS is a new disease
Emergence of Anti microbial resistance
340 million new cases in 1999( other than HIV) India : India Syphilis… prevalence 2.4 in Aurangabad CSW 1.2 in Kerala
LGV..in south TN
Other STIs Genital herpes, HPV Slide 6: Age:20-24 yr olds
Sex: Males> female
Marital status :higher among single, divorced, separated
Demographic factors : Younger popln, migration, popln explosion, education Syndromic management : Syndromic management “Giving you the best that I got”…until… : “Giving you the best that I got”…until… Cheap
Test STI – Aetiologic Case Management : STI – Aetiologic Case Management DISADVANTAGES:
Current tests often expensive and unreliable
Require sophisticated equipment and training
Often require clients to return days later
Return often not feasible: distance, fares, work, etc
Results in high default rates
Period of infectivity prolonged by Tx delay
Lab facilities unavailable at point needed STI – Syndromic Case Management : STI – Syndromic Case Management ADVANTAGES:
Identifies and treats by signs & symptoms
Syndromes easily recognised clinically
Small number of clinical syndromes
Tx given for majority of organisms
Simple and cost-effective
Valid, feasible, immediate Tx
Risk assessment increases performance STI – Syndromic Case Management : STI – Syndromic Case Management DISADVANTAGES:
Tendency to overtreat – justifiable in high prevalence settings (>20%)
Overuse of expensive drugs
Asymptomatic cases not fully addressed even with risk assessment
Management of cervical infections problematic
Vaginal discharge algorithm performs poorly in low prevalence settings e.g., ANC, FP STI – Syndromic Case Management : STI – Syndromic Case Management REQUIREMENTS:
Adequate medical history
Good sexual history
Complete STI clinical examination
Good supply of effective drugs Syndromic Flow Charts for SCM : Syndromic Flow Charts for SCM Urethral discharge
Genital ulcer disease (M & F)
Pelvic Inflammatory Disease (PID)
Asymptomatic clients at high risk of infection Slide 14: Essential Steps In STI Care Management* Syndrome
Assessment Diagnosis Treatment 5Cs Contact tracing
Counseling (screening tests) (diagnostic tools) * Adapted from Holmes & Ryan Risk Assessment Include: : Risk Assessment Include: Sexual behaviours
Sociodemographics/other high risk markers:
marital status: not living with steady partner
History of reproductive health
History of past STI Rapid Laboratory Tests : Rapid Laboratory Tests May be used to narrow the spectrum of initial therapy. They include:
Wet mount (vaginal discharge)
Gram stain (UD, Cvx mucopus)
Rapid serologic tests e.g., (HIV/GUD/syphilis) Programmatic Advantages to Syndromic Management of STIs : Programmatic Advantages to Syndromic Management of STIs Allows all STI clinicians to provide excellent care without referring
The most efficient system to realize a clinic’s dual responsibility – cure the patient and protect the community from STI Programmatic Advantages to Syndromic Management of STIs : Programmatic Advantages to Syndromic Management of STIs In busy clinics provides the best care possible in the most efficient manner
Used routinely by all STI clinicians will reduce waiting time and relieve congestion
Will simplify procedures and patient- flow within the clinic – thereby reducing environmental stress What is Urethral Discharge Syndrome? : What is Urethral Discharge Syndrome? Discharge coming from the urethral meatus
May be frank pus, mucopurulent, or serous (clear)
Occasionally discharge will be white in colour Gonococcal urethral discharge Photo: Cincinnati STD/HIV Training Ctr Genital Ulcer Disease : Genital Ulcer Disease Wilkinson and Stone, 1995; Fig 8.46 Holmes, 1999; Plate 32 J. Anderson, MD, ed. Syphilis Chancroid Herpes Simplex Genital Ulcer Disease : Genital Ulcer Disease Other Causes
Granuloma inguinale (Donovanosis)
. Slide 23: GENITAL ULCER SYNDROME History, Risk Assessment, Examination.
