Sexually Transmitted Infections

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Sexually Transmitted Infections …. STI / STD : 

Sexually Transmitted Infections …. STI / STD Daisy Dharmaraj Community Medicine ACS Medical college

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Definition: A group of communicable diseases that are transmitted by sexual contact Causative agents; Bacterial Viral Protozoal Fungal Ectoparasites

Slide 3: 

VD Venereal diseases …X 5 classical types to 20 or more now Second generation STDs HIV AIDS is a new disease True incidence? 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 Gonorrhea south TN Chancroid Donovanosis…South India Other STIs Genital herpes, HPV

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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 Non -Invasive 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%) Decreased specificity 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 Management guidelines Good supply of effective drugs

Syndromic Flow Charts for SCM : 

Syndromic Flow Charts for SCM Urethral discharge Genital ulcer disease (M & F) Vaginal discharge Pelvic Inflammatory Disease (PID) Scrotal swelling Inguinal swelling Ophthalmia neonatorum Asymptomatic clients at high risk of infection

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Essential Steps In STI Care Management* Syndrome Assessment Risk Assessment Diagnosis Treatment 5Cs Contact tracing Compliance Confidentiality Condom use Counseling (screening tests) (diagnostic tools) * Adapted from Holmes & Ryan

Risk Assessment Include: : 

Risk Assessment Include: Sexual behaviours Specific exposures Sociodemographics/other high risk markers: young age marital status: not living with steady partner partner problems 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) Darkfield (GUD/syphilis) 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 Lymphogranuloma venereum Granuloma inguinale (Donovanosis) Neoplasm .

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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 Chancroid & 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 Chlamydia Gonorrhoea Limitations of syndromic management Use local prevalence data, if available Risk assessment Partner treatment

Gonococcal Cervicitis : 

Gonococcal Cervicitis Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides

Vaginal Discharge: Risk Assessment : 

Vaginal Discharge: Risk Assessment

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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

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Step 3 Complaint of Vaginal Discharge Clean and Inspect Cervix No Mucopus etc., but Risk Score: 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

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Step 4 Complaint of Vaginal Discharge Observe Nature of Vaginal Discharge Runny, profuse or malodorous: Treat for TV and BV. White and curdlike: Treat for Candida

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Step 5 Complaint of Vaginal Discharge Prevention Messages Comply with Medication Counsel re Risk Reduction Condom use Contacts Confidentiality (assurance)

Pelvic Inflammatory Disease : 

Pelvic Inflammatory Disease Minimal criteria for diagnosis Simple supporting signs Fever >38.3°C Abnormal discharge Lower abdominal pain

Acute Salpingitis : 

Acute Salpingitis Source: Cincinnati STD/HIV Prevention Training Center

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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 Referral to Surgical or OBGYN no to all yes to any

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Complaint of Lower Abdominal Pain (LAP) Either: Temperature > 38oC Dyspareunia or previous PID Vaginal discharge Mucopurulent cervicitis Risk assessment positive With: 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 Intervention strategies Support components 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. Self medication 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

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MONITORING & EVALUATION National STD control program