Determine Number of Ulcers Solitary Lesion Multiple lesions
Recurrent at same site or with vesicles? Treat for Syphilis
& Chancroid Treat for
& Syphilis Treat for
Herpes Yes No Review in 7 days Review in 7 days Ulcer Persists Cured Refer Ulcer Persists Cured Refer Genital herpes vesicles : Genital herpes vesicles Typical vaginal discharge caused by trichomoniasis : Typical vaginal discharge caused by trichomoniasis Source: Seattle STD/HIV Prevention Training Center at the University of Washington “Strawberry cervix” due to T. vaginalis : “Strawberry cervix” due to T. vaginalis Source: Claire E. Stevens/Seattle STD/HIV Prevention Training Center at the University of Washington Causes of Abnormal Vaginal Discharge : Causes of Abnormal Vaginal Discharge Bacterial vaginosis
Overgrowth of anaerobic/facultative anaerobic flora
Associated with increased risk of PID, preterm labor, PROM
May enhance HIV transmission Causes of Abnormal Vaginal Discharge : Causes of Abnormal Vaginal Discharge Cervicitis
Limitations of syndromic management
Use local prevalence data, if available
Partner treatment Gonococcal Cervicitis : Gonococcal Cervicitis Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides Vaginal Discharge: Risk Assessment : Vaginal Discharge: Risk Assessment Slide 31: Step 1 Step 2 Step 3 Step 4 Step 5 Complaint of Vaginal Discharge Take History (esp. sexual). Determine Risk Score Do Bimanual Pelvic Exam, Pass speculum Clean and Inspect Cervix Observe nature of Vaginal Discharge Give Prevention Messages Slide 32: Step 3 Complaint of Vaginal Discharge Clean and Inspect Cervix No Mucopus etc., but
Tx for GC, CT, TV Mucopus, Erosion or Friability:
Treat for GC, CT & TV No Mucopus, Normal/No
Discharge, Risk score small:
No Tx but Counsel Slide 33: Step 4 Complaint of Vaginal Discharge Observe Nature
Vaginal Discharge Runny, profuse or malodorous:
Treat for TV and BV.
White and curdlike: Treat for Candida Slide 34: Step 5 Complaint of Vaginal Discharge Prevention Messages
Comply with Medication
Counsel re Risk Reduction
Confidentiality (assurance) Pelvic Inflammatory Disease : Pelvic Inflammatory Disease Minimal criteria for diagnosis
Simple supporting signs
Lower abdominal pain Acute Salpingitis : Acute Salpingitis Source: Cincinnati STD/HIV Prevention Training Center Slide 37: Complaint of Lower
Abdominal Pain (LAP) Take History and Assess Risk. Do Exam:
Abdominal, pelvic, bimanual, speculum Bowel or urinary symptoms?
Missed/overdue period; pregnant?
Recent childbirth or abortion?
Rebound tenderness; guarding?
Vaginal bleeding or pelvic mass? Immediate
OBGYN no to all yes to
any Slide 38: Complaint of Lower
Abdominal Pain (LAP) Either:
Temperature > 38oC
Dyspareunia or previous PID
Risk assessment positive
Pain on moving cervix/adnexa Treat for PID.
If IUD present:
Remove after 2-4 dys.
Examine and treat partner(s).
[40% may be asymptomatic].
Counsel re 4 Cs. Re-evaluate 3 days. Improved – complete Tx 10-14 days.
Not improved – refer hospital, (esp. if temperature elevated). Control of STI : Control of STI Initial planning
Monitoring and evaluation Initial planning : Initial planning Problem definition- prevalence, psycho social consequences- epidemiologcal surveys
Establishing priorities- feasibility. Define pop groups to be addressed.
Setting objectives- SMART Frame objectives. Cover larger population
Considering strategies- Intervention strategies : Intervention strategies Case detection-
Screening of general and specific population with an appropriate sensitive/ specific/ predictive test
Contact tracing- sexual partners identified, tested, investigated and treated.
Cluster testing of same socio sexual environment
Case holding and treatment- mainstay
Epidemiological / contact treatment while awaiting inv results.
Personal prophylaxis: contraceptives/ vaccines. Motivation. Acceptability. convenience
Health education- Behaviour change communication BCC Support components : Support components STD clinic; free.
Services available, long hrs of service. Anonymity.
Have 1 specialised centre which could coordinate.
Lab services- personnel, equipment. Relevant tests
Primary health care – universal coverage, community participation, equity, inter sectoral coordination
Information system: clinical notification, laboratory notification , sentinel and ad hoc surveillance. Population based sample surveys
Legislation. Immoral traffic act.
Social welfare measures Slide 43: MONITORING & EVALUATION
National STD control program THE END : THE END